Florid polypoid endometriosis of the cervix with left ureteric obstruction: a mimic of cervical malignancy.

Polypoid endometriosis, in contrast to typical (non-polypoid) endometriosis, presents as masses that project from a serosal or mucosal surface or from the lining of an endometriotic cyst. Generally large, these masses can simulate a malignant tumor on imaging and at surgery. We report a case of florid polypoid endometriosis arising from the cervix with extension into the left parametrium and involving the left ureter, mimicking a locally advanced cervical malignancy on ultrasound and magnetic resonance imaging.

The need for public education on HPV and cervical cancer prevention in Asia. Opinions of experts at the AOGIN conference.

Asia accounts for more than half of all cases of cervical cancer registered globally and improving prevention is urgently needed. A range of tools and strategies is now available to effectively prevent this disease, including two new prophylactic HPV vaccines approved and recommended for adolescents and young women. However, without communication these tools may have little impact on disease burden. The conferences of the Asia Oceania Research Organisation in Genital Infection and Neoplasia (AOGIN) bring together clinicians and scientists whose work is related to genital infections, particularly HPV, cervical dysplasia and neoplasia, as well as other anogenital cancers, with the aim of improving communication on prevention through human papillomavirus (HPV) vaccination and screening in Asian countries. The scope of this year's AOGIN conference was to extend education to include health workers, family doctors, paediatricians, governmental health agencies, and the general public through patients' testimonials that can reach out to women raising awareness of this silent disease. Community based initiatives and awareness campaigns were also reported, and can empower the people to engage in a dialog with local governments towards prioritization of cancer prevention programs, achieving more for the public than isolated actions. Parents and teachers are encouraged to communicate about these issues within families and schools. Evidence was discussed that males can participate in cervical cancer control as well, and prevention programs involving men should not be neglected as they may reduce genital disease burden in women. Opinion leaders proposed prevention measures to be considered for governmental decisions. While each country develops a locally appropriate policy for cervical cancer control there is a need to revise these programs regularly, as knowledge increases in response to public need, as well as to gather evidence about disease burden and the effectiveness of education and interventions. In conclusion, AOGIN is committed to improve communication with patients, health authorities, professional organizations and opinion leaders towards strengthening cervical cancer prevention in Asia, to achieve a timely steep reduction in this cancer.

Clinical trial experience with prophylactic HPV 6/11/16/18 VLP vaccine in young women from the Asia-Pacific region.

OBJECTIVE: To evaluate results of three phase 3 clinical trials of quadrivalent HPV 6/11/16/18 vaccination of young Asia-Pacific women. METHODS: A total of 814 women from the Asia-Pacific region (aged 16 to 26 years) received vaccine or placebo in 1 of 3 protocols. Descriptive analyses focused on the efficacy, safety, and immunogenicity of the vaccine and the natural history of HPV disease. RESULTS: Vaccine efficacy against disease caused by HPV types 6, 11, 16, or 18 was 100% for cervical intraepithelial neoplasia (0 vs 12 cases; 95% confidence interval [CI], 63.1%-100%) and 100% for vulvar and vaginal intraepithelial neoplasia or condylomata accuminata (0 vs 5 cases; 95% CI, -11.8% to 100%). The vaccination was highly immunogenic. Vaccine recipients experienced a significantly higher injection site adverse event rate (P=0.002). Compared with other world regions, lower rates of smoking and baseline positivity to 14 HPV types (including the vaccine types) were observed among Asia-Pacific participants. CONCLUSION: Prophylactic quadrivalent HPV 6/11/16/18 vaccination of young Asia-Pacific women demonstrated high efficacy, safety, and tolerability. Together with an observed low baseline HPV positivity rate, the Asia-pacific population is potentially an important cohort to benefit from vaccination.

Adenocarcinoma of the abdominal wall.

We report a rare case of adenocarcinoma confined to the umbilicus. A 60-year-old menopausal woman presented with an umbilical lump of four years. Excision biopsy showed adenocarcinoma with an appearance suggestive of metastasis from an ovarian cystadenocarcinoma. Tumour markers for ovarian malignancy were normal. Computer tomography did not reveal any evidence of ovarian malignancy. She defaulted on follow-up. After five years, she presented with a 6-cm irregular periumbilical mass. She agreed to undergo an excision biopsy of the mass with total abdominal hysterectomy and bilateral salpingo-oopherectomy with omentectomy. The frozen section of the tumour showed papillary adenocarcinoma. Histology showed adenocarcinoma favouring serous cancer. There was no tumour seen in the ovaries, uterus and omentum. On follow-up, there was no disease recurrence. The patient has been disease-free for two years post surgery.

