National cervical cancer burden estimation through systematic review and analysis of publicly available data in Pakistan.

BACKGROUND: Cervical cancer is a major cause of cancer-related deaths among women worldwide. Paucity of data on cervical cancer burden in countries like Pakistan hamper requisite resource allocation. OBJECTIVE: To estimate the burden of cervical cancer in Pakistan using available data sources. METHODS: We performed a systematic review to identify relevant data on Pakistan between 1995 to 2022. Study data identified through the systematic review that provided enough information to allow age specific incidence rates and age standardized incidence rates (ASIR) calculations for cervical cancer were merged. Population at risk estimates were derived and adjusted for important variables in the care-seeking pathway. The calculated ASIRs were applied to 2020 population estimates to estimate the number of cervical cancer cases in Pakistan. RESULTS: A total of 13 studies reported ASIRs for cervical cancer for Pakistan. Among the studies selected, the Karachi Cancer Registry reported the highest disease burden estimates for all reported time periods: 1995-1997 ASIR = 6.81, 1998-2002 ASIR = 7.47, and 2017-2019 ASIR = 6.02 per 100,000 women. Using data from Karachi, Punjab and Pakistan Atomic Energy Cancer Registries from 2015-2019, we derived an unadjusted ASIR for cervical cancer of 4.16 per 100,000 women (95% UI 3.28, 5.28). Varying model assumptions produced adjusted ASIRs ranging from 5.2 to 8.4 per 100,000 women. We derived an adjusted ASIR of 7.60, (95% UI 5.98, 10.01) and estimated 6166 (95% UI 4833, 8305) new cases of cervical cancer per year. CONCLUSION: The estimated cervical cancer burden in Pakistan is higher than the WHO target. Estimates are sensitive to health seeking behavior, and appropriate physician diagnostic intervention, factors that are relevant to the case of cervical cancer, a stigmatized disease in a low-lower middle income country setting. These estimates make the case for approaching cervical cancer elimination through a multi-pronged strategy.

An audit of gynae-oncology practices in ovarian cancer treatment based on enhanced recovery after surgery (ERAS) protocol amongst two gynae-oncology units, in UK and in Pakistan.

OBJECTIVE: To compare peri-operative practices and complications in ovarian cancer patients undergoing upfront surgery for primary disease under enhanced recovery after surgery protocol and traditional practices. METHODS: The retrospective cross-sectional study was done at the gynaecology departments of St Georges Hospital, United Kingdom, and the Aga Khan Hospital, Pakistan, and comprised data of an equal number of ovarian cancer patients from each centre who underwent ovarian cancer surgery from January 2015 to December 2016. The former centre practiced the enhanced recovery after surgery protocol, while the latter centre followed traditional practices. Data was analysed using SPSS 19. RESULTS: Of the 100 patients, there were 50(50%) in each group. Baseline variables were comparable except for diabetes which was more prevalent in the local group (p=0.03). Mechanical bowel preparation was performed in 47(94%) of local patients compared to 1(2%) in the other group, while the duration for nil-per-mouth status as well as the use of nasogastric tube and peritoneal drain were significantly different (p<0.05). Epidural anaesthesia was used in 39(78%) of patients in Pakistan compared to 4(8%) in the United Kingdom. The duration of thromboprophylaxis was also significantly different (p<0.05). CONCLUSIONS: Implementation of enhanced recovery after surgery protocol was found to have the potential to improve postoperative outcomes and good functional recovery without compromising patient safety.

Squamous cell carcinoma of uterine cervix metastatic to the axillary lymph node.

We report a case of an elderly woman, presenting with vesicouterine fistula and enlarged axillary lymph nodes. She had been diagnosed with cervical squamous cell carcinoma (SCC) in April 2015, for which she had received brachytherapy and concurrent chemoradiation therapy. The presence of enlarged axillary lymph nodes raised a suspicion for breast cancer with axillary metastases, but the bilateral mammograms did not show any discrete lesion in both breasts. The biopsy from axillary lymph node showed metastatic SCC, with block positivity for P16, confirming the origin from known cervical primary. Axillary lymph nodes are the least likely to be involved by tumours arising in the pelvis, as the lymphatic drainage of this region goes directly to the systemic circulation via the para-aortic lymph nodes and thoracic ducts. A complete clinical history is essential in such cases, to avoid misdiagnosis. Positron emission tomography CT helps in this regard.

Bartholin gland carcinoma in a young female: a rare disease in an unusual age group.

Primary Bartholin gland carcinoma (BGC) is an extremely rare disease. It typically presents in elderly women. It can be confused with Bartholin gland cyst, which is a benign condition leading to a delay in diagnosis and treatment. We are presenting a case report of BGC in a 35-year-old woman, which has created a diagnostic as well as therapeutic dilemma.

Obstetric patients in intensive care unit: Perspective from a teaching hospital in Pakistan.

OBJECTIVE: Review of obstetric cases admitted to the intensive care unit. DESIGN: Ten year retrospective review of individual patients' medical records. PARTICIPANTS: Records of obstetric patients admitted from 2005-2014. SETTING: Aga Khan University Hospital Karachi. MAIN OUTCOME MEASURES: Diagnosis at the time of admission, associated risk factors, and intervention required aspects of management and rate of mortality. FINDINGS: A total of 194 obstetric patients were admitted out of which 86.2% of patients had ventilator support. Mortality was not seen to be significantly associated with parity and antenatal/postnatal status. The median age of patients was 34 years, minimum length of stay was 24 hours and maximum stay was 53 days. Sixty one percent of patients were admitted to with organ system failure. The overall mortality rate was 21.64% (42/194). The mortality rate was five times more likely in patients who had gastro-intestinal complication {Odds Ratio=4.87; 95%CI: 1.65-14.36}. The largest group of patients {28.4%} presented with hematological diagnosis. CONCLUSION: When the intensive care unit admission became essential, primary diagnosis included: postpartum hemorrhage, hypertensive disorders, sepsis and infectious diseases. An increased vigilance of high-risk pregnant women and a stabilization of their condition before intervention is administered, improves the outcome of these women.

