Sultan Qaboos University Medical Journal

Primary Vaginal Epithelioid Haemangioendothelioma with Pulmonary Metastasis: <i>A case report and review of the literature</i>

Epithelioid haemangioendothelioma (EHE) is a rare vascular sarcoma of intermediate malignancy. In 2023, a 31-year-old female presented to a tertiary care hospital in Muscat, Oman, with symptoms later diagnosed as primary vaginal EHE. The patient had primary, locally invasive vaginal EHE that subsequently metastasised to the lungs. The patient experienced progression of systemic disease despite chemotherapy and was therefore transitioned to palliative chemotherapy. The clinical, radiological and histopathological findings as well as the diagnostic features that distinguish EHE from its aggressive mimic, epithelioid angiosarcoma, are described in this report. This case highlights the diagnostic challenges, the importance of molecular confirmation and the unpredictable clinical course of this ultra-rare malignancy. To the best of the authors' knowledge, this is the first reported case of primary vaginal EHE.

Cervical Deciduosis in Early Pregnancy Mimicking Malignancy: <i>A report of two cases</i>

Deciduosis is a benign condition characterised by the transformation of subepithelial connective tissue into decidual-like cells, typically occurring in response to hormonal changes during pregnancy. Although benign, cervical deciduosis may macroscopically resemble malignant lesions, leading to diagnostic uncertainty. This report presents two cases of cervical deciduosis diagnosed in early pregnancy. Both patients presented with first-trimester vaginal bleeding, and speculum examination revealed extensive wart-like lesions covering the cervix. Histopathological examination of cervical biopsies confirmed decidual changes. In pregnant women presenting with threatened miscarriage, a thorough local examination and biopsy of atypical cervical lesions are essential to exclude malignancy. As cervical deciduosis is a benign and self-limiting condition, no further treatment is usually required.

Interpreting a Diagnosis of Atypical Squamous Cells of Undetermined Significance in Cervical Cytology and its Association with Human Papillomavirus

Atypical squamous cells of undetermined significance (ASC-US) represent a diagnostic challenge during cervical cytology. This study aimed to review and identify high-risk human papillomavirus (HR-HPV) genotypes among previously diagnosed ASC-US cases in Kuwait. This retrospective study analysed 180 cases diagnosed as ASC-US between June 2017 and May 2018 at the Mubarak Al-Kabeer Hospital, Kuwait. Cervical specimens were assayed to determine the presence of HR-HPV DNA; subsequently, positive cases underwent genotyping and were categorised into three groups (HPV 16, HPV 18/45 and other HR-HPV types). In total, ASC-US was confirmed in only 105 cases (58.3%), with the remaining cases reclassified as negative for intraepithelial lesions or malignancy (NILM; 32.2%) and epithelial cell abnormalities (ECA; 9.4%). Of these, HR-HPV DNA was present in 20 ASC-US (19%), one NILM (1.7%) and six ECA (35.3%) cases. There were 62 Kuwaiti and 43 non-Kuwaiti women with confirmed ASC-US; of these, three (4.8%), six (9.7%) and four (6.5%) Kuwaitis and one (2.3%), one (2.3%) and five (11.6%) non-Kuwaitis had HPV 16, both HPV 16 and 18/45 and other HR-HPV genotypes, respectively. Of those with HR-HPV DNA, the NILM case had the HPV 18/45 genotype, while the six ECA cases had the HPV 16 (n = 1), both HPV 16 and 18/45 (n = 1) and other HR-HPV (n = 4) genotypes. Overall, HR-HPV DNA was present in 19% of ASC-US cases compared to 1.7% of NILM cases initially misdiagnosed as ASC-US. Re-review of cervical cytology diagnoses may reduce unnecessary costs associated with HR-HPV genotyping.

Knowledge of Risk Factors, Symptoms and Barriers to Seeking Medical Help for Cervical Cancer among Omani Women Attending Sultan Qaboos University Hospital

This study aimed to assess knowledge and attitudes among Omani woman regarding cervical cancer risk factors and symptoms as well as barriers to them seeking medical help. This cross-sectional study was conducted between December 2017 and March 2018 at the Sultan Qaboos University Hospital (SQUH) in Muscat, Oman. A validated Arabic-language version of the Cervical Cancer Awareness Measure questionnaire was used to collect data from 550 Omani women visiting SQUH during the study period. A total of 490 women participated (response rate: 89.1%) in this study. Overall, the women demonstrated low levels of knowledge of cervical cancer risk factors and symptoms (28.5% and 45.0%, respectively). The most frequently recognised risk factor was having many children (36.1%), while the most recognised symptom was unexplained vaginal bleeding (69.8%). Women reported that being too scared was the greatest barrier to seeking medical help (68.0%). Various factors were significantly associated with greater knowledge of cervical cancer signs and symptoms including education level (odds ratio [OR] = 2.85; 95% confidence interval [CI]: 1.0-8.22; Overall, Omani women demonstrated poor knowledge with regards to cervical cancer; in addition, they identified several emotional barriers to seeking medical help. Healthcare practitioners should reassure female patients to encourage care-seeking behaviour. A national screening programme is also recommended to increase awareness and early diagnosis of cervical cancer in Oman.

