Person:

Goodman, Annekathryn

A 60-year-old woman presented with abdominal pain and weight loss and was found to have serum calcium of 15.0 mg/dl. Serum parathyroid hormone-related peptide (PTHrP) returned elevated. Imaging suggested bilateral mature cystic teratomas. Her hypercalcemia was treated initially with intravenous saline, as well as intramuscular and subcutaneous calcitonin. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, and final pathology revealed malignant Brenner tumor in association with a mature cystic teratoma. Her postoperative PTHrP returned less than assay, and her total and ionized calcium fell below normal, requiring supplemental calcium and vitamin D. At follow-up one month after discharge, her calcium had normalized. We present the first reported case of hypercalcemia occurring in association with a malignant Brenner tumor. Malignancy-associated hypercalcemia occurs via four principal mechanisms: (1) tumor production of PTHrP; (2) osteolytic bone involvement by primary tumor or metastasis; (3) ectopic activation of vitamin D to (1,25-(OH)_2) vitamin D, and (4) ectopic production of parathyroid hormone. PTHrP-mediated hypercalcemia is the most common mechanism and was responsible in this case. In patients with paraneoplastic hypercalcemia who undergo surgical treatment, close monitoring and management of serum calcium is necessary both pre- and postoperatively.

Objective: To investigate the neutrophil-to-lymphocyte ratio (NLR) from peripheral blood, a general measure of inflammation, in ovarian cancer. Methods: White cell counts and CA125 levels before treatment, tumor features, and questionnaire data on 519 women with ovarian cancer at two Boston hospitals were recorded. Counts were log-transformed and effects on these by tumor features and epidemiologic variables assessed by analysis of variance and generalized linear models. Cox proportional hazards models were used to assess effects on overall survival. Results: Greater NLR was associated with higher tumor stage and grade, presence of ascites, and bilateral disease and correlated with risk factors including Jewish ethnicity, taller height, more ovulatory cycles, and family history of cancer in premenopausal women and talc use in all women. CA125 was positively correlated with neutrophil count, monocyte count, and NLR and inversely correlated with lymphocyte count. In a multivariate adjusted analysis, high NLR predicted poorer survival and high lymphocyte count better survival. Conclusion: An elevated NLR before treatment signals more aggressive disease and correlates with risk factors for ovarian cancer. CA125 directly correlates with neutrophils which may reflect secretion of both CA125 and neutrophilic growth factors by the tumor. CA125 inversely correlates with lymphocytes which may reflect the ability of some neutrophilic factors to induce lymphopenia and/or binding of CA125 to lymphocytes removing CA125 from the serum pool. Links between NLR, CA125, and epidemiologic factors may provide new clues about the pathogenesis and progression of ovarian cancer.

Objective

CA125 at presentation of ovarian cancer carries important prognostic significance; but, other than tumor characteristics, little is known about factors that influence CA125 levels. We examined the effect of epidemiologic variables and tumor features on CA125 at diagnosis and their effects on survival.

Methods

CA125 levels before treatment, tumor features, and questionnaire data were recorded on 805 women with ovarian cancer receiving care at Partners Hospitals. CA125 values were log-normalized and generalized linear, logistic, or Cox proportional hazards models used to identify predictors of CA125 and influence on survival in the subset of women with invasive, non-mucinous tumors.

Results

The importance of histology, grade, stage, laterality, and presence of ascites on CA125 level was confirmed. For non-mucinous invasive cancers, Jewish ethnicity, parity, prior breast cancer, and family history of breast or ovarian cancer predicted higher CA125 and greater body mass index (BMI), recurrent yeast infections, colitis, and appendectomy predicted lower CA125. A quadratic model best described the relationship between CA125 and age with lower levels in youngest and oldest women. In multivariate modeling, stage, ascites, and prior breast cancer were the strongest predictors of high CA125 and appendectomy and yeast infections strongest predictors of low CA125. A model with these variables plus CA125 revealed high CA125 remains a predictor of poorer survival.

Conclusions

Ovarian tumor features and presence of ascites are key determinants of CA125 at diagnosis, but epidemiologic features such as BMI, parity, prior breast cancer, and history of inflammatory conditions of the genitourinary or gastrointestinal tracts may also play a role.

African-born immigrants comprise one of the fastest growing populations in the U.S., nearly doubling its population size in recent years. However, it is also one of the most underrepresented groups in health-care research, especially research focused on gynecologic and breast malignancies. While the opportunity exists for access to an advanced health-care system, as immigrants migrate to the U.S., they encounter the same health-care inequalities that are faced by the native-born population based on ethnicity and social class, potentiated by limitations of health literacy and lack of familiarity with U.S. health systems. Given the continued influx of African-born immigrants in the U.S., we sought to understand the representation of this population in cervical and breast cancer research, recognizing the population’s high risk for these diseases at baseline while residing in their native countries. We determined that there is limited research in these diseases that disproportionately affect them; yet, there are identifiable and potentially modifiable factors that contribute to this paucity of evidence. This clinical commentary seeks to underscore the clear lack of research available involving African-born immigrants with respect to gynecologic and breast malignancies in the existing literature, demonstrate the need for more robust research in this population, and provide fundamental insights into barriers and solutions critical to the continued health of this growing population.

