Adjuvant Hysterectomy in Patients After Radiation for Locally Advanced Cervical Cancer: A Single-Center Prospective Longitudinal Study.

Introduction: Residual or recurrent cervical cancer post-CCRT is a challenging clinical issue, even though there has been much effort in recent decades to increase patient survival after radiation. There is a paucity of literature regarding the role of hysterectomy in recurrent/residual disease after radiation in LACC patients. Such a procedure is controversial and not routinely performed because of difficulties in obtaining tumor-free margins and the high rate of associated morbidity. Aims and Objectives: Evaluate outcomes and morbidities in patients who had undergone hysterectomy for residual or recurrent disease after radiation in LACC patients. Material and Methods: This is a prospective observational study on radiotherapy-treated LACC patients (IIB-III) with residual disease or recurrent disease who have undergone adjuvant hysterectomy. This study has been conducted at AHPGIC, Cuttack, with a sample size of 30 patients. Results: 18/30 patients underwent extrafascial hysterectomy, and rest 12 patients had radical hysterectomy. No significant difference in complications, achieving tumor free margins or recurrences post adjuvant hysterectomy based on the radicality of surgery was observed. 5 cases of recurrences post-adjuvant hysterectomy were detected. Some of the factors which had significant association with recurrences post adjuvant hysterectomy were non squamous histology, no preoperative brachytherapy, deep stromal invasion and positive surgical margins. Median follow-up time was 14 months (12-27 months). Conclusion: This study shows that adjuvant hysterectomy is feasible with good outcome and acceptable morbidity after chemoradiotherapy in cervical cancer patients "If selection of patients for adjuvant hysterectomy is appropriate."

Radical Oophorectomy for Advanced Ovarian Cancer: A Feasibility Study from Tertiary Care Cancer Centre in Eastern India.

Background: Radical oophorectomy was first performed by Hudson in order to remove an "intact ovarian tumour lodged in the pelvis, with the entire peritoneum remaining attached". We report 16 cases of radical oophorectomy done at our institute in the past 3 years and have analysed the perioperative morbidity as well as feasibility of performing the surgery without much of perioperative complication. Methods: Twenty-three patients with advanced ovarian cancer who underwent modified en bloc pelvic resection at our institute, between November 2018 and October 2021, were initially enrolled. Patients below 70 years, resectable disease on CT scan and no significant comorbidities were included. Exclusion criteria were extra-abdominal metastasis, secondary cancers or complete intestinal obstruction. Initially, 23 patients were enrolled out of which seven patients were excluded. Hence, a total of 16 patients with ovarian cancer extensively infiltrating into nearby pelvic organs and peritoneum were included. In Type 1 radical oophorectomy, retrograde modified radical hysterectomy alongwith in toto removal of the bilateral adnexae, pelvic cul-de-sac and affected pelvic peritoneum is done. Type 2 radical oophorectomy includes total parietal and visceral pelvic peritonectomy as well as an en bloc resection of the rectosigmoid colon below the peritoneal reflection. Results: Radical oophorectomy is feasible with acceptable complication rate. In our study, only one patient had burst abdomen that too due to the poor nutritional status of the patient. There was no surgery-related deaths, but one patient succumbed to pulmonary embolism 5 days after the operation. Conclusion: Hence, radical oophorectomy proves to be an effective, feasible and secure surgical technique in cases of advanced ovarian malignancies with extensive involvement of peritoneum, pelvis and visceras.

Role of perigastric arcade removal in serous epithelial ovarian cancers.

Introduction: Omentectomy is an essential part of cytoreductive surgery (CRS). However, removal of perigastric arcade (PGA) of the omentum is a controversial aspect of omentectomy in view of the fear of injury, vascular compromise and gastroparesis. Hence, we conducted a study to evaluate the necessity and effect of removal of PGA during omentectomy. Methods: The nature of the study was a prospective observational study. The study period was for 1 year between 1.3.2019 and 29.2.2020. Patients with stage III to IV serous epithelial ovarian cancers - chemo naive/post neoadjuvant chemotherapy, without macroscopic involvement of the PGA were included in the study. Patients were divided into two groups - those who had PGA removed (group 1) and those whose PGA was preserved (group 2). Pre, intra and postoperative factors between the two groups were compared using standard statistical methods. Results: Micrometastasis to PGA was present in 36.4% of the patients in group 1. The predictors for this involvement included gross involvement and microscopic involvement of the mobile part of the omentum (p < 0.001), pre surgery Meyer's score (p < 0.05) and requirement of peritonectomy (p < 0.05) during the CRS implying that higher the peritoneal carcinomatosis, more are the chances of microscopic involvement of PGA. On comparing postoperative outcomes between the two groups, we noted a statistically significant difference in intra-operative time (p < 0.01), prolonged recovery time with increased intensive care unit and hospital stay (p < 0.001) in group 1, although all with small absolute difference. However, there was no significant difference in major post-operative complications or time taken to tolerate soft diet. Conclusion: Micrometastasis to PGA was noted in significant number of cases. Its removal is also a safe procedure with minimal morbidity and good postoperative outcomes especially in cases with significant peritoneal carcinomatosis. Hence, it should be considered, provided we are achieving a complete cytoreduction otherwise.

