Amita Maheshwari - Academia.edu (original) (raw)
Papers by Amita Maheshwari
eClinicalMedicine
Background Adverse event reporting in oncology trials lacks temporal description. We propose a to... more Background Adverse event reporting in oncology trials lacks temporal description. We propose a toxicity summarizing method that incorporates time. Methods Patients recruited in a phase III trial (NCT01279135) that compared three-dimensional conformal radiotherapy (3DCRT) and intensity modulated radiotherapy (IMRT) for late toxicity in cervical cancer were included. Adverse events were reported using Common Terminology Criteria for Adverse Events (CTCAE) v3.0 and quality of life (QOL) with EORTC QLQ-C30 and CX24. A total of six symptoms with a related QOL question (diarrhoea, abdominal pain, anorexia, urinary incontinence, frequency and fatigue) were included. Month and severity score [MOSES= P (CTCAE grade x proportionate time)] was calculated. Cumulative-MOSES (C-MOSES) was calculated by summating these 6 individual MOSES. QoL was categorized as "substantially symptomatic" or "not". Receiver operator curve analysis was performed to determine the MOSES cut off that predicts for substantial QOL symptoms. CTCAE and MOSES were tested for accurately categorizing QOL impact. Findings In the construction dataset, 201/300 patients had symptoms. MOSES > 0.20 had higher accuracy than CTCAE for predicting impact on QOL related to diarrhoea (85% vs. 69%), anorexia (61% vs 51%), abdominal pain (71% vs. 57%), urinary incontinence (72% vs. 61%) and frequency (62% vs. 59%). C-MOSES > 0¢70 correlated with reduction in role functioning and global QOL. While no difference was seen in CTCAE grade ≥1 Gastrointestinal (GI) toxicity between 3DCRT or IMRT arm, 3DCRT had higher C-MOSES than IMRT (HR=0.64;95% CI 0.41 −0.99, p = 0.04). Interpretation MOSES has higher accuracy than CTCAE in categorizing symptom specific and functional QOL. These results require further external validation.
Indian Journal of Medical and Paediatric Oncology
Lymphoepithelioma-like carcinoma (LELC) of uterine cervix is an uncommon variant of squamous cell... more Lymphoepithelioma-like carcinoma (LELC) of uterine cervix is an uncommon variant of squamous cell carcinoma. It differs from the usual squamous cell carcinoma of the cervix in its morphology and clinical behavior. The prognosis of LELC of the cervix is better than squamous carcinoma. We report a case of LELC of cervix (FIGO stage IIB) in a 49-year-old woman who presented with six months history of postmenopausal bleeding per vaginum and was treated primarily with radical radiation therapy. She is free of disease for the last ten years.
metastatic workup with PETCT scan, we found a multicentric residual disease in the left breast al... more metastatic workup with PETCT scan, we found a multicentric residual disease in the left breast along with some ipsilateral axillary LN with significant uptake. The concurrent CECT done showed a uterine leiomyomam also. As she was strongly hormone receptor positive, had completed her family and was having mennorhagia probably attributable to uterine fibroids.She was offered hysterectomy with B/L salpingo-oophorectomy. She was keen for breast preservation but in view of her multicentricity of disease on the left breast she was counselled for mastectomy with upfront whole breast reconstruction with TRAM flap. She underwent left modified radical mastectomy with hysterectomy with BSO and TRAM flap reconstruction. The histopathological examination revealed a multicentric, multifocal ILC, grade II with heavy nodal involvement including extracapsular extension. The leiomyoma of uterus also showed tumor deposits from lobular carcinoma breast. Conclusion: We report a very rare case of metastatic pattern of carcinoma of breast. On literature review we found that it is common for the lobular carcinomas of breast to metastasise to gynaecologic organs. Uterine corpus is a very rare site of metastasis for extragenital cancers including breast. All the patients of primary lobular carcinoma of breast should be screened for gynaecologic secondaries in the preoperative workup with high degree of suspicion.
Current Concepts in Endometrial Cancer, 2017
• Advanced age, postmenopausal status, obesity, polycystic ovarian syndrome/ chronic anovulation,... more • Advanced age, postmenopausal status, obesity, polycystic ovarian syndrome/ chronic anovulation, and tamoxifen use are the important risk factors for endometrial carcinoma (EC). • Transvaginal ultrasonography is the imaging modality of first choice while evaluating women with postmenopausal bleeding. • Office endometrial biopsy (EB) is the first step for evaluating the endometrium among women with postmenopausal bleeding. • Once diagnosis of EC is confirmed, MRI is the most effective imaging modality for pre-management staging of EC especially in early stages, whereas CECT is effective in determining peritoneal deposits and parenchymal liver deposits. • PET-CT is found to be effective for distant metastases, more so in recurrent diseases.
