Relugolix, a novel oral gonadotropin-releasing hormone antagonist, in the treatment of pain symptoms associated with uterine fibroids: a randomized, placebo-controlled, phase 3 study in Japanese women

OBJECTIVE

To investigate the efficacy and safety of the oral gonadotropin-releasing hormone receptor antagonist, relugolix, in patients experiencing uterine fibroid-associated pain.

DESIGN

Phase 3, multicenter, randomized, double-blind, placebo-controlled study.

SETTING

Medical centers.

PATIENT(S)

Premenopausal Japanese women (N = 65) experiencing moderate-to-severe uterine fibroid-associated pain with a maximum Numerical Rating Scale (NRS) score of ≥4 were randomized and completed the study.

INTERVENTION(S)

Once-daily 40 mg relugolix (n = 33) or placebo (n = 32) for 12 weeks.

MAIN OUTCOME MEASURE(S)

Primary end point: proportion of patients with a maximum NRS score of ≤1 during the 28-day period before the final dose of study drug. Secondary end points: proportion of patients with no pain (NRS = 0) and percentage of days without pain during the 28-day period before the final dose of study drug; adverse events.

RESULT(S)

More patients receiving relugolix versus placebo achieved a maximum NRS score of ≤1 during the 28-day period before the final dose of study drug (57.6% vs. 3.1%). Similarly, more patients receiving relugolix versus placebo achieved a maximum NRS score of 0 (48.5% vs. 3.1%) and experienced more days without pain (96.4% vs. 71.4%). More patients receiving relugolix versus placebo experienced treatment-emergent adverse events (TEAEs; 87.9% vs. 56.3%); however, the rate of treatment discontinuation was low and not different between groups. Most TEAEs were mild to moderate in intensity. TEAEs (≥10%) included hot flush, metrorrhagia, hyperhidrosis, and menorrhagia, consistent with relugolix's mechanism of action, and viral upper respiratory tract infection.

CONCLUSION(S)

Relugolix improved uterine fibroid-associated pain and was well tolerated.

CLINICAL TRIAL REGISTRATION NUMBERS

NCT02655224.

JAPIC CLINICAL TRIAL INFORMATION

JapicCTI-163127.

Erythropoietin Receptor Antagonist Suppressed Ectopic Hemoglobin Synthesis in Xenografts of HeLa Cells to Promote Their Destruction

The aim of this study is to explore a cause-oriented therapy for patients with uterine cervical cancer that expresses erythropoietin (Epo) and its receptor (EpoR). Epo, by binding to EpoR, stimulates the proliferation and differentiation of erythroid progenitor cells into hemoglobin-containing red blood cells. In this study, we report that the HeLa cells in the xenografts expressed ε, γ, and α globins as well as myoglobin (Mb) to produce tetrameric α2ε2 and α2γ2 and monomeric Mb, most of which were significantly suppressed with an EpoR antagonist EMP9. Western blotting revealed that the EMP9 treatment inhibited the AKT-pAKT, MAPKs-pMAPKs, and STAT5-pSTAT5 signaling pathways. Moreover, the treatment induced apoptosis and suppression of the growth and inhibited the survival through disruption of the harmonized hemoprotein syntheses in the tumor cells concomitant with destruction of vascular nets in the xenografts. Furthermore, macrophages and natural killer (NK) cells with intense HIF-1α expression recruited significantly more in the degenerating foci of the xenografts. These findings were associated with the enhanced expressions of nNOS in the tumor cells and iNOS in macrophages and NK cells in the tumor sites. The treated tumor cells exhibited a substantial number of perforations on the cell surface, which indicates that the tumors were damaged by both the nNOS-induced nitric oxide (NO) production in the tumor cells as well as the iNOS-induced NO production in the innate immune cells. Taken together, these data suggest that HeLa cells constitutively acquire ε, γ and Mb synthetic capacity for their survival. Therefore, EMP9 treatment might be a cause-oriented and effective therapy for patients with squamous cell carcinoma of the uterine cervix.

