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Debulking surgery followed by systemic chemotherapy&mdash, including three-weekly intravenous paclitaxel and carboplatin (GOG-158)&mdash, is the cornerstone for advanced epithelial ovarian, fallopian tubal, and peritoneal cancer (EOC) treatment. In this scenario, Federation of Gynecology and Obstetrics (FIGO) stage, cell types, completeness of surgery, lymph nodes (LN) status, adjuvant chemotherapy regimens, survival status, progression-free survival (PFS), and overall survival (OS) of 192 patients diagnosed as having stage IIIA1&ndash, IVB EOC over January 2008&ndash, December 2017 were analyzed retrospectively. Of them, 100 (52.1%) patients had been debulked optimally. Of all cases, 64.1% and 10.9% demonstrated serous and clear-cell carcinoma. Moreover, the FIGO stage, surgery completeness, and LN status affected recurrence/persistence and mortality (all p &lt, 0.001). Clear cell carcinoma led to shorter survival than serous carcinoma (p = 0.002). Adjuvant chemotherapy regimens were divided into five main groups according to previous clinical trials. However, choice of chemotherapy failed to demonstrate significant differences in patient outcomes. Similar results were found in the sub-analysis of optimally debulked cases, except that intraperitoneal chemotherapy could reduce mortality risk when compared with GOG-158 (p = 0.042). Notably, retroperitoneal LN dissection in all cases or optimally debulked cases reduced risks of recurrence/persistence and mortality, and prolonged PFS and OS significantly (all p &lt, 0.05). Without optimal debulking, LN dissection led to little improvement in outcomes. Various modified chemotherapy regimens did not prolong PFS and OS or reduce recurrence/persistence and mortality risks. LN dissection is strongly recommended to improve the completeness of surgery and patient outcome. Clear cell type has a poorer outcome than serous type, which requires more aggressive treatment and follow-up.

Ovarian clear cell carcinoma (OCCC) is the second common histology of epithelial ovarian cancer in Taiwan. Stage IC is common, especially during minimally invasive surgery. Adjuvant chemotherapy in stage IC OCCC is unavoidable, and paclitaxel-based chemotherapy in Taiwan is self-paid. However, surgical spillage from minimally invasive surgery as a cause of unfavorable prognosis is still uncertain. The information of patients with stage IC OCCC, corresponding to a period of January 1995 to December 2016, was retrospectively collected following a chart and pathology review. Data regarding surgical methods, cytology status, regimens of adjuvant chemotherapy, survivorship, progression-free survival (PFS), and overall survival (OS) period were analyzed. In total, 88 patients were analyzed, and 64 and 24 patients were treated with paclitaxel- and nonpaclitaxel-based chemotherapy, respectively. Recurrence was identical between the two groups: PFS (47.5 &plusmn, 41.36 versus 54.0 &plusmn, 53.9 months, p = 0.157) and OS (53.5 &plusmn, 38.14 versus 79.0 &plusmn, 49.42 months, p = 0.070). Of the 88 patients, 12 had undergone laparoscopy for histological confirmation before complete open staging surgery, however, their PFS (49.5 &plusmn, 46.84 versus 49.0 &plusmn, 35.55 months, p = 0.719) and OS (56.5 &plusmn, 43.4 versus 51.0 &plusmn, 32.77 months, p = 0.600) were still comparable. Cytology results were only available for 51 patients, and positive washing cytology results seemed to worsen PFS (p = 0.026) but not OS (p = 0.446). In conclusion, adjuvant nonpaclitaxel chemotherapy and laparoscopic tumor spillage before the staging operation did not worsen the outcome in stage IC OCCC. Positive washing cytology has a negative effect on PFS but not on OS.

