Cervical cancer in pregnancy.

Carcinoma of the uterine cervix is one of the most common malignant neoplasms among women and remains the leading female malignancy in Thai women. Cervical cancer diagnosed during pregnancy remains a therapeutic challenge for physicians. Pregnant women should have cervical cytology screening at their first prenatal visit. In cases of cytological abnormality, colposcopy is indicated. Cervical conization is used for the diagnostic role only. The management of invasive cancer depends on the gestational age at diagnosis, stage of disease, patient’s desire of pregnancy, ethics and religious beliefs including family and decision making by multidisciplinary teams.

Comparison between Siriraj liquid-based and conventional cytology for detection of abnormal cervicovaginal smears: a split-sample study.

This study aimed to evaluate the correlation and agreement between Siriraj liquid-based cervical cytology (Siriraj -LBC) and conventional cytology. A total of 479 women who attended the Department of Obstetric and Gynaecology Siriraj Hospital for cervical cancer screening were enrolled. For each woman collection of cervical cells was performed using VCE technique. After smearing cells on a glass slide for conventional cytology, both broken ends of wooden spatula and cotton swabs were then placed into a plastic vial containing a specific preservative solution for Siriraj-LBC. All specimens were prepared and interpreted by experienced cytotechnologists at the Gynecologic Cytology Unit. Interpretations of the results from one technique were made without knowledge of those from the other technique. The results from both techniques were compared for agreement and correlation. Colposcopy or histology was used as the gold standard. The overall detection rate of abnormal cervicovaginal cells was higher by Siriraj-LBC than by conventional cytology (11.1% vs. 1.67%, P <0.001). These two techniques had high diagnostic agreement of 89.77%, and minimal to fair correlation with a Kappa of 0.128 (P<0.001) and a Spearman rho correlation coefficient of 0.394 (P <0.001). There were 49 cases whose Siriraj-LBC revealed higher cytologic grading than did the conventional cytology; there were no cases of the opposite result. The gold standard was available in 45 cases with abnormal cytology by Siriraj-LBC, revealing a positive predictive value (PPV) of 71.1% for Siriraj-LBC and 97.8% for conventional cytology, and a negative predictive value (NPV) of 42.2% for the conventional cytology. In conclusion, The results from Siriraj-LBC and conventional cytology have high diagnostic agreement and minimal to fair correlation. The Siriraj-LBC increases detection rate of abnormal cervicovaginal cells with probable decrease in false negatives but increase in false positives from the baseline values by conventional cytology. Therefore the screening performance of Siriraj-LBC is not inferior to the conventional cytology and this approach may be used as an alternative screening method for cervical cancer.

A case of ovarian endodermal sinus tumor diagnosed during pregnancy.

Pregnancy complicated by endodermal sinus tumor of the ovary is extremely rare. The authors present a case report of a pregnant woman with persistent left adnexal mass and subsequently found to have a primary endodermal sinus tumor of the ovary that was diagnosed at 19 weeks of gestation. After left salpingo-oophorectomy had been performed, the patient chose to terminate the pregnancy before the initiation of combination chemotherapy with bleomycin, etoposide, and cisplatin. The response to chemotherapy was not satisfactory. The patient expired after seven cycles of treatment had been completed because of pulmonary fibrosis and the drug toxicity of bleomycin.

Pre-operative prediction of serum CA125 level in women with ovarian masses.

OBJECTIVE: To assess the accuracy of serum CA125 at the level of more than 35 U/mL in predicting ovarian cancer using histopathology as a gold standard. MATERIAL AND METHOD: Blood samples were obtained from 120 women with ovarian masses scheduled for elective surgery at Siriraj Hospital between October 1, 2003 and August 31, 2004 and sent for the assay of serum CA125 levels. RESULTS: Of the 120 women enrolled, ovarian cancer was found in 59 cases (49.2%) and benign ovarian mass in 61 cases (50.8%). The sensitivity, specificity, and accuracy of serum CA125 at the cutoff level of 35 U/mL for prediction of ovarian cancer were 83.1%, 39.3%, and 60.8%, respectively; with 57.0% positive predictive value, 70.6% negative predictive value, 60.7% false positive rate, and 16.9% false negative rate. CONCLUSION: As stand-alone modality, serum CA125 of more than 35 U/mL in predicting ovarian cancer revealed modest diagnostic accuracy. There is a need to be careful for false positive in women at reproductive age group and false negative results in early-stage disease or ovarian cancer with low level of serum CA125.

