Department of Obstetrics and Gynaecology

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Bone involvement in patients with cervical carcinoma – a single institution cohort study
(Stellenbosch : Stellenbosch University, 2019-04) Butt, Jennifer Leigh; Botha, Matthys Hendrik; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
Introduction Bony metastases in cervical carcinoma are rare, occurring on average in 4.6% of patients. Autopsy studies indicate that it is underdiagnosed. It is important to recognise bony infiltration as palliative radiotherapy can relieve pain and prevent pathological fractures. As survival after the diagnosis of bone involvement is short, an appropriate palliative care plan should be tailored according to the patients’ limited prognosis. Methods A retrospective cohort analysis of women with cervical cancer, diagnosed between January 2014 and December 2015, was undertaken. Demographic, treatment and follow up data were collected for all women with bone metastases confirmed by imaging. Descriptive statistics were generated. Results The cohort study identified 642 patients with cervical carcinoma, of which 25 (3.89%) were diagnosed with bone involvement. Ten patients had bone involvement at diagnosis of cervical cancer and 15 had bone metastases at recurrence, occurring a median of 286 days after primary treatment. Survival after the diagnosis of bone metastases was short, with 88% of patients dying within the first 6 months. Women with a low WHO performance status at diagnosis of bone metastases had a significantly shorter survival (p=0.024). When a previously described prognostic score was applied, those with a high score had a significantly shorter survival (median 61 days) than those with a low score (median 158 days) (p=0.0065). Conclusions Although bone metastases are rare in women with cervical cancer, they are important to recognise as radiotherapy is a useful modality for palliating bone pain and reducing pathological fractures. Health care workers should be vigilant, especially during the first 2 years of follow up, to increased analgesic use and chronic pain as these may indicate bone involvement. Use of a prognostic score is valuable in tailoring treatment and counselling patients and their families with regard to survival. Survival after the diagnosis of bone involvement is short and a patient’s quality of life may be greatly improved by an appropriate radiotherapy and palliative care plan.
Endometrial cancer in young women. A retrospective matched cohort study.
(Stellenbosch : Stellenbosch University, 2021-12) Dowlut, Tariq Hussein; Botha, Matthys Hendrik; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
ENGLISH ABSTRACT: OBJECTIVE: Endometrial cancer is the second most common gynaecological cancer in South Africa. It typically arises in the sixth and seventh decades of life. However, an increasing number of premenopausal women are being diagnosed with endometrial cancer. Delay in diagnosis in younger women is due to symptoms being ascribed to abnormal uterine bleeding. The objective of this study was to carry a review of the clinical, pathological and management of endometrial cancers in younger women to identify risk factors, characterise histology and appraisal of treatment received. METHODS: We did a retrospective matched study of a cohort of women aged 55 years or younger with histologically confirmed endometrial carcinoma. Each case was matched to two randomly selected control cases of histologically proven endometrial cancer patients aged more than 55 years old. It was conducted at Tygerberg Hospital, the largest tertiary hospital in the Western Cape Province of South Africa. We examined patient folders from the Department of Gynaecologic Oncology from 2014 – 2018. Clinical characteristics including age, parity, hypertension, diabetes mellitus, hormone therapy, tamoxifen use, personal history of cancer and family history of cancer were obtained. Outcomes including histological type and grade, myometrial depth invasion, lympho‐vascular space invasion, lymph node involvement, extrauterine spread, stage, treatment plan and need for adjuvant therapy were reviewed. RESULTS: 15 patients 55 years of age or less were identified (range 40‐55, median 52). Only 20% were nulliparous. All the patients had at least class 2 obesity with 50% having class 3 obesity. The incidence of hypertension and diabetes were 66.7% and 56.7% respectively. Only 2 patients had a history of tamoxifen use for breast cancer. 33.3% had a personal history of a cancer and 26.7% reported having a first degree‐ relative with cancer. All the 15 patients (100%) in the younger cohort had Type I (endometrioid adenocarcinoma) compared to 50% in more than 55‐year‐old group. Statistical significance differences were found for histological grade (p‐value 0.004), myometrial depth invasion (p‐value 0.02), extrauterine spread other than lymph node (p‐value 0.006) and need for adjuvant therapy (p‐value 0.007). No significant differences were found for lympho‐vascular space invasion (p‐value 0.18), lymph node spread (p‐value 0.95) and stage (p‐value 0.107). Despite no statistical significance was found for overall disease stage between the two groups, 11 patients (73.4%) presented with stage I disease in the younger cohort. None of the patients received conservative management and were surgically staged by open laparotomy. CONCLUSION: Obesity is a significant risk factor in our population. Oestrogen excess seems to be the main aetiology of endometrial cancer in the local population. Younger patients typically present with Type I endometrioid adenocarcinoma, low grade and less myometrial invasion. There is less need for adjuvant radiotherapy in this group of patients.
