Molecular dynamics identifies semi-rigid domains in the PD-1 checkpoint receptor bound to its natural ligand PD-L1

Cells in danger of being erroneously attacked by leucocytes express PD-L1 on their surface. These cells activate PD-1 on attacking leucocytes and send them to death, thus curbing erroneous, autoimmune attack. Unfortunately, cancer cells exploit this mechanism: By expressing PD-L1, they guard themselves against leucocyte attack and thereby evade immune clearance. Checkpoint inhibitors are drugs which re-enable immune clearance of cancer cells by blocking the binding of PD-L1 to PD-1 receptors. It is therefore of utmost interest to investigate these binding mechanisms. We use three 600 ns all-atom molecular dynamics simulations to scrutinize molecular motions of PD-1 with its binding partner, the natural ligand PD-L1. Usually, atomic motion patterns are evaluated against whole molecules as a reference, disregarding that such a reference is a dynamic entity by itself, thus degrading stability of the reference. As a remedy, we identify semi-rigid domains, lending themselves as more stable and reliable reference frames against which even minute differences in molecular motion can be quantified precisely. We propose an unsupervised three-step procedure. In previous work of our group and others, minute differences in motion patterns proved decisive for differences in function. Here, several highly reliable frames of reference are established for future investigations based on molecular motion.

Sexual Function in Postmenopausal Women With Symptomatic Pelvic Organ Prolapse Treated Either with Locally Applied Estrogen or Placebo: Results of a Double-Masked, Placebo-Controlled, Multicenter Trial

BACKGROUND

Local estrogen therapy (LET) has beneficial effects on genitourinary atrophy; however it is currently unclear if LET improves sexual function in postmenopausal women with pelvic organ prolapse (POP).

AIM

To evaluate if LET vs placebo results in an improved sexual function in postmenopausal women with symptomatic POP.

METHODS

We performed a secondary analysis of sexual outcomes of a previous randomized controlled trial comparing LET and placebo in 120 postmenopausal women (60/group) with symptomatic POP stage ≥3 and planned prolapse surgery. Women were randomly assigned to receive local estrogen or placebo cream 6 weeks preoperatively. The effect of therapy vs placebo was assessed with ANOVA with interaction effect of time*group and a multivariable linear regression model was built to assess the impact of different variables on sexual function before therapy.

OUTCOMES

We evaluated the sexual function score in sexually active women of our study population using the German Pelvic Floor Questionnaire at recruitment time and again after 6 weeks of treatment.

RESULTS

Among 120 randomized women, 66 sexually active women remained for final analysis. There was no significant difference in the change of the sexual function score over time between the treatment groups (difference in changes in score from baseline to 6 weeks for Estrogen group vs control group was -0.110 with 95% CI -0.364 to 0.144) Multivariable analysis showed that no independent risk factor for unsatisfying sexual function score could be identified.

CLINICAL IMPLICATIONS

Based on our results, LET has no beneficial effect on sexual function in postmenopausal women with POP.

STRENGTHS AND LIMITATIONS

Main strength of our study lies in the study design and in the use of a condition- specific questionnaire. As this is a secondary analysis, this study may be insufficiently powered to identify differences in sexual data between groups.

CONCLUSION

LET had no impact on female sexuality in postmenopausal women with POP. Marschalek M-L, Bodner K, Kimberger O, et al. Sexual Function in Postmenopausal Women With Symptomatic Pelvic Organ Prolapse Treated Either with Locally Applied Estrogen or Placebo: Results of a Double-Masked, Placebo-Controlled, Multicenter Trial. J Sex Med 2022;19:1124-1130.

976Screening for cervical cancer with Human Papillomavirus testing: stand-alone is preferable over co-testing with cytology

Background

Cervical cancer screening can be conducted with cytology and Human Papillomavirus (HPV) testing but few studies have compared the latter directly to concomitant testing (co-testing). We compared these strategies to determine appropriate screening.

Methods

Within a randomised population-based cohort study conducted around Mainz, Germany, eligible women (≥30 years) were screened via Pap smear, liquid-based cytology (LBC) and HPV testing (HC2) and HPV genotyped post hoc (PCR). These tests formed three strategies: cytology (Pap or LBC) and HPV (HC2 or PCR) stand-alone and co-testing. Screen positives and 5% negative women were invited to colposcopy. Absolute and relative sensitivity, specificity, false positive rates (FPR) and number needed to colposcopy to detect one lesion (NNC) were calculated. Estimates were crude and verification bias-adjusted using stratified sampling with bootstrapped confidence intervals.

Results

Of 2,627 screened women, cytology stand-alone demonstrated lowest sensitivities (47%) and highest specificities (97%-99%) while HPV stand-alone demonstrated higher sensitivities (79%-95%) but lower specificities (94%-95%). Co-testing increased sensitivity (84%-99%) but not specificity (92%-95%). Relative sensitivities were similar between crude and adjusted estimates, with greater detection via HPV-based strategies. Specificity of co-testing with LBC relative to HPV stand-alone was near unity (0.99, 95% CI 0.99-1.00) but significantly lower than unity with Pap co-testing. FPR and NNC were greatest under co-testing.

Conclusions

HPV stand-alone screening in women over 30 years appears appropriate over co-testing as a screening strategy.

Key messages

Co-testing for cervical cancer does not appear to add any benefit in detection and may introduce unnecessary harms compared to HPV stand-alone screening.

Does preoperative locally applied estrogen treatment facilitate prolapse-associated symptoms in postmenopausal women with symptomatic pelvic organ prolapse? A randomised controlled double-masked, placebo-controlled, multicentre study

OBJECTIVE

To evaluate whether locally applied vaginal estrogen affects prolapse-associated complaints compared with placebo treatment in postmenopausal women prior to surgical prolapse repair.

DESIGN

Randomised, double-masked, placebo-controlled, multicentre study.

SETTING

Urogynaecology unit at the Medical University of Vienna and University Hospital of Tulln.

POPULATION

Postmenopausal women with symptomatic pelvic organ prolapse and planned surgical prolapse repair.

METHODS

Women were randomly assigned local estrogen cream or placebo cream 6 weeks preoperatively.

MAIN OUTCOME MEASURES

The primary outcome was differences in subjective prolapse-associated complaints after 6 weeks of treatment prior to surgery, assessed with the comprehensive German pelvic floor questionnaire. Secondary outcomes included differences in other pelvic floor-associated complaints (bladder, bowel or sexual function).

RESULTS

Out of 120 women randomised, 103 (86%) remained for the final analysis. After 6 weeks of treatment the prolapse domain score did not differ between the estrogen and the placebo groups (4.4 ± 0.19 versus 4.6 ± 0.19; mean difference, -0.21; 95% CI -0.74 to 0.33; P = 0.445). Multivariate analysis, including only women receiving the intervention, showed that none of the confounding factors modified the response to estradiol.

CONCLUSIONS

These results demonstrate that preoperative locally applied estrogen does not ameliorate prolapse-associated symptoms in postmenopausal women with symptomatic pelvic organ prolapse.

TWEETABLE ABSTRACT

Preoperative local estrogen does not ameliorate prolapse-associated symptoms in postmenopausal women with pelvic organ prolapse.

