bluuebunny/crossref_metadata_2025 huggingface dataset:
Sclerosing sex cord stromal tumour of the ovary: A rare variant of ovarian neoplasms in childhood and adolescence
Authors: Chopra Seema
Published: February 2021

Case Report: 19 yr old unmarried girl c/o abdominal distension, loss of appetite and Irregular menstrual cycles x 5 months. USG: gross ascites, liver, Lobulated isoechoic mass in right adnexa, 7x5 cm, abutting right ovary. CA125: 1297 U/ml. FNAC Degenerated crushed cells & stromal fragments. Few scattered benign oval/spindle cells. Laparoscopy f/b laparotomy: 6 litres of straw colored asciic fluid drained. Uterus, left adnexa normal. Rt ovarian mass 6x7 cm, bilobed, arising from ovary. Solid, stuck in POD Adherent to gut. Right oophrectomy done. CA-125: 22 u/ml on day 6 post op. HPE – Sclerosing stromal tumor.

Discussion: Sclerosing sex cord stromal tumour of the ovary is a rare tumor; accounts for 6% of ovarian stromal tumors Over a 100 reported tumors in literature. 80% of SST seen in second and third decade of life. Essentially a benign tumour, Usually a unilateral nonfunctioning tumor. Few cases with elevated serum CA-125 and hormonal abnormalities have been reported. Endocrine alterations caused by secretion of estrogen, progesterone or testosterone; induction of precocious puberty.

Conclusion: Unilateral oophrectomy is the treatment. No recurrence of the tumor in the patients treated by oophorectomy or by conservative resection of the tumor. Excision of the tumor isfollowed by normal menses, pregnancy has also been reported.
Growing teratoma syndrome: A case report
Authors: Gupta Swati , Shamsunder Saritha , Purwar Roli , Jha Vidya , Yadav A. K. , Malik Sunita , Verma Rakesh , Kataria S. P.
Published: February 2021

Introduction: Growing teratoma syndrome (GTS) or chemotherapeutic retro conversion is an extremely rare phenomenon seen in about 1.9-7.6% of patients being treated for non-seminomatous testicular germ cell tumor. It is even more rarely reported in females with only sporadic cases reported so far. It was described by logothetis et al and is described as conversion of immature teratoma to mature one after chemotherapy and presents as growing and metastasizing mass.

Case Report: We report a case of 10 year old girl who underwent conservative surgery for an adnexal mass reported as immature teratoma on histopathology. Following which she was given chemotherapy for rapidly developing ascites. After four cycles of chemotherapy, the pelvic mass increased in size with metastatic deposits around the liver. Re-laparotomy and removal of the ovarian mass and metastatic deposits was carried out in stages. The histopathology showed mature teratoma.

Conclusion: GTS is an extremely rare occurrence and it is important for the clinicians to know it to avoid misdiagnosis. Moreover, being a chemo-resistant tumor, early diagnosis and surgery are curative.
Sertoli cell tumor of ovary: A rare case report
Authors: Jethwani Umesh , Jethwani Divya
Published: February 2021

Introduction: Sertoli-Leydig cell tumor (SLCT) is a rare ovarian tumor, Constitute less than 0.5% of ovarian tumors. Most tumors are unilateral, confined to the ovaries. They are seen during the second and third decades of life. They are characterized by the presence of testicular structures that produce androgens. Patients have symptoms of virilization (depending on the quantity of androgen).

Case Report: A 42-year-old woman presented Amenorrhea for 14 months. Change in her voice for 1 year and Excessive hair growth on her face, chest, and limbs for the last 2 months. She complained of vague abdominal discomfort. No history of anorexia, weight loss, increased libido. Her medical and family history was unremarkable. On examination - Hirsutism and clitoromegaly. Lump of size 10x8 cm palpable in left iliac fossa. Vaginal examination revealed a firm and mobile cystic mass in the right adnexa. An ultrasound examination of the pelvis showed a 17x 13x 9-cm heterogeneous solid cystic mass replacing the left ovary. The right ovary and the uterus were normal. CECT Scan Abdomen-Large heterogenous encapsulated solid soft tissue mass lesions containing areas of calcification arising from left ovary of size 17x13x10.6cm causing displacement of urinary bladder and surrounding bowel loops. Serum testosterone level -2 ng/mL (normal, 0.2–1.2 ng/mL); (DHEAS), CA 125, and alpha fetoprotein (AFP) -normal. On Laparotmy-Large mass of size 17 X 13 cm arising from left adnexa. Uterus and right ovary grossly normal. Total Abdominal hysterectomy, B/L Salpingo-opherectomy and infracolic omentectomy was done. Peritoneal washing were sent for cytologic examination for malignant cells. No liver metastasis. The post operative period was uneventful. Histopathology revealed- confirmed it be Sertoli Leydig cell tumor. 3month follow up – resolution of her virilization symptoms. No increase of her hirsutism. Repeat testosterone levels - within normal range.

Conclusion: Only few cases of SLCT have been reported till date Prognosis depends on extent of disease, stage of disease, tumour differentiation, grade. The treatment should be individualized according to the location, state of spread and the patient’s condition.
Ovarian fibrothecoma: An uncommon cause of a large pelvic mass
Authors: Kumari Nikita , Kanwar Reenu , Bajaj Bindu , Kapoor Garima
Published: February 2021

Introduction: Ovarian fibrothecomas represent an ovarian stromal neoplasm developing in a wide spectrum of clinical settings. These tumors have been described as rare ovarian neoplasm, accounting for about 4% of all ovarian tumors. We report a case whose clinical presentation was highly deceptive and was clinically and radiologically diagnosed as malignant ovarian tumor. Ascitic fluid cytology revealed absence of malignant cells. On histopathological examination, it was diagnosed as benign fibrothecoma with cystic changes. Postoperative follow-up for about six months was uneventful.

