Search

OBJECTIVES: Enhanced recovery after surgery (ERAS) is a set of multidisciplinary, evidence proven guidelines which enhance perioperative recovery in various surgical branches. This study was planned as a pilot effort with the aim of evaluating the surgical team’s compliance to ERAS, in the absence of a structured programme, in the department of gynaecologic oncology of a tertiary care hospital in India. METHODS: This is a retrospective audit of patients who underwent elective surgery, in the department of gynaecologic oncology, in a tertiary care centre in India, between 15th August 2019 to 15th October 2019. Emergency operations and those surgeries with palliative intent were excluded from the study. Electronic outpatient and inpatient records of patients chosen by convenient sampling were examined. Adherence to 18 components (pre-operative, intra-operative and post-operative) from the ERAS guidelines pertaining to surgical care were analysed. RESULTS: A total of 50 patients were included. Mean age group was 50 years (22–76 years). Majority of patients (60%) had a Charlson Deyo score of 0. Excellent compliance was noted with respect to preoperative counselling (94%), intraoperative management (86%) and post-operative factors such as early ambulation, thromboprophylaxis and early discharge. Practices which required improvement included reduction of period of pre-operative fasting, prehabilitation, carbohydrate loading, gum chewing and coffee consumption and early initiation of feeding in post-operative period. CONCLUSION: Dedicated and co-ordinated team effort will ensure that an ERAS protocol is enforced. Periodic auditing will reveal inconsistencies in compliance and guarantee benefit to patients.

Purpose In a developing country like India, genomic data sets for even the most clinically relevant genes like BRCA1 and BRCA2 is rather scarce. Also, there is a need to identify and screen population specific BRCA hotspots to pave a way for affordable genetic testing strategies in clinical practice. Method This is an ambispective study to evaluate an NGS based approach to identify pathogenic variants in BRCA1 and BRCA2 genes among 430 patients with Breast and Ovarian cancers. The target enrichment was carried out using the in-house designed Multiplex-PCR followed by targeted Next-generation sequencing (NGS) for BRCA1 and BRCA2. Also, allele-specific PCR based genotyping of del185AG was carried out in additional 120 patients. Results In this study, we have identified 100 BRCA1 and BRCA2 variants and based on ACMG 2015 guidelines, these variants were classified as 46 pathogenic, 9 likely pathogenic, and 45 VUS. Of these variants, three were novel, two with likely pathogenic, and one variant of uncertain significance (VUS). The 185delAG was identified as a recurrent mutation in the Southern Indian population accounting for 25.45% of the pathogenic variants. In addition, a family history of cancers of the breast, ovary, pancreas, or prostate (BOPP) was found to be associated with a higher risk of identifying a deleterious BRCA1/2 variant [OR 3.2 (95%CI 1.84–5.77) p ≤ 0.001]. Conclusions These results suggest that Multiplex PCR-NGS is a sensitive and specific strategy for BRCA testing. However, ASPCR-based genotyping of BRCA1(NM_007300.4): c.68_69del followed by targeted NGS would be a cost-effective approach in south Indian patients.

Objective To determine the prevalence of Polymerase Epsilon gene (POLE) mutation, P53 mutations, and mismatch repair deficiency(dMMR) in endometrial cancer, followed by clinicopathological correlation and survival analysis Design- retrospective cohort tested prospectively and analysed for survival functions based on the findings Setting- Single institution, tertiary care centre Sample- Blocks of 48 consecutive patients with primary endometrial carcinoma were subjected to the molecular profiling Methods- Molecular classification of endometrial cancer by POLE ultramutated ,dMMR using IHC (MLH1, MH2, MSH6), and Copy number high/low (p53on IHC) was done on the preserved paraffin blocks Main Outcome Measures- prevalence of POLE mutation, P53 mutations, and deficient MMR in endometrial cancer, followed by clinicopathological correlation and survival analysis Results Eleven (22.9%) patients were dMMR , 3 ( 6.3%) had POLE mutation, while 2 (4.1%) had both POLE and P53 mutations (regarded as multiple classifiers). Twelve (25.0%) patients were found to have P53 mutations, while the remaining 20 (41.7%) had no specific molecular profile (NSMP). Median follow up duration was 43.5 (2-62) months with 8 recurrences and 9 deaths. Tumors with POLE mutation had the most favourable prognosis followed by the NSMP and the MMR mutated group while the P53 and multiple classifier groups had the worst prognosis in terms of OS ( Log rank p : 0.006) and PFS ( Log rank p : 0.001). Conclusion Integrated approach of molecular profiling should be expanded to routine testing in endometrial cancers to streamline treatment options and utilize targeted therapy such as immunotherapy Funding Institutional internal funding