Temporal trends in obstetric anal sphincter injury from the first vaginal delivery in Austria, Canada, Norway, and Sweden

INTRODUCTION

Obstetric anal sphincter injuries (OASI) are severe complications that can cause considerable short- and long-term morbidity. Austria, Canada, Norway, and Sweden have similar socio-economic characteristics, and all four countries have access to national birth registers. In this study, we hypothesized that the incidence of OASI should be very similar for different obstetric scenarios in these four countries. Therefore, the aim was to compare the incidence of OASI in these four countries in primiparous women, with spontaneous or instrumental delivery (vacuum or forceps), and in women with a first vaginal birth after cesarean section (VBAC).

MATERIAL AND METHODS

Aggregated data on 1 933 930 vaginally delivered primiparous women and women with VBAC were retrieved from the birth registers gathered in Austria, Canada, Norway, and Sweden. The annual rate of OASI (ICD-10 codes O70.2-O70.3) was presented as the percentage of women with a spontaneous delivery, vacuum or forceps delivery, and a VBAC during the period 2004-2016.

RESULTS

The incidence of OASI varied considerably between countries and over time. Canada and Sweden had the highest rates, and Austria and Norway the lowest. In Norway, the rate of OASI decreased consistently for all types of deliveries after introducing a perineal protection program in 2004 (p < 0.001). During vacuum delivery, the incidence of OASI varied between countries from 4.1% to 15.5% across the study period. In Canada and Norway, the rate of OASI after a forceps delivery was similar in 2004 at ~20% and with differing trajectories to 24.3% (β 0.49) and 6.2% (β -1.15) (trend, all p < 0.001) in 2016.

CONCLUSIONS

This comparative register study suggests that there may be considerable potential for lowering the incidence of OASI. The perineal protection program implemented by Norway has been successful. Each country should critically, without prejudice, analyze their current clinical practices and rate of OASI and consider the best preventive strategy.

Wide Variation in Post-Void Residual Management after Urogynecologic Surgery: A Survey of Urogynecologists' Practices

To date there is no standardized regimen or evidence-based practical guideline concerning post-void residual (PVR) measurement after urogynecologic surgeries. This survey aimed to evaluate current practice patterns and the approach taken among urogynecologists surrounding PVR measurement. An online survey was sent to members of several urogynecologic societies assessing pre- and postoperative management of patients undergoing urogynecologic surgery. A total of 204 urogynecologists from 21 countries participated in the survey. The vast majority of urogynecologists perform some kind of voiding trial to assess voiding function postoperatively. The cut-off values to perform catheterization, the methods of measurement, and the number of successfully passed voiding showed strong differences. Only 34.4% of the respondents consider routine PVR measurement after urogynecologic surgery to be evidence-based. PVR measurement after urogynecologic surgeries is widely performed and if pathological, it almost always provokes invasive treatment. However, there is a wide variation of implemented strategies, methods, and cut-off values. Scientific societies are challenged to devise a standardized regimen based on evidence for the management of urinary retention after urogynecologic surgery.

Decision theory for precision therapy of breast cancer

Correctly estimating the hormone receptor status for estrogen (ER) and progesterone (PGR) is crucial for precision therapy of breast cancer. It is known that conventional diagnostics (immunohistochemistry, IHC) yields a significant rate of wrongly diagnosed receptor status. Here we demonstrate how Dempster Shafer decision Theory (DST) enhances diagnostic precision by adding information from gene expression. We downloaded data of 3753 breast cancer patients from Gene Expression Omnibus. Information from IHC and gene expression was fused according to DST, and the clinical criterion for receptor positivity was re-modelled along DST. Receptor status predicted according to DST was compared with conventional assessment via IHC and gene-expression, and deviations were flagged as questionable. The survival of questionable cases turned out significantly worse (Kaplan Meier p < 1%) than for patients with receptor status confirmed by DST, indicating a substantial enhancement of diagnostic precision via DST. This study is not only relevant for precision medicine but also paves the way for introducing decision theory into OMICS data science.

Gene Expression-Based Prediction of Neoadjuvant Chemotherapy Response in Early Breast Cancer: Results of the Prospective Multicenter EXPRESSION Trial

PURPOSE

Expression-based classifiers to predict pathologic complete response (pCR) after neoadjuvant chemotherapy (NACT) are not routinely used in the clinic. We aimed to build and validate a classifier for pCR after NACT.

PATIENTS AND METHODS

We performed a prospective multicenter study (EXPRESSION) including 114 patients treated with anthracycline/taxane-based NACT. Pretreatment core needle biopsies from 91 patients were used for gene expression analysis and classifier construction, followed by validation in five external cohorts (n = 619).

RESULTS

A 20-gene classifier established in the EXPRESSION cohort using a Youden index-based cut-off point predicted pCR in the validation cohorts with an accuracy, AUC, negative predictive value (NPV), positive predictive value, sensitivity, and specificity of 0.811, 0.768, 0.829, 0.587, 0.216, and 0.962, respectively. Alternatively, aiming for a high NPV by defining the cut-off point for classification based on the complete responder with the lowest predicted probability of pCR in the EXPRESSION cohort led to an NPV of 0.960 upon external validation. With this extreme-low cut-off point, a recommendation to not treat with anthracycline/taxane-based NACT would be possible for 121 of 619 unselected patients (19.5%) and 112 of 322 patients with luminal breast cancer (34.8%). The analysis of the molecular subtypes showed that the identification of patients who do not achieve a pCR by the 20-gene classifier was particularly relevant in luminal breast cancer.

CONCLUSIONS

The novel 20-gene classifier reliably identifies patients who do not achieve a pCR in about one third of luminal breast cancers in both the EXPRESSION and combined validation cohorts.

Genetic association in female stress urinary incontinence based on proteomic findings: a case-control study

Introduction and hypothesis

Previous studies have indicated a hereditary component of stress urinary incontinence; however, evidence on candidate genes or single-nucleotide polymorphisms (SNPs) is scarce. We hypothesize a genetic association of female stress urinary incontinence based on significant differences of the urinary and serum proteomic pattern in the identical study population.

Methods

Case-control study of 19 patients and 19 controls. We searched for known SNPs of SUI candidate genes (COL1A1, MMP1, SERPINA5, UMOD) in the database of short genetic variations and PubMed. Genomic DNA was isolated using QIAamp DNA Blood Midi Kit (Qiagen). We performed Sanger sequencing of selected exons and introns.

Results

The rs885786 SNP of the SERPINA5 gene was identified in 15 cases and 10 controls (p = 0.09). The rs6113 SNP of the SERPINA5 gene was present in 4 controls compared to 0 cases (p = 0.105). The rs4293393, rs13333226 and rs13335818 SNPs of the UMOD gene were identified in five cases and two controls (p = 0.20), the rs1800012 SNP of the COL1A1 gene in five cases versus four controls (p = 0.24) and the homozygous rs1799750 SNP of the MMP1 gene in eight cases versus five controls (p = 0.18). The combination of the rs885786 SNP of the SERPINA5 gene and rs179970 SNP of the MMP1 gene was detected in ten cases versus five controls (p = 0.072).

Conclusions

We found nonsignificant trends toward associations of SNPs on the SERPINA5, UMOD and MMP1 gene and SUI.

Electronic supplementary material

The online version of this article (10.1007/s00192-019-03878-0) contains supplementary material, which is available to authorized users.

Risk and protective factors for obstetric anal sphincter injuries: A retrospective nationwide study

BACKGROUND

In view of the reported increase in obstetric anal sphincter injuries, the objective of this study was to evaluate the incidence of such injuries over time and the associated risk and protective factors.

