Didactic Benefits of Surgery on Body Donors during Live Surgery Events in Minimally Invasive Surgery

Background: Live surgery events serve as a valuable tool for surgical education, but also raise ethical concerns about patient safety and professional performance. In the present study, we evaluate the technical feasibility and didactic benefits of live surgery on body donors compared to real patients. Methods: A live surgery session performed on a body donor’s cadaver embalmed in ethanol–glycerol–lysoformin was integrated into the live surgery program presented at a major gynecological convention of minimally invasive surgery. Surgical procedures carried out in real patients were paralleled in the body donor, including the dissection and illustration of surgically relevant anatomical landmarks. A standardized questionnaire was filled by the participants (n = 208) to evaluate the appropriateness, effectiveness, and benefits of this novel concept. Results: The live surgery event was appreciated as a useful educational tool. With regard to the use of body donors, authenticity was rated high (85.5%), and the overall value of body donors for surgical education and training was rated very high (95.0%). The didactic benefit of simultaneous operations performed on body donors and real patients was considered particularly useful (95.5%), whereas complete replacement of real patients by body donors was not favored (14.5%). Conclusions: The study demonstrated both the technical feasibility and didactic benefits of performing minimally invasive surgery in body donors as part of live surgery events. This novel concept has the potential to enhance anatomical knowledge, providing insights into complex surgical procedures, and may serve to overcome yet unresolved ethical concerns related to live surgery events.

Postoperative Telephone-Based Questionnaire on Quality of Life after Robotic-Assisted Laparoscopic Hysterectomy versus Conventional Total Laparoscopic Hysterectomy

Aim: The objective of the study was to evaluate the benefits of robotic-surgery for hysterectomy compared to conventional laparoscopy for benign indications. A specially prepared telephone-based questionnaire was used postoperatively. Method: All women (n = 155) undergoing total laparoscopic hysterectomy for benign indications either by the robotic-assisted procedure (RALH) or conventional laparoscopy (CL) between 1 January 2013 and 31 December 2017 at the Department of the Gynecology, University Hospitals, Campus Kiel, Germany, were eligible for analysis. Intra-operative and postoperative parameters affecting the patients’ quality of life were assessed by a telephone-based questionnaire. The latter addressed postoperative pain, limitations of basic hygiene, daily activity, active pursuit of hobbies, sexual intercourse, and days of sick leave. All patients received the questionnaire by post at least three weeks prior to being contacted on the phone. Results: 78% of the contacted patients responded to the questionnaire; 96% (n = 115) of the patients said they would recommend the operation to other patients. Both groups needed 42 days to resume their regular hobbies. In whole 90.8% (n = 108) were total satisfied with the cosmetic result of the abdominal incision; the numbers in the respective groups were 80% (80% n = 36) in RALH and 97.3% (n = 72) in CL. The difference was significant on the Chi-square test (p = 0.002). 5% (n = 7) were dissatisfied with the scar (13.3%; n = 6) in the RALH group, and 1.4% (n = 1) in CL. In all 1.7 % of patients were dissatisfied with the position of the incisions; the respective numbers were 4.4 % (n = 2) in the RALH group and no patient in the CL group. 33% of patients experienced no limitations in regard of sexual intercourse after the operation. The median number of days taken to resume sexual intercourse after the operation was 56 days in the CL group, and 49 days in the RALH group. Nearly 30% (n = 25) were hesitant to resume intercourse. The median operating time was 145 min in the RALH group, which was significantly longer than the 117 min taken in the CL group (p < 0.001). Conclusions: The RALH procedure was associated with some minor advantages for the patients according to the results, however it does not have major significant advantages, especially in regard of early restoration of sexual function, while the CL shows shorter operating times and similar limitation. Postoperative counseling of patients should be aligned to their fears and expectations in regard of sexual function.

A Giant Mammary Hamartoma in a Young Breast Cancer Patient

Background

Hamartomas of the breast are rare benign tumors. Pre- and also postoperative differentiation from other benign or even malignant tumors is challenging.

Case Presentation

A 36-year-old female presented with a giant tumor of the left breast. The patient had suffered from an early breast cancer of the contralateral right breast the year before, which was treated with breast-conserving therapy, radiation, and endocrine therapy ever since. The hamartoma was classified as BI-RADS 2 in mammography and BI-RADS 4 in ultrasound. On clinical examination, a tumor of nearly 15 cm in size led to an abstruse deformity of the breast and the nipple-areola complex. We found an indolent, grand bulging tumor with an elastic texture directly beneath the skin. A biopsy that had been performed before was compatible with the suspected hamartoma. Because of the remaining diagnostic uncertainties after contralateral breast cancer and the progressive malformation of the left breast, a tumor extirpation utilizing a reduction mammaplasty was performed without complications. Subsequent genetic analyses excluded a loss of PTEN in this patient.

Conclusion

We presented the rare case of a 36-year-old woman with a history of breast cancer and a 700-g breast hamartoma. The preoperative and even the postoperative specification of a hamartoma remains challenging, and associations with genetic alterations should be considered.

