Tru-Cut Biopsy in Gynecological Cancer: Adequacy, Accuracy, Safety and Clinical Applicability

Purpose

Tru-cut biopsy is a minimally invasive technique used to obtain tissue samples for the diagnosis of tumors, especially in patients where primary surgery is not indicated. The aim of this study was to assess the adequacy, accuracy and safety of the tru-cut biopsy for diagnosis in gynecological cancer.

Methods

A retrospective population-based review of 328 biopsies was conducted. The indications for tru-cut biopsies were diagnosis of primary tumors, metastases of gynecological and non-gynecological tumors, and suspected recurrences. A tissue sample was considered adequate when the quality/quality was sufficient to identify the subtype/origin of the tumor. Potential factors affecting adequacy were analyzed using logistic regressions analyses. Accuracy was defined as agreement between the diagnosis of the tru-cut biopsy and the postoperative histology. The therapy plan was registered, and the clinical applicability of the tru-cut biopsy was investigated. Complications within 30 days after the biopsy procedure were registered.

Results

In total, 300 biopsies were identified as tru-cut biopsies. The overall adequacy was 86.3%, varying between 80.8% and 93.5%, respectively, when performed by a gynecological oncologist or a gynecologist with a subspecialty in ultrasound diagnosis. Sampling of a pelvic mass had a lower adequacy (81.6%) compared with sampling of the omentum (93.9%) or carcinomatosis (91.5%). The accuracy was 97.5%, and the complication rate was 1.3%.

Conclusion

The tru-cut biopsy is a safe and reliable diagnostic method with a high accuracy and a good adequacy, depending on the site of the tissue sample, indications for the biopsy and the experience of the operator.

Imaging ovarian cancer - from baseline characteristics to high-risk image factors

BACKGROUND

Imaging ovarian cancer (OC) includes evaluating peritoneal carcinomatosis (PC) and enlarged cardio phrenic lymph nodes (CPLN) by computed tomography (CT), and thorough evaluation is tedious work. A "CT short score" with high-risk CT parameters might be a more pragmatic approach, but it is not known if such a short score associates with aggressive OC subtypes and impaired OC survival. Further, it is not known if certain established OC risk factors are linked to high-risk CT-findings which would be important in image evaluation. Herein, we investigate a CT short score and its relation to baseline characteristics, OC subtypes, and survival.

METHODS

The Malmö Diet and Cancer Study is a prospective cohort that included 17,035 women (1991-1996). Baseline characteristics and tumor information on 159 OC and information on OC specific survival (last follow-up, 2017-12-31) was registered. A CT short score (CPLN and PC-index (PCI) in seven regions) was registered and associations with clinical stage [stage I vs. advanced stage (II-IV), histological type/grade (high grade serous and endometrioid vs. other subtypes], and OC-specific survival were analyzed with logistic and Cox regression, respectively. Parity and menopausal status were analyzed in relation to short score and PCI.

RESULTS

There was an association between higher short score and advanced clinical stage (adjusted OR 2.76 (1.42-5.38)), adjusted for age at diagnosis and histological type/grade. Higher short score was associated with impaired OC specific survival (adjusted HR 1.17 (1.01-1.35)), adjusted for age at diagnosis, histological type/grade, and clinical stage. There were no significant associations between parity, menopausal status, and short score/PCI.

CONCLUSIONS

CT short score was significantly associated with advanced clinical stages and impaired OC survival. A pragmatic approach (based on CT) to evaluate high risk image findings in OC could help reduce radiologists' workload and at the same time provide structured reports to surgeons and oncologists involved in OC care.

Age and Referral Route Impact the Access to Diagnosis for Women with Advanced Ovarian Cancer

Purpose

The majority of women with ovarian cancer are diagnosed in late stages. Most women do have symptoms prior to diagnosis, sometimes several months before the diagnosis. The aim of this study was to evaluate the timeline from the first presentation of symptoms to a physician until there is a reasonable suspicion of cancer, among women diagnosed with advanced stage ovarian cancer. We wanted to investigate which symptoms were the most common and whether there are other factors affecting the time interval before the suspicion of cancer was confirmed.

Patients and Methods

This was a retrospective population-based cohort study of women diagnosed with advanced ovarian cancer between January 1, 2017 and December 31, 2019 who were referred to Skane University Hospital Lund, Sweden. Data were collected from electronic medical records at Skane University Hospital. The time interval was recorded as the time from first physician consultation with predefined symptoms to the date when there was a reasonable suspicion of ovarian cancer. Data processing and statistical analysis were performed with the statistical software R.

Results

Among the 249 patients included in this study, the median time interval from the first consultation to the reasonable suspicion of cancer was 24 days. The first consultation in specialized care had a 70% decrease in delay compared to primary care. Emergency consultations had a 52.2% decrease in time delay compared to planned consultations. Older age was associated with an increase in the geometric mean by 54.7%, comparing the first to the third quartile. The most common symptom was abdominal pain.

Conclusion

The length of time interval from first presentation with symptoms relating to ovarian cancer to reasonable suspicion of cancer was associated with whether the consultation was in primary or specialized care, emergency or planned visit and the patient's age.

Ovarian tumor frozen section, a multidisciplinary affair

BACKGROUND

Ovarian Cancer (OC) constitute the eighth most common cancers among women worldwide. Surgery remains the cornerstone in the management of OC. Intraoperative frozen section (FS) diagnosis is widely used to decide the surgery course. We aimed to assess the reliability of intraoperative FS diagnosis for treatment planning of patients with suspected OC from a multidisciplinary perspective. The clinical consequences of reclassification and the multidisciplinary management of the therapy plan, is the secondary aim of this study. To our knowledge, this information is sparely investigated.

METHODS

A single-center, retrospective population-based study of patients who underwent surgery for suspected OC between 2018 and 2020. Histopathological outcomes were classified as benign, borderline, or malignant. The FS diagnosis was the diagnostic test, and the final histopathology report was the gold standard. Diagnostic capability for treatment planning was assessed, and modifications made possible by overall clinical knowledge were discussed.

RESULTS

A total of 358 patients were identified, of whom 187 were included in the FS group. Overall accuracy was 89.8%, and 19 patients were reclassified; the malignancy grade of 15 tumors was underestimated. Prevalence, sensitivity, specificity, positive predictive value, and negative predictive value for invasive malignancies on FS were 54.0% (CI 46.6-61.3%), 88.1% (CI 80.2-93.7%), 98.8% (CI 93.7-99.9%), 98.9% (CI 92.7-99.8%), and 87.6% (CI 80.6-92.4%), respectively. Tumors incorrectly graded by FS tended to be of borderline-related.

CONCLUSIONS

The reliability of the FS methodology was an accurate test to help perform appropriate surgery and plan swift oncological treatment. FS is a reliable method to diagnose invasive malignancies and benign pathology. The communication between the pathologist, surgeon, and medical oncologist is highly important for both intraoperative decision-making and postoperative patient care.

MET Expression and Cancer Stem Cell Networks Impact Outcome in High-Grade Serous Ovarian Cancer

Overexpression of the receptor tyrosine kinase MET has been linked to poor survival in several cancer types, and MET has been suggested to interact with stem cell networks. In vitro studies have further suggested a possible benefit of a combined treatment using PARP and MET inhibitors. We used a tissue microarray (TMA) with 130 samples of advanced-stage high-grade serous fallopian tube/ovarian cancer (HGSC) to investigate the prognostic value of MET protein expression alone and in combination with the stem cell factor SOX2. The possible synergistic effects of a PARP and MET inhibitor treatment were evaluated in two cell lines with BRCA1 or BRCA2 deficiency and in their BRCA1/2-proficient counterparts. Patients with tumors positive for MET had worse overall survival (log-rank test, p = 0.015) compared to patients with MET-negative tumors. The prognostic role of MET was even more prominent in the subgroup of patients with SOX2-negative tumors (p = 0.0081). No synergistic effects of the combined treatment with PARP and MET inhibitors were found in the cell lines examined. We conclude that MET expression could be used as a marker for OS in HGSC and that stemness should be taken into consideration when evaluating the mechanisms of this effect.

