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.

Comparison of risk prediction scores for cancer-associated thrombosis in ambulatory cancer patients not receiving thromboprophylaxis: A prospective cohort study in a South-East Asian population

INTRODUCTION

To date, there is limited data regarding the incidence and risk prediction of cancer-associated thrombosis among South-East Asian patients who do not receive thromboprophylaxis.

MATERIALS AND METHODS

This was a prospective cohort study conducted at a tertiary medical center from June 2020 to December 2021 in Thailand. We enrolled cancer patients aged ≥ 18 years, with ECOG score ≤ 1, scheduled to receive the first cycle of chemotherapy. We measured incidence of venous thromboembolism (VTE), all-cause mortality and performance of risk prediction scores.

RESULTS

A total of 457 patients were included with a mean age of 58.18 ± 12.60 years. By the end of 6 months period, VTE had occurred in 30 patients (6.56 %, 95%CI 4.36-9.21). The median time to the first thrombosis was 1.94 months (IQR 0.26-3.19). Cancer associated thrombosis incidence was 14.58 % for Khorana score ≥ 3, 6.67 % for scores 1-2 and 2.13 % for score 0. C-statistics were 0.50 (95%CI 0.41-0.60) for Khorana score cut-off ≥ 2, 0.57 (95%CI 0.49-0.65) for Khorana score ≥ 3, 0.55 (95%CI 0.46-0.65) for PROTECHT score ≥ 3, and 0.57 (95%CI 0.49-0.65) for CONKO score ≥ 3. Classifying cholangiocarcinoma as very-high-risk increased the Khorana score cut-off ≥ 3's C-statistic to 0.62 (95%CI 0.53-0.71).

CONCLUSIONS

A significant proportion of ambulatory South-East Asian cancer patients without thromboprophylaxis developed VTE. Further prospective studies investigating the benefit of thromboprophylaxis in high-risk patients with active cancer are warranted.

Profiling the Expression and Prognostic Values of FYN, A Non-Receptor Tyrosine Kinase, in Different Histological Types of Epithelial Ovarian Cancer

OBJECTIVE

This study was aimed at evaluating FYN expression among different histologic types of epithelial ovarian cancer (EOC) and its associated prognostics.

METHODS

The FYN expression levels using quantitative real-time PCR method were evaluated in 98 primary EOC. Receiver operating characteristic curve were used to select an optimal cut-off value for determining the presence or absence of a disease progression.

RESULT

The median level of FYN expression varied among different EOC types, being the highest in high-grade serous carcinomas and the lowest in clear cell carcinomas (CCC). Using the cutoff FYN value to predict disease progression, the FYN-positive group had a poorer progression-free survival (PFS) compared to the FYN-negative group (p = 0.001). In multivariate Cox regression analysis, FYN expression was an independent predictor for disease progression (Hazard ratio = 2.30; 95% CI: 1.21- 4.38; p = 0.011). In subgroup analysis, FYN expression was significantly associated with lower PFS in early stage CCC patients (p = 0.009).

CONCLUSION

FYN expression is variable among different types of EOC while impacting on the prognostic values in patients with early stage CCC.

Oncology and reproductive outcomes over 16 years of malignant ovarian germ cell tumors treated by fertility sparing surgery

BACKGROUND

Malignant ovarian germ cell tumors (MOGCT) are rare and frequently occur in women of young and reproductive age and the oncologic and reproductive outcomes after fertility-sparing surgery (FSS) for this disease are still limited.

AIM

To evaluate the oncology and reproductive outcomes of MOGCT patients who underwent FSS.

METHODS

All MOGCT patients who underwent FSS defined as the operation with a preserved uterus and at least one side of the ovary at our institute between January 2005 and December 2020 were retrospectively reviewed.

