The early surgical period in robotic radical hysterectomy is related to the recurrence after surgery in stage IB cervical cancer.

Objective: To identify the pattern of recurrence and assess the clinicopathologic prognostic factors for survival after robotic radical hysterectomy (RRH) in the treatment of stage IB cervical cancer. Methods: From December 2008 to March 2018, 64 cervical cancer patients who underwent RRH with pelvic lymph node dissection by a single surgeon were enrolled in this retrospective historical cohort timeline study. The patient's status was estimated in terms of operative outcomes, pathologic results, and survival outcomes. Results: The median follow-up was 63 months. The recurrence rate was 9.4% (6/64). There were two recurrences at the vaginal vault, two in the pelvic cavity, and two at the peritoneum in the intraabdominal cavity. The overall survival rate was 95.3% (61/64). When patients were divided into three groups in order based on surgery date, the first surgical period showed significantly higher recurrence rate (21%) compared to both the second (10%) and the third period (0%) (p=0.037). Multivariate analysis showed that the early period of RRH (p=0.025) and clinical tumor size more than 3 cm (p=0.003) were prognostic factors related to the recurrence. Although there was no statistical significance, there has been no recurrence since a uterine manipulator was not used. Conclusion: The early surgical period and large tumor were related to the disease recurrence after RRH. We suggest that the achievement of proficiency and appropriate patient selection are critical for prognosis after RRH in stage IB cervical cancer.

Treatment outcomes and complications in FIGO stage IIIC and IVB endometrioid endometrial cancer patients presenting as nodal spreads following systematic lymphadenectomy and adjuvant therapy.

OBJECTIVE: To evaluate the treatment outcomes and complications of patients with FIGO stage IIIC and IVB endometrioid endometrial cancer (EC) presenting primarily as nodal spreads following systematic lymphadenectomy and adjuvant therapy. MATERIAL AND METHODS: Forty-four FIGO stage IIIC and IVB endometrioid EC patients between July 2003 and March 2020 received staging procedures including systematic lymphadenectomy. The survival outcomes and late treatment-related complications were compared between adjuvant chemoradiation-based group and chemotherapy-based group. RESULTS: Of the 44 patients, 16 (36.4%) had stage IIIC1, 26 (59.1%) had stage IIIC2, and 2 (4.5%) had stage IVB disease. The median follow-up time was 54 months (range, 10-185 months). There was no statistical difference in mortality between the microscopic and macroscopic nodal groups (6.2% vs 4.3%, p > 0.999). Eleven patients (25.0%) and 33 patients (75.0%) received adjuvant chemoradiation and chemotherapy, respectively. The 5-year disease-free and overall survival rates were not different between the two groups (disease-free survival, 81.8% vs 82.1%, p = 0.743; overall survival, 90.9% vs 95.8%, p = 0.537). The incidence rates of grade 2 lymphedema (36.4% vs 9.1%, p = 0.032) and grade 2/3 gastrointestinal complications (36.4% vs 0.0%, p < 0.001) were higher in the chemoradiation-based group than those in the chemotherapy-based group. CONCLUSIONS: Systematic lymphadenectomy and adjuvant chemotherapy might be the preferred treatment for FIGO stage IIIC and IVB endometrioid EC patients presenting as nodal spreads given that no difference in patient survival was found, but a higher incidence of treatment-related complications was observed in the chemoradiation-based group.

Comparison of posterior rectal dissection techniques during rectosigmoid colon resection as part of cytoreductive surgery in patients with epithelial ovarian cancer: Close rectal dissection versus total mesorectal excision.

OBJECTIVE: The aim of this study was to evaluate the clinical outcomes of close rectal dissection (CRD) compared with those of total mesorectal excision (TME) as the posterior rectal dissection procedure during rectosigmoid colectomy performed as part of cytoreductive surgery in patients with epithelial ovarian cancer. METHODS: We retrospectively reviewed the medical records of 163 patients who underwent posterior rectal dissection for rectosigmoid resection, including low anterior resection or subtotal colectomy, as part of ovarian cancer surgery from 2006 to 2018. The TME technique was mainly performed by colorectal surgeons, and the CRD technique preserving the mesorectal tissue was performed by an experienced gynecologic oncology surgeon. The patients were divided into the TME group and the CRD group, and their clinical outcomes were analyzed. RESULTS: A total of 163 patients with ovarian cancer underwent rectosigmoid colon resection. Among the patients, 87 (53.4%) underwent CRD and 76 (46.6%) underwent TME as the posterior rectal dissection technique. The disease severity according to FIGO stage (p = .390) and the residual disease status (p = .412) were not statistically different between the 2 groups. However, the postoperative incidences of anastomotic leakage (p = .045) and prolonged ileus (>7 days, p = .055) were higher in the TME group. The pelvic recurrence rate and progression-free survival did not differ between the 2 groups (p = .663 and .790, respectively). CONCLUSIONS: Considering the perioperative outcomes, CRD may be an alternative technique for rectal dissection in ovarian cancer with less perioperative morbidity and equivalent oncologic outcomes.

