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.

Reproductive outcome following hysteroscopic treatment of the septate uterus: a result of 28 cases at Ramathibodi Hospital.

We reported the reproductive outcome of 28 patients with septate uterus who underwent hysteroscopic metroplasty between August 1994 and October 1999 at Ramathibodi Hospital. The majority of septa were partial. Most of the patients had recurrent pregnancy losses. Division of the septum was performed with scissors in 7, a new device of Versapoint bipolar electrode in 10, and by means of resectoscope in 11 patients. The operating time varied from 45 to 70 minutes with an average time of 50+/-5.5 minutes which included the time for laparoscopy. The blood loss during the operation was minimal. All 28 patients were discharged a few hours after the operation. There were no serious complications attributed to this study. Most of the patients had minor spotting but no significant bleeding for a few days after hysteroscopic surgery. Of the 28 patients, 4 patients have not tried to conceive because of personal reasons, and the other 5 patients were lost to follow-up. Fifteen patients who had postoperative hysterosalpingograms, demonstrated a normal uterine cavity. There were a total of 20 pregnancies after a mean period of 24+/-1.4 (range 6-42) months following hysteroscopic treatment, of which 15(75.0%) were carried to term, 3(15.0%) were spontaneous abortions, and 2(10.0%) are in progress. The rate of pregnancy wastage in the post-treatment group was 15 per cent compared with 96.3 per cent in the pretreatment group.

Reproductive outcome following hysteroscopic lysis of intrauterine adhesions: a result of 65 cases at Ramathibodi Hospital.

We reported the reproductive outcome of 65 patients with varying degrees of IUAs who underwent hysteroscopic adhesiolysis between August 1994 and December 1996 at Ramathibodi Hospital. Of the 65 patients treated, 29 had mild adhesions, 26 had moderate adhesions, and 10 had severe adhesions. Adhesions were lysed with hysteroscopic scissors in 25, with biopsy forceps through hysteroscope in 10, with electrosurgery using a monopolar probe in 22 patients, and with resectoscope in 8 patients. The mean duration of the procedure was 15 +/- 2.1 minutes. The mean follow-up was 12 +/- 1.4 months. Of the 44 patients who originally presented with secondary amenorrhea, 40 (90.9%) have normal menses, 4 (9.1%) have hypomenorrhea. Of the 6 patients who had hypomenorrhea, 5 (83.3%) have normal menses. Cyclic abdominal pain disappeared after treatment in all patients. Of the 45 patients with IUAs and infertility, 16 (35.6%) conceived. Two (20%) of the infertile patients with initially severe adhesions conceived. Of the 5 patients with RPL treated, delivered a full term baby and the other delivered a premature baby at 29 weeks of gestation. All 18 patients who delivered, had live births. Adhesion reformation was absent in patients with initially mild and moderate adhesion but occurred in 2 out of 10 (20%) patients with severe adhesions. These two patients initially suffered from secondary amenorrhea but reported hypomenorrhea after surgery. Both of them had tuberculosis of the genital tract. There were no serious complications occurring in all 65 procedures. All 65 patients were discharged a few hours after the operation.

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.

Malignant ascites in female patients: a seven-year review.

Malignant ascites is common in various types of advanced cancer. Our objective was to determine the primary site and the clinical characteristics of female patients presenting with malignant ascites as well as evaluating the outcome. The authors carried out a retrospective study of 118 cases of malignant ascites diagnosed from January 1986 to December 1992 in female patients. Of the 118 cases, the primary site of the neoplasms was gynecologic in 65 cases (cervix 4, endometrium 6, ovary 52, fallopian tube 3) = 55.1 per cent, non-gynecologic 29 cases (GI 18, lymphoma 8, breast 2, kidney 1) = 24.6 per cent, and unknown 24 cases = 20.3 per cent. The mean age of patients in the gynecologic, non-gynecologic and unknown primary site was 50.4, 45.5 and 59.3 years respectively. Surgery combined with chemotherapy was the main treatment in the gynecologic group, whereas, supportive and symptomatic management was the main treatment in the unknown primary group. Treatments in non-gynecologic group were supportive and symptomatic, surgery and chemotherapy. Survival was longer in gynecologic than in the nongynecologic and the unknown primary groups. The most common primary site of malignant ascites in females was ovarian cancer. In malignant ascites in females caused by gynecologic neoplasms, the prognosis as measured by survival was better than in the non-gynecologic and the unknown primary groups.

