Nigerian Journal of Clinical Practice

HPV Vaccine Recommendation Among Pediatricians: A KAP Study of Knowledge and Beliefs in Clinical Practice

Background: Human papillomavirus (HPV) infection is a leading cause of anogenital warts and cervical cancer. Despite the proven effectiveness of the HPV vaccine in preventing HPV-related diseases, vaccine uptake remains suboptimal. Aim: This study aims to assess pediatricians’ knowledge, attitudes, and practices regarding HPV-related diseases and vaccination to identify factors influencing vaccine recommendations. Methods: A cross-sectional, questionnaire-based study was conducted with 198 pediatricians. The survey comprised questions related to demographic characteristics, knowledge of HPV-related diseases and vaccines, and attitudes of pediatricians toward HPV vaccination. Statistical analyses included the Chi-square test, one-way ANOVA, and logistic regression to identify predictors of vaccine recommendation. Results: Among the participants, 84.8% recommended the HPV vaccine, with 45% doing so consistently. Pediatricians who recommended the vaccine had significantly higher knowledge scores than those who did not ( P < 0.05). Key barriers to recommending the vaccine included insufficient knowledge (51.7%) and the absence of the HPV vaccine in the National Vaccination Schedule (34.5%). Logistic regression revealed that adequate knowledge of HPV-related diseases (β = 1.84, P = 0.021) and the belief in the necessity of the vaccine (β = 0.95, P < 0.001) were significant predictors of recommending HPV vaccination. Conclusion: Pediatricians with higher knowledge levels are more likely to recommend HPV vaccination. Enhancing pediatricians’ knowledge through targeted training and education programs may improve vaccine uptake, contributing to the prevention of HPV-related cancers.

Prognostic Impact of Pretreatment Thrombocytosis in Epithelial Ovarian Cancer

Aims: This study was aimed at investigating the prognostic impact of pretreatment thrombocytosis in epithelial ovarian cancer (EOC) patients in Lagos, Nigeria. Methods: This was a retrospective cohort study involving the review of the clinical record of 72 patients with histologically confirmed EOC who were managed at the Lagos University Teaching Hospital, Lagos, Nigeria over a 7-year period from January 2010 to December 2016. Information on the sociodemographic data and platelet counts at diagnosis of EOC were retrieved from the patients' medical records. Descriptive statistics were then computed for all baseline patients' characteristics. Survival analyses were carried out using the Kaplan-Meier estimates. Multivariate analysis of these data was performed with the Cox proportional hazards model. Results: This study revealed that the prevalence of pretreatment thrombocytosis was 41.7% among the women with EOC. Fifty-three (73.6%) of the women had the advanced-stage disease (FIGO stage III-IV) while 52 (72.2%) had high-grade disease (II-III). The majority (66.7%) of the women had a serous histological type of EOC while 76.4% had documented recurrence. Pretreatment thrombocytosis was significantly associated with the women's parity (P = 0.009), serum carbohydrate antigen 125 levels (P = 0.018), median progression-free survival (PFS) (P < 0.001), 3-year median overall survival (OS) (P < 0.001), type of primary treatment (P = 0.002), extent of cytoreduction (P < 0.001), presence of ascites (P = 0.002), International Federation of Gynecology and Obstetrics (FIGO) stage (P = 0.008), and histological type (P = 0.011). Pretreatment thrombocytosis was negatively associated with PFS (hazard ratio [HR] = 0.25; 95% CI 0.83, 0.75; P = 0.014) and 3-year OS (HR = 0.03; 95% CI 0.03, 0.27; P = 0.002). Conclusions: The study suggests that pretreatment thrombocytosis may be a useful predictor of survivals in EOC patients.

