FIGO 2023 endometrial staging: a leap of faith into the new "prognostic based' rather than "anatomical based" staging-too fast too furious??

BACKGROUND: In 2023 FIGO revised the endometrial cancer staging system after 13 years. There is a lacuna of data regarding the performance and practicality of the revised 2023 FIGO staging schema for endometrial cancer from Low Middle-Income Countries (LMIC). OBJECTIVE: To estimate the shift of stage and adjuvant management of endometrial cancer based on the FIGO 2023 system compared to the FIGO 2009 system and assess the predictive potential of the FIGO 2023 system. MATERIAL AND METHODS: A retrospective study was conducted from 1st January 2017 to 31st December 2022. All patients with endometrial cancer were staged according to the FIGO 2023 and FIGO 2009 staging system. Follow-up of patients was done to determine recurrence. RESULTS: A total of 152 patients were included. Aggressive histology was seen in 66 (45%) patients. Eighteen (11%) had subserosal involvement. Substantial LVSI was noted in 23 (15%) of patients. Twenty-four (47%) patients of FIGO 2009 Stage IA and 26 patients (63%) of FIGO 2009 Stage IB were upstaged. Eleven (50%) patients of FIGO 2009 Stage IIIA were down staged to IA3. Overall 23 patients (15%) had a shift of stage. Fifteen out of 152 patients (15%) would have had a possible risk stratification change which would imply 23 patients (15%) would have needed a more radical treatment. Molecular classification was done in 32 patients; however, only 2 patients could afford POLE testing. Kaplan-Meier curves showed significant PFS differences in FIGO 2009 Stage IB and Stage IIIA when restaged according to the FIGO 2023 system. CONCLUSION: The FIGO 2023 endometrial staging is a more robust prognosticator; however, the practicality of molecular classification in LMICs is still a distant dream.

To study the survival outcomes of uncommon recurrences among patients with cervical cancer compared with loco-regional and nodal recurrences at a tertiary care center in North East India - Bridging the knowledge gap in the existing literature.

Background: Recurrence rates of FIGO stage IB-IIA and IIB-IVA cervical cancer  28-64  respectively. There is a scarcity of data on the recurrence recurrence pattern for unusual sites and theirrecurrence pattern for unusual sites and its association with survival and prognosis. Objective: To study overall survival in patients with distant metastasis compared to local and regional nodal metastasis. Methods: A retrospective study was done from 1/1/2017 to 30/12/22. Cervical cancer patients post primary treatments were included. Survival was analyzed with respect to 3 groups local, regional nodalconducted from 1/1/2017 to 30/12/22. Cervical cancer patients who had received primary post-primary treatments were included. Survival was analyzed with respect to three groups: local, regional nodal, and distant metastasis. Results: 225 patients had recurrences   post-completion of primary treatment, of which 105 (46.6%)(46.6 %) had local, 46 (20.4%)(20.4 %) had regional nodal, and 74 (33.3 %) had distant recurrences. The median time for recurrence in local, regional nodal, and atypical recurrences were 9, 9, and 13 months (p value - <0.05), respectively. Treatment included systemic chemotherapy 122 (54.2 %), metronomic therapy 19 (8.4 %), palliative radiotherapy 44 (19.5 %), palliative surgery 8 (3.5 %) and best supportive care 30 (13.3 %) patients. Median Time to treatment-death of patients after recurrence in local, nodal and distant recurrences was 17.0 months, 18.0 months and 10.0 months respectively (p value - < 0.05). Overall Survival of patients after primary treatment with local, nodal and distant recurrences was 35.0 months, 47.0 months and 50.0 months respectively (p value <0.05). Conclusion: Local recurrence is most common, followed by regional, nodal, and distant recurrences. Overall survival post recurrence was lowest for distant recurrences and highest for local recurrences however overall survival after primary treatment completion was highest for distant recurrence due to the late presen; however, tation of distant recurrences.

Our Experience of Distal and Total Urethrectomies in Post Irradiated Vulvar Malignancies in Low Resource Settings: A Single Centre Study.

