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Debulking surgery followed by systemic chemotherapy&mdash, including three-weekly intravenous paclitaxel and carboplatin (GOG-158)&mdash, is the cornerstone for advanced epithelial ovarian, fallopian tubal, and peritoneal cancer (EOC) treatment. In this scenario, Federation of Gynecology and Obstetrics (FIGO) stage, cell types, completeness of surgery, lymph nodes (LN) status, adjuvant chemotherapy regimens, survival status, progression-free survival (PFS), and overall survival (OS) of 192 patients diagnosed as having stage IIIA1&ndash, IVB EOC over January 2008&ndash, December 2017 were analyzed retrospectively. Of them, 100 (52.1%) patients had been debulked optimally. Of all cases, 64.1% and 10.9% demonstrated serous and clear-cell carcinoma. Moreover, the FIGO stage, surgery completeness, and LN status affected recurrence/persistence and mortality (all p &lt, 0.001). Clear cell carcinoma led to shorter survival than serous carcinoma (p = 0.002). Adjuvant chemotherapy regimens were divided into five main groups according to previous clinical trials. However, choice of chemotherapy failed to demonstrate significant differences in patient outcomes. Similar results were found in the sub-analysis of optimally debulked cases, except that intraperitoneal chemotherapy could reduce mortality risk when compared with GOG-158 (p = 0.042). Notably, retroperitoneal LN dissection in all cases or optimally debulked cases reduced risks of recurrence/persistence and mortality, and prolonged PFS and OS significantly (all p &lt, 0.05). Without optimal debulking, LN dissection led to little improvement in outcomes. Various modified chemotherapy regimens did not prolong PFS and OS or reduce recurrence/persistence and mortality risks. LN dissection is strongly recommended to improve the completeness of surgery and patient outcome. Clear cell type has a poorer outcome than serous type, which requires more aggressive treatment and follow-up.

Pelvic lymphadenectomy procedure is included as part of the standard protocol of radical hysterectomy for women with early-stage cervical cancer (Stage IA to IB1). However, an important sequel to lymphadenectomy procedure is the possible occurrence of lymphedema in the lower abdomen and lower extremities. Previous researches also find that women with lymphedema experience many emotional impacts, including depression, anxiety, and adjustment problems. Only approximately 10% of women with clinical stage IB cervical carcinoma were involved with metastatic disease. If we could better define the relevant lymphatic nodes that must be removed, it is then possible to limit routinely performed lymphadenectomy for regional nodal metastasis in the pelvis, and hence reduce the need for extended surgical staging (para-aortic lymphadenectomy). We systematically reviewed a body of literature and updated available information concerning the current progress on the application of sentinel lymph node biopsy in women with early-stage cervical cancer. All detection methods (preoperative injection of radiocolloid tracer, intraoperative injection of blue dye, or a combination of both techniques) demonstrated reasonable sensitivity (with a few exceptions), high specificity, low false-negative rate and high negative predictive value. The review of the literature in this paper should convince the readers that sentinel lymph node biopsy has the potential to improve the quality of life and the possibility to maintain relapse-free survival for women with cervical cancer. The proper identification of negative sentinel lymph node allows individualized therapy and may preclude the need of lymphadenectomy procedure in most of these women. Keywords: Cervix, Lymphadenectomy, Lymphoscintigraphy, Sentinel lymph node, Staging

The presence of pelvic lymph node metastases is without doubt the most significant prognostic factor that determines recurrences and survival of women with early-stage cervical cancer. To avoid the underdiagnosis of lymph node metastasis, pelvic lymphadenectomy procedure is routinely performed with radical hysterectomy procedure. However, the pelvic lymphadenectomy procedure may not be necessary in most of these women due to the relatively low incidence of pelvic lymph node metastasis. The removal of large numbers of pelvic lymph nodes could also render non-metastatic irreversible damages for these women, including vessel, nerve, or ureteral injuries; formation of lymphocysts; and lymphedema. Over the past decades, the concept of sentinel lymph node biopsy has emerged as a popular and widespread surgical technique for the evaluation of the pelvic lymph node status in gynecologic malignancies. The histological status of sentinel lymph node should be representative for all other lymph nodes in the regional drainage area. If metastasis is non-existent in the sentinel lymph node, the likelihood of metastatic spread in the remaining regional lymph nodes is very low. Further lymphadenectomy is therefore not necessary for a patient with negative sentinel lymph nodes. Since the uterine cervix has several lymphatic drainage pathways, it is a challenging task to assess the distribution pattern of sentinel lymph nodes in women with early-stage cervical cancer. This review article will adapt the methodology proposed in these studies to systematically review sentinel lymphatic mapping among women with early-stage cervical cancer. Keywords: Cervical cancer, Lymphadenectomy, Sentinel lymph node

Background: Although it is now possible to achieve permanent remission in a large percentage of gynecologic cancer (GC) cases, many GC patients in remission experience side effects or complications that influence their physical function and family relationships. Compared with other types of cancer patients, survivors of GC face greater challenges in terms of physical and psychological adaptations, and many of these do not receive sufficient assistance. An in-depth understanding of the lived experiences and demands of GC survivors is key to constructing comprehensive related healthcare services. Purpose: The aim of this study was to understand the lived experience of GC survivors in Taiwan to help their return to a healthy life. Methods: This was a phenomenological study. Twenty-three survivors of GC participated in semistructured interviews that were held in a private environment. The transcripts were based on synchronous recordings from the interviews. Giorgi's phenomenology analysis was adopted for data analysis. Results: Three themes with six subthemes were extracted from the data, including (a) the inner struggle of living with cancer and recurrence: repeatedly exploring the causes of cancer and treatment and facing a fear of cancer recurrence, (b) the interpretation and adjustment to cancer treatment: filled with fluctuating physical and mental distress and working to adopt a different perspective, and (c) the long passage of finding a desirable lifestyle: adjusting to long-term coexistence with side effects and realizing the strength of society, body, and mind. Conclusions/Implications for Practice: The journey of rehabilitation for GC survivors is very long. The participants in this study faced different respective challenges during the diagnosis, treatment, and adjustment phases. Conventional disease-oriented medical care cannot satisfy the requirements of cancer patients because of patient-decentralized services. Our results indicate that GC survivors face diverse problems, both physically and mentally. Healthcare professionals should work to facilitate the psychological adjustment of cancer survivors and provide timely professional advice in combination with social resources. These results may serve as a reference for cancer care professionals who are navigating healthcare services.

