Cost-utility analysis of treatments for stage IB cervical cancer / 부인종양

OBJECTIVE: To analyze the cost-utility of two common clinical practices for stage IB cervical cancer patients from provider and societal viewpoints. METHODS: A decision tree model was conducted to examine value for expenditure between the following: (1) radical hysterectomy with pelvic lymph node dissection (RHPLND) with or without postoperative adjuvant therapy according to the risk of recurrence and (2) concurrent chemoradiotherapy (CCRT). The relevant studies were identified to extract the probability data, and meta-analysis was performed. Direct medical costs were estimated from hospital database and medical records review. Direct non-medical costs and utility parameters were obtained through interviews with patients to estimate quality-adjusted life years (QALYs) outcome. The time horizon was according to the life expectancy of Thai women. RESULTS: From provider viewpoint, RHPLND and CCRT resulted in approximate costs of US $5,281 and US $5,218, respectively. The corresponding costs from societal viewpoint were US $6,533 and US $6,335, respectively. QALYs were 16.40 years for RHPLND and 15.94 years for CCRT. The estimated incremental cost effectiveness ratio of RHPLND in comparison to CCRT from provider and societal viewpoints were US $100/QALY and US $430/QALY, respectively. RHPLND had more cost-effectiveness than CCRT if patients did not need adjuvant therapy. The most effective parameter in model was a direct medical cost of CCRT. At the current ceiling ratio in Thailand, RHPLND provides better value for money than CCRT, with a probability of 75%. CONCLUSION: RHPLND is an efficient treatment for stage IB cervical cancer. This advantage is only for patients who require no adjuvant treatment.

Platelet to lymphocyte ratio as a prognostic factor for epithelial ovarian cancer / 부인종양

OBJECTIVE: To determine whether preoperative platelets to lymphocyte ratio (PLR) could predict disease stage, surgical outcome, and survival in patients with epithelial ovarian cancer (EOC). METHODS: Medical records of EOC patients who had surgery between January 2004 and December 2010 were reviewed. Clinicopathological and complete blood count data were collected. The optimal predictive value of PLR to predict advanced stage, suboptimal surgery, and survival was determined and compared with those of thrombocytosis (> or =400,000 cells/mm3) and neutrophil to lymphocyte ratio (NLR) > or =2.6. RESULTS: A total of 166 EOC patients were included in the study. PLR of 200 yielded better predictive values than those of thrombocytosis and NLR > or =2.6. The area under curve (AUC), sensitivity, specificity, positive and negative predictive values, and accuracy of PLR to predict advanced stage were: 0.66, 59.0%, 72.7%, 65.7%, 66.7%, and 66.3%, respectively. The corresponding values to predict suboptimal surgery were: 0.70, 70.0%, 69.8%, 50.0%, 84.4%, and 69.9%. The patients who had PLR> or =200 had significantly shorter progression-free and overall survivals than those with PLR2.6.

Platelet to lymphocyte ratio as a prognostic factor for epithelial ovarian cancer / 부인종양

OBJECTIVE: To determine whether preoperative platelets to lymphocyte ratio (PLR) could predict disease stage, surgical outcome, and survival in patients with epithelial ovarian cancer (EOC). METHODS: Medical records of EOC patients who had surgery between January 2004 and December 2010 were reviewed. Clinicopathological and complete blood count data were collected. The optimal predictive value of PLR to predict advanced stage, suboptimal surgery, and survival was determined and compared with those of thrombocytosis (> or =400,000 cells/mm3) and neutrophil to lymphocyte ratio (NLR) > or =2.6. RESULTS: A total of 166 EOC patients were included in the study. PLR of 200 yielded better predictive values than those of thrombocytosis and NLR > or =2.6. The area under curve (AUC), sensitivity, specificity, positive and negative predictive values, and accuracy of PLR to predict advanced stage were: 0.66, 59.0%, 72.7%, 65.7%, 66.7%, and 66.3%, respectively. The corresponding values to predict suboptimal surgery were: 0.70, 70.0%, 69.8%, 50.0%, 84.4%, and 69.9%. The patients who had PLR> or =200 had significantly shorter progression-free and overall survivals than those with PLR2.6.

