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.

Uterine leiomyosarcoma in asian patients: validation of the revised Federation of gynecology and obstetrics staging system and identification of prognostic classifiers.

BACKGROUND: In 2008, the Federation of Gynecology and Obstetrics (FIGO) revised their 1988 staging system for uterine leiomyosarcomas. In this article, we compare performance of the 2008 and 1988 FIGO systems. METHODS: Individual case data were manually culled. Staging was retrospectively assessed according to revised and 1998 FIGO criteria. Overall survival distribution was assessed by the Kaplan-Meier method. Harrell's concordance index was used to assess the discriminative ability of a fitted Cox model to predict overall survival. RESULTS: A total of 110 cases of uterine leiomyosarcomas were reviewed and data from 88 patients were analyzed. In all, 71% of cases were classified as stage I, 7% as stage II, 3% as stage III, and 19% as stage IV under the revised FIGO staging system. Nine patients (10.2%) were downstaged and none were upstaged. The revised FIGO system did not show a significant improvement over the 1988 FIGO system in the ability to discriminate the risk of death of patients between stages, with concordance indexes of 0.70 and 0.71, respectively. Most patients were classified as stage I with age, tumor grade, tumor size, and lymphovascular invasion as prognostic factors. CONCLUSION: The 2008 revised FIGO staging system for uterine leiomyosarcomas does not perform better than the 1988 system for uterine endometrial carcinomas. A better staging system is needed for these cases.

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.

Concurrent chemoradiotherapy incorporating high-dose rate brachytherapy for locally advanced cervical carcinoma: survival outcomes, patterns of failure, and prognostic factors.

BACKGROUND: This is a retrospective study evaluating the survival outcomes, patterns of failure, and prognostic factors of chemoradiotherapy incorporating high-dose rate brachytherapy in the treatment of locally advanced cervical cancer. METHODS: A review of 120 consecutive patients with Federation Internationale de Gynecologie et d'Obstetrique (FIGO) stages IB2 to IVA cervical cancer treated with concurrent cisplatin-based chemoradiotherapy between April 1999 and January 2005. Overall (OS) and disease-free survival (DFS) were analyzed using the Kaplan-Meier method. RESULTS: The 5-year OS and DFS rates were, respectively, 65.0% (35.0% IB2, 65.7% IIA-B, 71.0% IIIA-B, and 40.0% IVA) and 57.3% (30.0% IB2, 58.2% IIA-B, 64.0% IIIA-B, and 40.0% IVA). Most patients had squamous cell carcinoma (89.2%) and belonged to FIGO stages IIB (40.8%) and IIIB (30.8%). All but 4 patients completed the planned radiotherapy regimen. There were 48 documented recurrences, of which 13 were locoregional only, 26 were distant only, and 9 were both sites. Five patients (4.2%) experienced late grade 3 to 4 gastrointestinal toxicity. On multivariate analysis, a preradiotherapy hemoglobin level of less than 10 g/dL and tumor size of 4 cm or greater or bulky on computed tomography were independently significant variables for OS, whereas a nadir hemoglobin level of less than 10 g/dL and presence of radiologically enlarged pelvic or paraaortic lymph nodes were independently significant variables for DFS. CONCLUSIONS: We conclude that this regimen is efficacious and feasible, but the safety profile about concurrent administration of high-dose rate brachytherapy and chemotherapy should be studied further. Finally, for cervical cancer patients selected for nonsurgical treatment, radiological assessment of tumor size and lymph node status can provide valuable prognostic information over and above FIGO staging alone.

Management of endometrial cancer in Asia: consensus statement from the Asian Oncology Summit 2009.

Endometrial cancer is one of the gynaecological cancers that carries good overall prognosis because it is often detected at early stages of disease. The International Federation of Gynecology and Obstetrics replaced clinical staging with surgical staging in 1988 and updated the system in 2009. Controversies remain regarding the recommended screening protocol for women with a high risk of endometrial cancer, the role and benefit of retroperitoneal lymph-node dissection, the necessity of ovarian resection, the benefit and type of adjuvant radiation therapy, and the safety of hormone-replacement therapy after treatment. This article reviews the available evidence for optimum management of endometrial cancer and how management strategies can be applied in Asian countries with different levels of health-care resource availability and economic development. An overview of the literature for endometrial-cancer screening, diagnosis, and management is discussed. Consensus statements are formulated on the basis of basic, limited, enhanced, and maximum health-care resource availability, using the framework provided by the Breast Health Global Initiative.

Triage of ovarian masses.

BACKGROUND: Triage of ovarian masses for appropriate management is important in ensuring the best outcome for patients. The Risk of Malignancy Indices (RMI) seem to represent a low cost and effective tool for triage and management of women with ovarian masses. AIM: To review patients with an ovarian mass referred to the Gynaecological Cancer Centre at the Royal Hospital for Women, and to assess the effectiveness of the RMI in differentiating benign from malignant tumours in this group of patients. METHODS: A retrospective review of the case records of all patients with an ovarian mass referred to our centre from January 2003 to December 2005 was undertaken. RESULTS: Two hundred and four patients were eligible for RMI calculation. An RMI of < 200 correctly identified 83 of 108 (77%) benign ovarian tumours. An RMI of > 200 correctly identified 11 of 19 (58%) borderline ovarian tumours and 70 of 77 (91%) invasive ovarian tumours. An RMI of > 200 had a sensitivity of 84%, specificity of 77%, positive predictive value of 76% and negative predictive value of 85% in detecting both borderline and invasive ovarian tumours. The false negative rate for invasive tumours was 9%. CONCLUSIONS: This study showed that using RMI at a cut-off of 200 for referral could have prevented 83 benign cases (41%) from being referred. We propose that the RMI could be utilised as a triage tool for referral of ovarian masses to gynaecological cancer centres.

