Oncologist in Chiang Mai/Lampang/Lamphun

[Sophon]

Could anyone recommend a good oncologist in the Chiang Mai/Lampang/Lamphun area? My girlfriend has just noticed a lump in her abdomen, so we need someone well qualified to have a look at it. 

 

We live in Mae Tha, Lamphun but Mae Tha Hospital is known locally as "the slaughterhouse", which frankly doesn't instill confidence. I am also guessing that the larger hospitals in Chiang Mai and Lampang will have better doctors than the central hospital in Lamphun. Mae Tha is equidistant from Lampang and Chiang Mai (50 km), so either will do. We are already registered at Sripat hospital in Chiang Mai, so from a "minimise paperwork" standpoint a doctor there would be a bonus. But, of course, the qualifications of the doctor is he main consideration. 

 

If it turns out to be something that requires operation, there would be some advantages to having it done in Lampang, as that is where her mother and sister lives.

 

Thank you in advance for your input.

 

Sophon

[Sheryl]

You don't start with an oncologist for something like this, that comes in only later if it is (1) confirmed to be an abnormal mass; (2) biopsied and found to be a cancer and (3) not treatable by surgery alone.

 

When you say a lump in the abdomen, where exactly? And how big? Is it near the surface, like under the skin, or is it something she has to push in deeply to feel?

 

 

[Sophon]

13 hours ago, Sheryl said:

You don't start with an oncologist for something like this, that comes in only later if it is (1) confirmed to be an abnormal mass; (2) biopsied and found to be a cancer and (3) not treatable by surgery alone.

 

When you say a lump in the abdomen, where exactly? And how big? Is it near the surface, like under the skin, or is it something she has to push in deeply to feel?

 

 

It's in the middle of her lower abdomen and about the shape and size of a lime. It starts just under the skin (but doesn't feel like it's "attached" to the skin) and feels like it goes in quite deep in the abdomen. The lump feels quite hard, and there is no pain even when pressing hard against the lump.

 

I don't know why she didn't notice it until last week.

 

Sophon

[Sheryl]

If by the middle of the lower abdomen you mean in line with the navel but well below it, i.e. above the groin then I suggest to start by seeing a gynecologist at Sripat. They might refer to a urologisy, general surgeon or dermatologist but it's a starting place and she would likely need a gyn exam in any case.

I really do not know what this might be. A mass of that size in that location would ususlly be a distended bladder but if so there would be discomfort when pressing on it.

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[Sheryl]

If by the middle of the lower abdomen you mean in line with the navel but well below it, i.e. above the groin then I suggest to start by seeing a gynecologist at Sripat. They might refer to a urologisy, general surgeon or dermatologist but it's a starting place and she would likely need a gyn exam in any case.

I really do not know what this might be. A mass of that size in that location would ususlly be a distended bladder but if so there would be discomfort when pressing on it.

Sent from my SM-J701F using Thailand Forum - Thaivisa mobile app

[Sophon]

5 hours ago, Sheryl said:

If by the middle of the lower abdomen you mean in line with the navel but well below it, i.e. above the groin then I suggest to start by seeing a gynecologist at Sripat. They might refer to a urologisy, general surgeon or dermatologist but it's a starting place and she would likely need a gyn exam in any case.

I really do not know what this might be. A mass of that size in that location would ususlly be a distended bladder but if so there would be discomfort when pressing on it.

Sent from my SM-J701F using Thailand Forum - Thaivisa mobile app
 

Yes, in line with the naval and just above the pubic bone. We will go to Sripat and see a gynecologist as you suggest. Thanks for your help.

 

Sophon

[Sheryl]

Sophon, I neglected to ask the obvious, though the Gyn certainly will: is there any chance she is pregnant?

 

Once you know what it is, if any sort of extensive/expensive care is needed you should try to get it through the public channel. That means going to the hospital that covers the area where she is listed in a tabian ban (regardless of whether she actually lives there now) and, most likely, getting a referral letter from them to somewhere else.

 

 

[Sophon]

Unrelated (sort of) bonus question for Sheryl.

 

My GF is covered under the Universal Health care scheme (30 baht scheme), so currently we have to go to the small, local Mae Tha hospital if we want free treatment. But as we have no confidence in the quality of care there, we are thinking of moving her back to her mother's tabien bahn in Mueang Lampang. She would then have to go to the central hospital in Lampang. Have you heard anything about the quality of the doctors at that hospital?

 

Thanks again.

