Gauri Gandhi

Visual inspection of the cervix with acetic acid for cervical intraepithelial lesions.

Objective: Evaluation of visual inspection of the cervix with acetic acid (VIA) for screening cervical intraepithelial neoplasia. Methods: In this prospective study, 400 women were screened using the Papanicolaou (PAP) smear, VIA and colposcopy. Those who had positive results with any of the screening methods underwent large loop excision of the transformation zone (LLETZ). The sensitivity and specificity of each of the screening methods was analyzed. Results: The sensitivity of VIA (96.7%) was much higher than that of the Pap smear (50%), and almost as high as that of colposcopy (100%). The specificity of VIA (36.4%) was lower than that of the Pap smear (97%) and colposcopy (96.9%), resulting in high false‐positive rates for VIA. Two cases of endocervical lesions were missed with VIA. Conclusion: Visual inspection of the cervix with acetic acid is very sensitive for ectocervical lesions. The advantages of the VIA method are its low cost and ease of use (it can be used by paramedical workers), its high sensitivity and its immediate results (it is possible to “see and treat” at the first visit). Its main limitation is a high rate of false‐positive results, which may lead to overtreatment if a “see and treat” policy is applied.

Vitamin D and VDR gene polymorphism ( FokI ) in epithelial ovarian cancer in Indian population

IntroductionVitamin D deficiency and vitamin D receptor (VDR) gene polymorphism, FokI, is reported to increase the risk of many cancers. Role of vitamin D and its receptor polymorphisms in ovarian cancer has not been clearly defined.ObjectiveTo study the levels of serum vitamin D and occurrence of vitamin D receptor gene polymorphism (FokI) in cases of ovarian cancer.Material and methodsFokI genotyping was done by PCR-RFLP technique and vitamin D levels were estimated by chemiluminescence immunoassay.ResultsSerum vitamin D levels were significantly (p < 0.03) lower in ovarian cancer cases as compared to controls. The homozygous (TT) and heterozygous (CT) genotype predispose to the development of ovarian cancer in Indian population (OR: 2.37, 95% CI: 1.04-5.44) as compared to the homozygous (CC) genotype. Vitamin D deficiency and VDR gene polymorphism (FokI) act non-synergistically (p value < 0.4).ConclusionLow blood levels of vitamin D and VDR receptor polymorphism (FokI) might be a risk factor for the development of ovarian cancer. Other novel ligands of vitamin D receptor might be responsible for the non-synergistic effect.

Utility of Serum miR-125b as a Diagnostic and Prognostic Indicator and Its Alliance with a Panel of Tumor Suppressor Genes in Epithelial Ovarian Cancer

MicroRNAs (miRNAs) have been found to be dysregulated in epithelial ovarian cancer (EOC) and may function as either tumor suppressor genes (TSGs) or as oncogenes. Hypermethylation of miRNA silences the tumour suppressive function of a miRNA or hypermethylation of a TSG regulating that miRNA (or vice versa) leads to its loss of function. The present study aims to evaluate the impact of aberrant microRNA-125b (miR-125b) expression on various clinicopathological features in epithelial ovarian cancer and its association with anomalous methylation of several TSGs. We enrolled 70 newly diagnosed cases of epithelial ovarian cancer, recorded their clinical history and 70 healthy female volunteers. Serum miR-125b levels were determined by quantitative reverse transcription polymerase chain reaction (qRT-PCR) and the methylation status of various TSGs was investigated by methylation specific PCR. ROC curves were constructed to estimate the diagnostic and prognostic usefulness of miR-125b. The Kaplan—Meier method was applied to compare survival curves. Expression of miR-125b was found to be significantly upregulated (p<0.0001) in comparison with healthy controls. The expression level of miR-125b was found to be significantly associated with FIGO stage, lymph node and distant metastasis. ROC curve for diagnostic potential yielded significant AUC with an equitable sensitivity and specificity. ROC curves for prognosis yielded significant AUCs for histological grade, distal metastasis, lymph node status and survival. The expression of miR-125b also correlated significantly with the hypermethylation of TSGs. Our results indicate that DNA hypermethylation may be involved in the inactivation of miR-125b and miR-125b may function as a potential independent biomarker for clinical outcome in EOC.

Vaginal misoprostol versus vaginal estradiol in overcoming unsatisfactory colposcopy.

