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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.

Objectives Enhanced recovery after surgery (ERAS) protocols have been questioned in patients undergoing cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies. This survey was performed to study clinicians’ practice about ERAS in patients undergoing CRS-HIPEC. Methods An online survey, comprising 76 questions on elements of prehabilitation (n=11), preoperative (n=8), intraoperative (n=16) and postoperative (n=32) management, was conducted. The respondents included surgeons, anesthesiologists, and critical care specialists. Results The response rate was 66% (136/206 clinicians contacted). Ninety-one percent of respondents reported implementing ERAS practices. There was encouraging adherence to implement the prehabilitation (76–95%), preoperative (50–94%), and intraoperative (55–90%) ERAS practices. Mechanical bowel preparation was being used by 84.5%. Intra-abdominal drains usage was 94.7%, intercostal drains by 77.9% respondents. Nasogastric drainage was used by 84% of practitioners. The average hospital stay was 10 days as reported by 50% of respondents. A working protocol and ERAS checklist have been designed, based on the results of our study, following recent ERAS-CRS-HIPEC guidelines. This protocol will be prospectively validated. Conclusions Most respondents were implementing ERAS practices for patients undergoing CRS-HIPEC, though as an extrapolation of colorectal and gynecological guidelines. The adoption of postoperative practices was relatively low compared to other perioperative practices.

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.

Introduction: Cervical cytology has limited sensitivity to detect cervical pre-cancerous lesions. High-risk human papillomavirus (hr-HPV) DNA testing has high sensitivity but its specificity is limited. This study was done to assess the utility of p16INK4a/ki-67 dual stained cytology in improving the predictive value for high-grade cervical (CIN2+) lesions. Aim/Objective: To assess the significance of P16/Ki-67 immunocytochemistry in improving the predictive value for high-grade cervical intraepithelial (≥CIN 2+) lesions on Pap smear. Material and Methods: This was a prospective diagnostic study that included 93 patients with ASC-US/LSIL/ASC-H and HSIL on thin prep cervical smears and who also underwent hr-HPV DNA test and colposcopy-guided biopsy. Biopsy was the gold standard against which the performance of P16INK4a/Ki-67 and hr-HPV results were compared. Results: In women of all ages, sensitivity of (96.8%) hr-HPV test and p16/Ki-67 dual immunocytochemistry (≥1 positive cell) were similar and negative predictive value (NPV) was (97.1% vs. 97.9%) but the latter test showed better specificity (69.4% vs. 53.2%) and positive predictive value (PPV, 61.2% vs. 50.8%) for ≥CIN 2 lesions. A higher cut off of at least 10 positive cells gives a higher specificity and PPV, with slightly decreased sensitivity and NPV. Conclusion: Because high-risk HPV test has a high sensitivity and NPV, whereas P16/Ki-67 dual immunocytochemistry (≥10 positive cells) has a high specificity and PPV, the latter can be recommended as an ancillary test in hr-HPV-positive women to reduce the number of women going for colposcopy and biopsies.

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

Human papillomavirus (HPV) vaccination offers an excellent prospect for the primary prevention of cervical cancer. The bivalent and quadrivalent vaccines are both available in India. The nonavalent vaccine is licensed but not yet available. However, there still remain controversies regarding the vaccination of older women, immunocompromised females and other special groups. To provide recommendations for HPV vaccination in India. The Federation of Obstetric and Gynecological Societies of India (FOGSI) convened an expert group on cervical cancer prevention to formulate good clinical practice recommendations (GCPR) with respect to vaccine efficacy and safety, target groups, optimal timing and dosing schedules. HPV vaccines are licensed for females aged 9-45 years in India and have been seen to be safe and effective. FOGSI recommends HPV vaccination of all girls15 years of age as the best target group, in whom two-doses at an interval of 6 months, extendable to 18 months, are recommended. Three-doses are recommended in girls15 years of age, immunocompromised persons and sexual assault survivors. Older women and women with abnormal screening results may be vaccinated with an understanding that vaccination does not protect against already acquired infections and screening has to continue. Single-dose vaccination results are promising. Increased awareness is required to reduce vaccine hesitancy. HPV vaccination should be the priority to achieve the elimination of cervical cancer. The introduction of affordable HPV vaccines and reduced dose schedules will improve coverage.