Exploring options for the secondary prevention of cervical cancer in South Africa
(Stellenbosch University, 2024-12) Adams, Robyn Anne; Botha, Matthys Hendrik; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. Obstetrics and Gynaecology.
ENGLISH ABSTRACT: Cervical cancer stands as a significant global health challenge, impacting millions of women annually. While primary prevention measures like human papilloma virus (HPV) vaccination show promise, the role of secondary prevention, including screening programmes and early detection methods, is paramount. This thesis aims to assess and elucidate the multifaceted nature of secondary prevention strategies for cervical cancer. In Chapter 2, the evolution and current state of cervical cytology in South Africa is discussed, highlighting its successes and systemic challenges. The chapter emphasises the need for robust infrastructure, efficient follow-up systems, and the lessons learned from cytology that can inform the implementation of HPV DNA screening. In Chapter 3, the study findings suggest that visual inspection methods perform better in women living with HIV (WLWH) compared to HIV-negative women. This implies the justification for utilizing visual inspection methods in cervical cancer screening for WLWH. However, it is noted that these methods exhibit satisfactory sensitivity only under rigorous quality assurance measures, which might pose challenges in non-academic settings, potentially leading to over-treatment due to reduced specificity. Chapter 4 explores cervical cancer control guidelines in the Southern African Development Community (SADC) region, highlighting the reliance on visual inspection as a screening method, despite the World Health Organization (WHO) prioritizing HPV deoxyribose nucleic acid (DNA) testing in its guideline of 2021. HPV DNA testing offers high sensitivity and a negative predictive value approaching 100%, reducing the need for frequent follow-up visits and additional tests, thus enhancing cost-effectiveness. However, HPV DNA testing alone may not provide clinically relevant information without a triage test to identify women with clinically significant disease. A pragmatic advantage of HPV testing is its compatibility with triage tests like host-cell DNA methylation assessment, streamlining the diagnostic process and reducing discomfort for individuals undergoing screening. In South Africa, HPV testing is increasingly available, with reflex cytology recommended as the triage test, though molecular biomarkers like DNA methylation show promise for further risk stratification. However, more evidence is needed, particularly in low- and middle-income countries (LMICs), to support their inclusion in screening programmes. Chapter 5 discusses the potential of DNA methylation assays as triage tools, citing studies showing high sensitivity for cervical cancer detection. However, conclusive evidence is lacking, especially in LMICs, necessitating further research and adaptation of methylation assays for cost-effective use. Longitudinal studies focusing on women living with HIV are particularly crucial due to limited existing research. Chapter 6 outlines a study protocol comparing thermal ablation (TA) to large loop excision of the transformation zone (LLETZ) in treating cervical precancer, acknowledging South Africa's human immunodeficiency virus (HIV) burden and high-risk HPV prevalence. Understanding TA's efficacy including treatment failure rates is vital for adopting accessible treatments, considering the context of resource constraints. In summary, secondary prevention of cervical cancer involves a diverse array of strategies, from screening methods to treatment modalities. While HPV DNA testing represents a significant advancement, challenges remain in implementation, especially in LMICs. Further research, particularly on triage methods and treatment efficacy, is essential for improving outcomes, especially in populations disproportionately affected by cervical cancer.