Perioperative outcomes of extensive bowel resection during cytoreductive surgery in patients with advanced ovarian cancer.

BACKGROUND AND OBJECTIVES: To achieve optimal cytoreduction, extensive bowel resections are sometimes required in patients with advanced ovarian cancer. Few studies have focused on the extent or number of resections of bowel surgeries and their feasibility. METHODS: We retrospectively reviewed the medical records of patients with advanced ovarian cancer who underwent bowel surgery as part of debulking procedures at Ajou University Hospital from 2006 to 2018. Patients who received extensive bowel resections (two-segment resections or subtotal colectomy) were identified, and their perioperative outcomes were evaluated. RESULTS: A total of 172 patients underwent bowel surgery. Of them, 128 (74.4%) underwent one-segment bowel resection, 25 (14.5%) underwent two-segment bowel resections, and 19 (11.1%) underwent subtotal colectomy. Although the operative time, transfusion rate, and postoperative bleeding events were higher in patients who underwent extensive bowel resection, the rates of perioperative complications were not significantly higher in this group. Anastomotic leakage occurred in two (1.5%) patients in the one-segment resection group, one (4.2%) patient in the multiple resection group, and two (10.5%) patients in the subtotal colectomy group. CONCLUSIONS: Multiple bowel resections (up to two segments) are feasible and can be safely performed with an acceptable complication rate in patients with advanced ovarian cancer.

Risk factors for septic adverse events and their impact on survival in advanced ovarian cancer patients treated with neoadjuvant chemotherapy and interval debulking surgery.

OBJECTIVES: The aim of this study was to analyze risk factors for septic complications during adjuvant chemotherapy and their impact on survival in patients with advanced epithelial ovarian cancer treated with neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). METHODS: We retrospectively reviewed the medical records of 69 patients with advanced epithelial ovarian cancer from 2004 to 2017. All patients underwent three cycles of NACT followed by IDS and adjuvant chemotherapy. We identified grade 3 or 4 hematologic complications and severe adverse events accompanied by neutropenia, including sepsis or septic shock, that occurred during treatment. Clinicopathologic data including demographic factors, preoperative medical conditions, surgical procedures, and survival times were evaluated. RESULTS: Of 69 patients, 27 (39.1%), 6 (8.8%), and 2 (2.9%) patients experienced grade 3 or 4 neutropenia, anemia, and thrombocytopenia, respectively, during NACT. Thirteen patients (18.8%) had a neutropenic fever with sepsis and 2 patients (2.9%) died of septic shock during adjuvant chemotherapy. Concurrent medical disease, splenectomy during IDS, and anemia or thrombocytopenia during NACT were significant risk factors for septic adverse events. In multivariate analysis, anemia (hemoglobin < 8 g/dL, p = 0.004) during NACT was the only significant factor associated with septic adverse events during adjuvant chemotherapy. Although there was no significant difference in progression-free survival, overall survival was significantly shorter in patients with septic adverse events (median, 82.3 vs. 17.3 months, p = 0.007). CONCLUSIONS: Grade 3 anemia during NACT may be an early indicator for septic adverse events during adjuvant chemotherapy. Considering the adverse impact on survival, scheme and dose of adjuvant chemotherapy should be tailored, and careful follow-up evaluation should be ensured in this patient group.

Three-Year Recurrence-Free Survival in Patients With a Very Low Risk of Endometrial Cancer Who Did Not Undergo Lymph Node Dissection (Tree Retro): A Korean Multicenter Study.

