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A retrospective analysis on treatment and survival outcome of locally advanced cervical cancer with or without brachytherapy: A single institution study

Joan Kristel B. Abrenica ; Genalin F. Amparo

Philippine Journal of Obstetrics and Gynecology.2020;44(6):1-11.

Background: Concurrent chemoradiotherapy composed of pelvic external beam radiotherapy (PEBRT) with weekly chemotherapy plus intracavitary brachytherapy (ICBT) remains to be the treatment of choice for locally advanced cervical cancer (LACC). However, some patients are not suitable to have ICBT right after pelvic radiation. Locally, active chemotherapy is being given to these patients until they can undergo the procedure. Objective: The aim of the study was to determine the impact of ICBT in the treatment and survival outcomes of cervical cancer and to compare it with active chemotherapy. Methodology: This was a retrospective study of patients with LACC treated with or without brachytherapy in a single institution from January 2002 to December 2017. Results: The 5-year over-all survival (OS) and 5-year recurrence free survival (RFS) of patients with ICBT were both significantly improved compared to those without ICBT (p=0.001 and p=0.038), respectively. Factors that were significantly correlated with adequate response for brachytherapy were non-squamous cell histology (OR 0.65, CI 0.46- 092, p=0.016), initial tumor size of > 5cm (OR 0.41, CI 0.26-0.65, p=0.001), > 50% decrease in the original tumor size at the middle part of PEBRT (OR 1.83, CI 1.2-2.8, p=0.005), > 3 cycles of chemotherapy as radiosensitizers (OR 2.66, CI 1.79- 3.9, p=0.001), > 45 days duration of PEBRT (OR 0.63, CI 0.41-0.97, p=0.04) and > 2 episodes of anemia during PEBRT (OR 0.67, CI 0.52-0.85, p=0.001). Conclusion Brachytherapy offers significant improvement on tumor control and over-all survival for patients with LACC. Active chemotherapy may offer some benefit in terms of delaying tumor recurrence or progression. However, this did not translate to survival impact if the patient was not able to have brachytherapy at all.
brachytherapy ;

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Early experience of gynecologic robotic surgery in a tertiary government hospital

Efren J. Domingo ; Patrick Jose D. Padilla

Philippine Journal of Obstetrics and Gynecology.2020;44(6):12-16.

Background: Robotic surgery is a form of minimally invasive surgery wherein the surgeon controls the camera and instruments in a console, remote from the operating room table. Currently, the system in place is the da Vinci Surgical System which was approved by the United States Food and Drug Administration in 2000 for laparoscopic surgery. Since its approval in 2005 for Gynecologic procedures, the da Vinci Surgical System has been used for hysterectomies, lymph node dissections, sacrocolpopexies, myomectomies, and cerclage. Objective: This paper presents the initial seven cases of benign gynecologic diseases operated on utilizing the da Vinci Surgical System in our institution – six hysterectomies and one myomectomy. Methodology: Seven gynecologic surgeries that utilized the da Vinci Surgical System in 2019 until the first quarter of the year 2020 were done. Medical records of the seven patients were reviewed. Results: The average docking time was 38 minutes (range: 25 – 65 minutes) and the average console time was 227 minutes (range: 175 – 345 minutes). The average blood loss was 576 cc (range: 80 – 1200 cc). No cases converted to an abdominal laparotomy and no morbidities were reported. While two cases underwent blood transfusion intraoperatively, all cases were stable post-operatively and were for discharge after two days. On follow-up, all patients were stable with an unremarkable clinical course. Conclusion Our initial experience demonstrates that robotic surgery appears as a viable alternative to traditional approaches. As more cases are to be done in the future, fine-tuning of the logistical set-up and surgical skills are expected, as well as venturing into other gynecologic diseases such as malignancies. Further research must be conducted on various aspects of robotic surgery, such as but not limited to outcome comparison with traditional and other laparoscopic approaches, long term outcomes, patient safety, and patient experience and preference, among others.
Female ; Gynecologic Surgical Procedures

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A five-year review of the clinicopathologic profile of patients with hydatidiform mole at the Philippine General Hospital

Sherry Joahne L. Cañ ; ete - Villariasa ; Agnes L. Soriano-Estrella

Philippine Journal of Obstetrics and Gynecology.2020;44(6):17-22.