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.

Strumal carcinoid tumour of the ovary presenting with severe constipation.

A 30-year-old single woman presented with an incidental finding of abdominal mass associated with severe constipation. Her cancer antigen-25, alpha-foetoprotein and beta human chorionic gonadotropin levels were normal, but her carcinoembryonic antigen level was raised at 7.6 g/dL. Magnetic resonance imaging showed a 11.4 cm × 8.6 cm × 9.5 cm right ovarian mass with solid and cystic areas. An open right cystectomy was performed. Intraoperatively, she was found to have hirsutism and clitoromegaly. During the operation, there was a right ovarian 10-cm mass, with faecal loading from the caecum to the transverse colon. The uterus, fallopian tubes, left ovary and intraperitoneal survey were normal. Final histology confirmed strumal carcinoid tumour Stage 1A. This case report shows that a strumal carcinoid tumour can present with longstanding constipation as a patient's main complaint and may also be associated with hirsutism.

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.

HER2 amplification and clinicopathological characteristics in a large Asian cohort of rare mucinous ovarian cancer.

Mucinous epithelial ovarian cancer has a poor prognosis in the advanced stages and responds poorly to conventional chemotherapy. We aim to elucidate the clinicopathological factors and incidence of HER2 expression of this cancer in a large Asian retrospective cohort from Singapore. Of a total of 133 cases, the median age at diagnosis was 48.3 years (range, 15.8-89.0 years), comparatively younger than western cohorts. Most were Chinese (71%), followed by Malays (16%), others (9.0%), and Indians (5%). 24% were noted to have a significant family history of malignancy of which breast and gastrointestinal cancers the most prominent. Majority of the patients (80%) had stage I disease at diagnosis. Information on HER2 status was available in 113 cases (85%). Of these, 31 cases (27.4%) were HER2+, higher than 18.8% reported in western population. HER2 positivity appeared to be lower among Chinese and higher among Malays patients (p = 0.052). With the current standard of care, there was no discernible impact of HER2 status on overall survival. (HR = 1.79; 95% CI, 0.66-4.85; p = 0.249). On the other hand, positive family history of cancer, presence of lymphovascular invasion, and ovarian surface involvements were significantly associated with inferior overall survival on univariate and continued to be statistically significant after adjustment for stage. While these clinical factors identify high risk patients, it is promising that the finding of a high incidence of HER2 in our Asian population may allow development of a HER2 targeted therapy to improve the management of mucinous ovarian cancers.

Survival outcome of women with synchronous cancers of endometrium and ovary: a 10 year retrospective cohort study.

OBJECTIVE: Synchronous occurrence of endometrial and ovarian tumors is uncommon, and they affect less than 10% of women with endometrial or ovarian cancers. The aim of this study is to describe the epidemiological and clinical factors; and survival outcomes of women with these cancers. METHODS: This is a retrospective cohort study in a large tertiary institution in Singapore. The sample consists of women with endometrial and epithelial ovarian cancers followed up over a period of 10 years from 2000 to 2009. The epidemiological and clinical factors include age at diagnosis, histology types, grade and stage of disease. RESULTS: A total of 75 patients with synchronous ovarian and endometrial cancers were identified. However, only 46 patients met the inclusion criteria. The median follow-up was 74 months. The incidence rate for synchronous cancer is 8.7% of all epithelial ovarian cancers and 4.9% of all endometrial cancers diagnosed over this time frame. Mean age at diagnosis was 47.3 years old. The most common presenting symptom was abnormal uterine bleeding (36.9%) and 73.9% had endometrioid histology for both endometrial and ovarian cancers. The majority of the women (78%) presented were at early stages of 1 and 2. There were 6 (13.6%) cases of recurrence and the 5 year cumulative survival rate was at 84%. CONCLUSION: In our cohort, we found that majority of women afflicted with synchronous cancer of the endometrium and ovary were younger at age of diagnosis, had early stage of cancer and good survival.

Asian society of gynecologic oncology workshop 2010.

This workshop was held on July 31-August 1, 2010 and was organized to promote the academic environment and to enhance the communication among Asian countries prior to the 2nd biennial meeting of Australian Society of Gynaecologic Oncologists (ASGO), which will be held on November 3-5, 2011. We summarized the whole contents presented at the workshop. Regarding cervical cancer screening in Asia, particularly in low resource settings, and an update on human papillomavirus (HPV) vaccination was described for prevention and radical surgery overview, fertility sparing and less radical surgery, nerve sparing radical surgery and primary chemoradiotherapy in locally advanced cervical cancer, were discussed for management. As to surgical techniques, nerve sparing radical hysterectomy, optimal staging in early ovarian cancer, laparoscopic radical hysterectomy, one-port surgery and robotic surgery were introduced. After three topics of endometrial cancer, laparoscopic surgery versus open surgery, role of lymphadenectomy and fertility sparing treatment, there was a special additional time for clinical trials in Asia. Finally, chemotherapy including neo-adjuvant chemotherapy, optimal surgical management, and the basis of targeted therapy in ovarian cancer were presented.