Case: A 45 year old female presented to the gynae emergency with large abdominal lump of 20 weeks size with acute pain abdomen. She was admitted for initial management and thorough evaluation. Hematological and biochemical parameters were within normal limits. USG revealed a large multilocular, predominantly cystic lesion 20.9x9.6x11.4 cm in pelvis. CECT revealed ovarian cystadencarcinoma left ovary with locoregional mass effect, mild ascites and suspicious metastasis to internal iliac lymph nodes. Radiological and preoperative clinical diagnosis was malignant ovarian tumor. Panhysterectomy and omentectomy was performed. On gross examination, a well encapsulated, multinodular cystic tumor of left ovary about 17x14x7 cm was identified. Cut surface was mostly solid with few cystic areas. Uterus, cervix, right ovary and both tubes were unremarkable. On microscopic examination, multiple sections showed spindle shaped cells in storiform and palisading pattern. No mitotic activity was identified. On special staining, it was positive for vimentin, which is a characteristic feature of ovarian fibrothecoma.

Conclusion: The accurate preoperative diagnosis of ovarian fibrothecoma with cystic changes could have prevented the extensive surgical intervention such as bilateral salpingo- oopherectomy with hysterectomy.
Two interesting cases of granulosa cell tumor: A case report
Authors: Savita Pannu , Harsha Khullar
Published: February 2021

Introduction: Granulosa cell tumor (GCT) is an ovarian malignancy that arise from granulosa cells of the ovary. This tumour is a type of the sex cord-gonadal stromal tumour. GCT have good prognosis in comparison with other epithelial tumors.

Methodology: Two cases of granulosa cell tumors were diagnosed in sir Ganga ram hospital, Rajendernagar, New Delhi in December 2015 and January 2016. The patient’s age, clinical manifestations, radiological and histopathological findings were evaluated. One was in perimenopausal age group and other case was in postmenopausal age group. The clinical manifestations were menorrhagia and abdominal pain. Ultrasonographically, in one case focal hypoechoic zone showing peripheral hypervascularity with possibility of old hemorrhage follicular cyst was seen and in other case of granulosa cell tumors was both solid and cystic areas were seen. Histologically, variety of patterns like diffuse, trabecular, nodular, sheets, nests and fascicular patterns with nuclear grooving in ovarian tissue. In addition endometrial findings were suggestive of simple hyperplasia without atypia. Treatment modalility used was surgery i.e., Total hysterectomy and bilateral salpingo-oophorectomy in both cases.

Conclusion: Granulosa cell tumor of the ovary is a rare ovarian malignancy. Endometrial pathology to rule out endometrial carcinomaspecially when postmenopausal bleeding is concomitant finding is advised. Radical surgery is usually not required.
Study of factors to predict recurrence in early stage endometrial cancer
Authors: Bhatia Shruti , Das S. K.
Published: February 2021

Introduction: Risk stratification of patients with early endometrial cancer for recurrence is inadequate.

Objectives: To study factors that influence recurrence in uterus-confined, early stage endometrial cancer (UCD).

Patients and Methods: We studied 140 consecutive patients with endometrial cancer, operated at Action Cancer Hospital, Delhi, from August 2010 to September 2015. All patients underwent staging laparotomy, TAH + BSO + BLPND + para-aortic LN sampling, and omental biopsy. Adjuvant treatment was given as per the NCCN guidelines. They were followed up 3 monthly for 2 years, and 6 monthly thereafter. 121 patients (86.4%) had UCD (FIGO stages IA, IB, II). Excluding one post-operative mortality, and 4 who were lost to follow up, we included 116 patients in this study.

Results: The median age of these patients was 60.5 years (range: 35-81 years), with median BMI of 31.2 kg/m2 (range=19.8-57.5). Diabetes or hypertension was present in either or both of 76 (65.5%) patients. The median pelvic LN harvest was 17 (range: 4-42). Eight (6.9%) patients had non-endometroid histology, and 5 (4.3%) patients had LVSI. Grade 1, 2, and 3 tumor was found in 74 (63.8%), 30 (25.9%), and 12 (10.3%) patients, respectively. The median follow up was 28 months (range 5-61 months), and recurrence was seen in 13 (11.2%) patients. On univariate analysis we found that age, co-morbidities (DM and HT), LVSI, and non-endometroid histology were related to recurrence. The tumor grade and adjuvant treatment did not influence recurrence rates. On multivariate analysis, presence of comorbidities and non-endometroid histology were independently related to disease recurrence (p=0.044, and 0.011, respectively).

Conclusions: Disease recurrence was seen in one in ten patients with UCD, despite stage-appropriate treatment. Presence of co-morbidities and non-endometroid histology were independently related to recurrence.
Oral Abstract
Authors: Ram Dharma
Published: February 2021

Introduction: Uterine sarcoma accounts for nearly 3% of all uterine malignancies. They have 4 major pathology includes endometrial stromal sarcoma high grade, ESS low grade, uterine leiomyosarcoma (uLMS) and undifferentiated uterine sarcoma (UUS). Recent WHO classification 2014, recognizes low grade ESS and high grade ESS as distinct entity. They differ from endometrial carcinoma in their aggressive nature and poor prognosis. We review our database and found total 44 eligible patient treated at our institute.

Materials and Methods: Its retrospective analysis of computer based database of our institute from January 2009 to December 2015. We analyzed demographic, pathological, treatment and survival data.