OBJECTIVE: Randomized studies have not demonstrated a survival benefit of routine lymph node dissection in early-stage endometrial cancer. Many surgeons nevertheless perform lymph node dissection in all patients with early-stage endometrial cancer. This study aimed to ascertain the survival outcomes of very low-risk endometrial cancer patients (by the Korean Gynecologic Oncology Group [KGOG] criteria) who did not undergo lymph node dissection. MATERIALS AND METHODS: Medical records of 156 consecutive patients who underwent surgical staging without lymph node dissection were collected from 10 institutions. All patients fulfilled the KGOG criteria: (1) endometrioid corpus cancer diagnosed by preoperative endometrial biopsy, (2) serum cancer antigen-125 level ≤35 IU/mL, (3) <50% myometrial invasion with no extension beyond the uterine corpus by magnetic resonance imaging (MRI), and (4) no lymph nodes with a short diameter ≥1.0 cm by MRI or computed tomography. Sampling of <5 nodes was allowed at a surgeon's discretion. We evaluated the 3-year recurrence-free survival (RFS) and 5-year overall survival (OS) using the Kaplan-Meier method. RESULTS: The median patient age was 52 years (range, 24-86 years). The median follow-up was 59 months (range, 0-189 months). The 3-year RFS and 5-year OS were 98.6% (95% confidence interval [CI], 96.8%-100.0%) and 98.6% (95% CI, 96.7%-100.0%), respectively. No disease-related mortality occurred. The final pathology report revealed ≥50% myometrial invasion in 29 patients (18.6%) and extension beyond the uterine corpus in 2 patients (1.3%). One patient (0.6%) was diagnosed with lymph node metastasis after lymph node sampling. Eighteen patients (11.5%) received adjuvant therapy after the final pathologic results indicated high risk. CONCLUSIONS: Very low-risk patients who did not undergo lymph node dissection had acceptable survival outcomes. Omitting lymph node dissection may be reasonable in patients satisfying the KGOG criteria.

A study of clinicopathologic factors as indicators for early prediction of suboptimal debulking surgery after neoadjuvant chemotherapy in advanced ovarian cancer.

AIM: This study aimed to evaluate early clinicopathologic factors predicting gross residual disease after neoadjuvant chemotherapy in patients with advanced epithelial ovarian cancer. METHODS: We analyzed clinicopathologic data of 68 patients with ovarian cancer who were treated with neoadjuvant chemotherapy followed by interval debulking surgery (NAC-IDS) between March 2006 and December 2016. All the patients received three cycles of NAC followed IDS. We evaluated all possible clinicopathologic characteristics, including reduction rates of serum CA-125 after each NAC and seven initial abdominopelvic computed tomography (CT) findings related to disease severity. RESULTS: After IDS, no gross residual disease was found in 46 (67.6%) patients and 22 (33.4%) patients had gross residual disease. Multivariate analysis identified that reduction rate of CA-125 after 2nd NAC, body mass index (BMI) and small bowel lesion in the initial CT findings were significantly associated with gross residual disease after IDS (P = 0.005, 0.030, 0.001, respectively). The optimal cutoff value predicting gross residual disease were less than 50% of CA-125 reduction rate after 2nd NAC and low BMI (<23 kg/m2 ). The combined receiver operating characteristic curve analysis of these factors showed good performance for predicting gross residual disease after IDS (area under the curve = 0.845). CONCLUSION: A model using small bowel mesentery involvement on CT, BMI (<23 kg/m2 ) and less than 50% reduction of the initial CA-125 level after the 2nd NAC is highly predictive of gross residual disease after IDS in advanced ovarian cancer patients. These results may be helpful in further treatment planning and patients counseling.

Treatment outcomes in patients with FIGO stage IB-IIA cervical cancer and a focally disrupted cervical stromal ring on magnetic resonance imaging: A propensity score matching study.

