Robotic Systems in Operating Theaters: New Forms of Team-Machine Interaction in Health Care

BACKGROUND

Health information systems have developed rapidly and considerably during the last decades, taking advantage of many new technologies. Robots used in operating theaters represent an exceptional example of this trend. Yet, the more these systems are designed to act autonomously and intelligently, the more complex and ethical questions arise about serious implications of how future hybrid clinical team-machine interactions ought to be envisioned, in situations where actions and their decision-making are continuously shared between humans and machines.

OBJECTIVES

To discuss the many different viewpoints-from surgery, robotics, medical informatics, law, and ethics-that the challenges of novel team-machine interactions raise, together with potential consequences for health information systems, in particular on how to adequately consider what hybrid actions can be specified, and in which sense these do imply a sharing of autonomous decisions between (teams of) humans and machines, with robotic systems in operating theaters as an example.

RESULTS

Team-machine interaction and hybrid action of humans and intelligent machines, as is now becoming feasible, will lead to fundamental changes in a wide range of applications, not only in the context of robotic systems in surgical operating theaters. Collaboration of surgical teams in operating theaters as well as the roles, competencies, and responsibilities of humans (health care professionals) and machines (robotic systems) need to be reconsidered. Hospital information systems will in future not only have humans as users, but also provide the ground for actions of intelligent machines.

CONCLUSIONS

The expected significant changes in the relationship of humans and machines can only be appropriately analyzed and considered by inter- and multidisciplinary collaboration. Fundamentally new approaches are needed to construct the reasonable concepts surrounding hybrid action that will take into account the ascription of responsibility to the radically different types of human versus nonhuman intelligent agents involved.

Analysis of short-term efficacy as defined by RECIST and pathological response of neoadjuvant chemotherapy comprised paclitaxel and cisplatin followed by radical surgery in patients with locally advanced cervical cancer: A prospective observational study

The purpose of this study is to investigate short-term efficacy as defined by the Response Evaluation Criteria in Solid Tumors (RECIST) and pathological response of neoadjuvant chemotherapy (NACT) comprised of paclitaxel and cisplatin (TP) followed by radical surgery in patients with locally advanced cervical cancer (LACC).This is a prospective study involving 61 women with histologically confirmed LACC referred for NACT following radical surgery at Beijing Obstetrics and Gynecology Hospital between April 2013 and January 2015.The efficacy of NACT was evaluated by the RECIST. The total short-term efficacy of NACT was 91.8% (complete remission and partial remission). The cervical invasion ≤1/2 was 82.4% in the complete remission (CR) group, 46.2% in the partial remission (PR) group, and 20% in the stable disease (SD) group. The difference between groups was statistically significant (P = .012). The slides of all surgical specimens were reviewed and classified according to the Tumor Regression Grade (TRG). The good response was defined by good short-term efficacy (RECIST) and the difference between groups was statistically significant (P = .042). The route of administration of NACT is a factor predicting response to NACT. A significant higher response rate (P = .011) and lower chemotherapy-related adverse events (P < .05) were observed in the artery intervention (AI) group compared to those received NACT via intravenous (IV) route. All patients were followed-up to the last day of 2015 with the median follow-up time of 21.5 months for NACT. For the 61 patients referred for NACT in LACC, 2 patients had relapsed and 1 patient died from the disease.The study showed that the NACT comprised TP for LACC treatment had a significant local effect. It could reduce tumor myometrial invasion and regress tumor. The route of administrating NACT is a predicting factor to the NACT response; 2 cycles of NACT of AI treatment to LACC patients would obtain a desired response with low chemotherapy adverse events.

Analysis of short-term efficacy and pathological outcome of paclitaxel plus platinum as neoadjuvant chemotherapy in the treatment of locally advanced cervical cancer

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Background:The purpose of this study is to observe the short-term efficacy and pathological outcomes of paclitaxel combined with platinum (TP) as neoadjuvant chemotherapy (NACT) regimen in patients with locally advanced cervical cancer (LACC). Methods: This is a prospective study involving 61 women with histologically confirmed LACC referred for NACT at Beijing Obstetrics and Gynecology Hospital between April 2013 and January 2015. Results: The short-term efficacy of NACT was evaluated by the Response Evaluation Criteria in Solid Tumors (RECIST). The short-term efficacy of NACT was 91.8% (complete remission and partial remission). The cervical invasion ≤1/2 was 82.4% in the complete remission (CR) group, 46.2% in the partial remission(PR) group and 20% in the stable disease (SD) group. The difference between groups was statistically significant (p=0.012). The slides of all surgical specimens were reviewed and classified according to Tumor Regression Grade (TRG). The good response was defined by good short-term efficacy (RECIST) and the difference between the groups was statistically significant (p=0.042). The short-term efficacy of NACT in artery intervention (AI) group (70-80%) was better than that in intravenous (IV) group (20%-30%) and the difference was statistically significant (p=0.011). The patients with tumor diameter ≤5cm and multiple cycles of chemotherapy have good short-term efficacy of NACT in LACC. All patients were followed up to the last day of 2015 with the median follow-up time of 21.5 months for NACT. For the 61 patients referred for NACT in LACC, two patients had relapsed and 1 patient died from the disease. Conclusions: The study showed that the Paclitaxel plus platinum as NACT for LACC treatment had a significant local effects. It could reduce tumor myometrial invasion and regress tumor. The short-term efficacy of the treatment in the AI group was more effective than in the IV group, two cycles of NACT of AI treatment to LACC patients would obtain an optimal short-term efficacy. Clinical trial information: NCT02471027.

