台灣婦癌醫學會 Taiwan Association of Gynecologic Oncologists

                                                        本期編輯 陳子健 醫師   

壹、 會務報告

一、近期學會活動

二、婦癌專科醫師考試揭曉

本次考試計有7人報考 (台灣婦癌醫學會5人，中華民國婦癌醫學會2人)。其中，有兩位沒有通過筆試，四位沒有通過口試。最後，僅有任職於阮綜合醫院的廖正義醫師通過本屆的婦癌專科醫師考試。錄取率1/7。

三、「第十四屆台灣癌症聯合學術年會」壁報論文甄選

截稿日期：2009年2月15日（星期日）24：00止，逾時不予受理

獎勵內容：基礎、臨床類各10名，發表口頭報告、頒發獎狀、獎金（獎金部份：前3名每名3萬元，第4到第10名每名1萬元）

投稿方式：2008年11月16日起，至下列網站查詢及下載

          www.hancan.com.tw

※特別注意事項：本次壁報論文以網路上傳方式投稿，將會設定截止時間，請各會員務必配合，在截止時間之前完成上傳動作。

四、學會網站誠徵衛教文章

歡迎各位會員踴躍賜稿，以充實學會的網站內容。來稿請e-mail至tago.gyn@gmail.com

貳、 會員動態及意見與回應

(歡迎提供會員動態、意見，以及衛教文章（學會E-mail address: tago.gyn@gmail.com)

参、 前月文獻選錄

(Ref 1) Port-site metastasis 似乎不是大問題

(Ref 2) 對於recurrent endometrial cancer再度使用carboplatin+paclitaxel

(Ref 3) Bladder erosion: IP chemotherapy 之可能副作用

(Ref 4) 對於ovarian clear cell carcinoma 之保留生育能力

(Ref 5) i.p, bevacizumab 來緩解malignant ascites

(Ref 6) 卵巢癌復發使用platinum + gemcitabine + bevacizumab: 高效能，但合併高風險

(Ref 7) Cervical biopsy時，請患者咳嗽

(Ref 8) Cervical cytology: 液相薄層 vs. 傳統

(Ref 9) “”BRCA ness” syndrome

(Ref 10) 關於子宮下段之carcinoma

(Ref 11)  PET 無法有效預測post-chemotherapy germ cell tumor 之viability

(Ref 12) 關於停經婦女的ASC-H

(Ref 13) 懷孕時使用platinum derivatives

(Ref 14) NCCN guideline 是否作過頭了----- systemic pelvic lymphadenectomy對於early endometrial carcinoma的意義

(Ref 15) 關於成熟畸胎瘤裡面的SCC ----- 手術與化療為重

(Ref 16) 卵巢移植後的成功懷孕案例報告

(Ref 17) 臨終患者之delirium

(Ref 1) Port-site metastasis 似乎不是大問題

The rate of port-site metastases after 2251 laparoscopic procedures in women with underlying malignant disease.

Gynecol Oncol. 2008 Dec;111(3):431-7.

Zivanovic O, Sonoda Y, Diaz JP, Levine DA, Brown CL, Chi DS, Barakat RR, Abu-Rustum NR.
Department of Surgery, Gynecology Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
BACKGROUND: The aim was to describe the rate of laparoscopic trocar-related subcutaneous tumor implants in women with underlying malignant disease. METHODS: An analysis of a prospective database of all patients undergoing transperitoneal laparoscopic procedures for malignant conditions performed by the gynecologic oncology service. RESULTS: Between July 1991 and April 2007, laparoscopic procedures were performed in 1694 patients with a malignant intraabdominal condition and in 505 breast cancer patients undergoing risk-reducing, diagnostic or therapeutic laparoscopic procedures without intraabdominal disease. Port-site metastases were documented in 20 of 1694 patients (1.18%) who underwent laparoscopic procedures for a malignant intraabdominal condition. Of these, 15 patients had a diagnosis of epithelial ovarian or fallopian tube carcinoma, 2 had breast cancer, 2 had cervical cancer, and 1 had uterine cancer. Nineteen of 20 patients (95%) had simultaneous carcinomatosis or metastases to other sites at the time of port-site metastasis. Patients who developed port-site metastases within 7 months from the laparoscopic procedure had a median survival of 12 months whereas patients who developed port-site metastasis >7 months had a median survival of 37 months (P=0.004). No port-site recurrence was documented in patients undergoing risk-reducing, diagnostic or therapeutic laparoscopic procedures for breast cancer without intraabdominal disease. CONCLUSION: The rate of port-site tumor implantation after laparoscopic procedures in women with malignant disease is low and almost always occurs in the setting of synchronous, advanced intraabdominal or distant metastatic disease. The presence of port-site implantation is a surrogate for advanced disease and should not be used as an argument against laparoscopic surgery in gynecologic malignancies.

