Intraoperative subserosal approach to label sentinel nodes in intermediate and high-risk endometrial cancer

DESIGN

prospective experimental study.

PURPOSE OF INVESTIGATION

The purpose of this study was to evaluate feasibility and reliabil- ity of in vivo sentinel lymph node (SLN) mapping in patients with endometrial cancer and to verify a modified method of application of subserosal blue dye. Detection substance was applied subserosally in the uterine edges vicinity the round ligament of uterus and uterine vessels in the isthmic portion of the uterus.

MATERIALS AND METHODS

Eighteen patients with intermediate and high-risk endome- trial cancer Stages I-II were subjected to staging laparotomy with intraoperative detection of SLNs and subsequent completion of the pelvic and para-aortic lymphadenectomies. Harvested SLN was routinely examined by classical haematoxylin eosin staining and in case of negativity, immunohistochemistry with anti-keratin antibodies AEl/AE3 was applied.

RESULTS

Total of 773 lymph nodes were removed in 18 patients: pelvic 420 (54%) and para-aortic 353 (46%). SLNs were detected in 16 of 18 patients totalling 59 nodes (7.6% of all nodes). Forty-eight were identified in the pelvic area (81%) and 11 nodes (19%) in the para-aortic area. Three metastatic SLNs were found in two patients (11%). No false negative nodes were demonstrated.

CONCLUSION

Experimental study results indicate that the proposed modified approach to label SLNs is applicable. The presented modified approach brings the highest added value namely in women with a myomatous uterus and scars from previous surgical procedures on the uterus.

[Medical, legal and ethical aspects of fertility preservation in cancer survivor]

In recent years the number of the young women in fertile age which are oncologically treated is increasing. For these women chemotherapy and radiotherapy introduces potential risk of reproductive dysfunctions. Present techniques of assisted reproduction are offering possibilities to save reproductive functions even after the oncological treatment. As a perspective outlook seems to be frozen premature oocytes with IVM and fertilisation. With these fertility savings methods are naturally coming up some of the ethical and legal issues.

Malignant changes in adenomyosis in patients with endometrioid adenocarcinoma

OBJECTIVE

The aim of our retrospective study was to evaluate pathological changes in adenomyotic foci in hysterectomy specimens, and point out a possible mechanism of carcinogenesis in adenomyotic foci inside the myometrium.

METHODS

Retrospective analysis of clinical data; 219 patients were operated at our departments from 2003-2008 with the diagnosis of early endometrial cancer. Standard staging operation was used in all cases and all hysterectomy specimens were afterwards routinely analyzed.

RESULTS

Adenomyosis was found in 88 of a total of 219 hysterectomy specimens, while 205 of these 219 were affected by endometrioid adenocarcinoma, ten with clear cell carcinoma and four with papillary serous carcinoma. Within these subgroups adenomyosis was documented in 87 of 205 specimens with endometrioid adenocarcinoma (42.4%) and in one specimen of ten with clear cell carcinoma (2.2%), all found in the eutopic endometrium. All cases of malignant changes (n = 6) in adenomyosis were found exclusively with coexisting endometrioid adenocarcinoma: adenocarcinoma in adenomyosis was well or moderately differentiated in five cases, and poorly differentiated in just one case. Differentiation of the tumor in adenomyosis correlated with differentiation of the eutopic endometrial cancer in 50%. Hyperplastic changes like benign glandular hyperplasia, or atypical complex hyperplasia (ACH) were identified simultaneously in all cancer-positive adenomyotic foci.

CONCLUSION

Malignant changes in adenomyosis were present in 6.8% of patients with endometrial cancer. All malignancy-positive cases of adenomyosis were associated with endometrioid adenocarcinoma of the eutopic endometrium. Interestingly, in all these cases, different stages of hyperplastic changes were also simultaneously identified. This observation suggests a similar pathway of carcinogenesis in adenomyosis as is known in estrogen-responsive endometrial cancer type I.

[Reproductive outcome after laparoscopic myomectomy--retrospective analysis 1994-2007]

The aim of the study was to analyse the reproductive outcome after laparoscopic myomectomy (LM) in infertile patients. Between the years 1994-2007 were 351 infertile women operated in our department. The average age of the patients was 33.5. The total number of extirpated fibroids was 643, with the average of 1.7 per patient and the average size of 3.3 cm. 171 women (48.7%) became pregnant after LM. There were 119 deliveries, 16 spontaneous abortions and 6 ectopic pregnancies in this group. The caesarean section (CS) rate was 46.2% . Intramural localisation of the fibroid significantly correlated with the termination of pregnancy by CS. I. and II. trimester pregnancy loss correlated significantly with deep coagulation when conception occurred during 12 months after surgery. No uterine rupture was observed during pregnancy.

[Rectal duplication cyst--case report]

OBJECTIVE

The authors demonstrate a rare case of duplication anomaly of the rectum.

DESIGN

Case report.

SETTING

Institute for the Care of Mother and Child, Prague.

SUBJECT AND METHOD

We present a rare case of cystic rectal duplication in adult, completely removed and histologically confirmed. A literature review was summarized.

CONCLUSION

The case was complicated by delay in diagnosis, multiple operations, and by the association with endometriosis, as well. Mentioned anomaly is published in the Czech literature for the very first time.

Accuracy of intraoperative frozen section during laparoscopic management of early endometrial cancer

OBJECTIVE

The aim of our retrospective study was to correlate the intraoperative frozen section (FS) and permanent section (PS) diagnosis among patients with early-stage endometrial cancer (FIGO Stage I).

METHODS

Retrospective analysis of clinical data. A set of 63 women were operated by the technique of laparoscopic assisted vaginal hysterectomy with bilateral salpingo-oophorectomy (LAVH with BSO). All probands had intraoperative FS biopsy performed with grading and myometrial invasion assessment. These data were then compared with PS diagnosis. Statistical evaluation was used to detect diagnostic accuracy of FS (sensitivity, specificity and positive vs negative predictive value, and accuracy rate).

RESULTS

The average age was 61 years, BMI 32.4 kg/m2 and operation time including lymphadenectomy (LAE) was 108.7 minutes. Sensitivity of FS was 77.8%, specificity 98.1%, positive predictive value (PPV) 87.5%, negative predictive value (NPV) 96.4% and accuracy rate 95.2%. Suboptimal surgical management due to underevaluation of FS biopsy compared to PS diagnosis occurred in 2 patients (3.2%).

CONCLUSION

Combination of LAVH with BSO and use of intraoperative FS enables the surgeon to individualize surgical treatment for every patient to the extent of either performing complete operation together with LAE or not.

