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Arterial blood pressure (ABP) monitoring may permit the early diagnosis and management of cardiovascular disease (CVD); however, existing methods for measuring ABP outside the clinic use inconvenient cuff sphygmomanometry, or do not estimate continuous ABP waveforms. This study proposes a novel deep learning model DeepCNAP for estimating continuous BP waveform from a noninvasively measured photoplethysmography (PPG) signal in real-time. DeepCNAP was designed through the combination of deep convolutional networks and self-attention. The proposed method was constructed via 10-fold cross-validation based on the MIMIC database (the number of subjects = 942, recording time = 374.43 hours). The performance of DeepCNAP was evaluated from two perspectives: estimating ABP from PPG and classifying hemodynamically unstable events (i.e., hypertension, prehypertension, hypotension, and the normal state). The mean absolute errors of the BP estimates were 3.40 ± 4.36 mmHg for systolic BP, 1.75 ± 2.25 mmHg for diastolic BP, and 3.23 ± 2.21 mmHg for the BP waveform, indicating that DeepCNAP satisfies the standards of both the British Hypertension Society (BHS) and the Association for the Advancement of Medical Instrumentation (AAMI). From the estimated BP, hypertension, prehypertension, hypotension, and the normal state were classified with 99.44, 97.58, 92.23, and 94.64% accuracy, respectively. DeepCNAP enables feasible real-time estimation of invasively measured ABP from noninvasive PPG. With its noninvasive nature, high accuracy, and clinical relevance, the proposed model could be valuable in general wards at hospitals and for wearable devices in daily life.

PURPOSE Here, we compared the operative and perioperative outcomes between robot-assisted laparoscopic myomectomy (RALM) and abdominal myomectomy (AM) in patients with large (>10 cm) or heavy myomas (>250 g). MATERIALS AND METHODS We included 278 patients who underwent multi-port RALM (n=126) or AM (n=151) for large or heavy myomas in a tertiary care hospital between April 2019 and June 2020. The t-test, chi-square, Bonferroni's test, and multiple linear regression were used. RESULTS No differences were observed in age, body mass index, parity, or history of pelvic surgery between the two groups. Myoma diameters were not different (10.8±2.52 cm vs. 11.2±3.0 cm, p=0.233), but myomas were lighter in the RALM group than in the AM group (444.6±283.14 g vs. 604.68±368.35 g, respectively, p=0.001). The RALM group had a higher proportion of subserosal myomas, fewer myomas, fewer large myomas over >3 cm, lighter myomas, and longer total operating time. However, the RALM group also had shorter hospital stay and fewer short-term complications. Estimated blood loss (EBL) was not different between the two groups. The number of removed myomas was the most significant factor (coefficient=10.89, p

Study Objective To investigate the prognostic factors and impact of minimally invasive surgery (MIS) in surgically treated early-stage high-grade (HG) neuroendocrine cervical carcinoma (NECC). Design Retrospective cohort study. Setting Asan Medical Center, Seoul, Korea. Patients Patients with International Federation of Obstetrics and Gynecology (2009) stages IB1 to IIA HG NECC. Interventions All patients underwent radical hysterectomy (RH) with a laparotomy or an MIS approach. Measurements and Main Results Between 1993 and 2017, 47 patients with International Federation of Obstetrics and Gynecology stages IB1 to IIA1 HG NECC were initially treated with RH. Clinicopathologic variables of patients were retrospectively reviewed from electronic medical records. The median follow-up period was 28.2 months (interquartile range, 17.1–42). Stage IB1 disease was the most common (70.2%). Twenty-nine patients (61.7%) underwent RH by MIS. The overall survival (OS) and disease-free survival (DFS) rates were 63.8% and 38.3%, respectively. Lymph node metastasis and resection margin involvement were significant risk factors for DFS (hazard ratio [HR], 2.227; 95% confidence interval [CI], 1.018–4.871; p =.045 and HR, 6.494; 95% CI, 1.415–29.809; p =.016, respectively) and OS (HR, 3.236; 95% CI, 1.188–8.815; p =.022 and HR, 12.710; 95% CI, 1.128–143.152; p =.040, respectively). The Kaplan-Meier survival curves revealed no significant differences in OS and DFS between the laparotomy and MIS groups (50% vs 72.4% log-rank p =.196, 38.9% vs 37.9% p =.975). Conclusion Lymph node metastasis and resection margin involvement were poor prognostic factors of survival outcomes in initially surgically treated early-stage HG NECC. No difference was observed in the survival outcomes between the MIS and laparotomy approaches.

ObjectivesStaging procedure in borderline ovarian tumors is a topic of controversy. Upstaging in non-serous borderline ovarian tumors that are confined to the ovary is rare. The aim of this study was to assess the impact of surgical staging on clinical outcomes in mucinous borderline ovarian tumors.MethodsThis was a retrospective study conducted at the Asan Medical Center, Seoul, Korea between January 1990 and December 2015, that included 432 patients with mucinous borderline ovarian tumors and at least 6 months follow-up. These patients were divided into a ‘staging group’ and ‘unstaged group’. The staging group referred to patients who, in addition to hysterectomy and/or adnexal surgery, underwent at least one of the following: cytology, omental biopsy/omentectomy, peritoneal biopsy, lymph node biopsy/lymphadenectomy, or appendectomy. The unstaged group referred to patients who did not undergo any staging procedure but underwent adnexal surgery (cystectomy or oophorectomy).ResultsMedian patient age was 40 (range 9–87) years. A total of 367 patients (85%) underwent a staging procedure (staging group) and 65 (15.0%) patients did not (unstaged group). Among the staging group, 258, 4, 100, and 5 patients were FIGO stage IA, IB, IC, or II-III, respectively. Overall recurrence was confirmed in 15 patients and median time to recurrence was 13.4 (range 0.4–127.3) months. One patient was in the unstaged group and had borderline recurrence. Fourteen were in the staging group, and 11 of them had borderline and three had invasive recurrence. Extraovarian disease was found at recurrence only in two patients. There was no significant difference in recurrence-free survival (p=0.39) and in overall survival between the staging group and the unstaged group (p=0.40). In total, 16 (4.4%) of 367 patients who underwent a staging procedure were upstaged.ConclusionStaging in mucinous borderline ovarian tumors may be omitted if there is no obvious evidence of gross extraovarian disease.

The aim of this study is to analyze the correlation between clinically significant histologic results and HPV in women with AGC in pap test. Of the 311 women confirmed as AGC, 111 women (35.7%) was identified as positive for HPV. In the AGC analysis, cervical lesions were significantly more common in HPV positive group compared to HPV negative group (61.2% vs. 10.5%, p < 0.001). In contrast, endometrial lesions were not associated with HPV infection (8.1% vs. 4.5%, p = 0.12). The HPV-DNA testing in women with AGC may be a useful tool for predicting clinically significant cervical lesions.

Intracranial hypertension (IH) following acute phase traumatic brain injury (TBI) is associated with high mortality. Objective: This study proposes a novel parameter that may identify a potentially life-threatening IH (LTH) event and designs a machine learning model to predict LTH. Continuous recordings of intracranial pressure (ICP) and arterial blood pressure (ABP) from 273 TBI patients were used as the development dataset. The pressure-time dose (PTD) and pressure reactivity index (PRx) were calculated for each IH event, and an IH event with PRx > 0 and PTD > 5 was considered an LTH event. The association between the LTH parameters accumulated over five days and mortality was analyzed. A categorical boosting (CatBoost) model was employed to predict the occurrence of a future LTH event from the onset of IH using the ABP- and ICP-related parameters. Training and validation were performed on a total of 5,938 IH events. External performance evaluation was performed in 307 IH events included in the Cerebral Haemodynamic Autoregulatory Information System (CHARIS) database. The performance of the proposed model was evaluated through the area under the receiver operating characteristic curve (AUROC). The LTH parameters were able to distinguish between the deceased and surviving patients (AUROC > 0.7, p < 0.001). The CatBoost model predicted LTH with an AUROC = 0.7 on the external test dataset. This study demonstrated that the proposed LTH prediction model has a reasonable predictive capacity for mortality. The CatBoost model anticipates whether an IH event will develop into an LTH event. The findings of this study support the usefulness of ICP monitoring.

