Depot medroxyprogesterone acetate and epithelial ovarian cancer: a multicentre case-control study.

OBJECTIVE: To evaluate the effect of depot medroxyprogesterone acetate (DMPA) in protecting against epithelial ovarian cancer (EOC) and to evaluate factors associated with the risk of EOC. DESIGN: A multicentre, case-control study. SETTING: Twelve hospitals located across Thailand. POPULATION: Three hundred and thirty patients with EOC ('cases') and 982 matched controls were recruited from the 12 hospitals. Cases were newly diagnosed patients with EOC, demonstrated pathologically. Controls were age-matched patients admitted to different wards in the same hospital. METHODS: Cases and controls were interviewed by trained interviewers using a standardised pre-tested questionnaire. The factors associated with EOC were evaluated using univariate and multivariate analyses. MAIN OUTCOME MEASURES: The odds ratio (OR) and 95% confidence interval (95% CI) were calculated to assess the relationship between DMPA and EOC. RESULTS: The use of DMPA was found to be associated with a 39% reduction in the risk of EOC with an OR of 0.61 and a 95% CI of 0.44-0.85 (P = 0.002). A significant risk reduction (83%) was observed when the duration of DMPA use was >3 years (OR 0.17; 95% CI 0.07-0.39; P < 0.001). Other factors associated with a reduced risk of EOC were the use of combined oral contraceptive pills and breastfeeding. A factor associated with an increased risk of EOC was a family history of gynaecological cancer. CONCLUSIONS: The results suggest that DMPA may have a protective effect against EOC. If this effect is real, then it represents an important non-contraceptive benefit of DMPA.

Phase II study of high-dose megestrol acetate in platinum-refractory epithelial ovarian cancer.

Our objective was to determine the efficacy of megestrol acetate in the treatment of platinum-refractory epithelial ovarian cancer (EOC), and to evaluate the toxicities and quality of life (QOL) associated with this therapy. Patients with platinum-resistant epithelial ovarian cancer were treated with megestrol acetate (800 mg/day) orally for 28 days and then 400 mg/day for a minimum of 28 days before being assessed ready for evaluation of response to therapy. Patients who demonstrated a complete response (CR), partial response (PR) or stable disease were continued in the study until there was objective evidence of disease progression. All patients who went off study were followed up at regular intervals, every 2 months, to assess overall survival. Thirty-six patients were enrolled. Response was observed in seven of 36 patients (three CR and four PR). The response rate was 19.4% (95% CI 9-36). Four of the responders had the endometrioid cell type, while two were clear cell carcinoma and one was serouscystadenocarcinoma. All three CR patients had the histology of endometrioid carcinoma with the tumors located in the pelvis. Median survival of the study population was 5.8 months. Median survival in the responders was 12 months, while median survival in the non-responders was 5.5 months. Median progression-free survival in the responders was 8.3 months, while median progression-free survival in the non-responders was only 2 months. The majority of patients gained weight and had a fair quality of life score during treatment. The only toxicity observed was alopecia (grade 1) in four patients. We conclude that megestrol acetate has modest but definite activity in patients with platinum-refractory EOC, particularly in a small subset of the endometrioid subtype with limited disease in the pelvis. Only minimal toxicity was observed and the patients had a fair QOL score during the treatment.

Reproductive outcome following hysteroscopic treatment of the septate uterus: a result of 28 cases at Ramathibodi Hospital.

We reported the reproductive outcome of 28 patients with septate uterus who underwent hysteroscopic metroplasty between August 1994 and October 1999 at Ramathibodi Hospital. The majority of septa were partial. Most of the patients had recurrent pregnancy losses. Division of the septum was performed with scissors in 7, a new device of Versapoint bipolar electrode in 10, and by means of resectoscope in 11 patients. The operating time varied from 45 to 70 minutes with an average time of 50+/-5.5 minutes which included the time for laparoscopy. The blood loss during the operation was minimal. All 28 patients were discharged a few hours after the operation. There were no serious complications attributed to this study. Most of the patients had minor spotting but no significant bleeding for a few days after hysteroscopic surgery. Of the 28 patients, 4 patients have not tried to conceive because of personal reasons, and the other 5 patients were lost to follow-up. Fifteen patients who had postoperative hysterosalpingograms, demonstrated a normal uterine cavity. There were a total of 20 pregnancies after a mean period of 24+/-1.4 (range 6-42) months following hysteroscopic treatment, of which 15(75.0%) were carried to term, 3(15.0%) were spontaneous abortions, and 2(10.0%) are in progress. The rate of pregnancy wastage in the post-treatment group was 15 per cent compared with 96.3 per cent in the pretreatment group.

