The landscape of somatic mutations in Indonesian cervical cancer is predominated by the PI3K pathway.

OBJECTIVE: To investigate the prevalence of somatic mutations in Indonesian cervical carcinoma patients in the context of histology and human papillomavirus (HPV) type. METHODS: In total 174 somatic hot-spot mutations in 13 genes were analyzed by mass spectrometry in 137 Indonesian cervical carcinomas. RESULTS: In 66/137 tumors (48%) 95 mutations were identified. PIK3CA was most frequently mutated (24%), followed by FBXW7 (7%), CTNNB1 (6%), and PTEN (6%). In squamous cell carcinomas more often multiple mutations per sample (p=0.040), and more PIK3CA (p=0.039) and CTNNB1 (p=0.038) mutations were detected compared to adenocarcinomas. PIK3CA mutations were associated with HPV 16 positivity, CDKN2A mutations with HPV 52 positivity, and, interestingly, PTEN mutations with HPV negativity. Balinese tumor samples more often carried multiple mutations (p=0.019), and more CTNNB1, CDKN2A, and NRAS mutations compared to Javanese tumor samples. CONCLUSIONS: Potentially targetable somatic mutations occurred in 48% of Indonesian cervical carcinomas. The landscape of mutations is predominated by mutations concerning the PI3K pathway, and we prompt for more research on developing therapies targeting this pathway, explicitly for the more advanced stage cervical carcinoma patients.

Differences in genetic variation in antigen-processing machinery components and association with cervical carcinoma risk in two Indonesian populations.

Genetic variation of antigen-processing machinery (APM) components has been shown to be associated with cervical carcinoma risk and outcome in a genetically homogeneous Dutch population. However, the role of APM component single nucleotide polymorphisms (SNPs) in genetically heterogeneous populations with different distributions of human papillomavirus (HPV) subtypes remains unclear. Eleven non-synonymous, coding SNPs in the TAP1, TAP2, LMP2, LMP7 and ERAP1 genes were genotyped in cervical carcinoma patients and healthy controls from two distinct Indonesian populations (Balinese and Javanese). Individual genotype and allele distributions were investigated using single-marker analysis, and combined SNP effects were assessed by haplotype construction and haplotype interaction analysis. Allele distribution patterns in Bali and Java differed in relation to cervical carcinoma risk, with four ERAP1 SNPs and one TAP2 SNP in the Javanese population showing significant association with cervical carcinoma risk, while in the Balinese population, only one TAP2 SNP showed this association. Multimarker analysis demonstrated that in the Javanese patients, one specific haplotype, consisting of the ERAP1-575 locus on chromosome 5 and the TAP2-379 and TAP2-651 loci on chromosome 6, was significantly associated with cervical carcinoma risk (global P = 0.008); no significant haplotype associations were found in the Balinese population. These data indicate not only that genetic variation in APM component genes is associated with cervical carcinoma risk in Indonesia but also that the patterns of association differ depending on background genetic composition and possibly on differences in HPV type distribution.

Efficacy, safety, and patient-reported outcome of immune checkpoint inhibitor in gynecologic cancers: A systematic review and meta-analysis of randomized controlled trials.

Over the past decades, immune checkpoint inhibitors (ICIs) have shown dramatic efficacy in improving survival rates in multiple malignancies. Recently, gynecological cancer patients also showed to respond favorably to ICI treatment. This study aimed to evaluate the efficacy, safety, and patient-reported outcomes of ICI therapy in gynecological cancers. We conducted a systematic review and meta-analysis by retrieving literature from multiple electronic databases, such as MEDLINE, ScienceDirect, EBSCO, ProQuest, and Google Scholar. The protocol used in this study has been registered in PROSPERO (CRD42022369529). We included a total of 12 trials involving 8 therapies and 8,034 patients. ICI group demonstrated a longer OS (HR: 0.807; 95% CI: 0.719, 0.907; p = 0.000) and greater PFS improvement (HR: 0.809; 95% CI: 0.673, 0.973; p = 0.024) compared to the control group. There was no significant difference in the incidence of treatment-related adverse events [RR: 0.968; 95%CI: 0.936, 1.001; p = 0.061], but a higher incidence of immune-related adverse events (IRAEs) was observed in the ICI group (RR: 3.093; 95%CI: 1.933, 4.798; p = 0.000). Although the mean changes of QOL score from baseline was not significantly different between both groups (SMD: 0.048; 95% CI: -0.106, 0.202; p = 0.542), the time to definitive QOL deterioration was longer in the ICI group (HR: 0.508; 95% CI: 0.461, 0.560; p = 0.000). Despite having a higher incidence of IRAE, ICI was shown to improve survival rates and QOL of patients. Thus, it should be considered as a new standard of care for gynecologic cancers, especially in advanced stages.