Background: The clinical presentation of patients with hydatidiform mole have changed in recent years due to earlier diagnosis as a result of widespread use of ultrasonography and availability of assays for human chorionic gonadotrophin. Objective: To determine the clinicopathologic profile of patients diagnosed with hydatidiform mole at the Philippine General Hospital from January 2013 to August 2018. Methods: This retrospective cross-sectional study included all patients with histologically confirmed diagnosis of hydatidiform mole managed at the Philippine General Hospital from January 2013 to August 2018. Medical records of patients were retrieved. All abstracted variables were analyzed retrospectively. The level of significance for all sets of analysis was set at p-value < 0.05 using two-tailed comparisons. Results: From January 2013 to August 2018, a total of 435 patients diagnosed with hydatidiform mole were managed at the Philippine General Hospital with a prevalence rate of 15.7/1,000 pregnancies. Diagnosis was made in the first trimester in 52% of patients. A quarter of the patients had pre-evacuation B-hCG levels of more than 1 million mIU/mL. Vaginal bleeding was the most frequent presenting symptom but only 59% of the patients had anemia requiring blood transfusion. Majority (90.57%) had a histopathologic diagnosis of complete hydatidiform mole. Conclusion The prevalence and clinicopathologic profile of patients with hydatidiform mole in the Philippine General Hospital have remained largely unchanged.
hydatidiform mole ; Pregnancy ; Female ; gestational trophoblastic diseases

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Papillary squamous carcinoma of the cervix with metachronous clear cell renal cell carcinoma

Renee Riza C. Medalla ; Jericho Thaddeus P. Luna

Philippine Journal of Obstetrics and Gynecology.2020;44(6):23-27.

Multiple primary tumors can be classified as synchronous or metachronous. Cases have been reported, with a prevalence, in gynecologic malignancies, of 1.9 to 4.3%, and commonly occurring in endometrial and ovarian malignancies. Renal tumors coexisting with primary cervical cancer are mostly metastatic tumors, and at present, no case of cervical carcinoma metachronous with renal cell carcinoma has been reported on literature. This is a case of Papillary Squamous Cell Carcinoma of the cervix who developed a metachronous Clear Cell Renal Cell Carcinoma. Several months after the diagnosis of cervical cancer, she presented with an abdominal mass and signs of uremia secondary to obstructive uropathy. She underwent radical nephrectomy with contralateral percutaneous nephrostomy. Definitive plan for the cervical mass is concurrent chemotherapy and radiation, depending on the improvement in renal function. Currently, there are no clearly established guidelines in managing metachronous cervical and renal masses, and this presents a unique opportunity to document this case, and study its implications on management and prognosis.
Neoplasms, Multiple Primary ;

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Squamous cell carcinoma of the cervix with cranial metastasis: A case report

Maria Patricia Angelica M. Tanchuling ; Jean Anne B. Toral

Philippine Journal of Obstetrics and Gynecology.2020;44(6):28-31.

Squamous cell carcinoma is the most common female genital tract malignancy that typically spreads to the pelvic organs first by direct extension, and less commonly to distant sites through lymphangitic and hematogeneous spread. We report on a 47-year-old woman diagnosed with squamous cell carcinoma who underwent concurrent chemoradiation, presenting with a fronto-parietal scalp mass which on histopathologic examination also shows squamous cell carcinoma, likely metastatic.
Uterine Cervical Neoplasms ; skull ; scalp

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Recurrent Paget’s disease of the vulva in a split-thickness graft

Romelyn April P. Imperio-Onglao ; Jericho Thaddeus P. Luna

Philippine Journal of Obstetrics and Gynecology.2020;44(6):32-40.

Extramammary Paget’s disease (EMPD) of the vulva is a rare vulvar neoplasm but commonly arises during the postmenopausal period. Intraepithelial Paget’s disease may persist for prolonged periods without demonstrating invasion but with high rates of recurrence. Appearance of Paget’s disease in a split-thickness skin graft, is associated with an occurrence outside the grafted area. It demonstrates retrodissemination as the pathologic process hypothesized in the spread of the disease within the skin via lymphatics and vessels creating tissue bridges between sites of involvement. We present a case of an 81-year-old female, the patient came in for complaints of vulvar pruritus beginning at the left inguinal area three years prior to her diagnosis. She consulted with a dermatologist and was initially treated with steroids and emollients. Persistence of symptoms and enlargement of the lesion prompted a vulvar punch biopsy which showed Paget’s disease and referral to the Gynecologic Oncology service. Wide local excision with split-thickness skin grafting was performed. However, one year after her surgery, patient noted vulvar pain and palpable vulvar lesions. Biopsy was done which showed Extramammary Paget’s Disease recurrence. Patient underwent repeat wide local excision with frozen section, and split-thickness skin grafting. With the aid of frozen section, the intraepithelial involvement was noted to spread beyond the grossly apparent lesion. After 6 months post re-excision, patient noted vulvar pruritus and palpable vulvar lesions. Biopsy was done which showed Extramammary Paget’s Disease recurrence. Due to the proximity of the lesion to the sphincter and need for a colostomy, the patient did not consent for re-excision. Imiquimod 5% was chosen as the mode of treatment. The challenges of interventions are to remove or treat disease that may not be visible, without overtreatment and to minimize morbidity from radical surgery. Surgery remains the primary management for EMPD of the vulva. Imiquimod 5% can be used in recurrences. Despite the advances in the knowledge and management of vulvar Paget’s disease the high rate of recurrent disease remains a challenge for optimal management and would require frequent and long-term follow-up.
Paget Disease, Extramammary ; Female ; vulvar neoplasms ;