Prevalence of Cytological Abnormalities in Papanicolaou Smears and Risk Factors for Cervical Cancer Among Women in Muscat, Oman

This study aimed to estimate the prevalence of cytological abnormalities in Papanicolaou (Pap) smears and related risk factors among Omani women. A cross-sectional study was conducted from March to September 2019 at the gynaecology and family medicine clinics of Khoula Hospital and Sultan Qaboos University Hospital in Muscat. All asymptomatic Omani women aged between 21 and 65 years were included. Data regarding the participants' sociodemographic characteristics and known risk factors were collected using a self-reported sheet. Pap smears were performed and the results were reported by a cytotechnologist and histopathologist. A total of 442 women participated in the study (response rate: 100%). The mean age was 39.0 ± 9.7 years old. The prevalence of cervical cytological abnormalities was 3.7%. There was a significant association between human papillomavirus (HPV) infection and cervical cell abnormalities ( The prevalence of cervical cell abnormalities in Oman was similar to that observed in Arab countries and relatively low in comparison to findings from Western countries. A screening program should be implemented at the primary care level. The findings of this study also highlighted the need for a future vaccination program against HPV infections.

Correlation between Vascularity and Advancing Histological Grades of Oral Submucous Fibrosis with a Plausible Role in Malignisation

Endometrial cancer (EC) is the most common gynaecological cancer. The combination of lenvatinib and pembrolizumab has exhibited efficacy as the second line treatment for advanced EC, with a significant benefit in terms of progression free survival (PFS) and overall survival, but the adverse events (AE) profile is complex. AEs associated with the treatment may represent a limitation to this combination. Here, we report the case of a 38-year-old female patient diagnosed with stage IV EC elsewhere, whose disease progressed after the first line of treatment and was referred to a specialised cacncer centre in Muscat, Oman, in 2021. We treated her with the combination of lenvatinib and pembrolizumab. During the course of the treatment, she developed hand-foot syndrome grade III and hypothyroidism grade II. The AEs were managed with supportive medications, dose interruptions, dose reductions and multidisciplinary care, which allowed the continuation of the treatment. The patient achieved a good partial response and an ongoing PFS of more than 12 months.

Tension Subdural Hygroma Following Resection of Posterior Fossa Tumour in a Child

This study aimed to report the demographic features, clinical presentation, pathological types and long-term outcomes of patients diagnosed with endometrial cancer (EC) in Oman. EC is the sixth most common cancer in women worldwide and the fifth most common cancer in women in Oman. Survival outcomes of EC have not been reported previously from Oman. This retrospective study was carried out on consecutive patients treated at the Sultan Qaboos University Hospital, Muscat, Oman, between 2008 and 2020. Survival was estimated using the Kaplan and Meier method. A total of 50 patients with EC were included. The median age was 61 years (range: 31-86 years), and 72% of the patients had type I histology. Most patients were diagnosed with stage IA and IB EC (49% and 20%, respectively), and the majority had grade 1 or 2 tumours (40% and 34%, respectively). Overall, the 5-year survival and 10-year survival rates were estimated to be 70% and 56%, respectively. Weight (>75 kg) and body mass index (>30 kg/m Median age at presentation, histological sub-type, clinical stage and outcomes are comparable to the published literature. Almost two-thirds of the patients were obese. These data could be used as a benchmark for outcomes of EC in the region.

