Phase II study of concurrent cisplatinum with ifosfamide and radiotherapy in locally advanced squamous cell cervical carcinoma.

Objective: To evaluate the efficacy and toxicities of cisplatinum and ifosfamide administered concomitantly with radiation therapy in the treatment of locally advanced squamous cell cervical carcinoma (LASCC). Methods: Twenty patients with biopsy-proven squamous cervical carcinoma, FIGO stage II A to III B were entered into this study. All patients received standard radiotherapy (50 Gy in 25 fractions and brachytherapy at a dose of 268-28 Gy). Cisplatinum 70 mg/m2 plus ifosfamide 3 gm/m2 were administered totally for three cycles on Day 1, 21 and 42, concomitant with the radiotherapy schedule. Response and toxicities of treatment were evaluated and long term follow up was performed for disease free survival. Results: All patients received a course of concomitant chemoradiotherapy. Sixteen patients (80%) were able to receive a full course of chemotherapy, the remaining received 1-2 courses because of severe toxicities. The clinical complete response rate was 90% and overall 4 years survival rate was 85%. Grade 3 and 4 leucopenia occurred in 2 cases with one febrile neutropenia. Late complication revealed 2 cases of grade 3 cystitis. Conclusion: This study showed that concomitant chemoradiotherapy with cisplatinum plus ifosfamide was feasible for patients with LASCC. Further study of this regimen should be compared in randomized control trial (RCT) with cisplatinum alone and in the other histologic type of cervical cancer such as adenocarcinoma.

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%.

Response to initial treatment of low and intermediate risk gestational trophoblastic disease with methotrexate and folinic acid.

OBJECTIVES: To evaluate the response and toxicity of methotrexate and folinic acid given as primary treatment of low and intermediate risk gestational trophoblastic disease (GTD). MATERIAL AND METHOD: Medical records review was performed in patients who received methotrexate and folinic acid as a primary treatment of low and intermediate risk persistent GTD between January 1992 and December 2001. Response was defined as decline of beta human chorionic gonadotropin (hCG) to < or = 5 mlU/ml (remission) after methotrexate and folinic acid treatment. Response rate was estimated and factors associated with response were evaluated. RESULTS: Ninety four eligible patients were treated with intramuscular methotrexate and folinic acid. Complete remission was achieved in 64 cases (68%, 95% CI 58-78%). Mucositis (6.4%) and hepatotoxicity (6.4%) were the most common toxicity of methotrexate in the present study and none of these toxic effects was life threatening. Factors associated with response were initial serum hCG < or = 10,000 mlU/ml and stage I disease. CONCLUSION: Methotrexate with folinic acid is effective treatment for low and intermediate risk GTD with minimal severe toxicity.

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.

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.

Hemostatic control for intractable bleeding from advanced cancer of the uterine cervix by collagen fleece coated with fibrin glue: A report of 3 cases.

We report 3 cases of advanced cervical cancer with intractable vaginal bleeding. They had all been initially managed by vaginal packing which had failed on 2 occasions. In all cases, bleeding could be controlled by a collagen fleece coated with fibrin glue (Tacho Combฎ) without adverse side effect. Applying a collagen fleece coated with fibrin glue may be an alternative method of bleeding control in selected patients.

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.