Adult Granulosa Cell Tumor of Ovary: Clinical Study of 10 Cases Abstract Purpose To evaluate the clinicopathological entities of adult granulosa cell tumor of ovary. Method A retrospective analysis of ten cases of adult granulosa cell tumor of ovary managed in a tertiary care center (VPS Lakeshore hospital, Kochi) from 2004 to 2018. Results Ten cases were identified to have adult granulosa cell tumor (GCT). Mean age was 45.3 years (range 31–63 years). Irregular cycles, palpable mass and pain abdomen were presenting complains. Palpable abdomino-pelvic mass was present in 7 (70%). Only one case had preoperative rise in serum Ca125 level. Serum inhibin analysis was done in postoperative period only, and one case had raised inhibin. Out of ten cases, 6 underwent laparoscopic surgery for adnexal mass and diagnosis of GCT was made in the final histopathology report. Five of them underwent completion surgery later on. Adjuvant chemotherapy was given in three of the cases. Total of 7 cases (70%) had recurrence. Pelvis was common site of recurrence, and mean duration of recurrence was 5.08 years (24–132 months). Mean disease-free period was 3.97 years (6–132 months). There were four mortalities. The longest follow-up duration for single case till the date was 13 years with recurrence in between. Conclusion Granulosa cell tumor of ovary is rare form of ovarian malignancy. Stage is the important prognostic factor. It has good prognosis compared to epithelial ovarian neoplasm. It is difficult to predict preoperatively. Care should be taken to prevent spillage while dealing with adnexal mass which occurs commonly in minimal access surgery and mini-laparotomy.

Addition of Etoricoxib During Concurrent Chemo-radiation of Cervical Cancer Patients Could Result in Faster Resolution of Gross Disease: A Prospective Single-Institution Study Abstract Objective A prospective study was conducted to assess the effect of adding COX-2 inhibitor Etoricoxib during concurrent chemo-radiotherapy schedule of cervical cancer patients on tumour response and acute toxicities. Materials and Methods Forty patients of carcinoma cervix [mostly locally advanced] were treated using external beam radiotherapy (EBRT) [telecobalt, 45 Gy/20F/5F per week] concurrent with weekly cisplatin- or cisplatin + paclitaxel-based chemotherapy. Low-dose-rate (LDR) intracavitary brachytherapy (ICBT) 30 Gy to point A was delivered in between EBRT fractions in a single setting. Patients were prospectively allocated either to receive Etoricoxib 90 mg OD during the entire course of chemo-radiation [arm A] or not [arm B]. Weekly assessment with clinical evaluation and routine blood tests were done during the course of treatment, with pre-ICBT clinical evaluation taken into consideration for disease response comparison between arms. Results When evaluated clinically before intracavitary brachytherapy procedure, the gross disease was found to have regressed more in the arm receiving Etoricoxib [p = 0.042]. Acute grade-3 toxicities ranged between 5 and 15% for patients who received Etoricoxib and 10–15% for those who did not. Difference in toxicities was not statistically significant. Conclusion Addition of COX-2 inhibitor [Etoricoxib] during concurrent chemo-radiation results in a faster response of the primary disease in locally advanced cervical cancer patients, without a significant difference in acute toxicities.

A Suggested Strategy to Reduce Stump Carcinoma After Performing “Obligatory” Subtotal Hysterectomy

Patterns of First Relapse and Outcome in Patients with Locally Advanced Cervical Cancer After Radiochemotherapy: A Single Institutional Experience Abstract Purpose Radiochemotherapy followed by brachytherapy is the standard treatment in locally advanced cervical cancer. The aim of this study was to evaluate the patterns of first relapse, the treatment given and its outcome. Methods This is a retrospective analysis of electronic records of locally advanced cervical cancer patients treated in prospective trials from 2003 to 2014. Results Out of 1388 patients, relapse was seen in 316 (23%). Relapse was seen as—pelvic: 105 (7.6%), distant: 136 (10%), and both: 75 (5.4%). Local, regional, paraaortic and systemic relapses were seen in 148 (10.8%), 65 (4.7%), 102 (7.4%) and 163 (11.8%) patients, respectively. Post-relapse, 201/316 (63.6%) received palliative care alone. Treatment in the form of concurrent or sequential chemo-radiotherapy, surgery, stereotactic body radiotherapy and reirradiation using brachytherapy was received by 15 (4.7%), 7 (2.2%), 1 (0.3%) and 1(0.3%) patients, respectively; 65 (20.6%) received palliative chemotherapy, and 28 (8.9%) received palliative radiotherapy. Median post-relapse survival was 7 months (95% CI 5.9–8.1); and in those who received treatment versus supportive care was 10 (95% CI 7.0–13.0) versus 5 (95% CI 3.9–6.1) months (p < 0.001). The proportion of patients with > 1-year post-relapse survival was 85.7% in surgery, 66.7% in concurrent or sequential chemotherapy plus radiation, 32.3% in palliative chemotherapy, 14.3% in palliative radiotherapy and 13.4% in supportive care. Conclusion Distant failure is the predominant pattern of relapse seen in patients undergoing radiochemotherapy for locally advanced cervical cancer. Well-selected single-site relapses treated with surgery or chemotherapy plus radiation can have good post-relapse survival.

