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OBJECTIVE: To determine survival among patients with epithelial ovarian carcinoma (EOC) who underwent a second-look laparotomy (SLL) and those refusing the procedure. Also to analyze factor(s) influencing the survival of the patients. METHOD AND MATERIAL: Medical records were reviewed of patients with advanced EOC who were clinically free of disease after primary surgery and platinum-based chemotherapy between January 1, 1992, and December 31, 1998. All of them were offered SLL. Measurement outcomes include patient survival and disease-free survival. RESULTS: There were 50 patients with clinically complete remission after chemotherapy. Sixteen patients underwent SLL, and thirty-four patients refused the procedure (NSLL). Seven patients (43.8%) were reported to have positive SLL. After the median follow-up time of 35 months, 12 patients had died, and 5 patients were lost to follow-up. The median survival time for patients with SLL was about 60 months. Five-year survival rates of patients in the SLL, and NSLL groups were 37 per cent (95%CI = 7%-69%), and 88 per cent (95%CI = 65%-96%) respectively (P<0.001). The median time to relapse was about 25 months for patients with negative SLL. Five-year disease-free survival rates of patients in the negative SLL, and NSLL groups were 28 per cent (95%CI = 4%-59%), and 54 per cent (95%CI = 34%-70%) respectively (P=0.251). By Cox regression analysis, tumor grade was the only significant prognostic factor influencing patients' survival (HR = 6, 95%CI of HR = 1.2-34.2). CONCLUSION: The second-look laparotomy doesn't have a favorable impact on overall and disease-free survival. Tumor grade is the only independent prognostic variable for survival of the patients.

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OBJECTIVE: To review the outcome of the treatment in patients with malignant ovarian Germ cell tumors with respect to survival and surgical management at a single institution during 1990-1996. METHODS: Thirty-four patients with malignant ovarian Germ cell tumors were studied retrospectively for their surgical management. Fourteen patients had pure dysgerminoma, 11 endodermal sinus tumor, 6 immature teratoma, and 3 mixed Germ cell tumors. Nine patients had stage IA, 8 stage IC, 2 stage IIC, 8 stage III, 3 stage IV, and 4 referred patients with recurrent diseases. RESULTS: Nineteen patients underwent primary conservative surgery, 11 had primary nonconservative surgery. Twenty-two patients were treated with chemotherapy (BEP or EP or PVB regimen). Five patients with pure dysgerminoma received adjuvant radiotherapy. Persistent remission was achieved in 26 patients. Two patients (7.4%) had recurrence after remission. Seven patients had died of the diseases. Patients with complete clinical remission did not undergo second-look surgery. The overall survival was 78.8%, 100% for immature teratoma, 84.6% for pure dysgerminoma, 72.8% for endodermal sinus tumor, and 33.3% for mixed Germ cell tumors, with median follow-up time 31 (3-93) months. CONCLUSION: Patients with limited diseases regardless of histologic types can be safely managed by unilateral salpingo-oophorectomy followed by, if indicated, 3-4 courses of cisplatin-based chemotherapy. For advanced diseases, conservative surgery is advisable in patients with endodermal sinus tumor.

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Gestational choriocarcinoma metastasized to the nasal mucosa is extremely rare. An HIV-infected woman with choriocarcinoma presenting with a nasal mass is reported. The clinical findings are compared with a previous reported case. She responded to multiagent chemotherapy and has obtained complete remission. The role of HIV infection is also discussed.

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This study presented the outcome of 92 EOC patients treated by platinum or platinum analogue with cyclophosphamide from January 1, 1993 to December 31, 1995. There were 77 evaluable patients. The follow-up ranged from 4-42 months (median 14 months). The over all 3-year survival was 64 per cent and the median progression-free interval was 16 months for the whole group. There was no significant difference in survival between patients who received cisplatin and those who received carboplatin (P = 0.093). Patients who underwent optimal debulking surgery had significantly longer progression-free interval (P = 0.001) than those who had sub-optimal surgery. Fifty four per cent of patients with clear cell carcinoma died of the disease. Patients who received cisplatin had a drop out rate while on therapy more often (24% vs 5.3%) than that of carboplatin. Toxicities from chemotherapy were moderate but manageable.