Comparison of Risk Factors and survival of Type 1 and Type II Endometrial Cancers.

OBJECTIVE: To compare risk factors and progression free survival of type 1 & 2 endometrial cancers. METHODS: A retrospective analysis of 149 patients with early stage endometrial carcinoma treated between 1997 and 2012 in Aga Khan University Hospital, Karachi was performed. RESULTS: A total of 149 patients were analyzed. Type I tumors accounted for 92% of cases in the study while 8% were type II tumors. The mean age, BMI, parity, co-morbidities (hypertension & Diabetes), family history and history of polycystic disease were comparable in both groups. Overall better survival (113 Vs 24 months) was observed for type I endometrial cancer. CONCLUSION: Both types of endometrial cancer may share common etiologic factors. Despite the limitation of small numbers in one group this study confirms better survival in type 1 endometrial cancer.

Factors affecting mode of delivery in a nullipara at term with singleton pregnancy and vertex presentation (NTSV).

OBJECTIVE: To analyse the factors associated with Caesarean Section (CS) of Nulliparous, Term and Singleton pregnancies with Vertex presentation (NTSV) at a tertiary care hospital. METHODS: In this unmatched retrospective case-control study, 212 NTSV patients were identified through computerized medical record systems; the data was collected through predesigned Performa by reviewing medical record charts. One hundred six CS and spontaneous vaginal deliveries (SVD) were taken as cases and controls. RESULTS: The mean maternal age of cases (CS) was 26.64 (SD: 3.9) and of controls (SVD) was 26.7(SD: 3.9) years, whereas mean gestational age was 38.66±1.12 and 38.57±0.9 weeks for cases and controls respectively. Ninety per cent of women in the study group were delivered within 10 hours of active labour. Babies that weighed ≤3kg were 45% and >3kg were 55%. The possibility of being high risk was twice more among those delivered by CS. However, it was not statistically significant (p value 0.077). Labour was induced in 38% patients. The Odds of Induction of Labour (IOL) were two times more and delivering at night was three times more amongst CS. The likelihood of labour exceeding 10 hours was four times (81%) if the patient had a CS. Moreover 48% of the babies weighing >3kg were delivered through CS. Maternal age, high risk pregnancies, gender of baby and epidural analgesia were not statistically significant predictors of mode of delivery (MOD) in this study. CONCLUSION: Induction of Labour, night time delivery, prolonged labour and birth weight <3kg were found to be associated with the increased CS rate among NTSV. Therefore further research is required in order to address these factors and to reduce the increasing Caesarean Section.

Selective lymphadenectomy in endometrial cancer: Retrospective analysis of morbidity and survival data at a tertiary care centre.

OBJECTIVE: To compare perioperative morbidity and survival data between patients with early-stage endometrial cancer who did or did not undergo selective lymphadenectomy. METHODS: Retrospective analysis of 180 patients with early-stage endometrial carcinoma treated between 1999 and 2008 was performed in Aga Khan University Hospital, Karachi, Pakistan. RESULTS: Data from 180 patients were analysed. The selective lymphadenectomy group contained 108 women (60%) and the no lymphadenectomy group contained 72 women (40%). The median number of lymph nodes removed was 9. The mean age and extent of disease, as assessed by staging, tumour size, myometrial invasion, and lymphovascular invasion were comparable between groups. Upstaging of the disease to stage 3 and 4 occurred in 11% of patients in the lymphadenectomy group. There were no significant differences in the medical or surgical complications between groups. At a median follow-up of 26 months, both groups had comparable survival (lymphadenectomy versus no lymphadenectomy: 34 versus 32 months). Similar survival was noted for patients who underwent the removal of more or less than 5 pelvic lymph nodes. CONCLUSION: Selective lymphadenectomy offers the advantage of improved surgical staging but no therapeutic benefit in terms of overall survival.

Primary debulking surgery versus neo-adjuvant chemotherapy in stage III/IV ovarian cancer: Comparison of perioperative morbidity and survival data in Pakistani women.

OBJECTIVE: To compare the peri-operative morbidity and survival rates between ovarian cancer patients treated with two different approaches. METHODS: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised data related to patients with advanced stage ovarian carcinoma treated between 1999 and 2008. Medical records were reviewed and relevant demographic, clinical, surgical, pathologic and follow-up information was acquired. Progression-free survival and overall survival rates were compared between patients who underwent primary debulking surgery and those who had received neo-adjuvant chemotherapy before surgery. SPSS 19 was used for statistical analysis. RESULTS: Of the total 118 patients, 78(66%) had undergone primary debulking surgery and 40(34%) had received neo-adjuvant chemotherapy. The mean age and pre-operative carcinoma antigen-125 level were similar. The debulking group had 74(94.8%) patients with stage 3, and 4(5.1%) patients with stage 4 disease, while the other group had 32(80%) and 8(20%) with stage 3and 4 respectively. The frequency of optimal debulking was 42(56.8%) in the former group against 27(79.4%) in the latter (p=0.01). Duration of surgery, estimated blood loss >1500ml and stay at the intensive care unit were not statistically different (p>0.05). Rate of Urinary tract, bowel injury and bowel resections were also similar. There was no difference in the progression-free survival in both groups (p>0.05). CONCLUSIONS: Neo-adjuvant chemotherapy followed by interval debulking produced comparable survival rates and peri-operative complications.