Uterine sarcomas in Siriraj Hospital (1991-2005).

Objective: To study the incidence, clinical characteristics, treatments and outcomes in patients with uterine sarcomas at Siriraj Hospital. Methods: A medical record search of patients treated at Siriraj Hospital from January 1991 to December 2005 was performed for clinical characteristics and treatments. Survival curves were generated using Kaplan-Meier method. Results: Sixty uterine sarcomas were diagnosed during a 15-year period. The mean age was 49.3 years (range 27-74; SD 10.6). Abnormal bleeding was the most common presenting symptom (40%). Only 11.7% of the cases could be diagnosed preoperatively. Of 60 patients, 37 (61.6%) had leiomyosarcoma (LMS), 9 (15%) had malignant mixed mullerian tumor (MMMT), and 14 (23.3%) had endometrial stromal sarcoma (ESS). The distribution by FIGO staging was as follows: stage I: 47.5%, stage II: 15%, stage III: 17.5%, and stage IV: 20%. The treatment was mainly hysterectomy with adjuvant chemotherapy. The median follow-up time was 25 months. The five-year survival rate was 55.4%. Conclusion: The incidence of uterine sarcoma at Siriraj Hospital was 4.4% of uterine malignancies. The most common histologic type was leiomyosarcoma (61.6%). The common presenting symptoms were uterine bleeding and pelvic mass. In most cases, the treatment modality was surgery combined with chemotherapy. The overall 5-year survival rate of the studied group was 55.4%.

Sonographic morphological pattern in the pre-operative prediction of ovarian masses.

The study was undertaken to evaluate the accuracy of sonographic morphological pattern in the detection of ovarian malignancy. A total of 123 patients with a suspicion of ovarian pathology, who were scheduled for elective surgery at the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University were included in the study. All patients underwent sonographic examination prior to surgery by the same physician. The sonographic morphological pattern of each patient was compared to the histological diagnosis of the ovarian tumors. Of the 120 patients with an ovarian lesion, the sonographic morphological pattern of 10 had a sensitivity of 88.6 per cent and a specificity of 89.4 per cent in detection of malignant ovarian tumors. The positive predictive value, negative predictive value, and the accuracy rate were 77.5, 95.0, and 89.2 per cent, respectively. In the present study, a score of 9 would be the best discriminator between benign and malignant ovarian masses, giving a sensitivity of 97.1 per cent and specificity of 82.4 per cent. As stand alone, the present results confirm that ultrasonography is still a useful diagnostic tool in the differentiation of benign from malignant ovarian masses.

Color Doppler ultrasonography for prediction of malignant ovarian tumors.

The purpose of this cross-sectional study was to evaluate whether the pulsatility index determined by the color Doppler sonography could be used to distinguish between benign and malignant ovarian tumors. A total of 120 patients who had their ovarian tumors removed surgically at the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University were included in the study. Each patient had color Doppler sonography performed prior to laparotomy. The Doppler results were compared to the histological diagnosis of the ovarian tumors. Of the 113 patients whose intratumoral blood flow could be evaluated, the pulsatility index was significantly lower in malignant lesions than in benign lesions (0.85 +/- 0.46 vs 1.63 +/- 0.64, p<0.001). The sensitivity, specificity, and accuracy of the pre-operative pulsatility index (< or = 1.0) in detecting malignant ovarian tumors were 82.9 per cent, 80.8 per cent, and 81.4 per cent, respectively; with 65.9 per cent positive predictive value, 91.3 per cent negative predictive value, 19.2 per cent false positive rate, and 17.1 per cent false negative rate. The present results suggest that color Doppler sonography may be a useful clinical tool in the pre-operative evaluation of ovarian masses. However, the pulsatility indexes showed considerable overlap between benign and malignant lesions, indicating that color Doppler sonography has limitations in the differentiation of benign from malignant ovarian masses. The cost of the equipment and experience requirement also limits its use in general gynecologic practice.

Accuracy of residual urine measurement in post-operative gynecological patients by normal saline instillation versus Re-catheterization.