Multi-step microfluidic device for studying cancer metastasis.

This paper describes a multi-step microfluidic device for studying the deformation and extravasation of primary tumor cells. Prior to extravasation, primary tumor cells undergo sequential steps of deformation through the capillaries, before adhering and transmigrating through the endothelial lining and basement membrane. To study this cascade of events, we fabricated a multi-step microfluidic device whose microgaps were coated with Matrigel to mimic the basement membrane. The microchannel was lined with human microvascular endothelial cells (HMECs) to replicate the endothelial lining. Analysis of deformation, biological and migratory capabilities of various tumor cell lines viz. HepG2, HeLa, and MDA-MB 435S were quantified using the fabricated device. After deformation, the cells' viabilities were significantly reduced and their doubling times were simultaneously increased, indicating changes in their biological capability. However, cell deformation did not significantly reduce their cell motility. Cell motility was co-assessed using the cell's migration rate and the overall population's percentage migration under various conditions (no barrier, Matrigel and Matrigel-HMEC). The device was also used to quantify the effects of Matrigel and the endothelial lining on cell migration. Our results suggest that both played an independent role in inhibiting cell extravasation, with the Matrigel significantly slowing down cell movement and the endothelial lining reducing the total number of transmigrated cells.

Ovarian tumors of borderline malignancy: a review of 247 patients from 1991 to 2004.

Borderline ovarian tumors account for 15% of epithelial ovarian cancers and are different from invasive malignant carcinoma. Majority are early stage, occurring in women in the reproductive age group, where fertility is important. We reviewed retrospectively 247 such cases treated at the Gynaecological-Oncology Unit, KK Women's and Children's Hospital, between January 1991 and December 2004. The mean age was 38 years (16-89 years). Majority of the cases (92%) were FIGO stage I (Ia, 75%; Ib, 1%; and Ic, 16%). Seven (3.5%) patients were diagnosed as having stage II disease, six (2.5%) as stage IIIa, two (1%) as stage IIIb, and four (2%) as stage IIIc. Histological origin was as follows: mucinous (68%), serous (26%), endometrioid (2.6%), and clear cell (1.2%). Primary surgical procedures undertaken were as follows: hysterectomy with bilateral salpingo-oophorectomy (52%), unilateral salpingo-oophorectomy (33%), or ovarian cystectomy (15%). Adjuvant chemotherapy was administered in 13 patients (5.2% of cases), of which 4 patients were given chemotherapy only because of synchronous malignancies. There were six recurrences (2.4% of cases). Overall mean time to recurrence was 59 months. Recurrence rate for patients who underwent a primary pelvic clearance was 1.6% compared to fertility-sparing conservative surgery (3.3%; although P= 0.683). No significant difference was noted in recurrence and mortality between staged versus unstaged procedures. The overall survival rate was 98.0%. There were a total of five deaths (2.8%): three (1.5%) from invasive ovarian/peritoneal carcinoma and two from synchronous uterine malignancies. It appears that surgical resection is the mainstay of treatment, with conservative surgery where fertility is desired or pelvic clearance if the family is complete. Surgical staging is important to identify invasive extraovarian implants that portend an adverse prognosis. The role of adjuvant chemotherapy is not established.

Adjuvant sequential chemotherapy and radiotherapy in uterine papillary serous carcinoma.