Cumulative Inflammatory Burden Causing Multiple Complications after a Successful Pelvic Surgery for Advanced Ovarian Cancer

Vesicovaginal and rectovaginal fistulas may develop after pelvic metastasis of ovarian carcinoma. Purulent discharge from the vagina results in frequent vaginal or urinary tract infections, and triggers chronic inflammation. These incapacitating symptoms create serious medical and psychosocial problems, and result in low self-esteem and QoL. In this study, we present a metastatic ovarian cancer case admitted with bilateral nephrostomies, nonfunctioning colostomy, and high-volume recto- and vesicovaginal fistulas after debulking. She had frequent urinary tract infections and systemic inflammatory response syndrome. Surgery was performed successfully. However, we had to deal with complications, such as electrolyte imbalance, wound infection and continuing SIRS. Cumulative inflammatory burden caused by advanced carcinoma itself and its complications creates serious medical and psychosocial problems and should be managed with patience.

Radiology of Endometrial Cancer Receiving Adjuvant Radiotherapy

Background and Aim: The treatment of endometrial cancer (EC) includes surgical procedures which clinicians follow with radiotherapy (RT) for patients who have specific risk factors, but there is insufficient research about how RT affects pelvic blood vessels and rectal tissues during the first period after treatment. The research used contrast-enhanced magnetic resonance imaging (CE-MRI) to study changes in pelvic blood vessel dimensions and rectal tissue parameters that occur during the initial stages of external beam radiotherapy (EBRT) treatment for EC. Methods: Ninety-five female patients who underwent postoperative adjuvant EBRT for EC were included in the study. CE-MRI examinations were performed before radiotherapy (RT0) and at the 3-month post-radiotherapy follow-up (RT1). Rectum internal diameter (RID), rectum external diameter (RED), right external iliac artery diameter (REIAD), left external iliac artery diameter (LEIAD), right femoral artery diameter (RFAD), and left femoral artery diameters (LFAD) were measured in centimeters. Paired comparisons between RT0 and RT1 measurements were performed. Results: When the RED, RFAD, LFAD, and LEIAD were compared with the measurements conducted RT0 and RT1, it was seen that they showed significant decreases at RT1 when compared to the initial measurements ( P < 0.05). The findings demonstrated no significant changes in RID and REIAD measurements. The findings indicate that EBRT treatment produces different reactions in early tissue responses of the body. Conclusion: In the measurements of the vessels and rectum diameters using CE-MRI before and 3 months after EBRT, it was observed that EBRT therapy resulted in detectable reductions of rectal wall measurements and particular blood vessels in the pelvic area. The initial signs of radiation tissue damage have been detected through these changes that need additional evaluation through extended patient monitoring and complete medical evaluation.

Is Pelvic-Paraaortic Lymphadenectomy Necessary in Endometrial Cancer? A Retrospective Analysis of Lymph Node Metastasis Predictors and Outcomes in 275 Patients

Background: The diagnosis of endometrial cancer is made by surgical staging. Lymph node dissection (LND) in early-stage endometrial cancer is a controversial issue. Detection of pelvic lymph node metastasis in surgical staging is clinically very important. Metastases are associated with a higher risk of recurrence and highlight the importance of postoperative adjuvant treatments. Aim: We aimed to investigate the relationship between pelvic lymph node involvement and endometrial cancer prognostic factors and the predictive value of pelvic lymph node metastasis. Methods: The relationship and predictive value of pelvic lymph node metastasis (PLNM) in 275 patients, who underwent hysterectomy, bilateral salpingo-oophorectomy and at least pelvic LND for endometrial cancer in our Gynaecological Oncology Clinic between 2008 and 2021 were investigated. Results: PLNM was present in 31 (11.2%) patients. In univariate analyses, adnexal involvement, perineural involvement, perinodal involvement, cervical stromal involvement, peritoneal and omentum metastasis, cytology positivity, disease stage, Cerb, and CEA positivity were found to be significant with PLNM. PLNM was statistically found to affect 5-year survival ( P < 0.01). PLNM was also interpreted as a predictive criterion for paraaortic lymph node metastasis (PALNM). The most significant predictors in multivariate analysis are LVSI, depth of myometrial invasion and PALNM (LVSI P < 0.01, depth of myometrial invasion P < 0.001, PALNM P < 0.001). Conclusion: In this retrospective study, multivariate analyses showed that LVSI and depth of myometrial invasion were independent risk factors for pelvic lymph node involvement. Pelvic lymph node positivity was also a predictive factor for paraaortic lymph node involvement. There is no consensus on the surgical staging of endometrial cancer. Surgical staging therefore serves to identify patients for whom treatment for extrauterine disease is indicated and to avoid overtreatment of the majority of patients with localised disease. Routine paraaortic lymphadenectomy may not be necessary in patients without pelvic LN metastasis.