Factors related to the late presentation of women with vulvar cancer
(Stellenbosch : Stellenbosch University, 2018-12) Shah, S.; Butt, J.; Botha, Matthys Hendrik; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
Background Vulva cancer is increasing in incidence and becoming more prevalent amongst younger women. Over 50% of patients present with advanced stage disease at Tygerberg Hospital. The prognosis for late stage vulvar cancer is poor and the treatment has a high morbidity. The reasons for delayed presentation of cancer include a lack of knowledge about the disease, financial constraints, psychosocial factors, transport and access to health care. Objective To determine the reasons behind the late presentation of patients with vulva cancer at Tygerberg Hospital and to propose strategies to reduce avoidable factors, both patient-related and within the health care system, leading to the delay in diagnosis. Methods This prospective cohort study included all women presenting to the Tygerberg Oncology unit with a new diagnosis of histologically confirmed vulvar carcinoma between November 2015 and December 2016. An interview was conducted and a questionnaire completed. Data obtained included demographic, social, health seeking behavior, disease and transport related factors. Descriptive statistics were reported and comparisons between early and late stage disease were calculated using Microsoft Excel version 14 and Social Science Statistics Calculators. Results Fifteen of the 30 patients interviewed presented with early vulva cancer (FIGO stage 1 or 2), and 15 patients presented with late stage disease (FIGO stage 3 or 4). The youngest patient was 28 years old and the oldest patient in the study was 72 years. There were no significant differences noted between the early and late stage disease with regards demographic, social or transport factors. There was no correlation between the size of the vulva lesion and delay in presentation. Nineteen patients (63.3%) used alternative modalities before seeking help from a health care worker. Although 21 (70%) women had a gynecological examination at the primary health facility, many were treated with antibiotics or creams before a definitive diagnosis was made. Nineteen patients (63.3%) made 4 or more visits to the primary health care facility before being referred to Tygerberg Hospital for management. Conclusion A delay of diagnosis of vulva cancer can be attributed to patient delay in the lack of recognition and interpretation of seriousness of the symptoms of vulvar cancer. Similar to the available literature, a system delay was also noted on the part of the primary health care practitioner. Educating women about this once rare disease and raising suspicion in health care workers regarding the presentation of vulva cancer might aid in earlier health seeking behavior, a prompter biopsy and prevent delayed diagnosis.
The impact of HIV status on staging, treatment and outcomes in locally advanced cervical carcinoma
(Stellenbosch : Stellenbosch University, 2019-12) Simonds, Hannah; Botha, Matthys Hendrik; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
ENGLISH ABSTRACT: Cervical carcinoma is one of the most frequently diagnosed malignancies in women in many countries in sub-Saharan Africa, including South Africa. In sub-Saharan Africa, among women without HIV the age-standardised cervical cancer incidence rate is greater than 40 per 100 000. However, women infected with both the human-immunodeficiency virus (HIV) and the human papilloma virus (HPV) have a higher risk of developing cervical carcinoma than women infected with HPV alone. Published studies of the ideal staging methods, treatment algorithms, and outcomes for women with comorbid locally advanced cervical carcinoma and HIV are scarce. The aim of this body of work is to fill some of these gaps. We conducted four cohort studies of patients with locally advanced cervical carcinoma with or without HIV, recording demographic data, staging information and treatment delivered. Additional information gathered for individual studies included treatment response and survival outcomes. We evaluated the statistical significance of differences between HIV-positive and negative patients. Logistic regression models were utilised to evaluate risk for toxicity, treatment response, and survival outcomes. In the first of three retrospective cohort studies, among 383 patients, early response to chemoradiation was found to be related to advanced stage [OR 2.39, 95% CI 1.45-3.96] and completion of brachytherapy [OR 3.14; 95% CI 1.24-7.94] but not HIV status. In the second retrospective study, among 213 patients undergoing radical radiotherapy, acute Grade 3 / 4 toxicity was associated with receiving chemotherapy [OR4.41; 95%CI 1.76- 11.1; p 0.023] and having HIV [OR 2.16; 95% CI0.98-4.8; p 0.05]. In a prospective study of 492 patients, OS at 5 years was 49.5% (95%CI; 44.6% - 54.4%) among HIV-negative patients but only 35.9% (95% CI; 23.9% - 48.0%) among HIV-positive patients (p=0.002). In our Cox models, factors affecting outcome were HIV infection, stage IIIB disease, hydronephrosis, and delivery of concurrent chemotherapy. In the fourth cohort study, among 273 patients with locally advanced cervical carcinoma who underwent a radiotherapy planning PET-CT scan, overall 235 (84.5%) were upstaged. Upstaging was not associated with HIV status (HIV-negative 83.9% vs HIV-positive 87.2%; p=0.47). Following the PET-CT scan, among the 263 patients who attended for radiotherapy treatment, intent changed for 124 patients (46.3%): 53.6% of HIV-positive patients and 42.9% of HIV-negative patients (p=0.11). This body of work demonstrated that in HIV-positive patients, integration of PET-CT into staging algorithms for cervical carcinoma is a viable option. During treatment HIV-positive patients experienced increased toxicity, but most were able to complete treatment, and their 5-year overall survival was nearly 40%. Among women with locally advanced cervical cancer, those with HIV infection should be treated with the best standard of care. Future research should focus on factors that improve outcomes for these women.