Prognostic Factors of Granulosa Cell Tumors: A Retrospective Study in a Tertiary Care Cancer Centre of Eastern India.

Bhagyalaxmi NayakBackground and Aims The main objective of this study was to analyze the clinicopathological profile and prognostic factors of granulosa cell tumor (GCT). Method All the cases of ovarian cancer which were seen at our institute between January 2000 and December 2017 were reviewed. Data were analyzed with failure-free survival (FFS) as the primary end point. Results GCTs consisted of 2.66% of all ovarian cancers at our institute. The median age was 43 years. Majority of the patients (62.5%) were unstaged. Six patients (25%) had a fertility-preserving procedure. Forty two percent of the patients received adjuvant chemotherapy. Thirty eight percent of the patients developed recurrence. Considering tumor-related prognostic factors, there was a statistically significant decrease in FFS with the presence of hemorrhage ( p = < 0.001), larger tumors ( p = 0.042), and juvenile variant ( p = 0.002). On the contrary, when treatment-related factors were considered, there was no statistically significant improvement in FFS with the performance of lymphadenectomy ( p = 0.218), omentectomy ( p = 0.453), fertility sparing surgery ( p = 0.152), or administration of adjuvant chemotherapy ( p = 0.45). Conclusion Inherent tumor-related biological factors tend to play a more important role compared with treatment-related factors in GCTs. Hence, the traditional practice of performance of extensive staging procedures and routine adjuvant chemotherapy should be reviewed. Fertility-preserving surgery appears safe to be offered in early stages when desired. Although it is common knowledge that GCTs tend to be hemorrhagic tumors, this factor has not been well recognized as a prognostic indicator till date. Our study sheds some light on this aspect. Since these tumors have a tendency toward late recurrences, a long follow-up is prudent.

The Positive Predictive Values of the Breast Imaging Reporting and Data System (BI-RADS) 4 Lesions and its Mammographic Morphological Features.

The Breast Imaging Reporting and Data System (BI-RADS) is a comprehensive guideline to systematize breast imaging reporting, and as per its recommendations, any lesion with likelihoods of malignancy greater than 2% is deemed as suspicious and tissue diagnosis is recommended. The aim of the study is to determine the positive predictive value (PPV) of BI-RADS categories 4a, 4b, and 4c for malignancy and association of mammographic morphological features of BI-RADS 4 subgroups with malignant outcomes. We retrospectively reviewed all the patients undergoing mammography with BI-RADS score of 4 followed by biopsy from May 2019 to April 2020. The predictive values of BI-RADS 4 subcategories and morphological features with malignancy are performed taking histopathology report as the gold standard. The PPV of BI-RADS subcategories 4a, 4b, and 4c for malignancies were 34, 89, and 97%, respectively. BI-RADS 4c patients tend to be older (50.2 ± 12.2 vs. 44.6 ± 10.3 years) with larger mass (44 ± 16 vs. 32.9 ± 16.8 mm) at presentation than 4a. Postmenopausal state (P = 0.03) and older age (P = 0.019) were significantly associated with malignancy. There is no meaningful difference observed in the predictability of BI-RADS category 4c lesions among different breast density patterns. The overall higher PPV for BI-RADS 4a and 4b reflects subjectivity in subcategory assignments of BI-RADS 4. In patients, less than 40 years with the BI-RADS 4a category on mammograms may undergo supplementary imaging with MRI which may downscale the lesion classification in turn reducing unnecessary biopsy and surgery.

Geographical distribution of cervical cancer in Odisha: A 5-year retrospective study at a regional cancer center.

