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Background: The integration of molecular features into the already existing pathological classification of endometrial carcinomas will offer significant prognostic information. As the literature search reveals, there are no studies from India that have classified these carcinomas based on molecular subtypes. The aim of the study was to classify endometrial carcinomas into four subtypes based on their molecular and immunohistochemical features and to find out the association of each of these molecular subtypes with the other pathological parameters. Methods: A prospective study was done on 37 consecutive cases of fresh hysterectomy specimens, biopsy-proven as endometrial carcinomas between November 2019 and August 2020. Three immunohistochemical markers (p53, mismatch repair proteins, MutS homolog6 and Postmeiotic seggregation 2 respectively[MSH6, and PMS2]), along with DNA (deoxyribonucleic acid) sequencing of selected regions of the POLE gene was performed in each of the 37 cases. Endometrial carcinomas were subclassified into four subtypes, and the association of each of these four subtypes with the other pathological parameters was also explored. Statistical analysis was done using the IBM Statistical Package for the Social Science (SPSS) Version 20.0 software (IBM SPSS, USA). Results: Among the 37 cases studied, eight (21.6%) cases were p53 abnormal, eight (21.6%) cases showed MMR-D (mismatch repair deficient), one case (2.7%) showed mutation of POLE, and 21 cases (56.8%) were assembled under p53 wild-type. Higher grade endometrial carcinomas showed more (80.0%) p53 abnormal (P < 0.001). All the p53 wild-type (100%) were of Type 1 endometrial carcinoma subtype (P = 0.001) and low-grade type (90.5%; P = 0.005). Conclusion: Our study confirms that the type of carcinoma and grade correlates with p53 expression, p53 abnormal being associated with higher grade and type 2 endometrial carcinomas, whereas p53 wild-type is associated with low-grade and type 1 endometrial carcinoma. There was only one case of the POLE subtype identifiable in our study.

The latest International Federation of Gynaecology and Obstetrics (FIGO) staging for endometrial cancer incorporated molecular profiles and histopathological factors into the basic staging framework. This study was done to determine its implications when applied in real-world clinical practice. The main objectives were to analyse the stage shifts and determine the stage-wise 3-year overall survival (OS) and disease-free survival (DFS) between the two staging systems. It was a single-institution retrospective study that included all Endometrial cancer patients who underwent surgery between January 2015 and June 2021. Cases that underwent primary or incomplete surgery elsewhere and cases with histological types of cancer not included in FIGO 2023 staging were excluded from the study. All patients were staged according to FIGO 2009 and 2023 staging for endometrial cancer. This study found most stage shifts among stage I cases; based on aggressive histology, 33.8% ( = 65/192) of cases in stage IA and IB upstaged to stage IIC (2023). Meanwhile, among the advanced stages, most were downstaged, i.e., from stage IIIA to stage IA3 0.6% ( = 1/15), from stage IVB to stage IIIB2 (2023), i.e., 32% ( = 8/25). This study failed to show any significant differences in the stage-wise 3-year OS rate and DFS rate between the two staging systems. The present study provided preliminary data on the latest FIGO endometrial staging system. Due to the addition of subgroups based on prognostic factors, most upstages occurred in the early stages, while downshifts occurred in the advanced stages. There was no clinical difference in the 3-year OS and DFS rates.

The COVID-19 pandemic sweeping across the world has caused major disruptions in healthcare delivery and practice. A survey was conducted to assess the changes in the care of gynaecologic oncology patients in India. An online survey enquiring about the patient volumes and surgical load, and changes in practice protocols for endometrial, ovarian, cervical and vulval cancers was conducted in May, 2020. The total number of responses received was 153. Barring duplicates, 148 were analysed. There was a significant drop in gynaecologic oncology patients attending government hospitals as compared to the non-government sector. The drop was not significantly different in areas having low versus high COVID-19 case volumes. The treatment of endometrial cancers remained the same although there was a marked shift from minimal access surgery to conventional surgery. Advanced ovarian cancer was mostly managed by neoadjuvant chemotherapy. Cervical and vulval cancer management remained the same, but radiotherapy protocols were modified by most. Based on clinician responses, it appears that most practices across India have suffered a fall in patient volumes. The responses from government sectors point towards a bigger hit in this segment of practice. While the management of endometrial cancers and cervical cancers was mostly unchanged, most cases of advanced ovarian cancer received neoadjuvant chemotherapy. Cervical cancer, when managed by chemoradiation, was likely to have altered radiation schedules.

