Indian Journal of Gynecologic Oncology

Published by Springer-Verlag
Online ISSN: 2363-8397
Publications
Article
Background Complete cytoreduction (CC) is one of the most important prognostic factors for epithelial ovarian cancer (EOC). Response to neoadjuvant chemotherapy (NACT) is potentially important to predict CC as well as counseling the patients. We aimed to study if RECIST 1.1 response predicts CC in EOC following NACT.Materials and Methods This prospective observational study included 59 patients of EOC planned for NACT followed by interval debulking surgery (IDS). Response to NACT was assessed by RECIST 1.1 criteria. The level of cytoreduction during IDS was correlated with the radiological response. A Chi-square test was used for the group comparison.ResultsHalf (50%) of patients had an objective response to NACT. CC was feasible in a total of 35 (62.5%) patients. Both response and cytoreduction levels were independent of clinical parameters. We observed 100% CC rates in CR, 95.8% in PR, 50% in SD and 12.5% in PD categories. RECIST 1.1 response was found significantly (p < 0.01) associated with levels of cytoreduction. The sensitivity, specificity, positive predictive value and negative predictive value of RECIST to predict CC were 77.1%, 95.2%, 96.4% and 71.4%, respectively.ConclusionsRECIST 1.1 predicts CC in responders (CR/PR) well. We suggest against denying surgery solely based on RECIST criteria in the SD or PD patients. Given its imprecision in these circumstances, patient characteristics such as performance status, perioperative risk and comorbidities should be taken into account. The role of newer antineoplastic agents, three-dimensional or functional imaging and diagnostic laparoscopy should be explored further for predicting CC.
 
Article
Objective The objective of this study is to estimate the prevalence, management and follow-up of gestational trophoblastic disease (GTD) in a tertiary care center, Royal Hospital, in Oman over the last 11 years from January 2007 till December 2017. This study also looked into the reproductive outcome after trophoblastic disease treatment. Methods This retrospective, descriptive study was carried out at Royal Hospital from Jan. 2007 to Dec. 2017. All cases with a histopathological report of hydatidiform molar disease were included. Demographic characteristics, clinical presentation physical signs, treatment and follow-up including reproductive outcome and recurrence rate were included. Results Two hundred and thirty-six women with GTD were included in the study. Mean maternal age was 35 years, mean gravidity 5 and parity 3. Prevalence of complete mole was 83 cases (35.1%), partial mole 144 cases (61%), choriocarcinoma (0.42%), placental site (0.42%) and invasive mole (1.27%). Thyrotoxicosis, preeclampsia and anemia were 3.8%, 7.2% and 0.8%, respectively. Mean gestational age was 10.57 ± 3.2 weeks at presentation. Persistent disease was observed in 12.3%. About 5% received chemotherapy. Metastasis was reported in 4.7% of cases, 81.8% to the lung. About 38% conceived later. Conclusion This study highlights the importance of proper assessment and follow-up of histopathology diagnosis. GTD usually has a good prognosis and reproductive outcome if properly followed up and treated.
 
Article
PurposeInterval cytoreduction (IC) after a course of neoadjuvant chemotherapy is the preferentially followed management for advanced epithelial ovarian cancers. When planning an interval cytoreduction, it is important to assess the probability of achieving optimal surgery so as to avoid futile laparotomies. Several assessment techniques like CECT of the abdomen and pelvis, tumour marker-based response assessment and diagnostic laparoscopy are being used for this purpose with varying results. In our institute, we evaluated the utility of CA-125 value to predict the possibility of optimal surgery in advanced carcinoma ovary after neoadjuvant chemotherapy (NACT).Methods The data of treated advanced epithelial ovarian cancer were collected from the hospital records for the study period between February 2015 and February 2018 (n = 83). The cut-off value and percentage reduction of CA 125 in predicting optimal cytoreduction were analysed by receiver operator curve (ROC). These values were validated prospectively from March 2018 to September 2019 in 60 cases treated during this period. Statistical analysis was performed using SPSS 25.ResultsROC analysis revealed CA-125 value of 88.5 U/ml (i.e. twice the upper limit of normal value) had sensitivity of 100% and specificity of 94% (AUC = 0.98; P value < 0.001) to predict optimal cytoreduction. Similarly, 90.46% reduction in CA-125 value had a sensitivity of 72% and specificity of 71% (AUC = 0.72; P value = 0.047) to predict optimal IC. In the prospective validation, among those who had post-NACT CA-125 value of less than twice the upper limit of normal value, 98.14% (53 out of 54) had optimal surgery with a P value of 0.0001. Among those with more than 90% reduction in CA 125 value after neoadjuvant chemotherapy 94.8% (55 out of 58) had optimal cytoreduction (P value—0.012).Conclusion The post-chemo CA 125 value and percentage reduction of CA 125 after neoadjuvant chemotherapy have high sensitivity and positive predictive value in predicting optimal interval cytoreduction.
 
Article
Purpose Struma ovarii is a rare monodermal variant of ovarian teratoma accounting for only 2% of all mature teratomas. It is diagnosed when thyroid tissue is present in more than 50% of the specimen. Struma ovarii can rarely mimic advanced ovarian cancer and present with a complex ovarian mass, ascites and markedly elevated CA 125 levels. Only one such case is reported from India. Method We report a case of 43-year-old lady with struma ovarii who presented with a right adnexal mass, gross ascites, vulval and pedal edema and elevated CA 125 levels. She underwent total hysterectomy and bilateral salpingo-oophorectomy. ResultsThere was immediate resolution of ascites and normalization of CA 125 levels following surgery. She is disease-free now, 3 years after surgery. Conclusion Struma ovarii with pseudo-Meig’s syndrome and raised CA 125 levels poses a diagnostic challenge and can be mistaken for advanced carcinoma ovary.
 
Article
Backgrounds The risks of ovarian malignancy algorithm (ROMA) and human epididymis protein 4 (HE4) appear to be the promising predictors of epithelial ovarian cancer (EOC). However, conflicting results have been obtained in the diagnosis process when we compare ROMA, HE4, and CA125. Methods The databases (MEDLINE/PUBMED, EMBASE, Web of Science, Google Scholar, the Cochrane Library and ClinicalTrials.gov) and full-text bibliographies were searched for relevant abstracts. EOC predictive value of ROMA was systematically evaluated, and the predictive performance of ROMA, HE4 and CA125 was compared within the same population. In this meta-analysis, the pooled sensitivity, pooled specificity, pooled AUC, and pooled p value of each tumor marker as well as pooled number of patients and healthy individuals were calculated. Result Based on meta-analysis of 9 studies, the total sample size was obtained, 785 patients and 667 healthy individuals. The overall estimates of ROMA for EOC predicting pre-menopausal women with 95% CI were 86.9 sensitivity, 085.52 specificity, and 0.9 AUC. ROMA for EOC predicting pre-menopausal women was 90 sensitivity, 80.84 specificity, and 0.9 AUC. The overall estimates of CA125 and HE4 for EOC predicting with 95% CI were as follows: sensitivity (84.5 and 80.37), specificity (83.8 and 88.45), and AUC (0.85 and 0.87). Conclusion This meta-analysis highlighted that ROMA can help distinguish EOC from the benign stage in postmenopausal women. ROMA is less specific but more sensitive than HE4. Both ROMA and HE4 are more specific than CA125 for EOC prediction. CA125 has a higher accuracy for diagnosis than HE4 for EOC. ROMA is a good predictor to replace CA125, but its utilization requires further exploration.
 