ObjectiveThe aim of this article was to identify current practice patterns of care in the surgical and adjuvant management of endometrial cancer in East Asia (Korea, Japan, China, and Taiwan)MethodsA validated 20-item questionnaire on surgical and adjuvant procedures for endometrial cancer was sent to active members of the Gynecologic Oncology Group from 4 East Asian countries. Data were collected using an Internet survey database.ResultsA total of 376 members from Korea (n = 108), Japan (n = 140), China (n = 51), and Taiwan (n = 77) responded to the survey. With respect to early-stage endometrial cancer, laparotomy (57.7%) was the most preferred mode of surgery in Japan, whereas laparoscopy was the most common in the remaining 3 countries. For patients with presumed stage IA/G1 disease, approximately 65% of respondents favored systematic lymphadenectomy. For patients with presumed stage IB disease, most respondents stated that systematic lymphadenectomy should be performed (92.6% for stage IBG1, 95.8% for stage IBG3). Meanwhile, the extents of lymphadenectomy differed among countries (P < 0.001). Considerable agreement was noted between countries regarding indications for adjuvant therapy for stage IIIA or IIIC1 disease, whereas the preferred options for adjuvant therapy varied according to country (P < 0.001). Specifically, chemotherapy was the most common selection option in Japan, whereas concurrent chemoradiotherapy was preferred in the other countries.ConclusionsConsiderable agreement was identified with respect to the necessity for lymphadenectomy for surgical staging and the indications for adjuvant therapy. However, extents of surgery and preferred adjuvant treatment options for endometrial cancer varied widely between countries.

Objective: To describe the nationwide trends in the utilization of trachelectomy among Taiwanese women with surgically resectable cervical cancer over the past decade, and to compare associated demographic characteristics, in-hospital complications and related outcomes using a population-based dataset from 1998 to 2013. Materials and methods: We conducted a population-based, cohort study using inpatient admission claims data of Taiwan's National Health Insurance program. Women who underwent trachelectomy for cervical cancers were compared by age at surgery (younger than 40 years, 40–59 years, and 60 years or older). Results: Our study cohort consisted of 156 women. The overall utilization increased considerably during the study period, particularly in younger women aged 30–39 years. Compared with older women who had trachelectomy, women younger than 40 years were diagnosed more frequently in the later years of study (2007–2013, 69.9% vs 37.3%), were treated more frequently at medical centers (89.0% vs 60.2%) by physicians aged 55 years or older (50.7% vs 22.9%) with high case volume (50.7% vs 26.5%), were less likely to undergo concomitant surgeries for bilateral oophorectomy (1.4% vs 21.7%) and lysis of peritoneal adhesion (2.7% vs 24.1%), and were more likely to undergo lymph node excision (74.0% vs 47.0%) (P

The study compared the in-hospital complications and related outcomes between women who underwent bilateral salpingo-oophorectomy at hysterectomy for benign diseases and those who had hysterectomy only.We conducted a population-based, retrospective cohort study using data from Taiwan's National Health Insurance program. Women who underwent concurrent bilateral salpingo-oophorectomy at hysterectomy for benign indications (n = 34,509) were compared with those who had hysterectomy only (n = 176,305). Separate models were estimated to account for the effect of baseline comorbid condition, age, and hysterectomy approach on the relationship between bilateral salpingo-oophorectomy and study outcomes. A secondary analysis was also performed to evaluate the association of inpatient readmission within 30 days and complications among women who underwent bilateral salpingo-oophorectomy.The addition of a bilateral salpingo-oophorectomy to hysterectomy was associated with a lower risk of surgical complications, a longer length of hospital stay, and an increased risk of inpatient readmission within 30 days. Among women who underwent bilateral salpingo-oophorectomy, women with complications were also more likely to require inpatient readmission within 30 days than those without complications. Our data also suggested that bilateral salpingo-oophorectomy was not associated with an overall risk of medical complications, with the exception of urethral obstruction. The relationships remained even after adjustments by age, surgical indications, hysterectomy approach, and health-related risk factors, such as baseline comorbid condition and status of any prior catastrophic illness.Bilateral salpingo-oophorectomy at hysterectomy for benign conditions is not associated with an increased risk of in-hospital complications.

Ovarian clear cell carcinoma (OCCC) is the second common histology of epithelial ovarian cancer in Taiwan. Stage IC is common, especially during minimally invasive surgery. Adjuvant chemotherapy in stage IC OCCC is unavoidable, and paclitaxel-based chemotherapy in Taiwan is self-paid. However, surgical spillage from minimally invasive surgery as a cause of unfavorable prognosis is still uncertain. The information of patients with stage IC OCCC, corresponding to a period of January 1995 to December 2016, was retrospectively collected following a chart and pathology review. Data regarding surgical methods, cytology status, regimens of adjuvant chemotherapy, survivorship, progression-free survival (PFS), and overall survival (OS) period were analyzed. In total, 88 patients were analyzed, and 64 and 24 patients were treated with paclitaxel- and nonpaclitaxel-based chemotherapy, respectively. Recurrence was identical between the two groups: PFS (47.5 &plusmn, 41.36 versus 54.0 &plusmn, 53.9 months, p = 0.157) and OS (53.5 &plusmn, 38.14 versus 79.0 &plusmn, 49.42 months, p = 0.070). Of the 88 patients, 12 had undergone laparoscopy for histological confirmation before complete open staging surgery, however, their PFS (49.5 &plusmn, 46.84 versus 49.0 &plusmn, 35.55 months, p = 0.719) and OS (56.5 &plusmn, 43.4 versus 51.0 &plusmn, 32.77 months, p = 0.600) were still comparable. Cytology results were only available for 51 patients, and positive washing cytology results seemed to worsen PFS (p = 0.026) but not OS (p = 0.446). In conclusion, adjuvant nonpaclitaxel chemotherapy and laparoscopic tumor spillage before the staging operation did not worsen the outcome in stage IC OCCC. Positive washing cytology has a negative effect on PFS but not on OS.