Background and Aims: Transverse abdominis plane (TAP) block has been used regularly as part of multimodal analgesia for caesarean sections and other lower abdominal surgeries. Adequate postoperative analgesia provided with regional blocks allows faster postoperative recovery and better patient satisfaction. In our study, we are comparing the analgesic efficacy of laparoscopic-guided TAP block with port infiltration using a local anaesthetic in patients undergoing gynaecologic robotic surgeries. Methods: After obtaining approval from the hospital ethics committee, Central Trial Registry of India (CTRI) clearance and written informed consent from patients, this prospective double-blinded randomised control trial was conducted on patients undergoing robotic-assisted gynaecologic surgery under general anaesthesia. Group B patients received bilateral TAP block under direct laparoscopic vision with 15 ml of 0.1% ropivacaine on each side and Group C patients received routine port site infiltration with 30 ml of 0.1% ropivacaine. Postoperative pain score was measured till 24 hours, need for rescue analgesics, complications associated were noted. Independent two sample 't' test, Mann Whitney u test, Chi-square and Fisher's exact test were used for statistical analysis. Results: Pain score was significantly lower in Group B patients up to 24h (P < 0.001). The use of rescue analgesic was also significantly less in group B compared to Group C (P < 0.001). No adverse events were noted in both groups. Conclusion: Laparoscopic-guided TAP block is effective and superior to port site infiltration in providing postoperative analgesia in patients undergoing robotic-assisted gynaecologic surgery.

BackgroundMalignant transformation in endometriosis was first described by Sampson in 1925. There is now sufficient evidence of its association specifically with endometrioid (EOC) and clear cell ovarian cancer (CCOC). Whether endometriosis-associated ovarian cancer (EAOC) is a distinct clinicopathological entity from non-endometriosis-associated ovarian cancer (NEAOC) remains uncertain.ObjectivesThis study aimed to assess the impact of endometriosis on clinical characteristics and survival outcomes in EOC and CCOC.MethodsThis is a retrospective single-institution analysis of patients diagnosed with CCOC AND EOC between 2010 and 2021. Demographic and clinical presentation data were obtained from medical records. Patients were followed up till March 2023. Statistical analysis was done using the IBM SPSS Statistics 20 Windows.ResultsOf the 77 cases of CCOC and EOC ovary, 38 had histopathologically proven endometriosis. There was no difference in age (51.62 and 50.05 years, respectively), body mass index, parity, menopausal status and CA 125 levels at presentation. Ascites was more frequent in the absence of endometriosis (30% versus 8.1%, p = 0.015). However, this did not translate to a statistical difference in the stage, with the majority presenting in the early stage. (94% versus 83%). All 78 patients underwent primary cytoreduction with equal rates of optimal resection.There was no difference in the mean disease-free interval between EAOC and NEAOC (107.6 and 109.4 months, p 0.484). Recurrences were predominantly pelvic in both groups. The disease-specific survival was 111.7 and 120.1 months, respectively, with and without endometriosis. This was however not statistically significant (p 0.751).ConclusionIn the Indian population, endometriosis did not have any impact on the age at presentation, CA 125 levels, stage of the disease and survival outcomes in EOC and CCOC ovary.

Uterine leiomyosarcoma is a rare female reproductive system tumor which is difficult to distinguish from uterine leiomyoma preoperatively. Manual and power morcellation are used to remove the large uterus through the vagina or small abdominal incision. Worse outcome with use of power morcellation is now clear but impact of manual morcellation on survival outcome not established till date. The objective of the present study was to find impact of tumor spillage and to evaluate influencing factors for oncological outcome and prognosis in uterine leiomyosarcoma patients. This is a single-institutional retrospective cohort study including all uterine leiomyosarcoma patients from January 2005 to December 2017. Role of intraoperative tumor spillage and other influencing factors on oncological outcome were assessed. Thirty-three patients with median follow-up period of 49.7 months were evaluated. Stage 1 and absence of tumor spill had significant association with prolonged progression-free survival. Stage 1 uterine leiomyosarcoma (56.8 vs 6.8 months, p =  < 0.001), intraoperative tumor spillage (p = 0.03) and progression-free survival > 15 months (68.5 vs 12.2 months, p =  < 0.001) were favourable prognostic factors to predict better survival outcome but unable to establish significance on multivariate analysis. Survival plot did not reach median limit for stage I uterine leiomyosarcoma patients with preoperative suspicion. Age, site of recurrence and mitotic index had no significant association with better survival in the present study. Stage I disease and absence of tumor spillage during surgery improved progression-free survival but did not affect overall survival. Progression-free survival more than 15 months can predict better overall survival.

Objective To study the incidence of lymphedema in patients undergoing surgery for endometrial cancer and to see whether sentinel node mapping and biopsy results in reduced rates of lymphedema compared to PLND. Methods A retrospective single institution analysis including all patients who underwent surgery with nodal assessment for proven or suspected endometrial cancer between January 2010 and July 2021. Patients without 1-year postoperative follow-up were excluded from analysis. Data were obtained from electronic medical records. Each hemipelvis was considered a unit of study. SPSS v.20 was used for statistical analysis. Results Of the 816 hemipelvises in 408 patients, 486 underwent SLNB and 330 PLND. Mean age of SLNB group was younger (57 y and 59.8 y, P  < 0.001). Both the groups had similar confounding comorbidities. A mean of 2 (0–8) nodes were obtained in SLNB group and 7 (range 1–26) in PLND group. Average duration of surgery was 123.3 and 197.4min ( p  < 0.001), and blood loss was 41 and 221.8 ml ( p  < 0.001) with SLNB and PLND, respectively. Side-specific lymphedema occurred in 6.37% with PLND and 1.23% with SLNB ( p  < 0.001). Additionally, 1.7% patients in the PLND group and none in SLNB group reported heaviness of the lower limb without clinically obvious edema ( p  = 0.005). Two patients with edema after SLNB had varicose veins ipsilaterally. Pelvic Lymphocele was seen in 2.33% patients after PLND and 0.19% after SLNB ( p  = 0.010). Conclusion The present study shows that SLNB is associated with substantially reduced incidence of lymphedema with significantly lower operative time and blood loss.