[Late hematogenous infection of prosthetic joint]

The importance of prevention in late hematogenous infection is well understood but, because responsibility lies with general practitioners and other specialists, the orthopedic surgeon is usually not much interested. In both our and other countries, discussions are taking place on whether and to what extent antibiotic prevention should be carried out. Antibiotic prophylaxis of hematogenous infection is not indicated for all patients with joint arthroplasty, but only for a limited, defined group of patients at high risk. In these, however, the present state of knowledge suggests that prevention is necessary. A preventive treatment of late hematogenous infection is used for a procedure or a disease associated with risks in all the patients involved within two years of prosthetic joint implantation and, after this period, only in immunosuppressed patients. Surgery on the urogenital tract associated with the risk of bacteremia includes prostate gland surgery, operations for urinary bladder tumors, nephrolithotomy, extracorporeal lithotripsy and prostate biopsy. Certain conditions, such as urinary catheter presence, intermittent catheterization, urethral stent presence, urine retention and a history of urinary tract infection or prostate inflammation, pose an increased risk of bacterial colonization for the urogenital system. Dental procedures associated with a risk of bacteremia include tooth extraction, surgery on the parodontium, surgical extraction of an impacted tooth, dental implant treatment, procedures in a tooth's apical region, initial application of an orthodontic apparatus, intraligamentous blocks and also cleaning teeth and implants expected to bleed. Gynecological surgery with a risk of bacteremia are abdominal, vaginal and laparoscopic hysterectomies, surgery for cancer contaminated with vaginal bacteria, reconstruction surgery, operations on the pelvic floor for defects associated with urinary incontinence and use of xenotransplants. In obstetrics, a cesarean section carries some risks. In general surgery, the preventive administration of antibiotics is indicated, apart from situations always requiring antibiotic therapy, also for advanced forms of acute appendicitis, perirectal abscess, invasive endoscopy procedures on the colon, soft tissue phlegmona or abscess, surgical treatment of venous ulceration and pressure sores, and limb amputation. When inserting any piercing in patients with joint replacement at risk, it is recommended to do it with antibiotic administration; also, it is necessary to responsibly treat any inflammatory complication. The system of prevention for the late hematogenous infections of prosthetic joints is not developed as thoroughly as, for instance, it is in cardiology for patients with valve reconstruction. Because of the reasons given above, it is advisable to set up unambiguous guidelines for the prevention of late hematogenous infection in patients with joint replacement.

[Late hematogenous infection of prosthetic joints in our patients and proposal for a system of prevention]

PURPOSE OF THE STUDY

To design a prophylactic strategy for late hematogenous infection is not an easy task. It requires the assessment of risk factors for the patient as well as of a potential source of bacteremia. Cost effectiveness, efficacy of the antibiotic selected and complications associated with antibiotic treatment, such as allergic reactions and development of resistance to the antibiotic given, should also be considered. The aim of this retrospective study is to evaluate the occurrence of late hematogenous infection in our large group of patients, to analyze risk factors and to suggest an optimal system of antibiotic prophylaxis in order to prevent the development of this unwelcome complication.

MATERIAL AND METHODS

Since our objective was to include a large number of patients, a retrospective study was chosen as the method used. The patients treated for infectious complications of total joint replacement at the 1st Department of Orthopaedics, Teaching Hospital in Motol, 1st Faculty of Medicine, Charles University, in the years 1991 through 2004, were evaluated with the use of a targeted questionnaire and complete medical records. The group comprised 229 patients, 149 women and 80 men. Of these, 123 were treated for infection of total hip replacement, 102 for total knee replacement, two had infection of prosthetic shoulder joints and two had infection of elbow joint alloplasty.

RESULTS

Medical history of 37 patients (16.3 %) included infection of or a risk-associated procedure on the urogenital system (endoscopic or open surgery, prostate gland biopsy, extracorporeal lithotripsy). Six patients (2.6 %) underwent surgery with possible bacteremia (intestine resection for tumor, 2x; surgery for paronychium, 2x; cholecystectomy, 1x; and appendectomy, 1x). Dental surgery or mouth disease was recorded in 11 patients (4.8 %).

DISCUSSION

The authors suggest that the orthopedic surgeons performing joint replacement should assume their deal of responsibility and should provide relevant, comprehensive information to both the patient and the attending physician. These surgeons should be ready to remain involved in their patients' further therapies and, after assessing all risks, should be able to recommend an optimal prophylactic treatment. The introduction of a new preventive approach requires a simple and uncomplicated scheme. Any complicated and expensive system of preventive antibiotic administration will only meet with lack of understanding and with trivialization. The requirement that antibiotic treatment should be selected according to the site and type of risk-associated disease is logical, but, in our opinion, rather formal and unrealistic. The authors prefer a simple system permitting a rapid and overall introduction of preventive measures.

CONCLUSIONS

The groups of patients indicated for prevention of late hematogenous infection of prosthetic joints are clearly defined and, by no means, do they involve all patients with total joint replacement. Key words: prosthetic joint, infection, prevention, antibiotics, complication.

Bilateral avulsion of the puborectal muscle: magnetic resonance imaging-based three-dimensional reconstruction and comparison with a model of a healthy nulliparous woman

OBJECTIVES

Obstetric trauma to the puborectal muscle seems to be an important cause of pelvic floor dysfunction in women. Due to the complicated three-dimensional (3D) arrangement of the pelvic structures, two-dimensional images are not sufficient to demonstrate its relationships in a complex fashion. Thus, we aimed to create a 3D computer model to visualize the normal female pelvic floor anatomy and to compare this with the anatomy after bilateral avulsion of the puborectal muscle following delivery.

METHODS

We created two 3D computer models of the female pelvic floor, one of a healthy nulliparous woman and the other of a woman with bilateral puborectal muscle avulsion after vaginal delivery. The data for the models were obtained from magnetic resonance imaging examinations and the following structures were depicted: pelvic bones, puborectal muscle, internal obturator muscle, urethra, urinary bladder, vagina and rectum. The models were compared.

RESULTS

The models allowed us to demonstrate in three dimensions changes in the puborectal muscle after avulsion. Its relations to the bone, internal obturator muscle, perineal membrane and the deep part of the external anal sphincter were modeled and differences from the normal non-injured anatomy were demonstrated. Avulsion altered the support to the whole endopelvic fascia and destabilized both the anterior and the posterior vaginal walls.

CONCLUSIONS

The use of 3D technology including modeling allows for the acquisition of new knowledge and aids in the understanding of both normal and pathological pelvic anatomy.

[Cesarean scar ectopic pregnancy]

OBJECTIVE

To present our clinical experience with cases of ectopic implantation in the uterine scar of a prior cesarean section and to analyse current articles with this topic. The authors experienced two cases of cesarean scar pregnancy with different clinical management and outcome.

DESIGN

Review article, case report.

SETTING

Institute for the Care of Mother and Child, Prague, Institute for Postgraduate Medical Education, Prague.

RESULTS

We experienced two cases of cesarean scar pregnancy during the year 2006. Missed abortion in the 12th week of pregnancy was diagnosed in the first patient. During instrumental evacuation of the uterine cavity in the district hospital severe bleeding occured. After transfer to our department abdominal hysterectomy was performed. In the second case early ultrasonographic diagnosis of ectopic nidation was completed. Hysteroscopic evaluation of gestational sac with subsequent instrumental evacuation with ultrasonographic assistance was performed as a fertility saving operation. Subsequent systemic application of methotrexate was indicated after surgery.

CONCLUSION

Cesarean scar pregnancy occurs in 1/800 - 1/2216 normal pregnancies. Early sonographic diagnosis enables surgical or medicamentous treatment preserving the fertility of the patient. Late or absent diagnosis of pathological implantation can cause severe uterine bleeding. Treatment options preserving fertility can not be used and hysterectomy is then the only life saving procedure.