Advanced epithelial ovarian carcinoma in Thai women: should we continue to offer second-look laparotomy?

OBJECTIVE: To determine survival among patients with epithelial ovarian carcinoma (EOC) who underwent a second-look laparotomy (SLL) and those refusing the procedure. Also to analyze factor(s) influencing the survival of the patients. METHOD AND MATERIAL: Medical records were reviewed of patients with advanced EOC who were clinically free of disease after primary surgery and platinum-based chemotherapy between January 1, 1992, and December 31, 1998. All of them were offered SLL. Measurement outcomes include patient survival and disease-free survival. RESULTS: There were 50 patients with clinically complete remission after chemotherapy. Sixteen patients underwent SLL, and thirty-four patients refused the procedure (NSLL). Seven patients (43.8%) were reported to have positive SLL. After the median follow-up time of 35 months, 12 patients had died, and 5 patients were lost to follow-up. The median survival time for patients with SLL was about 60 months. Five-year survival rates of patients in the SLL, and NSLL groups were 37 per cent (95%CI = 7%-69%), and 88 per cent (95%CI = 65%-96%) respectively (P<0.001). The median time to relapse was about 25 months for patients with negative SLL. Five-year disease-free survival rates of patients in the negative SLL, and NSLL groups were 28 per cent (95%CI = 4%-59%), and 54 per cent (95%CI = 34%-70%) respectively (P=0.251). By Cox regression analysis, tumor grade was the only significant prognostic factor influencing patients' survival (HR = 6, 95%CI of HR = 1.2-34.2). CONCLUSION: The second-look laparotomy doesn't have a favorable impact on overall and disease-free survival. Tumor grade is the only independent prognostic variable for survival of the patients.

Sonohysterography in the diagnosis of abnormal uterine bleeding.

OBJECTIVE: The purpose of this study was to evaluate the value of sonohysterography in diagnosis of patients with abnormal uterine bleeding. METHOD: Fifty-five patients with abnormal uterine bleeding and transvaginal sonography suggested an abnormal endometrial echo were enrolled in the study. Sonohysterography was performed on all patients, using saline instilled through an endocervically placed catheter. The histologic or pathologic finding was evaluated after surgical procedures and compared with sonohysterography results. RESULTS: Sonohysterography was successfully completed in 52 cases (94.54%). Three cases had cervical stenosis and failed to pass the catheter into the uterine cavity. Mean age was 41.56 +/- 7.82 years (range 29-58 years). Forty-six of 52 sonohysterography demonstrated intrauterine abnormalities (29 endometrial polyps, 15 submucous myomas, 2 endometrial hyperplasia). The pathologic finding demonstrated 46 intrauterine pathologic cases (28 endometrial polyps, 15 submucous myomas, 3 endometrial hyperplasia). Sonohysterography had 97.82% sensitivity, 83.33% specificity, 97.82% positive predictive value, 83.33% negative predictive value, and 96.15% accuracy. CONCLUSION: Sonohysterography is a highly sensitive, specific, and accurate screening procedure for the evaluation of uterine cavity in abnormal uterine bleeding and is a simple, minimally invasive, and effective tool to use in the evaluation of patients.

Reproductive outcome following hysteroscopic lysis of intrauterine adhesions: a result of 65 cases at Ramathibodi Hospital.

