Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse.

PURPOSE: To evaluate long-term continuation rates, adverse events of ring pessary use at a minimum of 5 years follow-up, and factors associated with discontinuation in symptomatic pelvic organ prolapse (POP). METHODS: Women with symptomatic POP who were treated with vaginal ring pessary and had successful fittings were included. Adverse events and reasons for discontinuation of pessary use were recorded. Patients who were lost to follow-up were defined as discontinuation. RESULTS: During 12 year-period, 239 of 329 POP patients (72.6%) had successful fittings with ring pessary. The mean age was 67.8 ± 8.9 years (range 27-86) and 70% of patients had advanced stage. The cumulative probability of continued ring pessary use was 84.1%, 64.4%, 49.3%, and 33.5%, at 1, 3, 5, and 10 years, respectively. Most common reason for discontinuation was frequent expulsion (21.6%), followed by vaginal erosion (16.5%), no prolapse improvement (12.4%), and inability or inconvenience to do self-care (9.3%). However, 9 patients (9.3%) had improvement of prolapse and were able to discontinue pessary insertion. Age above 70 years, wide introitus, and incapability of self-care are independent factors associated with long-term discontinuation. Adverse events occurred in 23.4% of patients, 18.8% of them had vaginal erosion, 11.7% vaginal discharge/infection, and 18.4% de novo SUI. However, no statistical significance existed between those who continued and discontinued pessary use due to these adverse events. CONCLUSION: Ring pessary is an effective treatment in symptomatic POP, with acceptable long-term continuation rates and minor adverse events. Self-care of pessary is very important aiming to minimize adverse events. Advanced age, wide introitus and incapability of self-care were associated factors for long-term discontinuation.

ConCerv: a prospective trial of conservative surgery for low-risk early-stage cervical cancer.

OBJECTIVE: The objective of the ConCerv Trial was to prospectively evaluate the feasibility of conservative surgery in women with early-stage, low-risk cervical cancer. METHODS: From April 2010 to March 2019, a prospective, single-arm, multicenter study evaluated conservative surgery in participants from 16 sites in nine countries. Eligibility criteria included: (1) FIGO 2009 stage IA2-IB1 cervical carcinoma; (2) squamous cell (any grade) or adenocarcinoma (grade 1 or 2 only) histology; (3) tumor size <2 cm; (4) no lymphovascular space invasion; (5) depth of invasion <10 mm; (6) negative imaging for metastatic disease; and (7) negative conization margins. Cervical conization was performed to determine eligibility, with one repeat cone permitted. Eligible women desiring fertility preservation underwent a second surgery with pelvic lymph node assessment, consisting of sentinel lymph node biopsy and/or full pelvic lymph node dissection. Those not desiring fertility preservation underwent simple hysterectomy with lymph node assessment. Women who had undergone an 'inadvertent' simple hysterectomy with an unexpected post-operative diagnosis of cancer were also eligible if they met the above inclusion criteria and underwent a second surgery with pelvic lymph node dissection only. RESULTS: 100 evaluable patients were enrolled. Median age at surgery was 38 years (range 23-67). Stage was IA2 (33%) and IB1 (67%). Surgery included conization followed by lymph node assessment in 44 women, conization followed by simple hysterectomy with lymph node assessment in 40 women, and inadvertent simple hysterectomy followed by lymph node dissection in 16 women. Positive lymph nodes were noted in 5 patients (5%). Residual disease in the post-conization hysterectomy specimen was noted in 1/40 patients-that is, an immediate failure rate of 2.5%. Median follow-up was 36.3 months (range 0.0-68.3). Three patients developed recurrent disease within 2 years of surgery-that is, a cumulative incidence of 3.5% (95% CI 0.9% to 9.0%). DISCUSSION: Our prospective data show that select patients with early-stage, low-risk cervical carcinoma may be offered conservative surgery.

Gynecologic Surgery during the COVID-19 Pandemic: Is Universal Screening Mandatory?