AIMS: The objective of this study was to describe the clinicopathological details in patients referred to the Gynaecologic Oncology Department with possible ovarian or primary peritoneal cancer where the final diagnosis turned out to be abdominal tuberculosis. METHODOLOGY: Retrospective chart analysis of 23 cases diagnosed with abdominal tuberculosis who were admitted under the Division of Gynaecologic Oncology suspected to have disseminated peritoneal malignancy, during 2014–2017. RESULTS: There were 23 patients who were referred to the Gynaecologic Oncology outpatient for evaluation of ascites, to rule out malignancy. The mean age of this patient group was 35 years (SD 14.5, range 14–65). The mean CA 125 was 333.5 [400.7 (9.09–1568)]. Ascitic fluid analysis confirmed TB in 26%; omental biopsy revealed TB in 69%, and operative diagnostic procedures (laparoscopy and laparotomy) were done in 15 of the 23 patients which had a positive pick up rate of 100% to confirm the diagnosis of TB. Culture of ascitic fluid/omental tissue and PCR yields were poor with a pick up rate of 33% and 6%. CONCLUSIONS: Abdominal TB is common in India and can mimic ovarian malignancy, and hence, high degree of suspicion needed. The isolation of AFB is the gold standard for diagnosis of pulmonary tuberculosis but has a low yield in abdominal TB. Ultrasound-guided procedure is reasonable as an initial procedure. As much time can be lost in working up these patients through multiple diagnostic algorithms using ascitic tap, USG biopsy and then an operative procedure, diagnostic laparoscopy could be considered early in the work up. It is a simple, time-saving and cost-effective way of establishing a diagnosis sooner with least complications.

The literature on management of recurrent/metastatic uterine leiomyosarcomas is limited and metastasis to the abdominal wall is very rare. We operated on a 46-year-old woman who had a total abdominal hysterectomy elsewhere for a uterine tumor and presented with recurrence to the anterior abdominal wall, 9 months after the primary surgery. There were two large ulcerated abdominal wall masses. The challenge after complete excision of the tumor was to reconstruct the abdominal wall. We were able to close the defect with a dual mesh and a fasciocutaneous flap from the anterolateral thigh. She received adjuvant chemotherapy with gemcitabine and docetaxel. At the completion of chemotherapy, she was well and apparently disease free. She recurred in the left inguinal node after 9 months but responded to oral pazopanib followed by chemotherapy. This case report highlights the rare possibility of abdominal wall metastasis after initial surgery for leiomyosarcoma. It shows that good quality of life can be achieved by a multidisciplinary treatment of abdominal wall metastasis of uterine leiomyosarcoma.

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.

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.

To achieve optimal debulking, cytoreductive surgery often involves diaphragm stripping. We describe our complications and survival outcomes after diaphragm surgery in epithelial ovarian cancer. A retrospective analysis on patients with advanced stage epithelial ovarian cancer between January 2012 and September 2019. The details of the diaphragmatic resections and stripping and their complications were looked into. During the study period, 616 patients with epithelial ovarian cancers were operated of which, 81 (13.2%) had diaphragm surgery. The majority underwent diaphragm stripping (60%) while 33% had resection and 7% cases had diaphragmatic nodule excision. Optimal debulking was achieved in 89% of cases. The complexity of surgery was intermediate in 64% of patients and complex in 33% as per Aletti's scoring. Mean operating time was 300 min (SD113). Moderate to severe pleural effusion was seen in 26 (32. %) patients necessitating pleural tapping in 16% and single lumen pleurex catheter insertion in 11%. Median recurrence-free and overall survival were 22 (95% CI 16.9-27) and 32 months (95% CI 25.5-38) respectively. Diaphragm stripping and resection is an important step in achieving optimal debulking of advanced and recurrent ovarian cancer. Diaphragmatic disease clearance is a necessary skill to be acquired by the gynaecologic oncology surgeons. Choosing the patients correctly and anticipation of complications can reduce morbidity and mortality.