Results: Total 44 patient treated for uterine sarcoma at our institute. Among these 16 were operated at our institute during study period. Here we reporting results of operated patients at our institute. The histological diagnosis LMS (5/16), ESS-L (4/16), MMMT (3/16), UUS (3/16) and ESS-H (1/16). Stage distribution was stage I, (6/16) stage II, (5/16) stage III, (3/16) stage IV, (0/16) and unknown stage (2/16). Two patients underwent completion surgery for outside myomectomy. The adjuvant treatment was CT in 3/16, CT with RT in 7/16, HT in 4/16 and one lost to follow up with one was put on observation. Median follow up is 30 month with 14 patients alive and one lost to follow up. At last follow up 4 patients alive with metastatic disease and 10 patients alive with no evidence of disease.

Conclusion: Uterine sarcoma are uncommon disease with
Study of PTEN immunohistochemical expression in endometrial hyperplasia
Authors: Qureshi Sabuhi
Published: February 2021

Objective: The incidence of endometrial hyperplasia & carcinoma is increasing in developing nations. Newer techniques are being tried to recognise endometrial hyperplasia. One of these is tumor suppressor gene phosphatase & tensin homologue (PTEN). It is frequently inactivated i.e turned off in endometrial hyperplasia lesions. This is an early event in endometrial tumorigenesis that may occur in response to known endocrine risk factors & offers an informative immunohistochemical marker for premalignant disease. The present study was planned to study PTEN immunohistochemical expression in endometrial hyperplasia.

Methods: Women of >40 years of age presenting with abnormal uterine bleeding in the OPD of OBGYN Department of KG Medical University underwent endometrial biopsy. The histopathology of the biopsy tissue was done in department of Pathology of KG Medical University. The cases of endometrial hyperplasia were studied for PTEN immunohistochemical expression.

Results: 168 women of >40 years of age with abnormal uterine bleeding underwent endometrial biopsy. 50 women were diagnosed as endometrial hyperplasia. Of these, PTEN evaluation was done in 27 cases. Loss of PTEN expression was found in 11 cases (40.74%) of endometrial hyperplasia. Loss of PTEN expression was more in complex hyperplasia with atypia (66.66%) as compared to simple hyperplasia without atypia (29.4%).

Conclusion: There is positive correlation between loss of PTEN expression and grade of morphological differentiation of hyperplasia.
Clinicopathological analysis of early endometrial cancers
Authors: Singhal Seema , Jain Sunesh Kumar , Sharma D. N. , Mathur Sandeep , Bharti Juhi , Yadav Anshu , Roy K. K. , Singh Neeta , Meena Jyoti
Published: February 2021

Aim: The study objectives were evaluation of clinicopathological characteristics, correlations between the preoperative and postoperative tumor assessment in early stage endometrial cancer.

Materials and Methods: We conducted a prospective descriptive study of 30 cases of endometrial cancer stage 1 examined and treated at a tertiary care teaching institute between the years 2014-15.

Results: The patients’ mean age at the time of diagnosis was 56.4 years. The mean parity was two. Postmenopausal bleeding with or without abnormal vaginal discharge was the most frequent symptom; it was present in 84.7% of patients. Co morbidities like hypertension and diabetes were seen in 65% of women. 6/30 patients had family history of some malignancy. All the patients underwent Type I extrafascial hysterectomy with bilateral salpingo oophorectomy, one case had Type I extrafascial hysterectomy with infracolic omentectomy. A total of 10.6% cases had lymph nodes metastasis and none of these patients had ovarian metastasis or positive peritoneal cytology. None of the patients with superficial myometrial invasion (MI) had lymph node metastasis. None of the cases showed positive peritoneal cytology. Staging upgraded from 1a to 1b in 50% of subjects after final histopathological analysis. One patient who was operated as endometrial hyperplasia with atypia actually had endometrial adenocarcinoma in the postoperative specimen.

Conclusions: There is a poor correlation between the preoperative and the postoperative tumor assessment.
Leiomyosarcoma: Case report
Authors: Garg Poonam
Published: February 2021

Introduction: Uterine sarcomas are rare aggressive mesenchymal tumours with limited prognosis which accounts for only 2%-8% of all uterine malignancies. The most frequent type in uterine sarcomas is leiomyosarcoma (LMS) which is seen in about 60% of cases.

Case Report: We report 2 cases who presentated with different symptomology. After examination and imaging modalities, definitive diagnosis was made after histopathology report. Treatment in the form of neo adjuvant chemotherapy followed by Surgery and chemotherapy/radiotherapy was given. On follow up, both patients had relapse and later they died.

Conclusion: Rate of recurrence of leiomyosarcoma is high and prognosis depends upon age, grade, tumor size and mitotic rate. Overall survival rate ranges from 15% to 25% with a median survival of only 10 months. Early detection and more trials to evaluate treatment strategies can improve survival.
Presentation of endometrial carcinoma in young women
Authors: Lekhi Anshika , Manchanda Rahul , Jain Nidhi , Chithra Sravani , Kausar Hena
Published: February 2021

Background: Endometrial carcinoma is a disease of older postmenopausal women, and is relatively uncommon in patients younger than 40 years. Endometrial carcinomas in this age group may be familial, associated with Lynch syndrome, or sporadic. Patient usually has increased exposure to estrogen. In 2%–14% of cases, it occurs in young patients (less than 40 years of age) who are eager to preserve their fertility. Its treatment includes hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy and in some cases, radiation therapy. Prevention of fertility is major challenge encountered in such cases.

Aim: To present a case of young woman with endometrial carcinoma and through it to review the literature of its presentation and management in such groups.

Case: We report a case of endometrial cancer in a 35-year-old woman with previous 3 cesarean treated for abnormal uterine bleeding and cared for in our department.