SOX2 is a promising predictor of relapse and death in advanced stage high-grade serous ovarian cancer patients with residual disease after debulking surgery

The transcription factor SOX2 is a well-established and important stem cell marker. Its role in cancer biology remains unclear, but it has been proposed to also be a marker of cancer stem cells. We investigated the role of SOX2 protein expression in women with high-grade serous ovarian cancer (HGSOC) to determine its potential prognostic and treatment predictive value. We constructed a tissue microarray of 130 advanced stage HGSOC tumors with an average of 6 cores each, stained for SOX2 protein expression and evaluated survival outcomes. We also treated two HGSOC cell lines with carboplatin and paclitaxel and measured SOX2 expression by RT-PCR and immunoblotting at different doses and time-points. Among patients with non-radical debulking surgery overall and progression-free survival were shorter for patients with SOX2 positive tumors (mean 26 vs. 39 months, log-rank test: p = .0076, and mean 14 vs. 19 months, p = .055, respectively). Knockdown of SOX2 in cell lines did not affect growth inhibition following chemotherapy treatment. Our results show that SOX2 has a strong prognostic potential among HGSOC patients with residual tumor tissue after debulking surgery and suggest that SOX2 expressing cells remaining after non-radical debulking surgery may constitute a subpopulation of cancer stem cells with greater tumor-initiating potential.

Ovarian cancer subtypes and survival in relation to three comprehensive imaging parameters

Background

Ovarian cancer (OC) is usually detected in late clinical stages, and imaging at diagnosis is crucial. Peritoneal carcinomatosis (PC) and cardio phrenic lymph nodes (CPLN) are pathological findings of computed tomography (CT) and are relevant for surgical planning. Furthermore, mammographic breast density (BD) has shown an association with OC risk and might be prognostically relevant. However, it is not known if PC, CPLN, and BD are associated with aggressive OC subtypes and impaired OC survival. Herein, we investigated associations between three comprehensive image parameters and OC subtypes and survival.

Methods

The Malmö Diet and Cancer Study is a prospective study that included 17,035 women (1991–1996). Tumor information on 159 OC and information on OC specific survival (last follow-up, 2017-12-31) was registered. The CT and mammography closest to diagnosis were evaluated (Peritoneal Carcinomatosis Index PCI, CPLN, and BD). Associations between CT-PCI, CPLN, and BD vs. clinical stage [stage I vs. advanced stage (II-IV), histological type/grade (high grade serous and endometrioid vs. other subtypes], and OC-specific survival were analyzed by logistic and Cox regression.

Results

There was a significant association between higher CT-PCI score and advanced clinical stage (adjusted OR 1.26 (1.07–1.49)), adjusted for age at diagnosis and histological type/grade. Increasing CT-PCI was significantly associated with impaired OC specific survival (adjusted HR 1.04 (1.01–1.07)), adjusted for age at diagnosis, histological type/grade, and clinical stage. There was no significant association between PCI and histological type/grade, nor between BD or CPLN vs. the studied outcomes.

Conclusions

Image PCI score was significantly associated with advanced clinical stages and impaired OC survival. An objective approach (based on imaging) to scoring peritoneal carcinomatosis in ovarian cancer could help surgeons and oncologists to optimize surgical planning, treatment, and care.

PD-1/PD-L1 expression and tumor-infiltrating lymphocytes are prognostically favorable in advanced high-grade serous ovarian carcinoma

The response rate to checkpoint inhibitors for women with high-grade serous carcinoma of the ovary, fallopian tube, and peritoneum (HGSC) is modest, and development of predictive biomarkers is needed. The main focus has been on tumor cell PD-L1 expression, but its assessment alone is insufficient for patient selection in most malignancies. We mapped the presence of macrophages (CD68 and CD163) and lymphocytes (CD3) located within the tumor epithelium, the cell type–specific expression of PD-L1 and PD-1, and their impact on 5-year overall survival (OS) in a consecutive cohort of 130 women diagnosed with advanced HGSC between 2011 and 2015. PD-L1 was expressed mainly by macrophages (not by tumor cells) and PD-1 by lymphocytes. Women with higher CD3, PD-L1, and PD-1 expression had improved OS (P = 0.03, P = 0.007, and P = 0.02, respectively). In the external data set (203 women), high expression of CD274 (encoding PD-L1) was associated with improved OS (P = 0.03), in accordance with our results. Furthermore, higher CD163 expression was associated with better outcome in women with no residual tumor after primary surgery (P = 0.02). Thus, women with greater lymphocyte tumor infiltration had better outcome and PD-L1/PD-1 expression, regardless of PD-1/PD-L1 being markers for immune suppressive pathways, conferred a survival benefit in our cohort. Our results highlight that tumor immunity may be harnessed in subsets of HGSC.

Albumin infusion rate and plasma volume expansion: a randomized clinical trial in postoperative patients after major surgery

Background

Optimal infusion rate of colloids in patients with suspected hypovolemia is unknown, and the primary objective of the present study was to test if plasma volume expansion by 5% albumin is greater if fluid is administered slowly rather than rapidly.

Methods

Patients with signs of hypoperfusion after major abdominal surgery were randomized to intravenous infusion of 5% albumin at a dose of 10 ml/kg (ideal body weight) either rapidly (30 min) or slowly (180 min). Plasma volume was measured using radiolabeled albumin at baseline, at 30 min, and at 180 min after the start of infusion. Primary outcome was change in plasma volume from the start of infusion to 180 min after the start of infusion. Secondary outcomes included the change in the area under the plasma volume curve and transcapillary escape rate (TER) for albumin from 180 to 240 min after the start of albumin infusion.

Results

A total of 33 and 31 patients were included in the analysis in the slow and rapid groups, respectively. The change in plasma volume from the start of infusion to 180 min did not differ between the slow and rapid infusion groups (7.4 ± 2.6 vs. 6.5 ± 4.1 ml/kg; absolute difference, 0.9 ml/kg [95%CI, − 0.8 to 2.6], P = 0.301). Change in the area under the plasma volume curve was smaller in the slow than in the rapid infusion group and was 866 ± 341 and 1226 ± 419 min ml/kg, respectively, P < 0.001. TER for albumin did not differ and was 5.3 ± 3.1%/h and 5.4 ± 3%/h in the slow and in the rapid infusion groups, respectively, P = 0.931.

Conclusions

This study does not support our hypothesis that a slow infusion of colloid results in a greater plasma volume expansion than a rapid infusion. Instead, our result of a smaller change in the area under the plasma volume curve indicates that a slow infusion results in a less efficient plasma volume expansion, but further studies are required to confirm this finding. A rapid infusion has no effect on vascular leak as measured after completion of the infusion.

Trial registration

EudraCT2013-004446-42 registered December 23, 2014.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2477-7) contains supplementary material, which is available to authorized users.

Antibodies to Costimulatory Receptor 4-1BB Enhance Anti-tumor Immunity via T Regulatory Cell Depletion and Promotion of CD8 T Cell Effector Function

The costimulatory receptor 4-1BB is expressed on activated immune cells, including activated T cells. Antibodies targeting 4-1BB enhance the proliferation and survival of antigen-stimulated T cells in vitro and promote CD8 T cell-dependent anti-tumor immunity in pre-clinical cancer models. We found that T regulatory (Treg) cells infiltrating human or murine tumors expressed high amounts of 4-1BB. Intra-tumoral Treg cells were preferentially depleted by anti-4-1BB mAbs in vivo. Anti-4-1BB mAbs also promoted effector T cell agonism to promote tumor rejection. These distinct mechanisms were competitive and dependent on antibody isotype and FcγR availability. Administration of anti-4-1BB IgG2a, which preferentially depletes Treg cells, followed by either agonistic anti-4-1BB IgG1 or anti-PD-1 mAb augmented anti-tumor responses in multiple solid tumor models. An antibody engineered to optimize both FcγR-dependent Treg cell depleting capacity and FcγR-independent agonism delivered enhanced anti-tumor therapy. These insights into the effector mechanisms of anti-4-1BB mAbs lay the groundwork for translation into the clinic.

