Clinical and Management Dilemmas Concerning Early-Stage Cervical Cancer in Pregnancy - A Case Report.

Background: Cervical cancer in pregnancy is rare and its management remains a formidable challenge. Clinical upstaging is a serious concern. Presentation may mimic pregnancy-related conditions, thus delaying diagnosis and leading to an advanced stage at presentation. In addition, concerns regarding chemotherapy safety in pregnancy may hinder its administration. Definitive therapy may also be delayed due to pregnancy. Case Report: A 37-year-old G3P2A0 10-11 weeks pregnant woman was diagnosed with stage IB2 cervical cancer. We originally planned to perform neoadjuvant chemotherapy with paclitaxel 175mg/m2 and carboplatin 6 AUC every 21 days followed by caesarean section and radical hysterectomy. However, preoperatively, the tumor had grown further and progressed to stage IIB. Postpartum radiotherapy was thus indicated. Lower segmental caesarean section along with bilateral salpingectomy and ovarian transposition were performed. Radiotherapy was administered through external beam radiation therapy and brachytherapy. The patient delivered a small for gestational age male baby with no abnormalities. At 2-month follow-up, the infant appeared generally healthy. Conclusion: Cancer diagnosis during pregnancy adversely impacts women's physical and psychological states. Symptoms may mimic pregnancy-related conditions, thus delaying diagnosis. Its management involves a multidisciplinary team to protect both maternal and fetal health.

Giant hydronephrosis masquerading as ovarian tumor: a case report.

Giant hydronephrosis is defined as the accumulation of more than 1 l of fluid in the kidney's collecting system. Its presentation can mimic other conditions including ovarian tumor. Herein, the authors report a case of giant hydronephrosis caused by urolithiasis that mimics the presentation of an ovarian tumor. The authors also highlight the challenges in diagnosing this rare entity and the management options available. Case presentation: The authors present a case of a 65-year-old P5A0 woman with an abdominal tumor of 1-year duration that progressively increased in size. She also complained of mild left flank pain since a year ago. Ultrasonography revealed a large cystic mass in the lower to middle abdomen. Ovarian tumor was suspected and laparotomy was performed. Surgical exploration revealed a left giant hydronephrosis with normal gynecological organs. The postoperative course was uneventful, and she was discharged in satisfactory condition. Clinical discussion: Giant hydronephrosis should always be considered as a differential diagnosis when presented with a large abdominal cystic lesion. Conclusion: Routine screening for bilateral kidneys during gynecological ultrasonography will help detect giant hydronephrosis and prevent unplanned surgical interventions.

Comparison of Extravillous Intermediate Trophoblast Invasion Depth and Distribution Pattern Between Placenta Accreta and Non-Accreta.

BACKGROUND Placenta accreta spectrum (PAS) is a complex obstetric complication that poses a major risk for life-threatening hemorrhage. The pathogenesis of PAS is known to be related to placentogenesis, trophoblastic cells invasion, and previous obstetrical procedures that cause uterine wall defects. However, the precise mechanism of this disease has not been fully explained. This study aimed to evaluate the differences in maximum depth of invasion and distribution pattern of implantation site intermediate trophoblasts between PAS and non-accreta cases. MATERIAL AND METHODS This was an observational, analytic, cross-sectional study that utilized paraffin block specimen of peripartum hysterectomy performed in Hasan Sadikin General Hospital Bandung from 2018 to 2020. Sixty-four samples were obtained, then classified as PAS and non-accreta (normal placenta). Implantation site-intermediate trophoblasts were identified using CD-146 staining. Maximum invasion depth of intermediate trophoblasts was measured in micrometers, while the distribution pattern was assessed and classified into 2 groups: confluent and scattered. RESULTS We found that the maximum invasion depth of the intermediate trophoblasts was significantly higher in the PAS group compared to that of the non-accreta group (2453.52±1172.122 µm vs 1613.59±822.588 µm, P=0.009). The confluent distribution pattern was significantly more common in the PAS group compared to that of the non-accreta group (87.2% vs 17.6%, P=0.0001). CONCLUSIONS The findings of our study suggested that implantation site intermediate trophoblasts play a role in the pathophysiology of placenta accreta. Further studies are needed to determine factors that affect trophoblast invasion leading to placenta accreta spectrum.

Effect of Vitamin D analog supplementation on levator ani strength and plasma Vitamin D receptor expression in uterine prolapse patients.