Introduction: At diagnosis, women with vulvar cancer often present in locally advanced stage especially in developing countries, owing to the associated ignorance and social stigma. Generally tumour is seen involving adjacent organs, like the vagina, anus, and urethra. Damage to the sphincter system leads to urinary incontinence. Available evidence regarding urethral resections, subsequent lower urinary tract dysfunction and neo-meatus reconstruction in radical vulvar surgeries is scarce and conflicting. Methodology: Considering, the lack of literature on outcomes of partial and total urethrectomies post chemoradiation in advanced vulvar malignancies from India, in the current study, we analysed our experience of such cases that have been operated post chemoradiation over a span of 2 years (from January 2019 to January 2021). Results: DFS ( disease free survival) of more than 6 months was seen in 5 of our patients, however in view of local wound complications after primary closure, we recommend reconstruction with myocutaneous flaps. Also in view of incontinence observed in two of our patients who had undergone more than 1/2 of urethral resection, as a result of failed suprapubic catheterisation, further plan of urethral reconstruction should be considered especially in patients who have received prior radiation. Conclusion: Our small group of patients represents a unique cohort of patients in whom surgery was attempted after radiation therapy. We have seen that surgery is a feasible option after radiotherapy in patients with advanced disease.

Utilizing Condoms in Laparoscopic Gynecologic Cancer Surgeries: A Profitable Safeguard?

Minimally invasive approach is a well-established strategy in the initial exploration or definitive management of the eligible gynecological cancers. It provides the benefits of improved surgical recovery to the patients. However, the last step of the specimen extraction through the smallest incision possible is always challenging for most of the surgeons. The in-bag retrieval of specimen needs utmost attention in most of the malignancies for the preservation of tumor integrity to avoid tumor seedling and upstaging of the disease. The various kinds of commercially available bags are already being utilized for the retrieval of specimens. However, the venture into innovative methods of development of novel and economical specimen retrieval system is desirable owing to the high cost of the commercial endobags. Here, we have described a very simple, safe, and cost-effective technique of specimen retrieval using the ETO sterilized condoms for smaller specimens' extraction in gynecological cancer surgeries.

Intraoperative frozen section in gynaecology cancers with special reference to ovarian tumours: time to "unfreeze" the pitfalls in the path of the Derby horse of Oncology.

PURPOSE: In an oncological set up the role of frozen section biopsy is undeniable. They serve as an important tool for surgeon's intraoperative decision making but the diagnostic reliability of intraoperative frozen section may vary from institute to institute. The surgeon should be well aware of the accuracy of the frozen section reports in their setup to enable them to take decisions based on the report. This is why we had conducted a retrospective study at Dr B. Borooah Cancer Institute, Guwahati, Assam, India to find out our institutional frozen section accuracy. METHODS: The study was conducted from 1st January 2017 to 31st December 2022 (5 years). All gynaecology oncology patients who were operated on during the study period and had an intraoperative frozen section done were included in the study. Patients who had incomplete final histopathological report (HPR) or no final HPR were excluded from the study. Frozen section and final histopathology report were compared and analysed and discordant cases were analysed based on the degree of discordancy. RESULTS: For benign ovarian disease, the IFS accuracy, sensitivity and specificity are 96.7%, 100% and 93%, respectively. For borderline ovarian disease the IFS accuracy, sensitivity and specificity are 96.7%, 80% and 97.6%, respectively. For malignant ovarian disease the IFS accuracy, sensitivity and specificity are 95.4%, 89.1% and 100%, respectively. Sampling error was the most common cause of discordancy. CONCLUSION: Intraoperative frozen section may not have 100% diagnostic accuracy but still it is the running horse of our oncological institute.

Vulvar reconstruction in post-RT case using the versatile VRAM flap: reporting the rare extrapelvic approach.

Although primary vulvovaginal reconstruction following vulvectomy has a significant chance of improving patient outcomes, flap reconstruction is not a recognised component of the accepted standard of care for vulvar cancer. We provide a case of a patient who underwent successful vulvar reconstruction using the extrapelvic vertical rectus abdominis myocutaneous (VRAM) flap. This musculocutaneous flap offers adequate coverage and bulk to the perineal defect after excision in post-irradiated vulvar cancer.To proceed with sphincter-saving surgery, she was scheduled for neoadjuvant chemoradiation, as the lesion involved the urethra and perineal body. However, she experienced severe grade IV dermatitis after receiving 37 Gy of radiation. Though the lesion had reduced in size, it was still large enough to cause significant perineal deformity.We performed a vulvar reconstructive surgery using the uncommon but reliable extrapelvic VRAM flap. This well-vascularised VRAM flap is particularly useful in irradiated areas prone to poor healing. Postoperatively, the wound healed well and the patient underwent adjuvant therapy 6 weeks later. We emphasise the advantages of well-perfused muscle for the primary repair of prior irradiated perineal lesions.