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POGS 2019 report on obstetrical and gynecological indicators of healthcare

Annette M. Macayaon ; Maria Antonia E. Habana ; Helen R. Amorin

Philippine Journal of Obstetrics and Gynecology.2020;44(6):41-48.

Background: To address the need to improve the collation of vital statistical data from POGS-accredited institutions, the POGS Committee on Nationwide Statistics developed a new electronic census platform (now called the POGS Nationwide Statistics System or PNSS), that replaced the Integrated Statistical Information System (ISIS) which was started in 2008. Objectives: The aims of this paper are the following: (1) to present initial data gathered through the PNSS and compare it to the Department of Health (DOH) census; (2) to discuss obstetrical and gynecological indicators of healthcare and (3) to assess the limitations of the PNSS and recommend improvements. Methodology: This is a cross-sectional study that shall report obstetrical and gynecologic data generated from submissions of POGS-accredited hospitals from January to December 2019, through the PNSS. Charts and tables illustrating frequencies of the different health indices are presented. Health indices include crude livebirth rate, age-specific birth rate, adolescent birth rate, cesarean section rate, stillbirth rate, neonatal mortality rate, perinatal mortality rate, maternal mortality ratio, frequency of gynecologic admissions and procedures, and death secondary to gynecologic diseases. Results: The number of accredited hospitals that submitted their census with 100% compliance was 135, thus 91.8% of accredited hospitals had full compliance. A total of 365,947 cases were reported, 89% (326,026) of cases were obstetric cases and the remaining 11% (39,921) were gynecologic cases. For obstetrical health indicators: the livebirth rate is highest in the NCR 36%, with the highest age-specific birth rates in the 20-29 age groups; adolescent birth rate is 7.3%, overall CS rate is 32.8%, stillbirth rate is 14.3 per 1000 neonates, neonatal mortality rate is 3.65 per 1000 livebirths, perinatal mortality rate is 18.35 per 1000 total births and maternal mortality ratio is 81.72 per 100,000 livebirths. The most frequent indications for gynecologic admissions are leiomyoma uteri, Abnormal Uterine Bleeding-Polyp (AUB-P) and Abnormal Uterine Bleeding-Myoma (AUB-M), while endometrial biopsy/diagnostic curettage is the most frequent gynecologic procedure performed; There were 150 deaths (0.38%) reported among gynecologic cases and majority (96%) had gynecologic malignancies, with ovarian cancer being the highest (41%). Conclusion Nationwide statistics serve as strong evidence on which policies are created. It provides vital information that serves as a basis for decision-making, planning and implementation of health programs and basic services and can also be used for monitoring and evaluation. It is recommended that preparations be undertaken for an improved 2021 version with enhancing the mechanism of encoding and transmitting data, improving data quality and developing more health indicators. Regular coordination with the accredited hospitals is encouraged for a more accurate data outcome and compliance performance. Collaboration in identifying areas for research should be fostered.

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A comparison between palpation method and Johnson’s rule to estimate fetal weight in term singleton pregnancies with cephalic presentation in a tertiary hospital: A prospective cross-sectional study

Menabelle A. Marcaban ; Ma. Regale Noemi R. Ochoco-Sotto

Philippine Journal of Obstetrics and Gynecology.2020;44(5):1-8.

Background: Estimation of fetal weight through ultrasound or clinically, is important in the management of pregnant women. In low resource settings, where ultrasound is scarce, determination of the superior clinical method between Johnson’s rule and palpation method is of significant value. Objective: The objective of this study was to determine the best clinical method in estimating fetal weight in term parturients in a tertiary government hospital. 140 term mothers with singleton pregnancies in cephalic presentation were included in this study. Methodology: Fetal weight was estimated using both palpation method and Johnson’s rule and compared to the actual fetal weight. Effects of body mass index (BMI), cervical dilatation, and engagement on the accuracy of both methods were evaluated using one-way ANOVA and test of proportions. The accuracy of both methods were calculated by mean absolute error and bias. Bland-Altman analysis was used to see limits of agreement and the mean difference between estimated fetal weight to actual birthweight. Results: Mean estimated fetal weight (EFW) was 2846.39 ± 427.29g by Johnson’s and 2904.29 ± 372.79g by palpation with a mean actual birthweight of 3028.30 ± 441.52g. Using paired t-test, no significant differences were found in EFW by the two methods and actual birthweight. Palpation had more estimates that differed from actual by < 100 grams at 41.43% compared to 16.43% for Johnson’s with p < 0.001. Lower bias (7.11%) was seen in palpation compared to Johnson’s (12.09%) and with more precise estimates. Conclusion Palpation method is more accurate and reliable than Johnson’s rule. Clinical palpation is easy, cost effective, simple and should be considered as a diagnostic tool for fetal weight estimation especially in rural areas. The effect modifiers are cervical dilation for palpation and engagement for Johnson’s. BMI has no effect in accuracy of estimates in both methods.
Fetal Weight ; Fetus ; Prenatal Care ; Palpation ; Research Design ; Health Services