This study is aimed at evaluating the results of the universal preoperative screening for COVID-19 in gynecologic cases operated on during its outbreak in a tertiary care hospital in Bangkok, Thailand. A retrospective descriptive study was done on all patients who underwent elective or emergency gynecologic surgeries during the pandemic period in Thailand (April 15 to June 5, 2020). The COVID-19 screening results by symptom-based screening, risk-based screening, and RT-PCR for COVID-19 were collected from the electronic medical records. Among 129 patients who underwent gynecologic surgeries, none had a positive RT-PCR for COVID-19. Symptom-based screening found no patients with positive symptoms for COVID-19. Risk-based screening found 4 patients (3.1%) who were in contact with suspected or confirmed COVID-19 cases and 4 patients (3.1%) who were healthcare personnel. In conclusion, routine preoperative RT-PCR for COVID-19 may need to be reconsidered among asymptomatic individuals in a low-prevalence country during the well-controlled COVID-19 situation. Larger studies are required to ascertain the benefit of universal preoperative COVID-19 testing.

Lynch Syndrome in Thai Endometrial Cancer Patients.

BACKGROUND: Lynch syndrome increases lifetime risk of endometrial cancer to 40-60%. Screening with molecular tumor testing for mismatch repair (MMR) proteins have been recommended. This study aims to evaluate the incidence of MMR deficiency and germline mutation in endometrial cancer Thai patients. METHODS: Immunohistochemistry for MMR proteins, including MLH1, MSH2, MSH6 and PMS2 were tested in 166 surgical specimens. Patients who had MMR deficiencies were offered genetic counseling and a germline testing using gene-panel next generation sequencing. RESULTS: Fifty-eight of 166 patients (34.9%) had one or more MMR deficiencies which were: MLH1 and PMS2 in 42 patients (25.3%), MSH2 and MSH6 in 11 patients (6.6%), and MSH6 in 5 patients (3.0%). Of the 40 patients (24.1%) who met the revised Bethesda guidelines, 19 patients (47.5%) had MMR deficiency. In contrast, MMR deficiency was found in 39 of the 126 patients (31.0%) who did not meet the revised Bethesda guidelines. A total of 27 patients with MMR deficiencies agreed to have germline genetic testing. Germline MMR mutations were detected in 5 patients (18.5%) including MSH6 (n=2), PMS2 (n=2), and MLH1 mutations (n=1). Incidental germline mutations in other genes were detected in 3 patients (1 BRCA1, 1 PTEN, and 1 BARD1). Among 5 Lynch syndrome patients, 2 patients (40%) did not meet the revised Bethesda guidelines. Eight patients who met the revised Bethesda Guidelines but having MMR proficiency had genetic testing, but no germline mutation was detected. CONCLUSION: MMR deficiencies were detected in 34.9% of the endometrial cancer patients. Germline mutations were diagnosed in 3.0% of this cohort (5/166 patients). Lynch syndrome screening with MMR immunohistochemistry should be considered in all patients regardless of personal or family history of Lynch syndrome-related cancers.

Adherence to follow-up in women with cervical intraepithelial neoplasia grade 1.

OBJECTIVES: Adherence to follow-up is crucial for cervical intraepithelial neoplasia grade 1 (CIN1) because these women have a chance of progression to high-grade premalignant cervical lesions and cervical cancer. This study aimed to evaluate the rate of adherence to follow-up in women who were initially diagnosed with CIN 1 over a period of 24 months and to evaluate the regression and progression rate of CIN 1. MATERIAL AND METHODS: Of 1050 women who visited a colposcopy clinic from October 2013 through March 2017, 138 with histologically proven as CIN 1 were recruited. Adherence to follow-up, the regression and progression rate of CIN 1 were retrospectively assessed. RESULTS: Of the 138 women, 86 (62.3%) followed regularly until the study endpoint at 24 months. During the study period, 10 women received ablative treatment. The regression rate in women who had surveillance with cervical cytology was 69.7%, persistent disease of 18.4%, and progression to CIN 2-3 of 11.8%. In contrast, 80% of women who received ablative treatment had regression, 20% of them had persistent disease but none had progression. CONCLUSIONS: Nearly 40% of women with CIN 1 were lost to follow-up at 24 months. Adherence to the follow-up should be emphasized to all women. Intensive interventions to improve adherence and clinical outcome might be an option, particularly among women with poor compliance.

Preoperative markers for the prediction of high-risk features in endometrial cancer.