A Randomized Double-Blind Placebo-Controlled Trial to Evaluate the Effectof Vaginal Misoprostol in the Modification of Gross Cervical Anatomy in Patients with Unsatisfactory Colposcopy

coming soon

Visual inspection with acetic acid for detection of high grade lesion in atypical squamous cells and low grade squamous intraepithelial lesions from cervical Pap smear / 부인종양

OBJECTIVE: To evaluate the value of visual inspection with acetic acid (VIA) test to detect high grade lesion in women with atypical squamous cells or low grade squamous intraepithelial lesions cervical cytology. METHODS: Women with atypical squamous cells or low grade squamous intraepithelial lesions who were scheduled to undergo colposcopy at Vajira Hospital and met inclusion criteria were included. All participants underwent VIA test prior to usual steps of colposcopy. The VIA results were interpreted as positive or negative using the criteria by the International Agency for Cancer Research. The standard colposcopic examination and appropriate investigations for cervical pathology were then continued. The diagnostic values of VIA test including sensitivity, specificity, positive predictive value, and negative predictive value were determined using high grade lesion including cervical intraepithelial neoplasia 2-3 and squamous cell carcinoma as a threshold. RESULTS: Total of 106 women was included. The VIA test was positive in 33 women (31.1%) and negative in 73 women (68.9%). Among the women with VIA test positive, 14 had high grade lesion (42.4%) while 19 had no significant lesions. Only 2/73 (2.7%) cases with negative VIA test had high grade lesion (both had cervical intraepithelial neoplasia 2). The sensitivity, specificity, positive predictive value and negative predictive value with 95% confidence interval were 87.5% (81.2 to 93.8%), 78.8% (71.1 to 86.7%), 42.4% (33.0 to 51.8%), and 97.2% (94.2 to 1.0%) respectively. CONCLUSION: VIA as the intermediate test in atypical squamous cells and low grade squamous intraepithelial lesions cytology may reduce the necessity to refer some women for colposcopy.

Clinical Significance of Surgical Margin from Loop Electrosurgical Excision Procedure

Abstract Clinical Significance of Surgical Margin from Loop Electrosurgical Excision Procedure Chantawat       Sheanakul              MD* Sumonmal       Manusirivithaya    MD* Siriwan             Tangjetgamol        MD* Nantana           Kaewpila                 MD** Sura                  Chomxhalaem       MD* *Department of Obstetrics and Gynecology, BMA Medical College and Vajira Hospital **Department of Pathology, Srinakharinwirot University Objective: To determine the prevalence and the correlated factors of unfree surgical margin from LEEP (loop electrosurgical excision Procedure) together with the relationship between surgical margin and residual disease. Study design: Retrospective descriptive study. Subiects: One hundred and six women who underwent LEEP and were diagnosed as cervical intraepithelial neoplasia to microinvasive cervical cancer at BMA Medical College and Vajira Hospital between June 1, 1996 and May 31, 2001. Methods: Medical records and follow up information of the target population were retrospectively reviewed concerning the personal history, surgical margin from LEEP, pathological reports from LEEP and hysterectomy specimens. Main outcome measures: Prevalence of unfree surgical margin from LEEP, residual disease from hysterectomy specimens. Results: During the period of study, unfree surgical margin was found in 43 cases (40.6%). Unfree surgical margin was found in 71.4% of microinvasine, 38.2% and 25.0% in patients with HSIL (high grade squamous intraepithelial lesion) and LSIL (low grade squamous intraepithelial lesion) respectively. From 58 cases who underwent hysterectomy, residual disease was found in 40.6% of unfree surgical margin which was significantly higher than 11.5% in those with free surgical margin (p=0.014). Conclusion: The prevalence of unfree surgical margin from LEEP in this study was 40.6%. Severity of disease was the significant prognostic factor for unfree surgical margin and this positive margin was significantly correlated with the higher incidence of residual disease. Key words: surgical margin, residual disease, LEEP Vajira Med J 2002 ; 46 : 179 - 186