Background: Unsatisfactory colposcopy, an inability to visualize the entire transformation zone, is found in about 10-20% of the patients undergoing the procedure. These patients usually require conization for a comprehensive evaluation of the cervix. Our study aims to compare the efficacy and safety of vaginal misoprostol versus vaginal estradiol in overcoming unsatisfactory colposcopy. Methods: We studied 48 women with unsatisfactory colposcopy. They were randomized into two groups: group I (n = 24) received 200 µg misoprostol vaginally and colposcopy was repeated after 6 h, while the subjects in group II (n = 24) were prescribed a 7-day course of 50 µg estradiol for vaginal insertion followed by a repeat colposcopy. The efficacy and safety of these two drugs were compared. Results: Repeat colposcopy was satisfactory in 70.8% of the women given vaginal misoprostol compared to 82.6% of the women who used vaginal estradiol. The difference was not statistically significant. The adverse effects were reported more often by the women in the misoprostol group (41.6%) as compared to those in estradiol group (13%) (p = 0.04). Conclusion: Both estradiol and misoprostol were comparable in overcoming unsatisfactory colposcopy. However, a higher incidence of adverse effects was noted with misoprostol as compared to estradiol.

The conglomeration of diagnostic, prognostic and therapeutic potential of serum miR-199a and its association with clinicopathological features in epithelial ovarian cancer

Epithelial ovarian cancer (EOC) is the most lethal cause of morbidity and mortality worldwide. miRNA deregulation evinces a remarkable role in ovarian cancer tumorigenesis. miRNA-199a (miR-199a) is known to be involved in cancer development and progression. Although miR-199a has been studied in various cell types, its correlation with clinicopathological features in EOC has not been documented. In this study, we identified the clinicopathological hallmarks which might be perturbed due to the downregulation of serum miR-199a in EOC. Seventy serum samples from histopathologically confirmed EOC patients and 70 controls were collected. Total RNA from serum was isolated by Trizol method, polyadenylated and reverse transcribed into cDNA. Expression level of miR-199a was detected by using miRNA qRT-PCR. Relative expression was determined with matched controls using U6 snRNA as reference. Level of miR-199a expression was compared with distinct clinicopathological features. Expression of miR-199a was found to be significantly downregulated in comparison with matched normal controls. The expression level of miR-199a was found to be significantly associated with tumor stage, lymph node metastasis, and distal metastasis. Receiver operating characteristic (ROC) curve for diagnostic potential yielded significant area under the curve (AUC) with a considerable sensitivity and specificity. ROC curves for prognosis yielded significant AUCs for histological grade, distal metastasis, lymph node status, and survival. Our findings suggest that miR-199a downregulation might be a potential indicator for disease progression promoting the aggressive tumor progression and be identified as a diagnostic marker to predict the prognosis and survival in EOC patients.

Genetic and epigenetic alterations affecting PARK-2 expression in cervical neoplasm among North Indian patients

The recent investigation on PARK-2, a putative tumor suppressor gene, has found that it has been altered in multiple human malignancies. However, the clinical impact of PARK-2 alteration in uterine cervix carcinoma has not yet been studied. Therefore, we aimed to examine mutations, promoter hypermethylation, and protein expression of PARK-2 among the North Indian patients and their association with clinical parameters to evaluate the implication of PARK-2 in the genesis of cervical cancer. A total of 168 patient samples were processed for mutational analysis by single-strand conformation polymorphism, sequencing, and further in silico analysis of the identified mutations. Promoter hypermethylation by methylation-specific polymerase chain reaction and expression of PARK-2 were performed using immunohistochemistry. Statistical correlation between molecular findings and the clinicopathological parameters was taken to figure out the meaningful outcome. As per our findings, 3.5% (6/168) tumors showed novel missense mutations in exon 11 of PARK-2. In silico analysis showed high structural deviations manifested by mutations, A398D and Y391N, in both mutant proteins as compared to wild type. Promoter hypermethylation was observed in total of 29% of (48/168) tumor samples. Furthermore, 46.43% tumors (78/168) exhibited loss of PARK-2 expression in cervical carcinoma. The loss of expression of PARK-2 when correlated with clinical parameters resulted in significant association with tumor stage (p = 0.002) and with histological grade (p = 0.025). However, only clinical stage remained significant after Bonferroni correction (p < 0.007). A trend was observed between PARK-2 promoter hypermethylation and its protein expression. Our study provided sufficient information and insight for investigation of PARK-2 and highlighted its role as a tumor suppressor gene in cervical cancer in North Indian population.

