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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.

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.

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.

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.

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.

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.

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.