Shalini Rajaram

Serous endometrial cancer with an elusive preoperative diagnosis

Uterine serous carcinoma (USC) is an aggressive histological subtype of endometrial cancer that frequently presents with early extrauterine spread, often without uterine symptoms. We report a diagnostically challenging case of a postmenopausal woman presenting with malignant ascites, peritoneal metastases and deep vein thrombosis, but no abnormal uterine bleeding. Preoperative imaging and biopsies were inconclusive, suggesting a possible leiomyoma or ovarian malignancy. Exploratory laparotomy revealed widespread peritoneal disease, and histopathology demonstrated serous carcinoma confined to an endometrial polyp with lymphovascular space invasion but no myometrial invasion. Immunohistochemistry showed p53 and p16 positivity, focal WT1 (Wilms tumor 1 protein) positivity, weak ER (estrogen receptor) expression and MMR (mismatch repair) proficiency, confirming primary USC (International Federation of Gynaecology and Obstetrics (FIGO) stage IVB). The patient was initiated on paclitaxel–carboplatin chemotherapy. This case highlights the diagnostic difficulties of USC, its potential to mimic ovarian carcinoma and the importance of integrating surgical, pathological and molecular evaluation for accurate diagnosis and management.

Role of immunohistochemistry in the fertility-sparing management of Sertoli Leydig cell tumour

Ovarian Sertoli Leydig cell tumours (SLCTs) are rare and occur predominantly in young females. Categorised as less common ovarian cancers, they have a favourable prognosis, and fertility preservation is an option in early-stage disease, where fertility is desired. Here, we describe a case of a late adolescent girl, who presented after tumour excision of left ovarian mass. Her initial histopathology report showed mucinous adenocarcinoma of left ovary. Slide review and immunohistochemistry suggested stage IC, intermediate grade Sertoli Leydig cell tumour and the patient was kept on observation. Six months later, she underwent re-surgery with fertility preservation for suspected recurrence. Final histopathology showed no residual tumour. The girl has been disease-free for 4 years. This case highlights the importance of immunohistochemistry and extensive pathology review for diagnosis of this rare tumour. It emphasises that SLCT can masquerade as other poor-grade malignancies owing to histopathological overlap.

Liquid biopsy for diagnosing epithelial ovarian cancer: quantification of cell-free DNA and p53 mutational analysis

To isolate and quantify cell-free DNA, analysis for p53 mutations, and correlation with tumor burden in women with epithelial ovarian cancer compared with benign and borderline epithelial ovarian tumors. In this case-control study, plasma samples of eligible women collected 1 hour before surgery and based on final histopathology, women with epithelial ovarian cancer recruited as cases and borderline, and benign ovarian tumors as controls. Cell-free DNA extracted from plasma serum and quantified using Nanodrop Spectrophotometer. Amplification refractory mutation system-based polymerase chain reaction was used to detect point mutation in exon 8, codon 239 of p53 using primer pairs. p53 immunostaining was performed on tissue samples. A total of 40 women (20 cases of epithelial ovarian cancer and 10 each of benign and borderline ovarian tumors [controls]) were included in a 2:1:1 ratio. The mean cell-free DNA amount was 1330 ± 1705.4 ng/mL in women with epithelial ovarian cancer compared with 748.5 ± 444.8 and 448.5 ± 203.9 ng/mL in benign and borderline ovarian tumors, respectively (p = .023). In those with high-grade serous ovarian cancer, it was 2640 ± 2450.6 ng/mL compared with 600 ± 316.7 and 652.5 ± 158.9 ng/mL in low-grade serous and mucinous ovarian cancer, respectively (p = .006). In stage I and II ovarian cancer, these were 502.5 ± 134.4 and 330 ± 296.9 ng/mL, respectively, compared with 1655 ± 1924.8 ng/mL in stage III disease (p = .004). A total of 11 (55%) women with epithelial ovarian cancer harbored mutation in exon 8, codon 239 of p53 compared with 2 (20%) each in benign and borderline ovarian tumors (p = 0.07). Fair agreement was noted between cell-free DNA p53 mutation and abnormal tissue p53 staining on immunohistochemistry (κ = 0.41). Cell-free DNA amount was higher in women with epithelial ovarian cancer than women with benign and borderline ovarian tumors, with higher levels in advanced stage and high-grade serous carcinoma sub-type. Cell-free DNA p53 mutational analysis yielded fair concordance with tumor tissue p53 immunohistochemical results.

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.