Effects of an Antagonistic Analog of Growth Hormone-Releasing Hormone on Endometriosis in a Mouse Model and In Vitro

Endometriosis is a benign gynecologic disorder causing dysmenorrhea, pelvic pain, and subfertility. Receptors for the growth hormone-releasing hormone (GHRH) were found in endometriotic tissues. Antagonists of GHRH have been used to inhibit the growth of endometriotic endometrial stromal cells. In this study, the GHRH receptor splice variant (SV) 1 was detected in human endometrial tissue samples by Western blots and quantitative reverse transcription polymerase chain reaction (qRT-PCR). The highest messenger RNA (mRNA) and protein levels of SV1 were found in eutopic endometrium from patients with endometriosis compared to ectopic endometriotic tissues and endometrium from normal patients. The highest expression for GHRH mRNA was found by qRT-PCR in ectopic endometriosis lesions. In an in vivo mouse model with human endometrial explants from patients with endometriosis, 10 μg MIA-602 per day resulted in significantly smaller human endometrial xenotransplants after 4 weeks compared to mice treated with vehicle. The endometrial tissues expressed SV1 before and after xenotransplantation. The proliferation of endometrial stromal cells as well as the endometriosis cell lines 12-Z and 49-Z was decreased by exposure to 1 μM MIA-602 after 72 hours. The protein levels of epithelial growth factor receptors in 12-Z and 49-Z cell lines were reduced 48 and 72 hours after the administration of 1 μM MIA-602. MIA-602 decreased the activation of the MAP-kinases ERK-1/2. Our study demonstrates the presence of SV1 receptor as a target for treatment with GHRH antagonist in endometriosis. Endometrial tissues respond to MIA-602 with inhibition of proliferation in vitro and in vivo. The use of MIA-602 could be an effective supplement to the treatment strategies in endometriosis.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

SPIO processing in macrophages for MPI: The breast cancer MPI-SNLB-concept

Introduction

Breast cancer (BC) is the most common cancer in women worldwide. We aim to develop a new sentinel lymph node biopsy (SLNB) method with superparamagnetic iron oxide nanoparticles (SPIOs) and magnetic particle imaging (MPI) in BC to avoid tissue damaging while axillary surgery. As we know from i.v. SPIO application in magnetic resonance imaging (MRI), macrophages (MP) are key role player in processing of SPIOs (e.g. in liver) causing a drop of signal intensity. But, knowledge lacks concerning enrichment processes of SPIOs after injection in breast tissue, the adjacent lymphatic tissues and associated cells, especially in BC and metastatic lymph nodes. We already evaluated the distribution of SPIOs in an in vivo healthy and tumor mouse model. Based on these studies we investigate the processing of the SPIOs in MP.

Material and Methods

To evaluate SPIO processing, a mouse MP cell line J774A.1 was incubated either by Resovist in culture medium (RPMI, FBS), or culture medium only as control. MP were than analyzed by transmission electron microscopy (TEM). Additionally, this process was observed in vivo by multiphoton microscopy. Detection of SPIOs was realized by excitation at 1200 nm.

Results

Resovist had no toxic effects on cells.MP showed activity in phagocytosis of Resovist after incubation in TEM as well as in multiphoton microscopy. SPIOs were detectable within intracellular vesicles by TEM and 3-photon process. The first cell associated SPIO signal was detected after 1,5 min of incubation by in vivo imaging.

Conclusion

To our knowledge this is the first time a 3-photon device was used to image SPIOs in a bio-medical context. System wide scanning is known (MRI, MPI), but nowwe are also able to identify the link to subcellular processing and localization of SPIOs. Further processing of SPIOs in MP is under development.

