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2.  Prognostic factors for patients with cervical cancer treated with concurrent chemoradiotherapy: a retrospective analysis in a Japanese cohort 
Objective
Concurrent chemoradiotherapy (CCRT) is the primary treatment for locally advanced cervical cancer. We studied prognostic factors for patients treated with CCRT.
Methods
We retrospectively reviewed records of 85 consecutive patients with cervical cancer who were treated with CCRT between 2002 and 2011, with external beam radiation therapy, intracavitary brachytherapy, and platinum-based chemotherapy. Survival data were analyzed with Kaplan-Meier methods and Cox proportional hazard models.
Results
Of the 85 patients, 69 patients (81%) had International Federation of Gynecology and Obstetrics (FIGO) stage III/IV disease; 25 patients (29%) had pelvic lymph node enlargement (based on magnetic resonance imaging), and 64 patients (75%) achieved clinical remission following treatment. Median maximum tumor diameter was 5.5 cm. The 3- and 5-year overall survival rates were 60.3% and 55.5%, respectively. Cox regression analysis showed tumor diameter >6 cm (hazard ratio [HR], 2.3; 95% confidence interval [CI], 1.2 to 4.6), pelvic lymph node enlargement (HR, 2.2; 95% CI, 1.1 to 4.5), and distant metastasis (HR, 10.0; 95% CI, 3.7 to 27.0) were significantly and independently related to poor outcomes.
Conclusion
New treatment strategies should be considered for locally advanced cervical cancers with tumors >6 cm and radiologically enlarged pelvic lymph nodes.
doi:10.3802/jgo.2015.26.1.12
PMCID: PMC4302279  PMID: 25310853
Brachytherapy; Chemoradiotherapy; Proportional Hazards Models; Retrospective Studies; Uterine Cervical Neoplasms
3.  The incidence of pelvic and para-aortic lymph node metastasis in uterine papillary serous and clear cell carcinoma according to the SEER registry 
Objective
In this study we utilized the Surveillance, Epidemiology and End-Results (SEER) registry to identify risk factors for lymphatic spread and determine the incidence of pelvic and para-aortic lymph node metastases in patients with uterine papillary serous carcinoma (UPSC) and uterine clear cell carcinoma (UCCC) who underwent complete surgical staging and lymph node dissection.
Methods
Nine hundred seventy-two eligible patients diagnosed between 1998 to 2009 with International Federation of Gynecology and Obstetrics (FIGO) 1988 stage IA-IVA UPSC (n=685) or UCCC (n=287) were identified for analysis. Binomial logistic regression was used to determine risk factors for lymph node metastasis, with the incidence of pelvic and para-aortic lymph node metastases reported for each FIGO primary tumor stage. The Cox proportional hazards regression model was used to determine factors associated with overall survival.
Results
FIGO primary tumor stage was the only independent risk factor for lymph node metastasis (p<0.01). The incidence of pelvis-only and para-aortic lymph node involvement according to the FIGO primary tumor stage were as follows: IA (2.3%/3.8%), IB (7.5%/5.2%), IC (22.5%/16.9%), IIA (20.8%/13.2%), IIB (25.7%/14.9%), and III/IV (25.7%/24.3%). Prognostic factors for overall survival included lymph node involvement (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.09 to 1.85; p<0.01), patient age >60 years (HR, 1.70; 95% CI, 1.21 to 2.41; p<0.01), and advanced FIGO primary tumor stage (p<0.01). Tumor grade, histologic subtype, and patient race did not predict for either lymph node metastasis or overall survival.
Conclusion
There is a high incidence of both pelvic and para-aortic lymph node metastases for FIGO stages IC and above uterine papillary serous and clear cell carcinomas, suggesting a potential role for lymph node-directed therapy for these patients.
doi:10.3802/jgo.2015.26.1.19
PMCID: PMC4302280  PMID: 25310855
Adenocarcinoma Clear Cell; Lymphatic Metastasis; Registries; Risk Factors; Pelvis
4.  An analysis of current treatment practice in uterine papillary serous and clear cell carcinoma at two high volume cancer centers 
Objective
Despite the rarity of uterine papillary serous carcinoma (UPSC) and uterine clear cell carcinoma (UCCC), they contribute disproportionately to endometrial cancer deaths. Sufficient clinical information regarding treatment and prognosis is lacking. The aim of this study is to evaluate treatment outcomes in a rare cancer cohort based on the experience at two tertiary care cancer centers.
