Reduction of cycles of neoadjuvant chemotherapy for advanced epithelial ovarian, fallopian or primary peritoneal cancer (ROCOCO): study protocol for a phase III randomized controlled trial.

BACKGROUND: Primary debulking surgery (PDS) and adjuvant chemotherapy is the standard treatment for advanced ovarian, fallopian or primary peritoneal cancer. However, neoadjuvant chemotherapy (NAC) followed by interval debulking surgery (IDS) has been introduced as an alternative, showing similar efficacy and decreased postoperative complications compared with PDS. Although there is still no evidence for whether three or four cycles of NAC used clinically could be adequate, reducing one cycle of NAC is expected to remove more visible tumours and thereby improve prognosis. Thus, we proposed with this study to evaluate the efficacy and safety of reducing one cycle of NAC for advanced ovarian, fallopian or primary peritoneal cancer. METHODS: This study is a prospective, multi-centre, open-label, randomized phase III trial. A total of 298 patients with advanced ovarian, fallopian or primary peritoneal cancer will be recruited and randomly assigned to either three (control group) or two cycles of NAC (experimental group). After the NAC, we will conduct IDS with maximal cytoreduction and then administer the remaining three or four cycles for a total of six cycles of adjuvant chemotherapy. The primary end point is progression-free survival, and the secondary end points are time to tumour progression, overall survival, tumour response after NAC, IDS and adjuvant chemotherapy, radiologic investigation after IDS, tumour response by positron emission tomography-computed tomography after NAC, quality of life, adverse events, success rate of optimal cytoreduction, surgical complexity, postoperative complications and safety of IDS. We will assess these factors at screening, at every cycle of chemotherapy, at IDS, after the completion of chemotherapy, every 3 months for the first 2 years after the planned treatment and every 6 months thereafter for 3 years. DISCUSSION: We hypothesize that reducing one cycle of NAC will contribute to more resection of visible tumours despite 10% reduction of optimal cytoreduction, which could improve survival. Moreover, two cycles of NAC may increase postoperative complications by 5% compared with three cycles, which may be acceptable. TRIAL REGISTRATION: This study has been prospectively registered at ClinicalTrials.gov on Oct. 2nd, 2018 (NCT03693248, URL: https://clinicaltrials.gov/ct2/show/NCT03693248).

Anti-Hu antibody-mediated limbic encephalitis associated with cervical cancer: A case report.

A 55-year-old postmenopausal and multiparous woman presented to our department with recent memory disturbances associated with rapidly progressive positive Anti-Hu antibodies. She was subsequently diagnosed with anti-Hu antibody-related paraneoplastic limbic encephalitis. Clinical examination and imaging studies revealed a bulky cervical tumor with both parametrial and vaginal fornix extension; biopsy confirmed the tumor as cervical squamous cell carcinoma. In this case, we encountered a patient with anti-Hu-mediated paraneoplastic limbic encephalitis with a subsequent diagnosis of cervical cancer.

Comparison of cervical lengths using transabdominal and transvaginal sonography in midpregnancy.

OBJECTIVES: Cervical length assessment is helpful to predict and prevent preterm birth. However, transvaginal sonography is not easy to perform. The aim of this study was to investigate the relationship and discrepancies between cervical lengths measured by transabdominal and transvaginal sonography in midpregnancy. METHODS: Transabdominal and transvaginal cervical lengths were measured in 255 pregnant women between 20 and 29 gestational weeks. The discrepancies in cervical lengths between the two methods were analyzed for the following maternal and fetal conditions: (1) vertex versus breech fetal presentation, (2) whether the fetal presenting part overlay the cervical internal os, (3) whether both the internal os and external os were visible or only the internal os was clearly visible, (4) maternal bladder filling status, (5) maternal age, (6) parity, and (7) gestational age. RESULTS: The mean cervical lengths were not significantly different (mean ± SD, 3.88 ± 0.73 cm on transabdominal sonography and 3.93 ± 0.72 cm on transvaginal sonography; P = .129; Pearson r = 0.75). The 5th-percentile transabdominal cervical length was 26.0 mm, and the transvaginal length was 27.8 mm. There were significant discrepancies between the two methods in the cases in which a fetal presenting part overlay the internal os, in the cases in which the external os was not clearly visible, and in primiparous women. Transabdominal cervical measurements were consistently shorter than transvaginal measurements in the cases with discrepancies. CONCLUSIONS: Transabdominal cervical length measurements are correlated with transvaginal measurements overall, and the transabdominal length is consistently shorter than the transvaginal length in cases with discrepancies. Transabdominal sonography could be used as a cervical length screening tool.