Prevalence of high-grade squamous intraepithelial lesion within two years of large loop excision of the transformation zone at a tertiary hospital colposcopy clinic in Cape Town
(Stellenbosch : Stellenbosch University, 2022-11) Olujobi, Victor; Botha, Matthys Hendrik;
ENGLISH ABSTRACT: Background Large loop excision of the transformation zone (LLETZ) has become widely accepted as the technique of choice for the treatment of cervical intraepithelial neoplasia. Despite its high efficacy in preventing cervical cancer, variable rates of post-LLETZ residual/recurrent high-grade squamous intraepithelial lesion (HSIL), also known as treatment failure is reported globally. This study was conducted to determine the prevalence of treatment failure within two years of LLETZ treatment for HSIL at Tygerberg hospital. Aim To determine the proportion of women treated for high-grade cervical intraepithelial neoplasia who developed cytological HSIL within two years of LLETZ. Materials and Methods In this retrospective cohort study, the electronic medical records of the first 139 consecutive women who underwent LLETZ treatment in 2016 and had a final diagnosis of HSIL as well as at least one follow-up cytology within two years of LLETZ were reviewed. Setting: Tygerberg Hospital colposcopy clinic, one of two tertiary referral hospitals in Cape Town, South Africa. Results: The rate of recurrent HSIL at the first follow-up cytology after LLETZ was 17.3% (95% confidence interval [CI] 11.4 to 24.6). 68.3% of study participants had a normal cervical cytology at the first follow-up visit after LLETZ. LLETZ margins were positive for CIN2/CIN3 in 58.3% (81/139) of biopsies, with involvement of the endocervical margin in almost half of these cases. Age 40 and above was significantly associated with post-LLETZ HSIL recurrence (odds ratio [OR] = 2.7, 95% CI 1.03 to 7.07, p = 0.04). There was nonsignificant increase in the odds of post-LLETZ residual/recurrent HSIL among women living with HIV, (OR =2.0, 95% CI 0.68 to 6.10, p = 0.2). Also, a nonsignificant increase in treatment failure was found when cases with positive margins were compared with those with clear margins (OR = 2.3, 95% CI 0.69 to 7.53, p = 0.18), as well as when uncertain margin status was compared with clear margin status (OR = 1.27, 95% CI 0.20 to 8.10, p = 0.80). 16.7% (4/24) of treatment failure occurred among women with clear LLETZ margins, and no treatment failure was detected at follow-up when the ectocervical margin was the only involved margin. The rate of loss to follow-up for a second cytology within two years of LLETZ was 74.8%. Conclusions: Even though LETTZ is an effective modality for the treatment of CIN, one in six treated women develop treatment failure within two years of LLETZ. Women aged 40 and above at the time of LLETZ are at a higher risk of developing treatment failure. There is a high rate of loss to follow-up for a second cervical cytology in the study population. Key words: High grade squamous intra-epithelial lesion, large loop excision of the transformation zone, LEEP, residual, recurrent, cervical intraepithelial neoplasia, margin status, complete excision, recurrent, treatment failure, post-treatment disease.
A randomised study to evaluate two different skin closure techniques : subcuticular sutures vs. staples : an investigation into patient satisfaction
(Stellenbosch : Stellenbosch University, 2012-12) Kalim, Mahnaz; Botha, Matthys Hendrik; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
ENGLISH ABSTRACT: OBJECTIVE The purpose of the study is to establish the best method of wound closure with regards to patient satisfaction that includes wound cosmesis and pain. STUDY DESIGN One hundred patients were randomised to two groups for the closure of abdominal wounds; one group had subcuticular sutures and the other staples. They were followed up at 6 weeks. The primary outcome was patient satisfaction that includes wound cosmesis and pain. The secondary outcome was wound complications. RESULTS In women undergoing abdominal operations there was no difference as regards the patient satisfaction in both the groups, subcuticular sutures n= 51 vs. staples n=49 (P = 0.76). CONCLUSION Our study suggest that there is no statistically significant difference in the methods of wound closure, subcuticular sutures vs. staples as regards the patient satisfaction and the appearance of the scar leaving the decision in the hands of the surgeon to choose any method according to their own personnel preference and availability.
