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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 14-18

Audit of Operated Cases of Gynecological Malignancies in Two Years at A Tertiary Care Centre of Bihar


1 Senior Resident, Department of RCC, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna - 14, Bihar, India
2 Additional Professor, Department of RCC, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna - 14, Bihar, India
3 Gynecological Oncology, Department of RCC, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna - 14, Bihar, India

Date of Web Publication11-Dec-2020

Correspondence Address:
Sangeeta Panakj
Additional Professor, Gynecological Oncology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna -14, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Non communicable diseases are form a major bulk of patients in our country and are now the target of policy makers in India. Cancer is a cause of significant morbidity and mortality and that needs to be tackled aggressively. The current study is a review and analysis of patients attending the Gynecological Oncology department of a tertiary care center of Bihar. We have found that cancer of the cervix is the most common genital malignancy in our region however but most cases are diagnosed at later stage and not detected in the operable stages. Cancer cervix is followed closely by cancer of the ovary. Thus we conclude that to bring down the rates of cervical cancer in India the government like its western counterparts needs to implement strict screening guidelines and strengthen our primary health centers and community health centres with facilities for screening.

Keywords: Gynecological malignancies, cervix cancer, ovary cancer, screening.


How to cite this article:
Kumari A, Nazaneen S, Panakj S, Kumari A, Kumari J. Audit of Operated Cases of Gynecological Malignancies in Two Years at A Tertiary Care Centre of Bihar. J Indira Gandhi Inst Med Sci 2017;3:14-8

How to cite this URL:
Kumari A, Nazaneen S, Panakj S, Kumari A, Kumari J. Audit of Operated Cases of Gynecological Malignancies in Two Years at A Tertiary Care Centre of Bihar. J Indira Gandhi Inst Med Sci [serial online] 2017 [cited 2021 Dec 7];3:14-8. Available from: http://www.jigims.co.in/text.asp?2017/3/2/14/303139




  Introduction Top


Indian health agencies have now realized the burden of morbidity and mortality caused by non-communicable diseases in the country Various health plans are being designed and implemented to curb the problem. A major contributor to non-communicable diseases is cancer. India is still lagging behind in formulation and implementation of programs to prevent and control cancer. The scene is worst in the economically stricken and populous states like Bihar.

Women’s health issues are often neglected and now one of the forefront agendas of the government. The department of gynecological oncology, which has been functioning for years in the western countries, is existing in very few hospitals in India. This specialty is now an upcoming branch and is being developed in many hospitals.

Genital tract malignancies are associated with high mortality, morbidity and shortening of lifespan in women. Tumors of female genital tract have different patterns of distribution worldwide.

Over the past 50 years, organized screening programs in developed countries have contributed significantly to the decline in incidence and mortality of cancer of the uterine cervix. In contrast, largely due to lack of organized screening programs in most parts of developing countries, cervical cancer remains one of the major killer of women in these regions. Low socio-economic status, illiteracy, lack of accessibility to health care, cultural and religious inhibitions contribute to high incidence and mortality.

Ovarian cancer is reported to be the second major cause of death in women among female genital tract malignancies,[1] and at least 75% of patients present with advanced disease. In Bihar, no studies have dealt specifically with the frequency and patterns of female genital tract malignancy. Our study is aimed at providing baseline data on this topic for future studies in the state and to increase awareness on this subject.

In Bihar, Indira Gandhi Institute of Medical Sciences has had a functioning gynecological oncology department since 2008 and so we decided to review the data of female genital malignancies in this department.


  Materials and Methods Top


We carried out this retrospective study in the department of gynecological oncology of a tertiary care center in Bihar. The study covered a period of 2 years from January 2015 to December 2016. The data of out patients and in patients of the department for years 2015 and 2016 were retrieved. Case records of all patients admitted to gynecological oncology department were studied in detail and information on clinical, surgical and histopathological diagnosis was collected using a proforma. The data was analyzed and results expressed in descriptive statistics by simple percentages.


  Results and Analysis Top


During the two years under study 10,380 patients attended the outpatient department. Of these 190 cases of proven gynecological malignancy needing major or minor surgery were admitted in the ward. 308 Three hundred and eight cervical biopsies were performed and in 22 cases endometrial biopsy was taken. Of the 308 cervical biopsies 253 were found to have invasive carcinoma. The distribution of site wise carcinoma of the 190 admitted patients [Table 1] show the highest prevalence of cancer cervix (44.74%) followed closely by cancer of ovary(38.42%).