Endometrial "Scratching" An update and overview of current research

About one in every six couples is affected by sterility. Assisted reproduction procedures are currently the treatment of choice for a number of patients who desire children. Many causes of sterility can be overcome with the aid of in vitro fertilization, but successful implantation of the embryos is the major limiting factor. Failure of implantation may occur repetitively. In the treatment of sterility, many approaches have been used to overcome the barrier of implantation failure and improve the chances of successful nidation. Scratching the endometrium prior to embryo transfer has been suggested as one means of enhancing the likelihood of implantation. The current literature was examined to investigate if there was any possible benefit from endometrial scratching. The studies were divided according to whether the women suffered from recurrent implantation failure or not. In summary, it was found that unselected subfertile women generally benefit less from endometrial scratching, but scratching appears to be successful in women who have experienced repeated implantation failure. Although the heterogeneous body of data on the subject deserves further clarification. The latest data presented at “European Society of Human Reproduction and Embryology” 2018 in Barcelona suggested that the method should be abandoned.

Postoperative pain management in obstetrics and gynecology

The efficiency and quality of postoperative pain management may be considered unsatisfactory in Europe, as well as in the United States. Notwithstanding our better understanding of the physiology of pain and the development of new analgesia procedures, the improvement in satisfaction of patients has not be enhanced to the same degree. Obstetrics and gynecology are no exception to this statement. In fact, obstetrics and gynecology are surgical departments in which patients experience the greatest severity of postoperative pain. Current concepts of postoperative pain management are largely based on the administration of systemic non-opioid and opioid analgesics, supplemented with regional analgesia procedures and/or peripheral nerve blockades and, in some cases, the administration of other pain-relieving pharmaceutical agents. Based on the existing body of evidence, it would be appropriate to develop procedure-related concepts of analgesia. The concepts are based on the special circumstances of the respective department, and the scheme of analgesia is aligned to the respective interventions. Generally, however, a surgeon’s individual experience in dealing with the procedures and substances could be more significant than the theoretical advantages demonstrated in preceding investigations.

Cytoplasmic levels of high mobility group A2 determine survival prognoses in breast cancer patients

BACKGROUND

High mobility group A proteins are involved in chromatin remodeling, thereby influencing multiple fundamental biological processes. HMGA2 has been linked to oncogenic traits among a variety of malignancies.

OBJECTIVE

To determine the prognostic implications of subcellular distribution patterns of HMGA2 in breast cancer.

METHODS

Nuclear and cytoplasmic HMGA2 was evaluated in 342 breast cancer specimens and matched with clinico-pathological parameters.

RESULTS

Overall and cytoplasmic, but not nuclear, levels of HMGA2 correlated with better survival prognoses in our collective (hazard ratio (HR) 0.34, P = 0.001 and HR 0.34, P < 0.001, respectively). The protective effect of cytoplasmic HMGA2 persisted in the Luminal A and triple negative breast cancer subgroups. Evaluating Luminal A and B subgroups jointly, only cytoplasmic, but not overall or nuclear HMGA2 levels were associated with better survival (HR 0.42, 95% confidence interval 0.21, 0.86, P = 0.017), irrespective of tumor size and node status. The addition of HMGA2 overall and cytoplasmic scores strengthened the prognostic selectivity in a model of conventional breast cancer risk factors. No predictive significance with regard to endocrine or chemoendocrine therapies was observed.

CONCLUSION

Unexpectedly, we found a favorable survival probability upon overall levels of HMGA2 in our breast cancer collective, which was predominantly determined by the presence of HMGA2 in the cytoplasm.

[Does Apolipoprotein B Level in Early Pregnancy Predict Excessive Gestational Weight Gain and Adverse Pregnancy Outcome?]

INTRODUCTION

Excessive maternal gestational weight gain (GWG) is a risk factor for maternal and fetal complications. The lipid profile changes physiologically during pregnancy. Weight gain can affect lipid metabolism. The hypothesis of the study was that apoB levels early in pregnancy are associated with excessive GWG and predictive for adverse outcomes.

METHODS

Out of 547 patients there were 95 women with inadequate GWG, 171 with adequate GWG, and 281 with excessive GWG. Out of 581 patients there were 14 patients with pregnancy-induced hypertonus/pre-eclampsia, 67 with small-for-gestational-age (SGA) infants, and 7 with fetal growth restriction (FGR). ApoB levels were measured by ELISA.

RESULTS

There was no significant difference in apoB levels between the different GWG groups. We found significantly higher levels of apoB in overweight and obese patients compared to those with normal BMI. Smoking was correlated with higher apoB levels. There were no differences either between women with PIH/PE and normotensive women or between SGA/IUGR and pregnancies without. Women with pre-existing hypertension showed significantly higher apoB levels than the control group.

CONCLUSIONS

ApoB cannot be used as a marker for identifying the risk of excessive GWG or adverse pregnancy outcomes early in pregnancy. However, it may be involved in the pathophysiology of adverse pregnancy outcomes in high-risk patients.

[Ethical decision-making in the face of increasing economization of hospitals : A study on ethical mistrust in decisions taken on the length of hospital stay among students and doctors]

Are medical values receding in importance because of economization of the German health system? Within the frame of a vignette study, a case is presented based on prolongation of the hospitalization of an elderly and not entirely recovered patient. All respondents of the questionnaire predicted the relevance of decision criteria, such as medical accuracy, empathy towards the patient, and identification with the hospital. Participants (N = 1,239) believe that decision-makers view medical accuracy as the most important criterion, followed by empathy. The more the respondent had universalistic values, the more likely the person was to favor an extended hospitalization. The more security-oriented and less pro-social the respondent, the more likely the person was to support an early discharge. It can be concluded that in the course of their training doctors acquire their grounded deontological-ethical decision-making autonomy, which may in some cases contradict existing regulations.