Objective To determine the prevalence and study the association of ovarian, uterine, and breast cancers with endometriosis. Methods A cross-sectional study of all women with a tissue-proven diagnosis of endometriosis postoperatively in a tertiary care hospital between January 1, 2010, and December 31, 2019, was conducted to determine the prevalence of coexistent malignancy. Patient details were obtained from electronic clinical records. Univariate analysis followed by multivariate analysis was done to find independent risk factors associated with malignancy. Results Out of 800 patients, 104 (13.0%) were found to have coexistent malignancy: ovarian (50, 6.2%); endometrial (33, 4.1%); synchronous ovarian and endometrial (7, 0.9%); and breast (14, 1.8%). Increasing age (odds ratio [OR] 1.13; 95% confidence interval [CI] 1.09-1.16), higher levels of cancer antigen 125 (CA 125) (OR 1.002; 95% CI 1.001-1.005), postmenopausal status (OR 6.2; 95% CI 2.0-19.2), duration of endometriosis over 5 years (OR 4.7; 95% CI 2.5-9.0), and endometriomas larger than 8 cm (area under the curve 0.83) were predictive of coexistent malignancy. Conclusion Endometriosis is associated with an increased risk of ovarian, endometrial, and breast malignancy. Increasing age, postmenopausal status, higher levels of CA 125, larger endometrioma, and long-standing disease are predictive risk factors.

The global increase in cancer burden is a challenge for countries with scarce resources. Amongst all the malignancies, gynaecological cancer still continues to have a high incidence and prevalence leading to significant morbidity and mortality. While a multipronged strategy of decreasing the gynaecological cancer burden is a global priority, one of the key strategies to decrease the morbidity and mortality is to train gynaecological oncology specialists. Most of the developed nations have an established gynaecologic oncology training programme in the form of a well-designed curriculum and skill training. However, in developing countries where the actual disease burden of these cancers is highest, such focused training programmes have only started emerging and evolving over the past two decades. While it is a positive step to initiate such training programmes in a country like India, there are still gaps in the uniformity of curriculum and training. Also, exposure to modern practices in gynaecologic oncology surgery, chemotherapy and technology in radiation oncology, especially brachytherapy, is still insufficient in many centres. This review discusses some of the challenges and opportunities in the still evolving programmes for training gynaecologic oncologists in India.

This study aimed to compare the treatment outcomes in carcinoma cervix before and after gynecologic oncology sub-specialization at a tertiary care hospital, in India. This was a retrospective cohort study comparing women with operable cervical cancer who underwent radical hysterectomy before and after gynecologic oncology sub-specialization. Electronic medical records of women operated for early carcinoma cervix between 2001 and 2010 and 2011–2015 were reviewed and compared for treatment and oncological outcomes. Seventy-four patients were operated over 5 years after sub-specialization as against 59 over 10 years before sub-specialization, with similar clinical characteristics. After surgical-pathological examination, both cohorts were comparable with regard to mean tumor size, lymph nodes retrieved, deep stromal invasion, and involvement of lymph nodes, parametrium, and vaginal margins. After sub-specialization, the rate of intraoperative (3% versus 14%, p = 0.018) and postoperative complications (15% versus 46%, p

Primary peritoneal carcinoma (PPC) at presentation often masquerades as epithelial ovarian carcinoma (OC) but behaves different with respect to treatment response, recurrence patterns and has inferior outcomes. The objective of this study is to compare the clinicopathological features and survival outcomes of PPC and OC.Prospectively maintained database of patients presenting to the gynecologic oncology department at a tertiary hospital was reviewed between 1st January 2010 and 31st December 2020. A comparative analysis of high-grade serous stage III/IV PPC and OC was done. Demographics, treatment details, complications and survival outcomes were collected from electronic medical records.151 OC and 69 PPC patients were included. A higher proportion of women with PPC had reduced performance status prior to hysterectomy with salpingo-oophorectomy, a shorter symptom to treatment interval, and large volume ascites. A significantly lower number of women with PPC (4.3 vs. 46.1%; Plt; 0.001) underwent primary cytoreduction, had a lower median surgical complexity score (3 vs. 4; Plt; 0.001) but higher recurrence rates (66.7 vs. 47.0%; P = 0.041) as compared to the patients with OC. The median progression-free survival (PFS) was 18 (15-20) months in PPC and 23 (17-28) months in OC patients (log-rank P = 0.034), while the median overall survival (OS) was similar (44 vs. 48 months; log-rank P = 0.696). The presence of extraperitoneal disease and interval cytoreduction was associated with shorter PFS. Suboptimal cytoreduction and delay in adjuvant chemotherapy beyond 6 weeks post-surgery was associated with reduced OS.PPC is an aggressive disease with lower PFS compared to OC. Commonly presenting with large volume carcinomatosis, it is not amenable for primary cytoreduction, making the usage of neoadjuvant chemotherapy a common practice and pragmatic approach.

