A Tumor Necrosis Factor—α Promoter Polymorphism and Pregnancy Complications: Results of a Prospective Cohort Study in 1652 Pregnant Women

The purpose of this article is to investigate the frequency of the tumor necrosis factor-alpha (TNF-alpha) -308 G/A single nucleotide polymorphism in women with intrauterine fetal death, preeclampsia, preterm delivery, and small-for-gestational-age (SGA) infants. In a prospective cohort study, DNA from 1652 consecutive pregnant women was analyzed for TNF-alpha -308 G/A by polymerase chain reaction. Women who developed at least 1 of the predefined pregnancy complications were used as cases and compared to women without pregnancy complications. Of 1652 women, 268 (16.2%) developed at least 1 pregnancy complication. TNF-alpha -308 G/A allele frequencies (G: 463/536 [86%] and A: 73/536 [14%] vs G: 2366/2768 [85%] and A: 402/2768 [15%], respectively; P = .6; odds ratio [OR], 0.93; 95% confidence interval [CI], 0.69-1.25) and genotype distributions (G/G+G/A: 259/268 [97%] and A/A 9/268 [3%] vs G/G+G/A: 1352/1384 [98%] and A/A 32/1384 [2%], respectively; P = .4; OR, 0.20; 95% CI, 0.002-14.81) were not significantly different between cases and controls. The authors observed no statistically significant difference in TNF-a -308 G/A genotype distributions comparing controls and women with intrauterine fetal death, preeclampsia, preterm delivery <34 weeks' gestation, preterm delivery >34 weeks' gestation, SGA infants <3rd percentile, and SGA infants of the 4th to 10th percentile. TNF-alpha -308 G/A is not a genetic marker for identifying women at increased risk of common pregnancy complications.

Gene expression signatures of breast tissue before and after cross-sex hormone therapy in female-to-male transsexuals

OBJECTIVE

To evaluate gene expression signatures of breast tissue in female-to-male (FtM) transsexuals under cross-sex hormone therapy (HT).

DESIGN

Prospective cohort study.

SETTING

Academic research institution.

PATIENT(S)

Five hormone-naïve FtM transsexuals before and after HT.

INTERVENTION(S)

Breast tissue biopsy before and after 2 years of intramuscular testosterone undecanoate (1,000 mg every 12 wk) and oral lynestrenole (5 mg daily), and gene signature analysis by global gene expression array covering 28,869 genes.

MAIN OUTCOME MEASURE(S)

Differential regulation of specific genes and gene expression signatures.

RESULT(S)

We identified 2,250 differentially expressed probe sets. One hundred twenty probe sets showed >2-fold change, of which 77 (64.2%) were up-regulated and 43 (35.8%) down-regulated. Genes involved in transcription were most overrepresented, with 43 out of 97 (44.3%) annotated probes, e.g., the transcription factor complex activator protein 1, including all three Jun genes (c-Jun, JunB, and JunD), two Fos genes (c-Fos and FosB), and activating transcription factor 3. In a Database for Annotation, Visualization, and Integrated Discovery analysis of the 2,007 down-regulated probe sets, proteins of the ribosome pathway and of two pathways involved in protein degradation, i.e., proteasome- and ubiquitin-mediated proteolysis, were significantly down-regulated. We identified eight breast cancer-associated gene expression signatures significantly overlapping with differentially regulated probe sets after cross-sex HT.

CONCLUSION(S)

Cross-sex HT in FtM transsexuals leads to the up-regulation and down-regulation of 243 and 2,007 distinct genes, respectively, and is associated with breast cancer-related gene expression signatures.

OCT-4 expression in follicular and luteal phase endometrium: a pilot study

BACKGROUND

The stem cell marker Octamer-4 (OCT-4) is expressed in human endometrium. Menstrual cycle-dependency of OCT-4 expression has not been investigated to date.

METHODS

In a prospective, single center cohort study of 98 women undergoing hysteroscopy during the follicular (n = 49) and the luteal (n = 40) phases of the menstrual cycle, we obtained endometrial samples. Specimens were investigated for OCT-4 expression on the mRNA and protein levels using reverse transcriptase polymerase chain reaction (RT-PCR) and immunohistochemistry. Expression of OCT-4 was correlated to menstrual cycle phase.

