Successful multidisciplinary team management of placenta accreta spectrum disorder: A referral center model in a middle-income country.

OBJECTIVE: The aim of the study was to evaluate the outcomes of placenta accreta spectrum (PAS) disorder managed by a multidisciplinary care team (MCT) compared with a conventional care team (CCT) in a PAS referral center in Thailand. METHODS: This retrospective single-center cohort study analyzed PAS management outcomes in the PSU PAS Center between January 2010 and December 2022. The incidence of hemorrhage ≥3500 mL and the composite maternal and neonatal outcomes of PAS were compared before and after the introduction of an MCT in 2016. RESULTS: Of 227 PAS cases, 219 (96.5%) had pathological confirmation. There were 52 (22.9%) cases of placenta accreta, 119 (52.4%) cases of placenta increta, and 56 (24.7%) cases of placenta percreta. The incidence of estimated blood loss (EBL) ≥3500 mL decreased from 61.8% to 34.3% (P < 0.001) after the establishment of the MCT. The median EBL decreased from 4000 (IQR: 2600,7250) mL to 2250 (1300, 4750) mL (P < 0.001). EBL reduction was statistically significant in the accreta and increta groups (P < 0.001). Red blood cell transfusions decreased from five (3, 9) to two (1, 6) units (P < 0.001) per patient. The length of maternal hospital stays and ICU admissions were statistically shorter when PAS was managed by an MCT (P < 0.001). The length of newborn hospital and ICU stays decreased significantly (P < 0.001). CONCLUSION: The incidence of massive postpartum hemorrhage and a composite of maternal and neonatal morbidities in pregnant women with PAS disorder improved significantly after the establishment of an MCT to manage PAS in a middle-income country setting.

Effect of time interval between surgery and the initiation of adjuvant therapy on the oncologic outcomes of early-stage endometrial cancer.

OBJECTIVE: To identify the impact of time interval between surgery and initial adjuvant radiotherapy on oncologic outcomes in early-stage endometrial cancer. METHODS: This retrospective cohort study included patients with stage I/II endometrial cancer who underwent surgical staging and adjuvant therapy at Songklanagarind Hospital from January 1, 2007, to December 31, 2017. Patients were categorized into two groups: TI <6 weeks and TI ≥6 weeks. The effects of TI and clinicopathological factors on recurrence-free survival (RFS) and overall survival (OS) were analyzed using Cox proportional-hazards regression. RESULTS: In total, 177 patients were enrolled, with 52% receiving adjuvant radiotherapy at <6 weeks (overall median TI 5.7 weeks). The recurrence and death rates were 13% and 10.2%, respectively. The median follow-up time was 46.6 months. The overall 3-year RFS and OS rates were 88.2% and 85.2%, respectively. The TI significantly affected the 3-year RFS (94.4% vs 81.2%; P = 0.008) and 3-year OS (95.5% vs 83.2%; P = 0.012) in patients with TI <6 and ≥6 weeks, respectively. In multivariate analysis, the depth of myometrial invasion (MI), presence of lymphovascular space invasion, and TI were independent prognostic factors for both RFS and OS. Delaying the TI (≥6 weeks) was significantly associated with a worse RFS (hazard ratio [HR] 3.70; 95% confidence interval [CI]: 1.34-10.22; P = 0.012) and an inferior OS (HR 3.80; 95% CI: 1.23-11.69; P = 0.02). CONCLUSION: A delay in the TI between surgery and the initiation of adjuvant radiotherapy of ≥6 weeks negatively affected the oncologic outcomes in early-stage endometrial cancer.

Comparative outcomes between transvaginal endoscopic hysterectomy and total laparoscopic hysterectomy in patients with benign uterine disease: A single-center, retrospective, cohort, interrupted time-series study.

OBJECTIVES: To compare the surgical outcomes of total laparoscopic hysterectomy (TLH) and transvaginal endoscopic hysterectomy (TVEH) for benign uterine diseases. METHODS: This retrospective, cohort, interrupted time-series study included patients who underwent TLH between January 2013 and September 2016 and TVEH between October 2016 and June 2020. Median difference regression was used to compare the hospital length of stay (LOS) and operative time between the groups. Risk difference regression was used to analyze the proportion of patients who developed postoperative fever or vaginal stump infection. RESULTS: Of the total 171 patients enrolled, 101 and 70 underwent TVEH and TLH, respectively. The mean ages of patients in the TVEH and TLH groups were 46.49 and 46.17 years, respectively. No conversion was observed. Ureteric injury occurred in one patient in the TVEH group, whereas there was no organ injury in any of the patients in the TLH group. Compared with those in the TLH group, patients in the TVEH group had a significantly shorter median operative time, shorter hospital LOS, lower morphine use, and lower postoperative febrile morbidity rates. However, no significant difference was observed in the rate of vaginal stump infection between the groups. CONCLUSION: Given the shorter operative time, shorter hospital LOS, less febrile morbidity, and lower morphine use in patients with TVEH than in those with TLH, TVEH should be considered as an alternative hysterectomy procedure for benign uterine diseases.

