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ABSTRACT
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 88-126

Abstracts - RGCON 2016


Date of Web Publication2-Jan-2017

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How to cite this article:
. Abstracts - RGCON 2016. Asian J Oncol 2016;2:88-126

How to cite this URL:
. Abstracts - RGCON 2016. Asian J Oncol [serial online] 2016 [cited 2019 Feb 22];2:88-126. Available from: http://www.asjo.in/text.asp?2016/2/2/88/198824

Cervix: Oral Abstract

Comparison of the outcomes between locally advanced cervical squamous cell carcinoma and adenocarcinoma patients treated with definitive chemoradiation

P. Ahlawat, S. Mitra, M. K. Sharma, U. Saxena, I. K. Wahi, A. K. Choudhary, S. Tandon, P. Surkar

Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Objective:
To present comparison of survival outcomes between locally advanced adenocarcinoma and squamous cell carcinoma patients treated with definitive chemoradiation.

Methods: It is a retrospective analysis and direct comparison between adenocarcinoma and squamous cell carcinoma cervix treated from January 2011 to December 2015. Of 73 patients analyzed 61 had squamous carcinoma histology and remaining 12 had adenocarcinoma. Inclusion criteria were patients with locally advanced stage (IIA) who have completed definitive chemoradiation and were available for response evaluation at 3 months of completion of treatment. Endpoints for the study were disease response evaluation at 3 months, progression rate, median progression free survival, median recurrence free survival, median loco-regional control, median distant metastasis free survival, median overall survival.

Results: There was no significant difference between the two histology groups with respect to rate of achieving complete response (78.6 vs 75%, p = 0.718) and rate of disease progression (36% vs 50%, p = 0.517). There was no significant difference between median PFS (57.75 vs 17.74 months; p = 0.964), median RFS (NR vs 66.03 months; p = 0.876), median loco-regional control (not reached for both; p = 0.315), median DMFS (NR vs 66.03 months; p = 0.438) and median OS (NR vs 66.13 months; p = 0.884).

Conclusions: Locally advanced squamous cell carcinoma and adenocarcinoma treated with definitive chemoradiation have similar outcomes. Small sample size is the limitation of this study.

Cervix: Oral Abstract

Role of complementary cytology, colposcopy and histopathology in detecting premalignant and malignant lesions of cervix

Akanksha Mangla, Renuka Sinha 1

Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 1 Consultant Gynaecologist, Rama Medical College and Super-speciality Hospital, Ghaziabad, Uttar Pradesh, India

Objective:
Cervical cancer is the second most common gynecologic malignancy worldwide. India alone accounts for one fifth of total number of cases worldwide. The aim of our study was to calculate sensitivity, specificity, positive predictive value, negative predictive value, false positive rate and false negative rate of complementary cytology and colposcopy with histopathology as gold standard for detection of premalignant and malignant cervical lesions.

Methods: A cross sectional study was conducted at Vardhman Mahavir Medical College and Safdarjung hospital, Delhi, India. 100 non pregnant females with complaint of post coital or irregular vaginal bleeding and those who had unhealthy cervix on visual inspection were included in study.

Results: Colposcopy exhibited a high degree of accuracy in diagnosis of high grade lesions. Overall sensitivity of cytology was 50% whereas that of colposcopy was 83.3%. Cytology had specificity of 93.4% whereas colposcopy had specificity of 89.4%. 100% of high grade and invasive cancers on colposcopy were associated with similar findings on histology. The degree of agreement between cytology and colposcopy with histology was significant (p<0.001).

Conclusion: Colposcopy is sensitive method as compared to cytology, especially in the higher grade lesions and combination of both methods appears to be of higher diagnostic importance.

Cervix: Oral Abstract

The impact of tumour regression in locally advanced carcinoma cervix during external beam radiotherapy and the need for adaptive planning

Amit Kumar Choudhary

Deparment of Radiation Oncology, Rajiv Gandhi Cancer Institute, New Delhi

Aim:
To study the impact of tumour regression occurring during IMRT for locally advanced Carcinoma cervix and study dose distribution to target volume and OARs and hence the need for any replanning.

Methods and Materials: 40 patients undergoing IM-IGRT and weekly chemotherapy were included in the study. After 36Gy, a second planning CT-scan was done and target volume and OARs were recontoured. First plan (non-adaptive) was compared with second plan (adaptive plan) to evaluate whether it would still offer sufficient target coverage to the CTV and spare the OARs after having delivered 36Gy. Finally new plan was created based on CT-images to investigate whether creating a new treatment plan would optimize target coverage and critical organ sparing. To measure the response of the primary tumour and pathologic nodes to EBRT, the differences in the volumes of the primary GTV and nodal GTV between the pretreatment and intratreatment CT images was calculated. Second intratreatment IMRT plans was generated, using the delineations of the intratreatment CT images. The first IMRT plan (based on the first CT-scan or non adaptive plan) was compared with second IMRT plan (based on the second CT-scan or adaptive plan).

Results: 35% patients had regression in GTV in the range of 4.1% to 5%, 20% in the range of 1.1%-2%, 15% in the range of 2.1%-3% and 20% in the range of 6%-15%. There was significant mean decrease in GTV of 4.63cc (p=0.000). There was a significant decrease in CTV on repeat CT done after 36Gy by 23.31cc (p=0.000) and in PTV by 23.31cc (p=0.000). There was a statistically significant increase in CTV D98, CTV D95, CTV D50 and CTV D2 in repeat planning CT done after 36Gy. There was no significant alteration in OARs doses.

Conclusion: Despite tumour regression and increased target coverage in locally advanced carcinoma cervix after a delivery of 36Gy there was no sparing of OARs. Primary advantage of adaptive RT seems to be in greater target coverage with non-significant normal tissue sparing.

Cervix: Oral Abstract

Clinical comparison of toxicity pattern of two linear quadratic model-baesd fractionation schemes of high-dose-rate intracavitary brachytherapy for cervical cancer

Ankit Batra

Deparment of Radiation Oncology, King George Medical University, Lucknow, Uttar Pradesh, India

Introduction:
Carcinoma cervix is the fourth (GLOBACON 2012) most common cancer among women worldwide, and the main cancer affecting women in Sub-Saharan Africa, Central America and south-central Asia. In India, approx. 1,23,000 (GLOBACON 2012) new cases of carcinoma cervix are diagnosed each year. Brachytherapy is an integral part of treatment of cancer cervix. In the context of a developing country like us where maximum utilization of the resource is of prime importance to provide treatment to the large patient cohort, shortening the treatment duration and number of fractions always increases efficiency. In order to maximize the logistic benefits of HDR-BT while improving patient compliance and resource sparing, various fractionation regimens are used. Fractionation and dose adjustments of the total dose are radiobiologically important factors in lowering the incidence of complications without compromising the treatment results.

Aim: To compare patient outcomes and complications using two linear-quadratic model-based fractionation schemes of high-dose-rate intracavitary brachytherapy (HDR-IC) used to treat cervical cancer.

Materials and Methods: A prospective randomized study on 318 patients, with histologically proven advanced carcinoma cervix (stages IIB-IIIB) was enrolled in the study. All patients received External Beam Radio Therapy (EBRT) 50 Gy in 25 fractions with concurrent chemotherapy (cisplatin 35 mg/m 2 ) followed by IntraCavitary brachytherapy using high dose rate equipment. Patients were randomised after completion of EBRT into two arms: (1) Arm 1: HDR ICRT 6.5 Gy per fraction for 3 fractions,a week apart. (2) Arm 2: HDR ICRT, 9 Gy per fraction for 2 fractions, 1 week apart. On completion of treatment, patients were assessed monthly for 3 months followed by 3 monthly thereafter. Treatment response was assessed according to WHO criteria after one month of completion of radiotherapy. The RTOG criteria were used for radiation induced toxicities. We analyzed late toxicities in terms of Rectal, Bladder, Small Bowel toxicity and Vaginal Stenosis.

Results: Acute reactions in both the groups were comparable. None of the patient developed Grade 4 toxicity in our study and no toxicity related mortality was encountered. A slightly high frequency of late toxicity was observed in 9Gy Arm patients but was not statistically significant.

Conclusion: In our setup, HDR brachytherapy at 9 Gy per fraction in two fractions is safe, effective and resource saving method with good local control, survival, and manageable normal tissue toxicity.

Cervix: Oral Abstract

Identification of T- and B-cell epitopes in HPV-16 E7 gene isolated from cervical cancer patients

Anoop Kumar 1,2 , Inderjit Singh Yadav 3 , Rupinder Sekhon 4 , Dwaipayan Bharadwaj 2 , Mausumi Bharadwaj 1

1
Division of Molecular Genetics and Biochemistry, Institute of Cytology and Preventive Oncology, Noida, Uttar Pradesh, 2 Department of Biotechnology, School of Biotechnology, Jawaharlal Nehru University, 4 Department of Gynae-oncology, Rajiv Gandhi Institute and Research Center,

New Delhi, 3 Department of Biotechnology, School of Agricultural Biotechnology, Punjab Agricultural University, Ludhiana, Punjab, India

Introduction:
In India, cervical cancer is the most common cancer among females. Persistence infection with high risk human papillomaviruses (HR-HPV) is an etiological agent for cervical cancer development, especially HPV-16 is found to be exclusively high in cervical cancer cases in Indian population. The continuous expression and transforming ability of HPV E7 helps in progression of cervical cancer and other HPV related disease, which make E7 as a suitable targets for the development of therapeutic vaccines.

Objectives: Identification of T-& B-cell epitopes HPV-16 E7 gene isolated from in cervical cancer patients.

Materials and Methods: A total of 80 cervical cancer tissue biopsies were collected and processed for DNA extraction, HPV diagnosis and genotyping. E7 gene of HPV-16 positive samples were amplified and sequenced. Epitopes in E7 gene sequence were predicted by online freely available tools.

Results: In the present study we got 72 samples (90%) were positive for HPV and out of which 68 samples (94.4%) were positive for the HPV-16. HPV-16 positive samples were sequenced and translated. IEDB server was used for epitope analysis; 12 potent epitopes for the MHC-I alleles were identified in isolated E7 gene of HPV-16. The most potent epitopes were MHGDTPTLHEYM for HLA-C*07:01; LLMGTLGIVCPI for HLA-A*02:01 and MHGDTPTLHEYML for HLA-C*07:01; having percentile rank 0.2 for all three and antigencity score of 0.20011, 0.15358 and 0.10735, respectively.

Conclusion: This is an effective strategy to design immuno-therapeutics and therapeutic vaccine against HPV using E7 as target. These findings will be helpful in the development of effective vaccine for particular geographical region.

Cervix: Oral Abstract

Role of interstitial brachytherpy using template (mupit) in locally advanced carcinoma cervix

Ashish Bhange, Abhishek Gulia, Anirudh Punnakal, Anil Kumar Anand, Anil Kumar Bansal, Ch. Kartikeshwar Patro, Naveen Kumawat

Department of Radiation Oncology, Max Cancer Centre, Max Super Speciality Hospital, New Delhi, India

Introduction:
Locally advanced carcinoma cervix includes stages IIB, IIIA, IIIB and IVA. Interstitial brachytherapy has the potential to deliver adequate dose to lateral parametrium and to vagina. Hence, it is preferable in cases with distorted anatomy, extensive (lower) vaginal wall involvement, bulky residual disease post EBRT and parametrium involvement upto lateral pelvic wall.

Aim and Objective: To determine clinical outcome and complications (acute and chronic) in locally advanced carcinoma cervix, treated with interstitial brachytherapy using template (MUPIT - Martinez universal perineal interstitial template).

Materials and Methods: This study is a retrospective analysis of 37 cases of locally advanced carcinoma cervix (stage IIB-2, IIIB-30, IVA-5), treated with EBRT (dose-median 45Gy/25#) ΁ concurrent chemotherapy (CCT) - Inj. Cisplatin/Inj Carboplatin, followed by interstitial brachytherapy using MUPIT from December 2009 to June 2015. Initial treatment with EBRT ΁ CCT was followed by intertstitial brachytherapy. Under spinal anaesthesia and epidural analgesia, MUPIT application was done. Straight and divergent needles (median 26, range 19-29) were inserted to cover parametrium adequately. Needle position was verified with planning CT scan and Brachytherapy planning was done. Dose was normalized to 5 mm box surface from outermost needle with optimization of dose to OAR (Bladder, Rectum and Sigmoid colon). Prescription dose -25Gy in 5#. Treatment was delivered by Microselectron HDR using Ir192 source. Treatment fractions were delivered twice daily with min 6 Hrs. gap in-between fractions.

Results: The median duration of follow-up was 25 months. Local control was achieved in 28 patients with residual disease in 7 patients and local recurrence in 2 patients. 10 patients had acute lower GI toxicity {Grade1 (n=6), Grade 2 (n=4)}, 2 patients had acute Grade 1 bladder toxicity. 1 patient had grade 3 and 1 patient had grade 4 chronic bladder toxicity. Chronic rectal toxicity was seen in 10 patients {Grade 2 (n=4), Grade 3 (n=4), Grade 4 (n=2)}.

Conclusion: Local control was achieved in 28/37 patients (75.6%) and overall survival rate of 81.1% at median follow up of 25 months in patients with locally advanced carcinoma cervix and unfavorable prognostic factors.

Cervix: Oral Abstract

Pattern of distant metastases in treated cases of carcinoma cervix : An analysis

Ashok K. Chauhan, Paramjeet Kaur, Anil Khurana, Yashpal Verma, Nupur Bansal

Department of Radiotherapy, Pt BDS PGIMS, Rohtak, Haryana, India

Aims:
To analyze pattern of distant failure, site of metastases, number of metastases and duration in patient with carcinoma of cervix treated with concomitant chemoradiation.

Materials and Methods: From May 2011 to December 2015, 73 patients of carcinoma cervix who treated with radical treatment (concomitant chemoradiation followed by 3 session of HDR brachytherapy) with distant metastases presented at Department of Radiotherapy-II, Pt BDS PGIMS, Rohtak were evaluated retrospectively.

Results: Most of the female with metastases were in age group of 50-59 years (82%), 12% were in age group >60 and 6% were in < 50 year age group. Initial stage of presentation was 40% (29/73), 48% (35/73) and 12% (9/73) in stage II, III and IVA respectively. Out of which 93% had squamous cell carcinoma histology and 7% were having adenocarcinoma at time of presentation. Among them 49/73 (67%) had solitary metastases, 19/73 (26%) had two metastatic sites and 5/73 (7%) had multiple metastatic sites. Commonest site of distant metastases was paraaortic lymphnodes in 40% of cases, followed by liver, lungs, brains, cervical lymph nodes and one case of cutaneous metastases was also seen. Paraaortic lymphnodes, liver and lung metastases present in maximum number of patient with multiple metastases. Salvage chemotherapy given in 51 cases, palliative radiotherapy (30 Gy or 20 Gy) in 37 cases whereas in 5% of cases single session with 8 Gy was given.

Conclusion: A regular and long term follow up of patients with carcinoma of cervix is necessary to detect distant metastases. With early and proper diagnosis and treatment a better outcome could be achieved.

Cervix: Poster Abstract

Low dose radiation and chemotherapy significantly reduces hypoxic cell population in locally advanced cervix cancer-results of a phase II study

Saikat Das

Deparment of Radiation Oncology, Christian Medical College, Vellore, Tamil Nadu, India

Introduction:
Tumor hypoxia is one of the major causes of high incidence of treatment failures to chemoradiation which is the standard of care in locally advanced cervical cancer. The necessity of newer treatment options that can circumvent hypoxia is highly relevant in this group. Use of low dose radiation to enhance the efficacy of cell cycle specific chemotherapy by mechanism of chemopotentiation is one of the elegant approaches reported in the literature. We have already published the feasibility, efficacy and tolerance of low dose radiation and chemotherapy in neoadjuvant setting in cervical cancer. In this report we evaluated the role of this novel treatment regimen in reducing the hypoxic tumor cell population in cervical cancer.

Methods: Total 24 patients with stage IIB-IIIB squamous cell carcinoma cervix were treated with initial 2 cycles of paclitaxel and carboplatin and concurrent low dose radiotherapy prior to standard chemoradiation. Response was assessed clinically, radiologically (by MRI) and pathologically (four quadrant representative punch biopsy from the cervix) after 3 weeks of neoadjuvant treatment prior to chemoradiation. Immunohistochemistry of HIF-1a was done in the biopsy samples to determine the proportion, intensity and scoring of hypoxic cells.

Results: The proportion of positivity of base line HIF-1a was 42% (10 out of 24 patients). Low, moderate and high expressions were seen in 8%, 17% and 17% respectively. We observed nuclear positivity in 20%, and fine granular perinuclear cytoplasmic positivity in 80% cases. We failed to observe any association between expressions of HIF 1a in relation to the distance from blood vessels in tumor cord. The average age of patients in hypoxia positive and negative groups were 51.7 vs 48.36 yrs (p > 0.05). There was no difference of mean hemoglobin level (11.3 to 11.1, p > 0.05.) or MRI based tumor volume at baseline (57.1 vs. 52.4, p > 0.05) in HIF 1a positive and negative groups respectively. Low dose radiation and chemotherapy significantly reduced the tumor volume in bulky hypoxic tumors. The tumor volume reduction rate (TVRR) was significantly higher in hypoxic group (TVRR HIF_neg vs. TVRR HIF_pos 68.9 vs. 86.3, p = 0.02, t-test). There was significant improvement of diffusion MRI derived apparent diffusion coefficient (ADC) in hypoxic tumors with low dose radiation and chemotherapy (0.75 vs. 1.27, p = 0.12, Wilcoxon signed-rank test). Median score of percentage of hypoxic cells after neoadjuvant treatment were significantly higher in patients who developed subsequent local recurrence than the rest of the group (77% vs. 5% p = 0.009, Mann Whitney U test).

Conclusion: Overall all HIF 1 positivity was 42% in the present study. A predominantly perinuclear pattern of HIF 1 staining was found in cervix cancer. Low dose radiation and chemotherapy significantly reduced the hypoxic tumor bulk in cervical cancer.

Cervix: Poster Abstract

Incremental Role of 18 F-FDG PET with contrast enhanced CT (PET-CECT) in detection of recurrence of carcinoma cervix

S. Dash, A. Goel, S. Sogani

Deparment of Nuclear Medicine, House of Diagnostics, Faridabad, Haryana, India

Purpose:
To evaluate the role of 18 F-FDG PET with contrast enhanced CT (PET-CECT) in early detection of recurrence in follow up patients of carcinoma cervix.

Methods: Patients with histopathologically proven carcinoma cervix who underwent chemotherapy, radiotherapy and/or surgery and on follow up were recruited in the study. Fifty-two patients underwent 18 F-FDG PET-CECT for detection of recurrence. The median age was 51.5 (average = 53.4) years. PET-CECT studies were evaluated and analyzed separately by an experienced nuclear medicine physician and a radiologist independently. The physicians were blinded for the patient history. PET-CECT results were validated with histopathological correlation, conventional radiologic imaging/follow up PET-CECT study and clinical follow up.

Results: Out of 52 patients, 34 patients were reported as positive for recurrence, 17 of these were having active local recurrence and 31 patients had regional lymph nodal metastases, 14 patients had distant metastases (out of them 6 patients had distant lymph node metastases, 6 had pulmonary metastases, 4 had skeletal metastases and two had liver metastases). Remaining 18 patients were reported as negative for recurrence. The lung was the most common site for distant metastasis. Patient were then further evaluated based on histopathological correlation, conventional radiologic imaging and follow up PET-CECT scan and five were found to be false positive and one patient was identified as false negative. The sensitivity, specificity, positive and negative predictive value were derived to be 96.7%, 77.3%, 85.3% and 94.4%, respectively. Accuracy was calculated to be 88.5%.

Conclusions: 18 F-FDG PET-CECT is a very useful non-invasive modality for the early detection of recurrence and metastatic workup in patients with carcinoma cervix with a very high sensitivity and negative predictive value. It is also useful in targeting biopsy sites in suspected cases of recurrence.

Cervix: Oral Abstract

Evaluation of adequacy of conventional radiotherapy fields based on bony landmarks in cervical cancer patients using contrast enhanced CT

Tuli Deepak, M. K. Gupta, R. Seam, S. Sharma, M. Gupta, V. Fotedar, S. Vats, N. Himthani, A. Rana, R. Kaundal

Department of Radiotherapy and Oncology, RCC, IGMC, Shimla, Himachal Pradesh, India

Introduction:
Cervical cancer is the second leading cause of cancer death in Indian women. Although, it is known that in Western women the conventional pelvic fields based on bony landmarks provided inadequate coverage for pelvic lymph nodes in cervical cancer; it remains unclear in Indian patients because of the pelvic anatomic discrepancies. In the present study, we have tried to evaluate the adequacy of conventional pelvic fields based on bony landmarks by using CECT using pelvic vessels as surrogate of lymph nodes.

Aims and Objectives: To evaluate the lymph node location in CECT pelvis using vessels as surrogate markers.

(a) To compare the data, so obtained, with the usual radiotherapy field; where bony landmarks are used to define the field.

(b) To evaluate the adequacy of radiation portal defined on bony landm-arks in covering pelvic lymph nodes.

Materials and Methods: This study was conducted in the Department of Radiotherapy and Oncology, Regional Cancer Centre, IGMC, Shimla in patients suffering from carcinoma of cervix. Two dimensional radiation portals were designed on conventional simulator "Acuity." CECT pelvis was done in the same position along with same immobilization accessories used during conventional simulation. 2 mm thick slices were taken from L1 to mid femur. Using vessels as surrogates for lymph nodes and applying Taylors guidelines, adequacy of conventional GOG field was judged.

Results: Most of the parameters failed in this study, signifying inadequacy of GOG defined field in Indian population, detailed results will be discussed at the time of presentation.

Cervix: Oral Abstract

Audit on early stage carcinoma cervix primarily treated with radical surgery: A tertiary cancer care centre experience

Adarsh Dharmarajan, M. Geetha1

Departments of Surgical Oncology and 1 Epidemiology, Malabar Cancer Centre, Thalassery, Kerala, India

Introduction: C linical staging is universally accepted for ca cervix. In early stage of carcinoma cervix both radiation and radical hysterectomy given equivalent local control rates as well as survival. Poor prognostic factors following surgery would necessitate-post-operative adjuvant radiation. Selecting the patients who is unlikely to require adjuvant treatment after surgery spares them the toxicity of multiple treatment modalities, which is worse than alone.

Aim: To find out clinico-pathological correlation in early stage carcinoma cervix treated with the surgery.

Materials and Methods: It is a retrospective audit of study. All carcinoma cervix cases primarily treated with surgery.

Results: A total of 25 cases were treated in this study. The median age of patients observed with 48 years. The common symptoms and stage were vaginal discharge (i.e., 42.30%) and 1B1 (61.53%). Most of patients were treated with type III radical hysterectomy and their clinical staging was correlated with the final histo-pathological staging. A total of 11 (i.e., 42.30%) required adjuvant treatment among them 7 (63.633%), 1 (9.09%) and 3 (27.27%) patients were in 1B1 1B2 and 2A respectively. The chi-square test has been performed to compute the correlation between clinical and histo-pathological finding. It shows that significant amount of relation present between clinical and histo-pathological findings.

Cervix: Oral Abstract

Nation wide urgent need for colposcopy services: Cancer hospital based study

Vibha Gahlot, Ranjit Kumar

Mahavir Cancer Institute and Research Centre, Patna, Bihar, India


The cancer cervix is the second most common cancer among women worldwide. About 86% of the cases occur in developing countries and this is responsible for 88% of total deaths. In India 132,000 new cases are diagnosed each year with this disease and 74,000 deaths are recorded annually which accounts for the 1/3 rd of the global deaths from cervical cancer. This hospital based study is designed to look at the distribution of the disease in patients coming to the Mahavir Cancer Sansthan with the aim to achieve an early diagnosis and treatment and recognition of disease in its preinvasive state for better outcome and quality of life. The patient registry data in Mahavir Cancer Sansthan showed that the total number of patients from all cancer were 20,746 in year 2013-2014. The cervical cancer constituted 14% of the patients. 50% of the patients belong to the six district of Bihar which falls in Gangetic plain. 700 case notes have been reviewed for clinical staging at the time of the diagnosis. 71% of the patients were in stage 2b at the time of first clinical presentation, 24% in stage 3% and 4% were in stage 4. Only 1% patients were found in stage1. The colposcopy clinic data suggest only 0.04% patients have approached to us at preinvasive stage. We conclude from this study that although this hospital is mainly a referral cancer hospital 99% patient have reported to the hospital at stage 2b and beyond. Given the natural History of cervical cancer this is only the tip of iceberg. A robust system for colposcopy services needed to diagnose this disease at its preinvasive and micro invasive stage to reduce the morbidity and mortality and improvement in the quality of the life of the patients.

Key words: Cervical cancer; colposcopy; gangetic belt; preinvasive

Cervix: Oral Abstract

Comparative evaluation of concomitant chemoradiation with weekly cisplatin and gemcitabine versus weekly cisplatin in the management of locally advanced carcinoma of uterine cervix

Vikas Gupta, Ashok Kumar Chauhan, Paramjeet Kaur, Anil Khurana, Yashpal Verma, Nupur Bansal

Department of Radiotherapy, Regional Cancer Centre, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

Aim:
To evaluate feasibility of concomitant chemoradiation with weekly cisplatin and gemcitabine, and comparing the advantage of using this regimen over cisplatin alone in terms of disease control and toxicities in management of locally advanced carcinoma cervix.

Materials and Methods: The study has been conducted on fifty previously untreated, histopathologically proven FIGO stage II B - IV A patients of carcinoma cervix, attending the Department of Radiotherapy, Post Graduate Institute of Medical Sciences, Rohtak for definitive treatment by radiation therapy. The patients were divided randomly in two groups of 25 patients each. Group I received cisplatin 40 mg/m 2 and gemcitabine 125 mg/m 2 with concomitant external beam radiotherapy 50 Gy/25 fractions/5 weeks, followed by intracavitary high dose rate brachytherapy 7 Gy to point A, for 3 times, once in a week. Group II received concomitant chemotherapy with cisplatin 40 mg/m 2 weekly alone while radiotherapy schedule were same as in group I.

Results: Total treatment duration in group I and II were 9-11 and 8-10 weeks respectively. Complete response rate in group I and II were 92% and 80%. Grade III skin and mucosal reactions was 20% in group I and none in group II. Diarrhoea was 24% in group I & 8% in group II. Grade II & III leucopenia was seen in 28% and 4% cases of group I & group II respectively. Upper gastrointestinal and renal toxicities were comparable in both arms. After six month of follow up, no evidence of disease was seen in 92% and 80% cases of group I and group II.

Conclusion: If the toxicity is managed adequately in platinum based doublet group, it may produce improvement in response. Study is ongoing.

Cervix: Oral Abstract

Over view of clinical presentation, management and outcome of cervical cancer: A tertiary cancer centre experience

H. Shukla, K. Batra, R. Sekhon, S. Giri, S. Rawal

Deparment of Surgical Oncology, Rajiv Gandhi Cancer Institute, New Delhi

Objectives:
(a) To understand the profile of cervical cancer patients attending our hospital from January 2011 till January 2015. (b) To audit the type of care given to the patients with respect to their stage at presentation. (c) To compare the outcomes of open v/s robotic radical hysterectomy done for cervical cancer.

Methods: We prospectively analyzed all cases of cervical cancer from January 2011 to January 2015 presenting at our institute. Data was retrieved from patient's records and institute's tumor registry. We compared all patients undergoing open v/s robotic RH. All the data were analysed using SPSS version 21.

Results: A total of 562 patients were treated for cervical cancer during the time period between 2011-2015. Of these there were 316 (56%) cases taken up for surgery-212 robotic RH, 104 open radical hysterectomy and rest 246 (44%) patients received definitive CCRT. Most common age group was 40-54 yrs. IB1 stage was most common presenting stage. SCC was most common histology (75%). Immediate post op complication and oncological safety in terms of local recurrence was same in both groups. However length of stay and post operative blood requirement was significantly lower in robotic RH group. 45% of all patients who underwent surgery did not require adjuvant therapy in post op period while 35% patient required post op RT and 20% CCRT. 2.2% patient had local recurrence and most of the patients were in stage IIA1 at presentation.

Conclusion: Cervical cancer is the most common gynecological cancer in our hospital registry. Mostly women were in the age group of 40-54 years. Most common stage at presentation was 1B and the histology being SCC. Not many differences seen in open v/s robotic techniques of radical hysterectomy except for shorter hospital stay and less need of blood transfusion in the robotic group. Local recurrence rates are comparable in both open and robotic groups.

Key words: Robotic radical hysterectomy; open radical hysterectomy; cervical cancer

Cervix: Oral Abstract

Sample survey of cancer awareness in health care workers

Lalita, Saritha Shamsunder, Kavita Agarwal, Archana Mishra, Sunita Malik

Department of Obstetrics and Gynecology, Vardhmaan Mahaveer Medical College and Safdarjung Hospital, New Delhi, India

Objective:
To see the awareness about cancer in women among ASHA workers.

Place of Study: Awareness Sessions at Safdarjung Hospital, New Delhi.

Background: ASHA workers are the first point of contact for women in the community & bridge the back between the hospital and women. They have been instrumental in the success of the family planning programme & polio eradication program in India.

Materials and Methods: A questionnaire about educational status, awareness about breast & cervical cancer statistics, methods of screening and diagnosis was distributed to Accredited Social Health Activists appointed by the government at two educational sessions organized at Safdarjung hospital.

Results: Of the 200 ASHA workers attending, 188 completed the questionnaire. Their educational status ranged from 7 th standard to post-graduate, majority had studied up to 10 th standard. Their sources of information were mostly television and mobile phones, 23% had knowledge about internet, 36% were using Whats app. Only 28% knew about the commonest cancer in Indian women. Regarding breast cancer, 63% were aware of self examination of breasts, 41% knew the frequency of self examination; awareness about symptoms of breast cancer was prevalent in 46%, 24% knew about risk factors of breast cancer. Regarding Cervical Cancer, 28% knew about risk factors, 22% knew about symptoms of cervical cancer; 19% knew about screening methods for cervical cancer, 9.5% knew the screening intervals.

Conclusion: Health education about cancer prevention should start at the primary school level. Special educational & motivational sessions for ASHA workers could help in cancer prevention programs.

Cervix: Oral Abstract

Evaluation of biomarkers p16 ink4a /ki-67 in cervical cytology for diagnosis of cervical intraepithelial neoplasia

P. K. Sathija, S. Rajaram, V. K. Arora, B. Gupta, N. Goel 1

Departments of Obstetrics and Gynecology and 1 Pathology, UCMS and GTB Hospital, New Delhi, India

Background:
Novel biomarkers, P16 INK4a /Ki-67 are disease specific and identify risk of progression to cervical cancer.

Aim: To test the clinical utility of biomarkers p16 INK4a /Ki-67 in cervical intraepithelial neoplasia.

Methodology: Experimental study was conducted over an 18 month period at a tertiary care hospital. 3500 sexually active women between 30-55 years were screened by VIA/VILI, Pap test & HPV-DNA PCR. All screen positive women (n=280) underwent colposcopy and biopsy if required. At the time of colposcopy repeat cervical smear were taken for evaluation of p16 INK4a /Ki-67. Immunocytochemistry for p16 INK4A and Ki-67 was done by partitioning one slide into two parts for each biomarker. For p16 INK4A positivity, nuclear +/- cytoplasmic scoring and intensity score was calculated and final score obtained. For Ki-67 staining was exclusively nuclear. Staining patterns were categorized as negative, intermediate or strongly positive.

Results: 86 women with abnormal cytology were evaluated with p16 INK4A /Ki-67 immunocytochemistry and 20.9% (n=18) and 18.6% (n=16) were positive for each biomarker. For ASCUS (n=42) and LSIL (n=23) smears, specificity and NPV were 100% with a likelihood ratio (LR+) of 27 and 25 respectively suggesting good diagnostic accuracy. The combined sensitivity and specificity of p16 INK4a /Ki-67 in detecting CIN-2+ lesion was 76.9% and 95.8% respectively with LR+ of 18.72 in high grade smears.

Conclusions: p16 INK4A /Ki-67 evaluation in cervical cytology are valuable biomarkers in ruling out or detecting CIN2+ in ASCUS and LSIL smears. Unnecessary intervention in large number of low grade smears can be avoided by applying these biomarkers. In high grade smears detection rate of biomarkers p16 INK4A /Ki-67 was high and had a good diagnostic accuracy.

Cervix: Oral Abstract

IMRT in carcinoma cervix: Maximizing the gain and nipping the side effects: RGCI experience

Objective: To present a single institutional experience with acute toxicity, patterns of failure and survival in carcinoma cervix treated using definitive radiotherapy with IMRT technique.

Methods: It is a retrospective analysis of 64 patients with carcinoma cervix treated with definitive chemoradiation (IMRT) from April 2011 to Jan 2013. Patients with squamous or adenocarcinoma histology and no metastasis, treated with definitive radiotherapy (IMRT) with or without concurrent chemotherapy were included. Acute toxicities were presented as proportions and kaplainmeier computation was done to calculate 3 years disease free survival (DFS) and 3 years overall survival (OS).

Results: Median follow up was months for the entire cohort. Mean age was 55.9 years (SD 9.93). Majority of patients (92.8%) had locally advanced disease (FIGO II and III) and squamous cell carcinoma (96.9%). Mean dose to pelvis with IMRT was 49.75 Gy (SD 1.78) followed by ICRT, EBRT boost and implant in 79.7%, 17.2% and 3.1% respectively (as indicated). Response evaluation done at 3 months of treatment completion showed 83.6% complete response, 11.5% partial response and 4.9% progressive disease. During follow up 21.6% developed recurrence - 44.4% failed locally, 16.7% at para-aortic nodal region and 38.9% at distant sites. The 3 year DFS and OS was 70.8% and 60.3% respectively. Patients had tolerable acute toxicities. Incidences of grade ≥3 acute toxicity were 3.1% for anemia, 10.9% for neutropenia, 25% for thrombocytopenia, 1.5% for nausea, 0% for vomiting, 12% for GU and 12% for GI toxicities. Incidence of grade I, II and III radiation dermatitis were 38.89%, 27.78% and 22.2% respectively. None developed grade IV radiation dermatitis.

Conclusion: IMRT for carcinoma cervix seems to provide improved outcomes and toxicity profile, although it should be compared with conventional radiotherapy in a well randomized control setting so as to have true and meaningful comparison.

Cervix: Poster Abstract

Comparison between cystoscopy and CT scan findings of bladder involvement in carcinoma cervix in view of revised FIGO staging

Department of Urology, GMC, Patiala, Punjab, India

Aim:
To compare the findings of CT scan pelvis and cystoscopy findings of bladder involvement in carcinoma cervix in VIEW of revised FIGO staging and to demonstrate the accuracy of CT scan for pretreatment diagnosis of bladder involvement.

Methods: A prospective and comparative study was conducted in the department of Obstetrics and Gynaecology, Rajindra hospital Patiala on a number of 100 patients of carcinoma cervix who underwent both cystoscopy and CT scan pelvis to ascertain bladder involvement. Cystoscopy guided biopsy proven cases of bladder involvement were taken as true cases of bladder involvement in the study and the results of both modalities were analysed and compared.

Results: Out of 100 patients of carcinoma cervix, 28 patients showed bladder involvement on CT scan pelvis and 6 patients were proven as positive cases on cystoscopic guided bladder biopsy. The true positives in the study were 6 cases. True negatives were 94 cases. 22 patients were false positive on CT scan findings and there were no false negative patients for bladder involvement on CT scan pelvis findings in the study. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CT scan pelvis for bladder involvement were 100%, 76.60%, 21.43%, 100% and 78% respectively. CT scan pelvis was able to detect all cases of bladder involvement which came positive cystoscopy guided biopsy as well.

