INHBA(+) cancer-associated fibroblasts generate an immunosuppressive tumor microenvironment in ovarian cancer

Effective targeting of cancer-associated fibroblasts (CAFs) is hindered by the lack of specific biomarkers and a poor understanding of the mechanisms by which different populations of CAFs contribute to cancer progression. While the role of TGFβ in CAFs is well-studied, less attention has been focused on a structurally and functionally similar protein, Activin A (encoded by INHBA). Here, we identified INHBA(+) CAFs as key players in tumor promotion and immunosuppression. Spatiotemporal analyses of patient-matched primary, metastatic, and recurrent ovarian carcinomas revealed that aggressive metastatic tumors enriched in INHBA(+) CAFs were also enriched in regulatory T cells (Tregs). In ovarian cancer mouse models, intraperitoneal injection of the Activin A neutralizing antibody attenuated tumor progression and infiltration with pro-tumorigenic subsets of myofibroblasts and macrophages. Downregulation of INHBA in human ovarian CAFs inhibited pro-tumorigenic CAF functions. Co-culture of human ovarian CAFs and T cells revealed the dependence of Treg differentiation on direct contact with INHBA(+) CAFs. Mechanistically, INHBA/recombinant Activin A in CAFs induced the autocrine expression of PD-L1 through SMAD2-dependent signaling, which promoted Treg differentiation. Collectively, our study identified an INHBA(+) subset of immunomodulatory pro-tumoral CAFs as a potential therapeutic target in advanced ovarian cancers which typically show a poor response to immunotherapy.

Stability Determination of Intact Humanin-G with Characterizations of Oxidation and Dimerization Patterns

Humanin is the first identified mitochondrial-derived peptide. Humanin-G (HNG) is a variant of Humanin that has significantly higher cytoprotective properties. Here, we describe the stability features of HNG in different conditions and characterize HNG degradation, oxidation, and dimerization patterns over short-term and long-term periods. HNG solutions were prepared in high-performance liquid chromatography (HPLC) water or MO formulation and stored at either 4 °C or 37 °C. Stored HNG samples were analyzed using HPLC and high-resolution mass spectrometry (HRMS). Using HPLC, full-length HNG peptides in HPLC water decreased significantly with time and higher temperature, while HNG in MO formulation remained stable up to 95% at 4 °C on day 28. HNG peptides in HPLC water, phosphate-buffered saline (PBS) and MO formulation were incubated at 37 °C and analyzed at day 1, day 7 and day 14 using HRMS. Concentrations of full-length HNG peptide in HPLC water and PBS declined over time with a corresponding appearance of new peaks that increased over time. These new peaks were identified to be singly oxidized HNG, doubly oxidized HNG, homodimerized HNG, singly oxidized homodimerized HNG, and doubly oxidized homodimerized HNG. Our results may help researchers improve the experimental design to further understand the critical role of HNG in human diseases.

Comparison of laparoscopic enclosed electromechanical morcellation and vaginal enclosed scalpel morcellation at laparoscopic myomectomy: A prospective randomized trial

AIM

This study aimed to compare the laparoscopic-enclosed electromechanical morcellation (LEM) with vaginal-enclosed scalpel morcellation (VSM) in laparoscopic myomectomy procedures.

METHODS

One hundred eighteen patients who underwent laparoscopic myomectomy were enrolled the prospective randomized interventional clinical study in tertiary university hospital. After myomectomy, tissue removal was accomplished via either LEM using the in-glove morcellation technique or VSM.

RESULTS

The median tissue removal time was longer in the LEM group (25 min [range: 14-55]) than the VSM group (20 min [range: 6-38] [p = 0.001]). Rescue analgesia requirement was significantly higher in the LEM group than the VSM group (mean rank: 56.92 vs. 40.92 doses, respectively; p < 0.001). There was no significant difference between preoperative and postoperative third month total scores of female sexual function index (FSFI) and subdomains in the LEM group. Conversely, all subdomains and total scores of FSFI (26.5 [16.7-34.8] vs. 22.7 [15.2-28.7]) except pain significantly worsened 3 months after operation in the VSM group.

CONCLUSIONS

LEM was associated with a longer tissue removal time and increased postoperative analgesic requirement. On the other hand, VSM was associated with worsened postoperative sexual function from baseline.

Ovarian transplantation with robotic surgery and a neovascularizing human extracellular matrix scaffold: a case series in comparison to meta-analytic data

OBJECTIVE

To report our experience with robot-assisted (RA) autologous cryopreserved ovarian tissue transplantation (ACOTT) with the use of a neovascularizing extracellular matrix scaffold.