Background: The rapid and major advances being made in epigenetics are impacting pharmacology, giving rise to new sub-disciplines in pharmacology, pharmacoepigenetics, the study of the epigenetic basis of variation in response to drugs; and pharmacoepigenomics, the application of pharmacoepigenetics on a genome-wide scale. Methods: This article highlights the following aspects of pharmacoepigenetics and pharmacoepigenomics: epigenetic therapy, the role of epigenetics in pharmacokinetics, the relevance of epigenetics to adverse drug reactions, personalized medicine, drug addiction, and drug resistance, and the use of epigenetic biomarkers in drug therapy. Results: Epigenetics is having an increasing impact on several areas of pharmacology. Conclusion: Pharmacoepigenetics and pharmacoepigenomics are new sub-disciplines in pharmacology and are likely to have an increasing impact on the use of drugs in clinical practice.

Since majority (80%) of ovarian cancer patients present at an advanced stage, imaging performed on these patients have numerous findings. The combination of multiple findings on imaging, complexity of anatomical structures which are involved in ovarian cancer, and the need to perceive certain subtle imaging features which would impact management often makes it challenging to systematically review images of these patients. Similarly, it is difficult to effectively communicate these findings in radiology reports. Structured reporting that is geared toward clinical decision-making has been an area of recognized need. An understanding of the review areas, which aid clinical decision-making in a multidisciplinary team setting at our institution led us to the proposed structured reporting template for ovarian cancer. Through this review, the authors would like to share this reporting template with examples.

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.

Hysterectomy has a limited role in the management of gestational trophoblastic neoplasia because of the high effectiveness of chemotherapy and the young age of patients. In selected patients, it is believed to help in reducing the number of chemotherapy cycles, overcoming chemo-resistance, and treating acute haemorrhagic events. The present study aimed to evaluate the indications and outcomes of hysterectomy in patients with GTN at a tertiary care centre in India. Between 2012 and 2019, we identified all patients with GTN from the hospital database. Demographic, clinical, and follow-up details of patients who underwent hysterectomy were obtained from the electronic medical records. During the study period, 98 cases of GTN were treated at our centre of which 54% were low-risk and 46% were high-risk cases. Twenty-six patients (26%) underwent hysterectomy as part of their management for GTN. The patients belonging to the high-risk group had more hysterectomies (65%) with an odds ratio of 2.96. The common pathological diagnosis was choriocarcinoma in 44% and an invasive mole in 30% of patients. Bleeding, either intraperitoneal or vaginal, was the most common indication for hysterectomy (48%). The median number of chemotherapy cycles received was 5 in patients who had primary hysterectomy and 6 in patients who did not have hysterectomy. The majority of patients received EMACO (57.7%) chemotherapy. The mean duration of follow-up was 18 months (range 1–67). After treatment, complete remission was achieved in 94 out of 98 (95.9%) and also in all patients (100%) who had undergone hysterectomy as adjuvant procedure. Three patients died during treatment (3.06%), all belonging to the high-risk group, and one patient had a recurrence (0.01%). In selected cases of GTN, hysterectomy may be an effective means to reduce or eliminate tumour bulk, to overcome chemoresistance and manage acute bleeding events.

Systems biology, also referred to as network biology, is the study of the behavior of complex biological organization and processes in terms of their molecular constituents. Epigenetic mechanisms of gene expression are an important component of systems biology. In addition, epigenetics, like systems biology, attempts to make sense of biological systems that are dynamic and multi-compartmental. This chapter discusses the application of systems biology to psychiatric disorders. It focuses on the use of systems biology in elucidating the pathogenesis of psychiatric disorders, in identifying biomarkers for these disorders, and in identifying new drugs for these disorders.

Gestational trophoblastic disease (GTD) includes a broad spectrum of clinical diseases that arise from placental tissue. They include premalignant hydatidiform mole, malignant invasive mole, choriocarcinoma, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor (ETT). Ultrasound, the primary imaging modality of choice, can identify the disease and also give valuable information about invasiveness. CT and MRI are for staging. MRI is the choice modality for a suspicious extrauterine extension. PET-CT is of help in ascertaining recurrence and in cases with uncertain metastases. Uterine artery doppler provides insight on tumor vascularity, which correlates with the aggressiveness of the tumor and its response to chemotherapy. This chapter will review radiological findings of GTD and the role of imaging in making wise treatment choices in the management of GTD.

