All gynecologic oncologists should learn the endoscopic surgical technique.
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Female↗
Biomedical subjects
Kuan-Gen Huang
Publications and source records attributed to Kuan-Gen Huang.
Comparative benefits and limitations of 18F-FDG PET and CT-MRI in documented or suspected recurrent cervical cancer.
PURPOSE: The purpose of this study was to assess the comparative benefits and limitations of (18)F-fluorodeoxyglucose (FDG) PET and CT-MRI in documented or suspected recurrence of cervical cancer after primary treatment. METHODS: Three patient groups were enrolled. Group A patients had biopsy-documented recurrent or persistent cervical cancer. Group B patients had suspicion of recurrent tumour on CT-MRI without biopsy proof and were potentially curable. Group C patients were in complete remission after previous definitive treatment for histologically confirmed cervical carcinoma but had elevated serum squamous cell carcinoma antigen (tumour marker) levels despite negative CT-MRI. Clinical management decisions were recorded with CT-MRI alone and with additional FDG PET. Discordances and concordances between CT-MRI and FDG PET results were identified and related to final diagnosis as based on histopathology or follow-up. RESULTS: A total of 150 patients (ten regions per patient) were eligible for analysis, with 58 in group A, 52 in group B and 40 in group C. For the 149 discordant regions, 126 (84.6%) had final diagnoses. Of these final diagnoses, there was additional benefit from FDG PET over CT-MRI in 73.8% (93/126), with FDG PET correcting false negatives (FNs) on CT-MRI in 74.2% (69/93) and correcting false positives (FPs) on CT-MRI in 25.8% (24/93). Among lesions confirmed by FDG PET, 75.4% (52/69) were extra-pelvic. There was additional benefit of CT-MRI compared with FDG PET in 26.2% (33/126): in nine (27.3%) CT-MRI results were shown to be true positive (TP) whereas FDG PET yielded FN results, while in 24 (72.7%) CT-MRI corrected FP results on FDG PET. Among the nine FNs on FDG PET that were identified by CT-MRI, four were extra-pelvic. Among the FPs on FDG PET that were excluded by CT-MRI, 79.2% (19/24) were extra-pelvic. CONCLUSION: For recurrent cervical cancer, the benefits of FDG PET exceed those of CT-MRI owing to the ability of FDG PET to identify extra-pelvic metastases and its higher sensitivity and specificity.
Antigens, Neoplasm↗
Low value of [18F]-fluoro-2-deoxy-D-glucose positron emission tomography in primary staging of early-stage cervical cancer before radical hysterectomy.
PURPOSE: The role of positron emission tomography (PET) with [18F]-fluoro-2-deoxy-D-glucose (FDG) in early-stage cervical cancer is unclear. We aimed to investigate the clinical benefit of FDG-PET in primary staging before radical hysterectomy and pelvic lymphadenectomy (RH-PLND). PATIENTS AND METHODS: Patients with untreated stage IA2 to IIA adenocarcinoma (AD) or adenosquamous carcinoma (ASC) or nonbulky (< or = 4 cm) squamous cell carcinoma cervical cancer with magnetic resonance imaging (MRI) -defined negative nodal metastasis were enrolled onto a prospective study with a two-stage design. All patients had a preoperative dual-phase FDG-PET, technetium-99m-sulfur colloid lymphoscintigraphy, and intraoperative sentinel lymph node (LN) detection at RH-PLND. The gold standard of LN metastasis is histologic. A sample size of 120 patients was calculated to fit study aims (diagnostic efficacy of PET and sentinel LN sampling). An interim analysis was performed when 60 patients were accrued, which led to the current report. RESULTS: There were 36 SCCs, 20 ADs, and four ASCs. Of the 60 patients, 10 (16.7%) had pelvic LN metastases, and one (1.7%) had para-aortic LN (PALN) metastasis histologically. FDG-PET detected the single PALN metastasis (one of one patient) but detected only one (10%) of the 10 pelvic LN metastases. The PET false-negative pelvic LN micrometastases measured a median of 4.0 x 3.0 mm (range, 0.5 x 0.5 to 7 x 6 mm). The second stage of this trial will be continued without PET. CONCLUSION: This study shows that dual-phase FDG-PET has little value in primary, nonbulky, stage IA2 to IIA and MRI-defined, LN-negative cervical cancer.