(Ref 2) 對於recurrent endometrial cancer再度使用carboplatin+paclitaxel

Reuse of carboplatin and paclitaxel in patients with relapsed endometrial cancer--the British Columbia Cancer Agency experience.
Gynecol Oncol. 2008 Dec;111(3):474-7.

Mazgani M, Le N, Hoskins PJ; British Columbia Cancer Agency.
Division of Gynecologic Oncology, Vancouver Cancer Center, Vancouver, BC, Canada.
OBJECTIVE: To evaluate the efficacy of reusing carboplatin and taxol in women with relapsed endometrial cancer. METHODS: Retrospective analysis of our database of newly diagnosed high-risk patients with endometrial cancer treated with carboplatin-paclitaxel at diagnosis, with subsequent relapse for the period of 1995-2007. RESULTS: 111 patients of 200 relapsed. They had either endometroid or papillary serous histologies. Strategies utilized upon first relapse were: no treatment (n=33), surgery (n=4), hormones (n=8), irradiation (n=14) and chemotherapy (n=52). Carboplatin and paclitaxel was reused in 31 (60% of 52 retreated with chemotherapy or 29% of the total cohort of 111). There was no statistically significant difference in stage at diagnosis or grade at diagnosis between those retreated with chemotherapy or not or with carboplatin-paclitaxel versus another regimen. The patients retreated were a selected subgroup as only those with initial response or treated adjuvantly were offered carboplatin-paclitaxel. CR or PR were achieved in 8 (42%) patients with endometroid type cancer. In the papillary serous group 6 (50%) had CR or PR. Median PFS from first relapse was 8 months for endometroid and 9 months for papillary serous histology. OS was 15 months and 26 months respectively from first relapse. CONCLUSION: Carboplatin-taxol regimen is an efficacious treatment. Due to the patient selection these outcomes reported are likely to be an overstatement of what could be achieved in practice.

(Ref 3) Bladder erosion: IP chemotherapy 之可能副作用

Bladder erosion by an intraperitoneal chemotherapy catheter resulting in catheter protrusion through the external urethral meatus.

Gynecol Oncol. 2008 Dec;111(3):552-4

Bryant CS, Shah JP, Triest JA, Schimp VL, Morris RT.
Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA. csbryant@med.wayne.edu
BACKGROUND: Chemotherapy remains an essential part of the treatment of advanced ovarian cancer. Intraperitoneal (IP) administration has been demonstrated to provide a survival advantage over intravenous chemotherapy in three phase 3 studies. However, IP catheter complications have been a significant factor in aborting IP therapy. CASE: A 42-year-old woman receiving IP chemotherapy for carcinoma of the ovary presented with complaints of incontinence. Examination revealed the catheter protruding through the external urethral meatus. The reservoir was intact, and the catheter was immobile. Laparoscopic and cystoscopic evaluation demonstrated that the catheter tip had eroded through the dome of the bladder. The catheter was re-secured to the abdominal wall, and the bladder was laparoscopically repaired. IP chemotherapy was resumed 16 days postoperatively without incident. CONCLUSION: This is the first report of an IP catheter eroding through the bladder. Increased usage of IP chemotherapy may offer new challenges in the diagnosis and management of catheter-related complications.