Conclusion: Most endometrial carcinomas presenting in this young age are associated with estrogen excess. Pathologically they are usually low-grade endometrioid carcinomas with lower stage and are associated with favorable clinical outcomes. With this case the authors emphasize the need of endometrial reckoning in young females with abnormal bleeding before starting any medical treatment. Also highlighting the management options in such cases where fertility preservation holds challenge.
Metastatic gestational trophoblastic neoplasia presenting after a normal pregnancy
Authors: Purwar Roli , Shamsunder Saritha , Gupta Swati , Khanna Geetika , Rani Usha , Malik Sunita
Published: February 2021

Gestational Trophoblastic Neoplasia presenting after a normal delivery is very rare & seen in 1 in 1,60,000 pregnancies and is associated with a poor outcome due to delay in diagnosis. Only three cases have been reported in the literature till date. A 27 year old lady, P2L1 delivered a stillborn baby in some peripheral hospital. Intrapartumand post-partum period were uneventful. After a period of 2 months, in view of persistent bleeding pervaginumshe underwent dilatation & evacuation in the same hospital. Ultrasonography showed circumscribed lesion 4.1 x 3.6 cm in lower uterine segment indenting the endometrium. MRI showed a heterogeneous space (4.2 x 3.2 x 3.3 cm) occupying lesion extending to involve the anterior myometrium. She was discharged on single dose of methotrexate 50 mg intramuscular injection. After one month, she again had an episode of heavy bleeding pervaginum leading to shock, for which she was referred to Safdarjung Hospital for further management. At Safdarjung Hospital an emergency hysterectomy was performed as a lifesaving measure. Preoperative serum Bhcg was >1 lac mIU/ml. later it was reported as gestational choriocarcinoma by histopathology. Metastatic workup showed cannonball lesions in lungs. On the 10th post-op day, she had severe episode of headache followed by right sided hemiplegia. NCCT head showed multiple haemorrhagiclesion in bilateral parietal and right frontal region suggestive of brain metastasis. She was started on the EMA/CO regimen.

Conclusion: The main modality of treatment of choriocarcinoma is multiagent chemotherapy. Hysterectomy is generally reserved for those gestational trophoblasticneoplasia where it is chemotherapy resistant. Although in exceptional circumstances of heavy uncontrolled bleeding per vaginum hysterectomy is a lifesaving procedure, it is not curative to the other metastatic manifestations.
Clinicopathological analysis of early endometrial cancers
Authors: Singhal Seema , Jain Sunesh Kumar , Sharma D. N. , Mathur Sandeep , Bharti Juhi , Yadav Anshu , Roy K. K. , Singh Neeta , Meena Jyoti
Published: February 2021

Aim: The study objectives were evaluation of clinicopathological characteristics, correlations between the preoperative and postoperative tumor assessment in early stage endometrial cancer.

Materials and Methods: We conducted a prospective descriptive study of 30 cases of endometrial cancer stage 1 examined and treated at a tertiary care teaching institute between the years 2014-15.

Results: The patients’ mean age at the time of diagnosis was 56.4 years. The mean parity was two. Postmenopausal bleeding with or without abnormal vaginal discharge was the most frequent symptom; it was present in 84.7% of patients. Co morbidities like hypertension and diabetes were seen in 65% of women. 6/30 patients had family history of some malignancy. All the patients underwent Type I extrafascial hysterectomy with bilateral salpingo oophorectomy, one case had Type I extrafascial hysterectomy with infracolic omentectomy. A total of 10.6% cases had lymph nodes metastasis and none of these patients had ovarian metastasis or positive peritoneal cytology. None of the patients with superficial myometrial invasion (MI) had lymph node metastasis. None of the cases showed positive peritoneal cytology. Staging upgraded fom 1a to 1b in 50% of subjects after final histopathological analysis. One patient who was operated as endometrial hyperplasia with atypia actually had endometrial adenocarcinoma in the postoperative specimen.

Conclusions: There is a poor correlation between the preoperative and the postoperative tumor assessment.
A case of invasive mole presenting as perforation uterus and massive haemoperitonium
Authors: Sharma Arti
Published: February 2021

Gestational trophoblastic neoplasia (GTN) are rare tumours that constitute less than 1% of all gynecological malignancies. Invasive mole is a distinct subgroup of GTN, which follows approximately 10-15% of complete hydatiform moles. This is a case of invasive mole presenting as uterine perforation and massive haemoperitonium. The 35 year old parous woman presented with severe pallor, acute abdominal pain and hemoperitonium. She gave history of evacuation of a molar pregnancy four month back. Her serum B-HCG was elevated (80,000 IU/ml). Laprotomy revealed perforation through the uterine fundus with purple discolouration and grapes like vesicle with massive haemoperitonium. Patient was managed by hysterectomy and packed cell transfusion was given. Postoperative followup with B-HCG levels was done and chemotherapy (methotrexate and folinic acid) was given.
Role of radical surgery in early stages of vaginal cancer
Authors: Jain Vandana , Sekhon Rupinder , Giri Shveta , Rawal Sudhir
Published: February 2021

Objectives: The objective of our present study was to evaluate the efficacy of radical vaginectomy with or without radical hysterectomy in patients with FIGO stage I and II vaginal cancers.

Materials and Methods: A retrospective study was carried out on 13 patients aged 35 – 78 years. All the patients underwent radical surgery for vaginal cancer from April 2010 till June 2015. Kaplan- meier analyses was used to calculate the disease free survival and overall survival at 12 months.

Results: The mean age of patients was 54.9 years. Twelve patients were with FIGO stage I while one had stage II vaginal cancer. The histopathology was squamous cell cancer in 9 patients, small cell neuroendocrine cancer in two patients and malignant melanoma in 2 patients. The lesion was confined to upper 2/3 of vagina in 8 cases and lower 1/3 was involved in 5 cases. All the patients underwent radical surgery. Lymph node dissection was done in eleven patients out of whom lymph nodes were positive in 4 patients. Three patients had positive margins. Adjuvant treatment was given to patients with positive margins or positive nodes. Six patients did not require any adjuvant treatment and two patients defaulted adjuvant treatment. One patient developed Vesico-vaginal fistula. Over a follow up period ranging from 6 to 67 months, recurrence developed in two patients and one of them died of disease. The 12 months Disease free survival was 82.1% and 12 months Overall Survival was 90.9%.

