Dynamic Changes in Body Composition and Protein Intake in Epithelial Ovarian Cancer Patients Undergoing Chemotherapy: A Preliminary Study

BACKGROUND

Ovarian cancer patients often face poor nutritional status, with body composition (BC) serving as a significant prognostic indicator. Skeletal muscle mass (SMM) and fat-free mass (FFM) are crucial predictors of both survival and hospitalization duration. Increasing protein intake has been linked to improvements in SMM and FFM.

OBJECTIVE

This study aimed to document the alterations in BC parameters among ovarian cancer patients undergoing chemotherapy and correlate these changes with their nutrient intake.

METHODS

Twelve female patients with stage III ovarian cancer who received first-line chemotherapy were categorized based on their body mass indices (BMI). BC parameters were assessed using an 8-point bioelectrical impedance analysis with a frequency of 50 Hz-60 Hz and measurement impedance range of 10 Ω-1000 Ω. Nutrient intake (energy, protein, fat, and carbohydrate) was assessed before (T0), during the 3rd (T3), and 6th cycle of chemotherapy (T6) through 24-hour food recall.

RESULTS

Significant increases in body weight (BW)were observed in the underweight group (from 40.9 to 46.8 kg, p=0.001), concomitant with enhancements in all BC parameters. While changes were noted in SMM, they were not statistically significant (p=0.105).Among the underweight group, a protein intake above 1.2 g/kg BW led to an uptrend trend in SMM. Conversely, FFM in overweight/obese patients decreased significantly (from 37.6 to 36.4 kg, p=0.005) due to a a reduction in body water. Throughout chemotherapy, fat mass (FM), visceral fat (VAT), and phase angle (PhA) increased in all patient groups, reflecting heightened fat and carbohydrate intake.

CONCLUSION

Among stage III ovarian cancer patients, BC undergoes dynamic changes dynamically during the course of chemotherapy, with more pronounced enhancements observed in FFM among underweight patients. Notably, improvements in PhA, SMM or FFM were particularly evident among underweight patients with a protein intake above 1.2 g/kg BW.

Establishment of Epithelial Cell Culture from Ovarian Cancer Tissues: A Method Comparison Study

OBJECTIVE

This study aimed to determine the most effective method in establishing primary cell culture from epithelial serous ovarian cancer tissues with the highest yield of cells and percentage of epithelial cells.

METHODS

Primary and metastasis tissues from three serous ovarian cancer patients were processed using 18 different combinations of methods based on different factors: the source of tissue (primary site or metastasis site), the cell suspension method (explant method, enzymatic methods, or the addition of Percoll), and the alternatives of three different media. We compared the total count of cells, the percentage of epithelial cells, and the estimated number of epithelial cells per observation field. The calculation of cells from primary tissues were compared to metastasis tissues, and the difference was statistically analyzed using Mann Whitney-U test on SPSS software.

RESULT

The groups that were processed using dispase and trypsin resulted higher number of cells and higher percentage of epithelial cells when compared to the explant method. Among all media, we found that DMEM:F12 and McCoy's 5A media as equally useful in isolating and culturing epithelial cells. Statistically, the metastasis tissue derived more epithelial cells when compared to the primary tissue (102.32±82.65 vs 22.6±23.81, p=0.001).

CONCLUSION

The use of metastasis tissue processed with trypsin or dispase and cultured in DMEM:F12 or McCoy's 5A media was found to be the most efficient way to produce the highest amount of cells with high percentage of epithelial cells.

The Utility of Pre-Treatment Inflammation Markers as Associative Factors to the Adverse Outcomes of Vulvar Cancer: A Study on Staging, Nodal Involvement, and Metastasis Models

BACKGROUND

Given the role of inflammation in carcinogenesis, this study investigated the utility of pre-treatment inflammatory markers as associative indicators for advanced-stage disease, lymph node metastasis (LNM), and distant metastasis (DM) in vulvar cancer (VC).

METHODS

A cross-sectional study was conducted on 86 women with VC in a single centre in Jakarta, Indonesia. The laboratory data was based on C-reactive protein (CRP), procalcitonin, the erythrocyte sedimentation rate (ESR) and fourteen derived, recorded and calculated ratios: leukocyte-to-platelet (LPR), neutrophil-to-lymphocyte (NLR), derived neutrophil-to-lymphocyte (dNLR), neutrophil-to-monocyte (NMR), platelet-to-monocyte (PLR), lymphocyte-to-monocyte (LMR), basophil-to-monocyte (BLR), systemic immune-inflammation index (SII), body mass index, albumin, and NLR (BAN) score, haemoglobin-to-platelet (HPR), prognostic nutritional index (PNI), modified Glasgow Prognostic Score (mGPS), CRP-to-albumin, and CRP-to-procalcitonin. The optimal cut-off for each marker was determined using receiver operating characteristic (ROC) curve analysis, and their diagnostic indicator performances were assessed. The utility of these ratios as associative factors for three endpoints was further evaluated in multivariate regression models.

RESULTS

Investigated inflammatory markers exhibited specific performances for individual adverse outcomes, proving a fair to excellent ability in case finding and screening. After adjustment, the BAN score ≤ 334.89 (OR 9.20, p = 0.001) and ESR ≥ 104 (OR 4.18, p = 0.048) become two advanced-stage associative factors with AUC: 0.769. LNM was solely determined by higher NLR ≥ 2.83 (OR 4.15, p = 0.014) with AUC: 0.615. Meanwhile, BLR ≥ 0.035 (OR 5.67, p = 0.001) and ESR ≥ 84 (OR 6.01, p = 0.003) were contributing factors for DM, with AUC: 0.765.

CONCLUSIONS

Inflammatory markers are crucial for identifying the deleterious outcomes of VC. Accordingly, yielded models require external validation.

