Successfully conservative treatment of large cervical choriocarcinoma with profuse vaginal bleeding.

Primary choriocarcinoma of the uterine cervix is a rare disease. The accurate diagnosis of such a disease is difficult to achieve because of its rarity. Furthermore, the majority of cases presented with abnormal vaginal bleeding that could be caused by other more common conditions including, threatened abortion, cervical polyp, cervical pregnancy, or cervical cancer. In the present report, the authors present a case of large cervical choriocarcinoma with life-threatening vaginal bleeding, which was initially misdiagnosed as a cervical cancer The active cervical bleeding was successfully controlled with selective uterine arterial embolization. Remission of cervical choriocarcinoma was accomplished with combination chemotherapy without the need of hysterectomy.

Cytomorphologic comparison between rehydrated air-dried and conventional wet-fixed pap smears.

OBJECTIVE: To compare the cytomorphologic quality of the cervical (Pap) smears between two fixation techniques, rehydration of air-dried smears (AD) versus wet fixation (WF). MATERIAL AND METHOD: Paired-cervical smears (AD and WF) from 172 women who underwent cervical cytology screening at Chiang Mai University Hospital between August 2004 and September 2004 were prospectively evaluated for the cytologic parameters and the staining qualities. RESULTS: The mean age of the 172 women was 41.7 years +/-2 SD 18.1), 27 women (15.7%) were postmenopausal. Absence ofred blood cells in the smear background was significantly more frequent in AD smears than in WF specimens (p = 0.0006). Air-drying artifact was more frequent in AD smears compared to those of WF (p = 0.036) but was of only mild degree in all cases. There was no significant difference between AD and WF smears in the cytoplasmic quality including distinctness of cell border (p = 0.30) and satisfactory staining (p = 0.054). For the nuclear morphology, there was no significant difference between both fixation techniques in the distinctness of nuclear border (p = 0.26) and chromatin crispness (p = 0.23) of the endocervical nuclei. In squamous nuclei, AD smears had higher frequency of indistinct nuclear border and hazy chromatin compared to WF smears (p = 0.003 each). However, these were observed in only mild degree and did not affect the cytologic interpretation. CONCLUSION: The quality of AD smears was slightly inferior to WF smears but was still satisfactory for cervical cytology. AD technique may be acceptable as an alternative to wet fixation in cytologic cervical cancer screening.

Limited value of vaginal cytology in detecting recurrent disease after radical hysterectomy for early stage cervical carcinoma.

The objective of this study was to evaluate the value of vaginal cytology in routine surveillance for recurrent cervical cancer after surgery. We reviewed the medical records of 565 patients with stage IB-IIA cervical cancer who were treated with radical hysterectomy and pelvic lymphadenectomy (RHPL) and attended follow- up at Chiang Mai University Hospital between January 2000 and May 2006. With the median follow-up of 35 months (range 1-76 months), 23 (4%) patients developed recurrence. The interval from surgery to detection of recurrence ranged from 5-61 months with a median of 23 months. Of the total 4,376 vaginal smears, 5 (0.1%) showed abnormal cytology but only 1 had malignant cells and tumor recurrence. The sensitivity and specificity of vaginal cytology for detection of recurrence were 4.3% and 99.3%, respectively. In conclusion, vaginal cytology has limited value in detection of recurrence after RHPL for early-stage cervical cancer.

Clinical outcomes and prognostic factors of node-negative cervical cancer patients with deep stromal invasion or lymphovascular space involvement following radical hysterectomy.

OBJECTIVE: To evaluate the clinical outcomes and prognostic factors of node-negative cervical cancer patients who had deep stromal invasion (DSI) and/or lymphovascular space invasion (LVSI) following radical hysterectomy and pelvic lymphadenectomy (RHPL). MATERIAL AND METHOD: The medical records of 150 node-negative stage IA2-IIA cervical cancer patients who had DSI and/or LVSI after RHPL from 1999 to 2004 were reviewed. RESULTS: Eighty-eight (58.4%) patients were treated with RHPL alone. Twenty-eight (18.7%), 23 (15.4%), eight (5.3%), and three (2%) patients received postoperative chemotherapy, chemoradiation, radiotherapy, and brachytherapy, respectively. Overall, 11 (7.3%) patients developed recurrence. The estimated 5-year disease-free survival of the patients was 90.9%. By multivariate analysis, two factors, age of less than 35 years old and a non squamous histology, were significantly independent prognostic. Eight (5.3%) patients experienced treatment-related complications. CONCLUSION: Node-negative cervical cancer patients with DSI and/or LVSI had excellent clinical outcomes. Young age and non-squamous histology are significant independent prognostic factors.