Background: Cervical cancer is the second most common malignancy of women in Bangladesh. Surgery is the mainstay of treatment of patients with early invasive cancer confined to cervix. While the five-year survival rate after surgery for stage IB1 disease exceeds 90%, it is only 60% - 70% for stage IB2 and IIA2 (tumor size > 4 cm). To improve the outcome of treatment, two to three cycles of Neoadjuvant Chemotherapy (NACT) has been evaluated as a treatment strategy in stage IB2 and IIA2 diseases. Objectives: This study aimed to evaluate the role of neoadjuvant chemotherapy (NACT) followed by Radical Surgery (RS) among the patients with early bulky cervical cancer (Stage IB2 & IIA2) to reduce the tumor size to achieve radical resectibility. Methods: This study was carried out at the Gynaecological Oncology Division of the Department of Obstetrics and Gynecology at Bangabandhu Sheikh Mujib Medical University (BSMMU) during the period July 2015 to December 2015. Thirty-eight patients with early bulky cervical cancer without any prior medical or surgical treatment received NACT using intravenous paclitaxel 175 mg/m2 and cisplatin 75 mg/m2 followed by radical surgery. The primary outcome measure assessed the response to NACT to reduce the size of the tumor. Secondary outcome measures assessed the resectibility of tumor and compared the preoperative clinical stage to the postoperative pathological stage. This study also assessed the relationship of intraoperative and postoperative complications including the adverse effects of postoperative radiotherapy and chemoradiotherapy. Results: Clinical response to NACT was 94.7% (84.2% complete response + 10.5% partial response). Progressive disease was found in two cases (5.3%). Duration of surgery was less than 2 hours in 81.6% cases and greater than 3 hours in 13.2% cases only. All women lived 5 to 10 hours away from Dhaka and could not return for in person follow-up. It was possible to get telephone follow-up on twenty-four women (63%). Seven (29%) had died from their cancers within one year of their surgery. Seventeen women were alive and disease free two years after completeion of their treatment. Conclusion: NACT is a feasible approach for improving the resectability of early stage bulky cervical cancer at BSMMU.

Objective. To determine the frequency of high risk (HR) HPV and intraepithelial neoplasia following ASCUS pap cytology screens in menopausal women. Study Design. Following IRB approval, we performed a retrospective review of all cases of ASCUS pap tests, HPV results, and relevant clinical-pathologic data in women age 50 or over from November 2005 to January 2007 within a tertiary care center. Statistical analyses were performed in EXCEL. Results. 344 patients were analyzed for a total of 367 screening pap tests. 25.29% (87/344) patients were HR HPV positive, with greater percentages of HR HPV cases occurring in women age 65–74. Within HR HPV cases, 79.3% (69/87) underwent colposcopy. 27.5% (19/69) biopsy proven lesions were discovered, including cervical, vulvar or vaginal (intraepithelial neoplasia). Within the negative HR HPV group 3.1% (8/257) patients were diagnosed with dysplasia or carcinoma. Within both HR HPV positive and negative groups, patients with no prior history of lower genital tract lesions or cancer were identified. Conclusion. Reflex HPV testing plays an important role in ASCUS triage in menopausal women. Pap test screening and HPV testing should not be limited to women of reproductive age as they may aid in the diagnosis of intraepithelial neoplasia in women of older age.

Cervical cancer is a preventable disease. The risk factors for the development of cervical cancer include both biologic factors and social factors. In the United States, the leading risk factor for the development of cervical cancer is not having a Pap smear for five years prior to the diagnosis of cancer. In low and middle income countries, cervical cancer incidence and mortality are directly related to the lack of both screening programs and cancer treatment facilities. This paper examines the social ecology of cervical cancer. The literature is reviewed on social and cultural barriers to access to health care and its effect of cervical cancer rates and outcomes.

Language plays a central role in how gender and sexuality are described. In Bangla or Bengali, physicians, when educating and counseling women patients, do not have a socially acceptable word for “vagina”. If language is missing for female genitalia or important female sexual functions, could this absence reflect on the position of women in society, reproductive rights, and access to healthcare? Is there a relationship between language and the high rates of the gender-based cervical and breast cancers in some low and middle-income countries? This commentary examines scholarship on the topic of language, the female body, gender-based violence, disparities of healthcare for women, and the consequences of language on sexual attitudes and health.

Nosocomial or hospital acquired infections are a major challenge for low and middle income countries (LMICs) which have limited healthcare resources. Risk factors include the lack of appropriate hospital facilities such as isolation units, bed space, and sinks; inadequate waste management, contaminated equipment, inappropriate use of antibiotics and transmission of infection from the hands of healthcare workers and family caretakers due to inadequate hand washing. Nosocomial infections increase the costs of healthcare due to added antimicrobial treatment and prolonged hospitalization. Since the prevalence of nosocomial infections is generally higher in developing countries with limited resources, the socio-economic burden is even more severe in these countries. This review summarizes the current knowledge on the risks of hospital acquired infections and summarizes current recommendations for the development of hospital infrastructure and the institution of protocols to reduce these infections in LMICs such as Bangladesh.

Introduction: Port site metastases have been reported with laparoscopic surgery. The mechanism of action is unknown. Theories include tumor tracking, spillage, pneumoperitoneum, and immune factors. Methods: We report on a case of aggressive port site metastases and intra-abdominal recurrence after an uncomplicated laparoscopic hysterectomy for a grade 2, minimally invasive endometrioid adenocarcinoma of the uterus. The world literature on port site metastases in gynecological cancer is reviewed. Results: Port site metastases have two distinct presentations. In the first pattern, the metastases are isolated to the laparoscopic port sites. In the second pattern, port site metastases are associated with widespread intra-abdominal recurrence. Conclusion: Port site metastases are rare but occur with laparoscopic surgery. Meticulous attention to surgical technique including the use of specimen bags to isolate tissue and prevent spillage should be performed. Data registries should be instituted to track the incidence and outcomes of port site metastases.