METHODS

This was a retrospective cohort study from a national database of 168 137 primiparous women with term, singleton, cephalic, vaginal delivery between 2008 and 2014. The main outcome measure was obstetric anal sphincter injury. A multivariate regression model was used to identify risk and protective factors.

RESULTS

Age >19 years, birthweight >4000 g, and operative vaginal delivery were independent risk factors for obstetric anal sphincter injuries. Mediolateral episiotomy increased the risk for obstetric anal sphincter injuries in spontaneous vaginal birth (number needed to harm 333), whereas it was protective in vacuum delivery (number needed to treat 50). From 2008 to 2014, there was an increase in the rate of obstetric anal sphincter injuries (2.1% vs 3.1%, P < .01), vacuum deliveries (12.1% vs 12.8%, P < .01), and cesarean delivery after labor (17.1% vs 19.4%, P < .01), while forceps deliveries (0.4% vs 0.1%, P < .01) and episiotomy rate decreased (35.9% vs 26.4%, P < .01).

CONCLUSIONS

Episiotomy may be a risk or protective factor depending on the type of episiotomy and the clinical setting in which it is used. Our study supports a restrictive use of mediolateral episiotomy in spontaneous vaginal deliveries. In vacuum deliveries mediolateral episiotomy may help prevent obstetric anal sphincter injuries.

AB0 blood groups and rhesus factor expression as prognostic parameters in patients with epithelial ovarian cancer - a retrospective multi-centre study

BACKGROUND

AB0 blood groups and Rhesus factor expression have been associated with carcinogenesis, response to treatment and tumor progression in several malignancies. The aim of the present study was to test the hypothesis that AB0 blood groups and Rhesus factor expression are associated with clinical outcome in patients with epithelial ovarian cancer (EOC).

METHODS

AB0 blood groups and Rhesus factor expression were evaluated in a retrospective multicenter study including 518 patients with EOC. Their association with patients' survival was assessed using univariate and multivariable analyses.

RESULTS

Neither AB0 blood groups nor Rhesus factor expression were associated with clinico-pathological parameters, recurrence-free, cancer-specific, or overall survival. In a subgroup of patients with high-grade serous adenocarcinoma, however, blood groups B and AB were associated with a better 5-year cancer-specific survival rate compared to blood groups A and 0 (60.3 ± 8.6% vs. 43.8 ± 3.6%, p = 0.04). Yet, this was not significant in multivariable analysis.

CONCLUSIONS

AB0 blood groups and Rhesus factor expression are both neither associated with features of biologically aggressive disease nor clinical outcome in patients with EOC. Further investigation of the role of the blood group B antigen on cancer-specific survival in the subgroup of high-grade serous should be considered.

Transforming Growth Factor Beta 1 Serum Levels in Patients with Preinvasive and Invasive Lesions of the Breast

Transforming growth factor beta (TGF-β)1 is thought to be involved in breast carcinogenesis. TGF-β1 acts in an antiproliferative manner in the early stages of breast carcinogenesis, but promotes tumor progression and metastases in the advanced stages of the disease. No data have been published on serum TGF-β1 in breast cancer. We investigated TGF-β1 serum levels in patients with breast cancer (n=135), ductal carcinoma in situ (DCIS) I to III (n=67) or fibroadenoma (n=35), and in healthy women (n=40) to determine its value as a differentiation marker between malignant, pre-invasive and benign diseases and as a predictive marker for metastatic spread. Median (range) TGF-β1 serum levels in patients with breast cancer, DCIS I-III or benign breast lesions and in healthy women were 48.8 (18–82.4) pg/mL, 45.3 (26.9–58.3) pg/mL, 47.2 (17.2–80.5) pg/mL and 51.6 (30.9–65.1) pg/mL, respectively (p=0.2). In breast cancer patients TGF-β1 serum levels showed no statistically significant correlation with tumor stage, lymph node involvement, histological grade, estrogen receptor status and progesterone receptor status. Our data fail to indicate any correlation between serum TGF-β1 levels and clinicopathological parameters of breast diseases. Serum TGF-β1 levels do not provide clinical information in addition to established tumor markers.

Association of endogenous circulating sex steroids and condition-specific quality of life domains in postmenopausal women with pelvic floor disorders

Objective

To examine the relationship between endogenous sex steroids and various condition-specific quality of life domains in postmenopausal women with pelvic floor disorders. We hypothesized that woman with lowest androgen and estradiol concentrations would report worse scores of quality of life domains.

Methods

Forty-six women with pelvic organ prolapse (POP) and 47 cases with stress urinary incontinence (SUI) answered the validated pelvic floor questionnaire and underwent serum sex steroid measurement. A multivariate logistic regression model was used to determine the association between subjective outcome parameters and serum hormonal levels after adjusting for confounders.

Results

Univariate analysis revealed a strong inverse correlation between serum estradiol level (E2) and prolapse domain score (correlation coefficient = 0.005) as well as a significant positive correlation between SHBG level and prolapse domain score (correlation coefficient = 0.019) in cases with POP. Furthermore, the sex domain score showed a significant negative correlation with the androstendion (correlation coefficient = 0.020), DHEAS (correlation coefficient = 0.046) and testosterone level (correlation coefficient = 0.032) in the POP group. In the multivariate model, high serum SHBG (CI: 0.007–0.046) remained independently associated with worse scores in the prolapse domain and low serum DHEAS (CI: − 0.989 to 1.320) persisted as a significant predictor for a worse score in the sex domain. Regarding SUI cases, no association was noted between serum hormonal levels and quality of life related pelvic floor domains (correlation coefficient > 0.05).

Conclusion

Our results suggest that pelvic floor related quality of life might also be affected by endogenous sex steroids in POP, but not in SUI cases.

Gene expression information improves reliability of receptor status in breast cancer patients

Immunohistochemical (IHC) determination of receptor status in breast cancer patients is frequently inaccurate. Since it directs the choice of systemic therapy, it is essential to increase its reliability.

We increase the validity of IHC receptor expression by additionally considering gene expression (GE) measurements. Crisp therapeutic decisions are based on IHC estimates, even if they are borderline reliable. We further improve decision quality by a responsibility function, defining a critical domain for gene expression. Refined normalization is devised to file any newly diagnosed patient into existing data bases. Our approach renders receptor estimates more reliable by identifying patients with questionable receptor status. The approach is also more efficient since the rate of conclusive samples is increased. We have curated and evaluated gene expression data, together with clinical information, from 2880 breast cancer patients. Combining IHC with gene expression information yields a method more reliable and also more efficient as compared to common practice up to now.

Several types of possibly suboptimal treatment allocations, based on IHC receptor status alone, are enumerated. A ‘therapy allocation check’ identifies patients possibly miss-classified. Estrogen: false negative 8%, false positive 6%. Progesterone: false negative 14%, false positive 11%. HER2: false negative 2%, false positive 50%. Possible implications are discussed.

We propose an ‘expression look-up-plot’, allowing for a significant potential to improve the quality of precision medicine.

Methods are developed and exemplified here for breast cancer patients, but they may readily be transferred to diagnostic data relevant for therapeutic decisions in other fields of oncology.

Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence

CONTEXT

Surgical nonautologous meshes have been used for several decades to repair abdominal wall herniae. Implantable materials have been adopted for the treatment of female and male stress urinary incontinence (SUI) and female pelvic organ prolapse (POP).

OBJECTIVE

A consensus review of existing data based on published meta-analyses and reviews.

