Neuroendocrine carcinoma of the endometrium concomitant with Lynch syndrome: A case report.

BACKGROUND: Large-cell neuroendocrine carcinoma (NEC) is an uncommon type of tumor that can occur in the endometrium. This aggressive cancer requires definitive management. Here, we describe the clinical characteristics and treatment of a postmenopausal woman with large cell NEC of the endometrium. CASE SUMMARY: A 55-year-old Asian female presented with a 1-year history of postmenopausal vaginal bleeding. Transvaginal ultrasound revealed a thickened endometrium (30.2 mm) and a hypervascular tumor. Computed tomography revealed that the tumor had invaded more than half of the myometrium and spread to the pelvic lymph nodes. The tumor marker, carcinoembryonic antigen, was elevated (3.65 ng/mL). Endocervical biopsy revealed high-grade endometrial carcinoma. She underwent radical hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and bilateral pelvic and para-aortic lymph node dissection. Pathological examination revealed mixed neuroendocrine and endometrioid adenocarcinoma, pT2N0M0, grade 3, and International Federation of Gynecology and Obstetrics stage 2. Immunohistochemistry showed moderate estrogen and progesterone receptor expressions (20% and 1%, respectively), focal CD56 expression (NEC marker), positive staining for vimentin, p53 (wild type), and ki67 (90%), and loss of expression of PMS2 (Lynch syndrome marker). The patient received five cycles of cisplatin and etoposide after surgery. No recurrence was noted after 5 mo. CONCLUSION: We report the characteristics and successful management of a rare case of large-cell endometrial NEC concomitant with Lynch syndrome.

Effective reduction in inadequate Pap smears by using a saline-lubricated speculum and two glass slides.

OBJECTIVE: The aim of the study was to propose a method using saline lubrication and two glass slides to reduce the proportion of inadequate Pap smears. MATERIALS AND METHODS: This was a retrospective study of patients at a medical center in eastern Taiwan that performs 5000-6000 Pap smears annually. The extracted data only detailed the number and percentage of inadequate Pap smears. We applied two modifications to the conventional Pap smear technique. The first modification was lubricating the speculum with normal saline instead of jelly. The second modification was performing the smear on two glass slides instead of just one. We used the modified technique beginning in January 2017. Therefore, we collected data from 2016 (before the modified technique was employed) and 2018 (after the modified technique was employed). The categorical data are presented as numbers (percentages). The differences in the number and percentage of inadequate smears resulting from both techniques were assessed using the Chi-square test. RESULTS: During 2016 and 2018, 28 and 2 women received inadequate Pap smears among the total of 594 and 613 women who received Pap smears, respectively. The proportion of inadequate Pap smears was 4.71% and 0.33% in 2016 and 2018, respectively (P < 0.001). CONCLUSIONS: The use of this modified technique effectively reduced the percentage of inadequate Pap smears.

Iatrogenic Parasitic Myoma with Two Recurrence Times after Subsequent Myomectomy: A Rare and Complicated Case Report.

Increasing number of parasitic myoma (PM) cases due to specimen morcellation during minimally invasive surgery have been reported. The patient was a 46-year-old woman receiving laparoscopic subtotal hysterectomy due to fibroids. She was diagnosed as having PM and had two recurrences after subsequent myomectomies. To prevent recurrence, specimen-contained morcellation was performed during the myomectomies and postoperative ulipristal acetate was given, but with no effects. The interval between each recurrence decreased. Progressive lower abdominal pain and prominent vessels on the myoma were the two distinct clinical characteristics that differentiated PM from general myoma. This case study highlights the importance of specimen containment before morcellation in minimally invasive surgery and implies that the pathogenesis of PM recurrence is unknown.

Younger tamoxifen-treated breast cancer patients also had higher risk of endometrial cancer and the risk could be reduced by sequenced aromatase inhibitor use: A population-based study in Taiwan.

