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

Study of automated hematology analyzer’s scatterplot patterns in white blood cell disorders

Background: Automated hematology analyzers produce scattergrams that can be used as screening tool for various hematological conditions and efficiently shorten turnaround times. Aim was to study scattergram patterns of various while blood cell disorders and assess their efficacy compared to a peripheral blood smear for diagnosis of various disorders. Methods: Scattergram findings generated by UniCel® DxH 800 automated hematology analyzer, a 5-part differential analyzer. The graphic displays have been compiled over a period of 3 months from blood samples received for CBC. Samples that the counter flagged as abnormal for white blood cell were chosen. Based on the scatterplots, a preliminary diagnosis was formed. It was compared with the peripheral blood smear (PBS) findings which were taken as the gold standard. Results: The scatterplots showed unique patterns for various disorders on the basis of location, shape, size, density of the cells and their clustering. The scattergram analyser showed 90% sensitivity and 88% specificity for diagnosing hematological disorders. A 97-100% accuracy rate was reported showing excellent correlation between PBS result and WBC parameter result in cell counter analyzers. Conclusions: Not all cases of haematological malignancy exhibit cytopenias or cytosis at initial presentation. Therefore, these scatter plots offer helpful information that prompts a hematopathologist to suspiciously screen the peripheral smear in cases with normal counts. Scattergram analysis suspects a diagnosis earlier than peripheral smear examination. Given their strong correlation with a variety of WBC disorders and confirmed by PBS, WBC scatterplots can be used as a screening tool

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

Implementing a Public Private Partnership Model for Managing Urban Health in Ahmedabad

Governments in many developing countries acknowledge they are facing difficulties in their attempt to meet the basic health needs of their populations. They rely on contracting out to private (for-profit and not-for-profit) organizations as a strategy to meet the needs of underserved populations. For the most part, the public sector chooses to contract out primary healthcare services to the private sector to expand access, increase the availability of medicines and medical supplies, and improve the quality of care. In both urban and rural settings, private for-profit and non-profit health service providers serve both the rich and the poor. Communities often recognize private sector healthcare providers to be more responsive to their healthcare needs and preferences in terms of services available, suitable timings and geographical access etc. Private sector has always played a significant role in the delivery of health services in developing countries. Public-private-partnership (PPP) is an approach under which services are delivered by the private sector, while the responsibility for providing the resources rests with the government. Establishing a PPP requires a legal framework acceptable to all the partners, clarity on the commitment of resources, roles and responsibilities of each partner, as well as accountability to provide a given set of services at a desired level of quality and affordable user charges. Formalizing such an arrangement between partners requires conceptualising a framework for Public Private Partnership (PPP) to manage the delivery of health services. In this paper, we describe the design, development and implementation of a PPP for managing urban health services in Ahmedabad city, Gujarat. Our model has succeeded in bringing together compatible public and private partners to plan and deliver quality healthcare services to meet the community needs of Vasna ward, in Ahmedabad. The new Vasna Urban Health centre was inaugurated on July 23, by the Chief Minister of Guajarat. This new centre now serves about 120 outpatients everyday as against an average of 10 outpatients daily earlier.

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

Prevalence of hypomagnesemia in patients undergoing gynecological oncology surgery in tertiary care cancer institute of India

Background: Hypomagnesemia is an important but unknown risk factor for post-operative complications in patients undergoing surgery for presumed gynecological malignancy. This study aims to evaluate the prevalence of hypomagnesemia in patients undergoing surgery for presumed gynecological cancers referred to our tertiary care Cancer Institute.Methods: This is a prospective observational study of 100 patients admitted with provisional diagnosis of malignancy. They underwent surgery in one of the Gynecologic Oncology units at The Gujarat Cancer Research Institute, Ahmedabad from October 2016 to April 2017. Hypomagnesemia was defined a serum magnesium levels less than 1.8mg/dl.Results: The incidence of pre-operative hypomagnesemia in the entire cohort was 35%. Sixty three percent patients had normal pre-operative magnesium levels and hypermagnesemia was seen in 2% of study population. Patients with benign disease had 29.6% pre-operative hypomagnesemia compared with 39.6% in patients with gynecologic malignancy. Pre-operative hypomagnesemia and even falling levels in post-operative period are an important predictive marker for post-operative complications like increased post-operative pain, post-operative ileus, hypertension and even post-operative hypokalemia. Age, body mass index, hematocrit, surgical indication and length of hospital stay were not associated with hypomagnesemia. Patients undergoing neo-adjuvant chemotherapy before surgery had significant incidence of hypomagnesemia both pre-operatively and post-operatively.Conclusions: Hypomagnesemia is quite prevalent in patients of gynecologic-oncology undergoing surgery. Pre-operative hypomagnesemia and even falling levels in post-operative period have a bearing on the final surgical outcome. Hence pre-operative and post-operative magnesium levels may be included as a valuable marker in all patients undergoing surgery for gynecologic 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

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