Conclusions: With the revised FIGO staging which has given optional status to both CT scan and cystoscopy for bladder involvement in patients of carcinoma cervix, CT scan can be used as the preliminary modality for detective bladder involvement in patients of carcinoma cervix. The high sensitivity and negative predictive value of CT scan helps choose which patients should undergo cystoscopy and helps in better and more efficient pre-treatment evaluation of patients with carcinoma cervix for bladder involvement.

Cervix: Oral Abstract

Association of TNF-α rs-281865419 polymorphism with reproductive tract infections in Indian population

Vineeta Sharma 1,2 , Pallavi Singhal 1 , Anoop Kumar 1 , V. G. Ramachandran 2 , Shukla Das 2 , Mausumi Bharadwaj 1

1
Division of Molecular Genetics and Biochemistry, Institute of Cytology and Preventive Oncology, Noida, Uttar Pradesh, 2 Department of Microbiology, University College of Medical Science, Delhi University, New Delhi, India

Aim:
To investigate the presence of reproductive tract infections (RTIs) in symptomatic and asymptomatic women in North India and association of SNPs in TNFa gene (rs-281865419 C/T) with susceptibility to these RTIs.

Methods: We collected 100 symptomatic (cases) and 100 asymptomatic women (controls) samples and screened them for RTIs. Then genotyping of TNF-a gene was performed by PCR-RFLP.

Results: Among cases the frequencies of RTIs infection is higher than control. The prevalence of HPV, C. trachomatis, T. vaginalis, Bacterial vaginosis and N. gonorrhoeae are 28% & 6%; 11%, 32% respectively while in controls it was 5%, 2%, 1% and 8% & 1%. In the present study we found that the frequency of wild homozygous genotype (TT) was lower in cases 30% (6/20) as compared to controls 60% (12/20). The frequency of the heterozygous polymorphic genotype (CT) was higher in cases 65% (65/100) as compared to controls 32% (32/100). It was interesting to note that the frequency of the polymorphic homozygous genotype (CC) was higher in cases 15% (15/100) than controls 2% (2/100). While the frequency of the carrier genotype (CT + TT) was found to be more in cases 70% (70/100) than in controls 40/100 (40%). This study shows that T allele may be risk factor for Reproductive tract infections as its percentage is higher in cases as compare to normal controls.

Conclusion: TNF-a rs-281865419 locus may serve as an important biomarker for RTIs predisposition in Indian population though larger sample size is needed to validate the findings.

Cervix: Oral Abstract

Chemoradiation for the management of locally advanced carcinoma uterine cervix: Comparative evaluation of concomitant weekly versus three weekly cisplatin

Sulbha Mittal, Ashok Chauhan, Parajeet Kaur, Yash Pal Verma

Department of Radiation Oncology, Pt B.D. Sharma, PGIMS, Rohtak, Haryana, India

Aims and Objectives:
To determine and evaluate the difference/s, in terms of tumor control and side effects, between weekly and three weekly cisplatin concomitant with external beam radiotherapyfor locally advanced carcinoma of cervix.

Materials and Methods: The study was conducted in Radiotherapy Department, University of Health Sciences, Rohtak (India), on sixty previously untreated, histopathologically proven patients of locally advanced carcinoma of uterine cervix. The patients were treated with External Beam Radiotherapy (EBRT) 50 Gy/25 fractions over 5 weeks and concomitant cisplatin, followed by intra-cavitary HDR brachytherapy (ICBT) 700 cGy to point A; three times, once in a week. The patients were assigned randomly either of two groups of 30 patients each. In Group I (Study Group) the patients received three weekly cisplatin 75 mg/m 2 for 2 cycles whilein Group II (Control Group) the patients received weekly cisplatin 40 mg/m 2 for 5 cycles. Evaluation of response and toxicity was done weekly during treatment and monthly thereafter up to six months. The data thus obtained was assessed and analysed using La Morte statistical tool. The study was approved by Ethical committee of the institute and quality was periodically monitored by senior consultant and guide.

Results: Stage wise disease response in study and control respectively at the end of treatment was as follows: Stage IIA-CR (80% vs 100%), PR (20% vs 0%); Stage IIB-CR (80% vs 76.47%), PR (20% vs 23.53%); Stage IIIA-CR (60% vs 100%), PR (40% vs 0%); Stage IIIB-CR (60% vs 60%), PR (40% vs 20%), NR (0% vs 20%).

Stage wise disease status at the end of sixth month follow up was as follows: Stage IIA - NED (80% vs 100%), RD (20% vs 0%); Stage IIB - NED (80% vs 76.67%), RD (20% vs 23.53%); Stage IIIA - NED (60% vs 100%), RD (40% vs 0%); Stage IIIB - NED (60% vs 60%), RD (40% vs 40%). Tumor response was not significantly different in the two groups with respect to age distribution, rural/urban distribution, histopathological distribution and treatment interruption. Maximum level of hematological toxicity (WHO criteria) observed in study and control group respectively at the end of treatment was as follows: Anaemia; Grade II - 4 (13.33%) in both the groups, Leukopenia; Grade II - 1 (3.33%) vs 0 (0%). The worst acute skin reactions observed by the end of treatment in Group I and II respectively were grade II - 2 (6.67%) vs 0 (0%). The worst acute mucosal reactions were grade II - 5 (16.66%) vs 0 (0%). Upper Gastrointestinal toxicity (Grade II & III) was 16.7% versus 13.3% respectively. Lower gastrointestinal toxicity (Grade II & III) was 30.0% versus 36.7%. No significant weight loss was observed in either of the groups. Though, all the patients completed the intended treatment, treatment interruption for more than a week was observed in 10 (33.33%) vs 8 (26.67%) patients respectively, due to acute toxicities.

Conclusion: Three weekly cisplatin, concomitant with radiation seems to be the potential, effective and acceptable alternate as standard of treatment for locally advanced carcinoma cervix; especially for increased work load and limited resource setups.

Cervix: Oral Abstract

To evaluate the role of training session on 'Cervical Cancer Screening' in improving knowledge and attitude of Accredited Social Health Activists (ASHA) in East Delhi population

Nilanchali Singh, Shalini Rajaram, Bindiya Gupta, Anita Mendiratta, Sanjay Kumar

Department Obstetrics and Gynaecology, University College of Medical Sciences, Guru Tegh Bahadur Hospital, New Delhi, India

Background:
India has the world's largest load of cervical malignancy. A lot of it can be attributed to lack of cervical cancer screening awareness among the general population. The Accredited Social Health Activists (ASHA) are grass root workers who have good reach in the remote areas, where health care facilities are lacking. Training these ASHAs may increasethe general awareness about cervical cancer screening.

Methods: We organized a training programme of 250 ASHA workers in a tertiary care hospital with aim of improving their knowledge and attitude about cervical cancer screening which will eventually improve their practise of training women in general population. It comprised of 5 lectures in language they understand, slogans, posters, question answer session etc. A test comprising of 17 questions was conducted before and after session to check their knowledge and attitude.

Results : There was an overall improvement of 25% in knowledge of the ASHAs i.e. 38% answers were correct in pre-test and 63% were correct in post-test. Questions were pertaining to symptomatology, risk factors, screening methods, their utility and prerequisites of performing the screening tests, when and how often to repeat. Improvement was seen in all the areas. There was improvement in attitude too and most of them wanted themselves (98%), their relatives (100%) and the woman within their area (98%) to be screened for cancer cervix.

Conclusion: It was a small initiative and successful result was obtained after the training session of ASHAs. The impact on general population needs further evaluation.

Cervix: Poster Abstract

Neo-adjuvant chemotherapy followed by surgery versus definitive chemo radiation as treatment for localized carcinoma cervix

S. Singh, V. Goel, V. Talwar, S. Raina, S. Mitra 1 , U. Saxena 1 , R. Shekhon 2 , S. Rawal 2

Departments of Medical Oncology, 1 Radiation Oncology and 2 Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Background:
Cervical cancer is ranked as the most common cancer in Indian women, second most common cancer worldwide and the leading cause of death in the developing countries. In the developing countries majority of the patients are diagnosed at locally advanced stages. The standard treatment of locally advanced cervical cancer is concomitant chemoradiation (CTRT) using platinum based chemotherapy. However, some randomized studies have shown improved results for patients receiving neoadjuvant chemotherapy (NACT) followed by surgical resection in comparison to patient receiving radiation alone. The present study was designed to compare response to the treatment and survival of and NACT followed by radical surgery (RS) with CTRT in the patients of uterine cervix of a tertiary cancer care centre.

Patients and Methods: Retrospective study was performed in locally advanced/advance stage patients of cervix UTERI registered in the institute between years 2009 to 2013. Patients were included in the two groups, group A consists of 89 patients who have received NACT + RS and 67 patients in group B who have received CTRT. Clinical records were reviewed with particular reference to presenting complaint, clinical stage, response to the therapy, disease free survival and overall survival. Statistical analysis was done using SPSS version 22.

Results: In the neoadjuvant group (group A) (n=89) the median age of patients was 53 years (range 31-80 years), most of the patients (70%) were presented with complaint of postmenopausal bleeding. Of the total patients, 69 (77.5%) underwent to radical surgery and 5 (8.5%) received radiotherapy after NACT. From 69 patients, who had undergone to surgery, 54 (78.3%) had also received radiation. The overall response to induction chemotherapy was 84%. In the chemo radiation group (group B) (n=65) median age was 56 years (33-75 years). Vaginal bleeding (34%) followed by postmenopausal bleeding (32%) was major presenting complaint in this group. Overall response to the complete treatment was 91%. The median follow up time was 14.3 months in group A and 12.2 months in group B. The disease free survival for NACT group was 32 months (95% CI 26.8-36.5) whereas for CTRT group it was 28 months (95% CI 23.5-33) with 12 and 13 recurrences per group (p = .226). In NACT group overall survival was 46.2 months (95% CI 44-48.3) and for CTRT group it was 38.3 months (95%CI 36.6-40) with 3 and 2 deaths per group (p=.883).

Conclusion: Present study shows comparable results, with no difference in survival between both the groups. However, NACT + RS group had showed better disease free and overall survival than another group. Further studies should be performed with larger number of patients and longer duration of follow up.

Cervix: Oral Abstract

Radiotherapy after hysterectomy in carcinoma cervix: Audit from a tertiary care cancer hospital in India's largest state "Rajasthan"

Tej Prakash Soni, Aaditya Prakash, Tinku Takia, Jaishree Goyal

Department of Radiation Oncology, Bhagwan Mahaveer Cancer Hospital, New Delhi, India

Purpose:
To explore the reasons of hysterectomy and indications of post-hysterectomy radiotherapy in carcinoma cervix cases.

Methods: From January 2013 to May 2015, medical records of 64 cases of carcinoma cervix (post-hysterectomy) who were referred for radiotherapy to our hospital were analyzed retrospectively.

Results: Medical records of 64 cases were reviewed. The median age was 47 years. In 45% of females hysterectomy was done in towns, but in majority of cases (55%) hysterectomy was done in different cities of Rajasthan. Simple hysterectomy was done in 31 of (48%) cases. Wertheim's hysterectomy was done in remaining 33 cases (52%). 15 cases (23%) were treated by IMRT technique, while remaining 87% cases were treated by 3DCRT technique to dose of 50 Gy in 25 fractions followed by CVS brachytherapy. All cases also received concurrent chemotherapy. Reason for hysterectomy was analyzed. In 32 (50%) cases, biopsy from gross lesion at cervix or PAP smear test was not done before surgery. In 32 cases (50%) understaging of the tumor or inadequate staging before hysterectomy was performed. Histopathology report analysis revealed that in 9 cases (14%) primary tumor size was less than 4 cm, in 27 cases (64%) there was no comment on pT size, in 22% cases primary tumor was larger than 4 cm. Surprisingly in one case the pT size was 7 cm. LVSI was not seen in 18 cases (28%), positive in 20 case (31%) and with no comment in 26 cases. More than 50% of stroma thickness was involved in 54 cases (84%), and in remaining 10 cases there was no comment on stroma invasion. In 33 cases (52%) pelvic lymphadenectomy was done, in 48% cases lymph nodes were not addressed in surgery. In 36 cases (56%) pelvic lymph node metastasis was seen either in preoperative imaging (USG/CT scan) or in histopathology. Median follow-up duration was 6 months. Locoregional failure was seen in 10 cases (16%), 6 cases (9%) also developed distant metastasis.

Conclusion: Failure to perform biopsy from gross lesion at or under staging/inadequate staging before surgery was the main reasons for inappropriate hysterectomy for carcinoma cervix. Inappropriate hysterectomy followed by chemo-radiotherapy resulted in poor tumor control rate as in our study, 1 out of every 4 patients failed loco-regionally with median follow up of 6 months. Strict adherence to guidelines for cervical cancer diagnosis and treatment is advised to prevent inappropriate hysterectomy.

Cervix: Poster Abstract

Cervical cancer screening of female of rural community of Nepal: Knowledge, attitude and practices

Anju Shrestha

Nepal Cancer Hospital and Research Centre, Harrisidhi, Lalitpur, Nepal

Purpose and Objectives:
Cervical cancer is leading female cancer in Nepal. Despite the existence of effective screening using Pap smear, the uptake of screening is poor. This is mainly due to lack of knowledge, lack of availability of services in rural area and low priority of women's health issue. Objectives of this study were to determine the baseline information about the knowledge of cervical cancer and explore attitude and practice of Pap smear screening among the women of rural community of Nepal.

Materials and Methods : A cross sectional population based descriptive study of female attending free health camp in different rural community of Nepal organized by Nepal Cancer Hospital was conducted using self-administered questionnaire to elicit information on demographic characteristics, knowledge, screening behaviors and determinants of cervical cancer. Knowledge is elicited about eligibility for screening and screening interval according to American Congress of Obstetricians and Gynecologists (ACOG) guidelines. Practices are evaluated as having ever been screened themselves. Attitudes referred to the various reasons for not getting screened themselves.

Results: A total of 500 women participated in this study, out of which 44.4% (228) were either illiterate or just educated up to primary school. Mean age of participates were 40.6΁10.3 yrs. 47.4% (238) of women married before age of 18 and 57% (258) women had their first childbirth before age of 21 years. Only 33.8% (169) female knew that cervical cancer is preventable and is curable in early stage. Although 42.6% (213) women heard about Pap smear, only 38.2% (191) knew about eligibility of screening and 11% (55) knew about screening interval. However, knowledge of risk factors for cervical cancer was found in 8.2% (41).About 26.8% (134) women had done Pap test at least once. The most common reason for not doing Pap test is they never heard about it (41.8%: 209). The other reason includes do not know where to do (9.6%: 48); never adviced by doctor (9%: 45); embarrassment (2.4%: 12); fear of finding out cancer (3.2%: 16) and do not have any symptoms (2.4%: 12).

Conclusions : The study revealed low cervical cancer knowledge and poor screening behavior among the women. This may be suggestive of even poorer awareness and screening and practices among older women who are less educated or with no education.

Cervix: Oral Abstract

Image guided interstitial brachytherapy for locally advanced disease after external beam radiotherapy in a case of carcinoma cervix - our institutional experience

S. Tandon, S. Mitra, M. K. Sharma, U. Saxena, P. Ahlawat, I. Kaur, A. Chowdhary, P. Surkar

Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India

Purpose/Objective:
Cervical cancer is the third most common cancer in women worldwide. Definitive chemoradiation is the accepted standard of care for patients especially for locally advanced cervical cancers. Intracavitary brachytherapy (ICBT) is an important part of definitive radiotherapy shown to improve overall survival. Interstitial brachytherapy (ISBT) is generally reserved for patients either with extensive pelvic and/or vaginal residual disease after external beam radiotherapy (EBRT) or with anatomy not allowing ICBT with standard applicators in an attempt to improve local control. We have conducted an observational study for patients who underwent image guided HDR-ISBT at our institute.

Materials and Methods: Seven patients; diagnosed as a case of carcinoma cervix; were selected from the period of 2012 to 2015 who received EBRT by IMRT and for whom ICBT couldn't be done for various reasons. These patients were then taken up for Martinez Universal Perineal Interstitial Template (MUPIT) image based ISBT. A descriptive analysis was done for doses received by HRCTV, bladder, rectum and sigmoid colon. At the end of treatment, early response at 3 months along with overall survival (OS) and disease free survival (DFS) was also calculated.

Results: All the patients recruited were locally advanced with 3 patients in IIB, 1 patient in IIIA and 3 patients belonging to IIIB. The mean dose received by 95% high risk CTV (HRCTV) by IMRT was 49.75 Gy. Out of 7 patients, 3 were taken up for ISBT due to anatomical restriction whereas remaining 4 patients were included because of lack of dose coverage by ICBT. The mean doses received by 90% of HRCTV, 2 cc bladder, 2 cc rectum and 2 cc sigmoid colon were 20.58 Gy, 2.73 Gy, 3.19 Gy and 2.82 Gy respectively. The early response at 3 months was 57.14%. The DFS at one year and OS at 3 year were 53.6% and 53.3% respectively.

Conclusions: Our descriptive analysis of seven patients being treated by image based ISBT have revealed that locally advanced cervical cancer patients for whom ICBT is unsuitable can achieve equitable LRC and OS with a combination of EBRT by IMRT and image based HDR-ISBT.

Cervix: Poster Abstract

Breaking the myth: All carcinoma cervix presenting as pyometra will have only palliative treatment

C. Aarthi, A. C. Senthil Kumar, P. Sasireka 1

Departments of Surgery and 1 Obstetrics and Gynecology, Saveetha Medical College, Chennai, Tamil Nadu, India

Introduction:
Carcinoma cervix is the second most common female carcinoma. Every year in India, 1,22,844 women are diagnosed with carcinoma cervix and of them 67,477 die. Carcinoma cervix rates among women in the age group between 30-64 has decreased by 1.8% per year on average but still date account for 16%. Of these, advanced carcinoma are about 80% and early are only 20%.

Case Series: We are reporting 5 consecutive early carcinoma cervix cases who presented with pyometra and got treated at our hospital from April 2015-September 2015. Cases of early carcinoma cervix presented with pyometra were treated by pyometra drainage, intravenous antibiotics and appropriate treatment in the form of surgery (4 cases underwent Wertheim's hysterectomy and 1 case had radical chemo radiation as she opted for same in view of high cardiac risk for anaesthesia). All 5 of them are disease free at the end of treatment with follow up of minimum 4 months duration (range 4-10).

Conclusion: The idea is to emphasize that all carcinoma cervix with pyometra are not necessarily advanced and can still be given radical treatment like surgery or radiotherapy after pyometra drainage.

Cervix: Poster Abstract

Comparative dosimetric study between point and volume based brachytherapy in definitive treatment of de novo carcinoma cervix

Rahat Hadi, Mohammad Azam, Pooja Gupta, Satyajeet Rath, Mohammad Ali, Chandra Prakash, Anoop Kumar Srivastava, S. Farzana

Department of Radiation Oncology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Introduction:
Cervical cancer has a high incidence in developing countries including India. Brachytherapy (BT) is an important component in the curative management of carcinoma of the cervix, and significantly improves survival. In gynaecologic BT, correlation between the radiation dose and the normal tissue effects have been assessed using point doses. Since 1985, these points have been defined in the international commission of radiation units and measurements (ICRU-38) report. However GEC-ESTRO recommended volume based treatment planning in their respective series (I-IV). For cervical cancer BT, the correlation of ICRU point doses and volume based treatment planning is investigational till date. Analysis becomes feasible when cross sectional image-based treatment planning for BT using computerized tomography (CT) or magnetic resonance imaging (MRI) is utilised as per GEC-ESTRO recommendation.

Methods: It is a retrospective pilot study includes patients (pts.) of carcinoma cervix treated with high dose rate (HDR) BT 9 Gy in 2 fractions 1 week apart. All volume based dosimeteric parameters regarding high risk clinical target volume (HRCTV), intermediate risk clinical target volume (IRCTV) like D90, D100 and for organ at risk (OAR) D 0.1 cc, D 1.0 cc and D 2.0 cc were delineated and dose coverage was analysed in point dose based planning.

Results: We have analysed twenty pts. of squamous cell carcinoma (SCC) cervix. The median age was 52 yrs. (41-65 yrs), stage II B 10 pts. & III B 10 pts. The mean value of D90 & D100 in HRCTV during I and II session were 8.64, 6.75 and 5.76, 4.36 Gy respectively. Same values for IRCTV were 6.31, 4.91 and 3.68, 3.15 Gy respectively. Analysis of OARs demonstrated that mean dose received by 0.1, volume of bladder during I and II session received 10.68, 9.47, by 1 cc volume 8.39, 7.57 and by 2 cc volume 6.84, 6.21 Gy respectively. The mean dose received by 0.1 cc of rectum were 11.59, 10.12, by 1 cc volume 9.53, 8.19 and by 2 cc volume 7.76, 6.81 Gy respectively. In point based analysis mean dose delivered to bladder point during I and II session were 5.63, 6.02 and to rectum point were 5.98, 5.46 Gy respectively. Doses to 0.1 cc volume of bladder and rectum were higher in volume based BT as compared to point based BT in respective fractions.

Conclusion: Both HRCTV and IRCTV had better dose coverage in 1 st fraction as compared to 2 nd fraction. Point doses to bladder and rectum is underestimated in point based (ICRU-38) BT. We need more number of pts in prospective randomized trial for more consistent result.

Cervix: Poster Abstract

Primary clear cell adenocarcinoma of cervix in a young women: A rare entity

Nidhi Jain, Rahul Manchanda, Anshika Lekhi, Sravani Chithra, Hena Kausar

Department of Gynaecology, Manchanda Endoscopic Hospital, New Delhi


Cervical cancer is the most common gynaecological malignancy worldwide. The most common type of cervical carcinoma is squamous cell carcinoma followed by adenocarcinoma of cervix, which constitutes only 15% of cases. Adenocarcinoma of cervix can be categorized histologically into clear cell, mucinous, endometrioid, serous and mesonephric subtypes. Clear cell adenocarcinoma (CCA) most commonly occurs in the ovary, followed by endometrium, vagina, and cervix. Primary CCA of cervix is a rare neoplastic entity, which occurs in young women exposed to diethylstilbestrol (DES) in utero. It is extremely rare in women withoutin utero DES exposure and in such cases it concerns mostly postmenopausal women. Here, we present a case of 30 year old woman who presented with primary infertility. There was no history of in-utero exposure to diethyl stilbestrol. She was diagnosed a case of cervical fibroid on ultrasonography. Diagnostic hysteroscopy was done and she was found to have friable, vascular growth in endocervix, which was extending to uterine cavity. Biopsy was taken. On histopathology, moderately differentiated clear cell adenocarcinoma of cervix was reported. Through this case, authors would like to highlight the probability of rare occurrence and how to manage challenges posed by cervical cancer in young girl wishing to conceive, stressing on the role of hysteroscopy in diagnosis.

Key words: Adenocarcinoma, cervix, DES exposure

Cervix: Poster Abstract

Carcinoma uterine cervix metastasis to the skin: A rare case report

Gajender Singh, Sant Parkash Kataria 1 , Rajeev Sen 1

Department of Pathology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India, 1 Department of Radiation Oncology

Introduction:
Most common site of metastasis from carcinoma cervix is lung, liver, bone and brain. Cutaneous metastasis is rare occurrence in carcinoma cervix. Incidence reported ranges from 0.1 to 2%. Common morphological pattern of skin metastases are nodules, plaques and inflammatory telangiectatic lesions.

Materials and Methods: A 68 years old postmenopausal female diagnosed as squamous cell carcinoma of cervix stage III B. She was given chemotherapy and radiotherapy and on regular follow up without no evidence of disease locally. After two years she presented with a sub cutaneous nodule of approximately 5x4 cm size just below the left scapula of one month duration. There was no similar swelling in any other region. It was rapidly increased in size and painful. The FNAC of the nodule showed metastatic from squamous cell carcinoma. PET scan showed metastases in bilateral lung and pelvic lymph node with no evidence of local disease. Excision biopsy of the nodule confirmed the diagnosis.

Conclusion: Cutaneous metastases from carcinoma cervix are rare. Differential diagnoses include benign dermatitis, subcutaneous phycomycosis, and plaque like mycosis fungoides.

Cervix: Poster Abstract

Early stage adenocarcinoma of cervix with ovarian micrometastasis

Mathur Neha Satyaprakash, Pratibha Singh, SuyashaVyas

Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Introduction:
Adenocarcinoma of cervix is a rare malignancy of cervix. It is an aggressive tumour with high incidence of metastasis. Ovarian metastasis in early stage adenocarcinoma is rare. Metastasis is usually seen when there is some other coexisting finding. In premenopausal patient and low risk category, ovarian metastasis is very rare.

Case Report: The present case is a 40 yrs old parous women, with complaints of discharge per vaginum. Her colposcopy showed an erosion on the lower lip. Radical hysterectomy with bilateral oophorectomy was planned. The histopathology was a well differentiated adenocarcinoma with surface ovarian metastasis on one side.

Discussion: Early stage adenocarcinoma of cervix can rarely present with ovarian metastasis. Thus radical surgery with oophorectomy is a an aggressive but practical approach in these patients.

Cervix: Poster Abstract

Retrospective analysis of Ca cervix postoperative: An institutional study

Chandra Prakash

Department of Radiation Oncology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Introduction:
Carcinoma of cervix is one of the leading causes of death worldwide and in developing countries like India. Cervical cancer is third most common cancer among women however there is a good chance of curability if diagnosed in early stage.

Materials and Methods: We had analysed 78 patient of carcinoma of cervix post op who were registered from 2012 to 2015 at Dr. Ram Manohar Lohia Institute of Medical Sciences.

Results: We analysed 78 patients between age of 32-70 years and median age is 50 year. Among all patients squamous cell carcinoma is most common (65 patient), adenocarcinoma were 12 and lieomyosarcoma was 1 patient. Among all patient 12 were of adenocarcinoma, 1 of lieomyosarcoma and 65 patient of squamous cell carcinoma. On examination 55 patients were NAD and 23 were residual. Among squamous cell carcinoma 35 were moderate differentiated, 18 were well differentiated and 12 were of poorly differentiated. On examination 55 patients were NAD rest were having disease. Gap between EBRT and SORBO ranging from 3 to 99 days and median is 27 days and median is 29 days. Treatment length varies from 4 cm to 8 cm and median is 6 cm. Ovoide size ranges from 2.5 cm to 3.5 cm and median is 2.5 cm. Dose per fraction ranges from 5 Gy to 9 Gy and median was 9 Gy. Median fraction of session were 2. Out of 78 patients 2 were developed metastasis and 6 having residual disease. 28 patients were NAD and rest were referral and send back to parent hospital.

Conclusion: Due to lack of resources and awareness of disease maximum number of patient presented with advanced stage. The recommended treatment time could not be achieved due to scarcity of cancer centres, treatment time is prolonged. We have not found any relation between treatment length and outcome. We are still investigating to conclude to found out relation among these variables.

Cervix: Poster Abstract

Diagnostic dilemma of mesonephric adenocarcinoma cervix

Abhishek Soni, Nupur Bansal, A. K. Dhull, Vivek Kaushal, Rajeev Atri, Monica Verma

Department of Radiotherapy and Biochemistry, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India

Introduction:
Mesonephric carcinoma is a rare type of epithelial tumor of the uterine cervix which derive from the remnants of the paired mesonephric (Wolff's) ducts. The incidence of such neoplasms is difficult to determine due to rarity, previous misclassification of clear cell carcinomas and yolk sac tumours as mesonephric carcinomas and potential underreporting due to misclassification of mesonephric carcinoma as Mullerian tumours or mesonephric hyperplasia. The evidence regarding the clinical course, prognosis and optimal treatment is limited.

Materials and Methods: Searches were performed on MEDLINE, EMBASE and Google Scholarly articles. All the relevant articles were included in the study. Only approximate 40 cases have been reported till now.

Discussion: Mesonephric adenocarcinoma cervix has different morphologies like ductal, tubular, solid, retiform, sex-cord like pattern, clear cell and serous papillary structures. IHC assessment is helpful in differentiating it from Mullerian counterpart, as it is negative for CEA, CK20, p16, PAX2, ER/PR and vimentin and positive for CD10, calretinin, CK7, CAM5.2 and EMA. It has no relation with HPV infection. Unlike squamous epithelial carcinoma, it is rarely presenting with the abnormal cervical smear result, has more advanced age at presentation and its incidence does not appear to decline with age. The diagnosis has been supported by endometrial curettings, directed/cone cervical biopsies and hysterectomy specimens. The majority of patients are diagnosed at stage IB with mean DFS of 48.6 months. Recurrence rate is 23%, with a mean interval of 40 months. Hysterectomy is the primary treatment. Advanced stage disease of adenocarcinoma seemed to respond to radiotherapy, but for the MMMTs the combination of chemotherapy with radiotherapy appears to be preferable.

Conclusion: Rarity of the neoplasm, varied morphology, mix presentation and very low number of cases leads to difficulty in correct diagnosis in a small biopsy specimen. IHC helpful in differentiating it from other lesions.

Cervix: Poster Abstract

Study on cervical cancer screening amongst nurses

Astha Srivastava, Bindiya Gupta, Vikas Lakha, Shilpa Singh

Department of Obstetrics and Gynaecology, UCMS and GTB Hospital, New Delhi, India

Objective:
To study the knowledge, attitude and practice of nurses at tertiary centre regarding cervical cancer screening.

Material and Methods: Validated questionnaire was circulated amongst staff nurses at tertiary care centre after taking informed consent.

Results and Discussion : Cancer of cervix is the most common genital tract malignancy in female and it is ranked second to breast cancer. It has a positive association with HPV infection. Cervical cancer incidence and mortality have declined substantially following introduction of screening programmes. This present study investigated the knowledge, attitude and practice of nurses at GTB Hospital towards cervical cancer risk factors, sign & symptoms and screening as they are important health professionals. In our study, the results showed that 99% of respondents were aware of Pap smear as screening programme and about 60-70% were aware of HPV as positive organism, but most of them never had a Pap smear done before. Majority of them did not know VIA, VILI and colposcopy as screening techniques.

Conclusion: It may thus be recommended that institutions should periodically organize seminars and training for health personnel especially the nurses which form a group of professionals that should give health education to women about cervical cancer.

Cervix: Poster Abstract

Chemoradiation for the management of locally advanced carcinoma uterine cervix: Comparative evaluation of concomitant weekly versus three weekly cisplatin

Sulbha Mittal

Department of Radiation Oncology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India

Aims and Objectives:
To determine and evaluate the difference/s, in terms of tumor control and side effects, between weekly and three weekly cisplatin concomitant with external beam radiotherapyfor locally advanced carcinoma of cervix.

Materials and Methods: The study was conducted in Radiotherapy Department, University of Health Sciences, Rohtak (India), on sixty previously untreated, histopathologically proven patients of locally advanced carcinoma of uterine cervix. The patients were treated with External Beam Radiotherapy (EBRT) 50 Gy/25 fractions over 5 weeks and concomitant cisplatin, followed by intra-cavitary HDR brachytherapy (ICBT) 700 cGy to point A; three times, once in a week. The patients were assigned randomly either of two groups of 30 patients each. In Group I (Study Group) the patients received three weekly cisplatin 75 mg/m 2 for 2 cycles whilein Group II (Control Group) the patients received weekly cisplatin 40 mg/m 2 for 5 cycles. Evaluation of response and toxicity was done weekly during treatment and monthly thereafter up to six months. The data thus obtained was assessed and analysed using LaMorte statistical tool. The study was approved by Ethical Committee of the institute and quality was periodically monitored by senior consultant and guide.

Results: Stage wise disease response in study and control respectively at the end of treatment was as follows: Stage IIA - CR (80% vs 100%), PR ( 20% vs 0%); Stage IIB - CR (80% vs 76.47%), PR ( 20% vs 23.53%); Stage IIIA - CR ( 60% vs 100%), PR ( 40% vs 0%); Stage IIIB - CR (60% vs 60%), PR (40% vs 20%), NR(0% vs 20%). Stage wise disease status at the end of sixth month follow up was as follows: Stage IIA - NED (80% vs 100%), RD (20% vs 0%); Stage IIB - NED ( 80% vs 76.67%), RD (20% vs 23.53%); Stage IIIA - NED (60% vs 100%), RD (40% vs 0%); Stage IIIB - NED (60% vs 60%), RD (40% vs 40%). Tumor response was not significantly different in the two groups with respect to age distribution, rural/ urban distribution, histopathological distribution and treatment interruption. Maximum level of hematological toxicity (WHO criteria) observed in study and control group respectively at the end of treatment was as follows: Anaemia; Grade II - 4 (13.33%) in both the groups, leukopenia; Grade II - 1 (3.33%) vs 0 (0%). The worst acute skin reactions observed by the end of treatment in Group I and II respectively were Grade II - 2 (6.67%) vs 0 (0%). The worst acute mucosal reactions were Grade II - 5(16.66%) vs 0 (0%).

Upper gastrointestinal toxicity (Grade II & III) was 16.7% versus 13.3% respectively. Lower gastrointestinal toxicity (Grade II & III) was 30.0% versus 36.7%. No significant weight loss was observed in either of the groups. Though, all the patients completed the intended treatment, treatment interruption for more than a week was observed in 10 (33.33%) vs 8 (26.67%) patients respectively, due to acute toxicities.

Conclusion: Three weekly cisplatin, concomitant with radiation seems to be the potential, effective and acceptable alternate as standard of treatment for locally advanced carcinoma cervix; especially for increased work load and limited resource setups.

Cervix: Poster Abstract

Comparison of Keyes punch biopsy instrument with cervical punch biopsy forceps for diagnosing cervical lesions

Natasha Tyagi, Amita Suneja, Kiran Mishra 1 , Sandhya Jain, Neelam B. Vaid, Kiran Guleria

Departments of Obstetrics and Gynaecology and 1 Pathology, UCMS and GTB Hospital, New Delhi, India

Aims:
To assess the feasibility and efficacy of Keyes punch biopsy instrument (KP) in diagnosing cervical lesions and compare it with cervical punch biopsy forceps (CP).

Methods: 75 women having adequate colposcopy with abnormal transformation zone were included and paired colposcopic directed biopsies were taken using KP followed by CP from the same target area. The outcome parameters were compared using paired t-test, Wilcoxon signed rank test and McNemar test.

Results: It was feasible in all cases to take cervical biopsy with KP and CP. Volume of gross specimen obtained by KP was less than CP (0.076΁0.097 vs 0.101΁0.156 cm 3 , p=0.061), however on microscopic examination, mean length and depth of tissue in KP was greater than CP by 0.06 mm (p=0.810) and 0.14 mm (p=0.634) respectively. There was an exact agreement with final surgical specimen in 42% of cases in both forceps. Agreement within 1 degree was found in 25% of cases with KP and in 17% of cases with CP. Both the forceps equally missed microinvasive lesions but KP was inferior to CP for invasive cancer.

Conclusion: KP is almost at par with CP for diagnosing preinvasive cervical lesions and is a useful adjunct to the existing armamentarium of biopsy forceps.

Cervix: Oral Abstract

The impact of tumour regression in locally advanced carcinoma cervix during external beam radiotherapy and the need for adaptive planning

Aim: To study the impact of tumour regression occurring during IMRT for locally advanced carcinoma cervix and study dose distribution to target volume and OARs and hence the need for any replanning.