Identification of 12 new susceptibility loci for different histotypes of epithelial ovarian cancer

To identify common alleles associated with different histotypes of epithelial ovarian cancer (EOC), we pooled data from multiple genome-wide genotyping projects totaling 25,509 EOC cases and 40,941 controls. We identified nine new susceptibility loci for different EOC histotypes: six for serous EOC histotypes (3q28, 4q32.3, 8q21.11, 10q24.33, 18q11.2 and 22q12.1), two for mucinous EOC (3q22.3 and 9q31.1) and one for endometrioid EOC (5q12.3). We then performed meta-analysis on the results for high-grade serous ovarian cancer with the results from analysis of 31,448 BRCA1 and BRCA2 mutation carriers, including 3,887 mutation carriers with EOC. This identified three additional susceptibility loci at 2q13, 8q24.1 and 12q24.31. Integrated analyses of genes and regulatory biofeatures at each locus predicted candidate susceptibility genes, including OBFC1, a new candidate susceptibility gene for low-grade and borderline serous EOC.

The importance of albumin infusion rate for plasma volume expansion following major abdominal surgery - AIR: study protocol for a randomised controlled trial

BACKGROUND

Administration of fluids to restore normovolaemia is one of the most common therapeutic interventions performed peri-operatively and in the critically ill, but no study has evaluated the importance of infusion rate for the plasma volume-expanding effect of a resuscitation fluid. The present study is designed to test the hypothesis that a slow infusion of resuscitation fluid results in better plasma volume expansion than a rapid infusion.

METHODS/DESIGN

The study is a single-centre, assessor-blinded, parallel-group, randomised prospective study. Patients over 40 years of age admitted to the post-operative care unit after a Whipple procedure or major gynaecological surgery and presenting with signs of hypovolaemia are eligible for inclusion. Patients are randomised in a 1:1 fashion with no stratification to either rapid (30 minutes) or slow (180 minutes) infusion of 5% albumin at a dose of 10 ml/kg ideal body weight. Plasma volume is measured using 125I human serum albumin at baseline (prior to albumin infusion) as well as at 30 minutes and 180 minutes after infusion start. The primary endpoint is change in plasma volume from baseline to 180 minutes after the start of 5% albumin infusion. Secondary endpoints include the integral of plasma volume over time from baseline to 180 minutes after the start of the infusion and transcapillary escape rate of albumin (%/h) from 180 minutes to 240 minutes after the start of albumin infusion. In addition, diuresis, change in central venous oxygen saturation, lactate and blood pressure will be evaluated. A total of 70 patients will be included in the study, and the study has 80% power to detect a difference of 4 ml/kg in plasma volume expansion between the two groups.

DISCUSSION

The present study is the first clinical investigation of the importance of infusion rate for the plasma volume-expanding effect of a resuscitation fluid.

TRIAL REGISTRATION

EudraCT identifier: 2013-004446-42 . Registration date: 20 December 2013. ClinicalTrials.gov identifier: NCT02728921 . Registration date: 31 March 2016.

Abstract 3348: Expression of putative cancer stem cell markers in fallopian tube epithelium from women at increased risk of developing high-grade serous ovarian cancer

Pre-neoplastic p53 signature containing lesions, termed serous tubal intraepithelial carcinomas (STICs), have been identified in the fimbriae of women predisposed to ovarian cancer and in patients with sporadic high grade serous ovarian cancer (HGSOC). These findings instigated the theory that HGSOC originates from fallopian tube epithelium (FTE) and not from ovarian surface epithelium (OSE), and has now become an accepted paradigm for HGSOC genesis. However, only few studies have investigated the stem cell niche in the human fallopian tube. Instead, most research on ovarian cancer stem cells has focused on cells isolated from primary ovarian tumors or cell lines.

In this study we performed immunohistochemistry to explore the presence of putative ovarian cancer stem cells in fallopian tubes from women who had undergone a risk reducing salpingo-oophorectomy (RRSO) due to a germline BRCA1/2 mutation and/or strong family history. Sections of frozen tissue from 14 RRSO patients (10 BRCA1/2 mutation carriers, 4 tested negative for BRCA1/2 mutations) were used in immunohistochemistry for p53 and the proposed cancer stem cell markers ALDH1, CD44, CD117, CD133, LGR5 and SOX2.

Presence of a p53 signature (&gt;12 consecutive cell nuclei in normal appearing FTE) was observed in 1 of 10 BRCA1/2 mutation carriers and none of the non-carriers. ALDH1 and CD44 positive staining of varying intensity was found in both FTE cells and stromal cells within the fallopian tube mucosa in all cases. On the other hand, no CD117 positive epithelial cells were observed in any of the samples, though strongly stained CD117+ mast cells were present in all sections. Most FTE cells were weakly positive for CD133 in all sections, while only one case showed positive LGR5 staining of FTE cells. Finally, SOX2 positive FTE cells were found in all samples. In most cases, the fimbriated end of the fallopian tube harbored more SOX2 positive cells than the more proximal end.

This is an initial attempt at visualizing proposed ovarian cancer stem cells in the fallopian tubes of women predisposed to developing HGSOC. Further research is needed to validate the significance of these findings, including investigating additional markers, testing different antibodies and performing multiple labeling experiments. Based on the currently prevailing theory that HGSOC originates from STICs in the fimbriated end of the fallopian tube, we find SOX2 to be the most promising candidate for further investigations, since SOX2 was the only marker found to be differentially expressed throughout the fallopian tube. Elucidating the cell of origin and etiology of HGSOC has important implications for early detection and preventive therapeutic approaches.

Citation Format: Anna Ebbesson, Susanne Malander, Päivi Kannisto, Anita Ringberg, Anna Måsbäck, Ingrid A. Hedenfalk. Expression of putative cancer stem cell markers in fallopian tube epithelium from women at increased risk of developing high-grade serous ovarian cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3348.

[Cervical cancer is a clinical challenge]

Cervical cancer is the third most common female cancer world wide. In Sweden, some 450 cases are diagnosed annually. One out of three affected Swedish women is under the age of 40. Survival for all stages is 73 % in Sweden. Human papilloma virus (HPV) can be detected in the majority of all cervical cancers. Treatment consists of surgery for early stages, and a combination of chemoradiation and brachytherapy for locally advanced disease. For metastatic disease, the treatment is palliative. Late side effects after treatment may have serious impact on the quality of life. There is a strong need for more efficient treatment of metastatic disease. Current lines of research include surgical strategies, optimised radiotherapy, neoadjuvant therapy, targeted therapy, and immunotherapy including therapeutic vaccines.

Molecular subtyping of serous ovarian tumors reveals multiple connections to intrinsic breast cancer subtypes

OBJECTIVE

Transcriptional profiling of epithelial ovarian cancer has revealed molecular subtypes correlating to biological and clinical features. We aimed to determine gene expression differences between malignant, benign and borderline serous ovarian tumors, and investigate similarities with the well-established intrinsic molecular subtypes of breast cancer.

METHODS

Global gene expression profiling using Illumina's HT12 Bead Arrays was applied to 59 fresh-frozen serous ovarian malignant, benign and borderline tumors. Nearest centroid classification was performed applying previously published gene profiles for the ovarian and breast cancer subtypes. Correlations to gene expression modules representing key biological breast cancer features were also sought. Validation was performed using an independent, publicly available dataset.