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Studies on CA 125 in hydatidiform mole are limited. The objective of this study was to measure the preevacuation serum CA 125 level in patients with complete hydatidiform mole and to determine whether it could predict the later development of persistent trophoblastic disease. Preevacuation serum CA 125 levels were immunoradiometrically measured in 69 patients with histologically confirmed complete hydatidiform mole. The mean (range) serum CA 125 level was 63.7 (10.5-404.7) U/ml. Using 35 U/ml as the cutoff point, the elevated CA 125 levels were observed in 53.6% (37/69) of the patients. The mean serum CA 125 level of patients who later developed persistent trophoblastic disease was not significantly higher than that of those who had benign course (78.9 vs 52.6 U/ml, P > 0.05). In conclusion, the preevacuation serum CA 125 level was elevated in about half of patients with complete hydatidiform mole and it could not be used to predict the subsequent development of persistent trophoblastic disease.

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OBJECTIVE: To compare the short-term outcome of cold-knife conization between suture and non-suture (with Monsel's solution pack) methods. METHODS: Between February, 1990 and March, 1992, 142 patients underwent cold-knife conization were randomly allocated into 2 groups. The hemostasis was done by suture in one group and by Monsel's solution pack without suture in the other group. The patients' and cone specimens' characteristics as well as short-term outcome were recorded and compared using Chi-square test, Fisher exact test and t-test where appropriate. RESULTS: The patients' characteristics, cone size, and histologic diagnosis of both groups were comparable. The non-suture group had shorter operative time (10.69 +/- 7.86 vs. 20.04 +/- 6.99 minutes) and lesser late hemorrhage (2.9 vs. 15.9%) than the suture group (p < 0.05). There was no statistical difference in the operative blood loss. CONCLUSION: The non-suture method of conization should replace the traditional suture method.

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This is a prospective non-randomized study of 127 patients with stage IIB carcinoma of the cervix treated with irradiation and followed by surgery at Ramathibodi Hospital between 1980 and 1989. The criteria for combined treatment were an enlarged cervical mass of over 5 cm, including a barrel-shaped cervix, inadequate or improper radium insertion due to obliterated cervical os, and endometrial extension. The 5-year survival rate was 84.37%. The incidence of pelvic failure was 10.2% and extrapelvic failure was 6.3%. Those revealing residual disease in hysterectomy specimens had a worse prognosis. The increase in the survival rate in this study as compared to other reports may have been due to the use of higher dosages of irradiation. It is concluded that combined treatment was effective in dealing with poor prognosis groups of carcinoma of the cervix. It improved the pelvic and extrapelvic control as well as the survival rate with acceptable complications.

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Catheterization, which is widely accepted as an important factor to urinary tract infection, is routinely done during cesarean section. This randomized study was conducted to compare the incidence of urinary tract infection between patients who underwent cesarean section using intermittent catheterization and indwelling catheterization, at the Department of Obstetrics and Gynecology, Ramathibodi Hospital from August 1991 to December 1991. Sixteen of 51 patients (31.4%) of the intermittent group and 9 of 47 patients (19.1%) of the indwelling group developed urinary tract infection. The difference was not statistically significant. Of the patients in the intermittent group 39.2 per cent were found to have postoperative urinary retention requiring recatheterization, whereas all cases in the indwelling group could void after its removal. Klebsiella pneumoniae was the commonest isolated organism. Indwelling catheterization was concluded to be the favourable method.

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A prospective study for detecting gestational diabetes mellitus was undertaken to evaluate the use of one hour plasma glucose level after 50 g glucose loading test (1-hr GLT) as compared to the traditional 3-hours 100 g oral glucose tolerance test (3-hr OGTT) in 396 high risk cases. Each patient, had 1-hr GLT and 3-hr OGTT performed in a separate week. Forty-two cases (10.6%) who had abnormal 3-hr OGTT were classified as gestational diabetes (GDM). One hundred and sixty cases (40.4%) had an abnormal 1-hr GLT (plasma glucose level > or = 140 mg/dl). Thirty-six of these 160 cases (22.5%) had an abnormal 3-hr OGTT. In 236 women (59.6%) that had normal 1-hr GLT (plasma glucose level < 140 mg/dl) only 6 cases (2.5%) had an abnormal 3-hr OGTT. If 1-hr plasma glucose level > or = 150 mg/dl was used as the cutoff point, 110 cases (27.8%) were found to have abnormal 1-hr GLT, and 35 of these 110 cases (31.8%) had an abnormal 3-hr OGTT. Seven of 286 women (2.4%) that had normal 1-hr GLT (plasma glucose level < 150 mg/dl) had an abnormal 3-hr OGTT. The sensitivity and specificity of the 1-hr GLT when abnormal 3-hr OGTT was used as gold standard for detecting GDM were 85.7% and 65% respectively (BS > or = 140 mg/dl). Whereas the sensitivity and specificity were 83.3% and 78.8% respectively when plasma glucose level > 150 mg/dl was used as the cut point.(ABSTRACT TRUNCATED AT 250 WORDS)

