Diagnostic Performance and Agreement of Preoperative, Intraoperative Evaluations, and Final Pathology for Lymphadenectomy and Lymph Node Involvement in Endometrial Cancer

Objective: To determine the accuracy of clinical parameters examined by preoperative and intraoperative evaluations compared with final histological results in patients with endometrial cancer, and to evaluate the application of preoperative investigations, intraoperative evaluations, and final histological results in predicting lymph node involvement Material and Method: The medical records of the patients diagnosed with endometrial cancer who had surgical staging between January 1, 2006 and December 31, 2012 at Songklanagarind Hospital were retrospectively reviewed. The agreement of clinical parameters identified through preoperative investigations and intraoperative evaluations with the final histology findings were calculated using kappa statistics. The diagnostic performance of preoperative investigations, intraoperative evaluations, and final histological results to predict lymph node involvement were calculated in terms of sensitivity, specificity, positive predictive value, and negative predictive value. Results: Preoperative investigations showed a slight to fair agreement whereas intraoperative evaluations had a fair to moderate agreement in detecting clinical parameters compared with the final histological results. Endocervical curettage and endometrial biopsy exhibited the highest sensitivity, pelvic ultrasonography the highest specificity, and intraoperative evaluations had a high-level sensitivity and specificity Conclusion: Preoperative investigations have role as an adjunctive evaluation, whereas intraoperative gross assessment remains the most accurate and useful method of detecting patients for lymphadenectomy.

Prevalence and correlates of HPV among women attending family-planning clinics in Thailand.

BACKGROUND: Cervical cancer is the most common cancer among women of reproductive age in Thailand. However, information on the prevalence and correlates of anogenital HPV infection in Thailand is sparse. METHODS: HPV genotype information, reproductive factors, sexual behavior, other STI and clinical information, and cervical cytology and histology were assessed at enrollment among one thousand two hundred and fifty-six (n=1,256) HIV negative women aged 20-37 from Thailand enrolled in a prospective study of the natural history of HPV. The type-specific prevalence of HPV was estimated using cervical swab specimens from healthy women and women with a diagnosis of CIN 2/3 at baseline. Prevalence ratios (95% CI) were estimated using Poisson regression to quantify the association of demographic, behavioral, and clinical correlates with prevalent HPV infection. RESULTS: Overall, 307 (24.6%) and 175 (14.0%) of women were positive for any HPV type and any HR-HPV type, respectively; the most common types were 72, 52, 62, and 16. Among women diagnosed with CIN 2/3 at enrollment (n=11), the most prevalent HPV types were 52 and 16. In multivariate analysis, HPV prevalence at enrollment was higher among women with: long-term combined oral contraceptive use, a higher number of lifetime sexual partners, a prior Chlamydia infection, and a current diagnosis of Bacterial Vaginosis. CONCLUSION: The study findings provide important information that can be used in the evaluation of primary and secondary interventions designed to reduce the burden of cervical cancer in Thailand.

Management and clinical outcomes of endometrial hyperplasia during a 13-year period in Songklanagarind Hospital.

BACKGROUND: Endometrial hyperplasia has long been considered a precursor of endometrial cancer but there is no consensus regarding its management. OBJECTIVE: To identify management practices and evaluate outcomes of treatments for women diagnosed with endometrial hyperplasia (EH). MATERIAL AND METHOD: The medical records of endometrial hyperplasia at Songklanagarind Hospital between January 2000 and December 2012 were retrospectively reviewed. RESULTS: Two hundred ninety seven patients were diagnosed with endometrial hyperplasia during the study period. Four patients who did not come for treatment and could not be contacted were excluded Therefore, 293 patients were included in the study. Simple hyperplasia (SH) was the most common diagnosis accounting for 79.2% of all cases, followed by complex hyperplasia (CH) 13.0%, complex atypical hyperplasia (CAH) 5.8%, and simple atypical hyperplasia (SAH) 2.0%. Seventy-eight percent (18/23) of the patients with atypical endometrial hyperplasia were treated by hysterectomy compared with 9.6% (26/270) of patients without atypia. Of the patients diagnosed with atypical EH, 30.4% (7/23) were associated with endometrial carcinoma. Overall, 6% (12/201) of the women who had initial non-hysterectomy management and had additional tissue taken to assess response, had persistent disease, and 1% (2/201) had progressive disease. Eleven patients (5.9%), who had an initial complete regression during the non-hysterectomy management, experienced a recurrence to EH and 2.1% (4/187) were found to have recurrence to endometrial cancer CONCLUSION: The majority of patients with atypical hyperplasia were managed by initial hysterectomy. The high risk of concomitant endometrial cancer supports this choice of treatment. In the non-atypical EH, the initial non-hysterectomy management was common but EH recurrence and progression to endometrial cancer after the initial regression occurs often. Therefore, long-term follow-up should be advised.