RESULTS

5,944 genes were significantly differentially expressed between benign and malignant serous ovarian tumors, with cell cycle processes enriched in the malignant subgroup. Borderline tumors were split between the two clusters. Significant correlations between the malignant serous tumors and the highly aggressive ovarian cancer signatures, and the basal-like breast cancer subtype were found. The benign and borderline serous tumors together were significantly correlated to the normal-like breast cancer subtype and the ovarian cancer signature derived from borderline tumors. The borderline tumors in the study dataset, in addition, also correlated significantly to the luminal A breast cancer subtype. These findings remained when analyzed in an independent dataset, supporting links between the molecular subtypes of ovarian cancer and breast cancer beyond those recently acknowledged.

CONCLUSIONS

These data link the transcriptional profiles of serous ovarian cancer to the intrinsic molecular subtypes of breast cancer, in line with the shared clinical and molecular features between high-grade serous ovarian cancer and basal-like breast cancer, and suggest that biomarkers and targeted therapies may overlap between these tumor subsets. The link between benign and borderline ovarian cancer and luminal breast cancer may indicate endocrine responsiveness in a subset of ovarian cancers.

Elderly women above screening age diagnosed with cervical cancer have a worse prognosis

AIM

To analyze the cervical screening history in women with cervical cancer and their outcome.

DESIGN

All women diagnosed with cervical cancer between January 2009 and December 2010 in the South Sweden region were included in the audit.

MATERIALS AND METHODS

Cervical cancer was registered in 165 women in 2009 and 2010. Their screening history was analyzed, and was classified as normal or imperfect. The method of discovering the cancer was either by symptoms or by screening. The main outcome measured was overall survival in cervical cancer related to cervical screening history.

RESULTS

Women above 65 years of age were more frequently diagnosed with advanced-stage disease (The International Federation of Gynecology and Obstetrics II-IV) (n=36 out of 43; 84%) compared to women below 65 years of age (n=35 out of 122; 29%) (p<0.001). All patients diagnosed by the cervical screening program were still alive (30/30) at the median follow-up time (36 months), showing better overall survival compared to women below screening age in whom cancer was discovered due to symptoms (68/98; p<0.001). Cox proportional hazards model showed that women beyond screening age (>65 years old) with normal screening history had a worse prognosis, with a hazard ratio of 4.8 (95% confidence interval=1.9-12.1, p=0.001), and women (>65 years old) who had not followed the screening program had a hazard ratio of 5.9 (95% confidence interval I 2.4-14.6, p<0.001), compared to women under 65 years old who had followed the screening program.

CONCLUSION

Cervical cancer in women above the age of 65 years is discovered at advanced stages of the disease and their prognosis is poor.

Simulated life-threatening emergency during robot-assisted surgery

BACKGROUND

With the increasing use of robot-assisted techniques for urologic and gynecologic surgery in patients with severe comorbidities, the risk of a critical incidence during surgery increases. Due to limited access to the patient the start of effective measures to treat a life-threatening emergency could be delayed. Therefore, we tested the management of an acute emergency in an operating room setting with a full-size simulator in six complete teams.

METHODS

A full-size simulator (ISTAN, Meti, CA), modified to hold five trocars, was placed in a regular operating room and connected to a robotic system. Six teams (each with three nurses, one anesthesiologist, two urologists or gynecologists) were introduced to the scenario. Subsequently, myocardial fibrillation occurred. Time to first chest compression, removal of the robot, first defibrillation, and stabilization of circulation were obtained. After 7 weeks the simulation was repeated.

RESULTS

The time to the start of chest compressions, removal of the robotic system, and first defibrillation were significantly improved at the second simulation. Time for restoration of stable circulation was improved from 417 ± 125 seconds to 224 ± 37 seconds (P=0.0054). Unexpected delays occurred during the first simulation because trocars had been removed from the patient but not from the robot, thus preventing the robot to be moved.

CONCLUSION

Following proper training, resuscitation can be started within seconds. A repetition of the simulation significantly improved time for all steps of resuscitation. An emergency simulation of a multidisciplinary team in a real operating room setting can be strongly recommended.

Implementation of robot-assisted gynecologic surgery for patients with low and high BMI in a German gynecological cancer center

PURPOSE

To present a single center outcome from an initial series of gynecological robotic cases with a special reference to obese patients.

METHODS

A retrospective evaluation of 116 women, undergoing elective gynecologic robot-assisted surgery from February 2011 to December 2012. Procedures included hysterectomy (HE), radical HE, adnexectomy, myomectomy, pelvic lymphadenectomy and paraaortic lymphadenectomy, sentinel node extraction, and omentectomy. The feasibility and outcome were investigated in relation to normal and high body mass index (BMI < 30 and BMI ≥ 30).

RESULTS

The overall complication rate was low (15/116; 12.9 %). The number of perioperative complications was not different between the patients with normal BMI compared to those with high BMI. Five operations were converted to open surgery due to vascular injury (2), intestinal injury (2) and one insufficiently exposed paraaortic field in an endometrial cancer patient. Urinary bladder was injured once. Late complications included vaginal dehisce (2), vaginal hemorrhage (1), cuff hematoma (4), lymphocyst (1) and two urinary tract injuries. The rate of the late complications was not significantly different in the two groups of patients (p = 0.139). A significant difference in patients' positioning time was observed between normal weighted and obese patients (35 and 55 min, p < 0.001).

CONCLUSION

Robotic procedure was feasible and could be implemented for treating the first setting of mixed indications for gynecologic surgery. Robotic surgery may offer particular advantages in obese patients with no conversions and no wound complications.

Gray-scale and color Doppler ultrasound characteristics of endometrial cancer in relation to stage, grade and tumor size

OBJECTIVES

To describe the gray-scale and vascular characteristics of endometrial cancer in relation to stage, grade and size using two-dimensional (2D)/three-dimensional (3D) transvaginal ultrasound.

METHODS

This was a prospective multicenter study including 144 women with endometrial cancer undergoing transvaginal ultrasound before surgery. The sonographic characteristics assessed were echogenicity, endometrial/myometrial border, fibroids, vascular pattern, color score and tumor/uterus anteroposterior (AP) ratio. Histological assessment of tumor stage, grade, type and growth pattern was performed.

RESULTS

Hyperechoic or isoechoic tumors were more often seen in Stage IA cancer, whereas mixed or hypoechoic tumors were more often found in cancers of Stage IB or greater (P = 0.003). Hyperechogenicity was more common in Grade 1-2 tumors (i.e. well or moderately differentiated) (P = 0.02) and in tumors with a tumor/uterine AP ratio of < 50% (P = 0.002), whereas a non-hyperechoic appearance was more commonly found in Grade 3 tumors (i.e. poorly differentiated) and in tumors with a tumor/uterine AP ratio of ≥ 50%. Multiple global vessels were more often seen in tumors of Stage IB or greater than in Stage IA tumors (P = 0.02), in Grade 3 tumors than in Grade 1 and 2 tumors (P = 0.02) and in tumors with a tumor/uterine AP ratio of ≥ 50% (P < 0.001). A moderate/high color score was significantly more common in tumors of higher stage (P = 0.03) and larger size (P = 0.001).

CONCLUSION

The sonographic appearance of endometrial cancer is significantly associated with tumor stage, grade and size. More advanced tumors often have a mixed/hypoechoic echogenicity, a higher color score and multiple globally entering vessels, whereas less advanced tumors are more often hyperechoic and have no or a low color score.

Sonographic characteristics of squamous cell cancer and adenocarcinoma of the uterine cervix

OBJECTIVE

The objective of this study was to describe the sonographic characteristics of squamous cell cancer (SCC) and adenocarcinoma (AC) of the cervix using transvaginal ultrasound.

