Abnormal uterine cervical cytology in a large tertiary hospital in Bangkok metropolis: Prevalence, management, and outcomes.

OBJECTIVES: To determine the prevalence of abnormal cervical cytology, management, and association with clinical significant histopathology including cervical intraepithelial neoplasia II or adenocarcinoma in situ and more severe lesions. MATERIALS AND METHODS: Women with abnormal cervical cytology from January 2005 to December 2009 were identified from the archives of Department of Anatomical Pathology and Department of Obstetrics and Gynecology. Demographic data, type of abnormal cytology, management, and their associated histopathology were collected. RESULTS: During the study period: 2533/54,179 women (4.7%) had abnormal cervical Pap test. Squamous lesions were more common than glandular lesions: 2309 (4.3%) compared to 224 (0.4%). Atypical squamous cell (ASC) was most commonly found (1449 or 2.7%), whereas low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intra-epithelial lesion (HSIL), or squamous cell carcinoma (SCC) were found in 648 (1.2%) and 212 (0.4%), respectively. Among abnormal glandular cytology, atypical glandular cell (AGC) was most commonly found (199 women or 0.4%) whereas adenocarcinoma and endometrial cell in woman aged >40 year were found in only 14 (0.02%) and 11 women (0.02%), respectively. Majority (77.3%) underwent further investigations. We found that 13.0% of ASC, 20.3% of LSIL, and 78.7% of HSIL and SCC had clinical significant histopathology. In glandular abnormalities: 14.9% of AGC, 33.3% of women aged >40 years with endometrial cell, and 66.7% of adenocarcinoma were histologically proven to be of clinical significant. CONCLUSIONS: ASC was the most common abnormal cervical cytology. Cytology abnormalities of HSIL and SCC had the highest association with clinical significant histopathology.

Sexual dysfunction in Thai women with early-stage cervical cancer after radical hysterectomy.

We determined the prevalence of sexual dysfunction in women with early-stage cervical cancer who had undergone radical hysterectomy in three institutions of Thailand. An interview was conducted according to the structured questionnaire composing of seven domains of sexual function: frequency, desire, arousal, lubrication, orgasm, satisfaction, and dyspareunia. From 105 women included in the study, mean age was 45.3 +/- 7.8 years. Seventy-five (71.4%) were in premenopausal period. Eight out of 105 women (7.6%) never resumed their sexual intercourse after radical hysterectomy, 97 women resumed their sexual intercourse during 1-36 months postoperation (median, 4 months). Dyspareunia was increased in approximately 37% of women, while the other six domains of sexual function were decreased, ranging from approximately 40-60%. Of interest, only 10.5% of these cervical cancer women had some information of sexual function from medical or paramedical personnel, 17.1% obtained it from other laymen or public media, and 61.9% had never had it from any resources. Our conclusion is-sexual dysfunction is a common problem after cervical cancer treatment, but it has not been well aware of. These findings may necessitate health care providers to be more considerate on this problem.

Adjuvant therapy for early-stage endometrial cancer: a review.

Most patients with endometrial cancer (EMC) present their symptoms early in their course, leading to an overall favorable outcome. However, some patients who are in early-stage diseases may carry some risk features that would hamper their prognoses. For these early-stage diseases with high risk of recurrences, radiation therapy certainly plays a major role as an adjuvant treatment. Despite an excellent local diseases control by radiation, systemic failures are still encountered. To improve the prognoses, other types of adjuvant therapy have been attempted. In this review, various options of adjuvant treatment for this early-stage EMC including radiation therapy, chemotherapy, and hormonal therapy are discussed.

Lymph node size in uterine cancer: A revisit.

To study whether lymph node size is a good predictor of lymph node metastasis in uterine cancer, we reviewed the pathologic sections of pelvic and para-aortic lymph node removed from uterine cancer patients who underwent surgical staging in our institution from January 1994 to December 2004. The long axis of each individual node was measured. Out of 4280 total nodes obtained (178 cases), 86 nodes (28 cases) were positive for metastatic cancer (2.0% of total nodes or 15.7% of cases). Among the positive nodes, 11 nodes (12.8%) had nodal long axis <5 mm, 34 nodes (39.5%) had long axis of 5-9 mm, and 32 (37.2%) and 9 nodes (10.5%) had long axes of 10-19 mm and >20 mm, respectively. More than half (52.3%) of these positive nodal long axes were less than 10 mm. At lymph node size of 10 mm that was the common point of reference for pathologic enlargement, the sensitivity, specificity, negative and positive predictive value of lymph node to predict metastatic cancer were 47.7%, 76.7%, 98.6%, and 4.0%, respectively. From these findings, we tended to conclude that lymph node size is not a good predictor of lymph node metastasis in uterine cancer.

