Clinical-pathological presentation, treatment and outcomes of ovarian cancer cases at moi teaching and referral hospital (mtrh), eldoret

Introduction: Ovarian cancer is the third most frequent cause of death amongst gynecological cancers both locally and globally. It presents with vague nonspecific symptoms and is histologically heterogeneous. Ovarian cancer management is primarily surgical followed by adjuvant chemotherapy depending on the histological type and the surgical stage. Objectives: To determine the clinical-pathological presentation, treatment and outcomes of ovarian cancer patients at Moi Teaching and Referral Hospital (MTRH), Eldoret. Methods: This was a retrospective chart review of ovarian cancer patients managed between January 2010 and August 2017 at MTRH. Data were analyzed using STATA version 15. Survival trends were generated using Kaplan Meier method. Results: A total of 124 medical charts of patients with ovarian cancer were retrieved, 29 had incomplete data and were excluded, and 95 were evaluable and included in this review. Over half, (63%) presented in stage 3 and 4 though there was no significant association between histology and stage of disease [X2(6) =4.72, p=0.58]. The median age at diagnosis was 47 years with 55-80 years being the modal age group (36%). Majority (57%) were married and 83.9% were unemployed. Only 66% had documented histopathology, with Epithelial Ovarian Cancer (EOC) being most common (70%), [serous (50%) and mucinous (11.4%)]. Sex cord stromal tumors 11%. Germ cell tumors amounted to 11% (dygerminomas 50%and Yolk sac tumors (25%) Bivariate analysis revealed significant association only between histology and parity [X2 (6) = 28.8, p\u3c0.001]. Those reviewed contributed a total of 138.2 person-years to the study and 11(12%) died, giving a diseasespecific mortality rate of 79.6 per 1,000 person years (95% CI: 44.1-143.8). Mortality was highest among those with epithelial histology 109 (95% CI: 48.8-241.9) per 1,000 person years and those who had neoadjuvant chemotherapy then surgery as a treatment option, 373.1 (95% CI: 93.3-1491.8) per 1,000 person years. Those who underwent upfront surgery followed by adjuvant chemotherapy and sex cord stromal cancer had higher survival probability. Conclusion: Ovarian cancer at MTRH is diagnosed at advanced stages III and IV of disease and has a lower median age at presentation. EOC is the commonest histological type and serous subtype is the most lethal. Mortality was highest among those with EOC and those who underwent neoadjuvant chemotherapy. Granulosa cell tumor is the only sex cord stromal type reported in our setting and it exhibited a higher survival probability. Germ cell tumors were mainly found in nulliparous women

Epidemiological profile and clinico-pathological features of pediatric gynecological cancers at Moi Teaching & Referral Hospital, Kenya

Background: The main pediatric (0–18 years) gynecologic cancers include stromal carcinomas (juvenile granulosa cell tumors and Sertoli-Leydig cell tumors), genital rhabdomyosarcomas and ovarian germ cell. Outcomes depend on time of diagnosis, stage, tumor type and treatment which can have long-term effects on the reproductive career of these patients. This study seeks to analyze the trends in clinical-pathologic presentation, treatment and outcomes in the cases seen at our facility. This is the first paper identifying these cancers published from sub-Saharan Africa. Method: Retrospective review of clinico-pathologic profiles and treatment outcomes of pediatric gynecologic oncology patients managed at MTRH between 2010 and 2020. Data was abstracted from gynecologic oncology database and medical charts. Results: Records of 40 patients were analyzed. Most, (92.5%, 37/40) of the patients were between 10 and 18 years. Ovarian germ cell tumors were the leading histological diagnosis in 72.5% (29/40) of the patients; with dysgerminomas being the commonest subtype seen in 12 of the 37 patients (32.4%). The patients received platinum-based chemotherapy in 70% of cases (28/40). There were 14 deaths among the 40 patients (35%) Conclusion: Surgery remains the main stay of treatment and fertility-sparing surgery with or without adjuvant platinum-based chemotherapy are the standard of care with excellent prognosis following early detection and treatment initiation. LMICs face several challenges in access to quality care and that affects survival of these patients. Due to its commonality, ovarian germ cell cancers warrant a high index of suspicion amongst primary care providers attending to adnexal masses in this age group

