Efficacy and Safety Profile of Tuberculin Protein Purified Derivative Injection As Immunotherapy For the Treatment of Cutaneous and Anogenital Warts: A Review Article

Introduction

Various treatments available today for anogenital and cutaneous warts have limitations, including time-consuming, challenging to perform, and the risk of scarring. A new treatment using tuberculin purified protein derivative (PPD) has been developed, which is expected to generate cellular immunity against HPV.

Objective

To assess the evidence for the efficacy and safety of PPD treatment for cutaneous and anogenital warts.

Materials and methods

A literature search was performed with the keyword-based search on digital libraries, including the National Library of Medicine, Cochrane Controlled Register of Trial, and Google Scholar, using the following terms: anogenital warts, condyloma acuminata, cutaneous warts, human papillomavirus, immunotherapy, and tuberculin purified protein derivative. Original studies on treating cutaneous or anogenital warts with PPD were included. The results were 47 clinical trials and 4 case reports. Most of the research was done in countries with common Mycobacterium tuberculosis infection. The treatment showed good efficacy. Comparative studies showed that the treatment has similar efficacy with other immunotherapies. No significant side effects were reported, with evidence of the safety use on the pregnant population.

Conclusion

Based on good efficacy and safety, PPD can be considered an alternative therapy, especially in countries where tuberculosis is frequent.

Expression of PD-1 and PD-L1 in Endometrial Cancer: Molecular and Clinical Significance

The landscape of diagnosing and treating endometrial cancer is undergoing a profound transformation due to the integration of molecular analysis and innovative therapeutic approaches. For several decades, the cornerstone treatments for endometrial cancer have included surgical resection, cytotoxic chemotherapy, hormonal therapy, and radiation therapy. However, in recent years, the concept of personalised medicine has gained momentum, reshaping the way clinicians approach cancer treatment. Tailoring treatments based on specific biomarkers has evolved into a standard practice in both initial and recurrent therapy protocols. This review aims to provide an in-depth exploration of the current state of molecular analysis and treatment strategies in the context of endometrial cancer, focusing on the immunological aspect of the PD-1/PD-L1 axis. Furthermore, it seeks to shed light on emerging and innovative approaches that hold promise for the future modulation of endometrial cancer treatments. In essence, as researchers delve into the complex molecular landscape of endometrial cancer and harness the understanding of the PD-1/PD-L1 axis, we are paving the way for more targeted, effective, and personalised therapies that have the potential to significantly improve the outcomes and quality of life for patients with this challenging disease.

Efficacy and Safety of PD-1/PD-L1 Inhibitor as Single-Agent Immunotherapy in Endometrial Cancer: A Systematic Review and Meta-Analysis

The programmed cell death protein 1 (PD-1)/programmed cell death ligand 1 (PD-L1) pathway plays a crucial role in the immune escape mechanism and growth of cancer cells in endometrial cancer (EC). Clinical trials investigating PD-1/PD-L1 inhibitor have shown promising results in other cancers, but their efficacy in EC still remains uncertain. Therefore, this meta-analysis aims to provide an updated and robust analysis of the effectiveness and safety of PD-1/PDL1 inhibitor as single-agent immunotherapy in EC, focusing on the objective response rate (ORR), disease control rate (DCR), and adverse events (AEs). This meta-analysis utilized STATA version 17 and RevMan version 5.4 software to pool the results of relevant studies. Five studies conducted between 2017 and 2022, comprising a total of 480 EC patients enrolled for PD-1/PD-L1 inhibitor immunotherapy met the inclusion criteria. The pooled proportion of EC patients who achieved ORR through PD-1/PD-L1 inhibitor treatment was 26.0% (95% CI: 16.0-36.0%; p < 0.05). Subgroup analysis based on mismatch repair (MMR) status showed an ORR of 44.0% (95% CI: 38.0-50.0%; p = 0.32) for the deficient mismatch repair (dMMR) group and 8.0% (95% CI: 0.0-16.0%; p = 0.07) for the proficient mismatch repair (pMMR) group. Pooled proportion analysis by DCR demonstrated an odds ratio (OR) of 41.0% (95% CI: 36.0-46.0%, p = 0.83) for patients undergoing PD-1/PD-L1 inhibitor treatment. Subgroup analysis based on MMR status revealed DCR of 54.0% (95% CI: 47.0-62.0%; p = 0.83) for the dMMR group, and 31.0% (95% CI: 25.0-39.0%; p = 0.14) for the pMMR group. The efficacy of PD-1/PD-L1 inhibitors was significantly higher in the dMMR group compared to the pMMR group, in terms of both ORR (OR = 6.30; 95% CI = 3.60-11.03; p < 0.05) and DCR (OR = 2.57; 95% CI = 1.66-3.99; p < 0.05). In terms of safety issues, the pooled proportion of patients experiencing at least one adverse event was 69.0% (95% CI: 65.0-73.0%; p > 0.05), with grade three or higher AEs occurring in 16.0% of cases (95% CI: 12.0-19.0%; p > 0.05). Based on the subgroup analysis of MMR status, PD-1/PD-L1 inhibitor immunotherapy showed significantly better efficacy among dMMR patients. These findings suggest that patients with dMMR status may be more suitable for this treatment approach. However, further research on PD-1/PD-L1 inhibitor immunotherapy strategies is needed to fully explore their potential and improve treatment outcomes in EC.

Non-Invasive Prenatal Testing (NIPT): Reliability, Challenges, and Future Directions

Non-invasive prenatal testing was first discovered in 1988; it was primarily thought to be able to detect common aneuploidies, such as Patau syndrome (T13), Edward Syndrome (T18), and Down syndrome (T21). It comprises a simple technique involving the analysis of cell-free foetal DNA (cffDNA) obtained through maternal serum, using advances in next-generation sequencing. NIPT has shown promise as a simple and low-risk screening test, leading various governments and private organizations worldwide to dedicate significant resources towards its integration into national healthcare initiatives as well as the formation of consortia and research studies aimed at standardizing its implementation. This article aims to review the reliability of NIPT while discussing the current challenges prevalent among different communities worldwide.