A personalized nomogram for predicting 3-year overall survival of patients with uterine carcinosarcoma in a tertiary care hospital in Southern Thailand.

OBJECTIVE: To develop a nomogram for predicting 3-year overall survival (OS) and outcomes of surgically staged patients with uterine carcinosarcomas (UCS). METHODS: This retrospective study analyzed the clinicopathological characteristics, treatment data, and oncological outcomes of 69 patients diagnosed with UCS between January 2002 and September 2018. Significant prognostic factors for OS were identified and integrated to develop a nomogram. Concordance probability (CP) was used as a precision measure. The model was internally validated using bootstrapping samples to correct overfitting. RESULTS: The median follow-up time was 19.4 months (range, 0.77-106.13 months). The 3-year OS was 41.8% (95% confidence interval [CI], 29.9-58.3%). The International Federation of Gynecology and Obstetrics (FIGO) stage and adjuvant chemotherapy were independent factors for OS. The CP of the nomogram integrating with body mass index (BMI), FIGO stage, and adjuvant chemotherapy was 0.72 (95% CI, 0.70-0.75). In addition, the calibration curves for the probability of 3-year OS demonstrated good agreement between the nomogram-predicted and observed data. CONCLUSION: The established nomogram using BMI, FIGO stage, and adjuvant chemotherapy accurately predicted the 3-year OS of patients with UCS. The nomogram was useful for patient counselling and deciding on follow-up strategies.

Secondary Erythrocytosis Associated with Uterine Myoma Is Rare but Should Be of Concern.

Myomatous erythrocytosis syndrome (MES) is a rare gynecological condition, defined by the presence of the clinical triad of erythrocytosis, uterine fibroids, and normalization of red blood cell counts after the surgical removal of uterine fibroids. Herein, we report the case of a woman, in the postmenopausal stage, with the clinical triad of MES. She had a history of erythrocytosis of unknown etiology and underwent phlebotomy for a year prior to visiting our hospital. Pre-operative hemoglobin (Hb) level, hematocrit (Hct) level, and red blood cell (RBC) count were 18.1 g/dL, 56.1%, and 6.52 million cells/µL, respectively. She underwent exploratory laparotomy, transabdominal hysterectomy, and bilateral salpingo-oophorectomy. The operative findings revealed a large uterine myoma, and the pathology result was compatible with uterine leiomyoma. All hematologic parameters returned to the normal range on post-operative day 1. Her hematologic parameters returned to normal values 4 weeks after surgery with a Hb level of 13.5 g/dL, Hct level of 41.2%, and RBC count of 4.92 million cells/µL. The exact pathophysiology of this condition remains unknown. However, surgical removal of uterine myoma is the mainstay of treatment. Despite the rarity of this condition, its diagnosis should be considered in patients presenting with erythrocytosis and uterine masses.

Impact of appendectomy of a grossly normal appendix on the survival outcomes of mucinous ovarian carcinomas in a tertiary hospital.

OBJECTIVE: To evaluate the survival outcomes of appendectomy for a grossly normal appendix in patients with mucinous ovarian carcinomas. METHODS: Retrospective cohort study. Patients with mucinous ovarian carcinomas with grossly normal appendices who underwent primary surgery between 2002 and 2022 were enrolled. The overall survival (OS) and progression-free survival (PFS) of appendectomy and non-appendectomy groups were analyzed using the Kaplan-Meier method and compared using the log-rank test. Univariate and multivariate Cox regression analyses were used to determine the independent factors associated with OS and PFS. RESULTS: Of 192 patients, appendectomy was performed in 138 (71.9%). Three (1.6%) patients had primary appendiceal tumors and two (1.0%) had appendiceal metastases of ovarian origin. The median follow-up time was 68.8 months. The OS and PFS were better in patients in the appendectomy group than in those in the non-appendectomy group (5-year OS: 80.72% vs. 65.05%, P = 0.012; 5-year PFS: 76.32% vs. 58.60%, P = 0.020). Independent factors associated with poor OS and PFS were no omentectomy, peritoneal seeding, and advanced International Federation of Gynecology and Obstetrics (FIGO) stage. CONCLUSION: Appendectomy of a grossly normal appendix was not an independent prognostic factor for OS and PFS in patients with mucinous ovarian carcinomas.