Anticancer Potential of Cinnamon Bark Extract (Cinnamomum burmanii) with Cisplatin Combination against P-glycoprotein and Apoptotic Influx Biomarkers

Objective: To prove the effect of the combination of cinnamon bark extract with cisplatin in reducing efflux and increasing influx in SKOV3 ovarian cancer cell cultures by measuring the expression of p-glycoprotein, CTR1 and the annexim V. Methods: This research is an experimental study using SKOV3 ovarian cancer cells stored in the SCTE IMERI FKUI Laboratory, carried out in the Stem Cells and Tissues Engineering Research Cluster laboratory. The cells were then harvested by adding trypsin-EDTA to the culture as much as 1 mL, and rotated at 2000 rpm for 5 minutes. Then the cells were added with antibodies and dissolved with a stain buffer solution and read on a flow cytometry device. We used ethyl acetate extract from cinnamon bark against the SKOV3 cell line . IC50 of Cinnamon bark extract we got from MTS test. We tested the levels of IC50, 3/4 IC50, 1/2 IC50, and 1/4 IC50 of cinnamon bark extract with a combination of IC50, 3/4 IC50 , 1/2 IC50, and 1/4 IC50 cisplatin against the viability of the SKOV3 cell line with single cisplatin IC50 comparator. We also examined the levels of annexin V as a marker of apoptosis in the SKOV3 cell line to see if the cell cycle arrest induced by cinnamon bark extract could cause apoptosis of the SKOV3 cell line. We assessed the sample distribution using the Shapiro-Wilk test because of the sample size . To assess the comparison of parameters (differences in p Glycoprotein and CTR-1 expression between treatment groups in normally distributed data, the test was used analysis of variance (ANOVA). ANOVA is a comparative test to analyze the difference in the mean (mean) of data from two or more variables in the same population. The Bonferroni test was used to analyze the same or different samples (equal and unequal) in each treatment. Results: From this study, it was found that the combination of IC 50 cinnamon bark extract and IC 50 cisplatin was able to lower p-glycoprotein levels higher with a lower mean value than the other treatment groups with p<0.001. In the test group, the lowest p-glycoprotein expression was found in the combination 1 test group, namely the 1 x IC50 combination. The value of p-glycoprotein expression in the combination group 1 was 1.20%. As for CTR 1, the combination of IC 50 cinnamon bark and IC 50 cisplatin, had the highest CTR1 levels among the three other treatment groups, with p > 0.001. In the test group, the highest CTR1 expression was found in the combination 1 test group, namely the 1 x IC50 combination. The value of CTR1 expression in the combination group 1 was 12%. Conclusion: The combination of cinnamon bark extract with cisplatin was shown to reduce efflux by decreasing p-glycoprotein expression and increasing influx by increasing CTR1 expression in SKOV3 ovarian cancer cell cultures.

The Effect of Melatonin and Cisplatin Combination Using Copper-Transporting ATPase-1, P-Glycoprotein, and Gamma-Glutamylcysteinylglycine on Ovarian Cancer Biological Cell SKOV3

Background: Ovarian cancer is fifth most common female cancer and third most common  cancer in Indonesia, but most are advanced stage patients that experiencing recurrence, which indicates resistance to treatment especially to cisplatin. Melatonin appears as an alternative that can support apoptotic effect of cisplatin as a chemotherapy regimen. Aim: To determine effect of combination melatonin and cisplatin compared with cisplatin only chemotherapy on chemotherapy resistance with Copper Transporting ATPase-1 (CTR-1), P-glycoprotein (P-Gp), and Gamma-Glutamylcysteinylglycine (GSH)  biomarkers in ovarian cancer biological cells SKOV3 Methods: This research design was experimental laboratory, post-test only control group design, using SKOV3 cell culture. This study was performed in the SCTE IMERI FKUI laboratory and Integrated Laboratory FKUI. MTS assay was used to calculate IC50 of each materials. The materials used were melatonin (concentration was 25,50,100,200,300 nM), cisplatin (concentration was 0.1, 0.5, 1, 2, 5 mM), and doxorubicin (concentration 10,20,40,50,80,100,200 µM). IC50 melatonin was 1,841 mM, IC50 cisplatin was 117,5 µM, and IC50 doxorubicin was 14,72 µM. Samples were control negative group, IC50 doxorubicin as a control positive, IC50 cisplatin, IC50 melatonin, combination group of melatonin and cisplatin were 1xIC50, ¾xIC50, ½xIC50, and ¼xIC50. ANOVA and Bonferroni test were used for statistical test. Results: Based on data processing, IC50 of melatonin was 1,841 mM, IC50 of doxorubicin was 14,72 mM, while IC50 of cisplatin was 117.5 μM. The mean expression of CTR-1 in IC50 melatonin group was 15.77 ± 0.21 and in IC50 cisplatin group was 10.87 ± 0.91, mean expression in IC50 doxorubicin group was 30,33 ±  0,4. Meanwhile, mean expression of CTR-1 in IC50 cisplatin was 7,37±0,7, and in combination 1 group (1xIC50 melatonin and 1xIC50 cisplatin) was 19,73±1.0,49. For P glycoprotein, mean expression in IC50 cisplatin was 16±1,59, in IC50 melatonin group was 7,37±0,21, in IC50 doxorubicin was 0, and in combination 1 group (1xIC50 melatonin and 1xIC50 cisplatin) was 6,7±0,17. Last, in GSH, mean expression in IC50 cisplatin group was 33,2±0,87, in IC50 melatonin group was 12,57±0,12, in IC50 doxorubicin group was 1,33±0,66, and in combination 1 group (1xIC50 melatonin and 1xIC50 cisplatin) was 11,73±0,67. There was significant difference of CTR-1 expression in combination 1 group which was higher (19.73%),  p-glycoprotein expression in combination 1 group which was lower (6,7%), and also GSH expression in combination 1 group was lower (11,73%) compared to other groups. Conclusion: The group 1 combination of 1xIC50 melatonin and 1x IC50 cislatin with 1.841 mM and cisplatin 117.5 uM were able to reduce cisplatin chemotherapy resistance by increasing drug influx activity by increasing CTR-1 expression, decreasing drug efflux through decreasing p-glycoprotein expression, and decreased DNA repair activity through decreased GSH expression.  