OBJECTIVE: The aim of this study was to compare treatment outcomes of primary concurrent chemoradiation therapy (CCRT) versus radical hysterectomy (RH) followed by adjuvant RT or CCRT in patients with FIGO stage IB-IIA cervical cancer with focal disruption of the cervical stromal ring on magnetic resonance imaging (MRI). METHODS: We retrospectively analyzed the clinicopathological data of 156 patients with FIGO stage IB-IIA cervical cancer showing a focal disruption of the stromal ring on MRI between March 2000 and March 2015. Treatment outcomes were compared between the RT-based (n=54) group and RH-based group (n=54) after propensity score matching of each of the patients using a logistic regression model, including age, tumor size on MRI, pelvic lymph node enlargement on MRI, and histology. RESULTS: Five-year disease-free survival rate was 83.1% for the RT-based group and 77.4% for the RH-based group (p=0.228). Five-year disease-specific survival rate was 84.3% for the RT-based group and 83.5% for the RH-based group (p=0.434). Incidence rates of late grade 3 genitourinary adverse reactions (14.8% vs. 0.0%, p=0.006) were significantly higher in the RH-based group than those in the RT-based group. CONCLUSIONS: Primary CCRT might be the preferred treatment for FIGO stage IB-IIA cervical cancer patients with focal disruption of cervical stromal ring on MRI given that no difference in patient's survival was found, but higher incidence of treatment-related complications was observed in the RH-based group. Also, primary radical surgery should be done more cautiously in these patients.

Preoperative nomogram for prediction of microscopic parametrial infiltration in patients with FIGO stage IB cervical cancer treated with radical hysterectomy.

OBJECTIVE: This study aimed to establish a nomogram to predict microscopic parametrial infiltration (PMI) by combining preoperative clinicopathologic factors in FIGO stage IB cervical cancer patients treated by radical hysterectomy (RH). METHODS: We retrospectively analyzed clinicopathologic data of 298 patients with FIGO stage IB cervical cancer treated by RH between February 2000 and March 2015. The nomogram was developed based on multivariate logistic regression analysis of preoperative clinicopathologic data. The accuracy and discriminative ability of the nomogram were evaluated by a concordance index and calibration curve. The low-risk group was predefined as having a predicted probability of PMI <10%. RESULTS: Multivariate analysis identified diameter-based tumor volume and disruption of the cervical stromal ring on magnetic resonance imaging, serum squamous cell carcinoma antigen level, and menopausal status as independent prognostic factors associated with PMI. The concordance index of the nomogram was 0.940 (95% CI, 0.908-0.967), and calibration plots revealed good agreement between the observed probabilities and nomogram-predicted probabilities (Hosmer Lemeshow test, p=0.574). The nomogram classified 200 out of 298 patients (67.1%) as low risk. In the low-risk group, the predicted probability of PMI was 3.5% and the actual PMI rate was 2.5% (5 out of 200). CONCLUSIONS: We developed a preoperative nomogram predicting microscopic PMI in surgically treated FIGO stage IB cervical cancer patients. The probabilities derived from this nomogram may have the potential to provide valuable guidance for physicians regarding the primary management of FIGO stage IB cervical cancer patients.

Predicting Model of Lymph Node Metastasis Using Preoperative Tumor Grade, Transvaginal Ultrasound, and Serum CA-125 Level in Patients With Endometrial Cancer.

OBJECTIVE: The purpose of this study was to evaluate the predicting model for lymph node metastasis using preoperative tumor grade, transvaginal sonography (TVS), and serum cancer antigen 125 (CA-125) level in patients with endometrial cancer. MATERIALS AND METHODS: Between January 2000 and February 2013, we identified 172 consecutive patients with surgically staged endometrial cancer. Transvaginal sonography was performed by an expert gynecologic radiologist in all patients. All patients had complete staging surgery including total hysterectomy with bilateral pelvic and para-aortic lymphadenectomy and were staged according to the 2009 International Federation of Gynecology and Obstetrics classification. Various clinicopathologic data were obtained from medical records and were retrospectively analyzed. RESULTS: Of 172 patients, 138 patients presented with stage I (118 IA and 20 IB), 12 had stage II, 18 had stage III (2 IIIA, 1 IIIB, 8 IIIC1, and 7 IIIC2), and 2 had stage IV diseases. Most patients had endometrioid adenocarcinoma (88.4%), and others (12.6%) had nonendometrioid histology. Eighteen patients (10.5%) were found to have lymph node metastasis. Deep myometrial invasion on preoperative TVS (≥50%), high serum CA-125 level (≥ 35 IU/mL), preoperative grade 2 or 3 tumors were significant preoperative factors predicting lymph node metastasis. There was no significant association between preoperative histology and lymph node metastasis. We calculated the simple model predicting lymph node metastasis based on preoperative tumor grade, TVS findings, and CA-125 level using logistic regression analysis. The sensitivity and specificity of this model were 94% and 57%, respectively (area under the curve, 0.84; 95% confidence interval [CI], 0.74-0.93; P < 0.01). CONCLUSIONS: Preoperative tumor grade, myometrial invasion on preoperative TVS, and CA-125 can accurately predict lymph node metastasis in patients with endometrial cancer. The current study suggests the possibility that TVS could be positively used for preoperative evaluation strategy in the low-resource countries instead of expensive imaging modalities such as magnetic resonance imaging or positron emission tomography-computed tomography.