(Ref 4) 對於ovarian clear cell carcinoma 之fertility-sparing

Is there any possibility of fertility-sparing surgery in patients with clear-cell carcinoma of the ovary?
Gynecol Oncol. 2008 Dec;111(3):523-6.
Kajiyama H, Shibata K, Suzuki S, Ino K, Yamamoto E, Mizuno K, Sakakibara K, Matsuzawa K, Takeda A, Kinoshita Y, Kawai M, Nagasaka T, Nawa A, Kikkawa F.
Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan. kajiyama@med.nagoya-u.ac.jp
BACKGROUND: In epithelial ovarian cancer (EOC), fertility-sparing surgery (FSS) has mainly been chosen for stage IA disease. The purpose of this study was to clarify the clinical outcome of patients with clear-cell carcinoma of the ovary (CCC) who would usually undergo radical surgery. CASES: After a central pathological review and search of the medical records from multiple institutions between 1988 and 2005, a total of 10 CCC patients treated with FSS were retrospectively evaluated in the current study. The mean age was 35.9 years (range: 32-39 years). The median follow-up time was 35.4 months (range: 21.7-153.2 months). The stage was IA in 4 patients, and IC in 6 patients [IC(b) in 5 patients, and IC(2) in one]. Nine patients received adjuvant chemotherapy. Nine patients were alive and one patient with stage IC(2) died of the disease at a follow-up time of 36.8 months. Five pregnancies were observed in 4 patients. CONCLUSIONS: Although there is no worldwide criterion for FSS in CCC patients at present, it seems that, in selected patients, this surgical approach could be adopted. This should be investigated by additional studies in a larger series.

(Ref 5) i.p, bevacizumab 來緩解malignant ascites

Intraperitoneal bevacizumab for the palliation of malignant ascites in refractory ovarian cancer.
Gynecol Oncol. 2008 Dec;111(3):530-2.
Hamilton CA, Maxwell GL, Chernofsky MR, Bernstein SA, Farley JH, Rose GS.
Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Walter Reed Army Medical Center, Washington, DC 20307-5001, USA. chad.hamilton@comcast.net
BACKGROUND: Malignant ascites often has a profound impact on the quality of life of patients with refractory ovarian cancer. Current treatments, including dietary, medical, and procedural are often temporary and unsatisfactory options in patients approaching the end of life. CASE: We present a case of an 88 year-old receiving home hospice care with refractory ovarian cancer and severe symptomatic ascites. We performed a paracentesis and treated her with intraperitoneal bevacizumab with dramatic improvement in her ascites and the quality of her final weeks of life. CONCLUSION: Intraperitoneal bevacizumab may be a useful tool in the palliation of malignant ascites and is worthy of further study.

(Ref 6) 卵巢癌復發使用platinum + gemcitabine + bevacizumab: 高效能，但合併高風險

Combination gemcitabine, platinum, and bevacizumab for the treatment of recurrent ovarian cancer.

Gynecol Oncol. 2008 Dec;111(3):461-6.
Richardson DL, Backes FJ, Seamon LG, Zanagnolo V, O'Malley DM, Cohn DE, Fowler JM, Copeland LJ.
Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The Ohio State University College of Medicine, Columbus, OH, USA.
OBJECTIVE: To describe the response rate (RR), progression-free survival (PFS), and toxicity profile of combination gemcitabine, platinum, and bevacizumab (GPB) for the treatment of recurrent epithelial ovarian cancer (EOC). METHODS: A chart review of all patients with recurrent EOC who were treated with D1, D15 GPB in a 28-day cycle at a single institution was performed. Standard doses were gemcitabine 1000 mg/m(2), cisplatin 30 mg/m(2) or carboplatin AUC 3, and bevacizumab 10 mg/kg. All patients were analyzed for toxicity. RR and PFS were assessed in all patients who received at least 2 cycles of GPB. RESULTS: Thirty-five patients were identified, and 33 received at least 2 cycles of GPB. The majority of patients (80%) were platinum sensitive. Patients received a median of 6 cycles of GPB (range 1-24). Sixteen patients (48%) had a complete response (CR), and 10 patients (30%) had a partial response (PR), for a total RR of 78%. An additional 5 patients (15%) had stable disease, and only 2 (6%) patients had progressive disease. The median overall PFS was 12 months (95% CI 7-15), with a median follow-up time of 10 months (2-22). Two patients (6%) had bowel perforations, and both survived. Hematologic toxicities were most common, with 29% and 14% of patients experiencing grade 3 or 4 neutropenia and thrombocytopenia respectively. CONCLUSIONS: The combination of GPB demonstrated excellent efficacy for the treatment of recurrent EOC. However, serious toxicities occurred, and the safety profile of this combination requires further study.