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.

Diagnostic hysteroscopy: a result of 125 patients at Ramathibodi Hospital.

This report summarizes the diagnostic hysteroscopic experience with 125 selected patients. The procedures were all performed under propofol anesthesia. The main indications for diagnostic hysteroscopy were infertility with suspected intrauterine lesions and abnormal uterine bleeding in premenopausal women. The procedures were successful in 123 (98.4%) patients. Cervical dilatation was required in 35 (28%) patients. Of the 125 diagnostic examinations, 91 (72.80%) had intrauterine abnormalities. This result showed that an important factor that appears to influence the prevalence of pathology are the gynecological problems and/or symptoms of the patients. The commonest finding in patients with infertility was intrauterine adhesions, whereas, endometrial polyps was the most common finding found in premenopausal women with abnormal uterine bleeding. There was no complication attributable to this procedure. Our experience suggests that the efficacy and safety of this procedure depend on proper selection of patients, type of anesthesia, the medium for uterine distention, and most importantly the experience of the operator.

Post-cesarean section urinary tract infection: a comparison between intermittent and indwelling catheterization.

Catheterization, which is widely accepted as an important factor to urinary tract infection, is routinely done during cesarean section. This randomized study was conducted to compare the incidence of urinary tract infection between patients who underwent cesarean section using intermittent catheterization and indwelling catheterization, at the Department of Obstetrics and Gynecology, Ramathibodi Hospital from August 1991 to December 1991. Sixteen of 51 patients (31.4%) of the intermittent group and 9 of 47 patients (19.1%) of the indwelling group developed urinary tract infection. The difference was not statistically significant. Of the patients in the intermittent group 39.2 per cent were found to have postoperative urinary retention requiring recatheterization, whereas all cases in the indwelling group could void after its removal. Klebsiella pneumoniae was the commonest isolated organism. Indwelling catheterization was concluded to be the favourable method.

Cytologic evaluation of smears obtained by self-collection vaginal tampon.

Papanicolaou (Pap) smear test is an established method of cervical cancer screening. However, most women in Thailand are still reluctant to undergo pelvic examination. A prospective study was carried out on the use of self inserted vaginal tampon to collect specimens for Pap test in 126 patients at Ramathibodi Hospital from September to October 1990. The tampons which were inserted overnight and removed by the patients themselves were smeared across a glass slide and immediately fixed in 95 per cent ethyl alcohol. Ninety-six point two per cent of the slides had adequate cells of good quality to be interpreted. The remaining 3.98 per cent could not be interpreted due to the lack of cells and poor cell fixation. It is concluded that the smears obtained by this method are satisfactory for cytologic evaluation.

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.

Hospital charge of gynecological in-patients at Ramathibodi Hospital.

There have been few studies of hospital charge done in Thailand and that led us to be aware of health economics. In this cross sectional study, 182 gynecological in-patients admitted between July 1 and 31, 1990 were recruited. Mean hospital charge was 3,258.50 baht. The patients's employers bore the main financial burden (48%). The hospital bore 9 per cent of this total financial burden, and the rest (44%) was self paid. The amount of hospital charge may depend on some factors. Further study of this subject should be conducted.

Trends in uterine curettage among women under 30 with abnormal uterine bleeding at Ramathibodi Hospital.

This study represents the follow-up on number and trends of uterine curettage in women aged under 30 with menstrual disturbances in this institution. The total number of patients under 30 seen at the gynecological outpatient service with AUB decreased over the year studied, from January 1, 1987 to December 31, 1990. The trends in uterine curettage among this group of patients have also decreased, 125 (16.6%) cases in 1987, 101 (17.2%) cases in 1988, 75 (14.2%) cases in 1989 and 72 (14.1%) cases in 1990. The majority of patients had no significant pathology on the curetting tissues. Endometrial hyperplasia was found in 8 cases (4.6%). There was no case of endometrial carcinoma.