Article
CA-125 is the tumor marker for surface epithelial carcinoma of ovary, and it is used to determine the response to chemotherapy, relapse, and disease progression. Neoadjuvant chemotherapy followed by interval debulking surgery is an acceptable treatment for patients with advanced disease. Most patients will require 2–4 cycles of neoadjuvant chemotherapy. However, some patients receive more than 4 cycles of neoadjuvant chemotherapy in many centers, and the most common reason for this is extensive disease at the beginning of neoadjuvant chemotherapy. To determine if a normal CA-125 level following neoadjuvant chemotherapy is an indicator of satisfactory reduction in the extent of the disease and should CA-125 levels be considered in deciding the number of cycles of neoadjuvant chemotherapy. The histopathology report of all patients who underwent successful interval cytoreduction between 01-09-2020 and 31-08-2021 was analyzed to determine if the preoperative CA-125 level following neoadjuvant chemotherapy is reflective of the extent of disease resolution. There was no correlation between the pre-neoadjuvant chemotherapy CA-125 level, pre-operative CA-125 level, and the histopathology report. Some patients with a very high pre-neoadjuvant chemotherapy and pre-operative CA-125 level had no extra-ovarian involvement. Conversely, some patients with a low pre-neoadjuvant chemotherapy and a pre-operative CA-125 level had significant extra-ovarian involvement. After how many cycles of neoadjuvant chemotherapy should surgery be performed must be decided by clinical examination and imagining. The purpose of neoadjuvant chemotherapy is to increase the rate of achieving complete cytoreduction in patients with extensive disease and poor performance status. Administering more than 3–4 cycles can be counterproductive.
 
Article
Background The aim of this study is to assess the diagnostic value of lysophosphatidic acid (LPA) in epithelial ovarian cancer (EOC) patients in comparison with CA125. Methods The study included 41 women with EOC and 41 women with benign ovarian tumor. Serum CA-125 and LPA levels were measured and correlated with histopathological examination results. Results Ovarian cancer patients have increased LPA and cancer antigen CA-125 levels compared to patients with benign ovarian tumor (LPA: ovarian cancer vs. benign ovarian tumor: 2.43 ± 1.69 vs. 0.6 ± 0.71 μmol/L; CA-125: ovarian cancer vs. benign ovarian tumor: 604.55 ± 865.84 vs. 86.71 ± 194.87 U/mL), which showed statistically significant differences (both P < 0.05). LPA with advanced sensitivity (92.68%), specificity (87.8%), positive predictive value (88.37%) and negative predictive value (92.31%) is compared with CA-125 in the diagnosis of ovarian cancer. The areas under the receiver operating characteristic curve are in the diagnosis of ovarian cancer (LPA: 0.925; CA-125: 0.779). Conclusion LPA has greater value, and it is a better biomarker for diagnosis of EOC compared to CA-125.
 
Article
Background The ovarian cancer patients have good survival benefit with optimal primary cytoreduction. Preoperative evaluation with imaging and tumour markers for the possibility of optimisation has been routinely practiced. Imaging though provides good insight about operability; the mesenteric, bowel and peritoneal surface diseases are not detected by imaging. The present study evaluates the role of Ca 125 in detecting optimisation in primary cytoreduction. Materials and Methods Prospective observational study of 194 patients of stage III epithelial ovarian cancer, with nonmucinous histology, was analyzed for the Ca 125 level in relation to optimisation. ResultsThe statistical analysis of study results showed the p value of correlation between Ca 125 values, and residual disease was 0.7 which was statistically not significant. Conclusion The results of the present study conclude that the serum Ca 125 levels do not correlate with the optimisation in cytoreduction.
 
Article
PurposeTo find out the proportion of HPV sub types 16 & 18 in invasive cervical carcinoma.Methods This is a prospective observational study performed on 100 women with invasive cervical cancer. RT PCR was performed on the DNA extracted from the punch biopsy using RNA primers specific for subtypes 16 and 18.ResultsThe mean age of the population was 53.25 years. The mean age of coitus was 19.25 years. Around 70% of the patients belong to class 4 or above socioeconomic status. The most common presenting symptom was vaginal discharge seen in 40% of the cases. The most common stage was stage IIB (40%) followed by IIIB (22%). 52% of the population had Grade 3 disease. In our study, the proportion of HPV-positive cancer was 64%. 60% of the patients were positive for HPV 16 subtype, and 22% were positive for HPV 18 subtypes. 18% were positive for both HPV 16 and 18. All stage IV A and IV B patients had HPV positivity.Conclusion Around two-third of the cervical cancer are attributed to high-risk HPV 16 and 18. Bivalent vaccine can reduce a significant proportion of cases in our country.
 
Article
PurposeThis research was carried out with the intention to see the detection rate of HPV-16/18 E6 oncoprotein expression in different categories of cervical neoplasia and to find out its association with increasing neoplastic state, using lateral flow test “Onco E6 Cervical Test” designed for low-resource settings.MethodsA cross-sectional study was conducted at Gynecologic Oncology Outpatient Department (OPD) of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, from May 2018 to April 2019. Histopathologically diagnosed CIN I, CIN II, CIN III, and cervical cancer cases of age 21–70 years who were compliant to allow cervical swab collection for E6 oncoprotein test were selected by purposive sampling.ResultsE6 oncoprotein expression was 4.44% (2/45), 28.57% (4/14), 50% (2/4), and 77.78% (28/36) for CIN I, CIN II, CIN III, and cervical cancer cases, respectively. Thirty-six women of total 99 (N = 99) study participants were found E6 positive (detection rate 36.36%). Type distribution showed 83.33% (30/36) type 16, 13.89% (5/36) type 18, and 2.78% (1/36) co-infection with types 16 and 18. Considering CIN I the reference category, E6 oncoprotein expression was found associated with CIN II (OR = 6.95, p = 0.052), significantly associated with CIN III (OR = 18.10, p = 0.026), and highly significantly associated with cervical cancer (OR = 43.57, p < 0.001).Conclusion Association of E6 oncoprotein expression is significant for CIN III and highly significant for cervical cancer. The presence of E6 oncoprotein expression in CIN lesions can identify true cancer precursors with risk of cancer development in the future and can be utilized in cancer screening program.
 
Article
Introduction Cervical cancer is the second leading cause of deaths due to cancer, among Indian women. Persistent infection of high-risk genotypes of human papillomavirus (HPV) is the leading cause of cervical cancer. The aim of the study was to estimate the incidence of HPV 16 and 18 infections in cervical cancer patients from Jabalpur, Madhya Pradesh, India. Materials and Methods In this hospital-based study, cervical biopsy samples, received from tertiary healthcare hospital, were subjected to molecular tests for HPV 16 and HPV 18. The p53 polymorphism at the 72 position was studied by PCR. The clinical and sociodemographic information of the patients was analyzed using SPSS 20. Result A total of 87 cervical carcinoma tissues were analyzed by type-specific PCR for its presence. Forty-five (51.7%) were infected with HPV 16, and 27 (31%) had HPV 18. Coinfection of HPV 16 and HPV 18 was detected in 15 (17.2%) patients. The overall HPV incidence was 65.5% (n = 57). Arginine (Arg) homozygosity dominance was not significant among cervical carcinoma patients. Illiteracy was significantly associated with HPV incidence. Conclusion The findings indicate HPV 16 and HPV 18 are the major causes of cervical carcinoma in Central India. HPV 16 was more prominent infection than HPV 18. Arg homozygosity at the 72 position in p53 gene was not associated with cervical carcinoma. A community-based study will be useful to establish the prevalence of HPV, which will help in interventions such as vaccination in the area.
 
Article
Purpose The objective of the present study was to determine the prevalence of human papillomavirus (HPV) 16/18 infection among the women attending the gynecological outpatient clinic at SMGS Hospital and to find out the correlation between cervical cytology and HPV DNA testing. Materials and Methods Women with ≥30 years of age visiting the gynecology outpatient with varied complaints were subjected to Pap smear. In total, 300 samples were subjected to PCR using consensus primer for HPV. The samples that were positive for HPV DNA were subsequently assessed for HPV types 16 and 18. Results Out of 300 patients, 113 (37.6 %) women tested positive for HPV DNA and out of 113 HPV-positive samples 23 (7.66 %) tested positive for high-risk HPV, i.e., HPV 16 (5 samples) and HPV 18 (18 samples). A statistically higher prevalence of HPV was observed in rural, low socioeconomic and poorly educated group. No association of HPV prevalence was noted with parity, age at marriage and age at first child birth. Increase in HPV prevalence was observed with the increase in abnormality in cervical cytology. HPV infection was present in 18.91 % of women with normal cytology, 31.11 % in inflammatory smear, 32.14 % in ASCUS, 54.16 % in LSIL, 77.77 % in HSIL and 100 % in cancer cervix patients. HPV 16/18 infection was present in 1.35 % of women with normal cytology and 20.63 % of women with abnormal cytology report. Conclusions The study generates epidemiological data of prevalence of subclinical HPV in the women visiting a tertiary care institute. The data generated will be useful for laying guidelines for mass screening of HPV, treatment and prophylaxis in the local population.
 