RESULTS

Of 89 women sampled, 49 were in the follicular phase and 40 were in the luteal phase. OCT-4 mRNA was detected in all samples. Increased OCT-4 mRNA levels in the follicular and luteal phases was found in 35/49 (71%) and 27/40 (68%) of women, respectively (p = 0.9). Increased expression of OCT-4 protein was identified in 56/89 (63%) samples. Increased expression of OCT-4 protein in the follicular and luteal phases was found in 33/49 (67%) and 23/40 (58%) of women, respectively (p = 0.5).

CONCLUSIONS

On the mRNA and protein levels, OCT-4 is not differentially expressed during the menstrual cycle. Endometrial OCT-4 is not involved in or modulated by hormone-induced cyclical changes of the endometrium.

Prognostic value of human epidermal growth factor receptor 2 (Her-2)/neu in patients with advanced ovarian cancer treated with platinum/paclitaxel as first-line chemotherapy: a retrospective evaluation of the AGO-OVAR 3 Trial by the AGO OVAR Germany

OBJECTIVES

Results on the prognostic value of human epidermal growth factor receptor 2 (HER-2)/neu in ovarian cancer are inconsistent. This exploratory analysis evaluates Her-2/neu as a prognostic factor in a large cohort of patients with advanced-stage ovarian cancer treated with platinum/paclitaxel as first-line chemotherapy within a prospective randomized trial.

METHODS

Her-2/neu expression was assessed by immunohistochemistry in 359 patients (46%) treated within the AGO-OVAR 3 trial (n = 783). Patients received either cisplatin/paclitaxel or carboplatin/paclitaxel according to the study protocol. Immunohistochemistry results were scored according to the Dako score.

RESULTS

Her-2/neu Dako scores of 0 or 1+ was found in 337 patients (94%) and a score of 2+ or 3+ in 22 patients (6%). Her-2/neu overexpression (2+/3+) was associated with a higher International Federation of Gynecology and Obstetrics stage and larger postoperative residual disease. There were no significant differences in response to chemotherapy between the Her-2/neu score subgroups and in progression-free survival time. In a multivariate analysis, the Her-2/neu score had no significant impact on overall survival time.

CONCLUSIONS

In the present study, Her-2/neu overexpression in patients with advanced-stage ovarian cancer was rare and provided no evidence for a prognostic value of Her-2/neu in patients with advanced ovarian cancer treated with platinum/paclitaxel.

Non-contraceptive benefits of oral contraceptives

BACKGROUND

There is increasing awareness of the opportunity that many contraceptive interventions may provide for additional health benefits. However, treatment of medical problems with oral contraceptives (OCs) is often an 'off-label' practice.

OBJECTIVE

The aim of this review is to summarize available data on non-contraceptive benefits of OCs.

METHODS

Review of the literature.

RESULTS

OCs have been shown to reduce the risk of ovarian, endometrial, and colorectal cancer. It has been suggested that OCs may be used in treatment of endometriosis, menorrhagia, and uterine leiomyomas. Pelvic inflammatory disease, dysmenorrhea, premenstrual syndrome, and acne have been shown to improve under OCs.

CONCLUSION

OCs are important for global and female health. Besides contraception, non-contraceptive effects of OCs are evidence based, well established, and commonly used in clinical practice.

Endocervical cytobrush for the detection of cervical dysplasia before large loop excision of the transformation zone (LLETZ)

BACKGROUND

We aimed to identify the number of histologically verified cervical intraepithelial neoplasia (CIN)/cervical cancer lesions detected by endocervical cytobrush (EC) which have been missed by repeat PAP smear and colposcopy before large loop excision of the transformation zone (LLETZ).

PATIENTS AND METHODS

A retrospective cohort study of 1,676 consecutive patients in a colposcopy clinic undergoing repeat PAP smear, colposcopy, biopsy, and subsequent LLETZ.