Sexual functioning and marital satisfaction among endometriosis patients in Malaysia: a cross-sectional study

Endometriosis affects the sexual functioning and marital satisfaction of couples in a complex manner due to its clinical presentation of the disease. This study aimed to evaluate the prevalence of sexual dysfunction and marital disharmony among women with endometriosis beyond their diagnosis and treatment. A cross-sectional online survey was conducted among women with endometriosis in an endometriosis society at a Malaysian university hospital. Sociodemographic and clinical data were collected. Sexual function was measured using the Malay Version Female Sexual Function Index (MVFSFI), while marital satisfaction was evaluated with the Malay Version Golombok Rust Inventory for Marital Satisfaction (MVGRIMS). A total of 166 patients participated in this survey. The median age was 35 years (Interquartile range, IQR:32.00-39.25 years); 91.6% of participants were Malay. The median score of MVFSFI was 56.00 (IQR: 34.75-68.00). Most of the study subjects (n = 96) reported poor to very severe marital satisfaction problems, equivalent to MVGRIMS transformed score of more than 5. High levels of MVGRIMS scores have a moderately strong negative correlation with lower scores for most domains of the MVFSFI. In the stepwise multiple logistic regression, only MVFSFI total scores (p = 0.029), MVFSFI lubrication scores (p = 0.009), and MVFSFI satisfaction (p = 0.010) scores were significantly associated with poor marital satisfaction. Both sexual dysfunction and marital satisfactions commonly affect women with endometriosis and are closely interlinked. Targeted efforts should be made in multiple aspects to improve the quality of sexual functioning and marital satisfaction among endometriosis patients.

Successful treatment of anogenital warts with single dose Bacillus Calmette Guerin vaccine without prior sensitization in tuberculosis endemic country: Two case report

Anogenital Warts (AGWs) are benign proliferations caused by Human Papillomavirus (HPV) infection on the genital or anal areas. Various therapeutic options are available for the treatment of AGWs but there is no best or ideal therapy, and the recurrence of AGWs is significantly high. A promising new therapy that is currently being evaluated is immunotherapy with the intralesional Bacillus Calmette-Guérin (BCG) vaccine. Two cases of a 23-year-old woman and a 41-year-old man were presented with manifestations of condyloma acuminata type AGWs. The patients were immunocompetent and received single dose intralesional BCG vaccine on the largest lesion. Clinical improvements of AGWs lesions were noted starting on the 14th day after receiving therapy by the disappearance of some lesions with no recurrence and side effects. Intralesional BCG vaccine activates the immune system, treats other AGWs lesions that do not receive an intralesional injection, and also prevents recurrence. Although the intralesional BCG vaccine is effective for treating AGWs, further evaluation is still needed for its recurrence.

Sexual Dysfunction among Gynaecological Cancer Survivors: A Descriptive Cross-Sectional Study in Malaysia

BACKGROUND

Sexual dysfunction is a major issue among gynaecological cancer survivors. This study aimed to evaluate the prevalence of sexual dysfunction among survivors of gynaecological cancer in Malaysia and to determine its risk factors.

METHODS

A cross-sectional study was conducted of 116 married women with gynaecological cancer who attended the gynaeoncology and oncology clinics at Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Sociodemographic and clinical data were collected. Sexual dysfunction was measured using the Malay Version Female Sexual Function Index (MVFSFI). Univariate and multivariate logistic regression analyses were used to determine the risk factors of female sexual dysfunction.

RESULTS

The prevalence of sexual dysfunction among gynaecological cancer survivors was 60% (70 out of 116). Sexual dissatisfaction was the most prevalent domain of sexual dysfunction at 68.1%. Sexual dysfunction was significantly associated with low education levels (Primary level, AOR = 4.92, 95% CI: 1.12-21.63; secondary level, AOR = 4.06, 95% CI: 1.14-14.44). Non-Malays were significantly more likely to have sexual dysfunction compared with Malays (AOR = 3.57, 95% CI: 1.16-11.06). In terms of treatment, combinations of surgery and radiotherapy (AOR = 4.66, 95% CI: 1.01-21.47) as well as surgery and chemoradiation (AOR = 5.77, 95% CI: 1.20-27.85) were considered.

CONCLUSIONS

Gynaecological cancer survivors with lower education levels, non-Malay ethnicity, and receiving treatment combinations of surgery and radiotherapy or surgery and chemoradiation have a higher risk of sexual dysfunction. A holistic approach in managing the various sociocultural and clinical issues is required to prevent sexual dysfunction among these patients.

PD-L1 Expression in Endometrial Cancer and Its Association with Clinicopathological Features: A Systematic Review and Meta-Analysis

Simple Summary

In women, endometrial cancer is a crucial cancer cause-death, which is still not fully explored in its pathogenesis and immune system. Early detection is essential for proper treatment and follow-up in affected patients. This systematic review and meta-analysis aim to pool the prevalence of PD-L1 in endometrial cancer and its association with clinicopathological features. The pooled prevalence of PD-L1 was 34.26% in tumour cells, and 51.39% in immune cells among endometrial cancer patients. There was significant association of PD-L1 expression in both tumour cells and immune cells with advanced stage endometrial cancer. The presence of lympho-vascular invasion and poor overall survival were also associated with PD-L1 expression in immune cells. These information enable clinicians to stratify endometrial cancer patients for anti-PD-1/PD-L1 immune therapy.