Laparoscopic oophorectomy either with or without hysterectomy for early breast cancer

OBJECTIVES

The aim of this study was to assess the surgical results, complications and pathological findings of laparoscopic ovarian ablation either with or without hysterectomy in women with early-stage breast cancer (BC).

METHODS

Ninety women in early breast cancer stage who underwent laparoscopic bilateral salpingo-oophorectomy (BSO) either with or without hysterectomy were identified in a retrospective study conducted between January 2000 and December 2006. Tamoxifen antiestrogen therapy was used prior to hysterectomy.

RESULTS

Forty-eight consecutive patients underwent laparoscopic hysterectomy with bilateral salpingo-oophorectomy and 42 with ovarian ablation only. The mean operative time for the laparoscopic hysterectomy and bilateral salpingo-oophorectomy or BSO alone was 82 min and 47.8 min, respectively. Blood loss was minimal in both groups (range: 20-250 ml). The rate of postoperative complications was very low (4.4%). One of all ovaries removed by laparoscopy showed ovarian breast carcinoma metastasis. Histopathologic examination revealed concomitant findings of leiomyoma, adenomyosis or endometrial abnormalities in 64.5% of hysterectomy specimens.

CONCLUSION

Our experience with ovarian ablation either with or without hysterectomy confirmed that the use of a minimally invasive technique is feasible. We assume that ovarian ablation and hysterectomy is an appropriate treatment for premenopausal women at risk (BRCA positive) or for patients with concomitant benign uterine pathology, treated with tamoxifen in first-line therapy. Removing the uterus allows women to take only estrogens rather than combination HRT. Further investigation into the indications of disease where laparoscopic ablative surgery is appropriate in the management of early breast cancer is needed.

[Laparoscopic correction of posttraumatic uterovaginal descent with rectal prolapse]

A case review of laparoscopic management of the uterovaginal descent and rectal prolaps in one step in a young female following her complicated pelvic fracture.

[Mechanisms influencing implantation of the embryo--the last-years' news]

OBJECTIVE

To summarize recent knowledge concerning mechanisms which influence the implantation of embryo.

DESIGN

Literature-based overview.

SETTING

Institute for the Care of Mother and Child, Prague. SUBJECT OF THE STUDY: Factors influencing implantation of embryo in the uterus elicit increased interest due to study of unexplained failures of embryotransfer following the successful in vitro fertilization. Our article points to recent information about physiology and pathology of mechanisms controlling implantation, namely the factors of immunity (antibodies, cells, cytokines and other mediators) whose exact regulation on the feto-maternal interface is a crucial precondition of successful implantation. Also the genetics of early embryo, as well as the possibilities of modern endoscopic techniques offer new insight onto mechanisms of implantation. Recommendations for diagnostics and treatment of implantation failure are given in the end of the article.

[Clinical comparison of laparoscopy-assisted vaginal hysterectomy (LAVH) and total laparoscopy hysterectomy (TLH) in women with benign disease of uterus--a prospective randomized study]

OBJECTIVE

To compare two techniques of hysterectomy.

DESIGN

Prospective, randomised study.

SETTING

Institute for the Mother and Child Care, Prague.

METHODS

85 patients randomized into two groups--laparoscopically assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH). The criteria studied were length of the procedure, blood loss, complication rate, uterus weight, rate of conversions, consumption of analgesics, inflammatory response.

RESULTS

Mean length of the procedure for LAVH, TLH was 85 and 111 min, respectivelly, the mean blood loss 306 and 184 ml. There was no difference in inflammatory response and use of antibiotics. Consumption of analgesics was higher in the TLH group. Conversions to laparotomy occurred only in the LAVH group. Only in the TLH group we noticed serious postoperative complications.

CONCLUSION

LAVH seems to be the preferable technique of hysterectomy for benign diseases of the uterus.

[Pregnancy after laparoscopic myomectomy--long-term follow up]

OBJECTIVE

Analysis of pregnancy related complications in infertile patient after laparoscopic myometomy (LM).

DESIGN

Retrospective analytic study.

SETTING

Institute for the Care of Mother and Child, Prague; Institute for Postgraduate Medical Education, Prague.

METHODS

The study group were infertile patients referred to our department with the finding of uterine fibroid(s). In all patients LM was the method of choice. Thorough information and results from all infertile patient after LM were assessed and analysed with 18 months follow-up after surgery.

RESULTS

The aim of our study was to evaluate pregnancy rate and the possible risks during pregnancy and delivery following LM. We analysed 69 patients after LM. Mean size of a fibroid was 3.3 cm and the number of removed fibroids in one patient was 1.8. The conception rate after LM was 56.5%. We didn't observe any increased incidence of fetomaternal morbidity or severe pregnancy and labour related complications. There was no uterine rupture after LM in our group. The cesarean section was rate 44.8%.

CONCLUSIONS

The impact of fiborids on infertility is still controversial. LM in infertile patient is one of the most common surgical procedure. The appropriate surgical management of uterine scar is mandatory. This operation must be performed by skilled reproductive surgeon. Thorough information to the patient before and after LM is necessary. The pregnancy following LM is at high risk with increased caesarean section rate.

[Reproductive outcome in women with ovarian endometriosis--retrospective analytical study]

OBJECTIVE

To evaluate our clinical results and reproductive outcome after laparoscopic surgery for ovarian endometriosis in infertile women.

DESIGN

Analytic retrospective study.

SETTING

Institute for the Mother and Child Care, Prague, Institute for Postgraduate Medical Education, Prague, Czech republic.

RESULTS

Surgical treatment in infertile patient should be conservative as much as possible. Laparoscopic surgery has the potential to achieve very good results in the treatment of endometriomas. Surgical treatment of the endometriotic cyst is still controversial. There are several surgical options in the treatment of an endometrioma. In our department we use laparoscopic stripping of the capsule. During 2000-2003 we operated on 70 infertile women with an endometrioma. The average age of the patients was 30.5 year and the average diameter of all endometriomas was 5.0 cm. The cumulative delivery rate after surgery was 55.7 % (n = 39).

CONCLUSION

We present our clinical results after laparoscopic conservative surgery for ovarian endometriosis. The achieved pregnancy rate in our group is comparable to the results published in other studies.

[Pregnancy complications after intrauterine hysteroscopic surgery]

OBJECTIVE

To evaluate our clinical experience of cases of pregnancy after transcervical septum resection and endometrial ablation. There are several case reports in the literature showing increase fetomaternal morbidity after intrauterine surgery.

DESIGN

Analytic retrospective study.

SETTING

Mother and Child Care Institute, Prague, Institute for Postgraduate Medical Education, Prague.

RESULTS

There were three cases of severe complications during pregnancy after intrauterine surgery. We experienced one case of uterine rupture after transcervical septum resection in the second stage of labour. The other two cases were pregnancies after endometrial ablation and septum resection complicated with severe bleeding in the second trimester.

CONCLUSION

Pregnancies after some types of intrauterine surgery (septum resection, endometrial ablation) are at high risk. They can lead to increased fetomaternal morbidity. We recommend intensive prenatal care with immediate surgical intervention when complications occur.

[The management of uterine fibroids: Czech and Slovak Gynecologic Endoscopy Working Group (CSGE) clinical practice guidelines]

OBJECTIVE

The objective of this paper is to give a guideline to the management of uterine fibroids.

DESIGN

Review.

SETTING

Czech Society Gynecological Endoscopic Working Group.

