Lymph Node Metastasis and Patterns of Recurrence in Vulvar Carcinoma: 10 Years' Single Center Experience

Vulvar carcinoma is a relatively rare malignancy and there is a paucity of data, especially from India and other developing countries regarding the prognostic factors impacting recurrence and survival. A retrospective observational study was conducted in the Department of Gynecologic Oncology at a tertiary care, regional cancer institute, including all patients with carcinoma vulva who underwent surgery between 2009 and 2018. Demographic profile, surgical-pathological information, details of neo-adjuvant chemotherapy, adjuvant radiation and chemotherapy, and peri-operative complications were analyzed. Long-term follow-up data was gathered, with an evaluation of various prognostic factors impacting recurrence and overall survival outcome. Forty-five cases with mean age of 56.2 years (range 29-82) were treated during the study period. Surgery was the initial treatment modality in 41 (91.1%) cases. Neo-adjuvant chemotherapy prior to surgery was given to four cases. After complete surgico-pathological staging, most patients had stage I disease (26 cases, 57.8%) and 22.2% had stage II disease. Owing to microscopic lymph node involvement, seven cases (15.6%) belonged to FIGO stage III disease. Two cases had stage IVA disease with fixed groin nodes. Adjuvant chemotherapy in the form of 5-fluoro uracil and cisplatin was administered to four out of the nine patients with nodal involvement. The remaining five were advised adjuvant groin radiation. At a median follow-up of 34 months (range 2-114 months), 12 cases (26.7%) experienced a recurrence and one case with stage IVA disease progressed during adjuvant chemotherapy. The 5-year overall survival was 76.6% and the 5-year disease-free survival was 69.6%. There were a total number of 10 deaths, of which seven were due to disease recurrence or progression and the remaining 30% of deaths were due to medical co-morbid conditions. Overall survival was negatively impacted by increasing age (age > 60 years), number of positive nodes, presence of perinodal spread, and stage of the disease. Recurrence-free survival was significantly reduced in those with the presence of peri-nodal spread and lympho-vascular space invasion. The incidence of lymph node metastasis was found to be higher in patients with age > 60 years, increasing tumor size, presence of lympho-vascular space invasion and the number of lymph nodes removed. In carcinoma vulva, treatment should be individualized with multidisciplinary cooperation. In our series, we found that the stage of disease, nodal positivity, and nodal positivity with extra-capsular spread were significant prognostic factors impacting survival on analysis. Lymph nodal positivity was associated with increasing tumour size, presence of lympho-vascular invasion, and patient age.

Clinico-Pathological Characteristics, Management, and Prognostic Factors of Patients with Uterine Carcinosarcoma: a Retrospective Analysis

Uterine carcinosarcoma is a rare, highly aggressive, rapidly progressing neoplasm associated with a poor prognosis. It comprises 1-5% of all uterine malignancies but accounts for 16.4% of all deaths caused by uterine malignancies. There is a definite paucity of data available from the Indian subcontinent. Hence, we retrospectively conducted this study to analyze the clinical and pathological characteristics and outcomes of women with uterine carcinosarcoma in the past 10 years managed at the tertiary care center. This is a retrospective study of women with histologically proven uterine carcinosarcoma treated at a tertiary cancer center in South India between August 2009 and April 2019. Inpatient and outpatient records were reviewed; clinicopathological data were collected; and follow-up and survival data were ascertained. Over a period of 10 years, 20 patients were diagnosed with uterine carcinosarcoma. The majority of patients were postmenopausal (80%). Post-menopausal bleeding was the main presenting complaint in about 80% of patients. More than two-thirds of patients presented in the early stage (stage I, 55%; stage II, 20%). All patients underwent staging laparotomy. Patients with good performance status (85%) received adjuvant concurrent chemoradiotherapy and chemotherapy. At a median follow-up of 40 months, 7 (35%) patients were alive, out of which 6 are disease-free and 1 had a recurrence. The event-free survival at a median follow-up of 40 months was 40% and the overall survival was 48.5%. The outcome did not significantly differ based on the age, tumor histology (heterologous versus homologous), stage, and depth of myometrial invasion. Uterine carcinosarcoma, though rare, needs to be recognized as a distinct entity, and treated aggressively. Surgery is the cornerstone of therapy. Adjuvant concurrent chemoradiation and chemotherapy improve local control and may delay recurrence, but have shown little survival advantage. The optimal adjuvant treatment for this uncommon disease is yet to be established, highlighting the need for larger multicentric studies on this tumor.