Article
Purpose To evaluate the accuracy of ¹⁸F-FDG PET/CT in detecting regional lymph node metastasis in patients with endometrial cancer. Methods A retrospective analysis was done for 50 patients having biopsy-proven endometrial cancer who underwent FDG PET/CT as a part of preoperative evaluation. All of these underwent Type I hysterectomy with lymphadenectomy either by open or robot-assisted surgery. PET/CT findings were then compared with the final histopathology. The criterion for malignancy on PET/CT images was increased FDG uptake by a lymph node independent of its size. Results Hyper-metabolic FDG-avid lymph nodes were present in 9 out of 50 patients. Twelve patients had metastasis to lymph nodes on histopathology, and 38 were negative for nodal metastasis. The overall sensitivity, specificity, positive and negative predictive value and accuracy of PET/CT for detecting nodal metastases were 66.67, 97.4, 88.9, 90.24 and 90%, respectively. Conclusion Though FDG PET/CT has a high specificity and negative predictive value, its accuracy in diagnosing nodal metastasis in patients with endometrial cancer is limited because of its low sensitivity.
 
Article
Objective Incidentalomas in 18F-FDG PET/CT scan are a real and known challenge in oncological physician work, and to establish the nature of incidental findings is mandatory for subsequent clinical decision.The aim of this study is to evaluate the prevalence and the clinical significance of 18F-FDG PET/CT gynecological incidental uptake.Materials and Methods We have retrospectively evaluated 11,000 women who underwent 18F-FDG PET/CT from January 2008 to December 2015. The PET images were analyzed qualitatively, and the value of maximum standardized uptake value (SUVmax) was measured for the semi-quantitative analysis. Second imaging or histological examination was performed to obtain the final diagnosis.ResultsUnexpected FDG uptake in female reproductive organs was found in 125 (1.1%) 18F-FDG PET scan performed in 125 different women. 70 focal uptake was in reported in uterus, 33 in ovaries and 13 in both sites. In 64 patients, gynecological uptake was judged as physiological, in 41 as indeterminate and in 20 as malignant. After subsequent follow-up, 13 incidentalomas were classified as malignant, 19 as benign and 93 as physiological. Average SUVmax in malignant lesions was significantly higher than non-malignant (19.64 vs 6.91; p < 0.01), and ROC analysis shows a cutoff value of 8.4 with a sensitivity of 100% and specificity of 77%. No patients with uptake judged as physiological found malignancy after follow-up exams. Eleven of the 13 malignancies were found in the 25 women in menopause.Conclusion18F-FDG gynecological uptake can have many different meanings: a correct anamnesis, related to the PET images, could be useful in characterization of physiological uptake. SUVmax was significantly higher in malignant lesion, and incidental findings in menopause have a higher probability of malignancy.
 
Article
Importance: Exploring methods to mitigate the effect of COVID-19 pandemic on routine cancer screening activities among women. Objective: To investigate the effectiveness of telephone-based outreach as a substitute for physical screening for breast among screened women, during COVID-19 lockdown. Design/setting/subjects: Asymptomatic women aged 30-59 years were screened for breast and cervix cancers in the Chennai region, between January 2017 and March 2020 and are due for screening follow-up. A database from the population-based cancer screening program organized by the Cancer Institute during the above period was used for the study. Outcome data were obtained through the period from October 2020 to March 2021. Intervention: Phone-based breast self-examination awareness, inquiry about breast cancer symptoms, and guiding clinical management. Outcome measure: Compliance to BSE protocol after 8-16 weeks, presence of significant symptoms, and incidence of early breast cancer. Results: Among 12,242 screened women, 6716 (56.8%) responded to a phone-based BSE intervention and 53 women had breast-related symptoms. Thirty-two (60.4%) women reported for further evaluation, and five invasive breast cancers were identified. Conclusion and relevance: In a low-resource setting where there are no existent screening programs, simple interventions like teaching breast self-examination of women through tele-counseling can result in early detection of breast cancers.
 
Article
Aim: To assess the knowledge, attitudes and practices (KAP) regarding the corona virus disease 2019 (COVID-19) pandemic among patients and their attendants visiting the gynaecologic oncology outpatient department (OPD) and to assess the factors associated with a KAP score. Methodology: A KAP cross-sectional survey was conducted over three months exploring KAP relevant to COVID-19. Mann-Whitney U test and Kruskal-Wallis test were used to compare the differences in knowledge, attitude and practice by demographic characteristics. Correlation between knowledge, attitude and practice was done using Spearman's rank correlation test. Binary logistic regression analyses were applied to identify possible determinants of good knowledge, attitude and practice. Results: A total of 521 completed questionnaires were included. The study revealed an overall good knowledge (16.09/20), attitude (8.34/10) and practice (12.73/14) scores. Education status, standard of living (rural/urban) and economic status determined an adequate overall knowledge, attitude and practice score, while an adequate practice score varied significantly by standard of living and education status. Significant positive linear correlations were found between knowledge-attitude (r = 0.513), knowledge-practice (r = 0.407) and attitude-practice (r = 0.407). Conclusion: The study demonstrated good overall knowledge, attitude and practices towards COVID-19 pandemic among gynaecological oncology OPD patients and their attendants. Supplementary information: The online version contains supplementary material available at 10.1007/s40944-022-00624-1.
 
Management options for 'Advanced' stage disease
Article
PurposeThe notorious COVID 19 pandemic has caused rapid and drastic changes in cancer care worldwide in 2020. This online survey aims to assess the extent to which the pandemic has affected cancer care in gynecological oncology amongst members of the Association of Gynecological Oncologists of India (AGOI), a registered professional society founded in 1991.Methods We developed and administered a cross-sectional, flash survey to members of AGOI in the first week of April 2020. Data were analyzed using Microsoft Office Excel 2016. Results were expressed as percentages of total responses excluding blank or unattended response. Overall theme-specific responses were described as a spectrum of findings, and related inferences were drawn.ResultsAmong approached practitioners, 90 responded to the survey, more than 80% were practicing consultants, and more than 50% from academic institutions. The results of the study showed that the ongoing pandemic had severely affected gynecological oncology practice and care amongst all respondents. There were modifications in diagnostic pathways, interventions, and follow-ups across all organ sites. There was a near-unanimous opinion on the use of general safety measures to combat the virus and to use complete PPEs in a high-risk situation. There were mixed responses to alternative educational activities, especially using electronic technology and distant learning methods. There was optimism among respondents with regards to the current situation normalizing in 3–6 months.Conclusion This study documents the pandemic affected scenario of gynecological cancer care and perceptions of Gynecological Oncologists in India. A significant effect on all aspects of cancer care was observed. Technological learning methods, both for patient care and educational activities, were being adopted by many respondents.
 
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Patients demography, pre-operative status, surgical com- plexity and types of surgery Patient and surgical parameters Number %
Intra-operative parameters and post-operative outcome based on cancer site
Article
PurposeThe timely management of cancer surgery suffered due to COVID-19 and nationwide lockdown. Continuing cancer surgery was a challenge faced by all. We present our experience on cancer surgery in a cancer centre with high volume of patients and limited resources during early pandemic.Methods We retrospectively analysed our operation theatre database on surgery and anaesthesia from 1st April to 30th June 2020.ResultsA total of 457 surgeries were done—complex major, major, intermediate and minor surgeries constituted 43%, 25%, 12% and 20%, respectively. Median age of patient was 50 years, and 76% were below 60. The median ASA class was I (I–IV), and 97% were ASA I and II. The median Eastern Cooperative Oncology Group score was 0 (0–3), and 92% had score 0 and 1. Major cases done under regional anaesthesia were 30.7%. Median length of intensive care unit stay was 1 (1–6) days, and length of hospital stay was 7 (7–15) days. Clavien–Dindo Grade II complication in patients above 60 years was 16.4% and below 60 years was 17.6% (p = 0.76). 10% in ASA I compared to 26% of ASA II (p = 0.00) and 15.9% with ECOG 0 and 1 compared to 30.9% with ECOG 3 and 4 (p = 0.01) had grade II complication. Four (1%) patients had Grade ≥ III CD complication. Covid testing was undertaken in 52% patients pre-operatively, and there was no positive case in post-operative period.Conclusions Adopting and implementing institutional policy catering to limited resource available at our centre, we facilitated cancer surgery.
 