RESULTS

Sixty-two patients were recruited for this study. The median age was 22 years old and over 77% were nulliparous. The three most common histology findings were immature teratoma (32.2%), dysgerminoma (24.2%), and yolk sac tumor (24.2%). The distribution of stage was as follows; Stage I, 74.8%; stage II, 9.7%; stage III, 11.3%; and stage IV, 4.8%. Forty-three (67.7%) patients received adjuvant chemotherapy. With a median follow-up time of 96.3 mo, the 10-year progression-free survival and overall survival were 82.4% and 91%, respectively. For reproductive outcomes, of 43 patients who received adjuvant chemotherapy, 18 (41.9%) had normal menstruation, and 17 (39.5%) resumed menstruation with a median time of 4 mo. Of about 14 patients who desired to conceive, four were pregnant and delivered good outcomes. Only one case was aborted. Therefore, the successful pregnancy rate was 28.6%

CONCLUSION

The oncology and reproductive outcomes of MOGCT treated by FSS are excellent. Many patients show a long survival time with normal menstruation. However, the obstetric outcome is not quite satisfactory.

Effectiveness of enhanced recovery after surgery protocol in open gynecologic oncology surgery: A randomized controlled trial

OBJECTIVE

To examine the effectiveness of applying the recommended enhanced recovery after surgery (ERAS) protocol compared with our usual care in women with gynecologic malignancy undergoing elective laparotomy.

METHODS

From June 2020 to May 2021, 93 women with gynecologic cancers (cervix, endometrium, and ovary) undergoing elective laparotomy at our institution were randomly assigned into an intervention group (ERAS protocol, 46 women) or control group (usual care, 47 women). For the intervention group, each woman was brought through the pre-specified ERAS protocol starting from preoperative counseling to postoperative management. For the control group, participants underwent routine standard care. The primary outcomes were length of hospital stay and postoperative pain.

RESULTS

The intervention group demonstrated shorter hospital stay by 20 h (47.48 h vs 67.17 h, P = 0.02) with lower postoperative pain score at postoperative day 0 (1.58 vs 4.00, P < 0.01) and day 1 (1.00 vs 2.67, P < 0.01) while having decreased opioid consumption (P < 0.01). The intervention group also had faster recovery of gastrointestinal function. Overall, good compliance to most of the ERAS pathway domains was obtained.

CONCLUSION

The ERAS protocol demonstrates benefits on shortening hospital stay, reducing pain, and bowel function recovery without increasing complications in our population.

CLINICAL TRIAL REGISTRATION

The present study was registered at clinicaltrials.gov (NCT04201626) on December 3, 2019. Initial participant enrollment began on June 1, 2020. Access through URL of the registration site: https://clinicaltrials.gov/ct2/show/NCT04201626?cond=ERAS&cntry=TH&draw=2&rank=3.

Prevalence and risk factor of post-operative lower extremities deep vein thrombosis in patients undergoing gynecologic surgery: a single-institute cross-sectional study

Background and aim

The study of prevalence and risk factors of postoperative lower limb deep vein thrombosis (DVT) in Thai gynecologic patients was limited. The present study was conducted to evaluate this issue.

Methods

The patients were age > 15 years old without a history of DVT or pulmonary emboli (PE) scheduled for laparotomy or vaginal gynecologic surgery between May and November 2020 were invited to participate. All of these patients were scheduled for a complete duplex ultrasound to detect lower limb DVT 72 h before and within 14 days after the operation. The patients without DVT were scheduled for an interview by telephone about DVT symptoms 30 days after the operation. The clinical variables were compared using univariate and multivariate analysis to identify the independent factors related to the development of DVT.

Results

One hundred and twelve patients met the inclusion criteria. Of these patients, 44 cases (39.3%) were diagnosed as malignancy and 102 patients underwent a hysterectomy. Post-operative DVTs were detected in six patients (5.4%) and all except one had a malignancy. Thus, the prevalence of DVT in malignancy cases was five in 44 patients (11.4%). The independent risk factors for postoperative DVT were age > 60-year-old and receiving a perioperative blood transfusion. Five of six DVT patients received low molecular-weight heparin for treatment of DVT and none developed PE. The rest of the participants reported no symptom-related DVTs from the interview 30 days after the operation.

Conclusion

The prevalence of postoperative DVT in gynecologic patients was 5%, and the independent risk factors were elderly patients and receiving a perioperative blood transfusion.