Objective: Previous Western studies reported that older (≥50 years) breast cancer survivors with tamoxifen treatment had higher risk of endometrial cancer. This study aims to disclose whether younger (<50 years) tamoxifen-treated breast cancer patients also had higher risk of endometrial cancer and to examine whether sequenced aromatase inhibitor (AI) use could reduce the risk. Materials and Methods: A population-based cohort of 39,216 newly diagnosed breast cancer patients was identified from Taiwan National Health Insurance Database from 1999 to 2012. The risk of endometrial cancer in nonusers (n = 14,588), tamoxifen-only (n = 19,302), and sequenced AI (n = 5326) users was compared with Cox regression analysis and was adjusted with age, diabetes, hypertension, and chemotherapy. Results: During the 14-year study period, 133 patients were diagnosed with subsequent endometrial cancers. Compared with nonusers, tamoxifen-only users had higher risk of endometrial cancer (14-year incidence 1.7% vs. 0.3%; adjusted hazard ratio [HR] 3.90; 95% confidence interval [CI], 2.37-6.42). This was observed in both older (≥50 years) and younger (40-50 years) age groups. Adjusted HR (95% CI) for the latter was 3.74 (1.65-8.48). This risk persisted after cessation of tamoxifen use. The risk of endometrial cancer was lower in sequenced AI when compared with tamoxifen-only users (adjusted HR 0.43; 95% CI, 0.25-0.72). Conclusions: Not only patients ≥50 years but also younger (40-49 years) patients with tamoxifen treatment had higher risk of subsequent endometrial cancer in this nation-wide cohort. We suggest regular gynecologic monitoring not only during active use but also during follow-up phase. Sequenced AI use may reduce the risk of endometrial cancer in tamoxifen-treated breast cancer patients.

Safety and efficacy of contained manual morcellation during laparoscopic or robotic gynecological surgery.

OBJECTIVE: To assess the safety and efficacy of contained manual morcellation (CMM) with a tissue pouch during minimally invasive robotic or laparoscopic surgeries. METHODS: A retrospective cohort study included women who underwent robotic or laparoendoscopic single-site surgery at a tertiary referral center between February 2014 and April 2017. The specimen was postoperatively contained, sliced into one or more long strips, and then pulled out. The surgical type, specimen containment time, containment failure rate, specimen weight, manual morcellation time, and overall CMM speed (g/min) were recorded. Surgical complications related (bowel or bladder injury, ureteral injury, vascular injuries, and tumor dissemination) or not related (delayed wound healing, infection, and hernia) to CMM were also documented. The patients were followed up for 2 years. RESULTS: A total of 165 cases were recorded, comprising 149 cases that underwent laparoscopic and 16 that underwent robotic gynecological surgeries. The average time for specimen containment and manual morcellation in CMM was 6.7 ± 5.0 and 13.2 ± 11.2 min, respectively. The mean morcellation speed was 25.1 ± 8.5 g/min. Among the specimens, those of the uterus with adenomyosis had the lowest CMM speed (21.4 ± 8.0 g/min), whereas those of the uterus with myoma had the highest speed (27.5 ± 8.9 g/min). The pouch perforation rate after CMM was 13.3% and no pouch-related complication was noted. CONCLUSION: CMM is an efficient method for specimen removal.

Current Treatments for Female Pelvic Floor Dysfunctions.

As global population aging, the issue of pelvic floor dysfunctions becomes increasingly. Millions of women were affected every year. The treatment of pelvic floor dysfunction has evolved in the past decade. This review aims to provide the current information on the treatment for female pelvic floor dysfunction, including pelvic organ prolapse (POP), urinary, fecal incontinence (FI), and myofascial pelvic pain among women. We used PubMed, Embase, and Web of Science to search for studies that were related to pelvic floor dysfunction regarding the POP, urinary, FI, and treatments. The development of laparoscopic surgery and synthetic and biological materials for pelvic floor reconstructive surgery were summarized. The surgical outcomes and complications of different pelvic floor reconstructive surgeries were compared. New devices for FI and the potential modified pelvic floor reconstructive surgery were also discussed here. Female pelvic medicine will continue to evolve for better treatment in the future. The pelvic floor reconstructive surgery tends to be minimally invasive approach with synthetic graft use.

