Role of CD44 and CD24 Expression on 2-years Disease Free Survival in Patients with Advanced Epithelial Ovarian Carcinoma

OBJECTIVE

Ovarian cancer is one of the most common cancers with a high mortality rate worldwide. Despite optimal surgical therapy and chemotherapy, recurrence is still common. Cancer stem cells expressing CD44 and CD24 are thought to be contributing factors in recurrence.

METHODS

A cohort retrospective study with survival analysis was carried out on advanced ovarian cancer patients who underwent optimal debulking surgery followed by 6 cycles of chemotherapy at Cipto Mangunkusumo General Hospital and Fatmawati General Hospital from January 2019 to March 2023. Immunohistochemical examination was performed on tumor tissue with CD44 and CD24 expression were assessed using the H-Score method then determined the cut off-point expression level using the ROC curve. Furthermore, the relationship between these expression levels with the disease-free survival was assessed using the survival curve.

RESULTS

There were 48 subjects who were included in the study. There were high expression levels of CD44 in 47.9% and CD24 in 50% of cases. High CD44 expression had mean and median survival of 13.2 ± 1.8 and 11 months (HR 5.05, 95% CI 1.84- 13.85). High CD24 expression had mean and median survival of 13.5 ± 2.4 and 7 months (HR 7.73, 95% CI 2.58 - 23.15). The combination of the two high expressions had mean and median survival of 10.44 ± 1.88 and 7 months.

CONCLUSION

High expression of CD44 and CD24 will shorten the disease-free survival of patients with advanced ovarian cancer.

High ALDH-1 Expression Predicts Non-Complete Response of Radiotherapy in Stage III Squamous Cell Cervical Carcinoma Patients

BACKGROUND

ALDH1 is a cervical cancer stem cell marker that has radioresistance profile. Recurrence and metastasis following radiotherapy are still being problems of most patients. This study aimed to determine the correlation between ALDH1 and radiotherapy response in stage III squamous cell cervical carcinoma (SCCC) of the cervix.

METHODS

A total 58 of 360 patients of stage III SCCC who received external beem radiation and brachytherapy (2016-2021) at Cipto Mangunkusumo Hospital met the eligibility criteria of this study. Pre- and post-irradiation MRI examinations and ALDH expression with immunohistochemistry (Santa Cruz®) were performed on formalin-fixed paraffin-embedded of pre-treatment cervical tissue biopsy taken from RSCM pathological anatomy laboratory. Patients were divided into two groups, complete responders vs non-complete responders. ALDH-1 scores were compared between two groups to assess ALDH-1 expression. The statistical analyses were carried out by SPSS 24.

RESULTS

The optimal ALDH-1 score cut-off point on the radiation response was 166.05 pg/mL which was obtained from the analysis of the ROC curve. The AUC value was 0.682 with sensitivity and specificity, 63,6% and 64%, respectively. ALDH score ≥166.05 increased the risk by 3.127 times for not achieving complete response (adj OR 3.127, 95% CI 1.034 - 9.456, p = 0.043). Pre-radiation tumor size (p = 0.593), degree of differentiation (p = 0.161), renal abnormalities (p = 0.114), and keratinization (p = 0.477) were not associated with radiation response.

CONCLUSIONS

High ALDH expression was associated with non-complete radiation response in stage III squamous cell cervical carcinoma. 
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Knowledge, Attitude, and Practice on Cervical Cancer and HPV Vaccination among Medical Students in Jakarta, Indonesia: A Cross-Sectional Study