Conclusion: Stage I and selected stage II vaginal cancer patients have good outcomes in terms of survival and local tumor control if managed judiciously by initial surgery followed by selective adjuvant therapy.
Retrospective analysis of acute and late gastrointestinal and hematological toxicities with extended field radiation in gynaecological malignancies: A single institution data
Authors: Medichelme Chaitanya , Juneja Shagun , Punnakal Anirudh , Garg Charu , Bansal Indu , Chaudhoory Amal Roy , Bansal Anil Kumar , Anand Anil Kumar
Published: February 2021

Purpose: The aim of this study is to report a preliminary analysis of our clinical experience with extended field pelvic (conformal) radiation, with or without concurrent chemotherapy, in gynaecological malignancies.

Materials and Methods: 27 women with gynaecological malignancies (17 with Carcinoma Cervix and 10 with Carcinoma Endometrium) were treated between November 2009 and October 2015 with Extended Field abdomino-pelvic radiation. All patients were treated with conformal radiation (Intensity Modulated Radiotherpy or Volumetric Modulated Arc Therapy). All patients underwent CT Simulation followed by target and OAR delineation as per RTOG guidelines. Dose prescriped was 45-50 Gy in 1.8 Gy per fraction and boost to gross node upto 54-56 Gy. Planning was done on Eclipse Planning system, and treatment was delivered on 6 MV linac. Concurrent chemotherapy was given when indicated. All toxicities were scored according to Common Terminology Criteria for Adverse Events (CTCAE v 4.03). Dosimetric parameters were correlated with toxicities.

Results: Median follow up was 9.5 months (Range 0-52 months). 14 (51.8%) patients developed Grade 1 and 2 acute hematological toxicity and 1 (0.04%) developed Grade 3 toxicity. 10 (37%) patients developed Grade 1 and 2 acute gastrointestinal toxicity and 1 (0.04%) developed grade 4 toxicity. 3 (11.12%) patients had late toxicity in the form of prolonged leucopenia, SAIO, and Irritable Bowel Syndrome. 1 patient did not complete her treatment due to persistent leucopenia (Grade 3).

Conclusion: Extended field Radiation in Gynaecological malignancies is a reasonably well tolerated procedure when treated with IMRT or VMAT, with acceptable toxicity profile.
Anaplastic large cell lymphoma ALK negative vs. peripheral T cell lymphoma (NOS) - diagnostic dilemma
Authors: Rana Seema , Tangri Rajiv
Published: February 2021

Middle aged female presented with generalised lymphadenopathy and fever for last one month. Peripheral blood findings were within normal limits. There was no extra nodal involvement. FNAC performed initially from a cervical node suggested possibility of Hodgkin’s lymphoma and a whole node biopsy was performed. Histopathogical examination revealed effaced nodal architecture and a polymorphous population of lymphocytes, plasma cells, neutrophils and scattered large mononuclear cells with prominent nucleolus. An initial panel of CD3, CD20, LCA, CD15, CD30 and PAX5 was performed. The large atypical cells were positive for LCA, CD3 and CD30 with variable positivity for CD15. CD 30 showed Golgi and membranous staining. These large atypical cells were negative for PAX5 and CD20. In view of above findings, Hodgkin’s lymphoma was ruled out and a possibility of Non- Hodgkin’s lymphoma was considered. Further IHC markers were performed which included CD2, CD5, CD7, EMA, Alk, CD10 and KI67. CD5 showed variable positivity. The cells of interest were negative for CD2, CD7, ALK and EMA. Ki 67 index was 70-80%. Overall histological and IHC findings favoured Alk negative Anaplastic large cell lymphoma. Differential diagnosis considered was peripheral T cell lymphoma (NOS). Hodgkin’s lymphoma, peripheral T cell lymphoma (NOS) and anaplastic large cell lymphoma share common histomorphological findings. With careful analysis of Immunohistochemistry, it is easier to categorise Hodgkin’s lymphoma. ALK negative anaplastic large cell lymphoma and peripheral T cell lymphoma (NOS) are difficult to categorise and show overlapping features. We in this case have discussed clinical, histomorphological and IHC pattern of Alk negative Anaplastic large cell lymphoma.
Cohort study of vulvar cancer cases over a period of 10 years
Authors: Singh Nisha
Published: February 2021

Objective: To study the risk factors, management protocols and outcome of vulvar cancer cases over a period of 10 years in a tertiary care hospital.

Methods: It is a retrospective cohort study of vulvar cancer from January 2004 to January 2014 at King George Medical University, Lucknow. Hospital records of 41 patients with histologically proven diagnosis of vulvar cancer were studied from Department of Obstetrics and Gynecology and Department of Radiotherapy. The presence of risk factors, stage of disease, treatment modalities used and disease outcome in terms survival were studied. The data collected was analyzed and compared with the published literature.

Results: The mean age for diagnosis of vulvar cancer was 52 years and peak incidence was seen in age group of 50-70 years. Incidence was significantly more in multiparous (p = 0.001) and postmenopausal women (p = 0.007). An average of 4.1 cases were seen per year. 97.56% cases were squamous cell carcinomas including one case of verrucous carcinoma. Only one non-squamous case of Bowen’s disease was seen. 20 cases belonged to early stage (1 and 2) while 21cases had advanced disease (3 and 4). 48.78% cases were primarily treated with surgery, 26.83% with radiotherapy, 7.3% with chemotherapy and 17.07% with combined chemoradiation. 78% of surgically treated cases had mean survival of 5 years. Mean survival of 1 year was recorded in advanced disease cases. Limitation of the study was poor follow up after treatment.