Methods
Clinicopathologic data were retrospectively collected on 279 patients with UPSC and UCCC treated between 1995 to 2011. Mode of surgery, use of adjuvant treatment, and dissection of paraaoritc lymph nodes were evaluated for their association with overall survival (OS) and progression-free survival (PFS).
Results
40.9% of patients presented with stage I disease, 6.8% of patients presented with stage II disease and 52.3% of patients presented with stages III and IV. Median follow-up was 31 months (range, 1 to 194 months). OS and PFS at 5 years were 63.0% and 51.9%, respectively. OS and PFS were not affected by mode of surgery (open vs. robotic approach; OS: hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.28 to 1.62; PFS: HR, 0.78; 95% CI, 0.40 to 1.56). Adjuvant treatment was associated with improved OS in stages IB-II (HR, 0.14; 95% CI, 0.02 to 0.78; p=0.026) but not in stage IA disease. There was no difference in OS or PFS based on the performance of a paraaoritc lymph node dissection.
Conclusion
Minimally invasive surgical staging appears a reasonable strategy for patients with non-bulky UPSC and UCCC and was not associated with diminished survival. Adjuvant treatment improved 5-year survival in stages IB-II disease.
doi:10.3802/jgo.2015.26.1.25
PMCID: PMC4302281  PMID: 25376917
Adenocarcinoma, Clear Cell; Disease-free Survival; Endometrial Neoplasms; Lymph Node Excision; Retrospective Studies
5.  Clinical implication of surgically treated early-stage cervical cancer with multiple high-risk factors 
Objective
Presence of high-risk factor in cervical cancer is known to be associated with decreased survival outcomes. However, the significance of multiple high-risk factors in early-stage cervical cancer related to survival outcomes, recurrence patterns, and treatment implications is not well elucidated.
Methods
A retrospective study was conducted for surgically treated cervical cancer patients (stage IA2-IIB, n=540). Surgical-pathological risk factors were examined and tumors expressing ≥1 high-risk factors (nodal metastasis, parametrial involvement, or positive surgical margin) were eligible for analysis (n=177, 32.8%). Survival analysis was performed based on the number of high-risk factors and the type of adjuvant therapy.
Results
There were 68 cases (38.4%) expressed multiple high-risk factors (2 high-risk factors: n=58, 32.8%; 3 high-risk factors: n=10, 5.6%). Multiple high-risk factors remained an independent prognosticator for decreased survival outcomes after controlling for age, histology, stage, and treatment type (disease-free survival: hazard ratio [HR], 2.34; p=0.002; overall survival: HR, 2.32; p=0.007). Postoperatively, 101 cases (57.1%) received concurrent chemoradiotherapy (CCRT) and 76 cases (42.9%) received radiotherapy (RT) alone. CCRT was beneficial in single high-risk factor cases: HRs for CCRT over RT alone for cumulative risk of locoregional and distant recurrence, 0.27 (p=0.022) and 0.27 (p=0.005), respectively. However, tumor expressing multiple high-risk factors completely offset the benefit of CCRT over RT alone for the risk of distant recurrence: HR for locoregional and distant recurrence, 0.31 (p=0.071) and 0.99 (p=0.980), respectively.
Conclusion
Special consideration for the significance of multiple high-risk factors merits further investigation in the management of surgically treated early-stage cervical cancer.
doi:10.3802/jgo.2015.26.1.3
PMCID: PMC4302282  PMID: 25310856
Combined Modality Therapy; Neoplasm Recurrence, Local; Retrospective Studies; Risk Factors; Survival Analysis; Uterine Cervical Neoplasms
6.  Risk group criteria for tailoring adjuvant treatment in patients with endometrial cancer: a validation study of the Gynecologic Oncology Group criteria 
Objective
The purpose of this study is to validate the Gynecologic Oncology Group (GOG) criteria for adjuvant treatment in a different cohort of patients and to evaluate the simplified risk criteria predicting the prognosis and tailoring adjuvant treatment in patients with surgically staged endometrial cancer.