Phase II study of fulvestrant 250 mg/month in patients with recurrent or metastatic endometrial cancer: a study of the Arbeitsgemeinschaft Gynäkologische Onkologie

OBJECTIVES

The aim of this study is to evaluate the activity and toxicity of fulvestrant, a pure estrogen receptor antagonist in patients with advanced or recurrent endometrial cancer, expressing estrogen and/or progesterone receptors (ER/PR).

METHODS

Eligible patients with advanced or recurrent endometrial cancer not amenable to curative surgery and/or radiotherapy were treated with fulvestrant at a dose of 250 mg by IM injection every 4 weeks for at least 12 weeks. Therapy was continued until disease progression, death, intolerable side effects or end of study. Response was assessed in patients with at least one target lesion according to WHO-criteria.

RESULTS

Thirty-five patients were enrolled in this study and received at least one injection of fulvestrant (intention to treat-population, ITT). Twenty six patients received the intended 3 injections of fulvestrant (per protocol population, PP). There was no complete response but 4 partial responses (11.4% ITT) and 8 stable diseases. The median time to progression was 2.3 months (ITT). Overall survival was 13.2 months (ITT). Treatment was well tolerated.

CONCLUSIONS

Fulvestrant at a dose of 250 mg IM every 4 weeks has marginal activity and good tolerability in patients with ER and/or PR positive advanced or recurrent endometrial cancer. A loading dose strategy and the use of 500 mg/4 weeks might improve the efficacy of this treatment.

Abstract P2-10-25: Prognostic value of relative change in tumor marker CA 27.29 in early stage breast cancer – The SUCCESS trial

Background: MUC1 based tumor markers like CA27.29 (TM) in breast cancer are routinely used in metastatic disease as early marker for treatment efficacy. However, in early stage disease data is sparse. In this analysis, we looked at the impact of individual change in CA27.29 on prognosis instead of using a threshold.

Methods: The SUCCESS Trial compares FEC-docetaxel (Doc) vs. FEC-Doc-Gemcitabine (Doc-G) regime and two vs. five year treatment with Zoledronat in 3754 patients (pts) with primary breast cancer (N+ or high risk N0). We measured CA27.29 after surgery but before chemotherapy (CHT) as baseline and compared it to CA27.29 levels 2 years thereafter with the ST AIA-PACK Ca27.29 reagent using MUC-1 for AIA-600II (Tosoh Bioscience, Tessenderlo, Belgium).

Results: CA27.29 data is available of 2,015 pts. 119 pts (5.9%) had TM over the threshold of 32U/ml before CHT and 56 (2.8%) 2years thereafter. To examine the relative change of tumor marker, pts were divided into 3 groups:

increase: change &gt;=5 U/ml; stable: change &lt;±5U/ml; decrease: change &gt; = −5 U/ml.

123 (6.1%) pts had increasing (&gt;=5 U/ml), 1419 (70.4%) had stable, 473 (23.5%) had decreasing TM levels from before CHT to 2 years thereafter. The majority of pts with increasing TM (86 pts; 69.9%) had levels below the usual threshold of 32U/ml at all times. Patients with an increase &gt;=5 U/ml had an 81% increased risk for recurrence (HR = 1.810 [CI: 1.111–2.948]) and reduced overall survival (HR = 1.020 [CI: 1.004–1.037]). In the multivariate analysis taking into account tumor size, nodal status, grading, age, hormonal and HER2/neu receptor status increasing CA27.29 levels were an independent prognostic marker.

Conclusions: An increase of the tumor marker CA27.29 2 years after CHT compared to pre-chemotherapy baseline was associated with a worse prognosis. By using this approach, more patients at risk for recurrence were detected than with the standard threshold approach. Therefore, the use of relative change could help to identify more patients at risk for relapse who might benefit from an intensified follow up.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-25.

Results of the first interim analysis of the CARMA study to investigate efficacy and safety profile of catumaxomab in clinical practice

