Introduction: Cervical cancer has a high incidence in developing countries including India. Brachytherapy (BT) is an important component in the curative management of carcinoma of the cervix, and significantly improves survival. In gynaecologic BT, correlation between the radiation dose and the normal tissue effects have been assessed using point doses. Since 1985, these points have been defined in the international commission of radiation units and measurements (ICRU-38) report. However GEC-ESTRO recommended volume based treatment planning in their respective series (I-IV). For cervical cancer BT, the correlation of ICRU point doses and volume based treatment planning is investigational till date. Analysis becomes feasible when cross sectional image-based treatment planning for BT using computerized tomography (CT) or magnetic resonance imaging (MRI) is utilised as per GEC-ESTRO recommendation. Methods: It is a retrospective pilot study includes patients (pts.) of carcinoma cervix treated with high dose rate (HDR) BT 9 Gy in 2 fractions 1 week apart. All volume based dosimeteric parameters regarding high risk clinical target volume (HRCTV), intermediate risk clinical target volume (IRCTV) like D90, D100 and for organ at risk (OAR) D 0.1 cc, D 1.0 cc and D 2.0 cc were delineated and dose coverage was analysed in point dose based planning. Results: We have analysed twenty pts. of squamous cell carcinoma (SCC) cervix. The median age was 52 yrs. (41-65 yrs), stage II B 10 pts. & III B 10 pts. The mean value of D90 & D100 in HRCTV during I and II session were 8.64, 6.75 and 5.76, 4.36 Gy respectively. Same values for IRCTV were 6.31, 4.91 and 3.68, 3.15 Gy respectively. Analysis of OARs demonstrated that mean dose received by 0.1, volume of bladder during I and II session received 10.68, 9.47, by 1 cc volume 8.39, 7.57 and by 2 cc volume 6.84, 6.21 Gy respectively. The mean dose received by 0.1 cc of rectum were 11.59, 10.12, by 1 cc volume 9.53, 8.19 and by 2 cc volume 7.76, 6.81 Gy respectively. In point based analysis mean dose delivered to bladder point during I and II session were 5.63, 6.02 and to rectum point were 5.98, 5.46 Gy respectively. Doses to 0.1 cc volume of bladder and rectum were higher in volume based BT as compared to point based BT in respective fractions. Conclusion: Both HRCTV and IRCTV had better dose coverage in 1st fraction as compared to 2nd fraction. Point doses to bladder and rectum is underestimated in point based (ICRU-38) BT. We need more number of pts in prospective randomized trial for more consistent result.

Introduction: Carcinoma cervix is the second most common female carcinoma. Every year in India, 1,22,844 women are diagnosed with carcinoma cervix and of them 67,477 die. Carcinoma cervix rates among women in the age group between 30-64 has decreased by 1.8% per year on average but still date account for 16%. Of these, advanced carcinoma are about 80% and early are only 20%. Case Series: We are reporting 5 consecutive early carcinoma cervix cases who presented with pyometra and got treated at our hospital from April 2015-September 2015. Cases of early carcinoma cervix presented with pyometra were treated by pyometra drainage, intravenous antibiotics and appropriate treatment in the form of surgery (4 cases underwent Wertheim’s hysterectomy and 1 case had radical chemo radiation as she opted for same in view of high cardiac risk for anaesthesia). All 5 of them are disease free at the end of treatment with follow up of minimum 4 months duration (range 4-10). Conclusion: The idea is to emphasize that all carcinoma cervix with pyometra are not necessarily advanced and can still be given radical treatment like surgery or radiotherapy after pyometra drainage.

Background: Pelvic radiotherapy may damage the vagina and cause vaginal stenosis. Its incidence in the literature ranges from 1.2% to 88%. To prevent vaginal stenosis, routine vaginal dilation is recommended during and after pelvic radiotherapy. Materials and Methods: The objective was to examine critically the evidence behind this guideline. Searches included the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and Google scholarly articles. All the relevant articles were included in the study. Discussion: Various studies gave recommendations on dilation during or immediately after radiotherapy. Literature does not support routine vaginal dilatation during or immediately after pelvic radiotherapy. Occasional penetration might prevent the sides of the vagina adhering to each other, and dilation might be valuable once the inflammatory and psychological scarring has settled. Two trials demonstrated that encouraging vaginal dilation increased patient compliance, but no difference was found in sexual function scores in the first trial. One retrospective study reported that dilation lowered stenosis rates, but the control group is not comparable. One study involving 89 women revealed that the median vaginal length was 6 cm, six to ten weeks after radiation therapy, but women tolerated a 9-cm dilator/measurer after 4 months of dilation experience. One trial showed no significant advantage by inserting mitomycin C. A study of five women reported that vaginal stenosis can be treated by dilation even many years after radiotherapy. Dilation during or immediately after radiotherapy can cause damage, and there is no evidence that it prevents stenosis. Dilation might stretch the vagina if commenced after the inflammatory phase. Dilation has been associated with traumatic rectovaginal fistulae and psychological consequences. Conclusion: Vaginal dilation might help treat the late effects of radiotherapy, but it must not be assumed that this applies to the acute toxicity phase. Routine dilation during treatment is not supported by good evidence. Prophylactic and therapeutic dilation therapy needs to be considered separately and research is needed to determine when dilation therapy should start on a large population.

