Sertoli-Leydig cell tumor of the ovary: analysis of a single institution database.

AIM: To evaluate the clinicopathological features, management, survival and prognostic factors of patients with Sertoli-Leydig cell tumors of the ovary (SLCT) managed at a single institution. MATERIAL AND METHODS: The clinical records of patients with Sertoli-Leydig cell tumors of the ovary managed at the KK Women's and Children's Hospital, Singapore, between October 1998 and December 2008 were reviewed. Data of pathological features, treatment given and progress on follow-up was studied. RESULTS: Sertoli-Leydig cell tumor of the ovary accounted for 1.3% of malignant ovarian neoplasms. The median age of the patient was 30 years. The most common mode of presentation was with hormonal-related symptoms (80%) in the form of secondary amenorrhea, irregular menses and features of virilization. Thirteen of the 15 patients underwent surgical staging and all were found to have stage-I disease at the time of diagnosis. Ten patients with intermediate and poorly differentiated tumors received adjuvant bleomycin, etoposide and cisplatin (BEP) chemotherapy. Recurrent disease was detected in two patients (13.3%) during a median follow-up of 63 months, both of whom had poorly differentiated type of tumor. Both these patients underwent optimal debulking surgery followed by postoperative chemotherapy (BEP regimen). There were no disease -elated deaths and all patients were under complete remission at the last follow-up. CONCLUSION: As most Sertoli-Leydig cell tumors of the ovary are seen in young women and detected while still in the early stages, a favorable outcome can be achieved by conservative surgery. Patients with moderate and poorly differentiated types of tumors benefit from adjuvant chemotherapy. Recurrences tend to occur early and are commonly seen in patients with poorly differentiated tumors.

Stage 1C grade 3 endometrial cancer: the KK Hospital gynaecological oncology group experience.

OBJECTIVE: It is our standard of care to include pelvic lymph node dissection (PLND) in the staging of endometrial cancer, followed by adjuvant vaginal vault brachytherapy. We report our experience and outcome of patients with stage 1C grade 3 endometrial cancer from KK Hospital Singapore. METHODS: Records of patients with a diagnosis of stage 1C grade 3 endometrial cancer (based on the 1988 FIGO [International Federation of Gynecology and Obstetrics] staging system) from 1995 to 2008 were retrospectively reviewed. Details of surgery, chemotherapy, and radiotherapy were recorded, as were prognostic factors such as histological subtype and number of lymph nodes removed. Dates and sites of relapses were noted. RESULTS: A total of 31 cases were reviewed; 29 had sufficient records to be analyzed, of which one was excluded as she had a second primary cancer (breast). Median follow-up was 50.1 months (15.5-154 months). All cases underwent total hysterectomy and bilateral salpingo-oophorectomy; the majority (22 [76%]) had PLND as well. Those who did not undergo PLND received external beam radiotherapy instead. All but 1 case received postoperative vaginal vault brachytherapy. Eight of 10 patients with nonendometrioid adenocarcinoma (eg, clear cell) histology also received adjuvant chemotherapy. There were 5 systemic relapses (17.9%) and 1 pelvic recurrence (3.6%). The 5-year disease-free survival is 78.6%. No serious (grade 3 or 4) adverse effects were recorded. CONCLUSION: Pelvic lymph node dissection and vaginal vault brachytherapy seem to be effective in preventing locoregional recurrences, with few associated adverse effects. However, the rate of systemic relapse is relatively high. Adjuvant chemotherapy should also be considered for cases with poor prognostic factors.

Leiomyomatosis peritonealis disseminata and subcutaneous myoma--a rare complication of laparoscopic myomectomy.

We present a case of leiomyomatosis peritonealis disseminata (LPD) after laparoscopic myomectomy with imaging features corroborating laparoscopic tract dissemination of the tumor. This would suggest a subset cases of LPD may be secondary to transcoelomic dissemination of a primary uterine leiomyoma rather than de novo peritoneal metaplasia. To our knowledge, this is the first case report of LPD and subcutaneous leiomyoma complicating laparoscopic surgery. The imaging features of LPD are reviewed. Radiologists as well as clinicians should consider LPD as a potential complication of laparoscopic myomectomy.

Vaginal metastasis presenting as postmenopausal bleeding.

Vaginal cancer is rare worldwide and represents 2% of all gynaecological cancers in Singapore. Primary vaginal malignancies are rare and vaginal metastases constitute the majority of vaginal malignancies. Most of these metastases arise from the cervix, endometrium or ovary, although they can also metastasise from distant sites such as the colon, breast and pancreas. We report a rare case of vaginal metastasis in a patient with previous gastric and rectal adenocarcinomas. An 89-year-old woman with a history of gastric and rectal malignancy presented with postmenopausal bleeding. A 2-cm vaginal tumour at the introitus was discovered upon examination. This case demonstrates the importance of performing a gynaecological examination during follow-up for patients with a history of malignancy. The prognosis for vaginal metastasis is poor, as it is often associated with disseminated disease. Depending on the extent of the lesions, radiotherapy or surgery can be considered.

Survival Impact of Secondary Cytoreductive Surgery for Recurrent Ovarian Cancer in an Asian Population.

