Nakarin Sirisabya

Management of endometrial cancer in Asia: consensus statement from the Asian Oncology Summit 2009

Endometrial cancer is one of the gynaecological cancers that carries good overall prognosis because it is often detected at early stages of disease. The International Federation of Gynecology and Obstetrics replaced clinical staging with surgical staging in 1988 and updated the system in 2009. Controversies remain regarding the recommended screening protocol for women with a high risk of endometrial cancer, the role and benefit of retroperitoneal lymph-node dissection, the necessity of ovarian resection, the benefit and type of adjuvant radiation therapy, and the safety of hormone-replacement therapy after treatment. This article reviews the available evidence for optimum management of endometrial cancer and how management strategies can be applied in Asian countries with different levels of health-care resource availability and economic development. An overview of the literature for endometrial-cancer screening, diagnosis, and management is discussed. Consensus statements are formulated on the basis of basic, limited, enhanced, and maximum health-care resource availability, using the framework provided by the Breast Health Global Initiative.

Prevention of blood transfusion with intravenous iron in gynecologic cancer patients receiving platinum-based chemotherapy

OBJECTIVES To compare the efficacy of intravenous iron and oral iron for prevention of blood transfusions in gynecologic cancer patients receiving platinum-based chemotherapy. MATERIALS AND METHODS Sixty-four non anemic gynecologic cancer patients receiving adjuvant platinum-based chemotherapy were stratified and randomized according to baseline hemoglobin levels and chemotherapy regimen. The study group received 200mg of intravenous iron sucrose immediately after each chemotherapy infusion. The control group received oral ferrous fumarate at a dose of 200mg three times a day. Complete blood count was monitored before each chemotherapy infusion. Blood transfusions were given if hemoglobin level was below 10mg/dl. RESULTS There were 32 patients in each group. No significant differences in baseline hemoglobin levels and baseline characteristics were demonstrated between both groups. Nine patients (28.1%) in the study group and 18 patients (56.3%) in the control group required blood transfusion through 6 cycles of chemotherapy (p=0.02). Fewer median number of total packed red cell units were required in the study group compared to the control group (0 and 0.5 unit, respectively, p=0.04). Serious adverse events and hypersensitivity reactions were not reported. However, constipation was significantly higher in the control group (3.1% and 40.6%, p=<0.001). CONCLUSIONS Intravenous iron is an effective, well-tolerated treatment for primary prevention of blood transfusions in gynecologic cancer patients receiving platinum-based chemotherapy, associated with less constipation than the oral formulation.

Pyomyoma in a Perimenopausal Woman with Intrauterine Device

Pyomyoma (suppurative leiomyoma) is a rare disease, which is considered to be a serious complication of uterine leiomyoma. Since 1945, only 18 patients have been reported and ours is the 19th. Although it is frequently reported in pregnant women or postmenopausal women who have vascular disease, our case is a 42-year-old woman in the perimenopausal period who presented with fever and a tender lower abdominal mass. She used the intrauterine device as a contraceptive method but leiomyoma had never been found before. Ultrasonographic findings suggested an ovarian tumor. She was diagnosed as having infected malignant ovarian cancer with an elevated CA 125 level that was initially treated with broad spectrum antibiotics; then she underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Pathological findings showed acute and chronic inflammation of the endometrium with abscess formation in an intramural leiomyoma. The intrauterine device might be the origin of pyomyoma due to a direct spread of the infection from the uterine cavity. Pyomyoma may be difficult to diagnose especially in those with a nonspecific clinical presentation without any history of leiomyoma. Delayed diagnosis may result in serious complications, whereas adequate surgery and broad spectrum antibiotics may decrease serious morbidity and mortality.

Is complete surgical staging necessary in clinically early-stage endometrial carcinoma?

The purpose of this study was to evaluate the incidence of pelvic/para-aortic node metastases and the other pathological characteristics from medical records of patients with endometrial carcinoma treated at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, between1996 and 2005. The records of 213 patients with endometrial carcinoma who had complete surgical staging were reviewed. A particular focus was on clinically early-stage disease. Clinical staging could be determined in 206 patients. Of the 206 patients, 182 (88.3%) presented with clinical stage I disease. However, only 142 (78%) of these patients were confirmed as surgical stage I and 22% were upstaged. Preoperative histologic grade was diagnosed inaccurately in 15.9% of patients and 7.7% were upgraded. Of patients with preoperative histologic grade 1, 33% had deep myometrial invasion, 8.2% had pelvic node metastasis, and 3.3% had para-aortic node metastasis. Even in clinical stage IaG1, pelvic node metastasis occurred in 5.6% and para-aortic node metastasis in 1.3%. It has been suggested that complete surgical staging may not be necessary in patients with low-risk endometrial carcinoma who have disease limited to the uterus without grade 3 or deep myometrial invasion. However, proper selection of such low-risk patients remains problematic. In situations where there is limited preoperative and intraoperative assessment of high-risk factors, particularly radiographic imaging and frozen section assessment, the role of complete surgical staging is beneficial.