Diagnostic laparoscopy at Ramathibodi Hospital: 1979-1988.

A 10-year review of diagnostic laparoscopy at Ramathibodi Hospital was presented. There was a total of 6,033 laparoscopies performed from 1979 to 1988, of which 1,416 (23.5%) were diagnostic. The three most frequent indications were suspected ectopic pregnancy (459 cases, 32.4%), endometriosis (409 cases, 28.9%) and infertility (308 cases, 21.8%). The trend in performing diagnostic laparoscopy has been increasing from 79 procedures in 1979 to 230 in 1988. Laparoscopy plays a major role in making definitive diagnosis in many cases. Complications were found in only 4 cases (2.8/1,000 procedures).

Recurrence of cervical carcinoma following radical hysterectomy and pelvic node dissection.

The aim of this report is to review the clinical pattern of the recurrent cases. From May 1969 to December 1988, 200 patients with cervical carcinoma stage IB were treated with radical hysterectomy and pelvic node dissection at the Department of Obstetrics and Gynaecology, Ramathibodi Hospital, Mahidol University. One hundred and eighty-two patients were included in this study. Twenty-one patients (11.5%) developed recurrent cervical carcinoma. Most of the recurrence were diagnosed within 3 years after surgery. The most common recurrent site was pelvic sidewall. Patients' complaint and abnormal physical findings accounted for 81 percent of the first evidence. Treatment of recurrences was radiation in 15, chemotherapy in 3 and symptomatic treatment in the remaining three. Nine patients died of the recurrent tumor. The median time from recurrence to death was 24 months (range 12-65). The majority of the deaths occurred in the first three years after detection of recurrence. Radiation may be beneficial in treatment of recurrent tumor and in regional control of tumor after surgery.

Assessment of endocervical curettage in colposcopy.

Colposcopy has become an accepted diagnostic procedure in the management of patients with abnormal cervical cytology. To assess the value of the endocervical curettage in colposcopy, a retrospective review of 125 cases who had the procedure done during the 20-month period (January 1986-August 1988) was carried out. The ECC were positive in 3 out of 57 (5.3%) patients with satisfactory examination and 24 out of 68 (35.3%) patients with unsatisfactory examination. In all 27 cases, there was insufficient tissue to make a diagnosis of invasive carcinoma. Of the 125 patients studied seventy-two (29 in the satisfactory group and 43 in the unsatisfactory group) underwent conization and/or hysterectomy. Endocervical curettage did not eliminate the need for cone biopsy in all cases of unsatisfactory colposcopy. The tissue diagnosis on ECC did not increase the diagnostic accuracy derived from the colposcopic directed biopsies in either group. There were 20 cases of invasive carcinoma (13 MIC, 7 invasive) in this study, the ECC were positive in 9. We concluded that the ECC has limited value in colposcopy.

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.

Survival of patients with stage I epithelial ovarian carcinoma, 1981-1985 at Ramathibodi Hospital.

Thirty-one patients with stage I epithelial ovarian carcinoma were treated during 1981 and 1985. Fourteen cases were stage Ia, two stage Ib and fifteen stage Ic. Twenty-eight cases had at least a TAH with BSO. Postoperatively, twenty-one patients received melphalan as adjuvant chemotherapy (mean of 11 courses). There were 8 patients who received no adjunctive therapy. One patient had radiation treatment and the remaining one received hormonal treatment. Eighty-seven per cent (27 out of 31) of tumors were of borderline type or well differentiated, four were moderately well differentiated. Poorly differentiated tumor was not observed in our series. The follow-up (31 patients) ranged from 0-82 months with a median of 52 months. The overall 5-year survival was 95.4 per cent. There was one reported death whose tumor was stage Ic grade 1 and who had received melphalan postoperatively. No serious adverse effects were noted among patients who received melphalan.

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.