Background Sarcopenia is commonly observed in patients with advanced‐stage epithelial ovarian cancer (EOC). However, the effect of body composition changes—during primary debulking surgery (PDS) and adjuvant platinum‐based chemotherapy—on outcomes of patients with advanced‐stage EOC is unknown. This study aimed to evaluate the association between body composition changes and outcomes of patients with stage III EOC treated with PDS and adjuvant platinum‐based chemotherapy. Methods Pre‐treatment and post‐treatment computed tomography (CT) images of 139 patients with stage III EOC were analysed. All CT images were contrast‐enhanced scans and were acquired according to a standardized protocol. The skeletal muscle index (SMI), skeletal muscle radiodensity (SMD), and total adipose tissue index were measured using CT images obtained at the L3 vertebral level. Predictors of overall survival were identified using Cox regression models. Results The median follow‐up was 37.9 months. The median duration between pre‐treatment and post‐treatment CT was 182 days (interquartile range: 161–225 days). Patients experienced an average SMI loss of 1.8%/180 days (95% confidence interval: −3.1 to −0.4; P = 0.01) and SMD loss of 1.7%/180 days (95% confidence interval: −3.3 to −0.03; P = 0.046). SMI and SMD changes were weakly correlated with body mass index changes (Spearman ρ for SMI, 0.15, P = 0.07; ρ for SMD, 0.02, P = 0.82). The modified Glasgow prognostic score was associated with SMI loss (odds ratio: 2.42, 95% confidence interval: 1.03–5.69; P = 0.04). The median time to disease recurrence was significantly shorter in patients with SMI loss ≥5% after treatment than in those with SMI loss

Chia-Sui Weng,1,* Chao-Chih Wu,2,* Tze-Chien Chen,1 Jen-Ruei Chen,1 Chueh-Yi Huang,1 Chih-Long Chang1–3 1Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan; 2Department of Medical Research, MacKay Memorial Hospital, New Taipei City, Taiwan; 3Department of Medicine, Mackay Medical College, New Taipei City, Taiwan*These authors contributed equally to this workCorrespondence: Chih-Long ChangDepartment of Obstetrics and Gynecology, Mackay Memorial Hospital, 92, Section 2, Chung-Shan North Road, Taipei, TaiwanTel +886-2-25433535 Fax +886-2-25232448Email clchang@mmc.edu.twPurpose: The aim of this study is to analyze the outcomes of platinum-sensitive (PS) recurrent ovarian cancer treated with pegylated liposomal doxorubicin and carboplatin (CD) versus paclitaxel and carboplatin (CP). Clinical features were examined to characterize the patient population that would benefit from CD.Materials and methods: This is a retrospective review of 122 cases at a tertiary hospital. Patients with PS recurrent ovarian cancer who received CD or CP were included. Progression-free survival (PFS) and overall survival (OS) were evaluated through the Kaplan–Meier method and log-rank test. Cox proportional hazards regression was used to examine PFS predictors.Results: In total, 122 patients (75% with first recurrence and 25% with second recurrence) were included. The majority of the patients were diagnosed at an advanced stage and with the histology of serous carcinoma. Median PFS and OS were 14.8 and 55.5 months in the CD group and 13.5 and 56.8 months in the CP group. Subgroup analysis of patients revealed that the CD group had longer median PFS than the CP group among patients with PFI>12 months. Additionally, during the second recurrence, longer PFS was observed in the CD group than in the CP group (medians 22.3 and 13.5 months, respectively, p = 0.019).Conclusion: Comparable outcomes in recurrent platinum-sensitive ovarian cancer treated with CD versus CP were presented in this study. Longer PFS in CD group was observed among patients with PFI for more than 12 months or in second recurrence.Keywords: Lipo-Dox, platinum-sensitive ovarian cancer &nbsp

Uterine sarcoma is a very aggressive and highly lethal disease. Even after a comprehensive staging surgery or en block cytoreduction surgery followed by multimodality therapy (often chemotherapy and/or radiation therapy), many patients relapse or present with distant metastases, and finally die of diseases. The worst outcome of uterine sarcomas is partly because of their rarity, unknown etiology, and highly divergent genetic aberration. Uterine sarcomas are often classified into four distinct subtypes, including uterine leiomyosarcoma, low-grade uterine endometrial stromal sarcoma, high-grade uterine endometrial stromal sarcoma, and undifferentiated uterine sarcoma. Currently, evidence from tumor biology found that these tumors showed alternation and/or mutation of genomes and the intracellular signal pathway. In addition, some preclinical studies showed promising results for targeting receptor tyrosine kinase signaling, phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin pathway, various kinds of growth factor pathways, Wnt/beta-catenin signaling pathway, transforming growth factor β/bone morphogenetic protein signal pathway, aurora kinase A, MDM2 proto-oncogene, histone deacetylases, sex hormone receptors, certain types of oncoproteins, and/or loss of tumor suppressor genes. The current review is attempted to summarize the recurrent advance of targeted therapy for uterine sarcomas.