Intraoperative blood volume loss according to gestational age at delivery among pregnant women with placenta accreta spectrum (PAS): an 11-year experience in Songklanagarind Hospital.

A retrospective study was conducted to evaluate the intraoperative blood volume loss in pregnant women with PAS according to gestational age at delivery. A total of 116 women were enrolled, 39 (33.6%) had an intraoperative massive blood loss (>5000 ml). The massive haemorrhage group had statistically significantly higher percentages of increta and percreta type than the non-massive haemorrhage group (94.9 vs. 67.5%, p < .001). Multiple linear regression analysis showed a decreasing trend of intraoperative blood loss after 34 weeks' gestation with the nadir period between 35 and 36+6 weeks' gestation, especially from 36-36+6 weeks' gestation which was statistically significant, p <.05. The perinatal morbidities from 36-36+6 weeks were not statistically significantly different from 37 weeks' gestation. Therefore, we recommend that pregnant women with PAS and stable clinical symptoms should be scheduled for caesarean hysterectomy from 36-36+6 weeks' gestation.Impact statementWhat is already known on this subject? Massive obstetric haemorrhage from PAS disorders is the main concern for caesarean hysterectomy among these patients as it leads to secondary complications including coagulopathy, multisystem organ failure, and death.What do the results of this study add? The amount of intraoperative blood loss in pregnant women who underwent caesarean hysterectomy due to PAS, was lowest from 36-36+6 weeks' gestation.What are the implications of these findings for clinical practice and/or further research? We recommend that pregnant women with PAS and stable clinical symptoms should be scheduled for caesarean hysterectomy from 36-36+6 weeks' gestation.

Fear of cancer recurrence and its predictors among cervical cancer survivors.

OBJECTIVE: To identify the characteristics of fear of cancer recurrence (FCR) in cervical cancer survivors (CCSs) and investigate the relationship of FCR with demographic and medical characteristics, level of quality of life (QOL), and psychological distress. We also aimed to determine the predictors of FCR. METHODS: The short version of the Fear of Progression Questionnaire (FoP-Q-SF), the Hospital Anxiety and Depression Scale (HADS), and the Functional Assessment of Cancer Therapy-Cervical (FACT-Cx) questionnaire were administered to 699 CCSs who had complete treatment at Songklanagarind Hospital between 2006 and 2016. Analysis was performed to determine potential predictors associated with FCR. RESULTS: Among the 12 items of the FoP-Q-SF, the 3 greatest fears were 1) worrying about what would happen to their family; 2) being afraid of pain; and 3) fear of disease progression. The prevalences of anxiety and depression disorder were 20.46% and 9.44%, respectively. CCSs who had FCR at the 5th quintile were more likely to have medical co-morbidities, low FACT-Cx scores in all domains and a high HADS scores (anxiety and depression disorder). Multivariate analysis showed that only anxiety disorder (odds ratio [OR]=4.99; p<0.001) and low FACT-Cx score (total) (OR=6.14; p<0.001) were identified as independent predictors for FCR at the 5th quintile. CONCLUSION: FCR is an important problem in cervical cancer which should be addressed during post-treatment care. Only anxiety disorder and low QOL were independently associated with high FCR.

Impact of time interval between radical hysterectomy with pelvic node dissection and initial adjuvant therapy on oncological outcomes of early stage cervical cancer.

OBJECTIVE: To determine the impact of time interval (TI) from radical hysterectomy with pelvic node dissection (RHND) to adjuvant therapy on oncological outcomes in cervical cancer. METHODS: The study included 110 stage IA2-IB1 cervical cancer patients who underwent RHND and adjuvant therapy. The patients were divided into 2 groups based on the cut-off points of TI of 4 and 6 weeks, respectively. The associations of TI and clinicopathologic factors with oncological outcomes were evaluated using Cox proportional-hazards regression. RESULTS: The median TI was 4.5 weeks. There were no statistical differences in 5-year recurrence-free survival (RFS) (89.2% vs. 81.0%, and 83.2% vs. 100.0%) or 5-year overall survival (OS) rates (90.9% vs. 97.2%, and 93.2% vs. 100.0%) between patients according to TI (≤4 vs. >4, and ≤6 vs. >6 weeks, respectively). Deep stromal invasion (p=0.037), and parametrial involvement (PI) (p=0.002) were identified as independent prognostic factors for RFS, together with the interaction between TI and squamous cell carcinoma histology (p<0.001). In patients with squamous cell carcinoma, a TI longer than 4 weeks was significantly associated with a worse RFS (hazard ratio [HR]=15.8; 95% confidence interval [CI]=1.4-173.9; p=0.024). Univariate analysis showed that only tumor size (p=0.023), and PI (p=0.003) were significantly associated with OS. CONCLUSION: Delay in administering adjuvant therapy more than 4 weeks after RHND in early stage squamous cell cervical cancer results in poorer RFS.