Initial Preoperative Hemoglobin Level Affects the Rate of Decline in Anti-Müllerian Hormone Levels after Laparoscopic Ovarian Cystectomy in Women with Ovarian Endometriosis.

OBJECTIVES: To determine the factors affecting the decline in ovarian reserve following laparoscopic ovarian cystectomy (LOC) in women with ovarian endometriosis. METHODS: This retrospective study included 22 women, aged 25-45 years, with regular menstrual cycles who underwent unilateral LOC and were diagnosed with ovarian endometriosis at a university hospital. Blood samples were collected preoperatively and on the third postoperative day to determine the serum anti-Müllerian hormone (AMH) levels for assessment of the decline in ovarian reserve during the early postoperative period. RESULTS: The preoperative hemoglobin level, white blood cell count, and AMH level were associated with changes in the AMH level after unilateral LOC. Among these parameters, only the preoperative hemoglobin level was correlated with the rate of decline in postoperative AMH levels. The preoperative serum AMH level was correlated with the amount of postoperative AMH change but not with its rate of decline. CONCLUSIONS: Preoperative hemoglobin levels may be associated with the rate of decline in AMH levels in the early postoperative period after unilateral LOC.

Using Type I Collagen Gel to Prevent Postoperative Intrauterine Adhesion: A Multicenter Retrospective Study.

We evaluated the clinical outcomes of using type 1 collagen gel after therapeutic resectoscopy; overall, 150 women aged > 20 who planned to undergo therapeutic resectoscopy were enrolled. The patients were randomly assigned to either of the anti-adhesive treatment groups: the type 1 collagen gel (Collabarrier®) (study group; N = 75) or the sodium hyaluronate and sodium carboxymethylcellulose gel group (control group; N = 75) after resectoscopy. One month after applying anti-adhesive materials, postoperative intrauterine adhesions were evaluated using second-look hysteroscopy; the incidence rate of postoperative intrauterine adhesions examined through second-look hysteroscopy showed no significant differences between the groups. There were no statistical differences between the frequency and mean scores of the type and intensity of adhesions in both groups. Finally, no significant differences in adverse events, serious adverse events, adverse device effects, and serious adverse device effects were noted between the two groups; type 1 collagen gel can be effectively and safely used in intrauterine surgery to minimize postoperative adhesions, thereby eventually decreasing the prevalence of infertility, secondary amenorrhea, and recurrent pregnancy loss in reproductive women.

Up-regulation of inhibitors of DNA binding/differentiation gene during alendronate-induced osteoblast differentiation.

PURPOSE: To investigate the effect of alendronate on the expression of Id genes in osteoblast differentiation. METHODS: C2C12 cells were treated with alendronate for various concentrations and time periods. For evaluation of alendronate-induced osteoblast differentiation in C2C12 cells, alkaline phosphatase (ALP) activity was measured. The expression of osteoblast differentiation markers such as ALP, type-1 collagen (Col 1), and osteocalcin (OCN), and the expression of Id-1 and Id-2 were measured by RT-PCR. In order to understand the mechanism underlying the regulation of Id genes, the promoter region of the Id-1 gene was identified. Database analysis of the promoter region for Id-1 using known consensus sequences identified several putative response elements, including CCAAT/enhancer-binding protein beta (C/EBPß). RESULTS: Alendronate treatment significantly increased not only ALP activity but also the expression of ALP, Col 1, and OCN, Id-1 and Id-2. C/EBPß and alendronate cooperatively increased the promoter activity and expression of Id-1. CONCLUSIONS: These results suggest that C/EBPß-mediated Id-1 transcriptional activation may regulate alendronate-induced osteoblast differentiation of C2C12 cells.

Factors Associated with Cyto-Histological Misinterpretation of Cervical Smear according to Menopausal Status.

