Indocyanine green fluorescence applied to gynecologic oncology: beyond sentinel lymph node

Indocyanine green (ICG), a well-known molecule employed in medicine for over five decades, has emerged as a versatile dye widely embraced across various surgical disciplines. In gynecologic oncology, its prevalent use revolves around the detection of sentinel lymph nodes. However, the true potential of ICG extends beyond this singular application, owing to its pragmatic utility, cost-effectiveness, and safety profile. Furthermore, ICG has been introduced in the theranostic landscape, marking a significant juncture in the evolution of its clinical utility. This narrative review aims to describe the expanding horizons of ICG fluorescence in gynecologic oncology, beyond the sentinel lymph node biopsy. The manifold applications reported within this manuscript include: 1) lymphography; 2) angiography; 3) nerve visualization; 4) ICG-driven resections; and 5) theranostic. The extensive exploration across these numerous applications, some of which are still in the pre-clinical phase, serves as a hypothesis generator, aiming to stimulate the development of clinical studies capable of expanding the use of this drug in our field, enhancing the care of gynecological cancer patients.

Association of Four Interleukin-8 Polymorphisms (-251 A>T, +781 C>T, +1633 C>T, +2767 A>T) with Ovarian Cancer Risk: Focus on Menopausal Status and Endometriosis-Related Subtypes

Interleukin-8 (IL-8) is involved in the regulation of inflammatory processes and carcinogenesis. Single-nucleotide polymorphisms (SNPs) within the IL-8 gene have been shown to alter the risks of lung, gastric, or hepatocellular carcinomas. To date, only one study examined the role of IL-8 SNPs in ovarian cancer (OC), suggesting an association between two IL-8 SNPs and OC risk. In this study, we investigated four common IL-8 SNPs, rs4073 (-251 A>T), rs2227306 (+781 C>T), rs2227543 (+1633 C>T), and rs1126647 (+2767 A>T), using the restriction fragment length polymorphism (PCR-RFLP) technique. Our study included a cohort of 413 women of Central European descent, consisting of 200 OC patients and 213 healthy controls. The most common (73.5%) histological type was high-grade serous OC (HGSOC), whereas 28/200 (14%) patients had endometriosis-related (clear cell or endometrioid) OC subtypes (EROC). In postmenopausal women, three of the four investigated SNPs, rs4073 (-251 A>T), rs2227306 (+781 C>T), and rs2227543 (+1633 C>T), were associated with OC risk. Furthermore, we are the first to report a significant relationship between the T allele or TT genotype of SNP rs1126647 (+2767 A>T) and the EROC subtype (p = 0.02 in the co-dominant model). The TT homozygotes were found more than twice as often in EROC compared to other OC subtypes (39% vs. 19%, p = 0.015). None of the examined SNPs appeared to influence OC risk in premenopausal women, nor were they associated with the aggressive HGSOC subtype or the stage of disease at the initial diagnosis.

Uterine Tumors Resembling Ovarian Sex Cord Tumors (UTROSCTs): A Scoping Review of 511 Cases, Including 2 New Cases

Uterine Tumors Resembling Ovarian Sex Cord Tumors (UTROSCTs) are rare uterine mesenchymal neoplasms with uncertain biological potential. These tumors, which affect both premenopausal and postmenopausal women, usually have a benign clinical course. Nevertheless, local recurrences and distant metastases have been described. By analyzing 511 cases retrieved from individual reports and cases series, we provide here the most comprehensive overview of UTROSCT cases available in the literature, supplemented by two new cases of UTROSCTs. Case 1 was an asymptomatic 31-year-old woman who underwent a laparoscopic resection of a presumed leiomyoma. Case 2 was a 58-year-old postmenopausal woman with abnormal vaginal bleeding who underwent an outpatient hysteroscopic biopsy of a suspicious endometrial area. In both cases, immunohistochemical positivity for Calretinin and Inhibin was noted, typical for a sex cord differentiation. In both cases, total laparoscopic hysterectomy with bilateral salpingo-oophorectomy was performed. In light of the available literature, no pathognomonic clinical or imaging finding can be attributed to UTROSCT. Patients usually present with abnormal uterine bleeding or pelvic discomfort, but 20% of them are asymptomatic. In most cases, a simple hysterectomy appears to be the appropriate treatment, but for women who wish to become pregnant, uterus-preserving approaches should be discussed after excluding risk factors. Age, tumor size, lymphovascular space invasion, nuclear atypia, and cervical involvement are not reliable prognostic factors in UTROSCT. The current research suggests that aggressive cases (with extrauterine spread or recurrence) can be identified based on a distinct genetic and immunohistochemical phenotype. For instance, UTROSCTs characterized by GREB1::NCOA1-3 fusions and PD-L1 molecule expression appear to be predisposed to more aggressive behaviors and recurrence, with GREB1::NCOA2 being the most common gene fusion in recurrent tumors. Hence, redefining the criteria for UTROSCTs may allow a better selection of women suitable for fertility-sparing treatments or requiring more aggressive treatments in the future.