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.

OBJECTIVES: Most patients with postmenopausal bleeding do not have endometrial cancer. The primary objective was to evaluate risk factors for endometrial cancer among postmenopausal women with bleeding. METHODS: This was a retrospective cross-sectional study. Women with postmenopausal bleeding presenting to a gynecology clinic were included in the study. Data on potential risk factors for endometrial cancer or atypical hyperplasia were collected. Univariate and multivariate analyses were performed to assess the risk factors. RESULTS: Among 212 women studied, 24 (11.3%) women had endometrial cancer. There were 38 (17.9%) with cervical cancer and 3 (1.4%) with ovarian cancer. Women 55 or older had an odds ratio of 7.5 (95% CI 2.2 to 26.2) as compared to women below 55 years (p value = 0.002). Women with 2 or more episodes of postmenopausal bleeding had an odds ratio of 4.9 (95% CI 1.1 to 23.0) and those who had either diabetes or hypertension had an odds ratio of 3.1 (95% CI 1.3 to 7.4) of endometrial cancer as compared to those who did not. CONCLUSIONS: A third of patients with postmenopausal bleeding had a gynecological cancer. Age, frequency of bleeding, diabetes and hypertension, and increased endometrial thickness were independent risk factors for endometrial cancer.

To assess the relevance of enlarged cardiophrenic lymph nodes (CPLN) seen on staging CT of ovarian cancer patients. Retrospective cohort study of consecutive patients with primary ovarian malignancy who underwent staging CT between 2013 and 2016. Images were reviewed by two radiologists in consensus. Enlarged CPLN was defined as a short axis diameter ≥ 7 mm. Clinical and imaging findings; management decisions; outcome of cytoreductive surgery and survival were compared between patients with and without enlarged CPLN on staging CT. Enlarged CPLN were found in 42 patients (41.5%) and was significantly associated with higher radiological PCI (p = 0.002); large volume upper abdominal disease (p = 0.001); enlarged lesser omental, periportal and supra-renal para-aortic lymph nodes (p ≤ 0.05); unfavorable sites of disease involvement (p

Cutaneous metastasis from cervical cancer is rare. We report four consecutive cases of abdominal wall metastasis after patients had inappropriate surgery for cervical cancer. 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. All 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. 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.

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.

The objective of this study is to determine the diagnostic accuracy of frozen section in detecting epithelial ovarian tumor histological types and its effect on management. A retrospective review was done of all patients who had an intraoperative frozen section for an indeterminate ovarian tumor over a six-year period. The reference standard was final histology. The validity indices for frozen section in diagnosing benign, borderline, and malignant lesions were determined. One hundred thirty-five intraoperative frozen section–diagnosed epithelial ovarian tumors were reviewed. The mean age was 44.9 ± 14.2 years, the median parity was 2, and 57% (77/135) of patients were post-menopausal. The commonest histological subtype was mucinous 48.1% (65/135) on frozen section and 46.7% (63/135) on final histology. The overall concordance rate of frozen section to final histology was 81.5% (ƙ = 0.719, p = 0.0001). The accuracy, sensitivity, specificity, and positive predictive value of frozen section to diagnose benign lesions were 86.7%, 85.7%, 97.2%, and 79.2% respectively. In borderline tumors, the diagnostic test characteristics were 88.1%, 81.2%, 90.3%, and 72.2%. For malignant lesions, these values were 88.1%, 77.8%, 95.1%, and 91.3% respectively. The odds ratios for frozen section being correct were 40.9 (95% CI 14.8–113.5) for benign lesions, 40.3 (95% CI 13.4–121.3) for borderline tumors, and 67.4 (95% CI 20.5–222.0) for malignancy. Over-treatment or under-treatment occurred in 19.3% of patients. Intraoperative frozen section is useful in situations where the nature of the ovarian tumor is uncertain. However, borderline ovarian tumors are more likely to be over-diagnosed. About a fifth of patients received inappropriate treatments based on the frozen section report.