Cancer Stem Cells (CD44+/CD24-), RAD6, DDB2 Immunohistochemistry Expression and IHC-UNEDO Scoring System As Predictor of Ovarian Cancer Chemoresistance.

Backgrounds: Ovarian cancer is a deadly women cancer with many chemoresistance after standard treatment. Ovarian cancer tissues' CD44+/CD24- (CSCs), RAD6 overexpression and DDB2 underexpression are associated with chemoresistance, recurrence, and poor prognosis of the disease because of the existence of cancer stem cells (CSCs). We tried to analyze the expression of those three proteins while building a predictor scoring system to predict the ovarian cancer chemoresistance from the ovarian cancer tissue immunohistochemistry. Materials and Methods: We conducted a cohort study of 64 patients divided into two groups (32 patients in each group) at the Cipto Mangunkusumo, Tarakan, Dharmais, and Fatmawati Hospital which are located in Jakarta city, Indonesia. The patients underwent cytoreductive debulking and histopathological examination continued by six series of chemotherapy followed by six months of observation. We divided the groups into chemoresistant and chemosensitive by using Response Criteria in Solid Tumors (RECIST) criteria. Ovarian cancer tissue immunohistochemistry tests were then performed to count the CSCs, RAD6 and DDB2 expressions. Results: We found relationship between increased CSCs, RAD6 and reduced DDB2 (p < 0.05) expression in ovarian cancer tissue with the chemoresistance. A possible predictor scoring system named IHC-UNEDO scoring was built to aid the ovarian cancer chemoresistance prediction. Conclusions: The conclusion is that CSCs, RAD6 and DDB2 expressions are significantly associated with ovarian cancer chemoresistance, and IHC-UNEDO scoring should be considered as a tool to predict ovarian cancer chemoresistance.

Surveillance of Indonesian female sexual function after hysterectomy.

BACKGROUND: Sexual function is one component of quality of life that could be fulfilled by humans. Hysterectomy, which is an operative procedure in women, may cause disturbance in sexual function. AIM: This study aims to determine the surveillance of sexual function after hysterectomy. METHODS: This is a cross-sectional study involving 92 gynecological tumor patients who had undergone a hysterectomy by open laparotomy procedure for at least 3 months. Evaluation of sexual dysfunction using the female sexual function index (FSFI-6) questionnaire, which assesses sexual function in the form of sexual disorder, sexual dysfunction, desire disorders, stimulation, orgasm disorders, and pain. The study was conducted in September-November 2018 in Dr. Cipto Mangunkusumo Hospital, Jakarta. The patients were divided into total and radical hysterectomy groups and whether castration was performed. RESULTS: The total group had 71 total hysterectomy and 21 radical hysterectomy patients. Sexual dysfunction (radical hysterectomy 47.6%, n = 10/21; total hysterectomy 28.2%, n = 20/71; castration 33.8%, n = 24/71; and without castration 28.6%, n = 6/21); orgasmic disorders (total hysterectomy 28.2%, n = 20/71; radical hysterectomy 47.6%, n = 10/21; castration 33.8%, n = 24/71; without castration 28.6%, n = 6/21); and pain disorder (radical hysterectomy 28.6%, n = 6/21; compared with 9.9%, n = 7/71 total hysterectomy). CONCLUSION: No significant differences were found between sexual function after radical hysterectomy and total hysterectomy, as well as between the castration groups. Based on these findings, sexual function is an important reference for health professionals to be considered in conducting counseling before and after surgery.

Histopathological and biomarker complete response after neoadjuvant chemotherapy of advanced stage yolk sac tumor of the ovary: A case report and literature review.

