Study of neoadjuvant chemotherapy in advanced malignant ovarian germ cell tumors at a tertiary center in western India.

OBJECTIVE: To study clinical characters and outcomes in patients of malignant ovarian germ cell tumor (MOGCT) undergoing surgery following neoadjuvant chemotherapy (NACT). METHODS: Retrospective study of patients undergoing surgery following NACT for MOGCT at our institute. Platinum based chemotherapy was given in all patients in NACT. RESULTS: Between March 2013 and February 2023, 30 patients had surgery after NACT. Patient's median age was 22 years (range, 12 to 35 years) and median follow up 42months (range, 6 to 132 months). Majority had endodermal sinus tumor (n=12), dysgerminoma (n=9) and mixed GCT (n=7). All had either International Federation of Gynecology and Obstetrics (FIGO) stage 3 (n=19) or FIGO stage 4 disease (n=11). Complete response to NACT seen in 5 patients and 23 patients had partial response. Fertility sparing surgery in 18 patients and complete surgery in 12 patients. Suboptimal surgery was seen in 4 patients. Currently, 20 of 30 patients are alive and disease free, 3 lost for follow up and 7 patients had progression after adjuvant therapy. Five patients had mortality-4 with progression and 1 with bleomycin toxicity. Fifteen of 17 eligible patients have resumed menstruation and one had successful pregnancy. Prognostic factors noted in study are stage, optimal surgery and viable tumor in histopathology. Dysgerminoma had better outcome than other histology. CONCLUSION: NACT may be a reasonable option in patients with extensive unresectable disease or in whom fertility sparing is not possible or in the poor general condition. Fertility sparing surgery can be attempted post neoadjuvant chemotherapy without adversely affecting prognosis.

Female genital tract melanoma: Analysis from a regional cancer institute.

OBJECTIVE: Malignant melanoma of the genital tract comprises 3% of all melanomas afflicting females. They are characterized by poor prognosis with 5-year survival of 0-25% and high incidence for distant metastasis. This study was performed to assess various clinical features, treatment options, and thre management of genital melanomas. MATERIALS AND METHODS: This was a retrospective analysis where records of patients with genital melanomas between 2005 to 2018 were reviewed to obtain demographic and clinical information, including age of diagnosis, presenting symptoms, performance status, pathology reports, treatment, follow-up, and survival. RESULTS: Between 2005 and 2018, 31 women were analyzed. The median age was 53.5 (range: 28.5-85) years. Vaginal bleeding was the most common presenting symptom (80.6%), followed by discharge (29%), mass in the vagina/perineum (19.3%), pain (16.1%), and difficulty in micturition (9.6%). The most common site of origin was the vagina (67.7%), followed by that vulva (19.3%) and cervix (12.9%). Tumor diameter was more than 3 cm in 74.2% (23/31). Out of 31 patients, only 16 opted for treatment. Four patients underwent surgery, 10 received primary chemotherapy, and two needed palliative radiotherapy for heavy bleeding. The median survival in the treatment group was 5 (range: 2.5-28) months, almost similar to patients not receiving any treatment (5 months, range: 2-11). CONCLUSION: Genital melanoma are rare but aggressive tumors. Diagnosis is usually made with biopsy. No effective treatment strategy is yet available. However, surgery is the preferred first- line treatment, radiotherapy and chemotherapy have been used in adjuvant settings.

Prognostic value of lymph node ratio in surgically treated cases of vulvar cancer: a tertiary care centre experience.

OBJECTIVE: This study aimed to study the patterns of recurrence in surgically treated cases of vulvar cancer (VC) and determine the factors associated with recurrence, with a special emphasis on lymph node ratio (LNR). METHODS: This retrospective study examined VC patients primarily treated with surgery at our institute from January 2005 to December 2015. Demographic data, clinical characteristics, surgicohistopathological data, adjuvant treatment, follow up, and recurrence site and treatment were studied. RESULTS: Among the 111 cases treated, a recurrence rate of 18.9% was noted. Recurrence was most commonly local (61.9%). On univariate and multivariable analyses of clinicopathological parameters, an LNR >20 had the highest hazard ratio for recurrence. CONCLUSION: LNR may provide useful prognostic information in VC patients with positive inguinal lymph node status.

Does preoperative CA-125 cutoff value and percent reduction in CA-125 levels correlate with surgical and survival outcome after neoadjuvant chemotherapy in patients with advanced-stage ovarian cancer? - Our experience from a tertiary cancer institute.

AIM: The aim of the study is to evaluate percent fall in CA-125 levels after neoadjuvant chemotherapy (NAC) and preoperative CA-125 value to predict surgical and survival outcomes in women with advanced-stage epithelial ovarian cancer (EOC). METHODS: A retrospective review of 406 women receiving NAC for advanced-stage EOC from January 2012 to July 2015 was conducted. Data were collected for demography, radiographic profile, CA-125 levels before and after NAC, chemotherapy, and surgicopathological information. Percent fall in CA-125 was categorized into two groups: <95% (R < 95) and >95% (R > 95) fall from prechemotherapy to preoperative levels. Similarly, women were also categorized using preoperative CA-125 levels of <100 and >100 U/ml. A subset of women from January 2012 to December 2013 was followed to June 2015 for evidence of any recurrence to determine survival outcomes. RESULTS: About 56% women had R > 95 and 44% had R < 95. As compared to R < 95, R > 95 group was more likely to have complete cytoreduction (P = 0.00). Furthermore, women with R > 95 had significant better progression-free survival (PFS) as compared to women with R < 95 (P = 0.009) but no difference in overall survival (OS) (P = 0.28). Women with preoperative CA-125 <100 had significant higher number of complete cytoreduction (55% vs. 40%; P = 0.00) and were associated with both PFS (P = 0.007) and OS benefit (P = 0.02). CONCLUSION: Our data showed that >95% fall in CA-125 and an absolute preoperative CA-125 value of <100 U/ml is associated with better surgical and survival outcome in women with advanced EOC. These data are important in patient counseling and treatment planning.