Vulval Intraepithelial Neoplasia 3 (VIN) is a chronic, premalignant condition affecting the vulval skin. The age standardised incidence is approximately one per 100,000 women, with a peak at 30-49 years of age, and has risen over recent decades. This study would analyse the pattern of presentation, diagnosis, treatment and follow up of patients diagnosed with VIN 3 over a period of ten years at a tertiary care centre in India.This was a retrospective study conducted on all patients diagnosed to have VIN 3 between 1 January 2010 to 30 November 2019 in the Department of Gynaecologic Oncology, Christian Medical College, Vellore were included in this study. The outpatient records of the patients were obtained from an electronic registry.A total of 18 patients were diagnosed of VIN 3 during this time period. Sixteen patients were older than 50 years. Abnormal PAP was noted in 10 patients (HSIL-7, LSIL-2, ASC-H-1). Four patients had coexisting VAIN 3. About 16 patients underwent primary simple vulvectomy or wide local excision. Two patients were managed conservatively. Nine patients had recurrence with mean disease free interval of 12.5 months (4-36 months). Cryotherapy was used in 2 patients. Imiquimod was used in 3 patients. Surgical margins was achieved in 7 patients out of which 5 patients had recurrence. About 50% of patients with involved margins on biopsy had recurrence. Mean duration of follow up was 17 months (4-105 months). About 8 patients developed squamous cell carcinoma of genital tract on follow up.VIN 3 has a high rate of progression to invasive SCC. Regression of VIN is rare. Proper follow up and treatment of VIN 3 goes a long way in preventing the morbidity associated with vulval cancer.

ObjectivesThis study aimed to assess sexual health and quality of life (QoL) in endometrial cancer survivors and the factors influencing these variables.MethodsA mixed method design comprising quantitative (cohort design) and qualitative (face-to-face interviews) aspects was chosen. A total of 132 patients who underwent surgery alone, surgery followed by adjuvant vaginal brachytherapy, or surgery followed by chemotherapy and radiation were included. Female Sexual Function Index (FSFI) and Functional Assessment of Cancer Therapy General (FACT-G) questionnaires were used to assess the participants’ sexual health and QoL at 6 months and 1 year post-treatment. Multivariate logistic regression models were used to analyze the factors associated with general and sexual well-being.ResultsAt 1 year, 89% of the participants still had low sexual function scores. Survivors over 50 years (OR 284.7, 95% CI 13 to 364, pConclusionsThis study demonstrated the high prevalence of low sexual function and poor QoL in endometrial cancer survivors. There was a communication gap between the women and their partners as well as their healthcare providers. This study highlights the need for discussion about the survivors’ sexual well-being and QoL.

Introduction/Background* Many countries worldwide have recommended testing high-risk human papillomavirus (HPV) types for primary cervical cancer screening. New easy and patient-friendly screening methods for identifying high-risk HPV types are under evaluation and may facilitate the use of HPV testing in low-resource countries. Methodology Aim To compare the accuracy of detecting high-risk HPV DNA on dried cervicovaginal secretions on filter paper to the standard technique. Methods our study was a prospective diagnostic study where we recruited 40 patients with abnormal pap smear cytology. Three samples were collected from each patient, 1) self-collected cervicovaginal sample on filter paper, 2) cervical sample on filter paper collected by a physician, and 3) a cytobrush sample in specimen transport medium (STM) for analysis. Qualitative testing for high-risk HPV DNA was done using the hybrid capture technique. Sensitivity, specificity and NPV and PPV, and agreement of new method with the standard procedure were calculated. Result(s)* Of the 40 patients, 32.5% had low-grade lesions, and 67.5% had high-grade lesions on the pap smear. The overall prevalence of High-risk HPV in the sample was 67.5%. Detection of high-risk HPV DNA in the cervical sample collected on filter paper by the physician had a sensitivity of 77.8%, specificity 100%, positive predictive value 100%, and negative predictive value of 68.4%, taking STM as the gold standard. The patient‘s self-sampling of cervicovaginal secretions on filter paper also showed similar results, with sensitivity 66.7%, specificity 100%, PPV 100%, and NPV 59.1%. The agreement between the STM method and physician collected cervical sample on filter paper was substantial, kappa: 0.695(P= Conclusion* Our study showed that dried cervicovaginal samples collected by the patient on filter paper to detect High-Risk HPV could be done with acceptable accuracy and cost. It can be used as an alternative STM method for screening cervical cancer where a more uncomplicated, cost-effective technique may be better.