MATERIAL AND METHOD

The bibliographic data from Medline were reviewed from 2003-2004 using the key words: fibroid--leiomyoma--uterine artery occlusion--hysterectomy--myomectomy.

CONCLUSION

The clinical guideline was prepared after the analysed data were supplied using the material and criteria of Society of Obstetricians and Gynaecologists of Canada (SOGC) for the management of uterine fibroids.

[Immunopathological and histopathological aspects of ectopic implantation with possible effect on fertility disorders]

OBJECTIVE

To evaluate leucocytic infiltration of fetomaternal interface in ectopic pregnancy and to evaluate the changes in cell immunity against trophoblast (AT-CMI) in women with extrauterine pregnancy (GEU) in their medical history. To assess the effect of these factors on possible fertility disorders in a woman.

DESIGN

A retrospective study.

SETTING

Mother and Child Care Institute, Prague.

METHODS

In most of the patients, we addressed GEU through laparoscopy. The tube was extirpated in toto and immediately fixed in Baker's solution. Thereafter, it was prepared in a dissection microscope and then processed in a standard way. In order to identify the intensity of AT-CMI, we used the leucocyte migration inhibition test. The cytotrophoblastic cell line JAR was used as an antigen. The degree of inhibition of the migration was monitored by means of a computer image analyser. Inhibition of migration below 75% was rated as favourable.

RESULTS

We monitored the presence of inflammatory infiltrate in the place of implantation and correlated the findings with the hCG levels and the presence of the foetal ovum or its part in the tube. In 28 patients (23.5%) of the total number of 119 patients in the group, we observed an inflammatory infiltrate in the place of implantation. In these patients, the hCG levels were lower and in 17 of them (60.7%) we did not prove the presence of a foetal ovum or its parts. In women with GEU in their medical history, the AT-CMI positivity was established in 61.1% of the women 1 year after surgery, in 56.8% of the women 1-3 years after surgery and in 41.2% of the women 3 years after surgery.

CONCLUSION

Ectopic pregnancy involves a pathological fetomaternal interface. The leucocytic infiltrate in the area of implantation may be of secondary character and may cause gradual destruction of the ectopically positioned product of conception. The results of our study indicate a possible participation of the increased AT-CMI in the destruction of the ectopically located trophoblast. Persisting anti-trophoblast immunity may influence the occurrence and course of further gravidities.

[Laparoscopic ovariopexy--modality of ovarian endometriosis treatment]

OBJECTIVE

Case report of a successful treatment of ovarian endometriosis by laparoscopic ovariopexy in infertile women.

DESIGN

Case report.

SETTING

Institute for the Care of Mother and Child, Prague, Institute for Postgraduate Medical Education, Prague.

RESULTS

Conservative treatment of ovarian endometriosis is often complicated by postoperative periadnexal adhaesions which may result in pelvic pain or ongoing infertility. Temporary laparoscopic ovarian suspension--ovariopexis is a very effective method in postoperative adhaesion prevention and in the treatment of ovarian endometriosis in infertile patient. We observed successful cases of laparoscopic treatment of ovarian endometriosis.

CONCLUSION

Laparoscopic ovariopexis is a simple and effective method for treatment of ovarian endometriosis and prevention of extensive periadnexal adhaesions.

[Laparoscopic myomectomy in infertile women]

OBJECTIVE

Evaluation of laparoscopic myomectomy in infertile patient.

DESIGN

Literary review.

SETTING

Institute for the Care of Mother and Child, Prague, Institute for Postgraduate Medical Education, Prague.

METHODS

Information and results of laparoscopic myomectomy in infertile patient were assessed and analysed.

RESULTS

Laparoscopic myomectomy in infertile patient is one of the most common surgical procedures. There are several complications after this procedure--adhesion formation, bleeding and uterine rupture during following pregnancy. The incidence of adhesion formation after laparoscopic myomectomy especially in case of intramural and deep subserosal fibroids of posterior uterine wall is high, almost in 60-90%. The uterine rupture following myomectomy represents only 2% of all uterine ruptures in pregnancy.

CONCLUSIONS

The laparoscopic approach in uterine fibroids treatment has been clearly established. The appropriate surgical management of uterine defect is mandatory. This approach is the best prevention of postoperative complications--adhaesions and uterine rupture.

[Classification of twins and their ultrasonographic diagnosis]

OBJECTIVE

Systematic classification of all forms of twins and mechanisms of twinning.

DESIGN

Review of published cases. Morphogenesis based on personal experience related to human blastogenesis including observation of anterior twinning in two early human embryos.

SETTING

Institute for the Care of Mother and Child, Prague, Department of Gynecology and Obstetrics, 1st Medical Faculty, Charles University, Prague, Department of Medical Genetics, Medical Faculty, Palacký University Olomouc, Institut Unica, Brno.

METHODS

Analysis of cases described in literature completed by observed cases.

RESULTS

Classification of twins. A) Separated twins: 1. dichorial a) monozygotic (very rare), b) dizygotic (most frequent); 2. monochorial (always monozygotic) a) diamnial, b) monoamnial. B) Conjoined twins (always monozygotic) 1. isopagi (equal conjoined twins) a) originating from peripheral fusions of two germ discs, b) originating from duplications of axial structures; 2. heteropagi (unequal conjoined twins): autosit (main twin), heterosit (parasitic twin).

CONCLUSION

The developmental mechanisms of twinning are discussed, special attention is paid to equal conjoined twins and to the possibilities of their early prenatal ultrasonographic diagnostics.

[Distension media in hysteroscopy--use and complications]

OBJECTIVE

Review of distending media used in hysteroscopic surgery.

TYPE OF STUDY

Overview.

SETTING

Institute for the Care of Mother and Child, Prague.

METHODS

Analysis of data from the literature.

RESULTS

The author reviewed the use of distending media in hysteroscopic surgery with most serious complication--fluid overload syndrome.

CONCLUSION

Fluid overload syndromee is a very dangerous and often underestimated complication during hysteroscopic surgery which needs immediate and appropriate management.

The detection of HPV DNA improves the recognition of cervical intraepithelial lesions

Reasons that influence the efficacy of cervical cancer screening are failure to screen all women at risk, as well as inherent technical limitations of the conventional cervical smear. HPV DNA testing is a supplementary, objective test less independent on sampling failure. The aim of this study was to compare results of HPV DNA screening to cytological smears (CS) and histological diagnosis. From January 1995 to January 1999, cytological smears, cells for HPV DNA analysis and cervical biopsies were obtained from 280 women included in this study.

STATISTICAL METHODS

Fisher's exact test (2x2 contingency tables, P<0.01), Pearson Chi-square, P< 0.05, Spearman's rank correlation R. Sixty patients (21.4%) tested positive for low-risk (LR-HPV), 227 (81.1%) positive for high-risk HPV (HR-HPV). The CS proved to be a strong predictor for the histological diagnosis, reaching a sensitivity of 93.4%, a specificity of 65.8% and a positive predictive value (PPV) of 77.4%. By combining cytology and HPV DNA testing, the sensitivity could be considerably enhanced (99.0%), though at a price of loss in specificity (30.1%). HPV DNA testing, available as a commercially standardized product, leads to a significant rise in sensitivity when used as an additional diagnostic tool to cytological screening methods and thus contributes to reduce the incidence of cervical carcinomas.