Endometrial stromal tumors are rare uterine tumors (

Objective: To dissect the correlated hematologic markers that reflect the clinical outcome or treatment response in patients receiving dose-dense chemotherapy with a combination of platinum (cisplatin or carboplatin) and paclitaxel. Materials and Methods: From 2009 to 2014, we enrolled 55 ovarian cancer patients (total 67 courses) including first-line, persistent, platinum-sensitive, or platinum-resistant disease in MacKay Memorial Hospital, Taipei, Taiwan. Weekly pretreatment complete blood counts and calculated ratios [platelet/neutrophil ratio, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), neutrophil/monocyte ratio, platelet/monocyte ratio, lymphocyte/monocyte ratio] during dose-dense chemotherapy were collected. By grouping these hematologic biomarkers into three different response subgroups (responsive, stable, and nonresponsive) according to CA125 trend, the data were analyzed using one-way analysis of variance, and using post hoc-Tukey test for comparing each other. A p value < 0.05 was considered to be statistically significant. Results: Absolute counts of lymphocytes and platelets, PLR, platelet/neutrophil ratio, platelet/monocyte ratio (all p < 0.001), and NLR (p=0.013) had statistically significant differences. Moreover, using box-and-whisker plot, absolute count of lymphocyte, PLR, and NLR showed most remarkable discrepancy in responsive, stable, and nonresponsive patients. Subgroup analysis for primary, platinum-sensitive, and platinum-resistant patients further revealed that PLR and NLR were significantly correlated to the outcome of dose-dense chemotherapy. Conclusion: Lower PLR or lower NLR had better treatment response for dose-dense chemotherapy and are possible markers for representing treatment response in dose-dense chemotherapy. For a clinician, this is useful for timing when to switch to another chemotherapy regimen.

To investigate the clinicopathological features and treatment outcomes in patients with stage I, high-risk endometrial cancer. Patients with International Federation of Gynecology and Obstetrics stage I, papillary serous, clear cell, or grade 3 endometrioid carcinoma treated between 2000 and 2012 were analyzed for the clinical and pathological factors in relation to prognosis. A total of 267 patients (stage IA, n = 175, stage IB, n = 92) were included. Among the clinicopathological features, stage and age were significant prognostic factors. The recurrence rate and overall survival for stage IB versus IA were 22.8% versus 9.1% (p = 0.003) and 149.7 months versus 201.8 months (p &lt, 0.001), respectively. The patients &gt, 60 years of age also had a higher recurrence rate (21.7% versus 9.7%, p = 0.008) and poorer survival (102.0 months versus 196.8 months, p = 0.001) than those &le, 60 years of age. Distant recurrence (64.9%) occurred more frequently than local recurrence (24.3%) and local combined with distant recurrence (10.8%) (p &lt, 0.001). The postoperative treatment modality had no impact on tumor recurrence rate, recurrence site, or overall survival. Distant recurrence is a major cause of treatment failure in patients with stage I, high-risk endometrial cancer. However, current adjuvant treatment appeared to have little effect in preventing its occurrence.

Objective The goal of this study is to assess the feasibility of simple extrafascial hysterectomy for patients with clinical stage IA1 cervical squamous cell carcinoma (SCC) after once conization regardless of any pathologic risk factor. Materials and Methods All cases with T1a1, SCC lesion in their cervical cone specimen were retrospectively collected after chart and pathology review for the period between January 2002 and December 2009. All cases underwent subsequent hysterectomies within a month of diagnosis. Pathologic risk factors of conization, surgical scale of hysterectomy, residual lesion of the uterus, necessity of adjuvant radiation therapy, complications, and survival were analyzed in this study. Results Eighty-one cases were identified from the registry. Most were managed by simple hysterectomy (SH; 60/81, 74%), and the remaining 21 cases underwent modified radical hysterectomy (MRH). All cases without any risk factors in their cone specimens demonstrated residual lesion ≤T1a1 in both SH and MRH groups, whereas those with existing risk factor were confirmed positive for residual lesions ≤T1a1 [SH, 95.8% (46/48) vs. MRH, 75% (15/20)]. Only two cases in the SH group received adjuvant radiation for residual lesions >T1a1. On the contrary, 15 cases in the MRH group can receive smaller scale surgery than MRH. All cases were recurrence-free without any permanent treatment-related complication by the end of the study. Conclusion Extrafascial simple hysterectomy may be recommended for clinical T1a1 cervical SCC regardless of the pathologic risk factor.