Objective: To dissect the correlated hematologic markers that reflect the clinical outcome or treatment response in patients receiving dose-dense chemotherapy with a combination of platinum (cisplatin or carboplatin) and paclitaxel. Materials and Methods: From 2009 to 2014, we enrolled 55 ovarian cancer patients (total 67 courses) including first-line, persistent, platinum-sensitive, or platinum-resistant disease in MacKay Memorial Hospital, Taipei, Taiwan. Weekly pretreatment complete blood counts and calculated ratios [platelet/neutrophil ratio, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), neutrophil/monocyte ratio, platelet/monocyte ratio, lymphocyte/monocyte ratio] during dose-dense chemotherapy were collected. By grouping these hematologic biomarkers into three different response subgroups (responsive, stable, and nonresponsive) according to CA125 trend, the data were analyzed using one-way analysis of variance, and using post hoc-Tukey test for comparing each other. A p value < 0.05 was considered to be statistically significant. Results: Absolute counts of lymphocytes and platelets, PLR, platelet/neutrophil ratio, platelet/monocyte ratio (all p < 0.001), and NLR (p=0.013) had statistically significant differences. Moreover, using box-and-whisker plot, absolute count of lymphocyte, PLR, and NLR showed most remarkable discrepancy in responsive, stable, and nonresponsive patients. Subgroup analysis for primary, platinum-sensitive, and platinum-resistant patients further revealed that PLR and NLR were significantly correlated to the outcome of dose-dense chemotherapy. Conclusion: Lower PLR or lower NLR had better treatment response for dose-dense chemotherapy and are possible markers for representing treatment response in dose-dense chemotherapy. For a clinician, this is useful for timing when to switch to another chemotherapy regimen.

Objective To assess the risk of stroke (and subtypes of stroke) in women after elective bilateral salpingo-oophorectomy at hysterectomy for benign diseases. Study design We conducted a nationwide population-based, retrospective cohort study using claims data from Taiwan's National Health Insurance program between 1997 and 2013. Women aged 20 years or more who underwent bilateral salpingo-oophorectomy at hysterectomy for benign diseases (n = 1083) were compared with women who did not undergo bilateral salpingo-oophorectomy at hysterectomy for benign diseases (n = 3903). The follow-up period ranged from 10 to 16 years. Age-adjusted (or unadjusted) and multivariate Cox proportional hazards regression models were used to estimate the risk of stroke between the two groups. Main outcome measures A diagnosis of stroke (and subtypes of stroke). Results We did not find a significant association between bilateral salpingo-oophorectomy and the risk of incident stroke (or subtypes of stroke) over an average follow-up of 13 years. Among women aged 50 years or more who used estrogen therapy, the risk of developing stroke was 64% lower in those who had undergone bilateral salpingo-oophorectomy (hazard ratio, 0.36; 95% confidence interval, 0.16–0.79) than in those who had undergone hysterectomy only. Conclusion This study suggests that the use of estrogen after bilateral salpingo-oophorectomy at hysterectomy for benign diseases reduces the risk of stroke in women aged 50 years or more.

Objective Gynecologists in Taiwan are lacking a comprehensive picture of the changes in clinical practice and indications of hysterectomy over a long period of time. The aims of this study were to examine the national trends in the utilization of hysterectomy and to explore changes in its utilization rate over a 14-year period from 1997 to 2010. Materials and methods We conducted a population-based trend analysis using the claims data from the Taiwan's National Health Insurance program. Results We identified a total of 341,993 women aged 20 years or older who underwent hysterectomy between 1997 and 2010. The total number of hysterectomies increased from 22,961 in 1997 to 27,757 cases in 1999, followed by a decline to 22,351 in 2010. Overall, 5406 fewer hysterectomies (−19.5%) were performed in 2010 when compared with those performed in 1999. The number of hysterectomies performed decreased from 1997 to 2010 for precancerous lesions (−55.6%), chronic pelvic pain (−35.2%), uterine leiomyoma (−13.1%), and uterine prolapse (−7.2%). However, the utilization of hysterectomy increased for endometriosis (+76.3%) and gynecologic cancer (+22.7%) during the same time frame. Conclusion The clinical utilization and primary indications of hysterectomy changed substantially in Taiwan from 1997 to 2010. The continued monitoring of changes in hysterectomy rates will be critical for understanding the appropriate indications for hysterectomy and oophorectomy, the emergence of alternative managements for uterine disorders, and future trends in women's reproductive health.

Objective The goal of this study is to assess the feasibility of simple extrafascial hysterectomy for patients with clinical stage IA1 cervical squamous cell carcinoma (SCC) after once conization regardless of any pathologic risk factor. Materials and Methods All cases with T1a1, SCC lesion in their cervical cone specimen were retrospectively collected after chart and pathology review for the period between January 2002 and December 2009. All cases underwent subsequent hysterectomies within a month of diagnosis. Pathologic risk factors of conization, surgical scale of hysterectomy, residual lesion of the uterus, necessity of adjuvant radiation therapy, complications, and survival were analyzed in this study. Results Eighty-one cases were identified from the registry. Most were managed by simple hysterectomy (SH; 60/81, 74%), and the remaining 21 cases underwent modified radical hysterectomy (MRH). All cases without any risk factors in their cone specimens demonstrated residual lesion ≤T1a1 in both SH and MRH groups, whereas those with existing risk factor were confirmed positive for residual lesions ≤T1a1 [SH, 95.8% (46/48) vs. MRH, 75% (15/20)]. Only two cases in the SH group received adjuvant radiation for residual lesions >T1a1. On the contrary, 15 cases in the MRH group can receive smaller scale surgery than MRH. All cases were recurrence-free without any permanent treatment-related complication by the end of the study. Conclusion Extrafascial simple hysterectomy may be recommended for clinical T1a1 cervical SCC regardless of the pathologic risk factor.