ACT-FASTER, a Prospective Cohort Study Exploring Treatment Patterns with Fulvestrant and Exemestane in Postmenopausal Patients with Advanced Hormone Receptor-Positive Breast Cancer under Real-Life Conditions in Germany

Background

Endocrine therapy is recommended for the treatment of postmenopausal women with hormone receptor-positive (HR+) advanced breast cancer (ABC).

Methods

ACT-FASTER was a German prospective non-interventional cohort study in postmenopausal women with HR+ ABC receiving fulvestrant 500 mg as first line (1 L), second line (2 L) or third line (3 L), or exemestane (any line) in the real-world palliative setting. Primary study objectives included the effectiveness of fulvestrant according to line of palliative treatment measured by time to progression (TTP), and real-life data on the epidemiology and management of these patients.

Results

Of 498 evaluable patients (mean age 67.5 years), 99% were estrogen receptor-positive. On study, 86.7% of patients received fulvestrant 500 mg and 13.3% exemestane. Median TTP was 9.7 months in patients receiving fulvestrant 1 L; 6.8 months for 2 L; and 6.7 months for 3 L. The comparison between fulvestrant 1 L palliative treatment and 2 L or 3 L showed that early initiation of treatment prolonged TTP (hazard ratio 1.26; 95% confidence interval 1.08-1.48). Treatments were well tolerated.

Conclusion

Fulvestrant 500 mg was administered successfully to patients under daily practice conditions, and both medications were well tolerated. TTP was longest in patients treated with fulvestrant 500 mg 1 L compared with 2 L and 3 L in the palliative care setting.

Complementary and alternative medicine and musculoskeletal pain in the first year of adjuvant aromatase inhibitor treatment in early breast cancer patients

Background

Patients with breast cancer (BC) show strong interest in complementary and alternative medicine (CAM), particularly for adverse effects of adjuvant endocrine treatment — e.g., with letrozole. Letrozole often induces myalgia/limb pain and arthralgia, with potential noncompliance and treatment termination. This analysis investigated whether CAM before aromatase inhibitor (AI) therapy is associated with pain development and the intensity of AI-induced musculoskeletal syndrome (AIMSS) during the first year of treatment.

Patients and methods

The multicenter phase IV PreFace study evaluated letrozole therapy in postmenopausal, hormone receptor–positive patients with early BC. Patients were asked about CAM use before, 6 months after, and 12 months after treatment started. They recorded pain every month for 1 year in a diary including questions about pain and numeric pain rating scales. Data were analyzed for patients who provided pain information for all time points.

Results

Of 1396 patients included, 901 (64.5%) had used CAM before AI treatment. Throughout the observation period, patients with CAM before AI treatment had higher pain values, for both myalgia/limb pain and arthralgia, than non-users. Pain increased significantly in both groups over time, with the largest increase during the first 6 months. No significant difference of pain increase was noted regarding CAM use.

Conclusions

CAM use does not prevent or improve the development of AIMSS. Pain intensity was generally greater in the CAM group. Therefore, because of the risk of non-compliance and treatment discontinuation due to the development of higher pain levels, special attention must be paid to patient education and aftercare in these patients.

•

Pain levels of myalgia/limb pain and arthralgia increase under letrozole intake.

•

Within one year pain levels increase in both, CAM users as well as non-CAM users.

•

In CAM users pain levels were higher at all time points than in non-CAM users.

•

The greatest increase of pain levels was noted in the first six treatment months.

•

CAM does not prevent or improve the development of myalgia/limb pain and arthralgia.

Uterine anomalies and endometriosis

INTRODUCTION

Endometriosis is a common disease in women of reproductive age. In addition to causing pain, it may also reduce fertility. The coexistence of endometriosis and congenital uterine anomalies (CUA) has been frequently reported in the published literature. The present report is a review of existing studies on the subject and our own hitherto unpublished data.

EVIDENCE ACQUISITION

The electronic search was conducted using the Pubmed database with specific keyword combinations including endometriosis, adenomyosis, infertility, Müllerian malformations/anomalies, and septate uterus. The principal aspects addressed in the present study were: diagnosis, management, and classification of CUA, their impact on fertility and coexistence with endometriosis.

EVIDENCE SYNTHESIS

Endometriosis and CUA are frequently detected in the exploration of infertility, because both of these are liable to impair fertility. Endometriosis is associated with obstructive anomalies and nonobstructive malformations, especially those concerning the septate uterus. The diagnosis and management of CUA have been discussed for several years. Various classification systems have been proposed.

CONCLUSIONS

The analysis of the existing literature has revealed the absence of any consensus about the management, diagnosis, and classification of CUA, especially with regard to the septate uterus. We need to find and speak a common language in order to avoid inappropriate or unnecessary surgery and optimize the individual patient's treatment. The combined presence of endometriosis or adenomyosis and CUA is a reason to perform precise diagnostic imaging investigations and early surgery for the purpose of enhancing the chances of pregnancy in infertile patients. Further research is needed on the subject.

SNiPER: a novel hypermethylation biomarker panel for liquid biopsy based early breast cancer detection

Introduction

Mammography is the gold standard for early breast cancer detection, but shows important limitations. Blood-based approaches on basis of cell-free DNA (cfDNA) provide minimally invasive screening tools to characterize epigenetic alterations of tumor suppressor genes and could serve as a liquid biopsy, complementing mammography.