Methods: 80 ASA physical status I-II patients, 30-65 years, BMI ≤30 undergoing surgery for 120-180 minutes. Computer randomisation, 40 each, in dexmedetomidine group D and in propofol group P. Induction with fentanyl 1.5 mcg mkg−1 and propofol 2 mg kg−1. Maintained with desflurane 3-5% with air 50% and O2 50%. In D group (bolus 0.5 mcg mkg−1 for 10 minutes then maintenance 0.2-0.5 mcg mkg−1 hr−1) and in P group (propofol @ 50-150 mcg kg−1 min−1) started. At docking of robotic arms single dose morphine @ 0.075 mg kg−1 in both groups is given. Hemodynamic stability (MAP and HR) is adjusted within 20% of base line values. Results: Early and intermediate recovery was fast in D group and total fentanyl requirement intraoperatively was less in D group. Discussion: Dexmedetomidine is known to decrease sympathetic outflow and circulating catecholamine’s levels therefore has caused decrease in both MAP and HR similar to propofol. Dexmedetomidine has analgesia sparing effect hence less total fentanyl dose both intraoperatively. Patients with dexmedetomidine are early aroused, so early and intermediate recoveries were faster with dexmedetomidine than propofol. Thus dexmedetomidine may prove to be useful adjuvant for robotic surgeries. Conclusion: Dexmedetomidine more effective for both intraoperative and postoperative analgesia. Recoveries both early and intermediate are faster in dexmedetomidine group.

Aim: To investigate the presence of reproductive tract infections (RTIs) in symptomatic and asymptomatic women in North India and association of SNPs in TNFα gene (rs-281865419 C/T) with susceptibility to these RTIs. Methods: We collected 100 symptomatic (cases) and 100 asymptomatic women (controls) samples and screened them for RTIs. Then genotyping of TNF-α gene was performed by PCR-RFLP. Results: Among cases the frequencies of RTIs infection is higher than control. The prevalence of HPV, C. trachomatis, T. vaginalis, Bacterial vaginosis and N. gonorrhoeae are 28% & 6%; 11%, 32% respectively while in controls it was 5%, 2%, 1% and 8% & 1%. In the present study we found that the frequency of wild homozygous genotype (TT) was lower in cases 30% (6/20) as compared to controls 60% (12/20). The frequency of the heterozygous polymorphic genotype (CT) was higher in cases 65% (65/100) as compared to controls 32% (32/100). It was interesting to note that the frequency of the polymorphic homozygous genotype (CC) was higher in cases 15% (15/100) than controls 2% (2/100). While the frequency of the carrier genotype (CT + TT) was found to be more in cases 70% (70/100) than in controls 40/100 (40%). This study shows that T allele may be risk factor for Reproductive tract infections as its percentage is higher in cases as compare to normal controls. Conclusion: TNF-? rs-281865419 locus may serve as an important biomarker for RTIs predisposition in Indian population though larger sample size is needed to validate the findings.

Objectives: To study cases of cervical cancer managed/unmanaged in rural India and to analyze the reasons for poor outcome. Methods: This is a retrospective study of 218 cases of cervical cancers between 2008-2013 with resultant outcome in terms of treatment or absence of treatment in spite of diagnosis. Reasons for not taking the treatment have been analyzed. Also, analysis of 21 cases of simple hysterectomy with resultant complications like VVF, RVF has been done. Indications of surgery, operating surgeon, availability of preoperative/postoperative HPR, slides/blocks, discharge summary and disease status at the time of referral was done. Results: 44% refused to take treatment in spite of stage III diagnosis citing financial constraints, distance to be traveled daily for RT and apathetic attitude of family towards females. 20.65% opted for other hospitals. 29.8% took complete treatment. 80% of females were illiterate and dependent. 9.7% had simple hysterectomy for invasive disease. 95% of simple hysterectomies were performed by general surgeons in private setups resulting in 19% of complications like VVF, RVF. 100% cases of simple Hysterectomy did not have pre-operative biopsy. Only 50% cases had post-operative biopsy report and in none of the cases were slide/blocks available for review as trained pathologists were not available. General surgeons who had performed surgery were neither trained in doing P/V examinations nor aware of staging of cervical cancer. Conclusion: Illiteracy, poverty and absence of implementation of cancer control programs are the major hurdles in control of cervical cancer. The study highlights the absence of Government’s will to control cervical cancer in rural India. It emphasizes on the need of intensive training and health education of gynaecologists and surgeons at district/rural level, lack of which is a primary factor for violation of medical ethics by the doctors.

