Ayush Heda

Sentinel lymph node biopsy in early stage ovarian cancer: A prospective observational study

Sentinel lymph node (SLN) biopsy is a technique to assess lymph node status in various cancers to avoid systematic lymphadenectomy and limit morbidity. This study aimed to evaluate the role of SLNB in epithelial ovarian cancer using a combination of radioactive tracer and blue dye. This prospective observational study included 29 patients with suspected stage I and II epithelial ovarian cancer. The tracer was injected subperitoneally at the utero-ovarian and infundibulopelvic ligaments. SLNs were identified followed by systematic lymphadenectomy. SLNs were subjected to ultrastaging. Detection rate, sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of SLNB was calculated. SLN detection was performed using combination of tracers for 10 cases while SLN detection was performed using methylene blue alone for 19 cases. The SLN detection rate was 100 % using both tracers while it was 89.5 % using methylene blue alone. Detection rate was 37.9 % (n = 11/29) in the para-aortic region alone, 20.7 % (n = 6/29) in the pelvic region alone and 34.5 % (n = 10/29) in both. There were 21 cases with malignant histology while there were 4 cases each of benign and borderline histology. The overall sensitivity, specificity, positive predictive value, and negative predictive value of SLNB were 100 % when sentinel node was detected in a patient. Ultrastaging detected isolated tumor cells (ITC) in five cases. No complications related to SLNB were observed. SLNB is a feasible and accurate technique to assess lymph node status in epithelial ovarian cancer using a combination of radioactive tracer and blue dye. Ultrastaging detected ITCs, however their clinical implication is not yet known.

Curious phenomenon of ‘hook effect’ in invasive mole

Gestational trophoblastic disease is a group of pregnancy-related trophoblastic tumours. Gestational trophoblastic neoplasia refers to its invasive and malignant forms: invasive mole, choriocarcinoma, placental site trophoblastic tumour and epithelioid trophoblastic tumour. Patients exhibit elevated beta human chorionic gonadotropin (β hCG) levels, sometimes exceeding 100 000 mIU/mL. When the serum levels of hCG surpass 500 000 mIU/mL, there is a possibility of encountering a phenomenon called ‘hook effect’ which causes erroneously low or negative value when using the immunometric hCG assays that are presently available in the commercial market. We present a rare case involving a female in mid-30s with an invasive molar pregnancy presenting with bleeding, an abdominal mass, hypertension and hyperthyroidism. Despite a negative urine β hCG test, her serum hCG, after dilution, was recalculated to over 850 000 mIU/mL. MRI confirmed invasive mole. Post-hysterectomy, she received methotrexate chemotherapy. Her β hCG normalised after two cycles, and she remains disease-free for 14 months.

Counselling to Screening: Honing an Institutional Cervical Cancer Screening Program

Cervical cancer screening is an important tool in WHO's global strategy for cervical cancer elimination. The objective of the study was to suggest and study the impact of capacity building interventions to increase cervical cancer screening rates in women aged 30-49 years attending the gynecological OPD. As part of a multicentric study, qualitative research was carried out at a tertiary care institute (from September 2021 to June 2022) to gather information regarding the existing cervical cancer screening practices, analyze factors preventing universal screening, and develop troubleshooting strategies. A fishbone analysis was done to identify barriers to cervical cancer screening. Stepwise sequential implementation of seven Plan-Do-Study-Act (PDSA) cycles which included; doctors training, policy formation, dedicated counsellor and reminders on social network groups, OPD card stamps, reading and educational material, screening in all OPD rooms and finally establishment of dedicated screening room. The effect of each on counselling and screening of eligible women was noted. With the implementation of these PDSA cycles, the rates of eligible women being screened increased from 10.6% at baseline to 44.8% at the end of the study period. The percentage of counselled women increased to 70% and it was observed that counselled women were more likely to get screened. Educating women about the importance of cervical cancer screening and the creation of a dedicated screening room were the two most important quality improvement interventions.