Erythropoietin is involved in hemoprotein syntheses in developing human decidua

Before establishment of feto-placental circulation, decidua can synthesize hemoproteins to maintain oxygen homeostasis in situ. Using the human decidua of induced abortions ranging from 5 to 8 weeks of gestation, we determined the expression levels of erythropoietin, erythropoietin receptor, cytoglobin, myoglobin, embryonic-, fetal- and adult hemoglobin mRNA by quantitative RT-PCR analysis and identified their proteins by Western blot and immunohistochemical analyses. Erythropoietin signaling was demonstrated in phosphatidylinositol-3-kinase/protein kinase B pathway by Western blot, and the transcriptional factors for erythroid and non-erythroid heme synthesis were examined by RT-PCR analysis. In decidua, erythropoietin and its receptor mRNAs, erythropoietin receptor protein and phosphatidylinositol-3-kinase, were expressed with a peak at 6 weeks of gestation. Moreover, the decidua during 5 to 8 weeks of gestation expressed embryonic, fetal and adult hemoglobins additionally cytoglobin and myoglobin at transcriptional and protein levels. The heme portion of these hemoproteins is considered to be synthesized by non-erythroid δ-aminolevulinate synthase. These hemoproteins were discernible especially in decidual cells concomitant with cytotrophoblast cells and macrophage in these developing decidua. Considering the different capacity for oxygen binding and dissociation among hemoglobins with the oxygen storage capacity for cytoglobin and myoglobin, these hemoproteins appear to play a role in oxygen demand in decidua in situ before development of feto-placental circulation under the control of erythropoietin signaling.

Exposure to ethinyl estradiol prenatally and/or after sexual maturity induces endometriotic and precancerous lesions in uteri and ovaries of mice

Unrecognizable exposure to estrogenic substance may cause estrogen-dependent diseases, endometriosis and cancer. Pregnant mice (ICR/Jcl, CLEA) were exposed to 0.01 mg ethinyl estradiol (EE2 )/kg per day or vehicle (olive oil) through oral intubation from day 11 to 17 of gestation. They delivered their offspring and raised them. When the experimental female F1 mice were at 8 weeks of age, they were not exposed to EE2 or to the same dose of EE2 or to vehicle twice a week until 20 weeks of age. The control female F1 mice were exposed to the same dose of EE2 or vehicle alone, similarly. All mice were killed at 28 weeks of age. The resected uteri and ovaries were processed for microscopic examinations and for determination of the aromatase mRNA levels and aromatase protein through quantitative RT-PCR and Western blotting, respectively. Adenomyosis and adenocarcinomatous changes were significantly discernible in the EE2 -exposed uteri, and incidence of ectopic glands and serous cysts were significantly increased in the prenatally EE2 -exposed ovaries as compared with respective controls. Significant upregulation of the aromatase mRNA was seen in the prenatally EE2 -exposed uteri and in the EE2 -exposed ovaries. The aromatase protein was identified in all ovaries examined, and in EE2 -exposed uteri but not in controls and confirmed its localization in eutopic and ectopic glands, abnormally proliferated lesions and the lining of the cysts. Taken together, continuous EE2 exposure may cause endometriotic and precancerous lesions due to excessive estrogen synthesis in both target organs.

The significance of laparoscopy in determining the optimal management plan for infertile patients with suspected tubal pathology revealed by hysterosalpingography

The fallopian tube has numerous functions, including ovum pick-up, the place of fertilization of the ovum and cleavage of the embryo, and transfer of the embryo to the uterus. Tubal pathology impairs functions of the fallopian tube and reduces fertility. The degree of tubal pathology determines the possibility for fertility. The evaluation of the fallopian tube is necessary to determine the management plan of infertility. Hysterosalpingography (HSG) is often performed as a first line approach to assess tubal patency and the presence of adhesions; however, HSG has limitations in detecting tubal pathology. In the current study, we evaluated the significance of laparoscopy in determining the optimal management plan for infertile patients with suspected tubal pathology revealed by HSG. Between 1997 and 2009, 127 patients with suspected tubal pathology as demonstrated by HSG underwent laparoscopy at Kinki University Hospital, and a retrospective analysis was performed. Of 87 patients with unilateral tubal pathology revealed by HSG, 20 patients (23.0%) were given an indication for assisted reproductive technology (ART), based on the laparoscopic findings. Of 40 patients with bilateral tubal pathology revealed by HSG, 33 patients (82.5%) with bilateral tubal pathology detected by laparoscopy were given a high indication for ART. Laparoscopy enables exact evaluation of the fallopian tube and selection of the optimal management plan in infertile patients with suspected tubal pathology revealed by HSG. Therefore, laparoscopy should be performed in infertile patients with suspected tubal pathology revealed by HSG, as it is of diagnostic importance.

Estimation of preoperative uterine weight in uterine myoma and uterine adenomyosis

INTRODUCTION

Uterine myoma and uterine adenomyosis frequently occur in sexually mature women. Total hysterectomy is the treatment of choice when the symptoms are severe. To select an operative procedure from abdominal, vaginal, and laparoscopic methods, precise estimation of the preoperative uterine weight is desired. In this study, we estimated the preoperative uterine weight with preoperative images in cases of uterine myoma and uterine adenomyosis.