Indian Journal of Gynecologic Oncology, 2019
Purpose Radiochemotherapy followed by brachytherapy is the standard treatment in locally advanced... more Purpose Radiochemotherapy followed by brachytherapy is the standard treatment in locally advanced cervical cancer. The aim of this study was to evaluate the patterns of first relapse, the treatment given and its outcome. Methods This is a retrospective analysis of electronic records of locally advanced cervical cancer patients treated in prospective trials from 2003 to 2014. Results Out of 1388 patients, relapse was seen in 316 (23%). Relapse was seen as-pelvic: 105 (7.6%), distant: 136 (10%), and both: 75 (5.4%). Local, regional, paraaortic and systemic relapses were seen in 148 (10.8%), 65 (4.7%), 102 (7.4%) and 163 (11.8%) patients, respectively. Post-relapse, 201/316 (63.6%) received palliative care alone. Treatment in the form of concurrent or sequential chemo-radiotherapy, surgery, stereotactic body radiotherapy and reirradiation using brachytherapy was received by 15 (4.7%), 7 (2.2%), 1 (0.3%) and 1(0.3%) patients, respectively; 65 (20.6%) received palliative chemotherapy, and 28 (8.9%) received palliative radiotherapy. Median post-relapse survival was 7 months (95% CI 5.9-8.1); and in those who received treatment versus supportive care was 10 (95% CI 7.0-13.0) versus 5 (95% CI 3.9-6.1) months (p \ 0.001). The proportion of patients with [ 1-year post-relapse survival was 85.7% in surgery, 66.7% in concurrent or sequential chemotherapy plus radiation, 32.3% in palliative chemotherapy, 14.3% in palliative radiotherapy and 13.4% in supportive care. Conclusion Distant failure is the predominant pattern of relapse seen in patients undergoing radiochemotherapy for locally advanced cervical cancer. Well-selected single-site relapses treated with surgery or chemotherapy plus radiation can have good post-relapse survival.
Indian Journal of Gynecologic Oncology, 2019
Objectives The aim of this study was to quantify the shift in patients from the FIGO 2009 to the ... more Objectives The aim of this study was to quantify the shift in patients from the FIGO 2009 to the FIGO 2018 staging using a prospectively collected dataset where pre-treatment MRI and PET-CT were used. A secondary aim was to explore the distribution of known prognostic factors in both staging schema. Methods Prospectively collected dataset of 1047 cervix cancer patients staged with MRI and PET-CT, between 1996 and 2014, were redistributed using FIGO 2018 staging criteria. Standard deviation inter-quartile and contingency tables were used to present the distribution of patients according to FIGO 2009 and FIGO 2018 criteria. Logistic regression was used to evaluate the association of node positivity and nodal size. Results and Discussion In total, 853 patients were available for analyses. Based on MRI and PET findings, according to FIGO 2009, the incidence of lymph node metastasis was similar in (1) stages 1b1 and 2a1, (2) 1b, 2a2, 2b and 3a (3) 3b and 4a. Nodal metastases were found in 43% patients who were upstaged from FIGO 2009 to newly created FIGO 2018 stages 3c1 and 3c2. Contribution to stage 3c1 came from 31, 41, 29, 30, 32, 33 and 34% of stages 1b1, 1b2, 2a1, 2a2, 3a and 3b, respectively. FIGO 2009 stages 1b1 and 1b2 contributed 5 and 6%, stages 2a1, 2a2, 2b and 3a contributed 16, 15 and 15% to para-aortic nodes, while stage 3b contributed 24%. These findings will likely influence cervix cancer treatment policies.
CANCER REPORTS, 2019
Background: One of the primary treatment strategies for advanced epithelial ovarian cancers inclu... more Background: One of the primary treatment strategies for advanced epithelial ovarian cancers includes neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) and adjuvant chemotherapy. Compliance to treatment is important to possibly improve outcomes. Aim: To audit treatment compliance and its effect on overall survival (OS) and disease free survival (DFS) in women undergoing IDS. Methods and Results: Women diagnosed with advanced epithelial ovarian cancer undergoing IDS were included. Details of compliance to chemotherapy and surgery as per standard guidelines were assessed, and correlation with survival was studied. Reasons for protocol deviation at various levels were documented and analysed. A total of 182 patients were included. The total number of deviations was 134 with deviation at any level being 89 (48.9%) and at all levels 5%. Both patient-and treatment-related factors contributed towards deviation. Deviation or noncompliance towards treatment resulted in a significantly reduced 5-year OS (34.4% vs 58.2%; P = .001) compared with compliant patients, which retained its significance on multivariate analysis (P = .024) as well. Conclusion: Deviation from treatment guidelines resulted in a significantly lower 5year OS compared with those who remained treatment compliant. Both patient-and treatment-related factors contributed towards noncompliance and hence towards lower survival.
Indian Journal of Cancer, 2018
Background Cervical cancer is the second most common cancer among Indian women. This present retr... more Background Cervical cancer is the second most common cancer among Indian women. This present retrospective study was conducted to report patient outcomes with locally advanced cervical cancer treated in the year 2010. Materials and Methods Case records of cervical cancer patients registered from January 1, 2010, to December 31, 2010 were retrieved. A total of 1200 patients were registered, of which 583 received either definitive or adjuvant radiotherapy (RT). Of these, 345 patients who received complete treatment at our hospital were included for outcome analysis. Descriptive statistics were used to summarize patient- and treatment-related variables, and Kaplan-Meier analysis was performed for survival analysis. Results The median age was 56 years (range: 33-90). Squamous carcinoma was the most common histology (91.4%) and the majority were FIGO Stage III (45.4%). Median follow-up of the cohort was 44 months (1-85 months). The 5-year disease-free survival (DFS) across stages was 50%. Most important predictor of DFS was FIGO staging (Stage II vs. Stage III: 62% vs. 45%) and use of concurrent chemoradiotherapy (CTRT) l (RT vs. CTRT: 32% vs. 57%, respectively). Patients aged >70 years had a significantly poor DFS at 5 years; however, did not have any effect on survival. Grade 3 or more late toxicity was seen in only 5% of the patients. Conclusion Five-year DFS of 62% and 45% of Stage II and III patients treated under routine care represents comparable stage-matched results to the rest of the world, respectively.