[Ventral prolapse of the embryo: case report]

OBJECTIVE

A pathologic human embryo 3 mm long affected by a "ventral prolaps" was present in a product of conception implanted within the Fallopian tube. The gestational age was 7 weeks. The malformation was characterized by a deep protrusion of the embryonal body (containing the medullary tube and the notochord adherent to the ceiling of the yolk sac) through the umbilical ring of the germ disc delineated by ectoderm covered mesenchymal streaks with primordia of the umbilical veins. Similar two affected embryos were depicted by Kollmann in his Handatlas in 1907, but were considered normal.

DESIGN

Case report.

SETTING

Institute for the Care of Mother and Child, Prague, Institute for Postgraduate Medical Education, Prague.

RESULTS

Implanted product of conception found within the Fallopian tube exhibited a characteristic embryonic defect described as the "ventral prolaps".

CONCLUSION

Ventral prolaps of the embryo represents a characteristic embryonal malformation of unknown developmental significance.

[Proliferating mole in menopause imitating choriocarcinoma recurrence--case report]

OBJECTIVE

To show the possibility of new invasive mole arising after 2 years of menopause, after choriocarcinoma cured by chemotherapy 5 years ago.

SETTING

Trofoblastic disease center (TDC), Prague, Institution for care of mother and child, Prague.

CASE REPORT

Patient 50-years-old with choriocarcinoma, in consequence to invasive mole, was cured by chemotheraphy. After 5 years of clinical and laboratory remission and after two years of menopause new pregnancy with invasive mole arised imitating relapse of choriocarcinoma.

Is high-risk human papillomavirus infection associated with cervical intraepithelial neoplasia eliminated after conization by large-loop excision of the transformation zone?

OBJECTIVE

To investigate whether high-risk HPV infection associated with cervical intraepithelial neoplasia (CIN) was successfully eliminated after electrosurgical conization by large-loop excision of the transformation zone (LLETZ).

STUDY DESIGN

142 women, who were admitted for conization of CIN 1-3 were recruited into a prospective follow-up study of HPV infection, including cervical sampling for HPV DNA before, and then 3, 6 and 12 months after surgery. We examined whether there were any differences in the rate of HPV DNA positivity after LLETZ between specific risk groups, such as patients with primary (i.e. before surgical treatment) high-risk HPV infection, CIN of different grades, and positive margins.

RESULTS

We did not detect statistically significant differences between specific risk groups. According to the assay used (hybrid capture II) at the last follow-up visit 94% of primarily infected patients were completely free from infection with high-risk HPV types, while 6% had persisting HPV infection.

CONCLUSIONS

With a detection limit of 5000 genomes/ml HPV DNA the hybrid capture II results revealed, that after electrosurgical removal of CIN in 94% of patients testing positive for high-risk HPV DNA prior to surgery were negative 12 months post-surgery.

[Ectopic omental pregnancy--laparoscopic diagnosis and therapy]

OBJECTIVE

Description of a very rare case of primary omental pregnancy.

DESIGN

Case report.

SETTING

Institute for the Care of Mother and Child, Prenatal Diagnostic Centre, Prague, Institute for Postgraduate Medical Education, Prague.

SUBJECT AND METHOD

Implanted product of spontaneous conception was found in the omentum. The gestational sac on omentum had the appearance of a haemorrhagic tumor 2 cm in diameter.

CONCLUSION

After dissection, an intact embryo of 7 mm with a 4 mm yolk sac was discovered.

Oncogenic potential of c-erbB-2 and its association with c-K-ras in premalignant and malignant lesions of the human uterine endometrium

The aim of this study was to detect activated c-K-ras by gene point mutation and to find c-erbB-2 gene amplification with p185 expression in association with the c-K-ras gene product p21 in the human endometrium. Specimens obtained from 25 normal, 31 hyperplastic and 72 malignant samples of the human endometrium were examined for point mutation in codons 12, 13 and 61 of the c-K-ras by direct sequencing and c-erbB-2 gene amplification with p185 and p21 expression by differential polymerase chain reaction (DPCR) and immunohistochemistry. Neither the normal endometrium nor endometrial hyperplasias were found to have mutations in the c-K-ras gene, although a double mutation of codons 12 and 13 as a single-point mutation was observed in one case of endometrioid carcinoma (2.8%). In each of two other cases of endometrioid carcinoma (2/72), two single-point mutations of codon 13 (5.6%) were shown. Using DPCR, we found c-erbB-2 to be amplified in 15 premalignant (48%) and 45 malignant (63%) samples. We noticed that nonamplification of the c-erbB-2 gene was associated with the absence of immunoreactivity. Our data indicate that, while c-erbB-2 plays a role in the early development of endometrioid carcinomas, c-K-ras gene activation by point mutation does not.

[Ovarian implantation of the embryo in IVF and ET--early mole with proliferative trophoblast]

OBJECTIVE

Case report of a very rare case of ovarian implantation after IVF and ET treated by laparoscopy.

DESIGN

Case report.

SETTING

Institute for the Care of Mother and Child, Prenatal Diagnostic Centre and Trophoblastic Disease Centre, Prague, Institute for Postgraduate Medical Education, Prague.

RESULTS

We observed implanted product of conception found within the ovarian stroma 35 days after ET. At laparoscopy, the genital sac appeared as an inconspicious haemorrhagic cyst, 2 cm in diameter. After dissection, in the intact sac appeared amorphous 2 mm embryo and 3 mm yolk sac. The trophoblast of the anchoring chorionic villi exhibited marked hyperproliferation and was classified as a proliferating mole.

CONCLUSION

The intact early product of conception exhibited trophoblastic hyperplasia.

Bcl-2 expression as a novel immunohistochemical marker for ruptured tubal ectopic pregnancy

Programmed cell death by apoptosis occurs in fetal and maternal tissues during early pregnancy and plays an important role during implantation, decidualization, and in fetal development. In the regulation of apoptosis, bcl-2 is one of the central controlling genes, and acts by protecting the cell against apoptosis. It is postulated that invasiveness of ectopic trophoblast towards and through the muscularis zone of the tubal wall consequently leading to tubal rupture might be due to disturbed regulation of apoptosis. By means of immunohistochemistry and a computerized image analysis, bcl-2 immunostaining was localized and quantified in 36 randomly selected paraffin-embedded ectopic trophoblast tissue specimens collected from women undergoing surgery for ruptured (n = 18) and non-ruptured (n = 18) tubal ectopic pregnancies. Immunostaining was found in the villi syncytiotrophoblast in all patients, while the percentage of positive bcl-2 immunostained area (%PA) (P = 0.0009) and staining intensity (P = 0.0042) were consistently greater in the group of ruptured ectopic pregnancies. Including the variables %PA and saturation into a logistic regression model for a probability threshold of 0.5 (<0.5 = non-ruptured ectopic pregnancy, >0.5 = ruptured ectopic pregnancy) to identify tubal rupture, a sensitivity and specificity of 94.4% were found. It is suggested that elevated bcl-2 immunostaining in the syncytiotrophoblast layer reflects unlimited cell survival of ectopic trophoblast and could lead to the establishment of a circulating marker for tubal rupture.