Background We aimed to review the burden and the potential impact of human papillomavirus (HPV) vaccines on HPV-related diseases in the Republic of Korea and to discuss cervical cancer prevention practices in this country. Methods Cancer burden statistics were retrieved from GLOBOCAN-2018 and Statistics Korea. HPV disease burden was assessed via systematic review. Vaccine types relative contribution (RC) was estimated using data from an international project using formalin-fixed paraffin-embedded specimens. Results Despite a downtrend in cervical cancer in recent years, Korean rates remain high. In contrast, oropharyngeal cancer incidence has gradually increased and other anogenital cancers remain rare. In Korea, HPV prevalence in general population is around 20%. In cervical cancer, RC of HPVs 16/18 (74.0%) increased to 92.0% when including HPVs 31/33/45/52/58. Limited information was available for other HPV-related cancer sites. Regarding prevention, since the inclusion of the HPV vaccine into the National Immunization Program, almost half (49%) of the target cohort in 2016 had received the first dose of vaccine. Further, percentage of women screened with pap has increased from 41.1%-2009 to 53.0%-2016. Conclusions HPV-related disease burden in Korea is significant. Results suggest that the combination of effective and high coverage HPV vaccination and screening programmes could substantially impact on HPV-related disease in Korea., Highlights • HPV-related disease burden (cancer and genital warts) in Korea is significant. • HPV16 is the most frequent genotype, causing itself more than 60% of HPV-related cancers. • HPV vaccine types 16/18/31/33/45/52/58/6/11 cause 92.0% of cervical cancers. • HPV vaccines could significantly impact on the HPV-related disease burden.

Objective To investigate the expression of different histone deacetylases and their association with disease characteristics and survival outcomes in uterine leiomyosarcoma patients. Methods The immunohistochemical expression of different histone deacetylases and p53 by tissue microarray and histological subtypes were assessed in tumor tissue samples of 42 eligible patients. Results Histone deacetylases 1–4, 6 and 8 showed prevalent and strong (3+) expression (88.1, 90.5, 95.2, 92.9, 83.3 and 100%, respectively). Histone deacetylases 5, 7 and 9 showed infrequent strong expression (33.3, 50 and 38.1%, respectively). There were trends of higher disease-free survival rates according to the combination of weaker expression of histone deacetylase 5, 7 or 9 with positive p53 expression or with non-epithelial subtype. The patients with triple-positive favorable prognostic factors (any of weaker histone deacetylase 5, 7 and 9 expression, p53 positive, and non-epithelioid subtype) had the better survival outcomes while the patients with other combinations had the worse survival outcomes. In multivariate analysis, histone deacetylase 5 in combination with epithelioid subtype was an independent predictor for disease-free survival. Conclusions Expression of histone deacetylase 5, 7 and 9 is a potential prognostic marker in uterine leiomyosarcoma when combined with pathologically relevant prognostic factors (p53 and histological subtype). This prevalent and strong histone deacetylase expression warrants further study in well-designed investigations of histone deacetylases as therapeutic targets in uterine leiomyosarcoma.

The aim of this study is to determine the rate of clinically significant histopathologic lesions in women identified with atypical glandular cells (AGC). Five-hundered and forty patients with AGC, from a cohort of 1013 with AGC, met inclusion criteria for this study by having a proper histologic evaluation. Clinically significant histologic results were obtained in 170 cases with AGC (31.5%). Of the 170 clinically significant cases, 86 of 540 (15.9%) were diagnosed with malignant lesions. The findings of clinically significant lesions in more than 30% of patients support the recommendation that women identified with AGC require extensive histologic examination.

Neurogenic claudication is a typical manifestation of lumbar spinal stenosis (LSS). However, its pathophysiology is still unclear. The severity of clinical symptoms has been shown not to correlate with the degree of structural stenosis. Altered cerebrospinal fluid (CSF) flow has been suggested as one of the causative factors of LSS. The objectives of this study were to compare CSF dynamics at the lumbosacral level between patients with LSS and healthy controls and to investigate whether CSF dynamics parameters explain symptom severity in LSS. Phase-contrast magnetic resonance imaging (PC-MRI) was conducted to measure CSF dynamics in 18 healthy controls and 9 patients with LSS. Cephalic peak, caudal peak, and peak-to-peak CSF velocities were evaluated at the lumbosacral level in the patients and controls. The power of CSF dynamics parameters to predict symptom severity was determined using a linear regression analysis adjusted for demographic and structural variables. Significantly attenuated CSF flow velocity was observed in the patients compared with the controls. The cephalic peak, caudal peak, and peak-to-peak velocities at the lumbar level were greater in the controls than in the patients (p2 = 0.410) to the model with age, body mass index, and the minimum anterior-posterior diameter (adjusted R2 = 0.306), and the peak-to-peak velocity was the only statistically significant variable. CSF dynamics variables showed an association with the severity of LSS symptoms, independent of structural stenosis. PC-MRI can help to further our understanding of the pathophysiology of neurogenic claudication and support the diagnosis of LSS.

The lymph node status is the most important prognostic factor for endometrial cancer. This study aimed to assess whether sentinel lymph node mapping (SLNM) is applicable in endometrial cancer. A retrospective review of patients with endometrial cancer who were diagnosed and treated in Asan Medical Centre from September 2015 to December 2017 was conducted. One hundred patients underwent robotic (da Vinci®) or laparoscopic surgical treatment, including SLNM with indocyanine green (ICG) fluorescence detection using the Firefly® and NIR/ICG systems. At least one lymph node area was observed in 100% of SLNM cases. Sentinel node detection and frozen biopsy were performed in all cases, and all patients with metastasis were found on SLNM. The sensitivity and negative predictive value were both 100% in the patient-by-patient and station-by-station analyses. SLNM appears to be a feasible method to reduce the morbidity and increase the detection rate in early-stage endometrial carcinoma.What is already known on this subject? There are studies that it is safe to diagnose the possibility of lymph node metastasis through sentinel lymph node mapping in endometrial cancer.What do the results of this study add? In this study, it is shown that the accuracy of sentinel lymph node mapping is 100% accurate.What are the implications of these findings for clinical practise and/or further research? Therefore, total lymphadenectomy will not be necessary for the future.

We aimed to investigate the effectiveness of continuing medical therapy in patients who did not achieve complete response (CR) despite 9 months of progestin treatment. We also sought to determine the prognostic factors associated with achieving CR among these patients.We retrospectively analyzed 51 patients with presumed stage IA, grade 1 or 2 endometrioid adenocarcinoma who had persistent disease on biopsy performed at 9-12 months after at least 9 months of progestin-based therapy. Data on clinicopathological factors and oncological and obstetrical outcomes following continuous hormonal treatment were extracted from the patients' medical records and analyzed. Univariate and multivariate analyses for predicting CR were performed.Thirty-seven (72.5%) of 51 patients achieved CR after prolonged fertility-sparing treatment. Median time to CR from starting initial progestin was 17.3 months (range, 12.1-91.7 months). On univariate analysis, history of polycystic ovarian syndrome, histologic grade 2, and not achieving partial response (PR) until 12 months were significantly associated with failure to CR (odds ratio [OR], 6.188, 95% confidence interval [CI], 1.405-27.244, p = 0.018; OR, 9.722, 95% CI, 1.614-58.581, p = 0.013; and OR, 21.750, 95% CI, 4.016-117.783, p 0.001, respectively). Multivariate analysis revealed that not achieving PR until 12 months was an independent prognostic factor predicting failure to CR after prolonged progestin therapy (OR, 21.803, 95% CI, 3.601-132.025, p = 0.001).Continued medical treatment is effective for persistent early endometrial carcinoma after at least 9 months of progestin therapy in young women who want to preserve their fertility.

OBJECTIVE We investigated the feasibility and safety of fertility-sparing surgery (FSS) in patients with epithelial ovarian cancer (EOC) with dense adhesions. METHODS Patients were divided into cases with and without dense adhesions in this retrospective study. RESULTS Of the 95 eligible patients, 29 patients had dense adhesions. Mean age, proportion of staging procedure, distribution of histologic type, and co-presence of endometriosis were different (p=0.003, 0.033, 0.011, and 0.011, respectively). The median follow-up period was 57.8 (0.4-230.0) months. There were no differences in the rates of recurrence (21.2% vs. 20.7%, p=1.000) or death (16.7% vs. 6.9%, p=0.332) between the 2 groups. There was no difference in the pattern of recurrence or in disease-free survival (DFS) and overall survival (OS) between the 2 groups. In multivariate analysis, pretreatment cancer antigen-125 >35 U/mL and International Federation of Gynecology and Obstetrics stage IC were significant factors of worse DFS and OS, while dense adhesion was not a prognostic factor for both DFS (hazard ratio [HR]=0.9; 95% confidence interval [CI]=0.3-2.7; p=0.792) and OS (HR=0.2; 95% CI=0.1-1.8; p=0.142), nor were age, proportion of staging procedure, histologic type, and co-presence of endometriosis. Moreover, the distribution of those 2 significant prognostic factors was not different between the 2 groups. Dense adhesions were subgrouped into non-tumor and tumor associated dense adhesions for further analysis and the results were same. CONCLUSION FSS is feasible and safe in EOC, regardless of the presence of dense adhesions.