DESIGN

Case series with meta-analytic update.

SETTING

Academic.

PATIENT(S)

Seven recipients of RA-ACOTT.

INTERVENTION(S)

Before or shortly after initiating chemotherapy, ovarian tissue was cryopreserved from 7 women, who then underwent RA-ACOTT 9.9 ± 1.8 years (range, 7-12 years) later. Perioperatively, they received transdermal estrogen and low-dose aspirin to enhance graft vascularization. Ovarian cortical pieces were thawed and sutured on an extracellular matrix scaffold, which was then robotically anastomosed to the bivalved remaining ovary in 6 cases and retroperitoneally (heterotopic) to the lower abdomen in 1 case.

MAIN OUTCOME MEASURE(S)

Ovarian function return, the number of oocytes/embryos, aneuploidy %, live births, and neonatal outcomes were recorded. Graft longevity was compared with the mean from the meta-analytic data.

RESULT(S)

Ovarian function returned 13.9 ± 2.7 weeks (11-16.2 weeks) after ACOTT, and oocytes were retrieved in all cases with 12.3 ± 6.9 embryos generated. In contrast to orthotopic, the heterotopic ACOTT demonstrated low embryo quality and an 80% aneuploidy rate. A recipient did not attempt to conceive and 2 needed a surrogate, whereas 4 of 4 delivered 6 healthy children, compared with 115 of 460 (25% pregnancy rate) from the meta-analytic data (n = 79). The mean graft longevity (43.2 ± 23.6/47.4 ± 22.8 months with/without sensitivity analysis) trended longer than the meta-analytic mean (29.4 ± 22.7), even after matching age at cryopreservation.

CONCLUSION(S)

In this series, RA-ACOTT resulted in extended graft longevity, with ovarian functions restored in all cases, even when the tissues were cryopreserved after chemotherapy exposure.

Comparison of open and a novel closed vitrification system with slow freezing for human ovarian tissue cryopreservation

PURPOSE

To investigate the differences concerning post-thawing/warming follicle survival, DNA damage and apoptosis in human ovarian tissues cryopreserved by slow freezing, open, or closed vitrification methods.

METHODS

A total of 50 pieces of 5 × 5 × 1 mm ovarian cortical pieces were harvested (5 donor ovaries; mean age 31 ± 6.62 years). From each donor, one cortical piece was used as baseline; the remaining were randomly assigned to slow freezing (SF), vitrification using open device (VF-open), or closed device (VF-closed) groups. After 8-10 weeks of cryostorage, tissues were evaluated 4 h after thawing/warming. Histological analysis was evaluated for follicle survival (primordial and primary follicle densities) by H&E staining. The percentages of primordial and primary follicles with DNA double-strand breaks (γH2AX) and apoptotic cell death pathway activation (AC3) were immunohistochemically assessed. Data were analysed using one-way ANOVA and LSD post hoc comparison.

RESULTS

Compared to the baseline, primordial follicle (pdf) densities significantly declined in all cryopreserved groups (SF, VF-open, and VF-closed, P < 0.05). However, the total and non-apoptotic pdf densities were similar among SF, VF-open, and VF-closed. SF and VF with either open or closed devices did not increase the percentages of primordial or primary follicles with DNA double-strand breaks (DSBs) or apoptosis compared to the baseline or among the freezing methods in the present study.

CONCLUSION

Based on the intact primordial follicle survival, DNA damage, and apoptosis rates after thawing/warming, SF vs VF with either open or newly developed closed devices appear to be comparable.

Individual-oocyte transcriptomic analysis shows that genotoxic chemotherapy depletes human primordial follicle reserve in vivo by triggering proapoptotic pathways without growth activation