Methods

Potential biomarkers were identified from The Cancer Genome Atlas (TCGA), using HumanMethylation450-BeadChip data. Promoter methylation status was evaluated quantitatively by pyrosequencing in a serum test cohort (n = 103), a serum validation cohort (n = 368) and a plasma cohort (n = 125).

Results

SPAG6, NKX2-6 and PER1 were identified as novel biomarker candidates. ITIH5 was included on basis of our previous work. In the serum test cohort, a panel of SPAG6 and ITIH5 showed 63% sensitivity for DCIS and 51% sensitivity for early invasive tumor (pT1, pN0) detection at 80% specificity. The serum validation cohort revealed 50% sensitivity for DCIS detection on basis of NKX2-6 and ITIH5. Furthermore, an inverse correlation between methylation frequency and cfDNA concentration was uncovered. Therefore, markers were tested in a plasma cohort, achieving a 64% sensitivity for breast cancer detection using SPAG6, PER1 and ITIH5.

Conclusions

Although liquid biopsy remains challenging, a combination of SPAG6, NKX2-6, ITIH5 and PER1 (SNiPER) provides a promising tool for blood-based breast cancer detection.

Estimating fetal cholesterol synthesis rates by cord blood analysis in intrauterine growth restriction and normally grown fetuses

BACKGROUND

Cholesterol is an essential component in human development. In fetuses affected by intrauterine growth restriction (IUGR), fetal blood cholesterol levels are low. Whether this is the result of a reduced materno-fetal cholesterol transport, or due to low fetal de novo synthesis rates, remains a matter of debate. By analyzing cholesterol interbolites and plant sterols we aimed at deeper insights into transplacental cholesterol transport and fetal cholesterol handling in IUGR with potential targets for future therapy. We hypothesized that placental insufficiency results in a diminished cholesterol supply to the fetus.

METHODS

Venous umbilical cord sera were sampled post-partum from fetuses delivered between 24 weeks of gestation and at full term. IUGR fetuses were matched to 49 adequate-for-age delivered preterm and term neonates (CTRL) according to gestational age at delivery. Cholesterol was measured by gas chromatography-flame ionization detection using 5a-cholestane as internal standard. Cholesterol precursors and synthesis markers, such as lanosterol, lathosterol, and desmosterol, the absorption markers, 5α-cholestanol and plant sterols, such as campesterol and sitosterol, as well as enzymatically oxidized cholesterol metabolites (oxysterols), such as 24S- or 27-hydroxycholesterol, were analyzed by gas chromatography-mass spectrometry, using epicoprostanol as internal standard for the non-cholesterol sterols and deuterium labeled oxysterols for 24S- and 27-hydroxycholesterol.

RESULTS

Mean cholesterol levels were 25% lower in IUGR compared with CTRL (p < 0.0001). Lanosterol and lathosterol to cholesterol ratios were similar in IUGR and CTRL. In relation to cholesterol mean, desmosterol, 24S-hydroxycholesterol, and 27-hydroxycholesterol levels were higher by 30.0, 39.1 and 60.7%, respectively, in IUGR compared to CTRL (p < 0.0001). Equally, 5α-cholestanol, campesterol, and β-sitosterol to cholesterol ratios were higher in IUGR than in CTRL (17.2%, p < 0.004; 33.5%, p < 0.002; 29.3%, p < 0.021).

CONCLUSIONS

Cholesterol deficiency in IUGR is the result of diminished fetal de novo synthesis rates rather than diminished maternal supply. However, increased oxysterol- and phytosterol to cholesterol ratios suggest a lower sterol elimination rate. This is likely caused by a restricted hepatobiliary function. Understanding the fetal cholesterol metabolism is important, not only for neonatal nutrition, but also for the development of strategies to reduce the known risk of future cardiovascular diseases in the IUGR fetus.

Treatment of Early Breast Cancer Patients: Evidence, Controversies, Consensus: Focusing on Systemic Therapy - German Experts' Opinions for the 16th International St. Gallen Consensus Conference (Vienna 2019)

A German working group of leading breast cancer experts have discussed the votes at the International St. Gallen Consensus Conference in Vienna for the treatment of primary breast cancer with regard to the German AGO (Ar-beitsgemeinschaft Gynäkologische Onkologie) recommendations for clinical practice in Germany. Three of the German breast cancer experts were also members of this year's St. Gallen panel. Comparing the St. Gallen recommendations with the annually updated treatment recommendations of the Gynecological Oncology Working Group (AGO Mamma 2019) and the German S3 Guideline is useful, because the recommendations of the St. Gallen panel are based on expert opinions of different countries and disciplines. The focus of this article is on systemic therapy. The motto of this year's 16th St. Gallen Consensus Conference was "Estimating the magnitude of clinical benefit." The rationale behind this motto is that, for every treatment decision, a benefit-risk assessment must be taken into consideration for each patient.

Large scale multifactorial likelihood quantitative analysis of BRCA1 and BRCA2 variants: An ENIGMA resource to support clinical variant classification

The multifactorial likelihood analysis method has demonstrated utility for quantitative assessment of variant pathogenicity for multiple cancer syndrome genes. Independent data types currently incorporated in the model for assessing BRCA1 and BRCA2 variants include clinically calibrated prior probability of pathogenicity based on variant location and bioinformatic prediction of variant effect, co-segregation, family cancer history profile, co-occurrence with a pathogenic variant in the same gene, breast tumor pathology, and case-control information. Research and clinical data for multifactorial likelihood analysis were collated for 1,395 BRCA1/2 predominantly intronic and missense variants, enabling classification based on posterior probability of pathogenicity for 734 variants: 447 variants were classified as (likely) benign, and 94 as (likely) pathogenic; and 248 classifications were new or considerably altered relative to ClinVar submissions. Classifications were compared with information not yet included in the likelihood model, and evidence strengths aligned to those recommended for ACMG/AMP classification codes. Altered mRNA splicing or function relative to known nonpathogenic variant controls were moderately to strongly predictive of variant pathogenicity. Variant absence in population datasets provided supporting evidence for variant pathogenicity. These findings have direct relevance for BRCA1 and BRCA2 variant evaluation, and justify the need for gene-specific calibration of evidence types used for variant classification.