Neglected Anatomical Areas in Ovarian Cancer: Significance for Optimal Debulking Surgery

Ovarian cancer (OC), the most lethal gynecological malignancy, usually presents in advanced stages. Characterized by peritoneal and lymphatic dissemination, OC necessitates a complex surgical approach usually involving the upper abdomen with the aim of achieving optimal cytoreduction without visible macroscopic disease (R0). Failures in optimal cytoreduction, essential for prognosis, often stem from overlooking anatomical neglected sites that harbor residual tumor. Concealed OC metastases may be found in anatomical locations such as the omental bursa; Morison's pouch; the base of the round ligament and hepatic bridge; the splenic hilum; and suprarenal, retrocrural, cardiophrenic and inguinal lymph nodes. Hence, mastery of anatomy is crucial, given the necessity for maneuvers like liver mobilization, diaphragmatic peritonectomy and splenectomy, as well as dissection of suprarenal, celiac, and cardiophrenic lymph nodes in most cases. This article provides a meticulous anatomical description of neglected anatomical areas during OC surgery and describes surgical steps essential for the dissection of these "neglected" areas. This knowledge should equip clinicians with the tools needed for safe and complete cytoreduction in OC patients.

Surgical Anatomy and Dissection of the Hypogastric Plexus in Nerve-Sparing Radical Hysterectomy

Radical hysterectomy is a central surgical procedure in gynecological oncology. A nerve-sparing approach is essential to minimize complications from iatrogenic injury to the pelvic nerves, resulting in postoperative urinary, anorectal, and sexual dysfunction. The hypogastric plexus (HP), a complex network of sympathetic and parasympathetic nerves, plays a critical role in pelvic autonomic innervation. This article offers a comprehensive overview of the surgical anatomy of the HP and provides a step-by-step description of HP dissection, with a particular emphasis on preserving the bladder nerve branches of the inferior HP. A thorough understanding and mastery of the anatomical and surgical nuances of HP dissection are crucial for optimizing outcomes in nerve-sparing gynecologic-oncological procedures.

Internal Iliac Artery Ligation in Obstetrics and Gynecology: Surgical Anatomy and Surgical Considerations

The internal iliac artery (IIA) is the main arterial vessel of the pelvis. It supplies the pelvic viscera, pelvic walls, perineum, and gluteal region. In cases of severe obstetrical or gynecologic hemorrhage, IIA ligation can be a lifesaving procedure. Regrettably, IIA ligation has not gained widespread popularity, primarily due to limited surgical training and concerns regarding possible complications, including buttock claudication, impotence, and urinary bladder and rectum necroses. Nowadays, selective arterial embolization or temporary balloon occlusion are increasingly utilized alternatives, which can be applied preoperatively or intraoperatively for threatening severe genital or pelvic bleeding. However, IIA ligation retains its relevance, as the previously described procedures are not always available and have limitations. This article provides a step-by-step guide to the IIA ligation procedure and its possible complications. It also includes a detailed description of the anatomy of the IIA and pelvic arterial anastomoses. This review highlights the importance of a thorough understanding of pelvic anatomy as a prerequisite for safe IIA ligation and posits that training in this procedure should be an integral part of obstetrics and gynecology curricula.

Surgical Anatomy of the Liver-Significance in Ovarian Cancer Surgery

INTRODUCTION

Ovarian cancer is the leading cause of death among all gynecological malignancies. Most patients present with an advanced stage of the disease. The routes of spread in ovarian cancer include peritoneal dissemination, direct invasion, and lymphatic or hematogenous spread, with peritoneal and lymphatic spread being the most common among them. The flow direction of the peritoneal fluid makes the right subphrenic space a target site for peritoneal metastases, and the most frequently affected anatomical area in advanced cases is the right upper quadrant. Complete cytoreduction with no macroscopically visible disease is the most important prognostic factor.

METHODS

We reviewed published clinical anatomy reports associated with surgery of the liver in cases of advanced ovarian cancer.

RESULTS

The disease could disseminate anatomical areas, where complex surgery is required-Morrison's pouch, the liver surface, or porta hepatis. The aim of the present article is to emphasize and delineate the gross anatomy of the liver and its surgical application for oncogynecologists. Moreover, the association between the gross and microscopic anatomy of the liver is discussed. Additionally, the vascular supply and variations of the liver are clearly described.

CONCLUSIONS

Oncogynecologists performing liver mobilization, diaphragmatic stripping, and porta hepatis dissection must have a thorough knowledge of liver anatomy, including morphology, variations, functional status, potential diagnostic imaging mistakes, and anatomical limits of dissection.