Abstract

Endometrial cancer (EC) is one of the most common malignancies of the female genital tract and its current treatment mainly relies on surgical removal of the tumour bulk, followed by adjuvant radiotherapy with or without chemotherapy/hormonal therapy. However, the outcomes of these approaches are often unsatisfactory and are associated with severe toxicity and a higher recurrence rate of the disease. Thus, more clinical research exploring novel medical intervention is needed. Involvement of the immune pathway in cancer has become important and the finding of a high positive expression of programmed cell death-ligand 1 (PD-L1) in EC may offer a better targeted therapeutic approach. Numerous studies on the PD-L1 role in EC have been conducted, but the results remained inconclusive. Hence, this systematic review was conducted to provide an update and robust analysis in order to determine the pooled prevalence of PD-L1 expression in EC and evaluate its association with clinicopathological features in different focuses of tumour cells (TC) and immune cells (IC). A comprehensive literature search was conducted using the PubMed, Web of Science, and Scopus databases. Twelve articles between 2016 and 2021 with 3023 EC cases met the inclusion criteria. The effect of PD-L1 expression on the outcome parameters was estimated by the odds ratios (ORs) with 95% confidence intervals (CIs) for each study. The pooled prevalence of PD-L1 was 34.26% and 51.39% in the tumour cell and immune cell, respectively, among women with EC. The PD-L1 expression was significantly associated with Stage III/IV disease (in both TC and IC) and correlated to the presence of lympho-vascular invasion in IC. However, the PD-L1 expression in TC was not associated with the age groups, histology types, myometrial invasion, and lympho-vascular invasion. In IC, PD-L1 expression was not associated with age group, histology type, and myometrial invasion. The meta-analysis survival outcomes of PD-L1 high expression had a significant association with worse OS in IC but not in TC.

SARS-CoV-2 Infection in Pregnancy: Placental Histomorphological Patterns, Disease Severity and Perinatal Outcomes

The association between maternal COVID-19 infection, placental histomorphology and perinatal outcomes is uncertain. The published studies on how placental structure is affected after SARS-CoV-2 virus in COVID-19-infected pregnant women are lacking. We investigated the effects of maternal SARS-CoV-2 infection on placental histomorphology and pregnancy outcomes. A retrospective cohort study on 47 pregnant women with confirmed SARS-CoV-2 infection, matched with non-infected controls, was conducted. Relevant clinicopathological data and primary birth outcomes were recorded. Histomorphology and SARS-CoV-2 immunohistochemistry analyses of placental tissues were performed. Only 1 of 47 cases showed SARS-CoV-2 immunoreactivity in the syncytiotrophoblasts. Histologically, decidual vasculopathy (n = 22/47, p = 0.004), maternal vascular thrombosis (n = 9/47, p = 0.015) and chronic histiocytic intervillositis (n = 10/47, p = 0.027) were significantly higher in the COVID-19-infected placentas when compared to the control group. Maternal vascular thrombosis was a significant feature in the active COVID-19 group. A significant lower gestational age (p < 0.001)) at delivery and a higher caesarean section rate (p = 0.007) were observed in the active SARS-CoV-2-infected cases, resulting in a significant lower fetal-placental weight ratio (p = 0.022) and poorer Apgar score (p < 0.001). Notably, active (p = 0.027), symptomatic (p = 0.039), severe-critical (p = 0.002) maternal COVID-19 infection and placental inflammation (p = 0.011) were associated with an increased risk of preterm delivery. Altered placental villous maturation and severe-critical maternal COVID-19 infection were associated with an elevated risk of poor Apgar scores at birth (p = 0.018) and maternal mortality (p = 0.023), respectively.

The impact of the COVID-19 pandemic on the national HPV immunization program in Malaysia

In Malaysia, the HPV immunization program has been introduced since 2010 as part of the national immunization plan for female students aged 13 years old. It was a very successful immunization program with good responses from students and parents until the start of COVID-19 pandemic in 2020. The COVID-19 pandemic caused the schools to be closed and resulted about 225000 female students aged 13 years old either missed their vaccination or have incomplete doses of HPV vaccination in 2020 and 2021. This could possibly lead to an increase in cases of cervical cancer and genital warts in the upcoming years. Hence, a wellorganized catch-up HPV vaccination program is vital in ensuring the aim of achieving zero HPV-related infections in the future.

Dysregulated Exosomes Result in Suppression of the Immune Response of Pregnant COVID-19 Convalescent Women

A successful pregnancy outcome is dependent on a delicate balance between inflammatory and anti-inflammatory processes throughout the different trimesters. Interruption in this balance can lead to an adverse outcome resulting in pregnancy loss. Since late 2019, the emergence of the new SARS-CoV-2 virus has affected lives worldwide, including pregnant women; therefore, there is an urgent need to address different approaches in relation to prevention, diagnostics, and therapeutics. Early pregnancy is affected by SARS-CoV-2 infection leading to fetal demise. Available evidence also suggests that 90% of pregnant women infected with the SARS-CoV-2 virus seem to be asymptomatic. Nonetheless, it is still unclear how COVID-19 affects exosome production in pregnant women recovered from COVID-19 and how these exosomes regulate the adaptive immune response. In this study, we found several exosomes including CD9, CD31, CD40, CD45, CD41b, CD42a, CD62P, CD69, CD81, CD105, and HLA-DRDPDQ in the plasma of COVID-19-recovered pregnant women were significantly less abundant than the control group. Furthermore, to understand how these exosomes affect the adaptive immune response, we co-cultured the peripheral blood mononuclear cells (PBMCs) from healthy control (HC) pregnant women with exosomes of either Preg-HC or Preg-recovered COVID-19 women. We identified that Preg-recovered COVID-19 women have reduced capacity for the inflammatory cytokine TNF-α from cytotoxic CD8⁺ T cells. In summary, our study highlights that pregnant recovered COVID-19 women have reduced production of several exosomes and possess fewer immunogenic properties. Our study implicates that exosomes can control inflammation and antigen presentation capacity of immune cells, thus limiting the infection in pregnant women.

Antenatal Corticosteroids to Asian Women Prior to Elective Cesarean Section at Early Term and Effects on Neonatal Respiratory Outcomes

This exploratory study aimed to evaluate the effects of antenatal corticosteroids in singleton pregnancies of Asian women prior to elective cesarean section (CS) at early term on neonatal respiratory outcomes.

METHODS

This is a pilot and pragmatic randomized trial conducted at a university hospital in Malaysia. Women with singleton pregnancies planned for elective CS between 37+0 and 38+6 weeks gestation were randomly allocated into the intervention group, where they received two doses of IM dexamethasone 12 mg of 12 h apart, 24 h prior to surgery OR into the standard care, control group, and both groups received the normal routine antenatal care. The primary outcome measures were neonatal respiratory illnesses, NICU admission and length of stay.