EVIDENCE ACQUISITION

This document summarises the deliberations of a consensus group meeting convened by the European Association of Urology (EAU) and the European Urogynecological Association, to explore the current evidence relating to the use of polypropylene (PP) materials used for the treatment of SUI and POP, with reference to the 2016 EAU guidelines (European Association of Urology 2016), the European Commission's SCENIHR report on the use of surgical meshes (SCENIHR 2015), other available high-quality evidence, guidelines, and national recommendations.

EVIDENCE SYNTHESIS

Current data suggest that the use of nonautologous durable materials in surgery has well-established benefits but significant risks, which are specific to the condition and location they are used for. Various graft-related complications have been described-such as infection, chronic pain including dyspareunia, exposure in the vagina, shrinkage, erosion into other organs of xenografts, synthetic PP tapes (used in SUI), and meshes (used in POP)-which differ from the complications seen with abdominal herniae.

CONCLUSIONS

When considering surgery for SUI, it is essential to evaluate the available options, which may include synthetic midurethral slings (MUSs) using PP tapes, bulking agents, colposuspension, and autologous sling surgery. The use of synthetic MUSs for surgical treatment of SUI in both male and female patients has good efficacy and acceptable morbidity. Synthetic mesh for POP should be used only in complex cases with recurrent prolapse in the same compartment and restricted to those surgeons with appropriate training who are working in multidisciplinary referral centres.

PATIENT SUMMARY

Synthetic slings can be safely used in the surgical treatment of stress incontinence in both male and female patients. Patients need to be aware of the alternative therapy and potential risks and complications of this therapy. Synthetic mesh for treating prolapse should be used only in complex cases with recurrent prolapse in specialist referral centres.

Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis

Background

Vesicovaginal fistulas (VVF) are the most commonly acquired fistulas of the urinary tract, but we lack a standardized algorithm for their management. Surgery is the most commonly preferred approach to treat women with primary VVF following benign gynaecologic surgery.

Objective

To carry out a systematic review and meta-analysis on the effectiveness of operative techniques or conservative treatment for patients with postsurgical VVF. Our secondary objective was to define the surgical time and determine the types of study designs.

Methods

PubMed, Old Medline, Embase and Cochrane Central Register of Controlled Trials were used as data sources. This systematic review was modelled on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, including a registration number (CRD42012002097).

Results

We reviewed 282 full text articles to identify 124 studies for inclusion. In all, 1379/1430 (96.4%) patients were treated surgically. Overall, the transvaginal approach was performed in the majority of patients (39%), followed by a transabdominal/transvesical route (36%), a laparoscopic/robotic approach (15%) and a combined transabdominal-transvaginal approach in 3% of cases. Success rate of conservative treatment was 92.86% (95%CI: 79.54–99.89), 97.98% in surgical cases (95% CI: 96.13–99.29) and 91.63% (95% CI: 87.68–97.03) in patients with prolonged catheter drainage followed by surgery. 79/124 studies (63.7%) provided information for the length of follow-up, but showed a poor reporting standard regarding prognosis. Complications were studied only selectively. Due to the inconsistency of these data it was impossible to analyse them collectively.

Conclusions

Although the literature is imprecise and inconsistent, existing studies indicate that operation, mainly through a transvaginal approach, is the most commonly preferred treatment strategy in females with postsurgical VVF. Our data showed no clear odds-on favorite regarding disease management as well as surgical approach and current evidence on the surgical management of VVF does not allow any accurate estimation of success and complication rates. Standardisation of the terminology is required so that VVF can be managed with a proper surgical treatment algorithm based on characteristics of the fistula.

The Impact of the Duration of Adjuvant Chemotherapy on Survival in Patients with Epithelial Ovarian Cancer - A Retrospective Study

Objective

The aim of the present study was to investigate the prognostic role of the duration of adjuvant chemotherapy in patients with epithelial ovarian, fallopian tube and primary peritoneal cancer (EOC).

Materials and Methods

Within the present study we retrospectively evaluated the data of 165 consecutive patients with EOC treated with primary surgery followed by six completed cycles of platinum-taxan based intravenous adjuvant chemotherapy. Medians of total duration of chemotherapy were compared with clinical-pathological parameters. Patients were stratified into four risk groups according to the delay in days of total duration of chemotherapy, and univariate and multivariable survival analyses were performed.

Results

The median duration of six completed cycles of chemotherapy comprised 113 days (IQR 107–124 days). Uni- and multivariable survival analyses revealed a delay of total duration of chemotherapy of at least 9 days to be associated with progression-free (PFS), cancer-specific (CSS) and overall survival (OS). Hazard ratios (HR), confidence intervals (95% CI) and p-values for PFS, CSS and OS due to delay of chemo-duration were 2.9 (1.6–5.4; p = 0.001), 2.9 (1.3–6.2; p = 0.008) and 2.6 (1.3–5.4; p = 0.008), respectively.

Prolonged total chemo-duration was associated with the amount of postoperative residual disease (p = 0.001) and the patients’ age (p = 0.03).

Conclusion

The present study suggests a prolonged duration of adjuvant chemotherapy after primary surgery to adversely affect PFS, CSS and OS in patients with EOC. Yet larger studies are required to validate our results.

Pelvic organ prolapse and endogenous circulating sex steroids in postmenopausal women: A case control-study

OBJECTIVE

We compared sex steroid levels of postmenopausal patients with symptomatic pelvic organ prolapse (POP) with postmenopausal matched patients without any sign of POP. Furthermore, we evaluated a possible relationship between sex steroid levels and various urogynecologic parameters in cases with POP. Main outcome of interest were differences in circulating estradiol levels between the two groups.

STUDY DESIGN

We conducted a case-control study and 46 postmenopausal women with symptomatic POP≥stage 2 were matched 1:1 with 46 urogynecologic healthy women. Blood samples were drawn from all patients for assessment for estradiol (E2), Follicle-stimulating hormone (FSH), Luteinizing hormone (LH), testosterone (T), androstendion (AEON), dehydroepiandrosterone sulphate (DHEAS) and sex hormone binding globulin (SHBG) with an Electrochemiluminescence immunoassay.

RESULTS

Our study failed to show any statistically significant differences in sex steroid levels between women with and without POP (p>0.05). However, serum concentration of E2 (p<0,0001), free testosterone (p=0,034) and DHEAS (p=0,024) was statistically significant lower in patients with severe prolapse stage. Serum levels of E2 were statistically significant higher in cases with moderate-strong Oxford Grading Scale (p<0,0001). Low circulating E2 (p=0,019) as well as menopausal age (p=0,022) remained independent risk factors for POP in multiple logistic regression analysis.

CONCLUSION

The significant low hormonal levels in cases with high POP-Q stage as well as the significant higher estradiol levels in patients with strong Oxford Grading Scale may indicate that endogenous circulating sex steroids might have a potential role in the severity and progression of POP.

The role of fibroblast growth factor 2 in patients with uterine smooth muscle tumors: an immunohistochemical study

OBJECTIVE

Fibroblast growth factor 2 (FGF-2) is considered to be a potent stimulator of angiogenesis and seems therefore to play an important role in the growth of tumors. We compared the immunohistochemical profile of FGF-2 in patients with uterine leiomyomas, smooth muscle tumors of uncertain malignant potential (STUMP) and leiomyosarcoma (LMS). Furthermore, we tried to clarify the prognostic role of FGF-2 in uterine leiomyosarcoma.