Enhanced recovery protocols consist of a bundle of concepts including early feeding, opioid-sparing multimodal pain management, and euvolemia, with the overarching goal of hastening postoperative recovery. Enhanced recovery after surgery has been shown to reduce hospital length of stay, reduce costs, and decrease perioperative opioid requirements in benign and oncologic gynecologic surgery. Interventions without supporting evidence of benefit, such as the use of mechanical bowel preparation, routine use of nasogastric tubes and surgical drains, caloric restriction, routine use of intravenous opioid analgesics, and over-vigorous intravenous hydration should be discouraged to improve broader endpoints such as patient satisfaction and overall recovery. Successful implementation requires engagement from a multidisciplinary team including surgeons, anesthesiologists, nurses, and pharmacists.

Background: Borderline ovarian tumors are non-invasive tumors that display greater epithelial proliferation and cytological atypia than benign tumors, but less than carcinomas. They may be treated conservatively in young women, however there is a concern for recurrence and progression to frank malignancy. We aimed to study the clinicopathological features of borderline ovarian tumors and their risk of recurrence.Methods: We reviewed the electronic and paper charts of all borderline ovarian tumors operated between January 1, 2001 and December 31, 2019 at a tertiary level teaching hospital in India. Descriptive statistics such as proportions and means were used. A survival analysis was done for recurrence and death.Results: A total of 93 borderline ovarian tumor patients were identified. The most common histology in our study was mucinous 60 (63%) followed by serous 28 (29%). Ninety two (99%) of them were stage I at diagnosis. Microinvasion was present in 27 (26%) of the cases. Out of the 30 fertility sparing operations performed (unilateral salpingo-oophorectomy/cytectomy), 4 (13%) had recurrences and progressed to malignancy. The overall malignancy rate was 4%. There was one mortality secondary to septic shock.Conclusions: Borderline ovarian tumors account for 10-20% of ovarian epithelial tumors and have extremely good prognosis affecting majorly the reproductive aged women. The low recurrence rate and good five year survival rate, at all the stages of the disease enables to incorporate fertility sparing surgeries as part of the staging.

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.

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.

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.

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.

To determine factors influencing failure-to-rescue in patients with complications following cytoreductive surgery and HIPEC. A retrospective analysis of patients enrolled in the Indian HIPEC registry was performed. Complications were graded according to the CTCAE classification version 4.3. The 30- and 90-day morbidity were both recorded. Three hundred seventy-eight patients undergoing CRS with/without HIPEC for peritoneal metastases from various primary sites, between January 2013 and December 2017 were included. The median PCI was 11 [range 0–39] and a CC-0/1 resection was achieved in 353 (93.5%). Grade 3–4 morbidity was seen 95 (25.1%) at 30 days and 122 (32.5%) at 90 days. The most common complications were pulmonary complications (6.8%), neutropenia (3.7%), systemic sepsis (3.4%), anastomotic leaks (1.5%), and spontaneous bowel perforations (1.3%). Twenty-five (6.6%) patients died within 90 days of surgery due to complications. The failure-to-rescue rate was 20.4%. Pulmonary complications (p = 0.03), systemic sepsis (p 20 (p = 0.002) increased the risk of failure-to-rescue. The independent predictors were spontaneous bowel perforation (p = 0.05) and systemic sepsis (p = 0.001) and PCI > 20 (p = 0.02). The primary tumor site did not have an impact on the FTR rate (p = 0.09) or on the grade 3–4 morbidity (p = 0.08). Nearly one-fifth of the patients who developed complications succumbed to them. Systemic sepsis, spontaneous bowel perforations, and pulmonary complications increased the risk of FTR and multidisciplinary teams should develop protocols to prevent, identify, and effectively treat such complications. All surgeons pursuing this specialty should perform a regular audit of their results, irrespective of their experience. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s13193-019-00877-x) contains supplementary material, which is available to authorized users.