Use of Palliative Cisplatinum for Advanced Cervical Cancer in a Resource-Poor Setting: A Case Series From Kenya

Purpose: To evaluate the effectiveness and feasibility of cisplatinum for palliative treatment of advanced cervical cancer in a resource-poor setting. Methods: An observational case series is reported from a university teaching hospital in Kenya. All women presenting with advanced cervical cancer and planned for palliative cisplatinum therapy from 2010 to 2014 were included. Women were treated with cisplatinum 50 mg/m2 every 4 weeks in an outpatient setting. Data on tumor stage and symptoms control were prospectively collected in an electronic database. The main outcome measure was control of symptoms such as bleeding, discharge, and pain. Results: Of the women who originally presented with bleeding, 62% reported improvement in this symptom, 31.3% reported the bleeding completely stopped, 58% had improvement of their vaginal discharge, and 20.5% reported complete resolution. Of the women who presented with pain, 54% reported improvement; 30.9% reported pain had completely resolved. After each treatment cycle, approximately 30% of patients did not return for their next treatment. Conclusion: Cisplatinum as palliative treatment of advanced cervical cancer is feasible in a resource-poor setting and leads to effective symptom control. However, unknown barriers may inhibit women from returning for regular treatment

Use of Palliative Cisplatinum for Advanced Cervical Cancer in a Resource-Poor Setting: A Case Series From Kenya

Purpose: To evaluate the effectiveness and feasibility of cisplatinum for palliative treatment of advanced cervical cancer in a resource-poor setting. Methods: An observational case series is reported from a university teaching hospital in Kenya. All women presenting with advanced cervical cancer and planned for palliative cisplatinum therapy from 2010 to 2014 were included. Women were treated with cisplatinum 50 mg/m2 every 4 weeks in an outpatient setting. Data on tumor stage and symptoms control were prospectively collected in an electronic database. The main outcome measure was control of symptoms such as bleeding, discharge, and pain. Results: Of the women who originally presented with bleeding, 62% reported improvement in this symptom, 31.3% reported the bleeding completely stopped, 58% had improvement of their vaginal discharge, and 20.5% reported complete resolution. Of the women who presented with pain, 54% reported improvement; 30.9% reported pain had completely resolved. After each treatment cycle, approximately 30% of patients did not return for their next treatment. Conclusion: Cisplatinum as palliative treatment of advanced cervical cancer is feasible in a resource-poor setting and leads to effective symptom control. However, unknown barriers may inhibit women from returning for regular treatment

Cisplatin for The palliative treatment of cervical cancer at Moi Teaching and Referral Hospital, Eldoret, Kenya: A two-year experience

Objective: In Sub Saharan Africa access to radiation therapy for women with advanced cervical cancer is poor due to the scarcity of radiation machines. In Kenya there is one public functional cobalt machine for a population of 40 million. The cost both direct and indirect are mostly too high for women. We adapted the use of Cisplatin 50 mg/m2 with a 3-4 week interval as an alternative. The effect of this treatment for symptom control is evaluated. Methods: Women with advanced stage cervix cancer who were not able to go for radiotherapy were planned for palliative chemotherapy with cisplatin 50 mg/m2 iv in combination with iv fluids and antiemetics. We continued chemotherapy until symptoms had subsided or to a maximum of 6 cycles. All women that were offered palliative chemotherapy were included for this study. Data were collected systematically at every visit and captured in an electronic database. Results are evaluated using a descriptive analysis. Results: In 2011 and 2012 88 women were planned for palliative chemotherapy. 61 went on to have at least one course of chemo. The women not getting chemo progressed quickly, were unfit due to kidney failure, sought treatment elsewhere or were lost to follow up. Stage was distributed as follows: FIGO Stage 1 1.1%, 2A 1.1% (both women delayed treatment and came back with advanced stage), 2B 9.1%, 3A 24%, 3B 55%, 4A 9.1%. The median number of three courses were given (range 1-6) On presentation 88% of women had bleeding, 69% had discharge and 67% complained of pain. For the women that got at least one course of chemo and who could be evaluated during a follow up visit, bleeding improved for 37/43(86%) women, discharge improved for 28/36(78%) women and pain improved for 24/35(69%) women. Conclusion: Prior to initiating this program advanced cervical cancer patients who presented to hospital were transfused and sent home to die. We have demonstrated that palliative chemotherapy with Cisplatin is feasible and effective in a low resource setting. Bleeding, discharge and pain all improved for the majority of patients who presented to hospital with advanced cervix cancer