Primary leiomyosarcoma of peritoneal cavity

Leiomyosarcomas of soft tissue are the rare tumors and the retroperitoneum is the most common site involved. We report a case of primary leiomyosarcoma of the peritoneal cavity which clinically presented with suprapubic, freely mobile, nontender mass which measured 10×10 cm in size. Contrast enhanced computed tomography revealed well defined heterogenous hypodense solid cystic mass. The mass was surgically excised out in its entirety. The histopathological examination revealed spindle cells arranged in alternating fascicles having pleomorphic nuclei, indistinct margin and eosinophilic cytoplasm with foci of haemorrhage, necrosis and 5-6 mitosis/HPF. The spindle cells were immunoreactive for smooth muscle actin, desmin and negative for S-100, CD-34 and c-kit. Histopathology and immunohistochemistry were helpful in making the final confirmatory diagnosis. Leiomyosarcomas are aggressive tumors, with poor prognosis and often difficult to treat. The survival rates are lowest among all soft tissue sarcomas.

Intraoperative cytology of ovarian neoplasms with an attempt to grade epithelial tumors

Background: Intraoperative cytology (IOC) is a simple and quick technique with excellent preservation of cellular details. In the present study, we have evaluated the role of IOC by various methods of smear preparation and compared it with frozen section diagnosis. A scoring system was followed for epithelial tumors for characterization and grading on the basis of cellularity, pattern, nuclear, cytoplasmic features, and background details. Materials and Methods: The study was conducted during a time span of 2 years in total 48 cases of ovarian tumors. Fine-needle aspiration cytology, touch/imprint, scrape, and crush techniques were used. The smears so prepared were processed for toluidine blue and Giemsa and Papanicolaou staining. Cases were cytomorphologically categorized into four groups: Indeterminate; unequivocally benign; borderline tumor with equivocal morphology; and unequivocally malignant (graded into well, moderately, and poorly differentiated). Results: In our study, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 88.88, 96, 96, 88.88, and 92.31%, respectively, were recorded. This was comparable to frozen section diagnosis with a sensitivity, specificity, PPV, NPV, and accuracy of 85.18, 96.15, 95.83, 86.21, and 90.56%, respectively. In epithelial tumors, cytological grading correlated with histopathological grading in 85.29% cases of epithelial tumors. Conclusion: IOC gives comparable results to frozen section and can be used for intraoperative assessment of ovarian tumors. Grading of epithelial tumors on IOC can be performed and may become an important step in intraoperative decision-making for better management and outcome of the patient.

Pregnancy at 65, risks and complications

A 65-year-old postmenopausal pregnant woman was referred with antepartum hemorrhage at 29 weeks of gestation. Postadmission diagnosed with chronic hypertension, gestational diabetes mellitus, valvular heart disease, and placenta previa. Her pregnancy was terminated by cesarean delivery at 32 weeks as she had a bout of bleeding per vaginum. Most of the placenta was adherent with no plane of cleavage; therefore, cesarean hysterectomy was performed. Baby birth weight was 1650 g and was shifted to nursery for observation and mother needed Intensive Care Unit care postcesarean. On the 15th day, both healthy mother and baby were discharged. Although pregnancy is possible in postmenopausal women with hormone support but the incidence of complications remain very high. It raises a need for developing well-laid guidelines for performing in vitro fertilization in older age group women.

Prognostic and diagnostic significance of epigenetic alterations of p16 and DAPK1 promoter sequences in patients with epithelial ovarian carcinoma (EOC).

62 Background: Novel strategies for early detection of EOC, the most common and second most lethal cancer in Indian women, are urgently needed. Silencing tumor suppressor genes via DNA methylation has established hypermethylation as one of the most frequent molecular alterations that may initiate and drive many types of human neoplasia including EOC. To determine the alterations of tumor suppressor gene DAPK1 and p16INK4A in EOC patients to explore the possibilities of identifying potential minimally invasive markers in blood of the patients, which could help in the clinical practice as a diagnostic and prognostic marker. METHODS Fifty EOC patients with primary epithelial ovarian cancer were selected for the study; these patients were followed for a median of 20 months. Genomic DNA extracted from fresh peripheral blood and serum followed by sodium bisulfate modification. The DAPK1 and p16 methylation was detected using methylation-specific PCR (MSP). The DAPK1 and p16 methylation status was correlated with age, stage,menopause, Ca125.5 and clinic pathological features. RESULTS The frequencies of DAPK1 and p16 methylation in EOC patients was found to be 68% and 84% respectively . Aberrant methylation of DAPK1 and p16 was associated with age at diagnosis (p = 0.043) .The significant association was seen with age,menopause. Patients with high methylation indices had poor prognosis (p<0.001, Hazards ratio=14.58) with age (p = 0.043), and tumor stage (p = 0.033). Aberrant methylation of DAPK1 and p16 was strongly associated with EOC patients (p = 0.037 respectively). CONCLUSIONS our results that the methylated loci of TSGs (DAPK1 and p16) may be employed as clinically useful biomarkers for prognosis and diagnosis of EOC noninvasively using readily available body fluid by MS-PCR and proved to be efficient and cost-effective method.