AGO Recommendations for the Diagnosis and Treatment of Patients with Locally Advanced and Metastatic Breast Cancer: Update 2019

Every year the Breast Committee of the Arbeitsgemeinschaft Gynäkologische Onkologie (German Gynecological Oncology Group, AGO), a group of gynecological oncologists specialized in breast cancer and interdisciplinary members specialized in pathology, radiologic diagnostics, medical oncology, and radiation oncology, prepares and updates evidence-based recommendations for the diagnosis and treatment of patients with early and metastatic breast cancer. Every update is performed according to a documented rule-fixed algorithm, by thoroughly reviewing and scoring the recent publications for their scientific validity and clinical relevance. This current publication presents the 2019 update on the recommendations for metastatic breast cancer.

Living with Male Breast Cancer: A Qualitative Study of Men's Experiences and Care Needs

Background

Male breast cancer (MBC) is rare, and most previous studies limited their focus on clinical aspects of the disease. Psychosocial implications and care needs of MBC patients are poorly understood.

Objectives

The aim of this study is to explore the experiences of men living with breast cancer and to identify supportive care needs.

Methods

Eighteen men were interviewed using qualitative, semi-structured telephone interviews. Qualitative content analysis was used to analyze the data.

Results

The majority of men did not have negative feelings about having a "women's disease," although some felt that stigmatization threatened their masculinity. Male sex was perceived as hindering access to adequate care. Patients identified key barriers including (1) a lack of awareness and experience of treating males among health professionals; (2) treatment and available information were based on evidence for females; and (3) lacking support services.

Conclusion

To improve MBC care, it is important to raise awareness of the disease and to adapt treatment strategies, patient information, and support services to meet the needs of men.

Primary Therapy of Early Breast Cancer: Evidence, Controversies, Consensus: Spectrum of Opinion of German Specialists on the 16th St. Gallen International Breast Cancer Conference (Vienna 2019)

The results of the international St. Gallen Consensus Conference for the treatment of patients with primary breast cancer were discussed this year by a working group of leading breast cancer experts in view of the therapy recommendations for everyday clinical practice in Germany. Three of the breast cancer experts are also members of this year's St. Gallen panel. The comparison of the St. Gallen recommendations with the annually updated treatment recommendations of the AGO 2019 as well as the S3 guideline is useful, since the recommendations of the St. Gallen panel represent the opinions of experts from various countries and disciplines. The recommendations of the S3 guideline and AGO are based on evidence-based research of the literature. This year's 16th St. Gallen conference featured the motto "Magnitude of clinical benefit". In addition to the evidence-based data, each therapeutic decision must also undergo a benefit/risk assessment of the patient's individual situation and be discussed with the patient.

Preexisting musculoskeletal burden and its development under letrozole treatment in early breast cancer patients

One of the most common adverse events (AEs) occurring during treatment with aromatase inhibitors (AIs) is musculoskeletal pain. The aim of our study was to analyze the influence of preexisting muscle/limb pain and joint pain on the development of AI-induced musculoskeletal AEs. Women eligible for upfront adjuvant endocrine therapy with letrozole were included in the PreFace study, a multicenter phase IV trial. During the first treatment year, they were asked to record musculoskeletal AEs monthly by answering questions regarding pain symptoms and rating the pain intensity on a numeric rating scale from 0 (no pain) to 10 (very strong pain). Pain values were compared using nonparametric statistical tests. Overall, 1,416 patients were evaluable. The average pain value over all time points in women with preexisting muscle/limb pain was 4.3 (median 4.3); in those without preexisting pain, it was 2.0 (median 1.7). In patients without preexisting muscle/limb pain, pain levels increased relatively strongly within the first 6 months (mean increase +0.9, p < 0.00001) in comparison with those with preexisting pain (mean increase +0.3, p < 0.001), resulting in a statistically significant difference (p < 0.00001) between the two groups. The development of joint pain was similar in the two groups. Women without preexisting muscle/limb pain or joint pain have the greatest increase in pain after the start of adjuvant AI therapy. Women with preexisting pain have significantly higher pain values. The main increase in pain values takes place during the first 6 months of treatment.

A Prospective Two Center Study Comparing Breast Cancer Lesion Size Defined by 2D Shear Wave Elastography, B-Mode Ultrasound, and Mammography with the Histopathological Size

PURPOSE

 The aim of the present study was to determine the accuracy of breast cancer measurement with 2 D shear wave elastography (2 D SWE), B-mode ultrasound, and mammography by comparing these methods with the actual histopathological tumor size.

MATERIALS AND METHODS

 135 patients with proven malignant breast lesions at two centers were included in a prospective study. The maximum lesion diameter was measured by 2 D SWE, B-mode ultrasound, and mammography. After surgery, the histopathological tumor size was measured by a pathologist.