Survival rate of recurrent cervical cancer patients.

OBJECTIVES: To determine the survival rate of recurrent cervical cancer patients and factors influencing survival. MATERIAL AND METHOD: The subjects were identified from the Gynecologic Oncology Unit tumor registry record The pathological, clinical data including the follow-up information of recurrent cervical cancer patients who were treated in the Gynecologic Oncology Unit, Bangkok Metropolitan Administration Medical College and Vajira Hospital between 1992 and 2003 were retrospective reviewed. RESULTS: During the study period, 144 recurrent cervical cancer patients were identified. Mean age of the patients was 52 years. The median time from complete primary treatment to disease recurrence was 14.8 months. Seventy-two patients (50%) had previous stage III disease. The most common histopalogy was squamous cell carcinoma (72.9%). Approximately half of the recurrences were local (73 patients or 50.7%) and distal recurrences were encountered in 71 patients or 49.3%. Overall 109 patients received treatmentfor their recurrences, i.e. radiation alone (55 patients, 38.2%), chemotherapy (31 patients, 21.5%), chemotherapy and radiation (18 patients, 12.5%), surgery (5 patients, 3.5%), and 35 patients (24.3%) received only supportive treatment. Two-year survival rate of the group was 18.5%. Median survival was 8 months (95%CI, 7-10 months). The patients with only local recurrence had a 2-year survival rate of 22.2% compared to 14.6% in those with distant recurrence. (p = 0.245). Two-year survival rate of those who received any kind of treatment was 22.4% compared to 4.0% in those who received only supportive treatment (p = 0.014 and 0.017 in univariable and multivariable analysis respectively). CONCLUSION: Survival rate of recurrent cervical cancer was low, especially in those who received only supportive treatment.

The growing teratoma syndrome: a case report and a review of the literature.

We present the case of a 5-year-old girl with ovarian immature teratoma, which recurred a few months after an incomplete surgical staging. The recurrent masses, located in the upper abdomen and lower pelvis, were accompanied by rise in levels of serum alpha-fetoprotein. The patient and her parents refused surgical resection of these recurrent masses; therefore, chemotherapy was promptly given. After multiple cycles of chemotherapy, all the masses remained stable in size despite normalization of the tumor marker. Subsequent complete resection of the masses showed only mature teratoma (MT) component without any residual malignant germ cell tumor. The patient was disease free for 2 years, when another episode of recurrence developed as a 5-cm mass in the perihepatic area. The third laparotomy revealed a tumor mass, histologically composed of only MT tissue. She is now doing well without any evidence of the disease, 24 months after the last surgery.

Antiemetic effect of ginger in gynecologic oncology patients receiving cisplatin.

To determine whether ginger had antiemetic effect in cisplatin-induced emesis, we conducted a randomized, double-blinded crossover study in 48 gynecologic cancer patients receiving cisplatin-based chemotherapy. Subjects were randomly allocated to regimen A or regimen B in their first cycle of the study. All patients received standard antiemetics in the first day of cisplatin administration. In regimen A, capsules of ginger root powder were given orally 1 g /day for 5 days, starting on the first day of chemotherapy. In regimen B, placebo was given on the first day and metoclopramide was given orally thereafter for 4 days. The patients were then crossed over to receive the other antiemetic regimen in their next cycle of chemotherapy. Among 43 evaluable patients who received both cycles of treatment, success in controls of nausea and emesis were not significantly different between the two regimens in both acute and delayed phases. Restlessness, as a side effect, occurred more often in metoclopramide arm compared to ginger arm (P=0.109). In conclusion, addition of ginger to standard antiemetic regimen has no advantage in reducing nausea or vomiting in acute phase of cisplatin-induced emesis. In delayed phase, ginger and metoclopramide have no statistically significant difference in efficacy.

Third-line chemotherapy in platinum- and paclitaxel-resistant ovarian, fallopian tube, and primary peritoneal carcinoma patients.