Annals of Diagnostic Pathology, 2019
We present clinicopathological and molecular cytogenetic features of five rare cases of Ewing sar... more We present clinicopathological and molecular cytogenetic features of five rare cases of Ewing sarcomas, occurring in the female genital tract. A 40 year-old lady presented with a 5.4 cm-sized vaginal mass of 3 months duration, which was histopathologically diagnosed as ES. She defaulted chemotherapy and 8 months later, presented with a recurrence. She underwent chemotherapy and radiotherapy. A 45 year-old lady presented with recurrent vaginal bleeding, for which she underwent total abdominal hysterectomy (TAH) and unilateral salpingo-oophorectomy (USO), 2 and 1/2 years back. Subsequent vaginal biopsy was reported inconclusively, elsewhere. Thereafter, a 5 cm-sized, residual cervicovaginal mass was reported as ES. She completed induction chemotherapy with a significant response. A 35 year-old-lady was referred with a 4 cm-sized cervical mass, for which she underwent TAH-USO with pelvic and para-aortic lymphadenectomy. A 39 year-old-lady presented with a right labial lesion, which recurred. She underwent initial excision, chemotherapy, wide excision and brachytherapy. A year later, she developed multiple metastases; received palliative radiotherapy and died-of-disease. A 16 year-old girl presented with perineal swelling of 4 months duration. She underwent surgical excision of a recurrent right-sided labial cyst, followed by chemotherapy. On histopathological review, all 5 cases were malignant round cell tumors. Immunohistochemically, tumor cells displayed MIC2/CD99 and Fli1 positivity, along with focal positivity for pan cytokeratin (AE1/AE3) (cases 1 and 2) and p63 (case 2). Furthermore, tumor cells in the 1st, 2nd, 3rd and 5th cases displayed EWSR1 rearrangement. Five uncommon cases of ES involving the female genital tract are presented with diagnostic challenges and therapeutic implications.
Indian journal of cancer
Ovarian cancer is the fourth most common cancer in Indian women. Majority of these are epithelial... more Ovarian cancer is the fourth most common cancer in Indian women. Majority of these are epithelial ovarian cancers (EOCs), most of which present in advanced stage. Women with poor performance status and/or those unlikely to achieve optimal debulking at upfront surgery, benefit from neoadjuvant chemotherapy (NACT) followed by interval cytoreduction, with lesser surgical morbidity and equal survival rates as compared to primary cytoreduction. This was a retrospective analysis of patients with advanced ovarian cancer, treated with NACT followed by interval debulking surgery at Tata Memorial Hospital from January 2014 to December 2014. Epithelial cancers constituted 84.4% (n = 406) of all cases of ovarian malignancies. Of these, overwhelming majority (84.3%, n = 342) were in the advanced stage. Sixty percent of all EOC patients received NACT. The mean baseline serum CA-125 level in women treated with NACT was 4294.7 U/ml (range, 11-151,200 U/ml). The median number of NACT cycles (paclita...
Journal of global oncology, 2018
Standard guidelines for the management of early and locally advanced cervical cancer are availabl... more Standard guidelines for the management of early and locally advanced cervical cancer are available from various academic consortiums nationally and internationally. However, implementing standard-of-care treatment poses unique challenges within low- and middle-income countries, such as India, where diverse clinical care practices may exist. The National Cancer Grid, a consortium of 108 institutions in India, aims to homogenize care for patients with cervical cancer by achieving consensus on not only imaging and management, but also in addressing potential solutions to prevalent challenges that affect the homogenous implementation of standard-of-care treatment. These guidelines therefore represent a consensus statement of the National Cancer Grid gynecologic cancer expert group and will assist in homogenization of the therapeutic management of patients with cervical cancer in India.
JAMA oncology, Jan 8, 2018
The evidence for concurrent chemoradiotherapy (CT-RT) in International Federation of Gynecology a... more The evidence for concurrent chemoradiotherapy (CT-RT) in International Federation of Gynecology and Obstetrics (FIGO) stage IIIB squamous cell carcinoma of the uterine cervix is not robust. This study reports the final results of a randomized clinical trial of concurrent cisplatin-based CT-RT and radiotherapy alone (RT) in women with FIGO stage IIIB squamous cell carcinoma of the uterine cervix. To investigate the benefit of concurrent CT-RT in FIGO stage IIIB squamous cell carcinoma of the uterine cervix. This phase 3 open-label randomized clinical trial accrued 850 women in Mumbai, India, between July 7, 2003, and September 22, 2011. Of 2121 screened, 850 women with FIGO stage IIIB squamous cell carcinoma of the uterine cervix suitable for concurrent cisplatin chemotherapy were randomly assigned to CT-RT and RT using block randomization (1:1). The data were updated for a minimum follow-up period of 5 years until December 2016. The final analyses were performed in February and Marc...
Gynecologic oncology, Feb 1, 2018
With an aim to investigate the impact of Human Papilloma Virus (HPV) 16/18 infection on clinical ... more With an aim to investigate the impact of Human Papilloma Virus (HPV) 16/18 infection on clinical outcomes in locally advanced cervical cancers treated with radical radio (chemo) therapy, we undertook this prospective study. Between May 2010 and April 2012, 150 histologically proven cervical cancer patients treated with radio (chemo) therapy were accrued. Cervical biopsies/brushings were collected at pre-treatment, end of treatment and at 3 monthly intervals up to 24months. Quantitative estimation of HPV 16/18 was done using real-time polymerase chain reaction (RT-PCR) and correlated with various clinical end-points. Out of 150 patients accrued, 135 patients were considered for final analysis. Pre-treatment HPV16/18 DNA was detected in 126 (93%) patients, with HPV-16 present in 91%. The mean log (±SD) HPV-16 and HPV-18 viral load at pre-treatment was 4.76 (±2.5) and 0.14 (±2.1) copies/10ng of DNA, respectively. Though significant decline in viral load was observed on follow-ups (p<...