A total of 90 post-operative gynecological patients, who needed residual urine measurement were studied in the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University between June 1, 1999 and April 30, 2000. Residual urine in each patient was measured by the normal saline instillation technique, followed by re-catheterization which is considered as the gold standard. The accuracy and agreement of the results of residual urine measurement by the two techniques were calculated. In comparison with re-catheterization, the accuracy of the normal saline instillation technique was 83.3%, sensitivity was 66.7%, specificity was 96.1%, positive predictive value was 92.8%, negative predictive value was 79%, false positive rate was 3.9%, and false negative rate was 33.3%. The Kappa coefficient was 0.65 (P < 0.001). No complications from either technique were found. Residual urine measurement in post-operative gynecologic patients by normal saline instillation yielded fair to good agreement with re-catheterization. Due to a high percentage of false negative rate, this new method may not be suitable for current clinical practice. Improvement in the technique and further studies are needed.

Borderline epithelial ovarian tumor: A study of 48 cases.

Borderline epithelial ovarian tumor is a special entity of ovarian tumor. Compared with invasive epithelial ovarian cancer, borderline tumors have a much more favorable prognosis. Several issues remain unclear in the management of patients with borderline ovarian tumor. Objective : To review the clinical features, treatment and survival status of patients with borderline epithelial ovarian tumors. Materials and methods : A retrospective review of the records of 48 patients with borderline epithelial ovarian tumors registered at the Gynaecologic Oncology Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University from January 1, 1986 - December 31, 1998 was performed. Results : Ninety percent of the patients had stage I disease. Mucinous cell type was found in 77.1% and serous cell type was found in 22.9%. All the patients received surgery and most of the patients received adjuvant chemotherapy. Mean follow up time was 38.94 months and the 10 - year survival rate was 97.92%. Three patients had recurrence of disease. All patients with recurrence did so within 12 months. Conclusion : The prognosis of patients with borderline epithelial ovarian tumor is good. Conservative surgery should be performed for stage I patients who wish to remain fertile.

Primary ovarian tumors in postmenopausal women: A 10-year review.

This retrospective study reports on 403 postmenopausal women with ovarian tumors treated at Siriraj Hospital over a ten-year period from 1988-1997. Of the total, 206 (51.1%) were benign, and 197 (48.9%) were malignant. Common epithelium was the most common type (77.9%) and germ cell was the second most common tumor (13.9%), found in this age group. The risk of malignancy increased with age of the patient (p<0.001). More than half of the cases had advanced disease (stage III or IV). Nulliparity, absominal distension as the presenting symptom and bilaterality were more commonly found in patients with malignant disease than those with benign tumors. However, tumor size between the tow group was not significantly different.

Evaluation of depth of myometrial invasion by gross visual estimation versus microscopic technique.

A diagnostic test evaluation was performed to compare the evaluation of depth of myometrial invasion by gross visual estimation versus microscopic examination in the uteri of 40 patients who had endometrial adenocarcinoma and underwent surgical treatment in Siriraj Hospital from November 1993 to March 1995. The accuracy of gross visual estimation was 85%, the sensitivity was 63.6% (95% CI=31.6-87.6), the specificity was 93.1% (95%CI=75.8-98.8), the positive predictive value was 77.8% (95% CI=40.2-96.1), the negative predictive value was 87.1% (95% CI=69.2-95.8), the false positive rate was 6.9% and the false negative rate was 36.4%. Although gross visual estimation showed good specificity, high false negative rate and should not be used in preference to microscopic examination.

Primary ovarian cancer: A five-year review.

This retrospective study reports on 187 cases of ovarian carcinoma treated at Siriraj Hospital over five-year period from 1988-1992. The incidence was 17.6% of all ovarian tumors. Common epithelium was the most common group found in this study (85%). A total of 9.1% of the patients were in the germ cell group and the rest were in the stromal cell group (5.9%). The mean ages of the common epithelium germ cell and stromal cell groups were 47.5+14, 28.6+17.4 and 56.9+18.3 years respectively. The common presenting symptom was either abdominal mass (40.1%) or abdominal bloating (32.6%). The tumors, which developed in nearly three-fourths of the patients (72.2%), were between 6.20 cm in greatest diameter. Serous, dysgerminoma and granulosa cell tumors were the most common cell types found in the common epithelium, germ cell and stromal cell groups respectively. Half of the patients (50.8%) were in an advanced stage of the disease and radical surgery was performed in 62.3% of the patients.