Gonadotoxic chemotherapeutics, such as cyclophosphamide, can cause early menopause and infertility in women. Earlier histological studies showed ovarian reserve depletion via severe DNA damage and apoptosis, but others suggested activation of PI3K/PTEN/Akt pathway and follicle ‘burn-out’ as a cause. Using a human ovarian xenograft model, we performed single-cell RNA-sequencing on laser-captured individual primordial follicle oocytes 12 h after a single cyclophosphamide injection to determine the mechanisms of acute follicle loss after gonadotoxic chemotherapy. RNA-sequencing showed 190 differentially expressed genes between the cyclophosphamide- and vehicle-exposed oocytes. Ingenuity Pathway Analysis predicted a significant decrease in the expression of anti-apoptotic pro-Akt PECAM1 (p = 2.13E-09), IKBKE (p = 0.0001), and ANGPT1 (p = 0.003), and reduced activation of PI3K/PTEN/Akt after cyclophosphamide. The qRT-PCR and immunostaining confirmed that in primordial follicle oocytes, cyclophosphamide did not change the expressions of Akt (p = 0.9), rpS6 (p = 0.3), Foxo3a (p = 0.12) and anti-apoptotic Bcl2 (p = 0.17), nor affect their phosphorylation status. There was significantly increased DNA damage by γH2AX (p = 0.0002) and apoptosis by active-caspase-3 (p = 0.0001) staining in the primordial follicles and no change in the growing follicles 12 h after chemotherapy. These data support that the mechanism of acute follicle loss by cyclophosphamide is via apoptosis, rather than growth activation of primordial follicle oocytes in the human ovary.

Dual targeting of GSK3B and HDACs reduces tumor growth and improves survival in an ovarian cancer mouse model

Objective.

To investigate the anti-tumor effect of a newly-developed dual inhibitor (APCS-540) of glycogen synthase kinase 3 beta (GSK3B) and histone deacetylases (HDACs) in ovarian cancer cells.

Methods.

The effects of APCS-540 on cancer cell proliferation, migration, invasion and cancer stemness were investigated in vitro in human (KURAMOCHI, OVCA420, OVSAHO) and mouse (BR-Luc, ID8, MOSE-HRas-Myc) ovarian cancer cells. Cisplatin-sensitive (A2780) and cisplatin-resistant (A2780cis) cell lines were used to evaluate APCS-540’s effect on chemoresistance. The immunocompetent syngeneic mouse model BR-Luc was used to test the effect of APCS-540 on ovarian cancer progression and survival.

Results.

APCS-540 showed significant anti-tumor effects in vitro in both human and mouse ovarian cancer cells. Importantly, APCS-540 demonstrated marked cytotoxicity against cisplatin-resistant cancer cells and reversed cisplatin-resistance when used in combination with platinum. APCS-540 significantly decreased cancer cell invasion. A significant 66% increase in survival was observed in mice treated with APCS-540 compared to control mice.

Conclusion.

Dual inhibition of GSK3B and HDACs via APCS-540 showed potent anti-tumor activity in vitro and in vivo, suggesting that APCS-540 may provide a novel treatment option for ovarian cancer, including the platinum-resistant disease.

Are Epithelial Ovarian Cancers of the Mesenchymal Subtype Actually Intraperitoneal Metastases to the Ovary?

Primary ovarian high-grade serous carcinoma (HGSC) has been classified into 4 molecular subtypes: Immunoreactive, Proliferative, Differentiated, and Mesenchymal (Mes), of which the Mes subtype (Mes-HGSC) is associated with the worst clinical outcomes. We propose that Mes-HGSC comprise clusters of cancer and associated stromal cells that detached from tumors in the upper abdomen/omentum and disseminated in the peritoneal cavity, including to the ovary. Using comparative analyses of multiple transcriptomic data sets, we provide the following evidence that the phenotype of Mes-HGSC matches the phenotype of tumors in the upper abdomen/omentum: (1) irrespective of the primary ovarian HGSC molecular subtype, matched upper abdominal/omental metastases were typically of the Mes subtype, (2) the Mes subtype was present at the ovarian site only in patients with concurrent upper abdominal/omental metastases and not in those with HGSC confined to the ovary, and (3) ovarian Mes-HGSC had an expression profile characteristic of stromal cells in the upper abdominal/omental metastases. We suggest that ovarian Mes-HGSC signifies advanced intraperitoneal tumor dissemination to the ovary rather than a subtype of primary ovarian HGSC. This is consistent with the presence of upper abdominal/omental disease, suboptimal debulking, and worst survival previously reported in patients with ovarian Mes-HGSC compared to other molecular subtypes.

Increased chemotherapy-induced ovarian reserve loss in women with germline BRCA mutations due to oocyte deoxyribonucleic acid double strand break repair deficiency

OBJECTIVE

To assess whether woman who have BRCA mutations (WBM) experience more declines in ovarian reserve after chemotherapy treatment, as it induces oocyte death by deoxyribonucleic acid (DNA) damage, and BRCA mutations result in DNA damage repair deficiency.

DESIGN

Longitudinal cohort study.

SETTING

Academic centers.