 

Sophon

[Sophon]

5 minutes ago, Sheryl said:

Sophon, I neglected to ask the obvious, though the Gyn certainly will: is there any chance she is pregnant?

No, I had a vasectomy many years ago, so no chance of that. 

 

Sophon

[Sheryl]

11 minutes ago, Sophon said:

Unrelated (sort of) bonus question for Sheryl.

 

My GF is covered under the Universal Health care scheme (30 baht scheme), so currently we have to go to the small, local Mae Tha hospital if we want free treatment. But as we have no confidence in the quality of care there, we are thinking of moving her back to her mother's tabien bahn in Mueang Lampang. She would then have to go to the central hospital in Lampang. Have you heard anything about the quality of the doctors at that hospital?

 

Thanks again.

 

Sophon

Mae Tha is simply a 30 bed community hospital and will refer almost anything at all complex to Lamphun hospital. There is comparatively little that can actually be handled at community hospitals like Mae Tha  other than really minor simple  sort of problems. Defintely the mass she has (if that is what it is and not an anatomical structure) , would be immediately referred to Lamphun Hospital, there is nothing a community hospital can do or would be expected to do other than refer for something like that.

 

Lampang is a regional hospital so has far more range of expertise than does Lamphun which is just a regular provincial level facility. So assuming it is physically accessible she is indeed better off being listed in a tabian ban in Lampang. Not only will she avoid having to first go to a community hospital and get a referral letter, but she will get care at a regional level rather than provinicial level facility.

 

BTW not to worry you, but it does sometimes happen that vasectomies fail, or GFs stray. The former is not common but it can happen.  Anyhow Gyn will assess this and  well as other possibilities such as uterine enlargment from fibroids. From the location you describe, the mass is in the area where an enlarged uterus would be felt.

[Sophon]

So we went to Sripat hospital today, and it turned out to be a rather large ovarian cyst in the left ovary. In addition there is also a smaller cyst in the right ovary as well as some abnormalities in the uterus. This is the ultrasound report: 

 

Sheryl, the doctor tried explaining the findings, but I would appreciate if you could explain the ultrasound report in plain English.

 

The doctor took some biopsies, and we will get the result on the 28th. Because of the size of the large cyst and the risk that it might burst, she was quite certain that the left ovary would have to be removed, and depending on what they find during the operation, it could also be necessary to remove the right ovary as well as do a hysterectomy. Since we don't want to have kids, the doctor seemed to recommend a hysterectomy even if not absolutely necessary (which I am not sure I am all that happy about). What is the current thinking about removing the uterus (as a precaution against future cancer), if it is not clinically indicated? My GF doesn't have a family history of cancer, and from what I have read removing the uterus could have serious future consequences for her health. 

 

My girlfriend isn't too scared about having the operation, and if it turns out to be cancer, we will cross that bridge when we come to it. She is, however, concerned about going into early menopause (she is 44). Exactly which organs has to be removed to trigger onset of menopause?

 

It would also be very much appreciated, if you could recommend a surgeon and an estimate on cost. We were quoted around 50k baht for having the operation at Suan Dok hospital, so that is our baseline for now.

 

Thank again.

 

Sophon

 

 

[Lacessit]

On 10/16/2018 at 5:16 PM, Sophon said:

No, I had a vasectomy many years ago, so no chance of that. 

 

Sophon

Er - vasectomies are not always 100% successful.

[Sheryl]

1. She has what are commonly caused fibroids (myoma) of the uterus. They are not cancerous but in some women will cause excessive menstrual bleeding and cramps. If not causing symptoms they do nto need treatment. If there are troublesomne symptoms, in a woman who does not want children treatment would be hysterectomy.

 

2. On the right ovary there is a fluid-filled cyst that might be due to endometriosis (so called "chocolate cyst"), that is a condition where bits of endometrial (uterine) tissue grow in other parts of the pelvis. If so this is not cancerous or dangerous per se, but can cause cramps and (not relevant for you) is a common cause of infertility. It is not necessary to treat in a woman not wanting to conceive unless symptoms are troublesome; the condition will spontaneously resolve after menopause.  It is not sure this cyst is due to endometriosis, might also just be what is called a "functional cyst" (cysts that occur after ovulation and disappear or change in size at other points in the menstrual cycle - if this were the only finding the thing to do would be to repeat the ultrasound at the start of her next period to see if still there and of same size or not, functional cysts will shrink or disappear by that time). A malignant tumor cannot be totally excluded but the findings aren't particularly suspicious for it.