METHODS

Women with early stage cervical cancer undergoing transvaginal ultrasound examination before surgery were prospectively included. The sonographic characteristics were assessed with regard to tumor morphology, vascularization, size, extension and location. Histological assessment of tumor subtype, size, growth pattern, extension and location was performed. Both sonographic and histological assessments were carried out according to a standardized protocol.

RESULTS

Fifty-five women were recruited. Ten were excluded because no tumor was seen on ultrasound examination and five were excluded because radical surgery was aborted as a result of positive lymph nodes, detected using the sentinel node technique. Among the remaining 40 women, 20 had AC and 20 had SCC. At pathological examination, 34 women had tumors confined to the cervix, three had parametrial invasion and three had vaginal invasion. Hypoechogenicity was associated with SCC in 73% (11/15) of the women, while isoechogenicity indicated AC in 68% (13/19) of the women (P = 0.03). Mixed echogenicity (n = 4) showed a non-significant association with larger tumor volume (P = 0.23). Hyperechogenicity was found in two women, both of whom had the less malignant villoglandular AC. Color Doppler signals were found in all cases of AC and in 90% (18/20) of cases of SCC, compared with most normal cervical tissue in which virtually no detectable vascularization was found.

CONCLUSION

We found that the sonographic appearance of SCC and AC differs. This knowledge should be useful in the clinical evaluation of cervical tumors.

The sentinel node concept in early cervical cancer performs well in tumors smaller than 2 cm

OBJECTIVE

The aim of the study was to evaluate the sentinel node (SLN) concept for lymphatic mapping in early stage cervical cancer.

METHODS

105 women with early stage (1a1-2a) cervical cancer were scheduled for the sentinel node procedure in conjunction with a complete pelvic lymphadenectomy. The day before surgery, 1-1.5 mL 120MBq Tc(99) albumin nanocolloid was injected submucosally at four points around the tumor followed by a lymphoscintigram (LSG) to achieve an overview of the radiotracer uptake.

RESULTS

During surgery, the overall detection rate (gamma probe) of at least one SLN was 90% (94/105 women) whereas at least one SLN was identified in 94% (61/65 women) with a tumor <or=2 cm. Bilateral SLNs were identified in 62/105 (59%) of the women. Among 18 women with any metastatic lymph node 17 had a metastatic SLN (sensitivity 94%, 95% CI 73-100%). Among 61 women with a tumor <or=2 cm, all five women with any metastatic lymph node also had a metastatic SLN (sensitivity 100%). One woman with a 1.5-cm squamous epithelial carcinoma had metastatic positive SLNs on each side but also one metastatic bulky (>2 cm) node without radiotracer uptake. The negative predictive value for patients with cervical cancers <or=2 cm was 100%.

CONCLUSIONS

The SLN-technique seems to be an accurate method for identifying lymph node metastases in cervical cancer patients with tumors of 2 cm or smaller. In case of a unilateral SLN only, a complete lymphadenectomy should be performed on the radionegative side. All bulky nodes must be removed.

Combretastatin A-1 phosphate potentiates the antitumor activity of carboplatin and paclitaxel in a severe combined immunodeficiency disease (SCID) mouse model of human ovarian carcinoma

In search for new therapeutic modalities to target epithelial ovarian carcinomas, we investigated the effect of the antiangiogenic drug combretastatin A-1 phosphate (CA1P) as a single treatment or in combination with established therapy, ie, carboplatin and paclitaxel. Five different human epithelial ovarian carcinoma cell lines were inoculated subcutaneously into FOX CHASE CB-77 severe combined immunodeficiency disease (SCID) mice. When tumors reached a volume of approximately 100 mm(3), the treatment was initiated. All drugs were given intraperitoneally at weekly doses. CA1P was more effective as an antitumor agent than combretastatin A-4 phosphate as a single-drug treatment or in combination with carboplatin and paclitaxel. CA1P had a strong tumor outgrowth inhibiting effect on four out of five tumors included in this study. Comparing animals receiving CA1P with animals receiving a combination of carboplatin and paclitaxel, CA1P was more effective on two out of three tested tumors, whereas carboplatin and paclitaxel were more effective on one out of three of the tumors. We show that treatment of human ovarian carcinomas with CA1P in the SCID mouse model results in a strong antitumor effect both as a single-drug treatment and as an enhancement of the therapeutic effect in a combination treatment protocol with carboplatin and paclitaxel.

Effects of vasoactive intestinal polypeptide (VIP) on the neuromuscular complex in the bovine ovarian follicle wall

1. When stimulating the local nerves in the bovine ovarian follicle wall preparation (4 Hz, 1 ms pulse duration and 7.5 V between the electrodes) vasoactive intestinal polypeptide reduced the neurogenic contraction and at the highest concentration tested (3 x 10(-7) M) almost abolished the response. Peptide histidine isoleucine only slightly reduced the contraction. 2. Strips from the follicle wall of bovine ovaries were incubated in Krebs-Ringer solution containing [3H]-noradrenaline for measurement of transmitter liberation during electrical field stimulation (5 Hz frequency, 1 ms pulse duration, 10 V between the electrodes). Vasoactive intestinal polypeptide had no effect on the electrically induced efflux of radioactivity. 3. Vasoactive intestinal polypeptide and its related peptide, peptide histidine isoleucine, relaxed precontracted follicle strips dose dependently with I(max) at 3 x 10(-7) M of 60% and 40% respectively. 4. Vasoactive intestinal polypeptide 10(-7) M did not alter the EC50 value of the noradrenaline-(10(-9)-10(-4) M) or carbachol-induced (10(-8)-3 x 10(-4) M) contraction in the follicle strips, but significantly reduced the E(max) value of the noradrenaline but not the carbochol-mediated contraction. 5. These results suggests that vasoactive intestinal polypeptide, and to some extent peptide histidine isoleucine, have a postjunctional role in ovarian follicle contractility and might further interfere with the ovulatory process.

The influence of neuropeptide Y and norepinephrine on ovulation in the rat ovary

Neuropeptide Y (NPY) was measured in tissue extracts from ovaries of rats treated with pregnant mare serum gonadotropin (PMSG). The extracted NPY-immunoreactive material was identical to synthetic human NPY with regard to size and hydrophobicity as evaluated by gel filtration and high performance liquid chromatography. The concentration of NPY was related to the estrous cycle and a maximum was observed in relation to the endogenous luteinizing hormone (LH) peak. NPY immunoreactivity was demonstrated by immunohistochemistry to be localized within nerve fibers supplying blood vessels and follicles. The increase in the NPY content could not be related to accumulation around specific ovarian structures. Employing an in vitro set-up, NPY (10(-7) M) was unable to induce ovulation and did not increase the ovulation rate in LH-stimulated ovaries. The combination of NPY (10(-7) M) and NE (10(-7) M) did not significantly increase the number of ovulations compared to that induced by NE (10(-7) M) alone. In conclusion, NPY content in the ovary is related to the estrous cycle, but NPY does not seem to have any direct effect on the ovulatory process.

Vasoactive intestinal polypeptide in the PMSG-primed immature rat ovary and its effect on ovulation in the isolated rat ovary perfused in vitro

The immature rat ovary contains VIP immunoreactive nerve fibres sparsely distributed around blood vessels, in the interstitial gland and around follicles. The VIP concentration, measured radioimmunologically, decreased significantly after PMSG treatment (10 i.u.), probably due to ovarian enlargement and oedema, while the total VIP content (total of 0.12 pmol in both ovaries) did not change after PMSG priming. The ovulatory effect of VIP was studied using in-vitro perfused ovaries from immature 28-day-old rats primed with 10 i.u. PMSG. In all ovaries perfused, VIP (10(-7) M) induced ovulations with a rate of 2.33 +/- 0.56. The ovulation rate was significantly lower than that of ovaries stimulated by LH (0.1 microgram/ml) (5.20 +/- 0.86 ovulations per ovary). No synergistic effect on the ovulation rate was seen when LH and VIP were administered together (5.20 +/- 0.49 ovulations per ovary). The results suggest that the neuropeptide VIP may represent one of the local factors involved in the ovulation process.