Materials and Methods: 40 patients undergoing IM-IGRT and weekly chemotherapy were included in the study. After 36 Gy, a second planning CT-scan was done and target volume and OARs were recontoured. First plan (non-adaptive) was compared with second plan (adaptive plan) to evaluate whether it would still offer sufficient target coverage to the CTV and spare the OARs after having delivered 36 Gy. Finally new plan was created based on CT-images to investigate whether creating a new treatment plan would optimize target coverage and critical organ sparing. To measure the response of the primary tumour and pathologic nodes to EBRT, the differences in the volumes of the primary GTV and nodal GTV between the pretreatment and intratreatment CT images was calculated. Second intratreatment IMRT plans was generated, using the delineations of the intratreatment CT images. The first IMRT plan (based on the first CT-scan or non adaptive plan) was compared with second IMRT plan (based on the second CT-scan or adaptive plan).

Results: 35% patients had regression in GTV in the range of 4.1% to 5%, 20% in the range of 1.1%-2%, 15% in the range of 2.1%-3% and 20% in the range of 6%-15%. There was significant mean decrease in GTV of 4.63 cc (p=0.000). There was a significant decrease in CTV on repeat CT done after 36 Gy by 23.31 cc (p=0.000) and in PTV by 23.31 cc (p=0.000). There was a statistically significant increase in CTV D98, CTV D95, CTV D50 and CTV D2 in repeat planning CT done after 36 Gy. There was no significant alteration in OARs doses.

Conclusion: Despite tumour regression and increased target coverage in locally advanced carcinoma cervix after a delivery of 36 Gy there was no sparing of OARs. Primary advantage of adaptive RT seems to be in greater target coverage with non-significant normal tissue sparing.

Ovary: Oral Abstract

A prospective study evaluating preoperative (clinical, imaging) and intraoperative predictors of suboptimal debulking in advanced epithelial ovarian cancer

Anupama Rajanbabu, Kiran Bagul, Venkatesan

Department of Surgical Oncology, Amrita Institute

Introduction:
In advanced epithelial ovarian cancer, there is a survival benefit for patients who achieve optimalcytoreduction. Suboptimallycytoreduced patients are at risk of the increased morbidity of a surgery without associated survival benefit. Predicting which patients can undergo optimal cytoreduction represents a critical decision-making point. Present study analyses the predictors, pre operative (clinical and radiologic) and intraoperative of suboptimal debulking.

Methods: This was a prospective observational study conducted at Amrita Institute of Medical Sciences from March 2013 to May 2015. All the patients with clinically (physical examination, laboratory and imaging results) diagnosed Stage IIIc epithelial ovarian, fallopian tube, or primary peritoneal carcinoma (PPC) who were planed for primary debulking surgery were included. The demographic data and details of tumor markers, radiological investigations including CT scan, intra operative findings and histopathologic details were collected. Statistical analysis was done using SPSS v20.0.

Results: 36 patients fit the inclusion criteria. Gross ascites wasthe clinical parameter found to be associated with suboptimal debulking. CT scan had low sensitivity (35-53%) in diagnosing small bowel mesenteric and porta hepatis disease and high sensitivity in diagnosing diffuse peritoneal thickening, omental disease, diaphragmatic and nodal disease. On univariate analysis diffuse peritoneal thickening and small bowel serosa and mesenteric disease were significantly consistent with sub optimal debulking.

Conclusion: Finding out disease at the sites which are associated with suboptimal debulking (diffuse peritoneal thickening, smallbowel mesenteric and serosal disease) pre operatively or at the beginning of surgery can predict optimal debulking and can help avoid un necessary surgery.

Ovary: Oral Abstract

Evaluation of different methods to assess homologous recombination status and sensitivity to PARP inhibitors in ovarian cancer

Asima Mukhopadhyay, Nicola Curtin, Richard Edmondson 1

Department of Gynae Oncology, University of Newcastle, Newcastle Upon Tyne, 1 Dperatment of Internal Medicine, University of Manchester, Manchester, UK

Methods:
Matched samples of ascites and tumor tissue were taken from patients undergoing surgery for epithelial ovarian cancer. Tumor samples were formalin fixed and paraffin embedded (FFPE); ascites samples were used to generate primary cultures (PC). HR status was determined in PCs as previously described. [1] IC 50 for the PARP inhibitor Rucaparib was estimated using SRB assays. DNA was extracted from the FFPE tissue. The following techniques were evaluated in PCs or paired FFPE samples: DR-GFP reporter assay, PARP activity assay, BRCA1 expression on immunohistochemistry, BRCA1 methylation status and BRCA1/2 mutation analysis. A next generation sequencing based assay was used to detect mutations and other genomic alterations in a large panel of cancer-associated genes, including BRCA1/2.

Results: Paired samples were collected from 64 patients and characterized for HR function. 47/64 (76%) were high grade serous. 44% (28/64)) were HR defective (HRD) by Rad51 assay and correlated with Rucaparib sensitivity (PPV-92%, NPV-100%). Molecular analysis revealed that all mutations and other genomic alterations detected in ascites derived PCs were also found in matched FFPE tumor tissues. All tumors with serous histology contained p53 mutations, whilst the remaining tumors without p53 mutations were non-serous in histology. DR-GFP assay was unreliable in PC due to poor transfection. In a subset of 50 cancers there was reduced BRCA1 expression in the HRD vs. HRC tumours (34.8% vs. 22.7%, ns) whilst in a further subset of 30 cases there was no difference in endogenous or stimulated PARP activity between HRD and HRC tumours. Deleterious BRCA2 mutations were identified in 7 tumors, 6 of which were HRD. Only 1 deleterious BRCA1 mutation was detected but methylation of BRCA1 was identified in 13 of 64 (20%) tumors, 7 of which were HRD. Mutation of BRCA2 was mutually exclusive to methylation of BRCA1. HRD vs. HRC tumours showed BRCA1 methylation (25% vs. 17%) and BRCA1/2 mutation (21% vs. 0.3%). 14/28 (50%) HR defective tumors do not have BRCA1/2 mutations or BRCA1 methylation, suggesting other mechanisms can also result in a HR defective phenotype.28/64 (43%) of samples demonstrated the HR defective phenotype. In all cases HR status correlated with sensitivity to Rucaparib.

Conclusion: As expected, deleterious BRCA2 mutations conferred a HRD phenotype in cells but methylation of BRCA1 was not universally associated with HRD. This may be as a result of only partial silencing of the gene by methylation and further work is required to identify thresholds of methylation which may predict HR status. The use of BRCA1/2 mutation testing alone is unlikely to identify the majority of HR defective ovarian tumors. Assessment of functional status of HRD is the preferred option and further technologies should be developed to simplify the Rad51 assay.

Ovary: Oral Abstract

Evaluation of supragastric lesser sac using a laparoscope during cytoreductive surgery in epithelial ovarian carcinoma: A site for occult metastasis

Asima Mukhopadhyay, Kaustav Basu, William Helm 1

Tata Medical Center, Kolkata, West Bengal, India, 1 Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, UK

Background:
The supragastric lesser sac (SGLS) is a site of metastasis from epithelial ovarian cancer (EOC). Since this region is difficult to access and represents a confluence of critical structures, it may be a barrier to complete cytoreductive surgery (CRS).

Methods: The SGLS was explored in consecutive patients undergoing CRS with EOC. After a xipho-pubic laparotomy incision, the SGLS was examined; visualisation and treatment was aided by using a laparoscope. Resectable disease was cleared using the following methods alone or in combination: direct tumor excision, argon beam coagulation, plasma jet or electrocautery.

Results: 30 patients were evaluated between November 2013 and August 2014 in NGOC, Gateshead. SGLSM was present in 21/30 (70%) of EOCs, 19/25 (76%) high grade serous disease, 21/26 (81%) stage ≥3 disease, 18/20 (90%) with PCI score ≥15, 12/15 (80%) with ascites ≥500 ml, 13/18 (72%) at primary surgery and 8/10 (80%) at interval surgery. Sites included: lesser omentum (11), caudate lobe (10), groove of ligamentum venosum (6), floor (20), upper recess (7), subpyloric space (6), FOW (13), coeliac axis (5), porta hepatis (6), anterior surface of pancreas (2) retro-pancreatic (2). Size of metastases: <2.5mm = 3, <1 cm = 8, ≥1 cm = 7. Pre-operative CT scan identified 4/22 (18%) cases. In 18/21 patients SGLSM was completely resected or ablated; there were no complications. End Result: Optimal 27/30 (90%) including no visible disease = 18, <2.5 mm = 5; 17/21 (81%) cases would have been ≥2.5 mm residual disease if SGLS was not evaluated/treated. In a further cohort of 30 patients evaluated at Tata Medical Center, Kolkata, SGLSM was present in 18 (60%) of patients. CC1 resection was obtained in >90% cases.

Conclusion: EOC frequently metastasizes to the SGLS and is often resectable. Lack of meticulous examination may result in incomplete resection; evaluation should be performed at least in stage ≥3 disease when the surgical intent is total clearance of disease.

Ovary: Oral Abstract

Implementing quality indicators for cytoreductive surgery in ovarian cancer: Experience from a tertiary referral center in Eastern India

Asima Mukhopadhyay, Basumita Chakraborti, Anik Ghosh, Jaydip Bhaumik

Tata Medical Center, Kolkata, West Bengal, India

Background:
Debate continues whether primary surgery or neo-adjuvant chemotherapy (NACT) or primary debulking surgery (PDS) should be offered in advanced epithelial ovarian cancer as frontline therapy. Since 2015, there has been a paradigm shift at Tata Medical center, whereas increasing number of patients are being offered PDS and a quality improvement programme was initiated. Recently, ESGO in October 2015 has published a document indicating 10 quality indicators for cytoreductive surgery in advanced ovarian cancer surgery.

Aim: We compared our performance against all 10 quality indicators.

Results: Primary cytoreduction rate has increased from 20% in 2012 to >70% at the end of 2015. Optimal cytoreduction rates were obtained in 90% cases and recently complete (CCO/CC1) cytoreduction rates are being achieved in >80% cases. All 10 quality indicators were achieved successfully including prospective documentation of morbidity and surgical findings in all cases. Morbidity figures are showing a downwards trend after the initial learning curve.

Conclusions: Implementation of a quality improvement programme is the key to overcome the barriers of implementing a cytoreductive program in advanced ovarian cancer. However, standards similar to developed countries can be achieved through a dedicated team effort.

Ovary: Oral Abstract

Clinico-pathological correlation of homologous recombination status in epithelial ovarian cancer: Surgeon's perspective

Asima Mukhopadhyay 1,2 , Nicola Curtin 2 , Richard Edmondson 3

1
Tata Medical Center, Kolkata, West Bengal, India, 2 Newcastle University, Newcastle Upon Tyne, 3 University of Manchester, Manchester, UK

Background:
TCGA data using expensive multi-modality diagnostic platforms have shown that 50% epithelial ovarian cancers (EOCs) are estimated to be homologous recombination (HR) deficient (HRD). We developed a functional assay for HR using gamma H2AX-Rad51 immunofluoresence. [1]

Methods : Primary cultures were developed in 50 consecutive EOCs from ascetic fluid and HR assay was performed.

Results: 50% patients were HRD based on the functional assay and show improved ex-vivo chemosensitivity to PARP inhibitor (PARPi) (PPV = 92%, NPV = 100%). HRD patients showed improved platinum sensitivity (53.8% vs 16.7%), survival (12 month OS - 41.7% vs. 11.5%) and optimal cytoreduction (80% vs. 62%) rates compared to HR competent (HRC) tumours which are less responsive and represent an unmet clinical need.

Conclusions: Personalised surgical and chemotherapeutic strategies may be developed for HR stratified EOCs. Primary surgery may be the preferred approach in HRC due to poor chemoresponse; surgical expertise/environment should be optimised to ensure optimal surgical outcome. Intra-operative hyperthermic treatment and selective HR inhibitors may improve subsequent chemoresponse in HRC and are currently being investigated.

Reference

1.

Mukhopadhyay A, Plummer ER, Elattar A, Soohoo S, Uzir B, Quinn JE, et al. Clinicopathological features of homologous recombination-deficient epithelial ovarian cancers: Sensitivity to PARP inhibitors, platinum, and survival. Cancer Res. 2012;72:5675-82.

Ovary: Oral Abstract

Diagnostic accuracy of intraoperative frozen section in ovarian neoplasms: Experience in a tertiary oncology centre

Anu Bajracharya, Rupinder Sekhon, Shweta Giri, Sudhir Rawal

RGCI and RC, New Delhi, India

Aims and Objectives:
This study is done to assess the accuracy of intraoperative frozen section in the diagnosis of various categories of ovarian neoplasm conducted in RGCI.

Materials and Methods: Introperative frozen sections for suspected ovarian neoplasm that underwent surgery as primary line of therapy at this institution were analyzed retrospectively from Jan. 2014 - Dec. 2015. The results of frozen section were compared with the final histopathologic diagnosis on paraffin sections and the overall accuracy, sensitivity, specificity, positive and negative predictive values were determined.

Results: The study included 159 cases and the mean age of patients was 44.72 ΁ 14.28 years (Range 19-75 years). The mean size of tumor was 12.5 ΁ 5.9 cm. Sensitivity of frozen section for benign, borderline and malignant tumors was 98.53%, 73.33% and 94.74% respectively. And the related specificities were 95.60%, 96.53% and 100% respectively. There were 150 concordant cases and 9 discordant cases. Overall diagnostic accuracy of frozen section was 94.33%.

Conclusion: Intraoperative frozen section diagnosis appears to be an accurate and comparable technique for the histopathology diagnosis of ovarian tumours. It is a valuable tool to guide the surgical management of these patients.

Key words: Frozen section; ovarian neoplasm

Ovary: Oral Abstract

Modified posterior pelvic exenteration and rectosigmoid anastomosis for advance epithelial ovarian cancer: A safe cytoreductive procedure

Rashmi Rekha Bora

Fortis Memorial Research Institute, Gurgaon, Haryana, India

Introduction:
Surgery plays an important role in the management of advanced stage ovarian cancer and is complex involving surgical procedures including peritonectomy, splenectomy, diaphragmatic stripping, retroperitoneal lymph node dissection and bowel resection including resection of recto-sigmoid.

Objective: To assess the safety and efficacy of the patients undergoing modified posterior pelvic exenteration and rectosigmoid anastomosis achieving in optimal cytoreduction.

Methods: Between June 2011 and June 2014 a total of 100 patients underwent surgical cytoreduction for advanced epithelial ovarian cancer of which 20 patients had undergone modified posterior pelvic exenteration with rectosigmoid anastomosis. The present study includes a retrospective analysis of these 20 patients. Rectosigmoid anastomosis was done using circular stapler in these patients. All patients had a PS score of 1 or 2.

Results: The median age of patients was 50 years. The optimal status of no macroscopic residual disease was achieved in all patients. Modified posterior pelvic exenteration with rectosigmoid anastomosis was carried out to achieve optimal status of surgical cytoreduction in 20 patients out of which fifteen patients had primary surgical cytoreduction, three patients had interval surgical cytoreduction surgery after receiving three cycles of neoadjuvant chemotherapy with paclitaxel & carboplatin while two patients had this procedure as a part of secondary surgical cytoreduction. The most common histology was papillary serous carcinoma. Average blood loss was 500 ml. Mean operative time was 6 hours. There were no intra operative complications. Bowel movements returned to normal in 3 to 5 days. The median length of hospital stay was 7 days. The median time to start post-operative chemotherapy was 32 days. There was no major morbidity and mortality.

Conclusion: Modified posterior pelvic exenteration with rectosigmoid anastomosis should be performed when indicated as a part of cytoreduction. In our experience this is a safe and effective procedure to achieve optimal status in advanced ovarian cancer.

Ovary: Oral Abstract

Evaluation of ovarian reserve in women undergoing ovarian cystectomy by laparoscopy and laparotomy

Amandeep Chahal, Pushpa Dahiya

PGIMS, Rohtak, Haryana, India


Ovarian cysts are one of the commonest problems encountered in the gynecological field. Majority of these cysts are functional i.e., disappear spontaneously, while few need cystectomy. Ovarian cystectomy is done by laparotomy and laparoscopic technique. The method to achieve haemostasis in the ovarian bed after cyst removal varies with the type of technique. Electrocoagulation is used to achieve haemostasis in laparoscopic cystectomy while the bleeding vessels are sutured for haemostasis in cystectomy by laparotomy. Both the modalities of management varies in terms of compromise of ovarian reserve. The study was carried out to evaluate the surgical impact of benign ovarian masses on ovarian reserve as measured by serum levels of antimullerian harmone. In this prospective study on 30 women of reproductive age group with benign ovarian masses, 15 women were enrolled for laparoscopic ovarian cystectomy and another 15 women were enrolled for cystectomy by laparotomy and ovarian reserve was measured by levels of serum AMH preoperatively, postoperative one week and postoperative 3 months using standard ELISA assay kit. The preoperative, postoperative one week and postoperative 3 months levels of mean AMH were 4.74 ΁ 1.86 ng/ml, 2.92 ΁ 1.45 ng/ml and 2.64 ΁ 0.96 ng/ml respectively, in women undergoing laparoscopic cystectomy and 3.98 ΁ 1.35 ng/ml, 2.48 ΁ 0.64 ng/ml and 2.11 ΁ 0.63 ng/ml respectively in women undergoing ovarian cystectomy by laparotomy. So there was decline of mean AMH levels in postoperative one week and postoperative 3 months samples in both of the groups of enrolled women. However, this decline varied with the type of cyst removed and is insignificantly greater in laparoscopy group, wherein electrocoagulation may cause extensive and sustained damage to ovarian tissue.

Ovary: Oral Abstract

Multiple recurrence of granulosa cell tumor of the ovary: A case report and literature review

Varkha Chandra, Sandhya Jain, Neerja Goel, Bindia Gupta, Shalini Rajaram

Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India

Introduction:
Granulosa cell tumors comprise approximately 5% of all ovarian malignancy and account for 70% of malignant sex cord stromal tumors. Granulosa cell tumors have been diagnosed from infancy, the peak incidence being perimenopausal age. The potential of malignancy of these tumors is low, recurrences are often late and found in 10-33% of cases.

Case Report: A 32-year-old P1L1 presented with large abdominal mass for which she underwent staging laparotomy with debulking surgery. She was a known case of granulosa cell tumor in the past and had undergone three laparotomies, along with chemotherapy. At the age of 13 years, she was diagnosed with a stage IA granulosa cell tumor (GCT) of the ovary first time. She underwent surgical staging and removal of left sided adnexal mass, after which she was asymptomatic for 7 years. In 2003 she again presented with lump abdomen for which she underwent resection of adnexal mass, histopathology was consistent with recurrent GCT. After second surgery she also received two cycles of chemotherapy. Despite adjuvant chemotherapy, patient presented again after three years in 2006 with adnexal mass and was found to have a third recurrence. At that time, she received 6 cycles of chemotherapy and the mass regressed. Meanwhile she got married and had one child. After four year in 2010 she again presented with lump abdomen and she underwent surgical staging, total abdominal hysterectomy with right salphingo ophorectomy along with removal of mass. After five year in 2015 she again presented with lump abdomen; there was a large pelvic mass which was removed and patient referred for chemotherapy.

Discussion: GCTS which a rare malignant tumors of ovary tend to be associated with late recurrences. Although most recurrences occurs within 10 years after initial diagnosis, there are occasional reports of recurrences after10 years. We experienced the rare case of a patient who relapsed multiple times over 20 years, despite surgical and targeted treatment. In conclusion the long history of granulosa cell tumor highlights the importance of extended follow up of the patient.

Key words: Granulosa cell tumor; recurrent disease; chemotherapy; surgical staging

Ovary: Oral Abstract

Role of IL-6 and VEGF in epithelial ovarian cancer

Venus Dalal

AIIMS, India

Introduction:
Over the last two decades there is a trend toward increasing incidence of ovarian cancer cases. CA-125 and some other tumor markers are known to have prognostic importance. Some cytokines have also been studied for their role in prognosis; IL-6 and VEGF are among them. It is hypothesized that these cytokines might affect the clinical progression of patients with ovarian cancer.

Aim and Objectives: To measure and correlate the effect of levels of IL-6 and VEGF in ascitic fluid on presentation, treatment response and outcome in patients with epithelial carcinoma ovary and to determine whether levels of IL-6 significantly correlate with progression-free survival.

Materials and Methods: Thirty patients with epithelial ovarian carcinoma and 15 patients who were undergoing hysterectomy for benign condition were recruited. Once patients found fit for study, they were taken up for primary debulking surgery. Ascitic fluid was collected and sent for measuring IL 6 and VEGF levels. Peritoneal washings taken from patients posted for total abdominal hysterectomy for benign pathology was used as control to achieve the values of IL-6 and VEGF in the study population. Patients were followed up for 1 year after surgery with ultrasound abdomen and pelvis and serum CA 125 levels.

Results: Median value of IL-6 in ascetic fluid was 8563.18 pg/ml in EOC cases and 17 pg/ml in benign pathology group and of VEGF was 6090.35 pg/ml and 34.01 pg/ml, which were found to be significantly higher in cases compared to control group (p = 0.0001). Levels of VEGF was significantly higher in patients with positive ascitic fluid cytology (p = 0.009) and ascitic fluid volume >1L (p = 0.021). Correlation of VEGF and IL6 levels with other prognostic was not statistically significant. Levels of IL-6 and VEGF in ascitic fluid did not correlate statistically with survival time or with recurrence (p = 0.651).

Conclusion: Levels of VEGF in ascitic fluid were found to correlate with ascitic fluid cytology and volume but not with FIGO stage, histological grade, histological type, tumor size, residual tumor, CA 125 levels, chemotherapy response, presentation and with overall outcome and survival time. None of the above mentioned prognostic factors were found to correlate with levels of IL-6 in ascitic fluid.

Ovary: Oral Abstract

Clinico-pathological characterstics of epithelial ovarian malignancy in young female

Dhananjay Ghuge, Alok Tiwari, Subraharsh Singh, Satinder Kaur 1

Departments of Surgical Oncology and 1 Gyaneoncology, Dharamshila Cancer Hospital and Research Center, New Delhi, India

Background and Objective
: Epithelial ovarian cancer mostly appears in aged women, but rarely in young women. Little is known about the clinical characteristics and prognosis of epithelial ovarian cancer in women aged below 40 years. This study was to evaluate the clinical and histopathological characteristics of young patients with epithelial ovarian cancer.

Methods: A total of 31 patients with confirmed epithelial ovarian cancer under the age of 40 years between 2007 to 2015 were retrospectively analyzed.

Results: Mean age of the patient is 32 years. The common symptoms included abdominal pain (21 patient 67%), self detected pelvic mass (9 patient 29%) and 1 patient with bleeding per vaginum. The average maximum diameter of tumour is 10.7 cm. Family history positive in 8 patient (5 ca.breast and 3 ca.ovary). Mean level of CA.125 is 883.36 u/ml.CA 125 level lowest is of 6 u/ml and highest is of 7557 u/ml. Tumour located bilaterally in 14 patient (45%). Ascitis present in 18 patient (58%). Pleural effusion seen in 6 patient (19%). Twenty six cases underwent optimal cytoreduction out of them 7 taken NACT.Two patient underwent fertility preservation surgery.Three patient underwent palliative chemotherapy due to unwillingness. Eleven patient classified as stage III and stage IV each (35% of each), six patient is of stage I (19%) and three patient of stage II (9.6%). Serous adenocarcinoma (80.6%) and mucinous adenocarcinoma (19%) are the common histopathological findings. Thirteen patient (41.9%) has well differentiated tumour, eight (25.8%) has moderately differentiated and ten (32.25%) has poorely differentiated tumour. Twenty eight patient received platinum and paclitaxel-based chemotherapy before or after operation.

Conclusion: Young women with epithelial ovarian cancer under the age of 40 years mostly have serous adenocarcinoma; well differentiated and tumors are normally bilateral. The ovarian function can be preserved (fertility preservation) in part of stage Ia and Grade I patients.

Ovary: Oral Abstract

Role of CA 19-9 in complex ovarian tumors

Dhanya S. Thomas, Ajit Sebastian, Vinotha Thomas, Anitha Thomas, Rachel Chandy, Abraham Peedicayil

Department of Gynaecologic Oncology, CMC Hospital, Vellore, Tamil Nadu, India

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.

Ovary: Oral Abstract

Clinical outcomes of cytoreductive surgery and HIPEC in advanced and recurrent epithelial ovarian cancers with peritoneal carcinomatosis

Shveta Giri, Swati Shah, Rupinder Sekhon, Sudhir Rawal

Introduction:
The role of surgery for peritoneal carcinomatosis (PC) has slowly evolved from palliation to potential curative intent. Attempting to remove all visible tumor deposits, "surgical cytoreduction" (CRS) was reported in 1930s for ovarian cancer and eventually became an accepted therapy with proven survival benefit. The new approach of combining CRS and hyperthermic intraperitoneal chemotherapy (HIPEC) to treat peritoneal metastasis offer hope for long term survival in this group of patients.The risk and benefit of this approach continued to be debated. A prospective study was conducted to understand the perioperative outcomes of CRS and HIPEC.

Aim: To evaluate the perioperative outcomes associated with CRS and HIPEC in Advanced and Recurrent Epithelial Ovarian Cancer with PC.

Method: Prospective analysis of patients undergoing CRS and HIPEC from November 2014 to July 2015 was done. Inclusion criteria included localized disease in peritoneal cavity, no distant metastasis and PS <2. Grade 3/4 complications from day of surgery until 30 days postoperatively were recorded.

Results: We performed CRS and HIPEC in 20 patients from November 2014 to June 2015. HIPEC Plus regimens included Cisplatin (50 mg/m 2 ) and Lipodox (15 mg/m 2 ) intraperitoneally and Ifosphamide (1300 mg/m 2 ) and Mesna (260 mg/m 2 ). Infusion time was 90 minutes with a temperature range of 41-43 o C. Out of 20 patients 6 (30%) underwent primary debulking surgery and 14 (70%) underwent secondary debulking surgery. PCI score ranged from 2-26 (mean 13.65). Mean operating time was 6.42 hrs and average blood loss was 1046 ml. Average hospital stay was 8 days and SICU stay was 4.9 days (range 3-14 days). Total 26 adverse events were observed of which grade 1 were 11 (42%), grade 2 were 8 (30%), grade were 3 (11.5%) and grade 4 were 2 (8%). Most common complication was hematological (8) followed by respiratory (6), sepsis (4) renal (2), GI (2). 4 patients (5 events) developed grade 3 or 4 complications in the form of septicaemia, pulmonary embolism, GI fistula of which 2 patients expited and remaining recovered although required prolonged hospitalization. Increased morbidity were observed in cases with symptomatic relapse, higher PCI score and CA 125 level higher than 250 U/ml.

Most of the adverse events were grade 1 and 2 and were managed by observation only or GCSF support, transfusions and other minor interventions. The combined grade 3-4 morbidity was 20% (4 out of 20) which consisted of neutropenia, infection and respiratory complications. One patient required relaparotomy and two patients expired attributed to pulmonary embolism and septicaemia respectively.

Conclusion: Enthusiasm associated with improvement in survival is often dampened by increased perioperative mortality and morbidity figures and therefore CRS and HIPEC has not yet been considered standard of care by many centres. HIPEC after extensive cytoreductive surgery for ovarian cancer is a procedure whth acceptable morbidity that patients can tolerate. More follow up is needed to determinr the effect of HIPEC on survival. Till such time more data are obtained by way of larger randomised trials, this approach remains investigational.

Ovary: Oral Abstract

Audit on the role and efficacy of PET/CT in recurrent ovarian cancer settings in a tertiary care centre in India

K. R. Suhas

RGCI and RC, New Delhi, India


Ovarian cancers tend to recur in 15-70% cases. CA-125 - is a tumor marker used for monitoring therapeutic response, and in surveillance, for recurrent disease. However, it has a limited role as a persistent high level can signify either recurrence or persistence of residual tumor. Metastases from ovarian cancer primarily involve the peritoneum rather than parenchymal sites; thus, the presence of small-volume recurrence or metastatic deposits on the visceral surfaces poses a challenge for interpretation of CT and MR images.

PET/CT utilizes its property of higher accumulation in malignant cells to provide both anatomic and functional information for diagnosing malignant tumors.

Objectives: The objectives of the study were to find the correlation between PET/CT findings and final histopathological diagnosis after a secondary cytoreductive surgery in suspected ovarian cancer recurrences.

Materials and Methods: PET/CT was done in cases with rising or above normal CA-125 and no radiological findings. These patients with abnormal PET/CT findings were taken up for a secondary cytoreductive surgery and histopathological proven were taken as the standard against which PET/CT positive findings was compared.

Results: The mean age in our group of patients with suspected recurrence was 53 years (Range 39-74 years). Of the 52 patients with suspected recurrence, 40 patietnts with a PET-CT scan with findings suggestive of an avid uptake underwent surgery. 22 patients had serous histology, 12 mucinous and 8 had clear cell carcinoma. Stage-wise distribution at the time of primary surgery is as follows stage I-3, stage II-7, stage III-26, stage IV-4. Of the 40 patients who underwent a second look surgery 32 had histopathologically confirmed recurrence. PET-CT detected a total of 86 lesions in the 40 patients who underwent surgery. Of these, 38 were in the lymph nodes 28 in para-aortic and 10 in pelvic, 32 were peritoneal lesions and 14 were pelvic, 2 were metastatic in the parenchyma of liver. Detection of the lesion on PET-CT was size dependant, of the 9 lesions were missed on PET-CT, 7 were less than 0.5 cm. The mean diameter of the lesions detected was 2.2 cm (range 0.3-6.2 cm). PET-CT accurately identified 62 of 70 histopathologically proven lesions. The overall lesion-based sensitivity of PET-CT is 88.6%, specificity 56.2%, Positive predictive value being 72.1%, negative predictive value of 69.2%. Accuracy of detecting lesions greater than 1 cm is 78.6% (44 of 56 lesions).

Conclusions: Corelation between PET/CT and histopathologicaldisease: k (cohen value) = 0.81 which suggests excellent correlation. For selected patients with ovarian cancer recurrence may benefit from a comprehensive radiographic imaging survey (PET-CT) at the time of even no or minimal CA-125 elevation in early detection and successful cytoreductive surgical resection and an increase in overall survival.

Ovary: Oral Abstract

Clinicopathological review of epithelial ovarian tumors in young females and reproductive and survival outcome: Ten years expierence from a tertiary center

Kusum Lata, Nutan Agarwal, Neerja Bhatla, Alka Kriplani

All India Institute of Medical Sciences, New Delhi, India

Objective:
To find out the prevalence of epithelial ovarian tumors in young females and correlation with reproductive and survival outcome.

Design: Retrospective study.

Setting: Tertiary referral hospital.

Methods: A retrospective analysis of females from 9-35 year of age group treated for ovarian tumors between January 2003 to July 2013 was performed. Variables studied included age, presenting symptoms, imaging, tumor markers, surgical findings, type of surgery, histopathology reports and follow-up.

Main Outcome Measures: Histopathological variant, FIGO stage, reproductive and survival outcome.

Results: A total of 155 patients were found to have ovarian tumors. Mean age at time of diagnosis was 24.9 ΁ 1.8 years (range 9-35). Clinical presentation in majority of the cases was abdominal pain in 68 (43.8%), ascites in 13 (8.3%) mass in abdomen in 25 (16%), followed by irregular menstrual cycles in 15 (9.6%), infertility in 18 (11.6%) 12 (7.7%) were found to be incidental on ultrasound examination while 4 women were found to have virilising symptoms. There were 76 (49.1%) cases of epithelial ovarian tumors, 6 (0.03%) of borderline tumors and 30 (19.3%) were of malignant ovarian tumors while 40 (25.8%) were benign. Stage IA (N = 80), Stage I 8 (n = 2), Stage III (N = 6) and Stage IV (N = 12). Females were further subdivided into three age groups 9-15 years, 15-25 years and 25 to 35 years for determining outcome of epitheliail tumors. Reproductive and survival outcome were studied in each stage.

Conclusions : Limited data exists about the histological type distribution, surgical treatment and overall survival of epithelial ovarian tumors in women aged below 35 years. Young patients have higher overall progression-free survival and a better clinical outcome than older patients. Any women presenting with pain and nonspecific symptoms should be investigated and evaluated properly.

Ovary: Oral Abstract

Association of organochlorine pesticides and risk of epithelial ovarian cancer: A case control study

Darshana Mazumdar

AIIMS, New Delhi, India

Background:
Organochlorine pesticides (OCPs) belongs to the class of hydrocarbons characterized by its cyclic structure. Due to their persistent nature OCP gets accumulated in the food chain and cause possible adverse health effects specifically various hormone mediated disorders. Ovarian cancer is also one of the hormone dependant cancer and begins with the transformation of cells that comprises the ovaries including surface epithelial, germ cells, etc. It has been suggested that endocrine disruption, exposure to xenobiotic and subsequent oxidative stress may antedate ovarian cancer and contribute to its pathogenesis. However, no report regarding any association of OCP level with etiology of epithelial ovarian cancer is so far available among North Indian population.

Methods: A total of 120 subjects were included in this case control study, consisting of 60 histological proven cases of epithelial ovarian cancer and 60 controls subjects. Quantification of OCP levels was done by Perkin Elmer Gas Chromatograph (GC) equipped with 63Ni selective Electron Capture Detector.

Results: Levels of b-HCH, endosulfan I, p'p'-DDT, p'p'-DDE and heptachlor were found significantly high in cases of epithelial ovarian cancer as compared to control. A significant association was also observed between higher levels of b-HCH and heptachlor and EOC with odds ratio of 2.76 and 2.97 respectively.

Conclusion: Results indicate the plausible role of OCPs with the pathogenesis of epithelial ovarian cancer among North Indian population. Moreover, it is one of the first report suggesting significant level of heptachlor among north Indian women population with epithelial ovarian cancer.

Ovary: Oral Abstract

Female adnexal tumour of probable wolffian origin: A rare case report

Nehal Dhaduk, Mamta Dagar, Mala Srivastava, Punita Bhardwaj, Tina Verma, Indrani Ganguli, Nayak

Introduction:
Female adnexal tumour of probable wolffian origin (FATWO), is a rare neoplasm arising within the leaves of a broad ligament or hanging from it or a fallopian tube. It is considered a tumour of low malignant potential which shares similar histological and immunochemical features with mesonephric remnants.

Case: Here we present a case repot of a 40 years old, nulliparous female who presented with acute pain abdomen and fever since 2 days. Her LMP was 30.09.2015 and her past menstrual cycles were irregular. She was nulliparous with history of infertility. In past medical history revealed her to be a known diabetic for 5 years, with uncontrolled blood sugars. Patient was hemodynamically stable. On per abdominal examination there was generalized tenderness all over the abdomen with guarding and rigidity. On per speculum examination vaginal discharge was noted with unhealthy cervix. Per vaginal examination revealed a tender mass of approximately 8 cm Χ 6 cm was felt on left fornix. All her base line investigations were normal. The salient investigations like CA-125 35.60 IU/L, CEA 3.46, Beta-HCG 2.29 were normal. On imaging, MRI showed a well defined solid cum cystic space occupying lesion of 9 cm Χ 8 cm arising from left adnexa with evidence of right hemorrhagic adnexal cyst 6 cm Χ 7 cm and hydro/hematosalpinx noted. There was well defined space occupying lesion in the pelvis on the left of the uterus which is likely a broad ligament leiomyoma. Diagnosis of acute abdomen was made with adnexal mass probably infectious in origin. Injectable antibiotics were started. In view of acute pain abdomen decision for surgical intervention was taken. Laparoscopic findings revealed bilateral ovarian abscess with left sided broad ligament mass (solid consistency) probably leiomyoma. Right tube and ovary were normal. Drainage of tubo-ovarian abscess with left salpingo-oophorectomy with right salpingectomy with adhesiolysis was done and sent for histopathology. HPE reported Female adnexal tumour of probable wolffian origin (FATWO) which was positive for vimentin and CD10, possibly arising from left sided broad ligament. Patient underwent radical hysterectomy with omentectomy with appendicectomy was done.in view of FATWO.

