Comparison of surgical and oncologic outcomes in patients with clear cell ovarian carcinoma associated with and without endometriosis

PURPOSE

To compare clinical characteristics, surgical and oncologic outcomes of clear cell ovarian cancer among patients with cancer arising from endometriosis, cancer coexisting with endometriosis, and cancer without endometriosis.

METHODS

A retrospective chart review of patients diagnosed with clear cell ovarian cancer during January 1998-March 2013 was performed. All histopathology specimens were reviewed by a gynecologic pathologist and classified into one of the three following endometriosis status groups: arising group, coexisting group, or without group. The primary outcome was disease-specific survival (DSS). The secondary outcomes were progression-free survival, surgical morbidities, response rate, recurrence rate, and cancer-specific death.

RESULTS

Finally, 249 patients were included. There were 82, 96, and 71 patients in the arising, coexisting, and without groups, respectively. Regarding baseline characteristics among groups, the without group was significantly older and had more advanced diseases. There was a significant difference in progression-free survival between the arising group and the without group (p = 0.003). Five-year progression-free survival rates were 62.8% in the arising group, 50.2% in the coexisting group, and 38.3% in the without group. DSS was not significantly different among groups. Multivariate analysis revealed ovarian surface invasion (HR = 2.76) and pelvic lymphadenectomy (HR = 0.39) to be independent prognostic factors for progression-free survival, whereas no remission after primary treatment (HR = 8.03) and pelvic lymphadenectomy (HR = 0.21) were prognostic factors for DSS. Intraoperative blood loss and residual tumor were significantly higher in the without group.

CONCLUSIONS

Endometriosis status was found not to significantly influence surgical and oncologic outcomes in patients with clear cell ovarian cancer.

Gestational Trophoblastic Neoplasia with Gum Metastasis: A Case Study and Literature Review

Gestational trophoblastic neoplasia (GTN) is an uncommon group of pregnancy-related malignancies. Delayed diagnosis is a prognostic factor for worse outcome. GTN is even harder to diagnose if the site of metastasis is uncommon. The reported case is a 27-year-old G₂P₁A₁ woman who presented to our center with acute transient generalized tonic-clonic seizure. She had developed hemoptysis for the 2 preceding weeks, which had been treated as pneumonia. She had then noticed multiple gum lesions and vaginal spotting 1 week before her presentation. Her serum β-human chorionic gonadotropin level was 77,474 IU/L without evidence of pregnancy. She was diagnosed with GTN with lung, brain, and gum metastases. The patient was staged as IV with a World Health Organization prognostic score of 14. Etoposide, methotrexate, actinomycin D alternating with cyclophosphamide, and vincristine weekly (EMACO) were given. The gum lesions disappeared after 2 cycles of the multiagent chemotherapy, and complete remission was achieved after 8 cycles. This case study will increase awareness of uncommon metastatic sites of GTN. Any associated vaginal bleeding should be considered a clue to metastatic GTN.

Comparison of Siriraj liquid-based solution and standard transport media for the detection of high-risk human papillomavirus in cervical specimens

PURPOSE

To evaluate the performance of Siriraj liquid-based solution for human papillomavirus (HPV) DNA testing compared with standard transport media.

METHODS

This cross-sectional study enrolled 217 women aged 30 years or older who attended for cervical cancer screening or had abnormal cervical cytology, or were diagnosed with cervical cancer at the Department of Obstetrics-Gynecology, Siriraj Hospital from March 2015 to January 2016. We excluded patients with a history of any cervical procedures, hysterectomy, or previous treatment with pelvic irradiation or chemotherapy. Two cervical specimens were collected from each participant. The standard Cervi-Collect Specimen Collection Kit was used to preserve the first sample, and Siriraj liquid-based solution was used for the second one. All samples were sent for HPV DNA testing using the same standard high-risk HPV assay. HPV test results were recorded and statistically analyzed.

RESULTS

The results showed agreement between standard transport media and Siriraj liquid-based solution for HPV DNA testing, at a kappa value of 0.935 (P < 0.001). We found no discorrelation for the detection of HPV 16, which accounts for approximately 50% of cervical cancers. The relative sensitivity of Siriraj liquid-based solution and standard transport media in patients with high-grade cervical intraepithelial neoplasia or worse (CIN2+) is 98% (50/51). The relative specificity of Siriraj liquid-based solution and standard transport media in patients with non-CIN2+ is 98.1% (102/104).