PURPOSE: To evaluate the efficacy and toxicity of adjuvant combination of sequential chemotherapy followed by radiotherapy in uterine papillary serous carcinoma (UPSC). METHODS AND MATERIALS: From April 1994 to June 2003, 26 patients (median age 61.7 years, range 46.9-78.4) with UPSC were treated with a platinum-based chemoradiation protocol after definitive surgery. 9 patients were assigned as stage I (35%), 4 were stage II (15%), 11 were stage III (42%), and 2 were stage IV (8%) according to the FIGO staging for gynecological cancers. All patients underwent total hysterectomy, salpingo-oophorectomy, pelvic +/- perioartic lymph nodes dissection/sampling, omentectomy, and peritoneal washing. The adjuvant chemoradiation protocol consists of 4 cycles of platinum-based chemotherapy followed by pelvic irradiation and vaginal vault brachytherapy. In selected stage I patients with no or minimal myometrial invasion, only vault brachytherapy was given after adjuvant chemotherapy. RESULTS: After a median follow-up of 28 months (range 9-113 months), 14 (54%) patients were alive and free of disease. 12 out of these 14 patients were FIGO stage I/II. 9 patients (35%) had died (8 from distant metastases). The Kaplan-Meier 2-year and 5-year survival estimates were 69.5% and 57%, respectively. Only 4 (15%) patients had pelvic recurrence. None of the patients developed local vault recurrence. The treatment was well tolerated, only 1 patient developed congestive cardiac failure from the chemotherapy and 6 patients had grade 2 peripheral neuropathy on follow-up. CONCLUSION: In our series of UPSC patients treated with adjuvant chemotherapy followed by radiotherapy, local control can be achieved in a majority of patients. Distant failure remains the major cause of mortality. Further investigations into finding a more effective systemic therapy are required if improvement in outcome for this form of uterine cancer is to be achieved.

Tailoring the field and indication of adjuvant pelvic radiation for patients with FIGO stage Ib lymph nodes-negative cervical carcinoma following radical surgery based on the GOG score--a pilot study.

INTRODUCTION: The traditional indications for adjuvant pelvic radiotherapy (RT) for International Federation of Obstetrics and Gynecology (FIGO) stage Ib1 lymph nodes-negative cervix carcinoma following radical surgery based on histopathological factors, such as deep stromal invasion and lymphovascular space invasion (LVSI), were often inconsistently applied. The perceived risk of relapse was subjectively determined. This pilot study attempts to determine if the treatment outcome will be affected when the indication for RT is based on the Gynecologic Oncology Group (GOG) Risk Score (RS) and the field of adjuvant RT is tailored to the RS. MATERIALS AND METHODS: From 1997 to 1999, 55 patients with FIGO stage Ib1 lymph nodes-negative cervical carcinoma limited to the cervix were prescribed RT following radical surgery, based on their RS, as follows: RS <40, RT is omitted; RS >40 to <120, modified (smaller) field RT; and RS >120, standard field pelvic RT. Their incidence and site of recurrence were compared with a similar cohort of 40 patients who were treated prior to 1997. RESULTS: Prior to 1997, of the 40 patients, 10 patients were given standard field RT. There were 2 (5%) recurrent diseases. The mean duration of follow-up was 61.6 months (range, 1 to 103 months). The RS of 23 of the 30 patients who were not given RT were available. The mean RS was 22 with 5 patients having a score of >40. From 1997 onwards, of the 55 patients, 28 (51%) did not require RT, 13 (23%) were treated with modified (smaller) field RT and 14 (26%) were given standard field RT. There were 2 (3.6%) cases of relapse. The mean duration of follow-up was 36.4 months (range, 5 to 60 months). All patients with a RS of <40 did not suffer any relapse. Their survival outcomes were better when compared to patients who did not have any RT in the GOG Study. CONCLUSIONS: The results of this study indicated that postoperative adjuvant RT given to patients with a high GOG RS of >120, significantly improved their 5-year recurrence rate and disease-free survival, as compared with the similar group of patients who were without adjuvant therapy in the GOG study. Patients with a GOG risk-score of <40 may be safely spared from adjuvant pelvic RT. The current treatment protocol did not compromise the outcome in patients, compared with the use of a less precise treatment protocol in the past.

Bowel surgery for epithelial ovarian cancer--an early case series.

OBJECTIVES: The aims of this study were to review our local experience with bowel surgery for epithelial ovarian cancer at the Gynaecological Cancer Centre, KK Women's and Children's Hospital, and to document the outcome of such surgery as well as their complication rates. MATERIALS AND METHODS: The retrospective medical records of 38 patients with epithelial ovarian cancer who underwent surgery including bowel surgery from January 1997 to May 2002 at the Gynaecological Cancer Centre, KK Women's and Children's Hospital, Singapore, were reviewed. RESULTS: Indications for surgery were predominantly debulking of disease. Fifty-eight per cent of patients had primary debulking surgery, 34% had debulking of recurrence and 3% had interval debulking. Only 5% of patients had bowel obstruction as the only indication for surgery. Rectosigmoid resection was the most common bowel operation overall, being performed in 76.3% of patients. The stoma rate for rectosigmoid resection was 61%. The remaining procedures included 7 colectomies, 1 intestinal bypass procedure and 1 intestinal diversion procedure. Optimal debulking (defined as < 1 cm of residual disease) was achieved in the majority (71%). The median operating time was 4 hours. The median blood loss was 1300 mL. The major complication rate was 10.5%. Major complications encountered were as follows: 1 patient (2.6%) had an anastomotic leak, 2 patients (5.3%) had intra-abdominal abscess and 1 patient (2.6%) developed intestinal fistula. Three patients (7.8%) required a re-operation within 30 days. There were 3 deaths (7.8%) within 30 days of surgery. CONCLUSION: Bowel surgery is commonly indicated for epithelial ovarian cancer to facilitate optimal debulking. Such surgery is feasible with acceptable complication rates in our local centre.