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The aim of this report is to review the clinical pattern of the recurrent cases. From May 1969 to December 1988, 200 patients with cervical carcinoma stage IB were treated with radical hysterectomy and pelvic node dissection at the Department of Obstetrics and Gynaecology, Ramathibodi Hospital, Mahidol University. One hundred and eighty-two patients were included in this study. Twenty-one patients (11.5%) developed recurrent cervical carcinoma. Most of the recurrence were diagnosed within 3 years after surgery. The most common recurrent site was pelvic sidewall. Patients' complaint and abnormal physical findings accounted for 81 percent of the first evidence. Treatment of recurrences was radiation in 15, chemotherapy in 3 and symptomatic treatment in the remaining three. Nine patients died of the recurrent tumor. The median time from recurrence to death was 24 months (range 12-65). The majority of the deaths occurred in the first three years after detection of recurrence. Radiation may be beneficial in treatment of recurrent tumor and in regional control of tumor after surgery.

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Radical hysterectomy with pelvic lymphadenectomy is the treatment of choice for stage IB cervical carcinoma. Recurrence of disease usually results in poor prognosis. The prognostic factors associated with recurrence were analyzed in 182 patients with stage IB cervical carcinoma treated with radical hysterectomy with pelvic lymphadenectomy at Department of Obstetrics and Gynaecology, Ramathibodi Hospital from May 1969 to December 1988. Twenty-one patients (11.5%) developed recurrent cervical cancer. Factors which were found to have statistical significance associated with recurrence were positive lymph node, positive surgical margin and cervical lesion size of 3 cm or more. The application of these factors was discussed.

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Hydatidiform mole (HM) is not uncommon in our country. Its dangerous sequalae is the fatal persistent trophoblastic disease (PTD). The prognostic risk factors for the development of PTD were analyzed in 108 cases of HM treated in Ramathibodi Hospital from 1978 to 1986. Statistical univariate analysis was by calculation of relative risk (RR) and chi-square test. The incidence of PTD was 27.8 per cent. The significant risk factors were the presence of theca-lutein cyst, gestational age of less than 16 weeks, "large for date" uterus, and patients' age of 40 years or more. Their RR were 4.25, 3.11, 3.00 and 2.68 respectively. These findings were comparable with previous reports. The use of prophylactic chemotherapy in patients with these risk factors was suggested.

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Uterine sarcoma is a rare gynecological malignancy. This retrospective study covered a period of 18 years and during that time 15 cases of uterine sarcoma were treated in Ramathibodi Hospital. It represented an incidence of 6 per 10,000 gynecological admissions. There were 9 leiomyosarcomas, 3 endometrial stromal sarcomas, 2 mixed mullerian sarcomas, and one rhabdomyosarcoma. The average age of the patients was 45.67 years, 3 under 40 and five after menopause. The mean parity was 4. The most common presenting symptoms were vaginal bleeding and abdominal mass. The diagnostic curettage was positive in only 2 out of 7 cases. All were treated by hysterectomy and bilateral salpingo-oophorectomy. Two out of 4 cases who received adjuvant radiotherapy or chemotherapy were still-alive at 1 and 3 year follow-up. The crude survival rate was 40 per cent.