Expression of Dkk 1 in Endometrial Endometrioid Carcinoma & Its Correlation with Wnt / β-catenin Signaling Pathway

Endometrial cancer is the most prevalent form of cancer affecting female reproductive organs. The most common histologic type, endometrioid carcinoma, accounts for 75-80% of all endometrial cancer cases. Studies on DKK1 expression profiles and their inhibitory role in the Wnt signalling pathway in the genesis and development of endometrial carcinoma are scarce. This study aimed to investigate DKK1 expression in endometrial carcinoma and its correlation with the Wnt/β-catenin pathway. A total of 160 formalin-fixed paraffin-embedded samples were included in this study (50 cases of endometrial atypical hyperplasia, 50 cases of endometrioid endometrial carcinoma, 30 cases of proliferative endometrium and 30 cases of secretory endometrium). The expression patterns of DKK1, E-cadherin, β-catenin and c-Myc in endometrial atypical hyperplasia and carcinoma were investigated and compared with that of proliferative and secretory endometrium. Immunohistochemistry and analysis were performed from July 2018 to June 2020. A decreasing pattern of immunopositivity for DKK1, E-cadherin and β-catenin from proliferative/secretory endometrium to endometrial atypical hyperplasia and endometrioid carcinoma was found. Increasing c-Myc immunopositivity was noted from proliferative/secretory endometrium to endometrial atypical hyperplasia and endometrioid carcinoma. Moreover, decreasing DKK1 immunopositivity was well correlated with E-cadherin, β-catenin and c-Myc immunopositivity. Decreasing DKK1 positivity from benign endometrium to endometrioid carcinoma suggests a negative regulatory function of DKK1 in endometrioid carcinoma. DKK1 is downregulated in the Wnt signalling pathway in endometrioid endometrial carcinoma. Therefore, DKK1 is promising as a biomarker for screening endometrioid carcinoma. Future studies should examine the reactivation of the DKK1 gene, which may be a valuable strategy for antagonising the Wnt signalling pathway.

Hymenialdisine is Cytotoxic Against Cisplatin-Sensitive but not Against Cisplatin-Resistant Cell Lines

New compounds are needed to overcome the resistance to commonly used cytotoxic chemotherapy for epithelial ovarian cancer. Marine sponges are a rich source of diverse chemical compounds and hymenialdisine has been found to have antiproliferative effects. This study aimed to investigate the cytotoxic effect of hymenialdisine in cisplatin-sensitive and cisplatin resistant ovarian cancer cell lines. This study took place at Sultan Qaboos University, Muscat, Oman between August and November, 2019. The anti-cancer effects of hymenialdisine or cisplatin were assessed using treating cells with different concentrations of hymenialdisine and cisplatin. Cell viability was determined using the AlamarBlue The half-maximal inhibitory concentration (IC50) of cisplatin was estimated at 31.4 μM for A2780S and 76.9 μM for A2780CP, whereas the IC50 of hymenialdisine was evaluated at 146.8 μM for A2780S cells. Despite the higher concentrations of hymenialdisine (up to 300 μM), IC50 could not be determined for the A2780CP cell line. When compared to cisplatin, hymenialdisine was less toxic against both A2780S and A2780CP ovarian cancer cell lines.

Extrarenal Wilms' Tumour of the Ovary

Wilms' tumour (nephroblastoma) is the most common abdominal malignancy in children. Extrarenal Wilms' tumour is rare, with limited reports in the literature. We report a two-year-old girl who presented to a tertiary care hospital in Muscat, Oman, in 2019 with an abdominal mass. The patient was diagnosed with unilateral ovarian Wilms' tumour (initially diagnosed by closed biopsy and confirmed later by histopathology study of the excised tumour). This report highlights the unusual location and presentation of Wilms' tumour and presents the medical challenge in both the initial clinical impression and pathological diagnosis. Furthermore, this report details the therapeutic plan and shows the good outcome achieved by using the classic renal Wilms' tumour therapy protocols.

Women’s Knowledge of Cervical Cancer

This study aimed to assess knowledge of cervical cancer and its prevention among Omani women aged 20-65 years. This cross-sectional study took place across eight primary healthcare institutions in Al Buraimi Governorate, Oman, between November 2018 and February 2019. It was carried out on the basis of a predesigned, validated and self-administered questionnaire containing 55 questions. Data from 791 completed questionnaires were included in the final analysis, which represents a response rate of 79.1%. The results indicated that 86.7% of surveyed women had previously heard of cervical cancer and 13.0% expected this disease to affect them in the future. The results also showed that women were less aware of the association between the human papillomavirus (HPV) and cervical cancer (24.7%). The participants considered the HPV infection and initiation of sexual intercourse below 17 years of age as the lowest risks associated with cervical cancer. Moreover, 63.8% of the participants were unaware of the availability of a vaccination 'against HPV-related cervical cancer' and many respondents were unaware of a Pap test. Those women aged over 30 years, married and with a high level of education were more likely to be aware of cervical cancer. Generally, there was inadequate knowledge and awareness of cervical cancer among women aged 20-65 years. Young women aged 20-30 years showed relatively lesser knowledge of cervical cancer as compared to their older counterparts. Thus, concerted efforts are needed to promote such awareness among women in Oman.