Conclusion: Female adnexal tumour of probable wolffian origin (FATWO), is a rare neoplasm which is usually considered as benign, although in some cases metastasis on recurrences have been reported even after a long interval following the initial diagnosis. Pre-operative diagnosis of FATWO is very difficult because of the rarity of the disease and paucity of the literature available.

Ovary: Oral Abstract

Role of human epididymis protein 4 for detection of ovarian carcinoma in adnexal masses: A pilot study

Nidhi Bansal, A. Suneja, K. Guleria, N. B. Vaid, K. Mishra, S. Bhatt, M. Mehndiratta

UCMS and GTB Hospital, New Delhi, India

Introduction:
HE4 is a novel tumour biomarker used for early diagnosis of ovarian cancer. This study evaluated the diagnostic accuracy of HE4 alone and in combination with CA125, risk of malignancy index (RMI), risk of malignancy algorithm (ROMA).

Methods: It was a cross sectional study conducted recruiting 88 women with adnexal masses who were planned for surgery. After baseline work up and ultrasound examination, serum samples were collected for estimation of CA 125 and HE4 levels. Serum HE4 levels were estimated using ELISA kit. RMI and ROMA score were calculated and diagnostic accuracy of HE4, CA 125, RMI, ROMA and their combination were compared. Cut off for HE4 and ROMA score were calculated using ROC curve.

Results: Of 88 subjects, 66 were analyzed with 19 malignant (including 5 LMP) and 47 benign cases. The median value of HE4 among malignant cases was found to be significantly higher than among the benign cases. PPV and NPV of HE4 at a cut off 130.8 pMol/ml was 85.7% and 77.9% respectively. Highest PPV (88.9%) with acceptable NPV (80.7%) was found with ROMA followed by HE4 (PPV 85.7%; NPV 77.97%), RMI (PPV 76.92%; NPV 83%) and CA125 (PPV 52%; NPV 80.85%).

Conclusion: HE4 levels were lower in Indian population both in malignant and benign tumours as compared to other studies. HE4 is a good discriminator and gives best accuracy when it is combined with CA125 in a logistic algorithm, ROMA.

Ovary: Oral Abstract

Gestational trophoblastic neoplasia: Retrospective analysis of clinical profile, treatment pattern and outcome

Paramjeet Kaur, Ashok K. Chauhan, Anil Khurana, Yashpal Verma, Nupur Bansal

Department of Radiotherapy, Pt. B.D. Sharma, PGIMS, Rohtak, Haryana, India

Background:
Gestational trophoblastic disease is a spectrum of cellular proliferation arising from the placental villous trophoblast. Gestational triphoblastic neoplasia (GTN) is a collective term for GTD that invade locally or metastasize. GTD includes hydatidiform mole (complete and partial) and GTN include invasive mole, choricocarcinoma, placental site trophoblastic tumor and epitheliod trophoblastic tumor.

Aim: To evaluate clinicopathological profile, treatment pattern and clinical outcome in patients with gestational trophoblastic neoplasia (GTN).

Materials and Methods: Twelve cases of gestational trophoblastic neoplasia treated between 2012 to November 2015 in Department of Radiotherapy - II, PGIMS, Rohtak were evaluated in this retrospective study. Data was analyzed on the basis of age, histopathology, stage, type of treatment received and treatment related toxicities. Disease free survival was estimated.

Result: Out of 12 women 7 (58 %) had hydatidiform mole, 4 (33%) invasive mole and 1 (8%) had choriocarcinoma. All the cases were given chemotherapy. Two patients had low risk disease. Among high risk group seven patients had score of less than 7 and five patients had risk score of 7 or higher. Five patients were given single agent methotrexate, seven patients received multidrug regimens. All patients are on regular follow up. One patient (high risk group) expired as she did not receive treatment.

Conclusion: GTN are rare and proliferative disorders with proper diagnosis and treatment most of the cases are amenable to treatment with favorable outcome.

Ovary: Oral Abstract

Study of efficacy and safety of adjuvant intraperitoneal chemotherapy in carcinoma ovary

Prashant, Varun Goel, Sajjan Singh, Vineet Talwar, Pankaj Goyal, Amitabh Upadhyay

RGCI & RC, New Delhi, India

Background:
The benefit of administering chemotherapy directly into the peritoneal cavity is supported by preclinical, clinical and pharmacokinetic data. In view of paucity of data from the Indian subcontinent, we decided to study the response and tolerability of intraperitoneal (I/P) chemotherapy in carcinoma ovary in Indian population.

Methods: In this observational study, from March 2013 to June 2015, the efficacy and tolerability of adjuvant I/P chemotherapy in optimally cytoreduced stage III epithelial ovarian cancer patients were assessed. Treatment consisted of 135 mg/m 2 of i.v. paclitaxel over a 3-hours period on day 1 followed by AUC 5 carboplatin i.v. on day 2 and 60 mg/m 2 of i.p. paclitaxel on day 8 every 3 weekly for six cycles.

Results: Total 50 patients were enrolled. The median age of patients was 53 yrs (32 yrs - 67 yrs). Out of a total of 240 I/P cycles, 225 cycles (93%) were completed. 30 patients (75%) received all the 6 cycles by IP route , 6 patients completed 5, 3 patients completed 4 cycles and 1 completed 3 I/P cycles. 4 Out of 30 patients who completed all 6 cycles of I/P chemotherapy, had one or more adjustment including delay while in 3 patients (7.5%) dose had to be reduced. after median follow up of 14 months, 8 patients (12.5%) had local or systemic recurrence, 2 patients (5%) had progression during treatment and died due to disease. median progression free survival not reached yet. One patients had vaginal leak. Catheter block was seen in five cases. Two cases had needle displacement and extravasations of drug around the port chamber. 6 patients had severe abdominal pain and cramp (grade 3) after infusion of saline. Hematologic toxicity was evaluated in all patients and in all cycles. Grade 3 or 4 Leucopenia was experienced by 25 patients (50%) but Febrile Neutropenia occurred in only 5 (10%) patients. Grade 3 or 4 anemia occurred in 17 (42.5%) and grade 3 or 4 thrombocytopenia was experienced by 6 patients (15%). Renal complication present in 3 patients (7.5%) and transient transfusion reaction developed in 5 patients. mucositis present in 21 patients.

Conclusions: Adjuvant I/P chemotherapy in optimally cytoreduced epithelial ovarian cancer is active and well tolerated in Indian patients.

Ovary: Oral Abstract

To assess the role of addition of bevacizumab therapy to carboplatin and paclitaxel as frontline treatment of epithelial ovarian cancer

Richa Vatsa, Sunesh Kumar, Lalit Kumar

AIIMS, New Delhi, India

Introduction:
Efforts are going on for development of new drugs for epithelial ovarian cancer (EOC). We assessed safety profile of bevacizumab, a VEGF receptor blocking antibody in treatment of EOC.

Methods: We assigned women with EOC to carboplatin (area under curve, 5 or 6) and paclitaxel (175 mg/square meter of body-surface area), given every 3 weeks for 6 cycles, or to this regimen plus bevacizumab (15 mg/kilogram body weight), given concurrently every 3 weeks for 5 or 6 cycles and continued for 30 additional cycles. Primary outcome measures was safety profile of bevacizumab and secondary outcome was to see progression free survival (PFS).

Results: Out of 30 patients, 10 were in Bevacizuma arm (Arm A) and 20 in conventional chemotherapy arm (Arm B). Haematological toxicity, GI perforation and proteinuria was similar in both. Other toxicities e.g. bleeding complication (p = 0.002) and hypertension (p = 0.04) was more in Arm A. PFS was similar in both arms; 24 months in Arm A and 22 months in Arm B (p = 0.565). 4 (40%) patients in arm A discontinued treatment, two (20%) because of disease progression after PFS of 9 and 6 months, two because of development of toxicity considered to be due to bevacizumab; of which one developed jejenal perforation and disease progression after PFS of 6 months and 1 because of development of persistent proteinuria of grade 3 after 18 months.

Conclusion: Bevacizumab therapy does not improve PFS in EOC but increases toxicity spectrum of chemotherapy.

Ovary: Oral Abstract

Two interesting cases of granulosa cell tumor: A case report

Pannu Savita, Khullar Harsha

Institute of Obstetrics and Gynaecology, Sir Ganga Ram Hospital, New Delhi, India

Introduction:
Granulosa cell tumor (GCT) is an ovarian malignancy that arise from granulosa cells of the ovary. This tumour is a type of the sex cord-gonadal stromal tumour. GCT have good prognosis in comparison with other epithelial tumors.

Methodology: Two cases of granulosa cell tumors were diagnosed in sir Ganga ram hospital, Rajender Nagar, New Delhi in December 2015 and January 2016. The patient's age, clinical manifestations, radiological and histopathological findings were evaluated. One was in perimenopausal age group and other case was in postmenopausal age group. The clinical manifestations were menorrhagia and abdominal pain. Ultrasonographically, in one case focal hypoechoic zone showing peripheral hypervascularity with possibility of old hemorrhage follicular cyst was seen and in other case of granulosa cell tumors was both solid and cystic areas were seen. Histologically, variety of patterns like diffuse, trabecular, nodular, sheets, nests and fascicular patterns with nuclear grooving in ovarian tissue. In addition endometrial findings were suggestive of simple hyperplasia without atypia. Treatment modalility used was surgery i.e. Total hysterectomy and bilateral salpingo-oophorectomy in both cases.

Conclusion: Granulosa cell tumor of the ovary is a rare ovarian malignancy. Endometrial pathology to rule out endometrial carcinoma specially when postmenopausal bleeding is concomitant finding is advised. Radical surgery is usually not required.

Key words: Endometrial pathology; granulosa cell tumor; histopathological findings; ovary

Ovary: Oral Abstract

Outcome of bowel resection in women with advanced ovarian carcinoma

Ajit Sebastian, Dhanya Susan Thomas, Anitha Thomas, Rachel Chandy, Abraham Peedicayil

Christian Medical College and Hospital, Vellore, Tamil Nadu, India

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.

Ovary: Oral Abstract

Clinical outcomes of cytoreductive surgery and HIPEC in advanced and recurrent epithelial ovarian cancers with peritoneal carcinomatosis

Shveta Giri, Swati Shah, Rupinder Sekhon, Sudhir Rawal

Introduction:
The role of surgery for Peritoneal carcinomatosis (PC) has slowly evolved from palliation to potential curative intent. Attempting to remove all visible tumor deposits, "surgical cytoreduction" (CRS) was reported in 1930s for ovarian cancer and eventually became an accepted therapy with proven survival benefit. The new approach of combining CRS and Hyperthermic intraperitoneal chemotherapy (HIPEC) to treat peritoneal metastasis offer hope for long term survival in this group of patients.The risk and benefit of this approach continued to be debated. A prospective study was conducted to understand the perioperative outcomes of CRS & HIPEC.

Aim: To evaluate the perioperative outcomes associated with CRS & HIPEC in Advanced and Recurrent Epithelial Ovarian Cancer with PC.

Methods: Prospective analysis of patients undergoing CRS & HIPEC from November 2014 to July 2015 was done. Inclusion criteria included localized disease in peritoneal cavity, no distant metastasis and PS <2. Grade 3/4 complications from day of surgery until 30 days postoperatively were recorded.

Results: We performed CRS & HIPEC in 20 patients from Nov 2014 to June 2015. HIPEC Plus regimens included Cisplatin (50 mg/ m2) and Lipodox (15 mg/m2) intraperitoneally and Ifosphamide (1300 mg/m2) & Mesna (260 mg/m2) Infusion time was 90 minutes with a temperature range of 41-43 o C. Out of 20 patients 6 (30%) underwent primary debulking surgery and 14(70%) underwent secondary debulking surgery. PCI score ranged from 2-26 (mean 13.65). Mean operating time was 6.42 hrs and average blood loss was 1046 ml. Average hospital stay was 8 days and SICU stay was 4.9 days (range 3-14 days). Total 26 adverse events were observed of which grade 1 were 11 (42%), grade 2 were 8 (30%), grade were 3 (11.5%) and grade4 were 2 (8%). Most common complication was hematological (8) followed by respiratory (6), sepsis (4) renal (2), GI (2). 4 patients (5 events) developed grade3 or 4 complications in the form of septicaemia, pulmonary embolism, GI fistula of which 2 patients expited and remaining recovered although required prolonged hospitalization. Increased morbidity were observed in cases with symptomatic relapse, higher PCI score and CA 125 level higher than 250 U/ml.

Most of the adverse events were grade 1 and 2 and were managed by observation only or GCSF support, transfusions and other minor interventions. The combined grade 3-4 morbidity was 20% (4out of 20) which consisted of neutropenia, infection and respiratory complications. One patient required relaparotomy and two patients expired attributed to pulmonary embolism and septicaemia respectively.

Conclusion: Enthusiasm associated with improvement in survival is often dampened by increased perioperative mortality and morbidity figures and therefore CRS & HIPEC has not yet been considered standard of care by many centres. HIPEC after extensive cytoreductive surgery for ovarian cancer is a procedure whth acceptable morbidity that patients can tolerate. More follow up is needed to determinr the effect of HIPEC on survival. Till such time more data are obtained by way of larger randomised trials, this approach remains investigational.

Ovary: Oral Abstract

Neoadjuvant chemotherapy in epithelial ovarian cancer: Largest single institute experience

Siva Kumar

Cancer Institute (WIA), Chennai, Tamil Nadu, India

Purpose:
Neoadjuvant chemotherapy followed by interval debulking surgery (IDS) is an alternative treatment option, compared to the current standard of care primary debulking surgery for treating advanced epithelial ovarian cancer (EOC). We present our institute experience of neoadjuvant chemotherapy strategy in the management of EOC which is one of the largest single institute experience.

Methods: This is a retrospective analysis of patients with epithelial ovarian cancer who were treated in our institute between 2000 and 2006. Patient with advanced disease by clinical and imaging were treated with 3 cycles ofneoadjuvant chemotherapy and then taken up for interval debulking surgery (IDS) who had static or partial or complete response to chemotherapy. The remaining chemotherapy is delivered after the surgery.Patient who had limited disease had primary debulking surgery and then adjuvant chemotherapy according to institute protocol.Outcomes in terms of disease free and overall survival were analysed.

Results: This retrospective analysis included 59 patients with limited disease who had primary debulking surgeryand 283 patients with advanced disease who recievedneoadjuvant chemotherapy. The median age was 50 years and majority are in the 50-59 years age group.Age more than 60 years represent 14.5%. Postmenopausal women were 55.3% and premenopausal women were 44.7 %. Multiparity is higher 70.2% than the uniparity 16.4% ornulliparity 11.7%. Abdomen distension 42% and pain 25% are the most common symptoms. Advanced stage was the most common presentation 71% with stage III-56.1% and stage IV-14.9%. Among the neoadjuvant chemotherapy group 126/283 (44.5%) had optimal cytoreduction, 44/283 (15.5%) had suboptimal cytoreduction and 113/283 (40%) not suitable for IDS. The 5 year disease free and overall survival was 30.8% and 41.5% in the NACT group with advanced disease and 58.5% and 75.8% in the primary cytoreduction group who had limited diseaserespectively. The 5 years overall survival among the IDS group with optimal cytoreduction was 57.1% and 11.7% for the suboptimal cytoreduction group. The 5 years survival was not affected by the number ofneoadjuvant chemotherapycycles delivered before surgery in the IDS group. Patient who received paclitaxol + carboplatin as first line chemotherapy had better survival than carboplatin alone or cyclophosphamide + cisplatin.

Conclusion: NACT as an alternative option to primary debulking surgery in operable EOC is still debatable. But for patient with high disease burden where optimal cytoreduction is not possible NACT strategy is a valid option.Recent randomised controlled trials from Europe had shown the noninferiority of neoadjuvant chemotherapy followed by IDS when compared to the primary debulking surgery in operable advanced EOC.

Key words: Epithelial ovarian cancer; interval debulking surgery; neoadjuvant chemotherapy

Ovary: Oral Abstract

Neoadjuvant chemotherapy in epithelial ovarian cancer: Largest single institute experience

Siva Kumar

Cancer Institute (WIA), Chennai, Tamil Nadu, India

Purpose:
Neoadjuvant chemotherapy followed by interval debulking surgery (IDS) is an alternative treatment option, compared to the current standard of care primary debulking surgery for treating advanced epithelial ovarian cancer (EOC). We present our institute experience of neoadjuvant chemotherapy strategy in the management of EOC which is one of the largest single institute experience.

Methods: This is a retrospective analysis of patients with epithelial ovarian cancer who were treated in our institute between 2000 and 2006. Patient with advanced disease by clinical and imaging were treated with 3 cycles of neoadjuvant chemotherapy and then taken up for interval debulking surgery (IDS) who had static or partial or complete response to chemotherapy. The remaining chemotherapy is delivered after the surgery.Patient who had limited disease had primary debulking surgery and then adjuvant chemotherapy according to institute protocol.Outcomes in terms of disease free and overall survival were analysed.

Results: This retrospective analysis included 59 patients with limited disease who had primary debulking surgery and 283 patients with advanced disease who received neoadjuvant chemotherapy. The median age was 50 years and majority are in the 50-59 years age group.Age more than 60 years represent 14.5%. Postmenopausal women were55.3 % and premenopausal women were 44.7 %. Multiparity is higher 70.2% than the uniparity 16.4% ornulliparity 11.7%. Abdomen distension 42% and pain 25 % are the most common symptoms. Advanced stage was the most common presentation 71% with stage III-56.1% and stage IV-14.9%. Among the neoadjuvant chemotherapy group 126/283(44.5%) had optimal cytoreduction,44/283 (15.5%) had suboptimal cytoreduction and 113/283 (40%) not suitable for IDS. The 5 year disease free and overall survival was 30.8% and 41.5% in the NACT group with advanced disease and 58.5% and 75.8% in the primary cytoreduction group who had limited diseaserespectively. The 5 years overall survival among the IDS group with optimal cytoreduction was 57.1% and 11.7% for the suboptimal cytoreduction group. The 5 years survival was not affected by the number of neoadjuvant chemotherapy cycles delivered before surgery in the IDS group. Patient who received paclitaxol + carboplatin as first line chemotherapy had better survival than carboplatin alone or cyclophosphamide + cisplatin.

Conclusion: NACT as an alternative option to primary debulking surgery in operable EOC is still debatable. But for patient with high disease burden where optimal cytoreduction is not possible NACT strategy is a valid option. Recent randomised controlled trials from Europe had shown the noninferiority of neoadjuvant chemotherapy followed by IDS when compared to the primary debulking surgery in operable advanced EOC.

Key words: Epithelial ovarian cancer; interval debulking surgery; neoadjuvant chemotherapy

Ovary: Oral Abstract

Malignant ovarian germ cell tumors in children: A single centre experience

Priyanka Soni, Shalini Mishra, Sandeep Jain, Gauri Kapoor

Background:
Germ-cell tumors (GCT) are the commonest ovarian neoplasm in the first two decades of life.

Aim: To study the profile of ovarian GCT in children and their outcome.

Methods: Retrospective study of all cases of malignant ovarian GCT in the pediatric age (up to 18 years) was done from January 2002 to December 2015. The medical records of all admitted cases during this period were reviewed and the data was analysed with respect to age at diagnosis, clinical presentation, tumor markers, surgical stage, tumor histology, therapy, clinical course, and outcome.

Results: Girls with malignant ovarian GCT were seen at our institute during the study period. Out of these 25 underwent treatment. Mean age at presentation was 11.7 years (range: 3-18 years). Abdominal pain was the commonest presentation. Twelve (47.3%) had right sided disease, 11 (42%) had left sided disease and 2 had bilateral disease. Twelve cases (57.8%) were diagnosed as stage I disease, 5 (10.5%) as stage II, 7 (26.3%) as stage III and 1 (5.2%) as stage IV. Elevated AFP >1000 was found in 9 (47.3%), elevated B-HCG (>50) in 7 (42%) and elevated LDH (>1000) in 7 (36.8%) patients at presentation. Twenty (73.6%) patients underwent surgery prior to chemotherapy out of which 4 (21%) patients presented after undergoing surgery at other centre. Fourteen (57.8%) patients received 4 cycles of BEP based chemotherapy, 6 (21%) received 3 cycles, 2 (10.5%) received 2 cycles and 1 patient did not receive any chemotherapy as it was mature teratoma. The most common histology was dysgerminoma in 8 (42%) patients followed by mixed germ cell tumor in 4 (21%), teratoma in 3 (15.7%), embryonal carcinoma in 2 (10.5%) and yolk sac tumor and mature teratoma in 1 patient each. Four (21%) patients had relapse on contralateral side which was salvaged. 1 patient presented with relapse who underwent only surgery outside, 1 patient had ovarian torsion. Median follow up is 27months. The event free survival rate was 78.9%.

Conclusion: This study confirms an excellent outcome for girls with ovarian germ cell tumor. Patients with advanced surgical stage relapsed frequently. The mainstay of treatment is fertility preserving surgery and cisplatin-based chemotherapy.

Ovary: Oral Abstract

Role of cancer antigen 19-9 in complex ovarian tumors

Dhanya S. Thomas, Ajit Sebastian, Vinotha Thomas, Anitha Thomas, Rachel Chandy, Abraham Peedicayil

Department of Gynaecologic Oncology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

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.

Ovary: Oral Abstract

Single centre experience of ovarian germ cell tumours over 8 years

P. Veena

JIPMER, Puducherry, India

Introduction:
Germ cell tumours comprise approximately 15-20% of all ovarian tumours. Two third of ovarian tumours in first two decades of life are germ cell tumours. Majority of ovarian germ cell tumours are benign teratomas. The malignant germ cell tumours are usually solid and arise from totipotent germ cells. Over the past 3 decades the clinical outcome of women with ovarian germ cell tumours (OGCT) have significantly improved mainly due to development of more effective chemotherapy regimens.

Objective: To study the clinic pathological features, treatment and survival of women with ovarian germ cell tumours.

Methods: This is a retrospective descriptive study taken from the case files of patients with histo-pathologically proven ovarian germ cell tumours who were treated in JIPMER over 8 years from 2007 to 2014.

Results: There were totally 63 patients with ovarian germ cell tumours over 8 years who were treated in JIPMER. The age at presentation varies from 12 years to 65 years with a median age of 26.5 years. Three were pre pubertal and 1 was post-menopausal. Twenty two women (34%) were unmarried and 5 were pregnant at the time of presentation. Forty eight (76%) of them did not have any menstrual abnormalities. Pain abdomen (55%) was the most common presentation. Ten of them presented with acute abdomen of which 8 were torsion, 1 was ruptured dermoid and 1 was infected dermoid. Another 6 patients had torsion which was diagnosed only during surgery. Majority (68%) were benign tumours (dermoid) and among malignant tumours, there were 6 dysgerminomas, 5 immature teratomas, 5 mixed germ cell tumours and 4 yolk sac tumours. Almost half (22 out of 43) of women with benign tumours were <25 years whereas 3/4 th (14 out of 20) of women with malignant germ cell tumours were <25 years. The most common tumour marker which was elevated was alpha feto protein (8) followed by LDH (5). Fertility sparing surgery (salpingo-ovariotomy) was commonly performed which was 95% (41/43) in benign tumours and 60% (8/20) in malignant tumours. Contra lateral ovary was biopsied in only 5 patients with suspected involvement (negative on final HPR). Out of 20 women with malignant ovarian tumours 7 were in advanced stage (Stage III). Majority of them recovered well from surgery, only 12% had post-operative febrile morbidity and one patient had subclavian vein thrombosis on post op D9 which required anticoagulants. 7 of 20 women received chemotherapy (BEP) for 4 cycles. No serious side effects of chemotherapy were noted in these women. 3 out of 20 women with malignant germ cell tumour were lost to follow up. No recurrences have been found in rest of the women and there are no deaths till last follow up.

Conclusion: Advances in the field of medicine like effective chemotherapy regimens, improved imaging, precise surgical staging and fertility sparing surgical procedures enable women not only to preserve the reproductive function but also to improve their quality of life.

Ovary: Poster Abstract

Cystic adnexal lesion on USG - causing a diagnostic dilemma in oncology institute

Abhinav Aggarwal

Fellow (Onco-Radiology), Department of Radiology, RGCIRC, Rohini, New Delhi, India


Adnexal lesions are one of the most common cause of gynecological complains, including possibility of ectopic pregnancy in reproductive age group. Ultrasound is the first imaging modality used for evaluation of adnexal lesions. On ultrasound large non-adnexal lesions can be confused as adnexal lesions causing a diagnostic dilemma, rendering use of cross-sectional imaging mandatory. We present a case of middle-aged female who was diagnosed with a right adnexal lesion (possibly malignant) on ultrasound, but on further evaluation was found to be suffering from a benign non-adenexal etiology.

Ovary: Poster Abstract

Role of intraoperative frozen section in the diagnosis of ovarian tumors: Experience at Gujarat Cancer and Research Institute

Ruchi Arora

Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India

Background:
The surgical management of ovarian tumors depends on their correct categorization as benign, borderline or malignant. Ovarian neoplasms are an important cause of morbidity and mortality in women. This study was undertaken to evaluate the accuracy of intra-operative frozen section in the diagnosis of various categories of ovarian neoplasms.

Methods: Intraoperative frozen section diagnosis was retrospectively evaluated in 125 patients with suspected ovarian neoplasms who underwent surgery as primary line of therapy at our institution. This was compared with the final histopathologic diagnosis on paraffin sections.

Results: In 125 patients frozen section report had a sensitivity of 100%, 95.55% and 50% for benign, malignant and borderline tumors respectively. The corresponding specificities were 92.45%, 98.75% and 99.14% respectively. The overall accuracy of frozen section diagnosis was 95.2%. The majority of cases of disagreement were in the mucinous and borderline tumors.

Conclusion: Intraoperative frozen section has high accuracy in the diagnosis of suspected ovarian neoplasms. It is a valuable tool to guide the surgical management of these patients and should be routinely used in all major oncology centers.

Key words: Frozen section; intraoperative; ovarian tumor

Ovary: Poster Abstract

Multiple recurrence of granulosa cell tumor of the ovary: A case report and literature review

Varkha Chandra, Sandhya Jain, Neerja Goel, Bindia Gupta, Shalini Rajaram

Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India

Introduction:
Granulosa cell tumors comprise approximately 5% of all ovarian malignancy and account for 70% of malignant sex cord stromal tumors. Granulosa cell tumors have been diagnosed from infancy, the peak incidence being perimenopausal age. The potential of malignancy of these tumors is low, recurrences are often late and found in 10-33% of cases.

Case Report: A 32-year-old P1L1 presented with large abdominal mass for which she underwent staging laparotomy with debulking surgery. She was a known case of granulosa cell tumor in the past and had undergone three laparotomies, along with chemotherapy. At the age of 13 yrs, she was diagnosed with a stage IA granulosa cell tumor (GCT) of the ovary first time. She underwent surgical staging and removal of left sided adnexal mass, after which she was asymptomatic for 7 years. In 2003 she again presented with lump abdomen for which she underwent resection of adnexal mass, histopathology was consistent with recurrent GCT. After second surgery she also received two cycles of chemotherapy. Despite adjuvant chemotherapy, patient presented again after three years in 2006 with adnexal mass and was found to have a third recurrence. At that time, she received 6 cycles of chemotherapy and the mass regressed. Meanwhile she got married and had one child. After four year in 2010 she again presented with lump abdomen and she underwent surgical staging, total abdominal hysterectomy with right salphingo ophorectomy along with removal of mass. After five year in 2015 she again presented with lump abdomen; there was a large pelvic mass which was removed and patient referred for chemotherapy.

Discussion: GCTS which a rare malignant tumors of ovary tend to be associated with late recurrences. Although most recurrences occurs within 10 years after initial diagnosis, there are occasional reports of recurrences after10 years. We experienced the rare case of a patient who relapsed multiple times over 20 years, despite surgical and targeted treatment.

Conclusion: The long history of granulosa cell tumor highlights the importance of extended follow up of the patient.

Key words: Chemotherapy; granulosa cell tumor, recurrent disease, surgical staging

Ovary: Poster Abstract

Successful pregnancy outcome in recurrent ovarian cancer

Sushila Chaudhary

Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India


Incidences of ovarian cancer in pregnancy are increasing nowadays due to routine use of ultrasonography in first trimester and postponement of childbirth to an older age. Reported incidence of ovarian tumor in pregnancy is 1:1000 among them3.6% are malignant. We report a case of recurrent ovarian tumor with successful pregnancy outcome. She was a 26 yr old primi had ovarian cancer recurrence 2 year after primary surgery. In present pregnancy she was given chemotherapy with two doses of carboplatin, and had viable baby at 34 weeks of pregnancy. At present mother and baby are doing well and on regular follow-up at radiotherapy departments.

Ovary: Poster Abstract

Sclerosing sex cord stromal tumour of the ovary: A rare variant of ovarian neoplasms in childhood and adolescence

Seema Chopra

Post Graduate Institute of Medical Education and Research, Chandigarh, India

Case Report:
19 yr old unmarried girl c/o abdominal distension, loss of appetite and Irregular menstrual cycles x 5 months. USG: gross ascites, liver, Lobulated isoechoic mass in right adnexa, 7x5 cm, abutting right ovary. CA125: 1297 U/ml. FNAC Degenerated crushed cells & stromal fragments. Few scattered benign oval/ spindle cells. Laparoscopy f/b laparotomy: 6 litres of straw colored asciic fluid drained. Uterus, left adnexa normal. Rt ovarian mass 6x7 cm, bilobed, arising from ovary. Solid, stuck in POD Adherent to gut. Right oophrectomy done. CA-125: 22 u/ml on day 6 post op. HPE - Sclerosing stromal tumor.

Discussion: Sclerosing sex cord stromal tumour of the ovary is a rare tumor; accounts for 6% of ovarian stromal tumors Over a 100 reported tumors in literature. 80% of SST seen in second and third decade of life. Essentially a benign tumour, Usually a unilateral nonfunctioning tumor. Few cases with elevated serum CA-125 and hormonal abnormalities have been reported. Endocrine alterations caused by secretion of estrogen, progesterone or testosterone; induction of precocious puberty.

Conclusion: Unilateral oophrectomy is the treatment. No recurrence of the tumor in the patients treated by oophorectomy or by conservative resection of the tumor. Excision of the tumor isfollowed by normal menses, pregnancy has also been reported.

Ovary: Poster Abstract

Juvenile granulosa cell tumor

Geetanjali Tuteja, S. Unmesh, S. Shree, Archana, S. Rudra

MMIMSR, Ambala, Haryana, India


The differential diagnosis for precocious puberty in a young female includes peripheral causes. This case report documents a rare cause of isosexual precocious puberty, a juvenile granulosa cell tumour of the ovary-and a brief literature review. A one year-old baby girl presented with mass abdomen, vaginal discharge and rapid onset of pubertal development. She underwent an exploratory laparotomy for tumour resection. Pathology reported a juvenile granulosa cell tumour of the ovary. Early stage granulosa cell tumor surgically treated has good prognosis. Adjuvant chemotherapy is not indicated in this setting.

Ovary: Poster Abstract

Growing teratoma syndrome: A case report

Swati Gupta, Saritha Shamsunder, Roli Purwar, Vidya Jha, A. K. Yadav Sunita Malik, Rakesh Verma, S. P. Kataria

Departments of Gynecology, Oncology and 1 Pathology, VMMC and Safdarjung Hospital, New Delhi, India

Introduction:
Growing teratoma syndrome (GTS) or chemotherapeutic retro conversion is an extremely rare phenomenon seen in about 1.9-7.6% of patients being treated for non-seminomatous testicular germ cell tumor. It is even more rarely reported in females with only sporadic cases reported so far. It was described by logothetis et al and is described as conversion of immature teratoma to mature one after chemotherapy and presents as growing and metastasizing mass.

Case Report: We report a case of 10 year old girl who underwent conservative surgery for an adnexal mass reported as immature teratoma on histopathology. Following which she was given chemotherapy for rapidly developing ascites. After four cycles of chemotherapy, the pelvic mass increased in size with metastatic deposits around the liver. Re-laparotomy and removal of the ovarian mass and metastatic deposits was carried out in stages. The histopathology showed mature teratoma.

Conclusion: GTS is an extremely rare occurrence and it is important for the clinicians to know it to avoid misdiagnosis. Moreover, being a chemo-resistant tumor, early diagnosis and surgery are curative.

Ovary: Poster Abstract

Sertoli cell tumor of ovary: A rare case report

Umesh Jethwani, Divya Jethwani

R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India

Introduction:
Sertoli-Leydig cell tumor (SLCT) is a rare ovarian tumor, Constitute less than 0.5% of ovarian tumors. Most tumors are unilateral, confined to the ovaries. They are seen during the second and third decades of life. They are characterized by the presence of testicular structures that produce androgens. Patients have symptoms of virilization (depending on the quantity of androgen).

Case Report: A 42-year-old woman presented Amenorrhea for 14 months. Change in her voice for 1 year and Excessive hair growth on her face, chest, and limbs for the last 2 months. She complained of vague abdominal discomfort .No history of anorexia, weight loss, increased libido. Her medical and family history was unremarkable. On examination - Hirsutism and clitoromegaly. Lump of size 10x8 cm palpable in left iliac fossa. Vaginal examination revealed a firm and mobile cystic mass in the right adnexa .An ultrasound examination of the pelvis showed a 17x 13x 9-cm heterogeneous solid cystic mass replacing the left ovary. The right ovary and the uterus were normal .CECT Scan Abdomen-Large heterogenous encapsulated solid soft tissue mass lesions containing areas of calcification arising from left ovary of size 17x13x10.6cm causing displacement of urinary bladder and surrounding bowel loops.Serum testosterone level -2 ng/mL (normal, 0.2-1.2 ng/mL); (DHEAS), CA 125, and alpha fetoprotein (AFP) -normal. On Laparotmy-

Large mass of size 17 X 13 cm arising from left adnexa. Uterus and right ovary grossly normal. Total Abdominal hysterectomy, B/L Salpingo-opherectomy and infracolic omentectomy was done. Peritoneal washing were sent for cytologic examination for malignant cells. No liver metastasis. The post operative period was uneventful. Histopathology revealed- confirmed it be Sertoli Leydig cell tumor.3month follow up - resolution of her virilization symptoms. No increase of her hirsutism. Repeat testosterone levels - within normal range.

Conclusion: Only few cases of SLCT have been reported till date Prognosis depends on extent of disease, stage of disease, tumour differentiation, grade. The treatment should be individualized according to the location, state of spread and the patient's condition.



Ovary: Poster Abstract

Ovarian fibrothecoma: An uncommon cause of a large pelvic mass

Nikita Kumari, Reenu Kanwar, Bindu Bajaj, Garima Kapoor

Introduction:
Ovarian fibrothecomas represent an ovarian stromal neoplasm developing in a wide spectrum of clinical settings. These tumors have been described as rare ovarian neoplasm, accounting for about 4% of all ovarian tumors. We report a case whose clinical presentation was highly deceptive and was clinically and radiologically diagnosed as malignant ovarian tumor. Ascitic fluid cytology revealed absence of malignant cells. On histopathological examination, it was diagnosed as benign fibrothecoma with cystic changes. Postoperative follow-up for about six months was uneventful.

Case: A 45 year old female presented to the gynae emergency with large abdominal lump of 20 weeks size with acute pain abdomen. She was admitted for initial management and thorough evaluation. Hematological and biochemical parameters were within normal limits. USG revealed a large multilocular, predominantly cystic lesion 20.9x9.6x11.4 cm in pelvis. CECT revealed ovarian cystadencarcinoma left ovary with locoregional mass effect, mild ascites and suspicious metastasis to internal iliac lymph nodes. Radiological and preoperative clinical diagnosis was malignant ovarian tumor. Panhysterectomy and omentectomy was performed. On gross examination, a well encapsulated, multinodular cystic tumor of left ovary about 17x14x7 cm was identified. Cut surface was mostly solid with few cystic areas. Uterus, cervix, right ovary and both tubes were unremarkable. On microscopic examination, multiple sections showed spindle shaped cells in storiform and palisading pattern. No mitotic activity was identified. On special staining, it was positive for vimentin, which is a characteristic feature of ovarian fibrothecoma.