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The distribution of different malignancies in the various age groups is depicted in [Table 2] and shows the highest prevalence of cancer cervix in the age group 41-50 years and cancer ovary was again commonest in age group of 41 to 50 years.
Table 2: Distribution of admitted individual malignant female genital tract tumors by age and anatomical site

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The various histological variants of the cases of gynecological malignancies are depicted in [Table 3]. Squamous cell carcinoma is the most common type of cancer cervix. Serous cystadenocarcinoma was the most common variant of cancer ovary followed closely by mucinous cystadenocarcinoma.
Table 3: Distribution of the histological types of gynecological cancers in the study population

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The results of Cervical biopsy performed in 308 patients revealed invasive carcinoma in 253 patients of these only 52 patients underwent surgery [Table 5].
Table 4: Age distribution of Gynecological malignancy

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Table 5: Ratio of operated cases among cancer ovary.

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Table 5: Results of cervix biopsy.

Of the 73 admitted cases of cancer ovary 60 underwent cyto-reductive surgery. 22 underwent primary cyto-reduction and 38 were debulked after chemotherapy [Table 5].


  Discussion Top


Gynecological malignancies are a common cancer and is a major cause of mortality and morbidity among females. The distribution of these cancers vary in different parts of the world and among different populations. In the two years under review more than 10,000 patients, both new and old, attended to in the out patients department of Gynaecological oncology. Out of these 190 patients of histologically proven cancer were admitted and underwent major surgery. A major bulk of the admitted patients were of cancer of cervix (44.74%). Ovarian cancer was 38.42% , endometrial cancer was 15.26% , two cases of cancer vulva and one case of choriocarcinima. A study of 2016 from Bhubaneswar , Odisha, India, showed that cancer cervix 48.30%, ovarian cancer 33.05%, endometrial cancer 13.56%,choriocarcinoma 2.54%, vulval, vaginal and fallopian tube malignancy 0.85%.[2] Chhabra et al conducted a study in Maharashtra in between 1985 and 1999. Gynecological malignancies comprised 42.52% of all female malignancies. Cervical cancer (80%) and ovarian cancer (15%) were the main gynecological tumours.[3] Study conducted in the United Kingdom on the incidence of gynecological malignancies among different ethnic groups showed breast cancer to be the most common cancer among Indians residing there. This was followed by cancer of endometrium, ovary and cervix respectively.[4] This difference in the rates of cancer can possibly be explained by the implementation of cervical cancer screening programs in the United Kingdom. The higher rates of cancer endometrium can be contributed to the difference in dietary habits and lifestyle in the two countries.

Every year in India, 122,844 women are diagnosed with cervical cancer and 67,477 die from this disease.[5] Cervical cancer is one cancer which has very sensitive and specific screening tests and the developed nations have been successful in reducing the incidence of cervical cancer by strict and routine implementation of screening programs. India lacks such routine screening policies and several studies have been conducted to look for the ideal screening test in our set up.

Sankaranarayanan et al. in a cluster-randomized trial, with 131,746 healthy women, randomly assigned women to undergo screening by HPV testing, cytologic testing, or VIA, or to receive a standard care (control group).[6] In the HPV- testing group, cervical cancer was diagnosed in 127 patients (of whom 39 had Stage II or higher), as compared with 118 patients (of whom 82 had advanced disease) in the control group (hazard ratio for the detection of advanced cancer in the HPV-testing group, 0.47; 95% confidence interval [95% CI]: 0.32-0.69). There were 34 deaths from cancer in the HPV-testing group, as compared with 64 in the control group (hazard ratio, 0.52; 95% CI: 0.33-0.83). No significant reductions in the number of advanced cancers or deaths were observed in the cytologic-testing group or in the VIA group, as compared with the control group. Shastri et al. studied the effect of VIA screening by primary health workers in a randomized controlled study.[7] Four rounds of cancer education and VIA screening were conducted by primary health workers at 24-month intervals in the screening group, while cancer education was offered once at recruitment to the control group. The incidence of invasive cervical cancer was 26.74 per 100,000 in the screening group and 27.49 per 100,000 in the control group. Compliance to treatment for invasive cancer was 86.34% in the screening group and 72.29% in the control group. The screening group showed a 31% reduction in cervical cancer mortality (mortality rate ratio risk ratio = 0.69; 95% CI: 0.54-0.88; P = 0.003) compared to the control group.