Immunocytochemical demonstration of contractile cells in the human ovarian follicle

Actin- and myosin-like immunoreactivity is found in cells located in the theca externa of the follicle wall of the human ovary, and corresponding to previously observed myoid cells. The immunocytochemical observation provides direct structural evidence that non-vascular contractile cells are also present in the follicle wall in humans. As expected, perifollicular blood vessels showed a positive immunoreaction for actin and myosin in their smooth muscle walls.

The neuropeptides vasoactive intestinal polypeptide, peptide histidine isoleucine and neuropeptide Y modulate [3H]noradrenaline release from sympathetic nerves in the choroid plexus

The neurotransmitter peptides vasoactive intestinal polypeptide (VIP), peptide histidine isoleucine (PHI) and neuropeptide Y (NPY) are located in nerve fibers supplying the pig choroid plexus, which receives an abundant sympathetic innervation. We characterized the release of [3H]noradrenaline ([3H]NA) from this tissue elicited by electrical field stimulation and studied the effects of the above-mentioned peptides on this release. The release of [3H]NA was found to be almost exclusively of neurogenic origin, despite there being a marked non-neuronal uptake of [3H]NA into the epithelium of the choroid plexus. NPY significantly decreased the release of [3H]NA by approximately 10% while VIP and PHI enhanced release by up to 25 and 35%, respectively, indicating a possible synergistic role of the two latter peptides and NA in the choroid plexus.

Histaminergic effects on the isolated rat ovarian artery during the estrous cycle

Histamine may play a role in many of the events occurring in the ovarian tissue and leading to ovulation. To elucidate the histaminergic influence on the ovarian vasculature, the mechanical response of the isolated rat ovarian artery to histamine and histamine agonists was investigated. Histamine relaxed the precontracted vessel segments in a concentration-dependent way, amounting to 82.7 +/- 4.3% of the papaverine-induced relaxation. This relaxant effect was counteracted by both the H1 antagonist, pyrilamine, and the H2 antagonist, cimetidine. That the effect of histamine was mediated by both histamine receptor subtypes was further confirmed by the relaxant effect produced in the presence of either of the H1-specific agonists, 2-pyridylethylamine and 2-methylhistamine on the one hand, and the H2-specific agonists, impromidine and 4-methylhistamine on the other. The H1 receptor-induced relaxation was mediated via an effect on the endothelium, whereas the H2 receptor-mediated relaxation was mostly a direct effect on the smooth musculature in the vessel wall. No major differences in the mechanical response of the rat ovarian artery were seen during the different stages of the estrous cycle, although at late proestrus, just before ovulation, the maximum relaxation induced by histamine was particularly high, in spite of a low sensitivity of the receptors for the amine.

Prejunctional alpha 2-adrenoreceptors modulate the stimulated release of noradrenaline in isolated follicle strips from bovine ovaries

1. Strips from the follicle wall of bovine ovaries were incubated in Krebs-Ringer solution containing 3H-noradrenaline for measurement of transmitter liberation during electrical field stimulation (5 Hz frequency, 1 ms pulse duration, 10 V between the electrodes). The effects of noradrenaline as well as selective alpha-adrenoreceptor agonists and antagonists were studied on the electrically induced efflux of radioactivity. 2. Noradrenaline (1 microM) inhibited the stimulated release of radioactivity. The alpha 2-adrenoreceptor agonist, oxymetazoline, significantly reduced the release of radioactivity in concentrations as low as 0.01 microM. The alpha 1-adrenoreceptor agonist, phenylephrine (0.01-1 microM), was without significant effect. 3. Phentolamine (0.01-1 microM) and the selective alpha 2-adrenoreceptor antagonist, idazoxan (0.01-1 microM) significantly enhanced the electrically evoked release. The alpha 1-adrenoreceptor antagonist, prazosin (0.01-1 microM), was without effect. Idazoxan (0.1 microM) reversed the inhibitory effect of oxymetazoline (0.1 microM). 4. It is concluded that administration of noradrenaline or the alpha 2-adrenoreceptor agonists reduces the release of labelled noradrenaline by acting on prejunctional alpha 2-adrenoreceptors in the noradrenergic nerves distributed in the wall of the bovine ovarian follicle. This is one of several prejunctional receptor mechanisms that modulate the activity of the sympathetic nerves innervating the smooth musculature of the follicle wall.

Serotonin uptake into cerebrovascular nerve fibers of rat, visualization by immunohistochemistry, disappearance following sympathectomy, and release during electrical stimulation

Immunohistochemistry as well as in vitro uptake and release of [3H]5-HT were performed on pial arteries of rat to investigate the nature of 5-HT containing nerve fibers. Immunoreactive fibers were constantly found only in the basilar, vertebral and superior cerebellar arteries, while in the other parts of the circle of Willis, 5-HT immunofluorescent fibers were absent. After systemic treatment with tryptophan following inhibition of monoamine oxidase with nialamide the immunofluorescence intensity was markedly enhanced. The 5-HT immunoreactive fibers disappeared after superior cervical ganglionectomy or intraventricular administration of 6-hydroxydopamine, but persisted after administration of 5,6-dihydroxytryptamine. When isolated vessels were incubated in low concentration of 5-HT (1 nM) together with nialamide, a very dense plexus of 5-HT immunoreactive fibers appeared in all branches of the circle of Willis. Uptake and release experiments were carried out by incubation of arterial preparations with 3 nM [3H]5-HT (together with nialamide), followed by electrical field stimulation, or by exposure to tyramine or 124 mM potassium, all of which induced a 100%-350% increase in the tritium release over prestimulation values. Preincubation with cocaine and bilateral superior cervical ganglionectomy abolished or markedly attenuated the release upon all modes of stimulation. The results suggested that the 5-HT observed by immunohistochemistry in pial arteries is located in sympathetic nerve terminals where it may serve as a neuromodulator that is released during nerve activation.

A heterogeneous population of alpha 1-adrenoceptors mediates contraction of the isolated follicle wall from the bovine ovary

Strips from Graafian follicles of bovine ovaries were tested for their contractile response in vitro in order to characterize the type of post-junctional alpha-adrenoceptor involved. Electrically induced contractions were inhibited concentration-dependently by the alpha 1-antagonist, prazosin. Besides noradrenaline the alpha 1-selective agonists, methoxamine and phenylephrine, caused the strips to contract, whereas the alpha 2-selective agonists clonidine, oxymetazoline and B-HT920 were without effect. However, the alpha 1-selective antagonist prazosin gave a line with a slope less than unity in the Schild plots with noradrenaline and methoxamine. From results obtained with or without the presence of two classes of neuronal uptake blockers (desipramine and cocaine) it is concluded that the post-junctional alpha 1-receptor population is inhomogeneous. The regular appearance of the Schild plot obtained with phenylephrine may be due to involvement also of a component of noradrenaline release by this agonist. The pA2 value in the test with phenylephrine was 9.27, with a corresponding kB of 3.81 +/- 1.15 X 10(-10) M.

Is serotonin involved in the ovulatory process of the rat ovary perfused in vitro?