(Ref 7) Cervical biopsy時，請患者咳嗽

Forced coughing versus local anesthesia and pain associated with cervical biopsy: a randomized trial.

Am J Obstet Gynecol. 2008 Dec;199(6):641.e1-3.
Schmid BC, Pils S, Heinze G, Hefler L, Reinthaller A, Speiser P.
Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria.
OBJECTIVE: Cervical biopsy often causes discomfort and pain. To compare local anesthesia (1% lidocaine) with forced coughing as pain relief, we quantified the actual pain experienced during cervical punch biopsies. STUDY DESIGN: For a prospective trial conducted at the Medical University of Vienna, 68 women undergoing cervical punch biopsies for assessment of abnormal cervical smears were randomized in 2 pain relief treatment groups. Patients' discomfort was assessed immediately after taking the biopsy using at 10-cm visual analog scale. RESULTS: No statistically significant difference was found between pain scores recorded for the 2 groups (P = .47, 95% confidence interval [CI], -0.4 to 1.3 cm). However, when local anesthesia was applied, the examination was significantly prolonged by a median of 2.11 min (P < .001; 95% CI, 1.6-2.8). CONCLUSION: Forced coughing during cervical biopsies reduces patients' discomfort to the same extent as local anesthesia, but is associated with a significantly reduced examination time.

(Ref 8) Cervical cytology: 液相薄層 vs. 傳統

Cytologic detection of cervical abnormalities using liquid-based compared with conventional cytology: a randomized controlled trial.
Obstet Gynecol. 2008 Dec;112(6):1327-34.

Siebers AG, Klinkhamer PJ, Arbyn M, Raifu AO, Massuger LF, Bulten J.
Department of Pathology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands. b.siebers@pathol.umcn.nl
OBJECTIVE: To compare test positivity rates of liquid-based and conventional cytology. METHODS: This study was a cluster randomized controlled trial with family practice as the unit of randomization, performed within the Dutch national cervical screening program. Women aged 30-60 years (n=89,784) recruited from 246 family practices were included. One-hundred twenty-two practices (49,222 individuals) were randomly assigned to the experimental arm, and 124 practices (40,562 participants), to the conventional arm. Inclusion was performed during a 3-year period between April 2003 and July 2006. Cytologic test positivity rates of liquid-based compared with conventional cytology was compared in terms of crude and adjusted odds ratios, applying a per-protocol analysis. RESULTS: Crude ratios of the odds of test positivity rates of liquid-based compared with conventional cytology for atypical squamous cells of undetermined significance or more severe, low-grade squamous intraepithelial lesion or more severe, and high-grade squamous intraepithelial lesion or more severe were 0.95 (95% confidence interval [CI] 0.82-1.10), 1.00 (95% CI 0.83-1.20), and 0.97 (95% CI 0.77-1.22), respectively. Liquid-based cytology resulted in fewer unsatisfactory tests (odds ratio 0.30, 95% CI 0.23-0.38). The results did not change when the odds ratios were adjusted for age, study site, study period, and urbanization level. Of 128 women screened with liquid-based cytology, one unsatisfactory preparation is avoided. CONCLUSION: This study found  no statistically significant difference in cytologic test positivity rates between liquid-based and conventional cytology. However, liquid-based cytology resulted in significantly fewer unsatisfactory tests. CLINICAL TRIAL REGISTRATION: Nederlands Trial Register, www.trialregister.nl, NTR1032 LEVEL OF EVIDENCE: I.