Uterine sarcomas account for 3–7% of all uterine cancers. Because of their rarity, unknown etiology, and highly divergent genetic aberration, there is a lack of consensus on risk factors for occurrence and predictive poor outcomes as well as optimal therapeutic choices. Tumor types according to the World Health Organization classification include leiomyosarcoma, endometrial stroma sarcoma, and undifferentiated sarcoma. Staging is done using the 2014 Federation International Gynecology and Obstetrics and 2010 American Joint Committee on Cancer tumor, lymph node, and metastases systems. Tumor grade can be classified based on the French Federation of Cancer Centers Sarcoma Group system or the Broder’s system that incorporates tumor differentiation, mitotic count, and tumor necrosis. This review is a series of articles discussing uterine sarcoma, and this is Part I, which focuses on one of the subtypes of uterine sarcomas—uterine leiomyosarcoma. The clinical characteristics, diagnosis, outcome, and recent advances are summarized in this article.

Background: Totally implantable port systems are generally recommended for prolonged central venous access in diverse settings, but their risk of complications remains unclear for patients with advanced cancer. Aim: The aim of this study was to assess the risk of port system failure in patients with advanced cancer. Design: We conducted a retrospective cohort study in a comprehensive cancer centre. Setting/participants: A detailed chart review was conducted among 566 patients with 573 ports inserted during January–June, 2009 (average 345.3 catheter-days). Cox regression analysis was applied to evaluate factors during insertion and early maintenance that could lead to premature removal of the port systems due to infection or occlusion. Results: Port system-related infection was significantly associated with receiving palliative care immediately after implantation (hazard ratio, HR = 7.3, 95% confidence interval, 95% CI = 1.2–46.0), after adjusting for probable confounders. Primary cancer site also impacted the occurrence of device-related infection. Receiving oncologic/palliative care (HR = 3.0, P = 0.064), advanced cancer stage (HR = 6.5, P = 0.077) and body surface area above 1.71 m2 (HR = 3.4, P = 0.029) increased the risk of port system occlusion. Conclusions: Our study indicates that totally implantable port systems yield a higher risk of complications in terminally ill patients. Further investigation should be carefully conducted to compare outcomes of various central venous access devices in patients with advanced cancer and to develop preventive strategies against catheter failure.

Summary Background Villoglandular adenocarcinoma (VGA) of the uterine cervix is a relatively rare subtype of endocervical adenocarcinomas that often occurs in early reproductive women. Methods Clinical cases were retrospectively collected from the cancer registry systems at Mackay Memorial Hospital (Taipei, Taiwan). Clinical histories on the subjects were extracted directly from chart review of records of clinic visits. Results The mean age of 12 subjects was 42 years, with 10 and 2 subjects clinically staged as IB1 (10 of 12) and IA2 (2 of 12), respectively, for the period between January 1, 1996, and December 31, 2007. Eleven subjects had classical Type III radical hysterectomy with or without bilateral salpingo-oophorectomy plus bilateral pelvic lymphadenectomy, and one received pelvic and para-aortic lymphadenectomy plus postoperative adjuvant treatment of weekly cisplatin concurrent with radiotherapy. Only one subject had confirmed pelvic lymph nodes metastases. Nine subjects had pure histologic type and others had mixed histologic type of VGA. Only one subject had a recurrence but was still alive. Most subjects were long-term survivors (greater than 5 years) (10 of 12). Conclusion In conclusion, this study confirms the young age of subjects with VGA and reemphasizes the difficulties in the diagnosis of VGA. Because the current management strategy renders good tumor control in young subjects with early-stage VGA, we would suggest that similar treatment should be considered for elder subjects with this rare category of cervical malignancy. Our experience shows that the primary management of subjects with early-stage VGA (International Federation of Gynecology and Obstetrics Stages IA2 to IIA1) is classical Type III radical hysterectomy plus salpingo-oophorectomy with bilateral pelvic lymphadenectomy at MMH. We hope our 12-case experience may contribute to the clinical decision making for subjects with this disease.