We reported the reproductive outcome of 65 patients with varying degrees of IUAs who underwent hysteroscopic adhesiolysis between August 1994 and December 1996 at Ramathibodi Hospital. Of the 65 patients treated, 29 had mild adhesions, 26 had moderate adhesions, and 10 had severe adhesions. Adhesions were lysed with hysteroscopic scissors in 25, with biopsy forceps through hysteroscope in 10, with electrosurgery using a monopolar probe in 22 patients, and with resectoscope in 8 patients. The mean duration of the procedure was 15 +/- 2.1 minutes. The mean follow-up was 12 +/- 1.4 months. Of the 44 patients who originally presented with secondary amenorrhea, 40 (90.9%) have normal menses, 4 (9.1%) have hypomenorrhea. Of the 6 patients who had hypomenorrhea, 5 (83.3%) have normal menses. Cyclic abdominal pain disappeared after treatment in all patients. Of the 45 patients with IUAs and infertility, 16 (35.6%) conceived. Two (20%) of the infertile patients with initially severe adhesions conceived. Of the 5 patients with RPL treated, delivered a full term baby and the other delivered a premature baby at 29 weeks of gestation. All 18 patients who delivered, had live births. Adhesion reformation was absent in patients with initially mild and moderate adhesion but occurred in 2 out of 10 (20%) patients with severe adhesions. These two patients initially suffered from secondary amenorrhea but reported hypomenorrhea after surgery. Both of them had tuberculosis of the genital tract. There were no serious complications occurring in all 65 procedures. All 65 patients were discharged a few hours after the operation.

Phase II study of high-dose paclitaxel in platinum-refractory epithelial ovarian cancer.

The purposes of this study were to determine the efficacy of paclitaxel, using a dose of 200 mg/m2 intravenous continuous infusion over 24 hours every three weeks in the treatement of platinum-refractory epithelial ovarian cancer (EOC) and to evaluate the toxicities. Eligibility criteria included: histologically proven EOC, platinum resistance, measurable disease, Zubrod performance status grade 0-2, expected survival of > 3 months and adequate hematological function. Response was assessed at three-cycle intervals or earlier if required. Twenty-one patients were recruited in this study. The response rate was 52% (2 CR, 9 PR) with a median duration of response of six months. The median progression-free interval was eight months and the median survival was 12 months. Leukopenia was the predominant toxic effect. Eighty-six percent of patients required granulocyte-colony stimulation factor (G-CSF). All patients had alopecia grade 3. In conclusion, high-dose paclitaxel is active in platinum-refractory EOC with manageable toxicities.

The efficacy of chemically-stabilized chlorite-matrix (TCDO) in the management of late postradiation cystitis.

Carcinoma of the uterine cervix is the most common cancer of women in Thailand. The most frequent complication after pelvic radiation for uterine cancer is radiation cystitis. The management of severe late postradiation cystis is far from satisfactory. The objective of this study was to evaluate the efficacy of chemically-stabilized chlorite-matrix (TCDO) in patients with severe radiation cystitis. This study was conducted at the Department of Obstetrics and Gynecology, Ramathibodi Hospital and the Department of Radiology, Siriraj Hospital between September 1997 and September 1998. Twenty patients with grade 3 radiation cystitis after radiotherapy were enrolled into this study. TCDO was administered at a dose of 0.5 ml/kg body weight per day on 5 consecutive days as intravenous infusion over 4 hours. The response rate after the first cycle was 80 per cent with 30 per cent of the patients showing complete response. The follow-up time (13 patients) ranging from 1-9 months revealed no recurrent bleeding. There were no side effects from TCDO therapy. The result suggests good efficacy of TCDO in the treatment of postradiation cystitis.

Recent management of malignant ovarian germ cell tumors: a study of 34 cases.

OBJECTIVE: To review the outcome of the treatment in patients with malignant ovarian Germ cell tumors with respect to survival and surgical management at a single institution during 1990-1996. METHODS: Thirty-four patients with malignant ovarian Germ cell tumors were studied retrospectively for their surgical management. Fourteen patients had pure dysgerminoma, 11 endodermal sinus tumor, 6 immature teratoma, and 3 mixed Germ cell tumors. Nine patients had stage IA, 8 stage IC, 2 stage IIC, 8 stage III, 3 stage IV, and 4 referred patients with recurrent diseases. RESULTS: Nineteen patients underwent primary conservative surgery, 11 had primary nonconservative surgery. Twenty-two patients were treated with chemotherapy (BEP or EP or PVB regimen). Five patients with pure dysgerminoma received adjuvant radiotherapy. Persistent remission was achieved in 26 patients. Two patients (7.4%) had recurrence after remission. Seven patients had died of the diseases. Patients with complete clinical remission did not undergo second-look surgery. The overall survival was 78.8%, 100% for immature teratoma, 84.6% for pure dysgerminoma, 72.8% for endodermal sinus tumor, and 33.3% for mixed Germ cell tumors, with median follow-up time 31 (3-93) months. CONCLUSION: Patients with limited diseases regardless of histologic types can be safely managed by unilateral salpingo-oophorectomy followed by, if indicated, 3-4 courses of cisplatin-based chemotherapy. For advanced diseases, conservative surgery is advisable in patients with endodermal sinus tumor.