Evaluation of fetal lung maturity by using free-floating particles in amniotic fluid ultrasonography.

The examination of amniotic fluid for the presence or absence of free-floating particles (FFPs) by real-time ultrasound was performed in 100 non-diabetic patients undergoing amniocentesis for maturity testing. A modified lecithin to sphingomyelin ratio (L/S ratio) was the gold standard of the test. The sensitivity and specificity were 97.6% and 62.5% respectively. The presence of FFPs had 93.2 positive predictive value and 83.3% negative predictive value. FFPs grade 2, 1, 0 had 100%, 70% and 16.7 positive predictive value respectively. The mean value of L/S ratio varied with the FFPs grading, with the mean of 5.09+ 2.48, 2.84 + 0.71, 2.02+ 0.01 in grade 2, 1 and 0 respectively. This study suggests that the presence of FFPs especially FFPs grade 2 on real-time ultrasound may be used to confirm fetal lung maturity.

Ovarian tumors in children and adolescents: A review of 52 cases.

This retrospective study reports on 52 cases of ovarian tumors in young females (under 20 years) treated at Siriraj Hospital over a five-year period from 1988 to 1992. The incidence was 4.7 percent of all ovarian tumors (1,103 cases). Of the total, 41 cases were benign, 10 were malignant and one was a borderlined tumor. In 31 cases (59.6 percent) germ cell tumors were found, of which 19.4 percent were malignant. The common presenting symptom was either abdominal mass (53.9 percent) or abdominal pain (26.9 percent). The tumors, which developed in more than half of the patients (57.7 percent), were between 6 and 15 cm in greatest diameter. Bilaterality was found in five patients (9.6 percent) and six (11.5 percent) and torsion of the tumor. Surgical treatment was conservative in 86.5 percent and radical in 13.5 percent of the patients.

Incidence and associated risk factors of peripartum hysterectomy.

We present a descriptive study of 86 pregnant women, who underwent peripartum hysterectomy at Siriraj Hospital between 1982 and 1992. The incidence was 0.5 per 1,000 deliveries. The indications leading to hysterectomy were uterine atony, uterine rupture, placenta previa, placenta accrete, tear bleeding, and uterine infection. Common complications were haemorrhage and infection. There were 6 maternal deaths (7%) from severe hemorrhage and all of them evinced coagulopathy. Furthermore, there were 9 fetal deaths (10.5%), 2 of them having congenital anomalies. This study indicates that lack of antenatal care, advanced maternal age multiparity, and abnormal delivery are the risk factors for peripartum hysterectomy. To reduce the prevalence and risk of peripartum hysterectomy; parity, appropriate maternal age at pregnancy, high quality antenatal care and good intrapartum care are factors to consider.

Comparison of newborn’s birth weight between twin pregnancy in adolescents and adults.

A retrospective study was done to compare infant mean birth weight between twin pregnancy in 60 adolescent and 120 adult gravidas who delivered at Siriraj Hospital during January, 1985 to December 1993. Adolescent twin pregnant women had significantly (p <0.01) lower infant mean birth weight (2,040.0 + 520.7 and 1,963.8+ 695.3 grams of the first and second twins respectively) than did adults (2,311.0+ 432.5 and 2,226.6+ 496.1 grams of the first and second twins respectively). However, the mean infant birth weight of the first and second twins of each group was not significantly different (p >0.05). Length of gestation was the predominant contributor to effect birth weight of the first and second twins while parity was the predominant contributor to effect only birth weight of the second twins.

Benign cystic teratoma of the ovary: A 5-year review.

This retrospective study reports on 321 cases of benign cystic teratoma of the ovary treated at Siriraj Hospital over a five-year period fro 1988-1992. The mean age of the patients was 33.6 + 11.8 years. Nearly 40% of the patients were asymptomatic when the teratoma was discovered, of the rest, the common presenting symptoms were abdominal pain (54.5%) or abdominal mass (34.5%). The tumors, which developed among more than half of the patients (54.8%), were between 6-10 cm in greatest diameter. In 33 patients (10.3%), the tumor was bilateral. Complications from the tumors were found in 46 patients (14.3%): 43 cases of torsion (93.5%); two of spontaneous rupture (4.3%); and one infected tumor (2.2%). Surgical treatment was conservative in 63.6% of patients and radical n 36.4% of the patients.