Phase II study of concurrent cisplatinum with ifosfamide and radiotherapy in locally advanced squamous cell cervical carcinoma.

Objective: To evaluate the efficacy and toxicities of cisplatinum and ifosfamide administered concomitantly with radiation therapy in the treatment of locally advanced squamous cell cervical carcinoma (LASCC). Methods: Twenty patients with biopsy-proven squamous cervical carcinoma, FIGO stage II A to III B were entered into this study. All patients received standard radiotherapy (50 Gy in 25 fractions and brachytherapy at a dose of 268-28 Gy). Cisplatinum 70 mg/m2 plus ifosfamide 3 gm/m2 were administered totally for three cycles on Day 1, 21 and 42, concomitant with the radiotherapy schedule. Response and toxicities of treatment were evaluated and long term follow up was performed for disease free survival. Results: All patients received a course of concomitant chemoradiotherapy. Sixteen patients (80%) were able to receive a full course of chemotherapy, the remaining received 1-2 courses because of severe toxicities. The clinical complete response rate was 90% and overall 4 years survival rate was 85%. Grade 3 and 4 leucopenia occurred in 2 cases with one febrile neutropenia. Late complication revealed 2 cases of grade 3 cystitis. Conclusion: This study showed that concomitant chemoradiotherapy with cisplatinum plus ifosfamide was feasible for patients with LASCC. Further study of this regimen should be compared in randomized control trial (RCT) with cisplatinum alone and in the other histologic type of cervical cancer such as adenocarcinoma.

Tubo ovarian abscess caused by streptococcus group B: A case report and literature review.

A 34 year-old Thai female woman who had a previous history of recurrent pelvic inflammatory disease or recurrent pelvic inflammatory disease (PID), presented with recurrent pelvic pain and high grade fever. She was admitted and a diagnosis of tubo ovarian abscess was made. Physical examination and ultrasonographic examination demonstrated high grade fever, adnexal tenderness and a right mixed solid cystic mass compatible with tubo ovarian abscess. Despite prescription of combined parenteral antibiotic, her symptoms did not improve. An exploratory laparotomy showed a left ovarian abscess with a kinked fallopian tube behind the uterus. A left salpingectomy with partial oophorectomy was performed. Cultured pus was identified as group B streptococci. Antibiotics therapy was continued until clinical improvment and she was discharged on the seventh post operative day. Tubo ovarian abscess or tubo ovarian abscess (TOA) is a serious consequence of PID. The streptococcus group B infection is a rare cause of TOA. There is a discussion about diagnosis, medical treatment and surgical treatment. Although medical treatment with broad-spectrum antibiotics has allowed patients to avoid operations, some of them who failed medical treatment required surgical treatment. Especially in women who need childbearing potential in future, conservative surgery has become the initial approach as well as this case report.

The prospective study of the value of extraperitoneal pelvic lymph node dissection for patients with stage IB2-IIB cervical cancer.

Objective: To evaluate the value of extraperitoneal pelvic node dissection as a new diagnostic tool for evaluation of retroperitoneal pelvic node status in cervical cancer stage IB2-IIB patients after neoadjuvant chemotherapy. Complications of the procedure were also evaluated. Methods: Patients with cervical cancer stage IB2-IIB received neoadjuvant chemotherapy for 3 cycles. After that the patients underwent extraperitoneal pelvic node dissection and the nodes were sent for frozen section. If the frozen section was negative for metastases, radical hysterectomy was performed. If the frozen section was positive, radical hysterectomy was abandoned and the patients were treated by radiation. The value of extraperitoneal pelvic node dissection as a diagnostic tool for evaluating the extent of the disease was compared to that of transperitoneal pelvic node dissection as historical control. Results: Twenty-three patients were included in the study. Nineteen patients (83%) underwent radical hysterectomy after extraperitoneal node dissection; however, the procedure was abandoned in 3 patients (13%) due to positive frozen section of the lymph nodes. The frozen section lymph node yielded a false negative result in one patient (4%). The operative time, lymph node yield and the incidence of postoperative complications were not statistically different between extraperitoneal approach and transperitoneal approach. Conclusion: Extrapertoneal pelvic node dissection seems more suitable than transperitoneal pelvic node dissection for the evaluation of retroperitoneal pelvic node status in cervical cancer patients.

Spontaneous rectus sheath hematoma mimicking a pelvic mass with complication: A case report.

A 53 years old woman presented with acute abdominal pain with a large and tense abdominopelvic mass, and hypovolemic shock without peritoneal signs. An ultrasonogram and a CT scan of lower abdomen demonstrated a large heteroechoic mass in the left side of the pelvis. Exploratory laparotomy revealed a concealed hematoma beneath the left rectal sheath occupying the left obturator fossa. The final diagnosis was spontaneous rectus sheath hematoma with retroperitoneal extension.

Placental polyp: A case report.

A 28-year-old widow, gravida 1, para 1 which took place ten years earlier, presented with heavy bleeding from the vagina. Pelvic examination revealed a hemorrhagic and necrotic mass protruding from the external cervical os. Further investigations demonstrated a positive urine pregnancy test and a low titer of serum beta-hCG (53.6 mIU/ml). Ultrasonography and color Doppler imaging showed a hyperechoic and hypovascularized mass in the cervical canal. During subsequent planned tissue biopsy, the bleeding was uncontrollable, thus a total abdominal hysterectomy was performed. The pathologic findings were compatible with a placental polyp.

p53 tumor suppressor gene mutation in ovarian cancer in Thai patients.