A retrospective study of surgical treatment and outcome among women with adnexal torsion in eastern Taiwan from 2010 to 2015.

BACKGROUND: Adnexal torsion is a gynecologic emergency that requires surgical treatment. In this study, we reviewed the surgical outcomes of women with adnexal torsion in eastern Taiwan (Hualien county, area 4,629 km2, 330,000 residents). METHODS: This retrospective study included 42 women diagnosed with surgically-proven adnexal torsion from January 1, 2010, to September 31, 2015. We compared the symptoms, objective findings, and surgical outcomes of patients who underwent laparotomy or laparoscopy. RESULTS: The laparoscopy and laparotomy groups included 27 and 15 patients, respectively. The most common symptom and sign was abdominal pain, followed by nausea and vomiting. In all patients, an adnexal tumor was detected through ultrasound. The median and range of time from admission to surgery was 1.5 (1-11.5) and 1.0 (1-11) hours in the laparotomy and laparoscopy groups, respectively. Compared with those undergoing laparotomy, the smaller tumor size [7 (4.2-10) vs. 10 (7-17) cm] and shorter hospital stay [4 (2-8) vs. 6 (3-9) days] in patients undergoing laparoscopy were significantly noted, respectively (P < 0.01). No differences were observed in age, operative time, and blood loss between both groups. The surgeries performed were mostly detorsion with cystectomy and adnexectomy. The most common pathology was a simple ovarian cyst, followed by teratoma. Regarding the surgical types, older age is the only risk factor for radical surgery. DISCUSSION: Acute onset of abdominal pain with a presenting ovarian tumor is the most common feature of adnexal torsion. Laparoscopic surgical group showed a small tumor size and a short ER hospital stay than laparotomy. Older age is the risk factor for radical surgery.

Trends of Opportunistic Salpingectomy.

BACKGROUND AND OBJECTIVES: This study analyzed the trends of opportunistic salpingectomy (OS) accompanied by hysterectomy in a 9-year follow-up period at a single institute. METHODS: This retrospective cohort study included 1184 women at Hualien Tzu Chi Hospital from 2007 to 2015 who underwent hysterectomy performed with or without OS. Parameters including patient age, operating time, surgical approach, length of hospital stay, and perioperative complications were evaluated. RESULTS: There was an increase in the number of hysterectomies with OS (from 8% to 80%; P < .001) over the study period. Minimal additional operating time was necessary for hysterectomy with OS (3.7 and 3.6 minutes in open and laparoscopic surgery, respectively). No significant differences were observed in the risks of hospital readmission or blood transfusions between women who underwent hysterectomy with OS performed with the open approach and those who underwent the procedure using the laparoscopic approach. From 2007 to 2015, the proportion of open hysterectomies decreased from 56% to 6%. CONCLUSION: The results of this 9-year follow-up study revealed that, as a cancer prevention method, OS seems to be feasible and safe, requires minimal extra time, and does not increase the morbidity or long-term sequelae.

Concurrent use of Chinese herbal medicine among hormone users and its association with ischemic stroke risk: A population-based study.