Ovarian carcinoma is a malignant disease with a high rate of recurrence, necessitating repeated chemotherapy treatments. We conducted a retrospective study in patients with platinum- and paclitaxel-resistant ovarian, fallopian tubes and primary peritoneal carcinoma patients treated at M.D. Anderson Cancer Center. We evaluated the responses, progression-free intervals, and overall survival duration of 51 patients after third-line chemotherapy treatment. The overall response rate was 16% (eight cases) with 2% complete response rate (one case) and 14% partial response rate (seven cases). Stable disease was achieved in 31% (16 cases). The progression-free intervals of 24 patients who had response and stable disease was 7.4 months (range, 1.4-18.4 months). The median overall survival of all patients was 15.8 months (95% CI, 8.1-23.4 months). The median survival duration of eight responders was not significantly different from that of 43 nonresponders, 18.9 months (95% CI, 2.4-35.4 months) versus 15.8 months (95% CI, 6.4-25.2 months), respectively (P = 0.73). In conclusion, third-line chemotherapy in our study results in a modest response and prolongation of progression-free interval without obvious impact on survival. The decision to utilize third-line chemotherapy will be a balance of the limited efficacy, toxicity of the agents, and the expertise of the clinician.

Accuracy of frozen section in diagnosis of ovarian mass.

To determine the accuracy of frozen section according to the status of malignancy and the histologic cell type, we reviewed the frozen and permanent pathologic reports of 212 resected ovarian masses in our hospital. The accuracy, sensitivity, specificity, positive, and negative predictive value of frozen section were studied. The overall accuracy to determine the status of malignancy was 90.9%. Sensitivity of the test was highest in the benign groups at 99.1% and lowest in the borderline groups at 50%. All inaccurate diagnoses were in the common epithelial groups. Problems in diagnosis of mucinous tumors and borderline tumors were striking. The accuracy of the test for histologic diagnosis was 91.9%. Most cases of the incorrect diagnosis (81.3%) were common epithelial tumors. In conclusion, the accuracy of frozen section in the diagnosis of ovarian mass was generally high with a few exceptions in large tumors, mucinous, or borderline tumors that yielded lower accuracy, sensitivity, specificity, and positive predictive value. We encourage both the surgeons and the pathologists to be cautious of these limitations. Additional number of frozen section taken for a mass larger than 10 cm may minimize the error in large tumors to some extent.

Squamous cell carcinoma arising from dermoid cyst: Case reports and review of literature.

Malignant transformation of a dermoid cyst is rare, with squamous cell carcinoma (SCC) being the most common type. During a 10-year period in our institution, we encountered only four cases of SCC out of 425 cases of dermoid cyst, an incidence of 0.94%. Two were of old age, in menopausal status (63 and 74 y), while the other two were in their early forties. Three cases presented with pelvic masses while the other one had nonspecific wasting symptoms and later diarrhea. Three were in early stage and have survived to date without evidence of disease at 8, 12, and 116 months after diagnosis. The other case, in stage III, had suboptimal surgery and responded partially to chemotherapy, subsequently progressed after cessation of the drug, and finally died within a year after diagnosis.

Can we rely on the size of the lymph node in determining nodal metastasis in ovarian carcinoma?

This study endeavored to determine whether lymph node size is a reliable indicator in determining lymph node metastasis in common epithelial ovarian cancer. We reviewed pathologic sections of pelvic and para-aortic lymph nodes removed from 104 ovarian carcinoma patients who underwent either primary surgical staging or secondary surgery from January 1994 to July 2001. All sections of each individual node were measured in two dimensions. The different sizes of nodes were studied statistically to determine the optimal sensitivity and specificity in predicting cancer metastasis. A nodal size of 10 mm was a specific point of interest. Of 2069 total nodes obtained, 110 nodes (5.3%) had metastatic cancer. More than half (55.4%) of these positive nodes had a nodal long axis of 10 mm and less. The sensitivity and specificity of nodal size at 10 mm were 44.5% and 81.1%, respectively. We conclude that lymph node size is not a good indicator in determining epithelial ovarian cancer metastasis. Mere sampling of only the enlarged nodes does not reflect the true positive incidence of nodal metastasis. To avoid inaccurate staging and improper management, complete lymph node dissection is proposed as part of surgical staging for ovarian cancer.

Retroperitoneal mucinous cystadenocarcinoma: a case report and review of literature.

This is a case report of retroperitoneal mucinous cystadenocarcinoma which was operated on for a preoperative diagnosis of ovarian tumor. The tumor had no connection to other intra-abdominal organs including bilateral normal ovaries. Grossly, it was a well encapsulated, unilocular cyst containing mucous material. Histology revealed a typical area of benign, low malignant potential and malignant mucinous epithelium. No particular microscopic features suggested the origin of the tumor. We additionally performed total hysterectomy, bilateral salpingooophorectomy, and appendectomy after tumor resection and found no tumor elsewhere from these specimens. Prophylactic chemotherapy was also given. The patient was doing well 18 months postoperation. Due to its rarity, the prognosis and optimal treatment cannot be concluded with confidence at this time until more cases are reported.