CONCLUSION

Siriraj liquid-based solution showed almost perfect agreement with the standard transport media for HPV DNA testing. This solution, costing 2 to 3 times less than the commercially available standard media, may be an alternative option for HPV DNA testing.

Pregnancy Outcomes after Conservative Surgery for Early-Stage Ovarian Neoplasms

Objective:

This retrospective, single institute study aimed to evaluate pregnancy and oncologic outcomes in reproductive-age Thai women with early-stage ovarian neoplasms undergoing conservative surgical treatment.

Methods:

Medical records of 84 women of reproductive age (15-45 years) with histologically confirmed early-stage (IA-IIC) borderline ovarian tumors or cancers who had undergone conservative surgery between January 2003 and December 2012 were retrospectively reviewed.

Results:

The mean age of patients at diagnosis was 28.0 years (SD 7.2). Histologically, 30 (35.7%) had borderline ovarian tumors, 28 (33.3%) epithelial cancers, 22 (26.2%) malignant germ cell tumors, and 4 (4.8%) sex cord stromal tumors. Thirty-five women (41.7%) had complete surgical staging performed, whereas 49 (58.3%) underwent an incomplete staging procedure. Thirty-four patients (40.5%) received postoperative chemotherapy. Among 29 patients subsequently attempting pregnancy, 15 conceived successfully (51.7%). Pregnancy outcomes were one spontaneous abortion and 14 viable births. There were no serious adverse obstetric and neonatal outcomes among women with documented live births and no reported fetal abnormalities. Pregnancy rates were not impacted by surgical staging (53.8% vs 50.0%, p=0.837) or adjuvant chemotherapy (55.6% vs 50.0%, p=0.782). The 5-year disease-free survival was 91.0% and pregnancy after conservative surgery did not affect progression-free survival (p=0.194).

Conclusion:

Conservative surgery with or without appropriate adjuvant chemotherapy can be offered to young women with early-stage ovarian neoplasms who wish to preserve their fertility potential.

Preoperative thrombocytosis and poor prognostic factors in endometrial cancer

This study aimed to evaluate the prevalence of preoperative thrombocytosis and its prognostic significance in Thai patients with endometrial cancer. We retrospectively reviewed the medical records of 238 cases who had undergone surgical staging procedures between January 2005 and December 2008. Associations between clinicopathological variables and preoperative platelet counts were analyzed using Pearson's chi square or two- tailed Fisher's exact tests. Survival analysis was performed with Kaplan-Meier estimates. Univariate and Cox- regression models were used to evaluate the prognostic impact of various factors including platelet count in terms of disease-free survival and overall survival. The mean preoperative platelet count was 315,437/μL (SD 100,167/ μL). Patients who had advanced stage, adnexal involvement, lymph node metastasis, and positive peritoneal cytology had significantly higher mean preoperative platelet counts when compared with those who had not. We found thrombocytosis (platelet count greater than 400,000/μL) in 18.1% of our patients with endometrial cancer. These had significant higher rates of advanced stage, cervical involvement, adnexal involvement, positive peritoneal cytology, and lymph node involvement than patients with a normal pretreatment platelet count. The 5-year disease-free survival and overall survival were significantly lower in patients who had thrombocytosis compared with those who had not (67.4% vs. 85.1%, p=0.001 and 86.0% vs. 94.9%, p=0.034, respectively). Thrombocytosis was shown to be a prognostic factor in the univariate but not the multivariate analysis. In conclusion, presence of thrombocytosis is not uncommon in endometrial cancer and may reflect unfavorable prognostic factors but its prognostic impact on survival needs to be clarified in further studies.

Long term outcomes of laser conization for high grade cervical intraepithelial neoplasia in Thai women

AIM

To report long term outcomes of laser conization for high grade cervical intraepithelial neoplasia (CIN) in Thai women.

MATERIALS AND METHODS

A retrospective cohort study was conducted in patients undergoing laser conization due to abnormal cervical cytology suggesting neoplasia during 1989 to 1994 and having follow-up data until December 2010. Conization was performed under colposcopy using a 0.5-mm CO2 laser beam with power density of 18,000-20,000 watts/cm2, and the surgical base was vaporized using a low power defocused beam. The follow-up protocol included cervical cytology and colposcopy. Long term outcome measures were failure rate (persistence and recurrence), post-conization status of transformation zone, and obstetric outcomes.