Possible different genotypes for human papillomavirus vaccination in lower middle-income countries towards cervical cancer elimination in 2030: a cross-sectional study

Purpose

Human papillomavirus (HPV) genotype and age distribution of HPV infection were crucial for the national vaccination and screening program planning. However, there was a limited study providing these data in the normal cervix population. This study aimed to explore the HPV genotypes profile of women with clinically normal cervix based on Visual Inspection of Acetic Acid (VIA) test.

Materials and Methods

A 7-year cross-sectional study was conducted from 2012 to 2018 in private and public health care centers in Jakarta. Subjects were recruited consecutively. Data were collected by anamnesis, VIA, and HPV DNA test using the polymerase chain reaction (PCR; SPF10-DEIA-LiPA25) method. HPV genotyping procedures include DNA extraction, PCR (SPF10-DEIA-LiPA25) using the HPV XpressMatrix kit (PT KalGen DNA, East Jakarta, Indonesia), and hybridization. The IBM SPSS ver. 20.0 (IBM Corp., Armonk, NY, USA) were used to analyze the data.

Results

A total of 1,397 subjects were collected. Positive HPV-DNA tests were found in 52 subjects (3.7%); 67% were single and 33% were multiple HPV infections. HPV 52 was the most frequently detected HPV genotype, followed by HPV 39, 16, 18 74, 44, 31, 54, and 66, respectively. The highest HPV infections in this population were in the 31–40 and 41–50 years old group.

Conclusion

This study suggested beneficial screening for women aged 31–50 years old. Instead of “original” nonavalent (HPV 16, 18, 6, 11, 31, 33, 45, 52, 58), the different “nonavalent” formula for HPV vaccines protecting against HPV 16, 18, 6, 11, 31, 39, 44, 52, 74 might be useful for Indonesian population. However, further multicenter studies with a huge sample size are still needed.

Comparison of matrix metalloproteinase-9 and E-cadherin expression in early- and late-onset preeclampsia

BACKGROUNDPreeclampsia (PE) is one of the most common pregnancy complications worldwide. Turnover of villous trophoblast is affected by impaired placental perfusion in preeclampsia. Among the various factors that influence pro and antiangiogenic factors in trophoblast invasion of PE are E-cadherin and matrix metalloproteinase-9 (MMP-9). The current classification scheme differentiates PE into two variants early-onset (EO) and late-onset (LO) PE. The aim of this study was to compare MMP-9 and E-cadherin expression between early- (EO) and late-onset (LO) PE. METHODSThis study used a cross-sectional design involving 26 women with gestational age <34 weeks (EO) and 38 women with gestational age ≥34 weeks (LO) from PE patients. Placentas born to preeclamptic mothers were taken in the form of small pieces of the maternal side to measure the levels of MMP-9 and E-cadherin by the ELISA method. Statistical analysis was assessed using the Mann Whitney and independent t-test with a significant p value <0.05. RESULTSSemiquantitative proteinuria levels were significantly higher in EO-PE group compared to LO-PE group (p=0.000). Mean E-cadherin levels were significant lower in the EO-PE group (125.94 ± 54.22 pg/mg) compared to LO-PE group (157.95 ± 54.12 pg/mg) (p=0.024). However, there was no significance difference in median MMP-9 levels between EO-PE group and LO-PE group (p=0.376). CONCLUSIONThis study demonstrate that E-cadherin had lower levels in preeclampsia patients who gave birth <34 weeks. This study indicated that lower levels of e-cadherin can lead to early delivery in preeclampsia patients.

Construction of plasmids expressing recombinant B cell epitopes of PD1

Latar Belakang: Pengobatan kanker di Indonesia umumnya menggunakan pengobatan dengan kemoterapi atau dengan operasi. Efek samping dari pengobatan ini antara lain adalah kerontokan rambut, mual dan penurunan berat badan. Saat ini sedang berkembang alternatif terapi kanker dengan menggunakan immunoterapi. Kemampuan sel kanker untuk menghindar dari sistem imun disebabkan adanya protein PD-1 pada sel T yang berikatan dengan ligannya PD-L1. Metode: Penelitian ini merupakan penelitian awal yaitu pembuatan rekombinan PQE PD-1 dan menggunakan bagian soluble dari PD-1 yang disebut dengan EP2PD1 yang akan digunakan untuk pembuatan antibodi monoklonal dan sistem pendeteksi antibodi monoklonal. Metode pembuatan rekombinan PD-1 dan EP2PD1 dengan cara penentuan sekuens epitop sel B yang paling imunogenik dilanjutkan dengan amplifikasi sekuen tersebut dengan PCR dan diligasi ke vektor pengekspresi PQE80. Hasil: Telah terbentuk konstruksi rekombinan PQE80 PD-1 dan PQEEP2PD1 yang diverifikasi menggunakan PCR koloni, pemotongan enzimatik dan sekuensing. Hasil penelitian menunjukkan bahwa epitop PD1 telah terklona ke PQE 80 dan tidak ditemukan mutasi dalam urutan asam amino. Kesimpulan: Konstruksi yang dibuat tidak mempunya mutasi dan dapat dilanjutkan untuk pembuatan antibodi monoklonal.  Kata Kunci: PD1, Epitop, Kanker, Immunotherapy   Abstract Background: Medications on cancer to date in Indonesia is mostly by surgical or chemotherapy, this type of medications is not always curing the patients. The side effect of the chemotherapy drugs sometimes more challenging such as hair loss, nausea and lost weight. One of the promising targets for cancer is using immune therapy. Cancer cells can avoid immune response by surprising immunity through activation of specific inhibitory signalling pathways, referred to as immune checkpoints. Immune check points like PD-1, PD-L1 are breakthrough therapies in oncology and this monoclonal antibody have been approved by the FDA for treatment. In this research we develop full PD-1 and part of PD1 sequence as an insert then we construct with plasmid PQE80L. This recombinant called PQE PD-1 and PQEEP2PD1. The aim of this study is to make recombinant which would be used to detect PD1 full clone monoclonal antibodies. Methods: In this study, we designed our recombinants using Indonesian HLA and others using in silico models, this prototype will not only cover Indonesian patients but also other country. Results: The result showed that the epitope sequence of PD1 has been clone to PQE 80 wt and verified using colony PCR, Enzyme Digestion and Sanger Sequencing. The Clone than will be expressed and injected to animal model to produce antibody. Conclusion: Construction of recombinant PQE PD-1 and PQE EP2PD1 are constructed without any mutation in the sequence, this recombinant can be used in the next study for protein expression of PQE PD-1 and PQE EP2PD1.  Keywords: PD1, Epitope , Cancer, Immunotherapy  