Late Recurrence of Early Stage Cervical Cancer more than 3 Years after Radical Hysterectomy with Pelvic Node Dissection.

BACKGROUND: The aim of this study was to compare the clinicopathological characteristics and outcomes of patients who developed late recurrence (> 3 years) of early stage cervical cancer after radical surgery with those of patients who developed early recurrence (≤ 3 years). We also investigated the risk factors of late recurrence. METHODS: The records of 515 patients with early stage cervical cancer diagnosed between 1999 and 2015 were reviewed. 53 patients developed recurrence, 35 early and 18 late, and their clinicopathological characteristics and outcomes were compared. Of the 515 patients, the records for 307 patients who remained tumor free for at least 3 years after radical surgery were further examined. RESULTS: No significant differences were found in clinicopathological characteristics and clinical outcomes between the early and late recurrence groups with regard to age, stage, histology, tumor size, lymphovascular space invasion, stromal invasion, parametrial involvement, node status, vaginal margin, preoperative blood testing, adjuvant therapy, symptom status at recurrence, site of recurrence and survival after recurrence. Late recurrence was detected in 18 of the 307 patients (5.9%). Only node status and deep stromal invasion (DSI) were independently associated with late recurrence. CONCLUSION: Lymph node metastasis and DSI are risk factors for late recurrence. Careful long-term follow-up is needed, particularly in cases with lymph node metastasis and/or DSI.

The Effect of Metformin on Oncological Outcomes in Patients With Cervical Cancer With Type 2 Diabetes Mellitus.

OBJECTIVE: The aim of this study was to evaluate any association between metformin use and oncological outcomes of cervical cancer in patients with type 2 diabetes mellitus (DM). METHODS: We retrospectively identified 248 patients with cervical cancer with type 2 DM who received primary treatment between 2004 and 2015. The clinicopathological characteristics and oncological outcomes were collected and analyzed. The patients were then separated into metformin use (n = 118) or non-metformin use (n = 130) groups. RESULTS: With a median follow-up of 2.85 years, patients who were given metformin had lower recurrence rate than patients who did not receive metformin (P = 0.011). The 5-year disease-free survival (DFS) and overall survival (OS) were 81.55% and 93.27% in the metformin use group, and 65.06% and 86.82% for the non-metformin use group, respectively. In multivariate analysis, non-metformin use (hazard ratio [HR], 1.89; P = 0.037), baseline hypertension (HR, 2.52; P = 0.005), and stage (HR for stage II vs I, 3.48; HR for stage III vs I, 6.45; P = 0.01) were independent adverse prognostic factors for DFS, whereas the statistically significant independent prognostic factors for OS were age (HR for age >65 vs ≤50, 3.86; P = 0.044) and stage (HR for stage III-IVA vs I-II, 3.45; P = 0.007). CONCLUSIONS: Our findings demonstrate that metformin use is associated with improved DFS, but not in OS in patients with cervical cancer with type 2 DM. Further large-scale and long-term follow-up studies are warranted to confirm the antitumor effects of metformin.

Clinical Aspects and Prognostic Factors for Survival in Patients with Recurrent Cervical Cancer after Radical Hysterectomy.

BACKGROUND: The aim of this study was to investigate the clinical aspects and prognostic factors for survival in patients with recurrent cervical cancer after radical hysterectomy with node dissection (RHND) for stages IA2-IB1. PATIENTS AND METHODS: Clinicopathologic characteristics of the primary tumor, pattern of recurrence, method of detection, salvage treatment, and outcome were reviewed from the medical records of patients who underwent RHND between 1987 and 2015. Prognostic factors were identified using a Cox regression model. RESULTS: Of 702 patients enrolled in the study, 84 (11.9%) had recurrence. 58, 17, and 9 patients had locoregional, distant, and combined recurrence, respectively. No association between clinicopathologic features and recurrence patterns was observed. Most recurrence patients (63.1%) complained of symptoms prior to examination. The majority of asymptomatic recurrence patients (71.4%) were diagnosed by physical and/or pelvic examination. 5-year overall survival after recurrence (SAR) was 34.3%. On multivariate analysis, pattern of recurrence (p = 0.003), symptom status (p = 0.011), age (p = 0.035), and white blood cell (WBC) count (p = 0.017) were independent prognostic factors for overall SAR. CONCLUSION: Only pattern of recurrence, symptom status, age, and WBC count were found to be prognostic factors in recurrent cervical cancer after RHND. Follow-up programs after RHND should be directed toward early detection of recurrence.