BACKGROUND: Preoperative evaluations aiming to assess high-risk features in clinical stage 1 endometrial cancer patients are crucial to refer these patients to gynecologic oncologists. Cancer antigen 125 (CA125) and human epididymis protein 4 (HE4) have been reported in endometrial cancer patients with poor prognostic factors. AIM: To evaluate the association between preoperative levels of CA125 and HE4 and high-risk features and establish optimal cut-off values in clinical stage 1 endometrial cancer. METHODS: A retrospective study was conducted in clinical stage 1 endometrial cancer patients who underwent primary surgery between January 2013 and December 2018. A total of 128 patients had preoperative serum CA125 and HE4 measurements. High-risk features included grade 3 tumors, large tumor sizes (more than 2 cm), deep myometrial invasion (more than 50%), lymphovascular space invasion (LVSI), cervical involvement, extrauterine involvement and node metastasis. Receiver operating characteristic (ROC) curves were generated to analyze the optimal cut-off values. RESULTS: The mean age of the patients was 57.4 years, and 69.5% of them were postmenopausal. Most patients presented with stage I disease (67.2%) and had the endometrioid subtype (97.7%). The median CA125 and HE4 levels in all patients were 22.1 U/mL and 104.7 pmol/L, respectively. CA125 and HE4 levels were significantly elevated in those with large tumor sizes, deep myometrial invasion, LVSI, extrauterine metastasis, and advanced stage, but node metastasis was associated with elevated CA125 only. According to the ROC curve, both serum markers had statistical significance for the prediction of high-risk features only in postmenopausal patients, with an optimal cut-off value of 20 U/mL for CA125 [area under the concentration-time curve (AUC) = 0.72, P = 0.002] and 113 pmol/L for HE4 (AUC = 0.70, P = 0.006). The combination of both serum markers had 80% sensitivity and 64.4% positive predictive value. Significantly worse 5-year disease-free survival was observed in patients with high levels of CA125 and HE4 (78.4% and 100%, respectively; P = 0.01). CONCLUSION: Preoperative CA125 levels greater than 20 U/mL or HE4 levels greater than 113 pmol/L are associated with an increased risk of having high-risk features and present as prognostic factors in clinical stage 1 postmenopausal endometrial cancer patients. This information is helpful for general gynecologists to refer high-risk patients to gynecologic oncologists to perform complete surgical staging.

Coexisting cancers with atypical glandular abnormalities by liquid-based cytology: A retrospective study in tertiary hospital in a high cervical cancer incident country.

OBJECTIVE: To determine the incidence of coexisting cancers in women with glandular cell abnormalities detected from liquid-based cytology and to compare the detection rate of premalignant and malignant lesions among various subtypes of glandular cell abnormalities. MATERIALS AND METHODS: From January 2014 to December 2016, liquid-based cytology was performed in 85,517 women. Using the Bethesda system 2001 criteria, abnormal cervical cytology was diagnosed in 3650 women (4.3%). Glandular cell abnormalities were diagnosed in 110 women (0.13%). Ten women with pre-existing genital tract cancers and 13 women who lost to follow up were excluded. Clinical characteristic, colposcopic finding, and histopathological data were reviewed in 87 women. RESULTS: High-grade premalignant and malignant lesions were diagnosed in 34 patients (39.1%). Co-existing cancer was diagnosed in 31 patients (35.6%); 15 cervical cancers (17.2%) and 16 endometrial cancers (18.4%). The detection rate of significant lesions (CIN2+ or malignant lesions) in patients with AGC-NOS was 14.9%, AGC-FN was 38.9% and AIS/adenocarcinoma was 90.9% (p < 0.001). CONCLUSION: Glandular cell abnormalities associated with high incidence of coexisting endometrial and cervical cancers. Comprehensive genital tract screening to evaluate gynecologic malignancy is strongly recommended in all women with glandular cell abnormalities.

Prevalence of Tissue BRCA Gene Mutation in Ovarian, Fallopian Tube, and Primary Peritoneal Cancers: A Multi-Institutional Study.