 

3. On the left ovary there is a large tumor. No differential diagnosis is suggested but from the description it too could be an endometrioma. You won't know for sure until surgery. Ovarian cancer cannot be ruled out, but it is favorable that the mass has a well defined border.

 

 

Regarding the surgery:

 

- removal of uterus does not cause any major health problems but is also not necessary if there is no uterine pathology causing undue symptoms. Especially given how close she is to menopause, no need to remove the uterus on account of the fibroids unless she is having really troublesome periods. A uterus should not be removed "just in case it later develops cancer".  If at the time of surgery it appears the ovarian mass is cancerous (from the ultrasound description, probably will not, the description is not unduly worrisome) that would be a different matter and complete removal of both ovaries and uterus would be appropriate.

 

- premature surgical menopause is caused if both ovaries are removed. Removal of just one ovary will not have that effect. Actually at 44, for a Thai woman she is probably not that far from natural menopause but the problem is that the abrupt nature of a surgical menopause causes much more severe symptoms. It would be reasonable to refuse removal of the right ovary unless there is evidence of malignancy in order to preserve  ovarian functions/avoid a surgical menopause.

 

It is sometimes possible to remove an ovarian cyst without removing the ovary itself and that also should be discussed. It is more challenging for the surgeon to do, just removing the whole thing is easier, but if it is possible and there is no indication of malignancy should be done that way so as to preserve ovarian function.

 

In short she should tell her surgeon she wants to keep at least 1 and preferrably both ovaries and does not want uterus removed, unless there is malignancy found.  And shop around if need tbe to find a surgeon who will respect this (if you go the self pay route).

 

50K is very, very inexpensive for this, would be for an open rather than laparscopic approach but even with that, very good price, you won't do better. 4-5 times that at a private  hospital.  She can of course get it done for free at Lamphun, a letter from the doc at Sripat along with her records will result in an immediate referral from Mae Tha Hospital but likely to Lampun not Lampang or CM as that would be their usual referral point. Going this route though she will nto be able to choose her surgeon and it may prove difficult to get much weight given to her preferences.

 

i will get back to you with some specific surgeon suggestions.

 

 

[Sheryl]

Prof. Jatupol Srisomboon

 

specializes in Gyn tumors and had specialty training in the US and Japan

[Sophon]

9 hours ago, Sheryl said:

Prof. Jatupol Srisomboon

 

specializes in Gyn tumors and had specialty training in the US and Japan

Thank you so much, Sheryl, for all your help. It is really appreciated.

 

You said that laparoscopic surgery is an option, and that sometimes the cyst can be removed without also removing the ovary. Is that also possibly an option with a cyst of this size (7-8 cm. in diameter)? Wouldn't the cyst have distended and basically destroyed the ovary?

 

Which hospital does professor Jatupol Srisomboon work at, and do you know if he also has private clinic hours?

 

My GF's (actually my wife by the end of today) sister had her uterus removed a few months ago in Lampang, but she reportedly kept her ovaries. So maybe the surgeon doing her operation would also be an option.

 

Sophon

[Sheryl]

Prof. Jatupol Srisomboon is at Sripat/CMU.

 

Whether they can remove the mass without removing the ovary depends on how tightly woven around it it is. No, the ovary will not have been destroyed by it. But depending on how it is structured it could be hard to disentangle it from the ovary. They won't know until they do the surgery.

 

The size alone does not preclude laparoscopic approach but they might prefer to do open so as to get a better look at what is going on. You need to have that discussion with the surgeon after he has reviewed the US. Laparoscopic surgery costs considerably more than open and it nto infrequently happens that they start off laparoscopically and then have to switch to open approach part way through, in which case you still pay the higher amount for use of laparoscope.  If she goes through public channel  (Mae Tha referral to probably Lamphun) laparoscopic is unlikely to be an option.

 

I think Mae Tha would refer to Lamphun, not Lampang though you can ask.  In any case the fact that a  surgeon did a hysterectomy does nto mean much, all Gyns do hysterectomies and normally a hysterectomy does nto remove ovaries.  If you are going to pay out of pocket for this, Sripat is definitely the best place to go.

 

 

[Sophon]

Today we went to see a gynecologist from Lampang hospital. From the ultrasound report he didn't feel there was any need to do anything about the uterus. He didn't now if it would be possible to save the left ovary, the decision would have to be made based on finding during the operation, but it shouldn't be a problem to remove the smaller cyst from the right ovary. He gave my wife a hormone injection of some kind, that should slightly shrink the large cyst, and at the same time make it seperate a little from the surrounding tissue making the operation easier.