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Background: The trifunctional antibody catumaxomab is approved in the EU for intraperitoneal (i.p.) treatment of malignant ascites in patients (pts) with EpCAM-positive carcinomas. Clinical data for catumaxomab are based on the pivotal trial and several phase I/II trials. So far, the routine use of catumaxomab in clinical practice has not been evaluated systematically. Therefore, a large prospective observational study was started in 2010. The study investigates the administration of catumaxomab in a total of 160 pts with malignant ascites under routine conditions in daily clinical practice. Here we show the results of the first pre-planned interim analysis. Methods: The analysis included 49 pts with malignant ascites due to EpCAM-positive carcinomas treated with i.p. catumaxomab under routine conditions in clinical practice. Participating centres were hospitals and practices of oncologists in Germany. Primary endpoint was puncture-free interval (PFI), secondary endpoints included safety and overall survival (OS). Results: At inclusion into the study pts already had undergone a median number of 9 ascites punctures. Malignant ascites had been diagnosed for the first time 3.3 months before (median). Patients suffered from typical ascites symptoms as follows: swelling (79.6%), pain (44.9%), dyspnea (26.5%), anorexia (26.5%), obstipation (12.2%). 49 pts were treated with catumaxomab, of whom 30 pts received all 4 infusions (61.2%). Median PFI was 108 days (d), the median OS was 102 d. Most frequent adverse events were fever, nausea and diarrhoe. Conclusions: This is the first systematic report on routine use of catumaxomab in clinical practice.. Although The study population mainly comprised patients with advanced tumor diseaset a clinical benefit after catumaxomab therapy could be demonstrated. The treatment showed an acceptable safety profile Theseresults are consistent with the data of the pivotal trial. The data will be evaluated in further analyses including larger patient numbers.

Bridge-1 is expressed in human breast carcinomas: silencing of Bridge-1 decreases Smad2, Smad3 and Smad4 expression in MCF-7 cells, a human breast cancer cell line

PURPOSE

The aim of the study was to investigate the expression of Bridge-1 in human breast carcinomas, and to determine the in vitro regulation of Bridge-1 by activin A and the influence of Bridge-1 on activin A signaling in the human breast cancer cell line MCF-7.

METHOD

Bridge-1 expression in human breast carcinomas was shown after staining paraffin slides with a specific antibody against Bridge-1. To gain insight into Bridge-1 function, immortalized, human breast cancer cells (MCF-7 cell line) were stimulated with activin A and the expression of Bridge-1 was analyzed by real-time PCR and Western blot. Next, Bridge-1 was downregulated via siRNA treatment in MCF-7 cells and the expression of Bridge-1, Smad2, 3 and 4 was investigated by real-time PCR and Western blot.

RESULTS

Human breast carcinoma cells showed nuclear and cytoplasmic localization of Bridge-1. Activin A stimulation of the immortalized human breast adenocarcinoma cell line MCF-7 showed an increase in Bridge-1 expression by real-time PCR and Western blot. Downregulation of Bridge-1 by Bridge-1-siRNA resulted in a decreased expression of Smad2, 3 and 4 of up to 50% compared to the treatment with non-targeting siRNA.

CONCLUSIONS

This study is the first to demonstrate the expression of Bridge-1 in human breast carcinomas. Bridge-1 expression is increased by activin A stimulation and itself seems to influence activin A signaling by affecting the expression of Smad2, 3 and 4.

Results from a phase II study to assess the efficacy and tolerability of fulvestrant 250 mg/month as treatment of recurrent or metastatic endometrial carcinoma

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Background: Fulvestrant (F) is a pure anti-estrogen with no agonistic action and no known adverse effects on the endometrium. This may be an advantage over tamoxifen, which has been successfully used in the treatment of hormone-receptor (HR) positive recurrent or metastatic endometrial carcinoma. Methods: This was an open label single-arm multicentre phase II study (AGO-Uterus 5) in patients with recurrent or metastatic endometrial carcinoma and measurable disease (RECIST). Pts. received monthly 250 mg F i.m. injections. The primary objective was clinical response after 3 injections, measured 4 weeks after injection 3 (ITT-pop.). Safety and tolerability were secondary endpoints. Results: Between March 2003 and May 2006, 35 pts. were included. Mean age was 70 years (range 45–83), first diagnosis was a mean 2.6 years ago, diagnosis of recurrence 10.2 months ago. 25 pts. (73.5%) had a FIGO 4B; 24 pts. (71%) had endometrioid cancer, 5 (15%) serous and 5 other carcinoma. All pts. had a positive ER and/or PgR status. 1 pt. had received no surgery for her disease; 21 pts. (61.8%) had prior radiotherapy; 13 pts. (38.2%) chemotherapy. 26 pts. were assessed as planned (ITT); 5 pts. received fewer than 3 injections, 4 pts. were not seen 4 weeks after inj. 3. Response to F was PR in 5 pts. (19.2%) and SD in 8 pts. (30.8%), adding up to a 50% disease control rate. 13 pts. had PD. Tolerability was good, no previously unknown side effects occurred. Conclusions: F showed encouraging response rates in our patient collective and was well tolerated. Further studies are warranted with F in HR pos. endometrial carcinoma. This study was supported by AstraZeneca. F is licensed for treatment of ER+, advanced breast cancer after an antioestrogen in postmenopausal women.

