Primary vulvovaginal choriocarcinoma: a case report of unusual presentation and literature review

Only one case of primary extra uterine vaginal choriocarcinoma and one case of primary vulvar choriocarcinoma have been reported in literature. This is a case of 27 year old lady who presented with a 10cm × 7cm× 5cm vulvar mass with pain abdomen since 1 month, to the Gynecologic oncology outpatient. The mass was smooth, hard and fixed to underlying structures. Multiple bilateral inguinal lymph nodes were enlarged. Vulvar biopsy with Immunohistochemistry proved it to be choriocarcinoma. CT scan thorax, abdomen and pelvis showed multiple bilateral lung metastases, empty uterine cavity and normal sized uterus with a vaginal mass extending up to introitus encasing urethra and anal canal with multiple enlarged pelvic & inguinal lymph nodes. Final diagnosis of Primary Vulvovaginal choriocarcinoma FIGO stage III and WHO score-12 was made. Multidrug chemotherapy with Etoposide, Methotrexate, Actinomycin-D, Folinic Acid, Cyclophosphamide and Vincristine (EMA-CO) was started then shifted to Etoposide, Methotrexate, Actinomycin-D, Folinic Acid and Cisplatin (EMA-EP) regimen followed by Paclitaxel & Carboplatin, because of poor response. Patient’s βHCG became 1.57IU/L with resolution of all lesions after 5 three weekly cycles of Paclitaxel & Carboplatin. Now she is planned for three more cycles of chemotherapy. This case highlights another atypical presentation of choriocarcinoma

A study of cytology and colposcopy in VIA (visual inspection of cervix with 5% acetic acid) positive women

Background: Cervical cancer is the most common cancer among Indian women. Cervical cancer is preventable in pre-invasive state when effective programmes are implemented to detect and treat its precursor lesions. "Single Visit" screen and treat strategy that uses VIA and colposcopy alone that eliminates the need for repeated visits due to delays in diagnostic results, will be highly attractive in terms of cost effectiveness and compliance to treatment, which is crucial to bring down the incidence and mortality due to cervical cancer. The present study evaluates the performance of colposcopy vs conventional cytology in estimating the presence and grade of cervical disease against the reference standard of histopathology as a secondary test modality to triage women found positive on primary screening by visual inspection with 5% acetic acid (VIA).Methods: This is a retrospective study carried out on 50 women aged between 18-50 years who tested positive on VIA between August 2013 to November 2015. Data were entered in the institution using standard computer software [EPIINFO software]. Diagnostic accuracy for single test was calculated using 2*2 tables and standard formulae.Results: The diagnostic accuracy of Pap smear was found to be 77% and that of Colposcopy was 87%. The accuracy of colposcopy was higher than that of Pap smear.Conclusions: Invasive cervical cancer is preceded by pre-invasive disease in most women. There is a lag time of 10-20 years before the disease progresses from pre-invasive to invasive disease. Prevention of invasive cancer is by screening, diagnosis and treatment of pre-invasive diseases. Thus, early diagnosis of CIN (cervical intraepithelial neoplasia) in adult women is a desirable goal

The diagnostic significance of hyperfibrinogenemia and thrombocytosis in patients with ovarian tumors/adnexal masses

Background: We aim to study the correlation of thrombocytosis and hyperfibrinogenemia with ovarian tumors and its role in the diagnosis of ovarian malignancy. And to evaluate the platelet and fibrinogen levels in early and advanced stage ovarian disease. Methods: This is a single centre prospective study. We evaluated plasma fibrinogen levels and plasma platelet levels in 250 patients in women presenting in our OPD with adnexal masses/ovarian tumors. Thrombocytosis was defined as a platelet count greater than >410,000/uL. Hyperfibrinogenemia was defined as a fibrinogen level higher than 360 mg/dL. The association between plasma fibrinogen, platelet levels and clinico-pathological, histopathological parameters were investigated in regards to: 1. Malignant or benign ovarian tumor. 2. Early or advanced disease in malignant ovarian tumors. A multivariate logistic regression model was performed to identify an independent association. Results: Thrombocytosis and hyperfibrinogenemia are seen to be associated with malignant ovarian tumors. In a multivariate model, plasma fibrinogen and plasma platelet levels were identified to be independently associated with the malignant ovarian tumours. Within the EOC cohort, patients with advanced stage disease had higher plasma fibrinogen levels than patients with early stage. Conclusions: In this study, we demonstrated that both thrombocytosis and hyperfibrinogenemia were positively associated with malignant ovarian tumors. They were also associated with advanced disease stage, elevated CA125 level and other markers. These finding are in accordance with the previous published data from patients with ovarian cancer, indicating that the platelet and fibrinogen levels increase in parallel with tumor progression and metastasis. Thus confirming the role of elevated platelet and fibrinogen levels in diagnosis and prognosis of ovarian Malignancy

Diagnostic accuracy of HE4 and risk of ovarian malignancy algorithm in prediction of ovarian cancer in patients with pelvic mass: a regional cancer centre experience