FIGO stage 1B2 cervical carcinoma--the KK Women's and Children's Hospital experience.

INTRODUCTION: The objectives of this review were to document the surgico-pathological characteristics of surgically resected FIGO stage 1B2 cervical carcinoma and to review our overall experience with this disease. MATERIALS AND METHODS: This is a retrospective review of 35 patients diagnosed and treated from September 1990 to November 2001. RESULTS: The median age was 42 years and the mean tumour diameter was 5.1 cm. Majority were squamous cell carcinomas (65.7%), 28.6% were adenocarcinomas and 5.7% were adeno-squamous carcinomas. The primary treatment comprised radical surgery in 77.1%, radiotherapy in 20% and neoadjuvant chemotherapy followed by radical surgery and adjuvant radiotherapy in 2.9%. Significant surgico-pathological features noted were deep stromal invasion (66.7%), lympho-vascular space invasion (55.6%), parametrial involvement (22.2%), positive margins (3.7%) and pelvic node metastases (33.3%). Postoperative radiation was given to 92.6% of the patients who underwent primary surgery, of whom 29% received concurrent chemotherapy. Radiation toxicity was mild with no grade 3 or 4 toxicity documented. For the patients who had surgery, the recurRence rate was 14.8% (11.1% pelvic and 3.7% distant) and the survival rate was 88.9%. For those who had primary radiation, the rate of persistent disease was 28.6%, the distant recurrence rate was 28.6% and the survival rate was 57.1%. CONCLUSION: FIGO stage 1B2 cervical carcinomas are associated with significant rates of adverse surgico-pathological features. The ideal primary treatment is yet to be established and should be determined by prospective randomised trials.

Endometrioid adenocarcinoma of the uterus: surgico-pathological correlations and role of pelvic lymphadenectomy.

INTRODUCTION: In 1988, FIGO added lymph node surgery to the staging system for endometrial cancer. This change remains controversial to date. From our study we aim to determine the significance of surgico-pathological parameters of endometrioid carcinoma for pelvic nodal metastases and survival, as well as to study the role of pelvic lymphadenectomy in the surgical treatment of this disease. MATERIALS AND METHODS: A retrospective study was conducted in 198 women with endometrioid carcinoma who underwent full surgical staging including pelvic lymphadenectomy. The multiple variant regression analysis and the multi-variant logistic regression analysis were applied in the analysis of relationship. RESULTS: A positive correlation between nodal metastases and grade, myometrial invasion, peritoneal cytology, adnexal involvement, lympho-vascular space involvement and tumour size was found. For survival, significant prognosticators were grade, myometrial invasion, peritoneal cytology, lympho-vascular space involvement, adnexal involvement, associated atypia and pelvic nodal metastases. Thirty-five per cent of the patients had high risk of recurrence based on uterine pathological factors but were node negative. They were spared external beam radiation and its associated morbidities, and were treated with adjuvant vault brachytherapy instead. Six per cent of the patients would have been understaged based on uterine factors alone if pelvic lymphadenectomy had not been done. CONCLUSION: We infer that routine pelvic lymphadenectomy should be considered for all surgically fit patients with endometrioid carcinoma. The accurate staging will allow individualized adjuvant therapy and prevent understaging and overtreatment.

Initial experience of laparoscopic management of apparent early endometrial cancer.