RESULTS

Data were available for 1,421 patients. EC identified 31/1,367 (2.2%) cases of CIN and/or cervical cancer missed by repeat PAP smear and colposcopy. Compared to repeat PAP smear and colposcopy, the combination of repeat PAP smear, colposcopy and EC increased the positive predictive value (PPV) (89.6% vs. 98.9%, p=0.07), but this difference was not statistically significant. Sensitivity (93.1% vs. 93.9%; p=0.8), specificity (27.7% vs. 27.7%; p=1.0), and negative predictive value (NPV) (11.9% vs. 13.1%, p=0.9) were also not significantly different. The number needed to screen (NNS) for identifying one additional case of CIN and/or invasive cancer by EC was 45. In a multivariate analysis, presence of CIN/cervical cancer in the LLETZ specimen and human papilloma virus infection, but not age, visibility of the transformation zone or presence of an endovcervical lesion were independently associated with the likelihood of CIN and/or invasive cancer detected by EC.

CONCLUSION

Adding EC to repeat PAP smear and colposcopy identifies 2.2% more cases of CIN and/or cervical cancer, but does not significantly increase the sensitivity, specificity, PPV or NPV of repeat PAP smear and colposcopy.

Clinical outcome monitoring in a reproductive surgery unit: a prospective cohort study in 796 patients

OBJECTIVE

To systematically monitor the frequency and risk factors of adverse events (AEs) in a reproductive surgery endoscopy unit.

DESIGN

Prospective cohort study.

SETTING

Academic research institution.

PATIENT(S)

All consecutive surgical patients of a reproductive surgery unit from December 2005 to March 2007.

INTERVENTION(S)

Monitoring for predefined AEs by trained observers.

MAIN OUTCOME MEASURE(S)

Number of preventable and not preventable AEs, medical errors, and system problems. Univariate analysis and multivariate logistic regression were used to identify risk factors of AEs.

RESULT(S)

Seven hundred ninety-six women were included. We identified 60 AEs in 45 patients (risk 6%; 95% confidence interval [CI] 1%-11%). Adverse events were postoperative fever (n = 1), wound breakdown (n = 1), intraoperative or postoperative administration of packed erythrocytes (n = 6), surgical revision (n = 7), unplanned readmission (n = 5), transfer to intensive care unit (n = 1), conversion (n = 8), intraoperative organ injury (n = 9), blood loss >500 mL (n = 3), surgery canceled (n = 15), and other AEs (n = 4). Six patients (risk 0.8%; 95% CI 0-2%) had multiple AEs. One (0.01%) and 11 (1.4%) AEs were deemed due to medical errors and system problems, respectively. Twelve and 48 AEs were deemed preventable and not preventable, respectively. In a univariate and multivariate analysis, only duration of surgery (odds ratio 3.78; 95% CI 1.95-7.33) was significantly associated with having an AE.

CONCLUSION(S)

Clinical outcome monitoring is a useful tool for assessing the outcome quality of reproductive surgery by identifying potentially preventable AEs and associated risk factors.

Accuracy of intraoperative frozen section analysis in borderline tumors of the ovary: A retrospective analysis of 96 cases and review of the literature

OBJECTIVE

To assess the sensitivity and positive predictive value (PPV) of intraoperative frozen section diagnosis of borderline tumors of the ovary (BTO).

METHODS

Retrospective analysis at the Department of Obstetrics and Gynecology, University of Vienna, between 1995 and 2007 and review of the literature. Frozen section analysis and definitive histology reports were compared. Univariate and multivariate regression models were used to assess the influence of patient and tumor characteristics on the likelihood of underdiagnosis and overdiagnosis.

RESULTS

Agreement between frozen section diagnosis and definitive histology was observed in 69/96 (71.9%) patients, yielding an overall sensitivity and a positive predictive value of 75.0% and 94.5%, respectively. Underdiagnosis and overdiagnosis occurred in 27/96 (28%) and 0/96 (0%) patients, respectively. In a univariate and multivariate analysis, tumor diameter, but not patient age, tumor histology, tumor stage, presence of a bilateral tumor, serum CA-125 and concurrent presence of endometriosis was a predictor of underdiagnosis of frozen section analysis. We identified 29 studies investigating the accuracy of frozen section analysis of BTO. Three studies exclusively examined BTO in 140, 48 and 33 cases, respectively. Data of these three studies and the present study were pooled, yielding an overall sensitivity and PPV of 71.1% and 84.3%, respectively. Overdiagnosis and underdiagnosis were identified in 21/317 (6.6%) and in 97/317 (30.6%) cases, respectively.