[Table: see text]

CA 27.29 as a tumour marker for risk evaluation and therapy monitoring in patients with primary breast cancer

Abstract #2004

Background:&#x2028; Several trials show that the use of tumor markers leads to an early diagnosis of tumor dissemination in breast cancer patients. Whether this improves the prognosis is still under discussion. In the SUCCESS Trial CA27.29 has been examined before and after adjuvant chemotherapy (n=3754).&#x2028; Methods:&#x2028; The SUCCESS Trial compares FEC-Docetaxel (Doc) vs. FEC-Doc-Gemcitabine (Doc-G) regime and two vs. five year treatment with Zoledronat in patients with primary breast cancer (N+ or high risk). CA27.29 has been measured with ST AIA-PACK Ca27.29 reagent using MUC-1 for AIA-600II (Tosoh Bioscience, Tessenderlo, Belgium). The cutoff for positivity of CA27.29 is 24 U/ml.&#x2028; Results:&#x2028; 2669 patients have been examined prospectively before and after chemotherapy. 22% of patients had a marker &gt;24 U/ml (n=587, mean 19.00, range 3.04-410.00) before and 40% (n=1058, mean 23.34, range 2.70-330.76) after chemotherapy. The correlation between both values was significant (p&lt;0.0005).&#x2028; While 17% showed elevated CA27.29 before and after therapy, 5% patients changed from positive to negative for CA27.29 afterwards. 55% were negative before and after therapy whereas 23% became positive after treatment.&#x2028; &#x2028; Before treatment the prevalence of elevated CA27.29 was equally distributed between the FEC-Doc and the FEC-Doc-G arm. After treatment 34.1% in the FEC-Doc arm showed an increased level vs. 45.6% in the FEC-Doc-G arm. The correlation analysis showed no significant coherence between hormonal status (ER: p&lt;0.323; PR: p&lt;0.078), HER2/neu status (p&lt;0.308), Grading (p&lt;0.565) and CA27.29 level. However, tumor size (p&lt;0.020) and the nodal status (p&lt;0.022) were significant associated with Ca27.29 levels.&#x2028; Conclusion:&#x2028; These results might indicate a close relation between Ca27.29 and tumour mass at primary diagnosis. Whether this marker will be useful for treatment monitoring will be shown by further follow-up in the Success-trial.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2004.

Laparoscopic management of early primary omental pregnancy

OBJECTIVE

To describe the successful laparoscopic management of an omental pregnancy.

DESIGN

Case report.

SETTING

University of Schleswig-Holstein, Campus Luebeck, Department of Gynecology and Obstetrics.

PATIENT(S)

A 25-year-old patient with an omental pregnancy.

INTERVENTION(S)

Laparoscopic partial omentectomy.

MAIN OUTCOME MEASURE(S)

Successful laparoscopic management of an omental pregnancy.

RESULT(S)

A 25-year-old woman reported having abdominal pain. Her urine pregnancy test was positive. She had been using an intrauterine copper device for a period of 2.5 years. Gynecologic examination revealed normal results, in the uterus and fallopian tubes especially, where no signs of pregnancy were found through clinical and sonographic examination. Because the patient had had increasing pain, a laparoscopy was performed. There was approximately 500 mL of dark blood found in the cul de sac. The uterus and fallopian tubes appeared normal and without any signs of pregnancy. However, there was a cavity detected in the omentum majus. A partial omentectomy then was performed laparoscopically. An omental pregnancy was confirmed by beta-hCG-positive trophoblast cells in the omentum majus.

CONCLUSION(S)

Omental pregnancy can be rather difficult to identify. If there is no evidence of tubal pregnancy, laparoscopy may help to confirm the diagnosis of omental pregnancy and simultaneously offer minimal invasive therapy.

Cell-specific enhancement of liposomal transfection by steroids in steroid receptor expressing cells

The DNA transfer efficiency in liposomal versus viral transfection is very low, mainly due to an insufficient nuclear transport of the delivered DNA after its endocytotic uptake to the cell. Ligand activation of intracellular steroid receptors and their subsequent mobilization to the nucleus could result in a co-transport of DNA to the nucleus. The augmentation of nuclear transport of DNA after steroid addition might cause enhanced transfection efficiency. We used cell lines from gynecologic malignoma expressing steroid receptors, such as T47D and Mcf-7 breast cancer cell lines, as well as receptor-negative cell lines, such as Hec1A from endometrium carcinoma or the breast cancer cell line MDA-MB-231. The cells were transfected by the liposomal transfection agent Dotap with the gene for firefly-luciferase as a reporter gene and transfection efficiencies were determined in the luciferase assay. We compared the effect of the addition of cholesterol and steroids in different cell lines on the transfection efficiency. The addition of cholesterol to transfection agents led to an enhancement of the luciferase activity in all cell lines. Steroids enhanced the transfection efficiency only in receptor-positive cell lines. The transfection efficiencies of HEC-1A or MDA-MB-231 cells were not enhanced by steroids. A progesterone preincubation of receptor-positive T47D cells resulted in a decrease of progesterone receptors and afterwards the progesterone enhanced transfection was dramatically diminished. We presume that the transfection enhancement by steroids is dependent on increased nuclear import of the delivered DNA only in the presence of steroid receptors. Steroid enhancement of transfection is different from the benefit of cholesterol for transfection that acts on general cellular properties or the transfection complex as such. Liposomal transfection in combination with steroids might be useful for a cell-specific enhancement of gene transfer for example in gynecological malignoma where subgroups are expressing high levels of steroid receptors.