Is Endometrial Sampler SAP-1 a Good Way to Diagnose the Common Intrauterine Occupying Lesions?—A Diagnostic Study

ABSTRACT Background: Intrauterine occupying lesion is clinically common in the female reproductive organs. Endometrial cancer is the most critical one among intrauterine occupying lesions, which accordingly is considered as the main indication for endometrial cancer screening, for which endometrial sampler SAP-1 was recommended as an effective sampling tool. Objective: This study aimed to evaluate the diagnostic efficacy of SAP-1 for endometrial polyp and uterine submucous myoma. Materials and Methods: From August 2018 to June 2022, patients who were hospitalized for undergoing hysteroscopy examination were enrolled in this study. Before the procedure, endometrial samples were collected by the method of SAP-1. The histological results were compared with those by hysteroscopy sampling to analyze the diagnostic efficacy of SAP-1. Results: The qualified rate for the SAP-1 sampling was 92.1%, which is a bit lower than that by method of hysteroscopy (95.3%). And the difference was not statistically significant (P > 0.05). Endometrial polyp (47.5%) and uterine submucous myoma (7.1%) accounted for the majority of endometrial lesions, while only 11.3% endometrial polyps (17/151) and 0% submucous myomas (0/23) were detected by SAP-1 sampling. Conclusion: Endometrial sampler SAP-1 is not effective in detection of solid intrauterine lesions indicated by the imaging examination. Hysteroscopy is recommended for definite diagnosis.

Systemic Inflammatory Response Index in Cervical Pathologies (Human Papillomavirus and Cervical Neoplasia) and its Prognostic Value in Disease Prediction

Background: Cervical pathologies, from chronic cervicitis to cervical cancer, are a global public health issue. Inflammation is crucial to these disorders’ development. The systemic inflammatory response may predict cancer and chronic inflammatory disease outcomes. Aim: This study aimed to determine the importance of systemic inflammatory response indicators in human papillomavirus (HPV) infection and cervical pathologies. Methods: In this retrospective analysis, pap smear, HPV, cervical biopsy, complete blood count (CBC) parameters, and systemic inflammatory response index (SIRI) of women who underwent gynecological examination were evaluated. Results: The study included 452 women. Mean platelet volume (MPV) was comparable in HPV other high-risk positive and negative women but lower in HPV Type-16/18 positive women (P < 0.001). Neutrophil/lymphocyte ratio, lymphocyte/monocyte ratio, eosinophil/lymphocyte ratio (ELR), platelet/lymphocyte ratio (PLR), systemic inflammatory index [SII (platelet × neutrophil/lymphocyte)], and SIRI (neutrophil × monocyte/lymphocyte) were also similar (P > 0.05). Low-grade intraepithelial lesion (LSIL) women have lower ages and pregnancies at pap smear (P < 0.05). The high-grade intraepithelial lesion (HSIL) group showed greater platelet (PLT) counts and decreased MPV than the other groups (P < 0.05). The LSIL group had considerably reduced eosinophil counts (P < 0.05). ELR was lower in the LSIL group (P = 0.004). PLR was the highest for HSIL and lowest for LSIL (P = 0.002). The SII was highest in the HSIL group and lowest in the LSIL group (P = 0.008). PLT and MPV were lower in the cervical biopsy-classified women than in the other cervical pathology and control groups (P = 0.03 and 0.001, respectively). Conclusion: We found a link between the mean PLT volume and HPV-related cervical disease.