Radiotherapy alone for invasive vaginal cancer: outcome with intracavitary high dose rate brachytherapy versus conventional low dose rate brachytherapy

PURPOSE

Our aim was to compare the role of remote afterloaded high-dose-rate brachytherapy (HDRB) with traditional low-dose-rate brachytherapy (LDRB) for patients with invasive primary vaginal carcinoma.

METHODS

The study group comprised 190 patients with invasive carcinoma of the vagina. The patients were staged according to the International Federation of Gynecology and Obstetrics (FIGO) staging system. Eighty patients were treated with intracavitary high-dose rate iridium 192 brachytherapy with or without external beam therapy. These patients are compared with a historical group of 110 patients treated with intracavitary low-dose-rate radium 226 or cesium 137 brachytherapy with or without external beam therapy.

RESULTS

No significant differences were found for stages, tumor grade or location between the two groups. Crude 5-year survival for all patients was 41% in the former LDRB group, 81% in stage I and 43% in stage II. Overall actuarial 3-year survival and disease-specific survival rates for all patients in the HDRB series were 51% and 66%, respectively. Disease-specific 3-year survival attained 83% in stage I and 66% in stage II. There were no significant differences in local and distant recurrences between the treatment modalities. The comparison of treatments with or without external beam radiation and of complications showed no significant differences between the HDRB and LDRB series.

CONCLUSION

With HDRB and its advantages of decreased radiation exposure and patient immobilization and precise positioning, treatment results to be obtained are at least similar to traditional LDRB for primary vaginal cancer.

High-dose versus low-dose rate brachytherapy in definitive radiotherapy of cervical cancer

BACKGROUND

To retrospectively compare the clinical outcome in cervical cancer patients treated by external irradiation and intracavitary high-dose rate (HDR) brachytherapy with iridium 192 versus low-dose rate (LDR) brachytherapy with radium 226 or caesium 139.

METHODS

450 LDR patients were treated from 1982 to 1986 and compared with 189 HDR patients treated from 1993 to 1999. Cobalt (CO) 60 treatment was replaced in the HDR group by modern megavoltage photon radiotherapy (Linac 25 MV). Brachytherapy was given in either 2 or 3 LDR radium 226 implants for the earlier patient cohort, and 3-6 HDR iridium 192 implants for the latter cohort. The primary endpoint assessed was the 3-year overall survival.

RESULTS

The median duration of follow-up was 70 months (range, 2-108 months) in the LDR group and 34 months (range, 4-69 months) in the HDR group. Actuarial overall 3-year survival after conventional LDR brachytherapy was 51.3%, versus 58.2% after HDR brachytherapy. No difference in 3-year survivors was seen in the small groups of stage I (68.3% vs. 84.6%) and stage IV (23.1% vs. 37.5%) patients. In stage II and III and in the overall group there were statistically significantly more 3-year survivors in the HDR group (58.1% vs. 78.9%, p < 0.001 in stage II; 37.3% vs. 53.8%, p < 0.01 in stage III; and 46.7% vs. 67.2%, p < 0.001 in the total group). Retrospectively assessed complication rates in the former LDR group were 3.8% for irreversible side effects, and 13.3% for chronic radiation damage. In the HDR group the actuarial late complication rates for grades 3 and 4 were 2.9% for the bladder, 4.0% for the bowel, and 6.1% for the rectum.

CONCLUSION

In our preliminary experience, HDR brachytherapy combined with external beam radiation produced similar and even better survival rates compared with the LDR series. HDR brachytherapy combined with external beam radiation is an efficient method for the treatment of cervical cancer and adverse side effects are comparable.

Papilloma virus and c-erbB-2 expression in diseases of the mammary nipple

PURPOSE

The detection of low/intermediate/high risk genital groups of human papillomavirus (HPV) in correlation with a growth-factor receptor c-erbB-2 in benign tumors of the mammary nipple.

MATERIALS AND METHODS

Ten nipple duct adenomas (NDAs) and twenty papillomas, all embedded in paraffin and taken from the breast, were analyzed for HPV DNA of the low- and high/intermediate-risk groups. Polymerase chain reaction (PCR) with HPV consensus primers (types 6/11/16/18/33) and dot-blot hybridization with type-specific primers were used for the detection of these HPV-DNA sequences. Indirect in situ PCR (ISPCR) was also used in one case of an HPV-DNA-positive papilloma. In addition, we examined c-erbB-2 oncogene expression in NDAs and central carcinomas of the mamma from an immunohistochemical perspective.

RESULTS

Using PCR and dot-blot hybridization we could not detect the gene sequences that are specific for the low- and high/intermediate-risk groups in any of the ten NDAs. Regarding the 20 cases of papilloma, a positive result for HPV types 6/11 was detected by indirect ISPCR; in one case in combination with a condyloma of the skin around the mammary nipple. The oncogene expression of c-erbB-2 displayed a strong signal in the papilloma cells and in the NDAs of the breast.

CONCLUSION

Our results showed that the HPV-DNA types of the low- and high/intermediate-risk groups are without relevance for the pathogenesis of benign diseases of the nipple. It was, therefore, not possible to establish a correlation between the oncogene expression of c-erbB-2 and the HPV-DNA types.

p53 polymorphism at codon 72--does it constitute a risk for squamous intraepithelial lesions and invasive cancer of the cervix in Central Europeans?

BACKGROUND

Polymorphisms of the tumour suppresser gene p53 especially at codon 72 are suspected to be associated with an increased risk for malignant transformation. In invasive cervical cancer, the arginine form of the p53 gene is estimated to be more susceptible to degradation mediated by tumour-associated human papilloma viruses (HPV) than the proline form.

METHODS

To test the prevalence of p53 polymorphism at codon 72 in 133 healthy women, 50 patients suffering from squamous intraepithelial lesions of the cervix (SIL), and 105 patients with invasive cervical cancer, we developed a polymerase chain reaction (PCR) and microtiter plate-based hybridisation assay. Furthermore, we tested whether the two p53 isoforms increased the risk of developing cervical cancer.

RESULTS

The proportions of individual homozygous for arginine, homozygous for proline and heterozygous for arginine and proline in the investigated patient groups did not significantly deviate from the Hardy-Weinberg equilibrium. We found no increased risk of developing cervical cancer in respect to p53 polymorphism, independent of histological diagnosis.

DISCUSSION

In conformity with other study groups, our findings do not support the hypothesis that the p53 polymorphism at codon 72 is important in determining an increased risk of developing HPV-associated SIL or invasive cervical cancer in Central Europeans.

Systemic methotrexate treatment of interstitial pregnancy--magnetic resonance imaging (MRI) as a valuable tool for monitoring treatment

OBJECTIVE

Interstitial pregnancy occurs in 2-4% of ectopic pregnancies and is defined as implantation of the trophoblast in the interstitial part of the tuba uterina. Therefore the term intramural pregnancy can also be found in the literature. In 20% of the cases that progress beyond 12 weeks of amenorrhea a potentially life-threatening rupture of the uterus occurs, leading to a maternal mortality rate of 2.5%. According to the literature until a few years ago diagnosis was mainly made intraoperatively, and resulted in cornual resection or hysterectomy per laparotomy. Better methods of diagnosis and treatment of interstitial pregnancy can help to decrease morbidity and mortality associated with this condition.