Cetrorelix in the treatment of female infertility and endometriosis

The use of cetrorelix within ovarian-stimulation protocols demonstrates several advantages compared with gonadotropin-releasing hormone (GnRH) agonist-containing protocols, which include, for example, significantly less time for analogue treatment and a reduction in the amount of gonadotropins needed. Furthermore, fewer side effects can be expected. There is no difference regarding endometrium quality and hormone profiles, and the results of assisted reproduction cycles are comparable. Cetrorelix also seems to be useful in the treatment of endometriosis which, in most cases, is an estrogen-dependent disease. Furthermore, fewer side effects occur with this agent (e.g., postmenopausal symptoms) and no estradiol add-back is needed. In the future, new nonpeptic GnRH antagonists are expected to be available for oral administration. Although they are still under investigation, these agents have the potential to improve patients' comfort and compliance.

Is Endometriosis Associated with Systemic Subclinical Inflammation?

Endometriosis is a pelvic inflammatory process with altered function of immune-related cells and increased number of activated macrophages in the peritoneal environment that secrete various local products, such as growth factors and cytokines. The elevation of cytokines and other factors in the peritoneal fluid is accompanied by the elevation of similar factors, such as CRP, SAA, TNF-alpha, MCP-1, IL-6, IL-8 and CCR1, in the peripheral blood of patients with endometriosis. CD44+ and CD14+ monocytes are significantly increased, while CD3+ T lymphocytes and CD20+ B lymphocytes show modest, but significant decrease in peripheral blood of women with endometriosis. This indicates that endometriosis could be viewed as a local disease with systemic subclinical manifestations. This review provides an overview of data on the changes of various factors in peripheral blood and their potential use as diagnostic tools in patients with endometriosis.

Quality of life in elderly men with androgen deficiency

The partial androgen deficiency in aging male (PADAM) has been of great interest to investigators and the public in the last few years. For males, androgens are said to be essential for the maintenance of quality of life (QoL) but there are no data available with respect to QoL and PADAM yet. In order to evaluate changes of individual well-being of males older than 50 years and with subnormal levels of free testosterone (FT) (<200 pmol l(-1)), these men were asked to fill in a questionnaire regarding QoL. The objective of this study was to compare age-matched males with androgen deficiency (group 1; n = 24) and normoandrogenic elderly men (group 2; n = 24) with respect to QoL and somatic indicators of the endocrine status. Participants suffered from benign prostatic hyperplasia (BPH) and were hospitalized for prostate surgery. Health-related QoL was assessed by the SF-12 Health Survey, including the physical health index and the mental health index. The SF-12 was enlarged by the scales 'vitality' and 'psychological well-being' of the SF-36. Additionally, patients were asked about social and clinical items. There were no statistically significant differences between the two groups regarding social and clinical parameters. The physical health index was reduced in group 1 (P < 0.05; effect size was medium (d = 0.57)) whereas the mental health index was similar in both groups. The correlation between the two health indices was very low and not statistically significant (r = 0.05, P = 0.72). Patients of group 1 described a lower vitality compared to group 2 (P < 0.05), but no differences could be observed regarding psychological well-being. Therefore, androgen-deficient patients seem to have the impression of a reduced physical ability. Our data emphasize that the subjective description of health-related aspects of QoL is a very sensitive methodological approach to discover psychological differences between patients. For the differentiation between androgen-deficient patients and those with normal testosterone levels the physical health index seems to be more sensitive than the mental health index. A question of interest is whether this difference remains detectable if testosterone is supplemented to androgen-deficient men. Whether testosterone supplementation is beneficial to these patients has to be carefully considered.