OBJECTIVE: The purpose of this study was to evaluate the use of proximal partial vaginectomy for the treatment of VaIN. STUDY DESIGN: Descriptive. METHODS: Between May 2009 and December 2017, 20 patients were identified who underwent partial vaginectomy for VaIN. The electronic medical records were reviewed and information collated. OPERATIVE TECHNIQUE: A circular incision in mid-vagina, was taken for all these patients and the upper vagina was closed over a gauze pack. The proximal vagina was then excised with the gauze inside. RESULTS: None of the patients had previously been treated for VaIN. The diagnosis was made on cytology/biopsy. Twelve of the 13 patients who were tested, were positive for high-risk HPV DNA, while one was negative. Thirteen (65%) had previous gynaecological surgery for cervical neoplasia (invasive cancer 6 and CIN 7) and the remaining 7 for apparent benign disease. There was one patient who went on to have a cone biopsy, and one had a modified radical hysterectomy at the same sitting. None of the patients had post-operative complications. Median hospital stay was 3 days (range 2–9). Follow-up (median 7 months, range 0–60) was available in 19 patients out of whom five had abnormal cytology, five were HPV DNA positive, and three had recurrent VaIN on follow-up biopsy and had re-excision for recurrence. One patient had vulvar intraepithelial neoplasia (VIN 3) and underwent excision. Another had CIN 3 and underwent excision of cervical stump. CONCLUSIONS: Vaginectomy appears to be a safe and efficacious procedure for treatment of VaIN. Patients have to be followed up with cytology, HPV testing, and biopsy to exclude vagina recurrence and HPV-related lesion at another site.

Objective: To investigate the ability of sildenafil to inhibit the contractility of isolated non pregnant human myometrium. Materials and Methods: The inhibitory effect of three concentrations (3, 10, and 30 µM) of sildenafil on 55 mM KCl-induced contractility of isolated non-pregnant human myometrium was studied. The ability of the guanylyl cyclase inhibitor ODQ (10 µM), the adenylyl cyclase inhibitor MDL-12,330A (10 µM), the non-specific potassium channel blocker TEA (2 mM), and the calcium-sensitive potassium (BKCa) channel blocker iberiotoxin (100 nM) to reverse the inhibition of 10 µM sildenafil on KCl-induced myometrial contractility was also studied. Results: Sildenafil produced a concentration-dependent inhibition of KCl-induced myometrial contractility that was statistically significant at all three concentrations of sildenafil used. The inhibition by 10 µM sildenafil of KCl-induced myometrial contractility was not reversed by the concurrent administration of ODQ or MDL-12,330A. The inhibition of 10 µM sildenafil of myometrial contractility was partially reversed by concurrent administration of TEA and totally and significantly reversed by the concurrent administration of iberiotoxin. Conclusions: These results suggest that sildenafil inhibits the contractility of isolated non-pregnant human myometrium. The results suggest that sildenafil does so by opening BKCa channels.

Background Cervical cancer is still the most common malignancy in Indian women with 127,000 new cases and 67,000 deaths each year. The aim of this study was to determine the community prevalence of HPV infection and the feasibility of self-collected vaginal swabs for HPV testing.

Background: The Indian HIPEC registry is a self-funded registry instituted by a group of Indian surgeons for patients with peritoneal metastases (PM) undergoing surgical treatment. This work was performed to • Evaluate outcomes of cytoreductive surgery ± HIPEC in patients enrolled in the registry. • Identify operational problems. Methods: A retrospective analysis of patients enrolled in the registry from March 2016 to September 2017 was performed. An online survey was performed to study the surgeons’ attitudes and existing practices pertaining to the registry and identify operational problems. Results: During the study period, 332 patients were enrolled in 8 participating centres. The common indication was ovarian cancer for three centres and pseudomyxoma peritonei for three others. The median PCI ranged from 3 to 23. A CC-0/1 resection was obtained in 94.7%. There was no significant difference in the morbidity (p = .25) and mortality (p = .19) rates between different centres. There was a high rate of failure-to-rescue (19.3%) patients with complications and the survival in patients with colorectal PM was inferior. A lack of dedicated personnel for data collection and entry was the main reason for only 10/43 surgeons contributing data. The other problem was the lack of complete electronic medical record systems at all centres. Conclusions: These results validate existing practices and identify country-specific problems that need to be addressed. Despite operational problems, the registry is an invaluable tool for audit and research. It shows the feasibility of fruitful collaboration between surgeons in the absence of any regulatory body or funding for the project.