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Carcinoma of the cervix is the most common malignant neoplasm among the female population. The treatment is surgery for stage IB and radiotherapy for all stages of disease. In a developing country like Thailand, the percentage of lost to follow-up after complete treatment is usually high. The purpose of this study is to present the follow-up and survival rate of patients with carcinoma of the cervix at Ramathibodi Hospital. From 1979 to 1983 there were 323 patients with carcinoma of the cervix who had been treated at Ramathibodi Hospital. The majority of patients (51.9%) were in stage II. The 5-year follow-up rate was 87.73 per cent which is better than the previous reports from Thailand. The 5-year survival rate was 93.75 per cent for stage I, 63.12 per cent for stage II and 42.22 per cent for stage III with an overall survival rate of 61.65 per cent. The 5-year survival rate in this study is not different from other reports.

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PIP: This paper compares 2 dosage regimens using the new analgesic Tramadol for outpatient interval laparoscopic sterilization. 100 patients were divided into 2 groups of 50 each. The women in the 1st group, with a mean body weight of 54.70 kg, were given Tramadol 1 mg/kg body weight. The women in the 2nd group were given Tramadol 100 mg. The 2 regimens were equally effective in pain relief, and side effects (nausea and vomiting) were not significantly different. The single dose of 100 mg Tramadol is recommended because of its ease of administration.^ieng

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PIP: Midazolam, a water soluble bensodiasepine, has proven to induce a sleep pattern and amnesic effect that makes it preferable for use as a premedication for outpatient surgery. Used in addition to the regular anesthesia, Midazolam obviates the ineffectiveness of the analgesic drug. Since 1970, neuroleptic analgesia has been used as a method of outpatient anesthesia. Unfortunately, neuroleptic analgesia has provided inadequate coverage of pain relief causing pain and discomfort to patients. When a sedation and anxiolytic premedication are used, the patient acceptance increases. In a study in Ramathibodi hospital, Bangkok, Thailand effectiveness of midazolam as a premedication drug in laparoscopic interval sterilization, 150 women capable of reproduction and who were schelduled for the operation were studied. All of the women received 15mg midazolam orally either 60 or 90 minutes before the operation. The women were divided into 3 groups of 50 classified by the type of analgesic administered (tramadol or pethidine). Heart and respiratory rates and blood pressure were measured prior to, during, and after the operation. No difference in the rate of amnesia was found among the 3 groups, and a rate of 36% of amnesia was found in the study. Those results were lower than earlier reports, possibly due to circumstances at the hospital such as lack of coordination between administration of the medication and timing of the surgery.^ieng

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PIP: The new synthetic analgesic Tramadol was compared with pethidine in a double-blind prospective design for interval laparoscopic sterilization of 50 women in each group at Ramathibodi Hospital, Mahidol University, Bangkok. Drugs were administered iv by slow injection, after 15 mg midazolam had been given orally, 15 minutes before surgery. Both dose levels were 1 mg/kg. The laparoscopic technique was single-entry monopolar cautery without transecting the tubes. Analgesic effects were rated as slight (pain felt when fallopian tube was grasped, more medication needed); moderate (pain felt during cautery, verbalization); or good (slight or no pain during cautery). Analgesia was slight in 10% of both groups, moderate in 36% and good in 54% of the Tramadol group, and moderate in 24% and good in 66% of the pethidine group. Side effects were nausea and vomiting in 10-14% of women with both analgesics, and drowsiness and hypotension in 6 and 2% of the pethidine group (n.s.). Tramadol has the advantage of being non-addictive, and not contraindicated for asthmatics, nor is it listed as dangerous and restricted in Thailand.^ieng

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PIP: To determine whether or not a previous abortion has a deleterious effect on the outcome of a subsequent pregnancy, 6443 delivery records at Ramathibodi hospital between January and December 1982 were reviewed. The 2 study groups consisted of 143 women who had previously had an induced abortion and 315 women who had previously had a spontaneous abortion. Control groups were women having a 2nd child after a normal 1st pregnancy. The 1st study group had fewer women under 19 and over 35 and a lower educational level. Group 2 had more women with a pregnancy interval of less than 2 years. There was no difference between the study groups and the controls in premature rupture of fetal membranes, placenta previa, cesarean sections, manual removal of placenta, retained secundine, postpartum hemorrhage, low birth weight, Apgar score less than 6, congenital abnormalities, or perinatal mortality. The only difference between both study groups and the controls was that there was a higher percentage of assisted deliveries in both study groups. This finding is probably the result of the fact that these were 1st births and is totally unrelated to previous abortion.^ieng

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