Phase II Trial on the Feasibility of Single-Dose Intraoperative Intraperitoneal Carboplatin in Advanced Epithelial Ovarian Cancer Following Optimal Cytoreductive Surgery

To evaluate the feasibility administering single-dose intraoperative intraperitoneal carboplatin (IP) in advanced epithelial ovarian cancer (EOC) after optimal primary or interval debulking surgery. A phase II non-randomized prospective study conducted at a regional cancer institute from January 2015 to December 2019. The advanced high-grade epithelial ovarian cancer FIGO stage IIIB-IVA was included. A total of 86 consented patients with optimal primary and interval cytoreductive surgeries received single-dose intraoperative IP carboplatin. The immediate (< 6 h), early (6-48 h), and late (48 h-21 days) perioperative complications were recorded and analyzed. The severity of adverse events was graded on the basis of National Cancer Institute Common Terminology Criteria for Adverse Events (version 3.0). A total of 86 patients received single-dose intra-operative IP carboplatin during the study period. The 12 (14%) patients underwent primary debulking surgery and 74(86%) interval debulking surgery (IDS). The 13 (15.1%) patients underwent laparoscopic/robotic IDS. All the patients tolerated the intraperitoneal carboplatin well with no or minimal adverse events. Three cases (3.5%) needed resuturing for the burst abdomen, three cases (3.5%) had paralytic ileus for 3-4 days, one case (1.2%) underwent re-explorative laparotomy for hemorrhage, and one case (1.2%) mortality due to due late sepsis. The 84 (97.7%) of 86 cases received scheduled IV chemotherapy on time. Single-dose intraoperative IP carboplatin is a feasible procedure with no or minimal manageable morbidity. The procedure is user friendly combining the prognostic benefits of IP chemotherapy with assurance of earliest timely administration of chemotherapy in advanced EOC. Our study is a hypothesis generating for the future clinical trials comparing single-dose NIPEC versus HIPEC in advanced EOC.

Impact of Optimal Therapy and Prognostic Factors in Malignant Germ Cell Tumors of Ovary: 20 Years' Institutional Experience

The objective of this study is to analyze the impact of clinicopathological and treatment-related factors on survival in patients with malignant ovarian germ cell tumor. A total of 253 patients of ovarian germ cell malignancy were retrospectively reviewed during 2000-2019. Out of these, 111 had primary treatment at our institute, which is a dedicated regional cancer center. The remaining 142 were operated elsewhere and were referred to us for adjuvant chemotherapy or with recurrent disease. The clinicopathological and treatment-related characteristics were analyzed for association with tumor persistence/recurrence or death. Among them, 107 were dysgerminomas; 60 had endodermal sinus tumor, 53 mixed germ cell tumors, and 31 immature teratoma; and one each had embryoma and primitive germ cell tumor. The median follow-up period was 19 months (range 0-214). Median time to recurrence or progression was 5 months. Forty-nine patients (19.4%) had a recurrence and there were 16 (6.3%) deaths. Five-year disease-free-survival was 71.3% and 5-year overall survival rate was 88.1%, for the entire cohort. Disease-free-survival was 90.4% and overall survival was 92.1% for patients entirely treated at the reporting institute. Sub-group analysis based on treatment adequacy showed that survival rate was 91.0% in patients who had timely and complete initial treatment versus 78.3% in patients where treatment was incomplete or delayed (p = 0.032). Factors affecting relapse were tumor histology, absence of surgical staging, presence of residual disease, inadequate response to chemotherapy, treatment outside reporting institute, and incomplete/delayed chemotherapy. Significant factors adversely affecting survival were presence of post-operative residual disease, tumor histology, incomplete response to chemotherapy, and inadequate/delayed treatment at primary setting. There was no statistically significant difference based on disease stage and whether fertility-sparing surgery or non-fertility-sparing surgery was performed. Prognosis of ovarian germ cell malignancies is excellent with timely, optimal treatment. The outcome improves significantly if managed adequately in the primary setting, involving dedicated gynecologic oncologists.