CONCLUSION

Intraoperative frozen section diagnosis of BTO has a low sensitivity and PPV and overdiagnosis and underdiagnosis are frequent. Surgical management based on intraoperative frozen section diagnosis should be used with caution.

A polymorphism of the CYP17 gene related to sex steroid metabolism is associated with female-to-male but not male-to-female transsexualism

OBJECTIVE

To assess the association between transsexualism and allele and genotype frequencies of the common cytochrome P450 (CYP) 17 -34 T>C single nucleotide polymorphism (SNP).

DESIGN

Case-control study.

SETTING

Academic research institution.

PATIENT(S)

102 male-to-female (MtF) and 49 female-to-male (FtM) transsexuals, 756 male controls, and 915 female controls.

INTERVENTION(S)

Buccal swabs and multiplex polymerase chain reaction on a microarray system.

MAIN OUTCOME MEASURE(S)

Analysis of the CYP17 -34 T>C SNP.

RESULT(S)

CYP17 -34 T>C SNP allele frequencies were statistically significantly different between FtM transsexuals and female controls (CYP17 T: 55/98 [56%] and CYP17 C: 43/98 [44%] versus CYP17 T: 1253/1826 [69%] and CYP17 C: 573/1826 [31%], respectively). In accordance, genotype distributions were also different between FtM transsexuals and female controls using a recessive genotype model (CYP17 T/T+T/C: 39/49 [80%] and C/C 10/49 [20%] vs. CYP17 T/T+T/C: 821/913 [90%] and C/C 92/913 [10%], respectively). The CYP17 -34 T>C allele and genotype distributions were not statistically significantly different between MtF transsexuals and male controls. Of note, the CYP17 -34 T>C allele distribution was gender-specific among controls (CYP17 C: males; 604 of 1512 [40%] vs. females; 573 of 1826 [31%]). The MtF transsexuals had an allele distribution equivalent to male controls, whereas FtM transsexuals did not follow the gender-specific allele distribution of female controls but rather had an allele distribution equivalent to MtF transsexuals and male controls.

CONCLUSION(S)

These data support CYP17 as a candidate gene of FtM transsexualism and indicate that loss of a female-specific CYP17 T -34C allele distribution pattern is associated with FtM transsexualism.

Methylenetetrahydrofolate reductase C677T polymorphism and pregnancy complications

OBJECTIVE

To investigate the frequency of the methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism in women with intrauterine fetal death, preeclampsia, preterm delivery, and small for gestational age (SGA) infants.

METHODS

In a prospective cohort study, DNA from 2,000 pregnant women were analyzed for MTHFR C677T by DNA microarray (wild-type allele, C; mutant allele, T).

RESULTS

One thousand six hundred seventy-five women completed the study. Of these, 16.6% (278 women with 556 genetic alleles) developed at least one pregnancy complication and were designated study cases. There were 1,397 women (with 2,794 genetic alleles) who served as controls. MTHFR C677T allele frequencies were significantly different between cases and controls (C [wild-type]: 346 of 556 [62%]; T [mutant]: 210 of 556 [38%] compared with C: 1,911 of 2,794 [68%]; T: 883 of 2,794 [32%]; P=.005; odds ratio [OR] 1.23, 95% confidence interval [CI] 1.06-1.42). Genotype distributions were also different between cases and controls (C/T+T/T [abnormal]: 174 of 278 [63%]; C/C [normal]: 104 of 278 [37%] compared with C/T+T/T: 728 of 1,397 [52%]; C/C 669 of 1,397 [48%]; P=.002; OR 1.54, 95% CI 1.18-2.02). The clinical effect of the MTHFR C677T polymorphism was restricted to women with SGA infants (P=.05; OR 1.33, 95% CI 1.00-1.77). No significant differences in genotype distributions were observed among women with intrauterine fetal death, preeclampsia, and preterm delivery.

CONCLUSION

MTHFR C677T is a genetic marker for identifying women at increased risk of SGA infants.

LEVEL OF EVIDENCE

II.