HCW after donning
OT setup for HIPEC
Article
Background Amidst the COVID pandemic, most guidelines have recommended delaying surgery and giving chemotherapy for with peritoneal surface malignancies. However, when all options are exhausted, complex surgery like CRS with HIPEC can be performed in select patients.Method To facilitate these complex surgeries with maximum safety, RT-PCR test for COVID-19 was performed for each patient. Personal protective equipment including N95 masks and face shields was used. A number of OT personals were limited. Taking these steps minimized the risk of COVID-19 infections among healthcare workers and patients.Conclusion After implementing these steps, we were able to perform complex CRS and HIPEC procedure during the pandemic and thus improve oncological outcomes.
 
Article
Extrauterine endometrial stromal sarcoma (ESS) is a rare entity and typified by delayed recurrence of primary ESS. Here, we present an unusual case of uterine ESS in a woman with a history of hysterectomy. A 19-year-old girl underwent hysterectomy and bilateral salpingo-oophorectomy for uterine ESS 12 months ago, and now after remaining disease-free for 9 months ago she was presented with ascites along with pelvic and peritoneal mass. Intraoperatively, large omental mass was found and optimal cytoreduction with total omentomy (supracolic and infracolic), total peritonectomy and hyperthermic intraperitoneal chemotherapy (HIPEC) was offered to the patient. Final histopathology report showed involvement of only omentum by ESS cells. IHC and receptor study was done, and it was positive for CD-10 and desmin and negative for CK-7. This case highlights the rarity of extrauterine ESS in the omentum with a known history of primary uterine ESS which was treated successfully with the above-mentioned procedure, though active and long-term surveillance is recommended to monitor for late recurrences.
 
Article
PurposeThe impact of the COVID-19 pandemic on world healthcare system and economy is unprecedented. Currently routine surgical procedures are at a halt globally, but whether one can delay cancer procedures remains an ethical issue, and still there is no clarity on how women with gynaecological cancers should be managed in these critical times.Methods Currently available literature on impact of COVID-19 on cancer was reviewed with special reference to its applicability to the Indian context.ResultsCancer cases are more susceptible for COVID-19 infection and rapid deterioration if they get infected. A tumour board should plan their management with a “do no harm” approach as the guiding principle. Teleconsultation may be used to advise patients for therapy and symptom control measures, as well as to advise new patients regarding diagnostic tests. Surgical decision making may be stratified into three categories: patients with low (not life threatening) or intermediate (potential for future morbidity or mortality) acuity may be delayed; those with high acuity may be taken up for planned therapy after explaining the risks. Assessment of the severity of disease, comorbid conditions, and logistic challenges, along with COVID census in their area are important variables for informed and individualized decision making. Safety of healthcare personnel needs to be ensured at the same time.Conclusion Currently available evidence is limited by small sample size, and full impact of this pandemic on cancer is yet to be seen. However, cancer care needs to be individualized taking all variables into consideration.
 
Guidelines for the use of PPE
Patient and disease characteristics
Chemotherapy characteristics
Article
PurposeThe entire world is currently facing a devastating crisis due to growing coronavirus pandemic, which was declared as a public health emergency by the World Health Organization on March 11, 2020. Management of cancer patients at this time is an overwhelming task. This study highlights our experience in the management of patients of gynecological malignancies over a period of 2 months during the COVID-19 pandemic.Methods Patients of confirmed gynecological malignancies who visited our outpatient clinic and those who received radiotherapy/chemotherapy in March and April 2020 were included for analysis. Guidelines issued by the National Institute of Health and Care Excellence, National Health Service, MD Anderson Cancer Centre and those by young oncologists in Italy were followed with minor modifications while managing the logistics and health worker safety.ResultsA total of 160 patients were treated in our department during this time period. In total, 44.4% of patients on treatment had associated comorbidities that imposed an additional risk. One hundred twenty-three patients continued treatment with their initial plan of radiotherapy or chemotherapy. New patients were prioritized based on the severity of clinical symptoms and whether the expected outcome would significantly affect their survival and quality of life. Patients were monitored for the development of treatment-related toxicities and COVID-19-related symptoms.Conclusions All oncology personnel need to identify the correct balance between risks and benefit and then proceed with further management. Thus, it is essential to cautiously select patients for treatment, minimizing the risk of exposure but adequately addressing the underlying disease.
 
Pharmacologic prophylaxis methods against COVID-19
a Level of stress while operating during COVID-19 pandemic, b Discomfort after donning PPE
Preoperative COVID-19 screening protocol
Details of PPE usage
Article
PurposeIn the absence of vaccine, proper use of personal protective equipment (PPE) is the most important strategy to protect healthcare workers against COVID-19 infection. The recommendations on pharmacological prophylaxis against COVID-19 infection are controversial. The aim of current study was to assess PPE practices during surgery on COVID-19 negative gynecological cancer patients and use of pharmacologic prophylaxis by clinicians practicing gynecologic oncology.Methods We disbursed a survey questionnaire through various social media platforms among clinicians practicing gynecologic oncology. The survey consisted of 37 questions divided into five subgroups evaluating demographic details, use of pharmacological prophylaxis against COVID-19, preoperative COVID-19 screening protocol, details on PPE usage and associated discomfort, if any.ResultsTwo hundred twenty oncologists from 13 countries responded to the survey. Pharmacological prophylaxis was being used by 85 (38.6%) respondents; most common agent was hydroxychloroquin (HCQ) by 24.5% respondents. Routine preoperative screening for COVID-19 was performed by 214 (97.3%) respondents. Some degree of discomfort during surgery due to PPE use was reported by 170 (77.3%) respondents, which was moderate to severe in 73 (33.2%) respondents. Most common difficulties associated with face mask/shield were problems in communication (69.5%) and breathing (58.1%). Eye protection was associated with poor visibility, fogging and headache. Unusual fatigue attributed to PPE use was experienced by 143(65%) respondents.Conclusion Use of pharmacological prophylaxis against COVID-19 is controversial and the same is reflected in our survey. Most respondents adhered to PPE use despite experiencing some physical discomfort.
 
Article
Background Each year in the USA, 22,280 women are diagnosed with ovarian cancer and 14,240 women die each year from this disease. While accounting for only 2.4% of all cancer deaths, the 5-year survival rate is extremely low at 46% which highlights the great need for continued research. The Familial Ovarian Cancer Registry’s goal since its inception has been to provide the tools needed for the development of improved screening, diagnosis and treatment of ovarian cancer. Methods All major articles produced from the inception of the registry using data either from registry pedigrees or registry samples were collected and reviewed by the authors. Results and Discussion Articles from the registry have contributed to the field of ovarian cancer research from 1981 to 2017 in many ways from better defining risks associated with ovarian cancer syndromes to looking at specifics of gene mutations in ovarian cancer registry families. The database continues to grow and provide new information for gene sequencing not only from participants but directly from tumor samples collected at Roswell Park Cancer Institute.
 