Robotic single-site versus laparoendoscopic single-site hysterectomy: a propensity score matching study.

BACKGROUND: The aim of this study was to compare the surgical outcomes of robotic single-site (RSS-H) and laparoendoscopic single-site total hysterectomy (LESS-H) and to evaluate the feasibility of RSS-H in patients with benign gynecologic disease. METHODS: The RSS-H was performed using the da Vinci single-site surgical platform, and the LESS-H using a single multi-channel port system at the umbilicus. Among 467 consecutive patients who had undergone total hysterectomy for benign gynecologic disease, surgical outcomes were compared between RSS-H group (n = 25) and LESS-H group (n = 442) after propensity score matching. RESULTS: All operations were completed robotically and laparoscopically without conversion to laparotomy, respectively. The RSS-H group had longer operating times and less operative bleeding compared to the LESS-H group. While the LESS-H showed 1.4% of major complication rate, the RSS-H had no perioperative complication. Even after propensity score matching, the RSS-H still showed longer operating times (170.9 vs 94.1 min, p < 0.0001) and less operative bleeding (median estimated blood loss, 20 vs 50 ml, p = 0.009; mean hemoglobin drop, 1.6 vs 2.0 g/dl, p = 0.038) than the LESS-H. CONCLUSIONS: The RSS-H could be a feasible and safe procedure in appropriately selected patients with benign gynecologic disease, and further experience and technical refinements will continue to improve operative results. Prospective randomized trials will permit the evaluation of the potential benefits of the RSS surgery as a minimally invasive surgical approach.

A Predictive Model for Parametrial Invasion in Patients With FIGO Stage IB Cervical Cancer: Individualized Approach for Primary Treatment.

OBJECTIVE: The aim of this study was to preoperatively identify high- and low-risk subgroups of patients with parametrial involvement in those with FIGO (International Federation of Gynecology and Obstetrics) stage IB cervical cancer treated with radical hysterectomy according to menopause. MATERIALS AND METHODS: We retrospectively reviewed data of 197 patients with FIGO stage IB cervical cancer. None of the patients had definite evidence of parametrial invasion in a preoperative examination and underwent type III radical hysterectomy between February 2006 and March 2015. Preoperative risk criteria predicting parametrial involvement were identified in premenopausal and postmenopausal women, respectively. RESULTS: Tumor size on magnetic resonance imaging (MRI) more than 4 cm (odds ratio [OR], 10.029; 95% confidence interval [95% CI], 2.300-43.741; P = 0.002) and serum squamous cell carcinoma-antigen level of 3.60 ng/mL or more (OR, 4.132; 95% CI, 1.086-5.723; P = 0.037) were independent factors for parametrial invasion in premenopausal women. Significant factors associated with parametrial involvement in postmenopausal women were tumor size on MRI more than 3 cm (OR, 11.353; 95% CI, 2.614-49.306; P = 0.001) and Cyfra 21-1 level of 2.40 ng/mL or more (OR, 8.048; 95% CI, 1.240-52.221; P = 0.029). Patients were categorized into low- and high-risk groups according to risk criteria. Significant differences in the rates of parametrial invasion were observed between the groups (2.3% vs 38.6% in the premenopausal group, P < 0.001; 11.1% vs 77.3% in the postmenopausal group, P < 0.001). CONCLUSIONS: A model using preoperative tumor size on MRI, serum squamous cell carcinoma-antigen, and Cyfra 21-1 level was highly predictive of parametrial invasion in patients with FIGO stage IB cervical cancer. In particular, postmenopausal women were likely to have microscopic parametrial invasion, even among tumors 3 cm or less. Therefore, individualized approaches considering several preoperative factors are needed.

Transvaginal Sonography-Guided Core Biopsy of Adnexal Masses as a Useful Diagnostic Alternative Replacing Cytologic Examination or Laparoscopy in Advanced Ovarian Cancer Patients.

