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A 38 year old nulliparous woman with pemphigus vulgaris (PV) on oral prednisolone and azathioprine was referred to the Gynaecology service for an abnormal cervical cytological smear showing low-grade squamous intraepithelial lesion. She was asymptomatic, reported no abnormal vaginal bleeding, and had a 10 pack-year history of smoking.Colposcopy was unsatisfactory with inadequate visualisation of the transformation zone due to severe cervico-vaginitis. A small focus of aceto-white epithelium was seen, surrounded by peeling, friable epithelium. HPV DNA test was negative. Punch biopsy demonstrated metaplastic squamous epithelium with intraepidermal suprabasal blister formation with acantholysis. Well-vascularised dermal papillae lined residual basal cells, giving rise to a tombstone appearance. There was no evidence of CIN/CGIN or invasive malignancy. An ulcer was also seen in the left buccal region.Repeat colposcopy after 6 weeks showed a small ulcerated area at the biopsy site with rolled healing edges, and a separate small ulcer. Cervical smear and colposcopy 6 months later were unremarkable.The incidence of cervical PV may be underestimated because women with PV are often managed by dermatologists without gynaecological input. In many published cases, cervical involvement was only detected after gynaecological examination due to symptoms such as dyspareunia, post-coital bleeding or vaginal discharge.Abstract 68 Figure 1(A) Cervical smear containing scattered groups of abnormal keratinocytes with enlarged hyperchromatic nuclei, irregular nuclear membranes and bi-nucleation with perinuclear halo in keeping with koilocytosis; (B) Colposcopic appearance (high magnification); (C) Cervical tissue showing intraepidermal and suprabasal blister formation; (D) Well vascularised dermal papillae with residual basal layer giving rise to tombstone appearance[Figure omitted. See PDF]Cervical smears of patients with PV typically display acantholysis, which may be misinterpreted as reparative, inflammatory, or neoplastic change. There have been reports of unnecessary hysterectomy due to such misdiagnoses. Review by an experienced cyto-pathologist is required in the event of diagnostic uncertainty.

Introduction/BackgroundFertility-sparing surgery (FSS) in stage I ovarian clear cell carcinoma (CCC) is not commonly offered due to concern about poorer outcomes despite paucity of evidence. The aim of this study is to review oncological outcomes of CCC patients treated with fertility sparing surgery, to provide evidence to guide practice.MethodologyClinical data of all CCC patients treated with FSS and followed-up in a single tertiary hospital were collected and used for analysis.ResultsOver the period from 2005 to 2018, there were in total 180 cases of stage I CCC treated in this hospital, of which five cases underwent FSS. The mean age of FSS patients at diagnosis was 33.6 years. Two cases were stage Ia and the other three Ic. Four cases received adjuvant chemotherapy. During the follow-up (median: 6 years), there was no recurrence. One patient conceived spontaneously and had term live birth, 6 years after completion of treatment. Overall survival of stage I CCC patients treated in this hospital during the same period was 92.8% and disease-free survival 88.3%.ConclusionIn the present cohort, FSS in selected early stage CCC of ovary did not have a negative impact on oncologic outcome. Further large-scale studies are needed to confirm the safety.DisclosureNothing to disclose.

Introduction/BackgroundEndocervical Gastric-type mucinous adenocarcinoma is a rare but recognised subtype of mucinous adenocarcinoma as per the WHO 2014 classification of endocervical adenocarcinomas. Although adenocarcinomas are less common than squamous cell carcinomas, their prevalence is increasing. It is important to distinguish the Gastric type from other endocervical adenocarcinomas as it is has a worse prognosis. Compared to other types of endocervical adenocarcinomas, chemotherapy may be less effective in the gastric-type. Of note, adenocarcinomas are not associated with HPV infection. With increasing uptake worldwide of primary HPV based screening for cervical cancers, diagnosis of non-HPV related cervical cancers might be missed.MethodologyA retrospective review of clinicopathologic features in patients with endocervical Gastric-type mucinous adenocarcinoma diagnosed between 2015 and 2019 in a single tertiary referral centre in Singapore.Results15 patients were diagnosed with endocervical Gastric-type mucinous adenocarcinoma between 2015 and 2019 with the average age of 56.4 years. 13 patients underwent examination under anaesthesia and clinical staging. Seven (53.8%) had Stage 1 disease,four (30.8%) had Stage 2 disease, one (7.7%) had Stage 3 disease and one (7.7%) had Stage 4 disease. 10 patients underwent primary treatment and follow-up our centre. 9 patients were early stage disease (Stage 1 to 2). Out of the 9 patients with early stage disease, 7 underwent surgery as primary treatment and 2 underwent radiotherapy and/or chemotherapy. 1 patient with Stage 4 disease underwent primary debulking surgery as the tumour was initially thought to be endometrial adenocarcinoma. 2 out of 10 patients have passed away from the disease during follow-up.ConclusionThe gastric subtype of cervical adenocarcinomas portends a poorer prognosis and good evidence on the optimal modality of treatment is lacking. There is need for multi-centred clinical trials to raise awareness for this rare subtype and formulate treatment options. Newer techniques incorporating molecular tests may help with the diagnosis.DisclosureNothing to disclose.