Role of Cancer Stem Cell, Apoptotic Factor, DNA Repair, and Telomerase Toward Radiation Therapy Response in Stage IIIB Cervical Cancer

Objectives

Cancer stem cells are involved in radioresistant cancers. Transcription factors Sry-related HMG box (SOX2) and octamer binding transcription factor 4 (OCT4) can confer pluripotent cell characteristics and self-renewal ability and are involved in carcinogenesis, metastasis, tumor recurrence, and resistance to therapy. Apoptosis, DNA repair, and telomerase factors also contribute to radioresistance. We sought to identify the role of SOX2 and OCT4 as cancer stem cell markers and their effects on apoptosis (via caspase 3), DNA repair (Chk1) and telomerase (hTERT) in conferring resistance to radiotherapy.

Methods

We conducted a case-control study of 40 patients with stage IIIB cervical squamous cell carcinoma who completed radiation therapy at Cipto Mangunkusumo Hospital, Jakarta, Indonesia. The patients were classified according to their treatment response as having exhibited a complete or incomplete response. Clinical follow-up and Pap smears were performed between six and 12 months after therapy for those with a good initial response to determine the final response to therapy. Immunohistochemistry was used to analyze SOX2, OCT4, caspase-3, Chk1, and hTERT expression in paraffin sections of the initial biopsy.

Results

Strong expression of SOX2 (p = 0.011, p = 0.001) and OCT4 (p < 0.001, p < 0.001) was significantly associated with both an incomplete initial and final therapy response, respectively. Multivariate analysis showed that SOX2 and OCT4 expression levels were the strongest markers of an incomplete response to radiotherapy (odds ratio (OR) = 5.12, p = 0.034, and OR = 17.03, p = 0.004, respectively).

Conclusions

Strong expression of SOX2 and OCT4 may be a good indicator of incomplete radiotherapy outcome in patients with stage IIIB cervical cancer.

CD133, CD44, and ALDH1A1 as cancer stem cell markers and prognostic factors in epithelial ovarian cancer

BACKGROUND Ovarian cancer is a heterogeneous disease, and most patients are diagnosed at an advanced stage. Epithelial ovarian cancer type II is characterized by rapid tumor growth and is genetically more labile than type I. This study was aimed to demonstrate the prognostic value of CSC by using the markers CD133, CD44, and ALDH1A1 in EOC.METHODS Clinicopathological and demographic data were collected from medical records. The markers CD133, CD44, and ALDH1A1 were examined with flow cytometry and immunohistochemistry. Cancer stem cell (CSC) marker expression in patients with ovarian cancer types I and II were related to chemotherapy and survival. In multivariate analysis, the prognosis model was tested for ten months.RESULTS The largest demographic consisted of patients aged ≥45 years, with stage I, poor differentiation, and type II, of which there were 40 samples (72.7%), 23 samples (41.8%), 30 samples (54.5%), and 16 samples (29.1%), respectively. There is a high correlation between the 10-month chemotherapy response and the 4 variables, i.e., age ≥45 years, type II, stage III–IV, and CD44, with an ROC of 80.75% and a post-test probability of 82.5%. Using the ROC curve, the highest chemoresistance score was 0.841, based on the combination of CSCs markers and clinicopathological factors, that is stage III–IV, age ≥45 years, poor differentiation, type II, negative CD133, high CD44, and high ALDH1A1.CONCLUSIONS CSC (CD133, CD44, and ALDH1A1) markers and clinicopathological factors are prognostic of epithelial ovarian cancer.

Post Marketing Surveillance Study of 2nd Dose Quadrivalent Human Papilloma Virus Vaccine in Elementary School Children in Jakarta, Indonesia: Safety Result and Implementation of School-Based HPV Immunization Program

Objective:

Quadrivalent human papillomavirus (QHPV) vaccine has been advised for routine vaccination of pre-adolescent girls globally, and a two-dose QHPV vaccination schedule has been introduced in Indonesia to vaccinate 5^th and 6^th grade elementary school female students. This post-marketing surveillance study evaluated the possible adverse events following immunization with the two-dose QHPV vaccine in Indonesia.

Methods:

Girls studying in grade 6 of five designated elementary schools in Jakarta, receiving their 2^nd dose of QHPV vaccine and provided informed consent (represented by their parents), were included in the study. Students who had received other immunizations either simultaneously or <1 month ago were excluded. Local and systemic reactions noted at 30 min, and 72 h to 28th day, after the immunization were recorded using a Children Symptom Dairy Card/Kartu Harian Anak Sekolah (KHAS/Student Daily Card).

Results:

A total of 500 students from 20 schools were included. No serious adverse events were reported during the study period. Fever (systemic reaction) of mild intensity was noted in 1.6 % (n=8) of participants, which subsided after day 6. Local reactions such as pain, redness and swelling were noted in 59.6% (n=295), 23.6% (n=118), and 17.2% (n=86) of participants, respectively. These resolved without any intervention in majority of the cases after day 5.

Conclusion:

These results along with the safety data from the pre-licensure clinical trials confirm the favorable safety profile of QHPV vaccine in pre-adolescent girls. The school-based two-dose QHPV immunization program in Indonesia is a safe and effective strategy for optimizing HPV vaccine coverage among pre-adolescent girls.