High-grade squamous intraepithelial lesion with endocervical cone margin involvement after cervical loop electrosurgical excision: what should a clinician do?

This study was undertaken to evaluate the incidence and severity of residual lesions in women featuring high-grade squamous intraepithelial lesion (HSIL) histology with endocervical cone margin involvement after the loop electrosurgical excision procedure (LEEP). The medical records of women undergoing LEEP at Chiang Mai University Hospital between October 2004 and February 2006 were retrospectively reviewed and 74 cases were identified. Nineteen women were excluded because of loss to follow-up. The remaining 4 were referred to other hospitals and 2 declined re-excision, leaving a study population of 55 women for analysis. Mean age+/-SD of the patients was 48.5+/-8.9 years. Residual lesions were noted in 26 (47.3%, 95%CI=33.7 to 61.2). Four (7.3%) had unrecognized invasive cervical carcinoma in subsequent specimens. In conclusion, approximately half of women with positive endocervical cone margins after LEEP for HSIL histology have residual disease. Repeat diagnostic excision is recommended for evaluation of lesions and severity.

Clinicopathologic analysis of women with synchronous primary carcinomas of the endometrium and ovary: 10- year experience from Chiang Mai University Hospital.

The aim of this study was to analyze the clinicopathologic features and survival outcomes of women with synchronous primary carcinomas of the endometrium and ovary that were treated at Chiang Mai University Hospital between January 1995 and December 2004. During the study period, 43 women with such tumors were identified. These carcinomas accounted for 0.58% (95%CI=0.42-0.79%) of all gynecologic malignancies. Median age at diagnosis was 49 years (range: 34-60 years). Median body mass index (BMI) was 21.6 kg/m2(range: 15.5-27.7 kg/m(2)). The majority of women (65%) were premenopausal. The most common presenting symptom was abnormal uterine bleeding (42%), followed by a pelvic mass (30%). Twenty-seven (62.8%, 95%CI= 46.7-77.0%) women had concordant endometrioid carcinomas of the endometrium and ovary. Five (11.6%) women experienced tumor recurrence with median follow up 39 months (range: 1-85 months). The overall 5-year survival was 85.2%. There was no significant difference in survival outcomes among the women who had endometrioid/endometrioid histology and those who had other histological subtypes (P=0.674). In conclusion, synchronous primary carcinomas of the endometrium and ovary, although uncommon, should be considered in differential diagnosis in premenopausal women presenting with abnormal uterine bleeding and ovarian tumors. The prognosis of patients with these tumors appears excellent.

Extent of lymphovascular space invasion and risk of pelvic lymph node metastases in stage IB1 cervical cancer.

OBJECTIVE: To evaluate whether the extent of lymphovascular space invasion (LVSI) is a risk factor for pelvic lymph node metastases in stage IBI cervical cancer. MATERIAL AND METHOD: The clinicopathological data of 397 patients with stage IB1 cervical cancer undergoing radical hysterectomy and pelvic lymphadenectomy (RHPL) at Chiang Mai University Hospital between January 1998 and December 2002 were analyzed. The histology, tumor grade, depth of stromal invasion, uterine corpus involvement, parametrial invasion and LVSI were analyzed for their association with pelvic node metastases. The extent of LVSI was classified as negative, minimal (< 10 LVSI/cervical specimen), and extensive (> or = 10 LVSI/cervical specimen). RESULTS: Of the 397 patients, 146 (36.8%) had tumors containing LVSI, 82 (20.7%) and 64 (16.1%) had minimal and extensive LVSI, respectively. Fifty nine (14.9%) patients had pelvic node metastases. Using multivariable analysis, LVSI (p < 0.001), depth of stromal invasion (p < 0.001), tumor grade (p < 0.001), and parametrial invasion (p < 0.001) were significant predictors of pelvic node metastases. The extent of LVSI either minimal or extensive degree significantly influenced pelvic node metastases. CONCLUSION: The presence of LVSI especially extensive involvement was significantly associated with the risk of pelvic node metastases in stage IB1 cervical cancer.

Radical surgery for T1 and T2 squamous cell carcinoma of the vulva through separate incisions.