BackgroundIn addition to glomerular lesions, renal vascular involvement is an important prognostic marker of lupus nephritis (LN). Among patients with various vascular changes, individuals with thromboticmicroangiopathy (TMA) present with severe clinical manifestations and have a high mortality.ObjectivesWe sought to assess renalout comes and response to anti-thrombotic treatmentsin addition to conventional immunosuppression in patients with biopsy proven LN and TMA.MethodsClinical and renal histopathological data for 97 patients with biopsy-proven LN and TMA were retrospectively analysed. Antibody profiles, induction and maintenance therapies for LN, and anti-thrombotic treatments were collected. TMA lesions were classified into acute and chronic (table 1). A complete renal response (CR) was defined as proteinuria <0.5 g/24 hour and normal or near-normal (within 10% of normal GFR if previously abnormal) GFR. Partial Response (PR) was defined as a≥50% reduction in proteinuria to subnephrotic levels and normal or near-normal GFR. Renal outcomes were assed at one year post biopsy.ResultsThe mean age of the patients was 38.9±15.2 years (range, 13–69 years). The study included 85 females (87.6%) and 12 males (12.4%). The clinical presentations were nephrotic syndrome, nephritic syndrome, and asymptomatic urinary abnormalitiesin 38 (39.2%), 20 (20.6%), 39 (40.2%) patients, respectively. Nine patients were classified Class III (9.3%, including 2 as ClassIII +V), 82 as Class IV (84.5%, 10 as Class IV-segmental(IV-S) (10.3%) and 72 as Class IV-global (IV-G) (74.2%),including 4 as Class IV-G+V) and 6 as Class V (6.2%). Forty-two(43%) patients presented with acute and 55 (57%) with features of chronic TMA. All patients had received treatment with standard immunosuppressants (55% mycophenolate, 39% cyclophosphamide, 6% other regimen) and steroids.Abstract OP0201 – Table 1At 12 months, CR was observed in 37 patients (38.1%), PR in 22 (22.6%) and no response in 38 (39.1%). Sixty-one patients (62.9%) were antiphospholipid positive (aPL) and 37 (38.1%) received anticoagulation with vitamin-K antagonist (VKA) and/or heparins. Presence of aPLs(OR, 2.4; 95% confidence interval-CI-, 1.2–7.3; p=0.03), anti-DNA positivity (OR, 12.8; 95% CI: 3.0 to 71.3; p=0.002), and chronic features of TMA (OR, 3.0; 95% CI: 1.2 to 17.5; p=0.04) were all found to be associated with no response. When limiting the analysis to aPL positive patients, after adjusting for type of immunosuppressant therapy and LN class on biopsy, variables that were significantly associated with CR +PR were features of acute TMA rather than chronic (OR, 8.62; 95% CI: 1.4 to 97.1; p=0.03) and the use of VKA/heparins(OR, 2.1; 95% CI, 1.02–16.2; p=0.046)ConclusionsIn patients with concomitant LN and TMA, the presence of aPL and chronic features of TMA were associated with poorer renal outcomes. In patients with aPL, the use of anticoagulation appeared protective and warrants further investigation as a therapeutic tool, especially in the setting of acute TMA.Disclosure of InterestNone declared