Methods
We performed a retrospective analysis of 261 consecutive patients with surgically staged endometrial cancer between January 2000 and February 2013. All patients had complete staging procedures and were surgically staged according to the 2009 International Federation of Gynecology and Obstetrics staging system. Clinical and pathologic data were obtained from medical records. We designed the simplified risk criteria for adjuvant treatment according to the risk factors associated with survival. The patients were divided into low and low-intermediate, high-intermediate, and high-risk groups according to the GOG criteria and simplified criteria and their survivals were compared. Receiver-operating characteristic curve analysis was used to evaluate the prognostic significance of both criteria.
Results
Median follow-up time was 48 months (range, 10 to 122 months). According to the GOG criteria, we identified 197 low and low-intermediate risk patients, 20 high-intermediate risk patients, and 44 high-risk patients. There were significant differences in disease-free (p<0.001) and overall survival (p<0.001) among the three groups. Using the simplified risk criteria, we identified 189 low and low-intermediate risk patients, 28 high-intermediate risk patients, and 44 high-risk patients. There were significant differences in disease-free (p<0.001) and overall survival (p<0.001) among the three groups. The performance of the simplified criteria (area under the curve [AUC]=0.829 and 0.916 for disease recurrences and deaths, respectively) was as good as the GOG criteria (AUC=0.836 and 0.921 for disease recurrences and deaths, respectively).
Conclusion
The simplified criteria may be easily applicable and offer useful information for planning strategy of adjuvant treatment in patients with surgically staged endometrial cancer as the GOG criteria.
doi:10.3802/jgo.2015.26.1.32
PMCID: PMC4302283  PMID: 25376915
Chemotherapy, Adjuvant; Disease-free Survival; Endometrial Neoplasms; Radiotherapy, Adjuvant; Risk Factors
7.  DNA mismatch repair-related protein loss as a prognostic factor in endometrial cancers 
Objective
Recent investigations have revealed DNA mismatch repair (MMR) gene mutations are closely related with carcinogenesis of endometrial cancer; however the impact of MMR protein expression on prognosis is not determined. Correlations between MMR-related protein expression and clinicopathological factors of endometrial cancers are analyzed in the present study.
Methods
A total of 191 endometrial cancer tissues treated between 1990 and 2007 in our hospital were enrolled. Immunoreactions for MSH2, MLH1, MSH6, and PMS2 on tissue microarray specimens and clinicopathological features were analyzed retrospectively.
Results
Seventy-six cases (40%) had at least one immunohistochemical alteration in MMR proteins (MMR-deficient group). There were statistically significant differences of histology, International Federation of Gynecology and Obstetrics (FIGO) stage, and histological grade between MMR-deficient group and the other cases (MMR-retained group). Response rate of first-line chemotherapy in evaluable cases was slightly higher in MMR-deficient cases (67% vs. 44%, p=0.34). MMR-deficient cases had significantly better progression-free and overall survival (OS) compared with MMR-retained cases. Multivariate analysis revealed MMR status was an independent prognostic factor for OS in endometrial cancers.
Conclusion
MMR-related proteins expression was identified as an independent prognostic factor for OS, suggesting that MMR was a key biomarker for further investigations of endometrial cancers.
doi:10.3802/jgo.2015.26.1.40
PMCID: PMC4302284  PMID: 25310854
Biological Markers; Carcinogenesis; DNA Mismatch Repair; Endometrial Neoplasms; Multivariate Analysis; Retrospective Studies
8.  Distinguishing benign from malignant pelvic mass utilizing an algorithm with HE4, menopausal status, and ultrasound findings 
Objective
The purpose of this study was to develop a risk prediction score for distinguishing benign ovarian mass from malignant tumors using CA-125, human epididymis protein 4 (HE4), ultrasound findings, and menopausal status. The risk prediction score was compared to the risk of malignancy index and risk of ovarian malignancy algorithm (ROMA).
Methods
This was a prospective, multicenter (n=6) study with patients from six Asian countries. Patients had a pelvic mass upon imaging and were scheduled to undergo surgery. Serum CA-125 and HE4 were measured on preoperative samples, and ultrasound findings were recorded. Regression analysis was performed and a risk prediction model was developed based on the significant factors. A bootstrap technique was applied to assess the validity of the HE4 model.