RESULTS

A total of 189 patients were recruited, 93 women in the intervention group and 96 as controls. Between the steroid and control groups, the mean gestation at CS was similar, 266.1 ± 3.2 days (38 weeks) vs. 265.8 ± 4.0 days (37+6 weeks), p = 0.53. The mean birthweight of infants was 3.06 ± 0.41 kg vs. 3.04 ± 0.37 kg, p = 0.71. Infants with respiratory morbidities were primarily due to transient tachypnea of newborn (9.7% vs. 6.3%), and congenital pneumonia (1.1% vs. 3.1%) but none had respiratory distress syndrome. Only four infants required NICU admission (2.2% vs. 3.1%, p = 0.63). Their average length of stay was not statistically different; 3.5 ± 2.1 days vs. 5.7 ± 1.5 days, p = 0.27.

CONCLUSIONS

Elective CS at early term before 39 weeks was associated with a modest overall incidence of neonatal respiratory illness (10.1%) in this Asian population. Antenatal dexamethasone did not diminish infants needing respiratory support, NICU admission and length of stay.

Perception and knowledge of human papillomavirus (HPV) vaccine for cervical cancer prevention among fully vaccinated female university students in the era of HPV vaccination: a cross-sectional study

OBJECTIVE

To assess the perception and knowledge of cervical cancer prevention among fully vaccinated female university students in the era of human papillomavirus (HPV) vaccination.

DESIGN

Cross-sectional using a validated questionnaire.

SETTING

Face-to-face interview at a public university in Malaysia.

PARTICIPANTS

384 fully vaccinated female students were included in the study.

RESULTS

The total knowledge score in the questionnaire was 18 and was ranked according to score level into three groups: poor (score ≤5), moderate (score 6-10) and good (score ≥11). Mean score for knowledge of cervical cancer prevention was 8.24 (SD ±3.85), with 170 respondents (44.3%) scoring moderate knowledge level. The mean score for knowledge of HPV infection and its association with cervical cancer was 4.56±2.47, while the mean score for knowledge of HPV vaccination for cervical cancer prevention was 3.68 (SD ±1.98). A total of 186 (48.4%) respondents perceived that regular Pap smear was unnecessary after HPV vaccination. Respondents' perceived seriousness and susceptibility of HPV infection correlated well with knowledge of cervical cancer prevention. Two main reasons for their acceptance of HPV vaccine were self-health awareness and free vaccination.

CONCLUSION

The knowledge of HPV vaccination for cervical cancer prevention was average among vaccinated university students. Many of them had poor knowledge about Pap smear and did not consider regular Pap smear as an important cervical cancer screening tool following HPV vaccination. There is still a need for continued health education to improve the perception and knowledge about HPV infection and cervical cancer prevention among young adults in the community.

Distant recurrence of endometrial cancer more than 10 years after hysterectomy: a case report

OBJECTIVES

Endometrial cancer is the sixth most common cancer among women and recurrence of after 10 years is extremely rare.

CASE PRESENTATION

We reported a comprehensive review of histopathology, investigations and treatment regarding a woman with distant recurrence of endometrial cancer to rectus abdominis muscle after 23 years from the primary surgery. Previous published literatures of similar case were included into the review analysis. A total of 11 similar cases had been reported. Overall, 9 (81.8%) cases were stage 1 disease and only 2 cases were classified as stage II disease. The majority, 6 (54.5%) cases were endometrial adenocarcinoma. Majority of the cases shared the similarity of low grade endometrial cancer with positive oestrogen receptor immunophynetype.

CONCLUSIONS

Thus, the phenomenon of 'cell dormancy' was hypothesized to explain the mechanism of late recurrence for these cases.

PTEN protein expression has role in predicting disease-free-interval in endometrioid endometrial carcinoma

OBJECTIVES

To determine the significance of tumour PTEN protein expression in endometrioid endometrial carcinoma (EEC) and it is correlation with tumour characteristics.

METHODS

A total of 30 eligible archived paraffin-embedded tissue blocks from 61 EEC cases (January 2015-December 2017) were retrieved from the Histopathology Laboratory in Universiti Kebangsaan Malaysia Medical Centre (UKMMC) following institutional ethic approval. For PTEN protein detection, immunohistochemistry (IHC) staining was performed and the data was correlated with clinicopathologic parameters.

RESULTS

Fourteen samples (46.7%) showed positive PTEN protein expression, while 16 (53.3%) were negative. The mean age was 62.00 ± 9.51 years old, while the mean Body Mass Index (BMI) was 27.28 ± 7.16 kg/m². There was no significant difference between age (p=0.27, 95% CI: -10.98 to 3.21) and BMI (p=0.67, 95% CI: -4.30 to 6.58) with PTEN protein expression. There were significant correlation between PTEN protein expression with myometrial invasion (p=0.010), but not with lymphovascular space invasion (p=0.743), grade (p=0.532), stage (p=0.733) and CA-125 level (p=0.47). The higher stage correlates with the presence of LVSI (p=0.002). PTEN positive associated with longer disease-free-interval (p=0.025), but not improving the overall survival (p=0.38).

CONCLUSIONS

Positive PTEN protein expression correlates with less myometrial invasion.

Oncofertility in Islam: The Malaysian Perspective

The implementation of oncofertility services is of great importance among cancer survivors of reproductive age to ensure a good quality of life. However, the uptake of this service among Muslim patients is very challenging because of inconclusive laws or evidence based on the Islamic perspective. Hence, we summarized the limited evidence available to consolidate current recommendations for oncofertility practices in the Muslim population in Malaysia. The available “fatwa” and “muzakarah” regarding reproductive procedures and gamete cryopreservation in Islam was searched from the recommendations of local and international bodies, including published and unpublished sources. The relevant information was then extracted according to the current understanding of dilemmas in oncofertility practices in Malaysia, tabulated, and consolidated. Most of the available “fatwa” has been revised by recent “muzakarah” to suit current oncofertility practices. Most Islamic organizations support the practice of oncofertility in Muslim hence indicates that oncofertility services are permissible. Therefore, proper recommendations and counseling are paramount to ensure understanding among Muslim patients.