OBJECTIVES: This study aimed to compare histological outcomes between pre-menopausal and post-menopausal women with cervical cytological abnormalities and to investigate the clinical factors affecting the misinterpretation of cytology and histology. METHODS: We conducted a retrospective analysis of 599 patients with abnormal cervical cytology who underwent loop electrosurgical excision procedure (LEEP) between January 2010 and May 2019. Baseline characteristics were collected, including age, height, weight, body mass index, gravity, parity, and menopausal status. In total, 477 pre-menopausal women and 122 post-menopausal women were recruited. RESULTS: Atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions were cytologically observed in 73.4% (135/184) of the pre-menopausal women, which were high-grade lesions confirmed by LEEP. In post-menopausal patients with cytology results that cannot exclude high-grade squamous intraepithelial lesions (ASC-H) or high-grade squamous intraepithelial lesions (HSIL), 27.0% (24/89) were confirmed to have histologically low-grade lesions. High-risk HPV (hrHPV) prevalence in abnormal cervical smears was 92.2%. Moreover, other hrHPVs had a higher risk of unexpected histological outcomes unrelated to cytologic results. CONCLUSIONS: Menopausal status and HPV infection are associated with misinterpretation of cervical cytology and histology. Therefore, the menopausal status of patients should be considered for the management of cervical cytology, and primary co-testing is recommended to identify women at risk of cervical abnormalities.

Effect of Hysterectomy on Ovarian Reserve in the Early Postoperative Period Based on the Type of Surgery.

OBJECTIVES: This study aimed to evaluate the influence of simple hysterectomy on the ovarian reserve based on the type of surgery. METHODS: Eighty-six premenopausal women between 31 and 48 years who underwent hysterectomy for benign gynecologic disease without additional adnexal surgery at a university hospital participated in this study. Seventy-one patients underwent laparoscopy-assisted vaginal hysterectomy (LAVH), and 15 patients underwent abdominal hysterectomy (AH). Blood samples were obtained from all study participants on preoperative day and 3 days after the operation to determine the anti-Müllerian hormone (AMH) levels. RESULTS: The postoperative reduction of the mean serum AMH level in the LAVH group (0.42 ± 0.76 ng/mL) was greater than that in the AH group, although the difference was not statistically significant (0.01 ± 0.60 ng/mL) (P = 0.053). The mean baseline AMH level (2.59 ± 2.33 ng/mL) was significantly reduced to 2.24 ± 2.08 ng/mL at 3 days after hysterectomy, and the mean rate of decline of AMH levels after surgery was 13.61% ± 30.81%. In subgroup analysis based on the type of surgery, the mean serum AMH level decreased significantly after surgery in the LAVH group, but no significant changes were found in serum AMH levels before and after the surgery in the AH group. CONCLUSIONS: These preliminary results suggest that simple hysterectomy affects the early postoperative decline of ovarian reserve, and these results might vary depending on the type of surgery.

Effect of gynecological cancer and its treatment on bone mineral density and the risk of osteoporosis and osteoporotic fracture.

OBJECTIVE: The purpose of this study was to evaluate the risk of osteopenia and osteoporosis by examining the bone mineral density (BMD) of the lumbar spine and femur in patients with gynecological cancer without bone metastasis and to evaluate the impact of treatment for different cancers on BMD. METHODS: This study retrospectively reviewed the medical records of 243 women with gynecological cancer and 240 controls between March 2010 and December 2016. Patients with cervical cancer (n=105), endometrial cancer (n=63), and ovarian cancer (n=75) were treated with total hysterectomy including bilateral salpingo-oophorectomy and/or chemotherapy and/or radiotherapy. For the control group, healthy post-menopausal women without gynecologic cancer were selected. RESULTS: Before anticancer treatment, the BMD of patients with cervical cancer and ovarian cancer was significantly lower than that of the controls, and the BMD of patients with endometrial cancer was not significantly different from that of the controls. However, the BMD of endometrial cancer significantly decreased after treatment. According to the treatment methods, there were significant differences in the BMD of L3, L4, and the femur neck. Changes in the BMD were lowest in patients who underwent surgical treatment only, and the highest bone loss was found in patients who underwent postoperative concurrent chemoradiotherapy. CONCLUSION: Patients with cervical and ovarian cancer had lower BMD than those in the control group before treatment, and patients with endometrial cancer had decreased bone density after treatment. Therefore, during the treatment of gynecological cancer, strategies should be implemented to mitigate these risks.

Large Cell Neuroendocrine Carcinoma of the Cervix with Sequential Metastasis to Different Sites: A Case Report.