A combination treatment of prednisone, aspirin, folate, and progesterone in women with idiopathic recurrent miscarriage: a matched-pair study

OBJECTIVE

To compare a combination treatment of prednisone, aspirin, folate, and progesterone with no treatment in women with idiopathic recurrent miscarriage (IRM).

DESIGN

Matched-pair study.

SETTING

Academic research institution.

SUBJECT(S)

Women with a history of IRM, defined as three or more consecutive miscarriages before 20 weeks' gestation without associated anatomic, cytogenetic, hormonal, and infectious pathologies or antiphospholipid syndrome.

INTERVENTION(S)

Eighty of 210 eligible women consented to participate and were treated with prednisone (20 mg/d) and progesterone (20 mg/d) for the first 12 weeks of gestation, aspirin (100 mg/d) for 38 weeks of gestation, and folate (5 mg every second day) throughout their pregnancies. Fifty of 80 women became pregnant; they were compared with 52 women with IRM (matched for age and number of miscarriages), who became pregnant without treatment during the same observation period.

MAIN OUTCOME MEASURE(S)

Live birth rate, complications of pregnancy, such as preeclampsia, premature birth, and intrauterine growth restriction, and therapy-related side effects.

RESULT(S)

The overall live birth rates of the treatment and control groups were 77% (40 of 52) and 35% (18 of 52) (P=.04). The rates of first and second trimester miscarriage among the treatment and control groups were 19% (10 of 52) and 0 (0 of 52), and 63% (33 of 52) and 2% (1 of 52), respectively (P=.09 and P=1.0, respectively). The median gestational age at birth and median birth weight did not differ between the groups. We observed two and three cases of premature birth among the treatment and control groups, respectively (P=.3) and no cases of intrauterine growth restriction and Cushing's disease. Of 80 women who started treatment, one woman had an ectopic pregnancy and one woman terminated her pregnancy due to fetal chromosome aberration (trisomy 18). Three women stopped treatment due to nausea, depression, and tachycardia.

CONCLUSION(S)

A combination treatment of prednisone, aspirin, folate, and progesterone is associated with a higher live birth rate compared with no treatment in women with IRM.

Genotype distribution of estrogen receptor-alpha, catechol-O-methyltransferase, and cytochrome P450 17 gene polymorphisms in Caucasian women with uterine leiomyomas

OBJECTIVE

To evaluate the association between the presence of uterine leiomyomas and three functional single nucleotide polymorphisms (SNPs) of the estrogen receptor alpha (ESR1), catechol-O-methyltransferase (COMT), and cytochrom P450 17 (CYP17A) genes, which have been described to modify the estrogen metabolism.

DESIGN

Prospective case control study.

SETTING

Academic research institution.

PATIENT(S)

One hundred thirty women with clinically and surgically diagnosed uterine leiomyomas and 139 population controls.

INTERVENTION(S)

Peripheral venous puncture.

MAIN OUTCOME MEASURE(S)

Polymerase chain reaction and pyrosequencing were performed to genotype women with respect to the ESR1 IVS1-397 T/C (PvuII), COMT G158A, and the CYP17A 34T-->C SNPs.

RESULT(S)

Comparing women with uterine leiomyomas and controls, no statistically significant differences with respect to allele frequency and genotype distribution were ascertained for ESR1 IVS 1-397 T/C (PvuII) (P=0.9 and P=0.6, respectively), COMT G158A (P=0.3 and P=0.6, respectively), and CYP17A 34T-->C (P=0.1 and P=0.5, respectively). When all two-way interactions of investigated SNPs were ascertained, no significant interactions were observed. In a multivariate model, no SNP was significantly associated with leiomyomas.

CONCLUSION(S)

Carriage of the ESR1 IVS1-397 T/C (PvuII), COMT G158A, and the CYP17A 34T-->C SNPs is not associated with the susceptibility to uterine leiomyoma in a Caucasian population.