BACKGROUND: Cervical cancer is the second-most common cancer in Indonesian women. While the cervical cancer screening has been integrated in Indonesian primary health-care facilities, the HPV vaccination has not yet become a national program. AIM: The objective of this research was to measure the knowledge, attitude, and behavior of medical students in Jakarta toward cervical cancer and its prevention. The result of this study could be implemented to develop a more comprehensive national educational program and public health policy. METHODS: We conducted a cross-sectional study on medical students at 10 different universities in Jakarta, Indonesia. Student’s knowledge, attitude, and behavior were collected through a self-administered online questionnaire consist of a total of 27 questions concerning cervical cancer epidemiology, pathogenesis, screening, diagnosis, and prevention. RESULTS: A total of 2159 medical students participated in this study. More than half (55%) of the students obtained satisfactory knowledge score. The students’ knowledge regarding HPV vaccination was low. However, 87.2% of them agreed to get the HPV vaccination. Only 7.0% had participated in cervical cancer screening program and only 16.8% had received HPV vaccination. Female gender, second or third year of study, and three universities had better odds to have good practice score. CONCLUSION: The knowledge and attitude score did not reflect on student’s practice on cervical cancer and its prevention. Effort to increase the awareness toward cervical cancer should be endorsed through university curriculum and public health policy.

Overall Survival and Related Factors of Advanced-stage Epithelial Ovarian Cancer Patients Underwent Debulking Surgery in Jakarta, Indonesia: A Single-center Experience

AIM: The worrisome prognosis of advanced-stage epithelial ovarian cancer (EOC) needs a new perspective from developing countries. Thus, we attempted to study the 5-year overall survival (OS) of advanced-stage EOC patients who underwent debulking surgery in an Indonesian tertiary hospital. METHODS: A retrospective study recruited forty-eight subjects between 2013 and 2015. We conducted multiple logistic regression analyses to predict risk factors leading to unwanted disease outcomes. The OS was evaluated through the Kaplan–Meier curve and Log-rank test. Cox proportional hazards regression examined prognostic factors of patients. RESULTS: Prominent characteristics of our patients were middle age (mean: 51.9 ± 8.9 years), obese, with normal menarche onset, multiparous, not using contraception, premenopausal, with serous EOC, and FIGO stage IIIC. The subjects mainly underwent primary debulking surgery (66.8%), with 47.9% of all individuals acquiring optimal results, 77.1% of patients treated had the residual disease (RD), and 52.1% got adjuvant chemotherapy. The risk factor for serous EOC was menopause (odds ratio [OR] = 4.82). The predictors of suboptimal surgery were serous EOC (OR = 8.25) and FIGO stage IV (OR = 11.13). The different OS and median survival were observed exclusively in RD, making it an independent prognostic factor (hazard ratio = 3.50). 5-year A five year OS and median survival for patients with advanced-stage EOC who underwent debulking surgery was 37.5% and 32 months, respectively. Optimal versus suboptimal debulking surgery yielded OS 43.5% versus 32% and median survival of 39 versus 29 months. Both optimal and suboptimal debulking surgery followed with chemotherapy demonstrated an OS 40% lower than those not administered (46.2% and 20%, respectively). The highest 5-year OS was in serous EOC (50%). Meanwhile, the most extended median survival was with mucinous EOC (45 months). CONCLUSION: Chemotherapy following optimal and suboptimal debulking surgery has the best OS among approaches researched in this study. RD is a significant prognostic factor among advanced-stage EOC. Suboptimal surgery outcomes can be predicted by stage and histological subtype.

The Prognostic Value of Cancer Stem Cell Markers in Cervical Cancer: A Systematic Review and Meta-Analysis

OBJECTIVES

Prognostic biomarkers in cervical cancer are widely investigated, including cancer stem cell (CSC) markers. However, their significance remains uncertain. This study aimed to determine the role of cervical cancer stem cell (CCSC) markers for survival.

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis (PROSPERO CRD42021237072) of studies reporting CCSC markers as the prognostic predictor based on PRISMA guidelines. We included English articles investigating associations of CCSCs expression in tissue tumor with overall survival (OS) or disease-free survival (DFS) from PubMed, EBSCO, and The Cochrane Library databases. The quality of studies was analyzed based on Newcastle-Ottawa Quality Assessment Scale.