The presence of 5-HT (serotonin) in ovarian tissue and its varying concentrations during the oestrous cycle suggests that it takes part in ovarian function and in the ovulatory process as one of several mediators of the inflammatory-type reaction preceding follicular rupture. With the aid of a recirculating perfusion model, in which the central stimulatory action of 5-HT was avoided, its direct ovarian effect on ovulation was studied using immature, pregnant, mare serum gonadotrophin (PMSG)-treated rats. Four out of five ovaries ovulated after the addition of 5-HT to the perfusion medium, though the ovulation rate (0.8 per ovary) did not reach the order of magnitude seen after luteinizing hormone (LH) stimulation (5.4 per ovary). The selective 5-HT2 receptor antagonist, ketanserin, did not significantly reduce the 5-HT induced ovulations, and moreover, reduced the LH-stimulated ovulations. The calcium entry blocker, nifedipine, had no effect on either 5-HT or LH induction ovulations.

Extracellular and intracellular calcium sources mediating contractile responses of smooth muscle in bovine ovarian follicle and ovarian artery

The relative importance of extracellular and intracellular calcium sources mediating smooth muscle contraction in ovarian follicle and ovarian artery was assessed in experiments on the influence of nifedipine, D-600, amrinone, diethylstilbestrol (DES), lanthanum and/or calcium removal on contractions induced by K+ depolarization, by noradrenaline, histamine and acetylcholine. The K+-induced response was biphasic in the ovarian artery but not in the ovarian follicle. The K+-induced contraction in both preparations was greatly inhibited by nifedipine (1 microM), D-600 (10 microM) and lanthanum (2 mM). Although both phases of the responses in the ovarian artery appeared to be completely dependent on extracellular calcium, phase I was significantly more sensitive to nifedipine than phase II. Incubation in calcium-free medium for 15 min almost abolished the K+-induced contraction. Noradrenaline- and histamine-induced contractions of ovarian follicle were essentially unaffected by nifedipine (1 microM) and D-600 (10 microM) whereas the noradrenaline-induced contraction in ovarian artery was inhibited significantly by D-600 (1 and 10 microM) but not nifedipine (1 microM). In calcium-free medium containing EGTA (1 mM) the responses of ovarian follicle to noradrenaline and histamine were reduced by 26 and 22% respectively. When preparations were stimulated with noradrenaline more than one in calcium-free medium, the contraction decreased progressively compared to time-matched controls. The response was 34% of the control after 50 min in calcium-free medium containing EGTA. In the ovarian artery the response obtained (6% of control) was significantly smaller (P less than 0.05) than that in the follicle.(ABSTRACT TRUNCATED AT 250 WORDS)

GABA suppresses stimulation-induced release of [3H]-noradrenaline from sympathetic nerve fibres in bovine ovarian follicles

1 Strips from the bovine ovarian follicle wall were incubated in Krebs-Ringer solution containing [3H]-noradrenaline in order to saturate sympathetic nerve fibres with radiolabelled transmitter. This allowed the study of field stimulation-evoked transmitter release. 80.3 +/- 3.9% of the tritium released upon stimulation (10 Hz, pulse duration 1 ms, 10 V between the electrodes) was noradrenaline. 2 The stimulated release of tritium was totally blocked in calcium-free, EGTA (1 mM) containing medium or by 1 microM tetrodotoxin. Chemical sympathectomy (6-hydroxydopamine treatment) in vitro reduced the tritium content of the strip by 85%. The neuronal amine uptake blocker desipramine (0.6 microM) was almost equally effective in inhibiting the incorporation of tritium. The extraneuronal amine uptake blocker normetanephrine (10 microM) reduced the tritium content by 30%. Together, the results suggest that the electrically evoked release of tritium reflects the release of [3H]-noradrenaline from sympathetic nerve fibres. 3 gamma-Aminobutyric acid (GABA) concentration-dependently reduced the electrically evoked tritium release. Also the GABAB-receptor agonist baclofen (30 microM) reduced the stimulated tritium release whereas muscimol (100 microM), a GABAA-receptor agonist, failed to affect the release. 4 The selective GABAA-receptor antagonist bicuculline (3 and 100 microM) did not block the effect of GABA, while 3-amino-1-propanesulphonic acid (3-APA), a blocker of GABAB-receptors reversed the inhibitory effect of GABA. The results suggest that neuronal GABAB-receptors are involved in the GABA-evoked suppression of stimulated noradrenaline release.

Characterization of presynaptic 5-HT receptors on adrenergic nerves supplying the bovine ovarian follicle

1. The effects of 5-hydroxytryptamine (5-HT) on contraction and release of [3H]-noradrenaline were investigated in vitro in bovine ovarian follicle strips. Using available selective agonists and antagonists, an effort was made to characterize the type of receptor mediating the inhibitory effect of 5-HT on neurogenic contraction and release of [3H]-noradrenaline by electrical field stimulation. 2. 5-Hydroxytryptamine inhibited the neurogenic contraction and release of [3H]-noradrenaline evoked by electrical field stimulation in a concentration-dependent manner. Like 5-HT, 5-carboxamidotryptamine (5-CT) and methysergide reduced the transmitter release as well as the neurogenic contraction, whereas 8-hydroxy-2-(di-n-propylamino) tetralin (8-OH-DPAT) failed to inhibit both responses in concentrations up to 0.1 microM. 3. The 5-HT (1 microM)-induced inhibition of contractile responses was more evident during stimulation at low frequencies (4 and 8 Hz) than during high frequency electrical stimulation (16 and 32 Hz). 4. Methiothepin (1 microM) and methysergide (10 microM) significantly antagonized the inhibitory effect of 5-HT on the electrically evoked release of tritium, whereas cyanopindolol, MDL 72222 and ketanserin (all 0.1 microM) were without effect. In addition, ketanserin, MDL 72222, cimetidine, pyrilamine, atropine, propranolol and indomethacin were without effect on the 5-HT-induced inhibition of the neurogenic contraction. 5. It is suggested that 5-HT inhibits the electrically evoked transmitter release from adrenergic nerves in the bovine ovarian follicle wall via prejunctional 5-HT1-like receptors. This was based on the findings that 5-CT was a potent agonist, methiothepin an antagonist and the lack of effect of MDL 72222, cyanopindolol and ketanserin.

Characterization of histamine receptors mediating contraction and relaxation of the ovarian follicle wall

Histamine is known to be present in ovarian tissue and may play a role in the ovulation process. The effect of histamine on the follicular smooth musculature was investigated using strips from the protruding part of mature bovine follicles, mounted in vitro for registration of isometric motor activity. Histamine contracted the preparation in a concentration-dependent manner. The response was inhibited competitively by the specific H1 receptor antagonist pyrilamine while the adrenergic alpha-receptor antagonist phentolamine had no clear-cut effect. A Schild plot revealed a pA2 value of 8.81, corresponding to a mean KB value (dissociation constant for receptor-antagonist complex) of (7.5 +/- 3.2) X 10(-9) M. After potassium depolarization and blockade of the contractile H1-receptors with pyrilamine, histamine induced a concentration-dependent relaxation of the follicle wall preparation. This response could be inhibited by the H2-receptor antagonist cimetidine (which also potentiated the contractile effect in the absence of pyrilamine). The pA2 value for the cimetidine-induced inhibition was 6.25, and KB was found to be (6.5 +/- 3.0) X 10(-7) M. The beta-receptor antagonist propranolol was effective only in very high concentrations. It is suggested that a possible role for histamine during follicle rupture is mediated via specific receptors in the follicular smooth musculature.