Assessment of luteinizing hormone level in the gonadotropin-releasing hormone antagonist protocol

In the GnRH-antagonist multiple-dose protocol, the LH level retrieved from a single measurement during ovarian stimulation and concomitant GnRH-antagonist administration can vary according to [1] the time point of sampling with respect to the GnRH-antagonist injection and [2] episodic changes in circulating LH concentration due to the pulsatile release of LH from the pituitary gland. To exemplify the size of pharmacodynamic effect of a single 0.25-mg cetrorelix administration on LH concentration profile and pulsatility, we measured endogenous LH levels every 15 minutes from 8 hours before the first cetrorelix administration until 24 hours thereafter on ovarian stimulation day 6 and 7 in a single patient.

Endometrial stromal sarcomas--a retrospective analysis of 11 patients

BACKGROUND

Endometrial stromal sarcoma (ESS) is a malignant tumour with its origin in the endometrial stroma. Little is known about the pathogenesis, risk factors, optimal therapy or outcome of this disease.

PATIENTS AND METHODS

Eleven patients with ESS, treated between 1972 and 1996, are reported on. The hospital records of all the patients, including pathology and operative reports, were reviewed and information on treatment, recurrence and survival was obtained.

RESULTS

The mean age of our patients was 56.6 years. The main symptom was abnormal vaginal bleeding. Most patients were diagnosed at FIGO stage I. Treatment modalities were surgery, radiation and, in one patient, chemotherapy. The median follow-up time was 42.1 months; 27.3% of the patients had local recurrence. The 1-year, 2-year and 5-year survival rates were 36.3%, 18.1% and 9.1%, respectively.

CONCLUSION

ESS is a uterine sarcoma with a difficult differential diagnosis. Patients are frequently diagnosed in an early tumour stage but still experience local or distant recurrence. The prognosis is poor, with early recurrence and low long-time survival rates. The treatment includes surgery and adjuvant radiation, with endocrine therapy being a promising new approach. In order to obtain more information about the pathogenesis of the tumour and to find the optimal therapy, it is necessary that studies, even with small numbers of patients, are undertaken.

Application of novel tissue microarrays to investigate expression of tryptase, chymase and KIT protein in placental mast cells

INTRODUCTION

Tissue microarrays comprise numerous small representative tissue samples from hundreds of different cases assembled on a single histologic slide, and therefore allow high throughput analysis of multiple specimens at the same time. Mast cells are paracrine cells found ubiquitously in connective tissue. Expression of the serine proteases tryptase and chymase, as well as KIT protein, the receptor for stem cell factor (SCF), has been demonstrated in mast cells. Because little is known about the role of mast cells in the placenta, we investigated the number and expression of chymase, tryptase, and KIT protein in placental mast cells using newly developed tissue microarrays.

MATERIALS AND METHODS

Tissue microarrays were prepared from archival paraffin tissue blocks of 90 placentae, including 15 normal ones as a control group. Gestational age of the placentae ranged from 7 to 42 weeks. Sections of formalin-fixed paraffin-embedded material were prepared on chemically activated cover-slides. The slides were cut in 4-mm(2) squares containing representative areas, and transferred to a tissue microarray. Hematoxylin and eosin (H&E), chloroacetate esterase (CAE), toluidine blue, periodic acid--Schiff (PAS), and immunohistochemical staining were performed. The number of mast cells and expression of chymase, tryptase, and KIT protein were evaluated in each case.

RESULTS

Mast cell numbers in placentae with inflammation/abortion exceeded that of normal placentae. Although statistically not significant, we furthermore observed an increase in chymase-positive mast cells in the group of placentae associated with fetal malformations/chromosomal aberrations compared with normal placentae.

DISCUSSION

Novel tissue microarray technique has been introduced into placental research, and allows multiple placental tissue samples to be effectively analyzed simultaneously. This study indicated an increased number of chymase-positive mast cells in placentae with fetal malformation/chromosomal aberration. Activation of angiotensin II by chymase may play a role in fetal malformation. Moreover, it has been speculated that mast cells may only express chymase (MC(C)). Our findings denote the presence of placental MC(C). However, further studies are needed to elucidate more precisely the role of mast cell chymase in the placenta.

FSH time-concentration profiles before and after administration of 0.25 mg cetrorelix in the gnRH-antagonist multiple-dose protocol for ovarian hyperstimulation

PURPOSE

To determine FSH concentration behavior before and after cetrorelix 0.25 mg administration in the GnRH-antagonist multiple-dose protocol on day 6 of ovarian stimulation with 150-300 IU daily recombinant FSH.

METHODS

Blood samples for FSH measurements were drawn from seven women every 15 min from 8 h prior to the first cetrorelix administration in the GnRH-antagonist multiple-dose protocol until 15-32 h thereafter.

RESULTS

No significant change of FSH concentration was observed.

CONCLUSIONS

This observation indicates that no rationale exists of increasing the daily FSH dosage concomitantly to the GnRH-antagonist administration to compensate for a drop of endogenous FSH.