BACKGROUND AND OBJECTIVE: Ovarian, fallopian tube, or primary peritoneal cancer patients with BRCA gene mutation have enhanced sensitivity to platinum-based regimens and PARP inhibitors. However, the knowledge regarding BRCA mutation in Thai patients is limited. This study aimed at identifying the prevalence and characteristics of somatic and germline BRCA 1 and 2 mutations in Thai patients with these cancers. MATERIALS AND METHODS: The paraffin blocks of tumors with histology of high grade serous, high grade endometrioid, or clear cell carcinoma obtained between June 2016 and December 2017 were analyzedto evaluate BRCA mutation using next-generation sequencing system. Blood or normal tissue paraffin blocks of positive patients were further tested for germline BRCA mutation. RESULTS: Tissue paraffin blocks of 178 patients were collected but only 139 were analyzed. Positive BRCA mutation was identified in 24 patients (17.3%): BRCA1 in 13 cases, BRCA2 in 10 cases, and BRCA1 and 2 in the rest one. Germline mutation study in blood or normal tissue in 23 positive patients revealed BRCA mutation in 14 cases, BRCA1 in 8 cases and BRCA 2  in 6 cases. Overall, the prevalence of somatic and germline mutation was 6.5% (9 out of 138 patients) and 8.7% (14 out of 138 patients), respectively. The most common histology associated with BRCA mutation was high grade serous cancer (27.3%). No significant difference was found between patients with or without BRCA mutation in terms of stage, outcome, platinum status, and survival outcome. CONCLUSION: BRCA mutation was demonstrated in less than 10% of Thai ovarian cancer patients. Higher rate of mutation was found in high grade serous cancer.
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BRCA immunohistochemistry for screening of BRCA mutation in epithelial ovarian cancer patients.

To evaluate BRCA1/2 immunohistochemistry (IHC) as a screening test for germline BRCA1/2 in epithelial ovarian cancer (EOC), tumor tissue from 105 EOC patients who had germline BRCA mutations, including 9 BRCA1 mutations, 6 BRCA2 mutations and 90 no BRCA mutations, were studied. Paraffin-embedded tissue blocks were stained for BRCA1 and BRCA2. Tumors were indicated as a loss of BRCA expression when neoplastic nuclear stained less than 10%. Loss of BRCA1 and/or BRCA2 expression was found in 36 patients (34.3%). BRCA1 IHC loss was found in 21 patients (20%) while 24 patients (22.9%) had BRCA2 IHC loss. There were no significant differences in patient characteristics between both groups. Loss of BRCA1 expression had 66.7% sensitivity, 84.3% specificity, 28.6% positive predictive value (PPV), and 96.4% negative predictive value (NPV) for detection of germline BRCA1 mutation. Meanwhile, loss of BRCA2 expression had 50% sensitivity, 78.8% specificity, 12.5% PPV, and 96.3% NPV for detection of germline BRCA2 mutation. There was no significant difference in survival outcomes between both groups. Based on high NPV, BRCA IHC may be useful to exclude patients without BRCA dysfunction if IHC showed intact expression. Only patients with BRCA IHC loss should be offered further genetic testing.

Germline mutations in Thai patients with nonmucinous epithelial ovarian cancer.

BACKGROUND: Genetic testing is widely recommended for all epithelial ovarian cancer (EOC) patients. However, an increased probability of identifying germline mutations has been reported in selected patients with risk factors such as a family history or personal history of cancer and high-grade serous carcinoma (HGSC) subtype. HGSC has been reported to be the most common subtype of EOC worldwide (approximately 70%). However, this subtype is less prevalent in Thai patients (reported as only 20%). The difference in the distribution of various subtypes of EOC may reflect the incidence of germline mutations in Thai EOC patients. AIM: To evaluate the frequencies of germline mutations in EOC patients and to compare the frequencies in those with and without clinical risk factors for hereditary ovarian cancer. METHODS: This cross-sectional study included 112 nonmucinous EOC patients who underwent primary surgery at our tertiary care hospital. Clinical risk factors for hereditary ovarian cancer were defined as follows: Age below 40 years, a significant family history of cancer, synchronous ovarian and endometrial cancer, and HGSC. Comprehensive germline mutations were detected by next-generation sequencing. RESULTS: Of a total of 112 patients, 82 (73.2%) patients had ≥ 1 risk factor and 30 (26.8%) patients had no risk factors. Germline mutations were detected in 26 patients: 20 (17.8%) patients had BRCA1/2 mutations, but 6 (5.4%) patients had mutations in other genes, including 1 in MLH1, 1 in MSH2, 1 in RAD51C, 2 in ATM and 1 in CDH1. Germline mutations were only detected in patients with risk factors (26 of 82, 31.7%), not in patients without risk factors (P < 0.001). A significant family history of cancer and HGSC were the only two significant risk factors associated with a higher proportion of germline mutations (56.3% vs 10% for those with and without a history of cancer, respectively, 40.8% vs 9.5% for those with and without HGSC). Germline BRCA mutations were detected in 38.8% of patients with HGSC but in only 1.6% of those with non-HGSC. An age below 40 years, personal history of breast cancer, and synchronous ovarian and endometrial cancer were not significant factors (14.3% vs 23.5%, 33.3% vs 21%, 22.2% vs 22.3%). CONCLUSION: Approximately one-third of EOC patients with risk factors had germline mutations. Almost all germline BRCA mutations were found in patients with the HGSC subtype. Selected patients with HGSC and a family history of cancer should be initially considered for genetic analysis in Thailand.