Surgical and Anatomical Basics of Pelvic Debulking Surgery for Advanced Ovarian Cancer - the "Hudson Procedure" as a Cornerstone of Complete Cytoreduction

Ovarian cancer (OC) is the fifth most common cause of death in women and accounts for more deaths than any other cancer of the female reproductive tract. OC usually spreads through peritoneal dissemination and direct invasion. Optimal cytoreduction (no macroscopic residual disease) and adjuvant platinum-based chemotherapy are the fundaments of OC treatment. OC is usually diagnosed at advanced stages, hence the obliteration of the Douglas pouch by the tumor as well as disseminated pelvic peritoneal carcinomatosis are commonly seen. Radical surgical cytoreduction typically requires a retroperitoneal approach to the pelvic masses and multivisceral resections in the upper abdomen. In 1968, Christopher Hudson introduced a new retroperitoneal surgical technique ("radical oophorectomy") for fixed ovarian tumors. Since then, numerous modifications have been described, including visceral peritonectomy, the "cocoon" technique, Bat-shaped en-bloc total peritonectomy (Sarta-Bat approach), or en-bloc resection of the pelvis. Although these modifications expanded the classical description in many ways, the concepts and key surgical steps are derived from the Hudson procedure. However, there are some gaps or disagreements regarding the anatomical or practical rationale for certain surgical steps. The purpose of this article is to outline the critical steps of radical pelvic cytoreduction ("Hudson procedure"), and to delineate the anatomical basis for the procedure in the proposed form. In addition, we discuss the controversies and address the perioperative morbidity associated with the procedure.

Long-term quality of life assessment after excisional treatment for cervical dysplasia

We evaluated factors influencing long-term health-related quality of life (HRQoL) after excisional treatments of low- and high grade squamous intraepithelial cervical lesions (SIL) in three groups of women (n = 160): nulliparas interested in reproduction (A), parous women interested in reproduction (B) and women without pregnancy desire (C). The HRQoL was assessed using the disease-specific FACIT-CD and the generic SF36v2 questionnaires. Anxiety and depression were evaluated by Beck's inventories. After median follow-up of 5 (2-18) years, FACIT-CD total score and the score for Emotional Well-Being (EWB) were significantly lower in group A. The total, EWB and REL (Relationships) scores of FACIT-CD were the highest in group B. Women operated for HSIL demonstrated lower REL quality in comparison to those with LSIL. Neither SF36v2 nor FACIT-CD total scores differed in relation to SIL grade or type of excision. 'SF36v2 Mental Component Summary Score' and 'being parous and interested in fertility' were independent predictors of disease-specific FACIT-CD score.Impact StatementWhat is already known on this subject? Long-term consequences of excisional treatments for cervical dysplasia on health-related quality of life (HRQoL) are not well reported.What do the results of this study add? Our study provides data on HRQoL in women treated with large loop excision of the transformation zone (LLETZ) or cold knife conization (CKC) obtained during the longest (median 5 years) follow-up as reported to date. We were able to show that having children and planning further pregnancies positively influenced HRQoL in these patients. In addition, we identified nulliparas with pregnancy desire as psychologically the most vulnerable group within the studied cohort.What are the implications of these findings for clinical practice and/or further research? Even several years after LLETZ or CKC, women may suffer from impaired Emotional Well-Being and reduced HRQoL. Awareness and assessment of these long-term consequences should be part of surveillance after excisional treatments for cervical dysplasia.

The Translational Role of miRNA in Polycystic Ovary Syndrome: From Bench to Bedside—A Systematic Literature Review

MicroRNAs (miRNAs) are small, non-coding RNAs that are essential for the regulation of post-transcriptional gene expression during tissue development and differentiation. They are involved in the regulation of manifold metabolic and hormonal processes and, within the female reproductive tract, in oocyte maturation and folliculogenesis. Altered miRNA levels have been observed in oncological and inflammatory diseases, diabetes or polycystic ovary syndrome (PCOS). Therefore, miRNAs are proving to be promising potential biomarkers. In women with PCOS, circulating miRNAs can be obtained from whole blood, serum, plasma, urine, and follicular fluid. Our systematic review summarizes data from 2010–2021 on miRNA expression in granulosa and theca cells; the relationship between miRNAs, hormonal changes, glucose and lipid metabolism in women with PCOS; and the potential role of altered miRNAs in fertility (oocyte quality) in PCOS. Furthermore, we discuss miRNAs as a potential therapeutic target in PCOS and as a diagnostic marker for PCOS.

Abnormal Uterine Bleeding in Perimenopausal Women: The Role of Hysteroscopy and Its Impact on Quality of Life and Sexuality

Abnormal uterine bleeding (AUB) is a frequent symptom in perimenopausal women. It is defined as uterine bleeding in which the duration, frequency, or amount of bleeding is considered excessive and negatively affects the woman’s quality of life (QoL) and psychological well-being. In cases of structural uterine pathology, hysterectomy (usually performed via a minimally invasive approach) offers definitive symptom relief and is associated with long-lasting improvement of QoL and sexuality. However, over the past 30 years, uterus-preserving treatments have been introduced as alternatives to hysterectomy. Hysteroscopic polypectomy, myomectomy, or endometrial resection/endometrial ablation are minimally invasive techniques that can be used as an alternative to hysterectomy to treat AUB due to benign conditions. Although associated with high patient satisfaction and short-term improvement in their QoL, hysteroscopic treatments do not eliminate the risk of AUB recurrence or the need for further intervention. Therefore, considering the impact of different treatment options on QoL and sexuality during preoperative shared decision making could help identify the most appropriate and personalized treatment options for perimenopausal women suffering from AUB.