Pattern of Care of Recurrent Cervical Cancer in Low-resource Settings: Challenges and Patient-initiated Follow-up as a Novel Opportunity.

Introduction: The availability of optimum diagnostic strategies remains a major problem in resource-constraint countries. This technique of patient-initiated follow-up (PIFU) has been recently adopted in the UK for gynecological cancers and has proven cost benefits. However, no study from the Indian subcontinent has ever been reported. Aims and Objectives: The primary objective was to study the pattern of care of recurrent cervical cancer in low-resource settings. The secondary objective was to compare the reliability of symptomatology/clinical evaluation and imaging methods on follow-up to detect recurrence and thus explore the feasibility of symptom-based PIFU. Materials and Methods: This was a single-institutional retrospective analysis of recurrent cervical cancer cases for a period of 3 years from January 2019 to January 2022. Patients who followed up for minimum of 6 months were included in the study. Results: In 57 of the total 69 patients, symptoms alone were the index diagnostic method. Interestingly, neither of the methods of recurrence detection had impact on overall survival (OS). Cox regression analysis revealed adverse impact of erratic/lost to follow-up (hazard ratio [HR] = 3.8) and pelvic side wall disease (HR = 1.33) on survival. Patients with positive para-aortic nodes had significantly shorter disease-free interval of 11 months, so adding systemic therapy to adjuvant treatment in this cohort needs to be further investigated. Conclusion: Our analysis showed that patients with recurrence who were diagnosed with clinical manifestations alone vis-à-vis the ones who were diagnosed primarily on routine follow-up visit by some imaging or diagnostic test had comparable oncologic outcomes. PIFU can be a "practice changing modality" in patient management system, especially in low-resource settings. It will prove to be a simple cost-effective method to detect recurrence and prevent fallouts. Our study points to the feasibility of PIFU in Indian scenario.

Reason for improper simple hysterectomy in invasive cervical cancer in Northeast India.

Objective: The objective of the study was to determine the reasons for improper simple hysterectomy in the presence of invasive cervical cancer in Northeast India. Materials and Methods: The medical records of 52 patients who had undergone improper simple hysterectomy in the presence of invasive cervical cancer and were referred to a tertiary regional cancer Institute at Guwahati, Assam, between January 2015 and December 2019 were reviewed. Results: Most of the patients presented with abnormal vaginal bleeding (40.4%). The failure to perform cervical cytology before the operation was quite high at 48.1% (25 patients). Interestingly, normal cytologic smear could still be found in 15.4% (8 patients) despite the presence of invasive cervical cancer. Failure to perform preoperative Papanicolaou smear, incomplete evaluation of cervical intraepithelial neoplasia (CIN) on cervical biopsy, and negative Papanicolaou smear accounted for 75% of the patients undergoing inappropriate simple hysterectomy. The most common indications for inappropriate operation were abnormal vaginal bleeding (40.4%) and CIN (19.2%). The reasons for inappropriate simple hysterectomy included lack of preoperative cervical cytology (48.1%), false-negative cervical cytology (15.4%), incomplete evaluation of cervical dysplasia or microinvasion on biopsy (11.5%). failure to perform indicated conization( 5.8%), emergency hysterectomy (3.8%), errors in colposcopic examination (3.8%), incomplete evaluation of an abnormal cervical cytology (3.8%), failure to review slide (3.8%) and failure to biopsy a gross cervica lesion (3.8%). Conclusion: Most improper simple hysterectomy resulted from deviation from guideline for cervical cancer detection protocols. Improper simple hysterectomy in the presence of invasive cervical cancer can be avoided if one sticks to the diagnostic guideline for patients with an abnormal cervical cytology.

Choriocarcinoma in Post-Menopausal Women- 3 Case Reports with Review of Literature.