(Ref 9) “”BRCA ness” syndrome

"BRCAness" syndrome in ovarian cancer: a case-control study describing the clinical features and outcome of patients with epithelial ovarian cancer associated with BRCA1 and BRCA2 mutations.
J Clin Oncol. 2008 Dec 1;26(34):5530-6.
Tan DS, Rothermundt C, Thomas K, Bancroft E, Eeles R, Shanley S, Ardern-Jones A, Norman A, Kaye SB, Gore ME.
Gynaecological Oncology and Cancer Genetics Units, Royal Marsden Hospital, London, UK.
PURPOSE: We evaluated the clinical impact of germ-line BRCA1/2 mutations in patients with epithelial ovarian cancer (EOC) on responses to first and subsequent lines of chemotherapy, treatment-free interval (TFI) between each line of therapy, and overall survival (OS). PATIENTS AND METHODS: Twenty-two EOC patients with germ-line BRCA1 or BRCA2 mutations (BRCA-positive) were selected from our database and matched (1:2) with 44 nonhereditary EOC controls (defined by no associated personal history of breast cancer and no family history of breast and ovarian cancer or an uninformative BRCA mutation test) for stage, histologic subtype, age, and year of diagnosis. All patients received primary platinum-based chemotherapy. Statistical comparisons included responses after first-, second-, and third-line treatment (chi(2)/Fisher's exact test) and median OS (Kaplan-Meier method/log-rank test). RESULTS: Compared with controls, BRCA-positive patients had higher overall (95.5% v 59.1%; P = .002) and complete response rates (81.8% v 43.2%; P = .004) to first line treatment, higher responses to second and third line platinum-based chemotherapy (second line, 91.7% v 40.9% [P = .004]; third line, 100% v 14.3% [P = .005]) and longer TFIs. A significant improvement in median OS in BRCA-positive patients compared with controls was observed from both time of diagnosis (8.4 v 2.9 years; P < .002) and time of first relapse (5 v 1.6 years; P < .001). BRCA status, stage, and length of first response were independent prognostic factors from time of first relapse. CONCLUSION: BRCA-positive EOC patients have better outcomes than nonhereditary EOC patients. There exists a clinical syndrome of BRCAness that includes serous histology, high response rates to first and subsequent lines of platinum-based treatment, longer TFIs between relapses, and improved OS.

(Ref 10) 關於子宮下段之carcinoma

Carcinoma of the lower uterine segment: a newly described association with Lynch syndrome.
J Clin Oncol. 2008 Dec 20;26(36):5965-71.
Westin SN, Lacour RA, Urbauer DL, Luthra R, Bodurka DC, Lu KH, Broaddus RR.
Department of Gynecologic Oncology and Division of Quantitative Sciences, The University of Texas M D Anderson Cancer Center, Houston, TX 77030, USA.
PURPOSE: Endometrial carcinoma in the lower uterine segment (LUS) is a poorly described cancer that can be clinically confused with endocervical carcinoma. We performed a case-comparison study to document the clinicopathologic characteristics of LUS tumors and their association with risk factors for endometrial cancer. PATIENTS AND METHODS: The clinical records and pathology reports from women who underwent hysterectomy at our institution for endometrial or endocervical adenocarcinoma over an 11-year interval were reviewed. The LUS group consisted of women with endometrial tumors that clearly originated between the lower uterine corpus and the upper endocervix. Immunohistochemistry and microsatellite instability and MLH1 methylation assays were performed. RESULTS: Thirty-five (3.5%) of 1,009 women had endometrial carcinoma of the LUS. Compared with patients with corpus tumors, LUS patients were younger, had higher stage tumors, and had more invasive tumors. Preoperative diagnosis of the LUS tumors more frequently included the possibility of endocervical adenocarcinoma. Seventy-three percent of the LUS tumors had an immunohistochemical expression pattern typical of conventional endometrioid adenocarcinoma. Ten (29%) of 35 women with LUS tumors were confirmed to have Lynch syndrome or were strongly suspected to have Lynch syndrome on the basis of tissue-based molecular assays. CONCLUSION: The prevalence of Lynch syndrome in patients with LUS endometrial carcinoma (29%) is much greater than that of the general endometrial cancer patient population (1.8%) or in endometrial cancer patients younger than age 50 years (8% to 9%). On the basis of our results, the possibility of Lynch syndrome should be considered in women with LUS tumors.