Hereditary Gynecologic Cancer Syndromes - A Narrative Review

Hereditary cancer syndromes are defined as syndromes, where the genetics of cancer are the result of low penetrant polymorphisms or of a single gene disorder inherited in a mendelian fashion. During the last decade, compelling evidence has accumulated that approximately 5-10% of all cancers could be attributed to hereditary cancer syndromes. A tremendous progress has been made over the last decade in the evaluation and management of these syndromes. However, hereditary syndromes associated with gynecologic malignancies still present significant challenge for oncogynecologists. Oncogynecologists tend to pay more attention to staging, histological type and treatment options of gynecological cancers than thinking of inherited cancers and taking a detailed family history. Moreover, physicians should also be familiar with screening strategies in patients with inherited gynecological cancers. Lynch syndrome and hereditary breast-ovarian cancer syndrome are the most common and widely discussed syndromes in medical literature. The aim of the present review article is to delineate and emphasize the majority of hereditary gynecological cancer syndromes, even these, which are rarely reported in oncogynecology. The following inherited cancers are briefly discussed: Lynch syndrome; "site-specific" ovarian cancer and hereditary breast-ovarian cancer syndrome; Cowden syndrome; Li-Fraumeni syndrome; Peutz-Jeghers syndrome; ataxia-telangiectasia; DICER1- syndrome; gonadal dysgenesis; tuberous sclerosis; multiple endocrine neoplasia type I, II; hereditary small cell carcinoma of the ovary, hypercalcemic type and hereditary undifferentiated uterine sarcoma; hereditary diffuse gastric cancer and MUTYH-associated polyposis. Epidemiology, pathogenesis, diagnosis, pathology and screening of these syndromes are discussed. General treatment recommendations are beyond the scope of this review.

Biomarker-Based Models for Preoperative Assessment of Adnexal Mass: A Multicenter Validation Study

Ovarian cancer (OC) is the most lethal genital malignancy in women. We aimed to develop and validate new proteomic-based models for non-invasive diagnosis of OC. We also compared them to the modified Risk of Ovarian Malignancy Algorithm (ROMA-50), the Copenhagen Index (CPH-I) and our earlier Proteomic Model 2017. Biomarkers were assessed using bead-based multiplex technology (Luminex®) in 356 women (250 with malignant and 106 with benign ovarian tumors) from five European centers. The training cohort included 279 women from three centers, and the validation cohort 77 women from two other centers. Of six previously studied serum proteins (CA125, HE4, osteopontin [OPN], prolactin, leptin, and macrophage migration inhibitory factor [MIF]), four contributed significantly to the Proteomic Model 2021 (CA125, OPN, prolactin, MIF), while leptin and HE4 were omitted by the algorithm. The Proteomic Model 2021 revealed a c-index of 0.98 (95% CI 0.96, 0.99) in the training cohort; however, in the validation cohort it only achieved a c-index of 0.82 (95% CI 0.72, 0.91). Adding patient age to the Proteomic Model 2021 constituted the Combined Model 2021, with a c-index of 0.99 (95% CI 0.97, 1) in the training cohort and a c-index of 0.86 (95% CI 0.78, 0.95) in the validation cohort. The Full Combined Model 2021 (all six proteins with age) yielded a c-index of 0.98 (95% CI 0.97, 0.99) in the training cohort and a c-index of 0.89 (95% CI 0.81, 0.97) in the validation cohort. The validation of our previous Proteomic Model 2017, as well as the ROMA-50 and CPH-I revealed a c-index of 0.9 (95% CI 0.82, 0.97), 0.54 (95% CI 0.38, 0.69) and 0.92 (95% CI 0.85, 0.98), respectively. In postmenopausal women, the three newly developed models all achieved a specificity of 1.00, a positive predictive value (PPV) of 1.00, and a sensitivity of >0.9. Performance in women under 50 years of age (c-index below 0.6) or with normal CA125 (c-index close to 0.5) was poor. CA125 and OPN had the best discriminating power as single markers. In summary, the CPH-I, the two combined 2021 Models, and the Proteomic Model 2017 showed satisfactory diagnostic accuracies, with no clear superiority of either model. Notably, although combining values of only four proteins with age, the Combined Model 2021 performed comparably to the Full Combined Model 2021. The models confirmed their exceptional diagnostic performance in women aged ≥50. All models outperformed the ROMA-50.

Association of Macronutrients Composition, Physical Activity and Serum Androgen Concentration in Young Women with Polycystic Ovary Syndrome