Fungating Growth of Squamous Cell Carcinoma in Long-Standing Meningocele

Squamous cell carcinoma is known to occur as a serious complication of chronic burns, scars, and ulcers, but very rarely has it been reported to occur in a long-neglected meningocele. The authors wish to present the case of a 21-year-old man who presented to us when a previously asymptomatic meningocele developed a squamous cell carcinoma on the meningocele sac. The squamous cell carcinoma was excised in toto, followed by excision of the redundant meningocele sac. The neural placode was closed and dural closure done with an artificial dural patch. Reconstruction of the defect thus created was performed by a lumbar perforator-based reverse latissimus dorsi myocutaneous flap. The patient did not develop any postoperative neurological deficits and made an uneventful recovery in the postoperative period. He received adjuvant radiation therapy and is doing well at 4 months' follow-up.

Recurrent Vaginal Cuff Dehiscence in a Treated Case of Carcinoma Cervix

Vaginal Cuff Dehiscence (VCD) is partial or total separation of anterior and posterior vaginal cuff layers. We report a case of recurrent vault cuff dehiscence in a patient of cervical carcinoma. A 60-year-old treated case of carcinoma cervix post surgery and radiotherapy was found to have vault dehiscence and intestinal prolapse second time during a routine speculum examination. She underwent an emergency laparotomy and closure of vault. Vaginal Cuff Dehiscence with Evisceration (VCDE) is a rare but potentially fatal complication following hysterectomy. Postoperative infection, poor technique, hematoma, coitus before healing, radiotherapy, corticosteroid therapy are the risk factors. Radiotherapy leads to progressive obliterative endarteritis and resultant tissue hypoxia. There is paucity of literature regarding the best management of VCD, but early corrective intervention is necessary. Patients and the treating physicians should be made aware of this possibility especially those receiving adjuvant radiation or cases of robotic or laparoscopic hysterectomies.

A Pilot Study Comparing Hysteroscopic Adhesiolysis by Conventional Resectoscope Versus Mini-resectoscope

Objectives

To compare the feasibility and efficacy of the mini-resectoscope with the conventional resectoscope in terms of the operative, menstrual, and reproductive outcome in hysteroscopic adhesiolysis in infertile women.

Methods

We conducted a parallel prospective randomized study at All India Institute of Medical Sciences, New Delhi. A total of 60 patients underwent hysteroscopic adhesiolysis using either conventional resectoscope (n = 30) or mini-resectoscope (n = 30). The primary outcome measures were pregnancy-related indicators. Secondary outcome measures were the operative parameters (cervical dilatation time, operation time, postoperative pain scores, fluid deficit, and preoperative and postoperative sodium levels), second-look hysteroscopy findings, and improvement in the menstrual pattern after surgery.

Results

Cervical dilatation time and pain score 30 minutes after the procedure were significantly lower in the mini-resectoscope group. Out of the total 21 cases with hypomenorrhea, 12 cases (57.1%) started having normal menstrual flow postsurgery. All amenorrheic patients resumed menstruation after surgery. However, nine cases continued to have hypomenorrhea. Over long-term follow-up, 16 patients out of 60 had conceived (seven in the conventional resectoscope group and nine in the mini-resectoscope group). There were three ongoing pregnancies, three abortions, one ectopic pregnancy, and nine term pregnancies. The difference between the two groups was not statistically significant.

Conclusions

The use of mini-resectoscope for hysteroscopic adhesiolysis is associated with reduced operative morbidity. Use of the mini-resectoscope is an effective and safe alternative to the conventional system.

A Prospective Randomized Study Comparing Unipolar Versus Bipolar Hysteroscopic Myomectomy in Infertile Women

Study Objective:

To compare the operative and reproductive outcome of hysteroscopic myomectomy using unipolar resectoscope versus bipolar resectoscope in patients with infertility and menorrhagia.