(Ref 11)  PET 無法有效預測post-chemotherapy germ cell tumor 之viability

[18F]Fluorodeoxyglucose positron emission tomography in nonseminomatous germ cell tumors after chemotherapy: the German multicenter positron emission tomography study group.
J Clin Oncol. 2008 Dec 20;26(36):5930-5.
Oechsle K, Hartmann M, Brenner W, Venz S, Weissbach L, Franzius C, Kliesch S, Mueller S, Krege S, Heicappell R, Bares R, Bokemeyer C, de Wit M; German Multicenter Positron Emission Tomography Study Group.
Department of Oncology/Hematology, Bone marrow transplantation/Pneumology, University Medical Center Eppendorf, Martinistr. 52, 20246 Hamburg, Germany. k.oechsle@uke.uni-hamburg.de
PURPOSE: In patients with metastatic nonseminomatous germ cell cancer (NSGCT), residual masses after chemotherapy (CTX) can consist of vital carcinoma, mature teratoma, or necrosis. This prospective trial has evaluated the accuracy of [(18)F]fluorodeoxyglucose positron emission tomography (FDG-PET) for the prediction of histology compared with computed tomography (CT) and serum tumor markers (STM). PATIENTS AND METHODS: A total of 121 patients with stage IIC or III NSGCT scheduled for secondary resection after cisplatin-based CTX were included. FDG-PET was performed after completion of CTX. All results were confirmed by histopathology and correlated to STM and CT. RESULTS: Prediction of tumor viability with FDG-PET was correct in 56%, which did not reach the expected clinically relevant level of 70%, and was not better than the accuracy of CT (55%) or STM (56%). Sensitivity and specificity of FDG-PET were 70% and 48%. The positive predictive values were not significantly different (55%, 61%, and 59% for CT, STM, and PET, respectively). Judging only vital carcinoma as a true malignant finding, the negative predictive value increased to 83% for FDG-PET. CONCLUSION: The presence of vital carcinoma and mature teratoma is common (55%) in residual masses in patients with NSGCT, and CT and STM cannot reliably predict absence of disease. In contrast to prior studies, this prospective trial, which is the only with histologic confirmation in all patients, demonstrated that FDG-PET is unable to give a clear additional clinical benefit to the standard diagnostic procedures, CT and STM, in the prediction of tumor viability in residual masses.

(Ref 12) 關於停經婦女的ASC-H

Atypical squamous cells, cannot exclude a high-grade intraepithelial lesion and its clinical significance in postmenopausal, pregnant, postpartum, and contraceptive-use patients.
Cancer. 2008 Dec 25;114(6):481-8.

Patton AL, Duncan L, Bloom L, Phaneuf G, Zafar N.
Pathology Department, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee.
BACKGROUND.: Previous studies have confirmed the low predictive value of a diagnosis of atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion (ASC-H) in a Papanicolaou (Pap) smear for subsequent high-grade dysplasia in the postmenopausal age group. It appears plausible that the decrease in estrogen inherent in the postmenopausal state likely produces reactive cytologic atypia, which is misinterpreted as ASC-H. The change in hormone levels observed in pregnant patients, postpartum patients, and contraceptive users, as a corollary, potentially could create a similar diagnostic dilemma. In the current study, the impact of age and altered hormone status on the frequency of ASC-H was assessed to answer the following questions: Is the low predictive value of ASC-H in postmenopausal women an age-related phenomenon, and do other states that result in decreased levels of estrogen relative to progesterone have a similar association? METHODS.: Pap smears that were diagnosed as ASC-H were divided into postmenopausal, pregnant, postpartum, and contraceptive-use categories. Each Pap smear slide was reviewed to assess the degree of atrophy and the character of atypical cells. The frequency of high-grade follow-up (histology and/or Digene Hybrid Capture II) in the postmenopausal group was compared with the frequency of high-grade follow-up in the pregnant, postpartum, and contraceptive-use categories using the chi-square test. The pregnant, postpartum, and contraceptive-use categories also were compared statistically among each other with the chi-square test. RESULTS.: In total, 195 cases met the criteria for study inclusion. The percentage of patients who had subsequent high-grade follow-up was 22.5% in the postmenopausal group, 79.6% in the pregnant group, 66.7% in the postpartum group, and 60% in the contraceptive-use group. When these data were subjected to the chi-square test, there was a statistically significant difference (P<.0001) between the predictive value of subsequent high-grade follow-up in the postmenopausal group compared with the other patient groups. When the chi-square test was applied to the intercomparison of the pregnant, postpartum, and contraceptive-use categories, there were no significant differences (P > .05) in high-grade follow-up between any of these groups. CONCLUSIONS.: The diagnosis of ASC-H in postmenopausal Pap smears has a low predictive value in the subsequent diagnosis of high-grade squamous lesions in stark contrast to the pregnant, postpartum, and contraceptive-use categories. This suggests that age rather than hormone alterations affects the capacity of ASC-H to predict subsequent high-grade squamous intraepithelial lesions. In addition, there are no definite cytomorphologic criteria that can be used to distinguish reliably between benign cellular changes and possible high-grade squamous lesions in these Pap smears. Digene Hybrid Capture II testing, although helpful, does not have 100% correlation with subsequent tissue/Pap smear follow-up and cannot be used alone to triage this group of women for colposcopy.