Brachytherapy, Jan 8, 2017
To investigate dose-response relationship between vaginal doses and long-term morbidity. Patients... more To investigate dose-response relationship between vaginal doses and long-term morbidity. Patients receiving adjuvant pelvic (chemo) radiation and brachytherapy for cervical cancer from January 2011 to December 2014 were included. Baseline vaginal length was determined clinically and from imaging at BT planning. Dose points were defined along mucosa and at 5 mm depth at 12, 3, 6, and 9 'o' clock positions at every 2 cm from apex to introitus. Cumulative equivalent doses in 2 Gy were calculated. Vaginal stenosis was reported in reference to baseline length according to CTCAE version 3.0. Receiver operator characteristics curve was used to identify dose thresholds for univariate and multivariate analysis. Overall, 78 women with median age of 49 (32-71) years were included. The median dose at vaginal apex mucosa and 5 mm depth was 118 Gy3 (78-198) and 81 Gy3 (70-149) respectively. At median follow-up of 36 (18-60) months, vaginal stenosis ≥25%, and grade ≥ II telangiectasia was ...
South Asian Journal of Cancer, 2016
Gynecological cancers are among the most common cancers in women and hence an important public he... more Gynecological cancers are among the most common cancers in women and hence an important public health issue. Due to the lack of cancer awareness, variable pathology, and dearth of proper screening facilities in developing countries such as India, most women report at advanced stages, adversely affecting the prognosis and clinical outcomes. Ovarian cancer has emerged as one of the most common malignancies affecting women in India and has shown an increase in the incidence rates over the years. Although cervical cancer is on a declining trend, it remains the second most common cancer in women after breast cancer. Many researchers in India have published important data in the field of gynecologic oncology, covering all domains such as basic sciences, preventive oncology, pathology, radiological imaging, and clinical outcomes. This work has given us an insight into the in-depth understanding of these cancers as well as the demographics and survival rates in the Indian population. This a...
Journal of cancer research and therapeutics
Somatic malignancy in an ovarian teratoma including a squamous carcinoma (SCC) is rare. Clinicopa... more Somatic malignancy in an ovarian teratoma including a squamous carcinoma (SCC) is rare. Clinicopathological features of 12 ovarian teratomas with coexistent SCCs are presented. Over a 10-year-period, 12 ovarian teratomas with coexistent SCCs were reviewed and analyzed. The age range was 31-68 years (median, 49), and the tumor size (nine cases) varied from 10 to 18 cm (mean, 12.4). Stage-wise (10 cases), 7 cases (70%) were in stage I; a single case (10%) in stage II, and two (20%) cases were in stage III. Microscopically, all 12 tumors revealed mature teratoma with SCC, as a discrete tumor (6, 50%), or arising from the epithelium of the teratoma in six (50%) cases. SCC component was commonly moderately differentiated (eight cases) or poorly differentiated (three cases). P63 immunostaining reinforced squamous differentiation in a single poorly differentiated SCC and CK5/6 in another tumor. All patients underwent surgery. Two cases revealed positive lymph nodes and contiguous colonic i...
Indian journal of pathology & microbiology
To study the histological features in uterine STUMP, and atypical leiomyomas (AL), and to correla... more To study the histological features in uterine STUMP, and atypical leiomyomas (AL), and to correlate with clinical outcome. From January 2004 to August 2010, a total of 21 cases were retrieved from records, labeled as STUMP(7), AL (5), AL with low risk of recurrence (2), smooth muscle tumor of low malignant potential (STLMP) (2), and symplastic leiomyoma (5). The slides were reviewed for coagulative tumor cell necrosis (CTCN), hyaline necrosis/ infarction type necrosis, presence and degree of cytological atypia, mitotic activity, epithelioid morphology and myxoid features. The other characteristics (such as size, circumscription, individual tumor cell necrosis), were noted, wherever available. The mean age was 45 years (median 46; range 24-67 yrs). CTCN was seen in 2 cases on examination of additional material; wherein a revised diagnosis of leiomyosarcoma had been given. Infarction type necrosis and individual cell necrosis was seen in 2 and 3 cases, respectively. Mitoses were less ...