INTRODUCTION: Yolk sac tumor is the second most common germ cell ovarian carcinoma. Neoadjuvant chemotherapy (NACT) is proposed as an alternative option for patients with advanced disease who are not eligible for primary debulking. We presented a case with a systematic review of advanced yolk sac tumors of the ovary with poor performance who gain benefit from NACT. CASE PRESENTATION: A 24-year-old female underwent NACT followed by surgery after being diagnosed with an advanced yolk sac tumor. A literature search was done based on the clinical question using the Patient/Problem, Intervention, Comparison, and Outcome (PICO) approach. Pubmed and Google Scholar were used to search the literature. DISCUSSION: Out of 111 manuscripts found, 2 articles were retrieved for detailed evaluation. The patient showed a complete response in tumor size, histopathology, and tumor markers after the NACT procedure followed by surgery. CONCLUSIONS: NACT is a suitable option for advanced yolk sac tumors of the ovary.

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

BACKGROUND: ALDH1 is a cervical cancer stem cell marker that has radioresistance profile. Recurrence and metastasis following radiotherapy are still being problems of most patients. This study aimed to determine the correlation between ALDH1 and radiotherapy response in stage III squamous cell cervical carcinoma (SCCC) of the cervix. METHODS: A total 58 of 360 patients of stage III SCCC who received external beem radiation and brachytherapy (2016-2021) at Cipto Mangunkusumo Hospital met the eligibility criteria of this study. Pre- and post-irradiation MRI examinations and ALDH expression with immunohistochemistry (Santa Cruz®) were performed on formalin-fixed paraffin-embedded of pre-treatment cervical tissue biopsy taken from RSCM pathological anatomy laboratory. Patients were divided into two groups, complete responders vs non-complete responders. ALDH-1 scores were compared between two groups to assess ALDH-1 expression. The statistical analyses were carried out by SPSS 24. RESULTS: The optimal ALDH-1 score cut-off point on the radiation response was 166.05 pg/mL which was obtained from the analysis of the ROC curve. The AUC value was 0.682 with sensitivity and specificity, 63,6% and 64%, respectively. ALDH score ≥166.05 increased the risk by 3.127 times for not achieving complete response (adj OR 3.127, 95% CI 1.034 - 9.456, p = 0.043). Pre-radiation tumor size (p = 0.593), degree of differentiation (p = 0.161), renal abnormalities (p = 0.114), and keratinization (p = 0.477) were not associated with radiation response. CONCLUSIONS: High ALDH expression was associated with non-complete radiation response in stage III squamous cell cervical carcinoma. 
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Cytomorphological analysis of uterine cervical pap smears in relation to human papillomavirus infection in Indonesian women.

OBJECTIVE: Cervical cancer is the number one cause of cancer-associated death in Indonesian women (30/100,000 annually), where no screening program is present. The Papanicolaou test is widely accepted as an effective screening method for cervical neoplasia detection and often shows certain cytological features associated with human papillomavirus (HPV) infection. Especially in developing countries, cytological investigation is still the method of choice as compared to the frequent use of HPV DNA testing in western countries. STUDY DESIGN: In the present study, we investigated the validity of the use of cytomorphological changes as a marker for HPV infection. A total of 140 smears collected in three different areas in Indonesia (Jakarta, Tasikmalaya and Bali) were analyzed. HPV DNA testing was performed using INNO-LiPA assays. RESULTS AND CONCLUSIONS: We found a highly significant association of classical koilocytosis, multinucleated cells, dyskeratosis-parakeratosis, nuclear membrane, enlarged nuclei, moderate/strong hyperchromasia and chromatin pattern with HPV positivity. Using classical and nonclassical cytomorphological parameters we found an overall sensitivity of 42% and a specificity of 90%. The combination of classical and nonclassical parameters led to a higher sensitivity of HPV positivity prediction. These results are of importance for cytologists in developing countries as molecular HPV testing still poses a major financial, logistic and expertise problem.

Complications of ovarian cancer surgery in Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta: A cross-sectional study.