Histamine stimulates progesterone synthesis and cyclic adenosine 3',5'-monophosphate accumulation in isolated preovulatory rat follicles

The effect of histamine on progesterone synthesis and cyclic adenosine 3',5'-monophosphate (cAMP) accumulation was studied in superfused and incubated follicles dissected free from immature rats treated with pregnant mare serum gonadotrophin (PMSG). Histamine, like LH, increased the progesterone synthesis, but to a smaller extent. The H2-antagonist, cimetidine, inhibited completely the histamine-induced progesterone increase while the H1-antagonist, pyrilamine, as well as propranolol and atropine did not affect the initial response but modified its duration. The specific H2-agonist, 4-methylhistamine, but not the H1-agonist, 2-methylhistamine, mimicked the effect of histamine on progesterone synthesis. In the presence of the phosphodiesterase inhibitor, IBMX, histamine increased tissue levels of cAMP. These results suggest that histamine stimulates progesterone synthesis via the H2-receptor with cAMP acting as secondary intracellular messenger.

Alteration by histamine of the sympathetic nerve-mediated contractions in the bovine ovarian follicle wall in vitro

The histaminergic effect on electrically induced contractions and tritium release was studied in vitro, using strips from the wall of mature bovine ovarian follicles. Follicular fluid and blood plasma from the animals were analysed for electrolyte, bicarbonate, glucose and total protein concentrations in order to compare them with the concentrations of these components in the Krebs-Ringer solution used in the experiments. Electrical field stimulation (EFS) of the follicle strip caused a contraction which was completely blocked by tetrodotoxin and was predominantly of adrenergic origin since phentolamine, in contrast to atropine, blocked the response. The neurogenic response was inhibited by histamine in a concentration-dependent way via the H1-receptor since the H1-antagonist, pyrilamine, counteracted the inhibitory effect of histamine while the H2-antagonist, cimetidine, potentiated the effect. This histaminergic response of EFS-induced contractions could be reproduced in experiments where the H1-agonist, 2-methylhistamine, was inhibitory while the H2-agonist, 4-methylhistamine, had no obvious influence on the twitch response. Histamine reduced the contractile response to exogenous noradrenaline via the H1-receptor, because pyrilamine counteracted, and cimetidine potentiated the effect. The histamine-induced depression of the motor response to EFS and exogenous noradrenaline was probably due to a postjunctional effect mediated by the H1-receptor. Experiments utilizing [3H]noradrenaline release during EFS did not suggest prejunctional effects of histamine. Chemical determinations on follicle fluid and plasma showed that the artificial follicular fluid imitated well the environmental conditions the follicle wall is exposed to in situ.

Evidence for prejunctional GABAB receptors mediating inhibition of ovarian follicle contraction induced by nerve stimulation

The motor effects of gamma-aminobutyric acid (GABA) on the bovine ovarian follicle were studied in vitro using strips from follicle walls. Electrical field stimulation of nerves in the preparation, secured by tetrodotoxin blockade, caused a contraction that was almost totally abolished by phentolamine and only slightly affected by atropine. This mainly adrenergic neurogenic response was inhibited by GABA in a dose-dependent way. The GABAA-receptor antagonists, bicuculline and picrotoxin, did not affect the GABA action whereas the GABAB-receptor antagonist, homotaurine, significantly inhibited the GABA effect. The GABAA-receptor agonist, muscimol, did not affect the contractile response while the GABAB-receptor agonist, baclofen, imitated the action of GABA. On the other hand, GABA had no direct contractile or relaxing effect on the follicle strips nor did it interfere with the contractile response induced by noradrenaline or acetylcholine. The findings suggest that activation of prejunctional GABAB receptors inhibits transmitter release from mainly adrenergic nerves associated with the follicle, thereby affecting nerve-mediated tension in the follicle wall.

Existence and coexistence of peptides in nerves of the mammalian ovary and oviduct demonstrated by immunocytochemistry

The immunocytochemical distribution of substance P (SP), gastrin releasing peptide (GRP), vasoactive intestinal polypeptide (VIP), peptide histidine isoleucine (PHI), and neuropeptide Y (NPY) was studied in the ovary and the Fallopian tube (oviduct) of rats, guinea-pigs, cows, pigs and humans. Generally, the nerve supply was better developed in the oviduct than in the ovary. GRP fibers were most scarce in all tissues. Nerves containing SP were particularly numerous in the oviduct of rat and guinea-pig, supplying the muscular wall and blood vessels. VIP and PHI coexisted in dense plexuses of nerves, not only around blood vessels but also in the follicular wall and the interstitial gland of the ovary, as well as within the smooth muscle layers and subepithelially in the oviduct. The general distribution of NPY was similar, but these immunoreactive nerves were even more numerous. Sequential staining for dopamine-beta-hydroxylase and NPY together with results of chemical sympathectomy with 6-hydroxydopamine suggested that NPY was stored in the noradrenergic sympathetic nerves.

Involvement of local adrenergic receptors in the process of ovulation in gonadotrophin-primed immature rats

Immature female rats were primed with 4 i.u. PMSG at 08:00 h of Day 26. This results in ovulation in the morning of Day 29. The number of ovulations was counted in terms of newly formed corpora lutea in the morning of Day 30. Various adrenergic drugs were delivered into the ovarian bursa bilaterally in the afternoon of Day 27 to study their effect on ovulation. A methyl cellulose gel solution was used as vehicle to minimize leakage from the bursa. Noradrenaline, terbutaline and 4-aminopyridine significantly enhanced the number of corpora lutea compared to control ovaries injected with gel vehicle alone. The effect of terbutaline was counteracted by propranolol. Phentolamine partly blocked the noradrenaline-induced enhancement and the antagonist alone significantly reduced the number of ovulations. The results indicate that stimulation of alpha-adrenergic receptors (probably via actions in the follicle wall) as well as beta-receptors (influencing steroid-producing cells) may interfere with the ovulation process.

Histochemistry and ultrastructure of adrenergic and acetylcholinesterase-containing nerves supplying follicles and endocrine cells in the guinea-pig ovary

The autonomic nerve supply of the guinea-pig ovary was investigated by a combination of light- and electron microscopy. At the light-microscopic level, adrenergic fibres were identified due to their formaldehyde-induced fluorescence. In addition, the ovary contained acetylcholinesterase-positive fibres. In all parts of the ovary, the adrenergic fibres were most numerous. At the ultrastructural level it was possible to identify the adrenergic nerve terminals with the aid of the false adrenergic transmitter, 5-hydroxy-dopamine. Thus, large numbers of adrenergic terminals, characterized by their content of 50-60 nm, electron-dense synaptic vesicles, were seen within the interstitial gland, where they formed close contacts with the endocrine cells (membrane-to-membrane distance, 20-100 nm). The follicular theca externa was also richly supplied by adrenergic nerves. At this location, close contacts (50-100 nm) were identified between the nerve terminals and the smooth muscle-like cells. Very few adrenergic nerve fibres were present in the theca interna of follicles or in the corpus luteum. Non-adrenergic nerve terminals, characterized by electron-lucent synaptic vesicles of 50-60 nm diameter, were observed together with the adrenergic fibres. They were always present in much lower numbers than the latter. No "p-type" nerves were identified by electron microscopy.

Intraovarian adrenergic nerves in the guinea-pig: development from fetal life to sexual maturity

The development of the intraovarian adrenergic nervous system was investigated in the guinea-pig by use of chemical determination of catecholamines with high performance liquid chromatography (HPLC) and with the formaldehyde-induced fluorescence method for visualization of adrenergic nerves (Falck-Hillarp technique). Ovaries from fetuses (39-40, 45-50, 55-57, 60-63 days of gestation) and young animals (1, 2, 3, 7, 14, 30, 40-45 days of age) were included in the study. The noradrenaline concentration was low in the ovaries from the youngest fetuses but increased with age, reaching a maximum level at 2 days post partum. A marked decrease in noradrenaline concentration from the second to the third day of life was found as a consequence of the rapid increase in the ovarian weight during this time. A similar decrease in ovarian noradrenaline concentration after a period of rapid ovarian growth was noted at 30 days of age. Measurable amounts of adrenaline were found in the ovary only in the fetal stages; the highest concentration (0.73 microgram) was detected at 55-57 days of gestation.