Results
A total of 414 women with a pelvic mass were enrolled in the study, of which 328 had documented ultrasound findings. The risk prediction model that contained HE4, menopausal status, and ultrasound findings exhibited the best performance compared to models with CA-125 alone, or a combination of CA-125 and HE4. This model classified 77.2% of women with ovarian cancer as medium or high risk, and 86% of women with benign disease as very-low, low, or medium-low risk. This model exhibited better sensitivity than ROMA, but ROMA exhibited better specificity. Both models performed better than CA-125 alone.
Conclusion
Combining ultrasound with HE4 can improve the sensitivity for detecting ovarian cancer compared to other algorithms.
doi:10.3802/jgo.2015.26.1.46
PMCID: PMC4302285  PMID: 25310857
Algorithms; CA-125 Antigen; Ovarian Neoplasms; Prospective Studies; Regression Analysis; Sensitivity and Specificity
9.  Hyperthermic intraperitoneal chemotherapy with cisplatin and paclitaxel in advanced ovarian cancer: a multicenter prospective observational study 
Objective
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been recently reported with favorable oncological outcomes as treatment of advanced epithelial ovarian cancer (EOC). The aim of this study was to demonstrate the feasibility of CRS+HIPEC with cisplatin and paclitaxel for the treatment of advanced EOC.
Methods
This is a prospective observational study of 54 patients, from April 2007 to October 2013, with primary or recurrent peritoneal carcinomatosis due to EOC. The mean age was 54.51±9.34. Thirty patients (59%) had primary EOC, and 24 patients (41%) had recurrent disease.
Results
Mean peritoneal cancer index was 10.11 (range, 0 to 28), complete cytoreduction (CC0) was achieved for 47 patients (87%), CC1 for seven patients (13%). Patients with suboptimal cytoreduction (CC2 and CC3) were not included in the study. The mean stay in intensive care unit was 4.73±5.51 days and the mean hospitalization time was 24.0±10.03 days. We did not observe any intraoperative death. Seven patients (13%) required additional operations. Three patients (5.6%) died within 30 days from the procedure. Severe complications were seen in 19 patients (35.2%). During the follow-up period, disease recurred in 33 patients (61.1%); the median disease-free survival time was 12.46 months and the median overall survival time was 32.91 months.
Conclusion
CRS+HIPEC with cisplatin and paclitaxel for advanced EOC is feasible with acceptable morbidity and mortality. Additional follow-up and further studies are needed to determine the effects of HIPEC on long term survival.
doi:10.3802/jgo.2015.26.1.54
PMCID: PMC4302286  PMID: 25376916
Cisplatin; Disease-free Survival; Ovarian Neoplasms; Paclitaxel; Prospective studies
10.  Single-site robotic surgery in gynecologic cancer: a pilot study 
Objective
To discuss the feasibility of single-site robotic surgery for benign gynecologic tumors and early stage gynecologic cancers.
Methods
In this single institution, prospective analysis, we analyzed six patients who had undergone single-site robotic surgery between December 2013 and August 2014. Surgery was performed using the da Vinci Si Surgical System. Patient characteristics and surgical outcomes were analyzed.
Results
Single-site robotic surgery was performed successfully in all six cases. The median patient age was 48 years, and the median body mass index was 25.5 kg/m2 (range, 22 to 33 kg/m2). The median total operative time was 211 minutes, and the median duration of intracorporeal vaginal cuff suturing was 32 minutes (range, 22 to 47 minutes). The median duration of pelvic lymph node dissection was 31 minutes on one side and 27 minutes on the other side. Patients' postoperative courses were uneventful. The median postoperative hospital stay was 4 days. No postoperative complications occurred.