RESULTS

Of 104 patients undergoing conization, 71 had therapeutic conization for high grade CIN and were followed up for a median time of 115 (range 12-260) months. There was one case of persistent and one of recurrent disease comprising a failure rate of 2.8%. The post treatment transformation zone was well visualized in 68.3% of 63 patients with an intact uterus. Sixteen patients achieved 25 pregnancies; none had second trimester miscarriage. The obstetric outcomes were unremarkable.

CONCLUSIONS

Laser conization under colposcopic visualization for the treatment of high grade CIN in Thai women has a low failure rate of 2.8%. The post-conization transformation zone could not be evaluated completely in approximately 30% of cases; therefore the follow-up protocol should include both cytology and colposcopy. Obstetric outcomes are not adversely affected by this therapeutic procedure.

Long-term outcomes of a loop electrosurgical excision procedure for cervical intraepithelial neoplasia in a high incidence country

AIM

To evaluate the operative, oncologic and obstetric outcomes of the loop electrosurgical excision procedure (LEEP) in cases with cervical neoplasia.

MATERIALS AND METHODS

A retrospective cohort study was conducted on patients who were suspected of cervical neoplasia and therefore undergoing LEEP at Siriraj Hospital, Mahidol University, Thailand, during 1995-2000. Outcome measures included operative complications in 407 LEEP patients and long-term outcomes in the 248 patients with cervical intraepithelial neoplasia (CIN) who were treated with only LEEP.

RESULTS

There were 407 patients undergoing LEEP; their mean age was 39.7±10.5 years. The histopathology of LEEP specimens revealed that 89 patients (21.9%) had lesions ≤CIN I, 295 patients (72.5%) had CIN II or III, and 23 patients (5.6%) had invasive lesions. Operative complications were found in 15 patients and included bleeding (n=9), and infection (n=7). After diagnostic LEEP, 133 patients underwent hysterectomy as the definite treatment for cervical neoplasia. Of 248 CIN patients who had LEEP only, seven (2.8%) had suffered recurrence after a median of 16 (range 6-93) months; one had CIN I, one had CIN II, and five had CIN III. All of these recurrent patients achieved remission on surgical treatment with re-LEEP (n=6) or simple hysterectomy (n=1). A significant factor affecting recurrent disease was the LEEP margin involved with the lesion (p=0.05). Kaplan-Meier analysis showed 5-year and 10-year disease-free survival (DFS) estimates of 99.9%. Twelve patients became pregnant a total of 14 times, resulting in 12 term deliveries and two miscarriages - one of which was due to an incompetent cervix.

CONCLUSIONS

LEEP for patients with cervical neoplasia delivers favorable surgical, oncologic and obstetric outcomes.

Presence of anemia and poor prognostic factors in patients with endometrial carcinoma

This study evaluated the relationship between pretreatment hemoglobin (Hb) and prognostic factors in Thai patients with endometrial cancer. Medical records of 228 patients who had undergone surgery between January 2005 and December 2007 were retrospectively reviewed. Associations between clinicopathological variables and pretreatment Hb levels were described using Pearson's chi square test or two-tailed Fisher's exact test. Survival analysis was performed with Kaplan-Meier estimates. Univariate and Cox-regression models were used to evaluate the prognostic impact of various factors, including Hb levels, in term of disease-free survival. The median duration of follow-up was 38.2 months. Eighty-nine patients (39%) had a preoperative Hb level of <12 g/dL, these having significantly higher rates of non-endometrioid histology, advanced FIGO stage, lymphovascular space invasion, cervical involvement, adnexal involvement, positive peritoneal cytology, and lymph node involvement than patients with Hb ≥12 g/dL. The 5-year disease-free and overall survival were significantly lower in patients with pretreatment Hb levels <12 g/dL compared with those with Hb ≥12 g/dL (79.3% vs. 89.2%, p=0.044 and 87.6% vs. 99.3%, p<0.001, respectively). In the multivariate analysis only histology, myometrial invasion, and lymphovascular invasion proved to be independent prognostic factors, whereas tumor grading, stage, cervical involvement, adnexal involvement, positive peritoneal cytology, lymph node involvement, and low Hb were not. In conclusion, presence of anemia before treatment may reflect poor prognostic factors in patients with endometrial cancer and low pretreatment hemoglobin level may have a prognostic impact on clinical outcome.