Introduction/Background* The aim of this audit is to assess the compliance of the Department of Gynaecological Oncology, in a tertiary care hospital, India in the management of advanced ovarian cancers, as per the updated European Society of Gynaecology Oncology(ESGO 2020) quality indicators for advanced ovarian cancer . Methodology Design A retrospective audit Setting Department of Gynaecologic Oncology, tertiary hospital in India, accredited by ESGO in 2019 Patients Electronic hospital records of 106 patients with advanced ovarian cancer, between Janary 1, 2019 – 31 December 2019 were identified, reviewed and analysed using SPSS Version 21. Result(s)* Ninety out of 106 patients, underwent cytoreductive surgeries by trained gynaecologic oncologists during this period. The first quality indicator target was not met as the complete resection and primary cytoreductive rates were 49% and 37% respectively. Other quality indicators with regard to case load, skills, training and surgeon’s experience were fulfilled. Majority (95%) of the patients were discussed in multi disciplinary board meet. Targets for quality indicators with regard to clinical trial recruitment, preoperative work up and discussion in multidisciplinary board, structured operative report, post-operative complication reporting were achieved. The department has supporting high dependency and intensive care units, but lacks an active perioperative management program. Compliance to pathology reporting was 64%. Overall, a total score of 25 was achieved. Conclusion* The revised quality indicators laid down by the ESGO helps in introspection and auditing of the department’s existing practices for advanced ovarian cancer. The audit revealed the need for judicious selection of patients for primary surgery, improving complete cytoreduction rates and a structured active perioperative management. Synoptic pathologic reporting improves completeness and accuracy.

In this retrospective analysis of 36 patients with recurrent ovarian cancer (ROC) treated with platinum pemetrexed doublet ± bevacizumab, the median age was 54.5 years (47-60) and 33 (91.7%) had serous histology. The overall response rate [ORR = complete (CR)+partial (PR) response] was 83.3%. At a median follow-up of 16 months, the median PFS was 13.8 months (95% CI: 10.849-20.580) and median OS 30.6 months, (95% CI: 21.46 months-NR). The incidence of Grade 3/4 anemia, thrombocytopenia, neutropenia and non-hematological toxicity was 19.4%, 3.9%, 16.6%, and 8.3%. Platinum pemetrexed chemotherapy in ROC is safe and effective treatment option.

Aims: Cervical cancer is one of the leading causes of cancer among women, worldwide. HIV-positive women tend to have persistent infection and infection with multiple human papillomavirus (HPV) types. There is a need for affordable HPV DNA tests as viable alternatives to the existing costly commercial assays. The aim of the study was to establish PGMY-CHUV reverse hybridization assay as a cost-effective tool for HPV genotyping. Study Design: This was a prospective study conducted in a tertiary care centre from March 2011 to July 2012. Subjects and Methods: Fifty cervical brush samples from HIV-infected women and 43 WHO reference samples were tested by both the CHUV assay and linear array (LA). Results: The CHUV assay in comparison to the LA showed a sensitivity of 91%, specificity of 52% and a moderate agreement for all samples that were compared. However, most high-risk HPV types were identified amongst the clinical samples, and the entire range of genotypes in the WHO reference panel was detected. Statistical Analysis: The accuracy indices such as sensitivity, specificity, positive predictive value and negative predictive value were calculated. The level of agreement (kappa value) between the two assays was also calculated. Conclusion: The CHUV assay had an acceptable sensitivity, but it lacked specificity for HPV detection. Despite the lower rates of detection of multiple infections from clinical samples, better results were obtained with the WHO reference samples and the ability of the assay to identify the entire range of genotypes suggests that it can be an efficient tool for genotyping.