Journal of Gynecologic Surgery, 2003
Damage to the lower ureters during pelvic surgery is a serious and well-recognized complication. ... more Damage to the lower ureters during pelvic surgery is a serious and well-recognized complication. In most series, ureteric injury occurred in 0.5%-1.0% of all pelvic operations. The incidence of ureteric injuries is high with extensive abdominal operations for carcinoma of cervix (1.5%-2.5%) more so with patients who had preoperative radiotherapy. We treated 34 women with iatrogenic ureteric injuries during a 20-year period following radical hysterectomy for carcinoma cervix. The time of recognition of injury in 25 cases was during primary surgery and treated immediately. Surgery was uneventful in 9 patients of whom 7 presented in the early postoperative period and 2 during follow-up. These patients were managed by ureteroneocystostomy, percutaneous nephrostomy (PCN), and double J (DJ) stenting. All the renal units were salvaged. Immediate ureteric repair is advocated for all injuries discovered intraoperatively. Action to prevent the development of iatrogenic ureteral injury must be taken in advance, and the management of ureteric injuries could be improved with prompt recognition and repair by a skilled surgeon. Unrecognized injuries cause prolonged morbidity, and their management can be difficult. (J GYNECOL SURG 19:133
eClinicalMedicine
Background Adverse event reporting in oncology trials lacks temporal description. We propose a to... more Background Adverse event reporting in oncology trials lacks temporal description. We propose a toxicity summarizing method that incorporates time. Methods Patients recruited in a phase III trial (NCT01279135) that compared three-dimensional conformal radiotherapy (3DCRT) and intensity modulated radiotherapy (IMRT) for late toxicity in cervical cancer were included. Adverse events were reported using Common Terminology Criteria for Adverse Events (CTCAE) v3.0 and quality of life (QOL) with EORTC QLQ-C30 and CX24. A total of six symptoms with a related QOL question (diarrhoea, abdominal pain, anorexia, urinary incontinence, frequency and fatigue) were included. Month and severity score [MOSES= P (CTCAE grade x proportionate time)] was calculated. Cumulative-MOSES (C-MOSES) was calculated by summating these 6 individual MOSES. QoL was categorized as "substantially symptomatic" or "not". Receiver operator curve analysis was performed to determine the MOSES cut off that predicts for substantial QOL symptoms. CTCAE and MOSES were tested for accurately categorizing QOL impact. Findings In the construction dataset, 201/300 patients had symptoms. MOSES > 0.20 had higher accuracy than CTCAE for predicting impact on QOL related to diarrhoea (85% vs. 69%), anorexia (61% vs 51%), abdominal pain (71% vs. 57%), urinary incontinence (72% vs. 61%) and frequency (62% vs. 59%). C-MOSES > 0¢70 correlated with reduction in role functioning and global QOL. While no difference was seen in CTCAE grade ≥1 Gastrointestinal (GI) toxicity between 3DCRT or IMRT arm, 3DCRT had higher C-MOSES than IMRT (HR=0.64;95% CI 0.41 −0.99, p = 0.04). Interpretation MOSES has higher accuracy than CTCAE in categorizing symptom specific and functional QOL. These results require further external validation.
Indian Journal of Medical and Paediatric Oncology
Lymphoepithelioma-like carcinoma (LELC) of uterine cervix is an uncommon variant of squamous cell... more Lymphoepithelioma-like carcinoma (LELC) of uterine cervix is an uncommon variant of squamous cell carcinoma. It differs from the usual squamous cell carcinoma of the cervix in its morphology and clinical behavior. The prognosis of LELC of the cervix is better than squamous carcinoma. We report a case of LELC of cervix (FIGO stage IIB) in a 49-year-old woman who presented with six months history of postmenopausal bleeding per vaginum and was treated primarily with radical radiation therapy. She is free of disease for the last ten years.
metastatic workup with PETCT scan, we found a multicentric residual disease in the left breast al... more metastatic workup with PETCT scan, we found a multicentric residual disease in the left breast along with some ipsilateral axillary LN with significant uptake. The concurrent CECT done showed a uterine leiomyomam also. As she was strongly hormone receptor positive, had completed her family and was having mennorhagia probably attributable to uterine fibroids.She was offered hysterectomy with B/L salpingo-oophorectomy. She was keen for breast preservation but in view of her multicentricity of disease on the left breast she was counselled for mastectomy with upfront whole breast reconstruction with TRAM flap. She underwent left modified radical mastectomy with hysterectomy with BSO and TRAM flap reconstruction. The histopathological examination revealed a multicentric, multifocal ILC, grade II with heavy nodal involvement including extracapsular extension. The leiomyoma of uterus also showed tumor deposits from lobular carcinoma breast. Conclusion: We report a very rare case of metastatic pattern of carcinoma of breast. On literature review we found that it is common for the lobular carcinomas of breast to metastasise to gynaecologic organs. Uterine corpus is a very rare site of metastasis for extragenital cancers including breast. All the patients of primary lobular carcinoma of breast should be screened for gynaecologic secondaries in the preoperative workup with high degree of suspicion.
Current Concepts in Endometrial Cancer, 2017
• Advanced age, postmenopausal status, obesity, polycystic ovarian syndrome/ chronic anovulation,... more • Advanced age, postmenopausal status, obesity, polycystic ovarian syndrome/ chronic anovulation, and tamoxifen use are the important risk factors for endometrial carcinoma (EC). • Transvaginal ultrasonography is the imaging modality of first choice while evaluating women with postmenopausal bleeding. • Office endometrial biopsy (EB) is the first step for evaluating the endometrium among women with postmenopausal bleeding. • Once diagnosis of EC is confirmed, MRI is the most effective imaging modality for pre-management staging of EC especially in early stages, whereas CECT is effective in determining peritoneal deposits and parenchymal liver deposits. • PET-CT is found to be effective for distant metastases, more so in recurrent diseases.