ObjectivesThe aim of this study was to compare surgical and oncologic outcomes of open and laparoscopic surgery in patients with borderline ovarian tumors (BOTs).Materials and MethodsThis study included patients with BOTs who underwent open (n = 433) or laparoscopic (n = 210) surgery between 1990 and 2015. Surgical outcomes, perioperative morbidity, and disease-free survival and overall survival were compared.ResultsThere was no significant difference in age, histologic type of tumor, and laterality of tumor. However, body mass index was slightly higher for the open surgery group (P = 0.046). The open surgery group had a higher serum cancer antigen 125 level (P < 0.001), larger tumor size (P < 0.001), more frequent radical surgery (P = 0.001), higher stage (P = 0.034), and higher incidence of invasive implants (P = 0.035). The operative time (P < 0.001), time interval to return of bowel movement (P < 0.001), and length of postoperative hospital stay (P < 0.001) were significantly shorter and estimated blood loss was significantly less (P < 0.001) in the laparoscopic group. Perioperative complications were documented in 5 (2.4%) patients in the laparoscopic surgery group and 17 (3.9%) in the open surgery group (P = 0.064). Twenty-three (5.3%) patients in the open surgery group and 9 (4.3%) in the laparoscopic surgery group had recurrence (P = 0.902) at a median follow-up of 57 months. The 10-year disease-free survival was 96% and 97% for the open and laparoscopic groups, respectively (P = 0.851), with no significant difference between the groups after adjusting for independent factors (odds ratio, 1.0; 95% confidence interval, 0.4–2.4; P = 0.999). The 10-year overall survival was 99% for both groups, respectively (P = 0.441).ConclusionsLaparoscopic surgery and open surgery showed similar survival outcomes in BOTs. The surgical outcomes of laparoscopic surgery were more favorable.

To evaluate the immunohistochemical (IHC) expression of hormone receptors and analyze the prognostic implication of these receptors in patients with endometrial stromal sarcoma (ESS). Fifty-one patients with ESS whose paraffin blocks and pathologic slides, which were obtained after hysterectomy, were available and included in this study. Clinicopathologic data were gathered from patients' medical records, and IHC staining of hormone receptors was performed using tissue microarrays. Estrogen receptor (ER)-alpha was expressed in 37 patients (72.5%), and strong immunoreactivity was observed in 27 patients (52.9%). However, ER-beta expression was observed in only two patients (3.9%). Progesterone receptor (PR) expression was identified in 36 patients (70.6%), and strong immunoreactivity was found in 26 patients (51%). Androgen receptor (AR) expression was observed in 30 patients (58.8%), and strong immunoreactivity was noted in 14 patients (27.5%). Gonadotropin-releasing hormone receptor (GnRH-R) expression was observed in 49 patients (96.1%), but no patient exhibited strong immunoreactivity. All patients expressed CYP19A1, and 43 patients (84.3%) had strong immunoreactivity. ER-alpha, PR, and AR positivity was associated with significantly better overall survival (OS). No patient with AR positivity died of ESS. When the patients were categorized according to ER-alpha, PR, and AR immunoreactivity, triple-positive ESS had the best OS, and triple-negative ESS was linked to the worst OS. Expression of hormone receptors was associated with favorable survival outcome in ESS. Hormone receptors that showed strong expression deserve further evaluation to clarify their importance as a therapeutic target and predictor of treatment response.

Objective The study aims to identify preoperative predictors of complete cytoreduction and early recurrence and death in epithelial ovarian, tubal, and peritoneal cancer after neoadjuvant chemotherapy (NACT). Methods We performed a retrospective analysis of 85 patients who underwent 3 cycles of NACT. Patients were divided into 2 groups according to residual tumor at interval debulking surgery (IDS), and clinicopathologic, surgical, and follow-up data were compared. Results Cancer antigen 125 (CA-125) levels before the IDS after completion of NACT were higher in the residual tumor group (42.0 vs 116.6 U/mL, P = 0.006). The drop rate of CA-125 after NACT was higher in the no residual tumor group (96.8% vs 89.9%, P = 0.001). Patients with residual tumor showed lower disease-free and overall survival outcomes than patients with no residual tumor. In univariate analysis, CA-125 of 100 U/mL or less before IDS and a drop rate after NACT greater than 80% were preoperative predictive factors for complete cytoreduction. In multivariate analysis, a drop rate of CA-125 after NACT greater than 80% was an independent preoperative predictive factor for complete cytoreduction (P = 0.002). Progressive disease on follow-up image during NACT was an independent preoperative predictive factor for early recurrence and death (P Conclusions A significant drop of CA-125 after NACT and progressive disease on follow-up image are independent preoperative predictors for complete cytoreduction and early recurrence and death.

Objective To identify risk factors for distant recurrence in node-positive cervical cancer patients who underwent radical hysterectomy and pelvic lymph node dissection (PLND) with para-aortic lymph node sampling (PALNS) or para-aortic lymph node dissection (PALND). Methods A total of 299 patients in whom lymph node metastasis was confirmed after radical surgery at Asan Medical Center for stage IA2 to IIB cervical cancer from February 2001 to December 2012 were identified. In all, 72 (24.1%) patients underwent PLND only and 227 (75.9%) underwent PLND with PALNS or PALND. Four patients were excluded due to diagnosed with small cell carcinoma. The clinicopathologic data of 223 patients were retrospectively analyzed. Distant recurrence was defined as recurrence at a site over the pelvic radiation field. Results Among all 223 study patients, the mean number of positive lymph nodes was 4.46. There were 54 (24.2%) patients with distant metastasis. Multivariate analyses using the Cox proportional hazards model showed that histologic types (HR=3.031, P ≤0.001 for adenocarcinoma, HR=2.302, P =0.066 for adenosquamous carcinoma), number of positive lymph nodes (HR=1.077, P ≤0.001), and surgical stage (HR=1.264, P =0.022) were independent risk factors for distant recurrence of cervical cancer. A scoring system for the prediction of distant recurrence was generated by incorporating these factors and showed good discrimination and calibration (concordance index of 0.753). In an internal validation set, this scoring system showed good discrimination with a C-statistics of 0.777. According to the Hosmer-Lemeshow test, the chi-square was 0.650 and the P -value was 0.723. Conclusions We have developed a robust scoring system that can predict the risk of distant recurrence in node-positive cervical cancer patients after radical operation. This scoring system was used to identify a group of patients who required systemic control of distant micrometastasis. This group of patients is an appropriate target for consolidation chemotherapy after concurrent chemoradiation therapy.

Objective To determine the accuracy of frozen section diagnosis and factors associated with final pathological diagnosis upgrade in patients with mucinous ovarian tumors. Methods This study included 1,032 patients with mucinous ovarian tumors who underwent frozen section diagnosis during surgery. Sensitivity, specificity, and diagnostic accuracy of frozen section diagnosis was calculated. Univariate and multivariate regression analyses were performed to determine factors associated with diagnosis upgrade in the final pathology report. Results The sensitivity and specificity of frozen section diagnosis were 99.1% (95% confidence interval [CI]=98%–99.6%) and 82.2% (95% CI=77.9%–85.7%), respectively, for benign mucinous tumors; 74.6% (95% CI=69.1%–79.4%) and 96.7% (95% CI=95.2%–97.8%), respectively, for mucinous borderline ovarian tumors; and 72.5% (95% CI=62.9%–80.3%) and 98.8% (95% CI=97.9%–99.3%), respectively, for invasive mucinous carcinomas. The multivariate analysis revealed that mixed tumor histology (odds ratio [OR]=2.8; 95% CI=1.3–6.3; p=0.012), tumor size >12 cm (OR=2.5; 95% CI=1.5–4.3; p=0.001), multilocular tumor (OR=2.9; 95% CI=1.4–6.0; p=0.006), and presence of a solid component in the tumor (OR=3.1; 95% CI=1.8–5.1; p12 cm, multilocular tumor, and presence of a solid component in the tumor were independent risk factors for final pathological diagnosis upgrade based on frozen section diagnosis.

In 2016, 9-valent human papillomavirus (HPV) vaccine has been newly introduced in Korea, thus the need to develop recommendations for the vaccine has raised. Until we decide to develop a guideline, no further studies on the bi-valent or quadri-valent HPV vaccine have been announced. We searched and reviewed the literatures focused on the efficacy of 9-valent HPV vaccine, the ideal age of 3-dose schedule vaccination, the efficacy of 9-valent HPV vaccine in middle-aged women, the efficacy of the 2-dose schedule vaccination, the safety of 9-valent HPV vaccine, the possibility of additional 9-valent HPV vaccination, and cross-vaccination of 9-valent HPV vaccine. So, Korean Society of Gynecologic Oncology (KSGO) developed a guideline only for 9-valent HPV vaccine.