Spontaneous perforation of pyometra in an elderly woman: a case report

Pyometra is an uncommon gynecologic condition that usually develops in elderly women. Most of the cases result from cervical occlusion by malignant or benign tumors, surgery, radiotherapy, or atrophic cervicitis. A spontaneous perforation of the uterus with generalized peritonitis is an extremely rare complication of pyometra and carries significant morbidity and mortality. Establishing a correct diagnosis preoperatively is not easy due to the non-specificity of the symptoms. The authors present a case report of peritonitis caused by spontaneously perforated pyometra that was diagnosed intraoperatively. The cervical canal was not occluded and the cause of perforation remains obscure.

Prognostic significance of hemoglobin levels in patients with primary epithelial ovarian carcinoma undergoing platinum-based chemotherapy

The aim of this study was to evaluate the prognostic impact of hemoglobin (Hb) levels before and throughout the course of platinum-based chemotherapy in patients with primary epithelial ovarian cancer (EOC). Medical records of patients who had undergone initial surgery followed by platinum-based chemotherapy for EOC were retrospectively studied. Univariate and Cox-regression models were used to evaluate the prognostic impact of various factors including Hb levels before and throughout chemotherapy in terms of overall survival. Additionally, sensitivity/specificity were calculated using receiver operating curves (ROCs) and Kaplan-Meier studies were used to determine optimal cut-off levels. The median duration of follow-up was 37.0 months. Degree of anemia before starting chemotherapy was significantly related to overall survival (p = 0.001), but the Hb level throughout chemotherapy demonstrated only a borderline relationship (p = 0.062). Only residual tumor after surgery and degree of anemia before starting chemotherapy proved to be independent prognostic factors (p = 0.013 and 0.015, respectively). With sensitivity/specificity and Kaplan-Meier analyses, a Hb level before starting chemotherapy of less than 10.5 g/dl was related to shorter overall survival (p = 0.002). In conclusion, pre-chemotherapy Hb level has a prognostic impact on overall survival in patients with EOC candidate to first-line platinum-based chemotherapy. However, the significance of decreased Hb levels during chemotherapy needs to be clarified in further prospective studies to determine optimal Hb levels for achieving a favorable outcome.

Prevalence and incidence of anemia in Thai patients with gynecologic cancer

This prospective, single institute, 6-month observational survey aimed to evaluate the prevalence, incidence, frequency, treatment of anemia, and trigger hemoglobin (Hb) level for initiating transfusion in patients with gynecologic malignancy. One hundred and eighty-six consecutive patients with gynecologic malignancy were analyzed between June and December 2009. Hb level data were collected for up to six data points or 6 months of scheduled visits. Tumor type, disease status, cancer treatment and anemia treatment as well as trigger Hb level for starting treatment were evaluated. The mean age of patients was 51 years. Prevalence of anemia at enrollment was 66.1% (123/186), with 36 of 186 patients (19.4%) having moderate to severe anemia (Hb < 10.0 g/dl). The highest prevalence was found among patients with endometrial cancer (72.2%) and ovarian cancer (72%), newly-diagnosed/receiving treatment (70.9%) and those receiving radiotherapy (75%). The incidence of anemia was 85.7% (54/63). Ovarian cancer had the highest association (87%). For disease status and cancer treatment, the incidence was highest in patients with persistent/recurrent disease (95.2%) and those who received radiotherapy (100%). One hundred and seventy-seven of 186 patients (95.2%) were ever anemic during the survey. Anemia was frequently reported in patients with all tumor types (93-100%), persistent/recurrent disease (98.3%) and those who received radiotherapy (100%) and 80.8% of patients who were ever anemic received treatment (oral iron, 42.9%; transfusion, 37.3%; and erythropoietic agent, 0.6%). In conclusion, the mean Hb trigger level for initiating transfusion as treatment of anemia was 8.6g/dL. The prevalence, incidence, and frequency of anemia are very high among patients with gynecologic malignancy; especially those with ovarian cancer, persistent/recurrent disease, and those receiving treatment.