Knowledge and Attitude Regarding Cervical Cancer and Human Papillomavirus in Oman

This study aimed to assess the knowledge of and attitude toward cervical cancer and human papillomavirus (HPV) among Omani women aged 18 years and older. This cross-sectional survey was conducted between September 2019 and February 2020 in primary healthcare facilities throughout Oman. A self-administered questionnaire was distributed to assess women's knowledge and attitude regarding cervical cancer and HPV. A total of 805 women participated in the study (response rate: 89%). Two-thirds of the participants had heard about cervical cancer (67.5%) while fewer were aware of HPV (15.8%). Approximately one-third of the women identified HPV as a risk factor for developing cervical cancer (38.9%). Very few participants knew of HPV vaccines (10.1%). A major source of information regarding both cervical cancer and HPV was social media (33.0%), as compared to healthcare providers (16.9%). Despite the poor knowledge, almost half of the participants were open to having their daughters (47.0%) and other schoolgirls (41.2%) vaccinated. Most participants had poor knowledge of cervical cancer and HPV, even those with a personal or family history of cervical cancer. The main source of knowledge was social media. Most participants were open to the idea of offering the HPV vaccine to their daughters and middle school-aged girls. Incorporating information about cervical cancer and HPV into school curricula and improving access to trusted medical knowledge through social media may help in enriching the public's knowledge and, possibly, correcting misinformation and related myths.

Breast and Ovarian Cancers’ Incidence Trends Among Iraqi Women During 2012–2022 and Their Relationship to Fertility Patterns

This study aimed to estimate the incidence trends of female breast cancer (BC) and ovarian cancer (OC) among women in Iraq and their relation to fertility patterns. This retrospective study utilised the Iraqi Cancer Registry annual reports for the years 2012-2022 and the World Bank data for Iraqi crude birth rate and total fertility data for the years 1992-2002. Simple linear regression analysis examined the relationship between these variables and incidence rates of BC and OC. A total of 63,446 women were newly diagnosed with BC from 2012-2022. The overall age standardised incidence rate (ASIR) of BC was 46.68/100,000 females. It increased significantly from 36.61/100,000 in 2012 to 61.89/100,000 in 2022 with an average annual percentage change (AAPC) of 4.83% (95% confidence interval [CI]: 2.69-7.08; Iraqi women are experiencing a rising incidence of breast and ovarian cancers over time. Lower fertility rates may partly play a role in this trend. Research and initiatives are necessary to identify and control the factors that are increasing this risk.

A Rare Case of Lung Hypoplasia, Cardiac Anomalies and Ovarian Tumour in a Patient with Mayer-Rokitansky-Küster-Hauser Syndrome

Hypoplasia of the lung is an uncommon congenital abnormality of the respiratory system in contrast to pulmonary agenesis. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is the congenital absence of the upper two-thirds of the vagina and uterus with normal secondary sexual characteristics, ovary and normal karyotype. We report a 31-year-old female patient who presented in 2022 with cough with expectoration, left-side chest pain and breathlessness for 4 years to tertiary hospital, Puducherry, India. She was evaluated for amenorrhoea and diagnosed as MRKH syndrome and the patient underwent right-side oophorectomy for right ovarian torsion with a tumour. Computed tomography pulmonary angiogram and fiberoptic endoscopy were suggestive of left lung hypoplasia and the patient was advised symptomatic treatment for lung hypoplasia and planned for vaginoplasty for which she refused.

Rare Presentation of Parasitic Leiomyomata in the Fallopian Tube and Ovarian Ligament: <i>Clinical, histopathologic, and imaging insights</i>

Fallopian tube leiomyomas are exceptionally rare parasitic tumours, usually identified incidentally during laparoscopic or open surgery. This report describes a 30-year-old woman who presented in 2025 to Al Emadi Hospital in Doha, Qatar with chronic pelvic pain and acute exacerbations. The diagnosis of fallopian tube leiomyoma was made through preoperative clinical and imaging findings, intraoperative observations, and histopathological analysis. In addition, this case includes the first documented instance of a parasitic leiomyoma of the ovarian ligament, lending support to the theory of metaplasia in its pathogenesis. Parasitic leiomyomas should be considered whenever a leiomyoma is detected outside the myometrium on imaging studies. The rare occurrence of fallopian tube leiomyomas warrants inclusion in the differential diagnosis of acute exacerbations of chronic pelvic pain in patients presenting with solid adnexal masses, particularly when such masses are palpable vaginally or visualised as distinct from the uterus. The absence of epidemiological data on parasitic leiomyomas of the fallopian tube and ovarian ligament underscores the need for further case reports and series to raise physician awareness of these extremely rare lesions.