To study treatment and survival outcomes of carcinoma vulva. The electronic charts of 30 patients with carcinoma vulva operated between October 2010 and December 2015 were reviewed. Univariate cox-proportional hazard tests were done for potential risk factors. Survival analysis was done using Kaplan–Meier plots and the log rank test. The median age was 59 with a range of 27–82 years. Most common (90%) histological type was squamous cell carcinoma. Most (66.7%) patients had early stage disease, while stage III was seen in 23.3% and stage IV in 10%. Primary surgery was done in 27/30 (90%) patients while three with stage IV had surgery following neoadjuvant therapy. Complications included wound dehiscence in 6/30 (20%), lymphocysts in 11/30 (36.7%), urinary infections in 3/30 (10%) and one death within 30 days. There were 6 recurrences (20%) and 10 deaths (33.3%). Mean recurrence-free survival was 84.6 (95% CI 67.6–101.6) months. Mean overall survival time was 70 (95% CI 53.1–86.9) months. Radical wide local excision with groin node dissection is possible in most early cases. Flaps can reduce wound breakdown. A multidisciplinary approach can ensure long-term survival with good quality of life.

Synchronous gynaecological tumours, being a rare entity, cause a diagnostic and management conundrum for oncologists using the current criteria for diagnosis. This study was conducted to identify the clinicopathological characteristics, treatment received and survival outcomes in women diagnosed with synchronous gynaecological cancers. A retrospective analysis was performed of patients diagnosed with synchronous gynaecological malignancies between January 2011 and December 2015 of at least two of the following sites: endometrium, cervix or ovary. Data were collected from electronic medical records. Categorical data were analysed by X2 test and Fischer’s test as appropriate. Survival was plotted by Kaplan–Meier curves. The study identified 20 patients diagnosed with synchronous cancers during this time: 19 cases had synchronous carcinoma of endometrium and ovary and one of cervix and ovary. The mean age at diagnosis was 48.6 years. Mean BMI was 27.4 kg/m2. Commonest presenting symptom was lower abdominal pain in 85% of women. Commonest synchronous tumour was endometrioid tumours of both endometrium and ovary. All patients underwent surgery followed by adjuvant treatment; 14 (70%) had chemotherapy, while 5 (25%) had chemo radiation. Of the 20 patients in our study group, 11(55%) patients had complete response, 8 (40%) had recurred after complete treatment, and 7 (35%) had expired. Extra pelvic extension and tumour size were important prognostic factors in determining the outcome. Overall survival was 38.5 months. Synchronous tumours tend to occur more frequently in young and parous women. Endometrial tumours synchronous to ovary were more common. It is important to recognise synchronous tumours as the postoperative adjuvant therapy can be tailored to achieve better survival.

Incidental diagnosis of carcinoma endometrium following hysterectomy requires clinical expertise from a gynecologic oncologist, with regard to subsequent management. We report our experience with completion staging in endometrial cancer, to determine the benefits and risks of completion staging in women with posthysterectomy diagnosis of endometrial cancer. Design: A retrospective case series of 20 women with postoperative diagnosis of endometrial cancer, who had undergone completion staging. Setting: A gynaecologic oncology unit in a tertiary level hospital in Tamil Nadu, India. Patients: Electronic medical records of patients who underwent completion staging between January 2011 and December 2014 for endometrial cancer were reviewed. Two hundred and sixty four women with endometrial cancer were evaluated during this period. Twenty women with carcinoma endometrium, with a mean age of 53 (range 31–67) who were previously inadequately staged, were found to be at risk of extrauterine disease, following histopathological review, consented to undergo completion staging over an average of 57 days (range 30–91) following the initial surgery. Forty-five percent (9/20) had a BMI of more than 30, and 40% (8/20) had metabolic syndrome. The most common indications for the initial surgery were perimenopausal abnormal uterine bleeding and postmenopausal bleeding. Only eight patients had a pre-hysterectomy endometrial sampling/biopsy (40%) of whom, one had a pre-operative diagnosis of carcinoma endometrium. Sixteen (80%) had pathological risk factors for lymph nodal involvement and in the others, besides histological grading, surgicopathological details for risk assessment were unavailable. Adnexae were retained in 11, and uterus was bisected/cored during surgery in three women. Following completion staging, 5/20 (25%) patients were upstaged, 9 (45%) required no adjuvant treatment, 5 required vaginal brachytherapy therapy alone and 5 were advised chemotherapy and radiation. Two patients during the study period of 48 months had disease recurrence, and two women died of disease progression. Complications of surgery included the following: iliac vein injury (1) and bladder injury (1). Patients with incidental diagnosis of endometrial cancer following hysterectomy after clinical and radiological assessment and histopathological review, should be offered completion staging, if at risk for extrauterine disease. Completion staging permits appropriate prognostication of disease and thereby allows tailoring of adjuvant treatment, avoiding risks of overtreatment and undertreatment.