PATIENTS

We describe two cases of interstitial pregnancies that were eventually diagnosed and also monitored by magnetic resonance imaging (MRI) after systemic methotrexate treatment. Both patients were uniparous and experienced their second spontaneous pregnancy.

METHODS

Treatment consisted of four doses (50 mg/m2 body surface area) of systemic intramuscular methotrexate alternating with four doses (6 mg) of intramuscular folic acid. When beta-hCG levels were undetectable, MRI results were compared with pre-therapeutic MRI findings.

RESULTS

In patients A and B, beta-hCG levels were undetectable 64 and 88 days after initiation of methotrexate treatment, while magnetic resonance imaging revealed nearly equally persisting interstitial pregnancies. They initially presented as hyperintense lesions with hypointense zones and changed into a hypointense lesion with a central hyperintense area for patient A, and a completely hyperintense lesion for patient B at the time of negative beta-hCG levels in follow-up MRI.

CONCLUSION

Systemic methotrexate treatment with an intramuscular regimen is effective in the treatment of interstitial pregnancy. MRI has the ability of correct tissue differentiation and objective three-dimensional measuring of interstitial pregnancy. We therefore propose this imaging modality as a valuable tool for monitoring systemic methotrexate treatment of interstitial pregnancy that should be used additionally to beta-hCG clearance curves.

Immunohistochemical expression of matrix metalloproteinases 1 and 2 (MMP-1 and MMP-2) and tissue inhibitor of metalloproteinase 2 (TIMP-2) in ruptured and non-ruptured tubal ectopic pregnancies

OBJECTIVE

Recent evidence suggests that matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) are crucial for trophoblast implantation in normal pregnancy. To evaluate the expression of MMP-1, MMP2, and the tissue inhibitor of MMP-2 (TIMP-2) along the invasive pathway of trophoblast in ruptured and non-ruptured tubal ectopic pregnancies, we performed a retrospective immunohistochemical study.

METHODS

In 15 tissue specimens of patients with ruptured (N = 7) and non-ruptured (N = 8) first trimester tubal ectopic pregnancies who underwent laparoscopic salpingectomy, immunohistochemical staining against MMP-1, MMP-2, and TIMP-2 was performed. Serial paraffin sections were photographed and digitized for a computerized quantitative image analysis. Mean percentages of positive stained areas by MMP-1, MMP-2, and TIMP-2 antibodies in the extravillous trophoblast were determined for ruptured and non-ruptured tubal ectopic pregnancies and compared.

RESULTS

In our 15 tissue specimens of ectopic pregnancies MMP-1 and TIMP-2 were found to be more prominent in the immunohistochemical distribution pattern than MMP-2. However, no statistically significant difference could be detected between the mean percentages of positive stained area by MMP-1, MMP-2, and TIMP-2 antibodies in ruptured and non-ruptured tubal pregnancies.

DISCUSSION

For the first time, we measured the comparative immunohistochemical expression of MMP-1, MMP-2, and TIMP-2 in ruptured and non-ruptured tubal ectopic pregnancies. Although our results did not show any statistically significant difference between ruptured and non-ruptured tubal ectopic pregnancies, we conclude that MMP-1, MMP-2, and TIMP-2 are functionally involved in the highly proliferative early first part of ectopic implantation.

Human papillomavirus in the cervix and placenta

OBJECTIVE

To determine the prevalence and association of human papillomavirus (HPV) infection in the cervices and placentas of pregnant women.

METHODS

Cervical samples were taken from 179 of 226 women who had placental biopsies because of abnormal ultrasound findings or were older than 35 years, to detect HPV infections with hybrid capture II tests. Polymerase chain reaction (PCR) was done on placental tissue of 147 of the 226 women to detect HPV DNA.

RESULTS

We found 44 of 179 women (24.6%, 95% confidence interval 18.3, 31.0) to test positive for HPV in their cervices. Logistic regression analyses showed decreased prevalence of HPV infection with increased maternal age (P =.039). The HPV DNA E6 PCR from the villus tissue was negative in the 147 cases examined. However, a significant contingency coefficient between low-risk HPV infection and elevated risk of chromosome aberration was found (&phi; = V = 0.15, P =.050).

CONCLUSION

The infection rate of 24.6% in women without clinical symptoms of HPV infection was high, but there seemed to be no virus transmission to the placenta in women with subclinical infections. Low-risk cervical HPV infection might be associated with a slightly higher risk of abnormal fetal karyotype.

Ectopic pregnancy

Ectopic pregnancy is a implantation occurring elsewhere than in the cavity of the uterus, whereas ninety-nine percent of extrauterine pregnancies occur in the fallopian tube. The incidence of extrauterine pregnancy has increased from 0.5% thirty years ago, to a present day 1-2%. The most frequent cause of tubal pregnancy is previous salpingitis. Mortality rates for tubal pregnancies used to be approximately 1.7% in the 1970s but dropped to 0.3% in 1980s.

DIAGNOSIS

Using transvaginal ultrasound it is possible to obtain positive evidence of an ectopic pregnancy at a very early stage. In cases of hCG titers>2,000 IU/l, intrauterine pregnancy can be diagnosed with certainty. The most important differential diagnosis of ectopic pregnancy is early intrauterine pregnancy.

CLINICAL MANAGEMENT AND THERAPY

Regardless of the therapeutic strategy selected by the physician, informing the patient is a major aspect of the management of ectopic pregnancy. If surgery is considered appropriate, the patient must be informed about the nature, side effects and complications of the procedure. However, it should be remembered that in some cases, the actual chances of cure first become apparent at surgery. In asymptomatic patients with a serum hCG titer <1,000 IU/l that is falling, it is appropriate to wait and watch. In clinically stable patients with an unruptured tubal pregnancy and steady hCG levels, systemic treatment with methotrexate might also be considered. In unruptured tubal pregnancy with a hCG titer between 1,000 and 2,500, a further therapeutic alternative is intratubal injection of prostaglandins, hyperosmolar glucose of NaCl. Generally speaking, the currently widespread laparoscopic surgical treatment of the fallopian tube hardly influences the risk of recurrence. If the gestational mass is larger, the serum hCG titer higher than the approximate limit of 2,500 mU/ml and/or the tube already ruptured, surgery is usually required.

PREVENTION

The most effective prevention is to avoid tubal inflammation or, in cases of preexisting inflammation, to administer effective therapy.

Could we treat more unruptured ectopic pregnancies with intramuscular methotrexate?