Complementary role of p57kip2 immunostaining in diagnosing hydatidiform mole subtypes

OBJECTIVES

Gestational trophoblastic disease comprises of a spectrum of pregnancy-related tumours which includes complete (CHM) and partial hydatidiform moles (PHM). Accurate diagnosis and subclassification of HM subtypes are crucial as prognosis differs. Histopathological examination using haemotoxylin and eosin (H&E) staining remains the basis for diagnosing HM, with only 80% accuracy. p57kip2 is a cyclin-dependent kinase inhibitor (CDKI) protein and is strongly paternally imprinted, being expressed from maternal allele. Therefore, complete mole (CHM) with only paternal genome has nearly absent expression of p57kip2 compared to partial mole (PHM) having both paternal and maternal genomes. This study is aimed to determine usefulness of p57kip2 immunohistochemistry (IHC) analysis in the diagnosis of HM subtypes.

METHODS

A total of 82 archived paraffin embedded HM tissues with subtypes classified based on H&E staining - 39 (47.5%) CHM, 41 (50.0%) PHM and two (2.43%) unclassified molar pregnancy were retrieved. All tissue samples were subjected for p57kip2 IHC analysis and HM subtypes were then reclassified.

RESULTS

A total of 66 cases (80.5%) were re-classified as CHM, 14 cases (17.1%) as PHM and two cases (2.4%) were decidual and cystic tissues. Analysis using p57kip2 immunostaining showed a diagnostic discrepancy of 33.0% from routine H&E staining and helps to improve the characterisation of the HM subtypes specifically at early gestations which have less distinctive morphologies.

CONCLUSIONS

IHC using p57kip2 monoclonal antibody should be considered as a routine ancillary test to H&E in improving the diagnosis of HM subtypes particularly in developing countries with limited resources.

Prognostic Value of TNFR2 and STAT3 among High-Grade Serous Ovarian Cancer Survivors According to Platinum Sensitivity

This study's goal was to determine the protein expression level of tumour necrosis factor receptor 2 (TNFR2) and signal transducer and activator of transcription 3 (STAT3) in high-grade serous ovarian cancer (HGSC) tissues in relation to the platinum-based chemotherapy response and the prognosis outcome. A total of 25 HGSC patients underwent primary surgical debulking followed by first-line adjuvant platinum-based chemotherapy. Tissue microarray (TMA) slides were constructed utilising archived formalin fixed paraffin embedded (FFPE). The protein expression of TNFR2 and STAT3 were analysed using immunohistochemistry (IHC) staining and subsequently were correlated to the clinicopathological characteristics, platinum sensitivity as well as the duration of progression-free survival. About 14 out of 25 patients (56.0%) were platinum-sensitive. The progression free survival was significantly longer in the platinum-sensitive (PS) group when compared to those with the platinum-resistant group (PR), p = 0.0001. Among patients with TNFR2 strong expression on ovarian tissue, there was a significantly longer progression-free survival interval of 540 days in the PS group compared to PR, p = 0.0001. Patients with STAT3 expression also showed significantly better progression-free survival of 660 days in the PS group when compared to the PR group, p = 0.0001. In conclusion, patients with strong TNFR2 and STAT3 expression in the ovarian tissue had significantly longer progression-free survival interval in the PS group. Nevertheless, further research with a larger number of tissues may be required to demonstrate further significant differences.

New Predictive Biomarkers for Ovarian Cancer

Ovarian cancer is the eighth-most common cause of death among women worldwide. In the absence of distinctive symptoms in the early stages, the majority of women are diagnosed in advanced stages of the disease. Surgical debulking and systemic adjuvant chemotherapy remain the mainstays of treatment, with the development of chemoresistance in up to 75% of patients with subsequent poor treatment response and reduced survival. Therefore, there is a critical need to revisit existing, and identify potential biomarkers that could lead to the development of novel and more effective predictors for ovarian cancer diagnosis and prognosis. The capacity of these biomarkers to predict the existence, stages, and associated therapeutic efficacy of ovarian cancer would enable improvements in the early diagnosis and survival of ovarian cancer patients. This review not only highlights current evidence-based ovarian-cancer-specific prognostic and diagnostic biomarkers but also provides an update on various technologies and methods currently used to identify novel biomarkers of ovarian cancer.

Oncologist-led BRCA counselling improves access to cancer genetic testing in middle-income Asian country, with no significant impact on psychosocial outcomes

BACKGROUND

Identifying patients with BRCA mutations is clinically important to inform on the potential response to treatment and for risk management of patients and their relatives. However, traditional referral routes may not meet clinical needs, and therefore, mainstreaming cancer genetics has been shown to be effective in some high-income and high health-literacy settings. To date, no study has reported on the feasibility of mainstreaming in low-income and middle-income settings, where the service considerations and health literacy could detrimentally affect the feasibility of mainstreaming.

METHODS

The Mainstreaming Genetic Counselling for Ovarian Cancer Patients (MaGiC) study is a prospective, two-arm observational study comparing oncologist-led and genetics-led counselling. This study included 790 multiethnic patients with ovarian cancer from 23 sites in Malaysia. We compared the impact of different method of delivery of genetic counselling on the uptake of genetic testing and assessed the feasibility, knowledge and satisfaction of patients with ovarian cancer.

RESULTS

Oncologists were satisfied with the mainstreaming experience, with 95% indicating a desire to incorporate testing into their clinical practice. The uptake of genetic testing was similar in the mainstreaming and genetics arm (80% and 79%, respectively). Patient satisfaction was high, whereas decision conflict and psychological impact were low in both arms of the study. Notably, decisional conflict, although lower than threshold, was higher for the mainstreaming group compared with the genetics arm. Overall, 13.5% of patients had a pathogenic variant in BRCA1 or BRCA2, and there was no difference between psychosocial measures for carriers in both arms.

CONCLUSION

The MaGiC study demonstrates that mainstreaming cancer genetics is feasible in low-resource and middle-resource Asian setting and increased coverage for genetic testing.