Gestational trophoblastic neoplasia is of uncommon occurrence in postmenopausal women, unlike in the reproductive age group. The diagnosis is based on levels of beta-human chorionic gonadotropin (hCG) in serum. The management is similar to that in premenopausal women. First case, fifty-two-year-old, P8 L4A3 postmenopausal female, presented with postmenopausal bleeding. Diagnosis of choriocarcinoma was made in view of raised serum betah-CG levels with uterine lesion with lung metastasis. The patient started on Multi-agent chemotherapy. The patient succumbed to death due to Grade III hematological toxicity while on the first cycle of the EMA/CO regimen. Second case, forty-two-year-old, P2 L2, postmenopausal, with a history of Choriocarcinoma 20 years, back presented with postmenopausal bleeding. After metastatic workup, the patient started on EMACO regimen. She is asymptomatic and on regular follow-up after 8 cycles of chemotherapy. Third case, forty-seven-year-old, P4 L4, postmenopausal, presented with histopathology report suggestive of choriocarcinoma after hysterectomy. After evaluation, lung metastasis was detected. The patient responded to eight cycles to Multi-agent chemotherapy and is on regular follow-up. Choriocarcinoma is a rare gynecological malignancy in postmenopausal women. High index of suspicion is required for its diagnosis. The prognosis of the disease is not encouraging as compared to the premenopausal woman.

Female genital tract melanoma: Analysis from a regional cancer institute.

OBJECTIVE: Malignant melanoma of the genital tract comprises 3% of all melanomas afflicting females. They are characterized by poor prognosis with 5-year survival of 0-25% and high incidence for distant metastasis. This study was performed to assess various clinical features, treatment options, and thre management of genital melanomas. MATERIALS AND METHODS: This was a retrospective analysis where records of patients with genital melanomas between 2005 to 2018 were reviewed to obtain demographic and clinical information, including age of diagnosis, presenting symptoms, performance status, pathology reports, treatment, follow-up, and survival. RESULTS: Between 2005 and 2018, 31 women were analyzed. The median age was 53.5 (range: 28.5-85) years. Vaginal bleeding was the most common presenting symptom (80.6%), followed by discharge (29%), mass in the vagina/perineum (19.3%), pain (16.1%), and difficulty in micturition (9.6%). The most common site of origin was the vagina (67.7%), followed by that vulva (19.3%) and cervix (12.9%). Tumor diameter was more than 3 cm in 74.2% (23/31). Out of 31 patients, only 16 opted for treatment. Four patients underwent surgery, 10 received primary chemotherapy, and two needed palliative radiotherapy for heavy bleeding. The median survival in the treatment group was 5 (range: 2.5-28) months, almost similar to patients not receiving any treatment (5 months, range: 2-11). CONCLUSION: Genital melanoma are rare but aggressive tumors. Diagnosis is usually made with biopsy. No effective treatment strategy is yet available. However, surgery is the preferred first- line treatment, radiotherapy and chemotherapy have been used in adjuvant settings.

An Overview of Vulvar Cancer: A Single-Center Study from Northeast India.

STUDY: Carcinoma vulva is a rare cancer of the female genital tract. It mostly presents in postmenopausal women. The treatment of vulvar cancer is surgery, chemoradiation, radiotherapy or a combination of all modalities. Here, we present a study of 33 cases of carcinoma vulva over a period of 2 years at a Northeast India regional cancer institute describing its demographic features and treatment outcomes. METHODOLOGY: A retrospective cohort study of vulvar cancer diagnosed at Northeast India regional cancer institute from January 2017 to December 2018. RESULTS: A total of 33 cases of biopsy proven carcinoma (Ca) vulva were studied. Maximum number of cases belonged to the age group: 60-69 years (39.4%). 66.67% cases had palpable inguinal lymph nodes at presentation, and 100% had squamous cell carcinoma on histopathology. Maximum number of cases belonged to stage III (44.8%), and least number of cases belonged to stage IV (10.3%) of FIGO 2009 staging of Ca vulva. 87.9% cases underwent treatment, and 12.1% were lost to follow-up. Out of the cases who underwent treatment, 55.2% cases were taken up for primary surgery and 44.8% cases for primary radiotherapy. 75% cases who underwent surgery received adjuvant radiotherapy. No complication was seen in patients post-radiation. But, 6.25% patients post-surgery developed lymphocyst and 18.75% patients developed wound necrosis (p > 0.05). CONCLUSION: Vulvar cancer is not a common malignancy of the female genital tract that presents in sixth and seventh decades of life and often with palpable inguinal lymph nodes. Though early stages of Ca vulva are treated by surgery, the incidence of immediate postoperative complications in our study was more as compared to post-radiotherapy. Also, maximum patients in the present study post-surgery received adjuvant radiotherapy. Thus, radiotherapy can be considered as the primary treatment modality for patients with early as well as advanced vulvar carcinoma.