Cervical cancer treatment for operable lesions in a low-resource contemporary setting

Background: To compare HIV+ and HIV- women with operable cervical cancer in a low resource contemporary setting. Methods: A retrospective study using well-matched controls from a Kenyan teaching and referral hospital. Results: 183 women were treated for cervical cancer between October 2007 and June 2011. The histologic subtype was squamous cell in all but one case. At presentation, 28 had operable lesions (Stage IA1–IIB1); 7 more received neoadjuvant chemotherapy prior to surgery. HIV seroprevalence was 54% (18/33) among initial operative cases and 57% among the neoadjuvant group (p=ns). Mean age was 42 (HIV+), and 43 (HIV-), (range 25-64). HIV- vs. HIV+ cervical cancer patients (mean CD4 count 373, 50%\u3c200) were detected by visual inspection with acetic acid (VIA) (18% (2/11)vs 68% (15/22) p=.099), symptoms (27%(3/11) vs 14%(3/22) p=.43), or Pap smear (45% (5/11) vs .09% (2/22) p=.06), respectively.HIV+ patients (two Stage IB1, two Stage IB2) did not require more downstaging than HIV- patients (two stage IIB, one stage IIIA) before surgery (18% (4/22) vs 27% (3/11) p=.63). Surgical treatments were not statistically different in either group and included radical hysterectomy(25), total abdominal hysterectomy(2), cesarean hysterectomy(1), and total vaginal hysterectomy(5). Postoperative complications included fever, dehiscence, DVT, ileus, fistula, and infectious complications (chest, urinary tract, wound). One HIV- patient suffered postoperative fever, vesicovaginal fistula, and wound dehiscence (overall complications .06%).Lymph node involvement was noted in 7 HIV+ and 3 HIV- patients who underwent full staging procedures (p=.004). Conclusions: In patients with operable cervical cancer, HIV serostatus does not affect complication rate or influence need for downstaging prior to surgery compared to a well-matched control group. HIV+ patients were not more likely to receive neoadjuvant chemotherapy but were more likely to have positive lymph nodes. VIA detected the majority of cervical cancers HIV+ patients

Successes and challenges of establishing a cervical cancer screening and treatment program in western Kenya

Objective; To describe the challenges and successes of integrating a public-sector cervical screening program into a large HIV care system in western Kenya. Methods; The present study was a programmatic description and a retrospective chart review of data collected from a cervical screening program based on visual inspection with acetic acid (VIA) between June 2009 and October 2011. Results; In total, 6787 women were screened: 1331 (19.6%) were VIA-positive, of whom 949 (71.3%) had HIV. Overall, 206 women underwent cryotherapy, 754 colposcopy, 143 loop electrical excision procedure (LEEP), and 27 hysterectomy. Among the colposcopy-guided biopsies, 27.9% had severe dysplasia and 10.9% had invasive cancer. There were 68 cases of cancer, equating to approximately 414 per 100 000 women per year. Despite aggressive strategies, the overall loss to follow-up was 31.5%: 27.9% were lost after a positive VIA screen, 49.3% between biopsy and LEEP, and 59.6% between biopsy and hysterectomy/chemotherapy. Conclusion; The established infrastructure of an HIV treatment program was successfully used to build capacity for cervical screening in a low-resource setting. By using task-shifting and evidence-based, low-cost approaches, population-based cervical screening in a rural African clinical network was found to feasible; however, loss to follow-up and poor pathology infrastructure remain important obstacles