Introduction/Background*Inflammatory myofibroblastic tumours (IMT) are rare spindle cell neoplasms of indeterminate malignant potential, commonly found in the lungs, but also originating from various organs ranging from head and neck, gastrointestinal to the genitourinary system. IMTs of the female gynaecological tract are rare and may mimic benign leiomyoma in both clinical presentation and appearance on imaging. We describe a case of uterine IMT, diagnosed after a laparoscopic myomectomy with in-bag morcellation.MethodologyResult(s)*A 37-year-old woman was on follow-up for uterine mass on pelvic ultrasound, slowly enlarging to 3.3cm, presumed to be a fibroid. Although she did not have significant pressure symptoms or menorrhagia, she requested for removal and underwent laparoscopic myomectomy with morcellation-in-bag.Intra-operatively, a 6cm mass was seen on the uterine posterior wall, macroscopically and morphologically consistent with that of benign leiomyoma. However, immunohistochemistry and molecular sequencing were positive for ALK-1 hence a diagnosis of IMT was made. Diffuse staining for desmin, H-caldesmon and ER was also noted. Following a multi-disciplinary tumour board, consensus was for a CT scan of the thorax, abdomen and pelvis(which showed no extra-uterine spread) and for regular surveillance scans.A review of the literature shows no universal consensus as to optimal treatment of uterine IMT. Majority of cases have been treated with surgical excision – open, laparoscopic or hysteroscopic. While most cases have a benign course with no recurrence/relapse, local recurrences are a known complication.Given controversies in recent years over power morcellation potentially leading to dissemination of undiagnosed uterine leiomyosarcomas, morcellation-in-bag has become standard practice for all laparoscopic myomectomies or hysterectomies requiring morcellation. There is little data regarding outcomes of other types of uterine tumours, or IMT specifically, with regards to outcomes following morcellation. The only two documented cases in the literature specifically involving morcellation resulted in local recurrences requiring further treatment.Conclusion*We present a case of uterine IMT diagnosed following laparoscopic myomectomy and in-bag morcellation. While the patient has no sign of extrauterine spread at present, further follow-up will be required to monitor for any progression or recurrence. Outcomes following morcellation or specific other treatment options will need to be further studied.

Introduction/BackgroundSentinel lymph node (SLN) mapping with indocyanine green (ICG) is emerging as a feasible alternative to pelvic lymphadenectomy in endometrial cancer staging. Although ICG SLN mapping is well established in robo-laparoscopic surgery, there is little literature validating its use in laparotomy.MethodologyThe technique, effectiveness and feasibility of SLN mapping with ICG during laparotomy for endometrial cancer is discussed. For each patient, intra-cervical ICG injection at the 3 and 9 o’clock positions was performed. Following peritoneal dissection, lymph node chains were inspected in near infrared mode using the Karl Storz Vitom(R) camera system. In each hemi-pelvis, if SLN mapping was not achieved, ipsilateral pelvic lymphadenectomy was performed. Full pelvic lymphadenectomy was also performed if there were suspicious nodes, large tumour size or extensive myometrial invasion.ResultsBetween March 2016 and February 2019, 37 patients with endometrial cancer underwent laparotomy. Average operating time was 133 minutes Median blood loss was 200 mls. There were no complications related to the use of ICG dye. The detection rate of SLNs was 92%. Bilateral pelvic SLNs mapping was achieved in 81% of patients, whereas 11% of patients had mapping to unilateral pelvic nodes. The median number of SLNs was 3. SLNs were mapped most commonly to the external iliac nodes, followed by the obturator and internal iliac nodes. In 3 patients (8.1%), SLNs were positive for metastases, resulting in a higher surgical stage and influencing the decision for adjuvant therapy. One patient also had mapping to a para-aortic node, which was positive for metastasis. Full pelvic lymphadenectomy was performed in 17 patients (46%). The sensitivity of SLN mapping in these patients was 100%, with no falsely negative SLNs.ConclusionSLN mapping with ICG is accurate and feasible in patients with endometrial cancer requiring laparotomy, and has a high detection rate and sensitivity comparable to that of robo-laparoscopic surgery.DisclosureNothing to disclose.

Orthopedic infections are typically treated with intravenous antibiotics. In this trial, 1054 participants with complex orthopedic infections were assigned to receive either oral or intravenous antibiotics for the first 6 weeks of treatment. At 1 year, oral therapy was noninferior to intravenous therapy.

The aim of this study was to determine whether the position of the tension-free vaginal tape (TVT) has an effect on the resolution of irritative symptoms in women undergoing the TVT operation. Initial audit suggested that more distally placed tapes were more likely to result in the resolution of irritative symptoms. An appropriately powered study was designed to test this theory. Seventy-seven women with urodynamic evidence of detrusor overactivity and urodynamic stress incontinence underwent a transperineal ultrasound scan to ascertain the position of the tape after a TVT. The tape was categorised as proximal, middle or distal urethra. The resolution of irritative symptoms was assessed compared to the TVT position. Forty-five women had distal tapes, 30 had mid-urethral tapes and two had proximal tapes. Women with the TVT placed on the distal urethra were no more likely to experience resolution of their irritative symptoms than women with tapes on the mid-urethra ( p  >  0.05). Placement of the TVT on any one part of the urethra is not more likely to result in resolution of irritative bladder symptoms.