Analysis of the Histopathological Characteristics and Expression of RIPK1 and NF- κB in Cervical Cancer in Kumasi, Ghana

Background: Cervical cancer is the second most common cancer in Kumasi, Ghana. The fact that survival rates are low, despite the advances made in clinical management necessitates exploration of alternatives to improve survival. Aim: This study reviews the histopathological and molecular characteristics of cervical cancer in relation to Receptor Interacting Protein Kinase 1 (RIPK1) and Nuclear Factor kappa B (NF-κB), which are involved in the regulation of inflammation, cell death and cell survival. Materials and Methods: The study reviewed 135 consecutive cases diagnosed from January 2015 to December 2016 in our centre. Clinicodemographic data were abstracted and suitable formalin fixed paraffin embedded (FFPE) tissue blocks were selected for tissue microarray construction and subsequent immunohistochemical assessment of RIPK1 and NF-κB expression. A statistical analysis of the data was done using SPSS version 26. Results: The mean age of the cases was 58.93 years with a standard deviation of 17.88. The histological type of most (96.3%) of the cases was the Squamous cell carcinoma (SCC). Majority (49.63%) of the cases were of histological grade 3, followed by grade 2 with 33.32% and grade 1 with 17.04% of cases. Both RIPK1 and NF-κB were highly expressed (56.6% and 69.3%, respectively) among the case. RIPK1 expression was significantly associated with NF-κB expression (P = 0.001). Conclusion: The significant co-expression of RIPK1 and NF-κB in the high-grade carcinomas suggest they are active in signalling pathways that supress apoptosis and enhance survival and/or proliferation.

Pregnancy Outcome Following Treatment of Premalignant Lesion of the Cervix in Southeast Nigeria; A Retrospective Case-Control Study

ABSTRACT Background: Treatment of cervical pre-cancers involves ablative and excisional therapies, and these have the potential to affect future pregnancy outcomes of women. Understanding the impact of the various treatment modalities on the outcome of pregnancies can motivate the development of interventions to improve pregnancy outcomes in women who had cervical pre-cancer treatment. Aim: We aimed to the effect of cervical pre-cancer treatment on second-trimester miscarriages and preterm births. Materials and Methods: Matched case-control study in which 373 women who had a pregnancy after cervical pre-cancer treatment were matched with 373 controls. McNemar Chi-square was used to compare the prevalence of second-trimester miscarriage and preterm birth between the study group and the matched controls. Conditional logistic regression analysis was done to determine the risk factors for second-trimester miscarriage and preterm birth. Results: Second-trimester miscarriages and preterm births were higher in women who had cervical pre-cancer treatment (AOR: 2.05, 95% CI: 1.174 – 3.693, p: 0.01) and (AOR: 2.74, 95% CI: 1.591 – 4.902, p: 0.0001) respectively. In addition, large loop excision of the transformation zone (LLETZ) of the cervix increased the odds of second-trimester miscarriage (AOR: 1.22, 95% CI: 1.034 – 1.441, p: 0.019) and preterm birth (AOR: 2.98, 95% CI: 1.793 – 3.965, p: 0.001). Cryotherapy and thermocoagulation were not associated with increased miscarriage and preterm birth. Treatment to pregnancy interval of ≥ 12 months decreased the odds of second-trimester miscarriage (AOR: 0.605, 95% CI: 0.502 – 0.808, p: 0.031) and preterm birth (AOR: 0.484, 95% CI: 0.317 – 0.738, p: 0.001). Conclusion: There is an increased odds of second-trimester miscarriage and preterm birth in women treated with LLETZ. A treatment-to-pregnancy interval of ≥ 12 months reduces this odd. Ablative therapies do not increase the odds of miscarriages and preterm births. This information could guide decisions on the choice of method of treatment for cervical pre-cancer in women of childbearing age.