BRCA mutation in high grade epithelial ovarian cancers.

OBJECTIVE: To identify the frequency of BRCA mutation in patients with high grade epithelial ovarian cancer (EOC). METHODS: Patients with EOC included fallopian tube cancer or peritoneal cancer with high grade serous or high grade endometrioid were recruited. BRCA1 and BRCA2 mutations were tested and analyzed by next generation sequencing system. RESULTS: A total of 87 patients were recruited; majority of them (88.5%) were EOC, 5.7% fallopian tube cancer, 4.6% peritoneal cancer, and 1.1% synchronous primary ovarian and endometrial cancer. Seventy-four patients (85.1%) had high grade serous carcinoma and 13 patients (14.9%) had high grade endometrioid carcinoma. Germline BRCA mutation was detected in 19 patients (21.8%); 14 patients (16.1%) had BRCA1 mutation and 5 patients (5.7%) had BRCA2 mutation. All BRCA mutations were found in patients with high grade serous carcinoma (25.7%) but none in high grade endometrioid carcinoma. Six from 19 patients (31.6%) who had BRCA mutation had no family history of breast and ovarian cancers. Higher frequency of BRCA mutation was detected in patients with fallopian tube cancer; 3 in 5 patients (60%) followed by peritoneal cancer; 2 in 4 patients (50%), and EOC; 14 in 77 patients (18.2%). CONCLUSION: The frequency of BRCA mutation in high grade serous carcinoma was 25.7%, none was found in high grade endometrioid carcinoma. High cost, unavailability of genetic testing, limited number of geneticists, may be barriers in limited resource countries. Selected patients especially high grade serous carcinoma should be considered initially.

The Effects of Active Hexose Correlated Compound (AHCC) on Levels of CD4+ and CD8+ in Patients with Epithelial Ovarian Cancer or Peritoneal Cancer Receiving Platinum Based Chemotherapy

Background: Adjuvant chemotherapy is a required treatment for most patients with epithelial ovarian cancer (EOC) or peritoneal cancer. However, it has many adverse events which may affect oncologic outcomes. Active hexose correlated compound (AHCC) has been reported to be an immunoenhancer to decrease adverse events of chemotherapy. Materials and Methods: Patients were randomized and allocated to receive either AHCC three grams/day (500mg/ capsule) or placebo. These drugs were administrated as two capsules orally three times a day throughout six cycles of chemotherapy. The primary outcome was a change of CD4+ and CD8+ T cell lymphocytes in peripheral blood samples from baseline to completion of chemotherapy. Secondary outcomes were rate of bone marrow suppression, adverse events and quality of life (QOL) as assessed by Thai version of the Functional Assessment of Cancer Therapy-General (FACT-G). Results: Study outcomes were analyzed in 28 patients, 14 patients in each group. Changes in CD4+ and CD8+ T cell lymphocytes levels were not significantly different between AHCC and placebo group; 43.5/ul (-237.5, 143.3) versus -69.5 /ul (-223.8, 165) for CD4+ level, p=0.61 and 49.5.0 /ul (-80, 153.3) versus 4.0 /ul (-173, 62.5) for CD8+ level, p=0.19. However, CD8+ levels were significantly higher in the AHCC group at the sixth cycle of chemotherapy; 392.5.0 /ul (310.8, 598) versus 259.5 /ul (170.5, 462.3), p=0.03. There was no difference in bone marrow suppression and QOL between the two groups. Adverse events in terms of nausea and vomiting significantly decreased but muscle pain significantly increased in the AHCC group. Conclusions: Changes in CD4+ and CD8+ T cell lymphocytes from baseline were not significantly increased in AHCC group. However, CD8+T cell lymphocytes levels were significantly higher in the AHCC group at the sixth cycle of chemotherapy.