Adult↗
Irradiation-induced uterine malignant mixed müllerian tumor.
OBJECTIVE: To report a case of a patient with cervical squamous cell carcinoma stage IIIB who was diagnosed with malignant mixed müllerian tumor (MMMT) 5 years after radiotherapy. CASE REPORT: A 57-year-old female patient with cervical squamous cell carcinoma FIGO stage IIIB received pelvic irradiation for her disease. After radiotherapy, she was followed-up every 6 months. At 60 months, Papanicolaou smear revealed abnormal cancer cells and secondary MMMT was diagnosed. The patient underwent surgical treatment followed by chemotherapy. However, the cancer recurred 8 months after surgery and the patient died 1 month later. CONCLUSION: Patients with cervical cancer administered irradiation many years previously remain at high risk of secondary malignancies. In these cases, long-term follow-up with extreme caution is mandatory. For patients with any types of symptoms, aggressive and immediate investigation is suggested in order to detect possible occult malignancies.
Adenocarcinoma↗
Comparison between the Hybrid Capture II Test and an SPF1/GP6+ PCR-based assay for detection of human papillomavirus DNA in cervical swab samples.
We compared the efficacy of human papillomavirus (HPV) DNA detection between a PCR-based genechip (Easychip HPV Blot [hereafter referred to as HPV Blot]; King Car, Taiwan) method and Hybrid Capture II (HCII; Digene, Gaithersburg, MD) in women with previous normal (n = 146) or abnormal (> or =atypical squamous cells of undetermined significance [ASCUS] [n = 208]) cytology. A total of 354 cervical swab samples were collected for HPV DNA assay by both HCII and SPF1/GP6+ PCR followed by HPV Blot tests. Colposcopy-directed biopsy was performed if clinically indicated. Of the 354 samples, HPV-positive rates by these two methods (HCII and HPV Blot) were 12.6% and 18.2% in 143 normal samples, 36.2% and 45.7% in 105 ASCUS samples, 57.4% and 57.4% in 94 low-grade squamous intraepithelial lesion samples, and 83.3% and 75.0% in 12 high-grade squamous intraepithelial lesion samples, respectively. The concordance of HPV Blot and HCII was 80.8% (286/354), and the agreement between the methods (kappa value, 0.68) was substantial. Discrepancies were further investigated by at least one of the following three methods: direct sequencing, type-specific PCR, and HPV Blot genotyping of cervical biopsy tissue. In the 15 HCII-positive samples, HPV Blot detected only non-HCII HPV genotypes; results of further verification methods were consistent with the latter test in the 15 samples. Of the 20 samples with HCII-negative and HPV Blot-positive results, 18 were found to contain the 13 HCII high-risk genotypes by verification methods. In only 16.7% (3/18) of the HCII-positive but HPV Blot-negative samples, further studies detected the 13 HCII genotypes. We conclude that HPV Blot seemed comparable to HCII for detection of HPV DNA in cervical swab samples.
Base Sequence↗
Benefits of intracervical injection of sterile saline solution in laparoscopically assisted vaginal hysterectomy with vaginal colpotomy and bladder mobilization.
OBJECTIVE: To evaluate the influence of intracervical saline injection on inexperienced operators and on laparoscopically assisted vaginal hysterectomy (LAVH). STUDY DESIGN: This retrospective study included 273 women undergoing LAVH. From July 1997 to June 2002, 138 LAVHs were performed with laparoscopically approached colpotomies and bladder mobilization. Among 135 LAVHs with a vaginal approach, colpotomies/bladder mobilization was done directly in 62 and in the other 73 after a circumferential intracervical saline injection. All operations were performed by inexperienced operators under the supervision of senior surgeons. Blood loss, operative time and complications were analyzed. RESULTS: The average follow-up period was 41.2 +/- 17.4 months (range, 12-72). No statistically significant differences were observed in age, hemoglobin levels or length of postoperative hospital stay. The incidence of postoperative infection, hematoma and bowel injury was not significantly different. LAVH with vaginal colpotomies/bladder mobilization and intracervical saline injection was associated with the smallest estimated blood loss (p = 0.002) and operative time (p < 0.001). LAVH with laparoscopic colpotomies and bladder mobilization had the longest operative time (p<0.001) and the highest bladder injury rate (p= 0.004). CONCLUSION: A circumferential injection of normal saline at the cervicovaginal junction is a good option for inexperienced operators.