The roles of dietary macronutrients and physical activity (PA) in patients with PCOS have not been sufficiently reported, especially in adolescent girls. To address this knowledge gap, we evaluated the associations between serum concentrations of total testosterone (tT), free testosterone (fT), androstenedione (A), dehydroepiandrosterone-sulfate (DHEA-S), sex hormone-binding globulin (SHBG) and dietary macronutrients intake as well as different types and levels of PA. The study population consisted of 96 girls of Caucasian ancestry, aged 14-18 years: 61 participants with polycystic ovary syndrome (PCOS) and 35 healthy controls. Serum tT, fT, A, DHEA-S, and SHBG were determined in fasting blood. Macronutrient intake and PA levels were assessed by using the three-day food record method and the Beliefs and Eating Habits Questionnaire (KomPAN), respectively. We found several positive correlations between dietary macronutrients such as total fat, saturated fatty acids (SFA), monounsaturated (MUFA) and polyunsaturated fatty acids (PUFA), and hormonal parameters across the entire cohort and in healthy girls. A positive correlation between SHBG and total protein consumption as well as an inverse correlation between SHBG and carbohydrate intake could be determined. No correlation between androgens and macronutrients was found in the PCOS group. In contrast, we observed an inverse correlation between androgen concentrations (except of DHEA-S) and "work/school" and/or "leisure time" PA only in PCOS patients. Moreover, the hormone levels differed according to PA intensity. In conclusion, the impact of diet and PA was strikingly different in adolescents with and without PCOS. These findings indicate that disturbed hormonal homeostasis in PCOS, at least in the youngest patients, likely "overtrump" dietary influences, and otherwise, PA offers a therapeutic potential that requires further evaluation of the long-term effects in randomized studies. (ClinicalTrial.gov Identifier: NCT04738409.).

Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review

Almost all gynecological and general-surgical operations are - or can be - performed laparoscopically. In comparison to an abdominal approach, the minimally invasive access offers several advantages; however, laparoscopy (both conventional and robotic-assisted) can be associated with a number of approach-specific complications. Although the majority of them are related to the laparoscopic entry, adverse events may also occur due to the presence of pneumoperitoneum or the use of laparoscopic instruments. Unfortunately, a high proportion of complications (especially affecting the bowel and ureter) remain unrecognized during surgery. This narrative review provides comprehensive up-to-date information about definitions, classifications, risk factors and incidence of surgical complications in conventional and robotic-assisted laparoscopy, with a special focus on gynecology. The topic is discussed from various perspectives, e.g. in the context of stage of surgery, injured organs, involved instruments, and in relation to malpractice claims.

Gene Expression of Kallikreins in Breast Cancer Cell Lines

BACKGROUND/AIM

This study analyzed the gene expression of the "classic" KLK1 and "new" kallikreins KLK4-KLK15, in relation to the molecular characteristics and in vitro invasiveness of 21 breast cancer (BC) and three normal breast-derived cell lines (CLs).

MATERIALS AND METHODS

Gene expression of KLKs was determined by using real-time polymerase chain reaction (PCR). The invasiveness of the CLs was examined using a fibroblast-collagen-based in vitro cell culture assay.

RESULTS

KLK5 and KLK7-KLK11 were down-regulated in several BCCLs. In contrast, KLK4, KLK8, KLK12 and KLK15 demonstrated strikingly high expression in two BCCLs, UACC 812 and MDA-MB 330. The KLK expression differed frequently according to the presence of androgen receptor (KLK1 and KLK5-KLK9), and occasionally according to estrogen receptor (KLK9) and EGFR (KLK7). Two KLK clusters were detected (first: KLK1, 4, 12, 15; second: all other KLKs), with two subclasses within the second cluster (KLK5-9 and KLK10, 11, 13, and 14). The CLs that expressed at least six KLKs belonged predominantly to basal or HER2 intrinsic subtypes. No KLK predicted the in vitro invasiveness of CLs.

CONCLUSION

Gene expression of KLKs was altered in BCCLs. This change was mostly down-regulation and often related to the presence of androgen receptor. The observed clusters point to a possible functional interplay of selected KLKs in BCCLs.

Pregnancy-Preserving Laparoscopic Treatment of Acute Hemoperitoneum Following Lutein Cyst Rupture in Early Gestation

Acute hemoperitoneum (AHP) in early gestation is commonly treated via laparotomy. A ruptured corpus luteum (CL) cyst is a rare cause of AHP in pregnancy. This case report describes a 33-year-old, hemodynamically stable G2/P1 who presented at 5+5 gestational weeks with an acute abdomen due to ruptured CL cyst (7 cm). Emergent laparoscopy was performed. After evacuation of 1 L of hemoperitoneum, an atraumatic hemostasis was obtained without diathermy by use of hemostatic matrix (Floseal^®). The ovary was reformed with an absorbable suture under preservation of CL. The postoperative recovery was uncomplicated. The hemoglobin drop was 2.8 g/dl. Further pregnancy course was uneventful. A healthy baby (2860 g) was delivered vaginally at 38+3 weeks of gestation. CONCLUSION: Laparoscopic approach to AHP in early pregnancy is suitable. CL preservation is feasible by use of atraumatic hemostatics.