Objective: To compare the incidence, maternal and fetal outcomes of gestational diabetes mellitus using one step vs. two step as a screening procedure. Methodology: A prospective randomized trial involving screening of 1000 pregnant women for gestational diabetes mellitus was conducted. Women were divided in two groups (500 each). Group A comprised of patients screened with two step approach (ACOG recommendation), Group B comprised of women screened by one step method (IADPSG criteria). Women diagnosed with ‘gestational diabetes’ were followed in antenatal clinic and incidence of GDM, maternal and fetal outcome between two groups were analyzed using SPSS. Results: The incidence of GDM was almost double using one step approach versus two step which was 19.2% and 11.8% respectively. Maternal outcomes were comparable in both the groups except the risk of preterm delivery which was 2.5 times more in group A than group B (odds ratio = 2.43 95% CI = 1.01-5.79). Further fetal outcomes were also comparable except neonatal hypoglycemia which was seen in 29.31% in group A vs. 7.4% in group B. In the group B 15 patients (15.8%) patients with GDM (based on FBS ≥92 mg/dl at 1st ANC visit) showed clinical symptoms & blood sugars in hypoglycemic range on MNT requiring resumption of normal diet. Conclusion: The incidence of GDM using IADPSG criteria was almost double versus ACOG criteria. Maternal and fetal outcomes were comparable except in 15.8% women diagnosed as GDM (using FBS ≥92 mg/dl at 1st ANC visit as per IADPSG) suffered from hypoglycemia. A large trial is being proposed before these criteria are adopted.

Purpose: To explore the reasons of hysterectomy and indications of post-hysterectomy radiotherapy in carcinoma cervix cases. Methods: From January 2013 to May 2015, medical records of 64 cases of carcinoma cervix (post-hysterectomy) who were referred for radiotherapy to our hospital were analyzed retrospectively. Results: Medical records of 64 cases were reviewed. The median age was 47 years. In 45% of females hysterectomy was done in towns, but in majority of cases (55%) hysterectomy was done in different cities of Rajasthan. Simple hysterectomy was done in 31 of (48%) cases. Wertheim’s hysterectomy was done in remaining 33 cases (52%). 15 cases (23%) were treated by IMRT technique, while remaining 87% cases were treated by 3DCRT technique to dose of 50 Gy in 25 fractions followed by CVS brachytherapy. All cases also received concurrent chemotherapy. Reason for hysterectomy was analyzed. In 32 (50%) cases, biopsy from gross lesion at cervix or PAP smear test was not done before surgery. In 32 cases (50%) understaging of the tumor or inadequate staging before hysterectomy was performed. Histopathology report analysis revealed that in 9 cases (14%) primary tumor size was less than 4 cm, in 27 cases (64%) there was no comment on pT size, in 22% cases primary tumor was larger than 4 cm. Surprisingly in one case the pT size was 7 cm. LVSI was not seen in 18 cases (28%), positive in 20 case (31%) and with no comment in 26 cases. More than 50% of stroma thickness was involved in 54 cases (84%), and in remaining 10 cases there was no comment on stroma invasion. In 33 cases (52%) pelvic lymphadenectomy was done, in 48% cases lymph nodes were not addressed in surgery. In 36 cases (56%) pelvic lymph node metastasis was seen either in preoperative imaging (USG/CT scan) or in histopathology. Median follow-up duration was 6 months. Locoregional failure was seen in 10 cases (16%), 6 cases (9%) also developed distant metastasis. Conclusion: Failure to perform biopsy from gross lesion at or under staging/inadequate staging before surgery was the main reasons for inappropriate hysterectomy for carcinoma cervix. Inappropriate hysterectomy followed by chemo-radiotherapy resulted in poor tumor control rate as in our study, 1 out of every 4 patients failed loco-regionally with median follow up of 6 months. Strict adherence to guidelines for cervical cancer diagnosis and treatment is advised to prevent inappropriate hysterectomy.

Aims and Objectives: To report a series of cases with breast and ovarian carcinomas either in same patient or in a family and identifying the importance of BRCA 1,2 genetic testing in such individuals. Materials and Methods: The medical records of breast and ovarian cancer patients operated over past 3 years at a single institute were reviewed retrospectively and their clinical profile, family history, final pathological reports and follow up data was collected. Results: 8 patients were found to have breast and ovarian malignancies, out of which 3 had synchronous breast and ovarian cancers, 4 had metachronous and 1 patient with ovarian cancer had history of breast cancer in family. Median age of presentation to the hospital was 47 years and median time interval in metachronous disease patients was 5.5 years. Conclusion: About 5% of people who have breast cancer and about 10% of women who have ovarian cancer have HBOC, caused by germline mutation in BRCA1, 2 gene. These individuals have increased risk of developing breast cancer at younger age, TNBC, or developing a second primary in breast or ovary plus an overall risk of breast/ovarian/prostate/pancreatic malignancies in other family members due to inheritable mutation. Identification of BRCA mutation in such individuals can help family members to undergo genetic counseling and follow different screening and prevention guidelines from general population thus reducing the cancer risks.