Uterine carcinosarcoma: A 10-Year single institution experience
(Stellenbosch : Stellenbosch University, 2019-12) Terblanche, Leana (Nee Oberholzer); Botha, Matthys Hendrik; Terblanche, Leana; Stellenbosch University. Faculty of edicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
Objective: This study aimed to determine 5-year progression-free and overall survival in patients with uterine carcinosarcoma, to determine clinical and surgical-pathologic features, to recognize patterns of recurrence and to identify prognostic factors influencing progression-free survival (PFS) and overall survival (OS). Materials and Methods: A total of 61 patients with uterine carcinosarcoma who were diagnosed between January 2005 and December 2014 were included. Demographic, clinicopathological, treatment and outcome information were obtained. Kaplan-Meier survival analysis and Cox proportional hazards models were used to determine the effects of variables on PFS and OS. Results: Eighteen patients (29%) presented as FIGO stage I disease, 5 patients (8%) as stage II, 16 patients (26%) as stage III and 22 patients (36%) as stage IV disease, of which 50 patients (82%) had surgery. Seventeen patients presented with recurrence of which 5 (29.4%) were local and 12 (70.6%) were outside the pelvis. Five-year PFS and 5-year OS were 17.3% (CI 8.9%-27.9%) and 19.7% (CI 10.6%-30.8%), respectively. In the univariate analysis, tumour diameter ≥ 100mm (HR 4.57, p-value 0.005) was associated with 5-year PFS and in univariate analysis of OS, a positive family history (HR 0.42, p-value 0.047), receiving a full staging operation (HR 0.37, p-value 0.008) and receiving any other modality of treatment, with or without surgery, (HR 0.48, p-value 0.012) was associated with better survival. An abnormal pap smear (HR 2.4, p-value 0.041), late-stage disease (HR 3.48, p-value < 0.001), presence of residual tumour (HR 3.66, p-value < 0.001), myometrial invasion more than 50% (HR 2.29, p-value 0.019), cervical involvement (HR 3.38, p-value 0.001) and adnexal involvement (HR 3.21, p-value 0.002) were associated with a higher risk of death. In the multivariate analysis, full staging operation was associated with a risk of progression of disease (HR 3.49, p-value 0.025). Advanced stage (HR 4.2, p-value < 0.001) was associated with a higher risk of death. Any other modality of treatment (HR 0.28, p-value < 0.001) and full staging laparotomy (HR 0.27, p-value 0.001) was a protective factor for death. Conclusions: Carcinosarcoma is an aggressive cancer with poorer survival than previously described. Biological or genetic factors may play a role in our study population. Most recurrences occur outside of the pelvis. Full staging surgery (including pelvic lymphadenectomy) and additional use of other modalities (either for radical or palliative intent) improve survival.
Vaginal vault haematoma following hysterectomy at a tertiary hospital
(Stellenbosch : Stellenbosch University, 2016-12) Eliya-Masamba, Martha; Botha, Matthys Hendrik; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
Background Hysterectomy is the second most commonly performed surgical procedure among women of the reproductive age group, after caesarean section. Vault haematoma is a recognized complication of hysterectomy that may be associated with postoperative morbidity. Ultrasound examination of the vault is useful in the diagnosis of post hysterectomy vault haematoma as a cause for febrile morbidity. This study was conducted to determine the incidence and clinical significance of post hysterectomy vault hematomas in a South African Academic setting. Methods This was a prospective descriptive observational study. Women aged 18 and above, scheduled for elective hysterectomy for benign indications were enrolled in the study after providing written informed consent. Transvaginal ultrasound scan was done at 48-72 hours post-operative and clinical notes were reviewed 3 months postoperatively. Results Fifty patients were included in the study. Incidence of vault haematoma in this cohort was 30% (95% CI 18-44%). The majority of vault haematomas was 2-5cm in largest diameter (67%) followed by those that were more than 5cm (27%) and those less than 2cm (6%). There was no statistically significant difference in the incidence of vault haematoma between the different routes of hysterectomy (Fisher’s exact 0.124) There was no association between the presence of a vault haematoma and postoperative morbidity (fever, haemoglobin level, prolonged hospital stay, complications at follow up). None of the patients with vault haematoma was symptomatic up to the time of discharge from the hospital. One patient with a vault haematoma more than 5cm was readmitted on Day 15 postoperative with a foul smelling vaginal discharge that was treated successfully with oral antibiotics. Conclusions Vault haematoma is a common finding following elective hysterectomy for benign gynaecological indications. Patients with vault haematomas are mostly asymptomatic. There is no association between the presence of a vault haematoma and postoperative morbidity.

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