Combined oral contraceptive use increases HPV persistence but not new HPV detection in a cohort of women from Thailand.

BACKGROUND: Women diagnosed with cervical cancer report longer duration and more recent use of combined oral contraceptives (COCs). It is unclear how COC use impacts risk of cervical carcinogenesis. METHODS: We estimated the risk of new human papillomavirus (HPV) DNA detection and persistence among 1135 human immunodeficiency virus (HIV)-negative women aged 20-37 years from Thailand who were followed for 18 months at 6-month intervals. Type-specific HPV DNA, demographic information, hormonal contraceptive use, sexual behavior, genital tract coinfection, and Papanicolaou test results were assessed at baseline and each follow-up. RESULTS: Women who reported current COC use during follow-up were less likely to clear HPV infection compared with nonusers, independent of sexual behavior, and Papanicolaou test diagnosis (AHR: 0.67 [95% CI: .49-.93]). Similar associations were not observed among women reporting current use of depomedroxyprogesterone acetate (DMPA). Neither COC nor DMPA use was significantly associated with new HPV DNA detection. CONCLUSIONS: These data do not support the hypothesis that contraceptive use is associated with cervical cancer risk via increased risk of HPV acquisition. The increased risk of HPV persistence observed among current COC users suggests a possible influence of female sex hormones on host response to HPV infection.

The association of hormonal contraceptive use and HPV prevalence.

Women diagnosed with cervical cancer report longer duration and more recent use of combined oral contraceptives (COCs). It is unclear whether COC use is associated with upstream events of human papillomavirus (HPV) infection prior to development of clinical disease. The objective of our study was to assess the association of contraceptive use on the risk for prevalent HPV infection in a cohort of long-term hormonal contraceptive (HC) users. One thousand and seventy (n = 1,070) HIV-negative women aged 20-37 from Thailand enrolled in a prospective study of the natural history of HPV. Baseline HPV genotype information, recency and duration of HC use, sexual behavior, other sexually transmitted infection (STI) information and cervical cytology and histology were assessed. At enrollment, 19.8% and 11.5% of women were infected with any HPV or any high-risk (HR)-HPV, respectively. After adjustment for age, current and past sexual risk behaviors, STI history and cytology, the use of COCs for >6 years was found to be associated with an increased risk of infection with any HPV [prevalence ratio (PR): 1.88 (1.21, 2.90)] and any HR-HPV [PR: 2.68 (1.47, 4.88)] as compared to never users. Recent, long-term COC use was associated with an increased risk for prevalent HPV infection independent of sexual behavior and cervical abnormalities. No similar association was observed for recent or long duration use of progestin-only contraceptives (i.e., depomedroxyprogesterone acetate). These data suggest that COC use may impact early upstream events in the natural history of HPV infection.

Malignant ovarian germ cell tumors: clinico-pathological presentation and survival outcomes.