The Effect of Surgical Intervention of Endometriosis to CA-125 and Pain

Endometriosis is an inflammatory condition characterised by the presence of endometrial growth beyond the uterine cavity. It is a debilitating disease requiring multiple modalities of treatment. In considering surgery as the option of treatment, the benefits should outweigh the risk. Besides direct surgical risk, intervention may lead to a reduction of ovarian reserve, in addition to premature menopause and low fecundity. To date, there is an inconclusive evidence to support any specific parameters in monitoring disease progression following surgical intervention. Serum cancer antigen (CA)-125 is expressed by coelomic epithelium and has been extensively studied as a biomarker for endometriosis. Elevated expression of CA-125 has been shown in endometrial tissues and the marker increased indirectly from peritoneal irritation that accompanies an extensive form of endometriosis. Additionally, the visual analogue scale (VAS) scores have been used as an objective measurement for measuring pain, especially in a complex disease such as endometriosis. This review aims to consolidate a series of clinical trials that utilised CA-125 level and VAS score as tools for monitoring patients undergoing surgery for endometriosis.

A single centre experience of metabolic syndrome and endometrial carcinoma: 5 years review

Endometrial cancer (EC) has been found to have a strong association with overweight and obesity. The aim of this study was to evaluate the link between metabolic syndrome and EC among patients. A total of 119 patients with histologically confirmed EC were recruited. About 102 cases of endometrioid carcinoma (Type I) and serous (n = 7), clear cell (n = 3) and carcinosarcoma (n = 7) were the Type II. Metabolic syndrome was significantly associated with increased risk of Type I EC (OR = 3.43, 95% CI = 1.12-10.46, p < .05) where obesity risk revealed as the main factor in Type I EC (OR = 3.88, 95% CI = 1.27-11.85, p < .05). There was no significant difference between both subtypes with other metabolic components and no impact on patients' overall survival and disease-free survival (p > .05). Metabolic syndrome was positively associated with an increased risk of Type I EC with obesity being the most influential risk factor.Impact statementWhat already known on this subject? Endometrial cancer (EC) is one of the most prevalent cancers worldwide and have a strong association with overweight and obesity of at least 40%, but there is conflicting evidence of an association of EC with metabolic syndrome (MS).What result of this study add? This study evaluated the link between EC and MS, such as high blood pressure, BMI, fasting blood sugar, triglyceride, Hyper Density Lipoprotein (HDL).What implications are of these findings for clinical practice & further research? Type I EC had and association with MS with obesity is the most potent risk factor. As the prevalence of metabolic syndrome is alarmingly high among adult Malaysians, the incidence of EC is projected to increase in the coming years. Proactive preventative measures and intervention essential for reducing the incidence of endometrial cancers. Future research to clarify the association between metabolic syndrome and endometrial cancer survival and to investigate other lifestyle factors that may affect the prognosis is needed.

The Psychological Impact of Movement Restriction during the COVID-19 Outbreak on Clinical Undergraduates: A Cross-Sectional Study

The COVID-19 pandemic has resulted in a Movement Control Order (MCO) in Malaysia and the subsequent closure of all educational institutions. We aimed to examine the psychological impact of the MCO among clinical undergraduates. A cross-sectional study was conducted using self-reported questionnaires that were distributed online using the Depression, Anxiety and Stress Scale-21 (DASS 21), Short Warwick Edinburgh Mental Well-Being Scale (SWEMWBS), and the newly designed MCO effect questionnaire. Seven hundred seventy-two students completed the survey. The prevalence of psychological distress was 52.8%, with around 60% of respondents reporting disruption to their daily lives. Older (p = 0.015) and more senior students (p < 0.001) were less likely to be anxious than their younger and junior counterparts, respectively. A greater number of social support (three or more) was linked to a lower score of depression (p = 0.005) and stress (p = 0.045). Undergraduates who received family support demonstrated lower depression scores (p = 0.037) and higher mental wellbeing (p = 0.020) compared to those without. Government support was independently associated with a lesser risk of depressive symptoms (Adjusted odds ratio, AOR 0.68; 95% confidence interval, CI 0.47–0.99) and a greater sense of mental wellbeing (AOR 1.54; 95% CI 1.06–2.22). The present finding provides evidence of a high prevalence of psychological distress among clinical undergraduates during the COVID-19 pandemic. Appropriate social support is important in alleviating anxiety and stress and promoting greater mental wellbeing amongst students during the nationwide quarantine.

Cellulitis: An unusual manifestation of Neisseria meningitidis infection

INTRODUCTION

Neisseria meningitidis infections often cause severe meningitis as well as bacteraemia. However, cellulitis in meningococcal diseases have rarely been described. Here, we report a case of right lower limb cellulitis caused by N. meningitidis.

CASE REPORT

A 69-year-old woman presented with fever and lower limb swelling. She had diabetes mellitus, hypertension, dyslipidaemia and a history of surgical resection of vulvar carcinoma. N. meningitidis was isolated from her blood culture.

DISCUSSION

This report provides additional evidence in support of N. meningitidis as a cause of cellulitis.

Pregnancy outcomes in systemic lupus erythematosus (SLE) women

Background Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory condition with multi-organ involvement predominantly affecting young women. There are very limited studies in pregnancy in Asian SLE patients and therefore we embarked on this study to identify pregnancy outcomes of Malaysian women with SLE. Materials and methods We performed a retrospective study of pregnancy outcomes in SLE patients in our institution from January 2007 to December 2014. A total of 71 pregnancies from 44 women were analysed. Results The mean age of our cohort was 30.5 ± 3.9 years. The rate of active disease at conception, antiphospholipid syndrome and lupus nephritis were 22.5%, 32.4% and 57.7% respectively. SLE flare occurred in 33 out of 71 pregnancies whereas 19 pregnancies were complicated with preeclampsia. The livebirth rate for our cohort was 78.9%, whilst preterm delivery was 42.9%. On univariate analysis, active disease and flare in pregnancy were both strongly associated with foetal loss and preterm delivery. Lupus nephritis (p = 0.011), SLE flare (p = 0.008) and antiphospholipid syndrome (p = 0.032) significantly increased the risk of preeclampsia. Aspirin and hydroxychloroquine were protective against foetal loss [odds ratio (OR) 0.12] and preeclampsia (OR 0.25), respectively. On multivariate analysis, active disease was a predictor of SLE flare (p = 0.002) and foetal loss (p = 0.018) and SLE flare was the main predictor of preterm delivery (p = 0.006). Conclusions Pregnancies in women with SLE should be planned and aspirin and HCQ use were beneficial in reducing adverse pregnancy outcomes.