BACKGROUND: Cancer cervix and breast are the two major female health problems in India. A hospital-based, 5-year (2010-2014) retrospective study was conducted at a regional cancer center of Odisha to analyze the present burden of cancer cervix in this state, which has a population of more than 45.5 million at present. MATERIALS AND METHODS: All the patients suffering from cancer cervix that was treated by radiotherapy during 2010-2014 at this center were analyzed year wise for age, stage of disease, and native area. RESULTS: Based on the Census 2011 data, it was calculated and found that from the low-literacy area on an average of 4.62 cervical cancer patients per million, from the medium-literacy area 6.56 patients per million, and from high-literacy area 19.11 patients per million of population have received radiotherapy in this hospital. More than 60% of patients with cervical cancer were from stage IIIB and in the age group of 50-55 years. DISCUSSION: Odisha has 83.7% female population in rural areas with literacy rate below 50%. Due to lack of awareness and unavailability of cancer care facilities at their reach, they mainly depend on various alternative medicines in unscientific manner for their health care. CONCLUSION: Strengthening of existing regional cancer center, development of oncology wings in all medical college hospitals by providing basic radiotherapy facilities, emphasizing more on district cancer control programs, decentralizing of NGO schemes, and facilitating with more cancer screening and awareness programs may help better registration, prevention, and treatment of cancer in Odisha.

Serous Tubal Carcinogenesis: The Recent Concept of Origin of Ovarian, Primary Peritoneal and Fallopian Tube High-Grade Serous Carcinoma.

Background: Pelvic (non-uterine) high-grade serous carcinomas (PHGSC) including ovarian, tubal and primary peritoneal serous carcinomas have increased death: incidence ratio due to presentation at advanced stage, rapid progression, poor prognosis and high morbidity. Ambiguity regarding their pathogenesis and lack of a proper screening method is the cause of their late detection and high fatality rate. This study was undertaken to assess the fallopian tube for the presence of precursor lesions in pelvic serous carcinoma. Methods: This was a prospective case-control study carried out in a tertiary care center. Consecutive specimens of 55 cases of pelvic high-grade serous carcinoma and 41 controls inclusive of 21 low-grade serous carcinoma, 10 benign adnexal masses and 10 normal adnexa were included in the study. Both side fallopian tubes in each case were subjected to histopathological examination and p53, Ki67 immunohistochemistry. Results: There were 55 cases of PHGSC comprising of 50 cases of ovarian HGSC, two cases of primary peritoneal carcinoma (PPC) and three cases of tubal carcinoma. Serous tubal intraepithelial carcinoma (STIC) was detected in 14 cases (28%), p53 signature in 13 cases (26%) and tubal intraepithelial lesion in transition in 10 cases (20%) of ovarian HGSC. One case (50%) of PPC and one (33%) case of tubal carcinoma revealed the presence of STIC. None of the controls exhibited any precursor lesion except ovarian low-grade serous carcinoma where p53 was detected in 20% of cases. Conclusion: This revelation concludes that fallopian tubes are the sites of precursors of PHGSC to a large extent. In the absence of a proper screening method of HGSC, prophylactic bilateral salpingectomy at hysterectomy for benign diseases can achieve ultimate goal of reduction in incidence of PHGSC.

HPV genotypes co-infections associated with cervical carcinoma: Special focus on phylogenetically related and non-vaccine targeted genotypes.

HPV is the major causative agent for cervical cancer. Study on the risk of cervical cancer associated with different hr-HPV genotypes would be useful for disease management and new vaccine strategy. With limited reports available, the present study aimed to investigate the pattern of HPV genotypes coinfections and risk of cervical carcinoma associated with them in Indian population. 15 HPV genotypes were detected by E6/E7 multiplex nested type-specific PCR in the HPV-positive cervical samples of 172 cervical cancer cases and 174 subjects with normal cytology. Association between the genotypes and cervical cancer was estimated by calculating the Odds ratio and 95% confidence interval. Risk of cervical carcinoma was associated with multiple genotypes excluding HPV16 (OR:5.87; 95% CI-1.28-26-29; p = .02), multiple genotypes excluding HPV18 (OR = 2.5; 95% CI = 1.09-6.05; p = .03), multiple genotypes of α9 species(OR = 5.3 95% CI = 1.14-24.03; p = .007), and multiple genotypes of α7 species (OR = 2.5; 95% CI = .49-13.45; p = .2). Genotypes not targeted by quadrivalent vaccine types (OR = 2.94 95% CI = 1.48-5.80; p = .001) conferred 2.94 fold higher risk of cervical carcinoma. Cases those coinfected with phylogenetically related genotypes (OR = 2.29; 95% CI(.69-7.59) p = .17) were at 2.9 fold higher risk of invasive cervical carcinoma than those infected with other genotypes although it is not statistically significant. Whereas phylogenetically unrelated genotypes coinfection is negatively associated with cervical carcinoma (OR = .44 95% CI (.244-.8) p = .007) and it is statistically significant.Genotypes not targeted by 9-valent vaccines (OR = .40; 95% CI = .19-.85; p = .017) associated with lesser risk of cervical carcinoma as compared to other genotypes. Subjects infected with any HPV genotype/genotypes excluding HPV16 in association with HPV 18 (OR = 4.1; 95% CI = 1.81-9.25 P = < .001) were at 4.1 fold higher risk of developing invasive cervical carcinoma.In conclusion, the risk of development of cervical cancer is genotype specific and might be associated with type-specific interactions between the genotypes in multiple infections.