Ovarian Fibroma: A Clinico-pathological Study of 23 Cases with Review of Literature.

PURPOSE: The purpose of this study was to correlate the clinical findings, RMI-4 index and frozen section, in cases of ovarian fibroma with the final histopathology. METHODS: This is a retrospective study of clinical and pathological features of 23 patients of ovarian fibroma. The patient's age ranged from 34 to 66 years (mean-49 years). The most common presenting symptom was abdominal pain. On clinical examination, the mean size of ovarian tumor was 9.5 cm, CA-125 levels were found to be raised in 14 patients, and it was associated with ascites in 10 patients. USG showed a well-circumscribed mass (with a mean size of 14 cm), on the left side in 14 cases and on the right side in 9 patients. RMI-4 was calculated in all the patients, and it revealed the possibility of a benign histology in 17 patients. All patients underwent exploratory laparotomy with the removal of ovarian tumor followed by frozen section examination. All but one (22/23) patient had positive correlation among frozen section and final histopathological findings. RESULT: Ovarian fibroma generally tends to occur in post-menopausal women. All the patients in our study of ovarian fibroma were symptomatic, with the presence of palpable mass in majority of patients. RMI-4 Index correlated very well with benign nature of disease. Frozen section has an invaluable role at surgery; fertility-conserving surgery is the choice in young women. CONCLUSION: Clinical findings, RMI-4 Index and frozen section, play vital roles before and during surgery in cases of benign ovarian tumors.

Granulosa cell tumours: a study of 37 cases.

OBJECTIVES: To evaluate the clinico-pathological features, surgical procedures and postoperative treatment and their relation to survival in women with granulosa cell tumours. METHODS: Data of 37 women with granulosa cell tumours were collected and reviewed retrospectively. Mann-Whitney test, log rank test and Kaplan-Meier survival analysis were applied appropriately. RESULTS: Thirty-seven women of median age 48.6 years were diagnosed in stage Ia (45.9 %), stage Ic (27 %), stage III (16.2 %) and unstaged (10.8 %). The median follow up was 5 years. Overall survival was 93 % at 5 years. Disease-free survival at 5 years was 63 %. Tumour stage and residual disease were associated with poor prognosis (p < 0.001). Mitotic rate and tumour grade were not of prognostic significance. CONCLUSIONS: Stage of disease and residual disease are valuable prognostic factors. Prospective studies with large sample sizes and long-term follow up are needed to confirm our findings.

Uterine carcinosarcomas: 8-year single center experience of 25 cases.

OBJECTIVES: The aim of this retrospective study was to evaluate the behavior and treatment outcomes of uterine carcinosarcomas in relation to their clinical and pathogenic features and to determine the optimal treatment strategy. Secondary objectives were to identify parameters predictive of survival. MATERIALS AND METHODS: The hospital records of all 25 patients of uterine carcinosarcoma operated between 2000 and 2008 in Gujarat cancer research institute, Ahmedabad, were reviewed. Patients who presented with clinical evidence of recurrent disease or those who had incomplete medical records were excluded from our analysis. The status of these patients was updated up to November, 2010. Patients were classified according to the new 2009 FIGO staging system for endometrial carcinoma, to see what difference the assigned stage has on survival with the old treatment strategy. Survival was calculated by Kaplan-Meier method and compared by Log-Rank test. Median survival time was derived with the Brookmeyer 95% confidence interval. For comparison of qualitative data, Chi-Square test and Fisher extract χ(2) were used. RESULTS: Median age of patients was 56 years (range, 36-77 years). Only 36% of patients had stage I at diagnosis and another 36% were stage III. Most of the tumors (56%) were with homologous sarcomatous components and 64% of tumors were high grade (grade 2/3) at diagnosis. Fifty-two percent patients received postoperative adjuvant treatment. Twelve patients had no postoperative treatment: two were lost to follow-up immediately after surgery, four could not receive adjuvant treatment on account of severe medical complications and age factor which could have increased morbidity, and six patients declined treatment. Four of these patients expired within one year of diagnosis, two other within 18 months, and rest were lost to follow-up. The difference in survival of 13 patients who had taken adjuvant treatment was significantly more than the group who had not taken adjuvant therapy (P=0.025). The overall 3-year disease-free survival of 13 patients who had taken adjuvant therapy was 40%. However, these adjuvant treatment modalities had borderline statistical significance on overall survival of patients (P=0.075). The only statistically significant predictor of survival in this study was stage of the disease (P=0.035). CONCLUSIONS: This highly aggressive uterine malignancy warrants comprehensive surgical staging to assess tumor dissemination followed by systematic adjuvant therapy in patients with both early and advanced disease. The value of pelvic Radiotherapy in addition to systemic treatment remains ill-defined. Stage is the significant predictor of survival for the disease. Our results indicate that in this highly aggressive malignancy, further exploration of potential outcome benefits of postoperative treatment, especially chemoradiation, is warranted in larger group of patients after comprehensive surgical staging.