Conclusion
When used to treat benign gynecologic tumors and early stage gynecologic cancers, the single-site da Vinci robotic surgery is feasible, safe, and produces favorable surgical outcomes.
doi:10.3802/jgo.2015.26.1.62
PMCID: PMC4302287  PMID: 25609162
Gynecology; Minimally Invasive Surgical Procedures; Operation Time; Postoperative Complications; Robotic Surgical Procedure; Single-site
11.  Asian Society of Gynecologic Oncology International Workshop 2014 
The Asian Society of Gynecologic Oncology International Workshop 2014 on gynecologic oncology was held in Asan Medical Center, Seoul, Korea on the 23rd to 24th August 2014. A total of 179 participants from 17 countries participated in the workshop, and the up-to-date findings on the management of gynecologic cancers were presented and discussed. This meeting focused on the new trends in the management of cervical cancer, fertility-sparing management of gynecologic cancers, surgical management of gynecologic cancers, and recent advances in translational research on gynecologic cancers.
doi:10.3802/jgo.2015.26.1.68
PMCID: PMC4302288  PMID: 25609163
Endometrial Neoplasms; Fertility Preservation; Laparoscopy; Ovarian Neoplasms; Uterine Cervical Neoplasms
12.  Are we ready for conservative treatment in ovarian cancer? 
doi:10.3802/jgo.2015.26.1.75
PMCID: PMC4302289  PMID: 25609164
13.  Magnivisualizer in the early detection of cervical neoplasia 
Journal of Gynecologic Oncology  2014;25(4):263-264.
doi:10.3802/jgo.2014.25.4.263
PMCID: PMC4195291  PMID: 25310029
14.  Human papillomavirus: wearisome or awesome issue? 
Journal of Gynecologic Oncology  2014;25(4):265-266.
doi:10.3802/jgo.2014.25.4.265
PMCID: PMC4195292  PMID: 25310030
17.  Defining the concept of locally advanced squamous cell carcinoma of the vulva: a new perspective based on standardization of criteria and current evidence 
Journal of Gynecologic Oncology  2014;25(4):272-278.
The phrase "locally advanced carcinoma of the vulva" has often been mentioned in the literature, though not accurately defined, or even leading to the interpretation overlapping. Grounded on cervical cancer experience, we are able to state that designing a tailored primary strategy based on clinically measurable adverse prognostic factors represents the cornerstone of therapy. This fact urged us to rethink about the real usefulness of the concept of locally advanced squamous cell carcinoma of the vulva. We will refer to this concept as a clinical entity emerging from a rigorous workup which is a valuable guiding tool in the context of a thorough debate about the best primary treatment approach to be used. Furthermore, bulky tumors of the vulva have been associated with a worse prognosis on several occasions. Some authors have questioned the fact that tumor size has not been considered in the staging system. Finally, a standardized definition will help us compare the results obtained, which is extremely necessary given the worldwide low prevalence of this disease.
doi:10.3802/jgo.2014.25.4.272
PMCID: PMC4195295  PMID: 25142626
Prevalence; Prognosis; Squamous cell carcinoma; Vulva
18.  Role of lymphadenectomy for ovarian cancer 
Journal of Gynecologic Oncology  2014;25(4):279-281.
Japan Society of Gynecologic Oncology (JSGO) recently revised its Ovarian Cancer Treatment Guidelines and the 4th edition will be released next year. This Guidelines state that lymphadenectomy is essential to allow accurate assessment of the clinical stage in early ovarian cancer, but there is no randomized controlled trial that shows any therapeutic efficacy of lymphadenectomy. In patients with advanced stage tumors, lymphadenectomy should be considered if optimal debulking has been performed. I fully agree with this recommendation of the JSGO and I would like to discuss the role of lymphadenectomy in the management of ovarian cancer.
doi:10.3802/jgo.2014.25.4.279
PMCID: PMC4195296  PMID: 25310033
Lymphadenectomy; Ovarian cancer
19.  Performance of a low cost magnifying device, magnivisualizer, versus colposcope for detection of pre-cancer and cancerous lesions of uterine cervix 
Journal of Gynecologic Oncology  2014;25(4):282-286.
Objective
To assess the performance of a low cost magnifying device (Magnivisualizer) compared to a standard optical colposcope for detection of precancerous and cancerous lesions of the uterine cervix.
Methods
A total of 659 consecutive symptomatic women attending a gynecologic outpatient clinic underwent unaided visual inspection followed by cytology, visual inspection of the cervix using 5% acetic acid (VIA), and VIA under magnification (VIAM) with the Magnivisualizer. All women, independently of test results, were referred for colposcopic examination. Colposcopic-directed biopsies were obtained from all positive lesions and compared to positive VIAM cases.