Background: Ovarian cancer remains as one of the deadliest gynecologic problems globally. Often appears in advanced state, its surgery proves to be a challenge for clinicians. This study aim to present complications surrounding ovarian cancer surgery. Materials and methods: This study was a cross-sectional study to analyze reports of intraoperative and postoperative complications in ovarian cancer patients undergoing laparotomy in Dr. Cipto Mangunkusumo National General Hospital, Jakarta from January 2018 to December 2019. Ovarian cancer patients undergoing laparotomy surgery were included in the study. Patients with a history of other cancers or having incomplete data were excluded from the study. Intraoperative complications included intestinal, ureter, bladder injury, and postoperative complications included paralytic ileus, surgical wound infection and sepsis were documented. Results: A total of 78 subjects were included in the study. The total proportion of complications was 19.2%. The most prevalent intraoperative complications were intestinal injury (12.8%), bladder injury (2.6%), and ureter injury (1.3%). Most prevalent postoperative complications reported were surgical wound infection (5.2%), sepsis (3.9%), while none of the patients had paralytic ileus. Conclusion: The proportion of intraoperative and postoperative complications in ovarian cancer surgery was still at alarming level (19.2%). Further steps are needed to ameliorate the rate of complications surrounding ovarian cancer surgery.

Histopathological discrepancy and variation of surgical management in mucinous ovarian cystadenoma and pseudomyxoma peritonei.

INTRODUCTION AND IMPORTANCE: Mucinous cystadenoma occurs in 10-15% of all ovarian tumors. Diagnosis and treatment should be decided precisely as it has a chance to develop into pseudomyxoma peritonei (PMP). Management of PMP might be challenging especially when repeated surgery is needed. CASE PRESENTATION: The first case, a 22-year-old lady with recurrent stomach enlargement for seven months. She had history of laparotomy surgery due to an ovarian tumor. Whole abdomen contrast CT scan showed a large cyst with mucinous fluid. We decided to do re-laparotomy and found a left ovarian cyst. Histological examination results confirm ovarian mucinous cystadenoma. The second case was, 55-year-old woman, with abdominal enlargement for six months. She had a history of laparotomy and chemotherapy due to pseudomyxoma peritonei. Post chemotherapy MRI showed persistent pseudomyxoma and two multilocular cysts from both adnexa. Debulking laparotomy was then conducted. We obtained 8 L of mucinous pseudomyxoma along with mucinous cyst from both ovaries. The final diagnosis concluded as a pseudomyxoma and we decide to close the follow-up of the patient. CLINICAL DISCUSSION: Pseudomyxoma is caused by the production of mucin originating from intra-abdominal organs. Open surgery should be prioritized when the mucinous cystadenoma is detected to do a complete peritoneum evaluation and avoid perioperatively ruptured mucinous neoplasm. Pseudomyxoma often needed repeated surgical treatment and may exhibit different surgical findings and different pathologies. CONCLUSION: Repeated surgery is logical and still no need for adjuvant chemotherapy in both cases. Accurate and precise diagnosis should be prioritized in order to prevent repeated surgery.

Could combination of radical hysterectomy and radiation effective in the treatment of primary cervical signet ring cell carcinoma?: A rare case report.

INTRODUCTION: Primary signet-ring cell carcinoma (PSRCC) of the uterine cervix mostly occurs due to the metastasis from the primary organ, such as the gastrointestinal tract or breast. This case describes the cervical PSRCC and its management as a rare case. PRESENTATION OF CASE: The 39-year-old female came to undergo cancer screening. Visual Inspection with Acetic Acid (VIA) examination result was negative with the feature of severe cervicitis, and then the patient was given Trichloroacetic Acid (TCA) procedure. Three weeks after TCA's procedure, speculum examination found morphological features of cervix malignancy. Cervical biopsy examination showed mucinous adenocarcinoma, signet ring cell variant, with lymphovascular invasion. Endometrial microcurettage specimen do not contain tumor mass. DISCUSSION: The risk factor for cervical cancer in this patient was early sexual intercourse. We suggested stage IB2 cervical cancer because the tumor size was 2 cm until 4 cm, there was no spreading to nearby lymph nodes nor distant sites. Then patient had performed a radical hysterectomy procedure with ovary transposition and a series of radiation therapy. The patient was in good condition and no metastases were found in the imaging study. CONCLUSION: The treatment of PSRCC of the uterine cervix is challenging. It was established from intraoperative findings, histopathology, and immunohistochemistry examination. The radical hysterectomy adjunct to radiation was effective in the treatment of the PSRCC of the uterine cervix.