Objectives To evaluate the outcome of fertility-sparing surgery among young women with early-stage clear cell carcinoma of the ovary. Methods In a retrospective study, data were reviewed for patients aged 45 years or younger who had FIGO stage I clear cell carcinoma of the ovary and had attended one institution in South Korea between December 1999 and December 2009. Outcomes were compared between women undergoing fertility-sparing surgery, defined as preservation of the uterus and at least one adnexa, and those undergoing radical surgery. Results Overall, 47 patients were included (22 underwent fertility-sparing surgery, 25 radical surgery). After a median follow-up of 72 months (range 8–175), 5 (23%) patients who underwent fertility-sparing surgery and 5 (20%) in the radical surgery group had recurrent disease ( P = 0.820). The mean time to recurrence was 19 months after fertility-sparing surgery versus 20 months after radical surgery ( P = 0.935). The anatomical location of recurrence did not differ. There was no difference in 5-year disease-free survival (77% vs 84%; P = 0.849) or 5-year overall survival (91% vs 88%; P = 0.480). Conclusion Fertility-sparing surgery was found to be a safe alternative for young women with FIGO stage I clear cell carcinoma of the ovary who wish to preserve fertility.

Background Palliative chemotherapy should be used with caution when attempting to alleviate symptoms in patients with end-stage cancer. However, palliative chemotherapy continues to be utilized in cancer patients during their last stages of life. In this study, we analyzed the pattern of chemotherapy administered during the last 6 months of life in patients with end-stage gynecologic cancer who were treated with active palliative chemotherapy for the past 10 years. Method We retrospectively analyzed the data for patients with gynecologic cancer who died after undergoing active palliative chemotherapy without receiving hospice management at Asan Medical Center from 2006 to 2015. Patients were divided into two groups: those who died between 2006 and 2010, and those who died between 2011 and 2015. Based on the electronic medical records, the demographic and baseline characteristics of the patients, hospital admission during the last 6 months, invasive procedures, palliative chemotherapy patterns, and the time of the last chemotherapy session were confirmed. Results A total of 193 patients with gynecologic cancer were eligible for this study. 92 patients died during 2006 to 2010, and 101 patients died during 2011 to 2015. The mean frequency of admission during the last 6 months was 5.12 for those who died in 2006–2010 and 6.06 for those who died during 2011–2015 (p = 0.003); similarly, the mean frequency of palliative chemotherapy during the last 6 months was 3.84 (2006–2010) vs. 4.93 times (2011–2015; p

OBJECTIVEFailure of cerebral autoregulation and subsequent hypoperfusion is common during the acute phase of traumatic brain injury (TBI). The cerebrovascular pressure-reactivity index (PRx) indirectly reflects cerebral autoregulation and has been used to derive optimal cerebral perfusion pressure (CPP). This study provides a method for the use of a combination of PRx, CPP, and intracranial pressure (ICP) to better evaluate the extent of cerebral hypoperfusion during the first 24 hours after TBI, allowing for a more accurate prediction of mortality risk.METHODSContinuous ICP and arterial blood pressure (ABP) signals acquired from 295 TBI patients during the first 24 hours after admission were retrospectively analyzed. The CPP at the lowest PRx was determined as the optimal CPP (CPPopt). The duration of a severe hypoperfusion event (dHP) was defined as the cumulative time that the PRx was > 0.2 and the CPP was < 70 mm Hg with the addition of intracranial hypertension (ICP > 20 or > 22 mm Hg). The outcome was determined as 6-month mortality.RESULTSThe cumulative duration of PRx > 0.2 and CPP < 70 mm Hg exhibited a significant association with mortality (p < 0.001). When utilized with basic clinical information available during the first 24 hours after admission (i.e., Glasgow Coma Scale score, age, and mean ICP), a dHP > 25 minutes yielded a significant predictive capacity for mortality (p < 0.05, area under the curve [AUC] = 0.75). The parameter was particularly predictive of mortality for patients with a mean ICP > 20 or > 22 mm Hg (AUC = 0.81 and 0.87, respectively).CONCLUSIONSA short duration (25 minutes) of severe hypoperfusion, evaluated as lowered CPP during worsened cerebrovascular reactivity during the 1st day after TBI, is highly indicative of mortality.

Background Lymph node metastasis is a significant predictive factor for disease recurrence and survival in cervical cancer patients. Given the importance of lymph node metastasis, it is imperative that patients harboring metastasis are identified and can undergo appropriate treatment. Sentinel lymph node (SLN) mapping has drawn attention as a lymph node mapping technique. We evaluated the feasibility and efficacy of (SLN) mapping using indocyanine green (ICG) in cervical cancer. Methods We performed a single-center, retrospective study of 103 surgically treated cervical cancer patients who underwent SLN mapping. After using ICG to detect SLN during surgery, we removed the SLNs followed by laparoscopic or robotic-assisted radical surgery and bilateral pelvic lymphadenectomy. Results Stage IB1 was the most common (61.17%). At least one SLN was detected in all cases. Eighty-eight patients (85.44%) had bilateral pelvic SLNs. The mean number of SLN per patient was 2.34. The side-specific sensitivity was 71.43%, the specificity was 100%, the negative predictive value (NPV) was 93.98%, and the false negative rate (FNR) was 28.57%. In cases of tumors smaller than 2 cm with negative lymph node metastasis on imaging, the study revealed a side-specific sensitivity of 100%, a specificity of 100%, a NPV of 100%, and a FNR of 0%. Large tumor size (≥ 4 cm), a previous history of a loop electrosurgical excision procedure (LEEP), depth of invasion (≥ 50%), the microscopic parametrial (PM) invasion, and vaginal extension were significantly associated with the false-negative detection of SLN. Moreover, the microscopic PM invasion was the only risk factor of the false-negative detection of SLN in multivariate analysis. Conclusion SLN mapping with ICG in cervical cancer is feasible and has high detection rate. The sensitivity of 100% was high enough to perform SLN biopsy alone in an early stage in which the tumor is less than 2 cm, with no lymphadenopathy on image examination. However, for large or invasive tumors, we would have to be cautious about performing SLN biopsy alone. Trial registration Retrospectively registered 2017-0600.

Objective To investigate the expression of androgen receptor (AR) and its correlation with disease status and survival outcome in uterine leiomyosarcoma with other hormone receptors. Methods The medical records and paraffin blocks of 42 patients were reviewed. The immunohistochemical expression of AR, estrogen receptor (ER), progesterone receptor (PR), gonadotropin releasing hormone (GnRH), and cytochrome P450, family 19, subfamily A, polypeptide 1 (CYP19A1) were assessed using tissue microarray. Results In total, AR expression was observed in 11 patients (26.2%). International Federation of Gynecology and Obstetrics (FIGO) stage and AR were independent factors for disease-free survival (DFS) in multivariate regression analysis (odds ratio [OR]=5.8; 95% confidence interval [CI]=1.2-28.4 and OR=0.2; 95% CI=0.05-0.90; p=0.029 and 0.032, respectively). There were no deaths in the AR expression group, whereas the 5-year overall survival (OS) was 54.8% in the no expression group (p=0.014). Co-expression of ER and/or PR with AR was associated with significantly better 5-year DFS and OS than those with negative AR (72.7% vs. 28.6% and 100% vs. 64.3%; p=0.020 and 0.036, respectively). AR may be an independent prognostic marker regardless of ER/PR. Conclusion AR can be a potential prognostic biomarker in uterine leiomyosarcoma.

Background This open-label phase III trial evaluated efficacy and safety of S-1 plus cisplatin vs. cisplatin alone as first-line chemotherapy in patients with stage IVB, recurrent, or persistent cervical cancer. Methods Patients were randomised (1:1) to S-1 plus cisplatin (study group) or cisplatin alone (control group). In each cycle, cisplatin 50 mg/m2 was administered on Day 1 in both groups. S-1 was administered orally at 80–120 mg daily on Days 1–14 of a 21-day cycle in the study group. The primary endpoint was overall survival (OS). Results A total of 375 patients were enrolled, of whom 364 (188, study group; 176, control group) received treatment. Median OS was 21.9 and 19.5 months in the study and control groups, respectively (log-rank P = 0.125; hazard ratio [HR] 0.84, 95% confidence interval [CI] 0.67–1.05). Median progression-free survival (PFS) was 7.3 and 4.9 months in the study and control groups, respectively (HR 0.62, 95% CI 0.48–0.80, P

Objective To analyze the oncologic and reproductive outcomes of pediatric and young adolescents with malignant ovarian germ cell tumors (MOGCTs). Methods Pediatric or young adolescent girls aged 16years or under with MOGCT were eligible for this study. Results Forty-two pediatric or adolescent girls with MOGCT met the inclusion criteria. The median age was 12years (range, 6–16years) and 29 patients were premenarchal. The most common histologic type was immature teratoma, and 30 patients (54.3%) had stage I MOGCT. All patients underwent fertility-sparing surgery, which was defined as the preservation of at least one adnexa and the uterus. No patient had residual disease after surgery. Thirteen patients had tumor spillage, two patients had a positive peritoneal cytology, and two patients had lymph node metastasis. After surgery, 31 patients received adjuvant chemotherapy with bleomyocin, etoposide, and cisplatin (BEP) (median, 4cycles; range, 1–6 cycles). After a median follow-up time of 93months (range, 22–217 months), six patients had a recurrence of the disease, and one patient died. The 5-year disease-free and overall survival rates were 85% and 97%, respectively. Among the surviving 41 patients, seven were premenarchal, 30 had regular menstruation, and three had irregular menstruation. No patient had premature ovarian failure. Conclusion All patients received uniform treatment consisting of fertility-sparing complete cytoreductive surgery followed by BEP chemotherapy. Regardless of histologic type and FIGO stage, the oncologic outcomes were excellent and the reproductive outcomes were favorable.

