Sonographic Features of Uterine Arteriovenous Malformation: A Case Series.

Uterine arteriovenous malformation (AVM) is very rare but potentially life-threatening. Early and accurate diagnosis is the cornerstone of its management. The objective of this study is to encourage sonographers to become familiar with a variety of grayscale sonographic features, facilitating rapid recognition of the patterns and prompting them to apply color flow Doppler for a diagnosis of uterine AVM and possible further investigations or interventions. We present six cases of uterine AVM presenting with abnormal uterine bleeding at varying degrees of severity, from abnormal menstruation to life-threatening bleeding following curettage. All initially provided some clues of uterine AVM upon grayscale ultrasound, leading to the application of color Doppler flow to support a diagnosis, with confirmation using abdominal computer tomography angiography (CTA) in most cases, resulting in definitive treatment using uterine artery embolization or other interventions. Most importantly, this study provides various sonographic features of uterine AVM, such as appearances of small tubular structures, spongy patterns, a conceptive-product-like appearance, and spaghetti-like patterns. Hopefully, familiarity with these sonographic features can facilitate practitioners to make an early diagnosis, leading to proper further investigation and intervention, and to prevent serious complications from potentially being caused by this subtle but very serious disorder.

Efficacy of Lidocaine Spray for Pain Reduction during Colposcopy-Directed Cervical Biopsies: A Randomized Controlled Trial.

Objectives: The objective of this study was to evaluate the efficacy of lidocaine spray in reducing the pain during colposcopy-directed cervical biopsy (CDB). Methods: From December 2017 to February 2019, 312 women undergoing CDBs were enrolled. The participants were randomized to three groups: group 1 (lidocaine spray), in which lidocaine spray was applied thoroughly to the cervix; group 2 (placebo), in which normal saline was applied thoroughly to the cervix; and group 3 (control), in which no anesthetic agent was applied to the cervix. Each woman completed a 10 cm visual analog scale to classify the subjective pain experience at three time points: baseline, immediately after biopsy, and 10 min after the procedure. The primary outcome of this study was the biopsy pain score. Results: The 312 enrolled women were randomly assigned to the three groups, amounting to 104 women per group. The clinical and pathological characteristics of the participants in all groups were comparable. The baseline, the biopsy, and the post-procedure pain scores were comparable among the three groups. There was a significant increase in the pain score from baseline to biopsy and from baseline to post-procedure in each group. The pain-score changes from baseline to biopsy in the lidocaine spray group significantly decreased when compared with the normal saline group (<0.001), and tended to decrease, though not significantly (p = 0.06), when compared with the control group. No complication with the intervention was observed. Conclusions: The application of lidocaine spray to the cervix has the benefit of reducing the pain associated with CDBs by a small amount. However, the intervention is safe and may be considered in nulliparous and/or overly anxious women undergoing the procedure.

Popcorn Appearance of Severely Calcified Uterine Leiomyoma: Image-Pathological Correlation.

Calcified subserous leiomyoma is a rare benign tumor commonly seen in the postmenopausal age group. Cases with severely calcified degeneration all over the mass are extremely rare. It causes diagnostic confusion with the solid calcified adnexal mass and the large bladder calculi in the pelvis. We hereby present a case of heavily calcified subserous uterine leiomyoma in a 66-year-old postmenopausal woman. An X-ray of the abdomen and pelvis and CT scan showed a pelvic mass with scattered popcorn appearance in the pelvis, representing severely calcified discrete spots all over the mass. Sonographically, different from typical uterine leiomyomas which exhibit recurrent refractory shadowing patterns, our case showed heavy homogeneous acoustic shadow obscuring all structures beneath the mass surface, resulting in a suboptimal ultrasound examination. Accordingly, CT scans, which are usually not a primary tool for the diagnosis of uterine leiomyomas, are helpful to characterize the mass and identify their organ of origin. The case presented here was treated with a hysterectomy with bilateral oophorectomy and was post-operatively confirmed for severely calcified subserous leiomyomas.

Comparisons of Effectiveness in Differentiating Benign from Malignant Ovarian Masses between Conventional and Modified Risk of Malignancy Index (RMI).