The traditional treatment for endometrial cancer is a staging laparotomy. In patients with apparent early stage disease, laparoscopic assisted vaginal hysterectomy has been employed as an alternative. We present a retrospective uncontrolled case series of 16 cases with apparent stage I endometrial cancer from November 1994 to April 2001 managed by laparoscopic assisted surgical staging (LASS) at the Gynaecological Oncology Department, KK Women's and Children's Hospital, Singapore. We have analysed outcome measures in terms of intra-operative complications, surgical morbidity and length of hospital stay, and have evaluated treatment success in terms of conversion to laparotomy, recurrent disease and mortality. Our findings indicate that LASS is a viable option in selected patients with apparent early endometrial cancer. Our initial experience with this modality of treatment thus proves that it has great potential in both treatment success and reduction of surgical morbidity. A larger case controlled trial would be ideal in order to substantiate these benefits.

A rare case of metastatic ovarian carcinoma originating from primary intrahepatic cholangiocarcinoma. Case report.

BACKGROUND: A rare case of metastatic ovarian carcinoma arising from intrahepatic cholangiocarcinoma is reported and the literature reviewed. CASE: A 49-year-old woman presented with ascites and a left pelvic mass. Optimal debulking surgery was carried out including a segmental resection of segment 5/6 of the liver. Histopathology confirmed an intrahepatic cholangiocarcinoma metastatic to the ovaries and omentum. CONCLUSION: Distinguishing a metastatic tumor from a primary ovarian tumoris critical for appropriate management. A high index of suspicion intraoperatively and subsequent expert pathological review are essential in making the correct diagnosis.

Malignant ovarian germ cell tumors: the KK Hospital experience.

Ovarian germ cell malignancies pose a therapeutic challenge especially amongst young patients. This is a retrospective review of 49 patients treated for such malignancies at KK Women's and Children's Hospital over a 13-year period. The relative proportion of such tumors was 6.2%. Age at presentation ranged from 14 to 51 years (mean 25.4 years). Forty-nine percent of tumors were immature teratomas and 81.6% had stage I disease. All patients had surgery initially and 67.3% required postoperative adjuvant chemotherapy. The patients were followed-up for one to 145 months (mean 51.6 months). All the 87.8% of patients on follow-up are alive and disease-free. There was one recurrence. Five patients had eight successful pregnancies, with no congenital anomalies. Mean duration when menstruation was resumed and regular was 2.5 and 3.5 months, respectively. With combination chemotherapy and conservative surgery, the outlook for patients is excellent, with emphasis on preservation of ovarian function and fertility.

Vulvar cancer--what do we know about our patients?

INTRODUCTION: Vulvar cancer is uncommon in Singapore and to date there have been no local reports on this rare cancer. This is a descriptive study that aims to evaluate our patients' profiles, their management and their outcomes. MATERIALS AND METHODS: Between January 1981 and December 1998, there were 35 patients with vulvar cancer treated at KK Women's and Children's Hospital. The case records of these patients were reviewed. Survival was calculated using the Kaplan-Meier method. RESULTS: The modal age at diagnosis was 74.0 years (range 17.0-89.0 years). Chinese patients accounted for 88% of the study group, Malays for 6%, Indians for 3% and other races made up 3% of the study group. The most common presenting symptom was an ulcer or lump (83.8%). Squamous cell carcinoma was the most common histological type (80.0%). Vulvar intraepithelial neoplasia III was found in 20% of the cases. There were five patients with other lower genital tract malignancies. Surgery was the most common treatment modality and wound breakdown was the most common complication. The overall five year survival was 75.9%. For stage 1&2 disease, the five year survival was 90.0%. For stage 3&4 disease, the five year survival was 26.0%. CONCLUSION: The rarity of vulvar cancer makes it best treated in a tertiary centre. There is a definite survival advantage in early diagnosis and treatment of vulvar cancer. Lymph node surgery was associated with a longer operating time and a higher chance of wound breakdown.

Management of adenocarcinoma in situ (ACIS) of the uteri cervix--a clinical dilemma.