In a comparative evaluation of HPV-DNA test versus colposcopy as secondary cervical cancer screening test to triage screen positive women on primary screening by VIA, Pimple and Shastri found that HPV DNA and colposcopy had a sensitivity of 61% and 43% and specificity of 99% and 99%, respectively, for detecting CIN2+ lesions.[8]

In a study comparing HPV DNA testing of self-collected vaginal samples with physician-collected cervical samples and cytology, Bhatla et al. found that PCR detected oncogenic HPV in 12.3% of self-collected samples and 13.0% of physician-collected samples.9 There was 93.8% agreement between physician- and self-collected samples. The sensitivity, specificity, PPV, and NPV of self-sampling for the detection of CIN2+ disease were 82.5%, 93.6%, 52.4%, and 98.4%, respectively, and concordance between HC2 and PCR was 90.9% for self-collected samples and 95.3% for physician-collected samples.

The developed nations are now moving on, from a cytology based screening to HPV based screening as it has been proven that the death rates due to cancer is significantly reduced in HPV screened populations. In India due to lack of facilities and low resource settngs the options of VIA and VILI have been studied and this has been proven to be beneficial in improving the patients compliance to treatment for cancer and thus reduce morbidity and mortality. While the more affording populations who are non-compliant to screening can be given the option of HPV-DNA testing and also self-sampling if they hesitate going to gynecologist.

We did cervcal biopsy in 308 patients of whom 253 patients had invasive carcinoma. The high positive rates can be explained by the fact that our institute is the testing referral center of Bihar and most cases are sent to us from periphery on the strong suspicion of malignancy. Out of the 253 biopsy proven cancer of the cervix only 52 patients (20.55%) underwent surgical management. Most cases were diagnosed in advanced stages and were given concurrent chemoradiation. Due to lack of screening and awareness patients present late to doctors and go through a chain of doctors before reaching cancer centre with treating facilities. All these factors contribute to the advanced stage presentation of most of the patients.

Cancer of the ovary was the second most common in our patients and contributed to 38.42% of total admissions. The most common age group affected was 41-50 years and the most common histology of these tumors was serous cystadenocarcinoma. Of the 73 cases 22 patients underwent primary cytoreduction, 48 underwent interval cytoreduction following NACT and 3 cases were found inoperable on laparotomy. Other studies have shown similar results.

A study of 957 ovarian neoplasms showed that most of the benign tumors occurred between 20 and 40 years of age, while the malignant lesions presented commonly between 41 and 50 years of age.10 The most common benign tumors were serous cystadenoma (29.9%), followed by mature teratoma (15.9%) and mucinous cystadenoma (11.1%). Serous cystadenocarcinoma was the predominant malignant tumor (11.3%) and 49.5% them were bilateral. Borderline serous tumors showed bilateral involvement more commonly (27.4%) than borderline mucinous tumors (15.7%). Most of the malignant tumors presented as Stage III (60%) or Stage II (20%) disease. The OS rate was 85% for Stage I tumors, 65% for Stage II, 30% for Stage III, and 15.5% for Stage IV tumors.

While primary cytoreduction has been the standard in the management of ovarian cancers, NACT followed by interval debulking has been shown to have similar survival rates. NACT has been found to be especially useful in patients with extensive upper abdomen and extensive peritoneal disease. Preoperative evaluation of peritoneal deposits using multidetector CT by Chandrashekhara et al. showed that the most common sites to have peritoneal deposits were the pouch of Douglas and the right subdiaphragmatic region.11 The sensitivity of CT in the detection of peritoneal deposits ranged from 33.3% to 88.9% (mean 61.58%). Sensitivity was low (33.3%) in the umbilical and left lumbar region and high in the pelvis (80%) and epigastrium (88.9%). The specificity for all findings was quite high, ranging from 88.9% to 97.1%.

NACT followed by interval debulking and then adjuvant chemotherapy has been found to be non inferior to primary cytoreduction followed by adjuvant chemotherapy. A 7-year audit from a tertiary care center reported that 41.4% of the patients of advanced EOC underwent primary surgery and 58.6% received NACT.12 An optimal debulking rate of 81% was achieved with 70% for primary surgery and 88% following NACT. The optimal cytoreduction rate has improved from 55% in 2004 to 97% in 2010. The progression-free survival (PFS) and OS in patients undergoing primary surgery were 23 and 40 months, respectively, while it was 22 and 40 months, respectively, in patients who received NACT.

With the advent of chemotherapy the rates of optimal cytoreduction to reduce the tumor load to zero has improved. The surgical skill of the operating surgeon is a major contributing factor towards achieving the goal of R zero. The of short of the department of gynecological oncology from the basic branches has the prospects of making trained surgeons for treating gynecological malignancies better.