OBJECTIVE: To compare the predictive performance in differentiating benign from malignant ovarian masses between the modified risk malignancy index (RMI) and the conventional RMI (RMI-1 and RMI-2). METHODS: Women scheduled for elective surgery because of adnexal masses were recruited to undergo pelvic sonography within 24 h before surgery to assess the sonographic characteristics of the masses, focusing on loculi, solid part, ascites, bilateralness, papillary projection, and color flow mapping (CFM). Preoperative CA-125 levels were also measured. Modified RMI, RMI-1, and RMI-2 systems were used to predict malignant masses. The gold standard was pathological or intraoperative diagnosis. RESULTS: A total of 342 ovarian masses, benign: 243 (71.1%); malignant: 99 (28.9%), meeting the inclusion criteria were analyzed. The sensitivity and the specificity of the modified RMI (87.9% and 81.9%) were significantly higher than those of RMI-1 (74.7% and 84.4%), and RMI-2 (79.8% and 81.1%, respectively). Based on ROC curves, the area under the curves were 0.930, 0.881 and 0.882 for modified RMI, RMI-1 and RMI-2, respectively. CONCLUSION: Modified RMI had better predictive performance than the conventional RMI in differentiating between benign and malignant ovarian masses. Modified RMI may be useful to help general gynecologists or practitioners to triage patients with an adnexal mass, especially in settings of low resources.

An Unruptured True Aneurysm of the Uterine Artery during Pregnancy.

The antenatal diagnosis of an unruptured true aneurysm of the uterine artery is extremely rare and has never been reported, whereas pseudoaneurysms associated with previous trauma or cesarean section have been reported several times. True aneurysms occur when the artery or vessel weakens and bulges, sometimes forming a blood-filled sac. Nearly all cases of pelvic true aneurysms involved ovarian arteries which ruptured during the peripartum period. The case presented here is unique in terms of being an unruptured true aneurysm of the uterine artery with a first diagnosis during pregnancy at 32 weeks of gestation and the spontaneous development of thrombosis in the aneurysm in late pregnancy, documented at 37 weeks of gestation. The diagnosis of a true aneurysm of the uterine artery was based on, (1) a demonstration of the cystic mass located in proximity to the lower segment of the uterus with ultrasound characteristics of arterial flow in the mass, and (2) the occurrence in a woman who had no history of trauma or surgery in the pelvis. The finding during cesarean section confirmed the prenatal sonographic finding. The pregnancy ended with successful outcomes.

Efficacy of Listening to Music on Pain Reduction during Colposcopy-Directed Cervical Biopsy: A Randomized, Controlled Trial.

Background and Objective: To investigate the efficacy of listening to music on pain reduction during colposcopy-directed cervical biopsy (CDB). Materials and Methods: From June 2020 to November 2021, 240 women undergoing CDB were enrolled. The participants were randomized into three groups: Group 1, colposcopic examination while wearing headphones and listening to music; Group 2, colposcopy while wearing headphones but not listening to music; Group 3 (control group), colposcopy while neither listening to music nor wearing headphones. All participating women completed a 10 cm visual analog scale for subjective pain at three time points: baseline, immediately after cervical biopsy, and 15 min after the procedure. The primary endpoint was the biopsy pain score. Result: Of the 240 women, a sample size of 80 was randomly assigned per group. The clinical-pathological and procedure-related characteristics of the participants in all groups were similar. The mean baseline pain score between each group was not significantly different (2.83 in the music group, 2.54 in group 2, and 2.94 in the control group, p = 0.47). There were no significant differences between each group in terms of mean biopsy pain score (4.21 in the music group, 4.24 in group 2, and 4.30 in the control group, p = 0.98). The differences in changes between the baseline pain score and the biopsy pain score were not statistically significant (1.39 in the music group, 1.70 in group 2, and 1.36 in the control group, p = 0.69). In the multiple comparison analysis, the differences in changes between the biopsy pain score and the baseline pain score between each group were also not statistically significant. There were no complications with the intervention observed. Conclusion: This study demonstrated that there was no beneficial effect of listening to music on pain reduction during colposcopy-directed cervical biopsies.

Risk of High-Grade Cervical Lesions in Atypical Squamous Cells of Undetermined Significance (ASC-US) Cytology: Comparison between HIV-Infected and HIV-Negative Women.