Accuracy of Frozen Section in Diagnosis of Ovarian Mass

Abstract Accuracy of Frozen Section in Diagnosis of Ovarian Mass Siriwan             Tangjitgamol            MD* Somneuk        Jesadapatrakul         MD** Sumonmal      Manusirivithaya        MD*   *Department of Obstetrics and Gynecology, BMA Medical College and Vajira Hospital **Department of Pathology, BMA Medical College and Vajira Hospital Objective: To determine the accuracy of frozen section compared to permanent section according to status of malignancy and histologic cell type. Study design:  Diagnostic study. Subjects:  Frozen and permanent pathological reports of 212 ovarian masses from 212 women who underwent ovarian resection at BMA Medical College and Vajira Hospital from January 1, 1992 to December 31, 2002 were studied. Methods:  All frozen and subsequent permanent pathological reports of ovarian masses from the studied group were reviewed.  The data of age, tumor size, number of frozen and permanent sections of the ovarian masses, the results of frozen and permanent section were taken from the pathological report.  The pathological slides were reviewed when there was discrepancy of frozen and permanent section diagnosis, in deferred diagnosis for status of malignancy and/ or histologic cell type. Main outcome measures:  Accuracy, sensitivity, specificity, positive predictive value, negative predictive value of frozen section. Results:  From 212 ovarian masses, there were 13 deferred cases which frozen section diagnosis for status of malignancy could not be given. Statistical analysis was then performed in 199 cases..  The overall accuracy was 90.9%.  Sensitivity of frozen section diagnosis was highest in the benign group at 99.1%, next was in the malignant group at 86.1% and lowest in borderline group at 50%.  The specificity were 90.7, 94.6 and 100.0% in the benign, borderline and malignant groups respectively.  Positive and negative predictive values of benign, borderline and malignant groups were 93.3, 41.2, 100.0% and 98.7, 96.2, 92.7%, respectively.  All inaccurate diagnosis were in the common epithelial group.  When the statistical data were analyzed according to histology subgroup of common epithelial tumor, sensitivity in diagnosis malignant and borderline mucinous were lower than non-mucinous tumor, 62.5% and 41.7% compared to 96.9% and 50.0% respectively.  For diagnosis of the histologic cell type, frozen section had 91.9% accuracy.  Thirteen out or 16 incorrect histologic diagnosis cases (81.3%) were in the common epithelial group while only three cases were germ cell tumor.   Conclusion:  The accuracy of frozen section in diagnosis of frozen section in diagnosis of ovarian mass was generally high according to both status of malignancy and histologic cell type.  There were exception in tumors with large size, mucinous or borderline tumor which yielded lower accuracy, sensitivity, specificity and positive predictive value than the other groups.  The surgeon should recognize these limitations and appraise the test result together with other clinical data.  This is to achieve for the correct final diagnosis and the proper management for the patient. Key word:  frozen section, ovarian mass, accuracy, malignancy, histologic cell type Vajira Med J 2003 ; 47 : 17 - 28

Results of Invasive Cervical Cancer Treatment at BMA Medical College and Vajira Hospital

Abstract Results of Invasive Cervical Cancer Treatment at BMA Medical College and Vajira Hospital Chantawat     Sheanakul               MD* Sumonmal     Manusirivithaya     MD* Thanathip      Tantiwattana           MD** Laddawan      Nakwong                  MD**   *Gynecologic Oncology Section, Department of Obstetrics and Gynecology, BMA Medical College and Vajira Hospital **Radiologic Oncology Section, Department of Radiology, BMA Medical College and Vajira Hospital Objective:  To study the clinical and pathological characteristics of invasive cervical cancer patients together with the prognostic factors and results of treatment in terms of overall 5- year survival rate. Study design:  Descriptive study. Subjects:  All 573 patients with pathological confirmation of invasive cervical cancer primarily were treated at BMA Medical College and Vajira Hospital between 1993-1998. Methods:  Medical records including out-patient records, in-patient records, gynecologic oncology registration records, radiation oncology records and pathological reports were retrospectively reviewed.  Patients' age, stage, histologic type, treatment and follow up information were recorded. Main outcome measures:  Overall 5-year survival rate. Results:  There were altogether 573 new cases of invasive cervical cancer treated at BMA Medical College and Vajira Hospital during the study period.  The mean age of the patients was 50.5+11.8 years.  Nearly 80% were squamous cell carcinoma, while the rest were adenocarcinoma of adenosquamous cell carcinoma.  Most of the patients (74.2%) were diagnosed in stage II or III, while stage I was diagnosed in only 16.6%  The overall 5-year survival rate for all stages was 61.5% (95% confidence interval of 57.0%, 66.1%).  The most important factor that correlated with survival rate was tumor stage.  Patients in stage I had higher survival rate than stage II, III and IV with the 5-year survival rate of 91.1%, 71.6%, 47.6%, and 20.6% respectively.  Adenocarcinoma tended to have lower survival rate comparing to squamous cell carcinoma, stag by stage but did not reach statistical significance. Conclusion:  Most cases of invasive cervical cancer were diagnosed in stage I or II and the frequent histologic cell type was squamous cell carcinoma.  The overall 5-year survival rate was 61.5%.  Tumor stage was the most significant prognostic factor. Key word:  cervical carcinoma, invasive, prognostic factors, 5- year survival rate Vajira Med J 2003 ; 47 : 93 - 102