RESULTS

From 413 publications, after study selection with inclusion and exclusion criteria, 22 studies were included. High expressions of CCSC markers were associated with poor OS and DFS (HR= 1.05, 95% CI: 1.03 - 1.07, P <0.0001; HR= 1.31, 95% CI: 1.09 - 1.17, P <0.00001; respectively). Sub-analysis of individual CCSC markers indicated significant correlations between CD44 (HR= 1.14, 95% CI: 1.07 - 1.22, P 0.0001), SOX2 (HR= 1.58, 95% CI: 1.17 - 2.14, P 0.003), OCT4 (HR= 1.03, 95% CI: 1.01 - 1.06, P 0.008), ALDH1 (HR= 1.36, 95% CI: 1.13 - 1.64, P 0.001), and CD49f (HR= 3.02, 95% CI: 1.37 - 6.64, P 0.006) with worse OS; OCT4 (HR= 1.14, 95% CI 1.06 - 1.22, P 0.0003), SOX2 (HR= 1.11, 95% CI: 1.06 - 1.16, P <0.0001), and ALDH1 (HR= 1.22, 95% CI: 1.10 - 1.35, P 0.0002) with poor DFS. We did not conduct a meta-analysis for MSI-1 and CK17 because only one study investigated those markers.

CONCLUSION

Expressions of OCT4, SOX2, and ALDH1 were associated with poor OS and DFS in cervical cancer tissue. These markers might have potential roles as prognostic biomarkers to predict unfavorable survival.

Early Gestational Age Placenta Accreta Case Report: Can We Avoid Missed Diagnosis?

Case series

Patients: Female, 34-year-old • Female, 35-year-old • Female, 32-year-old

Final Diagnosis: Placenta accrete

Symptoms: Vaginal bleeding

Medication: —

Clinical Procedure: —

Specialty: Obstetrics and Gynecology

Tobacco use and its association with HPV infection in normal uterine cervix: A study from a Sustainable Development Goals perspective

INTRODUCTION

To achieve the Sustainable Development Goals (SDGs) target 2030, the United Nations (UN) endorsed tobacco use reduction, which is essential in decreasing unnecessary deaths caused by tobacco-induced disease. This study investigates the association between tobacco use and Human Papillomavirus (HPV) infection in clinically normal uterine cervix populations from the SDGs perspective.

METHODS

This study is a 7-year cross-sectional study of a clinically normal uterine cervix population, based on negative Visual Inspection of Acetic Acid (VIA). Subjects were recruited consecutively from the medical records of several public and private health providers in Jakarta. The Statistical Product and Service Solutions (SPSS) for Windows version 20.0 were used to analyze the data.

RESULTS

A total of 1397 negative VIA subjects were collected, consisting of 4.9% (69/1397) tobacco users, and 95.1% (1328/1397) non-users. HPV-DNA positive were 4.3% (3/69) in the tobacco user group and 3.7% (49/1328) in the non-user group. Statistical analysis showed unadjusted OR was 1.19 (95% CI: 0.36–3.91, p=0.778) and adjusted OR was 1.18 (95% CI: 0.36–3.89, p=0.786). High-risk HPV (hrHPV) infections of tobacco and non-tobacco users’ groups were found in 2/3 and 27/49 (55.1%), respectively.

CONCLUSIONS

This study showed an insignificant statistical association between tobacco use and HPV infection in normal uterine cervix. However, the proportion of hrHPV infection was higher in tobacco users than non-users. From the SDGs perspective, cervical cancer is closely related to tobacco use and poverty. Further study is needed to support this result and evaluate other co-factor role-related cervical cancer history to achieve SDGs in 2030.