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.

iPMI: Machine Learning-Aided Identification of Parametrial Invasion in Women with Early-Stage Cervical Cancer

Radical hysterectomy is a recommended treatment for early-stage cervical cancer. However, the procedure is associated with significant morbidities resulting from the removal of the parametrium. Parametrial cancer invasion (PMI) is found in a minority of patients but the efficient system used to predict it is lacking. In this study, we develop a novel machine learning (ML)-based predictive model based on a random forest model (called iPMI) for the practical identification of PMI in women. Data of 1112 stage IA-IIA cervical cancer patients who underwent primary surgery were collected and considered as the training dataset, while data from an independent cohort of 116 consecutive patients were used as the independent test dataset. Based on these datasets, iPMI-Econ was then developed by using basic clinicopathological data available prior to surgery, while iPMI-Power was also introduced by adding pelvic node metastasis and uterine corpus invasion to the iPMI-Econ. Both 10-fold cross-validations and independent test results showed that iPMI-Power outperformed other well-known ML classifiers (e.g., logistic regression, decision tree, k-nearest neighbor, multi-layer perceptron, naive Bayes, support vector machine, and extreme gradient boosting). Upon comparison, it was found that iPMI-Power was effective and had a superior performance to other well-known ML classifiers in predicting PMI. It is anticipated that the proposed iPMI may serve as a cost-effective and rapid approach to guide important clinical decision-making.

Clinicopathological Prognostic Factors Influencing Survival Outcomes of Vulvar Cancer

Background:

The prognostic factors for survival in squamous cell carcinoma (SCCA) of vulva cancer such as groin node involvement, postmenopausal status, tumor size, margin status, tumor grade, lymph vascular space invasion (LVSI) were reported in the past. However, with limited data from Southeast - Asian population, the present study was conducted to evaluate the clinicopathological prognostic factors for survival outcomes of this disease after treatment with surgery.

Methods:

All SCCA vulva cancer patients who underwent surgery between January 2006 and December 2017 were reviewed. The clinicopathological factors were analyzed to identify the prognostic factors for the progression-free survival (PFS) and overall survival (OS) using the Kaplan- Meier method and Cox-Proportional Hazard model.

Results:

One hundred twenty-five patients were recruited. The independent poor prognostic factors for PFS were groin node-positive and pathologic tumor diameter of more than 25 mm. Whereas postmenopausal status and groin node positive were independent poor prognostic factors for OS.

Conclusion:

Groin node-positive was the only one independent poor prognostic factor for both PFS and OS. In addition, the tumor diameter longer than 25 mm. was independent poor prognostic factors for PFS while postmenopausal status was independent poor prognostic factors for OS. Special adjuvant treatment for patients with these factors should be further investigated.

Survival Outcomes and Prognostic Factors of Borderline Ovarian Tumors

Background and Objective: Borderline ovarian tumor (BOT) is a distinct but heterogeneous group of tumors defined by histopathology as atypical epithelial proliferation without stromal invasion. Women with BOT are usually younger than those with invasive carcinoma. This study aimed to evaluate the survival outcomes and prognostic factors of patients with BOT in a single institute in the northern region of Thailand. Methods: The medical records of patients with BOT who were treated at Chiang Mai University Hospital between January 1, 2008 and December 31, 2019 were reviewed. The survival outcomes were analyzed by the Kaplan-Meier method and prognostic factors were analyzed by univariate and multivariate approaches. Results: 168 patients with BOT were enrolled in the study. The median age was 48.8 years. At the median follow-up time of 25.4 months, 9 patients (5.3%) developed recurrence and 2 (1.1%) experienced progression to invasive carcinoma. The 5-year progression-free survival (PFS) and overall survival were 93.2% and 97.4%, respectively. By univariate analysis, advanced stage (p=0.02), tumor size smaller than 10 cm (p=0.03), conservative surgery (p=0.03), and bilateral tumors (p=0.07) were significantly associated with worse PFS. Hysterectomy was a protective factor for recurrence with the hazard ratio of 0.09 (95% CI, 0.01 – 0.77; p= 0.03). Cell types, pelvic lymphadenectomy, micro-invasion, and non-invasive peritoneal implant did not significantly affect PFS. By multivariate analysis, early stage (p=0.01), tumor size larger than 10 cm (p=0.04), and hysterectomy (p=0.03) were significantly associated with better survival. Conclusion: Patients with BOT had excellent survival outcomes. Tumor size of larger than 10 cm, early-stage disease, and hysterectomy were significant prognostic factors for better survival outcomes. Conservative surgery should be offered to patients who desire to preserve future fertility and long-term follow-up is needed to assure recurrence - free.