Objective Malignant Brenner tumors (MBTs) of the ovary are very rare, and their definition, biology, and treatment modality have not been established. This study investigated the clinical characteristics of MBTs and the importance of chemotherapy for recurrent disease. Materials and methods We conducted a retrospective analysis of 10 patients with MBT of the ovary treated at a single tertiary center from 1991 to 2013. Results The median age was 55.5 years (range, 37–68 years). Nine of the 10 patients were symptomatic. The median size of the ovarian tumors was 10.5 cm (range, 2.5–25.0 cm). The cancer antigen-125 level was elevated in three patients. Six patients had a stage I tumor, one had a stage II tumor, two had a stage III tumor, and one had a stage IV tumor. Six patients received systemic adjuvant chemotherapy after surgery. The mean follow-up duration was 54.5 months (range, 8–173 months). Disease recurrence occurred in four of the 10 patients. The median time to recurrence was 11 months (range, 9–18 months). Two patients with locoregional recurrence showed favorable results after chemotherapy, regardless of the initial stage of the tumor. The patient with the stage IIIC tumor is alive at 13 months after recurrence on current chemotherapy. The patient with the stage IV tumor showed no evidence of the disease > 12 years after the last chemotherapy. Lastly, two patients with distant recurrence died after showing a long-term survival of 49 months and 88 months, respectively, after recurrence and intensive chemotherapy. Conclusion Our results showed that systemic chemotherapy is beneficial in patients with recurrence of a primary MBT of the ovary, especially in the locoregional recurrence.

ObjectiveThe purpose of this study was to identify preoperative clinicopathological predictive factors for lymph node (LN) metastasis in women diagnosed with uterine papillary serous carcinoma (UPSC).MethodsWomen diagnosed with UPSC in our institution from 1997 to 2012 were identified. All patients underwent hysterectomy and bilateral salpingo-oophorectomy plus pelvic and/or para-aortic lymphadenectomy. The predictive values of the risk factors for LN metastasis were analyzed using χ2 and multivariate logistic regression analyses.ResultsA total of 94 patients met our study criteria. A CA-125 cutoff of 47.5 IU/mL on the receiver operating characteristic curve provided the best sensitivity and specificity (56.5% vs 90.1%, respectively) for LN metastasis prediction. The sensitivities and specificities of old age (≥60 years), body mass index of 25 kg/m2 or greater, deep myometrial invasion, tumor size greater than 2 cm, tumor size greater than 4 cm, preoperative CA-125 greater than 47.5 IU/mL, LN metastasis on imaging, and extrauterine spread on imaging for the presence of a positive LN were 39.1%, 34.8%, 30.4%, 34.8%, 21.7%, 56.5%, 43.5%, and 52.2%, and 52.1%, 45.1%, 78.9%, 57.7%, 83.1%, 90.1%, 93.0%, and 90.1%, respectively. Preoperative CA-125 (P < 0.001), LN metastasis on preoperative imaging (P < 0.001), and extrauterine spread on preoperative imaging (P = 0.009) were risk factors for LN metastasis on univariate analysis. Multivariate analysis revealed that preoperative CA-125 (P = 0.001) was the only independent risk factor for LN metastasis.ConclusionsPreoperative CA-125 is a preoperative predictive factor for LN metastasis in UPSC.

Objective Accurately predicting cytoreducibility in advanced-ovarian cancer is needed to establish preoperative plans, consider neoadjuvant chemotherapy, and improve clinical trial protocols. We aimed to develop a positron-emission tomography/computed tomography-based nomogram for predicting incomplete cytoreduction in advanced-ovarian cancer patients. Methods Between 2006 and 2012, 343 consecutive advanced-ovarian cancer patients underwent positron-emission tomography/computed tomography before primary cytoreduction: 240 and 103 patients were assigned to the model development or validation cohort, respectively. After reviewing the detailed surgical documentation, incomplete cytoreduction was defined as a remaining gross residual tumor. We evaluated each individual surgeon's surgical aggressiveness index (number of high-complex surgeries/total number of surgeries). Possible predictors, including surgical aggressiveness index and positron-emission tomography/computed tomography features, were analyzed using logistic regression modeling. A nomogram based on this model was developed and externally validated. Results Complete cytoreduction was achieved in 120 patients (35%). Surgical aggressiveness index and five positron-emission tomography/computed tomography features were independent predictors of incomplete cytoreduction. Our nomogram predicted incomplete cytoreduction by incorporating these variables and demonstrated good predictive accuracy (concordance index=0.881; 95% CI=0.838–0.923). The predictive accuracy of our validation cohort was also good (concordance index=0.881; 95% CI=0.790–0.932) and the predicted probability was close to the actual observed outcome. Our model demonstrated good performance across surgeons with varying degrees of surgical aggressiveness. Conclusion We have developed and validated a nomogram for predicting incomplete cytoreduction in advanced-ovarian cancer patients which may help stratify patients for clinical trials, establish meticulous preoperative plans, and determine if neoadjuvant chemotherapy is warranted.

Objective: To determine the role of preoperative serum cancer antigen 125 (CA 125) in malignant ovarian germ cell tumors (MOGCTs). Materials and methods: Using information from medical databases of Asan Medical Center (Seoul, Korea), we investigated 161 patients with histologically diagnosed MOGCTs and whose preoperative serum CA 125 had been checked. We determined the optimal cutoff value of CA 125 as > 249.5 U/mL in MOGCTs using a receiver operating characteristic curve. Results: The median patient age was 24 years (range, 6–52 years). The most common histologic type was immature teratoma. Most patients had stage I disease. Thirty-two patients (19.9%) had elevated preoperative serum CA 125 levels over 249.5 U/mL. On univariate analysis, tumor size, advanced stage, the presence of ascites, ovarian surface involvement, and tumor rupture were significantly associated with elevated preoperative CA 125 levels (>249.5 U/mL). In the median follow-up time of 87 months (range, 9–271 months), 14 patients had a recurrence, and 5 died of the disease. Patients with an elevated serum preoperative CA 125 level (>249.5 U/mL) had poorer disease-free survival, but this was not statistically significant. However, elevated preoperative CA 125 (>249.5 U/mL) was significantly associated with poorer overall survival. Conclusions: Elevated preoperative serum CA 125 may have prognostic value in patients with MOGCTs. Keywords: CA-125 antigen, Ovarian germ cell cancer, Prognosis

Objective The aim of this study was to evaluate the diagnostic value of integrated 18F-fluoro-2-deoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) for suspected recurrence of epithelial ovarian cancer (EOC) with non-disseminated lesions. Methods We retrospectively reviewed the medical records of recurrent EOC patients who underwent secondary cytoreduction from January 2000 to December 2013. A total of 134 patients underwent secondary cytoreduction after imaging with either 18F-FDG-PET/CT or contrast-enhanced computed tomography (CECT). Results In a patient-based analysis of 134 patients, 124 (92.5%) were confirmed to be positive for malignancy. Among 72 patients with suspected non-disseminated recurrence on 18F-FDG-PET/CT, 65 (89.0%) were confirmed to have recurrence, giving 98.5% sensitivity, 87.7% accuracy, and 88.9% positive predictive value (PPV). In the 65 patients with recurrence, residual tumor remained in 14 patients, giving an accuracy of patient selection for secondary cytoreduction of 69.4% (50/72) and it is higher than that of CECT (64.0%). In 169 lesions removed from patients who underwent preoperative 18F-FDG-PET/CT, 135 (79.9%) were confirmed to be positive for malignancy and 124 were accurately detected by 18F-FDG-PET/CT, giving 91.9% sensitivity, 81.1% accuracy, and 85.5% PPV. Foreign body granuloma was found in 33.3% of 21 lesions with false-positive 18F-FDG-PET/CT findings (7/21). The mean preoperative cancer antigen 125 (CA-125) level in false-positive patients was 28.8 U/mL. Conclusion Compared with CECT, 18F-FDG-PET/CT shows higher sensitivity in lesion-based analysis and better accuracy of patient selection for secondary cytoreduction. However, there is still a need for integration of the results of 18F-FDG-PET/CT, CECT, and CA-125 levels to aid treatment planning.