Background: The current study was performed with an objective to evaluate the diagnostic accuracy of HE4 (human epididymis protein) and ROMA in prediction of ovarian cancer in patients with pelvic mass and to compare HE4 and ROMA with CA-125, and RMI (risk of malignancy index) for ovarian cancer prediction in women with pelvic mass.Methods: This was a diagnostic study enrolling 200 patients with pelvic mass who had been scheduled for Primary surgery. Serum HE4 and CA 125 levels were measured. HE4, CA 125 and ROMA, RMI were evaluated for sensitivity, specificity, positive predictive value and negative predictive value. The receiver operating characteristic (ROC) plots were graphed and area under the curve (AUC) values was calculated to investigate the accuracy of each marker for predicting ovarian malignancy.Results: Overall, ROMA showed the highest accuracy as it correctly classified 139/200 (69.5%) patients compared with 133/200 (66.5%) in HE4 and 109/200 (54.5%) in CA 125 and RMI. There were more patients with benign tumors being correctly identified by HE4 (89/119, 74.7%) and ROMA (74/119, 62.1%), than CA 125 which identified 39/119 (32.7%) patients. In our study in premenopausal women ROMA and HE4 have comparable sensitivity (80%and 75%) but higher specificity (64% and 65%) and NPV (86% and 83%) as compared to CA125 which has sensitivity of (83%) but very low specificity (46%) in differentiating benign from malignant masses. In postmenopausal women, HE4 had highest specificity (88%) and, CA125 has highest sensitivity (86%) in detecting ovarian malignancy.Conclusions: HE4 and ROMA showed a high specificity, but were less sensitivity than CA-125 and RMI in premenopausal women. However, ROMA is of comparable sensitivity and HE4 has highest specificity as compared to CA125 in postmenopausal women

Early stage cervical cancer with negative pelvic lymph nodes: morbidity and survival patterns following radical hysterectomy and postoperative adjuvant radiotherapy

Background: The objective of the present study was to optimize the role of adjuvant radiotherapy in lymph node negative cervical cancer treated with radical hysterectomy and pelvic lymph node dissection, and to analyse patterns of failure and complication following surgery and radiotherapy in same patients.Methods: This is retrospective analysis of 98 patients of cancer cervix FIGO Stage IB; IIA treated with radical hysterectomy with bilateral lymphadenectomy and adjuvant radiotherapy between the years 2000 and 2007at our hospital. Among all node negative patients who were operated during this period 97 patients were high risk. [High risk-Two or more of following risk factors: primary tumor size >4 cm, cervical stromal invasion ≥1/2, lymph-vascular space invasion, Unfavorable histology,>].Results: Median follow up: 79 months [6 months to 109 months], Recurrence rate: 13.26% [2 Pelvic and 11 distant recurrence] Pelvic control rate: 98 %Radiotherapy Complications: 4 % [Grade 3-4].Conclusions: Adjuvant radiotherapy following radical hysterectomy in high risk node negative early cervical cancer is effective treatment. It reduces pelvic recurrence with acceptable morbidity

Primary retroperitoneal mucinous cystadenocarcinoma: a rare surgico-pathological entity

Ovarian cancer (OC) is the seventh most common cancer for females in the world. Epithelial OC is the most predominant pathologic subtype (85%-90%), with five major histotypes- serous, mucinous, endometrioid, brenner and clear cell tumour. Each have three pathological subtypes ie benign, borderline and malignant. Mucinous cystadenomas and carcinomas of the ovary are well-established and common tumors. Primary retroperitoneal mucinous cystadenomas and carcinomas are being very rare and histopathogenesis of which is still uncertain. Most pathologists suggest their origin through mucinous metaplasia in a pre-existing mesothelium-lined cyst. An accurate preoperative diagnosis of these tumors is challenging due to lack of established effective diagnostic measures. Hereby presenting a 50-year-old woman, who visited to the hospital with abdominal distension and discomfort since two months. Sonography and computed tomography scans were performed and showed large predominantly cystic lesion arising from right adnexa. Patient underwent exploratory laparotomy for removal of the tumor. Histology and immunohistochemistry revealed primary retroperitoneal mucinous cystadenocarcinoma

Drug prescribing pattern in surgical wards of a tertiary care hospital in Western part of India

Background: In surgical wards, drugs are required to manage pain, nausea, vomiting, infections, etc. A growing number of pharmaceutical products are available in present era. Irrational prescribing of drugs is prevalent worldwide. Drug utilization study can be used to assess prescribing patterns. Authors undertook this study to determine current practice of prescribing in surgical wards of the hospital.Methods: Authors conducted observational, noninterventional, descriptive study among patients admitted in surgical wards for one year. Authors have analysed collected data of 604 patients using descriptive statistics to determine utilization pattern of drugs and drug use indicators.Results: Appendicitis (14.9%) followed by hernia (10.6%) were leading diseases for admission. Mean duration of stay was 7.44. Average number of drugs in a prescription was 8.94. Antibiotics (32.07 %), analgesics (17.11 %) and antacids (16.09 %) were leading drug groups prescribed. Amikacin (5.81 %) followed by metronidazole (5.30 %) and ciprofloxacin (5.19 %) were commonly prescribed antimicrobial drugs. Tramadol (5.31 %) and pantoprazole (7.17 %) were leading drugs prescribed from analgesics and antacids respectively. All prescriptions had at least one injectable drug. At least one antibiotic was present in 92.05 % prescriptions. Majority of drugs (87.27 %) were prescribed by generic names. Proportion of drugs prescribed from essential medicine list was 84.22 %.Conclusions: Polypharmacy and injectable drug prescribing were common in practice. There is a scope for improving such prescribing practices among practitioners. Use of multiple antibiotics should be avoided whenever possible and usage should be evidence based