PATIENT(S)

The 108 evaluable women with breast cancer were stratified into those never tested (negative family history; n = 35) and those negative (n = 59) or positive (n = 14) for a pathogenic BRCA mutation.

INTERVENTION(S)

Sera were longitudinally obtained before and 12-24 months after chemotherapy treatment, assayed for antimüllerian hormone (AMH), and adjusted for age at sample collection.

MAIN OUTCOME MEASURE(S)

Ovarian recovery, defined as the geometric mean of the after chemotherapy age-adjusted AMH levels compared with baseline levels.

RESULT(S)

Compared with the controls, the before chemotherapy treatment AMH levels were 24% and 34% lower in those negative or positive for BRCA mutations, consistent with accelerated ovarian aging in WBM. The WBM had a threefold difference in AMH recovery after chemotherapy treatment (1.6%), when compared with BRCA negative (3.7%) and untested/low risk controls (5.2%). Limiting the analysis to the most common regimen, doxorubicin and cyclophosphamide followed by paclitaxel, showed similar results. These findings were mechanistically confirmed in an in vitro mouse oocyte BRCA knockdown bioassay, which showed that BRCA deficiency results in increased oocyte susceptibility to doxorubicin.

CONCLUSION(S)

Women who have pathogenic BRCA mutations are more likely to lose ovarian reserve after chemotherapy treatment, suggesting an emphasis on fertility preservation. Furthermore, our findings generate the hypothesis that DNA repair deficiency is a shared mechanism between aging, infertility, and cancer.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00823654.

Fertility preservation in gynecologic cancers

An increasing number of women in modern societies are delaying childbearing beyond the age of 35, and gynecologic cancers affect a significant proportion of reproductive age women who wish to preserve fertility for a future chance of childbearing. As a result, providing treatment options for fertility preservation in women with gynecologic cancer has become a crucial component of cancer survivorship care. In this review article, we discussed the current knowledge on fertility-sparing surgical approaches, as well as assisted reproductive technologies that can be utilized to preserve reproductive potential in women with cervical, endometrial, and ovarian cancer. A brief section on fertility preservation in pediatric gynecologic malignancies is also provided.

Abstract PD6-06: Impact of BRCA mutations on chemotherapy-induced loss of ovarian reserve: A prospective longitudinal study

Background: The BRCA1/2 genes are key members of the ataxia-telangiectasia mutated (ATM)-mediated DNA double strand break (DSB) repair pathway. Recent research showed that germline mutations in these genes result in DNA repair deficiency in oocytes, leading to accelerated ovarian aging as manifested by lower ovarian reserve and earlier age at natural menopause. Because we discovered that oocyte DNA repair is similarly critical in chemotherapy-induced ovarian follicle loss, we hypothesized that women with pathogenic mutations in BRCA1/2 genes may experience larger declines in ovarian reserve after chemotherapy. To gauge the degree of the chemotherapy-induced ovarian damage, we utilized serum anti-mullerian hormone (AMH), which is the most reliable current marker for assessing oocyte reserve.

Methods: Women with early stage breast cancer were enrolled before chemotherapy (Trial registration number: NCT00823654) between January 2009 and November 2017. Sera were obtained at baseline, before the initiation of treatment, and 18 to 24 months after the completion of chemotherapy. Stored sera were assayed at once for anti-mullerian hormone (AMH) and the results were adjusted for the women's age at sample collection. Of the 235 enrolled, 117 evaluable women were stratified into three groups, those never tested (based on NCCN Guidelines V 1.2018 ; n=38) and those negative (n=65) or positive (n=14) for a pathogenic BRCA mutation. Ovarian recovery was defined as the geometric mean of the post chemotherapy age-adjusted AMH levels compared to baseline.

Results: Compared to the lower risk (BRCA-untested) control group, AMH levels averaged 76% and 66% in those negative or positive for BRCA mutations (p=0.078). The geometric mean recoveries for the three groups (not tested, BRCA negative and BRCA positive) were 3.7%, 5.2% and 1.6%, respectively. The mean recovery in the BRCA mutation positive group was about one-third the 4.6% recovery in the other two groups combined (two group ANOVA, p=0.034, F=4.89). Given the potential of the ovarian recovery to be dependent on type of chemotherapy, the data were reanalyzed for all three BRCA groups after restriction to those treated with the AC-T (doxorubicin and cyclophosphamide followed by paclitaxel) regimen. Of the 108 women in the previous analysis, 83 (77%) were treated with AC-T; 25, 46 and 12 women in the three groups, respectively. The geometric mean AMH recoveries for these new groups were 3.2%, 4.7% and 1.3%. When the BRCA mutation positive group was compared with other two groups, the former had significantly worse recovery of serum AMH levels (ANOVA, p=0.044, F=4.2).