Delivery through cervicovaginal fistula - literature review and case report

Less than 10 deliveries via cervicovaginal fistula (CVF) with closed cervical os were reported so far. In the majority of cases, the patients had a history of induced abortions. The CVF was usually recognized due to postpartum hemorrhage. The facilitating role of prostaglandins used for labor induction was supposed. In all cases, the babies remained unaffected by the delivery route. We report a new case of a 37-year-old gravida 2, para 0, with a history of a paracervical tear following a first trimester abortion 11 years ago. The abortion and the laceration were not reported in the current obstetrical documentation. After labor induction using oral misoprostol in the 41 + 5 weeks of pregnancy, the patient delivered a healthy baby through a left-sided CVF, which imposed as bleeding paracervical laceration, 6 cm in diameter, extending to the vaginal fornix in the 3 o'clock position. The cervical os was only 1-1.5 cm dilated and imposed as an inelastic band ("squid ring") in the 9 o'clock position. The laceration was sutured under spinal anesthesia. The patient recovered quickly, and the postpartum hemoglobin drop was 2.8 g/dl. In conclusion, the possibility of CVF should be considered in women with a history of induced abortion.

Improvement of Perioperative Outcomes in Major Gynecological and Gynecologic-Oncological Surgery with Hemostatic Gelatin-Thrombin Matrix

AIM

To assess the impact of the use of intraoperative hemostatic gelatin-thrombin matrix (HM) (Floseal®, Baxter Healthcare) on transfusion rates and short-term perioperative outcomes in gynecological surgery.

PATIENTS AND METHODS

In this retrospective, single-center study, we evaluated data of 215 patients (83 cases and 132 controls) undergoing extensive gynecological surgery (e.g. oncological procedures) with and without intraoperative HM application.

RESULTS

Cases and controls did not differ according to age, preoperative hemoglobin (Hb) concentration, and Hb or C-reactive protein (CRP) levels at discharge. Patients receiving HM had significantly reduced operative (168 vs. 199 min, p=0.02) and hospitalization (9 vs. 14 days, p<0.001) times. The mean postoperative Hb drop (3.33 vs. 4.51 g/dl, p<0.001), and the mean postoperative increase in CRP (94.9 vs. 149.1 mg/l, p<0.001) were significantly less pronounced within the HM group. Despite more prevalent coagulopathy (48 vs. 31%, p=0.02), e.g. due to anticoagulant use (15.7 vs. 3%, p<0.001), patients treated using HM needed less frequent transfusions of packed red blood cells [odds ratio (OR)= 0.13, 95% confidence interval (CI)=0.07-0.24) and fresh frozen plasma (OR=0.51, 95% CI=0.24-1.05). In comparison to controls, the need for surgical revisions (OR 0.1, CI 95% 0.02-0.42) and intensive-care unit admissions (OR 0.15, 95% CI=0.08-0.30) was lower in patients treated with HM.

CONCLUSION

To our knowledge, our study is the largest case-control study focusing on Floseal® use in gynecology. The use of HM was associated with significantly better short-term perioperative outcomes. Due to its local action, HM seems to be particularly useful in patients in which anticoagulant medication cannot be paused.

Association of HER2 codon 655 polymorphism with ovarian cancer

The role of the human epidermal growth factor receptor 2 (HER2) codon 655 (Ile655Val) polymorphism in ovarian cancer is not fully understood. Two studies indicated a possible association between the Val allele and elevated risk or reduced prognosis of ovarian cancer. We investigated the HER2 codon 655 (rs1136201) polymorphism in 242 Austrian women-142 ovarian cancer patients and 100 healthy controls-by polymerase chain reaction and pyrosequencing. Associations between Ile655Val polymorphism and clinicopathological variables (e.g., age, FIGO stage, grading, serous vs. non-serous histology) were evaluated. The genotype distributions in ovarian cancer patients and controls were: AA; 66.2 %, AG; 25.35 %, GG; 8.45 %, and AA; 63 %, AG; 34 %, GG; 3.7 %, respectively (OR 1.15, CI 95 % 0.67-1.96). We observed a non-significant trend toward elevated cancer risk in Val/Val genotype (OR 2.98, CI 95 % 0.82-10.87, p = 0.10). Of note, 11 out of 12 Val/Val homozygotes were postmenopausal. The link between the Val/Val homozygosity and age over 50 years at diagnosis (OR 0.15, CI 95 % 0.02-1.2) was barely significant (p = 0.056). Summarizing, our data indicated a non-significant trend toward increased ovarian cancer risk in the Val/Val homozygosity, especially in women aged above 50 years. Further large-cohort studies focusing on the role of the HER2 codon 655 Val allele are needed.

HER2 Codon 655 (Ile/Val) Polymorphism and Breast Cancer in Austrian Women

BACKGROUND

The overexpression of the human epidermal growth factor receptor 2 (HER2) in breast cancer (BC) is associated with impaired prognosis. Data concerning the HER2 codon 655 polymorphism (Ile/Val) and BC risk are conflicting.

MATERIALS AND METHODS

We studied the HER2 codon 655 (rs1136201) polymorphism in 80 Austrian patients with BC and 100 healthy volunteers by pyrosequencing and polymerase chain reaction. Associations between codon 655 allelic variants and clinicopathological variables (e.g. age, stage of disease, tumor type, grading, and receptor status) were studied with 2×2 tables.

RESULTS

The genotypic distributions in patients with BC (AA: 63.75%, AG: 32.5%, GG: 3.75%) and controls (AA: 63%, AG: 34%, GG: 3.7%) were virtually identical (odds ratio=1.03, 95% confidence interval=0.56-1.90). A non-significant link between carrying at least one G allele and more aggressive tumor type (estrogen receptor-negative p=0.08, G3 tumor p=0.19) was observed.