High-risk epithelial ovarian cancer patients for hereditary ovarian cancer.

AIM: Risk assessment to identify patients at risk for hereditary ovarian cancer is important. The objectives of this study were to evaluate the frequency of high-risk epithelial ovarian cancer (EOC) patients and the frequency of germline mutation in these patients. METHODS: A total of 335 patients with histologically confirmed non-mucinous EOC were included. High-risk patients were defined as patients who had: (i) significant family history of breast/ovarian/colorectal/endometrial cancers; (ii) synchronous breast/endometrial/colorectal cancer; or (iii) high-grade serous carcinoma. Germline mutation was evaluated by Next Generation Sequencing system with the 27-genes panel. RESULTS: A total of 94 patients (28.1%) were high-risk patients, 5.1% had significant family history of cancers, 4.2% had synchronous primary cancers, and 22.1% had high-grade serous carcinoma. Germline mutation was detected in 10 of 35 patients (28.6%). Six germline mutations (17.1%) occurred in homologous recombination (HR) genes; these included three (8.6%) in BRCA1, one (2.9%) in BRCA2, and two (5.7%) in other HR genes (CHEK2 and RAD1C). Three patients (8.6%) had MMR gene mutations (one MLH1 and two MSH2) and one patient (2.9%) had other gene mutation (MUTYH). Of the 10 patients with germline mutation, 40% of patients had no significant family history of cancer. CONCLUSION: Up to 30% of EOC patients had risk factors for hereditary ovarian cancer. Germline mutation was identified in 28.6% of patients (11.4% BRCA mutation, 5.7% other HR genes mutation, 8.6% MMR mutation, and 2.9% mutation in other gene). The high cost of genetic testing is an important barrier. Selected patients with high-risk factors might be initially considered for genetic testing in a limited-resource setting.

Comparison of Perioperative and Oncologic Outcomes with Laparotomy, and Laparoscopic or Robotic Surgery for Women with Endometrial Cancer.

PURPOSE: To compare perioperative outcomes and oncologic outcomes in endometrial cancer patients treated with laparotomy, and laparoscopic or robotic surgery. MATERIALS AND METHODS: Endometrial cancer patients who underwent primary surgery from January 2011 to December 2014 were retrospectively reviewed. Perioperative outcomes, including estimated blood loss (EBL), operation time, number of lymph nodes retrieved, and intra and postoperative complications, were reviewed. Recovery time, disease free survival (DFS) and overall survival (OS) were compared. RESULTS: Of the total of 218 patients, 143 underwent laparotomy, 47 laparoscopy, and 28 robotic surgery. The laparotomy group had the highest EBL (300, 200, 200 ml, p<0.05) while the robotic group had the longest operative time (302 min) as compared with laparoscopy (180 min) and laparotomy (125 min) (p<0.05). Intra and postoperative complications were not different with any of the surgical approaches. No significant difference in number of lymph nodes retrieved was identified. The longest hospital stay was reported in the laparotomy group (four days) but there was no difference between the laparoscopy (three days) and robotic (three days) groups. Recovery was significantly faster in robotic group than laparotomy group (14 and 28 days, p=0.003). No significant difference in DFS and OS at 21 months of median follow up time was observed among the three groups. CONCLUSIONS: Minimally invasive surgery has more favorable outcomes, including lower blood loss, shorter hospital stay, and faster recovery time than laparotomy. It also has equivalent perioperative complications and short term oncologic outcomes. MIS is feasible as an alternative option to surgery of endometrial cancer.

Efficacy of acupuncture in prevention of delayed chemotherapy induced nausea and vomiting in gynecologic cancer patients.