Background: Carcinosarcoma is a rare malignancy, and reports are often mixed along with other sarcomas. The literature on uterine carcinosarcoma per se is sparse. Aims: This study aims to evaluate the demography, survival, and optimal treatment strategy of uterine carcinosarcoma. Settings and Design: A tertiary care center in India. The study design was descriptive with survival analysis. Materials and Methods: The medical records of all 18 patients admitted with uterine carcinosarcoma between January 2011 and December 2015 were reviewed. Baseline characteristics and outcomes were studied. Survival analysis was done using the Kaplan–Meier method and compared between treatment groups using the Log-rank test. Results: The total number of uterine malignancies operated in our center over this time period was 311 of which 18 were carcinosarcomas (5.7%). Median age of presentation was 61 years (36–77 years). Most women (94%) were postmenopausal and 67% of them presented with postmenopausal bleeding. Over half of the patients (56%) presented late (Stage III or IV). Only 11 (61%) had adjuvant treatment and 7 patients had expired at the time of follow-up. The median survival was 284 days (95% confidence interval 107–461). Patients who received adjuvant therapy did better compared to those who did not (P = 0.036). Conclusions: Carcinosarcomas are aggressive tumors of postmenopausal women who present with bleeding or discharge per vaginum. In spite of adequate surgical staging followed by adjuvant therapy, survival remains poor. Improvements in early detection and optimal therapy need to be made.

Persistence of human papilloma virus (HPV) after treatment for cervical neoplasia may be indicative of local recurrence. The aim of this study was to determine the prevalence of HPV in cervix or vagina after treatment for cervical neoplasia and to ascertain its association with local recurrence. Data were collected retrospectively from electronic hospital medical records. The cohort consisted of women who had undergone treatment for CIN 2, CIN 3 or cervical cancer between 1 January 2014 and 31 December 2016 at a teaching hospital in India for whom post-treatment HPV results were available. Local recurrence was defined as a positive vaginal or cervical biopsy or positive radiological (PET CT) findings. Out of a total of 101 patients, 26 had CIN 2 or 3 and 75 had cervical cancer. Post-treatment HPV was done in precancers and cancers after a mean duration of 14.9 and 8.2 months, respectively. Positive HPV detection occurred in 46.2% of precancers and 18.7% of cancers. Of the 12 precancers with positive post-treatment HPV, seven (58.3%) had recurrence, whereas among 14 cancers, three (21.4%) had recurrence. The relative risk (RR) was 4.1 (95% CI 1, 16.1) and p value 0.03 for recurrence with a positive HPV test after treatment for CIN as compared to a negative HPV result. For cancers, the RR was 3.3 (0.8, 13.9), with p = 0.09. Positive HPV detection post-treatment is a risk factor for local recurrence in cervical neoplasia, especially in premalignant lesions. Hence, HPV testing may be useful for post-treatment surveillance.

Steroid cell tumours of the ovary account for approximately 0.1% of all ovarian tumours. Association of these tumours with Von Hippel–Lindau syndrome is an extremely rare phenomenon. A 24-year-old female, diagnosed with Von Hippel–Lindau syndrome, with previous surgeries for cervical haemangioblastomas and pheochromocytoma was evaluated in the Reproductive Medicine Unit for secondary infertility and abnormal uterine bleeding. She was referred to the Gynaecologic Oncology Department with the sonological diagnosis of a left-sided complex adnexal mass. After evaluation, patient underwent laparoscopy proceed, peritoneal washings, chromopertubation, left salpingo-oophorectomy and omental biopsy. Histopathology was reported as a pure stromal tumour consistent with a benign steroid cell tumour (alpha inhibin positive), not otherwise specified. At the last visit, the patient was asymptomatic. Von Hippel–Lindau syndrome, an autosomal dominant inherited disorder, is characterized by the formation of tumours (haemangioblastomas in brain, spinal cord and retina), pheochromocytoma and cysts in many different parts of the body (kidneys, pancreas and genital tract). In women, broad ligament cystadenomas are commonly reported.Steroid cell tumours of the ovary are extremely rare. About 20% are malignant and nearly 95% unilateral. They can manifest at any age but majority occur in third or fourth decade. There are very few reported cases of steroid cell tumours in association with Von Hippel–Lindau syndrome. We present a case of an ovarian steroid cell tumour in a young patient of VHL syndrome. This focuses on the rarity of their association.