Conclusion: The accurate preoperative diagnosis of ovarian fibrothecoma with cystic changes could have prevented the extensive surgical intervention such as bilateral salpingo- oopherectomy with hysterectomy.

Ovary: Poster Abstract

Two interesting cases of granulosa cell tumor: A case report

Pannu Savita, Khullar Harsha

Institute of Obstetrics and Gynaecology, Sir Ganga Ram Hospital, New Delhi, India

Introduction:
Granulosa cell tumor (GCT) is an ovarian malignancy that arise from granulosa cells of the ovary. This tumour is a type of the sex cord-gonadal stromal tumour. GCT have good prognosis in comparison with other epithelial tumors.

Methodology: Two cases of granulosa cell tumors were diagnosed in sir Ganga ram hospital, Rajendernagar, New Delhi in December 2015 and January 2016. The patient's age, clinical manifestations, radiological and histopathological findings were evaluated. One was in perimenopausal age group and other case was in postmenopausal age group. The clinical manifestations were menorrhagia and abdominal pain. Ultrasonographically, in one case focal hypoechoic zone showing peripheral hypervascularity with possibility of old hemorrhage follicular cyst was seen and in other case of granulosa cell tumors was both solid and cystic areas were seen. Histologically, variety of patterns like diffuse, trabecular, nodular, sheets, nests and fascicular patterns with nuclear grooving in ovarian tissue. In addition endometrial findings were suggestive of simple hyperplasia without atypia. Treatment modalility used was surgery i.e., Total hysterectomy and bilateral salpingo-oophorectomy in both cases.

Conclusion: Granulosa cell tumor of the ovary is a rare ovarian malignancy. Endometrial pathology to rule out endometrial carcinomaspecially when postmenopausal bleeding is concomitant finding is advised. Radical surgery is usually not required.

Key words: Endometrial pathology; granulosa cell tumor; histopathological findings; ovary

Ovary: Poster Abstract

Unusually high serum Ca 19-9 in a benign ovarian tumor

Divya Pandey, Neha Pruthi, Sudha Salhan

VMMC and Safdarjung Hospital, New Delhi, India

Introduction:
Ovarian tumors have a varied spectrum of presentation. Tumors which look malignant clinico-biochemically can ultimately turn out to be benign. Tumor markers help in diagnosing various malignancies. Carbohydrate antigen 19-9 is one such marker seen to be elevated in some ovarian tumors.

Case: A 55 year old, lean and thin postmenopausal female presented to Gynae OPD with abdominal mass, anorexia and weight loss developing over last 6 months. During workup, she was found to have unusually high Ca 19-9 along with MRI findings suggestive of ovarian tumor. Staging laparotomy followed by total abdominal hysterectomy with bilateral salpingoophorectomy was performed. Per operative findings were suggestive of benign nature of ovarian tumor of size 18Χ 20 cm. Patient was kept under follow up. Histopathology report showed benign mucinous cystadenoma. The serum levels of Ca19-9 returned to normal 8 weeks following surgery. This case report shows a rare and significant elevation of Ca19-9 levels with benign mucinous cystadenoma of the ovary, thus showing that women with unusually elevated tumor markers and even symptoms suggesting malignancy may actually harbour a benign disease.

Conclusion: Unusually high Ca 19-9 may be associated with benign mucinous cystadenoma but thorough workup to rule out malignancy is a must in every case.

Ovary: Poster Abstract

Immature teratoma

Introduction: Immature teratoma represents 3% of all teratomas, 1 % of all ovarian cancers and 20% of malignant ovarian germ cell tumors. It is found either in pure form or as a component of a mixed germ cell tumor. It occurs essentially during the first two decades of life. According to WHO, immature teratoma is defined as a teratoma containing a variable amount of immature embryonal type neuroectodermal tissue

Case: We present here a report of 23 years old unmarried female who presented with complaint of abdominal pain since 1 month and her CT scan done outside, showed fibroid uterus. She had history of typhoid fever 1 month back for which USG was done which suggested large uterine fibroid. On examination she was hemodynamically stable. On abdominal examination a non-tender supra-pubic mass of 24 weeks size with firm consistency, irregular margin was felt. On investigation CA 125 was 64.90 IU/L, LD- 223, beta HCG- 1.14. On MRI a large abdomino-pelvic lesion, likely left adnexal lesion with multiple cystic areas, with hemorrhage, with ascites and enlarged retroperitoneal lymph nodes with omental infiltration suggestive of a possibility of malignant germ cell tumor. In view of large ovarian tumor, possibly malignant decision for staging laparotomy was taken. Intra-operatively a large irregular vascular solid mass of 20 x 20 cms with bosselated appearance with few cystic lesions over it was seen, arising from left ovary and was sent for frozen section which reported malignant mature teratoma with components of immature teratoma. She underwent laparotomy with left salpingo-oophorectomy with right ovarian biopsy, omentectomy, appendectomy with B/L pelvic lymphadenectomy. Histopathology was suggestive of grade III immature teratoma. In view of grade III immature teratoma, she received chemotherapy (BEP regimen) post-operatively and is currently under follow up.

Conclusion: This case reflects the importance of early diagnosis in cases of pelvic masses in young females. Fertility preservation should be considered in young women with germ cell tumors. Patients with grade II or III tumors or a mere advanced stage disease should be treated with adjuvant chemotherapy (BEP) in addition to surgery.

Ovary: Poster Abstract

Inguinal lymphadenopathy as a presentation for ovarian cancer

Swati Shah, Shveta Giri, Rupinder Sekhon, Sudhir Rawal

Ovarian carcinoma usually presents at an advanced stage with diffuse intra abdominal manifestations. Inguinal lymph node metastasis is rare event in ovarian cancer. We report 7 cases who presented with inguinal lymphadenopathy as the initial manifestation between January 2014 to January 2016. All patients underwent tru-cut biopsy from inguinal area. Morphology and IHC were suggestive of ovarian origin or female genital Tract origin. Two patients underwent primary debulking surgery while four patients were managed by neo-adjuvant chemotherapy followed by interval cytoreductive surgery owing to relatively poor performance status at presentation. One patient underwent secondary debulking in which inguinal Lymph node was positive for metastatic deposits.

Ovary: Poster Abstract

Shikha Madan

Primary pure ovarian leiomyosarcomas constitute a malignant subgroup of ovarian smooth muscle tumors which comprise only 1% of ovarian tumors. Their origin, etiology, histologic features, clinical behavior, and optimal treatment are still obscure. We report a case of leiomyosarcoma of ovary, diagnosed on histopathology in a 30 year old female.

Ovary: Poster Abstract

Pure primary non gestational choriocarcinoma ovary - diagnostic dilemma and treatment intricacy

Abhishek Soni, Nupur Bansal, A. K. Dhull, Vivek Kaushal, A. K. Chauhan

Introduction:
Germ cell tumors of the ovary include all neoplasm derived from primordial germ cells of the embryonal gonad. Five percent of germ cell tumors are malignant, representing three to five per cent of all ovarian carcinomas of which pure primary non-gestational ovarian choriocarcinoma accounts for less than one per cent of ovarian tumors. Primary choriocarcinoma of ovary could be gestational or nongestational in origin. They pose diagnostic challenges in reproductive age group patients because of elevated human chorionic gonadotrophin (hCG). Non-gestational choriocarcinoma (NGCO) is resistant to single agent chemotherapy, requiring more aggressive combination chemotherapy post surgery. Due to the rarity of the disease, this article reviews the treatment protocol for NGCO.

Methods: All the articles related to choriocarcinoma of ovary at Pubmed, Google scholarly article and Scopus were assessed and reviewed and their references were also reviewed and included in this article.

Discussion: Clinical diagnosis of NGCO is often challenging because the clinical symptoms are often nonspecific and can mimic other, more common conditions that occur in young women, such as a hemorrhagic ovarian cyst, tubo-ovarian abscess, ovarian torsion, and ectopic pregnancy. The symptoms of vaginal bleeding, elevated hCG level, pelvic pain, and an adnexal mass often lead to incorrect diagnosis of ectopic pregnancy, threatened or incomplete abortion, cervical polyp, or other types of malignancy. Non-gestational choriocarcinomas have been found to be resistant to single agent chemotherapy, have a worse prognosis, and therefore require aggressive combination chemotherapy. Adjuvant chemotherapy with the EMA (etoposide 100mg/m2, methotrexate 100mg/m2, actinomycin-D 0.5mg) regimen may be given, for six to nine courses at seven days interval. Studies suggest that the disease responds well to the combination of surgery and postoperative adjuvant chemotherapy. However, long term effects of such therapy should be further studied with more cases.

Conclusion: Because of the small number of patients with pure ovarian choriocarcinoma, a consensus on the treatment regimen including surgery and chemotherapy is lacking. Surgery with adjuvant combination chemotherapy is the standard treatment of choice.

Ovary: Poster Abstract

Juvenile granulosa cell tumor

Geetanjali Tuteja, S. Unmesh, S. Shree, Archana, S. Rudra

MMIMSR, Mullana, Ambala, Haryana, India


The differential diagnosis for precocious puberty in a young female includes peripheral causes. This case report documents a rare cause of isosexual precocious puberty, a juvenile granulosa cell tumour of the ovary-and a brief literature review. A one year-old baby girl presented with mass abdomen, vaginal discharge and rapid onset of pubertal development. She underwent an exploratory laparotomy for tumour resection. Pathology reported a juvenile granulosa cell tumour of the ovary. Early stage granulosa cell tumor surgically treated has good prognosis. Adjuvant chemotherapy is not indicated in this setting.

Endometrium: Oral Abstract

Study of factors to predict recurrence in early stage endometrial cancer

Shruti Bhatia, S. K. Das

Action Cancer Hospital, Paschim Vihar, New Delhi, India

Introduction:
Risk stratification of patients with early endometrial cancer for recurrence is inadequate.

Objectives: To study factors that influence recurrence in uterus-confined, early stage endometrial cancer (UCD).

Patients and Methods: We studied 140 consecutive patients with endometrial cancer, operated at Action Cancer Hospital, Delhi, from August 2010 to September 2015. All patients underwent staging laparotomy, TAH + BSO + BLPND + para-aortic LN sampling, and omental biopsy. Adjuvant treatment was given as per the NCCN guidelines. They were followed up 3 monthly for 2 years, and 6 monthly thereafter. 121 patients (86.4%) had UCD (FIGO stages IA, IB, II). Excluding one post-operative mortality, and 4 who were lost to follow up, we included 116 patients in this study.

Results: The median age of these patients was 60.5 years (range: 35-81 years), with median BMI of 31.2 kg/m 2 (range=19.8-57.5). Diabetes or hypertension was present in either or both of 76 (65.5%) patients. The median pelvic LN harvest was 17 (range: 4-42). Eight (6.9%) patients had non-endometroid histology, and 5 (4.3%) patients had LVSI. Grade 1, 2, and 3 tumor was found in 74 (63.8%), 30 (25.9%), and 12 (10.3%) patients, respectively. The median follow up was 28 months (range 5-61 months), and recurrence was seen in 13 (11.2%) patients. On univariate analysis we found that age, co-morbidities (DM and HT), LVSI, and non-endometroid histology were related to recurrence. The tumor grade and adjuvant treatment did not influence recurrence rates. On multivariate analysis, presence of comorbidities and non-endometroid histology were independently related to disease recurrence (p=0.044, and 0.011, respectively).

Conclusions: Disease recurrence was seen in one in ten patients with UCD, despite stage-appropriate treatment. Presence of co-morbidities and non-endometroid histology were independently related to recurrence.

Uterus: Oral Abstract

Outcomes of carcinosarcoma of the uterus

Anne George, Ajit Sebastian, Vinotha Thomas, Anitha Thomas, Rachel Chandy, Abraham Peedicayil

Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India

Objectives:
To evaluate the outcome of women with uterine carcinosarcoma.

Methods: The medical records of all patients admitted with uterine carcinosarcoma between January 2012 and October 2015 were reviewed. Baseline characteristics were compared and survival was calculated using Kaplan Meier method and compared using log rank test.

Results: The total number of uterine malignancies operated in our centre over this time period was 247 of which 33 were sarcomas (13%). Median age of presentation was 56 years (21-77 years). Most women were postmenopausal (76%) and 46% of them presented with post menopausal bleeding.

There were 16 carcinosarcomas of the uterus. Eight presented at Stage 1 (50%) and the remaining 8 in stage III or IV. All patients had TAH/BSO but only 15 had omentectomy and 12 had pelvic and para-aortic lymphadenectomy. Adjuvant treatment was given only to 10 (63%). Seven patients had expired at the time of follow up. The mean survival was 502 days (304-699) with a median of 284 days. Patients who received adjuvant therapy did better compared to those who did not (p=0.05).

Conclusions: Carcinosarcomas are aggressive tumours and the optimal therapy is yet to be determined. Adequate surgical staging followed by adjuvant therapy improves survival.

Uterus: Oral Abstract

Dharma Ram

Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Introduction:
Uterine sarcoma accounts for nearly 3% of all uterine malignancies. They have 4 major pathology includes endometrial stromal sarcoma high grade, ESS low grade, uterine leiomyosarcoma (uLMS) and undifferentiated uterine sarcoma (UUS). Recent WHO classification 2014, recognizes low grade ESS and high grade ESS as distinct entity. They differ from endometrial carcinoma in their aggressive nature and poor prognosis. We review our database and found total 44 eligible patient treated at our institute.

Materials and Methods: Its retrospective analysis of computer based database of our institute from January 2009 to December 2015. We analyzed demographic, pathological, treatment and survival data.

Results: Total 44 patient treated for uterine sarcoma at our institute. Among these 16 were operated at our institute during study period. Here we reporting results of operated patients at our institute. The histological diagnosis LMS (5/16), ESS-L (4/16), MMMT (3/16), UUS (3/16) and ESS-H (1/16). Stage distribution was stage I, (6/16) stage II, (5/16) stage III, (3/16) stage IV, (0/16) and unknown stage (2/16). Two patients underwent completion surgery for outside myomectomy. The adjuvant treatment was CT in 3/16, CT with RT in 7/16, HT in 4/16 and one lost to follow up with one was put on observation. Median follow up is 30 month with 14 patients alive and one lost to follow up. At last follow up 4 patients alive with metastatic disease and 10 patients alive with no evidence of disease.

Conclusion: Uterine sarcoma are uncommon disease with

Endometrium: Oral Abstract

Preoperative and intraoperative assesment of myometrial invasion and histological grade in endometrial cancer: Role of MRI and frozen section

Rohit Raghunath Ranade

Tata Memorial Centre, Mumbai, Maharashtra, India

Introduction:
The role of systematic lymphadenectomy in clinically early stage endometrial cancer is controversial. A number of factors can predict lymph node metastasis including myometrial invasion, tumor grade in endometrial cancers. The purpose of the present study is to evaluate the accuracy of preoperative MRI and intraoperative frozen section in determining the depth of myometrial invasion, cervical involvement, tumor size and lymph nodal status. We also studied the accuracy of preoperative endometrial biopsy and intraoperative frozen section in determining the grade of the tumor.

Materials and Methods: Medical records of 235 consecutive cases of clinically early stage endometrial cancer were reviewed retrospectively. A record of depth of myometrial invasion, tumor size, cervical involvement and presence of enlarged lymph nodes was made on a preoperative MRI. Similarly depth of myometrial invasion, tumor size, cervical involvement and grade of the tumor were recorded on an intraoperative frozen section. The grade of the tumor was also recorded on a preoperative endometrial biopsy. Standard statistical calculations were used.

Results: The sensitivity and specificity of MRI for myometrial invasion for the first 160 cases were 81.3 and 75%, respectively while that for frozen section were 80 and 96.2%, respectively. For tumor grade the sensitivity and specificity of preoperative endometrial biopsy were 60 and 95.6%, respectively while that of frozen section were 53.8 and 97.6%, respectively. For cervical involvement the sensitivity of MRI and frozen section was 62.5 and 98.4%, respectively. Updated results of the entire cohort of 235 cases will be presented at the conference if selected.

Conclusion: Although the sensitivity of both frozen section and MRI for predicting deep myometrial invasion was similar (80 vs 81.3%) but the specificity (96.2 vs 75%) and negative predictive value (92.7 vs 88.2%) of frozen section were superior to MRI. Both preoperative biopsy and intraoperative frozen section had low sensitivity (60 vs 53.8%) for detecting a high grade lesion.

Endometrium: Oral Abstract

Study of PTEN immunohistochemical expression in endometrial hyperplasia

Sabuhi Qureshi

King George's Medical University, Lucknow, Uttar Pradesh, India

Objective:
The incidence of endometrial hyperplasia & carcinoma is increasing in developing nations. Newer techniques are being tried to recognise endometrial hyperplasia. One of these is tumor suppressor gene phosphatase & tensin homologue (PTEN). It is frequently inactivated i.e turned off in endometrial hyperplasia lesions. This is an early event in endometrial tumorigenesis that may occur in response to known endocrine risk factors & offers an informative immunohistochemical marker for premalignant disease. The present study was planned to study PTEN immunohistochemical expression in endometrial hyperplasia.

Methods: Women of >40 years of age presenting with abnormal uterine bleeding in the OPD of OBGYN Department of KG Medical University underwent endometrial biopsy. The histopathology of the biopsy tissue was done in department of Pathology of KG Medical University. The cases of endometrial hyperplasia were studied for PTEN immunohistochemical expression.

Results: 168 women of >40 years of age with abnormal uterine bleeding underwent endometrial biopsy. 50 women were diagnosed as endometrial hyperplasia. Of these, PTEN evaluation was done in 27 cases. Loss of PTEN expression was found in 11 cases (40.74%) of endometrial hyperplasia. Loss of PTEN expression was more in complex hyperplasia with atypia (66.66%) as compared to simple hyperplasia without atypia (29.4%).

Conclusion: There is positive correlation between loss of PTEN expression and grade of morphological differentiation of hyperplasia.

Uterus: Poster Abstract

Clinicopathological analysis of early endometrial cancers

Seema Singhal, Sunesh Kumar Jain, D. N. Sharma 1 , Sandeep Mathur 2 , Juhi Bharti, Anshu Yadav, K. K. Roy, Neeta Singh, Jyoti Meena

Departments of Obstetrics and Gynaecology, 1 Radiotherapy and 2 Pathology, All India Institute of Medical Sciences, New Delhi, India

Aim:
The study objectives were evaluation of clinicopathological characteristics, correlations between the preoperative and postoperative tumor assessment in early stage endometrial cancer.

Materials and Methods: We conducted a prospective descriptive study of 30 cases of endometrial cancer stage 1 examined and treated at a tertiary care teaching institute between the years 2014-15.

Results: The patients' mean age at the time of diagnosis was 56.4 years. The mean parity was two. Postmenopausal bleeding with or without abnormal vaginal discharge was the most frequent symptom; it was present in 84.7% of patients. Co morbidities like hypertension and diabetes were seen in 65% of women. 6/30 patients had family history of some malignancy. All the patients underwent Type I extrafascial hysterectomy with bilateral salpingo oophorectomy, one case had Type I extrafascial hysterectomy with infracolic omentectomy. A total of 10.6% cases had lymph nodes metastasis and none of these patients had ovarian metastasis or positive peritoneal cytology. None of the patients with superficial myometrial invasion (MI) had lymph node metastasis. None of the cases showed positive peritoneal cytology. Staging upgraded from 1a to 1b in 50% of subjects after final histopathological analysis. One patient who was operated as endometrial hyperplasia with atypia actually had endometrial adenocarcinoma in the postoperative specimen.

Conclusions: There is a poor correlation between the preoperative and the postoperative tumor assessment.

Uterus: Poster Abstract

Leiomyosarcoma: Case report

Poonam Garg

Government Medical College and Rajindra Hospital, Patiala, Punjab, India

Introduction:
Uterine sarcomas are rare aggressive mesenchymal tumours with limited prognosis which accounts for only 2%-8% of all uterine malignancies. The most frequent type in uterine sarcomas is leiomyosarcoma (LMS) which is seen in about 60% of cases.

Case Report: We report 2 cases who presentated with different symptomology. After examination and imaging modalities, definitive diagnosis was made after histopathology report. Treatment in the form of neo adjuvant chemotherapy followed by Surgery and chemotherapy/radiotherapy was given. On follow up, both patients had relapse and later they died.

Conclusion: Rate of recurrence of leiomyosarcoma is high and prognosis depends upon age, grade, tumor size and mitotic rate. Overall survival rate ranges from 15% to 25% with a median survival of only 10 months. Early detection and more trials to evaluate treatment strategies can improve survival.

Uterus: Poster Abstract

Comparison of MRI findings with actual HPE findings in case of carcinoma endometrium

Shaveta Gupta

Department of Surgical and Gynae Oncology, Max Super Speciality Hospital, Mohali, Punjab, India

Objectives:
The objectives of this study is to investigate the correlation of magnetic resonance imaging (MRI) in predicting the depth of myometrial invasion, cervical involvement and lymph node involvement and actual histopathological findings in the women with endometrial cancer.

Methods: This is a reterospective study of the patients of endometrial cancer from Nov 2011 to Jan 2016 who underwent Surgery (Total abdominal Hystrectomy with B/l salpingoophorectomy with peritoneal washings with b/l pelvic lymphadenectomy with or without para aortic lymphadenectomy) at our centre Max Superspeciality Hospital. CE MRI Pelvis has been done pre operatively in every patient. After the surgery Histopathological reports of the specimen checked and compared with MRI findings of that case. The purpose of the study is to evaluate the validity of MRI findings of endometrial cancer in comparison to final histopathological findings.

Results: For the detection of myometrial invasion, overall sensitivity of MRI is 93.9%, specificity is 66.6%, for cervical involvement Senstivity is 60% and specificity 1s 93.75% and for detection of lymph node involvement sensitivity is 66.6% and specificity is 93.5%. Most common Finding on MRI is thickened endometrium with disruption of Junction jone.

Conclusions: Preoperative pelvic MRI is a sensitive method of identifying invasion to the myometrium in endometrial cancer. MRI Is a sensitive noninvasive modality in predicting locoregional spread in ca endometrium. Senstivity in detecting Myometrial invasion is high but sensitivity is less in detecting cervical involvement and lymph node involvement is less.

Endometrium: Poster Abstract

Gestational choriocarcinoma after term pregnancy: A case report

Radha

PGIMS, Rohtak, Haryana, India


Choriocarcinoma coexisting with or after a "normal" pregnancy has an incidence of one per 1,60,000 pregnancies. In case of choriocarcinoma after term pregnancy, early diagnosis by histopathological examination of the placenta is very important, the precocity of the diagnosis influencing the prognosis and tumor response to chemotherapy. In, this paper we report the case of a 28-year-old woman parity 2 with metastatic choriocarcinoma after term pregnancy, diagnosed at four months after the delivery of a healthy baby. An episode of abundant vaginal bleeding occurred after four months from delivery. The local examination revealed a vaginal tumor whose pathological examination on biopsy sample was inconclusive. Subsequently, she was admitted in our hospital with abundant vaginal bleeding, severe anemia and fever. Abdominal ultrasonography revealed an intracavitary uterine tumoral mass with signe of myometrial invasion to the uterine serosa, strong Doppler signal and moderate ascites. Pulmonary X-Ray and computed tomography scan excluded extrapelvic tumoral masses. The pretreatment human chorionic gonadotropin (HCG) level was 310300 Miu/ml and her FIGO risk factor score was 8 (high-risk group). Total hysterectomy with bilateral salpingo-oophorectomy and omentectomy was performed as an optimal cytoreduction. Postoperative remaining presented by the metastasis located in the lower two-thirds of vagina. Histopatholgical examination revealed uterine choriocarcinoma. Postoperative was initiated four courses of polychemotherapy. Case evaluation was favorable, with the normalization of the Beta-HCG value in two months postoperative and complete remission of vaginal metastasis in six weeks posteoperative.

Endometrium: Oral Abstract

Presentation of endometrial carcinoma in young women

Anshika Lekhi, Rahul Manchanda, Nidhi Jain, Sravani Chithra, Hena Kausar

Manchanda Endoscopy Centre, New Delhi, India

Background:
Endometrial carcinoma is a disease of older postmenopausal women, and is relatively uncommon in patients younger than 40 years. Endometrial carcinomas in this age group may be familial, associated with Lynch syndrome, or sporadic. Patient usually has increased exposure to estrogen. In 2%-14% of cases, it occurs in young patients (less than 40 years of age) who are eager to preserve their fertility. Its treatment includes hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy and in some cases, radiation therapy. Prevention of fertility is major challenge encountered in such cases.

Aim: To present a case of young woman with endometrial carcinoma and through it to review the literature of its presentation and management in such groups.

Case: We report a case of endometrial cancer in a 35-year-old woman with previous 3 cesarean treated for abnormal uterine bleeding and cared for in our department.

Conclusion: Most endometrial carcinomas presenting in this young age are associated with estrogen excess. Pathologically they are usually low-grade endometrioid carcinomas with lower stage and are associated with favorable clinical outcomes. With this case the authors emphasize the need of endometrial reckoning in young females with abnormal bleeding before starting any medical treatment. Also highlighting the management options in such cases where fertility preservation holds challenge.

Key words: Endometrial carcinoma; risk factor; treatment; young patient

Uterus: Poster Abstract

Metastatic gestational trophoblastic neoplasia presenting after a normal pregnancy

Roli Purwar, Saritha Shamsunder, Swati Gupta, Geetika Khanna 1 , Usha Rani, Sunita Malik

Departments of Obstetrics and Gynecology and 1 Pathology, VMMC and Safdarjung Hospital, New Delhi, India


Gestational Trophoblastic Neoplasia presenting after a normal delivery is very rare & seen in 1 in 1,60,000 pregnancies and is associated with a poor outcome due to delay in diagnosis. Only three cases have been reported in the literature till date. A 27 year old lady, P2L1 delivered a stillborn baby in some peripheral hospital. Intrapartumand post-partum period were uneventful. After a period of 2 months, in view of persistent bleeding pervaginumshe underwent dilatation & evacuation in the same hospital. Ultrasonography showed circumscribed lesion 4.1 x 3.6 cm in lower uterine segment indenting the endometrium. MRI showed a heterogeneous space (4.2 x 3.2 x 3.3 cm) occupying lesion extending to involve the anterior myometrium. She was discharged on single dose of methotrexate 50 mg intramuscular injection. After one month, she again had an episode of heavy bleeding pervaginum leading to shock, for which she was referred to Safdarjung Hospital for further management. At Safdarjung Hospital an emergency hysterectomy was performed as a lifesaving measure. Preoperative serum Bhcg was >1 lac mIU/ml. later it was reported as gestational choriocarcinoma by histopathology. Metastatic workup showed cannonball lesions in lungs. On the 10 th post-op day, she had severe episode of headache followed by right sided hemiplegia. NCCT head showed multiple haemorrhagiclesion in bilateral parietal and right frontal region suggestive of brain metastasis. She was started on the EMA/CO regimen.

Conclusion: The main modality of treatment of choriocarcinoma is multiagent chemotherapy. Hysterectomy is generally reserved for those gestational trophoblasticneoplasia where it is chemotherapy resistant. Although in exceptional circumstances of heavy uncontrolled bleeding per vaginum hysterectomy is a lifesaving procedure, it is not curative to the other metastatic manifestations.

Uterus: Poster Abstract

Clinicopathological analysis of early endometrial cancers

Seema Singhal, Sunesh Kumar Jain, D. N. Sharma 1 , Sandeep Mathur 2 , Juhi Bharti, Anshu Yadav, K. K. Roy, Neeta Singh, Jyoti Meena

Departments of Obstetrics and Gynaecology and 2 Pathology, All India Institute of Medical Sciences, 1 Department of Radiotherapy, BRAIRCH, All India Institute of Medical Sciences, New Delhi, India

Aim:
The study objectives were evaluation of clinicopathological characteristics, correlations between the preoperative and postoperative tumor assessment in early stage endometrial cancer.

Materials and Methods: We conducted a prospective descriptive study of 30 cases of endometrial cancer stage 1 examined and treated at a tertiary care teaching institute between the years 2014-15.

Results: The patients' mean age at the time of diagnosis was 56.4 years. The mean parity was two. Postmenopausal bleeding with or without abnormal vaginal discharge was the most frequent symptom; it was present in 84.7% of patients. Co morbidities like hypertension and diabetes were seen in 65% of women. 6/30 patients had family history of some malignancy. All the patients underwent Type I extrafascial hysterectomy with bilateral salpingo oophorectomy, one case had Type I extrafascial hysterectomy with infracolic omentectomy. A total of 10.6% cases had lymph nodes metastasis and none of these patients had ovarian metastasis or positive peritoneal cytology. None of the patients with superficial myometrial invasion (MI) had lymph node metastasis. None of the cases showed positive peritoneal cytology. Staging upgraded fom 1a to 1b in 50% of subjects after final histopathological analysis. One patient who was operated as endometrial hyperplasia with atypia actually had endometrial adenocarcinoma in the postoperative specimen.

Conclusions: There is a poor correlation between the preoperative and the postoperative tumor assessment.

Miscellaneous: Oral Abstract

Definition, etiopathogenesis, management and role of flouroquinolone prophylaxis in prevention of spontaneous bacterial peritonitis complicating malignant ascites

Rahul D. Arora

Tata Memorial Centre, Tata Memorial Hospital, Mumbai, Maharashtra, India

Background:
Malignancy related ascites encompasses multiple etiologies which include peritoneal carcinomatosis, hepatic synthetic dysfunction due to parenchymal involvement by the tumour, transcoeloemic metastasis and chylous ascites due to lymphatic obstruction. Primary Cancer type, liver metastasis and serum albumin have been listed as independent prognostic markers in malignant ascites. Spontaneous Bacterial Peritonitis is usually seen as a complication of decompensated chronic liver disease due to translocation of bacteria or haematogenous dissemination from a distant focus of infection. The combination of a positive peritoneal fluid culture and an ascitic fluid neutrophil count >250 cells/mm 3 and no evidence of intra-abdominal source of infection; or 2) culture negative neutrocytic ascites: the combination of negative peritoneal fluid bacterial culture and neutrophil count >500 cells/mm 3 , without antibiotics within 7 days with no obvious source of infection are used to define spontaneous bacterialperitonitis.Ciprofloxacin prophylaxis has been proposed as a prophylaxis to reduce the incidence and prevent the recurrence of spontaneous bacterial peritonitis.

Materials and Methods: A web search of indexed literature was carried out articles containing information on spontaneous bacterial peritonitis in the setting of malignancy or malignancy related ascites or malignant ascites. Articles that carried relevant information about etiopathogenesis, management and translational research in the context of malignant ascites were also included.

Results: A total of 32 articles were analysed and about half of them included in the discussion to answer the research question.

Discussion: Inflammatory cytokines released by tumor and immune cells compromise the mesothelial cell layer that lines the peritoneal cavity, exposing the underlying extracellular matrix to which cancer cells readily attach leading to formation of spheroids which imparts resistance to anoikis, apoptosis and chemotherapeutics leading to efficient feed forward progressive cycle of seeding and growth of peritoneal metastasis. Intraperitoneal metastasis can cause peritoneal dysfunction, adhesions and malignant ascites. Epithelial mesenchymal transistion and myofibroblastic transformation occur in the mesothelial cells in response to pathological stimuli. Vascular endothelial growth factor is an important mitogen for endothelial cells and plays an important role in increasing capillary vascular permeability. In preclinical studies systemic administration of VEGF Trap which acts as a decoy receptor for VEGF has shown to decrease the formation of ascites fluid and prevent tumour dissemination. Epithelial ovarian cancer cells have developed various mechanisms to evade immune surveillance like development of surface microvesicles which contain CD 95 ligand leading to apoptosis of immune cells. Higher levels of osteoproteogerin, IL 10 and leptin in the ascitic fluid have been associated with a poor prognosis in malignant ascites. Tethered bowel sign and presence of fluid in the omental bursa on CT have been shown to distinguish between malignant ascites and Cirrhotic ascites with accuracy. Immunological approaches to management of malignant ascites include use of intraperitoneal triamcinolone, interferon, long acting synthetic corticosteroids and the trifoliate antibody catumaxomab. VEGF Inhihibitors like octreotide and long acting depot preparations of lanreotide have also been shown to be feasible therapeutic options. Anti androgenic agents and PARP inhibitors have also been proposed as management options. Spontaneous bacterial peritonitis in the setting of malignancy in the absence of hepatic dysfunction has been reported to have a poorer prognosis than SBP in the setting of decompensated liver disease. Monomicrobial and polymicrobial bacterascites have been proposed in the absence of an elevated neutrophil ascitic fluid count that does not meet the diagnostic criteria. Extensive liver metastasis where the diseased liver can be expected to behave like a cirrhotic liver and gastrointestinal bleeding(on the basis of an isolated case report) have been considered as risk factors for the development of SBP in malignant ascites. In a case series of 8 patients with malignancy related ascites Patients with total ascitic fluid concentration of less than 1 gm per litre were found to be at risk for Spontaneous bacterial peritonitis and warrant flouroquinolone prophylaxis.

Conclusion: Spontaneous Bacterial Peritonitis complicating malignant ascites is questionable entity. Good quality Audits and Randomised control trials are warranted to in this domain to enable the definition of incidence, antecedent complications, management and prophylaxis to ensure applicability of translational research to the clinical domain.

Key words: Ciprofloxacin; malignant ascites; spontaneous bacterial peritonitis

Miscellaneous: Oral Abstract

A case of invasive mole presenting as perforation uterus and massive haemoperitonium

Arti Sharma

Teerthanker Mahaveer Medical College, Moradabad, Uttar Pradesh, India


Gestational trophoblastic neoplasia (GTN) are rare tumours that constitute less than 1% of all gynecological malignancies. Invasive mole is a distinct subgroup of GTN, which follows approximately 10-15% of complete hydatiform moles. This is a case of invasive mole presenting as uterine perforation and massive haemoperitonium. The 35 year old parous woman presented with severe pallor, acute abdominal pain and hemoperitonium. She gave history of evacuation of a molar pregnancy four month back. Her serum B-HCG was elevated (80,000 IU/ml). Laprotomy revealed perforation through the uterine fundus with purple discolouration and grapes like vesicle with massive haemoperitonium. Patient was managed by hysterectomy and packed cell transfusion was given. Postoperative followup with B-HCG levels was done and chemotherapy (methotrexate and folinic acid) was given.

Miscellaneous: Poster Abstract

Vulvar cancer: Patterns of recurrence and clinicopathological prognostic factors involved in recurrent cases

Kanika

RGCIRC

Objective:
Vulvar cancer is a rare disease, with an incidence of 0.6% of all female malignancies. With the advances in management of carcinoma vulva to individualisation of treatment to reduce the psychosexual impact an aggressive treatment can have, it is imperative to understand the patterns of recurrence and the common prognostic factors involved. The aim of this study was to determine prognostic variables for recurrence and survival and to identify patterns of recurrence in patients with vulvar cancer.

Materials and Methods: All patients (n=87) with primary vulvar cancer treated at the Rajiv Gandhi Cancer Institute between January, 2006 to January, 2015 who underwent surgery were retrospectively analysed regarding the prognostic relevance of different clinicopathological variables. Recurrences were evaluated with regard to their characteristics and localisation and the variables associated with them were analyzed.