Objective The aim of this study was to assess the benefits of the 2009 International Federation of Gynecology and Obstetrics (FIGO) staging system for survival of patients with Stage IIA1 and IIA2 cervical cancer (Cx Ca). Materials and Methods A study cohort of 51 patients with Stage IIA Cx Ca was retrospectively collected from the 2004–2009 hospital-based, long-form Cx Ca data registry at Mackay Memorial Hospital (Taipei, Taiwan). The survivorship and overall survival were compared between these two groups (Stages IIA1 and IIA2) using log-rank test. Results Thirty-six and 15 patients were classified into Stages IIA1 and IIA2, respectively. Stage IIA2 patients were younger than those with Stage IIA1 disease (mean age, 47.4 vs. 55.1 years, p = 0.008), but no significant difference was observed in confirmed pelvic lymph node status (21.4% vs. 38.5%, p = 0.280) between them. Although the 2-year and 5-year overall survival was better among Stage IIA1 patients, there was no significant difference in survival between Stage IIA1 and IIA2 groups (2-year, 90.6% vs. 77.8%; 5-year, 86.3% vs. 51.9%, p = 0.218). Conclusion Although there was a trend in survival difference between Stage IIA1 and IIA2 patients, the difference was not statistically significant. The revised FIGO 2009 staging system for Cx Ca defines a group of Stage IIA patients with bulky tumor (Stage IIA2) that are generally younger than Stage IIA1 patients. It is sensible to investigate an alternate or enhanced treatment scheme for Stage IIA2 patients. Ideally, the treatment scheme should prevent unnecessary radical surgery if a patient can be exposed to either chemotherapy or radiotherapy, alone or in combination.

Objective To estimate the safety and effectiveness of unidirectional knotless barbed suture compared to the traditional suture for repair of uterine wall defects through myomectomy via mini-laparotomy. Materials and Methods This was a prospective clinical study performed by a single surgeon in a medical center. Sixty-eight women with symptomatic myoma were enrolled. Their uterine wall defects were repaired either by unidirectional knotless barbed suture (Group A) or by traditional suture (Group B). The surgical time, intraoperative blood loss, and number of myomas in the two groups were analyzed by two-sample t test. Results Surgical time required from skin incision to complete closure was significantly lower in Group A than in Group B (50.2 ± 16.49 vs. 69.1 ± 25.33 min) ( p = 0.0008). The intraoperative blood loss was also lower in Group A (mean, 260.9 mL; range, 20–850 mL) than in Group B (mean, 394.7 mL; range, 50–2200 mL) but not statistically significant. Conclusion The unidirectional knotless barbed suture may facilitate the repair of uterine defects during mini-laparotomy myomectomy by significantly lowering operative time. It may also reduce the intraoperative blood loss.

OBJECTIVE To evaluate the clinical outcome and parameters related to coexisting endometrial carcinoma in women with tissue-diagnosed endometrial hyperplasia. METHODS Between January 1991 and December 2009, three hundred and eighty-six patients with the presumptive diagnosis of endometrial hyperplasia were retrieved. Among these, one hundred and twenty-five patients were identified as having coexisting endometrial carcinoma in hysterectomy specimens. The three hundred and eighty-six patients were divided into two groups: the hyperplasia-benign group (261 cases) and the hyperplasia-malignant group (125 cases). Several clinical parameters including age, menopausal status, history of abnormal uterine bleeding, obstetrical history, medical history of diabetes and hypertension, BMI, and preoperative pathologic results were investigated. RESULTS Age ≥53 (odds ratio [OR], 2.40; 95% confidence interval [CI], 1.26 to 4.57), menopausal status (OR, 2.07; 95% CI, 1.14 to 3.76), diabetes history (OR, 7.33; 95% CI, 2.79 to 19.26), abnormal uterine bleeding (OR, 3.99; 95% CI, 1.22 to 13.02), atypical endometrial hyperplasia (OR, 7.38; 95% CI, 4.03 to 13.49), and body mass index ≥27 (OR, 3.24; 95% CI, 1.76 to 5.97) were independent risk factors for prediction of endometrial hyperplasia coexisting with endometrial carcinoma. The diagnostic efficacy of atypical endometrial hyperplasia to predict the endometrial hyperplasia coexisting with endometrial carcinoma was better than or similar to those of other independent factors and combinations of these factors. CONCLUSION Coexisting malignancy should be considered when examining endometrial hyperplasia patients with the related risk factors, especially atypical endometrial hyperplasia.