Expression of CD44+/CD24-, RAD6 and DDB2 on chemotherapy response in ovarian Cancer: A prospective flow cytometry study.

Backgrounds: Ovarian cancer is the 8th deadliest common cancer in women around the world. Almost all ovarian cancer patients would experience chemoresistance, recurrence, and poor prognosis after cytoreductive surgery and platinum-based chemotherapy. Chemoresistant cancer cells have characteristic expressions of cancer stem cell proteins (CSCs) CD44+/CD24-, RAD6 and DDB2. The increased expression of CD44+/CD24-, RAD6, and decreased DDB2 are believed to be associated with chemoresistance, recurrence, and poor prognosis of the disease. Thus, this study's objective is to analyze the correlation between the expression of CD44+/CD24-, RAD6 and DDB2 with ovarian cancer chemoresistance. Materials and methods: This study was conducted with a prospective cohort of 64 patients who is divided into two groups (32 patients in each group) at the Obstetrics-gynecology and pathology department of Cipto Mangunkusumo, Tarakan, Dharmais, and Fatmawati Hospital. All suspected ovarian cancer patients underwent cytoreductive debulking and histopathological examination. Chemotherapy was given for six series followed by six months of observation. After the observation, we determined the therapy's response with the RECIST Criteria (Response Criteria in Solid Tumors) and then classified the results into chemoresistant or chemosensitive groups. Flow cytometry blood tests were then performed to examine the expression of CD44+/CD24-, RAD6 and DDB2. Results: There was a significant relationship between increased levels of CD44+/CD24-, and RAD6 (p < 0.05) levels with the chemoresistance of ovarian cancer. The logistic regression test showed that the CD44+/CD24- was better marker. Conclusions: These results indicate that CD44+/CD24 and RAD6 expressions are significantly associated with ovarian cancer chemoresistance, and CD44+/CD24- is the better marker to predict ovarian cancer chemoresistance.

CD44+/CD24- Expression as predictors of ovarian cancer chemoresistance: immunohistochemistry and flow cytometry study.

BACKGROUND: The conventional standard treatment for ovarian cancer is not very effective, and the disease is fatal for women. Cancer Stem Cells (CSCs) that express CD44+/CD24- can contribute to chemoresistance and a poor prognosis. We seek to investigate the expression of CSCs (CD44+/CD24-) in ovarian cancer and their predictive significance. METHODS: The ambispective cohort was performed on 64 patients (32 patients in each group) at four hospitals (Cipto Mangunkusumo, Tarakan, Fatmawati, and Dharmais Hospital). Debulking surgery was performed on the patients, followed by histopathological analysis. The patients had six rounds of chemotherapy and were under monitoring for six months. The therapeutic responses were evaluated using the RECIST criteria (Response Criteria in Solid Tumors) and categorized as chemoresistant or chemosensitive. Using immunohistochemistry, we directly assess the CSCs from ovarian cancer tissue and using flow cytometry to assess the CSCs from the blood. RESULTS: High CSCs expression and ovarian cancer chemoresistance were significantly related in both trials (p 0.05). A better outcome was obtained using CD44+/CD24- immunohistochemistry. CONCLUSIONS: We conclude that there is a substantial association between high CSCs expression and chemoresistance in ovarian cancer and that CSCs immunohistochemistry has a higher predictive value.

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.

Pilot Study on the Effect of a Single Topical Application of Trichloroacetic Acid 85% on Normal Cervical Tissue.

