Alex Mremi

Ovarian torsion of a large mature cystic teratoma complicating early pregnancy: a rare case report

Introduction and Importance: Adnexal torsion complicating early pregnancy is rare but should be suspected in pregnant women presenting with acute lower abdominal pain. Mature cystic teratomas (MCTs) are common benign ovarian tumors in women of reproductive age, but their occurrence during pregnancy complicated by torsion is rare. MCTs comprise 20% of all ovarian neoplasms and are commonly encountered in patients between 20 and 40 years of age. Early diagnosis is challenging due to overlapping symptoms with common pregnancy-related conditions, yet prompt recognition and intervention are crucial to preserve maternal and fetal outcomes. This case report aims to highlight the diagnostic and management challenges of adnexal torsion complicating early pregnancy. Case Presentation: We report the case of a 21-year-old primigravida from Northern Tanzania who presented at gestational age of 11 weeks and 4 days of gestation with a sudden-onset history of left lower abdominal pain for 6 h that progressively worsened over time. Abdominal ultrasonography revealed a large left adnexal cystic mass with internal echoes, thickened walls, and posterior acoustic enhancement, measuring 14.0 × 10.4 × 9.3 cm, consistent with a complex ovarian cyst. The uterus was enlarged and contained a viable intrauterine pregnancy with a crown–rump length of 48.6 mm, corresponding to 11 weeks and 4 days of gestation with active cardiac activity. The patient underwent an emergency laparotomy, which confirmed a viable intrauterine pregnancy alongside a large, twisted left ovarian cystic mass measuring 19.0 × 14.0 × 10.0 cm, with torsion of its pedicle around the mesovarium. Detorsion and left salpingo-oophorectomy were performed successfully. Histopathological examination confirmed the diagnosis of a MCT. Postoperative recovery was uneventful, and follow-up at 23 weeks showed a viable ongoing pregnancy. Clinical Discussion: MCTs are prone to torsion due to their size and mobility. Early surgical management is critical to prevent ischemic necrosis and ensure optimal maternal and fetal outcomes. In this case, a timely laparotomy and removal of the affected adnexa resulted in a favorable recovery and continuation of pregnancy. Conclusion: Ovarian torsion due to a MCT in early pregnancy is a rare but important differential diagnosis for acute abdominal pain. Prompt recognition and surgical intervention are vital to preserving maternal health and supporting pregnancy continuation.

Management of a Borderline Brenner Tumor of the Ovary in a Premenopausal Woman in Northern Tanzania. A Rare Case Report and Review of the Current Literature

ABSTRACTBrenner tumors are rare ovarian neoplasms that are typically small and unilateral. Most cases are benign; less than 5% of all Brenner tumors are borderline or proliferative. Brenner tumors originate from the follicular epithelium and consist of ovarian transitional cells surrounded by fibrous tissue. Here we present a case of a 49‐year‐old premenopausal woman from Northern Tanzania. This patient presented to our facility with acute abdominal pain. She also reported abdominal distention which was first noticed 12 months prior to presentation. Magnetic resonance imaging (MRI) identified a 21 × 17 × 5 cm complex cyst with a thickened wall on the right ovary. The radiological findings were suggestive of an ovarian cystadenoma; multiple intramural and subserosal uterine leiomyomas were also noted. A total abdominal hysterectomy (TAH) and bilateral salpingo‐oophorectomy (BSO) was performed. Histopathological findings identified an atypical proliferative borderline Brenner tumor of the right ovary. Postoperative recovery was uneventful, the patient was discharged and managed conservatively postoperatively.

A Rare Case of Large Ovarian Thecoma Diagnosed Histopathologically Following Surgical Management in a Premenopausal Woman: A Case Report and Review of the Current Literature

ABSTRACT Ovarian thecomas are rare sex cord‐stromal tumors of the ovary. These tumors are estimated to account for 1% of all ovarian neoplasms. Thecomas are primarily composed of cells that resemble theca cells, which are involved in estrogen production. While thecomas are more frequently observed in postmenopausal women, they can also occur in premenopausal women. This report presents a rare case of an ovarian thecoma in a premenopausal woman and reviews the current literature on the topic. Herein we endeavor to contribute to the current body of knowledge and provide guidance to clinicians managing similar cases. Our patient is 43 years old and was diagnosed with an ovarian thecoma after she presented to our facility complaining of abdominal pain and abdominal distension. She underwent a total abdominal hysterectomy and unilateral salpingo‐oophorectomy. Histopathological examination confirmed a benign thecoma. We demonstrate that it is crucial to consider this benign condition when evaluating solid ovarian tumors in premenopausal women.