Cullin 1 is not associated with late-onset preeclampsia

BackgroundLate-onset preeclampsia (PE) is preeclampsia occurring after 34 weeks of gestational age or later.  Cullin 1 (CUL1), a proangiogenic protein, is expressed in the placenta, where an imbalance between proangiogenic and antiangiogenic proteins during gestation can cause disturbance of trophoblast invasion. This defect results in vascular ischemia that may produce preeclampsia. The objective of this study was to determine the correlation between CUL1 as proangiogenic factor and late-onset preeclampsia. MethodsThis study was of analytical observational cross-sectional design and involved 44 preeclampsia patients with ³34 weeks of gestational age (late-onset PE). The CUL1 level in the subjects’ sera, taken before they gave birth, and in homogenates of their placenta, obtained per vaginam or by cesarean section, were examined by the ELISA technique.  Statistical analysis was performed with the Spearman correlation test with significant p value of <0.05.ResultsMedian maternal age was 31 years and median gestational age was 37 weeks.  Median serum CUL1 was 41.78 pg/mL and median placental homogenate CUL1 was 32.24 pg per milligram of total placental tissue protein. There was no significant correlation between serum CUL1 level and late-onset preeclampsia (r=-0.281; p=0.065). There was also no significant correlation between placental CUL1 level and late-onset preeclampsia (r=-0.166; p=0.281).ConclusionSerum CUL1 and placental CUL1 were not correlated with late-onset preeclampsia. However, this study indicated that low serum CUL1 tends to prolong gestational age in preeclampsia.

The Proportion of Lymph Node Metastasis in Patients with Stage IIA1 and IIA2 Cervical Cancer who were Treated for Radical Hysterectomy and Pelvic Lymphadenectomy

Objective: This study was designed to determine a difference in prognosis of stage IIA1 cervical cancer compared to stage IIA2 based on the incidence of metastasis to pelvic lymph nodes by radical hysterectomy. Methods:A cross sectional study was conducted among 108 stage II cervical cancer patient post radical hysterectomy in obstetric gynecologic department of Dr. CiptoMangunkusumo hospital since 2006-2016. Results: From 108 patients with cervical cancer stage IIA, 80 (74%) patients are stage IIA1 and the remaining the remaining 28 (26%) patients are stage IIA2. The average age of patients at stage IIA2 (47.79 years) younger than IIA1 (55.85 years) and also patient at stage IIA1 having a higher parity number which is 4 compare to stage IIA2 with the number of parity 2. The Involvement of lymph node metastasis in patients with stage IIA1 and IIA2 cervical cancer were 51 (63.75%) and 16 (57.14%) respectively. Conclusion: Metastatic factor to lymphnode in both stage have the same result. There was no difference in the proportion of lymph node metastasis occurring in both stage IIA cervical cancer stage which was corrected with radical hysterectomy and pelvic lymphadenectomy with p = 0,535. Changing staging does not seem to improve the prognosis. Keywords: cervical cancer, stage IIA, lymphnode metastatic   Tujuan:Membuktikan adanya perbedaan prognosis kanker servik stadium IIa1 dibanding stadium IIa2 berdasarkan kejadian metastasis ke kelenjar getah bening pelvik yang dilakukan histerektomi radikal. Metode: Dengan menggunakan metode potong lintang dilakukan pengambilan data  108 sampel pasien kanker serviks stadium IIA yang dilakukanpembedahanhisterektomiradikal di Departemen OnkologiGinekologi RSUP. Dr. Cipto Mangunkusumo Jakarta sejak tahun 2006 hingga tahun 2016. Hasil: Pasien kanker serviks stadium IIA1 sebanyak 80 (74%) pasien dan stadium IIA2 sebanyak 28 (26 %) pasien. Pada stadium IIA2 (47.79 tahun) didapatkan rata ratausiapasienlebihmudadibandingkan IIA1 (55.85 tahun). Pada stadium IIA1 jugadidapatkanjumlahparitas yang lebihtinggiyaitu 4 sedangkanpada stadium IIA2 denganjumlahparitas 2. Keterlibatan metastasis kelenjar getah bening pada pasien kanker serviks stadium IIA1 dan IIA2 berjumlah 51 (63.75%) dan 16 (57.14%) secara berurutan. Tidak terdapat perbedaan proporsi kejadian metastasis kelenjar getah bening pada kedua kelompok stadium kanker serviks pada stadium IIA dengan nilai p = 0,535. Kesimpulan: Faktor metastasis kelenjar getah bening pada kedua stadium memiliki hasil yang serupa.Tidak terdapat perbedaan proporsi kejadian metastasis kelenjar getah bening pada kedua kelompok stadium kanker serviks stadium IIA1 dan IIA2 yang ditatalaksna dengan histerektomi radikal dan limfadenektomi pelvis. Perubahan penetapan stadium sepertinya tidak memperbaiki prognosis. Kata kunci : Kanker serviks, stage IIA, kelenjar getah bening, faktor prognostik

Incidence of Pelvic and Paraaortic Lymph Node Metastasis in Epithelial Ovarian Cancer at a Tertiary Care Center