Subcutaneous metastasis of cancer of the endometrium

Background: Cancer of the endometrium is the third most common gynecological malignancy after cancer of the cervix and ovary in Kenya. Subcutaneous metastasis is unusual site for endometrial cancer. Few cases of cutaneous and subcutaneous metastases from cancer of endometrium have been reported in the literature. The main areas of cutaneous and subcutaneous metastases are abdominal, perineal surfaces, skin and toes. Disseminated lesions are associated with hematogenous spread, while some occur via lymphatic spread or contiguity. Case Presentation: We present a case of a 45-year-old female, Para 5 + 0, who presented to our gynecologic oncology clinic in July 2017. The patient was referred from a peripheral health facility for chemotherapy following radical hysterectomy in May 2017 for endometrial cancer. Histology results of the specimen taken during surgery showed endometrial Ca stage 2, grade 3. The patient developed a swelling on the right leg 6 months after completion of 6 cycles of carboplatin and paclitaxel. Biopsy from the leg showed features consistent with metastatic endometrioid adenocarcinoma. The patient was started on pegylated liposomal doxorubicin. Local radiation of the metastatic subcutaneous lesion was also done. Conclusion: Cutaneous and subcutaneous metastases from cancer of the endometrium are rare. We recommend histologic evaluation of subcutaneous masses developing in patients with endometrial cancer or in those suspected to have endometrial cancer

Successes and challenges of establishing a cervical cancer screening and treatment program in western Kenya

Objective: To describe the challenges and successes of integrating a public-sector cervical screening program into a large HIV care system in western Kenya. Methods: The present study was a programmatic description and a retrospective chart review of data collected from a cervical screening program based on visual inspection with acetic acid (VIA) between June 2009 and October 2011. Results: In total, 6787 women were screened: 1331 (19.6%) were VIA-positive, of whom 949 (71.3%) had HIV. Overall, 206 women underwent cryotherapy, 754 colposcopy, 143 loop electrical excision procedure (LEEP), and 27 hysterectomy. Among the colposcopy-guided biopsies, 27.9% had severe dysplasia and 10.9% had invasive cancer. There were 68 cases of cancer, equating to approximately 414 per 100 000 women per year. Despite aggressive strategies, the overall loss to follow-up was 31.5%: 27.9% were lost after a positive VIA screen, 49.3% between biopsy and LEEP, and 59.6% between biopsy and hysterectomy/chemotherapy. Conclusion: The established infrastructure of an HIV treatment program was successfully used to build capacity for cervical screening in a low-resource setting. By using task-shifting and evidence-based, low-cost approaches, population-based cervical screening in a rural African clinical network was found to feasible; however, loss to follow-up and poor pathology infrastructure remain important obstacles

Radical surgery for early cervical cancer in a resource limited setting: survival and challenges

Introduction: Cervical cancer is one of the most common cancers affecting women, with the highest incidence and mortality rates reported in East Africa. This study aimed to evaluate the outcomes of patients with early-stage cervical cancer treated with radical surgery in Western Kenya. Methodology|: This was a retrospective study of 131 consecutive patients with early cervical cancer (FIGOstage IA2-IIA) treated over 5 years at Moi Teaching and Referral Hospital in Western Kenya. Nonparametricstatistics, the log-rank test and Cox regression were used to evaluate the effects of the covariatesanalysed on survival. Results: The mean age was 44.8 years, and the modal age group was 41-50 years (38.9%). HIVseroprevalence was 45.8%, while squamous cell carcinoma was the predominant histologic type seen in123 (93.9%) patients. The surgical margins were positive in 4 (3.1%) patients. Pelvic nodal metastases wereseen in 42 (35.9%) patients. The number of patients who required adjuvant chemo-radiation was 51 (38.9%), but only 16 (31.4%) received it. All-cause mortality was 18.3%, with a five-year overall survival of 67.7%. The factors associated with mortality were age (HR= 2.28, p\u3c 0.001), HIV positivity (HR= 3.51, p= 0.009), tumour size (HR= 1.3, p= 0.047), and use of neoadjuvant chemotherapy (HR= 2.70, p 0.033). Conclusions: HIV seropositivity and age (per 10-year increase) are significant predictors of poor survival. The mechanism by which HIV negatively impacts survival requires further investigation