Prevalence and Potential Factors Related to Irreversible Chemotherapy-Induced Amenorrhea in Premenopausal Breast Cancer Patients

Objective: To evaluate the prevalence and potential factors related to irreversible chemotherapy-induced amenorrhea (CIA) in premenopausal women with breast cancer. Methods: First diagnosis breast cancer women in Stages I-III who had menstruation within three months before receiving chemotherapy and completed a course of treatment were interviewed about the menstrual cycle after a complete course of chemotherapy and the subsequent menstrual status. Clinical data were retrospectively reviewed. Age at starting chemotherapy was calculated for an optimal cut-off point by using the receiver operating characteristic curve to predict irreversible CIA. The clinicopathological variables were compared using univariate and multivariate analysis to identify the independent factors related to irreversible CIA. Results: One hundred and fifty-four premenopausal breast cancer women who met the inclusion criteria were interviewed. They were treated with chemotherapy between October 1999 and September 2018. The median age at the start of treatment was 43.5 years. One hundred forty-two patients (92.2%) developed CIA and 37 cases subsequently resumed menstruation (RM). Thus, the prevalence of irreversible CIA was 68.2%. The group > 45 years of age, estrogen receptor-positive, progesterone receptor-positive and maintenance treatment with tamoxifen significantly developed irreversible CIA in univariate analysis. However, only the > 45-year-old group was an independent factor for the CIA with an adjusted odds ratio of 23.04. Conclusion: Nearly 70% of premenopausal breast cancer women developed irreversible CIA and the independent factor for this event was being older than 45-years-old when receiving chemotherapy.

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

BACKGROUND AND OBJECTIVE

Ovarian, fallopian tube, or primary peritoneal cancer patients with BRCA gene mutation have enhanced sensitivity to platinum-based regimens and PARP inhibitors. However, the knowledge regarding BRCA mutation in Thai patients is limited. This study aimed at identifying the prevalence and characteristics of somatic and germline BRCA 1 and 2 mutations in Thai patients with these cancers.

MATERIALS AND METHODS

The paraffin blocks of tumors with histology of high grade serous, high grade endometrioid, or clear cell carcinoma obtained between June 2016 and December 2017 were analyzedto evaluate BRCA mutation using next-generation sequencing system. Blood or normal tissue paraffin blocks of positive patients were further tested for germline BRCA mutation.

RESULTS

Tissue paraffin blocks of 178 patients were collected but only 139 were analyzed. Positive BRCA mutation was identified in 24 patients (17.3%): BRCA1 in 13 cases, BRCA2 in 10 cases, and BRCA1 and 2 in the rest one. Germline mutation study in blood or normal tissue in 23 positive patients revealed BRCA mutation in 14 cases, BRCA1 in 8 cases and BRCA 2  in 6 cases. Overall, the prevalence of somatic and germline mutation was 6.5% (9 out of 138 patients) and 8.7% (14 out of 138 patients), respectively. The most common histology associated with BRCA mutation was high grade serous cancer (27.3%). No significant difference was found between patients with or without BRCA mutation in terms of stage, outcome, platinum status, and survival outcome.

CONCLUSION

BRCA mutation was demonstrated in less than 10% of Thai ovarian cancer patients. Higher rate of mutation was found in high grade serous cancer.
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Symptom and Anxiety Assessment in Gynecologic Cancer Patients Receiving Chemotherapy