Baseline characteristics Age in years, mean (range) 56.5 (22-92)
Top row describes FIGO 2009 stages and left column FIGO stages 2018
Median tumour volume, incidence of corpus invasion and nodal metastasis according to FIGO 2009 staging
Article
Objectives The aim of this study was to quantify the shift in patients from the FIGO 2009 to the FIGO 2018 staging using a prospectively collected dataset where pre-treatment MRI and PET-CT were used. A secondary aim was to explore the distribution of known prognostic factors in both staging schema. Methods Prospectively collected dataset of 1047 cervix cancer patients staged with MRI and PET-CT, between 1996 and 2014, were redistributed using FIGO 2018 staging criteria. Standard deviation inter-quartile and contingency tables were used to present the distribution of patients according to FIGO 2009 and FIGO 2018 criteria. Logistic regression was used to evaluate the association of node positivity and nodal size. Results and Discussion In total, 853 patients were available for analyses. Based on MRI and PET findings, according to FIGO 2009, the incidence of lymph node metastasis was similar in (1) stages 1b1 and 2a1, (2) 1b, 2a2, 2b and 3a (3) 3b and 4a. Nodal metastases were found in 43% patients who were upstaged from FIGO 2009 to newly created FIGO 2018 stages 3c1 and 3c2. Contribution to stage 3c1 came from 31, 41, 29, 30, 32, 33 and 34% of stages 1b1, 1b2, 2a1, 2a2, 3a and 3b, respectively. FIGO 2009 stages 1b1 and 1b2 contributed 5 and 6%, stages 2a1, 2a2, 2b and 3a contributed 16, 15 and 15% to para-aortic nodes, while stage 3b contributed 24%. These findings will likely influence cervix cancer treatment policies.
 
Article
Introduction Ovarian cancer is the fifth cause of cancer death among women. P53 gene and Ki67 can play a significant role in the progression of tumors. This study was conducted to review the frequency of P53 and Ki67 markers in different types of ovarian epithelial tumors and their relationship with the prognosis of the disease. Materials and Methods This descriptive analytical study was done on all paraffin-embedded blocks of patients with ovarian surface epithelial tumors (malignant, benign, and borderline) referred to pathology ward of Shahid Sadoughi educational General Hospital from 2013 to 2017 by using the census method. Ki67 and P53 immunohistochemical tests were then performed on all the samples. Data such as (age, pathology report, survival status, affected side, size of tumor) were extracted from the hospital folders. Data were analyzed in SPSS version 22. P < 0.05 was set as the level of statistical significance. Results A total of 86 cases, including 40 serous and mucinous carcinomas, 36 serous and mucinous cystadenomas, and ten serous and mucinous borderline tumors, were examined. The mean age of the patients was 44.29 ± 16.91 years, and their age range was 15–79. A significant relationship was found between the type of tumor and the frequency of P53 and Ki67 (P < 0.05). Nonetheless, no significant relationships were observed between tumor grade and these two markers. Ki67 staining susceptibility was significantly higher in the undifferentiated tumors than in the others (P < 0001). The mean survival was 40.67 months, and a significant relationship was observed between age and survival (P < 0.002) and age and the frequency of P53 and Ki67 and tumor type (P < 0.05). Discussion and Conclusion The results of this study showed that both P53 and Ki67 are predictors of overall survival, tumor type, disease grade, and disease prognosis in patients with different ovarian epithelial tumors and can be used in them alongside biopsy.
 
Article
Myths, superstition, and taboos are prevalent in India and often guide the patient’s perceptions about the cause and treatment of diseases. The preformed firm notions make the patients unreceptive to counseling by doctors and often lead them to take wrong decisions from their end. We report a patient with cancer of the ovary who because of her misconception of cancer surgery chose to undergo 21 cycles of chemotherapy and eventually faced near fatal complication after surgery.
 
Article
AimThis retrospective analysis aimed to evaluate the clinicopathological characteristics of primary mucinous tumors of the ovary (MOT) treated at a tertiary care center. Materials and Methods Demographic, clinicopathological, treatment and follow-up details of all patients with primary MOT treated from June 2015 till August 2019 were extracted from institutional cancer registry and Electronic Medical Records, after obtaining necessary clearance from institutional ethical committee, and institutional review board. The details obtained were tabulated and analyzed. ResultsThirty-one patients were identified to have primary MOT: 20 cystadenomas, 10 carcinomas (mOC) and one borderline (mBOT). MOT was frequently noted between the fourth to sixth decades. Abdominal distension was the most common symptom at presentation. In total, 70% of cystadenomas were less than 15 cm, while 90% of mOC were 15 cm and above. In total, 95% cystadenomas were unilateral, while all cases of mBOT and mOC were unilateral. mOC showed elevated CA 125 in 42.86% cases, elevated CEA in 42.86% cases and elevated CA 19–9 in 75% cases. Imaging showed 30% of mOC as benign cysts and 42.1% of cystadenomas as complex cyst. Frozen section correctly diagnosed cystadenomas and mBOT, and two mOC were underdiagnosed as borderline. All had upfront surgery. Of cystadenomas, 11 underwent salpingoovariotomy, and nine had hysterectomy and salpingoovariotomy. All the mOC and mBOT underwent staging laparotomy. Three cases of mOC had a fertility preserving approach. No cases had positive lymph nodes, and appendix showed normal histology. In total, 40% were stage 1a, 30% 1C1 and 30% IC3. Two patients received postoperative chemotherapy.Conclusions Differentiation between benign MOT and mOC is crucial. A multidisciplinary approach, involving clinician, radiologist and pathologist, helps in clinching the diagnosis. mOC present at a younger age and fertility-sparing procedures are reasonable options in early-stage MOT.
 
Article
Background and Purpose The availability of more advanced technology like hypo-fractionation has the potential of being the new standard of care in breast cancer. This study evaluates whether 3DCRT with a field-in-field technique (FIF) and a simultaneous integrated boost (SIB) could provide a dosimetrically comparable plan delivered to VMAT or IMRT. Materials and Methods 3DCRT-FIF-SIB, VMAT and IMRT-SIB plans were generated for 20 patients. The plans were compared for planning target volume coverage (PTV 95), homogeneity and conformity, dose delivered to lungs, heart and C/L breast. Results 3DCRT FIF provided better sparing of C/L breast V1 and V5, whole lung V5, p = 0.000. The VMAT plans spared heart V30: (0.1 ± 0.46 vs. 11.5 ± 18.3) p = 0.000 and I/L lung V20: (19.3 ± 5 vs. 32.2 ± 11.1) p = 0.000. It provided a better coverage V95: (97 ± 0.8 vs. 95 ± 2.9) p = 0.002 and sparing of the heart V30: (0.1 ± 0.5 vs. 8.6 ± 11.5) p < 0.002 and lungs I/L V20: (19.3 ± 5.0 vs. 30.7 ± 6.1) p = 0.000. The treatment was faster with less exposure in terms of MU: (529 ± 57.8 vs. 1024 ± 298) p = 0.000. Conclusions 3DCRT provides a dosimetrically acceptable alternative to more advanced technologies. VMAT and IMRT provide better sparing of heart and lungs. VMAT has a slight benefit of conformity, reduced exposure and shorter treatment time.
 
Article
Background Uterine corpus tumors are one of the most common reasons for morbidity and mortality of women around the world, and histopathological diagnosis is the key for better management of the patients. Aims To study the histopathology of uterine tumors, classify them as per WHO 2014 classification and correlate with clinical parameters. Methods A five-year study was conducted on 433 histopathologically diagnosed cases of uterine corpus tumors. Results Benign tumors were the most common (95.6%) followed by malignant (3.9%) and borderline (0.5%). Leiomyoma was the most common benign tumor (91.2%). Majority of the cases were multiparous females (88.6%) in fourth and fifth decades of life (77%) and presenting with heavy menstrual bleeding (35.9%). The most location was intramural (68.9%). Cellular leiomyoma (1.8%) was the most common histologic variant; the secondary change was hyalinization (27.8%). Endometrial carcinoma was the most common malignant tumor (3%) followed by leiomyosarcoma (0.5%) and adenosarcoma (0.2%). Majority of the women with endometrial carcinoma were multiparous (76.9%) and belonging to the age-group of 50–59 years (38.4%). The most common symptom was postmenopausal bleeding (76.9%). Endometrioid carcinoma grade I (75%) was the most common type of endometrial carcinoma. Other lesions were adenomyoma (N = 17), STUMP (N = 2), and one case each of adenomatoid tumor, endometrial stromal nodule and secondary tumor. Conclusion Benign tumors were more common than malignant tumors. Leiomyoma was the most common benign tumor, and endometrial carcinoma was the most common malignant tumor. Many uterine tumors present with similar clinical features. However, histopathology plays an important role in the accurate diagnosis of different types of tumors and thus helps in providing the patient with appropriate management.
 