Blood Loss, Surgical↗
Positron emission tomography for unexplained elevation of serum squamous cell carcinoma antigen levels during follow-up for patients with cervical malignancies: a phase II study.
BACKGROUND: During follow-up for patients with cervical carcinoma, elevation of serum squamous cell carcinoma antigen (SCC-Ag) levels in the absence of detectable recurrent lesions presents a diagnostic and therapeutic challenge. In the current prospective study, the authors evaluated the use of fluorine-18-labeled fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) to detect disease recurrence in this setting. METHODS: Women with cervical carcinoma who experienced complete responses to primary treatment or salvage therapy and who had no evidence of recurrent disease as detected by conventional methods but had serum SCC-Ag levels > or = 2.0 ng/mL on 2 consecutive occasions were eligible for the study. PET was performed within 2 weeks after the completion of conventional studies for the assessment of recurrence. RESULTS: Twenty-seven consecutive patients were registered for the current study. PET findings were positive for 19 patients: 14 who had a distant lesion or lesions, 2 who had a local lesion or lesions, and 3 who had both local and distant lesions. Of these 19 patients, 17 were confirmed to have recurrent disease; the remaining two were found to be free of disease but had severe anthracosis in the PET-positive mediastinal lymph nodes. Seven of the eight patients with negative PET findings were not found to have recurrent disease on follow-up. Overall, PET detected FDG-avid lesions in 17 (94%; P < 0.001) of the 18 patients with recurrent disease. Seven of these 18 patients received therapy with curative intent; complete control was achieved in 6, four of whom currently are alive and free of disease. The addition of PET in the current setting curbed the use of futile curative therapy and significantly increased overall survival for patients in the current cohort compared with a historical group of 30 consecutive patients who had elevated SCC-Ag levels as a first sign of recurrence. CONCLUSIONS: PET expedited the detection of recurrent cervical carcinoma in patients with unexplained elevation of SCC-Ag levels. Such expedited detection may have positive effects on patient survival.
Antigens, Neoplasm↗
Restaging of recurrent cervical carcinoma with dual-phase [18F]fluoro-2-deoxy-D-glucose positron emission tomography.
BACKGROUND: The clinical value of positron emission tomography (PET) with [18F]fluoro-2-deoxy-D-glucose (FDG) for primary staging in cervical carcinoma appears to be promising. The authors sought to evaluate the diagnostic efficacy and benefit of PET in restaging cervical carcinoma at the time of first recurrence. METHODS: Forty patients with cervical carcinoma who experienced confirmed treatment failure but who were feasible candidates for curative salvage therapy were enrolled prospectively in the current study. Restaging was performed with PET and with computed tomography and/or magnetic resonance imaging (CT/MRI). Dual-phase PET was performed by adding 3-hour-delayed images to the 40-minute scans. The results of the PET and CT/MRI scans were compared. Lesion status was determined by pathologic findings or by clinical follow-up. The receiver operating characteristic curve method with calculation of area under the curve (AUC) was used to evaluate diagnostic efficacy. The primary endpoint was percent improvement in restaging (with improvement indicated by treatment modification) after PET. The secondary endpoint was 2-year overall survival among study participants compared with comparable previously treated patients who did not undergo disease restaging with PET. RESULTS: Twenty-two patients (55%) had their treatment modified due to PET findings. PET was significantly superior to CT/MRI (sensitivity: 92% vs. 60%; AUC: 0.962 vs. 0.771; P<0.0001) in identifying metastatic lesions. For individuals receiving primary surgery, a significantly better 2-year overall survival rate was observed among study participants compared with patients who underwent disease restaging without PET (HR, 0.21 [95% confidence interval, 0.05-0.83]; P=0.020). CONCLUSIONS: Dual-phase FDG-PET is superior to CT/MRI in the restaging of recurrent cervical carcinoma. Restaging with PET provides benefit by allowing the physician to offer optimal management of recurrent cervical carcinoma.