ETHNOPHARMACOLOGICAL RELEVANCE: Previous studies had indicated that hormone therapy (HT) may increase the risk of ischemic stroke (IS) in menopausal women. However, little is known about the benefits and risks of use of Chinese herbal medicine (CHM) in conditions related to hormone use. The aim of this study is to explore the risk of IS in menopausal women treated with HT and CHM. MATERIALS AND METHODS: A total of 32,441 menopausal women without surgical menopause aged 40-65 years were selected from 2003 to 2010 using the 2-million random samples of the National Health Insurance Research Database in Taiwan. According to the medication usage of HT and CHM, we divided the current and recent users into two groups: an HT use-only group (n = 4989) and an HT/CHM group (n = 9265). Propensity-score matching samples (4079 pairs) were further created to deal with confounding by indication. The adjusted hazard ratios (HR) of IS were estimated by the robust Cox proportional hazards model. RESULTS: The incidence rate of IS in the HT/CHM group was significantly lower than in the HT group (4.5 vs. 12.8 per 1000 person-year, p < 0.001). Multivariate analysis results indicated that additional CHM use had a lower risk of IS compared to the HT group (HR = 0.3; 95% confidence interval [CI], 0.21-0.43). Further subgroup analyses and sensitivity analyses had similar findings. CONCLUSION: We found that combined use of HT and CHM was associated with a lower risk of IS. Further study is needed to examine possible mechanism underlying this association.

A review of ovary torsion.

Ovarian torsion is a rare but emergency condition in women. Early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity. Ovarian torsion refers to complete or partial rotation of the adnexal supporting organ with ischemia. It can affect females of all ages. Ovarian torsion occurs in around 2%-15% of patients who have surgical treatment of adnexal masses. The main risk in ovarian torsion is an ovarian mass. The most common symptom of ovarian torsion is acute onset of pelvic pain, followed by nausea and vomiting. Pelvic ultrasonography can provide information on ovarian cysts. Once ovarian torsion is suspected, surgery or detorsion is the mainstay of diagnosis and treatment.

Two-phase laparoendoscopic single-site cervical ligament-sparing hysterectomy: An initial experience.

OBJECTIVE: To report our initial experience with and the short-term outcomes of two-phase laparoendoscopic single-site cervical ligament-sparing hysterectomy (LESS-CLSH). MATERIALS AND METHODS: A retrospective case study included 40 women who underwent LESS-CLSH from January 2014 to December 2016 at Buddhist Tzu Chi General Hospital. Uterine specimens were extracted through contained manual morcellation with a tissue pouch. The first phase was LESS supracervical hysterectomy and conization of the internal orifice of the cervix. The second phase was transvaginal cervical conization and cylinderization. Women with a uterus diameter of >12 cm, a broad ligament myoma, or severe pelvic adhesion were categorized into a difficult group, and others were categorized into a nondifficult group. RESULTS: The difficult group required more time and had more blood loss than the nondifficult group. The mean surgical time was 187.2 ± 33.9 and 139.1 ± 20.7 min, and the mean blood loss was 533.3 ± 333.3 and 225.3 ± 168.2 mL in the difficult and nondifficult groups, respectively. The overall visual analog scale (VAS) pain scores at 0-4, 24, and 48 h after surgery were 7.1 ± 1.9, 4.2 ± 1.6, and 2.3 ± 1.5, respectively; no difference in the VAS pain scores, pain relief score, and hospitalization duration was observed between the two groups. Minor surgical complications or adverse events on follow-up were noted. Three months after surgery, the diameter and thickness of the cervix were decreased by approximately 0.5 and 1.0 cm, respectively. CONCLUSION: LESS-CLSH is a minimally invasive, safe, and feasible approach, even for difficult laparoscopic hysterectomy. Contained manual morcellation enables more controlled specimen removal than morcellation only.

Robotic single-site supracervical hysterectomy with manual morcellation: Preliminary experience.

AIM: To evaluate the feasibility, safety and peri- and postoperative outcomes of robotic single-site supracervical hysterectomy (RSSSH) for benign gynecologic disease. METHODS: We report 3 patients who received RSSSH for adenomyosis of the uterus from November 2015 to April 2016. We evaluated the feasibility, safety and outcomes among these patients. RESULTS: The mean surgical time was 244 min and the estimated blood loss was 216 mL, with no blood transfusion necessitated. The docking time was shortened gradually from 30 to 10 min. We spent 148 min on console operation. Manual morcellation time was also short, ranging from 5 to 10 min. The mean hospital stay was 5 d. Lower VAS pain score was also noted. There is no complication during or after surgery. CONCLUSION: RSSSH is feasible and safe, incurs less postoperative pain and gives good cosmetic appearance. The technique of in-bag, manual morcellation can avoid tumor dissemination.