Conclusions: These data show that women with breast cancer and pathogenic BRCA mutations have striking liability to chemotherapy-induced ovarian reserve loss and may have to be preferentially counselled on fertility preservation methods. In addition, taken together with the previous data showing that women with BRCA mutations may have accelerated ovarian aging, even unaffected reproductive age individuals may have to be proactive about family building or early preservation of their fertility (Supported by NIH R01HD053112).

Citation Format: Oktay K, Bedoschi G, Goldfarb SB, Taylan E, Titus S, Palomaki GE, Cigler T, Robson M, Dickler MN. Impact of BRCA mutations on chemotherapy-induced loss of ovarian reserve: A prospective longitudinal study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD6-06.

Does lymphadenectomy effect postoperative surgical morbidity and survival in patients with adult granulosa cell tumor of ovary?

AIM

To evaluate the effect of lymphadenectomy on surgical morbidity and survival in adult granulosa cell tumor (AGCT) of the ovary.

METHODS

Patients who underwent surgical treatment for AGCT between January 1993 and January 2016 were identified. Data were collected for patient age, menopausal status, surgical staging, lymphadenectomy, postoperative complications (anemia, wound infection, incisional hernia), length of hospital stay, follow-up duration, site and time for recurrence, management of recurrence and vital status. Histopathological records were also evaluated for number of cellular mitosis.

RESULTS

Lymphadenectomy (pelvic-paraaortic) was performed in 53 (53%) of 98 patients. Decrease in postoperative hemoglobin level and increased wound infection and longer hospital stay were significantly higher in lymphadenectomy group (P = 0.003, 0.043 and <0.001, respectively). Tumor stage (HR 95% CI 14.9 [2.43-92.8]) and number of mitoses >5 (HR 95% CI 14.9 [2.43-92.8]) were significantly associated with recurrence (P = <0.001 and 0.02, respectively). Tumor stage was the only prognostic factor for predicting overall survival (HR 95% CI 8.47 [2.17-33.2]). Lymphadenectomy showed no effect on disease-free survival and overall survival both in multivariate Cox regression analyses (P = 0.46 and 0.69, respectively). Disease-free survival and overall survival were similar in lymphadenectomy and no lymphadenectomy groups (Log Rank P = 0.382, 0.741, respectively).

CONCLUSION

Lymphadenectomy had no improved effect on survival and had negative effect on surgical morbidity in patients with AGCT.

Current state and controversies in fertility preservation in women with breast cancer

On average, over 25000 women are diagnosed with breast cancer under the age of 45 annually in the United States. Because an increasing number of young women delay childbearing to later life for various reasons, a growing population of women experience breast cancer before completing childbearing. In this context, preservation of fertility potential of breast cancer survivors has become an essential concept in modern cancer care. In this review, we will outline the currently available fertility preservation options for women with breast cancer of reproductive age, discuss the controversy behind hormonal suppression for gonadal protection against chemotherapy and highlight the importance of timely referral by cancer care providers.

Contained Morcellation: Review of Current Methods and Future Directions

Power morcellation of surgical specimen during laparoscopic surgery is a practical technology that provides the opportunity to perform several minimally invasive procedures. However, this technology brought forward additional risks and complications associated with dissemination of both benign and malignant tissues inside the abdominal cavity. Based on startling cases, Food and Drug Administration (FDA) announced a discouraging statement on the use of power morcellators that decreased the number of minimally invasive approaches in the following period. As a response to these concerns and negative impacts of the FDA statement, researchers developed several new approaches resulting in contained or in-bag morcellation methods. In this review, we aimed to discuss these current methods and provide an insight for future developments.

Ovarian serous cystadenoma with ectopic adrenal tissue in a 65-year-old patient: A case report

•

A very rare case of ectopic adrenal tissue (EAT) with ovarian serous cystadenoma is presented.

•

EATs usually disappear by age, however it can remain until old stages of life.

•

Surgically removal of all suspicious lesions is strongly recommended.

Introduction

Ectopic adrenal tissue is a very rare entity in adult females, especially in the ovary, and is generally diagnosed incidentally during surgery. Although it can present at various sites during childhood, it becomes atrophic by adulthood due to normally functioning adrenal glands. Patients are predominantly asymptomatic; however, in some cases endocrine symptoms such as hypertension and fasciotruncal obesity due to hormonal activity can be seen or neoplastic transformation can appear.