METHODS

We evaluated 403 patients with uterine myoma or uterine adenomyosis (uterus < 1000 g) between 1996 and 2010. All patients underwent a preoperative MRI and received a hysterectomy with the uterine weight recorded. Based on MR images, we measured (in centimeters) the maximum longitudinal diameter in the sagittal section (a), the maximum lateral diameter (b) and the maximum longitudinal diameter in the transverse section (c) of each uterus. A correlation coefficient was calculated between the weight of the removed uterus and the value of a × b × c for each individual uterus. Also, a regression analysis was performed between x (the value of a × b × c) and y (weight of the removed uterus).

RESULTS

A strong correlation was shown between the weight of the removed uterus and the value of a × b × c (r = 0.81, P < 0.01). As a result of the regression analysis, the regression equation y = 0.35x + 107 (R(2) = 0.66, P < 0.01) was obtained.

CONCLUSION

In this study, the estimated weight of the uterus was calculated by the formula y = 0.35x + 107 (x = a × b × c), and this could be the determining factor in choosing a surgical method for hysterectomy.

Cutaneous metastasis from primary adenocarcinoma of the vagina: a case report

Cutaneous metastasis in vaginal cancer is an extremely rare event and no cases of cutaneous metastasis from primary vaginal adenocarcinoma have been found. We report the clinicopathologic features, including cytopathologic findings, of the first case of cutaneous metastasis to the anterior chest wall from a sporadic-type advanced primary vaginal adenocarcinoma. Our present case suggested that cytopathologic examination should be performed as soon as possible when a patient exhibits multiple subcutaneous nodules or a painful cutaneous ulcer during treatment of advanced gynecologic cancer.

Retrospective evaluation of tumor markers in ovarian mature cystic teratoma and ovarian endometrioma

AIM

The aim of this study was to evaluate the correlation between clinicopathological characteristics and serum levels of tumor markers in patients with ovarian endometrioma (OE) and ovarian mature cystic teratoma (MCT).

MATERIAL AND METHODS

Values of CA125, CA19-9, and sialyl Tn antigen (STN) were retrospectively investigated in 321 patients with OE. CA125, CA19-9, STN, and squamous cell carcinoma antigen (SCC) were examined in 435 patients with MCT.

RESULTS

Mean values of CA125, CA19-9, and STN were 105.3 U/mL, 58.0 U/mL, and 31.1 U/mL in OE, while the values were 26.8 U/mL, 246.8 U/mL, and 24.7 U/mL in MCT. Abnormal elevation of CA125, CA19-9, and STN was observed in 53.3%, 38.9, and 13.5 of OE, and in 12.9, 50.6, and 4.6% of MCT, respectively. CA125 level was significantly higher in bilaterally occurring OE and premenopausal patients with MCT, while the value of CA19-9 was significantly higher in cases of bilaterally occurring MCT. Furthermore, the levels of CA125 and CA19-9 showed significant correlations with tumor diameter, while the levels of STN and SCC showed no significant correlations with tumor diameter. The highest CA125 level (9513 U/mL) was observed in OE and the highest CA19-9 level (25 590 U/mL) was observed in MCT.

CONCLUSION

Although abnormal increases in the levels of CA125 and CA19-9 were often observed, the levels of STN were not influenced by clinicopathologic factors in OE and MCT. Further studies of the clinical usefulness of STN for detecting malignant tumors in OE and MCT are needed.

Primary adenomyoma of the fallopian tube mimicking tubal malignant tumor

We report a rare case of adenomyoma localized only in the left fallopian tube mimicking tubal malignant tumor. A 45-year-old woman presented with mild pelvic pain, dysmenorrhea and left adnexal mass. Magnetic resonance imaging showed a solid tumor, suspected primary cancer of the fallopian tube, and serum carbohydrate antigen 125 was elevated to 72 U/mL (normal; 0-35). At surgery, the tumor was revealed as a left fallopian tube tumor without torsion. Postoperative histopathology showed that the tumor included bundle-like growing non-atypical leiomyoma cells and ectopic normal endometrium accompanied with endometrial stroma and we diagnosed primary adenomyoma of the left fallopian tube. Adenomyoma localized only in the fallopian tube is a rare entity and it can occur only in the fallopian tube.

Incidence of complications in patients with benign gynecological diseases by BMI and level of complexity of laparoscopic surgery

INTRODUCTION

Laparoscopic surgery has become a standard surgical method for benign gynecological diseases, but the technique can still be accompanied, albeit infrequently, by intraoperative or postoperative complications. It has been postulated that the frequency of complications differs according to patient body habitus or surgical challenge level. We evaluated the relationship between the complication rate at different levels of surgery and BMI in patients with benign gynecological diseases who have undergone laparoscopic surgery at our hospital.