Ovarian and uterine leiomyosarcoma: which one is the primary?

Uterine leiomyosarcoma (LMS) is rare but primary ovarian LMS is even rarer constituting less than 0.1% of all gynecologic disorders. Neither histologic features nor immunohistochemistry could be utilized to distinguish between uterine or ovarian origin. We illustrate a clinical case of metastatic LMS to the ovary in a woman with underlying uterine fibroid presenting with anemia with heavy menses.

Reviewing the role of progesterone therapy in endometriosis

Endometriosis is a benign, chronic inflammatory condition characterized by the presence and growth of endometrial implants outside the uterine cavity. The cause of endometriosis is multifactorial. It is due to the diversity of hypothesis and plausibility of hormonal alterations which could play a major role. Evidence has shown that progesterone resistance is a key factor for endometriosis sufferers. Medical therapy can avoid surgical intervention, which may lead to a reduced in ovarian reserve, and its effects of earlier menopause and reduced fecundity. Progesterone receptor isoform has provided new insight as the potential treatment. Progestin, anti-progestin and selective progesterone receptor modulators usage, which target these receptors, could avoid hypo-estrogenic side effects, which can be debilitating. Numerous types of these medications have been used on and off labeled to treat endometriosis with varying success. This review aims to consolidate series of clinical trials using progestins in endometriosis.

Post-transcriptional regulation of microRNAs in cancer: From prediction to validation

MicroRNA (miRNA) is a small non-coding RNA with an established function to regulate genes at the post-transcriptional level leading to suppression or degradation of its messenger RNA expression (mRNA). Its dysregulation plays a vital role in a variety of biological and pathological processes including cancer. A lot of algorithms have been established to predict the target sites of miRNA, but experimentally identifying and validating its target region is still lacking. Guidance in experimental procedures is really needed to find genuine miRNA targets. Therefore, in this review, we provide an outline on the workflow in predicting and validating the targeted sites of miRNA using several methods as a guideline for the scientists. The final outcome of this type of experiment is essential to explore the major impact of miRNAmRNA interaction involved in the biological processes and to assist miRNA-based drug development in the future.

Expression of NAD(P)H quinone dehydrogenase 1 (NQO1) is increased in the endometrium of women with endometrial cancer and women with polycystic ovary syndrome

OBJECTIVE

Women with a prior history of polycystic ovary syndrome (PCOS) have an increased risk of endometrial cancer (EC).

AIM

To investigate whether the endometrium of women with PCOS possesses gene expression changes similar to those found in EC.

DESIGN AND METHODS

Patients with EC, PCOS and control women unaffected by either PCOS or EC were recruited into a cross-sectional study at the Nottingham University Hospital, UK. For RNA sequencing, representative individual endometrial biopsies were obtained from women with EC, PCOS and a woman unaffected by PCOS or EC. Expression of a subset of differentially expressed genes identified by RNA sequencing, including NAD(P)H quinone dehydrogenase 1 (NQO1), was validated by quantitative reverse transcriptase PCR validation (n = 76) and in the cancer genome atlas UCEC (uterine corpus endometrioid carcinoma) RNA sequencing data set (n = 381). The expression of NQO1 was validated by immunohistochemistry in EC samples from a separate cohort (n = 91) comprised of consecutive patients who underwent hysterectomy at St Mary's Hospital, Manchester, between 2011 and 2013. A further 6 postmenopausal women with histologically normal endometrium who underwent hysterectomy for genital prolapse were also included. Informed consent and local ethics approval were obtained for the study.

RESULTS

We show for the first that NQO1 expression is significantly increased in the endometrium of women with PCOS and EC. Immunohistochemistry confirms significantly increased NQO1 protein expression in EC relative to nonmalignant endometrial tissue (P < .0001).

CONCLUSIONS

The results obtained here support a previously unrecognized molecular link between PCOS and EC involving NQO1.

Antenatal scoring system in predicting the success of planned vaginal birth following one previous caesarean section

This was a prospective observational study to determine the predictive factors for a successful vaginal birth after caesarean section (VBAC) and to develop a relevant antenatal scoring system. Patients with one previous caesarean section were included in this study. All data including maternal demographics, obstetric history, pregnancy progress and outcomes were collected and analysed. A total of 142 out of the 186 women (76.3%) had successful VBAC. History of previous vaginal delivery and non-recurrent indications for previous caesarean section were the significant predictive factors for a successful VBAC. Five variables for our scoring tool were selected. By using a proposed mean score of 4 out of 7, the scoring system had a sensitivity of 81.0%, specificity of 52.3% and a positive predictive value of 84.6%. VBAC antenatal scoring system was potentially a useful predictive tool in antenatal counselling. Impact statement What is already known on this subject: Planned vaginal birth after caesarean section (VBAC) is an important strategy to limit the overall caesarean section rate, which is related to maternal morbidities. However, trial of vaginal delivery does involve potential complications including scar dehiscence, postpartum haemorrhage and emergency hysterectomy. What the results of this study add: Clinical predictors of a successful VBAC include non-recurrent indications for the previous caesarean section, previous vaginal delivery, spontaneous onset of labour and birthweight less than 4kg. There were multiple screening tools developed to predict the likelihood of successful VBAC. These scoring systems involved various variables such as age, ethnicity, Bishop's score and previous caesarean indication. We had prospectively developed an antenatal scoring system based on five variables. Our result showed that patient with a score of four and above will have around 85% chance of successful VBAC. What the implications are of these findings for clinical practice and/or further research: We have also found that, estimated foetal weight based on ultrasound scan is a potential predictor for successful VBAC. This simple scoring method will be useful in-patient counselling regarding mode of delivery after one previous caesarean section. A multicentre study involving large cohort of patients is ideal to validate our scoring system.