This investigation compared the outcomes of vaginal and laparoscopic hysterectomies for nonprolapsed benign indications in older women.We conducted a population-based, retrospective propensity score-matched cohort study using data from the Taiwan's National Health Insurance program. Women who were aged 65 years or older with vaginal hysterectomy (n = 290) were compared with women who had laparoscopic hysterectomy for nonprolapsed benign indications (n = 290). Propensity score was calculated based on both patient- (age, socioeconomic status, residential urbanicity, comorbidity, status of any prior catastrophic illness, surgical diagnosis, and year of hysterectomy) and provider-related characteristics (physician's age and sex, hospital accreditation level, and ownership type).Women undergoing laparoscopic hysterectomy were not associated with increased risk of inpatient readmission within 30 days, in-hospital mortality, and in-hospital (including intraoperative) complications when compared with those who had vaginal hysterectomy. Women in the laparoscopic group had significantly shorter hospital stays than those in the vaginal group. The bleeding complications were mostly due to blood transfusion (2.1% in vaginal and 0.7% in laparoscopic hysterectomy groups) and urinary tract infection (1.0% in vaginal and 1.7% in laparoscopic hysterectomy groups). The surgical injury (intraoperative) complications included mostly surgical laceration of the urinary tract (0.7% in vaginal and 0.3% in laparoscopic hysterectomy groups).Advanced age alone should not be the limiting factor for surgical referral of laparoscopic hysterectomy. The shorter hospital stay and low in-hospital complications associated with laparoscopic, as opposed to vaginal hysterectomies, are important attributes of a surgical procedure essential to the postoperative care in older women aged 65 years or more.

Objective The study aimed to update the utilization trend and characterize the trachelectomy for benign and precancerous indications in Taiwanese women by comparing associated women, surgeon, and hospital-related characteristics. Materials and methods We conducted a population-based trend study using inpatient admission claims data from Taiwan's National Health Insurance program from 1998 to 2013. After excluding those who had prior subtotal hysterectomy, women who underwent trachelectomy for benign and precancerous indications were compared by age at surgery (younger than 40 years, n = 130; 40 and 59 years, n = 429; and 60 years or older, n = 439). Trend analysis by age groups and indication was performed for the utilization of trachelectomy. A separate descriptive analysis was also performed to evaluate the surgeon's total trachelectomy case volume during the study period. Results A total of 998 women who underwent trachelectomy for benign and precancerous indications were included in the study cohort. The overall utilization increased considerably by 100% over the study period. The most common indications for trachelectomy were genital prolapse (75.2%) and precancerous cervical lesion (21.0%). The majority of trachelectomies were performed with concomitant colporrhaphy for genital prolapse among older women without comorbid illness or any prior catastrophic illness. Most women (62.9%) were operated by a relatively small number of surgeons with high case volume (12.6%) during the study period. Compared to women older than 40 years, younger women had less comorbidities, more likely to be treated at private medical institution by surgeons of high case volume, and were less likely to undergo concomitant anterior and posterior colporrhaphy. Conclusions The overall utilization of trachelectomy for benign and precancerous indications has increased over the past 16-years from 1998 to 2013, particularly among older Taiwanese women without comorbid illness or any prior catastrophic illness.

Summary Background Villoglandular adenocarcinoma (VGA) of the uterine cervix is a relatively rare subtype of endocervical adenocarcinomas that often occurs in early reproductive women. Methods Clinical cases were retrospectively collected from the cancer registry systems at Mackay Memorial Hospital (Taipei, Taiwan). Clinical histories on the subjects were extracted directly from chart review of records of clinic visits. Results The mean age of 12 subjects was 42 years, with 10 and 2 subjects clinically staged as IB1 (10 of 12) and IA2 (2 of 12), respectively, for the period between January 1, 1996, and December 31, 2007. Eleven subjects had classical Type III radical hysterectomy with or without bilateral salpingo-oophorectomy plus bilateral pelvic lymphadenectomy, and one received pelvic and para-aortic lymphadenectomy plus postoperative adjuvant treatment of weekly cisplatin concurrent with radiotherapy. Only one subject had confirmed pelvic lymph nodes metastases. Nine subjects had pure histologic type and others had mixed histologic type of VGA. Only one subject had a recurrence but was still alive. Most subjects were long-term survivors (greater than 5 years) (10 of 12). Conclusion In conclusion, this study confirms the young age of subjects with VGA and reemphasizes the difficulties in the diagnosis of VGA. Because the current management strategy renders good tumor control in young subjects with early-stage VGA, we would suggest that similar treatment should be considered for elder subjects with this rare category of cervical malignancy. Our experience shows that the primary management of subjects with early-stage VGA (International Federation of Gynecology and Obstetrics Stages IA2 to IIA1) is classical Type III radical hysterectomy plus salpingo-oophorectomy with bilateral pelvic lymphadenectomy at MMH. We hope our 12-case experience may contribute to the clinical decision making for subjects with this disease.

Summary Objective To investigate the objective response rate to and tolerance of biweekly Lipo-Dox (TTY Biopharm Co. Ltd., Taipei, Taiwan) at a dosage of 20 mg/m2 in previously treated patients with recurrent cervical cancer. Materials and Methods This study was performed as a Simon's two-stage phase II clinical trial. Ten patients with recurrent cervical cancer were enrolled between April 2003 and December 2005 at the Mackay Memorial Hospital. Lipo-Dox (20 mg/m2 intravenous) diluted in 250 mL of 5% dextrose solution was administered at 2-weekly intervals. Results The mean age of the patients was 51 ± 11.1 years. The mean number of cycles of Lipo-Dox injection was 4.6 (range, 1—12 cycles). Nine patients (90%) had disease progression. Only one patient (10%) achieved a partial response, and this was also the only patient who experienced WHO grade 2 palmar-plantar erythrodysesthesia, which led to treatment delay for 2 months. The median survival time was 2 months (range, 2—6 months). The majority of patients experienced grade 1 or 2 anemia (30%), leukopenia (20%) or thrombocytopenia (20%), and others exhibited symptoms of nausea and vomiting (30%). Conclusion Salvage chemotherapy with Lipo-Dox at a dose of 20 mg/m2 administered at 2-weekly intervals produced limited responses in patients with recurrent cervical cancer. This trial will not proceed to the second stage. These results may discourage the management of recurrent cervical cancer with single-agent Lipo-Dox in future clinical trials.