CONCLUSION

Genotypic variation within the codon 655 of HER2 does not alter the BC risk in Caucasian Austrian women. The association between the G allele and more aggressive tumor types requires further investigation.

HER2 Codon 655 (Ile/Val) Polymorphism and Breast Cancer in Austrian Women

BACKGROUND

The overexpression of the human epidermal growth factor receptor 2 (HER2) in breast cancer (BC) is associated with impaired prognosis. Data concerning the HER2 codon 655 polymorphism (Ile/Val) and BC risk are conflicting.

MATERIALS AND METHODS

We studied the HER2 codon 655 (rs1136201) polymorphism in 80 Austrian patients with BC and 100 healthy volunteers by pyrosequencing and polymerase chain reaction. Associations between codon 655 allelic variants and clinicopathological variables (e.g. age, stage of disease, tumor type, grading, and receptor status) were studied with 2×2 tables.

RESULTS

The genotypic distributions in patients with BC (AA: 63.75%, AG: 32.5%, GG: 3.75%) and controls (AA: 63%, AG: 34%, GG: 3.7%) were virtually identical (odds ratio=1.03, 95% confidence interval=0.56-1.90). A non-significant link between carrying at least one G allele and more aggressive tumor type (estrogen receptor-negative p=0.08, G3 tumor p=0.19) was observed.

CONCLUSION

Genotypic variation within the codon 655 of HER2 does not alter the BC risk in Caucasian Austrian women. The association between the G allele and more aggressive tumor types requires further investigation.

Simple laboratory score improves the preoperative diagnosis of adnexal mass

We assessed the diagnostic accuracy of a newly developed laboratory score-based on CA125, platelet count (PLT), C-reactive protein (CRP), and fibrinogen levels-in the preoperative diagnosis of adnexal mass. In this retrospective single-center study, we analyzed records of 142 patients with 54 malignant (38 %) and 88 benign (62 %) ovarian tumors. Preoperative levels of CA125, PLT, CRP, and fibrinogen were dichotomized according to the common cutoff values (CA125, 35 U/ml; PLT, 350/nl; CRP, 5.0 mg/l; fibrinogen, 400 mg/dl), resulting in "1" for results above the cutoff and "0" for results within the normal ranges. The values (1 or 0) were summarized to a "low" (0-2) or "high" (3-4) score. Its diagnostic accuracy was compared to the "gold standard," CA125. All parameters differed significantly between malignant and benign cases. The score was false positive in 5/88 (5.7 %) and false negative in 13/54 (24 %) of cases. Conversely, CA125 was false positive in 18/88 (20.4 %) and false negative in 4/54 (7.4 %). The diagnostic accuracy of CA125 (>35 U/ml) was sensitivity 0.93, specificity 0.80, positive predictive value (PPV) 0.74, negative predictive value (NPV) 0.95, and positive likelihood ratio (weighted by prevalence) (+LH/p) 2.78. The diagnostic accuracy of the score was sensitivity 0.76, specificity 0.94, PPV 0.89, NPV 0.86, and +LH/p 8.2. In conclusion, the score is easy to use and generates no additional costs. It provides a better specificity, PPV, and +LH/p than CA125. The sensitivity and NPV are lower, but acceptable. A validation of the score in a large patient cohort is needed.

Psychological well-being of gynecologic and obstetric patients: a validation of the 12-item Well-Being Questionnaire (W-BQ12)

BACKGROUND

Gynecology and obstetrics are areas of medicine associated with emotionally loaded concerns. Both positive and negative aspects of psychological well-being can be assessed with the 12-item Well-Being Questionnaire (W-BQ12). Our study aimed to evaluate the psychometric properties of the W-BQ12 in gynecologic and obstetric patients.

METHODS

A cohort of 228 gynecologic patients, consisting of endocrinologic (n = 102) and obstetric (n = 126) subgroups, responded to a structured interview or to a questionnaire about sociodemographic and medical data, and to a set of psychometric tests: the W-BQ12, the Hospital Anxiety and Depression Scale (HADS), the Beck Depression Inventory (BDI), and the Hamilton Depression Scale (HAMD). Except for the current health problem, all probable confounding factors (psychiatric, oncologic, or other somatic morbidity, postmenopausal status) were excluded.

RESULTS

The W-BQ12 scores correlated significantly and adequately (r = 0.35-0.80) with reference instruments (HADS, BDI, and HAMD). The internal consistency, measured by Cronbach's alpha, was very good for the whole questionnaire (0.86) as well as for the subscales (0.76-0.79). The principal component analysis indicated a clear three-factor structure with eigenvalues >1. Factors 1 ("negative well-being"), 2 ("positive well-being"), and 3 ("energy") explained 22, 21, and 19 % of the variance, respectively.

CONCLUSIONS

The W-BQ12 is suitable for the global assessment of psychological well-being, as well as for differentiation between negative and positive well-being aspects in gynecologic patients.