Postradiotherapy Outcome on Cervical Cancer Stage IIIB Patients with and without Paraaortic Lymph Nodes Enlargement

Objective : To determine whether there are differences in clinical response after radiotherapy and 1 year survival in patients with advanced cervical cancer with and without enlargement of PALN.Method : An observational analytic study using a retrospective cohort method was done using consecutive sampling. The subjects of this study were all women with a primary diagnosis of stages IIB to IVB cervical cancer who came to the gynecological oncology clinic of Dr. Cipto Mangunkusumo National General Hospital and underwent MRI examination before undergoing treatment in January 2016 to May 2017Results: Among 76 subjects studied, there were 4 (5.1%) subjects who had enlarged PALN. There were no significant differences between the enlargement status of PALN and age (p = 0.829), age of first sexual intercourse (p = 0.33), parity (p = 0.642), mass diameter (p = 0.777). Patients with PALN enlargement have 2.13 times risk of having negative radiotherapy outcome (p = 0.02, OR 2.13, CI95% 1.12 – 4.07). There was no difference in 1-year survival between patients with and without enlargement of PALN (median 201 vs. 293, p = 0.072).Conclusion: Patients with PALN enlargement have increased risk of having negative radiotherapy outcome (p < 0.05). There were no differences in 1 year survival between patients with advanced cervical cancer with enlargement PALN.Keywords : cervical cancer,  lymph node enlargement, paraaortic, radiotherapy.   Abstrak Tujuan: Mengetahui adakah perbedaan respon klinis pascaradioterapi dan kesintasan 1 tahun pada pasien kanker serviks stadium lanjut dengan pembesaran KGB paraaorta dibandingkan tanpa pembesaran KGB paraaorta.Metode: Penelitian ini merupakan penelitian analitik observasional dengan menggunakan metode kohort retrospektif. Pengambilan sampel dilakukan dengan cara pengambilan sampel berturut-turut. Subyek penelitian ini adalah semua perempuan dengan diagnosis primer kanker serviks stadium IIB hingga IVB yang datang ke poliklinik Onkologi Ginekologi RSUPN Dr. Cipto Mangunkusumo dan menjalani pemeriksaan MRI sebelum dilakukan terapi pada bulan Januari 2016 hingga Mei 2017.Hasil: Dari 76 subjek yang diteliti, didapatkan sebanyak 4 (5,1%) subyek yang mengalami pembesaran KGB paraaorta. Tidak didapatkan perbedaan yang bermakna antara status pembesaran KGB paraaorta dan usia (p = 0,829), usia hubungan seksual pertama (p = 0,333), paritas (p = 0,642), dan diameter massa (p = 0,777). Pasien dengan pembesaran KGB paraaorta memiliki risiko 2,13 kali lipat (p = 0,02, OR 2,13, IK95% 1,12-4,07) memiliki risiko respon terapi negatif. Tidak terdapat perbedaan kesintasan 1 tahun antara pembesaran KGB paraaorta dan tidak (median 201 vs. 293, p = 0,072).Kesimpulan Pasien dengan pembesaran KGB paraaorta memiliki risiko lebih tinggi mengalami respon radioterapi negatif. (p < 0,05). Tidak terdapat kesintasan 1 tahun antara pasien kanker serviks stadium lanjut dengan dan tanpa pembesaran KGB.Kata kunci: kanker serviks,  paraaorta,  pembesaran KGB, radioterapi.

Activity of manganese superoxide dismutase (MnSOD) as a predictor of radiation therapy outcome in patients with stage IIIB squamous cell carcinoma cervical cancer