Design:

Randomized, prospective, parallel, comparative, single-blinded study.

Design Classification:

Canadian Task Force classification I.

Setting:

Tertiary care institute.

Patients:

Sixty women with submucous myoma and infertility.

Interventions:

Hysteroscopic myomectomy performed with unipolar resectoscope or bipolar resectoscope.

Measurements:

Primary outcome measures were the pregnancy-related indicators. Secondary outcome measures were the operative parameters, harmful outcomes related to the procedure, and comparison of improvement levels in the menstrual pattern after surgery between the two groups.

Main Results:

A total of 60 patients were randomized into two groups of equal size. Baseline characteristics were not significantly different between the two groups. Reduction in sodium level from pre- to postsurgery was significantly (P = 0.001) higher in the unipolar group. Nine patients (30%) in the unipolar group had hyponatremia in the postoperative period compared to none in the bipolar group (P = 0.002). However, there was no significant difference in the other operative parameters between the two groups. In both the groups, a significant improvement in the menstrual symptoms was observed after myomectomy. Pregnancy-related outcomes were similar in both the groups.

Conclusion:

The use of bipolar resectoscope for hysteroscopic myomectomy is associated with lesser risk of hyponatremia compared to unipolar resectoscope. Bipolar resectoscopic myomectomy is found to be an effective and safer alternative to unipolar resectoscopy with similar reproductive outcome.

Hysteroscopic septal resection using unipolar resectoscope versus bipolar resectoscope: Prospective, randomized study

AIM

To compare the operation and reproductive outcome of hysteroscopic septal resection using unipolar resectoscope verses bipolar resectoscope.

METHODS

In this prospective randomized study, 70 women underwent hysteroscopic septal resection using either unipolar resectoscope or bipolar resectoscope. Intraoperative parameters (operation time, fluid deficit and complications) and pre- and postoperative serum sodium levels were compared between the two groups. A second-look hysteroscopy was performed after 6 weeks. All pregnancies occurring during the follow-up period were recorded.

RESULTS

There was no statistically significant difference between the two groups in terms of operation parameters and second-look hysteroscopy findings. Six patients in the unipolar group were found to have hyponatremia in the postoperative period compared to none in the bipolar group (P = 0.025). Regarding reproductive outcome, the difference between the two groups was not significant.

CONCLUSION

The use of bipolar resectoscope is associated with lesser risk of hyponatremia compared to unipolar resectoscope. Bipolar resectoscopy is a safe alternative to unipolar resectoscopy with similar reproductive outcome.

Endoscopic sinus surgery in children with chronic sinus disease failed on medical management

This pilot study assessed the safety and efficacy of Endoscopic Sinus Surgery (ESS) in children with chronic sinus disease. A total of 150 patients were carefully evaluated for intractable signs and symptoms of chronic sinus disease and 40 children were deemed appropriate candidates for ESS. All patients were medical management failures. Thirty percent of these children had bronchial asthma and fifteen percent had allergies. All patients were followed for atleast one year after surgery. Overall success rate as assessed at one year was 85.3%. The success was evaluated by a scoring system evolved out of this study for the subjective relief of symptoms. The commonest surgical complication observed was synechiae between the middle turbinate and the lateral nasal wall, that developed in 10% cases. The revision surgery was required in only 5 children who had associated systemic illness like bronchial asthma or allergies.

Bronchial foreign body presenting as an accidental radiological finding

The aspiration of a foreign body in an airway is usually associated with respiratory distress, wheeze and persistent cough. The highest incidence of foreign body inhalation occurs between the age of 1 and 3 years [Ann. Otol. Rhinol. Laryngol. 89 (1980) 434: Med. J. Aust. 2 (1983) 322]. Asymptomatic and long standing foreign bodies may lead to complications such as recurrent pneumonia, bronchiectasis, atelectasis and even death. We present here a case of a metallic bronchial foreign body, which was discovered only as an accidental radiological finding on a chest X-ray, which was done for a mild lower respiratory tract infection, presumably 4 months after such an aspiration.