Endometriosis, defined by the presence of viable extrauterine endometrial glands and stroma, can grow or bleed cyclically, and possesses characteristics including a destructive, invasive, and metastatic nature. Since endometriosis may result in pelvic inflammation, adhesion, chronic pain, and infertility, and can progress to biologically malignant tumors, it is a long-term major health issue in women of reproductive age. In this review, we analyze the Taiwan domestic research addressing associations between endometriosis and other diseases. Concerning malignant tumors, we identified four studies on the links between endometriosis and ovarian cancer, one on breast cancer, two on endometrial cancer, one on colorectal cancer, and one on other malignancies, as well as one on associations between endometriosis and irritable bowel syndrome, one on links with migraine headache, three on links with pelvic inflammatory diseases, four on links with infertility, four on links with obesity, four on links with chronic liver disease, four on links with rheumatoid arthritis, four on links with chronic renal disease, five on links with diabetes mellitus, and five on links with cardiovascular diseases (hypertension, hyperlipidemia, etc.). The data available to date support that women with endometriosis might be at risk of some chronic illnesses and certain malignancies, although we consider the evidence for some comorbidities to be of low quality, for example, the association between colon cancer and adenomyosis/endometriosis. We still believe that the risk of comorbidity might be higher in women with endometriosis than that we supposed before. More research is needed to determine whether women with endometriosis are really at risk of these comorbidities.

The present study describes 31 clinical cases of neuroendocrine cervical carcinoma (NECC) treated at Mackay Memorial Hospital between January 1, 1991 and October 31, 2003. There are two cases of atypical carcinoid tumor (ACT), four cases of large-cell neuroendocrine carcinoma (LCNEC), and 25 cases of small-cell neuroendocrine carcinoma (SCNEC). Overall survival did not differ significantly in relation to surgery, tumor histology, age, FIGO stages, chemotherapeutic regimens or lymph node involvement. The specimens available did not permit HPV (human papillomavirus)-DNA analysis in 5 cases (5/31, 9.7%). The HPV viral infection was absent in 8 cases (8/31, 26%); 17 cases of HPV-18 (17/31); and 1 case of HPV-16 (1/31). The prognosis between mixed and pure type histologic patterns is not significant. The mean survival time for all patients was 32.3 months. The 2-year and 5-year survival rates were 54.8% and 31.5% for all patients. The results of this study reaffirm the biologically aggressive nature of this rare malignancy, its low survival rate, and its very unpredictable prognostic factors. Effective treatments of neuroendocrine cervical tumor still remain inconclusive. Further efforts are still required to identify prognostic factors for this uncommon disease.

Summary Objective Peritoneal tuberculosis (TB) is a fatal disease if not promptly diagnosed. We present a case of unexplained ascites with miliary peritoneal TB and a review of the literature. Case Report A 56-year-old woman was admitted to our hospital because of severe abdominal fullness for 20 days. Computed tomography scans of the abdomen showed massive ascites and a huge intrapelvic mass mimicking an ovarian dermoid cyst. Laboratory examinations revealed an elevated serum cancer antigen 125 level of 1,132.9 IU/mL and normal chest roentgenographic findings. About 5 L of ascitic fluid and many superficial whitish miliary deposits on the intra-abdominal and pelvic surfaces were found during exploratory laparotomy. A right ovarian cystic mass measuring 15 × 14 × 10 cm in size was noted and removed. Pathologic studies of the cyst revealed a mature cystic teratoma, and all the specimens from the peritoneum and the ovarian surface had chronic granulomatous inflammation with central caseous necrosis compatible with TB. She received postoperative anti-TB chemotherapy and was doing well 5 months after surgery. Conclusion Tuberculous peritonitis is not easy to diagnose. We suggest that tuberculous peritonitis associated with ovarian teratoma should be included in the differential diagnosis of peritoneal carcinomatosis.

Objective The aim of this study was to investigate the clinical and pathological characteristics of uterine clear cell carcinoma (UCCC) and the treatment of this disease in relation to patient outcomes. Methods The clinicopathological data for and the management of all patients with UCCC who presented between 1991 and 2010 at 11 member hospitals of the Taiwanese Gynecologic Oncology Group (TGOG) were retrospectively reviewed. Results There were no significant differences in 5-year overall survival (OS) rates between patients with pure UCCC (n=100) and non-pure UCCC (n=53) at the same surgical stage, with OS rates of 92.6%, and 87.7% for stage I; 83.3% and 83.3% for stage II; 64.0% and 67.8% for stage III; and 16.7% and 0% for stage IV (n=1), respectively. Tumor stage and age independently influenced the OS rate of UCCC. For the patients with early stage UCCC, the adjuvant therapy modality was the only significant prognostic factor for recurrence-free survival. The patients with early stage UCCC who received adjuvant therapy had excellent 5-year recurrence-free survival and OS rates compared to those who received radiotherapy (100% vs. 74%, p=0.01; 100% vs. 72%, p=0.03). Conclusions The 5-year survival rates of patients with pure UCCC and non-pure UCCC were similar. The prognosis for surgical staging of patients with stage I/II UCCC was encouraging. Postoperative adjuvant platinum-based chemotherapy is recommended for patients with early stage UCCC who are at a high risk of recurrence.