OBJECTIVE: We retrospectively reviewed 24 cases of adenocarcinoma in-situ (ACIS) of the cervix, managed at KK Hospital, with the objective of determining our local approach to its treatment, the consequent clinical outcome and problems encountered. METHODS: Except for one case, all patients were treated between 1991-1996. Nineteen cone biopsies (17 laser and 2 cold knife) and eleven hysterectomies were performed. The mean follow-up duration was 20.5 months (range: 1-75 months). RESULTS: The mean age was 44.2 years (range: 32-68) with 80% of the cohort being more than 35 years old and the mean parity was 2.2. Six (25%) patients were symptomatic. Majority (21/23) had an abnormal initial Pap smear. Glandular lesions were found in 39% (9/23) of Pap smear, 28% (6/21) of colposcopy, 58% (8/14) of cervical biopsies and in 3 of 4 endocervical curettage. Of the 17 laser cone biopsy specimens, lesion involved the surgical margin in 6 patients (35%). ACIS was found in conjunction with CIN in 14 patients (58%). Five hysterectomies were performed for involved surgical margin and one for dubious surgical margin of the prior cone biopsy, of which 3 had residual ACIS. At the time of the study, there was no case of recurrent ACIS or overt adenocarcinoma developing following cone biopsy. CONCLUSION: Preconisation diagnosis of ACIS using Pap smear, colposcopy and cervical biopsy was found to be difficult in our series. Concurrent CIN occurred in a sizeable portion of patients. Laser cone biopsy was the preferred method employed. Total hysterectomy was frequently employed following cone biopsy for treating possible residual disease. We recommend greater vigilance for this condition especially in patients with CIN and the need for regular endocervical sampling in the follow-up of patients treated by cone biopsy.

The treatment of uterine papillary serous carcinoma (UPSC): are we doing the right thing?

Tay EH, Ward BG. The treatment of uterine papillary serous carcinoma (UPSC): are we doing the right thing? In an earlier study(1) of 21 patients with uterine papillary serous carcinoma (UPSC), Ward et al. found a poor 3-year survival, even for patients with surgically documented localized disease, and a high rate of recurrence outside the field of treatment. Eight years later, we performed a retrospective study on 67 patients who were treated initially by surgery, which included the 21 patients previously reported, to evaluate any changes in the management approach since 1990 and its impact on the survival of such patients. The clinical characteristics of patients treated before and after 1990 were similar. However, after 1990, more patients had omentectomy and complete surgical staging (42% vs. 17%); chemotherapy was more widely used (63% vs. 33%); all chemotherapies were platinum-based regimens and less radiotherapy was administered (47% vs. 83%). The overall 3-year survival was 43% and 5-year survival was 35%, with a median survival period of 31 months. There was no significant difference in the survival outcome between patients managed before and after 1990, after adjusting for stage and spread of disease. Based on the results of this retrospective study, it appears that the current treatment strategy has not resulted in an improvement in the survival of patients with UPSC.

A 5-year review of FIGO stage IB cervical cancer in an Asian population.

OBJECTIVE: We studied the clinical patterns and outcome of patients with FIGO (1985) Stage 1b cervical cancer. In particular, looking at the clinico-pathological characteristics in relation with disease recurrence. PATIENTS & METHODS: Ninety-nine Asian patients were managed at (the former) K K Hospital, Singapore, from 1987 to 1991. The mean and median follow-up periods were 67 and 60 months respectively. This study was performed in 1995. RESULTS: The majority of the patients (81%) was treated by radical hysterectomy with or without adjuvant radiotherapy/chemotherapy while 15% were treated by radical pelvic radiotherapy alone and 4% of patients had pelvic radiotherapy following the diagnosis of cervical cancer after a simple hysterectomy. Thirteen patients developed tumour recurrence (13.1%). In these patients, there was a greater proportion of adenocarcinomas (31% vs 13%, p = 0.1065), lymph node metastases (45% vs 20%, p = 0.09) and surgical margins involvement (45% vs 7%) 7%, p = 0.004) while there seemed to be no difference in histological sub-types, vascular space involvement and cytological grading. The relative risks of developing tumour recurrence in patients with adenocarcinoma was 2.5 times (95% CI: 0.88-7.05), lymph-node metastasis: 2.3 times (95% CI: 0.96-4.93) and involved surgical margins; 5.9 times (95% CI: 2.27-15.5). The mean time to recurrence were 21.7 months with all of them detected within 36 months following primary therapy. All of them had abnormal physical findings while routine follow-up Pap smear was positive in only one patient (8%). In general, the outcome of salvage treatment was poor. CONCLUSIONS: In our group of patients with FIGO Stage lb cervix cancer, majority had radical surgery performed initially. Thirteen percent had disease recurrence, in which there were greater proportions of patients with adenocarcinoma, lymph-node metastasis, and involved surgical margins. The mean time-to-recurrence was 21.7 months with all detected by 36 months. Routine follow-up Pap smear seemed to be a poor indicator of disease status.