Results: Age, stage of tumor, size of tumor, location of tumor (central or lateral), lymph node metastasis, depth of invasion and involvement of resection margins, associated intraepithelial abnormality predicted disease-free and overall survival. In multivariate analysis, lymph node status and positive margin status was the most important independent prognostic factor (p = 0.002). Irrespective of the initial nodal involvement, recurrences occurred primarily in the vulvar region.

Conclusion: Inguinofemoral lymph node status and adequate margins at initial diagnosis is of critical prognostic importance for patients with vulvar cancer. Further tumour biological characteristics need to be identified to stratify patients with nodal involvement for adjuvant radiotherapy of the vulva to prevent local recurrences.

Miscellaneous: Poster Abstract

Case series: Breast and ovarian cancer syndrome

Aims and Objectives: To report a series of cases with breast and ovarian carcinomas either in same patient or in a family and identifying the importance of BRCA 1,2 genetic testing in such individuals.

Materials and Methods: The medical records of breast and ovarian cancer patients operated over past 3 years at a single institute were reviewed retrospectively and their clinical profile, family history, final pathological reports and follow up data was collected.

Results: 8 patients were found to have breast and ovarian malignancies, out of which 3 had synchronous breast and ovarian cancers, 4 had metachronous and 1 patient with ovarian cancer had history of breast cancer in family. Median age of presentation to the hospital was 47 years and median time interval in metachronous disease patients was 5.5 years.

Conclusion: About 5% of people who have breast cancer and about 10% of women who have ovarian cancer have HBOC, caused by germline mutation in BRCA1,2 gene. These individuals have increased risk of developing breast cancer at younger age, TNBC, or developing a second primary in breast or ovary plus an overall risk of breast/ovarian/prostate/pancreatic malignancies in other family members due to inheritable mutation. Identification of BRCA mutation in such individuals can help family members to undergo genetic counseling and follow different screening and prevention guidelines from general population thus reducing the cancer risks.

Miscellaneous: Poster Abstract

To find the prevalence of female genital tract malignancies in a tertiary care hospital

Dilpreet K. Pandher

Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Chandigarh, India


Genital tract and breast are two most common sites of malignancy in females. Out of the genital tract malignancies, carcinoma cervix is so far found to be the commonest followed by ovary and endometrium. In developed countries, carcinoma cervix incidence is comparatively quite low due to good regular screening of females. One year review of patients was done, who underwent definitive/debulking surgery for a diagnosed malignant pathology of the genital tract, in obstetrics and gynaecology department of Govt. medical College and Hospital, Chandigarh. Total 62 patients were operated, most common indication was carcinoma ovary, followed by endometrial cancer, cancer cervix and gestational trophoblastic neoplasia. 166 patients underwent biopsies for suspicious symptoms or the abnormal findings on examination and the patients with final malignancy report were either operated as described above and the inoperable cases were referred to oncotherapy department for further management.

Miscellaneous: Oral Abstract

Role of radical surgery in early stages of vaginal cancer

Vandana Jain, Rupinder Sekhon, Shveta Giri, Sudhir Rawal

Objectives:
The objective of our present study was to evaluate the efficacy of radical vaginectomy with or without radical hysterectomy in patients with FIGO stage I and II vaginal cancers.

Materials and Methods: A retrospective study was carried out on 13 patients aged 35 - 78 years. All the patients underwent radical surgery for vaginal cancer from April 2010 till June 2015. Kaplan- meier analyses was used to calculate the disease free survival and overall survival at 12 months.

Results: The mean age of patients was 54.9 years. Twelve patients were with FIGO stage I while one had stage II vaginal cancer. The histopathology was squamous cell cancer in 9 patients, small cell neuroendocrine cancer in two patients and malignant melanoma in 2 patients. The lesion was confined to upper 2/3 of vagina in 8 cases and lower 1/3 was involved in 5 cases. All the patients underwent radical surgery. Lymph node dissection was done in eleven patients out of whom lymph nodes were positive in 4 patients. Three patients had positive margins. Adjuvant treatment was given to patients with positive margins or positive nodes. Six patients did not require any adjuvant treatment and two patients defaulted adjuvant treatment. One patient developed Vesico-vaginal fistula. Over a follow up period ranging from 6 to 67 months, recurrence developed in two patients and one of them died of disease. The 12 months Disease free survival was 82.1% and 12 months Overall Survival was 90.9%.

Conclusion : Stage I and selected stage II vaginal cancer patients have good outcomes in terms of survival and local tumor control if managed judiciously by initial surgery followed by selective adjuvant therapy.

Key words : Adjuvant therapy; radical vaginectomy; vaginal cancer; vesico-vaginal fistula

Miscellaneous: Oral Abstract

Truth of evidence collection, follow up and patient retrieval systems for gynaecological cancer patients: An Indian survey

Manoj Sharma, Alpana Sharma 1

Maulana Azad Medical College, 1 All India Institute of Medical Sciences, New Delhi, India

Introduction:
The Evidence Based Medicine in oncological sciences is founded on many factors. Pathetic state of patient retrieval system and follow up are some of the inherent problems faced in developing countries. The absence of follow up seems to affect the patient survival, intervention in case of predictive recurrence, and it also fails to fortifies authenticity of research and survival data. Paper outlines histrionics, evolved/recommended methodologies, nationwide survey with regards to authenticity of Evidence Based Practices in Oncological research. It opens the facts sheet of awareness, practice of follow-up and obstacles faced in India institutions. Relevant for obstetricians adopting Gynec Oncology.

Aims and Objective: (1) To Evaluate the Evidence based practice of Gynec Oncology, (2) To evaluate the effectiveness of follow up methodologies, (3) Compliance of institutions and oncologist with regards to follow-up of Gynec cancer patients.

Materials and Methods: The follow up methodology propagated; 1-6 address system (IARC 3 Address System), 2-Postcarding, 3-SMS /Telephony, 4-Door to door patient retrieval, 5-Family Physician referrals/feedback, 6-Software Alert on follow up defaulters in the Hospital Based Cancer Registry. etc. A stock taking was started 10 years back with repeated circulars on dates of "The National Cancer Calendar" (one date every months) that were sent to some 10,000 E-mail address of personnel/institutions connected with oncological sciences. Over five years 150 postgraduate examinees and 50 faculty in various institutions were interviewed on their 1 - Practicing Evidence Based Gynec Oncology and 2 - Understanding of Follow up/patient retrieval system practices in Gynec cancers. As an inspector of a major medical accreditation institution 50 institutions were inspected and existence of their follow up methodologies were evaluated. 100 post graduate dissertations reviewed, were studied with regards to status of follow up in the study carried out or the existence of follow-up system in the institution. Undergraduate students and their text books were searched if they are educated about follow up and necessity of patient retrieval system and its significance in Medical sciences. Faculty/Specialist of Obs and Gyn departments were interviewed for the same.

Observations and Results: Response to circulars on follow up in cancer patients was cold shouldered, 95 percent of examinee PG students did not know how to follow up the cancer patients ,out which as many as 90 percent of their institutions did not have any follow up system in order. 99 percent of dissertation did not show any effort from the side of candidate for patient retrieval system in order to fortify the research data. Only 20 percent institutions had infrastructure and significant effort (including door to door retrieval) on following up the patients that are treated there. Non of the undergraduate text books had guidelines or teaching in follow up so were total blankness of concept of follow up with undergraduate students. The awareness of Evidence based practice of Gynec oncology in most of the faculty of Obs and Gyne Departments was abysmal and "Not Necessary or Not possible" issue.

Conclusion: Death and prolongation of survival both in curable and not so curable gynec cancers is directly related to Patient retrieval through follow up that generates evidence on Indian patients. In order to improve the survival and timely therapeutic intervention, follow up has to be strengthen at under graduate and post graduate medical teaching. This also applies for the authenticity of oncological research data that is produced in large numbers in developing countries. This is especially significant in the large poor socio economic gynec cancer patient population with poor literacy levels and far off homes from cancer treatment centres.

Miscellaneous: Oral Abstract

Retrospective analysis of acute and late gastrointestinal and hematological toxicities with extended field radiation in gynaecological malignancies: A single institution data

Chaitanya Medichelme, Shagun Juneja, Anirudh Punnakal, Charu Garg, Indu Bansal, Amal Roy Chaudhoory, Anil Kumar Bansal, Anil Kumar Anand

Department of Radiation Oncology, Max Cancer Center, Max Super Specialty Hospital, Saket, New Delhi, India

Purpose:
The aim of this study is to report a preliminary analysis of our clinical experience with extended field pelvic (conformal) radiation, with or without concurrent chemotherapy, in gynaecological malignancies.

Materials and Methods: 27 women with gynaecological malignancies (17 with Carcinoma Cervix and 10 with Carcinoma Endometrium) were treated between November 2009 and October 2015 with Extended Field abdomino-pelvic radiation. All patients were treated with conformal radiation (Intensity Modulated Radiotherpy or Volumetric Modulated Arc Therapy). All patients underwent CT Simulation followed by target and OAR delineation as per RTOG guidelines.Dose prescriped was 45-50 Gy in 1.8 Gy per fraction and boost to gross node upto 54-56 Gy. Planning was done on Eclipse Planning system, and treatment was delivered on 6 MV linac. Concurrent chemotherapy was given when indicated. All toxicities were scored according to Common Terminology Criteria for Adverse Events (CTCAE v 4.03). Dosimetric parameters were correlated with toxicities.

Results: Median follow up was 9.5 months (Range 0-52 months). 14 (51.8%) patients developed Grade 1 and 2 acute hematological toxicity and 1 (0.04%) developed Grade 3 toxicity. 10 (37%) patients developed Grade 1 and 2 acute gastrointestinal toxicity and 1 (0.04%) developed grade 4 toxicity. 3 (11.12%) patients had late toxicity in the form of prolonged leucopenia, SAIO, and Irritable Bowel Syndrome. 1 patient did not complete her treatment due to persistent leucopenia (Grade 3).

Conclusion: Extended field Radiation in Gynaecological malignancies is a reasonably well tolerated procedure when treated with IMRT or VMAT, with acceptable toxicity profile.

Miscellaneous: Oral Abstract

Satodiya Mohit Hematbhai

Objective:
To compare the incidence, maternal and fetal outcomes of gestational diabetes mellitus using one step vs. two step as a screening procedure.

Methodology: A prospective randomized trial involving screening of 1000 pregnant women for gestational diabetes mellitus was conducted. Women were divided in two groups (500 each). Group A comprised of patients screened with two step approach (ACOG recommendation), Group B comprised of women screened by one step method (IADPSG criteria). Women diagnosed with 'gestational diabetes' were followed in antenatal clinic and incidence of GDM, maternal and fetal outcome between two groups were analyzed using SPSS.

Results: The incidence of GDM was almost double using one step approach versus two step which was 19.2% and 11.8%respectively. Maternal outcomes were comparable in both the groups except the risk of preterm delivery which was 2.5 times more in group A than group B (odds ratio = 2.43 95% CI = 1.01-5.79). Further fetal outcomes were also comparable except neonatal hypoglycemia which was seen in 29.31% in group A vs. 7.4% in group B. In the group B 15 patients (15.8%) patients with GDM (based on FBS ≥ 92 mg/dl at 1 st ANC visit) showed clinical symptoms and blood sugars in hypoglycemic range on MNT requiring resumption of normal diet.

Conclusion: The incidence of GDM using IADPSG criteria was almost double versus ACOG criteria. Maternal and fetal outcomes were comparable except in 15.8% women diagnosed as GDM (using FBS ≥ 92 mg/dl at 1 st ANC visit as per IADPSG) suffered from hypoglycemia. A large trial is being proposed before these criteria are adopted.

Miscellaneous: Poster Abstract

Anaplastic large cell lymphoma ALK negative vs. peripheral T cell lymphoma (NOS) - diagnostic dilemma

Seema Rana, Rajiv Tangri

SRL Limited, SRL Diagnostics, Clinical Reference Laboratory, Gurgaon, Haryana, India


Middle aged female presented with generalised lymphadenopathy and fever for last one month. Peripheral blood findings were within normal limits. There was no extra nodal involvement. FNAC performed initially from a cervical node suggested possibility of Hodgkin's lymphoma and a whole node biopsy was performed. Histopathogical examination revealed effaced nodal architecture and a polymorphous population of lymphocytes, plasma cells, neutrophils and scattered large mononuclear cells with prominent nucleolus. An initial panel of CD3, CD20, LCA, CD15, CD30 and PAX5 was performed. The large atypical cells were positive for LCA, CD3 and CD30 with variable positivity for CD15. CD 30 showed Golgi and membranous staining. These large atypical cells were negative for PAX5 and CD20. In view of above findings, Hodgkin's lymphoma was ruled out and a possibility of Non- Hodgkin's lymphoma was considered. Further IHC markers were performed which included CD2, CD5, CD7, EMA, Alk, CD10 and KI67. CD5 showed variable positivity. The cells of interest were negative for CD2, CD7, ALK and EMA.Ki 67 index was 70-80%. Overall histological and IHC findings favoured Alk negative Anaplastic large cell lymphoma.Differential diagnosis considered was peripheral T cell lymphoma (NOS). Hodgkin's lymphoma, peripheral T cell lymphoma (NOS) and anaplastic large cell lymphoma share common histomorphological findings. With careful analysis of Immunohistochemistry, it is easier to categorise Hodgkin's lymphoma. ALK negative anaplastic large cell lymphoma and peripheral T cell lymphoma (NOS) are difficult to categorise and show overlapping features. We in this case have discussed clinical, histomorphological and IHC pattern of Alk negative Anaplastic large cell lymphoma.

Miscellaneous: Oral Abstract

Chronic vulval problems: A gynaecologist's perspective

Akanksha Sharma, Saritha Shamsunder 1 , Geetika Khanna 2 , Neeti Khunger 3 , Vijay Zutshi 1

Department of Gynaecology, Lok Nayak Hospital, Departments of 1 Gynaecology, 2 Pathology and 3 Dermatology, Safdarjung Hospital, New Delhi, India

Introduction:
Chronic vulval symptoms are common complaints in women seeking health care and can significantly interfere with a woman's sexual function and sense of well being. Many practitioners feel diagnostically challenged, particularly by chronic or recurrent forms of vulval disease. The aim of this study was to assess the role of various diagnostic modalities in evaluation of chronic vulval symptoms.

Methods: Between August 2012 and February 2014, 100 women presenting with chronic vulval symptoms (i.e. ≥ 3 months duration) were evaluated. All of them had a thorough clinical history taken including use of vulval washes and creams, a general and gynaecological examination. Patients having chronic vaginal discharge in addition had urethral, vaginal and cervical smear and culture. All women had a careful examination of the vulva with and without magnification. Vulval scrape cytology was taken after moistening the vulva with normal saline and stained by Pap stain. Colposcopy of the vulva was then carried out after applying 5% acetic acid and 1% toluidine blue dye. Vulval biopsy was taken from suspicious areas on colposcopy and further management was based on histopathology report.

Results: The mean age of women in our study was 43.57 years (range 22-80 years.), 70% women were pre-menopausal and 30% were post-menopausal. The mean duration of symptoms was 1.625 years (range 6 months - 15 years) and atypical vulval hygiene practices (excessive washing with soaps) was used in 77% of women. The commonest presenting complaint was pruritus in 92% of women; visible lesions on vulva were seen in 20%, pain in 6% and burning sensation in vulva in 5% of women. The histopathology was abnormal in 77 patients; the most common histopathological finding was non-neoplastic epithelial disorders in 64 women {Squamous cell hyperplasia (n=52), Lichen Sclerosus et atrophicus (n=6), other dermatoses including lichen Planus (n=6)}. Vulvar Intra-epithelial Neoplasia (VIN) was seen in 6 patients, 5 were squamous type VIN and 1 was non-squamous type (Paget's disease). Squamous cell carcinoma was seen in 3 patients; malignant melanoma, benign appendiceal tumor, angiofibroma and neurofibroma in 1 patient. Examination without magnification had sensitivity of 25.97% and with magnification was 29.87% and specificity was 100% for both of them. Cytology had sensitivity and specificity of 75.32% and 86.95% respectively and sensitivity and specificity of colposcopy was 77.92% and 17.39% respectively.

Conclusion: Clinical examination with and without magnification had low sensitivity but were highly specific in diagnosing vulvar lesions. A normal vulval smear and colposcopy have a high negative predictive value and are very reassuring. Colposcopy and biopsy is the gold standard for diagnosis, however clinical examination with naked eyes and magnifying glass are invaluable and can diagnose most of the neoplastic lesions.

Miscellaneous: Oral Abstract

Cohort study of vulvar cancer cases over a period of 10 years

Nisha Singh

King George Medical University, Lucknow, Uttar Pradesh, India

Objective
: To study the risk factors, management protocols and outcome of vulvar cancer cases over a period of 10 years in a tertiary care hospital.

Methods : It is a retrospective cohort study of vulvar cancer from January 2004 to January 2014 at King George Medical University, Lucknow. Hospital records of 41 patients with histologically proven diagnosis of vulvar cancer were studied from Department of Obstetrics and Gynecology and Department of Radiotherapy. The presence of risk factors, stage of disease, treatment modalities used and disease outcome in terms survival were studied. The data collected was analyzed and compared with the published literature.

Results: The mean age for diagnosis of vulvar cancer was 52 years and peak incidence was seen in age group of 50-70 years. Incidence was significantly more in multiparous (p = 0.001) and postmenopausal women (p = 0.007). An average of 4.1 cases were seen per year. 97.56% cases were squamous cell carcinomas including one case of verrucous carcinoma. Only one non-squamous case of Bowen's disease was seen. 20 cases belonged to early stage (1 and 2) while 21cases had advanced disease (3 and 4). 48.78% cases were primarily treated with surgery, 26.83% with radiotherapy, 7.3% with chemotherapy and 17.07% with combined chemoradiation. 78% of surgically treated cases had mean survival of 5 years. Mean survival of 1 year was recorded in advanced disease cases. Limitation of the study was poor follow up after treatment.

Conclusion: Incidence of vulvar cancer is significantly high in multiparous and postmenopausal women. Surgical treatment is the best option in early stage of disease (stage I and II) and gives high survival rates while advanced disease treated with chemoradiation has poor survival.

Miscellaneous: Oral Abstract

Association of TNF-α-rs 281865419 polymorphism with reproductive tract infections in Indian population

Vineeta Sharma 1,2 , Pallavi Singhal 1 , Anoop Kumar 1 , V. G. Ramachandran 2 , Shukla Das 2 , Mausumi Bharadwaj 1

1 Division of Molecular Genetics and Biochemistry, Institute of Cytology and Preventive Oncology, Noida, Uttar Pradesh, 2 Department of Microbiology, University College of Medical Science, Delhi University, New Delhi, India

Aim:
To investigate the presence of reproductive tract infections (RTIs) in symptomatic and asymptomatic women in North India and association of SNPs in TNFa gene (rs-281865419 C/T) with susceptibility to these RTIs.

Methods: We collected 100 symptomatic (cases) and 100 asymptomatic women (controls) samples and screened them for RTIs. Then genotyping of TNF-a gene was performed by PCR-RFLP.

Results: Among cases the frequencies of RTIs infection is higher than control. The prevalence of HPV, C. trachomatis, T. vaginalis, Bacterial vaginosis and N. gonorrhoeae are 28% and 6%; 11%, 32% respectively while in controls it was 5%, 2%, 1% and 8% and 1%. In the present study we found that the frequency of wild homozygous genotype (TT) was lower in cases 30% (6/20) as compared to controls 60% (12/20). The frequency of the heterozygous polymorphic genotype (CT) was higher in cases 65% (65/100) as compared to controls 32% (32/100). It was interesting to note that the frequency of the polymorphic homozygous genotype (CC) was higher in cases 15% (15/100) than controls 2% (2/100).While the frequency of the carrier genotype (CT + TT) was found to be more in cases 70% (70/100) than in controls 40/100 (40%). This study shows that T allele may be risk factor for reproductive tract infections as its percentage is higher in cases as compare to normal controls.

Conclusion: TNF-a rs-281865419 locus may serve as an important biomarker for RTIs predisposition in Indian population though larger sample size is needed to validate the findings.

Ovary: Poster Abstract

A rare case of ovarian and endometrial adenocarcinoma metastasized from carcinoma of jejunum

Sonam Agrawal, Pushpa Dahiya

PGIMS, Rohtak, Haryana, India

Introduction:
Krukenberg tumor of ovary is a rare clinical entity and accounts for 1-2% of all ovarian tumor. Stomach is most common primary site but other organs can also serve as a primary site. Accurate diagnosis of krukenberg tumor requires thorough endoscopic and histopathological examination to exclude primary tumor.

Case Report: 32 years old female presented with AUB for 2 months and history of jejunum carcinoma which was an incidental finding on biopsy after a surgery for intestinal obstruction. Endometrial biopsy showed endometrial carcinoma of mucin secreting signet ring type. CECT showed bilateral adnexal masses. Staging laparotomy was planned but due to dense adhesion and bladder and bowel infiltration optimal debulking could not be done and tumor was removed as much as possible. Patient was reffered for chemotherapy.

Conclusion: Krukenberg tumor is uncommon metastatic signet ring cell adenocarcinoma of ovary with transcoelomic spread. It is essential to rule out other ovarian malignancy to avoid the misdiagnosis and management of krukenberg tumor.

Miscellaneous: Poster Abstract

Prevalence of abnormal PAP smears in antenatal women in a tertiary hospital in India

Saritha Shamsunder 1,2 , Akriti Gautam 1,2 , Geetika Khanna 1,2 , Sunita Malik 1,2

Departments of 1 Gynecology and 2 Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Background:
Pregnancy provides a good time for opportunistic screening of our women who rarely attend for cervical screening. The prevalence of abnormal PAP smear in pregnant women in developed countries was 5-6%, however, no literature was available from India.

Aim: To determine the prevalence of abnormal PAP smears in antenatal women presenting to our antenatal clinic.

Methods: Women attending the antenatal clinic with gestation of <28 weeks were recruited after an informed consent and had a PAP smear by Ayre spatula and cytobrush or a broom type of cytobrush. The comfort level during smear taking & any problems noted were recorded using a pain score. The smears were stained using the PAP stain, were categorized as adequate or inadequate & classified as per Bethesda classification.

Results: We had 150 women participating, the mean age was 24.2 yrs, the mean period of gestation was 17 weeks; 43.9% were nulliparous. Smear adequacy rate was 71.5% overall. Pain during procedure was reported in 2.9% of women, 18.3% had minor discomfort; 78.6% were comfortable. Minor bleeding during smear taking was noted in 15%; this was more with the cytobrush & broom than the Ayre spatula alone. Abnormal smears were seen in three women; two had AGC & one had LSIL.

Conclusions: Opportunistic cervical screening during pregnancy is safe and well tolerated. Abnormal Cervical smears were seen in 2% of our pregnant women.

Miscellaneous: Poster Abstract

Inpatient pharmacologic management of malignant bowel obstruction

Rahul D. Arora

Department of Palliative Medicine, Tata Memorial Centre, Tata Memorial Hospital, Mumbai, Maharashtra, India

Background:
Management of life threatening complications encountered in Advanced Cancer is an important domain of Palliative Oncology. Malignant Bowel Obstruction is usually an indicator of poor prognosis in Advanced cancer. It is usually associated with malignancies in the gastrointestinal tract or those outside the gastrointestinal tract (gynaecological malignancies). MBO can also occur with primary peritoneal as well as secondary peritoneal malignancies. Diagnostic criteria for MBO include Clinical evidence of bowel obstruction, obstruction distal to the Ligament of Treitz, presence of primary intraabdominal or extra abdominal cancer with peritoneal involvement.

Materials: Detailed below are two cases of Malignant Bowel obstruction managed with Conservative inpatient nonoperative management with discussion of the proposed pharmacological protocol for the same.

Case Details: A 45 year old Postmenopausal female diagnosed as carcinoma ovary stage iiic with left lower limb Deep Venous Thrombosis post multiple lines of chemotherapy including Paclitaxel plus Carboplatin, Etoposide, Tamoxifen and Liposomal Doxorubin, Malignant pleural effusion post thoracentesis was seen in the wards. A 31 year old Female a known case of moderately differentiated carcinoma colon with transmural infiltration and serosal seeding along with omental deposits with hepatic metastasis was seen in the casualty with signs of Multiple episodes of bilious vomiting with colicky abdominal pain and diagnosed to have malignant bowel obstruction on clinic radiological evaluation. Both these patients were provided non operative management of malignant bowel obstruction, were kept nil per oral, nasogastric decompression was performed with ryles tube insertion, antisecretory medication Inj Octreotide 100 ug three times daily, Anti Edema measures Inj Dexamethasone 8 mg intravrenous three times daily, Anti spasmodic and anti secretory medication Inj Hyoscine Butyl bromide 10 mg three times daily, inj Metronidazole 500 mg intravenous three times daily and Pain medication Inj Tramadol hydrochloride 50 mg intravenous in 100 ml of normal saline three times daily. Both these patients developed hyperglycemia which was managed with human regular insulin prescribed as per the sliding scale.

Results: Ryles tube aspirate showed a decreasing trend and both the Patients achieved clinical resolution of symptoms underwent deintubation on Day 10 and Day 13 respectively and were taking oral feeds at the time of discharge. They were prescribed pharmacologic management of adhesive bowel obstruction consisting of Tab activated Dimethicone 40 mg three times daily, Tab Lactobacillus one tablet three times daily and Polyethylene glycol one satchet upto three times daily for 15 days at the time of discharge.

Results: Resolution of symptoms can be achieved by providing non operative pharmacological management outlined above which consists of adequate hydration, parenteral nutrition when indicated, antibiotics, decongestive anti edema measures, anti spasmodic and anti secretory medication.

Conclusion: Management of Hyperglycemia induced by Octreotide and Dexamethasone requires Insulin therapy. Optimum Duration, dosage and route of administration of Octreotide in management of Malignant Bowel Obstruction needs to be evaluated further.

Key words: Malignant bowel obstruction; octreotide; pharmacological management

Miscellaneous: Poster Abstract

Kanika Bajaj

MMIMSR, Mullana, Haryana, India


Tuberous sclerosis (TS) is a genetic disorder that is inherited in an autosomal dominant fashion with variable clinical manifestations including seizures, mental retardation, renal failure and pneumothorax. The literature on TS in pregnancy is largely based upon case reports which have shown a 43% complication rate including oligohydramnios, polyhydramnios, IUGR, hemorrhage from ruptured renal tumors, PPROM, renal failure, placental abruption and perinatal demise. We reporting a case of 33 yr old female with gravida 3 para 2 and live 2 with period of gestation 9 months with tuberous sclerosis, with severe oligohydramnios with fetal cardiomegaly and mild pericardial effusion and pleural effusion. She had facial angiofibromas along with bilateral renal angiomyolipomas. The previous fetal outcomes were normal, with facial angiofibroma. We report such a unique case having all clinically diagnostic physical sings of tuberous sclerosis with good fetal outcomes.

Miscellaneous: Poster Abstract

Vaginal dilator therapy to prevent stenosis from radiotherapy: A systematic review

Nupur Bansal, Abhishek Soni, Anil Khurana, Yashpal Verma, Paramjeet Kaur, Ashok Kumar Chauhan

Department of Radiotherapy, Pt. B.D.S. PGIMS, Rohtak, Haryana, India

Background:
Pelvic radiotherapy may damage the vagina and cause vaginal stenosis. Its incidence in the literature ranges from 1.2% to 88%. To prevent vaginal stenosis, routine vaginal dilation is recommended during and after pelvic radiotherapy.

Materials and Methods: The objective was to examine critically the evidence behind this guideline. Searches included the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and Google scholarly articles. All the relevant articles were included in the study.

Discussion: Various studies gave recommendations on dilation during or immediately after radiotherapy. Literature does not support routine vaginal dilatation during or immediately after pelvic radiotherapy. Occasional penetration might prevent the sides of the vagina adhering to each other, and dilation might be valuable once the inflammatory and psychological scarring has settled. Two trials demonstrated that encouraging vaginal dilation increased patient compliance, but no difference was found in sexual function scores in the first trial. One retrospective study reported that dilation lowered stenosis rates, but the control group is not comparable. One study involving 89 women revealed that the median vaginal length was 6 cm, six to ten weeks after radiation therapy, but women tolerated a 9-cm dilator/measurer after 4 months of dilation experience. One trial showed no significant advantage by inserting mitomycin C. A study of five women reported that vaginal stenosis can be treated by dilation even many years after radiotherapy. Dilation during or immediately after radiotherapy can cause damage, and there is no evidence that it prevents stenosis. Dilation might stretch the vagina if commenced after the inflammatory phase. Dilation has been associated with traumatic rectovaginal fistulae and psychological consequences.

Conclusion: Vaginal dilation might help treat the late effects of radiotherapy, but it must not be assumed that this applies to the acute toxicity phase. Routine dilation during treatment is not supported by good evidence. Prophylactic and therapeutic dilation therapy needs to be considered separately and research is needed to determine when dilation therapy should start on a large population.

Miscellaneous: Poster Abstract

Collision tumor of endometrial stromal sarcoma and squamous cell cancer: A rare entity

Bindiya Gupta, Shalini Rajaram, Sandhya Jain, Neerja Goel, Naveen Tanwar

A collision tumor is defined by the presence of two separate tumors in one organ on gross, microscopic, and immunohistochemical studies and they should be distinguished from malignant mullerian mixed tumors. A 60 year old lady P8L8 presented with blood stained vaginal discharge and post menopausal bleeding. Examination revealed a 1 x 2 cm cervical growth which was reported as squamous cell carcinoma cervix. Imaging revealed myohyperplasia with normal uterine cavity. The patient underwent Type III radical hysterectomy, bilateral salphingo-oophorectomy and bilateral pelvic lymphadenectomy. The uterine corpus revealed 5 cm growth in uterine cavity which was reported as high grade endometrial stromal sarcoma and the cervical growth was non keratinising squamous cell carcinoma infiltrating the former. The lymph nodes, parametria and vaginal cuff were free of tumor. The patient was referred for adjuvant chemotherapy and radiation therapy.

Miscellaneous: Poster Abstract

Case series: Breast and ovarian cancer syndrome

Aims and Objectives: To report a series of cases with breast and ovarian carcinomas either in same patient or in a family and identifying the importance of BRCA 1, 2 genetic testing in such individuals.

Materials and Methods: The medical records of breast and ovarian cancer patients operated over past 3 years at a single institute were reviewed retrospectively and their clinical profile, family history, final pathological reports and follow up data was collected.

Results: 8 patients were found to have breast and ovarian malignancies, out of which 3 had synchronous breast and ovarian cancers, 4 had metachronous and 1 patient with ovarian cancer had history of breast cancer in family. Median age of presentation to the hospital was 47 years and median time interval in metachronous disease patients was 5.5 years.

Conclusion: About 5% of people who have breast cancer and about 10% of women who have ovarian cancer have HBOC, caused by germline mutation in BRCA 1, 2 gene. These individuals have increased risk of developing breast cancer at younger age, TNBC, or developing a second primary in breast or ovary plus an overall risk of breast/ovarian/prostate/pancreatic malignancies in other family members due to inheritable mutation. Identification of BRCA mutation in such individuals can help family members to undergo genetic counseling and follow different screening and prevention guidelines from general population thus reducing the cancer risks.

Miscellaneous: Poster Abstract

Female adnexal tumour of probable wolffian origin: A rare case report

Nehal Dhaduk, Mamta Dagar, Mala Srivastava, Punita Bhardwaj, Tina Verma, Indrani Ganguli, Nayak

Introduction:
Female adnexal tumour of probable wolffian origin (FATWO), is a rare neoplasm arising within the leaves of a broad ligament or hanging from it or a fallopian tube. It is considered a tumour of low malignant potential which shares similar histological and immunochemical features with mesonephric remnants.

Case: Here we present a case repot of a 40 years old, nulliparous female who presented with acute pain abdomen and fever since 2 days. Her LMP was 30.09.2015 and her past menstrual cycles were irregular. She was nulliparous with history of infertility. In past medical history revealed her to be a known diabetic for 5 years, with uncontrolled blood sugars. Patient was hemodynamically stable. On per abdominal examination there was generalized tenderness all over the abdomen with guarding and rigidity. On per speculum examination vaginal discharge was noted with unhealthy cervix. Per vaginal examination revealed a tender mass of approximately 8 x 6 cm was felt on left fornix. All her base line investigations were normal. The salient investigations like CA-125 35.60 IU/L, CEA 3.46, Beta-HCG 2.29 were normal. On imaging, MRI showed a well defined solid cum cystic space occupying lesion of 9 x 8 cm arising from left adnexa with evidence of right hemorrhagic adnexal cyst 6 x 7 cm and hydro/hematosalpinx noted. There was well defined space occupying lesion in the pelvis on the left of the uterus which is likely a broad ligament leiomyoma. Diagnosis of acute abdomen was made with adnexal mass probably infectious in origin. Injectable antibiotics were started. In view of acute pain abdomen decision for surgical intervention was taken. Laparoscopic findings revealed bilateral ovarian abscess with left sided broad ligament mass (solid consistency) probably leiomyoma. Right tube and ovary were normal. Drainage of tubo-ovarian abscess with left salpingo-oophorectomy with right salpingectomy with adhesiolysis was done and sent for histopathology. HPE reported Female adnexal tumour of probable wolffian origin (FATWO) which was positive for vimentin and CD10, possibly arising from left sided broad ligament. Patient underwent radical hysterectomy with omentectomy with appendicectomy was done in view of FATWO.

Conclusion: Female adnexal tumour of probable wolffian origin (FATWO), is a rare neoplasm which is usually considered as benign, although in some cases metastasis on recurrences have been reported even after a long interval following the initial diagnosis. Pre-operative diagnosis of FATWO is very difficult because of the rarity of the disease and paucity of the literature available.

Endometrium: Poster Abstract

A rare case of invasive mole following evacuation of molar pregnancy and its management

Krati Gandhi, Pushpa Dahiya

PGIMS, Rohtak, Haryana, India

Introduction:
Gestational trophoblastic disease (GTD) is a spectrum of abnormal growth and proliferation of trophoblasts that continue even beyond the end of pregnancy. It comprises of hydatidiform mole, invasive mole, choriocarcinoma and placental site tumor. Invasive mole (Choreoadenoma destruens) comprises about 5-8% of all GTD. It has invasive and destructive potentialities.

Case Report: We report a case of 22 yr old female, G3P0A2, with 3 months amenorrhea with c/o pain abdomen since 4 days with no c/o bleeding p/v, with raised level of b hcg after two spontaneous abortions. On clinical examination vitals were stable. P/A ut 16-18 wks, doughy feel, slight tender. P/V os closed, ut 16-18 wks, bpv+. Ultrasonography shows multicystic lesion in cervix and vagina with loss of fat planes with UB. b hcg level was more than 5,00,000. Suction evacuation was done and products sent for histopathology. MRI Pelvis was also done in which invasive mole was diagnosed. 4 doses of inj. Methotrexte f/b folinic acid was given but b hcg levels did not fall by log 10. On histopath there was no evidence of invasive mole but 2 nd line chemotherapy (EMACO) was started on the basis of MRI findings. Patient has received 5 cycles of EMACO REGIME with b hcg level being followed and is on decreasing trend, has reached to 5.90 mIU/ml.

Conclusion: Patient of molar pregnancy should be followed regularly for early diagnosis of persistent gestational trophoblastic disease and adequate management as loss to follow up patients may land up into complications.

Miscellaneous: Poster Abstract

Vulvar myiasis: Atypical Presentation as carcinoma vulva

Savita Rani Singhal, Esha Gupta, Parul, S. K. Singhal

Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India


Myiasis is a parasitic infestation, rarely seen in the vulval region with more cases being reported in tropical, subtropical and warm temperate climate. Cutaneous myiasis can be misdiagnosed as cellulitis, leishmaniasis, sebaceous cysts, staphylococcal boil, insect bite or skin abscess. Knowledge of the characteristic clinical findings and the close inspection of skin lesions are key to diagnosing myiasis. We report a case of vulval maggots which was misdiagnosed as vulvar carcinoma and caused undue anxiety to the patient.