Article
PurposeThe present study aimed to assess the local control and overall survival of patients with stage IIB–IVA cervical cancer after definitive external beam chemoradiation and high-dose-rate miniaturized Cobalt-60 (Co-60) intracavitary BT.Methods This was a cross-sectional study that prospectively enrolled patients with cervical squamous cell carcinoma referred for BT as a part of their definitive treatment to Reza Radiotherapy & Oncology Center of Mashhad, Razavi Khorasan, Iran, between 2017 and 2018. The optimal dose of treatment was determined, and survival analysis was performed using the log-rank test at the level of p ≤ 0.05.ResultsA total of 65 patients were enrolled, and most of them had stage IIB (76.9%). With a median follow-up of 18 months, the 6-, 12-, 18-, and 24-month overall survival was 98%, 86%, 75%, and 50%, respectively. The optimal cutoff dose of high-risk clinical target volume (HR-CTV) was 85.06 gray (Gy). There was a trend in the reduction of survival in patients with higher stages and receiving lower doses to tumor; however, the results were not significant.Conclusions Based on the results of this study, a minimum total dose of 85 Gy to high-risk clinical tumor volume is essential to achieve an optimal local control.
 
Article
Purpose To test the clinical utility of biomarkers p16/Ki-67 expression in cervical cytology smears as a marker for transforming HPV infection. Setting and Design Experimental study at a tertiary care hospital. Methods Women who were screened positive on Pap and visual inspection tests (n = 280) underwent colposcopy and biopsy. p16/Ki-67 immunostaining was performed in abnormal Pap smears (n = 86), and HPV DNA testing was also performed in the same women. Statistical Analysis Sensitivity, specificity, negative predictive value, positive predictive value and likelihood ratios were calculated for each biomarker separately and in combination. McNemar test and receiver operating characteristic (ROC) curves were used to compare sensitivity and specificity of biomarkers with HPV DNA. Areas under the ROC curve (AUC) were compared using the Chi-square test. Results Eighty-six women with abnormal cytology were evaluated with p16/Ki-67 immunocytochemistry; 20.9% (n = 18) and 18.6% (n = 16) were positive for each biomarker, while dual marker was positive in 15% (n = 13). In all smears, the sensitivity of p16INK4a/Ki-67 in detecting CIN 2+ lesion was 76.9% and specificity was 95.8%. For ASCUS (n = 42) and LSIL (n = 23) smears, specificity and negative predictive value of p16/Ki-67 for CIN 2+ were 100% with a likelihood ratio (LR+) of 27 and 25, respectively, suggesting good diagnostic accuracy. In comparison with HPV DNA testing, combined marker p16/Ki-67 was significantly more specific (p = 0.003); AUC was 0.734 and 0.635, respectively. Conclusions p16/Ki-67 evaluation in cervical cytology is a valuable biomarker in triaging for CIN 2+ disease in ASCUS and LSIL smears.
 
Article
Purpose To determine whether burst abdomen can be prevented in gynecological malignancies by layered closure of the abdomen and by the routine use of Ryle’s tube, abdominal and subcutaneous drains. Methods A total of 43 patients underwent surgery through a midline vertical incision over a period of 10 months between January 01, 2015 and October 31, 2015. All incisions were closed by mass closure technique. No drains were used in any of the patients. Subcutaneous fat was approximated with interrupted sutures in patients who had a subcutaneous fat thickness of more than 2 cm. Skin was closed by mattress sutures. All patients were started on oral sips once bowel sounds were heard. Ryle’s tube was inserted postoperatively only if the patient developed distention. During the next 10 months, between November 01, 2015 and August 31, 2016, a total of 36 patients underwent surgery through a right paramedian incision. The abdominal closure was done by closing the peritoneum and rectus sheath separately. An abdominal drain and a subcutaneous drain were placed in all patients. In very thin patients with little subcutaneous fat, a mini suction drain was placed. No sutures were taken on subcutaneous fat even in morbidly obese patients. Skin was closed using staplers. Ryle’s tube was inserted in all patients during induction and was removed only after patients passed flatus. Oral sips were started only after the patient passed flatus. Results There were 3 cases of burst abdomen in the first group (6.9%). There were 4 full-length wound gapes and 3 partial wound gapes in the first group (16.2%). In the second group, there was just one case of burst abdomen (2.7%), one case of full-length wound gape (2.7%), and 1 case of stitch sinus (2.7%). Conclusion Layered closure of the abdomen and routine placement of Ryle’s tube, abdominal and subcutaneous drain, resulted in reduction in incidence of burst abdomen from 6.9 to 2.7% and incidence of wound gape from 16.3 to 2.7%. However, the most important factor in prevention of burst abdomen is control of predisposing factors. We still had one patient who had burst abdomen because of uncontrolled cough.
 
Case 1. CT image of abdominal wall metastasis [red arrow]
Case 4. Abdominal wall metastasis [red arrow] CT scan and on inspection
Article
IntroductionCutaneous metastasis from cervical cancer is rare. We report four consecutive cases of abdominal wall metastasis after patients had inappropriate surgery for cervical cancer.Methods Between January 2015 and September 2019, we encountered 34 cases of recurrent cervical cancer. The demographic, clinical and treatment details of 4 patients with abdominal wall metastasis were obtained from electronic medical records.ResultsAll four patients had had simple hysterectomy for cervical cancer elsewhere and presented with abdominal wall metastasis. All patients had squamous cell carcinoma. The duration between primary treatment and recurrence ranged between 6 and 18 months. The four patients were treated with either surgical excision or chemotherapy and radiation therapy. All patients were alive at the time of reporting.Conclusion If the recurrence is limited to the anterior abdominal wall, wide local excision with repair is possible. When abdominal wall metastasis is associated with pelvic recurrence in patients who were not given radiation initially, they can be offered chemoradiation with curative intent. Individualized treatment by a multidisciplinary team can give the patient the best chances at survival and the best quality of life.
 
Article
Ewing’s sarcoma (ES) is the second most common malignant bone tumor in children and young adults. ES also occurs as a primary soft tissue neoplasm without involvement of bone. Usual sites of involvement are the deep soft tissues of the lower extremity and paravertebral region. Clinical or imaging findings are non-specific, and diagnosis is based on histology. We reported a rare case of an Extraosseous Ewing Sarcoma (EES) developed in the soft tissues of the anterior abdominal wall in midline position in a 63-year-old woman who presented with a painful abdominal mass. The case was suspected to be carcinoma ovary with pelvic deposits, however on laparotomy it was found to be a malignant anterior abdominal wall mass. The final diagnosis on immunohistochemical staining was EES.
 
Article
Purpose To find out common causes of pelvis-abdominal (PA) lump in women of different age groups and to analyse clinical presentation and the histopathological finding of the PA lump in the gynaecology department of a referral hospital. Methods Sixty-eight women of 60 years or less who present with PA lump were recruited for the study. Women carrying intrauterine pregnancy were excluded from the study. Clinical and histopathological analysis of PA lump was done after operations. This was an observational study. Association was assessed by means of Chi-square test. For all statistical purposes, p < 0.05 was taken as statistically significant. Results 88.23 % of PA lumps were in the age of 21–50 years age groups. Uterine fibromyoma (38.23 %), ovarian tumour (26.47 %) and endometriosis (10.29 %) were common causes presenting with PA lump. The percentage of benign PA lump in the different age groups from 11 to 60 years was significant when compared with malignant histopathology (p value = 0.000 in each age group of 11–20, 21–30, 31–40, 41–50 and 51–60 years). Conclusions Uterine fibromyoma was the commonest PA lump followed by ovarian tumour and endometriosis in the women of different age groups from 11 to 60 years. Pain and lump abdomen were common clinical symptom and sign in ovarian malignancy. Histopathology showed that PA lump of women of 60 years or less was mostly benign in nature, which was significant.
 
Article
Introduction Endometrial carcinoma is the fourth most common carcinoma in females worldwide. Due to early symptoms, these are diagnosed at an early stage and thus have a good prognosis. Recurrences usually occur to the pelvic and para-aortic lymph nodes, vagina, peritoneum, and lungs. They occur rarely in the bones, brain, intra-abdominal organs, abdominal wall, and muscle. Case Report We present a case of a 42-years-old nulliparous female with diagnosed carcinoma of the endometrium who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy with surgical staging and presented after 30 months with an isolated recurrence of endometrioid carcinoma at an atypical location on the anterior abdominal wall.
 
