Surgical Staging of Differentiated Endometrial Cancer: An Analysis of Postoperative Outcome in a Gynecological Cancer Center in Sri Lanka.

INTRODUCTION: Even though surgico-pathological staging is recommended in poorly differentiated endometrial cancer, management of differentiated endometrial cancer is controversial. Preoperative pelvic and abdominal Magnetic Resonance Imaging (MRI) is recommended in well-differentiated endometrial cancer to identify patients with risk factors for regional metastasis. However, access to MRI is limited in Sri Lanka, and surgico-pathological staging is the primary staging method available for most patients with differentiated endometrial cancer. Our objective was to evaluate the outcome of surgical staging among differentiated endometrial cancer patients who underwent primary surgery at the gynecological cancer center of Apeksha Hospital Maharagama, Sri Lanka. METHODS: A retrospective study was conducted using the ongoing electronic database at the gynecological cancer center of the National Cancer Institute (Apeksha Hospital) in Maharagama, Sri Lanka. Data from December 2019 to December 2020 were selected for analysis. RESULTS: During the study period, 112 patients with endometrial cancer underwent hysterectomy. This study included 90 patients with differentiated endometrial cancer (International Federation of Gynecology and Obstetrics [FIGO] Grade 1 and Grade 2), out of which pelvic lymph node dissection was performed in 78 (86.7%) cases. Among the 90 patients, 54 (60%) had medical comorbidities. It was reported that 35% (n=32) of the patients had myometrial invasion of more than 50% thickness. Furthermore, 13.8% of patients with deep myometrial invasion had lymph node metastasis, while only one patient (2%) in the superficial or no myometrial invasion group had lymph node metastasis. Therefore, the absence of deep myometrial invasion has a negative predictive value of around 98% for excluding pelvic lymph node metastasis. CONCLUSION: Approximately one in seven patients with deeply infiltrating differentiated endometrial cancer had lymph node metastasis. In limited resource settings where preoperative pelvic MRI is not readily available, implementing a policy of routine surgical pelvic lymph node assessment would be beneficial. This approach would aid in detecting stage IIIc disease and also help avoid unnecessary pelvic irradiation.

Surgical management of cervical cancer in a resource-limited setting: One year of data from the National Cancer Institute, Sri Lanka.

OBJECTIVE: To evaluate the surgical management of cervical cancer without the use of preoperative pelvic imaging in a resource-limited setting. METHODS: A retrospective study was carried out using clinical records and the ongoing electronic database at the Gynaecological Oncology Unit, National Cancer Institute (Apeksha Hospital), Maharagama, Sri Lanka. Details regarding the radical hysterectomies carried out from January 1, 2019, to December 31, 2019, were retrospectively studied. RESULTS: Out of nearly 700 patients with cervical cancer admitted during the year 2019, 57 surgically managed radical hysterectomies were included. Of these, seven cases were ineligible and excluded and 50 cases of radical hysterectomies were included for analysis. Mean age was 53.6 ± 9.5 years and median parity was 3 (range 2-4). Of the cases, 94% were found to have no parametrial involvement showing the success of clinical examination in assessing local tumor spread. Overall, 11 (22.0%) were upstaged due to lymph node metastasis that was statistically significant. CONCLUSION: Preoperative clinical staging is a practical method in selecting surgically treatable cervical cancer in low- and middle-income countries (LMICs). Combining clinical assessment with comparatively more readily available computed tomography scans could be helpful in triaging patients for treatment of cervical cancer in LMICs.

Ultrasound parameters of pelvic organs and their age-related changes in a cohort of asymptomatic postmenopausal women: A community-based study.

OBJECTIVE: To describe the ultrasound parameters of pelvic organs and their age-related changes in a cohort of asymptomatic postmenopausal women and to describe the prevalence of ultrasound-detected pathologies in a Sri Lankan population. STUDY DESIGN: A large community-based longitudinal study using a randomly selected sample of postmenopausal women who have never used hormone replacement therapy. MAIN OUTCOME MEASURES: Uterine, endometrial and ovarian measurements at pelvic ultrasonography as described by the International Endometrial Tumor Analysis and the International Ovarian Tumor Analysis groups. RESULTS: A total of 815 postmenopausal women were approached and all volunteered to participate. This included women between the ages of 45 and 74 years with a median (interquartile range (IQR)) of 62.0 (10.0) years. The median (IQR) uterine volume was 18.1 (17) ml, while the median (IQR) of right and left ovarian volumes were 17.3 (22.9) ml and 18.2 (21.5) ml. Both uterine and ovarian volumes showed an age-related decline (p < 0.01). Furthermore, the ovarian volumes demonstrated an increase in size with a higher body mass index (p < 0.03 for left and p < 0.01 for right, respectively). Median (IQR) endometrial thickness among the population was 3.0 (1.0) mm and there was no age-related change observed. Sixty-one women had an ultrasound-detected gynaecological pathology with a prevalence of 7.5% (95% confidence interval (CI) 5.6-9.5). CONCLUSIONS: This study aimed at describing ultrasound parameters of pelvic organs among postmenopausal women of Sri Lanka was able to provide the reference values for uterine and ovarian volume among asymptomatic postmenopausal women. Both uterine and ovarian volumes demonstrated an age-related decline, whereas the endometrial thickness does not seem to relate to the age.

Validation of the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS) in two south- Asian languages.

INTRODUCTION: The multifaceted nature of pelvic floor disorders means that a systematic evaluation is required for optimal treatment outcome. It is also generally acknowledged that a valid tool is necessary to objectively assess symptoms reported by affected women. METHODS: The International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS) questionnaire was translated to Sinhala and Tamil and a validation study carried out among women attending gynecology clinics at North Colombo Teaching Hospital, Ragama, and the district general hospitals Mannar and Vavuniya. RESULTS: Content validity was assessed by the level of missing answers, which was < 4% and 2% for each item in Sinhala and Tamil, respectively. Construct validity was assessed by the ability of the questionnaire to differentiate between patients and controls. Both differentiated patients from controls on vaginal symptoms score (VSS) (p < 0.001), sexual symptoms score (SSS) (p < 0.01), and quality of life (QoL) (p < 0.001). There was a strong positive correlation between Pelvic Organ Prolapse Quantification (POP-Q) scores and VSS (Sinhala r s = 0.64, p < 0.001, Tamil r s = 0.65, p < 0.001), and QoL (Sinhala r s = 0.49, p < 0.001, Tamil r s = 0.60, p < 0.001). Internal consistency as assessed using Cronbach's coefficient alpha: 0.78 (0.76-0.78) and 0.83 (0.80-0.84) in Sinhala and Tamil, respectively. Test-retest reliability was assessed by weighted kappa scores (Sinhala 0.58-0.88 and Tamil 0.76-0.90). Both questionnaires were sensitive to change and showed that VSS and QoL improved following surgery (Wilcoxon matched-pairs signed-rank test p < 0.001). CONCLUSION: The validated Sinhala and Tamil translations of ICIQ-VS will be useful for assessing vaginal and sexual symptoms among women speaking Sinhala and Tamil.