Expression of Estrogen and Progesterone Receptor in Tumor Stroma Predicts Favorable Prognosis of Cervical Squamous Cell Carcinoma.

OBJECTIVES: The aim of this study was to investigate the expression of estrogen receptor α (ERα) and progesterone receptor B (PRB) in the stroma and carcinoma tissues of cervical cancer and their relationship to clinical characteristics and the status of human papillomavirus (HPV) infection. METHODS: Expressional levels of ERα and PRB in tissue blocks of 95 cervical carcinomas were independently scored by 2 pathologists. Human papillomavirus DNA, viral load, and genotypes were determined by polymerase chain reaction. Clinical characteristics were reviewed from chart and cancer registry. RESULTS: Estrogen receptor α and PRB were mainly expressed in the stroma but not in the carcinoma tissues of the cervical cancer, and their expressions were highly correlated. More stromal ERαs were found in early-stage tumors than in advanced-stage tumors. Greater stromal expressions of ERα and PRB were associated with a more favorable prognosis (P = 0.018 and P = 0.004, respectively). The expressions were not related to the differentiation of cancer, the status of HPV infection, the HPV load, or the genotype. In multivariate analysis, stromal ERα and PRB expressions were independently associated with a lower risk of mortality. The adjusted hazard ratios of mortality for low and high expressions of ERα were 0.19 (95% confidential interval [95% CI], 0.04-0.87) and 0.15 (95% CI, 0.03-0.81), respectively, whereas for low and high expressions of PRB hazard ratios were 0.46 (95% CI, 0.19-1.16) and 0.24 (95% CI, 0.06-0.96), respectively. CONCLUSIONS: This study showed that stromal ERα and PRB expressions are independent prognostic indicators of cervical squamous cell carcinoma.

Seprafilm® Application Method in Laparoscopic Surgery.

BACKGROUND AND OBJECTIVES: Postoperative adhesions occur less often in laparoscopies than in laparotomies, but the incidence can be reduced further. Seprafilm, a sodium hyaluronate/carboxymethylcellulose absorbable barrier, was developed to prevent adhesions after abdominal surgery, and is approved for postoperative adhesion prevention. However, Seprafilm is seldom used in laparoscopic surgery because of its tendency to break apart when it is inserted into the abdominal cavity through a trocar, resulting in a high placement failure rate. We propose a better method for applying the adhesion barrier Seprafilm in single- or multiport gynecologic surgery. METHODS: This is a retrospective analysis of patients who underwent multi- or single-port gynecologic laparoscopies from December 2014 through January 2016 in Buddhist Tzu Chi General Hospital, Hualien, 46 patients received Seprafilm (Genzyme Corp., Cambridge, MA, USA) via the proposed method. A piece of Seprafilm was cut into quarters. To moisten and soften the Seprafilm, each piece was placed on a wet wrung gauze until it became naturally curled. Two pieces of the film were rolled up with the backing paper that came from the package of Seprafilm. Holding the rolled Seprafilm with a grasper, the surgeon delivered it into the abdomen through a 11-mm trocar. RESULTS: The success rates of Seprafilm insertion and correct placement were 100% (46/46) and 95.7%, respectively. In 2 single-port (2/26) laparoscopic surgeries, the placement of the film failed; all placements in the multiport laparoscopic surgeries were successful (20/20). The average time required for placement of pieces of Seprafilm per surgery was 4.0 ± 1.47 minutes among all surgeries; significantly more time was needed in the single-port surgeries (mean, 4.4 ± 1.59 minutes) than in the multiport surgery (mean, 3.4 ± 1.13 minutes) (P < .05). CONCLUSIONS: This method of Seprafilm placement is a simple technique that does not need special equipment and ensures a high success rate. The placement of the film takes longer in single-port surgeries than in multiport surgeries.