IntroductionThe aim of this study was to evaluate the significance of ovarian endometriosis on the prognosis of ovarian clear cell carcinoma (OCCC).MethodsPatients with OCCC were divided into 2 groups according to the presence of ovarian endometriosis: group 1, no coexisting ovarian endometriosis; group 2, clear cell carcinoma arising from ovarian endometriosis or the presence of ovarian endometriosis elsewhere in the ovary. Clinicopathologic characteristics, disease-free survival (DFS), and overall survival (OS) were compared between the 2 groups.ResultsOf 155 patients with OCCC, 77 were categorized into group 1 and 78 into group 2. Group 2 patients were younger than group 1 (median age, 48 vs 51 years; P = 0.005) and had higher incidence of early-stage disease (stage I, 77% vs 58%; P = 0.001) and lower incidence of lymph node metastasis (4% vs 17%; P = 0.008). Group 2 patients were observed to have a significantly higher 5-year DFS (P < 0.001) and OS (P = 0.001) compared with group 1. In stage I disease, group 2 had a significantly higher 5-year DFS (P = 0.004) and OS (P = 0.016) than did group 1. In the multivariate analysis, coexisting endometriosis and advanced International Federation of Obstetrics and Gynecology stage were significant factors for both DFS and OS rates.ConclusionsOvarian clear cell carcinoma with endometriosis was found more frequently in younger women and had a higher incidence of early-stage disease and a lower incidence of lymph node metastasis compared with OCCC without endometriosis. Ovarian endometriosis was associated with improved prognostic factors and a better DFS and OS even in stage I disease. Ovarian endometriosis was an independent prognostic factor for OCCC.

Background We aimed to evaluate the efficacy and the safety of uterine preservation in patients with early-stage uterine adenosarcoma who want to preserve future fertility. Methods We performed a retrospective review of patients with stage I uterine adenosarcoma diagnosed and treated at a single institute from 1998 through 2014. Results Among the total of 31 patients, uterine preservation surgery was performed in 7 of the nulliparas. Of the 7 patients receiving uterine preservation surgery, 3 showed no evidence of disease (NED), 2 had persistent disease confined to the uterus, and 2 were alive with disease (AWD) after recurrence. One patient with an NED status had a vaginal delivery at term. In the uterine preservation group, 1 patient had sarcomatous overgrowth at the time of diagnosis and experienced disease recurrence. In the hysterectomy group, 3 of 24 patients had tumor recurrence. Of the five patients with tumor recurrence, four (80%) had sarcomatous overgrowth at diagnosis and it was significantly associated with recurrence by univariate analysis (OR 13.3, p = 0.027). Conclusions Uterine preservation represents a possible treatment option for young female patients who want to maintain fertility. However, a detailed explanation of the risk of recurrence is necessary, especially in patients with sarcomatous overgrowth, which seems to be associated with a higher risk of recurrence. Trial registration Retrospectively registered.

Objective To evaluate the prognostic value of metabolic parameters measured by preoperative ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET)/computed tomography (CT) in patients with uterine carcinosarcoma (UCS). Methods Data of 55 eligible patients with UCS who underwent preoperative ¹⁸F-FDG PET/CT and surgical staging were analyzed retrospectively. Maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV₂.₅), and total lesion glycolysis (TLG₂.₅) of the primary tumors were measured using a SUV threshold of 2.5. The optimal cutoff value of each parameter was determined by time-dependent receiver operating characteristic curve, and its impact on progression-free survival and overall survival was evaluated by Cox proportional hazards model. Results During a median follow-up period of 29 (range, 1.5-109.4) months, 47.3% (26/55) of the patients experienced disease progression, and the disease-associated mortality rate was 43.6% (24/55). Univariate analysis determined that hazard ratios (HRs) for disease progression for SUVmax (≥8.33), MTV₂.₅ (≥63.92 mL), and TLG₂.₅ (≥396.16) were 1.930 (95% confidence interval [CI]=0.793-4.701), 3.264 (95% CI=1.466-7.268), and 2.692 (95% CI=1.224-5.924), respectively. And, HRs for death were 1.979 (95% CI=0.774-5.060), 2.764 (95% CI=1.217-6.274), and 2.721 (95% CI=1.198-6.182), respectively. While peritoneal cytology, histology, and tumor diameter were independent prognostic factors in multivariate analysis, MTV and TLG were not. Conclusion Though MTV and TLG of primary UCS were not independent predictors compared to surgically obtained data, MTV and TLG of primary UCS may provide useful information on prognosis especially in patients who are not able to undergo surgical staging.

The aim of this study was to investigate the value of [18F]fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) in predicting lymph node status in node-negative endometrial cancer on preoperative magnetic resonance imaging (MRI). Patients with endometrial cancer who underwent both preoperative MRI and FDG-PET/CT followed by hysterectomy and lymphadenectomy were initially included. We then enrolled patients with MRI-defined node-negative disease (lymph nodes

Objective To evaluate the oncologic and reproductive outcomes and to analyze prognostic factors after fertility-sparing surgery in patients with early and advanced malignant ovarian germ cell tumors (MOGCTs). Methods This study included 171 patients who underwent fertility-sparing surgery. Data were gathered from patients' medical records. Survival analysis was performed using the log-rank test and Cox's proportional hazards model. Reproductive outcomes were analyzed. Results Twenty-five patients (14.6%) had recurrent disease, and five patients (2.9%) died of disease during the median follow-up time of 86months (range, 9–294months). The 5-year disease-free survival (DFS) was 86%, and the 5-year overall survival (OS) was 97%. The 5-year DFS was 84% for stage I and 89% for stage II–IV. The 5-year OS was 99% for stage I and 91% for stage II–IV. In multivariate analysis, yolk sac tumor, incomplete staging surgery, and residual tumor were independent risk factors for reduced DFS, and yolk sac tumor and residual tumor were independent risk factors for reduced OS. Reproductive and obstetric outcomes were evaluable in 124 patients, and 106 patients (85.5%) had regular menstruation, 12 patients (9.7%) had irregular menstruation, and six patients (4.8%) had premature menopause. Twenty patients tried to conceive, 15 patients (75%) succeeded in achieving 21 pregnancies, and 13 of the patients (65%) gave birth to 20 healthy babies. Conclusion Fertility-sparing surgery has excellent survival outcomes in young women with MOGCTs, even in advanced stages. Reproductive and obstetric outcomes were promising. Yolk sac tumor, incomplete surgical staging, and residual tumor were independent prognostic factors.

The purpose of this study was to evaluate the surgical feasibility of and survival outcome after laparoscopy in obese Korean women with endometrial cancer which has recently been increasing. We reviewed the medical records of the patients treated at our medical institution between 1999 and 2012. The patients were divided into three groups, non-obese (Body Mass Index [BMI]

Objectives Primary small cell carcinoma of the endometrium is a rare disease that can only be diagnosed at an advanced stage, and thus has a poor prognosis. In this study, the clinicopathologic characteristics of endometrial small cell carcinoma are described and the survival outcomes are discussed. Materials and methods The data from six patients from a single medical institution who were diagnosed with endometrial small cell carcinoma in the past 20 years were retrospectively reviewed. Results The median age of the six patients was 60 years. Vaginal bleeding was the most common symptom. All six patients underwent complete staging surgery, including hysterectomy, bilateral salpingoophorectomy, and systematic lymphadenectomy. Three of the patients were diagnosed with early stage disease, [International Federation of Gynecology and Obstetrics (FIGO) stage I or II], and the other three were in an advanced stage (FIGO stage III). Pathologically, deep myometrial invasion was observed in five (83.3%) of the patients, and lymphovascular invasion in six. As adjuvant therapy, four (66.7%) patients received platinum-based chemotherapy and one (16.7%) underwent concurrent chemoradiotherapy. During the median follow-up period of 16.2 months, recurrence developed in four patients (66.7%). There were disseminated recurrences on the peritoneum and lymph nodes in two cases, and distant metastasis to the brain in the other two cases. The median time to recurrence was 7.5 months (range, 315 months). One patient died of disease. Conclusion Small cell carcinoma of the endometrium shows an aggressive clinical behavior, such as a disseminated disease and distant metastasis within a short time to recurrence. Initial active management with complete surgical resection and systemic chemotherapy might improve outcomes, although further large studies should be done to confirm this.

The objective of this study was to assess whether the ratio of upper abdomen (UA) to lower abdomen (LA) (relative to the umbilicus) standardized fluorine 18 fluorodeoxyglucose uptake, as measured by preoperative positron emission tomography and computed tomography, is predictive of recurrence, survival, and suboptimal cytoreduction (residual tumor1.0 cm) in advanced-stage ovarian cancer (AOC).Positron emission tomography/computed tomography before surgical staging was performed in 159 AOC patients. The ratio between the highest maximum standardized uptake value (SUV(max)) in the UA and the LA was expressed as UA/LA SUV(max). Clinicopathological characteristics and follow-up information were collected retrospectively. Cox proportional hazards analysis was used to identify prognostic factors for recurrence and survival. Logistic regression analysis was used to identify predictors of suboptimal cytoreduction.The median age and follow-up period were 55 years (range, 27-80 years) and 32 months (range, 1-92 months), respectively; 133 and 26 patients had stage III and IV disease, respectively. There were 120 and 54 cases of recurrence and disease-specific death, respectively. Multivariate analysis showed that recurrence was associated significantly with high UA/LA SUV(max) (P0.05; hazard ratio [HR], 4.902; 95% confidence interval [CI], 2.521-9.531) and suboptimal cytoreduction (P0.05; HR, 2.431; 95% CI, 1.561-3.788), and that disease-specific death was significantly associated with high UA/LA SUV(max) (P0.05; HR, 2.777; 95% CI, 1.270-6.075), suboptimal cytoreduction (P0.05; HR, 1.951; 95% CI, 1.080-3.524), and histology (P0.05; HR, 4.134; 95% CI, 1.676-10.196). Upper abdomen/lower abdomen SUV(max) was the only independent predictor of suboptimal cytoreduction (P0.05; odds ratio, 4.644; 95% CI, 1.676-12.862).High preoperative UA/LA SUV(max) was significantly associated with poor prognosis and may be predictive of suboptimal cytoreduction in AOC. This parameter may be considered in the treatment of AOC patients.

