Advanced epithelial ovarian carcinoma in Thai women: should we continue to offer second-look laparotomy?

OBJECTIVE: To determine survival among patients with epithelial ovarian carcinoma (EOC) who underwent a second-look laparotomy (SLL) and those refusing the procedure. Also to analyze factor(s) influencing the survival of the patients. METHOD AND MATERIAL: Medical records were reviewed of patients with advanced EOC who were clinically free of disease after primary surgery and platinum-based chemotherapy between January 1, 1992, and December 31, 1998. All of them were offered SLL. Measurement outcomes include patient survival and disease-free survival. RESULTS: There were 50 patients with clinically complete remission after chemotherapy. Sixteen patients underwent SLL, and thirty-four patients refused the procedure (NSLL). Seven patients (43.8%) were reported to have positive SLL. After the median follow-up time of 35 months, 12 patients had died, and 5 patients were lost to follow-up. The median survival time for patients with SLL was about 60 months. Five-year survival rates of patients in the SLL, and NSLL groups were 37 per cent (95%CI = 7%-69%), and 88 per cent (95%CI = 65%-96%) respectively (P<0.001). The median time to relapse was about 25 months for patients with negative SLL. Five-year disease-free survival rates of patients in the negative SLL, and NSLL groups were 28 per cent (95%CI = 4%-59%), and 54 per cent (95%CI = 34%-70%) respectively (P=0.251). By Cox regression analysis, tumor grade was the only significant prognostic factor influencing patients' survival (HR = 6, 95%CI of HR = 1.2-34.2). CONCLUSION: The second-look laparotomy doesn't have a favorable impact on overall and disease-free survival. Tumor grade is the only independent prognostic variable for survival of the patients.

The efficacy of chemically-stabilized chlorite-matrix (TCDO) in the management of late postradiation cystitis.

Carcinoma of the uterine cervix is the most common cancer of women in Thailand. The most frequent complication after pelvic radiation for uterine cancer is radiation cystitis. The management of severe late postradiation cystis is far from satisfactory. The objective of this study was to evaluate the efficacy of chemically-stabilized chlorite-matrix (TCDO) in patients with severe radiation cystitis. This study was conducted at the Department of Obstetrics and Gynecology, Ramathibodi Hospital and the Department of Radiology, Siriraj Hospital between September 1997 and September 1998. Twenty patients with grade 3 radiation cystitis after radiotherapy were enrolled into this study. TCDO was administered at a dose of 0.5 ml/kg body weight per day on 5 consecutive days as intravenous infusion over 4 hours. The response rate after the first cycle was 80 per cent with 30 per cent of the patients showing complete response. The follow-up time (13 patients) ranging from 1-9 months revealed no recurrent bleeding. There were no side effects from TCDO therapy. The result suggests good efficacy of TCDO in the treatment of postradiation cystitis.

Epithelial ovarian cancer treated by platinum or platinum analogue with cyclophosphamide: experience in Ramathibodi Hospital.

This study presented the outcome of 92 EOC patients treated by platinum or platinum analogue with cyclophosphamide from January 1, 1993 to December 31, 1995. There were 77 evaluable patients. The follow-up ranged from 4-42 months (median 14 months). The over all 3-year survival was 64 per cent and the median progression-free interval was 16 months for the whole group. There was no significant difference in survival between patients who received cisplatin and those who received carboplatin (P = 0.093). Patients who underwent optimal debulking surgery had significantly longer progression-free interval (P = 0.001) than those who had sub-optimal surgery. Fifty four per cent of patients with clear cell carcinoma died of the disease. Patients who received cisplatin had a drop out rate while on therapy more often (24% vs 5.3%) than that of carboplatin. Toxicities from chemotherapy were moderate but manageable.

The experience in using whole pelvic irradiation in management of massive bleeding from carcinoma of the uterine cervix.

At the Radiation Therapy Section, Ramathibodi Hospital, from June 1, 1981 to May 31, 1991, there were 35 out of 1,683 new cases of carcinoma of the uterine cervix which presented with massive bleeding per vagina. All were treated via cobalt-60 teletherapy covering the whole pelvic region by 12 x 12 cm2 or 16 x 16 cm2 field sizes. Eighteen cases received a radiation dose of 300 cGy/fraction while 16 cases received 400 cGy and one case received 600 cGy. All had bleeding controlled within 2-6 fractions, twenty-two cases (62.9%) within 3 fractions and 34 cases (97.1%) within 5 fractions. There was no severe acute complication in all patients. In 10 patients who were followed up to the range of 3-70 months, median 16.5 showed no severe late complications.

Prognostic factors associated with recurrence in stage IB cervical carcinoma after radical hysterectomy and pelvic lymphadenectomy.