Results
The detection rate for VIA positive lesions was 12% (134/659), while it was 29% for VIAM positive lesions (191/659). The sensitivities of detection of cervical intraepithelial neoplasia (CIN) 2 and higher lesions were 61.7% for VIA, 88.3% for VIAM, and 86.7% for colposcopy, with a specificity of 58.5% for VIA, 55.8% for VIAM, and 90.4% for colposcopy. The performance of colposcopy and VIAM was moderate (κ, 0.48; 95% confidence interval [CI], 0.41 to 0.54) for detection of CIN 1 and higher lesions and excellent (κ, 0.87; 95% CI, 0.82 to 0.94) for detection of CIN 2 and higher lesions.
Conclusion
In low resource settings, where colposcopic facilities are not available at the community level, a simple low-cost, handheld Magnivisualizer can be considered a valid option for detection of cervical precancerous and cancerous lesions. However, it cannot replace traditional colposcopy because it has a low specificity that results in many unnecessary biopsies.
doi:10.3802/jgo.2014.25.4.282
PMCID: PMC4195297  PMID: 25142620
Ambulatory care facilities; Colposcopy; Sensitivity and Specificity; Uterine cervical dysplasia; Uterine cervical neoplasms
20.  The clinical performance of APTIMA human papillomavirus and Hybrid Capture 2 assays in the triage of lesser abnormal cervical cytologies 
Journal of Gynecologic Oncology  2014;25(4):287-292.
Objective
This study was performed to evaluate the clinical performance of APTIMA human papillomavirus (AHPV) assay and Hybrid Capture 2 (HC2) assay in screening for cervical disease, especially in women with atypical squamous cell of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL).
Methods
A total of 411 women diagnosed with ASC-US or LSIL were referred and further triaged by HC2 test. Prior to colposcopy, liquid-based cytology specimens were collected for the AHPV assay. Sensitivity and specificity were established based on the histological findings of cervical intraepithelial neoplasia (CIN).
Results
In all 411 subjects, the positive detection rate of AHPV assay was 70.8% (95% confidence interval [CI], 66.4 to 75.2), which was significantly lower than the positive detection rate of 94.9% obtained using HC2 test (95% CI, 92.3 to 96.8). Only one CIN 3-positive case was detected among the 120 AHPV-negative women, which was then confirmed by Pap smear test to be LSIL. The sensitivities of AHPV and HC2 for CIN 3 were similar (94.1% and 100%, respectively). However, AHPV showed a significantly higher specificity than HC2 test (30.2% and 5.3%, respectively; p<0.001).
Conclusion
AHPV assay is effective in identifying CIN 3-positive cases because of its high specificity and lower false-negative rate. The use of AHPV for the triage of ASC-US and LSIL might help to reduce the referral rate of colposcopy during cervical cancer screening.
doi:10.3802/jgo.2014.25.4.287
PMCID: PMC4195298  PMID: 25142625
Early detection of cancer; Human Papillomavirus; Triage; Uterine cervical dysplasia; Uterine cervical neoplasms
21.  Analysis of treatment modalities and prognosis on microinvasive cervical cancer: a 10-year cohort study in China 
Journal of Gynecologic Oncology  2014;25(4):293-300.
Objective
To explore appropriate treatment modality of microinvasive cervical cancer (MIC) and to analyze prognosis and risk factors of recurrence.
Methods
A cohort of 324 Chinese patients with MIC diagnosed and treated at Peking Union Medical College Hospital was retrospectively reviewed. Demographic features, treatment modalities, pathologic parameters, risk factors of residual disease, survival and risk factors of recurrence were analyzed.
Results
Of all patients, 280 cases were staged IA1 and 44 cases staged IA2 MIC. Twenty-five cases (7.7%) were found to have lympho-vascular space involvement (LVSI), but no parametrial involvement or ovarian metastasis was detected. Only one staged IA2 patient with LVSI was found to have lymph node metastasis. 32.4% patients (82/253) had residual diseases after conization. No significant difference of LVSI, lymph node metastasis and residual disease after coniztion was found between stage IA1 and IA2 MIC patients. Multivariate logistic analysis showed positive margin was the only independent risk factor of residual disease after conization (odds ratio [OR], 4.18; p<0.001). Recurrence occurred in five cases, but no mortality was found. Progression-free survival for stage IA1 patients treated by conization or hysterectomy was similar (92.3% and 98.8%, p=0.07). Cox regression analysis revealed LVSI as an independent risk factor for recurrence in stage IA1 patients (OR, 12.14; p=0.01).