Adult↗
Bladder injury after LAVH: a prospective, randomized comparison of vaginal and laparoscopic approaches to colpotomy during LAVH.
STUDY OBJECTIVE: To compare results of a vaginal approach to colpotomy (type IA) and laparoscopic-assisted abdominal colpotomy (type ID) in performing a laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Prospective, randomized study (Canadian Task Force classification I). SETTING: Tertiary teaching hospital. PATIENTS: Five hundred forty-one women, 274 in group 1 (type 1D) and 267 in group 2 (type 1A). INTERVENTION: LAVH with follow-up for 3 months to 5 years. MEASUREMENTS AND MAIN RESULTS: There were no statistically significant differences in age, preoperative and postoperative hemoglobin values, or postoperative hospital stay between groups. Operating time and estimated blood loss were significantly reduced in group 2 (p <0.001 and <0.001, respectively). Women in group 1 had nine urinary tract injuries (3.28%), including eight cases of intraoperative bladder injury (2.91%) and one vesicovaginal fistula (0.36%), but no ureteral injury. The bladder injury rate in group 2 was 0.37%, which was significantly lower (p = 0.038). There were no significant differences in ureteral or bowel injuries, pelvic hematomas, or pelvic abscesses. CONCLUSION: LAVH type IA achieved better results than type ID in preventing bladder injury.
Blood Loss, Surgical↗
Defining the priority of using 18F-FDG PET for recurrent cervical cancer.
UNLABELLED: PET with 18F-FDG has shown its potential in cervical cancer. For maximizing the benefits of this new imaging technology, we aimed to define the prognostic features of recurrent cervical cancer patients for selecting appropriate candidates using 18F-FDG PET. METHODS: Patients enrolled were from 2 independent prospective studies investigating the role of 18F-FDG PET in cervical cancer patients after definitive treatment with documented failure (CTRP-018) or unexplained elevated tumor marker serum levels (CTRP-016) and proven relapse after PET. A total of 55 eligible patients received PET and CT or MRI. Lesion status was determined from pathologic results or clinical follow-up. The benefits calculated were based on treatment that was modified because of the PET findings. The Cox proportional hazards ratio (HR) was used to select independent prognostic covariates. RESULTS: Thirty-six (65.5%) patients had treatment that was modified due to PET. Primary radiation (HR = 14.62; 95% confidence interval [CI] = 2.74-77.92), squamous cell carcinoma antigen (SCC-Ag) > or = 4 ng/mL (HR = 5.82; 95% CI = 1.53-22.04), and presence of symptoms (HR = 6.24; 95% CI = 1.99-19.61) at recurrence were significant factors associated with poor survival. A scoring system using these covariates defined 3 distinct prognostic groups: score < or = 1 (HR = 1.00); score = 2 (HR = 6.91; 95% CI = 1.49-32.14); and score = 3 (HR = 60.46; 95% CI = 9.68-378.09) (P < 0.0001). CONCLUSION: Using this risk score, 18F-FDG PET may offer maximal benefits by selecting appropriate recurrent cervical cancer patients for salvage therapy with precise restaging information.
Adult↗
Value of dual-phase 2-fluoro-2-deoxy-d-glucose positron emission tomography in cervical cancer.