Ten polymorphisms of estrogen-metabolizing genes and a family history of colon cancer--an association study of multiple gene-gene interactions

Estrogen replacement therapy is associated with a reduced risk of colon cancer. Therefore, we evaluated the following ten estrogen metabolism-associated single-nucleotide polymorphisms (SNPs) by sequencing-on-chip technology using solid-phase polymerase chain reaction (PCR) on oligonucleotide microarrays: catechol-O-methyltransferase (COMT) Val158Met G-->A, 17-beta-hydroxysteroid dehydrogenase type 1 (HSD17) vlV A-->C, cytochrome P-450 (CYP) 17 A2 allele T-->C, CYP1A1 MspI RFLP T-->C, CYP1A1 Ile462Val A-->G, CYP19 Arg264Cys C-->T, CYP19 C1558T C-->T, CYP 1B1 Leu432Val, CYP1B1 Asn453Ser, and estrogen receptor (ER) alpha IVS1 -401-->C in 76 patients with a family history of colon cancer and 722 healthy controls. Using stepwise logistic regression models, we found that none of the investigated SNPs is associated with a family history of colon cancer in a univariate and multivariate logistic regression model. In addition, when all two-way interactions of the investigated SNPs were ascertained, no significant interactions between SNPs were observed. In conclusion, we found no association between the carriage of one or multiple SNPs of the estrogen metabolism and a family history of colon cancer.

Ten estrogen-related polymorphisms and endometriosis: a study of multiple gene-gene interactions

OBJECTIVE

Genetic as well as hormonal factors are known to influence the development and clinical course of endometriosis. We aimed to investigate the association among 10 single nucleotide polymorphisms (SNPs) involved in the estrogen metabolism and endometriosis and to develop a multiple genetic model.

METHODS

In a case-control study, we investigated the genotype frequencies of 10 estrogen metabolizing SNPs in 32 patients with endometriosis and 790 healthy controls using sequencing-on-chip-technology with solid-phase polymerase chain reaction on oligonucleotide microarrays: catechol-O-methyltransferase, Val158Met G->A, 17-beta-hydroxysteroid dehydrogenase type 1 (HSD17), vlV A->C, cytochrome P450 (CYP), 17 A2 allele T->C, CYP1A1 MspI RFLP T->C, CYP1A1 Ile462Val A->G, CYP19 Arg264Cys C->T, CYP19 C1558T C->T, CYP 1B1 Leu432Val, CYP1B1 Asn453Ser, and estrogen receptor alpha IVS1 -401>C. Associations and 2-way interaction models between SNPs were calculated by stepwise logistic regression models.

RESULTS

In a univariate model, HSD17 vlV A->C was associated with a significantly increased risk of endometriosis (P = .004; odds ratio 3.9, 95% confidence interval 1.6-9.8). When all 2-way interactions of investigated SNPs were ascertained, no significant interactions among SNPs were observed. In a multivariate model, HSD17 vlV A->C was also significantly associated with endometriosis (P = .002).

CONCLUSION

We present data on multiple SNPs in patients with endometriosis indicating an association between HSD17 gene variation and the disease. Although not able to demonstrate interaction models of SNPs, we provide evidence of HSD17 vlV A->C as a low penetrance genetic marker of endometriosis.

LEVEL OF EVIDENCE

II-2.

A model for predicting age at menopause in white women

OBJECTIVE

To develop a model to predict the age at natural menopause and the risk for premenopausal hysterectomy.

DESIGN

Cross-sectional study.

SETTING

Multicenter study.

PATIENT(S)

A total of 1,345 white women.

INTERVENTION(S)

Ten single nucleotide polymorphisms (SNPs) of seven estrogen (E)-metabolizing genes (i.e., catechol-O-methyltransferase, 17-beta-hydroxysteroid dehydrogenase type 1, cytochrome P-450 [CYP] 17, CYP1A1, CYP1B1, CYP19, and E receptor [ER] alpha) were analyzed by sequencing-on-chip-technology.

MAIN OUTCOME MEASURE(S)

Patients' reproductive and medical histories were ascertained and correlated to genotypes.

RESULT(S)

The model incorporates the number of full term pregnancies, the body mass index (BMI), a history of breast surgery, and the presence of CYP17 and CYP1B1-4 polymorphisms as well as the BMI to predict age at natural menopause and the risk for undergoing premenopausal hysterectomy.

CONCLUSION(S)

We present the first model to date, which can predict age at natural menopause and the risk for undergoing premenopausal hysterectomy based on genotype information and personal history.