BACKGROUND AND OBJECTIVE: Women with human immunodeficiency virus (HIV) infection have an increased risk of HPV infection, cervical neoplasia. This study was undertaken to compare the risk of having high-grade cervical lesions defined as cervical intraepithelial neoplasia grade 2 or worse (CIN2+) in HIV-infected versus HIV-uninfected women who had atypical squamous cells of undetermined significance (ASC-US) on cervical cytology. METHODS: Fifty-seven HIV-positive women aged 25-65 years with ASC-US cytology undergoing colposcopic examination between January 2008 and December 2020 at Chiang Mai University Hospital were reviewed. By matching 1:5 ratio, 285 HIV-negative women with ASC-US cytology in the same period were recruited as controlled subjects for comparison. The patient characteristics, HIV status, CD4 cell count within 6 months of colposcopy, antiretroviral therapy, parity, contraception, smoking history, number of sexual partners, and histopathology on cervical biopsy were analyzed. RESULTS: Mean age ± SD of the HIV-positive and HIV-negative groups was 44.28 ± 8.53 years and 44.28 ± 9.68 years, respectively. HIV-positive women were significantly less likely to use contraceptive methods (36.8 % versus 48.8 % in HIV-negative women; P = 0.002). HIV-infected women significantly had more sexual partners than HIV-uninfected women. Both groups had similar risk for CIN 2+ (5.3 % in HIV-positive women compared with 4.9 % in HIV-negative women; odds ratio [OR] = 1.08, 95% confidence interval [CI] = 0.30 -3.87). After adjustment for no contraception use and number of sexual partners, the risk of CIN2+ in HIV-infected women remained unchanged; adjusted OR= 1.15, 95% CI = 0.27-4.92, P= 0.846). CONCLUSION: The risk of underlying high-grade cervical lesions in women with ASC-US on cervical cytology was approximately 5 %, regardless of HIV status.

Diagnostic Added-Value of Serum CA-125 on the IOTA Simple Rules and Derivation of Practical Combined Prediction Models (IOTA SR X CA-125).

BACKGROUND: This study aimed to evaluate the diagnostic added-value of serum CA-125 to the International Ovarian Tumor Analysis (IOTA) Simple Rules in order to facilitate differentiation between malignant and benign ovarian tumors before surgery. METHODS: A secondary analysis of a cross-sectional cohort of women scheduled for surgery in Maharaj Nakorn Chiang Mai Hospital between April 2010 and March 2018 was carried out. Demographic and clinical data were prospectively collected. Histopathologic diagnosis was used as the reference standard. Logistic regression was used for development of the model. Evaluation of the diagnostic added-value was based on the increment of the area under the receiver operating characteristic curve (AuROC). RESULTS: One hundred and forty-five women (30.3%) out of a total of 479 with adnexal masses had malignant ovarian tumors. The model that included information from the IOTA Simple Rules and serum CA-125 was significantly more superior to the model that used only information from the IOTA Simple Rules (AuROC 0.95 vs. 0.89, p < 0.001 for pre-menopause and AuROC 0.98 vs 0.83, p < 0.001 for post-menopause). CONCLUSIONS: The IOTA SR X CA-125 model showed high discriminative ability and is potentially useful as a decision tool for guiding patient referrals to oncologic specialists.

Transferability of the early-stage ovarian malignancy (EOM) score: an external validation study that includes advanced-stage and metastatic ovarian cancer.

PURPOSE: To validate the diagnostic performance of the Early-stage Ovarian Malignancy (EOM) score in an external dataset that includes advanced-stage and metastatic ovarian cancer. METHODS: The data from two cross-sectional cohorts were used in the statistical analysis. The development dataset of the EOM score was collected in Phrapokklao Hospital between September 2013 and December 2017. The validation dataset was collected in Maharaj Nakorn Chiang Mai Hospital between April 2010 and March 2018. The internal and external performance of the EOM score was evaluated in terms of discrimination via area under the receiver-operating characteristic curve (AuROC) and calibration. RESULTS: There were 270 and 479 patients included in the development and validation datasets, respectively. The prevalence of ovarian malignancy was 20.0% (54/270) in the development set and 30.3% (145/479) in the validation set. The EOM score had excellent discriminative ability in both the development and validation sets (AuROC 88.0 (95% CI 82.6, 93.9) and 88.0 (95% CI 84.3, 91.4), respectively). The EOM score also showed good calibration in both datasets. CONCLUSIONS: The EOM score had consistent diagnostic performance in the external validation data. It is recommended for use as a triage tool in patient referrals instead of the RMI in settings where experienced sonographers are not available.