Endometrial Cancer: Incidence of Retroperitoneal Lymph Node Metastasis and Clinico-pathological Factors Predicting Retroperitoneal Lymph Node Metastasis

Abstract Endometrial Cancer: Incidence of Retroperitoneal Lymph Node Metastasis and Clinico-pathological Factors Predicting Retroperitoneal Lymph Node Metastasis Surawute    Leelahakorn         MD* Siriwan       Tangjitgamol         MD* Sumonmal Manusirivithaya   MD, MSc (Clinical Epidemiology)* Jakkapan    Khunnarong         MD* * Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, BMA Medical College and Vajira Hospital Objectives: To evaluate the incidence of retroperitoneal lymph node (RLN) metastasis in endometrial carcinoma (EMC) and to assess the clinico-pathological factors predicting RLN metastasis. Study design: Retrospective study. Subjects: Two hundred and twenty five patients with clinical stage I-II EMC who underwent surgical staging at our institute during January 1993 and December 2007. Methods: Medical and pathological records of all EMC patients were reviewed. Clinico-pathological characteristics and other data were extracted and analyzed. Main outcome measures: Retroperitoneal lymph node metastasis. Results: Mean age of the patients was 55.0 ± 9.8 years (30-84 years). All patients had total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node resection. One hundred and seventy seven patients (78.7%) also had para-aortic lymph node resection. The most common histopathologic type was endometrioid adenocarcinoma (90.7%). Mean number of lymph nodes obtained was 23.2 ± 10.6 nodes. Retroperitoneal lymph node metastasis was found in 28 patients (12.4%): pelvic lymph node metastasis in 25 patients (11.1%) and para-aortic lymph node metastasis in 10 patients (4.4%). By univariable analysis, clear cell or papillary serous adenocarcinoma type, high grade (II-III) tumor, tumor size \> 2 cm, tumor located in lower uterine segment, cervical involvement, gross intra-abdominal metastasis, myometrial invasion more than inner half, lymph vascular space invasion and positive peritoneal cytology were significantly associated with RLN metastases. By multivariable analysis, only myometrial invasion more than inner half and lymph vascular space invasion were independently associated with RLN metastasis. Conclusion: RLN metastases were found in 12.4% of patients with clinical stage I and II EMC. Presence of myometrial invasion more than inner half and lymph vascular space invasion were significantly associated with RLN metastasis by multivariable analysis. Vajira Med J 2008 ; 52 : 129 - 138

Why There Has Been No Service Delivery Unit in Thai Public Health Service ?