Risk Factors for Parametrial Involvement in Early-Stage Cervical Cancer and Identification of Patients Suitable for Less Radical Surgery.

BACKGROUND: The aim of this study was to determine risk factors associated with parametrial involvement (PI) and to identify the subgroup of patients at low risk for PI. METHODS: The study comprised 565 patients with early-stage cervical cancer, who underwent radical hysterectomy with pelvic node dissection at Songklanagarind Hospital between 1987 and 2011. Analysis was performed to determine factors associated with PI. RESULTS: Overall, 24 (4.25%) women had PI. PI was more common in patients with non-squamous cell carcinoma, deep stromal invasion (DSI), tumor size > 2 cm, lymphovascular space invasion (LVSI), and pelvic node involvement. Multivariate analysis showed that DSI (p < 0.001) and tumor size > 2 cm (p < 0.001) were independently associated with PI. PI was linked with decreased recurrence-free (p < 0.001) and overall (p = 0.002) survival. Of 347 patients with tumor size ≤ 2 cm and no DSI, only 1 (0.29%) had PI. CONCLUSION: These findings confirm that PI in early-stage cervical cancer is uncommon. Risk factors associated with PI were DSI and tumor size > 2 cm. PI is a predictor of cervical cancer recurrence and decreased survival. Less radical surgery may be considered in low-risk patients.

Impact of diabetes mellitus on oncological outcomes after radical hysterectomy for early stage cervical cancer.

OBJECTIVE: To evaluate the relationship between type 2 diabetes mellitus (DM) and oncological outcomes in early stage cervical cancer patients who underwent radical surgical resection. METHODS: Patients with early stage cervical cancer diagnosed between 2001 and 2014 were retrospectively enrolled. We assessed the outcomes of 402 non-DM and 42 DM patients with cervical cancer. We tested the prognostic value of DM via Cox proportional hazard modeling. RESULTS: Patients with DM were more likely to be older and overweight. In the DM group, 20 and 22 patients were and were not taking metformin, respectively. The 5-year recurrence-free survival (RFS) and 5-year overall survival (OS) rate for the whole study population were 88.49% and 96.34%, respectively. In the DM group, there was no evidence that metformin affected the RFS (p=0.553) or the OS (p=0.429). In multivariate analysis, age (p=0.007), histology (p=0.006), and deep stromal invasion (p=0.007) were independent adverse prognostic factors for RFS. There was a borderline significant association of increased RFS with DM (p=0.051). However, a time-varying-effect Cox model revealed that the DM was associated with a worse RFS (hazard ratio, 11.15; 95% CI, 2.00 to 62.08, p=0.022) after 5 years. DM (p=0.008), age (p=0.009), and node status (p=0.001) were the only 3 independent prognostic factors for OS. CONCLUSION: Early stage cervical cancer patients with type 2 DM have a poorer oncological outcome than patients without DM.

Prognostic value of ABO blood group in patients with early stage cervical cancer treated with radical hysterectomy with pelvic node dissection.

This study aimed to evaluate the prognostic value of ABO blood groups in early-stage cervical cancer patients. The cohort included 413 patients diagnosed with stages IA2-IB1 cervical cancer who received a radical hysterectomy between 2002 and 2014. The 5-year recurrence-free survival (RFS) and overall survival (OS) were 93.13 and 96.81 % for blood group O, 87.68 and 88.22 % for blood group A, 81.66 and 89.40 % for blood group B, and 83.12 and 94.12 % for blood group AB groups, respectively. Patients were stratified for analysis as either blood group O or non-O. The 5-year RFS and OS were 93.13 and 96.81 % for blood group O and 83.66 and 89.76 % for blood group non-O, respectively. In multivariate analysis, age (P = 0.025), histology (P = 0.020), and deep stromal invasion (P = 0.006) were independent adverse prognostic factors for RFS, while the statistically significant independent prognostic factors for OS were age (P = 0.007) and parametrial involvement (P < 0.001). The Cox model did not show any significant effects of non-O blood group on survival outcome. However, a time-varying-effect Cox model revealed that the non-O blood group was associated with a worse RFS (hazard ratio (HR) 2.69, 95 % confidence interval (95%CI) 1.12-6.46, P = 0.017) and OS (HR 3.13, 95%CI 0.88-11.16, P = 0.053) during the first 5 years. These findings suggest that early-stage cervical cancer patients with a non-O blood group have poorer RFS than the O blood group, which is evidence during the first 5 years.