STUDY DESIGN

FGF-2 expression was investigated by immunohistochemistry from paraffin-embedded tissue in 26 patients with leiomyoma, in 24 cases with STUMP and in 21 patients with LMS. The immunohistochemical profile of these 3 tumor entities was compared and regarding LMS correlated with different clinicopathologic parameters.

RESULTS

FGF-2 was expressed in 85% of leiomyomas, in 88% of STUMP and in 57% of LMS. Significant differences regarding the frequency of FGF-2 expression were observed between leiomyoma and LMS as well as between STUMP and LMS (p<0.05). In uterine LMS FGF-2 expression was statistically more frequent in cases with high histological grade (p<0.05). Furthermore, FGF-2 positive tumors demonstrated a statistically significant higher rate of recurrence disease and tumor progression (p=0.005). Disease free as well as overall survival was significantly shortened in patients with FGF-2 positive compared to FGF-2 negative tumors (p<0.05).

CONCLUSION

The significant correlation between FGF-2 expression and high histological grade indicates that FGF-2 might work as a negative predictive factor. Higher rates of recurrence disease as well as shortened disease free and overall survival among FGF-2 positive LMS support the potential role as prognosticator for poor clinical outcome.

The prognostic role of metformin in patients with endometrial cancer: a retrospective study

OBJECTIVE

Metformin has recently been discussed to possess anticancer activities and to positively affect the risk of developing cancer. We performed the present study to investigate the association of metformin and survival in patients with endometrial cancer.

STUDY DESIGN

Within the present study we retrospectively reviewed the records of 465 consecutive patients with endometrial cancer. Drug intake of metformin was correlated with clinico-pathological parameters and the patients' survival. Chi-square test, Kruskal Wallis test, the product limit method of Kaplan and Meier, and multivariable Cox regression models were used to assess associations between metformin and clinico-pathological parameters and survival, as appropriate.

RESULTS

Eighty-seven (18.7%) patients suffered from diabetes and of these 46 (52.8%) used metformin at the time of diagnosis. When analysing all patients, metformin did not affect the patients' survival. However, within the subgroup of overweight patients metformin was associated with a prolongation of overall survival (p=0.04). Within this subgroup, diabetic patients who did not use metformin had a 2.3 times higher risk for death (95%CI 1.1-4.7; p=0.02) compared to non-diabetic patients and diabetic patients using metformin. Metformin was not associated with prolonged recurrence-free or cancer-specific survival, irrespective of the patients' body mass index (p=0.08 and p=0.4, respectively).

CONCLUSION

The results of our study might suggest a beneficial effect of metformin on overall survival in overweight diabetic patients with endometrial cancer. However, the question, if metformin can reduce the risk to die from endometrial cancer or improves all cause mortality only still remains open and needs further investigation.

Urinary proteomic pattern in female stress urinary incontinence: a pilot study

Introduction and hypothesis

Previous studies aiming to identify specific pre-defined urine protein biomarkers for stress urinary incontinence (SUI) have not identified clinically important differences. The hypothesis of our study was that the global distribution of urinary proteins, the proteome, differs between women with and those without SUI.

Methods

In this age-matched case–control study, we compared the urinary proteome of 20 women with SUI and 20 controls. Proteins were identified by applying high-performance liquid chromatography separation and tandem mass spectrometry detection. Data analysis was performed using Mascot 2.4.1 embedded in ProteinScape 3.1.

Results

We identified 828 different proteins. The concentration of six of those showed a significant difference between urine samples of SUI patients and those of controls (q value < 0.25). Four proteins showed a higher abundance in SUI samples compared with controls: plasma serine protease inhibitor (logFC 1.11), leucine-rich alpha-2-glycoprotein (logFC 3.91), lysosomal alpha-glucosidase (logFC 1.24), and peptidyl-prolyl cis- trans isomerase A (logFC 1.96). We identified two proteins in lower abundance in SUI samples compared with controls: uromodulin (logFC −4.87) and TALPID3 (logFC −1.99).

Conclusions

Overexpression of plasma serine protease inhibitor, leucine-rich alpha-2-glycoprotein, lysosomal alpha-glucosidase, and peptidyl-prolyl cis- trans isomerase A, and lower expression of uromodulin and TALPID3, in urine may be associated with female SUI.

Electronic supplementary material

The online version of this article (doi:10.1007/s00192-016-3033-5) contains supplementary material, which is available to authorized users

Urinary and anal dysfunction after laparoscopic versus laparotomic radical hysterectomy

OBJECTIVE

The aim of this study was to compare urinary and anal dysfunction after laparoscopic (LRH) and abdominal (ARH) radical hysterectomy for cervical cancer.

STUDY DESIGN

Consecutive patients who underwent radical hysterectomy for treatment of cervical cancer were enrolled in this study and divided into two groups, according to the surgical approach. Urinary and anal symptoms were evaluated before and 6 months after surgery.

RESULTS

Fifty-four women were considered: 27 LRH and 27 ARH. Urinary incontinence was significantly more frequent both after LRH (37% vs 86.9%, p=0.0004) and after ARH (33.3% vs 100%, p<0.0001); urge incontinence (3.7% vs 29.6%, p=0.02) and increased bladder sensation (0 vs 22.2%, p=0.02) were significantly more common postoperatively in patients undergone ARH. In both groups more patients complain about increase of straining during voiding (LRH: 0 vs 34.7%, p=0.009; ARH: 3.7% vs 29.6% p=0.02) after surgery. Postoperative constipation by obstructed defecation was more frequent after ARH (Wexner score: 0 vs 2, p=0.03) but not after LRH.

CONCLUSION

From our results, laparoscopic approach for radical hysterectomy seems to reduce the postoperative occurrence of urge incontinence, increased bladder sensation and constipation by obstructed defecation, in comparison with abdominal radical surgery.

The Prognostic Value of C-Reactive Protein Serum Levels in Patients with Uterine Leiomyosarcoma

Objective

C-reactive protein (CRP) has previously been shown to serve as a prognostic parameter in women with gynecologic malignancies. Due to the lack of valid prognostic markers for uterine leiomyosarcoma (ULMS) this study set out to investigate the value of pre-treatment CRP serum levels as prognostic parameter.

Methods

Data of women with ULMS were extracted from databases of three Austrian centres for gynaecologic oncology. Pre-treatment CRP serum levels were measured and correlated with clinico-pathological parameters. Univariate and multivariable survival analyses were performed.

Results

In total, 53 patients with ULMS were included into the analysis. Mean (SD) CRP serum level was 3.46 mg/dL (3.96). Solely, an association between pre-treatment CRP serum levels and tumor size (p = 0.04) but no other clinic-pathologic parameter such as tumor stage (p = 0.16), or histological grade (p = 0.07), was observed. Univariate and multivariable survival analyses revealed that CRP serum levels (HR 2.7 [1.1–7.2], p = 0.037) and tumor stage (HR 6.1 [1.9–19.5], p = 0.002) were the only independent prognostic factors for overall survival (OS) in patients with ULMS. Patients with high pre-treatment CRP serum levels showed impaired OS compared to women with low levels (5-year-OS rates: 22.6% and 52.3%, p = 0.007).

Conclusion

High pre-treatment CRP serum levels were independently associated with impaired prognosis in women with ULMS and might serve as a prognostic parameter in these patients.