OBJECTIVES: The aim of the study was to retrospectively evaluate treatment results in patients with T1 and T2 vulvar carcinoma. MATERIAL AND METHOD: The medical records of 46 patients with T1 and T2 SCC of the vulva undergoing radical excision of the tumor and groin node dissection at Chiang Mai University Hospital between January 1998 and December 2004 were reviewed. The tumor size, histologic grade, nodal status, lymph-vascular space invasion, lesion location, surgical marginal status, complications, recurrence and survival were analyzed. RESULTS: Mean age of the 46 patients (T1 = 15, T2 = 31) was 59 years with a range of 34-84 years. The incidence of lymph node metastases for T1 lesions was 13% compared to 35% for T2 lesions. Twenty nine patients (63%) experienced surgical complications, the most common one was lymphedema (16) while wound breakdown was noted in only 1 patient. With a median follow-up of 15 months, 14 patients (30%) developed recurrence, 3 (20%) and 11 (35%) in patients with T1 and T2 lesions respectively. The overall 5-year disease-free survival and 5-year survival were 37% and 40%, respectively. The 5-year survival of patients with T1 lesion was significantly higher than that of patients with T2 lesion (64% vs 31%, P = 0.04). Patients with negative nodes had significantly better survival than those with positive nodes (56% vs 18%, P = 0.02). In multivariable analysis, only the status of groin node remained as independent prognostic factors for survival. CONCLUSION: Radical excision and groin node dissection through separate incision for T1 and T2 squamous cell carcinoma of the vulva in this study has a less favorable survival outcome compared with the literature.

Concurrent cisplatin-based chemoradiation and adjuvant hysterectomy for bulky stage IB-IIA cervical cancer.

OBJECTIVES: To evaluate the outcomes and adverse effects of concurrent cisplatin-based chemoradiation and adjuvant hysterectomy for bulky stage IB-IIA cervical cancer MATERIAL AND METHOD: All eligible, thirty-four patients with bulky stage IB-IIA cervical cancer were assigned to receive weekly cisplatin 40 mg/m2 for 6 cycles concurrently with radiation followed by extrafascial hysterectomy 6 weeks after completion of radiation. RESULTS: Estimated 5-year progression-free and disease-free survival rates of 80% were observed after a median follow-up of 42 months. The overall recurrent rate was 18%. Grade 3 neutropenia and anemia were noted in only 5.9% and 2.9%, respectively. All acute toxicities were transient and were manageable. There were no treatment-related deaths or late toxicities. CONCLUSION: For appropriately selected patients with bulky stage IB-IIA cervical cancer, concurrent cisplatin-based chemoradiation followed by adjuvant hysterectomy offers an effective treatment option with acceptable toxicity.

Radiologic features and treatment outcomes of pulmonary metastasis in gestational trophoblastic neoplasia.

OBJECTIVE: To evaluate the radiologic patterns and treatment outcome of pulmonary metastasis in patients with gestational trophoblastic tumor (GTT). MATERIAL AND METHOD: The medical records and chest films of GTT patients treated at Chiang Mai University Hospital between January 1998 and June 2003 were reviewed. RESULTS: There were 85 GTT-patients in the study period. 32 cases (37.6%) had pulmonary metastasis diagnosed with chest X-rays. The most common radiologic pattern was well defined nodule. The radiologic features of patients who had lung metastases alone were not significantly different from those who had associated metastases in other organs. 27 patients (84.3%) received multiple chemotherapy and 6 required more than one regimen. The mean number of chemotherapy was 7 cycles (range 3-23). Adjuvant surgery consisted of hysterectomy (11), salpingo-oophorectomy (1), thoracotomy (2), and craniotomy (1). Four patients received whole brain irradiation for brain metastases. Among 10 patients with lung metastasis alone, 8 (80%) attained complete remission, the remaining 2 patients were lost to follow-up. Among 22 patients with associated multiple organ metastases, 16 (72.7%) had complete remission, 2 died from diseases, 4 were lost to follow-up. CONCLUSION: The most common radiologic pattern of pulmonary metastasis in GTT patients was well-defined multiple lung nodules. The radiologic features of patients who had lung metastases alone were not significantly different from those who developed metastases in other organs.

Treatment results of methotrexate and folinic acid as primary chemotherapy for nonmetastatic gestational trophoblastic neoplasia.

OBJECTIVE: To evaluate the efficacy and toxicity of methotrexate and folinic acid (MTX-FA) chemotherapy in patients with nonmetastatic gestational trophoblastic neoplasia (NMGTN). MATERIAL AND METHOD: Between 1997 and 2003, a total of 67 patients with NMGTN received treatment at the Chiang Mai University Hospital. Of the 67 patients, 55 were initially treated with methotrexate 1.0 mg/kg intramuscularly (IM) on day 1, 3,5, and 7 and folinic acid 0.1 mg/kg IM on day 2, 4, 6 and 8. Treatment courses were repeated every 14 days. Clinical characteristics and outcomes were analyzed RESULTS: All 55 patients with NMGTN were cured. Of the 55 patients initially treated with MTX-FA, 49 (89%) achieved complete remission. Six (11%) patients developed methotrexate resistance, 3 were cured with actinomycin D, 1 were cured with 5-fluorouracil followed by etoposide, 2 required hystertectomy to attain remission. No serious toxicity was noted CONCLUSION: Methotrexate and folinic acid chemotherapy is highly effective and well-tolerated in treating patients with nonmetastatic gestational trophoblastic neoplasia.