BACKGROUND Radiation is a standard therapy for cervical cancer. Unfortunately, not all patients undergoing radiation achieve a complete response. Previous studies have shown that manganese superoxide dismutase (MnSOD) acts against free radicals generated by radiation in cancer cells thus predicting worse outcome in radiation therapy. This study was aimed to assess and evaluate whether MnSOD activity can be used as a predictor of radiation therapy responses in patients with stage IIIB squamous cell carcinoma (SCC). METHODS A comparative cross-sectional study was conducted in the Gynecology Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta. The database from previous research was analyzed to identify positive and negative response samples. Measurement of MnSOD activity was done using spectrophotometry based on the McCord and Fridovich method using RanSOD® kit. The comparative data were obtained and then analyzed. RESULTS Among 76 samples, 49 (61.8%) patients had positive responses and 27 (38.2%) had negative responses. It is shown in this study that higher MnSOD activity is related to worse radiotherapy outcome in stage IIIB cancer patients. The relative risk value of having a worse outcome with high MnSOD activity is 1.849 (1.075–3.178, 95% CI). CONCLUSIONS Stage IIIB squamous cell carcinoma patients with high MnSOD activity are at higher risk of having a negative radiation therapy response compared with patients without high MnSOD activity.

Clinical and Laboratory Predictors of Deep Vein Thrombosis in Ovarian Malignant Tumor

Objective: To investigate the clinical and laboratory predictors of symptomatic deep vein thrombosis (DVT) in ovarian malignant tumor. Methods: One hundred sixteen patients with suspected ovarian malignant tumor were recruited. Age, body mass index (BMI); D-dimer, fibrinogen, thrombocyte level, comorbid, tumor diameter, staging, distant metastasis, ascites, histopathology, length of surgery, blood loss and transfusion were recorded. Results: Incidence of symptomatic DVT was 16.5% and 88.2% cases occurred before surgery. No case of symptomatic DVT during postoperative care was found. Predictors of DVT were distant metastasis (OR 28.99; 95% CI 3.83-219.52, BMI ≥ 22.7 kg/m2 (OR 15.52, 95% CI 2.24-107.37), D-Dimer ≥ 1700 mg/ml (OR 13.30, 95% CI 2.40- 73.84), advanced stage (OR 6.66; 95% CI 1.05-42.27), epithelial tumor (OR 6.5; 95% CI 0.34-125.75), tumor’s diameter ≥ 18.25 cm (OR 2.36, 95% CI 0.48-11.54), and comorbidity (OR 2.49, 95% CI 0.53-11.66). Prediction score of DVT were score 3 for distant metastasis, BMI ≥ 22.7 kg/m2, D-Dimer ≥ 1700 mg/ml, score 2 for advanced stage, score 1 for tumor diameter ≥ 18.25 cm, comorbid, epithelial tumor and score 0 for the absence of variables or its value less than the cut off. Total score ≥ 8 of 14 is the least score which has a good predictive value for DVT with AUC 0.92, 95% CI 0.86-0.92, probability 86.46%. Conclusion: Distant metastasis and D-dimer are independently associated with the development of DVT in ovarian malignant tumor. [Indones J Obstet Gynecol 2017; 5-3: 180-184] Keywords: deep vein thrombosis, D-dimer, ovarian malignant, tumor predictor

Management of Abnormal Cervical Cytology: Atypical Squamous Cells of Undetermined Significance (ASC-US) and Atypical Squamous Cells cannot exclude High Grade Intraepithelial Lesion (ASC-H)

Objective: To review for the management of abnormal cervical cytology: atypical squamous cells of undetermined significance (ASCUS) and atypical squamous cells cannot exclude high-grade intraepithelial lesion (ASC-H) as a treatment of cervical precancerous lesions in order to avoidexcessive treatment, reduce of unnecessary examinations and to provide cost effectively. Method: Literature study on published literatures and studies about the management of cervical cytology. Conclusion: The results of ASC-US cervical cytology and ASC-H is aninitial screening to detect precancerous cervical lesions. Definitive therapy should be done when finding a low-grade lesions (LSIL) and high degree of lesion(HSIL) squamous intraepithelial. A clinician expected to understand the natural history of HPV infection and the management of precancerous cervical lesions properly. [Indones J Obstet Gynecol 2013; 37-3: 166-170] Keywords: ASC-H, ASC-US, cervical cytology abnormalities, cervical precancerous lesion.