Objective The reciprocal regulation of c-Src and STAT3 activation seems to be associated with the poor response to c-Src inhibitors of ovarian cancer. This study aims to investigate inhibition of cell proliferation and enhancement of the cytotoxic effect of chemotherapeutic agents via simultaneous suppression of c-Src and STAT3 in ovarian cancer cell lines. Study design Specific siRNAs targeting c-Src and STAT3 were produced and transfected into an SKOV3 ovarian cancer cell line. We confirmed the downregulation of c-Src and STAT3 mRNAs by reverse transcriptase polymerase chain reaction. MTT assay was used to assess cytotoxicity following cisplatin administration. Protein expression level was evaluated by Western blot. Results Cell growth was significantly inhibited by c-Src or STAT3 siRNA. Cytotoxicity was not increased in cisplatin-treated SKOV3 by c-Src siRNA only or STAT3 siRNA only, but cell viability was decreased significantly in cisplatin-treated cells after simultaneous transfection with c-Src and STAT3 siRNAs. Specifically, the viability was significantly decreased from 30% to 55% within the IC50 concentration following simultaneous transfection with c-Src and STAT3 siRNAs, particularly after 72 h. Src and survivin protein expression level was significantly decreased at 72 h after transfection of c-Src and STAT3 siRNAs. Conclusions This study has demonstrated the principle that the simultaneous suppression of c-Src and STAT3 inhibits the growth of epithelial ovarian cancer cells and seems to enhance the cytotoxicity of chemotherapeutic agents in ovarian cancer.

To estimate the oncologic and pregnancy outcomes after oral progestin treatment of women of reproductive age with stage IA endometrial adenocarcinoma with stage IA, grade 1 differentiation with superficial myometrial invasion or stage IA, grade 2-3 differentiation with or without superficial myometrial invasion.Medical records of 48 women (age 40 years or younger) with endometrioid adenocarcinoma of the uterus who met inclusion criteria and were treated conservatively with oral progestin were reviewed. Follow-up was performed primarily with imaging techniques followed by endometrial biopsy when indicated.The median age was 30 years (range, 23-40 years). Fourteen patients (29.2%) received daily oral megestrol acetate (median dose 160 mg per day, range 40-240 mg per day) and 34 (70.8%) received daily oral medroxyprogesterone acetate (median dose 500 mg per day, range 80-1,000 mg per day). Complete responses were observed for 37 patients (77.1%) after the median treatment duration of 10 months (range 3-20 months). Complete response rates were 76.5%, 73.9%, and 87.5% for patients with stage IA, grade 2-3 without myometrial invasion (n=17), for patients with stage IA, grade 1 with superficial myometrial invasion (n=23), and for patients with stage IA, grade 2-3 with superficial myometrial invasion (n=8), respectively (P=.731). Recurrence rates for 37 patients who achieved complete response after a median follow-up time of 48 months (range 7-136 months) were 23.1%, 47.1%, and 71.4%, respectively (P=.104). None experienced disease progression or died of the disease. Nine patients gave birth to 10 healthy newborns.Progestin treatment appears to be reasonably effective for patients with stage IA, grade 2-3 differentiation without myometrial invasion and patients with stage IA grade 1 differentiation with superficial myometrial invasion.III.

Background An increase in incidence of cervical adenocarcinoma (CADC) has been reported in many countries, including Korea. However, few studies describe human papillomavirus (HPV) type distribution among CADC in Asia. Objective and methods This was a retrospective, hospital-based observational study between 2005 and 2010 to estimate the overall prevalence and distribution of HPV types among CDAC in Korean women. The study used hematoxylin & eosin and immunohistochemical staining (for the two biomarkers p16 and progesterone receptor [PR]) to diagnose and subtype CADC samples. HPV DNA was amplified by polymerase chain reaction (PCR) and HPV genotypes were identified using reverse hybridization. Results Of 196 cases submitted, 89.3% of the cases were confirmed as CADC. The mean age at diagnosis was 47.1 (standard deviation [SD] 11.9) years. No statistically significant differences in mean age at diagnosis by histological subtype were found. HPV DNA was detected in 90.3% (177/196) of CADC. HPV-18 was the most prevalent type (54.2%), followed by HPV-16 (44.1%) and HPV-45 (3.4%). Infection with any high-risk HPV type was identified in 97.7% of HPV-DNA-positive CADC. The biomarker p16 was positive in 92% of CADC cases and PR was positive in 19.6% of CADC. Conclusion HPV DNA was found in the large majority of CADC in Korean women, with HPV-18 being the most common type followed by HPV-16 and HPV-45. This study is among the first in Asia to specifically report HPV type distribution in CADC. This information will help inform policy decisions concerning HPV vaccination for the prevention of CADC.

Objective To determine the incidence of vaginal cuff dehiscence (VCD) among women undergoing hysterectomy according to clinico-surgical factors including surgical route, and to describe patient characteristics associated with VCD. Methods In a retrospective study, the medical records of all women who underwent hysterectomy between January 2005 and March 2011 at a university teaching hospital in Seoul, Republic of Korea, were reviewed. The incidence of VCD was determined in relation to the following factors: patient age, hysterectomy route, indication for hysterectomy, and extent of resection (either simple or radical hysterectomy). Results Among 9973 hysterectomies, 37 (0.37%) cases of VCD were identified. The incidence of VCD was significantly higher after abdominal hysterectomy (0.6%) than after laparoscopic (0.2%) or vaginal (0.4%) hysterectomy ( P = 0.016). Compared with laparoscopic approaches, abdominal hysterectomy was associated with a higher risk of VCD (odds ratio, 2.735; 95% confidence interval, 1.380–5.420). However, there was no significant difference in the incidence of VCD according to surgical indication or extent of resection. Conclusion Laparoscopic hysterectomy was found to be associated with a lower risk of VCD compared with abdominal hysterectomy. The lower risk is probably related to the different techniques used for colpotomy and cuff closure.

Objective To analyze the outcomes of second round of fertility-sparing management using progestin in patients with recurrent endometrial cancer after successful fertility-sparing management using progestin. Methods We reviewed 45 patients who had recurrence after achieving complete remission by fertility-sparing management using progestin for presumed stage IA, grade 1, endometrioid adenocarcinoma of the uterus. Of 45 patients, 33 tried progestin re-treatment at recurrence and were included in this study. Results Recurrent disease was atypical hyperplasia in 13 patients (39%) and grade 1 endometrioid adenocarcinoma in 20 patients (61%) which were confined to the endometrium. Thirty patients (91%) received medroxyprogesterone acetate (dose range, 80–500mg/day) and three patients (9%) received megestrol acetate (dose range, 80–160mg/day), with 29 patients receiving a dose of 500mg/day of medroxyprogesterone acetate. The median duration of treatment was 6months (range, 3–19months). Five patients failed to respond to progestin re-treatment and underwent definitive surgical treatment including hysterectomy. Twenty eight patients (85%) showed complete response to progestin re-treatment. The median follow-up time after progestin re-treatment in 28 patients who achieved complete remission was 51months (range, 24–160months). During follow-up, five patients had second recurrence after median time interval of 14months (range, 4–82months). All patients who tried progestin re-treatment are alive without evidence of disease. Conclusion Progestin re-treatment in patients with recurrent endometrial cancer was effective and safe. Therefore, this can be recommended for young women who still want to preserve fertility at recurrence after complete response to progestin.