OBJECTIVE: The aim of this study was to evaluate transvaginal sonography (TVS)-guided core biopsy of the adnexal masses for neoadjuvant chemotherapy (NACT) in patients with advanced ovarian malignancies. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 52 patients who had undergone TVS-guided core biopsies in our gynecologic cancer center between May 2009 and October 2015. TVS-guided core biopsies were performed on patients with advanced ovarian malignancies who were considered as candidates for NACT and patients with adnexal masses who required a differential diagnosis of non-gynecologic tumors. RESULTS: Thirty-seven patients (71.2%) were scheduled to undergo NACT owing to the presence of coexisting illness, age, tumor burden, and location of metastatic sites. Fifteen patients (28.8%) underwent TVS-guided core biopsies to determine if they had primary or secondary ovarian tumors. Histopathologic examinations revealed primary ovarian tumors in 44 patients (84.6%). Nongynecologic tumors including gastrointestinal stromal tumor and metastatic tumor from gallbladder, gastric, and colorectal cancer were found to be the second most common disease (n = 5 [9.6%]). Findings in the samples were nondiagnostic in 4 patients (5.8%). With respect to the histological concordance rate between TVS-guided core biopsy and surgical specimen, diagnostic accuracy was 93.6%. There were no biopsy-related complications. CONCLUSIONS: TVS-guided core biopsy may be a feasible procedure to diagnose adnexal masses, particularly in patients with advanced ovarian malignancies who are more likely to benefit from NACT.

Robotic or laparoscopic sacrohysteropexy versus open sacrohysteropexy for uterus preservation in pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare robotic or laparoscopic sacrohysteropexy (RLSH) and open sacrohysteropexy (OSH) as a surgical treatment for pelvic organ prolapse (POP). METHODS: Among 111 consecutive patients who had undergone sacrohysteropexy for POP, surgical outcomes and postoperative symptoms were compared between the RLSH (n = 54; robotic 14 cases and laparoscopic 40 cases) and OSH (n = 57). groups The medical records of enrolled patients were reviewed retrospectively. RESULTS: Compared with the OSH group, the RLSH group had shorter operating time (120.2 vs 187.5 min, p < 0.0001), less operative bleeding (median estimated blood loss 50 vs 150 ml; p < 0.0001; mean hemoglobin drop 1.4 vs 2.0 g/dl; p < 0.0001), and fewer postoperative symptoms (13 vs 45.6 %; p < 0.0001). Patients' overall satisfaction (94.4 vs 91.2 %; p = 0.717) and required reoperation due to postoperative complications (3.7 vs 1.8 %; p = 0.611) did not differ between groups. CONCLUSIONS: RLSH could be a feasible and safe procedure in patients with POP and should be considered as a surgical option that allows preservation of the uterus. Prospective randomized trials will permit the evaluation of potential benefits of RLSH as a minimally invasive surgical approach.

Patterns of recurrence and survival after abdominal versus laparoscopic/robotic radical hysterectomy in patients with early cervical cancer.

AIM: This study investigates the pattern of disease recurrence and identifies the clinicopathologic prognostic factors for patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB and IIA cervical carcinoma treated with laparoscopic/robotic radical hysterectomy (LRH/RRH). METHODS: We conducted a retrospective analysis of 128 patients with FIGO stage IB and IIA cervical cancer. Preoperative examination did not uncover definitive evidence of parametrial invasion or lymph node metastasis in any of the patients; therefore, all patients underwent LRH/RRH with retroperitoneal lymphadenectomy between April 2006 and December 2013. Sites of disease recurrence and all possible clinicopathologic factors related to the risk of disease recurrence were determined. RESULTS: Multivariate analysis demonstrated that laparoscopic intracorporeal colpotomy (P < 0.041, odds ratio 7.038, 95% confidence interval 1.059-15.183) represented a strong prognostic factor related to disease recurrence. We categorized the minimally invasive surgery group into LRH through vaginal colpotomy (LRH-VC; 79 patients) and LRH/RRH through intracorporeal colpotomy (LRH/RRH-IC; 49 patients) according to the colpotomic approaches. Disease recurrence was higher in the LRH/RRH-IC group than in the LRH-VC group (16.3% vs 5.1%, P = 0.057), with five patients in the LRH/RRH-IC group experiencing intraperitoneal spreads. CONCLUSIONS: Total laparoscopic/robotic intracorporeal colpotomy under CO2 pneumoperitoneum may carry a risk of positive vaginal cuff margin, as well as intraperitoneal tumor spreads in patients with early-stage cervical cancer treated with LRH/RRH.