Background: Side effects of chemotherapy usually disturbed the daily life of patients. During chemotherapy, quality of life of patients is affected by the severity of symptoms experienced. Objective: To evaluate the side effects experienced by gynecologic cancer patients receiving chemotherapy.Methods: Gynecologic cancer patients receiving chemotherapy (at least 1 cycle with standard premedication that included antiemetic drugs) between 18 June and 25 September 2019 were invited to this study. Participants were interviewed by our team for personal data and attitudes toward their disease and treatment. In addition, the Edmonton Symptom Assessment System (ESAS-Thai version) tool, and Multinational Association for Supportive Care in Cancer (MASCC) antiemetic tool were used to assess the symptoms during chemotherapy. Results: One hundred sixty-five participants entered this study. The mean age was 53.5. The three most common type of cancer were ovarian (37.6%), cervical (37.6%) and uterine cancer (21.8%). Most common chemotherapy was carboplatin plus paclitaxel (64.8%). Two-thirds of the participants believed they could be cured. The most common severe symptom from the ESAS tool was pain (20.6%), followed by fatigue (18.8%), appetite change (16.4%) and numbness (10.3%). In addition, 10.9% of patients experienced nausea/vomiting in acute phase, while 20.6% experienced it in the delayed phase. Conclusion: Our participants revealed positive attitudes toward cancer and treatment. Some patients experienced nausea and vomiting despite using antiemetic drugs. The most frequent self-reported symptom was pain. Therefore, pain control was necessary to improve their quality of life.

Primary signet ring cell carcinoma with neuroendocrine differentiation arising in mucinous borderline tumor of the ovary

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Primary signet ring cell carcinoma in ovarian mucinous tumor is rare.

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The most important differential diagnosis is metastatic carcinoma.

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We report a case of primary ovarian signet ring cell carcinoma in mucinous tumor.

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Clinicopathological correlation is essential to establish the correct diagnosis.

Relationships of Ex-Vivo Drug Resistance Assay and Cytokine Production with Clinicopathological Features in the Primary Cell Culture of Thai Ovarian and Fallopian Tube Cancer Patients

Objective: Our goal was to determine the ex-vivo drug resistance assay, as well as the cytokine production, in response to platinum-based chemotherapy treatment in primary culture cells established from the tumor tissue of ovarian or fallopian tube carcinoma patients, and to predict the clinical responses to chemotherapy. Methods: Sensitivity to the platinum-based drug was analyzed in two ovarian cancer cell lines and 19 tumor samples using the primary cell culture obtained from 19 patients having ovarian or fallopian tube cancer that had undergone surgery from 2014 to 2017. Results: Our findings in the ovarian cancer cell lines showed that SKOV3 cells displayed 10-fold greater resistance to cisplatin and 5.8 times more resistance to carboplatin than A2780 cells. SKOV3 cells displayed platinum-induced IL-6 and IL-8 overproduction whereas wild type A2780 displayed no detectable cytokine production. Regarding the primary cell culture obtained from patients, ex-vivo drug resistance assay results revealed that although extreme drug resistance was correlated with late stage ovarian cancer (P= 0.031), it could not independently predict or alter the outcomes of patients with ovarian or fallopian tube cancer. No relationship was found between basal cytokine secretion and the clinical parameters. However, carboplatin-induced IL-6 and IL-8 production had a significant association with the clinical response to chemotherapy (P=0.016 and P=0.038 respectively). Carboplatin-induced IL-8 overproduction was correlated with FIGO staging III-IV (P=0.026), but no correlation between carboplatin-induced IL-6 and FIGO staging (P= 0.061) was noted. Conclusion: These results suggest that cytokine production in response to platinum-based chemotherapy in primary culture cells may be useful as a predictive marker for the therapeutic outcomes among ovarian or fallopian tube cancer patients.