Knowledge, attitude and practices towards cervical cancer control among University students in Kilimanjaro region, Tanzania

Background Cervical cancer (CC) is a major public health issue in the sub-Saharan Africa region, partly due to limited public awareness among women at risk. University students are part of the age group that is at risk. Assessing their knowledge, attitude, and practices (KAP) about CC, its causes, and prevention methods can reveal gaps that need to be addressed through education. We aimed to assess KAP towards CC control and their determinants among University students in Tanzania. Methods A cross-sectional survey was conducted among 708 undergraduate students in three Universities, using a pre-tested questionnaire. Descriptive statistics and binary logistic regression were used to describe variables and identify associations between variables; a p-value of <0.5 determined the association. Results The majority of students (75.7%) were not knowledgeable, and 82.5% had a negative attitudes regarding CC. Only 25.4% had ever been screened against CC. Being female and a medical student in ≥4th year of studying were significantly associated with good knowledge and attitude of CC (p < 0.000), while other socio-demographic characteristics didn’t show any association. Conclusion The findings indicate that Tanzanian University students’ lack the basic knowledge and attitudes towards CC prevention and control, highlighting the need for comprehensive strategies to ensure no woman is left behind.

Barriers to adherence to cervical cancer screening care in Northern Tanzania

Abstract Background Cervical cancer disproportionately affects women in low- and middle-income countries compared to those in high-income countries because of the difference in quality and effectiveness of cervical cancer screening programs. An essential part of effective cervical cancer prevention is the continuum of care for a woman with a suspicious cervical lesion (SCL) consisting of appropriate treatment and, in Tanzania, a follow-up screening one year after treatment. This study aimed at identifying factors associated with non-adherence to the scheduled follow-up after treatment of a SCL. Additionally, the cervical cancer screening results one year after treatment were evaluated. Methods A total of 219 clients treated for a SCL between 2017 and 2021 from 8 centres in the Kilimanjaro region were interviewed. Contact and medical information of the clients was obtained at the facilities. Additionally, 11 in-depth interviews with healthcare providers were conducted. Results In the quantitative study, 143 (65.3%) clients treated for suspicious cervical lesions adhered to the recommended follow-up appointment. Significant factors associated with poor adherence were individual barriers such as failure to understand why they should return and access barriers to the health facility. The health workers mentioned a lack of awareness and financial challenges regarding transportation. Conclusion The complete journey of high-risk women needs attention, otherwise the primary screening will not be effective. Additional efforts are needed to address knowledge gaps and socio-economic problems during the follow-up.

Cervical cancer incidence in Denmark: Disentangling determinants of time trend

AbstractCervical cancer is a preventable disease. Nevertheless, stagnation has been seen in incidence rates also in countries with well‐functioning healthcare. On this basis, we investigated associations between control interventions and changes in cervical cancer incidence in Denmark from 2009 to 2022. Data on human papillomavirus (HPV)‐vaccination were retrieved from Staten's Serum Institute; on screening recommendations from Danish Health Authority, on screening performance from Danish Quality Database for Cervical Screening; and on cervical cancer incidence from Nordcan and Danish Cancer Register. We reported coverage with HPV vaccination (1+ dose); coverage with cervical cell samples; number of women with primary HPV tests; proportion of non‐normal cell samples without timely follow‐up; number of conizations; and cervical cancer incidence rates. In 2022, all women aged ≤29 had been offered childhood HPV vaccination with coverage of 80%–90%. By 2020–2022, the cervical cancer incidence rate in women aged 20–29 was 3 per 100,000; at level of disease elimination. In 2017, women aged 70+ were offered a one‐time HPV screening, and by 2020–2022, the old‐age peak in cervical cancer incidence had largely disappeared. From 2009 to 2022, proportion of non‐normal cell samples without timely follow‐up decreased from 20% to 10%, and conventional cytology was largely replaced by SurePath liquid‐based cytology; these factors could explain the steady decrease in cervical cancer incidence rate. Implementation of primary HPV screening in women aged 30–59 in 2021 was reflected in a, probably temporary, increase in the 2022 cervical cancer incidence rate. In conclusion, combined interventions with childhood HPV vaccination; one‐time HPV screening of elderly women; and better management of screening broke previous stagnation in cervical cancer incidence rate.