Clinical impact of high mobility group box 1 protein in epithelial ovarian cancer.

PURPOSE: The aim of this study was to confirm the expression of high mobility group box 1 (HMGB1) in patients with epithelial ovarian cancer (EOC) and to evaluate the prognostic significance of HMGB1. METHODS: A total of 74 patients with EOC comprised our cohort. Retrospectively collected tissue microarray from EOC patients treated with debulking surgery followed by taxane and platinum chemotherapy were analyzed for evaluation of the prognostic significance of HMGB1. Expression of HMGB1 was assessed by immunohistochemistry. RESULTS: The positive staining was detected in 80% of EOC patients and the rate of high HMGB1 expression was 42%. In advanced stage, patients with high HMGB1 expression showed a poorer prognosis than low HMGB1 expression group [median progression-free survival (PFS), 10.8 vs. 21.7 months, P = 0.005]. High HMGB1 expression was an independent predictor for PFS (P = 0.024). CONCLUSIONS: HMGB1 expression is expected as a promising biomarker for EOC and further studies are needed to assess potential roles in EOC.

Pretreatment serum CYFRA 21-1 level correlates significantly with survival of cervical cancer patients: a multivariate analysis of 506 cases.

OBJECTIVE: To determine whether pretreatment CYFRA 21-1 levels can be a useful prognostic indicator in cervical cancer with reference to squamous cell carcinoma-antigen (SCC-Ag). METHODS: We retrospectively analyzed data on 506 consecutive cervical cancer patients who were treated by radical hysterectomy or primary concurrent chemoradiation therapy. The pretreatment serum SCC-Ag and serum CYFRA 21-1 levels were measured in these patients. A multivariate analysis using Cox's proportional hazard model was performed to evaluate the prognostic significance of pretreatment variables. RESULTS: In patients who underwent radical hysterectomy, there was a significant correlation between pretreatment serum SCC-Ag/CYFRA 21-1 levels and patient age, advanced FIGO stage, large tumor size, lymph node metastasis, and deep stromal invasion. In the stepwise Cox regression analysis, large tumor size >4cm was an independent prognostic factor for disease-free survival (OR, 3.110; [95% CI, 1.588-6.093], P=0.001) and overall survival (OR, 8.497; [95% CI, 1.797-40.184], P=0.007) in patients with squamous cell carcinoma, while pretreatment CYFRA 21-1 (P=0.010) serum levels had a significant independent effect on overall survival. Likewise, pretreatment CYFRA 21-1 (P<0.001 and P=0.006) serum levels were the only independent prognostic factor for disease-free survival and overall survival in patients with non-squamous cell carcinoma. CONCLUSION: Pretreatment CYFRA 21-1 levels may be considered as a useful prognostic indicator in cervical cancer with reference to SCC-Ag.

Value of endocervical margin and high-risk human papillomavirus status after conization for high-grade cervical intraepithelial neoplasia, adenocarcinoma in situ, and microinvasive carcinoma of the uterine cervix.

OBJECTIVE: The aim of this study was to analyze clinico-pathologic factors and the optimal cut-off value of high-risk human papillomavirus (HR-HPV) viral load for predicting high-grade residual/recurrent disease after the conization in cervical intraepithelial neoplasia (CIN 2-3), adenocarcinoma in situ (AIS), and microinvasive carcinoma of the uterine cervix (MICA). METHODS: We retrospectively reviewed data from 701 patients with CIN 2-3, AIS, and MICA who underwent conization between September 2003 and June 2012. Receiver-operating characteristic curve analysis was used to find out the cut-off value of HR-HPV viral load for predicting residual/recurrent disease. Clinico-pathologic variables, including resection margin and HR-HPV status, were evaluated as possible predictors of residual/recurrent disease. RESULTS: At a cut-off value of 1.16 RLU/CO for post-cone HR-HPV viral load, the sensitivity was 88.2% and the specificity was 98.3%. Multivariate analysis demonstrated that post-cone cytology (p=0.001, OR=83.808, 95% CI=6.688-1050.232), endocervical margin status (p<0.001, OR=80.478, 95% CI=7.421-872.732), and post-cone HR-HPV status (p<0.001, OR=79.660, 95% CI=8.539-743.129) were significantly associated with residual/recurrent disease. The post-cone HR-HPV positivity was observed more in the patients who showed positive endocervical margin than in the patients with positive ectocervical margin (32.6% vs. 5.3%, p=0.002). CONCLUSIONS: Follow-up using liquid based cytology in combination with HR-HPV test at 12 months after the conization, and not the early HR-HPV test, might be acceptable. Post-cone endocervical margin status combined with post-cone HR-HPV test is critical for predicting residual/recurrent disease and clinical management.