Early-Stage Ovarian Malignancy Score versus Risk of Malignancy Indices: Accuracy and Clinical Utility for Preoperative Diagnosis of Women with Adnexal Masses.

Background and objectives: To compare the diagnostic accuracy and clinical utility of the Early-stage Ovarian Malignancy (EOM) score with the Risk of Malignancy Index (RMI) in the presurgical assessment of women presenting with adnexal masses. Materials and Methods: A secondary analysis was carried out in a retrospective cohort of women who presented with an adnexal mass and were scheduled for surgery at Phrapokklao Hospital between September 2013 and December 2017. The clinical characteristics, ultrasonographic features of the masses, and preoperative CA-125 levels were recorded. The EOM and the RMI score were calculated and compared in terms of accuracy and clinical utility. Decision curve analysis (DCA), which examined the net benefit (NB) of applying the EOM and the RMI in practice at a range of threshold probabilities, was presented. Results: In this study, data from 270 patients were analyzed. Fifty-four (20.0%) women in the sample had early-stage ovarian cancer. All four RMI versions demonstrated a lower sensitivity for the detection of patients with early-stage ovarian cancer compared to an EOM score ≥ 15. An EOM ≥ 15 resulted in a higher proportion of net true positive or NB than all versions of the RMIs from a threshold probability of 5% to 30%. Conclusions: It also showed a higher capability to reduce the number of inappropriate referrals than the RMIs at a threshold probability between 5% and 30%. The EOM score showed higher diagnostic sensitivity and has the potential to be clinically more useful than the RMIs to triage women who present with adnexal masses for referral to oncologic gynecologists. Further external validation is required to support our findings.

Comparison of the diagnostic accuracy of International Ovarian Tumor Analysis simple rules and the risk of malignancy index to discriminate between benign and malignant adnexal masses.

OBJECTIVE: To compare the diagnostic accuracy of International Ovarian Tumor Analysis (IOTA) simple rules and risk of malignancy index (RMI 1/RMI 2) scoring to discriminate between benign and malignant adnexal masses. METHODS: Secondary analysis of a cohort of patients scheduled for surgery for adnexal masses in a tertiary center between April 2010 and March 2018. Ultrasound examinations were performed by general gynecologists within 24 hours prior to surgery to evaluate sonographic features. Demographic data and preoperative CA 125 levels were recorded. IOTA rules and RMI scoring were applied to predict malignancy and prospectively recorded. Final diagnosis was based on pathological or intraoperative diagnosis. RESULTS: A total of 479 masses met the inclusion criteria and were retrieved from the database: 334 (69.7%) benign and 145 (30.3%) malignant. IOTA rules could be applied to 392 (81.8%) masses and were inconclusive in 87 (18.2%). Sensitivity and specificity of IOTA rules (83.8% and 92.0%, respectively) were significantly higher than RMI 1 (77.2% and 86.8%, respectively) and RMI 2 (82.1% and 82.6%, respectively). CONCLUSION: IOTA simple rules had higher diagnostic accuracy compared with RMI to discriminate between benign and malignant adnexal masses; however, nearly 20% of IOTA results were inconclusive and needed expert consultation.