The main reason for the restricted use of methotrexate in the treatment of ectopic pregnancy (EP) obviously is the fear of tubal rupture in patients with lower abdominal pain after the administration of methotrexate. Therefore, we wanted to find out if patient characteristics at first presentation, such as age, pretreatment beta-hCG level, adnexal mass as visualized by transvaginal ultrasonography, or history of prior EP, would identify patients at risk for tubal rupture if they were hemodynamically stable and showed no signs of peritoneal irritation. We examined whether more patients could have been treated medically with methotrexate, because tubal rupture was unforeseeable at first presentation and inclusion criteria for methotrexate treatment were fulfilled. From January 1996 to August 1998, 122 patients diagnosed as having EP were treated at the Gynecologic Department of the University Hospital of Vienna. Inclusion criteria for medical treatment with intramuscular methotrexate (50 mg/ m(2) body surface area) were (1) hemodynamic stability, (2) an unruptured ectopic mass < or = 5 cm at the greatest dimension demonstrated at transvaginal ultrasonography; (3) beta-hCG level < or = 5,000 mIU/ml; (4) no cardiac activity of the extrauterine embryo; (5) wish of future fertility, and (6) informed consent. Patients with hemodynamic instability, severe abdominal pain, an ectopic mass > or = 5 cm at the greatest dimension, beta-hCG levels > or = 5,000 mIU/ml, cardiac activity of the extrauterine embryo, and no wish of future fertility, or disagreement with methotrexate treatment, primarily underwent surgery. Despite the fact that none of the above patient characteristics at first presentation identified patients at risk for tubal rupture, only 60/122 patients (49%) actually underwent medical treatment whereas our inclusion criteria would have granted medical treatment in 101/122 patients (83%). We determined the actual and maximal possible percentages of patients with unruptured EP eligible for medical treatment of EP with intramuscular single-dose methotrexate 50 mg/m(2) body surface area. Our data show that tubal rupture in hemodynamically stable patients is not foreseeable and should not lead to a restricted use of medical treatment in patients preferring methotrexate.

Accuracy of intraoperative frozen-section diagnosis in stage I endometrial adenocarcinoma

The purpose of our study was to determine if frozen-section diagnosis accurately identified patients suffering from endometrial adenocarcinoma FIGO stage I for surgical staging consisting of total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal cytology, and complete bilateral pelvic lymphadenectomy in moderately differentiated tumors with myometrial invasion. In all poorly differentiated tumors, and in all tumors with deep myometrial invasion (more than 50%) surgical staging included additional para-aortic lymphadenectomy. We performed a retrospective study including 70 patients. Frozen-section diagnosis of myometrial invasion and tumor grade was compared with permanent-section diagnosis. The accuracy rates were determined, and compared with accuracy rates of frozen-section diagnosis in the literature, and a total accuracy rate for 624 patients suffering from stage I endometrial adenocarcinoma was evaluated. In our patient collective, the overall accuracy rate of frozen-section diagnosis for myometrial invasion and tumor grade was 80 and 84%, respectively. In the five comparable studies, the mean accuracy rate for myometrial invasion and tumor grade was 89 and 84%, respectively. In combination with the five comparable studies our recent study produced an accuracy rate of frozen-section diagnosis for myometrial invasion and tumor grade of 88 and 84% in 624 patients, respectively. Despite an accuracy level of frozen-section diagnosis for myometrial invasion of 80 and 84% for tumor grade in our patient collective, all patients who required surgical staging were accurately identified.

Relationship of serum levels of endogenous relaxin to cervical size in the second trimester and to cervical ripening at term

OBJECTIVE

To assess whether cervical size in the early second trimester and cervical ripening at term may be related to serum levels of endogenous relaxin, 17beta-oestradiol or progesterone.

DESIGN

A cross-sectional study investigating the relationship between hormone concentrations and cervical parameters as measured by ultrasound and Bishop score, respectively.

PARTICIPANTS

Uncomplicated human pregnancies with normal fetal outcome, 72 women in the second trimester and 40 women at term.

METHODS

Vaginal ultrasound and palpation were used to estimate cervical parameters. Hormones were analysed either by dissociation-enhanced fluoroimmunoassay (relaxin) or by automated electrochemiluminescent immunoassays.

RESULTS

Cervical length and diameter correlated positively during mid-gestation and negatively at term. During mid-gestation, but not at term, relaxin was significantly associated with cervical length and volume, and with progesterone. Bishop score only correlated inversely with progesterone at term.

CONCLUSION

Corpus luteum function is reflected by progesterone and relaxin in the early second trimester. An impact of relaxin on cervical growth, previously demonstrated by animal models and in vitro experiments, was confirmed during human mid-gestation. In contrast to many other species, human cervical ripening was not associated with endogenous relaxin at term, but with decreased progesterone.

Messenger RNA determination of estrogen receptor, progesterone receptor, pS2, and plasminogen activator inhibitor-1 by competitive reverse transcription-polymerase chain reaction in human breast cancer

Estrogen receptor (ER), progesterone receptor (PR), the estrogen-inducible protein pS2, and plasminogen activator inhibitor-1 (PAI-1) are important prognostic factors in primary breast cancer. The protein concentrations of these factors in breast tumors have been well documented. However, few data about the mRNA expression of ER, PR, pS2, and PAI-1 in breast cancer are available, which is mostly due to the limitations of conventional techniques for mRNA analysis. We have described a competitive reverse transcription-PCR system for the simultaneous quantification of ER, PR, pS2, and PAI-1 mRNA in tumor samples. Here, we evaluated 100 tumor biopsies from breast cancer patients for the mRNA expression of ER, PR, pS2, and PAI-1. The results were analyzed for correlations with protein status and with clinical data. Significant correlations between mRNA expression levels and protein concentrations of all tested markers were found. In only a few cases was there an obvious discordance between the measurable amounts of mRNA and protein, especially for ER and PR. In addition, ER, PR, and pS2 mRNA levels correlated significantly with each other. No correlation between PAI-1 mRNA amount and the expression of the other markers was found. With respect to clinical data, ER and PR mRNA levels were found to be inversely correlated to tumor size and histological grade but not to the lymph node status. pS2 and PAI-1 mRNA expression were not correlated with tumor size, grade, or lymph node involvement. In conclusion, competitive reverse transcription-PCR may be used as an alternative for the study of prognostic factors in human breast cancer and other malignancies. However, before mRNA expression is measured for diagnostics, a presumed concordance of mRNA and protein expression must be evaluated very carefully for every gene.

Prognostic significance of mutations in the p53 gene, particularly in the zinc-binding domains, in lymph node- and steroid receptor positive breast cancer patients. Austrian Breast Cancer Study Group

The aim of our study was to evaluate if p53 mutations, especially those in the L2/L3 domains of the p53 gene, add prognostic information for node-positive and steroid receptor positive breast cancer patients. Two hundred and five tumour samples from a randomised clinical trial of 596 lymph node- and steroid receptor positive breast cancer patients were included. All patients had been randomly allocated to receive 20 mg of adjuvant tamoxifen (TAM) daily for 2 years or TAM plus one cycle of low-dose, short-term chemotherapy. For detection of p53 mutations we used in vitro amplification by polymerase chain reaction and consecutively performed temperature gradient gel electrophoresis (PCR-TGGE) and direct sequencing. We found p53 mutations in 42/205 (20%) cases: 16/42 (38%) p53 mutations occurred within the L2/L3 domains of the p53 gene, and 26/42 (62%) outside the L2/L3 domains. p53 mutation served as a statistically significant parameter in predicting disease-free survival in univariate (P = 0.02) and multivariate (P = 0.009) analysis. For overall survival, no significant differences were observed. Patients with tumours that had p53 mutations within the L2/L3 domains of the gene showed no significant difference to those with mutations outside the L2/L3 domains for disease-free survival. For overall survival, mutations in the L2/L3 domains showed a marginally significant difference (P = 0.05) in multivariate analysis, but not in univariate analysis (P = 0.13). We conclude that mutation in the L2/L3 domains of the p53 gene is not an independent prognostic indicator of disease outcome for patients suffering from breast cancer with lymph node metastases and positive steroid receptors.