Objective: To investigate the incidence of pelvic and paraaorticlymph node metastasis in epithelial ovarian cancer.Methods: This was a cross-sectional study. Data were collectedfrom medical records, and from the cancer registry 1539 medicalrecords were obtained. From there, 863 patients were operatedand 676 were not, and only 401 medical records were foundcomplete, and 306 samples were excluded because they have beentreated with NAC and underwent surgery, patients who underwentsurgery but the results is not the epithelium, and patients whounderwent surgery, but the results were benign or borderline. And95 patients who underwent primary surgery and lymphadenectomyonly 55 patients have results in lymphadenectomy. This study usesa calculation of sample size with categorial descriptions, withprecision of 3% then obtained a minimum sample size of 261patients.Results: According to the characteristics of the study subjectsabove, the results were stage I, II, III respectively 60%, 10.9%, and29%. The metastasized of the lymph node paraaortic 9.1%, andpelvic/paraaortic 20% pelvic/paraaortic23.6%. Based on thedegree of differentiation the results were good differentiation30.9%, moderate differentiation 23.6%, and poor differentiation45.5%. We found that paraaortic lymph node metastasis weremost frequent at stadium III (43.8%). In relationship betweenlymph node metastasis with differentiation of epithelial ovariancancer, the most frequent epithelial ovarian cancer were one withpoor differentiation in pelvic/paraaortic lymph node with the sumof 69.2%. From analysis, there is significant difference betweenserous hystologic subtype with mucinosum subtype in pelviclymph node, significant difference between serous hystologicsubtype and clear cell in paraorta or pelvic lymph node andbetween the serous histology subtype and mucinous as well.Conclusion: Lymph node metastasis incident of ovarian epithelialcancer in paraaorta amounts 20%, pelvic 9.1% and pelvic orparaaortic 23.6%. Higher the stadium, the lymph node involvementswill be higher as well (pelvic and paraaortic). In stadium 1of mucinous subtype with well differentiation has minimal lymphnode involvement so we can be more selective in considering therisk and benefit of lymphadenectomy.[Indones J Obstet Gynecol 2018; 6-1: 60-63]Keywords: lymph node metastasis, ovarian cancer

Spirituality-Focused Palliative Care to Improve Indonesian Breast Cancer Patient Comfort

Background:

Palliative care is an approach that focuses on improving a patient's quality of life. This research aimed to develop a path model of the relationships between the variables of nursing care (information, emotional support, technical support, and palliative care), patient coping, family support, patient spirituality, and patient comfort expressed through physical and emotional mediators.

Method:

This cross-sectional study involved 308 breast cancer patients from 3 referral hospitals in Jakarta, Indonesia. A structural equation model with Kolcaba's theory was used to develop a theoretical model estimating the path or relationships between the key variables.

Results:

The results showed that palliative care significantly improved breast cancer patient comfort by reducing anxiety and depression. Furthermore, the study demonstrated a significant positive relationship between spirituality and emotional well-being.

Conclusion:

Spirituality-focused palliative care is fundamentally importance for breast cancer patients. Nurses play an essential role in providing spirituality-focused palliative care to promote comfort in breast cancer patients in Indonesia.

Human Papilloma Virus L1 Gene Methylation as a Potential Biomarker for Precancerous Cervical Lesion: a Preliminary Report

Objective: To determine whether HPV L1 gene methylation can be used in triage of precancerous cervical lesions. The main objective is to determine the genotype of HPV in cervical precancerous lesions and to determine the percentage, the sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of DNA HPV L1 methylation in precancerous cervical lesions. Methods: A number of 57 samples of paraffin blocks (FFPE) from precancerous lesions and cervical cancer biopsies in the Department of Pathology Faculty of Medicine-Cipto Mangunkusumo General Hospital that had been re-evaluated by the pathologist, underwent extraction of HPV DNA. The genotypes of HPV DNA were examined using primers GP5 / 6 and specific HPV 16, HPV 18 and HPV 52 probes and analyzed by real time PCR. Sequencing was performed on samples with unknown HPV DNA type that were detected using the specific probes to determine the type of HPV. Bisulfite conversion procedure was then performed for the samples that met the inclusion criteria. Results: There were 30 samples (52.6%) with CIN 1, 12 samples (21.1%) CIN 2, 9 samples (15.8%) CIN 3 and 6 samples (10.5%) of cervical cancer. Most of the samples were 36-45 years (35.1%). Of the total 57 samples, 55 samples were successfully extracted and determined the DNA genotyping of HPV (96.5%). HPV 16 infections both in the form of single or multiple was found to be 76.36%. The samples were mostly dominated by co-infection of HPV16 and 18 (49.1%) followed by HPV 16 (24.6%) and HPV 18 (14.0%). Based on the sequencing results there were other types of high risk HPV infection found: HPV 33, HPV 35, HPV 58 and also undeterminate risk HPV 53 and low risk HPV 54. After several procedures of optimization for methylation examination of HPV DNA L1 there was thin band found in electrophoresis procedure in 8 of 42 samples (19%) of HPV 16 after bisulfite conversion but once it was purified there weren’t any band found so we can not proceed to the stage sequencing. Until now we are still in the stage of optimizing the methylation procedure. Conclusion: HPV 16 infection were most commonly found in the form of single or multiple. Co-infection of HPV 16 and 18 were found in the majority of the samples. There were no significant correlation between HPV type and the severity of cervical lesions. Until now, the examination of DNA methylation HPV L1 already obtained eight samples of HPV 16 with a thin band on electrophoresis but the result could not be concluded because it is still in the process of optimization. [Indones J Obstet Gynecol 2017; 5-2: 120-126] Keywords: HPV DNA genotype, L1 gene methylation, precancerous cervical lesions

The Cost-Effectiveness of Quadrivalent Human Papillomavirus Vaccination in Indonesia

Objective: National cervical cancer prevention program has been initiated in Indonesia since April 2015 and the ministry of health has started efforts to integrate the HPV Vaccine in the national immunization program since Q4 2015. Thus, it becomes important to analyze the cost-effectiveness of HPV vaccine. The objective of this model is to examine the potential long-term epidemiologic and economic impact of quadrivalent HPV(qHPV;6/11/16/18) vaccination program in Indonesia. Methods: A previously validated transmission dynamic model was used to estimate the long-term epidemiologic and economic consequences of quadrivalent HPV vaccination by comparing cost-effectiveness of 2 dose qHPV vaccination strategy for girls 11-12 years old (with or without catch up; catch up dose for 12–26 years) versus Screening Only (Pap Smear) for reducing cost related to HPV type 6,11,16,18 (cervical cancer, CIN 1, CIN 2/3, and genital warts). Costs of an HPV disease episode-of-care (diagnosis and treatment) were calculated for base case analysis using local Indonesian cost. Result: 2-dose qHPV vaccination strategies without catch up reduce the overall incidence of HPV 16/18–related cervical cancer relative to screening by 54.4% over the 100 year following vaccine introduction. Likewise, vaccination strategies reduce the incidence of HPV type 16/18 CIN 2/3, CIN 1 by 69.1% and 71.8% respectively, also reducing HPV type 6/11 CIN 1, genital warts in female, genital warts in male by 82.9%,84.2%,82.1% respectively, at this time point. From total reduction of health care cost, 67.1% attributable for diseases caused by HPV type 16/18 and 32.9% attributable for diseases caused by HPV type 6/11. Without catch up, cost/QALY would be $450/year. However catch-up strategy is more cost effective versus vaccinates 12-year-old girls only; with cost/QALYs would be $390/year. Conclusion: HPV 6/11/16/18 vaccination of females in Indonesia are 1) substantially reduce genital warts, CIN, and cervical cancer; 2) improve quality of life, and 3) with the Indonesia GDP of USD 3,531.80 in 2014 , Cost/QALYs result with or without catch up is considered very cost-effective when implemented; however with catch up, the cost/QALY can be better.