Adjuvant treatment decisions for patients with endometrial cancer in Germany: results of the nationwide AGO pattern of care studies from the years 2013, 2009 and 2006

PURPOSE

In 2013, 2009 and 2006, the Arbeitsgemeinschaft Gynäkologische Onkologie evaluated the therapeutic approaches for endometrial carcinoma and the adherence to their guideline in Germany. Here, the adjuvant treatment decisions were presented.

METHODS

A questionnaire was developed and sent to all 682 German gynecological departments in 2013 (775 in 2009 and 500 in 2006, respectively). The results of the questionnaires were compared with the recommendations of the guideline and with each other using Fisher's exact test.

RESULTS

Responses were available in 40.0 % in 2013, 33.3 % in 2009 and 35.8 % in 2006. Participants recommended external beam radiotherapy (EBRT) in 13 out of 16 requested stages and vaginal brachytherapy (VBT) in only 10 out of 16 requested stages as suggested by the guideline. Comparing the results of 2013 with 2009, less participants used EBRT and VBT in 7 out of 16 and in 6 out of 16 requested stages, respectively. Conversely, more participants offered adjuvant chemotherapy (CT) in 2013 (90.4 %) compared to 61.9 % in 2009 (p < 0.001) and 48.8 % in 2006 (p < 0.001), respectively. However, the stage-adjusted recommendations of CT were not in line with the guideline in 11 out of 15 requested stages. In total, 77.3 % of the participants use a multiple drug schedule with a platinum and a taxane compound.

CONCLUSIONS

The results suggest non-adherence to the guideline concerning the stage-adjusted use of VBT and CT in endometrial carcinoma. These findings emphasize great uncertainties and the need of more clarifying trials. Furthermore, a shift from radiotherapy toward CT is observable.

Nationwide analysis on surgical procedures for patients with endometrial cancer in Germany: results of the AGO pattern of care studies from the years 2013, 2009, and 2006

PURPOSE

In 2013, 2009, and 2006, the Arbeitsgemeinschaft Gynäkologische Onkologie evaluated the therapeutic approaches and the adherence to their guidelines for endometrial carcinoma (EC) in Germany. Here, we present the results concerning the surgical procedures.

METHODS

A questionnaire was developed and sent to 682 German gynecological departments in 2013 (775 in 2009 and 500 in 2006). The results were compared with the recommendations of the guideline and with each other.

RESULTS

Responses were available in 40.0 % in 2013, 33.3 % in 2009, and 35.8 % in 2006, respectively. Pelvic lymphadenectomy (LAN) was performed in accordance with the guidelines with some exceptions in 2013, 2009, and 2006, whereas paraaortic LAN was performed in accordance with the guideline only in 2009. Histological high-risk subtypes of EC received pelvic and paraaortic LAN in 2013, 2009, and 2006 in accordance with the guidelines with small exceptions. LAN for Patients, who were postoperatively upstaged or upgraded, was not conducted in accordance with the guidelines in 2013, 2009, and 2006. In 2013, 84.6 % of the participants offered the laparoscopic approach (LSA) for hysterectomy and bilateral salpingo-oophorectomy, 63.3 % for pelvic LAN, and 49.1 % for paraaortic LAN, respectively. More participants offered the LSA in 2013 compared to 2009 and 2006 (p values <0.014).

CONCLUSIONS

The paraaortic LAN, the LSA as well as the second operation on patients who had postoperatively been upstaged were not conducted in accordance with the guideline [CORRECTED]. Improvements concerning surgical treatment are possible and might lead to higher survival rates and a reduction of morbidity in patients with EC in Germany.

Bladder function after radical hysterectomy for cervical cancer

AIM

To report the effects of radical hysterectomy and nerve-sparing techniques on lower urinary tract function in women.

METHODS

A literature search was performed in Pubmed and Medline using the keywords bladder after radical hysterectomy, nerve sparing radical hysterectomy, and urinary dysfunction following radical hysterectomy. Significant results and citations were reviewed manually by the authors.

RESULTS

The sympathetic and parasympathetic systems innervating the lower urinary tract may be disrupted due to resection of uterosacral and rectovaginal ligaments, the dorsal and lateral paracervix, the caudal part of the vesico-uterine ligaments, and the vagina. This supports the neurogenic etiology of early and late bladder dysfunction after radical surgery. Bladder disorders are also related to the extent of radical surgery. The neuropathopysiology of lower urinary tract symptoms after radical hysterectomy is not fully understood. Recent data have highlighted the role of urethral sphincter pressure in the etiology of postoperative incontinence. Various surgical approaches have been developed to preserve autonomic pelvic innervation.

CONCLUSIONS

Nerve-sparing techniques appear to improve bladder function without compromising overall survival. Studies comparing the effects of nerve-sparing radical hysterectomy with standard surgery yielded encouraging results in respect of postoperative lower urinary tract function. Clinical trials with a long period of follow-up are required for better comprehension of the complex pathophysiology of bladder dysfunction after radical hysterectomy.

Detrusor underactivity and the underactive bladder: a new clinical entity? A review of current terminology, definitions, epidemiology, aetiology, and diagnosis

CONTEXT

Detrusor underactivity (DU) is a common cause of lower urinary tract symptoms (LUTS) in both men and women, yet is poorly understood and underresearched.

OBJECTIVE

To review the current terminology, definitions, and diagnostic criteria in use, along with the epidemiology and aetiology of DU, as a basis for building a consensus on the standardisation of current concepts.

EVIDENCE ACQUISITION

The Medline and Embase databases were searched for original articles and reviews in the English language pertaining to DU. Search terms included underactive bladder, detrusor underactivity, impaired detrusor contractility, acontractile detrusor, detrusor failure, detrusor areflexia, raised PVR [postvoid residual], and urinary retention. Selected studies were assessed for content relating to DU.

EVIDENCE SYNTHESIS

A wide range of terminology is applied in contemporary usage. The only term defined by the standardisation document of the International Continence Society (ICS) in 2002 was the urodynamic term detrusor underactivity along with detrusor acontractility. The ICS definition provides a framework, considering the urodynamic abnormality of contraction and how this affects voiding; however, this is necessarily limited. DU is present in 9-48% of men and 12-45% of older women undergoing urodynamic evaluation for non-neurogenic LUTS. Multiple aetiologies are implicated, affecting myogenic function and neural control mechanisms, as well as the efferent and afferent innervations. Diagnostic criteria are based on urodynamic approximations relating to bladder contractility such as maximum flow rate and detrusor pressure at maximum flow. Other estimates rely on mathematical formulas to calculate isovolumetric contractility indexes or urodynamic "stop tests." Most methods have major disadvantages or are as yet poorly validated. Contraction strength is only one aspect of bladder voiding function. The others are the speed and persistence of the contraction.

CONCLUSIONS

The term detrusor underactivity and its associated symptoms and signs remain surrounded by ambiguity and confusion with a lack of accepted terminology, definition, and diagnostic methods and criteria. There is a need to reach a consensus on these aspects to allow standardisation of the literature and the development of optimal management approaches.

Changes in sexual function and quality of life after single-incision mid-urethral sling for treatment of female stress urinary incontinence

OBJECTIVES

To evaluate the effectiveness and assess the changes in sexual function and quality of life after placement of a single-incision sling for the treatment of female stress urinary incontinence.

STUDY DESIGN

A prospective study of women diagnosed with stress urinary incontinence. The single-incision sling was implanted and patients were followed postoperatively for 6 months. The postoperative rate of continence, complications, changes in sexual function, and patient-reported quality of life were evaluated. Female Sexual Function in sexually active patients was evaluated before and after the single-incision sling procedure using the Female Sexual Function Index. From January 2009 to November 2011, 73 patients were enrolled and underwent the procedure to implant the MiniArc® or Ajust® single-incision sling.