OBJECTIVE: To compare the efficacy between acupuncture and ondansetron in the prevention of delayed chemotherapy induced nausea and vomiting (CINV). METHODS: 70 patients were randomized to receive either 1) acupuncture at P6 point before chemotherapy infusion or 2) ondansetron 8 mg intravenously 30 min before chemotherapy infusion in their first cycle with cross-over of antiemetic regimen in the consecutive cycle. All patients received dexamethasone 5mg orally twice a day for 3 days. Patients were given additional does of ondansetron 4 mg orally every 12h if they experienced emesis. Emetic episode, severity of nausea score of 0-10 and adverse events were recorded. Complete response was defined as no nausea, no vomiting and no requirement of additional antiemetic drugs. FACT-G scale was used to evaluate quality of life (QOL) 7 days after each cycle of chemotherapy. RESULTS: The acupuncture group had a significantly higher rate of complete response in the prevention of delayed CINV (52.8% and 35.7%, P = 0.02). Compared to another group, the acupuncture group reported significantly lower delayed nausea (45.7% and 65.7%, P = 0.004), nausea score (P < 0.001) and fewer dosages of additional oral ondansetron (P = 0.002). Adverse effects were also significantly lower in the acupuncture group with less frequent constipation (P = 0.02) and insomnia (P = 0.01). Overall FACT-G scores were significantly higher in the acupuncture group. CONCLUSION: Acupuncture is effective in preventing delayed CINV and in promoting better QOL. With fewer adverse effects, it may be used as an alternative treatment option for CINV.

Feasibility and safety of robotic surgery for gynecologic cancers.

BACKGROUND: To determine surgical outcomes, perioperative complications, and patient outcomes in gynecologic cancer patients undergoing robotic surgery. MATERIALS AND METHODS: Surgical outcomes, including docking time, total operative time, console time, estimated blood loss (EBL), conversion rate and perioperative complications were retrospectively reviewed in 30 gynecologic cancer patients undergoing robotic surgery. Patient outcomes included recovery time and patient satisfaction, as scored by a visual analogue scale (VAS) from 0-10. RESULTS: The operations included 24 hysterectomies with pelvic lymphadenectomy (PLD) and/or para-aortic lymphadenectomy, four radical hysterectomies with PLD, and two radical trachelectomies with PLD. Mean docking time was 12.8 ± 9.7 min, total operative time was 345.5 ± 85.0 min, and console time was 281.9 ± 78.6 min. These times were decreased in the second half of the cases. There was no conversion rate. Three intraoperative complications, including one external iliac artery injury, one bladder injury, and one massive bleeding requiring blood transfusion were reported. Postoperative complications occurred in eight patients, most were minor. Only one patient had port herniation that required reoperation. Mean hospital stay was 3.5 ± 1.7 days, and recovery time was 14.2 ± 8.1 days. Two-thirds of patients felt very satisfied and one-third felt satisfied; the mean satisfaction score was 9.4 +0.9. Two patients with stage III endometrial cancer developed isolated port site metastasis at five and 13 months postoperatively. CONCLUSIONS: Robotic surgery for gynecologic cancer appears to be feasible, with acceptable perioperative complication rate, fast recovery time and high patient satisfaction.

Knowledge and acceptance of Thai women toward the pelvic floor muscle training.

BACKGROUND: Pelvic floor muscle training (PFMT) is considered as an effective management for relieving pelvic organ prolapse (POP) and urinary incontinence (UI). Although the benefits of PFMT are known among the health care professionals, the benefits from PFMT among the Thai women are not known. OBJECTIVE: To evaluate the basic knowledge and acceptance of PFMT in women who visited the gynecologic out-patient clinic. MATERIAL AND METHOD: A cross-sectional survey was conducted by administering a brief anonymous 2-part questionnaire to 415 women who visited the gynecologic out-patient clinic at King Chulalongkorn Memorial Hospital between November 2010 and January 2011. A questionnaire, consisting of 24 questions, was divided into two parts where part one, made up of 10 questions, collected demographic data and the remaining 14 questions in part 2 gathered more information about the knowledge and acceptance towards PFMT. These questionnaires required approximately five minutes for completion. RESULTS: Mean age of all women was 42.9 years. The percentage of patients having stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence (MUI) were 21.9%, 5.3%, and 15.2%, respectively. Overactive bladder (OAB) and pelvic organ prolapse (POP) were found in 19.5% and 9.9%, respectively. Half of the respondents were unaware of PFMT efficacy. Most of them (80.2%) never received instruction from their health care providers. However 52.8% of women expressed interest for requesting PFMT instruction while 84.6% were willing to practice if they were made aware of benefits. CONCLUSION: A limited understanding and acceptance of PFMT exists among Thai women. However if informed, most women express interest in practicing PFMT after clinic visit.

Lower urinary tract dysfunction and quality of life in cervical cancer survivors after concurrent chemoradiation versus radical hysterectomy.