Ruptured mature cystic teratomas mimicking advanced stage ovarian cancer: a report of 2 cases study.

Spontaneous rupture of mature cystic teratoma is uncommon. Chronic rupture of teratomas may result in granulomatous peritonitis. In rare cases, the clinical presentation and the intraoperative findings may mimic those of advanced stage ovarian cancers. Two cases of ruptured mature cystic teratomas mimicking malignancy are reported in 50- and 53-year-old patients. Both presented with abdominal distension and weight loss. Elevation of serum CA-125 (233 unit/ml) was detected in one case. Intraoperatively, nodular thickening of the omentum with marked peritoneal adhesion was observed in both cases. Ascites of 1500 ml was present in one case. Pathologic examination in both cases showed ovarian mature cystic teratomas with peritoneal granulomatous inflammations response to the released tumor content. Both patients were followed for 44 and 12 months and were free of symptoms without additional treatment other than surgery. Intraoperative pathologic consultation can help confirm the benign diagnosis and unnecessary major operation for malignancy can be avoided.

A "See and Treat" approach for high grade squamous intraepithelial lesion on cervical cytology.

OBJECTIVE: To examine the final histologic findings as well as to correlate colposcopic and histologic findings in patients who had a high-grade squamous intraepithelial lesion (HGSIL) on the Pap smear and underwent colposcopy followed by LEEP on the "See and Treat" basis without intervening colposcopically directed biopsy. MATERIAL AND METHOD: The medical records of patients with HGSIL on cytology who underwent LEEP without prior cervical biopsy at Chiang Mai University Hospital over a 5-month period were reviewed. The authors summarized the final LEEP histologic results and correlated colposcopic and histologic findings in these patients. RESULTS: Of 55 patients who had a see-and-treat LEEP, 53 patients (96%) had a high-grade intraepithelial lesion or higher. There were 11 patients (20%) who had invasive squamous cell carcinoma. Of 4 patients with a low-grade lesion on colposcopic examination, all had a high-grade lesion or higher on final histology. Forty-four patients (96%) with high-grade impression on colposcopy had high-grade or more severe lesion on the final histologic diagnosis. CONCLUSION: For patients with a high-grade lesion on the Pap smear, LEEP according to the "See and Treat" approach appeared to be a reasonable alternative to conventional colposcopically directed biopsy, especially in low resource settings.

Validity of antenatal diagnosis of intrauterine growth restriction by umbilical Doppler waveform index.

OBJECTIVE: To evaluate the validity of systolic/diastolic (S/D) ratio of the umbilical artery in predicting intrauterine growth restriction (IUGR). STUDY DESIGN: Diagnostic test study. SETTING: Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. SUBJECTS: Two hundred and twelve singleton pregnancies between 30 and 42 weeks' gestation with clinical suspicion of IUGR were recruited and followed-up between December 1st 1995 and June 30th 1998. They were sonographically examined for routine fetal biometry and S/D ratio of umbilical artery Doppler waveform measurement within 14 days of delivery. All of them had an accurate date of last menstrual period and were between 30-42 weeks' gestation. MATERIAL AND METHOD: The umbilical artery S/D ratio was obtained by the same experienced sonographer, using the same ultrasound machine, Aloka 680EX, (Tokyo, Japan). The S/D ratio of 3 or greater was considered abnormal, predicting IUGR prenatally for every gestational week. IUGR was defined as low birth weight of less than the 10th percentile of the standard birth weight curve of Maharaj Nakorn Chiang Mai Hospital. MAIN OUTCOME MEASURES: Sensitivity specificity positive predictive value and negative predictive value. RESULTS: The prevalence of IUGR among the study group was 50.9%. The S/D ratio of 3 or greater for predicting of IUGR gave the sensitivity, specificity, positive predictive value, and negative predictive value of 52.96%, 78.85%, 74.42% and 65.08%, respectively. CONCLUSION: The umbilical artery S/D ratio has relatively low sensitivity and is not a suitable test for IUGR screening. However, the specificity is rather high and it may be helpful in combination with other parameters.