Risk for radical hysterectomy failure.

During the period from July 1983 to December 1996, 685 patients who underwent radical hysterectomy as their primary treatment for cervical cancer and had optimal follow-up for at least three years were analyzed. Fifty seven patients (8.3%) had pelvic nodes metastasis and received postoperative whole pelvic radiation. Tumor recurrence was noted in 97 cases (14.2%). Nodal metastasis is the most significant prognostic factor for tumor recurrence. Patients with nodal metastasis had 42.1 per cent risk of recurrence compared to 11.6 per cent in those without nodal metastasis. Furthermore; risk of recurrence significantly increased if more than 1 node was involved. Other factors associated with a significantly higher risk of recurrence in multivariate analysis were tumor histology and clinical stage. Patients with nonsquamous cell carcinoma and clinical stage IIa had disease recurrence in 24.4 per cent and 30.3 per cent compared to only 11.7 per cent in squamous and 13.3 per cent in stage Ib. Tumor grade is the significant prognostic factor only in adenocarcinoma cell type but not in squamous cell type.

Comparative study of bulky stage IB and IA cervical cancer patients treated by radical hysterectomy with and without neoadjuvant chemotherapy: long-term follow-up.

One hundred and ninety patients with bulky (> 3 cm) stage IB and IIA cervical cancer who underwent radical hysterectomy between 1991 and 1994 at Maharaj Nakorn Chiang Mai Hospital were reviewed to determine whether neoadjuvant chemotherapy (NAC) with MVAC (Methotrexate, Vinblastine, Adriamycin, Cisplatin) improved survival. There were 42 patients treated with pre-operataive NAC (MVAC 1-3 courses) and 148 patients treated by primary surgery (PS). In the NAC group, the overall response rate from MVAC was 88.1 per cent with 31.0 per cent having complete clinical response and 7.1 per cent with complete pathological response. Pelvic lymph node metastasis was not significantly different between the NAC group (16.7%) and the PS group (18.2%). At a median follow-up of 64.5 months, 19.0 per cent in the NAC group and 18.2 per cent in the PS group had tumor recurrence. The 5-year progression free and overall survival was 80.8 per cent and 92.0 per cent respectively for the NAC group which was not significantly different from 80.2 per cent and 92.9 per cent respectively in the PS group. In conclusion, although NAC can decrease the tumor size and produce a high response rate, it does not improve survival in bulky stage IB and IIA cervical cancer patients.

Comparison of ondansetron-dexamethasone-lorazepam versus metoclopramide-dexamethasone-lorazepam in the control of cisplatin induced emesis.

The antiemetic effect of ondansetron-dexamethasone-lorazepam versus those of metoclopramide-dexamethasone-lorazepam were evaluated in 30 ovarian cancer patients undergoing treatment with the same chemotherapeutic regimen (cisplatin 60 mg/m2 and cyclophosphamide 700 mg/m2). Patients were randomly selected to receive either the ondansetron arm or the metoclopramide arm in their first cycle of chemotherapy, but were given an alternative combination in the second cycle. In the ondansetron arm, ondansetron was given 8 mg intravenously (i.v.) plus dexamethasone 20 mg i.v. and lorazepam 0.5 mg oral. For the metoclopramide arm, metoclopramide 10 mg was given i.v. plus dexamethasone 20 mg i.v. and lorazepam 0.5 mg oral. All antiemetics were given twice; 30 minutes before and 6 hours after chemotherapy. In the metoclopramide arm, metoclopramide 40 mg continuous infusion was also administered. During the acute phase, the ondansetron combination was significantly superior to the metoclopramide combination for all evaluation parameters. Complete control of emesis was 90 per cent vs 36.7 per cent, complete protection from nausea was 80 per cent vs 43.3 per cent, and complete protection from both nausea and vomiting was 73.3 per cent vs 30.0 per cent. Forty per cent of patients in the ondansetron arm did not complain of any adverse reaction compared to 13.4 per cent in the metoclopramide arm. It can be concluded, therefore, that a combination of ondansetron, dexamethasone and lorazepam appears to provide a significantly better emetic control with less adverse reaction than the metoclopramide combination in the acute nausea-vomiting phase after receiving cisplatin.