Conclusion
For stage IA1 patients with negative resection margin and no LVSI, conization can be an ideal treatment modality. For stage IA2 patients, more conservative surgery such as simple hysterectomy may be considered. LVSI is an independent risk factor for recurrence in patients with stage IA1 cervical cancer.
doi:10.3802/jgo.2014.25.4.293
PMCID: PMC4195299  PMID: 25142622
Conization; Disease-free survival; Lymphatic metastasis; Prognosis; Uterine cervical neoplasms
22.  Lymphadenectomy can be omitted for low-risk endometrial cancer based on preoperative assessments 
Journal of Gynecologic Oncology  2014;25(4):301-305.
Objective
According to the International Federation of Gynecology and Obstetrics staging, some surgeons perform lymphadenectomy in all patients with early stage endometrial cancer to enable the accurate staging. However, there are some risks to lymphadenectomy such as lower limb lymphedema. The aim of this study was to investigate whether preoperative assessment is useful to select the patients in whom lymphadenectomy can be safely omitted.
Methods
We evaluated the risk of lymph node metastasis (LNM) using LNM score (histological grade, tumor volume measured in magnetic resonance imaging [MRI], and serum CA-125), myometrial invasion and extrautrerine spread assessed by MRI. Fifty-six patients of which LNM score was 0 and myometrial invasion was less than 50% were consecutively enrolled in the study in which a lymphadenectomy was initially intended not to perform. We analyzed several histological findings and investigated the recurrence rate and overall survival.
Results
Fifty-one patients underwent surgery without lymphadenectomy. Five (8.9%) who had obvious myometrial invasion intraoperatively underwent systematic lymphadenectomy. One (1.8%) with endometrial cancer which was considered to arise from adenomyosis had para-aortic LNM. Negative predictive value of deep myometrial invasion was 96.4% (54/56). During the mean follow-up period of 55 months, one patient with deep myometrial invasion who refused an adjuvant therapy had tumor recurrence. The overall survival rate was 100% during the study period.
Conclusion
This preoperative assessment is useful to select the early stage endometrial cancer patients without risk of LNM and to safely omit lymphadenectomy.
doi:10.3802/jgo.2014.25.4.301
PMCID: PMC4195300  PMID: 25142623
CA-125 Antigen; Endometrial neoplasms; Lymph node excision; Magnetic Resonance Imaging; Neoplasm Recurrence
23.  Metastatic pattern of uterine leiomyosarcoma: retrospective analysis of the predictors and outcome in 113 patients 
Journal of Gynecologic Oncology  2014;25(4):306-312.
Objective
To describe metastatic pattern of uterine leiomyosarcomas (ULMS) and correlate it with clinical and histopathologic parameters.
Methods
We included 113 women (mean age, 53 years; range, 29 to 72 years) with histopathology-confirmed ULMS from 2000 to 2012. Distribution of metastases was noted from imaging by two radiologists in consensus. Predictors of development of metastases were analyzed with univariate and multivariate analysis. Impact of various clinical and histopathologic parameters on survival was compared using Log-rank test and Cox proportional hazard regression model.
Results
Distant metastases were seen in 81.4% (92/113) of the patients after median interval of 7 months (interquartile range, 1 to 21). Lung was most common site of metastases (74%) followed by peritoneum (41%), bones (33%), and liver (27%). Local tumor recurrence was noted in 57 patients (50%), 51 of whom had distant metastases. Statistically significant correlation was noted between local recurrence and peritoneal metastases (p<0.001) and between lung and other common sites of hematogeneous metastases (p<0.05). Age, serosal involvement, local recurrence, and the International Federation of Gynecology and Obstetrics (FIGO) stage were predictive factors for metastases. At the time of reporting, 65% (74/113) of the patients have died; median survival was 45 months. Stage, local recurrence, and age were poor prognostic factors.