Malignant ascites in female patients: a seven-year review.

Malignant ascites is common in various types of advanced cancer. Our objective was to determine the primary site and the clinical characteristics of female patients presenting with malignant ascites as well as evaluating the outcome. The authors carried out a retrospective study of 118 cases of malignant ascites diagnosed from January 1986 to December 1992 in female patients. Of the 118 cases, the primary site of the neoplasms was gynecologic in 65 cases (cervix 4, endometrium 6, ovary 52, fallopian tube 3) = 55.1 per cent, non-gynecologic 29 cases (GI 18, lymphoma 8, breast 2, kidney 1) = 24.6 per cent, and unknown 24 cases = 20.3 per cent. The mean age of patients in the gynecologic, non-gynecologic and unknown primary site was 50.4, 45.5 and 59.3 years respectively. Surgery combined with chemotherapy was the main treatment in the gynecologic group, whereas, supportive and symptomatic management was the main treatment in the unknown primary group. Treatments in non-gynecologic group were supportive and symptomatic, surgery and chemotherapy. Survival was longer in gynecologic than in the nongynecologic and the unknown primary groups. The most common primary site of malignant ascites in females was ovarian cancer. In malignant ascites in females caused by gynecologic neoplasms, the prognosis as measured by survival was better than in the non-gynecologic and the unknown primary groups.

An HIV-infected woman with choriocarcinoma presenting with a nasal mass.

Gestational choriocarcinoma metastasized to the nasal mucosa is extremely rare. An HIV-infected woman with choriocarcinoma presenting with a nasal mass is reported. The clinical findings are compared with a previous reported case. She responded to multiagent chemotherapy and has obtained complete remission. The role of HIV infection is also discussed.

Epithelial ovarian cancer treated by platinum or platinum analogue with cyclophosphamide: experience in Ramathibodi Hospital.

This study presented the outcome of 92 EOC patients treated by platinum or platinum analogue with cyclophosphamide from January 1, 1993 to December 31, 1995. There were 77 evaluable patients. The follow-up ranged from 4-42 months (median 14 months). The over all 3-year survival was 64 per cent and the median progression-free interval was 16 months for the whole group. There was no significant difference in survival between patients who received cisplatin and those who received carboplatin (P = 0.093). Patients who underwent optimal debulking surgery had significantly longer progression-free interval (P = 0.001) than those who had sub-optimal surgery. Fifty four per cent of patients with clear cell carcinoma died of the disease. Patients who received cisplatin had a drop out rate while on therapy more often (24% vs 5.3%) than that of carboplatin. Toxicities from chemotherapy were moderate but manageable.

Diagnostic hysteroscopy: a result of 125 patients at Ramathibodi Hospital.

This report summarizes the diagnostic hysteroscopic experience with 125 selected patients. The procedures were all performed under propofol anesthesia. The main indications for diagnostic hysteroscopy were infertility with suspected intrauterine lesions and abnormal uterine bleeding in premenopausal women. The procedures were successful in 123 (98.4%) patients. Cervical dilatation was required in 35 (28%) patients. Of the 125 diagnostic examinations, 91 (72.80%) had intrauterine abnormalities. This result showed that an important factor that appears to influence the prevalence of pathology are the gynecological problems and/or symptoms of the patients. The commonest finding in patients with infertility was intrauterine adhesions, whereas, endometrial polyps was the most common finding found in premenopausal women with abnormal uterine bleeding. There was no complication attributable to this procedure. Our experience suggests that the efficacy and safety of this procedure depend on proper selection of patients, type of anesthesia, the medium for uterine distention, and most importantly the experience of the operator.

A randomized study comparing suture with non-suture cold-knife conization.