PURPOSE: The role of positron emission tomography (PET) with fluorine-18-labeled fluoro-2-deoxy-d-glucose (FDG) in cervical cancer has not yet been well defined. We conducted a prospective study to investigate its efficacy in comparison with magnetic resonance imaging and/or computed tomography (MRI-CT). MATERIALS AND METHODS: Patients with untreated locally advanced (35%) or recurrent (65%) cervical cancer were enrolled onto this study. In the first part of this study, 41 patients had a conventional FDG-PET (40 minutes after injection), and in the second part, 94 patients received dual-phase PET (at both 40 minutes and 3 hours after injection). The overall results of PET scans were compared with MRI-CT, and the two protocols of PET were also compared with each other. Lesion status was determined by pathology results or clinical follow-up. The receiver operating characteristic curve method with area under the curve (AUC) calculation was used to evaluate the discriminative power. RESULTS: Overall (N = 135), FDG-PET was significantly superior to MRI-CT in identifying metastatic lesions (AUC, 0.971 v 0.879; P =.039), although the diagnostic accuracy was similar for local tumors. Dual-phase PET was also significantly better than the 40-minute PET (n = 94). The latter accurately recognized 70% of metastatic lesions and the former detected 90% (AUC, 0.943 v 0.951; P =.007). Dual-phase FDG-PET changed treatment of 29 patients (31%; upstaging 27% and downstaging 4%). CONCLUSION: This study shows that dual-phase FDG-PET is superior to conventional FDG-PET or MRI-CT in the evaluation of metastatic lesions in locally advanced or recurrent cervical cancer.
Adult↗
Randomized trial of surgical staging (extraperitoneal or laparoscopic) versus clinical staging in locally advanced cervical cancer.
OBJECTIVE: To define the role of pretreatment surgical staging for locally advanced cervical carcinoma. METHODS: A two-step randomized trial was conducted to compare clinical staging (arm A) versus surgical staging (arm B) and to compare the laparoscopic (LAP) with the extraperitoneal (EXP) approach in previously untreated locally advanced cervical carcinoma. After the first randomization, those in arm B were randomly allocated to either LAP or EXP. An interim analysis was planned to evaluate the feasibility of LAP versus EXP, which led to the current report. RESULTS: A total of 61 patients were eligible (arm A, 29; arm B, 32). The operation time, blood loss, and lymph node yield of LAP and EXP were not significantly different. Serious acute and late toxicity was not different between arm A and arm B, or LAP versus EXP. Para-aortic node metastasis was documented in 25% (95% confidence interval, 10% to 40%) of patients on arm B. An interim analysis was performed in January 2000. Patients on arm B had significantly worse progression-free survival than those on arm A. Hazard ratios of relapse/persistent or death were 3.13 (P = 0.005) and 1.76 (P = 0.150), respectively. Patient accrual was terminated according to the early stopping rules. With further follow-up till December 2001, the difference in progression-free survival remained significant (P = 0.003), and the difference in overall survival became significant (P = 0.024) as the data matured. CONCLUSION: The benefit of pretreatment surgical staging for cervical carcinoma remained unproven. The detrimental effects of surgical staging observed in this study must be considered in the design of clinical guidelines or future trials.
Adult↗
Laparoscopic radical trachelectomy for stage Ib1 cervical cancer.
Radical trachelectomy by vaginal approach is an alternative for young women with early-stage cervical cancer. We modified this procedure to treat two patients with stage Ib1 cervical cancer. With 100% laparoscopic pelvic lymphadenectomy and 80% laparoscopic approach, the technique is laparoscopic radical trachelectomy (LRT). Under direct enhanced vision of the laparoscope, it is easy to identify and preserve ascending branches of the uterine arteries and to divide ligaments surrounding the cervix and vagina. Vaginal procedures require only colpotomy, amputation of cervix, dividing caudal paracolpium, and corpus-vagina anastomosis. Short-term follow-up results of our first patients are satisfactory. Thus, LRT could be a useful alternative for women with early cervical cancer who want to preserve fertility.
Adult↗
Management of port-site metastasis after laparoscopic surgery for ovarian cancer.