Summary Postmenopausal bleeding is bleeding that occurs 12 or more months after the last menstrual period and accounts for 5% of all gynecologic office visits. While it is not always a symptom of cancer, the exclusion of endometrial hyperplasia and carcinoma is the key issue in the evaluation of patients with postmenopausal bleeding. The primary evaluation of postmenopausal women who present with abnormal uterine bleeding includes a medical history and a pelvic examination. Investigative studies, such as a uterine biopsy, ultrasound, hysteroscopy or dilation and curettage, may be required. Treatment will depend on the cause determined. The most important point is that irregular perimenopausal or postmenopausal bleeding should not be ignored or assumed to be a normal phenomenon.

SUMMARY Cervical cancer is the most common gynecologic malignancy worldwide. Squamous cell carcinoma, adenocar- cinoma, and adenosquamous carcinoma are the three major histologic types, and this cancer develops slowly and locally. Radical hysterectomy plus pelvic lymph node dissection or concurrent chemoradiation therapy (CCRT) is the standard treatment when the disease is at an early stage. CCRT remains the standard for locally advanced disease, and systemic chemotherapy plays a major role in disease with distant metastases. In recent decades, some new trends in treating this cancer have been discussed and applied. A series of clinical trials and retrospective studies support a more conservative surgical treatment in early-stage disease. Sentinel lymph node mapping is used to decrease the morbidities after nodal dissection. Some new concurrent chemothera- peutic agents and schedules have been developed to replace the traditional cisplatin-base agents in order to decrease the toxicity during CCRT. Consolidation chemotherapy after CCRT can help improve the outcome. Neoadjuvant chemotherapy plus radiotherapy has revealed itself as the potential application as part of a new therapeutic trend in treating locally advanced cervical cancer patients. In the Gynecologic Oncology Group (GOG) phase III trial (GOG-179), cisplatin plus topotecan was proved to prolong the patients' survival time. Vaccines, both prophylactic and therapeutic, will be the trend in the future. This article intends to review recent reports and update the available information relating to the current trends in the management of cer- vical cancer. (International Journal of Gerontology 2007; 1(2): 98-102)

Objectives. To evaluate the efficacy and safety of a distearoylphosphatidylcholine pegylated liposomal doxorubicin, Lipo-Dox®, in platinum-resistant or refractory epithelial ovarian cancer. Methods. A multicenter phase II trial enrolled women with platinum-resistant or refractory epithelial ovarian carcinoma and naive to anthracycline. Eligible patients had either measurable tumor(s) or elevated serum CA 125 titer. Lipodox was initiated with a dose of 45 mg/m2 at a 4-week interval with subsequent escalation or reduction. A total of six cycles were scheduled. Results. 29 patients, 20 with platinum-resistant and 9 with platinum refractory tumors, were enrolled. Lipo-Dox was given for an average of 4.6 cycles per patient with a total of 134 cycles. Among the 26 evaluable patients, one achieved CR, 5 PR and 9 SD. The overall response rate was 23.1% (95% CI, 6.8%–39.3%) with a median response duration of 11.6 weeks. 5 of the 6 responses were in patients with resistant disease. The median progression-free duration in the SD patients was 25.7 weeks. With a median follow-up of 13.8 months, the median progression-free and median overall survivals in the 26 patients were 5.4 months and 13.8 months, respectively. Hand–foot skin reaction occurred in 4.5% and skin pigmentation in 11.2% of all treatment cycles, all were Grade 1/2. Nausea and vomiting occurred in 14.2%, while anemia, leukopenia and thrombocytopenia occurred in 20.9%, 32.8% and 9% of cycle, respectively, and were mostly Grade 1 or 2. Conclusion. Lipo-Dox, the third liposome encapsulated doxorubicin, at 45 mg/m2 every 4 weeks, is effective against recurrent, platinum-resistant epithelial ovarian cancers.

Introduction Invasive procedures including loop electrosurgical excision, cervical conization, and endometrial sampling are often recommended when atypical glandular cells (AGC) are detected on Pap smear with unsatisfactory colposcopy. These invasive procedures may result in patient anxiety, increased medical expense, and increasing the risk of preterm delivery in subsequent pregnancies. This study was performed to assess methylation biomarkers in the triage of AGC on Pap smear for invasive procedures. Methods We conducted a multicenter study in 13 medical centers in Taiwan from May 2012 to May 2014. A total of 55 samples diagnosed “AGC not otherwise specified” (AGC-NOS) were included. All patients with AGC underwent colposcopy, cervical biopsy, endometrial sampling, and conization if indicated. Multiplex quantitative methylation-specific polymerase chain reaction (QMSPCR) was performed. Sensitivity, specificity, and accuracy were calculated for detecting CIN3+ and endometrial complex hyperplasia. Results In 55 patients with AGC, the sensitivity for methylated (m) SOX1m, PAX1 m, ZNF582m,PTPRRm, AJAP1m, HS3ST2m, and POU4F3m for detecting CIN3+ and endometrial complex hyperplasia lesions was 100, 86, 71, 86, 86, 57, and 100%; specificity was 67, 79, 85, 50, 52, 96, and 52%, respectively. Testing for high risk-HPV had a sensitivity of 57% and specificity of 75% for CIN3+ and endometrial complex hyperplasia lesions. Conclusion Methylated (m) SOX1m and POU4F3m could be new methylation biomarkers for detection of CIN3+ and endometrial complex hyperplasia in AGC. Women with AGC and positive SOX1m / POU4F3m, colposcopy, cervical conization or endometrial sampling should be considered.

