Roopa Hariprasad

Growing teratoma syndrome of ovary

Growing teratoma syndrome is an increase of tumor size containing only a mature teratoma component, during or after chemotherapy for germ cell tumors. Mature teratomatous elements are chemoresistant and have to be resected surgically. We describe three patients with malignant immature teratoma treated with chemotherapy and surgical resection. All three had an increase in the size of the mass after chemotherapy, surgery was possible, and histology revealed mature teratoma. One of the patients showed fluorodeoxy glucose positron emission tomography (FDG-PET) positivity for growing teratoma syndrome, but the histology revealed only mature teratoma. All three patients are alive, at 55, 72, and 103 months’ follow up after the initial diagnosis. Data collected from the literature are reviewed. Early recognition of this syndrome is essential as it offers hope for curative resection and avoids the use of ineffective chemotherapy.

Prevalence of bacterial vaginosis in pregnant women and predictive value of clinical diagnosis

PurposeTo study the prevalence of bacterial vaginosis (BV) in pregnant women and to evaluate the accuracy of clinical criteria for the diagnosis of BV.MethodsIn this observational study 502 asymptomatic pregnant women were screened for bacterial vaginosis in a rural health care facility by Gram stain. Accuracy of clinical diagnosis using individual and two of Amsel’s criteria was evaluated.ResultsThe frequency of BV was 8.6% by Nugent’s method. For Amsel’s criteria, sensitivity and specificity was 51.2 and 98%, with 71% PPV and 95.5% NPV. The most sensitive individual criterion was vaginal pH, but with lowest specificity. The criterion with highest specificity was clue cells. The combination of the two criteria, vaginal pH and positive amine test, had best positive and negative predictive values 60.5 and 97.8%, respectively.ConclusionThe diagnosis of BV according to Amsel’s criteria may be simplified using a combination of the two criteria, vaginal pH and amine test, in settings where microscopy or Gram staining is not available.

Clinical outcome of patients with uterine sarcomas

PURPOSE The aim of our retrospective analysis was to study and report the clinical outcome of patients with uterine sarcoma (US) treated at our center; and to share our experience with literature. MATERIALS AND METHODS We retrieved the information regarding the patients demography, clinico-pathological details, treatment given, survival, and complications of all the US patients treated at our center between the years 2000-2008. The three-year overall survival (OS) was determined with respect to various prognostic factors like age, stage of disease, histopathological type, adjuvant RT etc. RESULTS A total of 50 case records were retrieved for this retrospective analysis. Age ranged from 24 to 75 years with a median of 50 years. Carcinosarcoma was the commonest histopathological type (23/50 patients). FIGO stage distribution was: stage I, 27; stage II, 7; stage III, 12; stage IV, 2; and unknown stage, two patients. Forty-eight patients underwent surgery; 31 received postoperative radiation therapy (PORT) and 16 received chemotherapy therapy. Median follow-up period was 34 months (range 2-69 months). The three-year OS for the entire group of patients was 42%. Stage of the disease, histopathological type, and use of PORT were found significant prognostic factors for survival. CONCLUSION Although limited by small sample size and retrospective nature, ours is the only study on US being reported from India. Our results have demonstrated FIGO stage of the disease, histopathology and use of PORT to be the significant prognostic factor for survival. Use of chemotherapy in future trials is warranted.

Apolipoprotein A1 as a potential biomarker in the ascitic fluid for the differentiation of advanced ovarian cancers.

Abstract Context: Primary ovarian cancer and ovarian metastasis from non-ovarian cancers in advanced stage are closely mimicking conditions whose therapeutics and prognosis are different. Objective: To identify biomarkers that can differentiate the two variants of advanced ovarian cancers. Methods: Gel-based proteomics and antibody-based assays were used to study the differentially expressed proteins in the ascitic fluid of fourteen patients with advanced ovarian cancers. Results: Programmed Cell Death 1-Ligand 2, apolipoprotein A1, apolipoprotein A4 and anti-human fas antibody are differentially expressed proteins. Conclusions: Apolipoprotein A1 with a 61.8 ng/ml cut-off is a potential biomarker with the best differentiating statistical parameters.

Comparative Proteomic Analysis of Advanced Ovarian Cancer Tissue to Identify Potential Biomarkers of Responders and Nonresponders to First-Line Chemotherapy of Carboplatin and Paclitaxel

Conventional treatment for advanced ovarian cancer is an initial debulking surgery followed by chemotherapy combination of carboplatin and paclitaxel. Despite initial high response, three-fourths of these women experience disease recurrence with a dismal prognosis. Patients with advanced-stage ovarian cancer who underwent cytoreductive surgery were enrolled and tissue samples were collected. Post surgery, these patients were started on chemotherapy and followed up till the end of the cycle. Fluorescence-based differential in-gel expression coupled with mass spectrometric analysis was used for discovery phase of experiments, and real-time polymerase chain reaction, Western blotting, and pathway analysis were performed for expression and functional validation of differentially expressed proteins. While aldehyde reductase, hnRNP, cyclophilin A, heat shock protein-27, and actin are upregulated in responders, prohibitin, enoyl-coA hydratase, peroxiredoxin, and fibrin-β are upregulated in the nonresponders. The expressions of some of these proteins correlated with increased apoptotic activity in responders and decreased apoptotic activity in nonresponders. Therefore, the proteins qualify as potential biomarkers to predict chemotherapy response.