 

If we decide to have the operation in Lampang we would have two choices:

1. Move my wife to her mother's tabien bahn in Lampang, and have the operation under the universal health care scheme. However, doing it in this way there would be a one month waiting period after moving tabien bahn, so the operation couldn't be until late November. The only cost would be if we want a private room for my wife, and she she prefers to be in the general ward because there are always nurses around. Being in a private room you need someone to stay with you (or so she says).

2. Pay ourselves and have the operation under his private practice (I assume the actual operation will still be at the hospital?). For this he quoted a price of 20k baht, which sounds extremely cheap. But then, he only charged 200 baht for today's consultation and the hormone injection, se he clearly doesn't overcharge.

 

We will go back to Sri Pat hospital next Sunday for the results of the biopsies. When there, we will talk with a doctor there and after that make our decision about what to do.

 

Sophon

[Sheryl]

Given the size of that cyst on the left ovary there is an element of risk in waiting. Odds are she'd be OK but no guarantee. If it were me I'd rather pay for the peace of mind. There is one other possibility though, and that is to seek a referral from Mae Thai to Lampang in which case she'd be covered under the 30 baht scheme. Definitely Mae Tha will refer, they have to as they do not have the capacity for this surgery, but their first point of referral is to Lamphun provincial hospital. However Lampang is the regional referral site for that whole area and a case might be made that this is best done there.  See if the doctor at Lampang will provide a letter to docs at Mae Tha explaining her problem, needed surgery and asking them to issue a referral letter. I would say at least 50% chance of succeeding and then it won't cost you anything.

 

What your wife told you re private rooms is correct, someone  (friend or family) has to stay with the patient. She will probably not need to be in the hospital more than a few days. That someone an be you, though - it does nto need to be a medical attendant just someone to summon help if there is a problem.

 

I don't know about Lampang but conditions on the ward at the regional hospital where I live are pretty brutal - very hot and crowded, and  smelly (from all the sweating people packed in there) etc etc. Mosquitoes and flies because the windows have to be open due to the heat and no screens. I frankly can't stand it for more than an hour at a stretch max and you may find it the same in which case paying for a private room and staying there with your wife might be well worth it. The private rooms usually have a couch for relatives to sleep on and  air con. Where I live costs 1800 baht a night (1500 for the room and 300 nursing charge).

 

When they say someone has to be with the patient in a private room it does not mean you can't step out briefly, you can - but not for long (i.e. just to go get a cup of coffee and the like) and let the nurses know when doing so.

 

 

[Sophon]

My wife stayed with her sister in Lampang hospital about three months ago, when her sister had her hysterectomy. Her sister had a private room, so my wife saw the conditions both in the general ward and private room. We have 14 dogs that needs feeding morning and evening, so I would only be able to stay with her during the day. If she changes her mind about the private room, it will be her sister that will stay with her during the night.

 

The money is not a problem when we are talking about amounts as quoted here. We recently paid 25k for a dog that needed a leg amputation and a month long stay at CMU small animal clinic after being hit by a van, and it wasn't even one of our dogs, so I can certainly pay for my wife ????. But my wife is kind of cheap when it comes to things like this, and she doesn't like for us to pay if we don't have to. Neither of the doctors we have talked to seemed that concerned about the cyst bursting, although they both acknowledged that there is some risk with waiting.

 

We will decide after visiting Sri Pat on next Sunday. Actually, my wife will be making the decision, we will go with whatever doctor she feels confident with.

 

Thanks again for your help.

 

Sophon

[Sheryl]

I neglected to mention, about 20,000 baht is the usual charge for fee paying patient at a government hospital for abdominal surgery. So you need to be clear if that is the surgeon's fee or if he is not charging a fee, as it could be 20 + 20 or 40K total if 20 is a private fee for him . Which would still be very reasonable.

[Sophon]

We went back to Sri Pat hospital yesterday to get the result of the biopsies. This is the pathology report:

 

As the wife has decided she wants to have her operation in Lampang, where her family lives, we also got a letter from the Sripat doctor to the doctor in Lampang:

 

If I understood correctly, what was explained, my wife had a polyp on her cervix that was removed and tested. The test came back as non-malignant, so nothing to worry about.

 

She also has some abnormal and inflamed tissue in the vagina (adenosis). The result of the biopsy came back negative for cancer, but the doctor said that there is a risk, that at some point in the future the tissue could possibly develop and become cancerous.