Potential of AKNA as a Predictive Biomarker for Ovarian Cancer and Its Relationship to Tumor Grading

Background: Ovarian cancer exhibits a significant prevalence and incidence on a global scale. Low-grade or high-grade epithelial-type ovarian cancer can be classified by using the dualistic model. Inflammation has been associated with AKNA protein by cancer researchers. The potential of AKNA as a cancer biomarker is supported by its significance and association with ovarian carcinoma. Uninvestigated is this enormous potential. Aim: This study examines the correlation between AKNA expression in low-grade and high-grade ovarian tumors and its utility as a predictive biomarker for ovarian cancer. Methods: This study examined a total of thirty-one samples, which were classified into three groups: cyst, low-grade, and high-grade ovarian carcinoma. The departmental archive was accessed for the following information: age, tumor size, nuclear grade, mitosis, ovary volume, implant tumor status, lymph vascular invasion status, lymph node metastasis, and tumor-infiltrating lymphocyte. The expression of AKNA was determined using IHC staining. The information was collected and analyzed via analysis of variance. Results: The AKNA H-score shows the mean difference between all three groups (P < 0.001). Cysts had the highest AKNA expression, followed by low-grade and high-grade ovarian carcinoma. Conclusion: Higher-grade ovarian cancer expressed less AKNA compared to cysts or low-grade forms of the disease. This considerable difference suggests that AKNA might predict ovarian cancer tumor grade.

Survival Analysis and Death-Related Factor in Stage 4 Ovarian Cancer from the National Cancer Hospital in Indonesia

Background: The incidence and the mortality rate of ovarian cancer (OC) in Indonesia are higher than in the world, approximately 9.8% and 4.0%. As a cancer referral hospital, understanding the survival patterns and death-related factors is crucial for improving management. However, data on the survival is still lacking. Aim: To determine and analyze survival and death-related factors in stage IV OC patients. Materials and Methods: The data for this study were obtained from the cancer registry of Dharmais National Cancer Hospital from 2018 to 2022. This study included patients with suspected stage IV OC, diagnosed through histopathology and radiology. A retrospective cohort follow-up was conducted until June 2024. Bivariate and survival analyses were performed using SPSS version 30.0. Results: This study involved 100 subjects, and the results indicated that the histopathology sub type (P = 0.020), line of chemotherapy (P = 0.005), residual disease status (P = 0.001), and CA-125 levels (P = 0.009) had the significant impact on mortality. However, multivariate analysis revealed no independent mortality-related factors. Notably, the type of treatment emerged as the only variable that significantly influenced survival (P < 0.001). Conclusion: The histopathology sub type, line of chemotherapy, residual disease status, and CA-125 levels influenced the mortality in stage IV OC. Stage IV OC showed a significant association between treatment with overall survival (OS). Treatment with neoadjuvant chemotherapy (NACT) is highly recommended because it shows high survival rate and median OS results.

Knowledge about Cervical Cancer Prevention and Screening in Women with Cervical Cancer Attending Gynecological Services in Southern Mozambique

ABSTRACT Background: Mozambique has high rates of cervical cancer and cancer-related deaths among women. A high rate of refusal and low acceptance of treatment is observed among cervical cancer patients. The extent of their knowledge of the disease is unknown. Objectives: To assess knowledge about this disease (prevention, risk factors, and the possibilities of early diagnosis) in women with cervical cancer attended in gynecological services in Gaza province, Mozambique. Materials and Methods: This cross-sectional study took place in the city of Xai-Xai at the Provincial Hospital of Xai-Xai (HPXX) in the southern province of Gaza (Mozambique). Non-probability convenience sampling was used. Eligible patients (women) aged 35–50 years, diagnosed with cervical cancer and followed at the HPXX in the second quarter of 2021 (n = 60), took part in the survey during their scheduled consultations. Descriptive statistics were calculated using SPSS statistical software (version 16). Results: The study included 60 women, 39 (65%) HIV positive. More than half (55.0%) believed that having a single sexual partner was an effective form of prevention; 50.0% reported that excessive alcohol consumption and having many sexual partners could cause the disease, and 46.7% affirmed that having many children increased the risk. Thirty-eight (63.3%) women reported that early diagnosis of cervical cancer was important for receiving prompt treatment, and 54 (90.0%) said regular visits to the gynecologist were important for an early diagnosis. Thirty-five (58.3%) mentioned acetic acid screening as a diagnostic test. Conclusions: There are significant gaps in awareness of cervical cancer among high-risk groups.