Indian Journal of Gynecologic Oncology, 2019
Purpose Radiochemotherapy followed by brachytherapy is the standard treatment in locally advanced... more Purpose Radiochemotherapy followed by brachytherapy is the standard treatment in locally advanced cervical cancer. The aim of this study was to evaluate the patterns of first relapse, the treatment given and its outcome. Methods This is a retrospective analysis of electronic records of locally advanced cervical cancer patients treated in prospective trials from 2003 to 2014. Results Out of 1388 patients, relapse was seen in 316 (23%). Relapse was seen as-pelvic: 105 (7.6%), distant: 136 (10%), and both: 75 (5.4%). Local, regional, paraaortic and systemic relapses were seen in 148 (10.8%), 65 (4.7%), 102 (7.4%) and 163 (11.8%) patients, respectively. Post-relapse, 201/316 (63.6%) received palliative care alone. Treatment in the form of concurrent or sequential chemo-radiotherapy, surgery, stereotactic body radiotherapy and reirradiation using brachytherapy was received by 15 (4.7%), 7 (2.2%), 1 (0.3%) and 1(0.3%) patients, respectively; 65 (20.6%) received palliative chemotherapy, and 28 (8.9%) received palliative radiotherapy. Median post-relapse survival was 7 months (95% CI 5.9-8.1); and in those who received treatment versus supportive care was 10 (95% CI 7.0-13.0) versus 5 (95% CI 3.9-6.1) months (p \ 0.001). The proportion of patients with [ 1-year post-relapse survival was 85.7% in surgery, 66.7% in concurrent or sequential chemotherapy plus radiation, 32.3% in palliative chemotherapy, 14.3% in palliative radiotherapy and 13.4% in supportive care. Conclusion Distant failure is the predominant pattern of relapse seen in patients undergoing radiochemotherapy for locally advanced cervical cancer. Well-selected single-site relapses treated with surgery or chemotherapy plus radiation can have good post-relapse survival.
Indian Journal of Gynecologic Oncology, 2019
Objectives The aim of this study was to quantify the shift in patients from the FIGO 2009 to the ... more Objectives The aim of this study was to quantify the shift in patients from the FIGO 2009 to the FIGO 2018 staging using a prospectively collected dataset where pre-treatment MRI and PET-CT were used. A secondary aim was to explore the distribution of known prognostic factors in both staging schema. Methods Prospectively collected dataset of 1047 cervix cancer patients staged with MRI and PET-CT, between 1996 and 2014, were redistributed using FIGO 2018 staging criteria. Standard deviation inter-quartile and contingency tables were used to present the distribution of patients according to FIGO 2009 and FIGO 2018 criteria. Logistic regression was used to evaluate the association of node positivity and nodal size. Results and Discussion In total, 853 patients were available for analyses. Based on MRI and PET findings, according to FIGO 2009, the incidence of lymph node metastasis was similar in (1) stages 1b1 and 2a1, (2) 1b, 2a2, 2b and 3a (3) 3b and 4a. Nodal metastases were found in 43% patients who were upstaged from FIGO 2009 to newly created FIGO 2018 stages 3c1 and 3c2. Contribution to stage 3c1 came from 31, 41, 29, 30, 32, 33 and 34% of stages 1b1, 1b2, 2a1, 2a2, 3a and 3b, respectively. FIGO 2009 stages 1b1 and 1b2 contributed 5 and 6%, stages 2a1, 2a2, 2b and 3a contributed 16, 15 and 15% to para-aortic nodes, while stage 3b contributed 24%. These findings will likely influence cervix cancer treatment policies.
CANCER REPORTS, 2019
Background: One of the primary treatment strategies for advanced epithelial ovarian cancers inclu... more Background: One of the primary treatment strategies for advanced epithelial ovarian cancers includes neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) and adjuvant chemotherapy. Compliance to treatment is important to possibly improve outcomes. Aim: To audit treatment compliance and its effect on overall survival (OS) and disease free survival (DFS) in women undergoing IDS. Methods and Results: Women diagnosed with advanced epithelial ovarian cancer undergoing IDS were included. Details of compliance to chemotherapy and surgery as per standard guidelines were assessed, and correlation with survival was studied. Reasons for protocol deviation at various levels were documented and analysed. A total of 182 patients were included. The total number of deviations was 134 with deviation at any level being 89 (48.9%) and at all levels 5%. Both patient-and treatment-related factors contributed towards deviation. Deviation or noncompliance towards treatment resulted in a significantly reduced 5-year OS (34.4% vs 58.2%; P = .001) compared with compliant patients, which retained its significance on multivariate analysis (P = .024) as well. Conclusion: Deviation from treatment guidelines resulted in a significantly lower 5year OS compared with those who remained treatment compliant. Both patient-and treatment-related factors contributed towards noncompliance and hence towards lower survival.
Indian Journal of Cancer, 2018
Background Cervical cancer is the second most common cancer among Indian women. This present retr... more Background Cervical cancer is the second most common cancer among Indian women. This present retrospective study was conducted to report patient outcomes with locally advanced cervical cancer treated in the year 2010. Materials and Methods Case records of cervical cancer patients registered from January 1, 2010, to December 31, 2010 were retrieved. A total of 1200 patients were registered, of which 583 received either definitive or adjuvant radiotherapy (RT). Of these, 345 patients who received complete treatment at our hospital were included for outcome analysis. Descriptive statistics were used to summarize patient- and treatment-related variables, and Kaplan-Meier analysis was performed for survival analysis. Results The median age was 56 years (range: 33-90). Squamous carcinoma was the most common histology (91.4%) and the majority were FIGO Stage III (45.4%). Median follow-up of the cohort was 44 months (1-85 months). The 5-year disease-free survival (DFS) across stages was 50%. Most important predictor of DFS was FIGO staging (Stage II vs. Stage III: 62% vs. 45%) and use of concurrent chemoradiotherapy (CTRT) l (RT vs. CTRT: 32% vs. 57%, respectively). Patients aged >70 years had a significantly poor DFS at 5 years; however, did not have any effect on survival. Grade 3 or more late toxicity was seen in only 5% of the patients. Conclusion Five-year DFS of 62% and 45% of Stage II and III patients treated under routine care represents comparable stage-matched results to the rest of the world, respectively.