 

We are going back to the doctor in Lampang this week and discuss and schedule the operation of the ovarian cysts. The doctor in Lampang doesn't speak English that well, so I have a few questions to be better prepared:

1. Should/can the abnormal tissue in the vagina be surgically removed?

2. My wife had slight stomach pains yesterday evening (but is fine this morning, so probably something she ate). She started worrying that maybe the large cyst in her left ovary had burst, but I would expect that to cause major pain. What kind of symptoms should we be on the lookout for?

3. When her sister had her hysterectomy, she had "bikini line" surgery. I am guessing that means that the incision was horizontal rather than vertical? But won't that cause a longer and more painful recovery time (cutting through more muscle tissue)?

 

My wife has changed her mind (at least for now) about the private room vs. general ward, which is partly why she has decided on having the operation in Lampang. That way, she can have her sister stay with her in the room after the operation.

 

Thank you once again for your help.

 

Sophon

[Sheryl]

Your understanding of the biopsy findings is correct. But I would add that the vaginal adenosis is something often found in perfectly healthy women, for no apparent reason ("idiopathic") and about 10% of all women have it. It can precede the development of vaginal cancer but usually does not. The risk is higher if her mother took  female hormones while pregnant.

 

As to your specific questions:

 

1. No.  It is the vaginal wall itself that has atypical cells. The only way to remove would be very radical surgery of a type you do nto want to even think about, and is done only when there is definite vaginal cancer. The risks of it causing a problem later are small, it is reason to get regular annual GYN check ups but nothing more than that.

 

2. If the cyst ruptures pain will be very severe, her abdomen will be hard and rigid, she will know that something is seriously wrong. The pain would likely be on the side of the cyst.

 

3. Your wife is not having a hysterectomy so the question is not relevant. She is having removal of ovarian cysts and probably a unilateral oopherectomy (removal of one ovary). Different procedure.

 

But for what it is worth, horizontal incisions do not entail cutting through more muscle nor longer recovery times. However they are harder for the surgeon to work with than vertical incisions as they give less visualization.

 

What I know of your wife's situation (cysts on both ovaries, one small, one large, type not really known, could be endometriosis) I suspect they will need to do a single vertical incision so as to have good visualization of both ovaries and the entire pelvic region.(Remember the ovaries are not in the middle. They are to either side). If there is any suspicion of ovarian cancer they will need to remove some lymph nodes for biopsy as well. They will probably do what is called a "frozen section" during surgery, that is a rapid sort of mini-biopsy  of the mass done to help guide surgical decisions. A "bikini line" incision is probably not feasible, but your wife should discuss any concerns re the scar with her surgeon.

 

It sounds as if your wife is unclear on the procedure to be done and is confusing it with a hysterectomy. Might be worth explaining it to her along with a picture like this

 

 

[Sophon]

Thought I would do an update on this topic.

 

So my wife had her operation Friday at Lampang Hospital. Both cysts turned out to be chocolate cysts, which as I understand it is nothing to worry about, but to make sure samples of the cysts were sent for testing. We will get the pathology report in a months time. As expected, the left ovary was removed but she kept the right one. My wife is feeling OK after the operation with fairly low level pain (no need for painkillers), so she came home yesterday. 

 

The total cost for the procedure was:

• THB 1,010 for pre-operation tests (chest x-ray, EKG, blood and urine tests).
• THB 14,764 to the hospital for the operation including pathology report
• THB 5,000 doctor fee for the surgery (the doctor doing the surgery is head of the gynecology department)
• THB 6,600 for private room

So a bit over THB 27k for the surgery plus room. If adding the costs at Sripat hospital it came to a total of about THB 35K.

 

Thank you again Sheryl, you have been an immense help.

 

Sophon

Edited November 12, 2018 by Sophon

[Sheryl]

Thanks for the upodate, as I suspected it turns out ot have been endometriosis.

 

Good that they kept one ovary.

 

But be aware that she will still have the endometrosis until she reaches menopause and between now and then she may develop new "chocolate cysts". Hormone therapy may be advised to prevent this usually they start with ordinary birth control pills.

 

Price was quite reasonable but I wonder why you did not request a referral letter from Mae Tha as this could have been done for free?

[Sophon]

When my wife decided she wanted the operation done in Lampang (where her family lives), we just wanted it done as quickly as possible. And if going through Mae Tha hospital, we would probably just have been referred to Lamphun Hospital or possibly to a hospital in Chiang Mai. Besides, we had already moved her to her mother's tabien bahn, so any future problems will allow us to go straight to Lampang Hospital, so we were within the 30 day waiting period for changing tabien bahn.

 

Thanks again.

 

Sophon