To study the incidence of lymphedema in patients undergoing surgery for endometrial cancer and to see whether sentinel node mapping and biopsy results in reduced rates of lymphedema compared to PLND. A retrospective single institution analysis including all patients who underwent surgery with nodal assessment for proven or suspected endometrial cancer between January 2010 and July 2021. Patients without 1-year postoperative follow-up were excluded from analysis. Data were obtained from electronic medical records. Each hemipelvis was considered a unit of study. SPSS v.20 was used for statistical analysis. Of the 816 hemipelvises in 408 patients, 486 underwent SLNB and 330 PLND.Mean age of SLNB group was younger (57 y and 59.8 y,  < 0.001). Both the groups had similar confounding comorbidities. A mean of 2 (0-8) nodes were obtained in SLNB group and 7 (range 1-26) in PLND group. Average duration of surgery was 123.3 and 197.4min (  < 0.001), and blood loss was 41 and 221.8 ml (  < 0.001) with SLNB and PLND, respectively.Side-specific lymphedema occurred in 6.37% with PLND and 1.23% with SLNB (  < 0.001). Additionally, 1.7% patients in the PLND group and none in SLNB group reported heaviness of the lower limb without clinically obvious edema (  = 0.005). Two patients with edema after SLNB had varicose veins ipsilaterally. Pelvic Lymphocele was seen in 2.33% patients after PLND and 0.19% after SLNB (  = 0.010). The present study shows that SLNB is associated with substantially reduced incidence of lymphedema with significantly lower operative time and blood loss.

ObjectivesThis study aimed to assess the impact of endometriosis on clinical characteristics and survival outcomes in Endometrioid (EC) and clear cell (CCC) ovarian carcinoma.MethodsThis study investigated 78 cases of EC and CCC diagnosed between 2010 and 2021. Demographic and clinical presentation data were obtained from medical records. Patients were followed up till March 2022.ResultsOf the 78 cases of CCC and EC ovary, 38 had histopathologically proven endometriosis, ovary being the most common site. There was no difference in mean age (50.97 and 50.05 years), BMI, parity, menopausal status and CA 125 levels at presentation. Ascites was more frequent in the absence of endometriosis (30% vs 8%, p=0.020). However, this did not translate to a statistical difference in the stage, with majority presenting in early stage. (94% vs 83%). Progesterone receptor positivity on IHC was more likely in the presence of endometriosis (47% vs 18%, p=0.005). All 78 patients underwent primary cytoreduction with equal rates of optimal resection (97% and 98%). 74% with endometriosis and 83% without received adjuvant chemotherapy. 13% and 15% respectively received radiation, all of whom had CCC. There was no difference in the disease free interval (93.4 vs 97.3 months, p =0.587) and overall survival (100.2 vs 106.6 months, p= 0.716) in the patients with and without endometriosis. Recurrences were predominantly pelvic in both groups.ConclusionsIn the Indian population, endometriosis did not have any impact on the age at presentation, CA 125 levels, stage of the disease and survival out comes in EC and CCC ovary.

ObjectivesLaparoscopic pelvic SLNB using ICG, is a viable option, especially in LMICs where access to robot or its prohibitive cost are limiting factors. We looked into the feasibility, detection rate and location of sentinel nodes in laparoscopic staging for carcinoma endometrium using real time ICG fluorescence mapping of SLN.MethodsIn this single institution study,50 patients with endometrial cancer who underwent laparoscopic staging with SLNB from April 2021 to March 2022, were included.ResultsMean age was 55 years, and mean BMI- 29 kg/m2(range 21–39.5). 8(16%) patients had high risk histopathology with p53 positivity in preoperative endometrial biopsy. 8(16%) patients had >50% MI on MRI. Overall sentinel detection rate was 88% with bilateral sentinel detection rate being 86%. Most common location for first sentinel node was external iliac (46.59%), followed by obturator (26.1%), internal iliac (25%) and common iliac(2.27%). Mean number of nodes removed were 2 on either side. For the 6 patients with bilateral failed mapping, pelvic lymphadenectomy was done. One patient with unilateral sentinel detection had side specific hemipelvic lymphadenectomy. Mean duration of surgery was 82.5 min. 84% patients had Stage IA disease.7(14%) patients had stage IB disease. 1(2%) patient was Stage II. 80% patients were Low risk. 16% were high intermediate/high risk. No nodes were positive on ultrastaging.ConclusionsLaparoscopic staging with SLNB using ICG is a practicable approach for uterine limited disease on preoperative evaluation. It extends the benefits of minimally invasive surgery to these patients, while overcoming the limitations of prohibitive cost or availability of expensive equipment.