Factors Associated with Development of High-Grade Squamous Intraepithelial Lesions of the Uterine Cervix in Women Younger than 30 Years

Objective: To determine the factors associated with the increased risk of developing high-grade squamous intraepithelial lesions (HSIL) of the uterine cervix in women younger than 30 years compared with those aged ≥ 30 years who also had HSIL. Methods: Patients with HSIL who underwent loop electrosurgical excision procedure (LEEP) between January 2006 and July 2017 at Chiang Mai University Hospital were retrospectively reviewed. We analyzed the factors associated with the development of HSIL by comparing two age groups between women aged < 30 years and those aged ≥ 30 years. The factors analyzed included the well-recognized risk factors for cervical cancer, i.e. age at sexual debut, number of sexual partners, use of oral contraceptive (OC) pills, smoking history, sexually transmitted diseases and HIV status. Univariate and multivariate logistic regressions were used to assess factors associated with the increased risk of developing HSIL in women younger than 30 years compared with those aged ≥ 30 years. Results: During the study period, there were 345 patients with HSIL, 30 were < 30 years (case group) and 315 aged ≥ 30 years (control group). By multivariate analyses , early sexual debut(OR, 2.86; 95% CI, 1.01-8.13; P=0.047), multiple sexual partners (OR, 2.94; 95% CI, 1.23-7.02; P=0.015), history of genital warts (OR, 20.46; 95% CI, 2.27-183.72; P=0.007) and history of smoking (OR, 2.95; 95% CI, 1.10-7.93; P=0.032) were significantly associated with the development of HSIL in women younger than 30 years when compared with those aged ≥ 30 years. The OC use, HIV status and underlying diseases were not significantly different in both groups. Conclusion: Early age at sexual debut, multiple sexual partners, history of genital warts and smoking are significant risk factors for developing HSIL in women younger than 30 years. Cervical cancer screening should be considered in young women with such factors.

Cervical Screening Results Leading to Detection of Adenocarcinoma in Situ of the Uterine Cervix

Background: Adenocarcinoma in situ (AIS) of the uterine cervix is a preinvasive lesion of the invasive adenocarcinoma. We analyzed the cervical screening results leading to detecting the AIS lesions including the coexistence of AIS lesions with high-grade squamous intra-epithelial lesions (HSIL) and invasive carcinoma. Methods: Women who were diagnosed and received treatment for AIS at Chiang Mai University Hospital between January 1, 2007 and August 31, 2016 were retrospectively reviewed. The inclusion criteria were the women who had pathological diagnosis of AIS obtained from cervical punch biopsy or excisional cone biopsy with either loop electrosurgical excision procedure (LEEP) or cold-knife conization (CKC). The patient characteristics, diagnostic work-up and treatment details were reviewed, including the cervical screening results prior to the diagnosis of cervical AIS, pathologic results of excisional cone biopsy and hysterectomy specimens. Results: During the study period, 75 women with AIS pathology undergoing excisional cone biopsy with either LEEP (n=62) or CKC (n=13) were identified. The abnormal cytologic screening leading to detection of AIS was the squamous cell abnormality accounting for 57.3%. Abnormal glandular cytology accounted for 37.3%. The most common abnormal cervical screening results was HSIL cytology (n = 25) followed by AIS cytology (n = 13). Normal cytology was noted in 4 women in whom 3 were positive for HPV 18 and 1 had AIS on the endocervical polyp. AIS coexisted with HSIL and invasive carcinoma were detected in cone biopsy specimens in 21 (28%) and 29 (38.7%) patients, respectively. Conclusion: The majority of cervical screening results leading to detection of cervical AIS was the squamous cell abnormality accounting for 57.3% in which, HSIL cytology was the most common. Abnormal glandular cytology accounted for only 37.3%. Diagnostic cone excision is recommended if AIS lesion is noted in cervical biopsy specimen since nearly 40% have coexisting invasive lesions.

Sonographic Diagnosis of Tubal Cancer with IOTA Simple Rules Plus Pattern Recognition

Objective: To evaluate diagnostic performance of IOTA simple rules plus pattern recognition in predicting tubal cancer. Methods: Secondary analysis was performed on prospective database of our IOTA project. The patients recruited in the project were those who were scheduled for pelvic surgery due to adnexal masses. The patients underwent ultrasound examinations within 24 hours before surgery. On ultrasound examination, the masses were evaluated using the well-established IOTA simple rules plus pattern recognition (sausage-shaped appearance, incomplete septum, visible ipsilateral ovaries) to predict tubal cancer. The gold standard diagnosis was based on histological findings or operative findings. Results: A total of 482 patients, including 15 cases of tubal cancer, were evaluated by ultrasound preoperatively. The IOTA simple rules plus pattern recognition gave a sensitivity of 86.7% (13 in 15) and specificity of 97.4%. Sausage-shaped appearance was identified in nearly all cases (14 in 15). Incomplete septa and normal ovaries could be identified in 33.3% and 40%, respectively. Conclusion: IOTA simple rules plus pattern recognition is relatively effective in predicting tubal cancer. Thus, we propose the simple scheme in diagnosis of tubal cancer as follows. First of all, the adnexal masses are evaluated with IOTA simple rules. If the B-rules could be applied, tubal cancer is reliably excluded. If the M-rules could be applied or the result is inconclusive, careful delineation of the mass with pattern recognition should be performed.