RESULTS

 The mean difference in tumor size on 2 D SWE, B-mode ultrasound, and mammography on the one hand, and the actual tumor size on the other, was -0.03 cm, 0.16 cm and 0.10 cm, respectively. Lesion size on histopathological investigation was overestimated by 2 D SWE (p = 0.004) and underestimated by B-mode imaging (p < 0.001). All three imaging methods underestimated the size of invasive lobular cancers and lesions > 15 mm; 2 D SWE was most accurate in this regard.

CONCLUSION

 2 D SWE predicted lesion size more precisely than B-mode ultrasound or mammography. In cases of invasive lobular carcinoma, all three imaging methods underestimated lesion size, with 2 D SWE coming closest to the actual tumor size.

Linking pre-existing biorepositories for medical research: the PopGen 2.0 Network

The significance of human biorepositories for modern medical research, particularly for comprehensive population-based genetic analyses, is constantly growing. While large and centralized institutions are usually considered best suited to meet the increasing demand for high-quality “biobanks,” most medical research institutions still host rather heterogeneous and fragmented biobanking activities, undertaken by clinical departments with oftentimes rather different scientific scope. Undoubtedly, most clinicians and medical researchers would appreciate infrastructural support in terms of the storage and handling of their biosamples, but they are also likely to expect access to their samples avoiding extensive formal requirements. We report on the establishment of the PopGen 2.0 Network (P2N), an overarching alliance of initially seven biobanks from Northern Germany which adopted a joint but lean governance structure and use-and-access policy for their samples and data. In addition, the members of P2N have pursued an intense collaboration on ethical, legal and social issues and maintain a common IT infrastructure. The implementation of P2N has substantially improved the prospects of biobank-based research at the participating institutions. The network may thus serve as a role model for similar initiatives geared at linking pre-existing biorepositories for the benefit of research quality, efficiency, and transparency.

Concomitant intrauterine growth restriction alters the lipoprotein profile in preeclampsia

OBJECTIVE

Preeclampsia and intrauterine growth restriction (IUGR) are related conditions. We aimed to characterise common lipid changes.

METHODS

Triglyceride and cholesterol levels of patients 24-42 weeks of gestation with IUGR (n = 52), hypertensive IUGR (HIUGR, n = 28), and preeclampsia without IUGR (PE, n = 56) were compared to a control group (CTRL, n = 167). In addition, 60 sera (n = 10 of each pathology IUGR, HIUGR, PE (without IUGR) compared to n = 30 matched CTRL) of severe early onset cases <34 weeks of gestation were chosen and further analysed by ultracentrifugation lipid subfractionation including VLDL, IDL, LDL, and HDL composition.

RESULTS

In the full cohort we found low cholesterol in IUGR (p = 0.0405), while triglyceride levels were high in PE (p < 0.0001). Lipid concentrations in HIUGR did not differ significantly from CTRL. In the 60 patients analysed by lipid subfractionation, triglyceride levels were increased in the VLDL subfraction in PE (p < 0.01), however, LDL-bound ApoB and cholesterol levels were lower in IUGR and HIUGR (p < 0.0001 for total cholesterol and p < 0.001 for ApoB in both groups), but not in PE when compared to CTRL.

CONCLUSION

Low cholesterol, especially LDL cholesterol levels are a feature of IUGR while high triglyceride levels are a feature of preeclampsia. Increased VLDL-triglycerides suggest a disturbed conversion to LDL in preeclampsia. Of note, the presence of IUGR in hypertensive disorders further alters lipid profiles, which may explain heterogeneous data on lipid values for preeclampsia in the literature. Study groups have to be selected carefully to avoid misinterpretation.

RNA based individualized drug selection in breast cancer patients without patient-matched normal tissue

Background

While standard RNA expression tests stratify patients into risk groups, RNA-Seq can guide personalized drug selection based on expressed mutations, fusion genes, and differential expression (DE) between tumor and normal tissue. However, patient-matched normal tissue may be unavailable. Additionally, biological variability in normal tissue and technological biases may confound results. Therefore, we present normal expression reference data for two sequencing methods that are suitable for breast biopsies.

Results

We identified breast cancer related and drug related genes that are expressed uniformly across our normal samples. Large subsets of these genes are identical for formalin fixed paraffin embedded samples and fresh frozen samples. Adipocyte signatures were detected in frozen compared to formalin samples, prepared by surgeons and pathologists, respectively. Gene expression confounded by adipocytes was identified using fat tissue samples. Finally, immune repertoire statistics were obtained for healthy breast, tumor and fat tissues.

Conclusions

Our reference data can be used with patient tumor samples that are asservated and sequenced with a matching aforementioned method. Coefficients of variation are given for normal gene expression. Thus, potential drug selection can be based on confidently overexpressed genes and immune repertoire statistics.

Materials and Methods

Normal expression from formalin and frozen healthy breast tissue samples using Roche Kapa RiboErase (total RNA) (19 formalin, 9 frozen) and Illumina TruSeq RNA Access (targeted RNA-Seq, aka TruSeq RNA Exome) (11 formalin, 1 frozen), and fat tissue (6 frozen Access). Tumor DE using 10 formalin total RNA tumor samples and 1 frozen targeted RNA tumor sample.

Accuracy of tumor size measurement: comparison of B-mode ultrasound, strain elastography, and 2D and 3D shear wave elastography with histopathological lesion size

BACKGROUND

Predicting the exact extent of a breast tumor is of great importance for oncologic treatment strategies. Different types of elastography can be used as new tools for measuring lesion size.