Objectives This study aims to compare the treatment outcomes in carcinoma cervix before and after gynecologic oncology subspecialisation in a tertiary care hospital, in India. Methods A retrospective cohort study comparing women with operable cervical cancer who underwent radical hysterectomy before and after gynaecologic oncology subspecialization. Electronic medical records of women operated for early carcinoma cervix between 2001- 2010 (59) and 2011- 2015 (74) were reviewed and compared for outcomes. Results Seventy four patients were operated over 5 years after subspecialisation as against 59 over 10 years, with similar clinical characteristics (table 1) but with significant usage of three dimensional imaging (66% versus 38%). After surgical-pathological examination, both cohorts were comparable with regard to mean tumour size, lymph nodes retrieved, lymph nodal, parametrial ,vaginal margin and lymphovascular space involvement, and deep stromal invasion (table 2). However, lymphovascular space involvement was not reported in 66% (39/59) in the 2001–2010 cohort. After subspecialisation, the rate of intraoperative (3% versus 14%, p=0.018) and postoperative complications (15% versus 46%, p=0.0004) were lower. Adjuvant radiation was used more after subspecialisation (50% versus 24%, p= 0.00). Concurrent chemoradiation was not used in the 2001–2010 group. The follow up rates were similar in both groups with comparable 3-year recurrence-free survival and overall survival rates (table 3). Conclusions Gynaecological oncologic subspecialisation decreased intraoperative and postoperative complications and improved pathological reporting with appropriate tailoring of adjuvant therapy. However, increased rates of adjuvant treatment did not translate into better survival.

Objectives Hyperthermic IntraPeritoeneal Chemotherapy (HIPEC) after maximal cytroreduction is a promising modality of treating women with ovarian cancer. In order to determine the feasibility of setting up a HIPEC programme in India, we document our initial experience. Methods Ethics Committee clearance was obtained to start the programme. The electronic medical records of all patients who underwent HIPEC in our department was reviewed. Results A total of 14 patients underwent HIPEC in the first 2 years: one primary, 6 interval and 7 recurrent cytoreductions. The women had a mean age of 46.9 years (36 to 62), median performance score of 1 (o to 2) and a median peritoneal carcinomatosis index (PCI) of 10 (2 to 25). The histology was serous in 9, mucinous in 4 and endometrioid in one. Four patients had bowel resection of whom 2 had an end ileostomy and one had an end colostomy. The median duration of surgery was 9 hours (5 to 10) and the median completeness of cytoreduction score was 1 (0 to 2). The drugs used in HIPEC were Cisplatin and Oxaliplatin. The median duration of hospital stay was 9 days (6 to 21). Two patients were readmitted to hospital and 3 patients had re-laparotomy. The main complications were venous thromboembolism in one, bleeding in one and wound dehiscence in one. Conclusions Cytoreductive surgery with HIPEC is feasible in a low resource setting with acceptable morbidity where the main limitations are non-availability of operating time and patient’s ability to pay for treatment.

Cervical cancer is the second most common cancer among women in incidence and mortality in India. Early cervical cancer is treated primarily by radical hysterectomy where the ovaries may be preserved. The aim of this study was to report the complications and survival outcomes of radical hysterectomy. All 61 patients who underwent modified radical or radical hysterectomy for early-stage cervical cancer in the Department of Obstetrics and Gynaecology at a tertiary-level teaching hospital, between 2001 and 2010, were included. Patients who received neoadjuvant treatments were excluded. Clinical details were obtained from discharge summaries and medical records, both paper and electronic. The mean age of the patients was 53 years (SD 10) with a range of 33–77 years. Most tumours were squamous cell carcinomas (78%) and stage IB1 (72%). Most tumours (84%) were smaller than 4 cm in size. There were no perioperative deaths. The most common complications were urinary tract infections in 29% and voiding dysfunction in 23%. Injuries occurred in seven patients (11.5%): three ureters, three iliac vessels and one bowel. Blood transfusion rate was 31%. High risk factors were present in 14 patients (23%) and at least two intermediate risk factors in eight patients (13%). Adjuvant radiation therapy was given in these 22 patients. Seven patients were lost to follow-up. Recurrence occurred in ten patients and death occurred in eight patients, of whom disease was documented in seven. The recurrence-free survival was 79% at 3 years and 74% at 5 years. The overall survival was 89% at 3 years, 84% at 5 years and 79% at 10 years. Radical hysterectomy can cure the majority of patients with early cervical cancer. Patients with stages IB2 and IIA have significantly more recurrence and less survival.