Meigs' Syndrome with Elevated Serum CA125: Case Report and Review of the Literature

An elevated serum CA125 level in association with a pelvic mass, pleural effusion, and massive ascites usually signifies a dismal prognosis in a postmenopausal woman. However, surgery and histopathological examination are required for the correct diagnosis and treatment, since an elevated CA125 level can be falsely positive for ovarian malignancy. We present a case of Meigs’ syndrome due to right ovarian fibroma with elevated CA125 level in a postmenopausal woman.

Comparison between Siriraj liquid-based and conventional cytology for detection of abnormal cervicovaginal smears: a split-sample study

This study aimed to evaluate the correlation and agreement between Siriraj liquid-based cervical cytology (Siriraj -LBC) and conventional cytology. A total of 479 women who attended the Department of Obstetric and Gynaecology Siriraj Hospital for cervical cancer screening were enrolled. For each woman collection of cervical cells was performed using VCE technique. After smearing cells on a glass slide for conventional cytology, both broken ends of wooden spatula and cotton swabs were then placed into a plastic vial containing a specific preservative solution for Siriraj-LBC. All specimens were prepared and interpreted by experienced cytotechnologists at the Gynecologic Cytology Unit. Interpretations of the results from one technique were made without knowledge of those from the other technique. The results from both techniques were compared for agreement and correlation. Colposcopy or histology was used as the gold standard. The overall detection rate of abnormal cervicovaginal cells was higher by Siriraj-LBC than by conventional cytology (11.1% vs. 1.67%, P <0.001). These two techniques had high diagnostic agreement of 89.77%, and minimal to fair correlation with a Kappa of 0.128 (P<0.001) and a Spearman rho correlation coefficient of 0.394 (P <0.001). There were 49 cases whose Siriraj-LBC revealed higher cytologic grading than did the conventional cytology; there were no cases of the opposite result. The gold standard was available in 45 cases with abnormal cytology by Siriraj-LBC, revealing a positive predictive value (PPV) of 71.1% for Siriraj-LBC and 97.8% for conventional cytology, and a negative predictive value (NPV) of 42.2% for the conventional cytology. In conclusion, The results from Siriraj-LBC and conventional cytology have high diagnostic agreement and minimal to fair correlation. The Siriraj-LBC increases detection rate of abnormal cervicovaginal cells with probable decrease in false negatives but increase in false positives from the baseline values by conventional cytology. Therefore the screening performance of Siriraj-LBC is not inferior to the conventional cytology and this approach may be used as an alternative screening method for cervical cancer.

A case of ovarian endodermal sinus tumor diagnosed during pregnancy

Pregnancy complicated by endodermal sinus tumor of the ovary is extremely rare. The authors present a case report of a pregnant woman with persistent left adnexal mass and subsequently found to have a primary endodermal sinus tumor of the ovary that was diagnosed at 19 weeks of gestation. After left salpingo-oophorectomy had been performed, the patient chose to terminate the pregnancy before the initiation of combination chemotherapy with bleomycin, etoposide, and cisplatin. The response to chemotherapy was not satisfactory. The patient expired after seven cycles of treatment had been completed because of pulmonary fibrosis and the drug toxicity of bleomycin.

Pre-operative prediction of serum CA125 level in women with ovarian masses

OBJECTIVE

To assess the accuracy of serum CA125 at the level of more than 35 U/mL in predicting ovarian cancer using histopathology as a gold standard.

MATERIAL AND METHOD

Blood samples were obtained from 120 women with ovarian masses scheduled for elective surgery at Siriraj Hospital between October 1, 2003 and August 31, 2004 and sent for the assay of serum CA125 levels.

RESULTS

Of the 120 women enrolled, ovarian cancer was found in 59 cases (49.2%) and benign ovarian mass in 61 cases (50.8%). The sensitivity, specificity, and accuracy of serum CA125 at the cutoff level of 35 U/mL for prediction of ovarian cancer were 83.1%, 39.3%, and 60.8%, respectively; with 57.0% positive predictive value, 70.6% negative predictive value, 60.7% false positive rate, and 16.9% false negative rate.

CONCLUSION

As stand-alone modality, serum CA125 of more than 35 U/mL in predicting ovarian cancer revealed modest diagnostic accuracy. There is a need to be careful for false positive in women at reproductive age group and false negative results in early-stage disease or ovarian cancer with low level of serum CA125.