Abstract Why There Has Been No Service Delivery Unit in Thai Public Health Service ? Surasit                  Chitpitaklert                    MD, MPH, MHSc* Sumonmal            Manusirivithaya             MD, MSc (Clinical epidemiology)** Supawan              Sathorn                             MD*** Weerasak             Anutaungkoon               MD**** Gunn                     Limkool                              MD***** Wijitra                  Chaopanon                       BSc****** Aeumporn             Kanjanarungsichai       BSc* Jinda                     Rojanamatin                   MD******* Pornpimom          Massakulpan                  MD****** Thanathip            Tantivattana                   MD** Attapol                 Kerdarunsuksri             MD******** * Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima ** BMA Medical College and Vajira Hospital, Bangkok *** Sirivej Hospital, Chantaburi **** Khonkhen Hospital, KhonKhen ***** Phra Nung Kloa Hospital, Nonthaburi ****** Prasat Neurology Institute, Bangkok ******* Institute of Dermatology, Bangkok ******** Ratchapiphat Hospital, Bangkok Objective: To survey the knowledge and attitude of hospital administrators concerning the launching and management of Service Delivery Unit (SDU) in the health system. Study design: Descriptive study. Subjects: Forty two hospital administrators who attended the 38th Hospital Administrative course of Ramathibodi Hospital in the academic year 2009 (January 7-March 31, 2009) Methods: The subjects filled up the self-directed questionnaire regarding the SDU, which composed of 3 parts. Part I was the general characteristics of the subjects. Part II composed of 15 true or false questions concerning knowledge about SDU. Score point of 1 would be given when the answer was correct and 0 for the incorrect or the answer of uncertain. A total score  8 was graded as poor knowledge while score of 9-11 was graded as fair knowledge, and any score from 12-15 was graded as good knowledge. Part III composed of 5 open questions about the attitude and opinion in launching the SDU to the health system. Main outcome measures: Level of knowledge, attitudes and opinion towards SDU Results: Mean age of the subjects was 49.2 ± 5.4 years. All were government officer, with 23.0 ± 6.5 years mean duration of service. Most subjects were male (64.3%) and most (78.6%) were physicians. All were middle level hospital administrators, such as vice of the hospital director (40.5%) or the Departmental chairman, or chief of the sections (59.5%). Most worked for the Ministry of Public Health (76.2%) followed by Bangkok Metropolitan Administration (14.3%). Only 9.5% of the subjects had good knowledge while 47.6% and 42.9% had fair and poor knowledge respectively. Majority of them (87.5%) had good attitude about setting up the SDU in certain units of the hospital such as out-patient clinic. Conclusion: Most of the subjects had fair to poor knowledge concerning SDU, but most had good attitude about lauching SDU system in some units of the hospital. Vajira Med J 2009 ; 53 : 273-282

Expression of Estrogen Receptor and Progesterone Receptor in Epithelial Ovarian Tumors

Abstract Expression of Estrogen Receptor and Progesterone Receptor in Epithelial Ovarian Tumors Sujitra        Tanvanich               MSc (Pathobiology)* Siriwan       Tangjitgamol         MD*,** Sumonmal Manusirivithaya   MD, MSc (Clinical Epidemiology)** Somneuk    Jesadapatarakul MD* * Department of Anatomical Pathology, BMA Medical College and Vajira Hospital ** Department of Obstetrics and Gynecology, BMA Medical College and Vajira Hospital Objectives: To examine the expression of estrogen receptor (ER) and progesterone receptor (PR) in epithelial ovarian tumors and their associations with status of malignancy, histopathologic subtypes and grading. Study design: descriptive study. Subjects: Tissue of epithelial ovarian tumors resected at the BMA Medical College and Vajira Hospital between 1996-2005. Methods: The patients with epithelial ovarian tumors who were operated in our institution were identified. Samples of formalin-fixed, paraffin-embedded ovarian tumor tissue of patients were retrieved and processed for ER and PR immunohistochemical study. Data collected were: age, status of malignancy, tumor histologic subtype, and grade of malignant tumor. Expression of ER, PR and their associations with these pathological data were studied. Main outcome measures: Immunohistochemical expression of estrogen and progesterone receptors. Results: During the study period, 191 patients with epithelial ovarian tumors who were operated in our institution were identified. Mean age of the patients was 47.7 ± 14.6 years. Positive immunohistochemical expression of ER and PR were found in 29.8% and 34.0% respectively. ER expression was higher in malignant tumors than borderline and benign tumors, 39.6% versus 25.9% and 13.8% respectively while the expression of PR showed no different expression, 33.0% versus 33.3% and 36.2% respectively. Endometrioid tumors showed highest ER and PR expression 57.1% and 66.7% respectively, while clear cell tumors showed lowest expression of ER (5.9%) and mucinous for PR expression (9.6%). Focusing only on the malignant tumors, we found that the expression of ER and PR in mucinous and clear cell carcinomas were significantly lower than other cell types, 6.8% versus 62.9% for ER and 9.1% versus 50.0% for PR expression. Positive ER expression was significantly lower in well differentiated than moderately and poorly differentiated carcinomas, 11.8% versus 48.6% and 42.6% whereas there was no significant association between PR and grade of tumor. Conclusions: We demonstrated 29.8% of ER and 34.0% of PR expression in epithelial ovarian tumors. Expression of ER in malignant tumors was higher than benign and borderline tumors, whereas the expressions of PR of these tumors were nearly the same. Both receptors were lowly expressed in clear cell and mucinous tumors. ER expression was lower in well differentiated than moderately and poorly differentiated tumors while there was no significant association between PR and grade of tumors. Vajira Med J 2008 ; 52 : 249-256