Prognostic Value of Tumor Budding in Early-Stage Cervical Adenocarcinomas

Background: Tumor budding has recently been reported as an independent adverse prognostic factor for colorectal adenocarcinomas and other types of carcinoma in the digestive tract. This study aimed to evaluate the prognostic value of tumor budding in patients with early-stage cervical adenocarcinomas and any associations with other clinical and pathological features. Methods: Histological slides of patients with early-stage (IB-IIA) usual-type endocervical adenocarcinoma who underwent radical hysterectomy and pelvic lymph node dissection, without preoperative chemotherapy, between January 2006 and December 2012 were reviewed. Tumor budding was evaluated in routinely-stained sections and defined as detached single cells or clusters of fewer than 5 cells in a tumor invasive front and was stratified based on the number of bud counts in 10-high-power fields as low (<15 buds) and high (≥15 buds). Correlations between tumor bud count and other clinical and pathological variables including follow-up outcomes were assessed. Results: Of 129 patients, a high tumor bud count was observed in 15 (11.6%), positively associated with histologic grade 3 (p<0.001), invasive pattern C (Silva System) (p=0.004), lymph node metastasis (p=0.008), stage IB2-IIA (p=0.016), and tumor size >2 cm (p=0.036). Kaplan-Meyer analysis showed a significant decrease in both disease-free survival and cancer-specific survival for patients with a high tumor bud count (p=0.027 and 0.031, respectively). On multivariate analysis, histologic grade 3 was the only independent predictor for decreased disease-free survival (p=0.004) and cancer-specific survival (p=0.003). Conclusions: A high tumor budding count based on assessment of routinely-stained sections was found to be associated with decreased disease-free and cancer-specific survival in patients with early-stage cervical adenocarcinomas. However, it was not found to be an independent prognostic predictor in this study.

Comparison of Hypersensitivity Reactions to Carboplatin Retreatment in Gynecologic Cancer Patients between One and Two Hour Infusions: a Randomized Trial Study

Objective: To compare the incidence rate of carboplatin hypersensitivity reactions (HSRs) in gynecologic cancer patients receiving one-hour or two-hour carboplatin retreatment infusions. Setting: A Prospective Randomized Controlled Trial. Methods: Recurrent gynecologic cancer patients 25 to 80-years of age who were scheduled to receive carboplatin retreatment after previously receiving at least six cycles of carboplatin without a history of platinum allergy were invited to enroll. They were randomized to receive either a one-hour or two-hour carboplatin infusion in each cycle. The nurses recorded any occurrence of HSR. Patients who developed carboplatin HSR were discontinued from the study. Results: Forty-five patients were enrolled and randomized to receive either a one-hour carboplatin infusion arm in 69 cycles or a two-hour infusion arm in 67 cycles. Both groups were well balanced regarding median age, body mass index, type of cancer, history of drug allergy, median platinum free interval time, median total number of previous carboplatin cycles, premedication type, regimen and median total dose of carboplatin. Five (3.67%) of the 136 cycles resulted in carboplatin HSR, all of which were Grade 1. Of these, four cycles developed HSR during the one-hour infusion and only one cycle with a two-hour infusion (P=0.37). The onset of carboplatin HSR occurred within 30-105 minutes after infusion start. Conclusion: Extending the carboplatin infusion time to two hours from one hour did not significantly decrease carboplatin HSR.

Outcomes of Metastatic Gestational Trophoblastic Neoplasia: Fourteen Year Experience from a Northern Thailand Tertiary Care Center

Metastatic gestational trophoblastic neoplasia (GTN) is an uncommon cancer. The principal treatment consists of chemotherapy with or without surgery or radiotherapy. We here retrospectively reviewed the outcomes of metastatic GTN treated at our institute between January, 1999 and December, 2013. Sixty-three patients met the criteria. The median age was 30.0 years and almost 90% were referral cases. Nearly 40% of the studied patients presented with vaginal bleeding while 22.2% were asymptomatic. The most common antecedent pregnancy was hydatidiform mole (57.1%) followed by term pregnancy (20.6%). The median interval time from antecedent pregnancy to the development of GTN was three months and the median pretreatment B-hCG was 58,274 mIU/ ml. Stage III (74.6%) was the most common staging followed by stage IV (20.6%) and stage II (4.8%). The most frequent surgery was hysterectomy (31.7%). Thoracotomy and craniotomy were performed in three and two patients, respectively. The most common first line chemotherapy regimen was methotrexate and folinic acid (36.5%) followed by EMA (etoposide, methotrexate, actinomycin D) (34.9%), EMACO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine) (17.5%) with the remission rate of 66.7%. Nearly one-third of the patients were given a subsequent chemotherapy regimen after failure with the first line therapy and showed a final response rate of 73.0%. However, in stage IV, the response to first line treatment was only 38.5%. In conclusion, the outcomes of metastatic GTN were poor especially with the higher stages.