Miscellaneous: Poster Abstract

Massive peripheral giant cell granuloma associated with pregnancy

Vikas Jain

PDM Dental College and Research Institute, Bahadurgarh, Haryana, India


Peripheral giant cell granuloma (PGCG) is a relatively Common reactive exophytic lesion of the oral cavity. The influence of hormones has been suggested as contributory factor in PGCG development and predominance of these lesions in young females as well as some previously reported pregnancy related cases support this belief. It has been observed that majority of lesions present in the 4 th decade of life, when hormonal changes are more pronounced. Cailluette and Mattar in their study found that peripheral giant cell granuloma are under the influence of the ovarian hormones. However Chambers and Spector suggested peripheral giant cell granuloma to be enhanced by pregnancy rather than being pregnancy dependent. The responsiveness of gingiva to these hormones along with the immunosuppressive actions of the hormones contributes to the growth of the lesion. Clinically, PGCGs may present as polypoid or nodular lesions, predominantly bluish red with a smooth shiny or mamillated surface.

This poster will review the literature available on the association of Massive Peripheral Giant Cell Granuloma With Pregnancy with focus on possible causes of PGCG during pregnancy.

Miscellaneous: Poster Abstract

High precision radiotherapy for vulvar cancer in post renal transplantation: Dosimetric challenges

Subhashini John

Christian Medical College, Vellore, Tamil Nadu, India

Background:
Patients with renal transplant have a higher incidence of various malignancies. Delivery of adequate radiation dose to the pelvic target in such patients sparing the transplanted kidney is a dosimetric ordeal. Due to lack of sufficient data in the literature regarding the dose constraint of the transplanted pelvic kidney, plan evaluation becomes extremely challenging in this situation. Here we present comparative dosimetric plan evaluation data of treating a patient with carcinoma of the vulva with transplanted kidney.

Methods: We compared 3D conformal radiotherapy (3DCRT) and Intensity Modulated Radiotherapy (IMRT) plans for a patient diagnosed to have carcinoma of the vulva with a transplanted kidney. Total dose of radiotherapy (63 Gy) was delivered in two phases (45 Gy in 25 fractions and 18 Gy in 10 fractions respectively). We compared dose to planning target volume (PTV), and dose to organs at risk including the transplanted kidney in these two techniques. The volumes encompassed by different isodoses (50%, 20%, 10%, 5%) were also compared. Weekly renal function test was monitored.

Results: The dose received by 95% of the planning target volume in 3DCRT was 43.3 Gy (phase 1), 17.7 Gy (phase 2) and in IMRT was 43.74 Gy (phase 1), 17.3 Gy (phase 2). The mean doses received by kidney in Phase 1 3DCRT, Phase 1 IMRT, phase 2 3DCRT and phase 2 IMRT were 0.98 Gy, 3.05 Gy, 0.74 Gy, 0.13 Gy respectively. The volumes covered by 50%, 20%, 10%, 5% were higher with IMRT plan when compared with 3DCRT plans. The creatinine values remained stable through the treatment.

Conclusion: Radiotherapy in renal transplanted patients can be done with high precision radiotherapy techniques with strict dosimetric and image guided set up verification.

Miscellaneous: Poster Abstract

Case report of vaginal melanoma

Inderjit Kaur

Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India


Primary malignant melanoma of vagina is a rare disease with a predilection for local recurrence, distant metastasis and short survival time. Due to the low incidence and lack of reporting in the literature, treatment choices still remain controversial. We describe 2 cases of vaginal malignant melanoma. A 42 yr old female presented with complaints of post coital and per vaginal bleed of 1 month duration. Examination findings shows growth 6 cm x 6 cm on anterior vaginal wall, another 3 x 3 cm lesion on right lateral vagianl wall. Vaginal biopsy showed malignant melanoma, S-100 and HMB-45 positive while negative for CK and LCA. MRI Whole abdomen showed altered lesion [3.8 cm (AP), 6.0 cm (TR) and 4.9 cm (CC)] in upper 2/3 rd of vagina extending into vaginal fornices and abutting right lower cervix superiorly, right paravaginal extension and mesorectal fascia. No significant enlarged lymph nodes were seen. In view of localised disease she underwent Type III Radical hysterectomy with bilateral salpingo-ophorectomy with bilateral pelvic lymphnode dissection with total vaginectomy. Histopathology s/o 2 tumour nodules, one located in the anterior vaginal cuff measuring - 5 x 5 x 3.2 cm, another located in right lateral vaginal cuff measuring 2.5 x 3 x 1.5 cm, malignant melanoma with involvement of the cervix with full thickness stromal invasion (2.8/2.8 cm,) invading perivaginal soft tissue, distance of invasive carcinoma from closest stromal margin <0.1 cm (12 O' clock), LVI, PNI - not seen, all pelvic LN free (0/25). In view of positive margin and full thickness stromal involvement, she received radiotherapy to pelvis and Inguinal region to a dose of 45 Gy/25# followed by a boost of 16 Gy/8# to the tumour bed till 01/01/16. Another case is a 40 yrs female, presented with complaints of bloody discharge per vaginum of 4 months duration. On examination, there was a large growth occupying the vagina till introitus. Cervix normal, para free. MRI Pelvis showed altered lesion involving left lateral uterine cervix and upper 2/3 rd of vagina with full thickness stromal involvement with mild left parametrial, anterior and posterior paravaginal extension, measuring 2.9 x 4.5 x 5.3 cm. Few subcmlymphnodes were seen in bilateral external and internal iliac regions (L>R). Vaginal Biopsy was suggestive of Malignant Melanoma, expressing S-100, HMB 45 and SDX-10. Metastatic work up was negative. She underwent RH with total vaginectomy with bilateral PLND with RPLND. HPR showed exophytic black growth seen involving all quadrants of vagina, extending upwards into both lips of cervix - 7 x 6 x 2.5 cm, Malignant melanoma, distance of invasive carcinoma from closest margin: <0.1 cm (paravaginal soft tissue), 3/8 right Pelvic LN, ECE +, 01/9 Left pelvic LN , ECE absent, 0/6 Right common iliac LN, 0/1 Reperitoneal LN was seen. She received adjuvant radiotherapy to a dose of 50 Gy/25# to the pelvis and inguinals; boost of 6 Gy/3# to nodal regions showing ECE & 10Gy/5# to the primary region.

Miscellaneous: Poster Abstract

Case report of vaginal melanoma

Inderjit Kaur, Swarupa Mitra, Manoj Kumar Sharma, Upasna Saxena, Parveen Ahlawat, Amit Kumar Choudhary, Sarthak Tandon, Prashant Surkar

Primary malignant melanoma of vagina is a rare disease with a predilection for local recurrence, distant metastasis and short survival time. Due to the low incidence and lack of reporting in the literature, treatment choices still remain controversial. We describe 2 cases of vaginal malignant melanoma. A 42 yr old female presented with complaints of post coital and per vaginal bleed of 1 month duration. Examination findings show growth 6 cm x 6 cm on anterior vaginal wall, another 3 x 3 cm lesion on right lateral vaginal wall. Vaginal biopsy showed malignant melanoma, S-100 and HMB-45 positive while negative for CK and LCA. MRI Whole abdomen showed altered lesion [3.8cm (AP), 6.0cm (TR) and 4.9cm (CC)] in upper 2/3 rd of vagina extending into vaginal fornices and abutting right lower cervix superiorly, right paravaginal extension and mesorectal fascia. No significant enlarged lymph nodes were seen. In view of localised disease she underwent Type III Radical hysterectomy with bilateral salpingo-ophorectomy with bilateral pelvic lymphnode dissection with total vaginectomy. Histopathology s/o 2 tumour nodules, one located in the anterior vaginal cuff measuring - 5 x 5 x 3.2 cm, another located in right lateral vaginal cuff measuring 2.5 x 3 x 1.5 cm, malignant melanoma with involvement of the cervix with full thickness stromal invasion (2.8/2.8 cm,) invading perivaginal soft tissue, distance of invasive carcinoma from closest stromal margin <0.1cm (12 O' clock), LVI, PNI - not seen, all pelvic LN free (0/25). In view of positive margin and full thickness stromal involvement, she received radiotherapy to pelvis and Inguinal region to a dose of 45 Gy/25# followed by a boost of 16 Gy/8# to the tumour bed till 01/01/16. Another case is a 40 yrs female, presented with complaints of bloody discharge per vaginum of 4 months duration. On examination, there was a large growth occupying the vagina till introitus. Cervix normal, para free. MRI Pelvis showed altered lesion involving left lateral uterine cervix and upper 2/3 rd of vagina with full thickness stromal involvement with mild left parametrial, anterior and posterior paravaginal extension, measuring 2.9 x 4.5 x 5.3 cm. Few subcmlymphnodes were seen in bilateral external and internal iliac regions (L>R). Vaginal Biopsy was suggestive of Malignant Melanoma, expressing S-100, HMB 45 and SDX-10. Metastatic work up was negative. She underwent RH with total vaginectomy with bilateral PLND with RPLND. HPR showed exophytic black growth seen involving all quadrants of vagina, extending upwards into both lips of cervix - 7 x 6 x 2.5 cm, Malignant melanoma, distance of invasive carcinoma from closest margin: <0.1 cm (paravaginal soft tissue), 3/8 right Pelvic LN, ECE +, 01/9 Left pelvic LN , ECE absent, 0/6 Right common iliac LN, 0/1 Reperitoneal LN was seen. She received adjuvant radiotherapy to a dose of 50 Gy/25# to the pelvis and inguinals; boost of 6 Gy/3# to nodal regions showing ECE & 10 Gy/5# to the primary region.

Miscellaneous: Poster Abstract

Extra ovarian adult granulosa cell tumor of omentum: A report of a rare entity

Anil Khurana, Paramjeet Kaur, Ashok K. Chauhan, Yashpal Verma, Nupur Bansal

Department of Radiotherapy, Pt. BDS PGIMS, Rohtak, Haryana, India

Aims:
Extra ovarian granulosa cell tumor (GCT) is extremely rare tumor, assumed to arise from the ectopic gonadal tissue along the embryonal route of the genital ridge. A case of extra ovarian granulosa cell tumor of omentum in a 69 year old female presented here.

Materials and Methods: A 69 years old postmenopausal, hypertensive female presented with complaints of pain in right lumber and iliac region of one month duration. Pain was off and on and intermittent. The patient had a history of hysterectomy 12 years ago for fibroid uterus.

Results: Ultrasound examination of abdomen showed a hypoechoic lesion of size 78.1 mm x 57.3 mm in right iliac fossa with mild thickening of surrounding omentum. Another hypoechoic lesion of size 36.7 mm x 22.9 mm was seen in retroperitoneal region in supero-medial aspect of right kidney. CECT abdomen showed heterogeneously enhanced nodular lesion of size 6.6 x 6.8 cm in right lumbar region, mild thickening of surrounded omentum also seen however there was no evidence of infiltration to bowel loop seen. Uterus was not visualized. PET CT whole body revealed mildly metabolically active enlarged nodes in the bilateral level ib an ii, metabolically active large lobulated heterogeneously enhancing soft tissue density lesion in right lumbar region with non enhancing areas of necrosis. The lesion is closely abutting the anterior abdominal wall musculature antero laterally and small bowel loop medially surrounding mesenty shows increased vascularity and haziness. Colonoscopy findings were normal. Trucut biopsy of mass right lumbar region was positive for malignancy likely Round cell Sarcoma. A provisional diagnosis of retroperitoneal sarcoma of right lumbar region was made. She underwent exploratory laparotomy with excision of tumor. As per Operative findings there was approximately 8 x 7 cm, firm, omental mass present right to midline, arising from under surface of greater omentum. Ovaries were normal. Gross examination of omental mass showed nodular mass measuring 8 x 5 x 6 cm. External surface was multinodular and cut surface was grey brown to grey yellow with solid cystic areas and areas of necrosis. Microscopic examination of specimen showed Extraovarian Adult granulosa cell tumor/metastasis from occult granulose cell tumor. On IHC Vimentin, CK, SMA, Inhibin were positive, Ki67:15%, ER/PR were also positive and are negative for calretinin, thromobomodulin. Extensive necrosis was seen. After that she underwent rexploration and total omenectomy. HPE showed fat necrosis in omentum. All investigation showed no evidence of tumor in ovaries and at any other primary site then the patient finally diagnosed as having Granulosa cell tumor involving only omentum post op stage III C. Then patient was given six courses of chemotherapy with Inj Paclitaxel and Inj Carboplatin three weekly. Now patient is on regular follow up and disease free.

Conclusion: Extra ovarian adult granulosa cell tumor of omentum is rare tumor. Multimodal treatment approaches including surgery, multi-agent chemotherapy may provide a survival benefit for patients.

Miscellaneous: Ovary Abstract

Synchronous malignancy of ovary and cervix

Vani Malhotra, Smiti Nanda, Meenakshi Chauhan, Vandana Bhuria

Background:
Synchronous primary malignancies of the female genital tract constitute 1.7% of all genital malignancies.

Case: A 45-year-old para 5 woman presented with loss of appetite and abdominal distention. Provisional diagnosis of ovarian malignancy was made. Final histopathology of the specimen revealed ovarian papillary serous cystadenocacinoma with cervical leiomyosarcoma. She received chemotherapy.

Results: Patient is on regular follow-up.

Conclusion: The coexistence of primary neoplasms in the ovary and cervix are rare. A normal appearing organ may have a hidden malignancy. So, every surgical specimen should be subjected to detailed histopathological examination. Also, the possibility of synchronous malignancy elsewhere in body should be kept in mind while working on a genital malignancy.

Miscellaneous: Poster Abstract

Radical excision of a massive vulvo: Vaginal mass

J. Meena, A. Parthasarathy, R. Vatsa, N. Singh, S. Kumar, K. K. Roy, S. Singhal

Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India

Background:
Vulvo-vaginal masses has a varied presentation and causes. The most common differential diagnosis are Condylomata acuminata, Vulvular abscess, Vulvular/vaginal cysts, Vulval carcinoma, Vulval lipoma, Angiomyofibroblastoma and Aggressive Angiomyxoma. Surgical excision of the mass is the main method of treatment and the outcome differs with the histological diagnosis. We present a video of excision of a massive Vulvo vaginal mass in toto.

Case: A 45 year old P3 L3 female, presented with complaint of mass in perineal area & discharge per vaginum for 2 years. The mass was growing progressively and reached the present size. On examination there was a 9 X 8 cm irregular firm to cystic mass, arising from posterior wall of vagina and protruding out of introitus with bossellated surface. The mass also extended into right ischiorectal fossa, 10 X 10 cm mass with cystic, smooth surface that was irreducible with no cough impulse. CECT abdomen and pelvis revealed a well-defined 12 X 10 X 8 cm mass in right perineum arising from right lower lateral vaginal wall with ischiorectal fossa extension. There was no extension into cervix, bladder or rectum. Biopsy taken from the mass was inconclusive. A wide local excision was done under general anesthesia wherein an ischiorectal and vaginal mass of size 30 X 10 cm with irregular margin was excised in toto. Histopathology was suggestive of Aggressive Angiomyxoma. The patient is under follow up.

Discussion: Aggressive Angiomyxoma is a rare slow growing locally invasive mesenchymal tumor and has a substantial potential for recurrence. It is often misdiagnosed. Pre-operative diagnosis is difficult due to rarity of this entity and absence of diagnostic features, but it should be considered in case of masses in genital, perianal and pelvic region in a woman of reproductive age. Radical surgical excision is the first line of management. A long term follow up of the case is necessary and MRI is preferred method for detecting recurrences.

Miscellaneous: Poster Abstract

Distant pedicled musculocutaneous/fasciocutaneous flaps; a novel approach for reconstruction of large vulvar defects

Kripa Shanker Mishra

RGCIRC, New Delhi, India

Introduction:
Postablative reconstruction of vulvar defects is a difficult challenge. Local flaps carry a high incidence of delayed wound healing as local flaps may redistribute but not eliminate local wound tension. Repair of defect with distant pedicled flaps may avert local complications by minimising tension to the skin and increasing the initial biomechanical strength of wound. The aim of this study was to determine the clinical outcome of distant musculocutaneous & fasciocutaneous flaps used for postablative reconstruction of large vulvar defects.

Methods: Between January 2015 to December 2015 total three patients underwent vulvectomy and immediate reconstruction with distant pedicled flaps for vulvar carcinoma. Postoperative complications were recorded and clinical outcomes were evaluated.

Results: Two of the three flaps healed primarily. One flap was complicated by minor wound dehiscence, which healed with conservative treatment. Hospital stay and clinical course was shorter in comparison to local flaps and split skin graft.

Conclusions: Distant musculocutaneous and fasciocutaneous flaps provide excellent design flexibility and can be tailored to reconstruct postablative vulvar defects with good outcomes and minimal morbidity.

Miscellaneous: Poster Abstract

To find the prevalence of female genital tract malignancies in a tertiary care hospital

Dilpreet K. Pandher

Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Sector 32, Chandigarh, India


Genital tract and breast are two most common sites of malignancy in females. Out of the genital tract malignancies, carcinoma cervix is so far found to be the commonest followed by ovary and endometrium. In developed countries, carcinoma cervix incidence is comparatively quite low due to good regular screening of females. One year review of patients was done, who underwent definitive/debulking surgery for a diagnosed malignant pathology of the genital tract, in obstetrics and gynaecology department of Govt medical College and Hospital, Chandigarh. Total 62 patients were operated, most common indication was carcinoma ovary, followed by endometrial cancer, cancer cervix and gestational trophoblastic neoplasia. 166 patients underwent biopsies for suspicious symptoms or the abnormal findings on examination and the patients with final malignancy report were either operated as described above and the inoperable cases were referred to oncotherapy department for further management.

Miscellaneous: Poster Abstract

Gestational trophoblastic neoplasia: Retrospective analysis of clinical profile, treatment pattern and outcome

Paramjeet Kaur, Ashok K. Chauhan, Anil Khurana, Yashpal Verma, Nupur Bansal

Department of Radiotherapy, Pt. BDS PGIMS, Rohtak, Haryana, India

Background:
Gestational trophoblastic disease is a spectrum of cellular proliferation arising from the placental villous trophoblast. Gestational triphoblastic neoplasia (GTN) is a collective term for GTD that invade locally or metastasize. GTD includes hydatidiform mole (complete and partial) and GTN include invasive mole, choricocarcinoma, placental site trophoblastic tumor and epitheliod trophoblastic tumor.

Aim: To evaluate clinicopathological profile, treatment pattern and clinical outcome in patients with gestational trophoblastic neoplasia (GTN).

Materials and Methods: Twelve cases of gestational trophoblastic neoplasia treated between 2012 to November 2015 in deptt of Radiotherapy - II, PGIMS, Rohtak were evaluated in this retrospective study. Data was analyzed on the basis of age, histopathology, stage, type of treatment received and treatment related toxicities. Disease free survival was estimated.

Results: Out of 12 women 7 (58 %) had hydatidiform mole, 4 (33%) invasive mole and 01 (8%) had choriocarcinoma. All the cases were given chemotherapy. Two patients had low risk disease. Among high risk group seven patients had score of less than 7 and five patients had risk score of 7 or higher. Five patients were given single agent methotrexate, seven patients received multidrug regimens. All patients are on regular follow up. One patient (high risk group) expired as she did not receive treatment.

Conclusion: GTN are rare and proliferative disorders with proper diagnosis and treatment most of the cases are amenable to treatment with favorable outcome.

Miscellaneous: Poster Abstract

Vulvar melanoma: Rare gynaecological malignancy

Reena Rani, Asmita Rathore, Latika Sahu, Sangeeta Bhasin

Vulvar melanoma is a rare type of gynaecological malignancy. Its poor prognosis and aggressive course provides it more significance than any other vulvar cancer. The knowledge about vulvar melanoma tends to be relatively low as compared to that of squamous cell carcinoma of vulva. This lack of data is due to the infrequency with which vulvar melanoma occurs in any place. In this presentation we are reporting a rare case of vulvar melanoma in a 70 year old lady diagnosed after complaint of persistent vulvar itching discharge per vaginum and a growth on labia on examination. She underwent radical vulvectomy with bilateral inguinofemoral lymphadenectomy and radiotherapy in postoperative period.

Miscellaneous: Poster Abstract

A prospective observational analysis: Poor quality of life in cancer patient population of South Indian Territory Hospital, MGM Hospital, Warangal

A. Yedukondala Rao

Department of Radiation Oncology, Kakatiya Medical College, MGM Hospital, Warangal, Telangana, India


Over the ten years, Quality of Life (QOL) investigations of cancer patients have become an important evaluation parameter in the cancer clinical research and treatment evaluation programs. This study was carried out in tertiary hospital located at Warangal, Andhra Pradesh, India. We assessed the overall QOL of patients affected by cervical, breast, head and neck, and stomach cancers by using EORTC QLQ C-30, QLQ-BR23, QLQ-H&N35, QLQ-CX24, and QLQSTO22 on ≤2 cycles as Review-I and ≥5 cycles as Review-II. The data were analyzed for 104 individuals with mean age of 46.1} 11.2 years. In In head and neck cancer patients, physical, role, social function, pain, insomnia, diarrhoea, speech problems, swallowing, dry mouth were significant (P < 0.05). Breast cancer patients, physical, role function, future perspective, fatigue, pain, arm symptoms and upset by hair loss were significant (P < 0.05). In stomach cancer patients, physical, role function, nausea and vomiting, pain, financial problems, Dysphagia, reflux symptoms and eating restrictions were significant (P < 0.05). In cervical cancer patients, physical, emotional function, fatigue, nausea and vomiting, pain, insomnia, symptom experience scale, menopausal symptoms were significant (P < 0.05). Most of the findings are similar to earlier studies, which shows that, QOL was predominantly influenced by the above mentioned factors in this study population and they also have some interesting implications for.

Key words: Breast cancer; cervical cancer; head and neck cancer; quality of life; stomach cancer

Miscellaneous: Poster Abstract

Vulvar melanoma: Rare gynaecological malignancy

Reena Rani, Asmita Rathore, Latika Sahu, Sangeeta Bhasin

Maulana Azad Medical College, New Delhi, India


Vulvar melanoma is a rare type of gynaecological malignancy. Its poor prognosis and aggressive course provides it more significance than any other vulvar cancer. The knowledge about vulvar melanoma tends to be relatively low as compared to that of squamous cell carcinoma of vulva. This lack of data is due to the infrequency with which vulvar melanoma occurs in any place. In this presentation we are reporting a rare case of vulvar melanoma in a 70 year old lady diagnosed after complaint of persistent vulvar itching discharge per vaginum and a growth on labia on examination. She underwent radical vulvectomy with bilateral inguinofemoral lymphadenectomy and radiotherapy in postoperative period.

Miscellaneous: Poster Abstract

Pediatric vaginal rhabdomyosarcoma: Report of 2 cases

Sahitya Koneru, Silky Jain, Shalini Mishra, Sandeep Jain, Gauri Kapoor

Rajiv Gandhi Cancer Institute, New Delhi, India

Introduction:
Rhabdomyosarcoma (RMS) arising in the female genital tract is rare accounting for 3.5% of all RMS cases. Approximately half these occur in the vagina, a site that has been associated with a favorable prognosis. Optimal loco-regional treatment for patients with vaginal RMS remains controversial since wide local excision is mutilating and often not done. Two cases of vaginal RMS are reported who underwent chemotherapy and local control with brachytherapy.

Methods: Retrospective chart review was done between 2011 and 2015. During this interval, out of 31 cases of pediatric RMS managed at our institution, 2 had vaginal RMS. Their management and outcome is detailed below.

Results - Case Materials: Two patients, both aged 2 years at the time of diagnosis, presented with grape-like mass protruding from vaginal orifice and bleeding for 1-2 months. Characteristic MRI features were of a heterogeneously enhancing polypoidal soft tissue mass filling vaginal lumen and protruding out of introitus confirming Botryoidal RMS. Biopsy and histopathology was suggestive of embryonal RMS (IHC positive for desmin, myogenin and focally for myo-D1). Tumor in both the patients was staged as Stage1 Group 3 (low risk). They were started on neo-adjuvant chemotherapy as per IRS-Ѵ Protocol with 3 weekly cycles of vincristine, dactinomycin and cyclophosphamide for 33 weeks. They had near complete regression of tumor and received brachytherapy for residual thickening of the vaginal wall. They have been followed up for 24 months and 57 months respectively from presentation, and are disease free. They are on close surveillance with periodic examination under anesthesia and imaging. One patient developed post radiation vaginal synechiae requiring vaginal dilatation.

Conclusion: In patients with non-resected vaginal RMS, good outcome can be achieved by the use of brachytherapy for local control.

Miscellaneous: Poster Abstract

One step versus two step screening for gestational diabetes mellitus

Satodiya Mohit Hematbhai

Objective:
To compare the incidence, maternal and fetal outcomes of gestational diabetes mellitus using one step vs. two step as a screening procedure.

Methodology: A prospective randomized trial involving screening of 1000 pregnant women for gestational diabetes mellitus was conducted. Women were divided in two groups (500 each). Group A comprised of patients screened with two step approach (ACOG recommendation), Group B comprised of women screened by one step method (IADPSG criteria). Women diagnosed with 'gestational diabetes' were followed in antenatal clinic and incidence of GDM, maternal and fetal outcome between two groups were analyzed using SPSS.

Results: The incidence of GDM was almost double using one step approach versus two step which was 19.2% and 11.8% respectively. Maternal outcomes were comparable in both the groups except the risk of preterm delivery which was 2.5 times more in group A than group B (odds ratio = 2.43 95% CI = 1.01-5.79). Further fetal outcomes were also comparable except neonatal hypoglycemia which was seen in 29.31% in group A vs. 7.4% in group B. In the group B 15 patients (15.8%) patients with GDM (based on FBS ≥92 mg/dl at 1 st ANC visit) showed clinical symptoms & blood sugars in hypoglycemic range on MNT requiring resumption of normal diet.

Conclusion: The incidence of GDM using IADPSG criteria was almost double versus ACOG criteria. Maternal and fetal outcomes were comparable except in 15.8% women diagnosed as GDM (using FBS ≥92 mg/dl at 1 st ANC visit as per IADPSG) suffered from hypoglycemia. A large trial is being proposed before these criteria are adopted.

Miscellaneous: Poster Abstract

Paget's disease of the vulva in postmenopausal women: A case report

Eliza Shrestha, Rupinder Shekon, Shveta Giri, Sudhir Rawal

Vulvar Paget's disease is an extremely rare neoplasm that accounts for less than 1% of vulvar malignancies. We present a case of a 66 year old woman, who had an ulcerated lesion involving the labia majora bilaterally; lymph nodes were not palpable in the inguinal region bilaterally. A biopsy of the Vulva showed Paget's disease. She underwent radical Vulvectomy with Bilateral inguinal lymph node dissection. The specimens resected were reviewed with respect to involvement of the margins with Paget cells and the margin was negative. The patient remained disease free at 2 years follow up.

Key words : Paget's disease, Vulvar

Miscellaneous: Poster Abstract

Synchronous primary ovarian sex cord tumor and endometrial cancer

S. A. Iqbal, H. Shukla, V. Jain, S. Giri, R. Sekhon, S. Rawal

Synchronous primary tumors of female genital tract are rare with a rate of about 0.7-1.8% of all gynaecological tumours. Most common primary tumours presenting as synchronous lesions are ovary and endometrium. However, sex cord stromal tumors are rare variety of primary ovarian tumor and synchronous with endometrium is even much rarer. These tumors are detected usually in younger, overweight, nulliparous and perimenopausal female. Synchronous primary tumors of endometrium and ovary have a better prognosis than the either of above alone because these are usually low grade and diagnosed at early stage. We present a report of four cases of synchronous endometrial and sex cord stromal tumors of ovary.

Miscellaneous: Poster Abstract

An acute cardiac complication of HIPEC

Soumi Pathak

Recently, cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) has been described for both treatment and prevention of locoregional cancer of various origin. As this procedure involves large amount of blood and fluid loss during the CRS phase, and haemodynamic, metabolic, and coagulation changes during the HIPEC phase, thus thorough study and evaluation is needed to reduce the morbidity and mortality associated with this newer modality in treatment of cancer patients. We hereby describe a case report where a patient developed acute cardiac dysfunction in the immediate postoperative period following CRS with HIPEC. A 65 years old patient weighing 62 kg had undergone CRS with HIPEC for ovarian carcinoma. She had a blood loss of 1.5 L and ascetic fluid drainage of 1.5 L. Intraoperatively fluid was given according to stroke volume variation and two pack cell was transfused to maintain haemoglobin above 10 g. Two hours postoperatively she suddenly developed severe hypotension and an echocardiography done revealed a global left ventricular dysfunction with a 28% ejection fraction. She was intubated and put on inotropic support. Utrasound abdomen revealed fluids and features suggestive of intestinal perforation. So she was reopened on the 3 rd postoperative day and primary closure of the intestinal perforation was done. Thereafter she became haemodynamically stable and we were able to extubate her on the fourth post operative day. Thus we conclude that goal directed fluid therapy with advanced monitoring, thorough evaluation, skeptical vigilance and preemtive thinking is required to deal with the challenges posed by CRS with HIPEC.

Miscellaneous: Poster Abstract

Changing trends in coagulation profile of 30 patients undergoing CRS with HIPEC in the peri-operative period

Soumi Pathak

Background:
With advent of surgical advancements like HIPEC several unstudied pathophysiological aspects need to be evaluated. We studied the trends in coagulation profile in patients undergoing CRS with HIPEC in the peri-operative period, utilizing Thromboelastography (TEG) in comparison with standard coagulation tests. The utility of TEG as a guide for transfusion of blood products was also evaluated.

Materials and Methods: It was a Prospective observational Cohort study which included 30 consecutive patients undergoing CRS with HIPEC at RGCI in 2015.

Methodology: Preoperatively standard coagulation tests were done as a baseline. Intra-operative arterial blood samples were collected for ABG, PT, APTT, and TEG at following time points: before starting of HIPEC, after completion of HIPEC and on 1 and 2 postoperative days. Statistical analysis was done using Chi-square test and unpaired t-test for categorical and continuous variables. Pearson's correlation coefficient was calculated for analysing the correlation between the variables. P < 0.05 was considered statistically significant.

Results: A strong correlation was observed between PT & R values of TEG. Similar correlation was also observed between the a angle, MA of TEG and platelet count throughout the peri-operative period. Immediately post HIPEC, we observe value of APPT decreases while the other parameters of coagulation profile showed a rising trend. R value showed rising trend after CRS, a dip after HIPEC followed by a rising trend on first post operative day which normalizes only after second post operative day. It gives a mixed picture of both hypo and hyper coagulable state. a angle, MA rise immediately after HIPEC and continue to rise till the second postoperative day. There was no requirement of transfusion of blood and blood products as guided by the TEG findings and no clinical evidence of any bleeding or thromboembolic episode occurred.

Conclusion: To conclude, our study demonstrated TEG to be a useful and comprehensive tool to assess coagulopathy and accordingly guide blood product transfusion in patients undergoing CRS with HIPEC.

Miscellaneous: Poster Abstract

To compare the effects of dexmedetomidine versus propofol infusion on various parameters intraoperatively and their effects on the recovery profile postoperatively in patients undergoing laparoscopic assisted robotic pelvic surgeries

Tejinder Singh Jaggi

Rajiv Gandhi Cancer Hospital, New Delhi, India

Methods:
80 ASA physical status I-II patients, 30-65 years, BMI ≤30 undergoing surgery for 120-180 minutes. Computer randomisation, 40 each, in dexmedetomidine group D and in propofol group P. Induction with fentanyl 1.5 mcg mkg−1 and propofol 2 mg kg−1 . Maintained with desflurane 3-5% with air 50% and O 2 50%. In D group (bolus 0.5 mcg mkg−1 for 10 minutes then maintenance 0.2-0.5 mcg mkg−1 hr−1 ) and in P group (propofol @ 50-150 mcg kg−1 min−1 ) started. At docking of robotic arms single dose morphine @ 0.075 mg kg−1 in both groups is given. Hemodynamic stability (MAP and HR) is adjusted within 20% of base line values.

Results: Early and intermediate recovery was fast in D group and total fentanyl requirement intraoperatively was less in D group.

Discussion : Dexmedetomidine is known to decrease sympathetic outflow and circulating catecholamine's levels therefore has caused decrease in both MAP and HR similar to propofol. Dexmedetomidine has analgesia sparing effect hence less total fentanyl dose both intraoperatively. Patients with dexmedetomidine are early aroused, so early and intermediate recoveries were faster with dexmedetomidine than propofol. Thus dexmedetomidine may prove to be useful adjuvant for robotic surgeries.

Conclusion: Dexmedetomidine more effective for both intraoperative and postoperative analgesia. Recoveries both early and intermediate are faster in dexmedetomidine group.

Miscellaneous: Poster Abstract

Synchronous primary malignancy of ovary and cervix with different histopathology: A rare case report

Alok Tiwari, Dhananjay Gughe, Radhika Dureja, Satinder Kaur

Dharamshila Hospital and Research Centre, New Delhi, India


Concurrent different histopathological types of gynecologic tumors arise rarely. We present ovarian serous and cervical squamous cell carcinoma formed synchronously. A 51-year-old woman with a poor general condition was admitted with gradual distension of abdomen for 1 year with gradual loss of weight and appetite for the last three months and pain in the abdomen and irregular vaginal bleeding for the last two months. There was no family history of malignancy of genital tract, breast or colon. On examination she was cachexic, pale, dehydrated, tachypnoeic and had edema over feet. Per abdomen examination revealed solid, non-mobile palpable mass arising from pelvis. Per vaginal examination revealed large mass in pelvis and uterus can not be felt separately on per speculum examination there was small endocervical erosion, hypertrophied cervix. On per rectal examination bilateral parametria were free. Her tumor marker were evaluated and CA-125 was found to be raised (CA 125: 915.6 u/ml U/mL); rest tumor markers were normal. Cervical punch biopsy was suggestive of moderately differentiated carcinoma and pap smear was also suggestive of cervical cancer. MRI findings revealed a mass of altered signal intensity 2.5 Χ 1.5 Χ 2.2 cm with diffusion restriction and post contrast enhancement in the anterior lip of cervix and another large, lobulated predominantly solid mass, hypo intense on T1, intermediate on T2 with diffusion restriction and post contrast enhancement in the right adnexal region abutting the small bowel and sigmoid colon optimal debulking surgery with standard protocol was done. Histopathology report revealed squamous cell carcinoma of cervix, grade III and high grade serous cystadenocarcinoma of ovary. Tumour deposits from ovary were seen on right fallopian tube and right parametrium. Squamous cell carcinoma cervix involved ectocervix, endocervix and infiltrated near full thickness of cervical stroma, endomyometrium, vaginal cuff, paracervical tissue omentum and appendix were free of tumour. Twenty five right pelvic lymphnodes dissected were free of tumour, (00/25). One out of fifteen lymphnode dissected were involved with extra capsular extent, 01/15 and thirteen para aortic lymph node dissected were free of tumor. Immunohistochemistry markers: Ovarian mass-tumour cell expressed ck, vimentin, wt-1 with focal Ck positivity, no expression of ck20, p63,ck5/6 and CEA seen. Cervical tumour-tumour cells expressed ck, ck7, p63 and ck5/6 no expression of ck20, wt-1. Based on our case report we need to keep in mind that even if patient presents with symptoms pertaining to a single malignancy; still the rare possibility of synchronous malignancies should be looked for by doing proper investigations. In our case, patient had symptoms pertaining to ovarian malignancy; whereas cervical malignancy was diagnosed after investigating the patient. Histologic examination should be done properly as the prognosis depends on the malignancies being metastatic or synchronous one appropriate management should be offered in all such cases. Long term follow up of such patients should be maintained to determine the prognosis.