Background: Early detection and treatment of cervical intraepithelial neoplasia (CIN) through a "see and treat" approach is a pillar of cervical cancer prevention programs in developing countries such as Indonesia. One of the major challenges faced is the limited N2O or CO2 gas supply for cryotherapy. Thus, an alternative therapeutic method such as trichloroacetic acid (TCA) topical application is needed as an alternative solution. The effectiveness of this therapy will depend on its destructive effect on eliminating the whole lesion in CIN. Objective: To estimate the extent of damage in the normal cervical tissue after a single topical application of 85% TCA solution. Design and Methods: This research was an intervention study carried out by applying ±5 ml of 85% TCA solution into the cervix of 40 patients scheduled for total hysterectomy for indications other than cervical pathology 24 h before surgery. The extent of tissue destruction was determined microscopically using histopathological specimens. The study protocol is registered at www.clinicaltrial.gov (ID NCT04911075). Results: In the final analysis, 39 subjects were included. The necrotic area was detected at the superficial layer, accompanied by the full epithelial erosion thickness. In addition, there were also fibrotic areas resembling burned tissue in the stroma. The mean depth of destruction was 1.16 ± 0.01 mm in the anterior lip and 1.01 ± 0.06 mm in the posterior lip. There was no significant depth difference between the anterior and posterior lips (p ≥0.05). Moreover, the 85% TCA topical application was tolerable, as represented by the fact that the vast majority (82.1%) of participants experienced pain with a visual analog scale score of <4. Conclusion: Single dose of TCA 85% in topical solution was able to destroy the normal cervical tissue with a deeper mean depth than the mean depth of CIN III in squamous epithelium.

Massive obstetric haemorrhage on post caesarean subtotal hysterectomy due to late detection of occult placenta percreta: A case report.

INTRODUCTION: Placenta accreta syndrome is a significant cause of maternal mortality and morbidity. Therefore, a multidiscipline approach is essential to overcome this life-threatening disorder for the mother and fetus. PRESENTATION OF CASE: A 32-year-old women gravida 3 parity 2, 34 weeks gestation come due to recurrent antepartum haemorrhage. She had twice prior caesarean section. Ultrasound assessment suggests total placenta previa and elevating suspicion to placenta accreta. However, intraoperatively its sign is unavailable. Although we have done subtotal hysterectomy, massive bleeding still occurring. Therefore, we present management of unexpected placenta percreta. DISCUSSION: Management of unexpected placenta percreta involves prenatal diagnosis, haemoglobin optimization, surgical management anticipating haemorrhage, dedicated maternal ICU, blood bank providing massive transfusion and blood component. CONCLUSION: Close monitoring is important in catastrophe management of Placenta Accreta Syndrome.

Case report: Caesarean scar endometriosis - A rare entity.

INTRODUCTION AND IMPORTANCE: Caesarean scar endometriosis (CSE) is a rare form of endometriosis due to previous surgical scars from obstetrical and gynecological procedures. The incidence of CSE was 0.08% and quite difficult to diagnose. CASE PRESENTATION: A 37-year-old multiparous woman came with intermittent pain in her lower left abdominal region and lump with a bluish color and solid consistency on the left side of the caesarean scar. Ultrasounds findings show a solid mass, measured 45 × 40 × 39 mm with neovascularization color score: 4. In April 2021, we performed mass resection, intraoperatively we found solid mass with no adhesion and infiltration found. Histological examination results confirm external endometriosis from the mass and the fascia was free from endometriosis. The symptoms reported relief after the procedure. CLINICAL DISCUSSION: Scar endometriosis is largely related to previous abdominal surgery like caesarean section, the mass increase in size during menses and becomes symptomatic. CSE develop ranging 12 months to 21 years and could mimic other hernias or tumor, that's why careful and precise examination is needed. The imaging modality we use in this case was ultrasonography which is the best and most accessible, reliable and cost-effective to diagnose. We performed large surgical excision of the lesion with reconstruction of damaged tissue to prevent recurrence and conversion to malignancy. CONCLUSION: Caesarean scar endometriosis should be considered in women of reproductive age with lower abdominal pain and/or mass at the caesarean scar from previous delivery or following obstetric-gynecologic surgery.

Skin metastases originated from cervical cancer: A rare case report.

INTRODUCTION: Metastases in cervical cancer could be spread through direct local invasion, lymphatic dissemination, or hematogenous dissemination. The most common sites of distant metastases are lungs, bone, and liver. Skin metastases from cervical cancer are categorized as a rare occurrence of metastases. This rarity of the cases has led us to report it. CASE DESCRIPTION: A 66-year-old multiparous woman diagnosed with stage IIA cervical cancer seven years ago, then she came into our outpatient clinic complained about a brownish white color mass on the left side of the neck that keeps getting bigger over time came from a skin lesion. The lesion was first treated with topical steroid but there was no improvement. Biopsy was done and the result showed a carcinoma metastasis that led to adenosquamous carcinoma or cervical adenocarcinoma. The patient went through chemoradiation with biosensitizer paclitaxel 120 mg/m2 for six cycles, which began in August 2019 until October 2019. The treatment progress showed a promising result. We observed the patient during treatment until two months after finishing the treatment. At the last visit, the patient came to our outpatient clinic, the mass size decreased significantly, and the skin showed an excellent regeneration sign. CONCLUSION: The physicians should always consider the patient's history and pay more attention to skin lesions in patients with a history of cervical cancer. The physicians should also perform a thorough physical examination and biopsy to confirm the diagnosis.

