A cluster randomized, controlled trial of breast and cervix cancer screening in Mumbai, India: methodology and interim results after three rounds of screening

Cervix and Breast cancers are the most common cancers among women worldwide and extract a large toll in developing countries. In May 1998, supported by a grant from the NCI (US), the Tata Memorial Hospital, Mumbai, India, started a cluster-randomized, controlled, screening-trial for cervix and breast cancer using trained primary health workers to provide health-education, visual-inspection of cervix (with 4% acetic acid-VIA) and clinical breast examination (CBE) in the screening arm, and only health education in the control arm. Four rounds of screening at 2-year intervals will be followed by 8 years of monitoring for incidence and mortality from cervix and breast cancers. The methodology and interim results after three rounds of screening are presented here. Good randomization was achieved between the screening (n = 75360) and control arms (n = 76178). In the screening arm we see: High screening participation rates; Low attrition; Good compliance to diagnostic confirmation; Significant downstaging; Excellent treatment completion rate; Improving case fatality ratios. The ever-screened and never-screened participants in the screening arm show significant differences with reference to the variables religion, language, age, education, occupation, income and health-seeking behavior for gynecological and breast-related complaints. During the same period, in the control arm we see excellent participation rate for health education; Low attrition and a good number of symptomatic referrals for both cervix and breast

Is human papillomavirus vaccination likely to be a useful strategy in India?

Two vaccines that protect against infection by some of the oncogenic human papillomavirus (HPV) subtypes have recently been licensed for use in population-based vaccination strategies in many countries. However, these products are being promoted as ′cervical cancer vaccines′ based on inadequate data. Specifically, there remain several concerns about the duration of immunogenicity, length of follow-up of trial subjects, endpoints chosen in vaccine trials, applicability of trial results to real populations, the safety of these products, and their cost-effectiveness as public health interventions. Furthermore, it is unlikely that vaccination will obviate the need for setting up robust and cost-effective screening programs in countries like India. This article will discuss various aspects of HPV vaccination from a public health perspective, especially from the point of view of its relevance to India and other South Asian countries

Cytopathological features of scar endometriosis mimicking an adenocarcinoma: A diagnostic pitfall

Scar endometriosis can be a diagnostic challenge in fine-needle aspiration cytology (FNAC) smears that at times, is the first diagnostic modality in such cases. The challenge is amplified when the clinical details are limited and cytopathological features reveal nuclear atypia. A 33-year-old lady presented with an abdominal swelling that she noticed after she met with a scald. Clinically, the swelling was located lateral to her 3-year-old pfannenstiel incision scar. The initial diagnosis on FNAC was metastatic adenocarcinoma. On review, smears were hypercellular, comprising epithelial cells in groups and focally, regular glandular arrangements, imperceptibly admixed with numerous, relatively smaller, short spindly cells. Epithelial cells exhibited mild to focally, moderate nuclear enlargement/atypia. Subsequent biopsy and excision revealed endometrial glands exhibiting focal nuclear atypia with adjacent stroma. Diagnosis of endometriosis was offered. The results were reinforced with positive estrogen receptor staining in the glands and stroma, along with CD10 positivity in the stroma. The patient was recommended gonadotropin releasing hormone analogs and is presently free of disease a year after her diagnosis. FNAC can be a pitfall in the diagnosis of endometriosis. Correct diagnosis has significant therapeutic implications. Although presence of atypia in such cases should not delude the diagnosing cytopathologist for consideration of endometriosis, it should be documented. The value of clinical history in such cases cannot be overemphasized

Squamous carcinoma coexistent with teratoma of ovary: A clinicopathological study of 12 cases diagnosed over a 10-year period at a tertiary cancer referral center

Background: Somatic malignancy in an ovarian teratoma including a squamous carcinoma (SCC) is rare. Clinicopathological features of 12 ovarian teratomas with coexistent SCCs are presented. Materials and Methods: Over a 10-year-period, 12 ovarian teratomas with coexistent SCCs were reviewed and analyzed. Results: The age range was 31-68 years (median, 49), and the tumor size (nine cases) varied from 10 to 18 cm (mean, 12.4). Stage-wise (10 cases), 7 cases (70%) were in stage I; a single case (10%) in stage II, and two (20%) cases were in stage III. Microscopically, all 12 tumors revealed mature teratoma with SCC, as a discrete tumor (6, 50%), or arising from the epithelium of the teratoma in six (50%) cases. SCC component was commonly moderately differentiated (eight cases) or poorly differentiated (three cases). P63 immunostaining reinforced squamous differentiation in a single poorly differentiated SCC and CK5/6 in another tumor. All patients underwent surgery. Two cases revealed positive lymph nodes and contiguous colonic involvement. Three patients (stages II and III) underwent adjuvant chemotherapy (CT). Outcomes (seven patients) (3-58 months) included five patients who are free-of-disease (all stage I) and two patients who are alive-with-disease (stages I and III). Conclusion: SCC and coexistent ovarian teratomas are rare. Most cases present at an early stage, commonly in perimenopausal women. Teratomas occurring in such patients should be optimally sampled for SCC. Teratomas coexistent with SCC are invariably mature-type. P63 is useful in differentiating poorly differentiated SCC from germ cell tumor components. Surgery forms the treatment mainstay. Adjuvant CT may be offered in high-stage that forms as an adverse prognostic parameter