Conclusion: Incidence of vulvar cancer is significantly high in multiparous and postmenopausal women. Surgical treatment is the best option in early stage of disease (stage I and II) and gives high survival rates while advanced disease treated with chemoradiation has poor survival.
Association of TNF-α–rs 281865419 polymorphism with reproductive tract infections in Indian population
Authors: Sharma Vineeta , Singhal Pallavi , Kumar Anoop , Ramachandran V. G. , Das Shukla , Bharadwaj Mausumi
Published: February 2021

Aim: To investigate the presence of reproductive tract infections (RTIs) in symptomatic and asymptomatic women in North India and association of SNPs in TNF? gene (rs-281865419 C/T) with susceptibility to these RTIs.

Methods: We collected 100 symptomatic (cases) and 100 asymptomatic women (controls) samples and screened them for RTIs. Then genotyping of TNF-? gene was performed by PCR-RFLP.

Results: Among cases the frequencies of RTIs infection is higher than control. The prevalence of HPV, C. trachomatis, T. vaginalis, Bacterial vaginosis and N. gonorrhoeae are 28% and 6%; 11%, 32% respectively while in controls it was 5%, 2%, 1% and 8% and 1%. In the present study we found that the frequency of wild homozygous genotype (TT) was lower in cases 30% (6/20) as compared to controls 60% (12/20). The frequency of the heterozygous polymorphic genotype (CT) was higher in cases 65% (65/100) as compared to controls 32% (32/100). It was interesting to note that the frequency of the polymorphic homozygous genotype (CC) was higher in cases 15% (15/100) than controls 2% (2/100). While the frequency of the carrier genotype (CT + TT) was found to be more in cases 70% (70/100) than in controls 40/100 (40%). This study shows that T allele may be risk factor for reproductive tract infections as its percentage is higher in cases as compare to normal controls.

Conclusion: TNF-? rs-281865419 locus may serve as an important biomarker for RTIs predisposition in Indian population though larger sample size is needed to validate the findings.
Vaginal dilator therapy to prevent stenosis from radiotherapy: A systematic review
Authors: Bansal Nupur , Soni Abhishek , Khurana Anil , Verma Yashpal , Kaur Paramjeet , Chauhan Ashok Kumar
Published: February 2021

Background: Pelvic radiotherapy may damage the vagina and cause vaginal stenosis. Its incidence in the literature ranges from 1.2% to 88%. To prevent vaginal stenosis, routine vaginal dilation is recommended during and after pelvic radiotherapy.

Materials and Methods: The objective was to examine critically the evidence behind this guideline. Searches included the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and Google scholarly articles. All the relevant articles were included in the study.

Discussion: Various studies gave recommendations on dilation during or immediately after radiotherapy. Literature does not support routine vaginal dilatation during or immediately after pelvic radiotherapy. Occasional penetration might prevent the sides of the vagina adhering to each other, and dilation might be valuable once the inflammatory and psychological scarring has settled. Two trials demonstrated that encouraging vaginal dilation increased patient compliance, but no difference was found in sexual function scores in the first trial. One retrospective study reported that dilation lowered stenosis rates, but the control group is not comparable. One study involving 89 women revealed that the median vaginal length was 6 cm, six to ten weeks after radiation therapy, but women tolerated a 9-cm dilator/measurer after 4 months of dilation experience. One trial showed no significant advantage by inserting mitomycin C. A study of five women reported that vaginal stenosis can be treated by dilation even many years after radiotherapy. Dilation during or immediately after radiotherapy can cause damage, and there is no evidence that it prevents stenosis. Dilation might stretch the vagina if commenced after the inflammatory phase. Dilation has been associated with traumatic rectovaginal fistulae and psychological consequences.

Conclusion: Vaginal dilation might help treat the late effects of radiotherapy, but it must not be assumed that this applies to the acute toxicity phase. Routine dilation during treatment is not supported by good evidence. Prophylactic and therapeutic dilation therapy needs to be considered separately and research is needed to determine when dilation therapy should start on a large population.
Female adnexal tumour of probable wolffian origin: A rare case report
Authors: Dhaduk Nehal , Dagar Mamta , Srivastava Mala , Bhardwaj Punita , Verma Tina , Ganguli Indrani ,   Nayak
Published: February 2021

Introduction: Female adnexal tumour of probable wolffian origin (FATWO), is a rare neoplasm arising within the leaves of a broad ligament or hanging from it or a fallopian tube. It is considered a tumour of low malignant potential which shares similar histological and immunochemical features with mesonephric remnants.

Case: Here we present a case repot of a 40 years old, nulliparous female who presented with acute pain abdomen and fever since 2 days. Her LMP was 30.09.2015 and her past menstrual cycles were irregular. She was nulliparous with history of infertility. In past medical history revealed her to be a known diabetic for 5 years, with uncontrolled blood sugars. Patient was hemodynamically stable. On per abdominal examination there was generalized tenderness all over the abdomen with guarding and rigidity. On per speculum examination vaginal discharge was noted with unhealthy cervix. Per vaginal examination revealed a tender mass of approximately 8 x 6 cm was felt on left fornix. All her base line investigations were normal. The salient investigations like CA-125 35.60 IU/L, CEA 3.46, Beta-HCG 2.29 were normal. On imaging, MRI showed a well defined solid cum cystic space occupying lesion of 9 x 8 cm arising from left adnexa with evidence of right hemorrhagic adnexal cyst 6 x 7 cm and hydro/hematosalpinx noted. There was well defined space occupying lesion in the pelvis on the left of the uterus which is likely a broad ligament leiomyoma. Diagnosis of acute abdomen was made with adnexal mass probably infectious in origin. Injectable antibiotics were started. In view of acute pain abdomen decision for surgical intervention was taken. Laparoscopic findings revealed bilateral ovarian abscess with left sided broad ligament mass (solid consistency) probably leiomyoma. Right tube and ovary were normal. Drainage of tuboovarian abscess with left salpingo-oophorectomy with right salpingectomy with adhesiolysis was done and sent for histopathology. HPE reported Female adnexal tumour of probable wolffian origin (FATWO) which was positive for vimentin and CD10, possibly arising from left sided broad ligament. Patient underwent radical hysterectomy with omentectomy with appendicectomy was done in view of FATWO.