OBJECTIVE: The purpose of this study was to define the clinical features and long-term prognosis of port-site metastasis after primary laparoscopic surgery for ovarian cancer. STUDY DESIGN: All the patients with epithelial ovarian cancer or borderline malignancy who had undergone primary laparoscopic surgery at our institution were reviewed. The clinicopathologic parameters, flow cytometric parameters, p53, p27, bax, HER-2/neu, and bcl-2 by immunostaining, presentation of port-site implants, management of the individual patient, and long-term outcome were analyzed. CANCERLINE and MEDLINE (1960-2002) were searched for related papers. RESULTS: Between 1993 and 2001, of the 31 patients with epithelial ovarian cancer or borderline malignancy who underwent primary laparoscopic surgery at Chang Gung Memorial Hospital, 6 (19.4%) had port-site metastasis. The other 2 patients were referred after port-site metastasis. Tumors with port-site recurrences had higher S-fraction than those without (median: 18.2% vs 9.9%, P =.003; relative risk ratio: >15.5% vs <or=15.5% = 38.33; 95% CI, 3.3-449.2). Those patients who have port-site metastasis develop during chemotherapy (n = 2) or after adequate chemotherapy had been given (n = 2) all died of cancer. Two patients have been currently alive without disease, the tumors of whom were p27-positive and p53-, HER-2/neu -, bcl-2-negative. CONCLUSION: Port-site metastasis after laparoscopic surgery, during chemotherapy or when adequate chemotherapy has been given, is usually associated with poor outcome. Further investigations are necessary to define the mechanisms and effective management to prevent and treat this serious complication.
Adult↗
Comparison of laparoscopic and conventional surgery in the treatment of early cervical cancer.
STUDY OBJECTIVE: To compare efficacy, results, and complications of laparoscopic-assisted radical hysterectomy (LARH) and pelvic lymphadenectomy with abdominal radical hysterectomy (ARH) and pelvic lymphadenectomy in management of early (stages 1a2, 1b) invasive cervical carcinoma. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Sixty women enrolled for radical hysterectomy as most appropriate primary treatment. INTERVENTION: Radical hysterectomy performed by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS: Thirty patients each underwent LARH and ARH. The groups did not differ in terms of age, weight, disease stage, operating time, and hospital stay. Mean blood loss was 962 +/- 543 ml for ARH and 450 +/- 284 ml for LARH. No laparoscopic procedure was converted to laparotomy. There was no significant difference in intraoperative and postoperative complications. There was no significant difference in recurrence rates. CONCLUSION: LARH with pelvic lymphadenectomy does not increase recurrence rates and morbidity when performed by experienced endoscopists and oncologists.
Adult↗
Total laparoscopic radical hysterectomy using Lee-Huang portal and McCartney transvaginal tube.
A surgical approach to the treatment of invasive cervical carcinoma 1b1 may result in decreased mortality and morbidity as well as better functional quality of life. Laparoscopic-assisted radical vaginal hysterectomy (LARVH) is an alternative treatment for early cervical cancer, with parts of the procedures performed vaginally. We modified LARVH to total laparoscopic radical hysterectomy (TLRH) using Lee-Huang portal and McCartney transvaginal tube. The advantage of TLRH for cervical cancer is that the entire procedure is performed under direct observation. It may reduce the possibility of visceral organ injury during vaginal procedures and could minimize vaginal bleeding due to dissection. The Lee-Huang portal as primary laparoscopic port affords wide access to the abdominal cavity and proper visual angle, and increases the working distance. A plastic McCartney transvaginal tube placed inside the vagina maintains pneumoperitoneum and performs a circular incision on the vagina around the uterus with ease. Our preliminary experience with 12 patients suggests that this method of TLRH is feasible for selected patients and may be a useful alternative in treating early cervical cancer.
Biopsy, Needle↗
Total laparoscopic radical parametrectomy.
Although the surgical approach to early invasive cervical carcinoma may result in a better functional quality of life, the majority of patients with occult cervical cancer posthysterectomy still are treated with radiation therapy. Obviously, a radical operation still is considered a technically difficult task. Recently, laparoscopic-assisted vaginal radical parametrectomy (LAVRP) has been reported as an alternative treatment for this situation. In laparoscopic-assisted vaginal radical hysterectomy (LARVH), parts of the procedure are performed vaginally. We modified LAVRP in treating cervical cancer as through the laparoscope completely total laparoscopic radical parametrectomy (TLRP). The major advantage of TLRP for occult cervical cancer is that the entire surgery is performed under direct observation. It may reduce the possibility of visceral organ injury during vaginal procedures and could minimize the vaginal bleeding from vaginal dissection. Our preliminary experiences suggest that TLRP is feasible for carefully selected candidates.
Endometrium↗