PURPOSE

To provide evidence regarding the accuracy of tumor size measurement of strain elastography (SE), two-dimensional (2D) and three-dimensional (3D) shear wave elastography (SWE), and conventional B-image ultrasound.

MATERIAL AND METHODS

In this prospective study, the diameter of 105 malignant breast lesions was measured by SE, 2D and 3D SWE, and B-mode ultrasound. The histopathological lesion size was compared to all imaging-based measuring methods.

RESULTS

The mean lesion size of all breast carcinomas was 1.54 cm. B-mode ultrasound underestimates breast cancer size in 65.7 % of all cases in this study ( P < 0.0001). Mean lesion size was more accurately determined by SE, 2D and 3D SWE compared to B-mode ultrasound. Absolute differences between measured and actual lesion are smaller for B-mode ultrasound (0.26 cm) than for SE (0.41 cm) and 2D and 3D SWE (0.41 cm and 0.44 cm, respectively).

CONCLUSION

B-mode ultrasound allows more accurate lesion size measurement than SE and 2D or 3D SWE but has a significantly higher risk of underestimating tumor size which could lead to incomplete margins during surgery. 3D SWE was not superior to 2D SWE or SE but by trend more precise in predicting the size of invasive lobular carcinoma.

Evaluation of the effects of sensorimotor exercise on physical and psychological parameters in breast cancer patients undergoing neurotoxic chemotherapy

INTRODUCTION

Breast cancer is the most common cancer disease of women in industrialized countries. Neurotoxic chemotherapy drugs are known to harm peripheral nerves and cause a chemotherapy-induced peripheral neuropathy (CIPN). CIPN is one of the most common adverse events associated with Paclitaxel chemotherapy and may remain present long after the termination of chemotherapy. Thus, it reduces the patients' quality of life (QoL) both during chemotherapy and onwards, and can impose a danger on breast cancer survivors due to an increased risk of falling and fall-related injuries.

METHODS

The aim of this randomized-controlled trial (RCT) (n = 36) (IG: intervention group, n = 17) (CG: control group, n = 19) was to determine whether sensorimotor exercises have a positive effect on physical and psychological parameters in breast cancer patients undergoing neurotoxic chemotherapy (Paclitaxel).

RESULTS

As a result, we were able to show significant improvements in postural stability in monopedal stance [left leg 16.17 ± 3.67 vs. 21.55 ± 5.33 (p < 0.001) and right leg 15.14 ± 2.30 vs. 20.85 ± 5.05 (p < 0.001)] and in bipedal stance [T1 vs. T0, - 0.49 (IG) vs. + 1.14 (CG) p = 0.039].

DISCUSSION

These results in posturography correlate with the clinical presentation with intervention group patients scoring significantly better on the Fullerton Advanced Balance Scale [37.71 ± 2.73 vs. 34.47 ± 3.98 (p = 0.004)]. Moderate strength training successfully prevented a strength loss in the IG that was remarkable in the CG (- 1.60 vs. 0.60, p = 0.029). Concerning the psychological parameters assessed via EORTC- and MFI-questionnaires, no significant improvements were found.

CONCLUSION

Future studies should focus on the correlation of clinical and posturometry findings and subjective QOL such as the long-term-development of CIPN.

SOFIA: A Novel Automated Breast Ultrasound System Used on Patients in the Prone Position: A Pilot Study on Lesion Detection in Comparison to Handheld Grayscale Ultrasound

Introduction

Most of the currently available automated breast ultrasound systems require patients to be in the supine position. Previous data, however, show a high recall rate with this method due to artifacts. The novel automated breast ultrasound scanner SOFIA scans the breast with the patient in a prone position, resulting in even compression of breast tissue. We present our initial results with this examination method.

Material and Methods

63 patients were analyzed using a handheld B-mode ultrasound. In cases of BI-RADS 1, 2 or 5, a SOFIA scan was performed. Sensitivity, specificity and accuracy were calculated. Interobserver agreement was evaluated using Cohenʼs kappa. The duration of the scan was measured for both methods.

Results

No BI-RADS 5 lesion was missed with SOFIA. The SOFIA had an additional recall rate of 16.67% compared to B-mode ultrasound. The sensitivity, specificity and accuracy of SOFIA was 100, 83.33 and 88.89%, respectively. Cohenʼs kappa showed substantial agreement (κ = 0.769) between examiner 1 (B-mode) and examiner 2 (SOFIA). The mean scan duration for the B-mode system and the SOFIA system was 24.21 minutes and 12.94 minutes, respectively. In four cases, D-cup breasts were not scanned in their entirety.

Conclusion

No cancer was missed when SOFIA was used in this preselected study population. The scanning time was approximately half of that required for B-mode ultrasound. The additional unnecessary recall rate was 16.67%. Larger D cup-size breasts were difficult to position and resulted in an incomplete image in four cases.

Comparison of Two Different Ultrasound Devices Using Strain Elastography Technology in the Diagnosis of Breast Lesions Related to the Histologic Results

This study was conducted to provide evidence that elastograms of two different devices and different manufacturers using the same technical approach provide the same diagnoses. A total of 110 breast lesions were prospectively analysed by two experts in ultrasound, using the strain elastography function from two different manufacturers (Hitachi HI-RTE, Hitachi Medical Systems, Wiesbaden, Germany; and Siemens eSie Touch, Siemens Medical Systems, Erlangen, Germany). Results were compared with the histopathologic results. Applying the Bowker test of symmetry, no statistically significant difference between the two elastography functions of these two devices was found (p = 0.120). The Cohen's kappa of k = 0.591 showed moderate strength of agreement between the two elastograms. The two examiners yielded moderate strength of agreement analysing the elastograms (Hitachi HI-RTE, k = 0.478; Siemens eSie Touch, k = 0.441). In conclusion, evidence is provided that elastograms of the same lesion generated by two different ultrasound devices equipped with a strain elastography function do not significantly differ.