Sessile Serrated Adenoma of the Appendix Coexists with Anaplastic Carcinoma Mural Nodules Originating from Ovarian Mucinous Tumors

Sessile serrated adenomas (SSA) of the appendix and anaplastic carcinoma mural nodules arising in the mucinous ovarian tumors (MOT) are rare lesions. We report a case of SSA in the appendix coexisting with an anaplastic carcinoma mural nodule in MOT. No BRAC1/BRAC2 germline mutations were found in the peripheral blood sample. The paraffin-embedded tissue from normal tissue (as a control), MOT, mural nodule, and SSA of the appendix were separately sequenced by next-generation sequencing (NGS). Based on the NGS results, stop-gain, chromosome DEL or TRA in mural nodules and SSA were detected, which were different from those in the mucinous tumors. In conclusion, we reported a case of SSA in the appendix coexisting with a mural nodule in MOT. We describe the morphological characteristics and molecular detection results in this case. There was no clear genetic evidence of a correlation between these two rare pathological types.

Piperlongumine increases the apoptotic effect of doxorubicin and paclitaxel in a cervical cancer cell line

Piperlongumine (PL) is an alkaloid derived from the edible pepper (Piper longum L) and it has been described to have various biologic activities including anticancer effects. Our aim in this study was to assess the cytotoxic role of PL on a cervical cancer cell line (HeLa) and to evaluate the effects of PL/doxorubicin and PL/paclitaxel combination therapies on apoptotic cancer cell death. The cytotoxicity, IC50 doses by MTT assay confirmed by fluorescent imaging, and apoptotic cell rates by Annexin V staining using flow cytometry were determined for PL, doxorubicin, paclitaxel, and for their combinations. It was shown that the PL by itself induced the apoptosis in HeLa cells. PL in combination with doxorubicin and paclitaxel increased apoptotic cell death compared to either chemotherapeutic agent alone. We conclude that the PL inhibits cancer cell growth by inducing apoptosis and has a potential anticancer activity in cervical cancer, especially when combined with doxorubicin and paclitaxel.

Role of acoustic radiation force-based elasticity imaging in endometrium pathologies

Ultrasonography is difficult to distinguish between endometrial pathologies and often requires curettage. ARFI (Acoustic Radiation Force-Based Elasticity Imaging) is a new ultrasonography elastography method. Using ARFI, it is possible to obtain information about the likelihood of the tissue benign or malignant. The aim of this study is to evaluate the contribution of ARFI to differentiate endometrial pathologies in hysterectomy specimens. Our study was prospectively, January-May 2017, performed in randomly 45 cases of 41-91 years of age (mean 58.3 years) who have decided to have hysterectomy. Hysterectomy was performed for uterine prolapse and endometrial hyperplasia in elderly patients and menorrhagia in young patients. Pathology results were compared with ARFI values and endometrial thickness. ANNOVA test was used for the comparison of ARFI values. Pathology revealed 14 cases of endometrial atrophy, 11 cases of proliferative phase, 10 cases of polyp, 6 cases of endometrial hyperplasia, and 4 cases of endometrium cancer. There is a statistically significant difference between mean ARFI values of endometrium, subendometrium, and myometrium of the groups (P < 0.05). There was a statistically significant difference between the mean endometrial thickness of the groups (P < 0.05). Endometrium ARFI contributes to the differential diagnosis of endometrial pathologies. Subendometrial and myometrial ARFI values decrease in polyps and increase in hyperplasia. Our study shows that the addition of subendometrium ARFI to gray-scale sonography before deciding on invasive procedures in endometrial pathologies may improve diagnostic accuracy. We concluded that further in vivo studies will establish the usefulness of this technique for preoperative diagnostic measures.