OBJECTIVE: To evaluate clinico-pathological features, treatment, survival, and prognostic factors of patients with malignant ovarian germ cell tumors. DESIGN: Descriptive study. SETTING: Bangkok Metropolitan Administration Medical College and Vajira Hospital and Prince of Songkla University. POPULATION: Malignant ovarian germ cell tumor patients treated between January 1996 and December 2007. METHODS: Clinico-pathological data were collected. Patients with malignant tumors arising from benign cystic teratoma were excluded. Survival and potential prognostic factors were analyzed. MAIN OUTCOME MEASURES: Clinico-pathological features, survival. RESULTS: One hundred and thirty patients were identified. The median age was 21 years (range, 4-44 years). The most common complaint was pelvic or abdominal mass (63%). Primary surgery was performed by a gynecologic oncologist in only 39.2% of cases. More than half (64.2%) had early stage disease (stages I-II) and the majority had conservative surgery (73.1%). The most common histopathology was dysgerminoma. Of 124 patients with available follow-up data, 22 did not receive adjuvant treatment; 1 had whole abdominal radiation; and 101 had chemotherapy. Of 89 patients who were evaluable for responses, 4 patients had progressive disease while 85 had complete response. The five-year progression-free survival (PFS) and overall survival (OS) were 82.4% [95% confidence interval (CI), 75.4-89.5%)] and 92.4% (95% CI, 87.6-97.2%), respectively. Only preoperative tumor marker elevation was a significant poor prognostic factor for PFS. CONCLUSIONS: Malignant ovarian germ cell tumors have a good prognosis with conservative surgical treatment. Chemotherapy is important. Elevated preoperative serum tumor markers are a poor prognostic factor for PFS.

Correlation of p53 and Ki-67 (MIB-1) expressions with clinicopathological features and prognosis of early stage cervical squamous cell carcinomas.

AIM: To evaluate the prognostic significance of the expression of p53 and Ki-67, and their correlation with various clinicopathological factors in patients with squamous cell carcinoma of the uterine cervix treated by radical hysterectomy. METHODS: Two hundred and thirty five patients diagnosed between 1987 and 2004 were investigated for p53 and Ki-67 expression by immunohistochemistry. The relationship of these proteins and other potential prognostic factors with recurrence-free survival (RFS) was evaluated. RESULTS: The mean age of the patients was 43.9 years (range, 27-68). There were 28 cases with stage IA2 (11.9%) and 207 cases with stage IB1 (88.1%). The overall 5-year RFS was 91.1% (95% confidence interval [CI] 86.0, 94.4). p53 and Ki-67 expressions were seen in 33.6% and 81.3% of cases, respectively. p53 expression was significantly associated only with parametrial or marginal involvement (P = 0.005), while Ki-67 expression significantly correlated only with larger tumor (P = 0.011) and parametrial or marginal involvement (P = 0.024). There was significant correlation between the expression of p53 and Ki-67 (P = 0.021). In multivariate analysis, Ki-67 expression (hazard ratio for >or=3rd vs 1st tertile [>or=30% vs <20% expression] = 16.0, 95%CI 2.1-124.5; P = 0.0015) appeared to be an independent prognostic factor for RFS, while no prognostic significance of p53 expression was found. CONCLUSION: Ki-67 expression is an independent prognostic parameter for RFS in patients with early stage squamous cell carcinoma of the uterine cervix. Ki-67 expression at or above the cut-off point of 30.0% had significantly poorer RFS.

Comparison of success rate and complications of contour-loop excision of the transformation zone (C-LETZ) with cold knife conization (CKC) in high grade lesion (HGL) from colposcopic impression.

OBJECTIVE: To compare the complications and success rate of Contour-Loop Excision of the Transformation Zone (C-LETZ) with Cold Knife Conization (CKC) in High Grade Lesion (HGL). MATERIAL AND METHOD: Between April 1st, 2007 and November 30th, 2007, forty-five C-LETZs were performed in patients who had Pap smear result of High grade Squamous Intraepithelial Lesion (HSIL) or Squamous Cell Carcinoma (SCC) combined with colposcopic impression of satisfactory HGL by using the "See and Treat" approach. Success rate, tissue size, operating time, blood loss, intra-operative, and post-operative complications (2 weeks) were recorded to compare with the retrospective results from therapeutic CKC. RESULTS: Forty-five cases of C-LETZ and 50 cases of CKC were compared. Using the "See and Treat" approach, the over-treatment rate was 6.7% (3/45). The success rate and tissue size were not different between both groups. The operating time, blood loss, and post-operative infection were significantly less in the C-LETZ group. CONCLUSION: The authors compared CKC with C-LETZ, which is a new method for the management ofHGL of the cervix and found C-LETZ to be a favorable method with comparable efficacy but with significantly less morbidity, and suitable as a "See and Treat" method in a hospital outpatient clinic.