Effect of lidocaine spray during colposcopy-directed cervical biopsy: A randomized controlled trial.

AIM: We aimed to examine the effect of lidocaine spray in reducing pain during colposcopy-directed cervical biopsy (CDB). METHODS: Two hundred women with abnormal cervical screening test results and abnormal colposcopic findings that required a CDB during April to December 2015 were enrolled. The participants were randomly assigned into one of two groups. For group 1 (lidocaine group), 10% lidocaine spray was applied thoroughly to the ectocervix. For group 2, no anesthesia was given. The primary outcome of this study was the biopsy pain score. RESULTS: Of the 200 women enrolled, 100 were randomly assigned to group 1 and 100 were in group 2. The baseline, biopsy, and postprocedure pain scores were comparable between the study groups. The mean difference between the biopsy and the baseline pain scores and the mean difference of the postprocedure pain scores from baseline were statistically significantly higher in the no-anesthesia group (group 2), P = 0.01 and P = 0.02, respectively. However, the degree of pain was minimal in both groups. There were no complications observed in any participants. CONCLUSION: Lidocaine spray reduces pain during colposcopy-directed cervical biopsy; however, the clinically meaningful effect of such a procedure cannot be demonstrated in this study.

Subsequent Oophorectomy and Ovarian Cancer after Hysterectomy for Benign Gynecologic Conditions at Chiang Mai University Hospital.

This study was undertaken to determine the incidence of subsequent oophorectomy due to ovarian pathology or ovarian cancer in women with prior hysterectomy for benign gynecologic conditions at Chiang Mai University Hospital. Medical records of women who underwent hysterectomy for benign gynecologic diseases and pre-cancerous lesions between January 1, 2004 and December 31, 2013 at Chiang Mai University Hospital were retrospectively reviewed. The incidence and indications of oophorectomy following hysterectomy were analyzed. During the study period, 1,035 women had hysterectomy for benign gynecologic conditions. Of these, 590 women underwent hysterectomy with bilateral salpingo-oophorectomy and 445 hysterectomy with bilateral ovarian preservation or unilateral salpingo-oophorectomy. The median age was 47 years (range, 11-75 years). Ten women (2.45 %) had subsequent oophorectomy for benign ovarian cysts. No case of ovarian cancer was found. The mean time interval between hysterectomy and subsequent oophorectomy was 43.1 months (range, 2-97 months) and the mean follow-up time for this patient cohort was 51 months (range, 1.3-124.9 months). According to our hospital-based data, the incidence of subsequent oophorectomy in women with prior hysterectomy for benign gynecologic conditions is low and all present with benign conditions.

Rapid recovery from catastrophic paraneoplastic anti-NMDAR encephalitis secondary to an ovarian teratoma following ovarian cystectomy.

This report is aimed to describe a life-threatening case of anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis secondary to ovarian teratoma with rapid recovery in 1 day after the removal of the tumour. A 23-year-old woman presented with sudden headache, personality changes and seizure. After neurological assessment, limbic or herpes encephalitis was provisionally diagnosed and treated with intravenous immunoglobulin, acyclovir and steroids. The patient had progressive severe neurological symptoms, requiring prolonged intubation and mechanical ventilation. An anti-NMDAR antibody test revealed positive in serum and cerebrospinal fluid at 3 weeks of admission. Pelvic ultrasound examination and CT scan revealed bilateral small ovarian teratomas. Bilateral ovarian cystectomy was performed by open surgery. The patient showed rapid improvement and no longer needed intubation 2 days after the operation. In conclusion, we described a catastrophic case of ovarian teratoma-associated encephalitis with delayed diagnosis but rapid recovery after ovarian cystectomy. This information can probably be helpful to neurologists and gynaecologists.