Spatial and Temporal Analyses of Cervical Cancer Patients in Upper Northern Thailand

Background: Cervical cancer is a major public health problem worldwide. There have been several studies indicating that risk is associated with geographic location and that the incidence of cervical cancer has changed over time. In Thailand, incidence rates have also been found to be different in each region. Methods: Participants were women living or having lived in upper Northern Thailand and subjected to cervical screening at Maharaj Nakorn Chiang Mai Hospital between January 2010 and December 2014. Generalized additive models with Loess smooth curve fitting were applied to estimate the risk of cervical cancer. For the spatial analysis, Google Maps were employed to find the geographical locations of the participants’ addresses. The Quantum Geographic Information System was used to make a map of cervical cancer risk. Two univariate smooths: x equal to the residency duration was used in the temporal analysis of residency duration, and x equal to the calendar year that participants moved to upper Northern Thailand or birth year for participants already living there, were used in the temporal analysis of the earliest year. The spatial-temporal analysis was conducted in the same way as the spatial analysis except that the data were split into overlapping calendar years. Results: In the spatial analysis, the risk of cervical cancer was shown to be highest in the Eastern sector of upper Northern Thailand (p-value <0.001). In the temporal analysis of residency duration, the risk was shown to be steadily increasing (p-value =0.008), and in the temporal analysis of the earliest year, the risk was observed to be steadily decreasing (p-value=0.016). In the spatial-temporal analysis, the risk was stably higher in Chiang Rai and Nan provinces compared to Chiang Mai province. According to the display movement over time, the odds of developing cervical cancer declined in all provinces. Conclusions: The risk of cervical cancer has decreased over time but, in some areas, there is a higher risk than in the major province of Chiang Mai. Therefore, we should promote cervical cancer screening coverage in all areas, especially where access is difficult and/or to women of lower socioeconomic status.

Genotyping for Human Papillomavirus (HPV) 16/18/52/58 Has a Higher Performance than HPV16/18 Genotyping in Triaging Women with Positive High-risk HPV Test in Northern Thailand

Background

Testing for high-risk human papillomavirus DNA (HPV test) has gained increasing acceptance as an alternative method to cytology in cervical cancer screening. Compared to cytology, HPV test has a higher sensitivity for the detection of histologic high-grade squamous intraepithelial lesion or worse (HSIL+), but this could lead to a large colposcopy burden. Genotyping for HPV16/18 has been recommended in triaging HPV-positive women. This study was aimed to evaluate the screening performance of HPV testing and the role of genotyping triage in Northern Thailand.

Methods

A population-based cervical screening program was performed in Chiang Mai (Northern Thailand) using cytology (conventional Pap test) and HPV test (Hybrid Capture 2). Women who had abnormal cytology or were HPV-positive were referred for colposcopy. Cervical samples from these women were genotyped using the Linear Array assay.

Results

Of 5,456 women, 2.0% had abnormal Pap test results and 6.5% tested positive with Hybrid Capture 2. Of 5,433 women eligible for analysis, 355 with any positive test had histologic confirmation and 57 of these had histologic HSIL+. The sensitivity for histologic HSIL+ detection was 64.9% for Pap test and 100% for Hybrid Capture 2, but the ratio of colposcopy per detection of each HSIL+ was more than two-fold higher with Hybrid Capture 2 than Pap test (5.9 versus 2.8). Genotyping results were available in 316 samples. HPV52, HPV16, and HPV58 were the three most common genotypes among women with histologic HSIL+. Performance of genotyping triage using HPV16/18/52/58 was superior to that of HPV16/18, with a higher sensitivity (85.7% versus 28.6%) and negative predictive value (94.2% versus 83.9%).

Conclusions

In Northern Thailand, HPV testing with genotyping triage shows better screening performance than cervical cytology alone. In this region, the addition of genotyping for HPV52/58 to HPV16/18 is deemed necessary in triaging women with positive HPV test.