Situation analysis for management of abnormal Pap smears in the lower southern Thailand.

OBJECTIVE: To identify the resources for management of abnormal Pap smears and the treatment facilities in pre-invasive cervical neoplasia in the lower southern Thailand. METHODS: After reviewing the necessary data, an expert meeting was scheduled for questionnaire development. The questionnaires were then sent to the general, regional, and university hospitals in the lower southern Thailand for self-evaluation and on-site visits were made for intensive interviews, exploring the services and treatment facilities for women with abnormal Pap smears. RESULTS: All of the 12 target hospitals provided passive cervical cancer screening although the quality of cytological services was obscure and the process of patient notification for the results of the abnormal Pap smears was not convincing. There was a limitation in the pathological laboratory services. The incidence of the abnormal Pap smears in the one-year period of the study, defined as atypical squamous cells of undetermined significance (ASCUS) or above and high grade squamous intraepithelial lesions (HSIL) or above were 1.24% (95% CI 1.15-1.32) and 0.36% (95% CI 0.30-0.43) respectively. All but one hospital reported having a colposcope, but only one could provide standard colposcopy services. The efficiency of the referral system is questionable. CONCLUSION: The resources for the management of abnormal Pap smears as well as the conventional referral system need to be reorganized. The data from this survey support the concept of a centralized colposcopy service with the University hospital as suitable place for the referral center. Two further 2 hospitals have potential for future development as referral centers.

Clinico-pathological profile of vulva cancer in southern Thailand: analysis of 66 cases.

OBJECTIVE: To evaluate the clinico-pathologic findings and treatment outcome of women with vulva cancer in Southern Thailand. MATERIAL AND METHOD: The authors retrospectively reviewed the medical records of 66 women who had been treated with surgery from June 1984 to October 2003 at the Department of Obstetrics and Gynecology, Prince of Songkla University. RESULTS: The patients' age ranged from 30 to 87 years, mean 58.2 years. Two most common presentations were vulva mass (89.4%) and pruritus (57.6%). Duration of symptoms at presentation ranged form 1 month to 5 years. Most cases were squamous cell carcinoma (82.0%). The distribution by FIGO surgical stage I, II, III and IV was 9.1%, 47.0%, 34.8% and 9.1%, respectively. The most common complication was wound infection (45.5%), followed by wound dehiscence, lymphosis and leg edema (each 15.2%). The 5-year survival (and 95% CI) for stages I, II, III and IV was 100%, 96% (76-99%), 94% (63-99%) and 60 (13-88%), respectively. The 5-year survival for node-positive cases was 82% (54-94%) versus 100% for node-negative cases (p = 0.0003). Stage was a significant predictor of survival (p = 0.0142) and disease-free survival (p = 0.0112). CONCLUSION: Stage and nodal involvement are predictors of survival, and stage is a predictor of disease-free survival.

Lack of effect of perioperative blood transfusion during radical hysterectomy with lymph node dissection on the prognosis of cervical cancer stage Ib.

The aim of this retrospective study was to analyze the effects of perioperative blood transfusion during radical hysterectomy with lymph node dissection on the prognosis of cervical cancer stage Ib. A total of 295 patients who had undergone surgery from 1987-2002 were included. Forty seven patients underwent conization before definite surgery, and 2 patients were subsequently lost to follow up. Among the remaining 246 patients, 97 received allogenic blood transfusion, 38 received autologous blood transfusion, and 111 received no transfusion. The clinicopathologic finding of these three groups were reviewed and analyzed. There was no significant difference among three groups in age, chief complaints, duration of symptoms, size of lesion, histopathology, grade, margin or parametrium involvement, node status or postoperative adjuvant treatment. The most prominent presenting symptoms were abnormal vaginal discharge, abnormal vaginal bleeding, and postcoital bleeding. Although the 5-year disease-free survival (DFS) (and 95% CI) for autologous blood transfused group was 90.9% (74.4-97.0%), falling to 88.1% (77.8-93.8%) in untransfused blood group and 81.7% (71.3-88.6%) in allogenic transfused blood group, there were no significant differences among three groups (P = 0.699). In multivariate analyses, only age (P = 0.046), size of lesion (P = 0.024) and histology (P = 0.046) were statistically significantly associated with DFS, whereas transfusion status was not. In conclusion, there is no evidence that perioperative blood transfusion affects DFS of patients undergoing radical hysterectomy and pelvic lymphadenectomy. Only age, size of lesion and histology were statistically significantly associated with DFS.