Expression analysis of p16 and TOP2A protein biomarkers in cervical cancer lesions and their correlation with clinico-histopathological characteristics in a referral hospital, Tanzania

Introduction Biomarkers yield important information for early diagnosis of cervical cancer. However, they are rarely applied for prognosis of cervical cancer in Tanzania, where visual inspection assay with acetic acid or Lugol’s iodine and Pap test are being used as the standard screening/ diagnostic methods. Methods This was a retrospective hospital-based cross-sectional study that was conducted to assess cyclin-dependent kinase inhibitor (p16) and topoisomerase II-alpha (TOP2A) proteins expression among women seeking cervical cancer care at Kilimanjaro Christian Medical Centre, Tanzania between May 1, 2017 and May 10, 2018. Immunohistochemistry technique was used to detect the expressions of p16 and TOP2A proteins from the retrieved formalin-fixed and paraffin-embedded (FFPE) cervical biopsies. Results A total of 145 patients, with a mean age of 52.1 ± 12.9 years, were included in this study. Upon immunohistochemistry staining, 103 (71.0%) and 90 (62.1%) were p16 and TOP2A positive respectively. There was a strong association between histopathological class and p16/TOP2A expression levels (Fisher’s exact test, p<0.001). Moreover, there was a strong positive correlation between p16/TOP2A and cancerous cervical lesions (Spearman’s rank correlation coefficients = 0.833 and 0.687, p = 0.006 and 0.005, respectively). The age-adjusted odds ratio for predicting cervical cancer lesions were independently significant for p16/TOP2A biomarkers in FFPE cervical tissues [p16: OR = 1.142 (95% CI: 1.059–1.232, p<0.001) and TOP2A: OR = 1.046 (95% CI: 1.008–1.085, p = 0.015)]. Importantly, the diagnostic performance of p16 was higher than that of TOP2A in the diagnosis of cancerous lesions from non-cancerous cervical lesions (sensitivity: 97.2% versus 77.6%, accuracy: 92.8% versus 87.8%, respectively). Conclusion Our study has highlighted that over-expression of TOP2A is related to the grade of cervical intraepithelial neoplasia but does not predict prognosis in cervical cancer. Similarly, expression of p16 is related to degree of histological dysplasia and malignancy, suggesting its prognostic and predictive value in the management of cervical cancers. Further bigger studies are needed to validate their applications in the early diagnosis of cervical cancer.

Acceptability and feasibility of self‐sampling and follow‐up attendance after text message delivery of human papillomavirus results: A cross‐sectional study nested in a cohort in rural Tanzania

AbstractIntroductionThe objective was to determine if self‐collection of vaginal samples for human papillomavirus (HPV) testing was acceptable and feasible in rural Tanzania and to assess the extent of attendance at a follow‐up appointment among women who tested HPV‐positive after delivery of HPV results via text messages.Material and methodsA combined cross‐sectional and cohort study was conducted among women aged 25‐60 years from rural Kilimanjaro, Tanzania. Women were offered HPV self‐sampling or traditional visual inspection of the cervix with acetic acid. If HPV self‐sampling was preferred, participants received instructions on self‐collection with an Evalyn Brush. A questionnaire was used to assess the acceptability and feasibility of the self‐sampling procedure for the participants and delivery of HPV results via text messages. A mobile text message platform was used to send private text messages with the screening results to the participants.ResultsA total of 1108 women were enrolled and self‐collected an HPV sample; 11.8% tested positive for high‐risk HPV. The majority (98.9%) agreed that they had no trouble in understanding the instructions on how to perform the self‐collection and that they would recommend it to a friend (94.5%) or as a standard screening method in Tanzania (95.5%). A minority of women experienced bleeding (2.4%) or pain (6%) while collecting the sample, while some were worried that they would get hurt (12.7%) or felt embarrassed (3.5%). The majority (98.4%) of women would like to receive the screening test results via text messages. Eighty‐two per cent of those who tested positive for high‐risk HPV attended the follow‐up appointment after receiving a text message reminder and an additional 16% attended after receiving both a text message and a phone call reminder whereas 2% did not attend follow up at all. Attendance was not influenced by age, marital status, education level, parity, or HIV status.ConclusionsHuman papillomavirus self‐sampling and text‐message feedback delivery are generally well‐perceived and accepted among rural Tanzanian women, and the majority of HPV‐positive women attended a follow‐up appointment after receiving their HPV results and follow‐up appointment via text messages. This screening method may have potential to be transferrable to other low‐income countries with a high incidence of cervical cancer and so improve cervical cancer screening attendances.