OBJECTIVE: The aim of this study was to evaluate the role of secondary cytoreductive surgery in Asian patients with recurrent ovarian cancer and to assess prognostic variables on overall post-recurrence survival time. METHODS: We conducted a retrospective review of patients with recurrent ovarian cancer who underwent secondary cytoreduction at the Gynaecological Cancer Center at the KK Women's and Children's Hospital, Singapore, between 1999 and 2009. Eligible patients included those who had been firstly treated by primary cytoreductive surgery and followed by adjuvant chemotherapy and had a period of clinical remission of at least six months and subsequently underwent secondary cytoreductive surgery for recurrence. Univariate analysis was performed to evaluate various variables influencing the overall survival. RESULTS: Twenty-five patients met our eligibility criteria. The median age was 52 years (range=31-78 years). The median time from completion of primary treatment to recurrence was 25.1 months (range=6.4-83.4). Secondary cytoreduction was optimal in 20 of 25 patients (80%). The median follow-up duration was 38.9 months (range=17.8-72.4) and median overall survival time was 33.1 months (95% confidence interval, 15.3-undefined.). Ten (40.0%) patients required bowel resection, but no end colostomy was performed. One (4.0%) patient had wedge resection of the liver, one (4.0%) had a distal pancreatectomy, one (4.0%) had a unilateral nephrectomy, and one (4.0%) had adrenalectomy. There were no operative deaths. The overall survival of patients who responded to secondary cytoreductive surgery and adjuvant chemotherapy was significantly longer than those patients who did not respond to the treatment. Of those patients who responded to the surgical management, patients with clear cell carcinoma fared well compared to those with the endometrioid, mucinous adenocarcinoma, and papillary serous type (p<0.001). Complete secondary cytoreductive surgery appeared to have some relationship to overall survival but was not statistically significant. CONCLUSION: In carefully selected patients with recurrent ovarian cancer, optimal cytoreductive surgery is possible and in a subgroup of patients who respond to surgery and chemotherapy survival is significantly longer.

Total laparoscopic Wertheim's radical hysterectomy versus Wertheim's radical abdominal hysterectomy in the management of stage I cervical cancer in Singapore: a pilot study.

INTRODUCTION: For many decades, Wertheim's radical hysterectomy via laparotomy, also known as Wertheim's radical abdominal hysterectomy (RAH), has been the traditional surgical approach for operable stage IB cervical cancer. However, many established cancer centres worldwide have recently shown total laparoscopic Wertheim's radical hysterectomy (TLRH) to be a safe and feasible alternative to the conventional abdominal route for early cervical cancer management. This technique was introduced in Singapore in 2009. METHODS: This was a prospective pilot study comparing TLRH with RAH in a single large tertiary institution in Singapore. Inclusion criteria included surgically fit patients with early cervical cancer and no radiological evidence of regional or distant metastases. RESULTS: From November 2009 to February 2011, a total of 18 TLRHs and 30 RAHs were performed. The median blood loss in the TLRH group was significantly lower than that in the RAH group (300 mL vs. 500 mL; p = 0.04). However, there was no statistically significant difference found between the two techniques in terms of operative time, hospital stay, bladder recovery, total lymph node yield or adjuvant treatment. No intraoperative bladder, ureteric or bowel complications were observed in the two groups. Postoperative complications occurred in 2 (11.1%) TLRH patients and 4 (13.3%) RAH patients. With a median follow-up of 37.3 (range 10-68) weeks, the rate of recurrence was found to be 5.6% for the TLRH group and 10.0% for the RAH group. CONCLUSION: The results of our study suggest that with appropriate patient selection and increased experience, TLRH can be a safe and effective procedure for the management of early cervical cancer in Singapore.

Diagnosis and management of Müllerian adenosarcoma of the uterine cervix.

OBJECTIVE: To report on the diagnosis and management of Müllerian adenosarcoma of the uterine cervix at a gynecologic oncology unit in Singapore. METHODS: Nine cases (1992-2008) were identified from the unit registry. All hospital records were retrospectively analyzed. RESULTS: Mean age at diagnosis was 45±12 years (range, 17-61 years). Presenting symptoms were abnormal vaginal bleeding (5 [55.6%] patients), introital mass (3 [33.3%] patients), and foul-smelling vaginal discharge (1 [11.1%] patient). Two (22.2%) patients were asymptomatic, with cervical polyps discovered incidentally on routine gynecologic check-up. All women had benign-looking cervical polyps and underwent polypectomy. Histology showed increased stromal cellularity with periglandular cuffs in all patients, and heterologous differentiation in 1(11.1%) patient. All 9 women had FIGO stage 1B disease. Seven (77.8%) patients underwent radical hysterectomy with bilateral adnexectomy and pelvic lymphadenectomy. One (11.1%) woman underwent cervical wedge resection and 1 (11.1%) refused definitive surgery. There was no recurrence in the 6 patients for whom complete follow-up data were available. CONCLUSION: Clinical diagnosis of Müllerian adenosarcoma of the uterine cervix may be challenging owing to the benign gross appearance of the cervical polyps. Surgery provides a good chance of cure with no recurrence.

Radical abdominal trachelectomy for stage IB1 cervical cancer in Singapore.

We report the first case of radical abdominal trachelectomy (RAT) and bilateral pelvic lymphadenectomy performed in Singapore, which was performed for a 35-year-old woman with stage IB1 cervical cancer, and review the current literature on this novel fertility-sparing surgery. Radical hysterectomy and pelvic lymphadenectomy are the conventional treatment for stage IB1 cervical cancer, but this results in the loss of fertility. However, the last 20 years have seen the development of fertility-sparing surgeries for young women with early-stage cervical cancer. Among these, laparoscopy-assisted radical vaginal trachelectomy (i.e. Dargent's procedure) is the most established technique, with good, documented long-term oncological and pregnancy outcomes. RAT, an alternative technique, was developed in the last decade. Although less than 200 reported cases worldwide have reported on the use of RAT, early data suggests good oncological outcome.