Non-puerperal uterine inversion and uterine sarcoma (malignant mixed müllerian tumor): report of an unusual case.

A 45-year-old woman with a history of cervical cancer (stage IIa), who had received complete radiation treatment 16 years previously, presented with a huge mass protruding from her vaginal introitus. She had had the condition for about 1 week. Diagnosis was difficult, and she elected to have a diagnostic laparoscopic procedure plus tumor removal. The pathologic investigation revealed a malignant mixed müllerian tumor of the endometrium. Post-operative course was uneventful. She underwent postoperative pelvic radiation. No recurrence was found during the 13 months follow up period. This rare case of chronic non-puerperal uterine inversion due to malignant mixed müllerian tumor (MMMT) is herein reported.

Prognostic significance of Bax, Bcl-2, and p53 expressions in cervical squamous cell carcinoma treated by radiotherapy.

OBJECTIVE: The objective was to determine the prognostic significance of the immunohistochemical expressions of Bax, Bcl-2, and p53 in squamous cell carcinoma of the uterine cervix treated by radiotherapy alone. METHODS: One hundred and seventy-four cases of squamous cell carcinoma of the cervix (stage Ib-IVa) diagnosed between January 1996 and December 1998 were investigated for Bax, Bcl-2, and p53 expressions and were correlated to the patients' survival. RESULTS: The mean age of the patients was 54.1 with a range of 29-82 years. There were 23 cases with stage I (13.2%), 99 stage II (56.9%), 51 stage III (29.3%), and 1 case with stage IV (0.6%). The 5-year disease-free survival (DFS) was 70.50% and overall survival (OS) was 65.95%. Bax, Bcl-2, and p53 expressions were seen in 68.4%, 25.9%, and 77.6% of cases, respectively. In multivariate analysis by Cox's regression, age, stage, Bax, and Bcl-2 expressions appeared to be independent prognostic predictors of DFS. Bax expression was associated with good survival (hazard ratio, 0.47) while Bcl-2 expression was associated with poor survival (HR, 2.51). In addition, a combination of Bcl-2+/Bax+ was significantly associated with poorer DFS compared to Bcl-2-/Bax+ (HR 3.55). However, none of the markers or combinations was associated with OS. CONCLUSIONS: Evaluation of Bax and Bcl-2 expressions and their co-expression provide independent prognostic information for the clinical course of the disease and therefore could be developed as a prognostic indicator for cervical cancer.

Correlation of risk categorization in gestational trophoblastic tumor between old and new combined staging and scoring system.

AIM: To determine the correlation of risk categorization in gestational trophoblastic tumor between the revised International Federation of Gynecology and Obstetrics (FIGO) staging system combined with the original World Health Organization (WHO) scoring system, and the new FIGO staging system combined with the modified WHO scoring system. METHODS: We reviewed the medical records of 124 patients with gestational trophoblastic disease seen at Songklanagarind Hospital from 1988 to 2000. All patients were classified retrospectively by the FIGO staging system (both the revised system in 1992 and the new system in 2000) and the WHO scoring system (both the original and the modified one). The correlation of risk categorization between the revised FIGO staging system combined with the original WHO scoring system (old combined system), and the new FIGO staging system combined with the modified WHO scoring system (new combined system) was studied, and the remission rates in discrepant groups were identified. RESULTS: The mean score was 9.7+/-5.0 (range 1-21) for the original WHO and 8.3+/-5.0 (range 1-20) for the modified WHO. The correlation of risk categorization between old and new combined systems was 97.9%. There was no patient in the low risk group as classified by the old combined system, but patients were classified as in the high risk group by the new combined system. One patient, who was in the high risk group classified by the old combined system, but in the low risk group classified by the new combined system, achieved complete remission after treatment with single agent chemotherapy. CONCLUSION: There was good correlation between the old and the new combined systems.