Endometrial cancer is the most common gynecological malignancy in the West, but in India, the incidence rates are low. This is evidenced by studies conducted on Indian populations in western countries.4 Most of these malignancies present at an early stage as the symptoms appear early and are thus associated with a good prognosis. Treatment of endometrial cancer comprises surgical staging and adjuvant radiotherapy and/or chemotherapy depending on the final surgico-pathological stage of the disease.

In our study 15.26 % of patients had endometrial cancer. Most patients were in the age group of 51-60.

The less common gynecological genital malignancies were choriocarcinoma and cancer of vulva.


  Conclusion Top


Cancer of the cervix is still the most common cancer of the female genital tract in our region closely followed by ovarian cancer. Even though there is a decline in the incidence in rates of cervid cancer the problem is still not solved and this decline cannot be attributed to screening for this disease. The implementation of screening of cancer cervix has helped the developed worlds to reduce the rates of this cancer drastically and they are now moving to screening methods which will reduce the mortality rates due to cancer cervix. In India the utility of more feasible methods of screening such as VIA(visual inspection with acetic acid),VILI(visual inspection with lugol’s iodine), Visual inspection under magnification have been studied successfully and implementation of these methods at all health levels especially at the primary health centers can form the first step towards controlling and preventing this deadly cancer.



 
  References Top

1.
Mohammed A, Ahmed SA, Oluwole OP, Avidine S. Malignant tumours of the female genital tract in Zaria: Analysis of 513 cases. Ann Afr Med. 2006;5:93-96.  Back to cited text no. 1
    
2.
P. Sujata1, Janmejaya Sahoo, Rajkumari P. and Gangadhar Sahoo1. Burden of Female Genital Tract Malignancies at A Tertiary Care Teaching Hospital. Int. J. Phar. & Biomedi. Rese. 2016, 3 (3): 1-5.  Back to cited text no. 2
    
3.
Chhabra S, Sonak M, Prem V, Sharma S. Gynaecological malignancies in a rural institute in India. J Obstet Gynaecol. 2002 Jul;22(4):426-9.  Back to cited text no. 3
    
4.
Megan H Shirley, Isobel Barnes, Shameq Sayeed, Alexander Finlayson and Raghib Ali. Incidence of breast and gynaecological cancers by ethnic group in England, 2001-2007: a descriptive study. BMC Cancer 2014, 14:979.  Back to cited text no. 4
    
5.
ICO Information Centre on HPV and Cancer (Summary Report 2014.08.22). Human Papillomavirus and Related Diseases in India; 2014.  Back to cited text no. 5
    
6.
Sankaranarayanan R, Nene BM, Shastri SS, Jayant K, Muwonge R, Budukh AM, et al. HPV screening for cervical cancer in rural India. N Engl J Med. 2009;360:1385-94.  Back to cited text no. 6
    
7.
Shastri SS, Mittra I, Mishra GA, Gupta S, Dikshit R, Singh S, et al. Effect of VIA screening by primary health workers: Randomized controlled study in Mumbai, India. J Natl Cancer Inst. 2014;106:dju009.  Back to cited text no. 7
    
8.
Pimple S, Shastri SS. Comparative evaluation of human papilloma virus-DNA test verses colposcopy as secondary cervical cancer screening test to triage screen positive women on primary screening by visual inspection with 5% acetic acid. Indian J Cancer. 2014;51:117-23.  Back to cited text no. 8
    
9.
Bhatla N, Dar L, Patro AR, Kumar P, Kriplani A, Gulati A, et al. Can human papillomavirus DNA testing of self-collected vaginal samples compare with physician-collected cervical samples and cytology for cervical cancer screening in developing countries? Cancer Epidemiol. 2009;33:446-50.  Back to cited text no. 9
    
10.
Mondal SK, Banyopadhyay R, Nag DR, Roychowdhury S, Mondal PK, Sinha SK. Histologic pattern, bilaterality and clinical evaluation of 957 ovarian neoplasms: A 10-year study in a tertiary hospital of Eastern India. J Cancer Res Ther. 2011;7:433-7.  Back to cited text no. 10
    
11.
Chandrashekhara SH, Thulkar S, Srivastava DN, Kumar L, Hariprasad R, Kumar S, et al. Pre-operative evaluation of peritoneal deposits using multidetector computed tomography in ovarian cancer. Br J Radiol. 2011;84:38-43.  Back to cited text no. 11
    
12.
Rajanbabu A, Kuriakose S, Ahmad SZ, Khadakban T, Khadakban D, Venkatesan R, et al. Evolution of surgery in advanced epithelial ovarian cancer in a dedicated gynaecologic oncology unit-seven year audit from a tertiary care centre in a developing country. Ecancermedicalscience. 2014;8:422  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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