Summary of current evidence on endometrial ablation
Clinical presentation of endometrial cancer after treatment with endometrial ablation
Risk factors in population of study
Article
This study is an evaluation of the long-term risk of endometrial cancer in patients undergoing EA with first- and second-generation ablative techniques. A variety of different endometrial ablation devices developed, with complication rate lower than the hysteroscopic resection. The incidence of endometrial cancer has risen by 57% in the last 20 years worldwide. More than 90% of patients will present with postmenopausal bleeding as the most common red flag symptom for endometrial cancer. A reasonable assumption is that through destruction of the endometrium, the incidence of endometrial cancer after EA should be reduced. However, there are concerns raised regarding intrauterine scarring and distortion of the uterine cavity after EA, which may delay the diagnosis of endometrial cancer. For this narrative review, four major search engines were explored (MEDLINE, Google Scholar, PubMed and EMBASE) up to December 2021, to retrieve articles that provide information about on incidence of endometrial cancer after endometrial ablation. Thirty-two cases have been identified and studied. This study has confirmed that 76.5% of endometrial cancer cases after EA were diagnosed at stage I, which is consistent with the evidence from the literature. It has also showed that endometrial ablation does not delay the diagnosis of endometrial cancer. All clinicians need to maintain high degree of suspicion and thus offer in-depth counselling to their patients. Patient selection is important, and thus, ablation should be offered only to women preferable without risk factors, along with a recent normal endometrial biopsy.
 
Article
Aim Cervical cytology is still the mainstay of cervical cancer screening programmes in developed countries, whereas this has not proved to be useful in low-resource settings. Purpose To audit abnormal Pap smears and their management in a tertiary care institution with an intention to improve quality of services rendered. Methods A list of all abnormal Pap smear (liquid-based cytology) reports between June 2012 and June 2013 was obtained from our cytopathology department. Electronic records of these patients were used to fill a proforma. The data were analysed using SPSS 19. Results A total of 11,984 women who attended the gynaecology clinic had Pap smears done, of which 130 were abnormal (1 %). The mean age of these women was 43. The median parity was 2 with a range of 0–6. Five women were previously treated for cancer cervix, 4 for CIN and 10 were HIV positive. ASCUS was reported in 25 (19 %), LSIL in 45 (35 %), HSIL in 41 (32 %), ASC-H in 11 (8 %), cancer in 6 (4 %) and AGC in 2 (2 %). Among those with abnormal smears, 33 women (25 %) were lost to follow up (7 HSIL, 15 LSIL and 11 ASCUS). Treatments offered included LEEP in 20 (15 %), conisation in 4 (3 %) and vaginectomy in 1. Sixteen patients eventually had hysterectomy (12 %). Immediate (see & treat) treatment was done after colposcopy in 10 women where the final biopsy was negative in 3, CIN I in 1, CIN II/III in 4 and invasive cancer in 2. Conclusion The follow-up of patients after Pap smear and treatment needs to be emphasized for the success of any cervical screening programme. See-and-treat methods could be carried out but have a risk of overtreatment.
 
Article
Background Abnormal uterine bleeding (AUB) is the most common clinical problem in gynecology with hysteroscopy permitting the direct visualization of uterine cavity to diagnose various intra-uterine lesions. Scientists have incorporated the usage of dyes to stain specific lesions in endometrium which is called as chromohysteroscopy.Aims and Objectives The present study was conducted on 100 women of perimenopausal age group (40–55 years) with the aim to strengthen the importance of chromohysteroscopy in patients of AUB and to widen its applicability in detecting subtle endometrial changes which can be missed on routine hysteroscopy.ResultsOn hysteroscopy, endometrium in 88 patients appeared to be normal, and 12 patients had abnormal endometrium (eight hyperplasic, three atrophic, one diffuse polypoidal). Out of these 12, only four patients had confirmed pathology on histopathological examinations (HPE) (two simple hyperplasia, one atrophic endometrium, one carcinoma endometrium). Thus, hysteroscopy had sensitivity of only 26.67% and specificity of 90.59% with PPV of 33.32 and PPV of 87.50 in predicting diffuse endometrial changes. Out of eight HE on hysteroscopy, only two (25%) were confirmed on histopathological examination. On chromohysteroscopy, out of 100 patients, 15 patients had dark stained endometrium, and among these, 12 patients had confirmed endometrial abnormalities on HPE (seven simple hyperplasia, four inflammatory endometrium, one carcinoma endometrium). Thus, chromohysteroscopy has sensitivity of 80.00% in detecting endometrial pathologies. Conclusion Methylene blue is relatively very safe dye with fewer complications and has more predilections for hyperplastic and inflammatory endometrium. It does not require any sophisticated instrumentation or clinical skills during its usage and can be successfully employed along with hysteroscopy to predict hidden pathological areas during hysteroscopy without any harm.
 
Article
Background Gynecological cancer is the fourth most common malignancy in women that affects female reproductive organs, including ovaries, fallopian tubes, uterus, cervix, vagina, and vulva. Breast cancer is also a malignant disease worldwide. Every year, over one million people were newly diagnosed with breast cancer. Apart from transfusion practice, blood group has established specific mode of inheritance and population-specific variation. The association between ABO blood group and several malignancies have been reported, including breast cancer, ovarian cancer, and cervical cancer. However, inconsistent results were obtained in various works on ABO blood group association with several malignancies and also inadequate research work on prognostic impact of ABO blood group among several cancers leads to uncertainty for cancer survival. In this background, the objective of present study is to understand the association between ABO blood group and the survival of different gynecological cancer patients of Bengali Hindu caste group. Materials and Methods The present study consists of 148 clinically diagnosed female cancer patients (breast, uterus, and cervical). Data were collected on blood group, age at marriage, age at menarche, age at menopause, parity, and age at first pregnancy. ResultExamination on survival and cancer revealed that the patients with A blood group have comparatively more survival time than other blood groups.
 
PRISMA flowchart for the study selection process
ABO blood group and ovarian cancer overall survival
Recurrence rate of ovarian cancer in different blood groups
Frequency of ABO blood groups in different FIGO stages of ovarian cancer patients
Article
Background Ovarian Cancer (OC), as the seventh most common cancer throughout the world, is one of the most lethal gynecologic malignancies in women. In addition to well-studied risk and prognostic factors of OC, such as age, obesity, stage, histology, etc., ABO blood groups associations with OC has been attracted the investigators’ focus in the recent decade. The objective of this study is to find any relationships between ABO blood groups and OC through a meta-analysis.Methods The databases of PubMed, Embase, and Web of Science were systematically searched by available MeSh terms for “Ovarian Cancer”, and “ABO blood group” up to August 1, 2020. Hazard ratio (HR) or odds ratio (OR) were extracted and used from studies for outcome estimation whenever appropriate with 95% confident interval (CI). Data were analyzed using CMA v. 2.2.064.ResultsFourteen papers, including 58,193 participants, entered in the systematic review. The meta-analysis indicated a substantially higher risk of developing OC in individuals with blood group A (OR 1.17, 95% CI 1.01–1.36) and AB (OR 1.27, 95% CI 1.02–1.59), but the subject was not significant in individuals with blood group B (OR 1.11, 95% CI 0.81–1.51). No associations were found between OC overall survival and blood group A (HR 1.14, 95% CI 0.79–1.64), AB (HR 1.00, 95% CI 0.69–1.45), and B (HR 0.88, 95% CI 0.58–1.33). Recurrence rates of OC for blood groups A, AB, B, and O were 30.8%, 34.3%, 33.6%, and 32.0%, respectively. Rates of mortality in different blood groups are as follows: A (31.8%), AB (31.1%), B (26.2%), and O (33.8%).Conclusion This systematic review and meta-analysis revealed a considerably increased risk of developing OC among individuals with blood group A and AB. However, no substantial impacts were found for ABO blood groups on the overall survival of the OC patients.
 