Annals of Diagnostic Pathology, 2019
We present clinicopathological and molecular cytogenetic features of five rare cases of Ewing sar... more We present clinicopathological and molecular cytogenetic features of five rare cases of Ewing sarcomas, occurring in the female genital tract. A 40 year-old lady presented with a 5.4 cm-sized vaginal mass of 3 months duration, which was histopathologically diagnosed as ES. She defaulted chemotherapy and 8 months later, presented with a recurrence. She underwent chemotherapy and radiotherapy. A 45 year-old lady presented with recurrent vaginal bleeding, for which she underwent total abdominal hysterectomy (TAH) and unilateral salpingo-oophorectomy (USO), 2 and 1/2 years back. Subsequent vaginal biopsy was reported inconclusively, elsewhere. Thereafter, a 5 cm-sized, residual cervicovaginal mass was reported as ES. She completed induction chemotherapy with a significant response. A 35 year-old-lady was referred with a 4 cm-sized cervical mass, for which she underwent TAH-USO with pelvic and para-aortic lymphadenectomy. A 39 year-old-lady presented with a right labial lesion, which recurred. She underwent initial excision, chemotherapy, wide excision and brachytherapy. A year later, she developed multiple metastases; received palliative radiotherapy and died-of-disease. A 16 year-old girl presented with perineal swelling of 4 months duration. She underwent surgical excision of a recurrent right-sided labial cyst, followed by chemotherapy. On histopathological review, all 5 cases were malignant round cell tumors. Immunohistochemically, tumor cells displayed MIC2/CD99 and Fli1 positivity, along with focal positivity for pan cytokeratin (AE1/AE3) (cases 1 and 2) and p63 (case 2). Furthermore, tumor cells in the 1st, 2nd, 3rd and 5th cases displayed EWSR1 rearrangement. Five uncommon cases of ES involving the female genital tract are presented with diagnostic challenges and therapeutic implications.
Indian journal of cancer
Ovarian cancer is the fourth most common cancer in Indian women. Majority of these are epithelial... more Ovarian cancer is the fourth most common cancer in Indian women. Majority of these are epithelial ovarian cancers (EOCs), most of which present in advanced stage. Women with poor performance status and/or those unlikely to achieve optimal debulking at upfront surgery, benefit from neoadjuvant chemotherapy (NACT) followed by interval cytoreduction, with lesser surgical morbidity and equal survival rates as compared to primary cytoreduction. This was a retrospective analysis of patients with advanced ovarian cancer, treated with NACT followed by interval debulking surgery at Tata Memorial Hospital from January 2014 to December 2014. Epithelial cancers constituted 84.4% (n = 406) of all cases of ovarian malignancies. Of these, overwhelming majority (84.3%, n = 342) were in the advanced stage. Sixty percent of all EOC patients received NACT. The mean baseline serum CA-125 level in women treated with NACT was 4294.7 U/ml (range, 11-151,200 U/ml). The median number of NACT cycles (paclita...
Journal of global oncology, 2018
Standard guidelines for the management of early and locally advanced cervical cancer are availabl... more Standard guidelines for the management of early and locally advanced cervical cancer are available from various academic consortiums nationally and internationally. However, implementing standard-of-care treatment poses unique challenges within low- and middle-income countries, such as India, where diverse clinical care practices may exist. The National Cancer Grid, a consortium of 108 institutions in India, aims to homogenize care for patients with cervical cancer by achieving consensus on not only imaging and management, but also in addressing potential solutions to prevalent challenges that affect the homogenous implementation of standard-of-care treatment. These guidelines therefore represent a consensus statement of the National Cancer Grid gynecologic cancer expert group and will assist in homogenization of the therapeutic management of patients with cervical cancer in India.
JAMA oncology, Jan 8, 2018
The evidence for concurrent chemoradiotherapy (CT-RT) in International Federation of Gynecology a... more The evidence for concurrent chemoradiotherapy (CT-RT) in International Federation of Gynecology and Obstetrics (FIGO) stage IIIB squamous cell carcinoma of the uterine cervix is not robust. This study reports the final results of a randomized clinical trial of concurrent cisplatin-based CT-RT and radiotherapy alone (RT) in women with FIGO stage IIIB squamous cell carcinoma of the uterine cervix. To investigate the benefit of concurrent CT-RT in FIGO stage IIIB squamous cell carcinoma of the uterine cervix. This phase 3 open-label randomized clinical trial accrued 850 women in Mumbai, India, between July 7, 2003, and September 22, 2011. Of 2121 screened, 850 women with FIGO stage IIIB squamous cell carcinoma of the uterine cervix suitable for concurrent cisplatin chemotherapy were randomly assigned to CT-RT and RT using block randomization (1:1). The data were updated for a minimum follow-up period of 5 years until December 2016. The final analyses were performed in February and Marc...
Gynecologic oncology, Feb 1, 2018
With an aim to investigate the impact of Human Papilloma Virus (HPV) 16/18 infection on clinical ... more With an aim to investigate the impact of Human Papilloma Virus (HPV) 16/18 infection on clinical outcomes in locally advanced cervical cancers treated with radical radio (chemo) therapy, we undertook this prospective study. Between May 2010 and April 2012, 150 histologically proven cervical cancer patients treated with radio (chemo) therapy were accrued. Cervical biopsies/brushings were collected at pre-treatment, end of treatment and at 3 monthly intervals up to 24months. Quantitative estimation of HPV 16/18 was done using real-time polymerase chain reaction (RT-PCR) and correlated with various clinical end-points. Out of 150 patients accrued, 135 patients were considered for final analysis. Pre-treatment HPV16/18 DNA was detected in 126 (93%) patients, with HPV-16 present in 91%. The mean log (±SD) HPV-16 and HPV-18 viral load at pre-treatment was 4.76 (±2.5) and 0.14 (±2.1) copies/10ng of DNA, respectively. Though significant decline in viral load was observed on follow-ups (p<...