Performance of HPV testing, Pap smear and VIA in women attending cervical cancer screening in Kilimanjaro region, Northern Tanzania: a cross-sectional study nested in a cohort

Objective There is a concern about performance of the screening approaches, where information on the quality of novel and affordable screening approaches that will perform well in remote areas is warranted. This lack of information makes it difficult to prioritise resource use in efforts to improve cervical cancer outcomes. We aimed to compare the diagnostic value of human papillomavirus (HPV) testing on self-collected samples, Pap smear and visual inspection of the cervix with acetic acid (VIA) tests for detection of high-grade cervical intraepithelial neoplasia or worse (CIN2+). Design A combined cross-sectional and cohort study. Setting Three primary healthcare centres in Kilimanjaro region, Tanzania. Participants 1620 women undergoing cervical cancer screening from December 2018 to September 2021. Inclusion criteria were being aged 25–60 years, and no history of premalignant or cervical cancer. Exclusion criteria were overt signs of cancer and previous hysterectomy. Interventions Participants underwent HPV self-sampling with Evalyn Brush and Care HPV kit assay was used to determine prevalence of high-risk HPV infection. Women with positive HPV test were together with a random sample of HPV negative women scheduled for follow-up where VIA was performed, and Pap smear and cervical biopsies obtained. Results Of 1620 women enrolled, 229 (14.1%) were HPV positive and 222 of these attended follow-up together with 290 (20.8%) women with negative HPV test. On VIA, 17.6% were positive. On Pap smear, 8.0% were classified as high-grade squamous intraepithelial lesion. The sensitivity and specificity, respectively, of the various tests, compared with histopathology for the detection of CIN2+ were: HPV test 62.5%, 59.3%; Pap smear 82.8%, 82.1% and; VIA 48.4%, 56.8%. When combined, the sensitivity and specificity for HPV and Pap smear were 90.6%, 70.6% while HPV and VIA were 65.6% and 75.5% for the detection of CIN2+. Conclusions The performance of care HPV testing on self-collected samples opens the possibility of increasing coverage and early detection in resource-constrained settings.

Initial evaluation of a new cervical screening strategy combining human papillomavirus genotyping and automated visual evaluation: the Human Papillomavirus–Automated Visual Evaluation Consortium

Abstract The HPV-Automated Visual Evaluation Consortium is validating a cervical screening strategy enabling accurate cervical screening in resource-limited settings. A rapid, low-cost human papillomavirus (HPV) assay permits sensitive HPV testing of self-collected vaginal specimens; HPV-negative women are reassured. Triage of positive participants combines HPV genotyping (4 groups in order of cancer risk) and visual inspection assisted by automated cervical visual evaluation that classifies cervical appearance as severe, indeterminate, or normal. Together, the combination predicts which women have precancer, permitting targeted management to those most needing treatment. We analyzed CIN3+ yield for each HPV-Automated Visual Evaluation risk level (HPV genotype crossed by automated cervical visual evaluation classification) from 9 clinical sites (Brazil, Cambodia, Dominican Republic, El Salvador, Eswatini, Honduras, Malawi, Nigeria, and Tanzania). Data from 1832 HPV-positive participants confirmed that HPV genotype and automated cervical visual evaluation classification strongly and independently predict risk of histologic CIN3+. The combination of these low-cost tests provided excellent risk stratification, warranting pre-implementation demonstration projects.