Presentation of case

A 65-year-old patient with progressive pelvic pain and postmenopausal vaginal bleeding was evaluated by transvaginal ultrasound, which revealed bilateral adnexal masses measuring 5 cm in size and a normal uterus with an increased endometrial thickness of 7 mm. Initially the endometrial sampling result was reported as benign. The patient underwent abdominal hysterectomy and bilateral salpingo-oophorectomy and the pathological diagnosis was again benign, with serous ovarian cystadenoma being found in both ovaries. The pathologist also reported incidental ectopic adrenal tissue on the wall of the left ovarian cystadenoma.

Discussion

Ectopic adrenal tissue is infrequent in female genital organs especially at older ages. Only a few cases of ovarian ectopic adrenal tissue have been reported. To the best of our knowledge the present case is the fourth report in the English literature, and is of additional importance given the patient’s age.

Conclusion

Ectopic adrenal tissues are generally asymptomatic and revealed incidentally during surgery; however some cases have demonstrated the risk of neoplastic transformation. Therefore, surgeons must be aware of this rare entity that bears the risk of malignancy, and should surgically remove all suspicious lesions.

Robotics in reproduction, fertility preservation, and ovarian transplantation

Robotic technology is one of the most promising and rapidly developing advancements of the twenty-first century with a potential to make significant contributions to reproductive surgery and preservation of fertility. Along with the major advances in cancer therapy, the number of female cancer survivors of reproductive age has dramatically increased. As a consequence, fertility preservation has gained more emphasis in reproductive science in the last few decades. A broad range of surgical procedures such as tubal reanastomosis, ovarian transposition, radical trachelectomy, and ovarian transplantation has been introduced to restore or preserve fertility in selected patients. These procedures can be accomplished through various surgical routes, including open surgery and minimally invasive approaches. In this review, we aim to present the current applications, advantages, and disadvantages of robotic technology in the field of reproductive surgery with a special interest in ovarian transplantation for fertility preservation.

Application of Decellularized Tissue Scaffolds in Ovarian Tissue Transplantation

In tissue engineering, decellularized scaffolds have been proved to have remarkable capacity to promote regeneration in various organs such as kidney, heart, lung, and liver. Marrying the field of cryobiology and reproductive medicine resulted in considerable progress and breakthroughs, which led to the emergence of ovarian tissue cryopreservation and transplantation as a promising option for fertility preservation. Here we describe an innovative application of decellularized tissue scaffolds as a regenerative platform for reconstruction of ovarian grafts for auto-transplantation.

The impact of salpingectomy and single-dose systemic methotrexate treatments on ovarian reserve in ectopic pregnancy

OBJECTIVE

To investigate the effects of salpingectomy and methotrexate treatments on ovarian reserve in ectopic pregnancy.

STUDY DESIGN

In this prospective study, a total of 131 patients with ectopic pregnancy were divided into 3 groups of methotrexate (MTX) only (Group-1, n: 55), salpingectomy only (Group-2, n: 61), and salpingectomy following MTX (Group-3, n: 15). Pretreatment and post-treatment anti-Müllerian hormone (AMH) levels were evaluated.

RESULTS

Significant differences in AMH levels were detected between group 1 and group 2 (2.52±1.28 vs. 1.96±1.66, p=0.043), and group 1 and group 3 (2.52±1.28 vs. 1.77±0.76, p=0.035) at one month postoperative. However, these differences disappeared at the 3rd postoperative month. When AMH levels were compared within the same group, postoperative one month AMH levels were significantly lower than the preoperative AMH levels only in group 3 (p=0.03). However, this difference also disappeared at the 3rd postoperative month.

CONCLUSION

Systemic single-dose methotrexate treatment, unilateral salpingectomy, and salpingectomy following methotrexate administration in ectopic pregnancy were reassuring based on pretreatment and post-treatment AMH levels. Current medical and surgical treatment approaches do not have an obvious negative effect on ovarian reserve.

Vaginal cuff dehiscence with bowel evisceration after robotic hysterectomy

Vaginal cuff dehisence with bowel evisceration after hysterectomy is a very rare complication. However, the incidance of this complication appears to be increased with the widely used techniques of laparoscopic surgery especially with robotic hysterectomy. In this case report we aimed to evaluate the risk factors and treatment methods for this complication.