Article
Women lack knowledge about HPV infection, vaccines, screening modalities, symptoms, and risk factors which is a major contributor in delayed diagnosis of cervical cancer and short life expectancy. This study aimed to examine the knowledge level about HPV infection, cervical cancer, and preventive measures such as HPV vaccination among women in Tamil Nadu, India. This was a web-based cross-sectional survey using predesigned questionnaire. Totally, 2100 women registered. Their responses were analyzed with a simple Fisher exact test. More than 50% of people were not aware of HPV infection, cervical cancer, and HPV vaccines, even women who have a better educational background. This study highlights the necessity to spread awareness about cervical cancer and the significant risk factors, symptoms, and preventive methods of cervical cancer.
 
Article
Objectives To identify cases needing genetic testing for hereditary breast and ovarian cancer (HBOC) syndrome among cases of breast and ovarian cancer and assess their acceptability for genetic testing. Materials and Methods One hundred patients of breast and/or ovarian cancer were recruited. A series of family meetings were done with patient and close family members. The first meeting was for pedigree chart preparation and identification of cases for genetic testing (HBOC) as per NCCN 2013 criteria. Second family meeting was held for counselling about genetic testing. Third meeting was held for recording acceptance or refusal for genetic testing. For those refusing the test, reasons for refusal were recorded. Outcome measures including prevalence of high-risk cases, acceptance rate for genetic testing and factors affecting the above acceptance rates among high-risk women were statistically analysed. Results Out of 100 patients of breast and ovarian cancer recruited in the study, 88 were found to be at high risk of HBOC. The most common criterion for high risk among breast cancer cases was age below 45 years. Family history of breast or ovarian cancer was present in 3.03% cases of ovarian cancer and 11.76 cases of breast cancer. Eleven (16.66%) cases of epithelial ovarian carcinoma and six (27.27%) cases of breast carcinoma accepted genetic testing. Socioeconomic status was found to have statistically significant correlation (p < 0.001 and p = 0.030) with acceptance for genetic testing. Conclusion Though it is a small sample study, there is huge burden of women needing genetic testing for HBOC. There is lack of awareness about familial nature of disease and low acceptance for genetic testing in our population. There is a significant effect of socioeconomic status on acceptance for genetic testing.
 
Lateral posterior approach (open surgery, right pelvic sidewall). The RL is retracted medially and dorsally. The posterior leaf of the broad ligament is incised in ventro-dorsal direction lateral to the ovarian vessels and lateral to the external iliac artery over the psoas major muscle. UT-uterus, RL-round ligament, PLBposterior leaf of broad ligament, OV-ovarian vessels. Arrow shows peritoneal incision line
Intraligamentary myoma located into the paravesical space (open surgery, right pelvic sidewall). Ellipse-retroperitoneal tumor location. Arrow 1-lateral anterior approach-peritoneal incision is performed lateral to the obliterated umbilical artery and medial to the external iliac vessels. Arrow 2-lateral posterior approach-peritoneal incision is performed in ventro-dorsal direction lateral to the ovarian vessels and lateral to the external iliac artery over the psoas major muscle. Arrow 3-peritoneal incision is made at the level of the vesicouterine peritoneal fold, until reaching the first peritoneal incision. UT-uterus, PBL-posterior leaf of broad ligament, ABLanterior leaf of broad ligament, B-bladder, RL-round ligament
Peritoneal closure after retroperitoneal myoma removal (open surgery, right pelvis sidewall). Arrow 1-peritoneal closure of the posterior leaf of the broad ligament, Arrow 2-peritoneal closure of the anterior leaf of the broad ligament. UT-uterus, EIA-external iliac artery, PM-psoas major muscle
Early split of the genitofemoral nerve (fresh cadaver, left pelvic sidewall). PMM-psoas major muscle, ON-obturator nerve, EIV-external iliac vein, EIA-external iliac artery, DCIV-deep circumflex iliac vein, gGFN-genital branch of the genitofemoral nerve, fGFN-femoral branch of the genitofemoral nerve
Article
IntroductionThe retroperitoneum in the pelvis includes all pelvic spaces (Retzius’, vesicocervical/vesicovaginal, rectovaginal, presacral, pararectal and paravesical) and vital structures such as nerves, vessels, lymph nodes and ureters. Eradication of endometriosis, myomectomy of intraligamentary myoma, urogynecological reconstructive and oncological exenterative surgery require wider anatomical knowledge in the retroperitoneum. Generally, the retroperitoneal space is used for plane of dissection when the peritoneal cavity is obliterated. In the medical literature, there are few articles reporting the important relationship between retroperitoneal accesses, anatomical landmarks and anatomical variations in surgery.Materials and methodsIn the present article, lateral transperitoneal accesses to the pelvic retroperitoneum by open surgery are discussed. Furthermore, anatomical landmarks and anatomical variations encountered during retroperitoneal dissection are analyzed. Providing comprehensive knowledge of lateral transperitoneal accesses to the pelvic retroperitoneum will decrease patient’s morbidity and mortality.Conclusions The recognition of retroperitoneal anatomical landmarks and anatomical variations will give surgeons more confidence. They should be familiar with anatomical variations, which are likely to occur during retroperitoneal accesses and dissection.
 
Article
Background Telemedicine is one of the leading medical territories, and telepathology and telecytology are subsets of telemedicine. This study was designed to evaluate static telepathology in cervical biopsies.Materials and Methods After obtaining approval from the ethics committee of the University, 90 cervical biopsies were extracted from the archive of CIN. These samples were blindly selected and evaluated by fourth-year pathology residents. Then, two experienced pathologists in the field of pathology evaluated the samples. They were reevaluated after 3 months. Data were coded and entered in the SPSS software version 16. The convergence of intrapersonal and interpersonal of diagnoses was compared.Results90 samples were evaluated which contained 270 glass slides. Samples were colored by the H&E method. A total of 808 digital images with a size of 675 megabits were extracted. Each image size was 835 kilobits with 1840 * 3260 mm dimensions. Convergence between pathologists and over a time period was examined. There was a relatively good convergence of intrapersonal and interpersonal of diagnoses for glass and digital slides. The reliability of the methods was acceptable and good.Conclusion In comparison, there is no significant difference in the intrapersonal and interpersonal reliability of diagnoses for glassy and digital slides, but the diagnosis agreement between them is lower.
 
Article
PurposeAccuracy of intraoperative frozen section diagnosis is extremely important in the evaluation of ovarian tumors so that suitable surgical procedures can be chosen. Therefore, the current study was aimed at measuring the diagnostic accuracy of the intraoperative frozen section to determine the surgical course of tumors.Methods This retrospective diagnostic accuracy study was conducted in the Department of Obstetrics and Gynecology, Emam Hossein Hospital. The case records of patients with ovarian mass who underwent surgery and intraoperatively frozen section assessments between September 2006 and December 2014 were analyzed. Demographic and clinical data, operative details, frozen section, and final histopathology examination were reviewed from the medical records.ResultsOne hundred and ninety-three patients with ovarian masses undergoing surgery and frozen section were included. The frozen section diagnoses were benign in 155 (80.31%), borderline in 10 (5.18%), and malignant in 28 (14.51%), whereas the final diagnosis was benign in 154 (79.80%), borderline in 9 (4.66%), and malignant in 30 (15.54%). The overall accuracy of intraoperative frozen section diagnosis was 98.9%. The sensitivity for frozen section diagnosis was 100% for benign, 89% for borderline, and 93.3% for malignant category, whereas the specificity was 97%, 99%, and 100%, respectively. There were three cases with discordance between the frozen section diagnoses and the final diagnoses, all of which were under-diagnosed by frozen section.Conclusion Frozen section was found to be accurate and useful in the intraoperative assessment of patients with ovarian neoplasm. The results may help to determine the type and extent of surgery.
 
Top-cited authors
s. P. Somashekhar
  • Manipal Education and Medical Group
Rohit Kumar C.
  • Manipal Hospital
Ashwin Kr
  • Manipal Hospital
Ahmed Samy El-agwany
  • Alexandria Faculty of Medicine
Vijay Kumar Ahuja
  • Manipal Hospital