(Ref 13) 懷孕時使用platinum derivatives

Use of platinum derivatives during pregnancy.
Cancer. 2008 Dec 1;113(11):3069-74.
Mir O, Berveiller P, Ropert S, Goffinet F, Goldwasser F.
Department of Medical Oncology, Assistance Publique-Hôpitaux de Paris, Faculty of Medicine, Cochin Teaching Hospital, Paris Descartes University, Paris, France. olivier.mir@cch.aphp.fr
The incidence of cancer during pregnancy is increasing given the trend for women to postpone childbearing. Knowledge of the potential toxicity and teratogenicity of chemotherapy agents is crucial for patient counseling. Platinum derivatives are active against various malignancies that occur more frequently during pregnancy: melanoma, cervical and ovarian cancers, and lung cancer. The authors of this article performed a systematic review of reports documenting the use of platinum derivatives during pregnancy in the English literature from 1977 through January 2008. Forty-three pregnancies were described: 36 patients received cisplatin, 6 patients received carboplatin, and 1 patient received both drugs. Two fetal malformations occurred after in utero exposure to cisplatin, but the causative link between cisplatin administration and these malformations remains speculative. However, either detectable cisplatin levels or platinum-DNA adducts were observed in neonates who were exposed to platinum derivatives during the third trimester, providing evidence for a late-onset transplacental transfer of these drugs. The administration of platinum derivatives, although feasible during the second and third trimesters of pregnancy, raises concern regarding the transplacental transfer of these drugs in late pregnancy and has unknown short- and long-term effects.

(Ref 14) NCCN guideline 是否作過頭了----- systemic pelvic lymphadenectomy對於early endometrial carcinoma的意義
Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial.
J Natl Cancer Inst. 2008 Dec 3;100(23):1707-16.
Benedetti Panici P, Basile S, Maneschi F, Alberto Lissoni A, Signorelli M, Scambia G, Angioli R, Tateo S, Mangili G, Katsaros D, Garozzo G, Campagnutta E, Donadello N, Greggi S, Melpignano M, Raspagliesi F, Ragni N, Cormio G, Grassi R, Franchi M, Giannarelli D, Fossati R, Torri V, Amoroso M, Crocè C, Mangioni C.
Department of Obstetrics and Gynecology, La Sapienza University of Rome, Rome, Italy. pierluigi.benedettipanici@uniroma1.it
BACKGROUND: Pelvic lymph nodes are the most common site of extrauterine tumor spread in early-stage endometrial cancer, but the clinical impact of lymphadenectomy has not been addressed in randomized studies. We conducted a randomized clinical trial to determine whether the addition of pelvic systematic lymphadenectomy to standard hysterectomy with bilateral salpingo-oophorectomy improves overall and disease-free survival. METHODS: From October 1, 1996, through March 31, 2006, 514 eligible patients with preoperative International Federation of Gynecology and Obstetrics stage I endometrial carcinoma were randomly assigned to undergo pelvic systematic lymphadenectomy (n = 264) or no lymphadenectomy (n = 250). Patients' clinical data, pathological tumor characteristics, and operative and early postoperative data were recorded at discharge from hospital. Late postoperative complications, adjuvant therapy, and follow-up data were collected 6 months after surgery. Survival was analyzed by use of the log-rank test and a Cox multivariable regression analysis. All statistical tests were two-sided. RESULTS: The median number of lymph nodes removed was 30 (interquartile range = 22-42) in the pelvic systematic lymphadenectomy arm and 0 (interquartile range = 0-0) in the no-lymphadenectomy arm (P < .001). Both early and late postoperative complications occurred statistically significantly more frequently in patients who had received pelvic systematic lymphadenectomy (81 patients in the lymphadenectomy arm and 34 patients in the no-lymphadenectomy arm, P = .001). Pelvic systematic lymphadenectomy improved surgical staging as statistically significantly more patients with lymph node metastases were found in the lymphadenectomy arm than in the no-lymphadenectomy arm (13.3% vs 3.2%, difference = 10.1%, 95% confidence interval [CI] = 5.3% to 14.9%, P < .001). At a median follow-up of 49 months, 78 events (ie, recurrence or death) had been observed and 53 patients had died. The unadjusted risks for first event and death were similar between the two arms (hazard ratio [HR] for first event = 1.10, 95% CI = 0.70 to 1.71, P = .68, and HR for death = 1.20, 95% CI = 0.70 to 2.07, P = .50). The 5-year disease-free and overall survival rates in an intention-to-treat analysis were similar between arms (81.0% and 85.9% in the lymphadenectomy arm and 81.7% and 90.0% in the no-lymphadenectomy arm, respectively). CONCLUSION: Although systematic pelvic lymphadenectomy statistically significantly improved surgical staging, it did not improve disease-free or overall survival.