Miscellaneous: Poster Abstract

Unusual clinical presentation of chriocarcinoma in young patients - Neulological meatastasis

Sushma Yadav

Pt. BDS PGIMS, Rohtak, Haryana, India

Introduction:
Choriocarcinoma is a malignant trophoblastic tumor, usually of placenta and characterized by 'early hematogenous spread' to lungs. Choriocarcinoma of placenta is preceded by - H. Mole (50%), spontaneous abortion (20%), ectopic pregnancy (2%) and normal term pregnancy (20%-30%). It is chemosensitive tumor and even in metastatic lesion cure rate is 90%-95%. Most common site of metastasis is lung and vagina, vulva, kidney, liver, ovaries, brain and intestine. If tumor is not diagnosed and managed timely, because of its vascularity, it bleeds profusely leading to death.

Cases : We encountered 2 rare cases, with age of 25 and 27 years respectively with choriocarcinoma with unusual clinical presentation. Both patients presented with neurological symptoms of brain metastasis and succumbed to death within a short span of time. In both cases histopathological report failed to detect chorio-carcinoma but b-HCG and radiological findings were suggestive of choriocarcinoma.

Conclusion : If b-HCG level are unusually high with radiological findings, the patients should be considered for chemotherapy even if HPE is inconclusive. Without chemotherapy chorio-carcinoma has a rapid progression and mortality which can be prevented by early suspicion and timely management.

Miscellaneous: Video Abstract

R-veil in carcinoma vulva

Vandana Jain, Rupinder Sekhon, Shveta Giri, Sudhir Rawal

Background:
Vulvar cancer accounts for about 3-5% of gynaecologic malignancies. Prognosis is strongly dependent on presence of inguinofemoral lymph node metastases. Effective management of regional lymph nodes is the most important factor in the curative management of early vulvar cancer. Despite careful dissection and maintaining vascularity of skin, surgical morbidity is seen in 50% cases. Video - endoscopic inguinofemoral lymphadenectomy was developed by Bishoff in 2003 by dissecting two cadaveric models and in one patient with stage T3N1M0 penile carcinoma. VEIL is an alternative to reduce the morbidity without compromising the oncologic outcomes. VEIL has continued to evolve into single site and robotic variants. R-VEIL is a minimally invasive procedure duplicating the standard open procedure with less morbidity.

Aims and Objectives: A video presentation to describe the technique of R-VEIL in vulvar cancer and discuss the advantages and outcome.

Conclusions: R-VEIL is an attractive minimally invasive technique to do inguinal block dissection in a single sitting in patients with vulvar carcinoma as the surgeon does not get tired as happens in VEIL technique. R-VEIL allows the removal of inguinal lymph nodes within the same limits as in open procedure and potentially reduces surgical morbidity. It is better accepted cosmetically and reduces hospital stay. Long term oncological results are not available. Randomized multi-institutional studies are required to prove its efficacy over open counterpart.

Miscellaneous: Poster Abstract

Radical excision of a massive vulvo-vaginal mass

J. Meena, A. Parthasarathy, R. Vatsa, N. Singh, S. Kumar, K. K. Roy, S. Singhal

Department of Obstetrics and gynaecology, AIIMS, New Delhi, India

Background:
Vulvo-vaginal masses has a varied presentation and causes. The most common differential diagnosis are condylomata acuminata, vulvular abscess, vulvular/vaginal cysts, vulval carcinoma, vulval lipoma, angiomyofibroblastoma and aggressive angiomyxoma. Surgical excision of the mass is the main method of treatment and the outcome differs with the histological diagnosis. We present a video of excision of a massive Vulvo vaginal mass in toto.

Case: A 45 year old P3 L3 female, presented with complaint of mass in perineal area and discharge per vaginum for 2 years. The mass was growing progressively and reached the present size. On examination there was a 9 Χ 8 cm irregular firm to cystic mass, arising from posterior wall of vagina and protruding out of introitus with bossellated surface. The mass also extended into right ischiorectal fossa, 10 Χ 10 cm mass with cystic, smooth surface that was irreducible with no cough impulse. CECT abdomen and pelvis revealed a well-defined 12 Χ 10 Χ 8 cm mass in right perineum arising from right lower lateral vaginal wall with ischiorectal fossa extension. There was no extension into cervix, bladder or rectum. Biopsy taken from the mass was inconclusive. A wide local excision was done under general anesthesia wherein an ischiorectal and vaginal mass of size 30 Χ 10 cm with irregular margin was excised in toto. Histopathology was suggestive of aggressive angiomyxoma. The patient is under follow up.

Discussion: Aggressive Angiomyxoma is a rare slow growing locally invasive mesenchymal tumor and has a substantial potential for recurrence. It is often misdiagnosed. Pre-operative diagnosis is difficult due to rarity of this entity and absence of diagnostic features, but it should be considered in case of masses in genital, perianal and pelvic region in a woman of reproductive age. Radical surgical excision is the first line of management. A long term follow up of the case is necessary and MRI is preferred method for detecting recurrences.

Miscellaneous: Video Abstract

Minimally invasive treatment options to borderline ovarian tumors

Punita Bhardwaj, T. K. Das, S. Batra, Roman

Gynaecology Endoscopy, Robotic Surgery Unit, Institute of Obstetrics and Gynaecology, Sir Ganga Ram Hospital, New Delhi, India


Borderline Ovarian tumors are tumors of uncertain malignant potential .They have favour able prognosis. They occur in younger women and present at an early stage. They are difficult to diagnose preoperatively as macroscopic picture is a combination of benign and invasive ovarian tumors. Over the years surgical treatment has changed from radical to conservative approach without overlooking oncologic safety. Follows up is essential. Prolonged follow up (>10 yrs) is required because of later recurrences. Special attention is to be paid to the conserved ovary in follow up.

Miscellaneous: Video Abstract

R-VEIL in carcinoma vulva

Vandana Jain, Rupinder Sekhon, Shveta Giri, Sudhir Rawal

Background:
Vulvar cancer accounts for about 3-5% of gynaecologic malignancies. Prognosis is strongly dependent on presence of inguinofemoral lymph node metastases. Effective management of regional lymph nodes is the most important factor in the curative management of early vulvar cancer. Despite careful dissection and maintaining vascularity of skin, surgical morbidity is seen in 50% cases. Video - endoscopic inguinofemoral lymphadenectomy was developed by Bishoff in 2003 by dissecting two cadaveric models and in one patient with stage T3N1M0 penile carcinoma. VEIL is an alternative to reduce the morbidity without compromising the oncologic outcomes. VEIL has continued to evolve into single site and robotic variants. R-VEIL is a minimally invasive procedure duplicating the standard open procedure with less morbidity.

Aims and Objectives: A video presentation to describe the technique of R-VEIL in vulvar cancer and discuss the advantages and outcome.

Conclusions: R - VEIL is an attractive minimally invasive technique to do inguinal block dissection in a single sitting in patients with vulvar carcinoma as the surgeon does not get tired as happens in VEIL technique. R-VEIL allows the removal of inguinal lymph nodes within the same limits as in open procedure and potentially reduces surgical morbidity. It is better accepted cosmetically and reduces hospital stay. Long term oncological results are not available. Randomized multi-institutional studies are required to prove its efficacy over open counterpart.

Miscellaneous: Video Abstract

Radical excision of a massive vulvo-vaginal mass

J. Meena, A. Parthasarathy, R. Vatsa, N. Singh, S. Kumar, K. K. Roy, S. Singhal

Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India

Background:
Vulvo-vaginal masses has a varied presentation and causes. The most common differential diagnosis are Condylomata acuminata, Vulvular abscess, Vulvular/vaginal cysts, Vulval carcinoma, Vulval lipoma, Angiomyofibroblastoma and Aggressive Angiomyxoma. Surgical excision of the mass is the main method of treatment and the outcome differs with the histological diagnosis. We present a video of excision of a massiveVulvo vaginal mass in toto.

Case: A 45 year old P3 L3female, presented with complaint of mass in perineal area & discharge per vaginum for 2 years. The mass was growing progressively and reached the present size. On examination there was a 9 X 8 cm irregular firm to cystic mass, arising from posterior wall of vagina and protruding out of introitus with bossellated surface. The mass also extended into right ischiorectal fossa, 10 X 10 cm mass with cystic, smooth surface that was irreducible with no cough impulse. CECT abdomen and pelvis revealed a well-defined 12 X 10 X 8 cm mass in right perineum arising from right lower lateral vaginal wall with ischiorectal fossa extension. There was no extension into cervix, bladder or rectum. Biopsy taken from the mass was inconclusive. A wide local excision was done under general anesthesia wherein an ischiorectal and vaginal mass of size 30 X 10 cm with irregular margin was excised in toto. Histopathology was suggestive of Aggressive Angiomyxoma. The patient is under follow up.

Discussion: Aggressive Angiomyxoma is a rare slow growing locally invasive mesenchymal tumor and has a substantial potential for recurrence. It is often misdiagnosed. Pre-operative diagnosis is difficult due to rarity of this entity and absence of diagnostic features, but it should be considered in case of masses in genital, perianal and pelvic region in a woman of reproductive age. Radical surgical excision is the first line of management. A long term follow up of the case is necessary and MRI is preferred method for detecting recurrences.

Missed Abstracts



Aim:
To compare the findings of CT scan pelvis and cystoscopy findings of bladder involvement in carcinoma cervix in VIEW of revised FIGO staging and to demonstrate the accuracy of CT scan for pretreatment diagnosis of bladder involvement.

Methods: A prospective and comparative study was conducted in the department of Obstetrics and Gynaecology, Rajindra hospital Patiala on a number of 100 patients of carcinoma cervix who underwent both cystoscopy and CT scan pelvis to ascertain bladder involvement. Cystoscopy guided biopsy proven cases of bladder involvement were taken as true cases of bladder involvement in the study and the results of both modalities were analysed and compared.

Results: Out of 100 patients of carcinoma cervix, 28 patients showed bladder involvement on CT scan pelvis and 6 patients were proven as positive cases on cystoscopic guided bladder biopsy. The true positives in the study were 6 cases. True negatives were 94 cases. 22 patients were false positive on CT scan findings

and there were no false negative patients for bladder involvement on CT scan pelvis findings in the study. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CT scan pelvis for bladder involvement were 100%, 76.60%, 21.43%, 100% and 78% respectively. CT scan pelvis was able to detect all cases of bladder involvement which came positive cystoscopy guided biopsy as well.

Conclusions: With the revised FIGO staging which has given optional status to both CT scan and cystoscopy for bladder involvement in patients of carcinoma cervix, CT scan can be used as the preliminary modality for detective bladder involvement in patients of carcinoma cervix. The high sensitivity and negative predictive value of CT scan helps choose which patients should undergo cystoscopy and helps in better and more efficient pre-treatment evaluation of patients with carcinoma cervix for bladder involvement.

Uterus: Poster Abstract

Laparoscopic radical hysterectomy: Results, recovery, recurrence - Our experience

Punita Bhardwaj, T. K. Das, S. Batra, Roman

Department of Gynaecology Endoscopy, Robotic Surgery Unit, Institute of Obstertrics and Gynaecolgy, Sir Ganga Ram Hospital, New Delhi, India


Gynaecology Oncology is a beneficiary of Minimally Invasive Approach. We present our experience. The laparoscopic approach is associated with less surgical morbidity, per operative bleeding and shorter hospital stay though the duration of operation might be longer. It has a longer learning curve. Laparoscopic radical hysterectomy with pelvic lymphadenectomy is a safe surgical option for treatment of Gynaecological cancers taking into account amount of bleeding, complications recovery and recurrence.

Cervix: Poster Abstract

Dosimetric evaluation of sigmoidal and bowel doses in the treatment of carcinoma of cervix using CT based volumetric imaging technique

Jyoti Bisht, Ravi Kant, Meenu Gupta, Vipul Nautiyal, Saurabh Bansal, Sunil Saini 1 , Mushtaq Ahmad

Departments of Radiotherapy and 1 Onco Surgery, Cancer Research Institute, SRH University, Dehradun, Uttarakhand, India

Purpose:
Radiation therapy is the main stray for the treatment of the cervical cancer. Normal organs such as bladder, rectum, sigmoid colon and bowel loops also get significant dose during treatment of carcinoma of cervix which often results late toxicity. The purpose of this study is evaluate CT image based volumetric doses of organ at risk and correlate the doses with the toxicity profile observed in cancer patients.

Materials and Methods: Sixty high dose rate intracavitary brachytherapy applications were performed in thirty patients of carcinoma of cervix. External beam therapy was planned for 46 Gy in 23 fractions followed by two brachytherapy sessions of 9 Gy/session. External beam radiotherapy was given by four field box technique to each patient. CT based treatment planning was done for each intracavitary brachytherapy application. Dose volume histogram was used for analysis of volumetric dose parameters and correlated with the RTOG defined normal organ toxicity profile of the patients.

Results: In the follow up of two years 2 (6.66%) patient had died, 12 (40%) patients had reported no significant problem, 3 (10%) patient got bladder toxicity of grade 2, 10 (33.33%) patients had reported small intestine toxicity of grade 1 and grade 2 while no information could be available for 3 (10%) patients. The average volume of rectum, sigmoid colon and bowel loops were 60.34 cc, 22.19 cc and 270.82 cc. The average, median and 2 cc volume doses for rectum 289 ΁ 121 cGy, 263 ΁ 113 cGy and 884 ΁ 444 cGy for sigmoid colon 409 ΁ 211 cGy, 366 ΁ 185 cGy and 693 ΁ 371 cGy resp. and for bowel loops 240 ΁ 169 cGy, 153 ΁ 59 cGy and 870 ΁ 222 cGy. The average and median sigmoid colon point doses were higher than rectum average (p= 0.000) and median doses (p =0.001) but 2cc volumetric doses of sigmoid colon are less than rectum 2cc volumetric doses (p = 0.013). For bowel loops the 2cc volumetric doses were much higher than average doses (p = 0.000) due to its large volume. The recto-sigmoidal toxicity profile were evaluated for sigmoidal max doses and rectum 2 cc volumetric dose profile. There was a poor correlation between rectum 2 cc volumetric dose and sigmoid 2 cc volumetric doses.

Conclusion: According to dose toxicity profile, sigmoidal doses represent an important role for dose constrains but till now no protocol has been formed for reporting the sigmoidal doses. This study attracts the attention for reporting the sigmoidal and bowl loop doses. This study demonstrates the possibility and role of volumetric imaging and dosimetry for improvement in dose constraints.

Uterus: Poster Abstract

Can initial grade of endometrial cancer presenting at Tata Medical Center, predict high risk factors which will require lymph node dissection and adjuvant therapy?

Basumita Chakraborti, Anik Ghosh, Jaydip Bhaumik, Asima Mukhopadhyay



Background:
Pre-operative tumor grade influences the type of surgery planned for endometrial cancer, while the final grade affects the adjuvant therapy.

Aims and Objectives: To predict whether pre surgery tumour grade can predict tlymph node dissection and adjuvant therapy in endometriod endometrial cancer.

Methods: Retrospective observational study. Data was obtained from electronic hospital medical records system. All women with a diagnosis of endometrioid endometrial cancer who attended TMC, Kolkata between September 2011 and June 2015 included. Review of the histology was asked in all patients and MDT was planned for all patients. Most of the patients operated in TMC underwent standard pre-operative imaging work up like MRI pelvis and CT upper abdomen and chest evaluation. Staging/completion surgery included total hysterectomy, BSO, pelvic +/- para aortic lymphadenectomy +/- Omental biopsy. The surgico-pathological evaluation included histology, grade, myometrial invasion, adnexal involvement and nodal involvement.

Results: 155 patients had both initial and final histology. Of total 67 patients with initial grade 1 histology, 8 (12%) were upgraded to G2 and 1 (1.5%) was upgraded to G3. 35 patients with G2 disease 2 (5.7%) were upgraded to G3. Among 8 patients with G3, 7 continued to be G3. Of the 67 patients with initial grade 1, > 50% invasion was seen in 25 (37.3%). Of 35 patients with initial G2, > 50% myometrial invasion was seen in 13 (37.1%) patients. Among 8 initial G3 patients, > 50% invasion was seen in 3 (37.5%) patients. Of these 67 patients with grade 1, pelvic lymph nodes were involved in 4 (6%) patients. None of the grade 2 tumors had pelvic lymph node involvement. One (12.5%) out of 8 patients with initial G3 tumor had pelvic lymph node involvement. Recurrence was seen in 3/67 (4.5%) of G1 patients, 7/35 (20%) with G2 cases and 1/8 (12.5%)with G3 cases.

Conclusion: Patients with initial G1 disease , about 13% were upgraded. Recurrence rate increased with G2 patients. For all initial grade tumors the mymetrial involvement > 50% was 37%. For initial G1 patients the pelvic lymph node involvement was found to be 6%. For G3 tumor the pelvic lymph node involvement was 12.5%.

Ovary: Poster Abstract

Dermoid cyst in an 82-year-old woman: Can be non malignant: Its management

Sravani Chithra, Rahul Manchanda, Hena Kausar, Nidhi Jain, Anshika lekhi



Dermoid cyst of ovary is the second most common type of ovarian germ cell tumor which constitutes 30 to 40% among ovarian tumors. It occurs mostly in women of reproductive age group between 20 and 40 years and very rarely in postmenopausal women. Postmenopause has its own set of symptoms and risks . One such risk is the possibility of malignancy of ovarian cyst with an incidence of 0.5 to 2%. We present an unusual and rare case of an 82 year old woman, who presented with complaints of pain abdomen and constipation for one year duration. Colonoscopy revealed diverticulitis. Despite being treated for diverticulitis, her symptoms persisted. CT was done which showed a right ovarian mass. Diagnostic laparoscopy was done and pus seen in the abdominal cavity was collected, bowel was distended, and dermoid cyst of ovary of 12 Χ 10 cm size which had undergone torsion three and a half times. Detorsion of ovary with right oophorectomy was done. Histopathology confirmed features of dermoid cyst with torsional changes in the wall and focal gangrene with no evidence of malignancy. Dermoid cyst occurs very rarely in postmenopausal women and treatment of choice is oophorectomy. Authors with this case highlight the proper management of ovarian dermoid cyst in symptomatic postmenopausal women.

Key words: Dermoid; malignancy; oophorectomy; torsion

Miscellaneous: Poster Abstract

Sujata Das



Haemangiomas of the ovary are very rare neoplasms with a wide age range and present with pain lower abdomen and adenexal mass. Many a times this is an incidental finding on surgery. These neoplasms should be considered in the differential diagnosis of haemorragic ovarian lesion. A 48 yr old female presented to us with pain lower abdomen and adenexal mass. Her routine investigations were normal. Her tumour markers were S. LDH 213, CEA 1.72, CA 125 was 2.3. Ultrasound findings showed a well defined echogenic mass in left ovary measuring 6 x 3.4 cm with no ascitis. Her cervical cytological findings were with in normal limits. Staging laprotomy was done and a bilobed solid ovarian mass was identified on left side. TAH with BSO was done and specimen saved for histopathology that finally showed cavernous haemangioma of ovary. Post op recovery was uneventful with subsequent relief of pain.

Miscellaneous: Poster Abstract

A rare case report of incidental solitary uterine metastasis in primary invasive lobular carcinoma of breast

Vivek Gupta, Amita Mishra, Namit Kalra, Bhawna Narula



Introduction:
Infiltrating Lobular carcinoma (ILC) of the breast is second most common cancer of breast next only to Infiltrating ductal carcinoma (IDC). It has a different metastatic pattern as compared to the IDC. Breast cancer is the most frequent primary site which spreads to gynaecologic organs.

Case Presentation: A 40 yrs old Iraqi lady presented as a diagnosed case of lobular carcinoma of left breast. She had already undergone a lumpectomy at Iraq a month back and now had come for completion of treatment. On metastatic workup with PETCT scan, we found a multicentric residual disease in the left breast along with some ipsilateral axillary LN with significant uptake. The concurrent CECT done showed a uterine leiomyomam also. As she was strongly hormone receptor positive, had completed her family and was having mennorhagia probably attributable to uterine fibroids.She was offered hysterectomy with B/L salpingo-oophorectomy. She was keen for breast preservation but in view of her multicentricity of disease on the left breast she was counselled for mastectomy with upfront whole breast reconstruction with TRAM flap. She underwent left modified radical mastectomy with hysterectomy with BSO and TRAM flap reconstruction. The histopathological examination revealed a multicentric, multifocal ILC, grade II with heavy nodal involvement including extracapsular extension. The leiomyoma of uterus also showed tumor deposits from lobular carcinoma breast.

Conclusion: We report a very rare case of metastatic pattern of carcinoma of breast. On literature review we found that it is common for the lobular carcinomas of breast to metastasise to gynaecologic organs. Uterine corpus is a very rare site of metastasis for extragenital cancers including breast. All the patients of primary lobular carcinoma of breast should be screened for gynaecologic secondaries in the preoperative workup with high degree of suspicion.

Ovary: Poster Abstract

Granulosa cell tumour of ovary in a benign looking adnexal mass: A rare occurrence and its management

Kausar Hena, Manchanda Rahul, Lekhi Anshika, Chitra C. H. Sravani, Jain Nidhi



Granulosa cell tumours are sex cord stromal tumours of the ovary which accounts for 1-2% of all ovarian malignancies. We present a case of a 22 yrs old unmarried girl with chief complaints of dysmenorrhoea for last 4 months. There were no other symptoms and her general physical examination revealed no abnormality. Ultrasonography showed a simple ovarian cyst of 7 x 8 cm in right adnexa with normal Doppler flow and no ascites. Her tumour markers were negative. Per-operative uterus and left sided ovary and upper abdomen was normal. Right ovary showed a simple unilocular cyst of around 8 x 8 cm and right ovarian cystectomy done. Surprisingly histopathological examination of cyst wall revealed granulosa cell tumour. Immunohistochemical staining was found to be positive especially with inhibin. Staging laparoscopy with peritoneal wash, multiple peritoneal biopsy with right sided salpingo-oopherectomy, left sided ovarian biopsy and dilatation and curettage was done. Cytological and histopathlogical examination were found to be normal. Post operatively patient received chemotherapy because cyst wall was ruptured per-operatively and patient is doing fine and disease free till now.

Key words: Adnexal mass; granulosa cell tumour; tumour markers

Miscellaneous: Poster Abstract

Development of nasal HPV vaccine formulations

D. Krishnakumar, K. S. Jaganathan

The Erode College of Pharmacy, Erode, Tamil Nadu, 1 JNTU, Hyderabad, Telangana, India


Cervical cancer is the second most cancer in women worldwide with over 500000 new cases and 275000 deaths being registered every year. With nearly 73000 women dying every year, India now tops the world in cervical cancer deaths. India represents 26.4% of all women dying of cervical cancer globally. Cervical cancer estimated to be responsible for about 5% of human cancers worldwide. Currently available vaccines may not provide complete protection against all HPV types as the protection is primarily type specific. Furthermore, the available vaccines are delivered via intramuscular route and require three doses and require cold chain supply which increases the cost of vaccine. Therefore a single dose vaccine delivered via non-invasive route (nasal) that protects against multiple HPV types would be a cost effective and better alternative to the currently available HPV vaccines. The main objective of this study was to prepare HPV antigen loaded poly (lactic-co-glycolic acid) (PLGA) and Tri Methyl Chitosan (TMC) coated PLGA microparticles and compare their efficacy as nasal vaccine. The developed formulations were characterized for size, zeta potential, entrapment efficiency, mucin adsorption ability, in vitro and in vivo studies. PLGA microparticles demonstrated negative zeta potential whereas PLGA-TMC microparticles showed higher positive zeta potential. The protein loading efficiency was found as above 80%. Results indicated that PLGA-TMC microparticles demonstrated substantially higher mucin adsorption when compared to PLGA microparticles. HPV antigen encapsulated in PLGA-TMC particles elicited a significantly higher secretory (IgA) immune response compared to that encapsulated in PLGA particles. Present study demonstrates that PLGA-TMC microparticles with specific size range can be a better carrier adjuvant for nasal subunit vaccines. Surface modified PLGA microparticles proved great potential as a nasal delivery system for HPV infections where systemic and mucosal responses are necessary particularly in conditions after viral pathogens invade the host through the mucosal surface.

Ovary: Poster Abstract

Retrospective analysis of surgical outcomes and survival in women with advanced ovarian cancer undergoing interval debulking surgery

Neha Kumar, Amita Maheshwari, Sudeep Gupta, Jaya Ghosh, Jyoti Bajpai, T. S. Shylasree, Rajendra Kerkar

Tata Memorial Hospital, Mumbai, Maharashtra, India

Introduction:
Both primary (PDS) and interval debulking surgery (IDS) have reported similar progression free survival (PFS) and overall survival (OS) rates in various studies. Complete resection of all macroscopic disease is the strongest independent variable in predicting survival in both groups.

Objective: To evaluate the demographics, surgical outcomes and survival in women with advanced ovarian cancer undergoing IDS.

Methods: All women with Stage IIIC or Stage IV epithelial ovarian or primary peritoneal cancer, registered at our institution from January 2010 to December 2010, who were treated with NACT followed by IDS, were included in the study. Demographic data, CA-125 levels (baseline and presurgery), chemotherapy and surgical details were collected. Progression free survival (PFS) and overall survival (OS) were calculated and Cox regression and Kaplan-Meier survival analysis were used to evaluate factors associated with survival.

Results: One hundred fifty women with Stage IIIC or Stage IV epithelial ovarian or primary peritoneal cancer were included in the analysis. The mean age was 51.08 years (27 to 73 years) and 97.3% had serous histology. Eighty percent (n = 120) had Stage IIIC and 20% (n = 30) had Stage IV disease. Ninety five percent women received Carboplatin and Paclitaxel or single agent Carboplatin as NACT and the median number of NACT cycles was 3. The median baseline CA-125 was 1649.3 U/ml (Range 16.4-235,100 U/ml) and the median CA-125 post NACT was 42.75 U/ml (Range 4.4-5151 U/ml). Seventy four percent women (n = 111) underwent an optimal cytoreduction - 62.7% (n = 94) had R0 and 11.3% (n = 17) had R1 resection. Twenty six percent women (n = 39) had R2 resection. The median CA-125 post NACT was 27.3 U/ml, 36 U/ml and 99 U/ml in women with R0, R1 and R2 resection respectively and the difference was statistically significant (p < 0.0005). The CA125 response was respectively, 97.6%, 95.7% and 93.8% in R0, R1 and R2 resection (p < 0.0005). The median follow up was 42.48 months (Range 1.48-70.93 months). The median PFS was 12.06 months (95% CI 10.02-14.1) - 12.98 months (95% CI 9.7-16.2) in R0, 9.56 months (95% CI 1.7-17.4) in R1 and 6.64 months (95% CI 4.9-8.3) in women with R2 resection (p = 0.158). The median OS was 38.9 months (95% CI 31.7-46.1) - 43.3 months (95% CI 33-53.5) in R0, 46.1 months (95% CI 26.6-65.5) in R1 and 28 months (95% CI 25-30.9) in R2 resection (p = 0.121). The median PFS and OS in women undergoing optimal cytoreduction (R0 and R1) was 12.98 months (95% CI 9.86-16.1) and 43.7 months (95% CI 34.7-52.7) respectively as compared to 6.64 months (95% CI 4.95-8.32) and 28 months (95% CI 25-30.9) respectively in women with R2 resection (PFS p = 0.064, OS p = 0.04). Multivariate analysis discussing the factors affecting the probability of optimal cytoreduction and the survival will be discussed.

Conclusion: In women with advanced ovarian cancer undergoing NACT followed by IDS, a high rate of optimal cytoreduction is achieved. Residual disease is a primary factor affecting the survival of these women.

Ovary: Poster Abstract

Primary signet ring cell mucinous carcinoma ovary: A very rare neoplasm

Amita Mishra, Archit Pandit, Namit Kalra, Bhawna Narula

Introduction:
Mucinous ovarian carcinomas are less common than serous and endometriod type, and are more frequently confined to the ovary at the time of diagnosis. But primary signet ring cell mucinous carcinomas of the ovary are extremely rare.

Case Presentation: A 40 yr old patient presented with extremely rare primary signet cell mucinous carcinoma of ovary. She presented with abdominal distension and frequency of urination for one month. She was evaluated and CECT whole abdomen was s/o large left ovarian mass. All the tumor markers were with in normal range. Laparotomy frozen section of left adnexal mass was done and was reported as malignant with sheets of signet ring cells seen. Hence complete staging laparotomy including TAH with RSO with bilateral pelvic lymph node dissection with total omentectomy with para aortic lymph node dissection. Final histopathology with IHC markers were S/O primary signet ring cell carcinoma of ovary with no extracapsular invasion, no lymph nodal involvement & no metastatic spread.

Conclusion: We present a very rare case of primary signet ring cell of ovary, confined to ovary itself. On literature review only 14 cases have been reported and of them very few are malignant.

Missed Abstracts

Clinical presentation and management of malignant germ cell ovarian tumours in BPKMCH

Jitendra Pariyar, Binuma Shrestha 1

Department of Gynecologic Oncology, Civil Service Hospital, Kathmandu, 1 Gynecologic Oncology Unit, B.P. Koirala Memorial Cancer Hospital, Bharatpur, Chitwan, Nepal

Background:
Germ cell malignancies account for about 5% of all ovarian cancers. These tumours grow rapidly and often produce symptoms quicker than the slow growing epithelial tumour. Commonly seen in the first two decades of life germ cell malignancies are highly chemosensitive and are potentially curable with surgery and chemotherapy. This study is the first of its kind regarding the epidemiology, management and outcome of patients with malignant germ cell tumour in Nepal.

Objective: To analyze the clinical presentation and management outcomes of malignant germ cell tumours managed in B.P. Koirala Memorial Cancer Hospital, Nepal.

Methodology: Descriptive study conducted in B.P. Koirala Memorial Cancer Hospital, Nepal. Case records of malignant germ cell tumours attending the hospital from January 1999 to December 2009 were analyzed regarding their illness history, clinical examination, investigations, treatment, follow-up and outcomes measured.

Observations: Total 65 cases of malignant germ cell tumours with age range from 2 to 58 years (mean 21.7 years) were received. 42% cases were Tibeto-Burmese; 30% were Indo-Aryans. There were 15 cases (23%) of dysgeminoma, 21 endodermal sinus tumor (32%), 16 Immature Cystic Teratoma (24.5%), 9 (14%) Mixed Germ Cell, 2 unclassified GCT (3.5%) and 2 malignant transformation in teratoma (3.5%). 33 (49.5%) patients had early stage disease, 37 (57%) underwent fertility preserving surgery. 4 cases (9%) due to disseminated disease, underwent neoadjuvant chemotherapy followed by debulking surgery. 51 cases (78.5%) received adjuvant chemotherapy (BEP or EP regimen). The overall survival was 70%.

Conclusion: Early stage germ cell malignancies can be safely managed by fertility preserving surgery followed by, chemotherapy if indicated. For advanced diseases, neoadjuvant chemotherapy followed by surgery can be undertaken with curable intent.

Cervix: Poster Abstract

Clinicopathological correlates and need for adjuvant radiotherapy in early stage carcinoma cervix

Apoorva Reddy, Shalini Rajaram, Bindiya Gupta, Shipra Garg 1 , Kiran Mishra 1 , Neerja Goel, Gita Radhakrishnan, N. B. Vaid

Departments of Obstetrics and Gynaecology and 1 Pathology, Guru Tegh Bahadur Hospital, UCMS, New Delhi, India

Objective:
To analyse clinical-pathological findings in women undergoing surgery for early stage carcinoma cervix and to determine the need for adjuvant radiotherapy.

Methods: The study was a retrospective one done to analyse data of women who had been operated for carcinoma cervix in the last 10 years at a tertiary hospital in Delhi. Type II/ III radical hysterectomy with pelvic lymphadenectomy was done depending on stage. Histopathological findings and need for adjuvant therapy based on presence of clinical and pathological criteria were studied.

Results: A total of 93 eligible patient records were included in the study. Mean age and parity was 48.09 ΁ 22.36 years and 4.29 ΁ 3.9 respectively. 47.31% (44) of the women had stage 1B1 carcinoma cervix; 31.18% (29) had stage 1B2 and 19.35% (18) had stage 2A disease. Average size of the tumour growth was 3.25 ΁ 2.46 cm with the largest being 7 cm. Keratinising squamous cell carcinoma was seen in 48.38% (45) of patients whereas the non-keratinising one was seen in 33.33% (31). Large cell variant was seen in 6.45% (6) whereas micro invasive cancer was seen in 4 women. Adenocarcinoma constituted only 3.2% (3) of the study group. Vaginal cuff involvement was present in 9.67% (9) of patients and an equal number had occult parametrial invasion. A significant number of these had stage 2A disease (16.66% and 22.22% respectively). Between 1B1 and 1B2 there was no significant difference in the incidence of vaginal cuff involvement and occult parametrial invasion (P equals to 0.206 and 1 respectively). Lymph nodes were positive in 24.73% with the obturator lymph node being the commonest involved (17). In stage 1b1 25% (11) had positive lymph nodes; in stage 1B2 34.48% (10) and in 2A only one woman had positive pelvic lymph nodes. This difference was also not significant (P = 0.434). About 50% (47) of patients were referred for adjuvant radiotherapy on the basis of the pathological findings. 61% (11) of patients with stage 2A disease, 51.7% (15) of patients with stage 1b2 and 45.45% (20) with stage 1B1 disease required adjuvant radiotherapy.

Conclusion: There was no significant difference in the pathological findings in patients of 1B1 and 1B2. Also the need for radiotherapy in both the groups was similar. Hence similar surgical approach to women with both 1B1 and 1B2 disease appears appropriate.

Cervix: Poster Abstract

Cervical cancer management in Rural India: Are we really living in 21 st century or need to focus on health education of our doctors

Sujata Mittal

Paras Hospital, Gurgaon, Haryana, India

Objectives:
To study cases of cervical cancer managed/unmanaged in rural India and to analyze the reasons for poor outcome.

Methods: This is a retrospective study of 218 cases of cervical cancers between 2008-2013 with resultant outcome in terms of treatment or absence of treatment in spite of diagnosis. Reasons for not taking the treatment have been analyzed. Also, analysis of 21 cases of simple hysterectomy with resultant complications like VVF, RVF has been done. Indications of surgery, operating surgeon, availability of preoperative/postoperative HPR, slides/blocks, discharge summary and disease status at the time of referral was done.

Results: 44% refused to take treatment in spite of stage III diagnosis citing financial constraints, distance to be traveled daily for RT and apathetic attitude of family towards females. 20.65% opted for other hospitals. 29.8% took complete treatment. 80% of females were illiterate and dependent. 9.7% had simple hysterectomy for invasive disease. 95% of simple hysterectomies were performed by general surgeons in private setups resulting in 19% of complications like VVF, RVF. 100% cases of simple Hysterectomy did not have pre-operative biopsy. Only 50% cases had post-operative biopsy report and in none of the cases were slide/blocks available for review as trained pathologists were not available. General surgeons who had performed surgery were neither trained in doing P/V examinations nor aware of staging of cervical cancer.

Conclusion: Illiteracy, poverty and absence of implementation of cancer control programs are the major hurdles in control of cervical cancer. The study highlights the absence of Government's will to control cervical cancer in rural India. It emphasizes on the need of intensive training and health education of gynaecologists and surgeons at district/rural level, lack of which is a primary factor for violation of medical ethics by the doctors.[2]




 

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