Background: Cancer antigen 19-9 (CA 19-9) is a tumor-associated mucin glycoprotein antigen that may be elevated in healthy individuals as well as in patients with benign and malignant tumors. It is useful in the management of pancreatic and other gastrointestinal tumors. CA 19-9 is also elevated in benign and malignant ovarian tumors. Aim: To study the pattern of serum CA 19-9 in complex ovarian tumors. Methods: The study design was descriptive, based on data collected from medical records. Patients with a complex ovarian mass, who were investigated with CA 19-9 and had undergone surgery, were included in the study. The study duration was 2 years from January 2014 to December 2015. A total of 273 patients (119 benign and 154 malignant) with complex ovarian mass and elevated CA 19-9 underwent surgery during the study period. Results: CA 19-9 was elevated in 55 patients (20%). Of these, 23 patients had benign tumors while 32 had malignant tumors. Among patients with benign tumors, 21 had dermoid, 23 had mucinous tumors and 75 had other types of tumors. CA 19-9 was elevated in 10 (47.6%) of the dermoids, 7 (30.4%) of the mucinous tumors and 6 (8%) of the other benign tumors. Among patients with malignant tumors, 138 were epithelial and 16 were non epithelial tumors. Of the epithelial tumors, 31 were mucinous and 107 were nonmucinous types. Overall, 29 (21%) had elevated CA 19-9. Of the epithelial tumors, 22.6% of the mucinous type and 20.6% of the non mucinous type had elevated CA 19-9. Among the non-epithelial tumors, 3 (18.8%) had elevated CA19-9. Conclusion: CA 19-9 is elevated in several conditions but most likely to be raised in dermoid cysts and mucinous tumours. CA19-9 levels need to be interpreted along with clinical and radiological findings.

Background: Cancer antigen 19-9 (CA 19-9) is a tumor-associated mucin glycoprotein antigen that may be elevated in healthy individuals as well as in patients with benign and malignant tumors. It is useful in the management of pancreatic and other gastrointestinal tumors. CA 19-9 is also elevated in benign and malignant ovarian tumors. Aim: To study the pattern of serum CA19-9 in complex ovarian tumors. Methods: The study design was descriptive, based on data collected from medical records. Patients with a complex ovarian mass, who were investigated with CA 19-9 and had undergone surgery, wereincluded in the study. The study duration was 2 years from January 2014 to December 2015. A total of 273 patients (119 - benign and 154 malignant) with complex ovarian mass and elevated CA 19-9 underwent surgery during the study period. Results: CA 19-9 was elevated in 55 patients (20%). Of these, 23 patients had benign tumors while 32 had malignant tumors.Among patients with benign tumors, 21 had dermoid, 23 had mucinous tumors and 75 had other types of tumors. CA 19-9 was elevated in 10 (47.6%) of the dermoids, 7 (30.4%) of the mucinous tumors and 6 (8%) of the other benign tumors. Among patients with malignant tumors, 138 were epithelial and 16 were non epithelial tumors. Of the epithelial tumors, 31 were mucinous and 107 were non mucinous types. Overall, 29 (21%) had elevated CA 19-9. Of the epithelial tumors, 22.6% of the mucinous type and 20.6% of the non mucinous type had elevated CA 19-9. Among the non-epithelial tumors, 3 (18.8%) had elevated CA19-9. Conclusion: CA 19-9 is elevated in several conditions but most likely to be raised in dermoid cysts and mucinous tumours. CA19-9 levels need to be interpreted along with clinical and radiological findings.

Objectives: To evaluate the outcome of women with uterine carcinosarcoma. Methods: The medical records of all patients admitted with uterine carcinosarcoma between January 2012 and October 2015 were reviewed. Baseline characteristics were compared and survival was calculated using Kaplan Meier method and compared using log rank test. Results: The total number of uterine malignancies operated in our centre over this time period was 247 of which 33 were sarcomas (13%). Median age of presentation was 56 years (21-77 years). Most women were postmenopausal (76%) and 46% of them presented with post menopausal bleeding.There were 16 carcinosarcomas of the uterus. Eight presented at Stage 1 (50%) and the remaining 8 in stage III or IV. All patients had TAH/BSO but only 15 had omentectomy and 12 had pelvic and para-aortic lymphadenectomy. Adjuvant treatment was given only to 10 (63%). Seven patients had expired at the time of follow up. The mean survival was 502 days (304-699) with a median of 284 days. Patients who received adjuvant therapy did better compared to those who did not (p=0.05). Conclusions: Carcinosarcomas are aggressive tumours and the optimal therapy is yet to be determined. Adequate surgical staging followed by adjuvant therapy improves survival.

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. To audit abnormal Pap smears and their management in a tertiary care institution with an intention to improve quality of services rendered. 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. 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. 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.