Lack of Relationship of Egg White Intake with Occurrence of Leukopenia in Gynecologic Cancer Patients during Chemotherapy

Egg white intake during chemotherapy is common advice for cancer patients for the prevention of leukopenia. However, the benefit is uncertain. We conducted this prospective study to identify the relationship of egg white intake for gynecologic cancer patients who received carboplatin and paclitaxel and the occurrence of leukopenia. Between January 2014 and January, 2015, 81 patients were interviewed regarding their intake of egg whites before receiving subsequent chemotherapy. The basic data, the details of egg white intake and the grade of leukopenia in the previous cycle were recorded. The mean age was 54.1 years and 80% of the patients had a diagnosis of ovarian or endometrial cancer. The patients were interviewed at cycles 1-3 in 45 cases, 4-6 in 45 cases and 7-9 in two cases. Subsequent dose reduction was found in 6.2% and granulocyte-stimulating growth factors was given at 4.9%. All the patients ate egg whites with variations in the number of eggs per day as follows: less than one (3), one to two (56), three to four (14) and five to six (8). Over 70% were recommended by nurses to eat egg whites and about 63% of patients received other supplemental food. Some 44.1% of the patients who ate less than or equal to two eggs per day and 36.4% who ate more than two eggs per day developed grade 2-4 leukopenia, P = 0.61. In conclusion, the data did not provide evidence in support of the conclusion that a greater egg white intake could significantly reduce the occurrence of leukopenia.

Allelic Characterization of IGF2 and H19 Gene Polymorphisms in Molar Tissues

BACKGROUND

To investigate the characteristics of allelic distribution of IGF2 and H19 gene polymorphisms in molar tissues compared to normal placentas.

MATERIALS AND METHODS

Forty-nine specimens of molar tissues as well as 100 control normal placental tissues, delivered on the same days, were collected. Polymerase chain reaction (PCR) with restriction fragment length polymorphism (RFLP) on 2% agarose gel electrophoresis was conducted to determine the allelic distribution. The ApaI polymorphism within exon 9 of IGF2 and the RsaI polymorphism within exon 5 of H19 were employed to identify the allelic distribution of the IGF2 and H19 genes, respectively. Then the data for these genes in the molar and normal placenta tissues were compared.

RESULTS

The allelic distribution of IGF2 genes found in molar tissue were 21 (42.9%) aa (undigested), 10 (20.4%) ab (heterozygous) and 18 (36.7%) bb (digested), while in normal placenta tissue the values were 22 (22%) aa, 51 (51%) ab, and 27 (27%) bb. The allelic distribution of H19 in molar tissues was 8 (16.2%) aa (undigested), 8 (16.3%) ab (heterozygous) and 33 (67.4%) bb (digested) and in normal placental tissue was 16 (16%) aa, 36 (36%) ab and 48 (48%) bb in normal placenta tissue. These results were significantly different with P values of 0.001 and 0.037 for the allelic distribution of IGF2 and H19, respectively.

CONCLUSIONS

Molar tissues showed significant differences of allelic distribution of IGF2 and H19 from normal placenta tissues.

Histologic Outcomes in HPV-Positive and Cervical Cytology- Negative Women - Screening Results in Northern Thailand

The objective of this study was to determine the prevalence of significant lesions defined as high grade squamous intraepithelial lesions (HSIL), adenocarcinoma in situ (AIS) and invasive carcinoma in women who had HPV-positive and cytology negative co-testing screening results. This retrospective study was conducted in Chiang Mai University Hospital between May, 2013 and August, 2014. Hybrid capture 2 (HC2) was used for HPV testing and conventional Pap smears for cytologic screening. A repeat liquid-based cytology (LBC) was performed in women with such co-testing results followed by colposcopy. Random biopsy was performed in cases of normal colposcopic findings. Further investigations were carried out according to the biopsy or the repeat LBC results. During the study period, 273 women met the criteria and participated in the study. The mean age of these women was 46.4 years with 30% of them reporting more than one partner. The median interval time to colposcopy was 165 days. About 40% showed an abnormality in the repeat cytology. Significant cervical lesions were found in 20 (7.3%) women, including 2 invasive cancers. Of interest was that only 2 of 20 significant lesions were diagnosed by colposcopic examination while the remainder were initially detected by cervical biopsy and abnormal repeat cytology. In conclusion, the prevalence of significant cervical lesions in HPV positive and cytology negative women in Northern Thailand was 7.3%. Further diagnostic work up with repeat cytology follow by colposcopy is recommended. Random biopsy should be performed even when the colposcopic findings are normal.