INTRODUCTION AND HYPOTHESIS: Lower urinary tract dysfunction (LUTD) is a common morbidity. Due to the different pathophysiology of LUT injury, we compared LUTD between patients who received concurrent chemoradiation (CCRT) and radical hysterectomy (RH). METHODS: Seventy cervical cancer survivors were evaluated with multichannel urodynamic studies. The CCRT group received a total dose of 54 Gy pelvic radiation with 2-3 high-dose-rate brachytherapy, concurrent with platinum-based chemotherapy. The RH group underwent type III RH without pre- or postoperative radiation. RESULTS: Overall, LUTD was insignificantly different between CCRT and RH (60 % and 68.6 %). Voiding dysfunction was significantly higher in RH, particularly high postvoid residual urine and void with abdominal straining. However, storage dysfunction, particularly low bladder compliance and increased bladder sensation, were significantly more prevalent in CCRT; urinary incontinence was not significantly different between groups. CONCLUSION: LUTD was prevalent in cervical cancer survivors. Different profiles of dysfunction were demonstrated. Voiding dysfunction was higher followng RH, but storage dysfunction was higher following CCRT.

Prevention of blood transfusion with intravenous iron in gynecologic cancer patients receiving platinum-based chemotherapy.

OBJECTIVES: To compare the efficacy of intravenous iron and oral iron for prevention of blood transfusions in gynecologic cancer patients receiving platinum-based chemotherapy. MATERIALS AND METHODS: Sixty-four non anemic gynecologic cancer patients receiving adjuvant platinum-based chemotherapy were stratified and randomized according to baseline hemoglobin levels and chemotherapy regimen. The study group received 200mg of intravenous iron sucrose immediately after each chemotherapy infusion. The control group received oral ferrous fumarate at a dose of 200mg three times a day. Complete blood count was monitored before each chemotherapy infusion. Blood transfusions were given if hemoglobin level was below 10mg/dl. RESULTS: There were 32 patients in each group. No significant differences in baseline hemoglobin levels and baseline characteristics were demonstrated between both groups. Nine patients (28.1%) in the study group and 18 patients (56.3%) in the control group required blood transfusion through 6 cycles of chemotherapy (p=0.02). Fewer median number of total packed red cell units were required in the study group compared to the control group (0 and 0.5 unit, respectively, p=0.04). Serious adverse events and hypersensitivity reactions were not reported. However, constipation was significantly higher in the control group (3.1% and 40.6%, p=<0.001). CONCLUSIONS: Intravenous iron is an effective, well-tolerated treatment for primary prevention of blood transfusions in gynecologic cancer patients receiving platinum-based chemotherapy, associated with less constipation than the oral formulation.

Rectal balloon training as an adjunctive method for pelvic floor muscle training in conservative management of stress urinary incontinence: a pilot study.

BACKGROUND: Pelvic floor muscle training (PFMT) is currently considered as the first line conservative management for women with stress urinary incontinence (SUI). However, it is difficult for some women to self-identify the contraction of the pelvic floor muscle after they were trained by verbal instruction. Various techniques including rectal balloon probe have been developed to improve PFMT. OBJECTIVE: To compare vaginal squeezing pressure, one-hour pad test, leakage episodes, rating scores about severity of SUI, and patient satisfaction between traditional PFMT and rectal balloon training (RBT). MATERIAL AND METHOD: Twenty-eight patients with SUI were randomized into two groups, PFMT, and RBT groups. The PFMT group was verbally instructed to perform exercise as the traditional technique. In the RBT group, a Foley catheter filled with tap water to create balloon was inserted into the rectum in combination with the same exercise as in the PFMT group. The vaginal squeezing pressure before and after 6-week exercise program was measured by biofeedback machine model MYO420. RESULTS: One patient in each group was lost to follow-up. This left 13 patients in each group. Both groups had statistically significant gained in vaginal squeezing pressure after exercise. The different pressure between pre and post exercise were 9.9 mmHg and 9.2 mmHg in PFMT and RBT group respectively (p = 0.84). Significant improvement of leakage episodes and self-rating scores assessed the severity of SUI after exercise was reported in both groups, although there was no significant difference between both groups. The number of patients wearing protection after exercise was lowered in both groups, which were 75% in PFMT group and 80% in RBT group. However satisfaction was greater after completing exercise in both groups. CONCLUSION: PFMT is an effective conservative treatment of SUI. PFMT combined with rectal balloon training did not provide greater strength of the pelvic floor muscle than isometric contraction.