Comparison of laparoscopic versus abdominal radical hysterectomy for FIGO stage IB and IIA cervical cancer with tumor diameter of 3 cm or greater.

OBJECTIVE: There have been many comparative reports on laparoscopic radical hysterectomy (LRH) versus abdominal radical hysterectomy (ARH) for early-stage cervical cancer. However, most of these studies included patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA2 and small (tumor diameter ≤2 or 3 cm) IB1 disease. The purpose of this study was to compare the feasibility, morbidity, and recurrence rate of LRH and ARH for FIGO stage IB and IIA cervical cancer with tumor diameter of 3 cm or greater. MATERIALS AND METHODS: We conducted a retrospective analysis of 88 patients with FIGO stage IB and IIA cervical cancer with tumor diameter of 3 cm or greater. All patients had no evidence of parametrial invasion and lymph node metastasis in preoperative gynecologic examination, pelvic magnetic resonance imaging, and positron emission tomography-computed tomography, and they all underwent LRH or ARH between February 2006 and March 2013. RESULTS: Among 88 patients, 40 patients received LRH whereas 48 underwent ARH. The mean estimated blood loss was 588.0 mL for the ARH group compared with 449.1 mL for the LRH group (P < 0.001). The mean operating time was similar in both groups (246.0 minutes in the ARH vs 254.5 minutes in the LRH group, P = 0.589). Return of bowel motility was observed earlier after LRH (1.8 vs 2.2 days, P = 0.042). The mean hospital stay was significantly shorter for the LRH group (14.8 vs 18.0 days, P = 0.044). There were no differences in histopathologic characteristics between the 2 groups. The mean tumor diameter was 44.4 mm in the LRH and 45.3 mm in the ARH group. Disease-free survival rates were 97.9% in the ARH and 97.5% in the LRH group (P = 0.818). CONCLUSIONS: Laparoscopic radical hysterectomy might be a feasible therapeutic procedure for the management of FIGO stage IB and IIA cervical cancer with tumor diameter of 3 cm or greater. Further randomized studies that could support this approach are necessary to evaluate long-term clinical outcome.

Robot-assisted versus conventional laparoscopic surgery for endometrial cancer: long-term comparison of outcomes.

Objective: There is a lack of multi-institutional large-volume and long-term follow-up data on comparisons between robot-assisted surgery and conventional laparoscopic surgery. This study compared the surgical and long-term survival outcomes between patients who underwent robot-assisted or conventional laparoscopic surgery for endometrial cancer. Methods: We retrospectively reviewed the data of patients from five large academic institutions who underwent either robot-assisted or conventional laparoscopic surgery for the treatment of endometrial cancer between 2012 and 2017, ensuring at least 5 years of potential follow-up. Intra- and postoperative outcomes, long-term disease-free survival, and overall survival were compared. Results: The study cohort included 1,003 unselected patients: 551 and 452 patients received conventional laparoscopic and robot-assisted surgery, respectively. The median follow-up duration was 57 months. Postoperative complications were significantly less likely to occur in the robot-assisted surgery group compared to the laparoscopic surgery group (7.74% vs. 13.79%, P = 0.002), primarily limited to minor complications. There were no significant differences in survival: 5-year disease-free survival was 91.2% versus 90.0% (P = 0.628) and overall survival was 97.9% versus 96.8% (P = 0.285) in the robot-assisted and laparoscopic surgery cohorts, respectively. Cox proportional hazard regression models demonstrated that the mode of surgery was not associated with disease-free survival (hazard ratio, 0.897; confidence interval, 0.563-1.429) or overall survival (hazard ratio, 0.791; confidence interval, 0.330-1.895) after adjusting for confounding factors. Conclusion: Robot-assisted surgery for endometrial cancer demonstrates comparable long-term survival outcomes and a reduced incidence of postoperative minor complications when compared to conventional laparoscopic surgery.