Neuroendocrine carcinoma of the cervix is rare, and prognosis is very poor. Because of its rarity, effective treatment of neuroendocrine carcinoma of the cervix has not been established. It has distinct patterns of metastasis, but can be successfully treated with radical surgery and platinum-based chemotherapy. We report a 50-year-old woman who was diagnosed with large cell neuroendocrine carcinoma of the cervix and underwent radical surgery followed by adjuvant chemoradiation therapy. She experienced recurrence several times and to different sites, with sequential metastasis to the lung, breast, and retroperitoneum, but nevertheless survived more than 5 years.

A Case of Uterine Carcinosarcoma Detected Simultaneously with Breast and Colon Cancer (Triple Primary Malignant Tumor).

Uterine carcinosarcoma, also known as malignant mixed Mullerian tumor of the uterus, is rare and rarely diagnosed simultaneously with cancers in other organs. We report a case of a 63-year-old woman who was simultaneously diagnosed with uterine carcinosarcoma, breast cancer, and colon cancer.

Monocytosis as a prognostic factor for survival in stage IB and IIA cervical cancer.

Objective: To measure hematologic parameters derived from the white blood cell (WBC) count and differential count (DC) as prognostic factors for survival in patients with stage IB and IIA cervical cancer. Methods: We retrospectively examined demographic, clinicopathologic, and laboratory parameters in a cohort of 233 patients with International Federation of Gynecology and Obstetrics stage IB and IIA cervical cancer who underwent surgical resection. We further assessed the effects of the WBC count and DC-derived hematologic parameters on progression-free survival (PFS) and overall survival (OS) after controlling for other parameters. Results: Patients were followed up for a median of 46.6 months (range, 9-142 months). The Kaplan-Meier estimates of PFS and OS at 5 years were 88.5% and 92.3%, respectively. In a multivariate analysis, we identified the absolute monocyte count (AMC) (hazard ratio [HR], 11.78; P <0.001) and tumor size (HR, 5.41; P = 0.003) as the strongest prognostic factors affecting PFS. We also identified AMC (HR, 23.29; P <0.001), tumor size, (HR, 5.27; P = 0.033), and lymph node involvement (HR, 3.90; P = 0.027) as the strongest prognostic factors affecting OS. AMC remained prognostic with respect to PFS or OS in a Cox model that controlled for the neutrophil-lymphocyte ratio or lymphocyte-monocyte ratio, although neither ratio was a significant prognostic factor for survival. Conclusions: Monocytosis and an increased tumor size were found to be independent prognostic factors affecting both PFS and OS in patients with stage IB and IIA cervical cancer.

Practice guidelines for management of ovarian cancer in Korea: a Korean Society of Gynecologic Oncology Consensus Statement.

Since after 2006 when the first edition of practice guidelines for gynecologic oncologic cancer treatment was released, the Korean Society of Gynecologic Oncology (KSGO) has published the following editions on a regular basis to suggest the best possible standard care considering updated scientific evidence as well as medical environment including insurance coverage. The Guidelines Revision Committee was summoned to revise the second edition of KSGO practice guidelines, which was published in July 2010, and develop the third edition. The current guidelines cover strategies for diagnosis and treatment of primary and recurrent ovarian cancer. In this edition, we introduced an advanced format based on evidence-based medicine, collecting up-to-date data mainly from MEDLINE, EMBASE, and Cochrane Library CENTRAL, and conducting a meta-analysis with systematic review. Eight key questions were raised by the committee members. For every key question, recommendations were developed by the consensus meetings and provided with evidence level and strength of the recommendation.

Metastatic uterine cancer looking as cervical fibroid in recurrent breast cancer woman: a case report.

Metastasis to the female genital tract from extragenital primary cancer is uncommon. In this case, a 46-year-old woman was diagnosed with invasive lobular carcinoma of the left breast in 2011. She had left breast conserving surgery, chemotherapy, radiation, and hormonal therapy (gosereline and tamoxifen). However, she developed menorrhagia after interruption of hormonal therapy and incidentally, the ultrasonogram of her pelvis showed a solid, large mass in the cervix. It looked like leiomyoma. Because of massive vaginal bleeding requiring multiple blood transfusions, she underwent total hysterectomy with bilateral salpingo-oophorectomy. Unexpectedly, however, histopathological examination revealed metastatic carcinoma, consistent with breast origin.The metastatic tumor involved the uterine corpus with spreading to the endocervix, left ovary, and multiple lymphovascular invasion was present. We described the rarity and risk of metastatic uterine cancer in patient with history of malignant tumor treatment.