Conclusion: Female adnexal tumour of probable wolffian origin (FATWO), is a rare neoplasm which is usually considered as benign, although in some cases metastasis on recurrences have been reported even after a long interval following the initial diagnosis. Pre-operative diagnosis of FATWO is very difficult because of the rarity of the disease and paucity of the literature available.
Vulvar myiasis: Atypical Presentation as carcinoma vulva
Authors: Singhal Savita Rani , Gupta Esha , Singhal S. K. ,   Parul
Published: February 2021

Myiasis is a parasitic infestation, rarely seen in the vulval region with more cases being reported in tropical, subtropical and warm temperate climate. Cutaneous myiasis can be misdiagnosed as cellulitis, leishmaniasis, sebaceous cysts, staphylococcal boil, insect bite or skin abscess. Knowledge of the characteristic clinical findings and the close inspection of skin lesions are key to diagnosing myiasis. We report a case of vulval maggots which was misdiagnosed as vulvar carcinoma and caused undue anxiety to the patient.
High precision radiotherapy for vulvar cancer in post renal transplantation: Dosimetric challenges
Authors: John Subhashini
Published: February 2021

Background: Patients with renal transplant have a higher incidence of various malignancies. Delivery of adequate radiation dose to the pelvic target in such patients sparing the transplanted kidney is a dosimetric ordeal. Due to lack of sufficient data in the literature regarding the dose constraint of the transplanted pelvic kidney, plan evaluation becomes extremely challenging in this situation. Here we present comparative dosimetric plan evaluation data of treating a patient with carcinoma of the vulva with transplanted kidney.

Methods: We compared 3D conformal radiotherapy (3DCRT) and Intensity Modulated Radiotherapy (IMRT) plans for a patient diagnosed to have carcinoma of the vulva with a transplanted kidney. Total dose of radiotherapy (63 Gy) was delivered in two phases (45 Gy in 25 fractions and 18 Gy in 10 fractions respectively). We compared dose to planning target volume (PTV), and dose to organs at risk including the transplanted kidney in these two techniques. The volumes encompassed by different isodoses (50%, 20%, 10%, 5%) were also compared. Weekly renal function test was monitored.

Results: The dose received by 95% of the planning target volume in 3DCRT was 43.3 Gy (phase 1), 17.7 Gy (phase 2) and in IMRT was 43.74 Gy (phase 1), 17.3 Gy (phase 2). The mean doses received by kidney in Phase 1 3DCRT, Phase 1 IMRT, phase 2 3DCRT and phase 2 IMRT were 0.98 Gy, 3.05 Gy, 0.74 Gy, 0.13 Gy respectively. The volumes covered by 50%, 20%, 10%, 5% were higher with IMRT plan when compared with 3DCRT plans. The creatinine values remained stable through the treatment.

Conclusion: Radiotherapy in renal transplanted patients can be done with high precision radiotherapy techniques with strict dosimetric and image guided set up verification.
Case report of vaginal melanoma
Authors: Kaur Inderjit
Published: February 2021

Primary malignant melanoma of vagina is a rare disease with a predilection for local recurrence, distant metastasis and short survival time. Due to the low incidence and lack of reporting in the literature, treatment choices still remain controversial. We describe 2 cases of vaginal malignant melanoma. A 42 yr old female presented with complaints of post coital and per vaginal bleed of 1 month duration. Examination findings shows growth 6 cm x 6 cm on anterior vaginal wall, another 3 x 3 cm lesion on right lateral vagianl wall. Vaginal biopsy showed malignant melanoma, S-100 and HMB-45 positive while negative for CK and LCA. MRI Whole abdomen showed altered lesion [3.8 cm (AP), 6.0 cm (TR) and 4.9 cm (CC)] in upper 2/3rd of vagina extending into vaginal fornices and abutting right lower cervix superiorly, right paravaginal extension and mesorectal fascia. No significant enlarged lymph nodes were seen. In view of localised disease she underwent Type III Radical hysterectomy with bilateral salpingo-ophorectomy with bilateral pelvic lymphnode dissection with total vaginectomy. Histopathology s/o 2 tumour nodules, one located in the anterior vaginal cuff measuring – 5 x 5 x 3.2 cm, another located in right lateral vaginal cuff measuring 2.5 x 3 x 1.5 cm, malignant melanoma with involvement of the cervix with full thickness stromal invasion (2.8/2.8 cm,) invading perivaginal soft tissue, distance of invasive carcinoma from closest stromal margin <0.1 cm (12 O’ clock), LVI, PNI – not seen, all pelvic LN free (0/25). In view of positive margin and full thickness stromal involvement, she received radiotherapy to pelvis and Inguinal region to a dose of 45 Gy/25# followed by a boost of 16 Gy/8# to the tumour bed till 01/01/16. Another case is a 40 yrs female, presented with complaints of bloody discharge per vaginum of 4 months duration. On examination, there was a large growth occupying the vagina till introitus. Cervix normal, para free. MRI Pelvis showed altered lesion involving left lateral uterine cervix and upper 2/3rd of vagina with full thickness stromal involvement with mild left parametrial, anterior and posterior paravaginal extension, measuring 2.9 x 4.5 x 5.3 cm. Few subcmlymphnodes were seen in bilateral external and internal iliac regions (L>R). Vaginal Biopsy was suggestive of Malignant Melanoma, expressing S-100, HMB 45 and SDX-10. Metastatic work up was negative. She underwent RH with total vaginectomy with bilateral PLND with RPLND. HPR showed exophytic black growth seen involving all quadrants of vagina, extending upwards into both lips of cervix – 7 x 6 x 2.5 cm, Malignant melanoma, distance of invasive carcinoma from closest margin: <0.1 cm (paravaginal soft tissue), 3/8 right Pelvic LN, ECE +, 01/9 Left pelvic LN, ECE absent, 0/6 Right common iliac LN, 0/1 Reperitoneal LN was seen. She received adjuvant radiotherapy to a dose of 50 Gy/25# to the pelvis and inguinals→ boost of 6 Gy/3# to nodal regions showing ECE & 10Gy/5# to the primary region.
Radical excision of a massive vulvo: Vaginal mass
Authors: Meena J. , Parthasarathy A. , Vatsa R. , Singh N. , Kumar S. , Roy K. K. , Singhal S.
Published: February 2021