OBJECTIVES: To characterize molecular mutations of p53 gene in Thai ovarian cancer and compare the mutations with their pathological and clinical findings. MATERIAL AND METHOD: Direct DNA sequencing of hot spot region of p53 gene (exons 5 to 8) from 28 primary ovarian cancer tissues, 2 metastatic tumors and their paired blood samples was performed. The detected mutations were compared to the pathological and clinical findings and responsiveness to treatments after 36 months of follow-up. RESULTS: One insertion and 4 point mutations in exon 5 of p53 gene were found in 5 out of 28 (18%) ovarian cancer patients. There was no mutation in the paired blood samples. The histological types of the detected tumors were 3 endometrioids and 2 serous cystadenocarcinomas. All 5 patients were in stage I to IV disease and showed overall 4 out of 5 (80%) complete response until 36 months after surgery followed by chemotherapy, compared to 14 out of 28 (50%) of complete response in all cases of ovarian cancer. CONCLUSION: The authors found 5 cases of ovarian cancer patients with p53 gene mutations giving the same response to complete standard treatment as all cases. Significant factors affecting responsiveness of these patients depended more on stages, grades and histological cell types of the cancer.

Validity of frozen section in cervical conization.

Objective: To evaluate the validity of pathological diagnosis of cervical cone specimens prepared by frozen section compared with paraffin section. Study design: Diagnostic test evaluation. Setting: Pathology division, Department of Obstetrics and Gynecology, faculty of Medicine Siriraj Hospital, Mahidol University. Methods: Cervical cone specimens from 78 patients who underwent cold knife conization at Siriraj Hospital from October 1997 to September 1998 were processed by frozen section technique and the pathological diagnoses were made immediately. The remaining cone tissue from each specimen was processed to produce permanent paraffin sections for a final diagnosis. The frozen and permanent pathological diagnoses were compared. Results: The pathological diagnosis from frozen section was in complete agreement with the permanent section in 60.26% of patients. When the subjects were divided into three groups; normal and CIN I, CIN II-III and MIC and invasive cancer, the Kappa analysis for agreement of the pathological diagnoses between the two methods was 0.46 (fair agreement). For the diagnosis of invasive cancer by frozen section, the sensitivity, specificity, positive and negative predictive value, false negative and false positive were 62.5, 97, 71.4, 95.8, 37.5 and 1.9%, respectively. There were three cases of invasive cancer on permanent paraffin section which were diagnosed by frozen section as MIC in tow cases and CIN III in the other. Conclusion: Frozen section evaluation of a cervical cone specimen carries only a moderate degree of agreement with permanent paraffin section. For the diagnosis of invasive cancer in this study, frozen section has a low sensitivity and a high false negative rate. The diagnosis of microinvasive cancer was subject to significant error. The diagnosis of microinvasive cancer by frozen section needs additional careful review of the permanent section.

Outcome of the ovarian epithelial Cancer stage I-II treated with cyclophosphamide plus cisplatinum or carboplatin.

The retrospective study outcome of the ovarian epithelial cancer stage I-II treated in Obstetrics and Gynaecological Department, Siriraj Hospital during June 1989 – June 1997, received postoperative chemotherapy cyclophosphamide plus cisplatinum (CP) or cyclophosphamide plus carboplatin (C-CP). Stage I disease of unfavourable prognosis 66 cases treated with CP and 25 cases of C-CP, achieved the 5-years disease free survival 82% and 86% respectively (P>0.05). Stage II disease of CP group, 21 cases and C-CP group, 7 cases achieved the 5-years disease-free survival 80% and 82% respectively (P>0.05). The toxicities of chemotreatment were manageble.

Evaluation of depth of myometrial invasion by gross visual estimation versus microscopic technique.

A diagnostic test evaluation was performed to compare the evaluation of depth of myometrial invasion by gross visual estimation versus microscopic examination in the uteri of 40 patients who had endometrial adenocarcinoma and underwent surgical treatment in Siriraj Hospital from November 1993 to March 1995. The accuracy of gross visual estimation was 85%, the sensitivity was 63.6% (95% CI=31.6-87.6), the specificity was 93.1% (95%CI=75.8-98.8), the positive predictive value was 77.8% (95% CI=40.2-96.1), the negative predictive value was 87.1% (95% CI=69.2-95.8), the false positive rate was 6.9% and the false negative rate was 36.4%. Although gross visual estimation showed good specificity, high false negative rate and should not be used in preference to microscopic examination.

Primary ovarian cancer: A five-year review.

This retrospective study reports on 187 cases of ovarian carcinoma treated at Siriraj Hospital over five-year period from 1988-1992. The incidence was 17.6% of all ovarian tumors. Common epithelium was the most common group found in this study (85%). A total of 9.1% of the patients were in the germ cell group and the rest were in the stromal cell group (5.9%). The mean ages of the common epithelium germ cell and stromal cell groups were 47.5+14, 28.6+17.4 and 56.9+18.3 years respectively. The common presenting symptom was either abdominal mass (40.1%) or abdominal bloating (32.6%). The tumors, which developed in nearly three-fourths of the patients (72.2%), were between 6.20 cm in greatest diameter. Serous, dysgerminoma and granulosa cell tumors were the most common cell types found in the common epithelium, germ cell and stromal cell groups respectively. Half of the patients (50.8%) were in an advanced stage of the disease and radical surgery was performed in 62.3% of the patients.