Sonographic morphological pattern in the pre-operative prediction of ovarian masses

The study was undertaken to evaluate the accuracy of sonographic morphological pattern in the detection of ovarian malignancy. A total of 123 patients with a suspicion of ovarian pathology, who were scheduled for elective surgery at the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University were included in the study. All patients underwent sonographic examination prior to surgery by the same physician. The sonographic morphological pattern of each patient was compared to the histological diagnosis of the ovarian tumors. Of the 120 patients with an ovarian lesion, the sonographic morphological pattern of 10 had a sensitivity of 88.6 per cent and a specificity of 89.4 per cent in detection of malignant ovarian tumors. The positive predictive value, negative predictive value, and the accuracy rate were 77.5, 95.0, and 89.2 per cent, respectively. In the present study, a score of 9 would be the best discriminator between benign and malignant ovarian masses, giving a sensitivity of 97.1 per cent and specificity of 82.4 per cent. As stand alone, the present results confirm that ultrasonography is still a useful diagnostic tool in the differentiation of benign from malignant ovarian masses.

Color Doppler ultrasonography for prediction of malignant ovarian tumors

The purpose of this cross-sectional study was to evaluate whether the pulsatility index determined by the color Doppler sonography could be used to distinguish between benign and malignant ovarian tumors. A total of 120 patients who had their ovarian tumors removed surgically at the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University were included in the study. Each patient had color Doppler sonography performed prior to laparotomy. The Doppler results were compared to the histological diagnosis of the ovarian tumors. Of the 113 patients whose intratumoral blood flow could be evaluated, the pulsatility index was significantly lower in malignant lesions than in benign lesions (0.85 +/- 0.46 vs 1.63 +/- 0.64, p<0.001). The sensitivity, specificity, and accuracy of the pre-operative pulsatility index (< or = 1.0) in detecting malignant ovarian tumors were 82.9 per cent, 80.8 per cent, and 81.4 per cent, respectively; with 65.9 per cent positive predictive value, 91.3 per cent negative predictive value, 19.2 per cent false positive rate, and 17.1 per cent false negative rate. The present results suggest that color Doppler sonography may be a useful clinical tool in the pre-operative evaluation of ovarian masses. However, the pulsatility indexes showed considerable overlap between benign and malignant lesions, indicating that color Doppler sonography has limitations in the differentiation of benign from malignant ovarian masses. The cost of the equipment and experience requirement also limits its use in general gynecologic practice.

Vulvar melanoma at the M. D. Anderson Cancer Center: 25 years later

The purpose of this study was to review the clinical course of patients diagnosed with vulvar melanoma. Charts of patients diagnosed between 1970 and 1997 were reviewed for demographics, lesion characteristics, disease duration and extent, and treatments. Actuarial survival curves were computed by the Kaplan Meier method and compared by Cox proportional hazards regressions. Fifty-one patients (median age 54) with vulvar melanoma presented with a vulvar mass (39%), pain (30%), bleeding (24%), and itching (20%). Anatomical distribution was mucosa of the vulva (65%), vulvar epidermal site (21%), or unspecified vulva (14%), with 20% having multifocal disease at diagnosis. Histologic types were superficial spreading or nodular (50% each). Median lesion characteristics were diameter 2 cm, Breslow index 4.4 mm, and Clark level IV. Distribution of patients per American Joint Committee on Cancer (AJCC) stage was 29%, 50%, 16%, and 7% for stages I, II, III and IV, respectively. Inguinal node metastases were unilateral in 16% and bilateral in 7%. Despite complete surgical resection, 32 patients (63%) recurred. Median survival for all patients was 41 months (range, 5-324), with 91% 5-year survival for patients with stage I and 31% for stage >or= IIA (P = 0.0002). As with cutaneous melanoma, the AJCC classification, Breslow's thickness, and Clark's levels are the major predictors of overall survival (P = 0.0001 each) and disease-free survival (P <or= 0.0001, 0.0004, and 0.0002, respectively). Surgical techniques do not seem to alter the prognosis. Because vulvar melanoma carries a poor prognosis at early stages, the use of adjuvant therapies needs to be studied prospectively in women affected with this disease.

