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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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Aim: To evaluate the mortality and morbidity related to bowel resection in women with advanced ovarian carcinoma. Methods: 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 disease free survival was assessed and the prognostic factors for disease free survival was also analysed by bivariate analysis. Results: 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 – 45 month). The mortality was 15% (7/47), while major morbidity like anastomotic leak were nil. The three variables considered for mortality were relaparotomy, paralytic ileus and surgical site infection. 6% (3/47) had relaparotomy, 21% (10/47) had paralytic iileus and 15% (7/47) had surgical site infection. The overall morbidity was 42.5% (20/47). A total 34% (16/47) of patients had stoma. 79% (37/47) patients had optimal debulking. Conclusion: Bowel resection in optimally selected cases of advanced carcinoma ovary is a good option with limited mortality and morbidity. Often, bowel resection is the only way to achieve optimal debulking.

We report an uncommon case of primary ovarian leiomyoma with torsion. Leiomyoma of the ovary is an extremely rare benign solid neoplasm of uncertain etiology. Our patient presented with abdominal pain and imaging showed right adnexal solid mass. All tumour markers except LDH were normal. The patient underwent laparotomy proceed right salpingo-ophorectomy. Intraoperatively, it was found to be twisted right ovarian solid tumour and histopathological examination revealed leiomyoma of ovary.