Validation of the Polish version of the Hospital Anxiety and Depression Scale in three populations of gynecologic patients

INTRODUCTION

We analyzed the psychometric properties of the Polish version of the Hospital Anxiety and Depression Scale (HADS) in gynecologic patients.

MATERIAL AND METHODS

A total of 252 patients, consisting of three subgroups - endocrinologic gynecology (n = 67), high-risk pregnancy (n = 124), and outpatient gynecologic clinic (n = 61) - responded to the HADS, the 12-item Well-being Questionnaire (W-BQ12), the Spielberger State-Trait Anxiety Inventory (STAI), the Beck Depression Inventory-II (BDI-II), and the Hamilton Depression Scale (HAMD). Socio-demographic data were obtained by self-report and interviews.

RESULTS

The HADS presented good internal consistency with Cronbach's α at 0.84 and 0.78 for depression and anxiety subscales, respectively, and 0.88 for the whole questionnaire. The principal component analysis with Eigenvalues > 1 revealed a three-factor structure. Factors 1 ("depression"), and 2 ("anxiety"), as well as the separate Factor 3, explained 23.48%, 21.42%, and 12.07% of the variance, respectively. The items with shared loadings were A1, A3, and A6. The HADS scores correlated strongly with other depression and well-being scales, but not with STAI-X1/X2.

CONCLUSIONS

The Polish HADS revealed a three-factor structure, and 3/7 HADS-A items showed ambiguous factor loadings. All other psychometric properties were satisfactory. The HADS seems to be suitable for use in gynecologic patients, preferentially as an indicator for global psychological distress.

Primary omental pregnancy with secondary implantation into posterior cul-de-sac: laparoscopic treatment using hemostatic matrix

Primary omental pregnancy is a rare form of ectopic pregnancy. Only a few reported cases have been treated using laparoscopy. Hemostasis after trophoblast removal can be challenging. A 25-year-old primigravida in week 8 of pregnancy was admitted to our hospital with a diagnosis of missed abortion. An ultrasound scan showed an empty uterine cavity and a gestational sac with a 15-mm embryo dorsal to the uterus, indicative of an ectopic pregnancy. The preoperative serum concentration of human chorionic gonadotropin was 33 600 U/mL. Laparoscopy was performed, which revealed an omental pregnancy invading the peritoneum of the Douglas pouch. After laparoscopic removal of the ectopic pregnancy with partial omentectomy, diffuse bleeding from the crater between both sacrouterine ligaments was treated using the gelatin-thrombin matrix (FloSeal). The final histologic analysis confirmed the omentum as the primary site of the ectopic pregnancy (multiple chorionic villi and decidua within the omental fat). The postoperative period was uneventful. This case expands the classic Studdiford criteria. Secondary peritoneal ectopic pregnancy implantation can occur not only after tubal rupture or expulsion of tubal ectopic pregnancy but also after primary implantation at any other ectopic site. The laparoscopic approach to abdominal pregnancy is safe and feasible if there is sufficient intraoperative hemostasis. The hemostatic matrix facilitates quick and effective control of bleeding.

[Contemporary views on perioperative complications and adhaesion formation after vaginal hysterectomy, in relation to peritoneal closure vs. non-closure in combination with open vs. closed vaginal cuff]

There exists few evidence about peritoneal closure vs. non-closure at vaginal hysterectomy as well as only scanty evidence for open vs. sutured vaginal cuff. It seems that non-closure of the peritoneum at vaginal hysterectomy holds no risks and probably some advantages, e.g. faster resumption of bowel function. In the light of the rare direct evidence from vaginal surgery and the strong evidence from cesarean section and abdominal hysterectomy, we recommend abandoning the routine closure of the peritoneum at vaginal hysterectomy. The vaginal cuff left open is probably also a safe procedure, if the hemostasis has been done carefully. The most promising modification of the vaginal incision-and-closure seems to be the "Benenden-Hospital technique" (V-shaped posterior incision and running longitudinal closure of the vaginal skin with partially non-sutured peritoneum).

[Correlation between platelet count and CA-125 in ovarian cancer]

OBJECTIVE

To determine whether a correlation between platelet count and CA-125 exists, and to compare the mean levels of CA-125 in groups with normal and elevated platelet counts.

DESIGN

A retrospective analysis of the medical records concerning to 31 ovarian cancer inpatients, treated 1998-2002 with primary surgery and subsequent platinum-based chemotherapy at the Division of Gynecology, Department of Perinatology and Gynecology, University Medical School Poznań.

MATERIALS AND METHODS

137 serum and whole blood samples collected from 31 ovarian cancer patients during their consecutive hospital stays.

RESULTS

There was a positive, moderate (r = 0.49) and highly significant (p < 0.0000001) correlation between platelet count and CA-125 levels. Thrombocytosis occurred in 45% patients before treatment, and in none when the 6th course of chemotherapy was given. In the thrombocytosis group, an average CA-125 level (913.5 U/ml) was significantly higher (p < 0.00001) then in the group with normal platelet count (103.7 U/ml).

CONCLUSIONS

Platelet count and CA-125 levels do correlate in blood samples taken from ovarian cancer patients at the same time.