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

BACKGROUND Placenta accreta is an abnormal invasive placenta that can be life-threatening because of the risk of hemorrhage. Its incidence has increased due to high cesarean delivery rates. Early gestational age placenta accreta is difficult to diagnose and misdiagnosis can lead to inappropriate treatment. CASE REPORT Patient 1, a 34-year-old woman (para 2 abortus 1) with 2 previous cesarean deliveries, was referred to our department for vaginal bleeding and abdominal pain. She received 2 curettages for blighted ovum; then, ultrasound examination found uterus perforation and fluid in the Douglas cavity. Exploratory laparotomy confirmed uterine perforation, and a hysterectomy was performed. Histopathological examination revealed placenta accreta. Patient 2, a 35-year-old woman (para 3) with 3 previous cesarean deliveries, was treated at a previous hospital for vaginal bleeding and stomach enlargement. She received serial chemotherapy for gestational trophoblastic neoplasia. Ultrasound examination showed a nonhomogeneous opacity in the lower uterine corpus with color score 4. Total abdominal hysterectomy was performed, and histopathological examination revealed placenta accreta. Patient 3, a 32-year-old woman (para 2) with 2 previous cesarean deliveries, had irregular vaginal bleeding suspected as gestational trophoblastic neoplasia due to ultrasound examination and positive beta-human chorionic gonadotropin. Ultrasound and MRI examination showed enlargement with nonhomogeneous opacity, color score 4, and bridging vessels. Due to our previous experience, we suspected it was a placenta accreta and performed a hysterectomy. The histopathology result indicated placenta accreta. CONCLUSIONS The key point in diagnosing placenta accreta properly is to evaluate the morphometric changes based on the structure using imaging like ultrasound. Collection and analysis of these data enables precise diagnosis in early gestational age placenta accreta.

Five-Year Cancer Epidemiology at the National Referral Hospital: Hospital-Based Cancer Registry Data in Indonesia.

PURPOSE: In 2016, there were 1,308,061 cases of cancer being treated in Indonesia, with 2.2 trillion rupiahs spent, amounting to $486,960,633 in US dollars (purchasing power parity 2016). The high burden of cancers in Indonesia requires a valid data collection to inform future cancer-related policies. The purpose of this study is to report cancer epidemiological data from 2008 to 2012 based on Hospital-Based Cancer Registry (HBCR) data from Cipto Mangunkusumo Hospital, Indonesia. METHODS: This was a descriptive study with cross-sectional design. Data were collected from Cipto Mangunkusumo Hospital HBCR 2008-2012. Demographical, diagnostic, stages of cancer, and histopathological types of cancer data were extracted. RESULTS: After screening, 18,216 cases were included. A total of 12,438 patients were older than 39 years of age (68.3%), with a female-to-male ratio of 9:5. Most patients have cancers at advanced stages (stages III and IV, 10.2%). The most common sites of cancer were cervix uteri (2,878 cases, 15.8%), breast (2,459 cases, 13.5%), hematopoietic and reticuloendothelial systems (1,422 cases, 7.8%), nasopharynx (1,338 cases, 7.4%), and lymph nodes (1,104 cases, 6.1%). CONCLUSION: From this HBCR, cancer incidence in female was almost twice the incidence in male, largely because of the burden of cervical and breast cancers. The cervix uteri as one of the top five cancer sites based on this HBCR, 2008-2012, are still approximately consistent with Global Cancer Incidence, Mortality and Prevalence 2018, which portrayed that Indonesia has been severely afflicted by cervical cancer cases more than any other Association of Southeast Asian Nations countries. The HBCR could serve as a robust database of epidemiological data for cancer cases in Indonesia.