Comparison of early postoperative decline of serum antiMüllerian hormone levels after unilateral laparoscopic ovarian cystectomy between patients categorized according to histologic diagnosis.

OBJECTIVE: To evaluate the change of ovarian reserve after unilateral laparoscopic ovarian cystectomy (LOC) in the early postoperative period between patients divided according to histologic diagnosis of cyst type. MATERIALS AND METHODS: Sixty-five patients who were undergoing unilateral LOC for benign ovarian disease were included in this study. All participants were divided into three groups according to histologic diagnosis: endometrioma (n=26), mature teratoma (n=24), and other benign cyst (n=15). Serum samples were collected preoperatively and 3-days postoperatively and assayed for antiMüllerian hormone (AMH) levels, and the changes between the two samples were analyzed. RESULTS: Preoperative AMH levels were not significantly different between the three groups. On postoperative Day 3 AMH levels of all three groups were significantly reduced compared with preoperative AMH levels. The rates of decline of AMH levels after LOC in patients with endometrioma (26.37±20.70%) and in those with teratoma (28.25±22.16%) were both significantly higher than those with other benign cyst (12.03±18.56%). No statistically significant differences were found in the rate of decline of AMH levels between patients with endometrioma and teratoma. Decline of AMH after LOC was not significantly correlated with age, body mass index, the size of cyst, or preoperative AMH levels. CONCLUSION: Our results suggest that ovarian reserve is reduced after unilateral LOC in the early postoperative period, and that the postoperative decline of AMH levels after LOC is similar between patients with endometrioma and those with mature teratoma.

The Lymphocyte-Monocyte Ratio Predicts Patient Survival and Aggressiveness of Endometrial Cancer.

OBJECTIVE: We assessed the prognostic implications of preoperative lymphocyte-monocyte ratio (LMR) in patients with endometrial cancer (EC). METHODS: We retrospectively examined the LMR as a prognostic variable in a cohort of 255 patients with EC who underwent surgical resection. Patients were categorized into two groups according to the LMR (LMR-low and LMR-high) using cutoff points determined by receiving operator characteristic (ROC) curve analysis. The primary objective was to correlate the LMR to clinicopathological factors; the secondary objective was to determine the survival significance of the LMR in patients with EC. RESULTS: Using data from the entire cohort, the most discriminative LMR cutoff value selected on the ROC curve was 3.28 for both disease-free survival (DFS) and overall survival (OS). The LMR-low and LMR-high groups included 33 (12.9%) and 222 patients (87.1%), respectively. The 5-year DFS rates in the LMR-low and LMR-high groups were 64.5 and 93.9% (P < 0.0001), respectively, and the 5-year OS rates in the two groups were 76.7 and 96.5% (P < 0.0001), respectively. On multivariate analysis, we identified histologic grade, International Federation of Gynecology and Obstetrics (FIGO) stage, and LMR levels as the strongest prognostic factors affecting DFS (P = 0.0037, P < 0.0001, and P < 0.0001, respectively), and FIGO stage and the LMR as the strongest prognostic factors predicting OS (P < 0.0001 and P < 0.0001, respectively). CONCLUSION: The LMR is an independent prognostic factor for both DFS and OS after surgical resection, and it provides additional prognostic value beyond standard clinicopathological parameters.

The Prognostic Value of Circumferential Resection Margin Involvement in Patients with Extraperitoneal Rectal Cancer.

The prognostic influence of circumferential resection margin (CRM) status in extraperitoneal rectal cancer probably differs from that of intraperitoneal rectal cancer because of its different anatomical and biological behaviors. However, previous reports have not provided the data focused on extraperitoneal rectal cancer. Therefore, the aim of this study was to examine the prognostic significance of the CRM status in patients with extraperitoneal rectal cancer. From January 2005 to December 2008, 248 patients were treated for extraperitoneal rectal cancer and enrolled in a prospectively collected database. Extraperitoneal rectal cancer was defined based on tumors located below the anterior peritoneal reflection, as determined intraoperatively by a surgeon. Cox model was used for multivariate analysis to examine risk factors of recurrence and mortality in the 248 patients, and multivariate logistic regression analysis was performed to identify predictors of recurrence and mortality in 135 patients with T3 rectal cancer. CRM involvement for extraperitoneal rectal cancer was present in 29 (11.7%) of the 248 patients, and was the identified predictor of local recurrence, overall recurrence, and death by multivariate Cox analysis. In the 135 patients with T3 cancer, CRM involvement was found to be associated with higher probability of local recurrence and mortality. In extraperitoneal rectal cancer, CRM involvement is an independent risk factor of recurrence and survival. Based on the results of the present study, it seems that CRM involvement in extraperitoneal rectal cancer is considered an indicator for (neo)adjuvant therapy rather than conventional TN status.