Acute small bowel obstruction caused by barbed suture on the second day after laparoscopic hysterosacropexy: A case report and literature review.

OBJECTIVE: To report a case of small bowel obstruction caused by barbed suture applied in hysterosacropexy, and possible solutions. CASE REPORT: A 57-year-old woman underwent laparoscopic hysterosacropexy for a Stage 2 uterine prolapse, presenting with acute abdominal pain and a bowel obstruction syndrome 2 days following the surgery. Conservative treatment was given, but the symptoms did not improve and gradually became worse. Diagnostic laparoscopy was performed on the 7th day after the hysterosacropexy, and the volvulus was found. The residual end of the barbed V-Loc adopted in the peritoneal closure was incidentally hooked to the mesentery and caused small bowel obstruction. The redundant V-Loc was released and cut off at 2 cm. Neither bowel ischemia nor significant bowel injury was noted. Two days later, she was discharged without complication. CONCLUSION: A barbed suture has a risk of bowel obstruction when used in surgery. To avoid a grave prognosis, early diagnosis and prompt management of complication is necessary.

Antiestrogen use in breast cancer patients reduces the risk of subsequent lung cancer: A population-based study.

BACKGROUND: There is accumulating epidemiological and preclinical evidence that estrogen might be a driver of lung cancer. Breast cancer survivors can offer a unique patient cohort to examine the effect of antiestrogen therapy on lung cancer carcinogenesis because many of these women would have received long-term selective estrogen receptor modulators (SERMs) and/or aromatase inhibitors (AIs) as adjuvant treatment. Our hypothesis is that estrogens play a role in lung cancer development, and that antiestrogen therapy would affect the incidence of subsequent lung cancer among breast cancer survivors. METHODS: Using the Taiwan National Health Insurance (NHI) database, the study included 40,900 survivors of non-metastatic breast cancer after primary surgery, and most antiestrogen users complied well with the medication regimen. We evaluate the effect of antiestrogen therapy on the incidence of subsequent lung cancers. RESULTS: This population-based study revealed that antiestrogen use in breast cancer patients was associated with a reduced risk of subsequent lung cancer in older patients (≥50 years) (HR 0.73, 95%CI 0.54-0.99) when compared with breast cancer survivors who did not use antiestrogens. CONCLUSION: The study supports the hypothesis that antiestrogen therapy modifies lung cancer carcinogenesis in older women. Further well-designed clinical trials to explore the potential of antiestrogens in lung cancer prevention and treatment would be worthwhile.

How the silent mentor program improves our surgical level and safety and nourishes our spiritual life.

We briefly share our experience of using the silent mentor program in the Medical Simulation Center (MSC) of Tzu Chi University (TCU), Hualien, Taiwan, to improve our minimally invasive surgical level and patient's safety. The silent mentor program, established in 2000 by the Department of Anatomy of TCU, is a pioneering clinical skill training program based on unembalmed bodies. This program provides three valuable advantages for surgery. The first is the comprehensive understanding of the deep or rarely observed but crucial structures of the human body, which is normally difficult to achieve in living humans. The second is gaining the first experience of a novel procedure or surgery on silent mentors rather than on living humans, which is essential for young surgeons to begin their careers. The third is evaluating the safety and feasibility of a novel surgical method. In addition to surgical techniques, the most valuable point of the program is the humane ceremonies conducted for silent mentors to nourish our soul. After the workshop, all the incision wounds on every silent mentor were carefully checked and sutured in the same manner as in closing surgical wounds in a patient. Subsequently, encoffining, cremation, and thanksgiving ceremonies were solemnly held, in the hope that the medical students or trainees would imperceptibly understand their responsibility to society and the silent mentor's expectations. The Asia-Pacific Association for Gynecologic Endoscopy and Minimally Invasive Therapy, or the Taiwan Association for Minimally Gynecology Therapy, or both can consider initiating a regular silent mentor program in the MSC of TCU. It is not only intended to improve the skills of surgeons but also to allow them to participate in the interactive ceremony and thus refresh their humanitarian knowledge.