(Ref 15) 關於成熟畸胎瘤裡面的SCC

Squamous-cell carcinoma in mature cystic teratoma of the ovary: systematic review and analysis of published data.
Lancet Oncol. 2008 Dec;9(12):1173-80.
Hackethal A, Brueggmann D, Bohlmann MK, Franke FE, Tinneberg HR, Münstedt K.
Department of Obstetrics and Gynecology, Justus-Liebig-University of Giessen, Giessen, Germany.
Up to a quarter of ovarian masses originate from germ cells, and many of these are mature cystic teratomas. The secondary development of malignancy is a rare but well-known phenomenon in patients with ovarian teratomas. Squamous-cell carcinoma accounts for 80% of secondary malignant transformations of ovarian teratomas. We aimed to do an up-to-date systematic review of this rare malignant transformation. 64 suitable studies provided information on 277 patients. Squamous-cell carcinoma in mature cystic teratoma was mainly found in women aged more than 50 years, with high concentrations of squamous-cell-carcinoma antigen and cancer antigen CA125, and with ovarian tumours more than 100 mm in size. Patients with FIGO stage Ia tumours had better survival than those with more advanced disease. Complete resection together with hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy for patients with advanced disease, followed by adjuvant chemotherapy with an alkylating drug was associated with higher survival, radiotherapy was not. We make proposals for investigation and treatment of this rare disorder.

(Ref 16) 卵巢移植後的成功懷孕案例報告

Successful pregnancy after microsurgical transplantation of an intact ovary.
N Engl J Med. 2008 Dec 11;359(24):2617-8.
Silber SJ, Grudzinskas G, Gosden RG.

(Ref 17) 臨終患者之delirium

Agitation and delirium at the end of life: "We couldn't manage him".
JAMA. 2008 Dec 24;300(24):2898-910, E1.
Breitbart W, Alici Y.
Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University, New York, New York 10022, USA. breitbaw@mskcc.org
Delirium is the most common neuropsychiatric complication experienced by patients with advanced illness, occurring in up to 85% of patients in the last weeks of life. Using the case of Mr L, a 59-year-old man with metastatic lung cancer who developed an agitated delirium in the last week of life, we review the evaluation and management of delirium near the end of life. Although some studies have identified agitation as a central feature of delirium in 13% to 46% of patients, other studies have found up to 80% of patients near the end of life develop a hypoactive, nonagitated delirium. Both the agitated (hyperactive) and nonagitated (hypoactive) forms of delirium are harbingers of impending death and are associated with increased morbidity in patients who are terminally ill, causing distress for patients, family members, and staff. Delirium is a sign of significant physiological disturbance, usually involving multiple causes, including infection, organ failure, and medication adverse effects. Often these causes of delirium are not reversible in the dying patient, and this influences the outcomes of its management. Delirium can also significantly interfere with the recognition and control of other physical and psychological symptoms, such as pain. Unfortunately, delirium is often misdiagnosed or unrecognized and thus inappropriately treated or untreated in terminally ill patients. To manage delirium in terminally ill patients, clinicians must be able to diagnose it accurately, undertake appropriate assessment of underlying causes, and understand the benefits and risks of the available pharmacological and nonpharmacological interventions.