Challenges in Detection and Management of Pre-invasive Glandular Lesions of the Cervix Abstract Despite the success of cervical screening, we continue to see an increase in pre-invasive glandular lesions, and subsequent adenocarcinomas of the cervix. Atypical glandular cells are reported in approximately 0.17–0.6% of cervical cytology samples; up to one-third have underlying pathology that requires further treatment. Glandular lesions of the cervix present unique diagnostic and therapeutic challenges. Colposcopy is often less reliable for assessment of glandular lesions. The role of HPV testing and ECC in diagnosis and surveillance is unclear. Conventional belief is that cold knife conization is superior to LEEP for management of adenocarcinoma in situ (AIS); however, more recent reviews suggest the procedures are oncologically equivalent so long as margins are interpretable and negative. As many young women with AIS desire fertility preservation, evidence on oncologic and obstetric outcomes following conservative management is emerging. The purpose of this review is to discuss some of the common challenges, from a clinician’s perspective, around detection and management of pre-invasive lesions of the cervix.

Editorial

Technical Aspects of Endosurgical Extraperitoneal Aortic Lymph Node Dissection in Gynaecologic Oncology Abstract Introduction Laparoscopic aortic node dissection can be performed using extraperitoneal techniques. The surgical technique has been made much easier by the development of multifunction instruments, combining sophisticated bipolar thermal fusion and sharp incision, or using harmonic hemostasis. These instruments improve ergonomy, and may reduce the lymphocyst formation rate, the more frequent complication of extraperitoneal lymph node dissection. Robotic assistance is feasible and safe, but that does not provide significant improvement in perioperative outcomes. Laparoscopic or robot-assisted single port has been used by several investigators, which led to the same conclusions. Interestingly, the left lateral extraperitoneal approach can be extended to the left pelvic sidewall, allowing to resect suspicious nodes, sentinel nodes or to complete left pelvic lymph node dissection. Materials and Methods In this paper, a review of the technical aspects including surgical steps, instrumentation, and comparative studies of perioperative outcomes has been carried out. A PubMed search was carried out from the year 1995, including the terms “extraperitoneal” “aortic” “lymph node dissection”. Comparative studies investigating the benefits of the extraperitoneal approach compared to the transperitoneal approach were carefully screened. One animal randomized study and one clinical randomized study are available, along with meta-analyses or reviews of retrospective comparative studies. Results No difference was observed in terms of duration of the surgery, blood loss, postoperative complications, hospital stay, and node yield. The extraperitoneal technique overall generates less adhesions, and the intraoperative complication rate is significantly lower than in the transperitoneal approach. The proportion of patients in whom the operation can be satisfactorily completed by this approach is over 90%. The advantages of the extraperitoneal approach are more in obese patients, in relation to the absence of interference of the bowel loops in the operative field, and a higher feasibility. Conclusion The extraperitoneal endosurgical approach is an indispensable tool which must be mastered by gynaecologic oncologists. Extraperitoneal aortic lymph node dissection can be used as a staging procedure, or a part of a full endoscopic operation encompassing intraperitoneal steps like omentectomy and hysterectomy in the surgical staging of endometrial and ovarian cancer.

Surgery for Cervical Cancer: Perspectives from Low- and Middle-Income Countries Abstract Purpose This review and opinion provides a very brief overview of current thinking about surgery for cervical cancer. The aim is to add the perspectives of gynaecologic oncologists working in low- and middle-income countries and consider where these may differ from the oft-quoted perspectives of professionals in high-income settings. Methods This article firstly explores aspects of cervical cancer and its treatment that differ between low- and middle-income countries (LMICs) and high-income countries. Secondly, newer developments in the surgical management of primary and recurrent cervical cancers are considered. Lastly, it is discussed where and why perspectives from LMIC may be different from the ‘global standard’. Results The reader will be challenged to rethink the applicability of widely published current opinions to all areas in the world. It is acknowledged that LMIC represents a large spectrum over multiple continents and that considerations will not apply to all settings. Some developments may be detrimental to countries without disease control, while other concepts offer hope and innovation. Conclusion Different conditions in LMIC and the solutions found by health professionals working there, must be noted by the wide fraternity as a contribution to science. Adherence to global guidelines should not be expected.

Making of a Gynecologic Oncologist Abstract It takes a special person to be a gynecologic oncologist, requiring special surgical skills, empathy and knowledge of female cancer. American Board of Obstetrics and Gynecology started a division of subspecialty in gynecology oncology in 1974 to train gynecologic oncologists in taking care of women with gynecologic malignancies. The curriculum was developed for candidates in training, and institutes were selected based on their expertise and availability of surgical, chemotherapy and radiation specialists following their board certification in obstetrics and gynecology. This article specifies all the current requirements and what it takes to be a gynecological oncologist for a person who is certified in obstetrics and gynecology and fits the criteria to become a gynecologic oncologist.

Review of the Outcomes of Ovarian Cancer Treated with Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy Abstract Ovarian, fallopian tube and primary peritoneal carcinomas (OVCA) most commonly present in advanced stages and despite aggressive surgical resection and chemotherapy will likely recur. Although OVCA can recur in the liver, chest or brain, it most commonly recurs within the peritoneal cavity. Peritoneal spread is problematic and often results in bowel obstruction and the inability to maintain nutritional goals. Given the lethality of peritoneal disease as well as the difficulty in treating this recurrence pattern, novel tactics to treat peritoneal dissemination have been a focus of research in OVCA. Heated intraperitoneal chemotherapy (HIPEC) has been well studied and is utilized to treat appendiceal malignancies, which similarly involve the peritoneum. HIPEC has been shown to improve survival and decrease the risk of peritoneal recurrence in patients with appendiceal malignancies. This technique has also been shown to improve outcomes in patients with peritoneal metastases due to colorectal cancers and gastric cancers. Over the past three decades, HIPEC has been used to treat OVCA with mixed results. The aim of this paper is to review the use of HIPEC in the treatment of OVCA in the upfront and recurrent setting.