Comparison of Sexual Function after Thermal Ablation Versus Loop Electrosurgical Excision Procedure (LEEP) for Cervical Intraepithelial Neoplasia (CIN 2 and 3): A Randomized Controlled Trial

The prevention of cervical cancer can be achieved by treating high-grade cervical precancerous lesions. Treatment options for cervical precancer include excisional procedures, and ablation treatments. Despite the long pre-invasive course of the disease, literature addressing sexual function post-treatment for cervical pre-invasive lesions is scarce. This study aims to bridge this gap and assess the sexual function and the acceptability, efficacy, safety, and complications of loop electrosurgical excision procedure (LEEP) versus thermal ablation. The prospective open-label randomized controlled trial recruited women aged 22-55 with histologically confirmed Cervical Intraepithelial Neoplasia (CIN) 2 and 3 lesions. Participants were randomly allocated to either thermal ablation or LEEP. All cases were followed up with a Pap smear at three- and six-months post treatment. Sexual health assessments were conducted using a questionnaire at baseline and 3 months post-procedure. Secondary outcome measures included comparison of acceptability, pain, and side effects between the two treatment measures. Out of 1356 screened cases, 60 were included in the study and randomized in two groups. The groups had similar baseline characteristics. Duration of LEEP was longer than thermal ablation (25.33 vs. 20.67 minutes), with higher pain reported 10 minutes post-procedure in the LEEP group. Three months post-procedure, both groups showed comparable acceptability and symptom relief. Sexual function parameters significantly improved in the thermal ablation group compared to LEEP, including satisfaction, desire, lubrication, flexibility, and ability to reach climax. LEEP and thermal ablation are effective treatments for CIN with similar efficacy at 6 months. Thermal ablation demonstrated advantages in procedure time and post-procedural pain but exhibited varying effects on sexual function, improving satisfaction and desire. In contrast, LEEP showed a decrease in satisfaction and potential alterations in lubrication and flexibility. Larger-sample, longer-term studies are recommended for further insights.

Community Screening for High-Risk Human Papilloma Virus Infection using Self-Sampling and ‘Point-Of-Care’ Test

HR-HPV types 16 and 18 are responsible for pre-invasive and invasive lesions of the cervix, accounting for 70-80% of the total subtypes. The aim of this study was to investigate the prevalence of high-risk HPV subtypes 16 and 18 in self-collected vaginal samples using real-time micro-PCR and to study the acceptability of self-sampling. Eligible women (30-65 years) were screened from a semi-urban area of Uttarakhand (India) using self-sampling. High-risk HPV genotypes (16/31 and 18/45) were tested using real-time micro-PCR technique with results available in one hour. The positive results were validated by standard RT-PCR for high-risk HPV 16, 18, separately and for 12 other high-risk genotypes, combined. Ease of the procedure, level of comfort, and recommendation to other women were studied and the acceptability of self-sampling was analyzed using the Likert scale. Of 975 eligible women screened, 45 participants tested positive for HR-HPV (16/31,18/45) using real-time micro-PCR with a prevalence of 4.6%. Positive samples were further tested through routine RT-PCR and 60% were found to be HR-HPV 16 and 18 positive. For self-sampling, 96.72% (n=943) participants were 'very satisfied' and 94.15% (n=918) found self-sampling to be 'very comfortable' and 88.51% (n=863) stated that they will strongly recommend this test to other eligible women in the community. We conclude that HR-HPV testing with limited genotyping showed a prevalence of 4.6%, 60% of these were HPV 16/18 positive. Point of care testing was feasible in the community and self-sampling was acceptable.

Large vulvar fibroepithelial polyp and review of differentials

Vulval fibroepithelial polyps (FEPs) are a rare type of vulval fibroblastic tumour commonly found in premenopausal women. It is important to obtain an accurate pathological diagnosis because, despite being benign, the condition shares some characteristics with malignant vulva lesions in its differential diagnosis. We present a case of young woman in her 20s with a giant FEP. After surgical excision, the patient did not manifest any signs of recurrence after 1-year follow-up. Our review focuses on the distinguishing characteristics of these rare neoplasms as we explore their differential diagnosis.