Conclusion
ULMS metastasizes most frequently to lung, peritoneum, bone, and liver. Local recurrence was associated with peritoneal spread and lung metastases with other sites of hematogeneous metastases. Age, FIGO stage and local recurrence predicted metastatic disease and advanced stage, older age and local recurrence predicted poor outcome.
doi:10.3802/jgo.2014.25.4.306
PMCID: PMC4195301  PMID: 25142630
Leiomyosarcoma; Neoplasm recurrence; Prognosis; Proportional Hazards Models
24.  The survival outcome and patterns of failure in node positive endometrial cancer patients treated with surgery and adjuvant radiotherapy with curative intent 
Journal of Gynecologic Oncology  2014;25(4):313-319.
Objective
The purpose of this study was to evaluate the patterns of failure, overall survival (OS), disease-free survival (DFS) and factors influencing outcome in endometrial cancer patients who presented with metastatic lymph nodes and were treated with curative intent.
Methods
One hundred and twenty-six patients treated between January 1996 to December 2008 with surgery and adjuvant radiotherapy were identified from our service's prospective database. Radiotherapy consisted of 45 Gy in 1.8 Gy fractions to the whole pelvis. The involved nodal sites were boosted to a total dose of 50.4 to 54 Gy.
Results
The 5-year OS rate was 61% and the 5-year DFS rate was 59%. Grade 3 endometrioid, serous, and clear cell histologies and involvement of upper para-aortic nodes had lower OS and DFS. The number of positive nodes did not influence survival. Among the histological groups, serous histology had the worst survival. Among the 54 patients relapsed, only three (6%) failed exclusively in the pelvis and the rest of the 94% failed in extrapelvic nodal or distant sites. Patients with grade 3 endometrioid, serous and clear cell histologies did not influence pelvic failure but had significant extrapelvic failures (p<0.001).
Conclusion
Majority of node positive endometrial cancer patients fail at extrapelvic sites. The most important factors influencing survival and extrapelvic failure are grade 3 endometrioid, clear cell and serous histologies and involvement of upper para-aortic nodes.
doi:10.3802/jgo.2014.25.4.313
PMCID: PMC4195302  PMID: 25142629
Endometrial neoplasms; Lymph nodes; Prospective studies; Radiotherapy; Survival rate
25.  Fertility sparing surgery in early stage epithelial ovarian cancer 
Journal of Gynecologic Oncology  2014;25(4):320-327.
Objective
Fertility sparing surgery (FSS) is a strategy often considered in young patients with early epithelial ovarian cancer. We investigated the role and the outcomes of FSS in eEOC patients who underwent comprehensive surgery.
Methods
From January 2003 to January 2011, 24 patients underwent fertility sparing surgery. Eighteen were one-to-one matched and balanced for stage, histologic type and grading with a group of patients who underwent radical comprehensive staging (n=18). Demographics, surgical procedures, morbidities, pathologic findings, recurrence-rate, pregnancy-rate and correlations with disease-free survival were assessed.
Results
A total of 36 patients had a complete surgical staging including lymphadenectomy and were therefore analyzed. Seven patients experienced a recurrence: four (22%) in the fertility sparing surgery group and three (16%) in the control group (p=not significant). Sites of recurrence were: residual ovary (two), abdominal wall and peritoneal carcinomatosis in the fertility sparing surgery group; pelvic (two) and abdominal wall in the control group. Recurrences in the fertility sparing surgery group appeared earlier (mean, 10.3 months) than in radical comprehensive staging group (mean, 53.3 months) p<0.001. Disease-free survival were comparable between the two groups (p=0.422). No deaths were reported. All the patients in fertility sparing surgery group recovered a regular period. Thirteen out of 18 (72.2%) attempted to have a pregnancy. Five (38%) achieved a spontaneous pregnancy with a full term delivery.
Conclusion
Fertility sparing surgery in early epithelial ovarian cancer submitted to a comprehensive surgical staging could be considered safe with oncological results comparable to radical surgery group.
doi:10.3802/jgo.2014.25.4.320
PMCID: PMC4195303  PMID: 25142621
Disease-free survival; Fertility; Lymph node excision; Neoplasm recurrence; Ovarian neoplasms; Pregnancy

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