In the management of patients with advanced-stage pure endometrioid-type endometrial cancer (E-EC), such as positive lymph nodes (stage III) or stage IV, treatment options are severely limited. This article aims to investigate the outcome of women with FIGO III-IV E-EC (based on FIGO 2009 system). The retrospective cohort study, based on the Taiwanese Gynecologic Oncology Group (TGOG-2005), enrolled patients undergoing staging surgery to have a pathologically confirmed FIGO III-IV E-EC from 22-member hospitals between 1991 and 2010. This cohort included 541 patients (stage III, n = 464; stage IV, n = 77). Five-year overall survival (OS) was 70.4%. Median progression-free survival (PFS) was 43 months (range 0–258 months) and median OS was 52 months (range 1–258 months). Multivariate analysis showed that FIGO stage, >1/2 myometrial invasion (hazard ratio [HR] 1.53, 95% confidence interval [CI] 1.12–2.09; P = 0.007), histological grade 3 (HR 2.0, 95% CI 1.47–2.75; P 1/2 myometrial invasion (HR 1.89, 95% CI 1.34–2.64; P 1/2 myometrial invasion and histological grade 3 are risky for disease-related mortality.

Purpose Point A, used for dose specification for intracavitary brachytherapy for cervical cancer, is the point at which the uterine artery and ureter cross. This study assessed compatibility of commonly used traditional point A (TPA) and actual anatomic point A (APA). Methods and Materials We visualized and placed radiopaque clips at the APA during pelvic and paraaortic lymphadenectomy in 11 patients with cervical carcinoma. Orthogonal and oblique radiographs were obtained after insertion of brachytherapy applicators. We measured the distance between the TPA and APA and estimated the brachytherapy dose to each of the two points. Results A total of 64 brachytherapy treatments were performed. The mean distances between the TPA and APA were 5.2 ± 1.0 cm on the right and 5.4 ± 1.1 cm on the left. The estimated brachytherapy doses delivered to the APA as a percentage of the presumed 500-cGy fraction size to the TPA were 35.2% (176.6 ± 59.0 cGy) on the right and 30.0% (150.2 ± 42.9 cGy) on the left. The marked discrepancy in the position of the two points was not related to individual kinetic variations during brachytherapy treatment, tumor size, or bladder filling. Conclusions The conventional TPA does not provide an accurate estimate of the APA determined during lymphadenectomy, indicating a need to reevaluate the current practice for determining the brachytherapy prescription for cervical cancer. ( ClinicalTrials.gov Identifier, NCT00319462)

A 90-year-old Taiwanese woman, para 8, was admitted to the emergency department with complaints of mild abdominal pain and constipation for 2 days but with no nausea, vomiting or recent weight loss. An enlarging lower abdominal mass had been present for approximately 1 year. The patient denied any prior abdominal operations, and her past medical history was unremarkable except for hypertension treated with an oral β-blocker. Upon arrival to the emergency department, she was afebrile but tachycardic with a pulse of 132 beats/minute and a blood pressure of 150/90 mmHg. The abdomen was soft with normoactive bowel sounds. Physical examination revealed a palpable and mobile lower abdominal mass protruding from the subumbilical to suprapubic area. White blood cell count was 7,400/mL with a normal differential count. Computed tomography of the abdomen was performed and revealed a large cystic mass with solid component and two calcified spots, which was thought to represent a malignant ovarian neoplasm (Figure). Tumor markers including CEA and CA-125 were analyzed; CEA level was 1.9 ng/mL (normal serum level, < 5.00 ng/mL) and CA-125 level was 27.94 U/mL (normal serum level, < 35 U/mL). Findings using less invasive procedures including a colonoscopy and a cystoscopy were unremarkable, so an exploratory laparotomy was performed under general anesthesia. Surgery revealed that the right adnexa was well encapsulated and twisted with ischemic change; it measured 21 × 17 × 6 cm. A right salpingo-oophorectomy was performed. Pathologic examination of the ovary and fallopian tube showed a simple cyst with hemorrhage and infarction.