Brachytherapy, Jan 8, 2017
To investigate dose-response relationship between vaginal doses and long-term morbidity. Patients... more To investigate dose-response relationship between vaginal doses and long-term morbidity. Patients receiving adjuvant pelvic (chemo) radiation and brachytherapy for cervical cancer from January 2011 to December 2014 were included. Baseline vaginal length was determined clinically and from imaging at BT planning. Dose points were defined along mucosa and at 5 mm depth at 12, 3, 6, and 9 'o' clock positions at every 2 cm from apex to introitus. Cumulative equivalent doses in 2 Gy were calculated. Vaginal stenosis was reported in reference to baseline length according to CTCAE version 3.0. Receiver operator characteristics curve was used to identify dose thresholds for univariate and multivariate analysis. Overall, 78 women with median age of 49 (32-71) years were included. The median dose at vaginal apex mucosa and 5 mm depth was 118 Gy3 (78-198) and 81 Gy3 (70-149) respectively. At median follow-up of 36 (18-60) months, vaginal stenosis ≥25%, and grade ≥ II telangiectasia was ...
South Asian Journal of Cancer, 2016
Gynecological cancers are among the most common cancers in women and hence an important public he... more Gynecological cancers are among the most common cancers in women and hence an important public health issue. Due to the lack of cancer awareness, variable pathology, and dearth of proper screening facilities in developing countries such as India, most women report at advanced stages, adversely affecting the prognosis and clinical outcomes. Ovarian cancer has emerged as one of the most common malignancies affecting women in India and has shown an increase in the incidence rates over the years. Although cervical cancer is on a declining trend, it remains the second most common cancer in women after breast cancer. Many researchers in India have published important data in the field of gynecologic oncology, covering all domains such as basic sciences, preventive oncology, pathology, radiological imaging, and clinical outcomes. This work has given us an insight into the in-depth understanding of these cancers as well as the demographics and survival rates in the Indian population. This a...
Journal of cancer research and therapeutics
Somatic malignancy in an ovarian teratoma including a squamous carcinoma (SCC) is rare. Clinicopa... more Somatic malignancy in an ovarian teratoma including a squamous carcinoma (SCC) is rare. Clinicopathological features of 12 ovarian teratomas with coexistent SCCs are presented. Over a 10-year-period, 12 ovarian teratomas with coexistent SCCs were reviewed and analyzed. The age range was 31-68 years (median, 49), and the tumor size (nine cases) varied from 10 to 18 cm (mean, 12.4). Stage-wise (10 cases), 7 cases (70%) were in stage I; a single case (10%) in stage II, and two (20%) cases were in stage III. Microscopically, all 12 tumors revealed mature teratoma with SCC, as a discrete tumor (6, 50%), or arising from the epithelium of the teratoma in six (50%) cases. SCC component was commonly moderately differentiated (eight cases) or poorly differentiated (three cases). P63 immunostaining reinforced squamous differentiation in a single poorly differentiated SCC and CK5/6 in another tumor. All patients underwent surgery. Two cases revealed positive lymph nodes and contiguous colonic i...
Indian journal of pathology & microbiology
To study the histological features in uterine STUMP, and atypical leiomyomas (AL), and to correla... more To study the histological features in uterine STUMP, and atypical leiomyomas (AL), and to correlate with clinical outcome. From January 2004 to August 2010, a total of 21 cases were retrieved from records, labeled as STUMP(7), AL (5), AL with low risk of recurrence (2), smooth muscle tumor of low malignant potential (STLMP) (2), and symplastic leiomyoma (5). The slides were reviewed for coagulative tumor cell necrosis (CTCN), hyaline necrosis/ infarction type necrosis, presence and degree of cytological atypia, mitotic activity, epithelioid morphology and myxoid features. The other characteristics (such as size, circumscription, individual tumor cell necrosis), were noted, wherever available. The mean age was 45 years (median 46; range 24-67 yrs). CTCN was seen in 2 cases on examination of additional material; wherein a revised diagnosis of leiomyosarcoma had been given. Infarction type necrosis and individual cell necrosis was seen in 2 and 3 cases, respectively. Mitoses were less ...
Journal of Gynecologic Surgery, 2003
Damage to the lower ureters during pelvic surgery is a serious and well-recognized complication. ... more Damage to the lower ureters during pelvic surgery is a serious and well-recognized complication. In most series, ureteric injury occurred in 0.5%-1.0% of all pelvic operations. The incidence of ureteric injuries is high with extensive abdominal operations for carcinoma of cervix (1.5%-2.5%) more so with patients who had preoperative radiotherapy. We treated 34 women with iatrogenic ureteric injuries during a 20-year period following radical hysterectomy for carcinoma cervix. The time of recognition of injury in 25 cases was during primary surgery and treated immediately. Surgery was uneventful in 9 patients of whom 7 presented in the early postoperative period and 2 during follow-up. These patients were managed by ureteroneocystostomy, percutaneous nephrostomy (PCN), and double J (DJ) stenting. All the renal units were salvaged. Immediate ureteric repair is advocated for all injuries discovered intraoperatively. Action to prevent the development of iatrogenic ureteral injury must be taken in advance, and the management of ureteric injuries could be improved with prompt recognition and repair by a skilled surgeon. Unrecognized injuries cause prolonged morbidity, and their management can be difficult. (J GYNECOL SURG 19:133