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Assessment of the knowledge, attitude and practice of pregnant women towards hepatitis B infection seen at a tertiary hospital in the Philippines

Maria Angelica B. Arada ; Stella Marie L. Jose

Philippine Journal of Obstetrics and Gynecology.2020;44(5):9-19.

Background: Multiple studies have described the insufficiency in knowledge, attitude and practices of the general population and of healthcare workers towards HBV infection across different countries. Objective: This study aims to assess the knowledge level and correlate it with the attitude and practices of pregnant women towards Hepatitis B infection. Methodology: This is a descriptive study on pregnant women consulting for their first antenatal visit in the outpatient department of a tertiary hospital. A structured self-administered questionnaire, adapted from a study by Han et al, was reviewed and modified by infectious disease experts, and then validated prior to use. 164 pregnant patients, aged 18-45 years old, were recruited. Logistic regression analysis was used to correlate attitude and practice to knowledge scores. Results: Most participants (48.78%) belonged to the 18-25 year old age group. Only 7.32% of the participants answered all knowledge questions correctly while 39.02% answered at least 2/3 of the questions correctly. Knowledge scores were not associated with patient demographic information but were correlated with their attitude and practices towards Hepatitis B infection. Conclusion A lack of knowledge regarding Hepatitis B infection exists among pregnant patients. Government and private institutions must invest time and effort to bridge this knowledge gap. Health promotion should be directed towards the pregnant population since vertical transmission remains to be the most common route of transmission in our country.
Hepatitis B ; Pregnancy ; Female ; Knowledge

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Sonographic features and clinical correlates of correctly positioned and malpositioned intrauterine device in women examined at a tertiary hospital: A five year review

Regina Rosario M. Panlilio-Vitriolo ; Nur Ainee D. Kamensa

Philippine Journal of Obstetrics and Gynecology.2020;44(5):20-28.

Background: Transvaginal ultrasound prior to IUD insertion may be helpful in appropriate patient selection and optimal patient conditions in preventing IUD malpositions and complications. Objective: To describe the sonographic features of correctly positioned and malpositioned intrauterine device (IUD) in women and correlate with associated symptoms and concurrent cervical, uterine and ovarian pathology Methodology: This is a 5-year retrospective cross-sectional study. Patients in a tertiary hospital with sonographically detected correctly positioned and malpositioned IUDs were selected from the Obstetrics and Gynecology Ultrasound Database from January 1, 2014 to December 31, 2018. The patient’s name and case number were used to review the patient’s charts for the demographic profile and other necessary data. Intrauterine device sonographic features were recorded, correlated clinically and analyzed statistically. Results: Three hundred two patients were eligible for the study with ages between 41 to 50 years old and with an average of 1 to 3 pregnancies and livebirths. Almost half of the women with malpositioned IUDs complained of missing IUD string. Sonographically, the IUD appeared echogenic with more than half demonstrating a linear echogenic stripe. The most common type of malpositioned IUD was partial or fully embedding the myometrium (45.2 %), followed by those located in the cervix or in the lower uterine segment (35.7%), partially expelled with IUD segment extending through the external cervical os (11.9%), and fragmented (4.7%). The least common malpositioning was malrotation of the IUD (2.3%). There were significantly more women with cervical disease among those who had correctly placed IUDs. Thirteen women were pregnant, 9 of whom had intrauterine pregnancies. 3 had ectopic pregnancies and 1 had an abortion. Eight of the 9 intrauterine pregnancies had malpositioned IUD and only 1 had correctly positioned IUD which was statistically significant. Conclusion Women with IUD who became pregnant and with missing IUD strings are important predictors to re-assess IUD placement. Uterine pathologies such as myomas and adenomyomas do not affect placement of intrauterine devices. IUDs remain in place in the presence of cervical diseases such as cervical malignancies.
Ultrasonography ; intrauterine devices ;

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