Effect of time interval from completion of neoadjuvant chemotherapy to starting of adjuvant chemotherapy after interval debulking surgery on survival of patients with advanced ovarian cancer

Background: To find the effect of time interval between completion of neo adjuvant chemotherapy to the starting of adjuvant chemotherapy on the RFS and OS of patients with advanced ovarian cancers. Methods: It is a retrospective study of 170 patients with histopathological proven epithelial ovarian cancers who received full treatment (NACT+IDS+POAC) at Gujarat cancer Research Institute, Ahmedabad between 2010- 2016. They were assessed and followed up for maximum 5 year. The time interval was defined as period from the completion of NACT including Interval de-bulking surgery to initiation of chemotherapy. Results: Out of 170 patients, 86 patients (50.5%) received adjuvant chemotherapy within 44 days after neoadjuvant chemotherapy while 84 patients (49.4%) received it after 44 days. There was no significant difference in patient characteristics between these two groups. The shorter and longer TI was having recurrence in 40 (53.48%) and47 (55.55%) patients respectively. Whereas overall survival was 67.44% and 47.61% respectively. Conclusions: Our analysis showed that patients with longer time interval >44 days had poorer recurrence free survival and overall survival in comparison to lesser TI group

Should the appendix always be removed during surgery for mucinous ovarian tumors?

Background: Appendectomy is performed in all mucinous ovarian tumors (MOT) identified intraoperatively to ensure microscopic metastases from appendix are not missed. Several recent studies suggested that appendectomy should only be performed in cases with a grossly abnormal appendix or with evidence of pseudomyxoma peritonei. Our study aimed to determine the frequency of malignancy in a grossly normal appendix in women undergoing surgery for borderline or malignant MOT.Methods: In a single institution retrospective study, women undergoing surgery for MOT from January 1, 2008 to June 30, 2016 were included. Women with benign MOT, those with a history of either prior appendicectomy or prior gastrointestinal (GI) malignancy were excluded.Results: Of 266 women identified with MOT, 153 with borderline and malignant MOT were included in the study after application of inclusion criteria. The study population comprised of 29 (18.95%) borderline and 124 (81.05%) malignant MOT. Among the borderline MOT, 13/29 had undergone appendectomy. Five (38.46%) had grossly abnormal appendices of whom 1 had mucinous cystadenoma, 3 had borderline mucinous tumor and 1 had mucinous cystadenocarcinoma of the appendix. Histology was normal in all 8 (61.54%) grossly normal appendices. Among the malignant MOT, 80/124 (64.52%) underwent appendicectomy. Nineteen (23.46%) had grossly abnormal appendices and histology was suggestive of adenocarcinoma of appendix. Histology was normal in all 62 (76.54%) macroscopically normal appendices.Conclusions: Present results suggest that appendectomy be performed only for those appendices that are grossly abnormal or associated with pseudomyxoma peritonei at surgery for MO

Study of epidemiology, clinicopathological correlation, prognostic factors and management in squamous cell carcinoma of vulva

Background: Carcinoma of the vulva is rare cancer, pruritus is the most common and long-lasting reported symptom. It is found to be associated with HPV and HIV infection. Currently, a more individualized and less radical treatment is suggested. In this study we evaluated epidemiology, clinicopathological prognostic factors, HPV distribution and risk factors for metastases to lymph nodes. We also reviewed multidisciplinary clinical management carried out at our institute.Methods: It is a prospective study of 25 biopsy proven cases of Squamous Cell Carcinoma of Vulva, treated at our center from September 2014 to September 2016. We collected the data regarding the clinical presentation, histological details, treatment given, survival and complications. HPV 16 and 18 testing were done using PCR method. Median follow up of the patients are for 24 months.Results: The mean age of patients was 54.6 years. Commonest presentation was perineal itching (36%). HPV 16/18 were positive in 25% of the patients. Radical vulvectomy with bilateral groin dissection was done in 14/25 (56%) patients. Among these 14 patients, 35.7 % (5/14) has lymph node metastases, disease free survival was 63.6% and overall survival was 81.1% for median follow up of 24 months. About one third of the patient presented with locally advanced disease.  Six (24%) patients received only chemo radiation as a treatment.Conclusions: HPV and HIV infection increase the risk of vulvar cancer. Individualization of treatment is necessary. The use of preoperative chemoradiation in locally advanced disease might have promising results in future