Mesonephric adenocarcinoma (endometrioid type) of endocervix with diffuse mesonephric hyperplasia involving cervical wall and myometrium: An unusual case report

Malignant mesonephric tumors are rare variants of cervical adenocarcinoma, derived from remnants of mesonephric ducts and are associated with mesonephric remnants and/or mesonephric hyperplasia. Few cases have been described in literature. We report an unusual case of cervical mesonephric adenocarcinoma of endometrioid type with squamous morules in association with diffuse mesonephric hyperplasia involving the cervical walls and extending into the myometrium

Clinicopathological spectrum of 19 adenosarcomas of female genital tract, including uncommon clinical associations and immunohistochemical profile, reviewed at a single institution

Background: Adenosarcomas of the female genital tract have been rarely documented as case series from our continent. Materials and Methods: Over a seven-year period, 19 adenosarcomas were critically reviewed. Results: Nineteen tumors occurred in the age range of 21-65 years (mean: 43), in the endometrium (8), endometrium and cervix (4), cervix (4), and ovary (3). Four cases displayed coexisting leiomyomas; two, adenomyosis; two on background endometriosis; and one in post-treated cervix carcinoma. Histopathologically, the tumors were low grade (10; 52.6%) and high grade (9; 47.3%), the latter with sarcomatous overgrowth (SO) (7/9 cases). Dedifferentiation (8, 42.1%) and conspicuous decidualization (2) were noted. Immunohistochemically, the tumors focally expressed CD10 (4/6), smooth muscle actin (SMA) (3/8), desmin (8/11); diffuse vimentin (7/7), and estrogen receptor/progesterone receptor (ER/PR) (2/4). Ki-67 (6 cases) varied 5-20%. Seventeen patients underwent surgery and four received adjuvant treatment (3/4 high-grade tumors). Five tumors recurred (4 high-grade tumors with SO) and one metastasized. Among 11 patients, five were alive with disease (AWD) (mean: 29.4 months) and six, free of disease (FOD) (mean: 15 months), the latter mostly with low-grade type tumors (83.3% cases). Conclusions: Diverse clinicopathological spectrum was noted within adenosarcomas. Low-grade tumors were less aggressive than high-grade ones, with SO. Immunohistochemically, lower CD10 and ER/PR positivity was noted in high-grade tumors. Surgery formed the mainstay of treatment. Adjuvant treatment was offered in high-grade subtypes, including in tumors with SO

Surgical route and pathological risk factors in early cervical cancer - Node Zero (SURPEC-N0)

Aim: The aim of this study is to compare disease-free survival (DFS) and overall survival (OS) in patients with stage I cervical cancer (≤ 4cms, lymph node-negative) undergoing open radical hysterectomy (ORH) vs. minimally invasive radical hysterectomy (MIRH).Methods: All patients undergoing radical hysterectomy between January 2012-December 2018 from the largest tertiary referral cancer centre were included. A 1:1 propensity matching was done based on four independent prognostic factors to compare DFS and OS with the route of surgery. Results: One hundred and ninety-nine patients were included during the study period. The median age of the cohort was 50 years. The median follow-up of patients was 47 months. Following 1:1 propensity matching, a total of 174 patients were analysed for DFS and OS in ORH (n = 87) and MIRH (n = 87) groups. Protective measure was used in two-thirds of the patients during MIRH. Twenty-nine patients (16.7%) had recurrences. For the matched cohort (n = 174), the DFS at 36 and 60 months was 84.8% (78.1%-89.6%) and 81% (73.4%-86.6%) respectively and the OS was 96.5% (91.7%-98.5%) and 95.6% (90.3%-98%) respectively. There was no statistically significant difference in DFS or OS between ORH and MIRH. Conclusion: The present study showed no difference in oncological outcomes in MIRH compared to ORH. Retrospective audits on patient characteristics such as screening/vaccination history along with surgical technique/load and matching for crucial risk factors should be factored in future studies to eliminate the possible methodological errors