RESULTS

Overall, 93.2% of the patients who successfully received a single-incision sling demonstrated total restoration of continence (83.6%) or improved continence (9.6%) at the 6-month postoperative visit. Improvements were seen in the quality of life scores related to global bladder feeling (87.7%) and the Female Sexual Function Index (preoperative score 23.86±5.67 vs postoperative score 27.25±4.66 [P<0.0001]).

CONCLUSION

Single-incision sling treatment for stress urinary incontinence led to improvements in continence and sexual function at 6 months of postoperative follow-up.

Different surgical approaches for stress urinary incontinence in women

Stress urinary incontinence (SUI) constitutes involuntary voiding as a consequence of rising intra-abdominal pressure caused by sphincter weakness. In recent years studies were published according to surgical SUI management evaluating and comparing therapy options and outcomes. Therapy options were evaluated using a Medline search, including only publications in English between 2000-2012. Key words used were: SUI, conservative and surgical treatment, midurethral sling, colposuspension. Surgical treatment options demonstrate significantly better results than conservative treatment. MUS demonstrate better subjective and objective cure rates than colposuspension; it is less invasive and more cost-effective. First line SUI therapy such as RP MUS and TVT seem to be favored when compared to transobturator techniques. Retropubic and transobturator MUS showed equivalent objective and subjective success rates. Open colposuspension is an effective treatment possibility for recurrent SUI after failed MUS. TVT, compared with other MUS, seems to show slightly better cure rates. but perioperative complications appear to be similar. Long-term results (>10 years) of repeated SUI surgery showed that the Burch procedure had the lowest 9-year cumulative incidence of repeat SUI surgery. Mini-sling techniques may be underestimated but long-time results are pending and closer monitoring of the adverse event profile must be carried out. MUS are first choice in the treatment of SUI, of which TVT, has the best cure rate. Colpussupension continues to have its place in recurrent SUI. The new mini-MUS needs a longer follow-up for final evaluation.

Sexual function and quality of life following retropubic TVT and single-incision sling in women with stress urinary incontinence: results of a prospective study

PURPOSE

The objective of this prospective cohort study was to compare effectiveness, morbidity, quality of life (QoL) and sexual function in women treated with tension-free vaginal tape (TVT) versus single-incision sling (SIS) in the treatment of female stress urinary incontinence (SUI).

METHODS

Retropubic TVT sling or SIS was implanted in local anesthesia and patients were followed post-operatively for 6 months. Evaluation was performed to assess post-operative rate of continence, complications, changes in sexual function and patient reported quality of life. Female sexual function was evaluated before and after sling procedure using Female Sexual Function Index (FSFI) in sexually active patients.

RESULTS

From January 2009 to December 2011, 150 patients were enrolled and underwent a procedure to implant the retropubic TVT (n = 75) or the MiniArc(®) and Ajust(®) SIS (n = 75). Overall, 93.3 % of the patients who successfully received SIS demonstrated total restoration (84 %) or improvement of continence (9.3 %) at the 6 month post-operative study visit. In TVT group we found 88 % total continence and 6.7 % improvement, respectively. Improvements were seen in the QoL scores related to global bladder feeling (89.3 %) in SIS group and 96 % for TVT. Post-operative FSFI score improves significantly and were comparable in both groups (SIS pre-operative 24.30 ± 4.56 to 27.22 ± 4.66 (P < 0.001) post-operative; TVT 24.63 ± 6.62 to 28.47 ± 4.41, respectively).

CONCLUSIONS

The SIS procedure appears to be as effective in improving incontinence-related quality of life and sexual function as the TVT through 6 months of post-operative follow-up. No differences in complications and sexual function were demonstrated between the groups.

Abstract P2-10-13: CD4 positive tumor-infiltrating lymphocytes are associated with improved prognosis in node-negative breast cancer

Background: The prognostic significance of CD8 positive cytotoxic lymphocytes in breast cancer is well accepted. However, the role of CD4 positive lymphocytes is ambiguous. We examined the prognostic relevance of CD4 positive tumor-infiltrating lymphocytes in previously published node-negative breast cancer cohorts using RNA expression.

Methods: Microarray based gene-expression data for CD4 (203547_at) were analyzed in four previously published cohorts (Mainz, Rotterdam, Transbig, Yu) of node-negative breast cancer patients not treated with adjuvant therapy (n = 824). A meta-analysis of previously published cohorts was performed using a random effects model. Prognostic significance of CD4 on metastasis-free survival (MFS) was examined in the whole cohort and in different molecular subtypes (ER+/HER2−, ER−/HER2−, HER2+). Independent prognostic relevance was analyzed using multivariate Cox regression.

Results: Higher RNA expression of CD4 was related to better MFS in a meta-analysis of the whole cohort (HR 0.66, 95% CI 0.49–0.90, p = 0.0074). Prognostic significance was most pronounced in the HER2+ positive molecular subtype (HR 0.32, 95% CI 0.14–0.75, p = 0.0091) as compared to ER+/HER2− (HR 0.62, 95% CI 0.29–1.32, P&gt;0.05) and ER−/HER2− (HR 0.61, 95% CI 0.28–1.35, P&gt;0.05) carcinomas of the breast. CD4 showed independent prognostic significance (HR 0.60, 95% CI 0.37–0.96, p = 0.032) in multivariate analysis. In addition to CD4, only histological grade of differentiation (HR 2.43, 95% CI 1.50–3.94, P &lt; 0.001) and tumor size (HR 1.87, 95% CI 1.19–2.94, p = 0.007), but not age, HER2 status or hormone receptor status retained an independent prognostic association with MFS.

Conclusion: CD4 positive tumor-infiltrating lymphocytes have independent prognostic significance in node-negative breast cancer. A higher expression is associated with improved outcome.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-13.

[Measurement of the infrapubic angle using 3D perineal ultrasound and its relationship to obstetrical parameters]

PURPOSE

Ultrasound has achieved an indispensable role in urogynecology. The introduction of 3 D technology has enabled sonographers to visualize structures in the axial plane. The angle of the infrapubic arc may enable us to presume the shape of the pelvis. Our aim was to describe a method for measuring the infrapubic angle and the interpubic space with 3 D perineal ultrasound through 3 D rotation, correlating them with the length of the 2nd stage of labor and the rate of levator defects.

MATERIALS AND METHODS

Women after vaginal delivery were recruited and underwent a 3 D perineal ultrasound on 2nd - 3 rd day postpartum. Volume datasets were analyzed to measure the infrapubic angle and the interpubic space independently by 2 urogynecologists. The interobserver reliability and the correlation between infrapubic arc angle and the length of the 2nd stage of labor and the occurrence of levator defects were calculated.

RESULTS

110 women were enrolled. With a correlation coefficient of 0.76, the relationship between the infrapubic angle measurements of the two observers was very good. A moderate to good correlation was found for the assessment of the interpubic gap, with r = 0.69. Between the infrapubic angle and length of the 2nd stage of labor, no statistical correlation for both observer measurements (p = 0.31; p = 0.78, respectively) was found. Also the correlation between the infrapubic arc angle and the occurrence of levator avulsions was not significant (p = 0.59; p = 0.39, respectively).