Radical hysterectomy with pelvic lymphadenectomy is the treatment of choice for stage IB cervical carcinoma. Recurrence of disease usually results in poor prognosis. The prognostic factors associated with recurrence were analyzed in 182 patients with stage IB cervical carcinoma treated with radical hysterectomy with pelvic lymphadenectomy at Department of Obstetrics and Gynaecology, Ramathibodi Hospital from May 1969 to December 1988. Twenty-one patients (11.5%) developed recurrent cervical cancer. Factors which were found to have statistical significance associated with recurrence were positive lymph node, positive surgical margin and cervical lesion size of 3 cm or more. The application of these factors was discussed.

The risk factors in the development of persistent trophoblastic disease following hydatidiform mole.

Hydatidiform mole (HM) is not uncommon in our country. Its dangerous sequalae is the fatal persistent trophoblastic disease (PTD). The prognostic risk factors for the development of PTD were analyzed in 108 cases of HM treated in Ramathibodi Hospital from 1978 to 1986. Statistical univariate analysis was by calculation of relative risk (RR) and chi-square test. The incidence of PTD was 27.8 per cent. The significant risk factors were the presence of theca-lutein cyst, gestational age of less than 16 weeks, "large for date" uterus, and patients' age of 40 years or more. Their RR were 4.25, 3.11, 3.00 and 2.68 respectively. These findings were comparable with previous reports. The use of prophylactic chemotherapy in patients with these risk factors was suggested.

Cervical cancer survival at Ramathibodi Hospital 1979-1983.

Carcinoma of the cervix is the most common malignant neoplasm among the female population. The treatment is surgery for stage IB and radiotherapy for all stages of disease. In a developing country like Thailand, the percentage of lost to follow-up after complete treatment is usually high. The purpose of this study is to present the follow-up and survival rate of patients with carcinoma of the cervix at Ramathibodi Hospital. From 1979 to 1983 there were 323 patients with carcinoma of the cervix who had been treated at Ramathibodi Hospital. The majority of patients (51.9%) were in stage II. The 5-year follow-up rate was 87.73 per cent which is better than the previous reports from Thailand. The 5-year survival rate was 93.75 per cent for stage I, 63.12 per cent for stage II and 42.22 per cent for stage III with an overall survival rate of 61.65 per cent. The 5-year survival rate in this study is not different from other reports.

Pattern of treatment failure among patients who died of invasive carcinoma of the uterine cervix.

During January 1979 to December 1982, 78 cases of invasive carcinoma of the uterine cervix (stage IB-IV) whose causes of death were established have been reviewed. The major causes of death were either pelvic failure, extrapelvic failure and the combination of both pelvic and extrapelvic failure, which were 47.5, 32.0 and 17.9 per cent respectively. Most of the patients died within 3 years after the established diagnosis of residual or recurrence or metastases of disease, more than half were dead within 12 months. To improve survival rate of the patients, ways must be found to overcome pelvic as well as extrapelvic failures.

Combined radiotherapy and hysterectomy in the treatment of high risk stage II invasive carcinoma of the uterine cervix: a preliminary report.

From January 1979 to December 1983, 187 cases of stage II, invasive carcinoma of the uterine cervix were studied prospectively to evaluate survival rate and treatment sequelae. Forty-one cases with any of these conditions; (a) partial response or inadequate radium insertion from obliterated cervical os; (b) endometrial extension; (c) enlarged cervical mass over 5 cm or barrel-shaped; and (d) with pelvic mass, were treated by the combination of radiotherapy and simple abdominal hysterectomy with bilateral salpingoophorectomy (group I), while the rest of 146 cases (group II) were treated by definitive radiotherapy alone. The 5-year follow-up rates were 87.8 per cent in group I and 70.6 per cent group II, respectively. The recurrence free survival rates at 5 years were 80.6 per cent in group I and 63.1 per cent in group II. The immediate and late sequelae were the same in both groups. We concluded that combined treatment was more effective than radiation alone in cases with a poorer prognosis.

Uterine sarcomas at Ramathibodi Hospital (1969-1986).

Uterine sarcoma is a rare gynecological malignancy. This retrospective study covered a period of 18 years and during that time 15 cases of uterine sarcoma were treated in Ramathibodi Hospital. It represented an incidence of 6 per 10,000 gynecological admissions. There were 9 leiomyosarcomas, 3 endometrial stromal sarcomas, 2 mixed mullerian sarcomas, and one rhabdomyosarcoma. The average age of the patients was 45.67 years, 3 under 40 and five after menopause. The mean parity was 4. The most common presenting symptoms were vaginal bleeding and abdominal mass. The diagnostic curettage was positive in only 2 out of 7 cases. All were treated by hysterectomy and bilateral salpingo-oophorectomy. Two out of 4 cases who received adjuvant radiotherapy or chemotherapy were still-alive at 1 and 3 year follow-up. The crude survival rate was 40 per cent.