Level of Retinol Deposit and Cervical Cancer

Objective: To analyze level of retinol deposit sufficiency in the natural history of cervical cancer. Methods: Serum retinol level was measured by ELISA from peripheral blood of subjects with normal cervix, cleared and persistent high risk human papilloma virus (HR-HPV) subclinical infection, and cervical cancer who fulfilled the inclusion and exclusion criteria. The study was held in Dr. Cipto Mangunkusumo and Fatmawati Hospital, Jakarta, within 2 years (August 2013- 2015). Blood was taken twice, consisting of post-8-hour fasting blood and 2 hours after 6000 IU retinyl palmitate oral administration. Results: Of 47 total samples, sufficient level of retinol deposit in normal cervix, cleared and persistent HR-HPV subclinical infection, and cervical cancer group was 85.0% (reference), 75.0% (OR 1.89), 33.3% (OR 11.33), and 75% (OR 1.89); respectively. Statistically, there was no significant difference from sufficiency level of retinol deposit between normal cervix and clearance HR-HPV subclinical infection (p=0.628), normal cervix and persistent HR-HPV subclinical infection (p=0.078), normal cervix and cervical cancer (p=0.433), cervical cancer and clearance HR-HPV subclinical infection (p=1.000), cervical cancer and persistent HR-HPV subclinical infection (p=0.430), persistent and clearance HR-HPV subclinical infection group (p=0.740). Conclusion: This study proves that normal cervix group has the highest level of retinol deposit sufficiency; however, it cannot be stated that cervical cancer group has less sufficiency level. Persistent HR-HPV subclinical infection group has the lowest level of retinol deposit (OR 11.33). There is no association between sufficient level of retinol deposit and clearance of HR-HPV. [Indones J Obstet Gynecol 2017; 5-1: 46-54] Keywords: cervical cancer, HR-HPV clearance, retinol deposit

A Simple Ultrasound Examination as Diagnostic Tool for Malignant Ovarian Tumor

Objective: To know the diagnostic value of simple ultrasound examination to detect malignant ovarian tumor. Method: This study used cross-sectional design in gynecology outpatientclinic at Dr. Cipto Mangunkusumo Hospital. We recruited the patients with ovarian tumor undergoing surgery between March and July 2015. Samples were taken using consecutive sampling. Analysis was done using Chi-square test and logistic regression to find the relationship between ultrasound morphologic patterns with histopathologic findings, where the significant relationship was p value less than 0.05. Furthermore, a model derived from logistic regression was made to calculate the probability having ovarian malignancy. Result: There were 80 subjects which 58 subjects (72.5%) had benign tumor and 22 subjects (27.5%) had malignant tumor. Ultrasound examination result using  2 morphologic patterns gave malignant result in 53.8% subjects with the sensitivity of 100%, specificity of 82.8%, positive predictive value of 68.8%, and negative predictive value of 100%. The most important patterns were irregular internal cyst wall, multilocular, presence of papillary projection, and presence of solid component. The probability of subject having ovarian malignancy with  3 morphologic patterns was more than 88.9%. Conclusion: Simple ultrasound examination can be used to detect malignant ovarian tumor. [Indones J Obstet Gynecol 2016; 4-4: 222-226] Keywords: diagnostic, histopathology, morphology pattern; ovarian tumor; ultrasonography

Perubahan Keluhan Seksual (Fisik dan Psikologis) pada Perempuan Pascaterapi Kanker Serviks Setelah Intervensi Keperawatan

Introduction: Despite increasing awareness related to sexual health for cervical cancer survivors, health care providers are passive in addressing their sexual issues. The objectives were to develop and investigate the effect of a sexual nursing intervention packet to mitigate sexual dysfunction among cervical cancer survivors.Methods: A sample of 104 survivors were participated consecutively based on required inclusive criteria in this quasi-experimental study. The sexual nursing intervention packet focused on the physical, psychological, and care of relational aspects of sexual health elements. The packet consisted of 6 weekly 2-hour sessions.Results: The participants reported poor sexual satisfaction and sexual function. There were no statistically signi fi cant differences in sexual interest, sexual arousal, orgasm, and vaginal lubrication improvement following the intervention, although all the variables in the intervention group were improved clinically. The sexual nursing intervention packet was effective in increasing sexual satisfaction and decreasing dispareunia among cervical cancer survivors.Conclusion: This study suggests that the quality of life in cervical cancer survivors could be improved with the sexual nursing intervention packet provided as part of supportive group care. This program may be more effective if delivered earlier and for a longer period. Implications for Practice: The sexual nursing intervention packet offers an opportunity to facilitate small-group dynamics that lay the ground for further contacts leading to earlier recognition of sexual problems and active involvement for sexual health improvement for cervical cancer survivors and nurses. It could be utilized for survivor education or support groups to increase sexual satisfaction following cancer treatment.