Clear cell carcinoma of ovary with squamous metaplasia: A unique histopathological observation

Squamous metaplasia though is commonly associated with ovarian endometrioid neoplasm, mixed mullerian tumor and Brenner tumors; it has not been described in an ovarian clear cell carcinoma. Unusual presence of squamous islands, either in the form of morules or keratin plaques, may create diagnostic difficulty in a clear cell carcinoma of ovary, and thus the other common associations should be ruled out. Here, we describe a case of clear cell carcinoma of the ovary, with both gross and microscopically identifiable squamous metaplasia. To the best of our knowledge, this is the first report on this rare association and should be documented for wider awareness.

Stemming the Wave of Cervical Cancer: Human Papillomavirus Vaccine Introduction in India

With the highest burden of cervical cancer mortality in theworld, India faces enormous loss of life, productivity, and suffering from this disease. The age-standardized incidence ratio for cervical cancer in India is 22 per 100,000 women per year, which is higher than the incidence in South East Asia (16.3 per 100,000) and in the world (14 per 100,000). Differences in mortality rates are even starker. Twenty-five percent of all global deaths as a result of cervical cancer occur in India. Although cervical cancer rates in India are decreasing, there is huge geographic variability, and the absolute number of patients is still expected to increase over the next decade as a result of population growth. Moreover, the decreasing incidence rate seems to be plateauing and is unlikely to decline further unless specific interventions are put in place.

Retention of Knowledge Levels of Health Care Providers in Cancer Screening Through Telementoring

Purpose Every year > 450,000 individuals are diagnosed with cancer and approximately 350,000 die of it in India. The Ministry of Health and Family Welfare has released an Operational Framework for the Management of Common Cancers that highlights population-based cancer screening programs in primary health care facilities by health care providers (HCPs) and capacity building of HCPs. The purpose of this study is to present a low-cost training model that is highly suitable for resource-deficient settings, such as those found in India, through Extension for Community Health Outcome (ECHO), a knowledge-sharing tool, to enable high-quality training of HCPs. Materials and Methods An in-person, 3-day training program was conducted for 27 HCPs in the tribal primary health care center of Gumballi in Karnataka, India, to teach the basics of cancer screening in oral, breast, and cervical cancer. The training of HCPs was done using the ECHO platform while they implemented the cancer screening, thus enabling them to build the much needed knowledge and skill set to conduct cancer screening in their respective communities. Results The knowledge level of the HCPs was tracked before the intervention, immediately after the 3-day training program, and 6 months after the ECHO intervention, which clearly showed progressive acquisition and retention of knowledge. A marked improvement in knowledge level score from an average of 6.3 to 13.7 on a 15-point scale was noticed after the initial in-person training. The average knowledge further increased to a score of 14.4 after 6 months as a result of training using the ECHO platform. Conclusion ECHO is an affordable and effective model to train HCPs in cancer screening in a resource-constrained setting.

The PEP project - Synergistic community based action in prevention, early detection and palliative care, to impact the cancer burden in India

With unprecedented surge in the incidence and prevalence of cancer in India, it has become imperative to strengthen the workforce for all the domains of cancer care. A large proportion of the activity required for prevention as well as for palliation, lie outside of tertiary institutions, in the community. Palliative care (PC) as a field is expanding exponentially across the country and the service providers often engage and work actively within the local community in their region. This article describes the scope for reducing the cancer burden in the community, through capacity building of community based PC healthcare functionaries in the domains of Prevention, and Early detection of common cancers along with Palliative care – the PEP domains. It suggests aligning and enhancing the workforce already active within the community for PC, for screening, and if feasible, for early detection of common cancers. The article describes possibilities of initiating PEP activities and offers a set of screening questionnaire that may be used when engaged with family/ community setting. The aim is to integrate the activities done, to detect the need for palliative care in a family / community, with that required to detect need for evaluation of most common cancers- oral, breast and cervix. The PEP concept may be adapted to different levels, based on the team presence in the communities, degree of engagement, and availability of trainers and healthcare personnel.

Pocket colposcope: could it improve attendance and increase access to cervical cancer screening programmes?

Papanicolaou smear-based cervical cancer screening programs have been successful in the developed world to reduce the burden of cervical cancer [1]. However, in lowresource settings, it is not a feasible option due to paucity of trained cytopathologists, difficulties in following up of screen positive women, absence of quality assurance measures, and poor healthcare infrastructure. Other barriers to cervical cancer screening in low-resource settings include lack of accessible, high-quality services, high cost, and the need for multiple visits [2]. The World Health Organization has recommended visual inspection with acetic acid (VIA) as an alternative to cytology-based screening in low-resource settings [3]. VIA has been most widely investigated and accepted as a potential alternative to cytology in low-resource settings [4]. VIA has been shown to be affordable, feasible, with a sensitivity ranging from 67% to 90% and results are available in the same sitting, hence is an accurate tool for implementation in limited resource settings. However, VIA has limitations in terms of low specificity, requirement of extensive training, and retraining of the health care providers, being a subjective test and a challenge in quality control. To address these challenges, many devices have been developed and are being tested widely to increase specificity, to acquire digital images of the cervix with or without magnification which can assist and complement subjective visual interpretation and potentially improve the performance of VIA. Quality assurance of any screening procedure requires a robust system of program management and coordination, paying attention not only to communication and technical aspects but also to qualification of personnel, especially when the screening test is subjective, as is the case in VIA. Developing low-cost, point of care, high-impact screening technologies that can reduce the incidence of cervical cancer is the need of the hour. In this commentary, we elucidate one such device where we see its potential in increasing the access to cervical cancer screening and improving the attendance of women attending the screening program. 2. POCKeT colposcope