Spontaneous conception following GnRHa and progestogen therapy in adenomyosis

Adenomyosis is a common gynaecological disorder that is associated with infertility and miscarriage. We report a case of adenomyosis presented with urinary retention and infertility. The patient successfully conceived spontaneously following GnRHa followed by progestogen therapy. This treatment option might provide a synergistic effect in improving fertility and pregnancy outcome for women with adenomyosis. This modality has no potential surgical risk; it minimises the long-term side effects of GnRHa and also provides luteal support.

Up-regulation of genes involved in the insulin signalling pathway (IGF1, PTEN and IGFBP1) in the endometrium may link polycystic ovarian syndrome and endometrial cancer

BACKGROUND

Endometrial cancer (EC) is the most common gynaecological cancer amongst women in the UK. Although previous studies have found that women with polycystic ovary syndrome (PCOS) have at least a three-fold increase in endometrial cancer (EC) risk compared to women without PCOS, the precise molecular mechanisms which link between PCOS and EC remain unclear. It has been suggested that insulin resistance may contribute to the increased risk of EC in PCOS. The specific expression of genes related to the insulin-signalling pathway including the IGF system in the endometrium of women with PCOS has however never been measured and compared to that in women with EC without PCOS and control women without EC or PCOS. .

OBJECTIVES

To test the hypothesis that insulin signalling plays a key role in the development of EC in women with PCOS by measuring and comparing the expression of three key genes involved in the insulin signalling pathway (IGF1, PTEN and IGFBP1) in endometrial tissue obtained from three groups of women; PCOS without EC, women with EC without PCOS and non-PCOS women without EC (controls). We also aimed to determine the correlation between the gene expressions to various clinical variables among participants.

METHODS

This was a cross-sectional study of 102 women in 3 groups (PCOS, EC and controls) at a University teaching hospital in the United Kingdom. Clinical assessment (blood pressure, body mass index (BMI) and waist-hip-circumference ratio), venepuntures (fasting blood sugar, insulin, lipid profile, hormones) and endometrial tissue biopsies were taken in all participants. Endometrial tissue RNA extraction was performed before real time polymerase-chain-reaction for the genes of interest (IGF1, IGFBP1 and PTEN) was carried out. To compare the baseline characteristics of the study population, One-Way-ANOVA test or the Independent t-test was used. For variables that were not normally distributed, the Spearman correlation test was used to calculate the r value. A "p" value of <0.05 was considered statistically significant.

RESULTS

IGF1, IGFBP1 and PTEN gene expression were significantly up-regulated in the endometrium of PCOS and EC women compared to controls. However there was no significant difference in the expression of these genes in PCOS compared to EC endometrium. The BMI of women with PCOS and controls, were not significantly different (29.28 (± 2.91) vs 28.58 (± 2.62) kg/m(2)) respectively, women with EC however had a higher mean BMI (32.22 (± 5.70) kg/m(2)). PCOS women were younger (31.8 (± 5.97) years) than women with EC (63.44 (± 10.07) years) and controls (43.68 (± 13.12) years). The changes in gene expression were independent of BMI, waist hip ratio, estradiol and androgen levels. Protein validation test in the serum samples in the three groups were consistent with the gene findings.

CONCLUSION

Women with PCOS and EC have an increased endometrial expression of genes (IGF1, IGFBP1 and PTEN) involved in the insulin signalling pathway compared with control women. This may explain the increased risk of EC in PCOS women. This study provides a strong basis for clinical trials aiming to prevent EC in women with PCOS by investigating drugs targeting the insulin signalling pathway. This panel of genes may also serve as clinically useful early biomarkers which predict which women with PCOS will go on to develop EC.

The effect of Metformin on endometrial tumor-regulatory genes and systemic metabolic parameters in polycystic ovarian syndrome--a proof-of-concept study

The aim of this proof-of-concept study was to determine the effects of three-month Metformin therapy on the expression of tumor-regulatory genes (p53, cyclin D2 and BCL-2) in the endometrium of women with polycystic ovary syndrome (PCOS). A total of 40 women, aged between 21 and 45 years with PCOS (Rotterdam criteria) were recruited. The participants were assessed at pre- and 3-month-post-Metformin therapy for the menstrual regularities, weight reduction, Ferriman Galway scores, fasting blood glucose (FBG), total cholesterol, LDL, HDL and p53, BCL-2 and cyclin D2 gene expression. Five participants conceived spontaneously after the initial recruitment. Majority (68%) resumed regular menstrual cycles after Metformin. There were significant reduction in BMI (p = 0.001), weight (p = 0.001) and Ferriman Galway scores (p = 0.001). A significant improvement was seen in mean FBG (p = 0.002), total cholesterol (p = 0.001), LDL (p = 0.003) and HDL cholesterol levels (p = 0.015). Tumor suppressor gene (p53) was significantly up-regulated after Metformin (10 out of 14 women), with p value 0.016. BCL-2 and cyclin D2 (oncogenes) were slightly up-regulated without significant difference (p = 0.119 and 0.155, respectively). In conclusion, Metformin therapy improved clinical and metabolic parameters in women with PCOS and up-regulated p53 tumor suppressor gene significantly. Further studies are however required to independently validate our findings.

A case report: metastatic choriocarcinoma to the gum

Choriocarcinoma is a rare neoplasia with a tendency of distant metastasis although highly sensitive to chemotherapy renders a good prognosis and outcome. Lungs, liver and cerebral metastasis are commonly implicated with maxillofacial region rarely involved. We illustrate a case of overwhelming metastatic choriocarcinoma to lungs, liver, brain and to the extreme of gum metastasis. Decompressive craniectomy for intracranial bleeding, multiple transfusions to correct anaemia and coagulopathy were done before high-risk-regime chemotherapy. Despite this, due to fulminant multi-organs involvement she finally succumbed to death. In conclusion, gum bleeding in choriocarcinoma may suggest metastasis and poor prognosis.