To evaluate the mortality and morbidity related to bowel resection in women with advanced ovarian carcinoma. Retrospective case series of 47 women with stage III and IV carcinoma ovary who underwent bowel resection, over the period of 5 years from Jan 2011 to Dec 2015. The risk factors for perioperative morbidity and death were determined by regression analysis. The disease free and overall survival were determined by Kaplan-Meier plots. In this cohort, 64% (30/47) had primary debulking, 21% (10/47) had interval debulking, and 15% (7/47) had secondary debulking. The mean period of follow-up was 23 months (1 to 45 months). There were no anastomotic leaks. The commonest morbidities were relaparotomy (8.5%), surgical site infection (12%), and paralytic ileus (19%). The overall morbidity was 42.6% (20/47). The 30-day mortality was 4.2% (2/47). The recurrence rate was 51% (20/47). The overall mortality from ovarian cancer in this cohort was 40% (19/47) during the follow-up period. Stage and histology seemed to be important risk factors for morbidity. Low BMI and sub-optimal debulking were significant risk factors for recurrence and death in univariate analysis. Bowel resection, in optimally selected cases of advanced carcinoma ovary, is often required for optimal cytoreduction. It carries a reasonable peri-operative mortality and morbidity and improves overall survival.

Background and Objectives. Angioleiomyoma is a benign perivascular neoplasm commonly involving subcutaneous tissue of extremities, head, and trunk region. They rarely involve the female genital tract. This study analyses clinicopathological features of 6 cases of uterine angioleiomyoma. Methods. Routine sections of 6 cases were reviewed and immunohistochemical markers namely muscle-specific actin, h-caldesmon, desmin, CD10, WT-1, HMB-45, and melan-A were done. Results. Of the 6 cases, 4 cases had tumor involving the corpus and 2 cases had tumor in the cervix. Grossly, all tumors had a whorled and congested cut surface. Microscopic examination of all the cases revealed circumscribed neoplasms composed of interlacing fascicles of benign perivascular smooth muscle cells with evenly distributed slit-like blood vessels (solid variant) along with vessels exhibiting thick muscular walls with swirling pattern (venous variant). In only 2 cases many dilated vessels were seen (cavernous variant). Immunohistochemically, all cases were positive for muscle-specific actin, h-caldesmon, and desmin. All cases were negative for CD10 and WT-1 ruling out endometrial stromal tumor and were negative for HMB-45 and melan-A ruling out perivascular epithelioid cell tumor (both endometrial stromal tumor and perivascular epithelioid cell tumor have prominent vessels but have different histomorphology). In all cases, surgical excision was curative and there were no intraoperative or postoperative complications. Follow-up of all the cases has been unremarkable. Conclusion. As the World Health Organization has not included angioleiomyoma in the classification of mesenchymal tumors of uterine corpus and cervix, we recommend that it should be included in the classification.

It is not clear how often epithelial tumours affect young women. This study aimed to evaluate the clinico-pathological pattern and survival outcome of women, 40 years and younger, with cancer ovary. Women 40 years and younger, operated between 2008 and 2012 for ovarian cancer, were retrospectively recruited and followed up. The study design was descriptive as well as a survival analysis. A hybrid of retrospective and prospective cohort design was used for risk factor analysis. Of the 115 women less than 40 years being operated for probable ovarian cancer, 22 were excluded for various reasons. Demographic details, clinical presentations, histopathological features, treatments and survival outcomes were studied. The primary outcomes looked for were death and recurrence. Secondary outcomes were complications of treatment and fertility. The predominant histology in the study population was epithelial tumour (70%), and serous adenocarcinoma was the commonest tumour type. The overall survival rate was 87%, and progression free survival was 63%. Time to death and recurrence were dependent on stage of disease, histology of tumour, primary treatment and residual disease at surgery. In multivariate analysis, the hazard ratio for recurrence in advanced stages was 12.6 (95% CI 3.5 to 45.5; p

This chapter discusses the concepts of psychiatry, neurology, and neuropsychiatry. The history of neuropsychiatry is outlined. The chapter also outlines the potential importance of epigenetics in the pathogenesis and management (prevention, diagnosis, and treatment) of neuropsychiatric disorders.

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.