The correlation of beta-subunit human chorionic gonadotropin level in the serum and first morning urine of patients with gestational trophoblastic disease

The purpose of this cross-sectional study was to determine the correlation of beta subunit human chorionic gonadotropin (beta-hCG) level in the serum and first morning urine samples of patients with gestational trophoblastic disease (GTD). A total of 81 paired serum and first morning urine samples from 24 patients diagnosed with GTD, who had their follow-up at the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University. The paired serum and first morning urine samples were measured for beta-hCG level, using enzyme-linked immunosorbent assay (ELISA). After logarithmic transformation, serum beta-hCG level was strongly and significantly correlated to those of first morning urine samples, with the correlation coefficient of 0.97 (p < 0.01). Among the disease-remission group (serum beta-hCG of less than 5 mIU/ml), the correlation coefficient was 0.52 (p < 0.01), which was still statistically significant. Stronger statistical significance was found in the disease-active group (serum beta-hCG of 5 mIU/ml or higher), with the correlation coefficient of 0.95 (p < 0.01). We concluded that the level of serum beta-hCG was strongly and significantly correlated with those of first morning urine samples, especially in patients with active disease. Determination of beta-hCG level using first morning urine samples can be used as an effective mean in the follow-up of patients with GTD.

Benign cystic teratoma of the ovary : a review of 608 patients

This retrospective study reports on 608 cases of benign cystic teratoma of the ovary treated at Siriraj Hospital over a ten-year period from 1988-1997. Mean age of the patients was 33.7 + 11.3 years. Approximately one-third of the patients (35.0%) were asymptomatic when the teratomas were discovered, of the rest, the common presenting symptoms were abdominal pain (52.9%) or palpable abdominal mass (30.6%). The tumors were between 6-10 cm in greatest diameter in more than half of the patients (53.6%) and in 78 patients (12.8%), the tumors were bilateral. Complications from the tumors were found in 72 patients (11.8%): 68 cases of torsion (94.4%); two were spontaneous rupture (2.8%); and two were infected (2.8%). The mean age of patients with twisted tumor was significantly less than that of patients with uncomplicated tumor (p = 0.02), and abdominal pain was found more commonly in the patients with twisted tumor (p < 0.001). Among cases with torsion, more than 90 per cent of the tumors were found to be of intermediate size (6-15 cm), while only 68.8 per cent were found in uncomplicated cases (p < 0.001). Surgical treatment was conservative in 63.8 per cent) and radical in 36.2 per cent of the patients.

Gemcitabine after bone marrow transplantation for refractory juvenile granulosa cell tumor

A 19-year-old woman with refractory juvenile granulosa cell tumors had persistent disease after PVB (cisplatin, vinblastine and bleomycin) and multiple high doses of ICE (ifosfamide, carboplatin and etoposide) with peripheral stem cell support. She achieved stable disease for 4 months with low dose intensity gemcitabine of 500 mg/m2/week. The planned dose had been 1250 mg/m2/week. The dose intensity was limited by myelosuppression especially thrombocytopenia. The use of thrombopoietic, in addition to erythropoietic and myelopoietic, agents may permit higher dose intensity of gemcitabine after bone marrow ablative therapy with resulting greater anti-tumor activity.

Docetaxel and cyclophosphamide induced remission in platinum and paclitaxel refractory ovarian cancer

Platinum-based chemotherapy is the standard treatment for advanced ovarian cancer, with response rates of 40-60%. In patients who fail platinum treatment, paclitaxel has resulted in response rates of 10-48%. Docetaxel has partial non-cross-resistance with and is twice as potent in vitro as paclitaxel in inhibiting microtubule disaggregation. The combination of docetaxel and cyclophosphamide is synergistic in pre-clinical studies and clinically active in breast cancer. We present the case of a patient with platinum and paclitaxel refractory ovarian cancer who achieved a remission with docetaxel and cyclophosphamide.

Carpal tunnel syndrome during pregnancy: prevalence and blood level of pyridoxine

The prevalence of CTS in third trimester pregnant women in the study in 28 per cent. With the use of NCS it was able to detect nearly 80 per cent of them who had no symptoms or signs. There was no association between the level of vitamin B6 or B6 deficiency and CTS. Since CTS may result in a permanent disability if undiagnosed or left untreated it is essential to make an early diagnosis and treat it especially older women and those who are edematous.