OBJECTIVE: To compare the short-term outcome of cold-knife conization between suture and non-suture (with Monsel's solution pack) methods. METHODS: Between February, 1990 and March, 1992, 142 patients underwent cold-knife conization were randomly allocated into 2 groups. The hemostasis was done by suture in one group and by Monsel's solution pack without suture in the other group. The patients' and cone specimens' characteristics as well as short-term outcome were recorded and compared using Chi-square test, Fisher exact test and t-test where appropriate. RESULTS: The patients' characteristics, cone size, and histologic diagnosis of both groups were comparable. The non-suture group had shorter operative time (10.69 +/- 7.86 vs. 20.04 +/- 6.99 minutes) and lesser late hemorrhage (2.9 vs. 15.9%) than the suture group (p < 0.05). There was no statistical difference in the operative blood loss. CONCLUSION: The non-suture method of conization should replace the traditional suture method.

Combined radiotherapy and hysterectomy in the treatment of high risk stage II invasive carcinoma of the uterine cervix.

This is a prospective non-randomized study of 127 patients with stage IIB carcinoma of the cervix treated with irradiation and followed by surgery at Ramathibodi Hospital between 1980 and 1989. The criteria for combined treatment were an enlarged cervical mass of over 5 cm, including a barrel-shaped cervix, inadequate or improper radium insertion due to obliterated cervical os, and endometrial extension. The 5-year survival rate was 84.37%. The incidence of pelvic failure was 10.2% and extrapelvic failure was 6.3%. Those revealing residual disease in hysterectomy specimens had a worse prognosis. The increase in the survival rate in this study as compared to other reports may have been due to the use of higher dosages of irradiation. It is concluded that combined treatment was effective in dealing with poor prognosis groups of carcinoma of the cervix. It improved the pelvic and extrapelvic control as well as the survival rate with acceptable complications.

Post-cesarean section urinary tract infection: a comparison between intermittent and indwelling catheterization.

Catheterization, which is widely accepted as an important factor to urinary tract infection, is routinely done during cesarean section. This randomized study was conducted to compare the incidence of urinary tract infection between patients who underwent cesarean section using intermittent catheterization and indwelling catheterization, at the Department of Obstetrics and Gynecology, Ramathibodi Hospital from August 1991 to December 1991. Sixteen of 51 patients (31.4%) of the intermittent group and 9 of 47 patients (19.1%) of the indwelling group developed urinary tract infection. The difference was not statistically significant. Of the patients in the intermittent group 39.2 per cent were found to have postoperative urinary retention requiring recatheterization, whereas all cases in the indwelling group could void after its removal. Klebsiella pneumoniae was the commonest isolated organism. Indwelling catheterization was concluded to be the favourable method.

Cytologic evaluation of smears obtained by self-collection vaginal tampon.

Papanicolaou (Pap) smear test is an established method of cervical cancer screening. However, most women in Thailand are still reluctant to undergo pelvic examination. A prospective study was carried out on the use of self inserted vaginal tampon to collect specimens for Pap test in 126 patients at Ramathibodi Hospital from September to October 1990. The tampons which were inserted overnight and removed by the patients themselves were smeared across a glass slide and immediately fixed in 95 per cent ethyl alcohol. Ninety-six point two per cent of the slides had adequate cells of good quality to be interpreted. The remaining 3.98 per cent could not be interpreted due to the lack of cells and poor cell fixation. It is concluded that the smears obtained by this method are satisfactory for cytologic evaluation.

Recurrence of cervical carcinoma following radical hysterectomy and pelvic node dissection.

The aim of this report is to review the clinical pattern of the recurrent cases. From May 1969 to December 1988, 200 patients with cervical carcinoma stage IB were treated with radical hysterectomy and pelvic node dissection at the Department of Obstetrics and Gynaecology, Ramathibodi Hospital, Mahidol University. One hundred and eighty-two patients were included in this study. Twenty-one patients (11.5%) developed recurrent cervical carcinoma. Most of the recurrence were diagnosed within 3 years after surgery. The most common recurrent site was pelvic sidewall. Patients' complaint and abnormal physical findings accounted for 81 percent of the first evidence. Treatment of recurrences was radiation in 15, chemotherapy in 3 and symptomatic treatment in the remaining three. Nine patients died of the recurrent tumor. The median time from recurrence to death was 24 months (range 12-65). The majority of the deaths occurred in the first three years after detection of recurrence. Radiation may be beneficial in treatment of recurrent tumor and in regional control of tumor after surgery.