CONCLUSION

3 D ultrasound technology enables us to identify and evaluate the interpubic gap and the infrapubic arc with a high inter-observer reproducibility. However, from our data, the infrapubic angle does not seem to influence the length of the 2nd stage of labor and the occurrence of levator defects.

Expression of aurora kinase A is associated with metastasis-free survival in node-negative breast cancer patients

BACKGROUND

Inhibitors targeting the cell cycle-regulated aurora kinase A (AURKA) are currently being developed. Here, we examine the prognostic impact of AURKA in node-negative breast cancer patients without adjuvant systemic therapy (n = 766).

METHODS

AURKA was analyzed using microarray-based gene-expression data from three independent cohorts of node-negative breast cancer patients. In multivariate Cox analyses, the prognostic impact of age, histological grade, tumor size, estrogen receptor (ER), and HER2 were considered.

RESULTS

Patients with higher AURKA expression had a shorter metastasis-free survival (MFS) in the Mainz (HR 1.93; 95% CI 1.34 - 2.78; P < 0.001), Rotterdam (HR 1.95; 95% CI 1.45- 2.63; P<0.001) and Transbig (HR 1.52; 95% CI 1.14-2.04; P=0.005) cohorts. AURKA was also associated with MFS in the molecular subtype ER+/HER2- carcinomas (HR 2.10; 95% CI 1.70-2.59; P<0.001), but not in ER-/HER2- nor in HER2+ carcinomas. In the multivariate Cox regression adjusted to age, grade and tumor size, AURKA showed independent prognostic significance in the ER+/HER2- subtype (HR 1.73; 95% CI 1.24-2.42; P=0.001). Prognosis of patients in the highest quartile of AURKA expression was particularly poor. In addition, AURKA correlated with the proliferation metagene (R=0.880; P<0.001), showed a positive association with grade (P<0.001), tumor size (P<0.001) and HER2 (P<0.001), and was inversely associated with ER status (P<0.001).

CONCLUSIONS

AURKA is associated with worse prognosis in estrogen receptor positive breast carcinomas. Patients with the highest AURKA expression (>75% percentile) have a particularly bad prognosis and may profit from therapy with AURKA inhibitors.

Immunoglobulin kappa C predicts overall survival in node-negative breast cancer

Background

Biomarkers of the immune system are currently not used as prognostic factors in breast cancer. We analyzed the association of the B cell/plasma cell marker immunoglobulin kappa C (IGKC) and survival of untreated node-negative breast cancer patients.

Material and Methods

IGKC expression was evaluated by immunostaining in a cohort of 335 node-negative breast cancer patients with a median follow-up of 152 months. The prognostic significance of IGKC for disease-free survival (DFS) and breast cancer-specific overall survival (OS) was evaluated with Kaplan-Meier survival analysis as well as univariate and multivariate Cox analysis adjusted for age at diagnosis, pT stage, histological grade, estrogen receptor (ER) status, progesterone receptor (PR) status, Ki-67 and human epidermal growth factor receptor 2 (HER-2) status.

Results

160 patients (47.7%) showed strong expression of IGKC. Univariate analysis showed that IGKC was significantly associated with DFS (P = 0.017, hazard ratio [HR] = 0.570, 95% confidence interval [CI] = 0.360–0.903) and OS (P = 0.011, HR = 0.438, 95% CI = 0.233–0.822) in the entire cohort. The significance of IGKC was especially strong in ER negative and in luminal B carcinomas. In multivariate analysis IGKC retained its significance independent of established clinical factors for DFS (P = 0.004, HR = 0.504, 95% CI = 0.315–0.804) as well as for OS (P = 0.002, HR = 0.371, 95% CI = 0.196–0.705).

Conclusion

Expression of IGKC has an independent protective impact on DFS and OS in node-negative breast cancer.

Cerebral metastases of an endometrial stromal sarcoma: report of the first case

BACKGROUND

Endometrial stromal sarcomas (ESSs) of the uterus are rare gynecological malignancies. Common locations of distant metastases are vagina, vulva, lung, mediastinum, abdomen, bones and ovaries.

CASE REPORT

We present the case of a 69-year-old woman with a Federation of Gynecology and Obstetrics (FIGO) IIb (classification 2009) ESS of the uterus of high-grade malignancy. Initially, a hysterectomy Piver II and total colpectomy were performed, followed by pelvic field irradiation. 8 months later, the patient suffered seizures and hemiparesis. A computed tomography (CT) scan revealed cerebral metastases, and irradiation of the brain was initiated. After completion of the staging examinations, additional metastases of lung, abdomen, mediastinum, vulva and inguinal lymph nodes were found. This is the first reported case of brain metastases of an ESS.

CONCLUSION

Appropriate treatment options like surgery, chemotherapy or endocrine therapy should be discussed on an individual basis since large-scale clinical trials have not yet been conducted in this rare entity.

Long-term outcomes of the Ajust Adjustable Single-Incision Sling for the treatment of stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of this study was to evaluate the effectiveness and overall safety of the Ajust Adjustable Single-Incision Sling in the treatment of female stress urinary incontinence.

METHODS

This was a prospective, multicenter study conducted in women diagnosed with stress urinary incontinence. The Ajust Sling was implanted and patients were followed postoperatively for up to 29 months. Evaluations were performed to assess postoperative rate of continence, complications, and patient quality of life (QOL).

RESULTS

From November 2008 through May 2009, 52 patients were enrolled and underwent a procedure to implant the Ajust Sling. Overall, 86.3 % of the patients who successfully received the Ajust Sling demonstrated total restoration or improvement of continence at the last study visit. QOL scores related to global bladder feeling and lifestyle improved. Only one patient reported the occurrence of mild pain which resolved without treatment or sequelae.

CONCLUSIONS

In long-term follow-up, the Ajust Sling was safe and effective, restoring or improving continence in 86.3 % of patients.

Prediction of late metastasis in node-negative breast cancer

10551

Background: Prediction of late metastasis is of clinical relevance in breast cancer. However, systematic genome-wide studies to identify genes associated with increased risk of metastasis 5 or more years after surgery are scarce. Methods: We examined the natural course of disease in three previously published cohorts (Mainz, Rotterdam, Transbig) including 766 node-negative breast cancer patients with gene array data who did not receive systemic chemotherapy in the adjuvant setting. We established a Cox regression based method adjusted for multiple testing that identified genes predicting late metastasis (5 or more years after surgery). Only those genes were accepted that showed similar results in all three cohorts. Metastasis-free survival (MFS) was analyzed with univariate and multivariate Cox regression. Results: We identified 9 genes [ABCC5 (Hazard Ratio (HR) 2.19, p=0.003), EDDM3B (HR 3.58, p=0.044), RAD23B (HR 0.37, p<0.001), XYLT2 (HR 2.19, p=0.027), DDX18 (HR 0.35, p=0.006), GPBP1L1 (HR 0.20, p=0.018), UBB (HR 9.73, p=0.025), RPS24 (HR 0.20, p=0.050), GPC1 (HR 2.36, p=0.013)] predicting late metastasis. These genes retained their independent prognostic significance after adjustment for established clinical factors (age, tumor size, grade, hormone receptor status, HER2) and biological motives like estrogen receptor, proliferation, B or T cells. These late-type genes are largely associated with resistance to hypoxia, apoptosis and DNA damage, suggesting that they might contribute to persistence of disseminated tumor cells. Conclusions: Genes associated with late metastasis offer a perspective to identify breast cancer patients suitable for additional and prolonged therapies.