Uterine prolapse is a pathological condition that can negatively impact women's quality of life. It is caused by weakening of the pelvic floor muscles. Function of levator ani muscle and other striated muscles is thought to be influenced by Vitamin D levels. Vitamin D exerts its biological effects by adhering to Vitamin D receptors (VDRs) present in striated muscles. We aim to analyze the effect of Vitamin D analog supplementation on levator ani muscle strength in uterine prolapse patients. This was a quasi-experimental study with a pre-post design on 24 postmenopausal women diagnosed with grade III and IV uterine prolapse. Vitamin D levels, VDR, levator ani muscle, and hand grip muscle strength were measured before and after three months of Vitamin D analog supplementation. We found that Vitamin D level, VDR serum level, levator ani muscle strength, and hand grip muscle strength all significantly increase (p < 0.001) following Vitamin D analog supplementation. The correlation coefficient between levator ani muscle and handgrip muscle strength was 0.616 and with p value of 0.001. To conclude, Vitamin D analog supplementation can significantly increase levator ani muscle strength in uterine prolapse patients. We propose that determining Vitamin D level in postmenopausal women and replenishing its deficiency with Vitamin D analog supplementation might aid in preventing POP progression.

A Rare Case of Ruptured Malignant Ovarian Brenner Tumor.

BACKGROUND Ovarian cancer is the leading cause of death in women with gynecological cancers. Ovarian Brenner tumor (BT) is an extremely rare type of epithelial ovarian cancer that accounts for about 1-3% of all ovarian cancers. Herein, we report a rare case of ruptured malignant ovarian Brenner tumor. CASE REPORT A 39-year-old P0A0 woman came to the Emergency Department (ED) with abdominal pain and tenderness. Perforated appendicitis was initially suspected and an emergency laparotomy was performed by the General Surgery Department. Then, a 25×20×15 cm grayish cystic mass originating from the right adnexa was found. We consulted intraoperatively with the Gynecology Oncology Department and decided to perform complete surgical staging. Histopathological examination confirmed the diagnosis of malignant Brenner tumor (MBT). The patient was then given adjuvant chemotherapy with a paclitaxel carboplatin regimen. In this case report, we present our case along with a review of the current literature regarding the diagnosis and therapy of malignant Brenner tumor. CONCLUSIONS Ovarian MBT is an extremely rare ovarian cancer. Diagnosing MBT can be challenging as there are no clinical, laboratory, or imaging features typical for it. Surgery is the mainstay treatment in MBT cases. The role of adjuvant chemotherapy in MBT is still being debated.

Cervical pre-cancerous lesion detection: development of smartphone-based VIA application using artificial intelligence.

OBJECTIVE: Visual inspection of cervix after acetic acid application (VIA) has been considered an alternative to Pap smear in resource-limited settings, like Indonesia. However, VIA results mainly depend on examiner's experience and with the lack of comprehensive training of healthcare workers, VIA accuracy keeps declining. We aimed to develop an artificial intelligence (AI)-based Android application that can automatically determine VIA results in real time and may be further developed as a health care support system in cervical cancer screening. RESULT: A total of 199 women who underwent VIA test was studied. Images of cervix before and after VIA test were taken with smartphone, then evaluated and labelled by experienced oncologist as VIA positive or negative. Our AI model training pipeline consists of 3 steps: image pre-processing, feature extraction, and classifier development. Out of the 199 data, 134 were used as train-validation data and the remaining 65 data were used as test data. The trained AI model generated a sensitivity of 80%, specificity of 96.4%, accuracy of 93.8%, precision of 80%, and ROC/AUC of 0.85 (95% CI 0.66-1.0). The developed AI-based Android application may potentially aid cervical cancer screening, especially in low resource settings.

Myxoid Liposarcoma of the Vulva: A Rare Malignancy Mimicking Benign Vulvar Mass.

BACKGROUND Liposarcoma of the vulva is an exceptionally rare malignant tumor. Clinically, vulvar liposarcoma often mimics benign lesions, thus misdiagnosis is common. Herein, we present a case of myxoid liposarcoma of the vulva. To the best of our knowledge, this is the first case report of vulvar liposarcoma from Indonesia. CASE REPORT We present a case of a 39-year-old woman with left vulvar mass of 6 years duration that progressively increased in size. The patient reported having pressure and discomfort, especially during movement, but reported no pain. Lipoma was initially suspected. Surgical excision was performed and histopathological examination revealed a well-differentiated myxoid liposarcoma. The base and excised margins of the tumor were free of malignant cells. Post-operative course was uneventful and she was discharged in a satisfactory condition. The patient had been under regular follow-up and is currently symptom- and recurrence-free. We also review other cases of vulvar liposarcoma to further comprehend characteristics of this rare malignant tumor. CONCLUSIONS Liposarcoma of the vulva occurs very rarely, but clinicians and pathologists should always consider it as a differential diagnosis when presented with vulvar mass. Biopsy of a vulvar mass is crucial. Surgical excision remains the mainstay of treatment. Adjuvant radiotherapy may be considered in certain cases. Comprehensive follow-up for recurrences or metastasis is recommended throughout life.