Background: Vulvo-vaginal masses has a varied presentation and causes. The most common differential diagnosis are Condylomata acuminata, Vulvular abscess, Vulvular/vaginal cysts, Vulval carcinoma, Vulval lipoma, Angiomyofibroblastoma and Aggressive Angiomyxoma. Surgical excision of the mass is the main method of treatment and the outcome differs with the histological diagnosis. We present a video of excision of a massive Vulvo vaginal mass in toto.

Case: A 45 year old P3 L3 female, presented with complaint of mass in perineal area & discharge per vaginum for 2 years. The mass was growing progressively and reached the present size. On examination there was a 9 X 8 cm irregular firm to cystic mass, arising from posterior wall of vagina and protruding out of introitus with bossellated surface. The mass also extended into right ischiorectal fossa, 10 X 10 cm mass with cystic, smooth surface that was irreducible with no cough impulse. CECT abdomen and pelvis revealed a well-defined 12 X 10 X 8 cm mass in right perineum arising from right lower lateral vaginal wall with ischiorectal fossa extension. There was no extension into cervix, bladder or rectum. Biopsy taken from the mass was inconclusive. A wide local excision was done under general anesthesia wherein an ischiorectal and vaginal mass of size 30 X 10 cm with irregular margin was excised in toto. Histopathology was suggestive of Aggressive Angiomyxoma. The patient is under follow up.

Discussion: Aggressive Angiomyxoma is a rare slow growing locally invasive mesenchymal tumor and has a substantial potential for recurrence. It is often misdiagnosed. Pre-operative diagnosis is difficult due to rarity of this entity and absence of diagnostic features, but it should be considered in case of masses in genital, perianal and pelvic region in a woman of reproductive age. Radical surgical excision is the first line of management. A long term follow up of the case is necessary and MRI is preferred method for detecting recurrences.
Vulvar melanoma: Rare gynaecological malignancy
Authors: Rani Reena , Rathore Asmita , Sahu Latika , Bhasin Sangeeta
Published: February 2021

Vulvar melanoma is a rare type of gynaecological malignancy. Its poor prognosis and aggressive course provides it more significance than any other vulvar cancer. The knowledge about vulvar melanoma tends to be relatively low as compared to that of squamous cell carcinoma of vulva. This lack of data is due to the infrequency with which vulvar melanoma occurs in any place. In this presentation we are reporting a rare case of vulvar melanoma in a 70 year old lady diagnosed after complaint of persistent vulvar itching discharge per vaginum and a growth on labia on examination. She underwent radical vulvectomy with bilateral inguinofemoral lymphadenectomy and radiotherapy in postoperative period.
Pediatric vaginal rhabdomyosarcoma: Report of 2 cases
Authors: Koneru Sahitya , Jain Silky , Mishra Shalini , Jain Sandeep , Kapoor Gauri
Published: February 2021

Introduction: Rhabdomyosarcoma (RMS) arising in the female genital tract is rare accounting for 3.5% of all RMS cases. Approximately half these occur in the vagina, a site that has been associated with a favorable prognosis. Optimal loco-regional treatment for patients with vaginal RMS remains controversial since wide local excision is mutilating and often not done. Two cases of vaginal RMS are reported who underwent chemotherapy and local control with brachytherapy.

Methods: Retrospective chart review was done between 2011 and 2015. During this interval, out of 31 cases of pediatric RMS managed at our institution, 2 had vaginal RMS. Their management and outcome is detailed below.

Results - Case Materials: Two patients, both aged 2 years at the time of diagnosis, presented with grape-like mass protruding from vaginal orifice and bleeding for 1-2 months. Characteristic MRI features were of a heterogeneously enhancing polypoidal soft tissue mass filling vaginal lumen and protruding out of introitus confirming Botryoidal RMS. Biopsy and histopathology was suggestive of embryonal RMS (IHC positive for desmin, myogenin and focally for myo-D1). Tumor in both the patients was staged as Stage1 Group 3 (low risk). They were started on neo-adjuvant chemotherapy as per IRS-? Protocol with 3 weekly cycles of vincristine, dactinomycin and cyclophosphamide for 33 weeks. They had near complete regression of tumor and received brachytherapy for residual thickening of the vaginal wall. They have been followed up for 24 months and 57 months respectively from presentation, and are disease free. They are on close surveillance with periodic examination under anesthesia and imaging. One patient developed post radiation vaginal synechiae requiring vaginal dilatation.

Conclusion: In patients with non-resected vaginal RMS, good outcome can be achieved by the use of brachytherapy for local control.