HPV Genotypes distribution in Indian women with and without cervical carcinoma: Implication for HPV vaccination program in Odisha, Eastern India.

BACKGROUND: Considering the limited cross protection offered by the current HPV vaccines, understanding the HPV genotype distribution among the different population is essential in predicting the efficacy of current vaccine and devising new vaccine strategy. The present work aimed at investigating the HPV genotypes distribution among women with and without cervical carcinoma in Odisha, Eastern India. METHODS: A total of 607 participants have been enrolled between January 2014 and June 2016. L1-PCR, sequencing, and E6/E7 nested multiplex type- specific PCR were performed for HPV detection and genotyping. Cytological distribution of 440 cases includes invasive cervical carcinoma or ICC (n = 210), inflammatory smear (n = 162), normal cytology (n = 68). Statistical analyses were performed by using SPSS version 20.0 software and MediCal version 14.10.2(7). A p-value of ≤ 0.05 was considered statistically significant. RESULTS: The overall prevalence of HPV infection was (359/595) 60.33%. Prevalence of HPV infection was 93.80% (197/210) in invasive cervical cancer (ICC) cases, 54.32% (88/162) in inflammatory smear and 19.11% (13/68) in normal cervical cytology. The most prevalent genotype was HPV16 (87.28%) followed by HPV18 (24.56%) and HPV 51(3.46%). The overall prevalence of single type was 76.58% and highest (78.9%) among ICC cases. The most frequent genotype combination after HPV16 + 18(9.4%) was HPV16 + 66 + 68(2.7%) which was frequently observed in inflammatory cytology. Age > 45years, parity ≥3, low socio-economic condition, rural residential area and post menopause state were significantly associated with HPV infection. Multiple infections did not have a significant association with any of the clinicopathological variables (stage, LN metastasis, cell type) except tumor size ≥ 2cm in ICC cases. The impact of 2v, 4v, and 9v vaccines in preventing cervical cancer in Odisha were 89.99, 91.65, and 92.16% respectively. CONCLUSION: This data would help planning an appropriate strategy for disease monitoring and provides baseline data for post-vaccination surveillance in the region. The nonavalent vaccine would be significant in preventing cervical carcinoma in Odisha. Hence an effective vaccination program based on regional HPV epidemiological profile along with the cervical cancer screening is necessary to reduce the cervical cancer burden in India.

Management of Ovarian Cancer in Elderly.

As a result of increasing life expectancy, the cancer incidence in older population is on the rise. Ovarian cancer (OC) is predominantly the disease of elderly women. More than half of all OC occur in women older than 65 years. The incidence of the disease increases with the advancing age, peaking during 7(th) decade of life and remains elevated until the age of 80 years. With the changing demographic scenario the percentage of elderly patients is increasing and gynaecologic oncologists need to focus more on these patients and their specific needs. Due to their higher risk of morbidity and mortality compared to younger patients, elderly patients with advanced ovarian cancer are challenging to treat and are often treated less radically. Their outcome is impaired despite no consistent prognostic effect of age itself. To offer optimal radical management of the elderly women with ovarian cancer and to avoid suboptimal treatment, biological age and functional status need to be considered before individualized treatment plans are defined. Pretreatment assessment can be achieved by using different assessment tools. Patients can tolerate surgery and chemotherapy, as long as they are individually assessed for their medical, psychological, and functional capabilities before therapeutic intervention is initiated. Prospective trials involving elderly women with ovarian cancer are the need of the day to offer justified evidenced based optimal treatment for those who will be benefited from the treatment.