OBJECTIVE This study aims to examine recent trends in the performance of elective bilateral salpingo-oophorectomy at benign hysterectomy and to identify associated patient and provider-related characteristics from 2000 to 2010. METHODS We conducted a population-based, pooled, cross-sectional study using claims data from Taiwan's National Health Insurance program. Women aged 20 years or older who underwent concurrent oophorectomy at benign hysterectomy (n = 26,419) were compared with women who did not undergo concurrent oophorectomy at benign hysterectomy (n = 153,793). A generalized estimating equation model was applied to logistic regressions, and separate models were estimated to account for age interactions. RESULTS The overall oophorectomy rate declined steadily from 22.1% in 2000 to 9.9% in 2010, particularly in women aged 45 to 49 years (decreased by 80%). Women aged 55 years or older who had a comorbid illness or a catastrophic illness, underwent abdominal or laparoscopic surgical operation, and were admitted to regional hospitals or medical centers were more likely to undergo oophorectomy at hysterectomy, whereas women with a preoperative diagnosis of uterine prolapse, with a well-defined monthly wage, and undergoing vaginal hysterectomy were less likely to undergo oophorectomy. CONCLUSIONS Age, socioeconomic status, presence of comorbid illness, hysterectomy approach, hospital accreditation level, and disease diagnosis influence oophorectomy rate in Taiwan, a country with national health insurance. Studies on the possible long-term health risks of elective oophorectomy and the emergence of increasing evidence on ovarian cancers of serous histology (such as tubal carcinoma) since the early 2000s may have influenced patients' and physicians' decision-making in favor of ovarian conservation, leading to the observed downward trend among Taiwanese women from 2000 to 2010.

ObjectiveThis study aimed to determine the clinical prognostic factors involved in carcinosarcoma of the ovary, fallopian tube, and peritoneum.Materials and MethodsThis retrospective study was undertaken by the Taiwanese Gynecologic Oncology Group. The retrieved clinical data included demographic characteristics, medical disease, tumor status, extent of surgery, and adjuvant chemotherapy.ResultsIn total, 63 patients with carcinosarcoma of the ovary, fallopian tube, and peritoneum were identified. Sixty-one patients with complete data were enrolled for further data analysis. The mean follow-up period was 1.0 year, and the mean overall survival was 15.4 months. By log-rank tests, age, menopausal status, parity, hypertension, diabetes, primary tumor size, para-aortic lymph node metastasis, pretreatment CA-125, preceding diagnostic surgery, hysterectomy, lymphadenectomy, other surgeries, and paclitaxel use were not predictive of overall survival.Omentectomy, no gross residual implants after surgery, platinum treatment, and no pelvic lymph node metastasis had a trend toward better survival. Early diagnosis at stage I and cisplatin/ifosfamide regimen were significant associated with a better overall survival in log-rank and simple Cox regression tests. Bilateral ovarian tumors and metastatic tumors larger than 2 cm were significantly associated with a poorer overall survival.ConclusionsEarly diagnosis at stage I, unilateral ovarian tumor, metastatic tumors less than 2 cm, and cisplatin/ifosfamide regimen were predictive of a better survival.Omentectomy and complete debulking surgery also showed a trend toward better survival. Thus, these treatment strategies should be applied in patients with carcinosarcoma of the ovary, fallopian tube, and peritoneum.

A 39-year-old female presented with abdominal distension. A right adnexal mass was found on physical examination, which was shown to be cystic on ultrasound. An exploratory laparotomy revealed a right ovarian mass, which was removed and a staging procedure was performed. Histologically, the mass was a borderline ovarian tumor with stromal microinvasion and hemangiomatous mural nodules.

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., link_to_OA_fulltext

Purpose Point A, used for dose specification for intracavitary brachytherapy for cervical cancer, is the point at which the uterine artery and ureter cross. This study assessed compatibility of commonly used traditional point A (TPA) and actual anatomic point A (APA). Methods and Materials We visualized and placed radiopaque clips at the APA during pelvic and paraaortic lymphadenectomy in 11 patients with cervical carcinoma. Orthogonal and oblique radiographs were obtained after insertion of brachytherapy applicators. We measured the distance between the TPA and APA and estimated the brachytherapy dose to each of the two points. Results A total of 64 brachytherapy treatments were performed. The mean distances between the TPA and APA were 5.2 ± 1.0 cm on the right and 5.4 ± 1.1 cm on the left. The estimated brachytherapy doses delivered to the APA as a percentage of the presumed 500-cGy fraction size to the TPA were 35.2% (176.6 ± 59.0 cGy) on the right and 30.0% (150.2 ± 42.9 cGy) on the left. The marked discrepancy in the position of the two points was not related to individual kinetic variations during brachytherapy treatment, tumor size, or bladder filling. Conclusions The conventional TPA does not provide an accurate estimate of the APA determined during lymphadenectomy, indicating a need to reevaluate the current practice for determining the brachytherapy prescription for cervical cancer. ( ClinicalTrials.gov Identifier, NCT00319462)

Purpose. To evaluate the relation between tumor response, treatment toxicity, and serum cytokine profiles in patients with cervical cancer receiving cisplatin-based chemoradiation. Patients and Methods. Forty-two patients with cervical carcinoma receiving chemoradiation were recruited. Hemogram, biochemistry profile, cytokine levels, tumor size, and toxicity were assessed weekly. Results. The absolute neutrophil count decreased accompanied by an increase in serum levels of G-CSF during chemoradiation. The sudden elevation of serum TGF-β 1 and VEGF levels after the first fraction of brachytherapy accompanied with the development of greater radiation therapy (RT) morbidity. Lower pretreatment TGF-β 1 and VEGF levels are associated with tumor response to chemoradiation. Conclusion. The serial changes in serum cytokines during chemoradiation may correlate with tumor regression and treatment morbidity.

Leiomyosarcoma of the broad ligament (LBL) is a very rare tumor. Up to 1989, there had been only 7 cases reported in the English literature. During recent 12 years, we have had 15 cases of leiomyosarcoma in our department. Among them, there were two cases of LBL. The others were leiomyosarcoma of the uterine corpus. The first patient was 36 years old. She received total abdominal hysterectomy, bilateral salpingo-oophorectomy and paraaortic lymph node sampling followed by chemotherapy with adriamycin. Intra-abdominal recurrence with hepatic metastasis occurred 18 months after operation and she received palliative radiotherapy. The second patient was 65 years old and received subtotal hysterectomy, bilateral salpingo-oophorectomy, omental biopsy and suprapubic cystostomy followed also by chemotherapy with adriamycin. She received segmental resection of ileum and ileostomy due to intestinal obstruction caused by metastasis 5 months after her initial operation. Both patients were still alive when reported with 33 and 26 months of survival, respectively. The nature and management for LBL are scarcely reported, accumulation of cases and clinical experiences are needed.