Polymorphisms of genes involved in innate immunity: association with preterm delivery

An altered inflammatory activity due to functionally relevant polymorphisms of the innate immune system may influence pathways leading to labour and, therefore, impact on the frequency of preterm birth. We examined five polymorphisms of the innate immune system in a large cohort of preterm very-low-birth-weight (VLBW, n = 909) and term-born infants (n = 491) and their mothers (n = 747). The primary outcome was preterm versus term birth. Frequencies of polymorphisms in mothers of term-born infants versus mothers of VLBW infants and term infants versus preterm VLBW infants (singletons) are given. Homozygous CD14-159T: 18.5 versus 21.8% (mothers) and 19.6 versus 21.2% (infants). Homozygous interleukin IL-6-174G: 28.8 versus 38% (P = 0.018, mothers) and 30 versus 32.7% (infants). Homozygous or heterozygous nuclear oligomerization domain NOD2-3020insC: 6.9 versus 6.1% (mothers) and 5.7 versus 5.1% (infants). Heterozygous or homozygous toll-like-receptor TLR2-Arg753Gln: 6.9 versus 6.1% (mothers) and 5.7 versus 5.1% (infants). Homozygous or heterozygous TLR4-896G: 8.1 versus 11.5% (mothers) and 11.6 versus 10.5% (infants). Although the homozygous maternal IL-6-174G genotype was found to be independently associated with preterm delivery in multivariate regression analysis, the incidence of intrauterine infection was not significantly increased in mothers of preterm VLBW-infants, carrying this or other polymorphisms of the innate immune system. The overall influence of the investigated polymorphisms on the development of preterm delivery seems moderate, since only the maternal IL6-174G genotype was associated with preterm birth and none of the polymorphisms were associated with intrauterine infection as the cause of preterm birth.

Additive effect of steroids and cholesterol on the liposomal transfection of the breast cancer cell line T-47D

The efficiency of gene transfer is many times higher in viral than in liposomal transfection. One reason for this is an insufficient intracellular transport of the exogenous DNA into the nucleus in lipofection. Using liposomal transfection techniques for gene therapy is safer than viral approaches, so it would be of great importance to find solutions for their enhancement. We found a 4.51-fold increase in liposomal transfection of T-47D breast cancer cells by the addition of progesterone and a 2.81-fold increase by the addition of cholesterol. The transfection efficiency was measured as the activity of the delivered reporter gene luciferase. The addition of progesterone and cholesterol in combination led to a further enhancement of the transfection efficiency up to 13.72-fold. This additive effect could also be seen when we combined cholesterol with other steroids, but not by the combination of different steroids. All of these steroids alone had also the potential to increase liposomal transfection. Therefore we suggest that steroids and cholesterol enhance liposomal transfection by different mechanisms. Both substances have been shown to shift the exogenous DNA from the cytosol to the nucleus. Steroids normally act through intracellular steroid receptors, which migrate into the nucleus upon activation. The transfected DNA might be co-transported to the nucleus together with the migration of the activated steroid receptors. Even if cholesterol causes also an intracellular shift of DNA to the nucleus, its impact on the fluidity of cellular membranes or on the stability of lipoplexes in serum containing media could be mainly responsible for its effect. If the steroid enhanced liposomal transfection is dependent on the presence of steroid receptors, a specifically-enhanced gene delivery for a subgroup of gynecological tumours expressing high levels of steroid receptors could be possible.

[Cumulus cell apoptosis as a predictor for oocyte quality in artificial reproduction technique]

OBJECTIVE

To be able to predict the success of ART reliable tests for determining the quality of the oocytes are necessary. Apart from a vague morphologic assessment via microscopy a direct analysis of the oocyte quality is not possible. Because of the very close relation between the oocyte and the cumulus cells the analysis of the cumulus cells might give sufficient information on the oocyte quality. In this study we correlate the apoptotic activity of cumulus cells to the outcome of fertilized oocytes after Intracytoplasmic Sperm Injection (ICSI).

MATERIAL AND METHODS

246 cumulus-oocyte-complexes from patients undergoing infertility treatment with the ICSI procedure were individually collected. The comet assay was used to determine the proportion of apoptotic cells within the cumulus population of each oocyte and correlated with oocyte fertilization and oocyte quality as well as with pregnancy outcome in 86 patients.

RESULTS

We were able to show that high quality embryos correlate to a low rate of apoptotic cells in their corresponding cumuli. Differences regarding the pregnancy outcome were statistically not significant.

CONCLUSIONS

Our results on cumulus cell apoptosis and embryo quality confirm other publications. To arrive at statistically proven criteria for the further development of single oocytes an increase in the number of analyzed patients is necessary.