Endometrial adenomyoma polyp caused postmenopausal bleeding mimicking uterine malignancy.

This case report presents a 66-year-oId postmenopausal woman with a case of endometrial adenomyomatous polyp (EAP) that presented as postmenopausal vaginal bleeding and mimicked endometrial cancer. The ultrasonography revealed a mildly enlarged uterus approximately 7.1 cm × 3.7 cm in size. The endometrium was 1.9 cm in diameter. The findings of magnetic resonance image (MRI) comprised abnormal intrauterine lesions with multiloculated cystic components. Endometrial biopsy by Pipelle was performed, and revealed hematoma. The hysteroscopy was then arranged, and two polypoid tumors were found. Tumor resection was performed, and the histology of the tumor was adenomyoma. EAP is a rare benign tumor of the uterus that is not easy to differentiate from endometrial cancer by ultrasound or MRI. Hysteroscopy is recommended when the results of tissue sampling by Pipelle differ from the image findings.

Hysterectomy and ovarian cystectomy using natural orifice transluminal endoscopic surgery: An initial experience at Tzu Chi General Hospital.

OBJECTIVES: The objective of this study is to report our initial experience with patients undergoing transvaginal natural orifice transluminal endoscopic surgery (NOTES). MATERIALS AND METHODS: From September 2016 to December 2016, patients who were not virgins and did not have pelvic inflammation or obliteration of the cul-de-sac who underwent NOTES hysterectomy or ovarian cystectomy (OC) were included in the study. RESULTS: Transvaginal NOTES was performed smoothly in six patients, two patients (mean age 35 years, mean body mass index [BMI] 25) received an OC and four patients (mean age 49 years, mean BMI 27) underwent a hysterectomy. One patient with a hysterectomy received concurrent adhesiolysis. The mean surgical times were 74 and 75 min and blood loss was 50 and 87.5 ml in the OC and hysterectomy groups, respectively. One patient with a hysterectomy had a postoperative fever with 38°C last for 2 days. Pain scores were 0 at 48 h postoperatively in both groups. CONCLUSION: Transvaginal NOTES is a feasible and safe technique for hysterectomy and OC in our patients and those in previous reports. This procedure was minimally invasive with no scars on the abdomen as well as little pain.

Antiestrogen use reduces risk of cervical neoplasia in breast cancer patients: a population-based study.

Estrogen has been proven to be a necessity for cervical carcinogenesis by transgenic mice studies. To determine whether long-term antiestrogens use could reduce the incidence of cervical neoplasia, a population-based cohort of 42,940 breast cancer patients with and without antiestrogen therapy were identified from the Taiwan National Health Insurance Database. All patients were followed for the most severe form of cervical neoplasia or until death. Their risks of cervical neoplasia were compared with Cox regression analysis and adjusted for age, Pap smear density and chemotherapy. Aromatase inhibitor (AI)-included antiestrogen users consistently exhibited a lower risk of low-grade cervical dysplasia [adjusted hazard ratio (HR) = 0.42, 95% CI 0.29 to 0.64, P < 0.0001] in the five-year follow-up analysis and in subgroup of regular Pap screenings (HR = 0.32, 95% CI, 0.20 to 0.50, P < 0.0001). A lower 10-year incidence of high-grade cervical dysplasia was also noted in the regular-screening group (HR = 0.49; 95% CI, 0.27 to 0.90; P = 0.0212), especially in the ≥ 50 years old group (HR = 0.34; 95% CI, 0.14 to 0.80; P = 0.014). The protection effect of Tamoxifen-only use for low-grade cervical dysplasia was only found in the young-age, regular-screening group (HR = 0.67; 95% CI, 0.48 to 0.93; P = 0.0167).In short, long-term use of AI-included antiestrogen conferred a lower risk of cervical neoplasia.