Summary Objective We present a rare case of loin subcutaneous epithelioid sarcoma originating from the multiple metastases of a uterine leiomyosarcoma. Case Report A 54-year-old postmenopausal woman, gravida 6, para 6, presented to the general surgery outpatient department (OPD). Loin mass excisional surgery was performed on August 6, 2002, and she was diagnosed with epithelioid sarcoma. Sharp intermittent lower abdominal pain, low grade fever and back pain were noted on the fifth day after this surgery. She was transferred to the gynecology OPD. Laparotomy, on August 26, 2002, found an enlarged uterus with multiple nodules on the liver surface, mesentery, small intestine surface, omentum and sub-diaphragm. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed because uterine fibroid was the most suspicious originating site of these metastatic lesions. After laparotomy, the abdominal distension and pain continued with little improvement. She died on September 17, 2002, as a result of multiple metastases of leiomyosarcoma in both lung fields and respiratory failure. Conclusion The abrupt appearance of skin or subcutaneous nodules should prompt the clinician to consider the possibility of metastatic disease, even in patients with no known history of malignant neoplasms. Uterine leiomyosarcomas are rarely diagnosed preoperatively, and the prognosis of uterine sarcoma is notorious for its difficult determination. The frequent development of distant metastases is the main reason for the poor survival observed in uterine sarcoma compared with other uterine malignancies.

Summary Cervical cancer is the most prevalent genital tract neoplasm in Taiwan. Generally speaking, surgical staging is superior to clinical staging since histologic verification of tumor extent correlates better with the biologic behavior of disease. However, a major shortcoming of surgical staging by laparotomy is not only its association with high morbidity and prolonged recovery time, but also the development of postoperative peritoneal adhesions. Adhesion formation limits the mobility of the intestinal loops and exposes them to excess irradiation. The ability to prevent postoperative peritoneal adhesions is the impetus behind the ongoing investigation into the use of laparoscopic surgery. This outstanding feature of laparoscopy is extremely significant in the management of patients with cervical cancer, who are subjected to radiotherapy after lymphadenectomy. Laparoscopic lymphadenectomy, either partial (lymph node sampling) or complete, leads to minimal postoperative peritoneal adhesions and permits accurate assessment of the extent of disease for cervical cancer patients with early or advanced disease. This paper reviews recent reports and updates available information concerning the current practice of laparoscopic pelvic and paraaortic lymphadenectomy in the management of cervical cancer. Various aspects of laparoscopic lymphadenectomy and its clinical role are addressed here, including complications and any controversial issues.

Summary Background Surgical staging using transperitoneal laparoscopic para-aortic lymph node dissection is an option for the pretreatment evaluation of locally advanced cervical cancer; however, its role for elderly patients (≥ 65 years) remains unclear. Methods Elderly patients with stage IIB–IVA cervical squamous cell carcinoma who underwent transperitoneal laparoscopic para-aortic lymph node dissection (TLSPAD) before radiation therapy (RT) or concurrent chemoradiation therapy (CCRT) during 1993–2001 were included in this retrospective study. The control group included elderly patients with the same clinical conditions, except they did not undergo TLSPAD. Survival and major bowel complications were compared between these two groups. Results The TLSPAD group consisted of 19 patients (median age: 72 years; range: 65–78 years), and the control group consisted of 37 patients (median age: 73 years; range: 65–86 years). In the TLSPAD group, para-aortic lymph node metastasis was noted in 15.8% of patients and another 15.8% were unable to have their lymph node laparoscopically retrieved. Although patients in the TLSPAD group demonstrated a higher rate of receiving CCRT than the control group, neither failure-free survival nor overall survival were statistically different between these two groups. Subsequent major bowel complications (e.g., fistula, bowel obstruction) were more frequent in the TLSPAD group (36.8%) than the control group (10.8%; p =0.032). Conclusion In elderly patients with locally advanced cervical squamous cell carcinoma, pretreatment TLSPAD might not improve survival and might be associated with an increased risk of subsequent major bowel complications. Extraperitoneal laparoscopic para-aortic lymphadenectomy might be a better method for the pretreatment surgical staging of elderly patients because it could potentially result in fewer bowel complications.

Nine hundred fifty-four patients, who received a radical hysterectomy and a bilateral pelvic lymphadenectomy, were included in this study which ran from January 1971 to December 1986. The subjects, by in large, ranged in age from 41 to 60. Of these cases, 62.5% were in clinical stage IB, while 26.2% were in stage IIA. Urinary tract fistula formations occurred in 2.4% of the cases and substantially decreased from 6.1% during 1971–1978 to 0.9% in the subsequent period from 1979 to 1986. The operative mortality rate was 0.4%. The follow-up included 438 cases that came from 1971 to 1981, and each was evaluated over a period of 5 years. Of these cases, 28 patients were lost during the follow-up period and were presumed to have died from cancer. The absolute 5-year survival rates for the patients in stage IB, stage IIA, and IIB were 86.1, 71.7, and 60.1%, respectively. The respective 5-year survival rates for patients with stage IB LN(−) and LN(+), i.e., without or with lymph node metastasis, were 87.7 and 73.1%. The survival rates for patients with stage IIA LN(−) and LN(+) were 79.8 and 40.9%, respectively. In retrospect, the 5-year survival rates seem to be related to age, parametrial involvement, and histological type. This study shows that because of improving surgical techniques and anesthesia, acceptable operative morbidity and mortality, as well as favorable 5-year survival rates, radical surgery seems to be the treatment of choice for patients with early invasive uterine cervical, and especially for younger women.