Application of HPV DNA Testing in Follow-up after Loop Electrosurgical Excision Procedures in Northern Thailand.

BACKGROUND: HPV DNA testing has been recently introduced as an adjunct test to cytology in the follow-up of patients after treatment for cervical lesions using the loop electrosurgical excision procedure (LEEP). The aim of this study was to evaluate the role of HPV testing in the detection of persistent or recurrent disease after LEEP in patients with cervical epithelial lesions in northern Thailand. MATERIALS AND METHODS: Patients who underwent LEEP as a treatment for histological low-grade (LSIL) or high-grade squamous intraepithelial lesion (HSIL) or worse at Chiang Mai University Hospital between June 2010 and May 2012 were included. Follow-ups were scheduled at 6-month intervals and continued for 2 years using co-testing (liquid-based cytology and Hybrid Capture 2 [HC2]) at 6 months and 24 months and liquid-based cytology alone at 12 and 18 months. RESULTS: Of 98 patients included, the histological diagnoses for LEEP included LSIL in 16 patients, and HSIL or worse in 82 patients. The LEEP margin status was negative in 84 patients (85.7%). At follow-up, 10 patients (10.2%) had persistent/recurrent lesions; 4 among LSIL patients (25.0%) and 6 in the group with HSIL or worse (7.3%). Only 2 of 82 patients (2.4%) with HSIL or worse diagnoses had histological HSIL in the persistent/recurrent lesions. Using histologically confirmed LSIL as the threshold for the detection of persistent/recurrent disease, cytology had a higher sensitivity than HC2 (90.0% versus 70.0%). At the 6-month follow-up appointment, combined cytology and HC2 (co-testing) had a higher sensitivity in predicting persistent/recurrent disease (80.0%) compared with that of cytology alone (70.0%) and HC2 (50.0%). CONCLUSIONS: After LEEP with a negative surgical margin, the rate of persistent/recurrent lesions is low. The addition of HPV testing at the 6-month visit to the usual cytology schedule may be an effective approach in the follow-up after LEEP.

IOTA simple rules in differentiating between benign and malignant ovarian tumors.

BACKGROUND: To evaluate the diagnostic performance of IOTA simple rules in differentiating between benign and malignant ovarian tumors. MATERIALS AND METHODS: A study of diagnostic performance was conducted on women scheduled for elective surgery due to ovarian masses between March 2007 and March 2012. All patients underwent ultrasound examination for IOTA simple rules within 24 hours of surgery. All examinations were performed by the authors, who had no any clinical information of the patients, to differentiate between benign and malignant adnexal masses using IOTA simple rules. Gold standard diagnosis was based on pathological or operative findings. RESULTS: A total of 398 adnexal masses, in 376 women, were available for analysis. Of them, the IOTA simple rules could be applied in 319 (80.1%) including 212 (66.5%) benign tumors and 107 (33.6%) malignant tumors. The simple rules yielded inconclusive results in 79 (19.9%) masses. In the 319 masses for which the IOTA simple rules could be applied, sensitivity was 82.9% and specificity 95.3%. CONCLUSIONS: The IOTA simple rules have high diagnostic performance in differentiating between benign and malignant adnexal masses. Nevertheless, inconclusive results are relatively common.

A case of ovarian paragonimiasis mimicking ovarian carcinoma.

BACKGROUND: The purpose of this report is to describe ovarian paragonimiasis, a rare form of lung fluke infestation, mimicking ovarian cancer. CASE: A 47-year-old Thai woman presented with a pelvic mass. Imaging suggested ovarian cancer with pulmonary and hepatic metastases. She was scheduled for complete surgical staging. However, a frozen section revealed Paragonimus eggs in the enlarged ovarian mass. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed instead of complete staging. All other lesions were also proven later to be Paragonimus infestation. Postoperative treatment with antiparasitic drugs resulted in dramatic improvement, with nearly complete resolution of all lesions at 4 months of follow-up. CONCLUSION: This is an unusual case of ovarian paragonimiasis mimicking ovarian cancer, which is instructive and informative for differential diagnoses of pelvic masses.