ADAM17 inhibition enhances platinum efficiency in ovarian cancer

Chemotherapeutic resistance evolves in about 70 % of ovarian cancer patients and is a major cause of death in this tumor entity. Novel approaches to overcome these therapeutic limitations are therefore highly warranted. A disintegrin and metalloprotease 17 (ADAM17) is highly expressed in ovarian cancer and required for releasing epidermal growth factor receptor (EGFR) ligands like amphiregulin (AREG). This factor has recently been detected in ascites of advanced stage ovarian cancer patients. However, it is not well understood, whether and how ADAM17 might contribute to chemo resistance of ovarian cancer.

In this study, we identified ADAM17 as an essential upstream regulator of AREG release under chemotherapeutic treatment in ovarian cancer cell lines and patient derived cells. In the majority of ovarian cancer cells cisplatin treatment resulted in enhanced ADAM17 activity, as shown by an increased shedding of AREG. Moreover, both mRNA and the protein content of AREG were dose-dependently increased by cisplatin exposure. Consequently, cisplatin strongly induced phosphorylation of ADAM17-downstream mediators, the EGFR and extracellular signal-regulated kinases (ERK). Phorbol 12-myristate 13-acetate (PMA), similarly to cisplatin, mediated AREG shedding and membrane fading of surface ADAM17.

Inhibition of ADAM17 with either GW280264X or the anti-ADAM17 antibody D1 (A12) as well as silencing of ADAM17 by siRNA selectively reduced AREG release. Thus, ADAM17 inhibition sensitized cancer cells to cisplatin-induced apoptosis, and significantly reduced cell viability.

Based on these findings, we propose that targeting of ADAM17 in parallel to chemotherapeutic treatment suppresses survival pathways and potentially diminish evolving secondary chemo resistance mechanisms.

Active Immunisation with Partner Lymphocytes in Female Patients Who Want to Become Pregnant - Current Status

Around 1 – 3% of all couples who try to have a child are affected by recurrent miscarriage. According to the WHO, recurrent miscarriage is defined as the occurrence of three or more consecutive miscarriages up to the 20th week of pregnancy. There are various causes of recurrent miscarriage; in many cases, the causes remain unclear, with the result that immunological factors are one of the possible causes discussed. For the motherʼs immune system, the embryo represents a semi-allogeneic transplant, as half of the embryoʼs genes are of paternal origin. In place of a conventional immune response, the embryo induces a secondary protection mechanism, which contributes to the successful implantation. When performing immunisation with partner lymphocytes, the patient receives an intradermal injection of her partnerʼs prepared lymphocytes into the volar side of the forearm in order to induce immunomodulation with a consequently increased rate of pregnancy and live birth. A prerequisite for this procedure is that all other possible causes of sterility have been ruled out in advance. Due to the highly heterogeneous nature of the data, a significant benefit as a result of the immunisation cannot yet be clearly proven. However, there are signs that the therapy may be effective when using lymphocytes that have been extracted as short a time beforehand as possible. Overall, the treatment represents a safe, low-risk procedure. Following a detailed informative discussion with the couple regarding the chances of success and following a detailed review of the indication and contraindications, immunisation with partner lymphocytes can be discussed with the couple on a case-by-case basis – provided that all other possible causes of sterility have been ruled out in advance.

[Combined treatment of endometriosis: radical yet gentle]

Endometriosis is the second most common benign female genital disease after uterine myoma. This review discusses the management of individual patients. This should take into account the severity of the disease and whether the patient desires to have children. Particular emphasis is laid on the anatomical intersections which, when injured, can lead to persistent damage of the anterior, middle or posterior compartment and are not infrequently the cause of urological and urogynaecological follow-up measures. Typical symptoms of endometriosis include chronic pelvic pain, subfertility, dysmenorrhoea, deep dyspareunia, cyclical bowel or bladder symptoms (e. g. dyschezia, bloating, constipation, rectal bleeding, diarrhoea and haematuria), abnormal menstrual bleeding, chronic fatigue and low back pain. Approx. 50 % of all female teenagers and up to 32 % of all women of reproductive age who have been operated for chronic pelvic pain or dysmenorrhoea suffer from endometriosis. The time interval between the first unspecific symptoms and the medical diagnosis of endometriosis is about 7 years. This is caused not only by the non-specific nature of the symptoms but also by the frequent lack of awareness on the part of the cooperating disciplines with which the patients have first contact. As the pathogenesis of endometriosis is not clearly understood, causal treatment is still impossible. Treatment options include expectant management, analgesia, hormonal medical therapy, surgical intervention and the combination of medical treatment before and/or after surgery. The treatment should be as radical as necessary and as minimal as possible. The recurrence rate among treated patients lies between 5 % and > 60 % and is very much dependent on integrated management and surgical skills. Consequently, to optimise the individual patient's treatment, a high degree of interdisciplinary cooperation in diagnosis and treatment is crucial and should be reserved to appropriate centres - especially in the case of deep infiltrating endometriosis.