The Outcomes of Primary Debulking Surgery and Neoadjuvant Chemotherapy in Advanced Ovarian Cancer

Objective: To compare the outcomes and survival rate of primary debulking surgery with neoadjuvant chemotherapy. Method: We selected advanced ovarian cancer patients from medical records. Subjects were allocated into groups of primary debulking surgery and neoajuvant chemotherapy by considering the inclusion and exclusion criteria. We analyzed the data using T test, Fisher’s exact, and chi-square. The survival rate was presented in Kaplan Meier curve, whereas the significance was tested with Logrank. We managed the data using STRATA software version 12. Result: We obtained 32 cases of primary debulking surgery group and 20 cases of the neoadjuvant chemotherapy group. Most of the subjects (44.2%) were 40-49 years old and 80.8% had delivered more than twice. The mean value of Ca-125 at admission was 3,594.8 u/ml (range 66.6 to 73,000 u/ml). Total of 31 subjects showed the serous histologic type (59.6%). There was no association between primary debulking surgery and neoadjuvant chemotherapy for the parameter of operative time, blood loss, organs injury, ICU stay, and hospital stay (p>0.05). Primary debulking surgery had a survival rate similar to neoadjuvant chemotherapy group (p=0.95). Conclusion: The perioperative outcomes of advanced ovarian cancer patients has similar result between primary debulking surgery and neoadjuvant chemotherapy. Primary debulking surgery has a survival rate similar to neoadjuvant chemotherapy group. [Indones J Obstet Gynecol 2016; 4-2: 111-115] Keywords: advanced ovarian cancer, neoadjuvant chemotherapy, primary debulking surgery

Effect of Smoking on Advanced Stage Cervical Cancer Patient Survival

Objective: The researchers aim to investigate the relationship between smoking habit and other factors as prognostic factors of cervical cancer. Method: We performed a retrospective and prospective cohort study with subjects that are stage IIB-IVB cervical cancer patients in Dr. Cipto Mangunkusumo Hospital followed up from August 2009 to April 2014. The subjects’medical records were reviewed, and patients were interviewed about their current condition by telephone. Questions asked include smoking habit, spouse’s smoking habit, and mortality status. Patients that could not be contacted by phone were excluded from the study. Statistical analysis was done using Stata 10. Result: Out of 390 cervical cancer patients stage IIB-IVB in 2009, there were 270 patients (69.2%) that were included in the inclusion criteria. Most of the patients are 40-59 years old (82.2%) and are nonsmokers (91.8%). The most frequent clinicopathological characteristic is IIIB (63.3%) and squamous cell carcinoma (71.9%). The 5- year survival rate is 22.6%. There is no statistical significance between advanced stage cervical cancer survival with the patients’ or patients’ husbands’ smoking habit. Conclusion: In our study, smoking habits do not aggravate survival rate of advanced stage cervical cancer patients but further research must be done with more sample. Stage, and tumor size both by physical examination and ultrasound can be used as the prognostic factor. [Indones J Obstet Gynecol 2015; 3: 170-176] Keywords: Brigmann Index, cervical cancer, smoking, survival

Survival and Side Effects of Cisplatin/Cyclophosphamide and Carboplatin/Paclitaxel Adjuvant Chemotherapy in Stage IC-IV Ovarian Cancer

Objective: To compare the survival and side effects in epithelial ovarian cancer patients receiving adjuvant chemotherapy of cisplatin/ cyclophosphamide and carboplatin/paclitaxel. Method: We recruited epithelial ovarian cancer patients receiving cisplatin/cyclophosphamide (group A) or carboplatin/paclitaxel (group B) adjuvant chemotherapy after surgery. Chemotherapy was given for six cycles. Overall survival and side effects were assessed. Result: A total of 49 patients were recruited, consisting of 25 patients for group A and 24 patients for group B. In this study, the overall survival of stage IC-IV ovarian cancer patients was 37.3 months in group A (95%CI=31.86-43.46) and 35.5 months (95%CI= 13.93- 43.46) in group B (p

Serum Level of Vascular Endothelial Growth Factor (VEGF) can be used to Assess Response of Radiation Therapy in Cervical Cancer

Objective: To compare the sensitivity and specificity of Squamous Cell Carcinoma (SCC) and Vascular Endothelial Growth Factor (VEGF) levels to assess the response of radiation therapy. Method: The study was conducted by the method of analytic observational cohort study in 24 patients with cervical cancer stage II-B and III-B in RSCM that met inclusion criteria. Examination of VEGF and SCC in serum samples was performed in the Prodia Laboratory Jakarta. The examination was conducted twice before and after radiation therapy. The subjects were treated by radiation therapy/chemoradiation according to standard procedures. After the completion of radiation was declared, the response of radiation therapy was conducted by clinical assessment. Result: Of the 24 subjects, we obtained a mean level of SCC pre-radiation was 23.43 ± 5.84 ng/ml and post-radiation was 2.19 ± 0.68 ng/ml. The mean VEGF pre-radiation was 790.41 ± 111.06 pg/ml and post-radiation was 497.47 ± 79.26 pg/ml. ROC curves of each tumor marker obtained SCC pre-radiation AUC 40%, p 0.53 (CI 0.18-0.68) and SCC post-radiation AUC 48.1%, p 0.91 (CI 0.21-0,75) can not be used as a diagnostic and prognostic factors of response to radiation therapy. VEGF pre-radiation produced an AUC of 17.5%, p 0.04 (CI 0.00-0.36), thus cannot be used as a prognostic factor for response to radiation therapy. VEGF after radiation produced an AUC of 92.5%, p 0.01 (CI 0.81-1.00), thus can be a diagnostic factor for response to radiation therapy. VEGF post-radiation with cut-off point 614.75 pg/ml had a sensitivity 80%, specificity 75%, NDP 94.12%, NDN 42.86%; RKP 3.2; RKN 0.26 and accuracy 79.16%. There is a significant correlation between the decrease of serum VEGF level post-radiation and a positive response of radiation therapy (p 0.01, CI 1.00-3.23). Conclusion: Examination of VEGF levels can be used to assess the response of radiation therapy with a sensitivity of 80% and specificity of 75%.  Keywords: cervical cancer, SCC, therapeutic response, VEGF