Comparison of Perioperative and Oncologic Outcomes with Laparotomy, and Laparoscopic or Robotic Surgery for Women with Endometrial Cancer

PURPOSE To compare perioperative outcomes and oncologic outcomes in endometrial cancer patients treated with laparotomy, and laparoscopic or robotic surgery. MATERIALS AND METHODS Endometrial cancer patients who underwent primary surgery from January 2011 to December 2014 were retrospectively reviewed. Perioperative outcomes, including estimated blood loss (EBL), operation time, number of lymph nodes retrieved, and intra and postoperative complications, were reviewed. Recovery time, disease free survival (DFS) and overall survival (OS) were compared. RESULTS Of the total of 218 patients, 143 underwent laparotomy, 47 laparoscopy, and 28 robotic surgery. The laparotomy group had the highest EBL (300, 200, 200 ml, p<0.05) while the robotic group had the longest operative time (302 min) as compared with laparoscopy (180 min) and laparotomy (125 min) (p<0.05). Intra and postoperative complications were not different with any of the surgical approaches. No significant difference in number of lymph nodes retrieved was identified. The longest hospital stay was reported in the laparotomy group (four days) but there was no difference between the laparoscopy (three days) and robotic (three days) groups. Recovery was significantly faster in robotic group than laparotomy group (14 and 28 days, p=0.003). No significant difference in DFS and OS at 21 months of median follow up time was observed among the three groups. CONCLUSIONS Minimally invasive surgery has more favorable outcomes, including lower blood loss, shorter hospital stay, and faster recovery time than laparotomy. It also has equivalent perioperative complications and short term oncologic outcomes. MIS is feasible as an alternative option to surgery of endometrial cancer.

Feasibility and Safety of Robotic Surgery for Gynecologic Cancers

BACKGROUND To determine surgical outcomes, perioperative complications, and patient outcomes in gynecologic cancer patients undergoing robotic surgery. MATERIALS AND METHODS Surgical outcomes, including docking time, total operative time, console time, estimated blood loss (EBL), conversion rate and perioperative complications were retrospectively reviewed in 30 gynecologic cancer patients undergoing robotic surgery. Patient outcomes included recovery time and patient satisfaction, as scored by a visual analogue scale (VAS) from 0-10. RESULTS The operations included 24 hysterectomies with pelvic lymphadenectomy (PLD) and/or para-aortic lymphadenectomy, four radical hysterectomies with PLD, and two radical trachelectomies with PLD. Mean docking time was 12.8 ± 9.7 min, total operative time was 345.5 ± 85.0 min, and console time was 281.9 ± 78.6 min. These times were decreased in the second half of the cases. There was no conversion rate. Three intraoperative complications, including one external iliac artery injury, one bladder injury, and one massive bleeding requiring blood transfusion were reported. Postoperative complications occurred in eight patients, most were minor. Only one patient had port herniation that required reoperation. Mean hospital stay was 3.5 ± 1.7 days, and recovery time was 14.2 ± 8.1 days. Two-thirds of patients felt very satisfied and one-third felt satisfied; the mean satisfaction score was 9.4 +0.9. Two patients with stage III endometrial cancer developed isolated port site metastasis at five and 13 months postoperatively. CONCLUSIONS Robotic surgery for gynecologic cancer appears to be feasible, with acceptable perioperative complication rate, fast recovery time and high patient satisfaction.

Characteristics of Gynecologic Oncology Patients in King Chulalongkorn Memorial Hospital - Complications and Outcome of Pelvic Exenteration

BACKGROUND Pelvic exenteration is a procedure which includes enbloc resection of pelvic organs followed by surgical reconstruction. Aims include both cure and palliation but data for pelvic exenteration in Thailand are very limited. OBJECTIVE This study was conducted to evaluate characteristics of patients, operative procedure outcomes and complications. MATERIALS AND METHODS This retrospective review covered all of the charts of exenteration patients during January 2002 to December 2011. Baseline characteristic of the patients were collected as well as details of clinical results. RESULTS A total of 13 cases of pelvic exenteration were included. Most underwent total pelvic exenteration (9 cases) and the remainder posterior and anterior exenteration. Their primary cancers were ovarian, cervical and vulva. Mean operative time was 532 minutes (SD 160.2, range 270- 750) and estimated blood loss was 2830 ml (1850, 1000-8000). Mean tumor size was 7.33 cm (3.75, 4-15). Mean hospital stay was 35.2 days (29.8, 13-109). The most common post operative complication was urinary tract infection. Overall disease free survival with a negative surgical margin was significantly better than in positive surgical margin patients (p=0.014). CONCLUSIONS Surgical margin was the most significant prognostic factor for disease free survival, in line with earlier studies.