The Lymphocyte-Monocyte Ratio Predicts Patient Survival and Aggressiveness of Ovarian Cancer.

OBJECTIVE: To measure the prognostic value of the lymphocyte-monocyte ratio (LMR) in patients with epithelial ovarian cancer (EOC). METHODS: We retrospectively examined the LMR as a prognosticator in a cohort of 234 patients with EOC who underwent surgical resection. Patients were categorized into two different groups based on the LMR (LMR-low and LMR-high) using cut-off values determined by receiver operating characteristic (ROC) curve analysis. The objective of the study was to assess the effect of the LMR on progression-free survival (PFS) and overall survival (OS), and to validate the LMR as an independent predictor of survival. RESULTS: Using the data collected from the whole cohort, the optimized LMR cut-off value selected on the ROC curve was 2.07 for both PFS and OS. The LMR-low and LMR-high groups included 48 (20.5%) and 186 patients (79.5%), respectively. The 5-year PFS rates in the LMR-low and LMR-high groups were 40.0 and 62.5% (P < 0.0001), respectively, and the 5-year OS rates in these two groups were 42.2 and 67.2% (P < 0.0001), respectively. On multivariate analysis, we identified age, International Federation of Gynecology and Obstetrics (FIGO) stage, and cancer antigen 125 levels to be the strongest valuable prognostic factors affecting PFS (P = 0.0421, P = 0.0012, and P = 0.0313, respectively) and age, FIGO stage, and the LMR as the most valuable prognostic factors predicting OS (P = 0.0064, P = 0.0029, and P = 0.0293, respectively). Conclusion : The LMR is an independent prognostic factor affecting the survival of patients with EOC.

Alternative surgical approaches for aggressive angiomyxoma at different sites in the pelvic cavity.

Aggressive angiomyxoma, a rare soft tissue benign neoplasm, predominantly occurs in the female pelvic peritoneum and perineum region during reproductive age. It is slow growing, locally infiltrative, and has a high risk of local recurrence and the neoplastic character of blood vessels. The standard treatment is surgery. We report three unusual aggressive angiomyxoma cases. The first case was a pedunculated mass of the left labium major; the second, a left perineal mass that infiltrated into the paravesical area via the obturator foramen; and the third, a big mass in the retroperitoneal cavity, found that growing aggressive angiomyxoma looked like lava expulsion in the pelvic area. After a thorough examination and full radiologic workup, we performed surgical excision in each patient via different approaches. Histopathologic findings were consistent with diagnosis of aggressive angiomyxoma. To date, no relapse has been observed.

Risk factors for malignant transformation of mature cystic teratoma.

OBJECTIVE: The aim of this study was to investigate the preoperative characteristics of benign mature cystic teratoma (MCT) and struma ovarii and their risk factors associated malignancies, and determine the appropriate treatment options for these tumors. METHODS: This was a retrospective study on 248 patients who were pathologically diagnosed with ovarian MCT, struma ovarii, or malignant transformations of these tumors at Inje University Haeundae Paik Hospital from March 2010 to January 2015. Routinely evaluated results of adnexal masses before surgery were compared. RESULTS: A total of six patients (2.4%) were confirmed to have malignant tumors. Of the struma ovarii patients, two out of five patients (40%) were confirmed to have malignancy. The mean age at the diagnosis of patients with malignant transformation of teratomas was 43.0 years (range, 27 to 67 years), which was higher than that of patients with benign teratomas (36.5 years). The mean diameter of the tumor before surgery in the malignant tumor group was 11.4 cm and larger than 6.5 cm of benign group (P=0.003). The mean CA-125 level in the malignant tumor group was higher than that in the benign tumor group (P=0.01). CONCLUSION: Risk factors for malignant transformation of MCT include elevated CA-125 levels, older age, large tumor masses, and postmenopausal status.