Objective Laparoscopic management in patients with malignant nonepithelial ovarian tumors (MNEOTs) was unpopular owing to the solid nature and relatively large size of the tumors. The purpose of this study was to evaluate the role of laparoscopy for MNEOTs. Methods Between January 1989 and September 2010, 28 patients with MNEOTs underwent laparoscopic surgery at our institution. These patients’ clinicopathologic data were retrospectively reviewed from medical records. Results Cases included 20 sex cord–stromal tumors (18 granulosa cell and 2 Sertoli-Leydig cell) and 8 malignant germ cell tumors (4 dysgerminomas, 2 immature teratomas, 1 choriocarcinoma, and 1 yolk sac tumor). The patients’ median age was 27 years (range, 16–35 years) for those with malignant germ cell tumors and 42 years (range, 7–57 years) for those with stromal tumors. The median primary tumor diameter was 10.4 cm (range, 3.3–20.8 cm). Laparoscopic pelvic and para-aortic lymph node dissections were performed in 9 cases. Laparoscopic removal of primary tumor and omentectomy were performed in 26 and 6 cases, respectively. Hand-assisted laparoscopic surgery was performed for one huge tumor that could not be entered into the endobag. The median operating time was 102 minutes (range, 45–300 minutes), and the median postoperative hospital stay was 3 days (range, 2–10 days). All patients had stage I disease. Five patients received adjuvant chemotherapy, and the median interval to chemotherapy was 14 days (range, 2–21 days). No intraoperative complication or conversion to laparotomy was observed. Only one postoperative febrile morbidity occurred. The median follow-up was 34.5 months (1–185 months). One patient developed recurrence, which was treated with chemotherapy. No patient died of their disease. Conclusion This is the first case series report of laparoscopic surgery for MNEOTs. Laparoscopic management seems feasible and safe without compromising survival. With additional evidence, laparoscopic surgery could be a safe therapeutic option for management of early-stage MNEOTs.

Objective Concurrent chemoradiotherapy is usually administered to patients with locally advanced cervical cancer (LACC). Extended-field chemoradiotherapy is required if para-aortic lymph node (PALN) metastasis is detected. This study aimed to construct a prediction model for PALN metastasis in patients with LACC before definitive treatment. Methods Between 2009 and 2016, all consecutive patients with LACC who underwent para-aortic lymphadenectomy at two tertiary centers were retrospectively analyzed. A multivariate logistic model was constructed, from which a prediction model for PALN metastasis was developed and internally validated. Before analysis, risk grouping was predefined based on the likelihood ratio. Results In total, 245 patients satisfied the eligibility criteria. Thirty-four patients (13.9%) had pathologically proven PALN metastases. Additionally, 16/222 (7.2%) patients with negative PALNs on positron emission tomography/computed tomography (PET/CT) had PALN metastasis. Moreover, 11/105 (10.5%) patients with both negative PALNs and positive pelvic lymph nodes on PET/CT had PALN metastasis. Tumor size on magnetic resonance imaging and PALN status on PET/CT were independent predictors of PALN metastasis. The model incorporating these two predictors displayed good discrimination and calibration (bootstrap-corrected concordance index=0.886; 95% confidence interval=0.825–0.947). The model categorized 169 (69%), 52 (22%), and 23 (9%) patients into low-, intermediate-, and high-risk groups, respectively. The predicted probabilities of PALN metastasis for these groups were 2.9, 20.8, and 76.2%, respectively. Conclusion We constructed a robust model predicting PALN metastasis in patients with LACC that may improve clinical trial design and help clinicians determine whether nodal-staging surgery should be performed.

Objective The aim of this study was to compare responses to single-agent chemotherapies and evaluate the predictive factors of resistance in low risk (LR) gestational trophoblastic disease (GTD). The chemotherapy agents included methotrexate (MTX) and actinomycin D (ACT-D). Methods We conducted a retrospective study of 126 patients with GTD who were treated between 2000 and 2013. A total of 71 patients with LR GTD were treated with MTX (8-day regimen or weekly regimen, n=53) or ACT-D (bi-weekly pulsed regimen or 5-day regimen, n=18). The successful treatment group and the failed treatment group were compared and analyzed to identify prognostic factors. Results The complete response rates were 83.3% for ACT-D and 62.2% for MTX, with no statistically significant difference. There was no severe adverse effect reported for either group. Longer interval durations from the index pregnancy (>2 months, p=0.040) and larger tumor size (>3 cm, p=0.020) were more common in non-responders than in responders; these results were statistically significant. Conclusion Based on our results, ACT-D may be a better option than MTX as a first-line single chemotherapy agent for LR GTD. The bi-weekly pulsed ACT-D regimen had minimal, or at least the same, toxicities compared with MTX. However, due to the lack of strong supporting evidence, it cannot be conclusively stated that this is the best single agent for first-line chemotherapy in LR GTD patients. Further larger controlled trials will be necessary to establish the best guidelines for GTD treatment.

To compare long-term survival outcomes and patterns of recurrence of laparoscopic radical hysterectomy (LRH) and open radical hysterectomy (ORH) in early-stage cervical adenocarcinoma.The medical records of 293 patients with stage IA2-IIA cervical adenocarcinomas who underwent radical hysterectomy were retrospectively reviewed.In total, 186 patients underwent LRH and 107 underwent ORH. There was no difference between the two surgery groups in clinicopathologic characteristics. There were no differences in disease-free survival (DFS) and overall survival (OS) between the LRH and ORH groups (88.7 vs. 84.1 %, P = 0.725; and 93.0 vs. 86.9 %, P = 0.735) for univariate analysis and multivariate analysis after adjusting for other significant prognostic factors. There was no difference in the patterns of recurrence between the two surgery groups (P = 0.220). The median time interval between surgery and the first recurrence were 25 months (range, 3-100 months) for LRH group and 14 months (range, 3-128 months) for ORH group (P = 0.230). The LRH group showed significantly fewer postoperative complications (P 0.001), less estimated blood loss (P 0.001), faster bowel movement recovery (P 0.001), shorter postoperative hospital stay (P 0.001), and a lower rate of wound dehiscence, ileus, lymphedema, infected lymphocele, and pelvic abscess (P = 0.004, 0.011, 0.017, and 0.040, respectively).LRH has comparable survival outcomes with ORH and did not affect the pattern of recurrence in early-stage adenocarcinoma of the uterine cervix. The surgical outcomes were more favorable than ORH.

ObjectivesThis study aimed to evaluate the safety of surgery alone followed by surveillance in young women with stage I malignant ovarian germ cell tumor (MOGCT).MethodsA retrospective review was performed on 31 patients with stage I MOGCT who were treated by surgery alone with follow-up.ResultsThe median patient age was 22 years (range, 6–45 years). The histological type was dysgerminoma in 17, immature teratoma in 11, yolk sac tumor in 1, and mixed MOGCT in 2 cases. Seventeen patients were stage IA, 1 was IB, and 13 were IC. All patients underwent fertility-sparing surgery, which involved either unilateral salpingo-oophorectomy or oophorectomy. Additionally, 12 (38.7%) patients underwent cystectomy of the contralateral ovary, but only 1 patient had MOGCT in the contralateral ovary. Twenty (65%) patients underwent a complete staging operation that included peritoneal exploration, biopsy, cytology, and/or omentectomy or omental biopsy; 7 (22.6%) patients who underwent pelvic and para-aortic lymphadenectomy. After a median follow-up time of 137 months (range, 24–268 months), 7 (22.6%) patients had recurrent disease, and underwent secondary surgery followed by chemotherapy with bleomycin, etoposide, and cisplatin (BEP). Six (86%) patients were successfully salvaged, but 1 died of disease progression. The 10-year disease-free survival rate was 77%, but the 10-year overall survival rate was 97%.ConclusionsFertility-sparing surgery alone with surveillance could be a safe treatment strategy. Most recurrence can be successfully salvaged by surgery and BEP chemotherapy and the overall survival is not compromised. Using this strategy, 77.4% of patients may avoid unnecessary BEP chemotherapy.

The aim of this study was to evaluate the role of complete surgical staging of a malignant ovarian germ cell tumor (MOGCT) that is apparently confined to the ovaries.This retrospective study included 135 patients with stage I MOGCT after surgery. Patients who were categorized with stage I disease without complete staging operation were staged as IX. Statistical analysis was performed using Chi-squared or Fisher's exact tests and a Cox proportional hazards model.Eighty-six patients (62.7 %) underwent a complete staging operation; 43 had stage IA disease, 3 had stage IB disease, and 40 had stage IC disease. Forty-nine patients (36.3 %) were staged as IX. After surgery, 93 patients (68.8 %) received adjuvant chemotherapy. In the observation group, the recurrence rates were 12.5 % (2/16), 14.3 % (1/7), and 47.4 % (9/19) for stage IA-IB, stage IC, and stage IX disease, respectively (stage IA-IB vs. stage IX, p = 0.035; stage IC vs. stage IX, p = 0.190). In the adjuvant chemotherapy group, the recurrence rates were 6.7 % (2/30), 6.1 % (2/33), and 6.7 % (2/30) for stage IA-IC, stage IC, and stage IX disease, respectively (stage IA-IC vs. stage IX, p 0.999; stage IC vs. stage IX, p 0.999). In multivariable survival analysis, complete surgical staging was significantly associated with improved disease-free survival in patients with stage I MOGCT (odds ratio 3.2; 95 % confidence interval 1.1-9.9; p = 0.049).Complete surgical staging is independently associated with prognosis in women with apparently early MOGCT who did not receive adjuvant chemotherapy. To enter surveillance strategy without adjuvant chemotherapy, complete surgical staging is mandatory.