METHODS

A total of 3231 patients who underwent laparoscopic surgery between 1989 and 2010 were enrolled in this study retrospectively. They were classified into four groups by surgery level (diagnostic laparoscopy or minor, major, or advanced laparoscopic surgery). At each challenge level, patients were classified into three groups based on BMI (as defined by the WHO): A group (underweight), BMI < 18.5; B group (healthy), BMI ≥ 18.5 and < 25; and C group (overweight), BMI ≥ 25. We compared the complication rates between the groups at each level of surgical challenge.

RESULTS

There was no difference in the complication rate between groups A, B and C at any of the surgical challenge levels. However, at the higher surgical difficulty levels, a higher incidence of overall complications was observed.

CONCLUSION

The complication rate differs between surgical levels, and complications can occur in any type of surgery, irrespective of the body habitus of the patient. The complication rate is higher when difficult surgical methods are employed, and extra caution is needed.

Indication for laparoscopically assisted vaginal hysterectomy

When uterine weight is greater than 800 grams, total abdominal hysterectomy is more appropriate than laparoscopic-assisted vaginal hysterectomy.

Objectives:

Total hysterectomy procedures include total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), and laparoscopically assisted vaginal hysterectomy (LAVH). Our institution has introduced LAVH as a preferred option to the more invasive TAH. To date, no reports have proposed surgical indications for LAVH based on statistical analysis of surgical results. The purpose of this study was to establish criteria for performing LAVH through statistical analysis of a retrospective review of surgical outcomes in LAVH cases at our institution over a period of 15 years.

Methods:

The medical records of 629 patients scheduled for LAVH for uterine fibroids and/or adenomyosis at our hospital were examined. Surgical results (blood loss, operative time, rates of conversion to laparotomy, and intra- and postoperative complications) were compared among 9 groups classified by uterine weight.

Results:

Statistically significant differences in surgical outcomes were found between the group with a uterine weight ≥800g and the other groups.

Conclusion:

We found that when the uterine weight was ≥800g, TAH was more appropriate because significant blood loss and/or complications would be expected during LAVH. A removed uterus weighing 800g is reportedly equivalent to a preoperative uterine size of approximately 12cm. Therefore, LAVH may be safely indicated for patients with a uterine size ≤12cm (approximately equivalent to the uterine size at 16-weeks gestation).

Incidental detection of breast apocrine carcinoma via endometrial cytology

Breast apocrine carcinoma is a rare malignancy characterized histologically by a predominance of acidophilic tumor cells exhibiting apocrine metaplasia. Apocrine tumors represent only about 0.4% of all breast cancers. Many cases are diagnosed at stage I or II; thus, the prognosis is better than that for other types of breast cancer. Here we present a 57-year-old female patient with primary apocrine breast carcinoma that was incidentally discovered by endometrial cytology. The patient had undergone routine uterine cancer screening at the age of 56 with resulting positive endometrial cytology. Subsequent histological examination of an endometrial biopsy revealed suspected metastatic uterine adenocarcinoma. Further evaluation revealed a 3-cm mass in the left breast, which was histopathologically diagnosed as breast cancer. Dual procedures were performed at the departments of gynecology and breast surgery. The patient underwent a modified radical mastectomy of the left breast and left axillary lymph node dissection. Laparotomy revealed multiple adhesions throughout the peritoneal cavity that suggested invasive metastatic cancer, and a right adnexectomy was performed. Histopathological examination of the resected left breast and right ovary tissues revealed apocrine carcinoma. Thus, stage IV breast cancer was diagnosed. The patient finished 6 cycles of paclitaxel and is now under observation on an outpatient basis. In this patient, breast cancer was discovered incidentally through a detailed work-up after a positive result of endometrial cytology. Uterine cancer screening has the potential, although rare, to detect metastatic cancer originating elsewhere. This should be taken into consideration during the work-up due to positive endometrial cytology.

Total abdominal hysterectomy versus laparoscopically-assisted vaginal hysterectomy versus total vaginal hysterectomy

INTRODUCTION

While total abdominal hysterectomy (TAH) and total vaginal hysterectomy (TVH) are conventional procedures, we have actively introduced laparoscopically-assisted vaginal hysterectomy (LAVH) since its advent. This study was the first attempt to retrospectively compare the surgical results, including invasiveness, among the three methods of performing a hysterectomy.

METHODS

The subjects included 1181 patients who underwent total hysterectomies (TAH, n=465; LAVH, n=629; TVH, n=87) due to uterine fibroids or uterine adenomyosis at our hospital between January 1995 and December 2009. The mean age, parity, weight of the removed uterus, operative time, blood loss, rates of intra- and post-operative complications, length of post-operative hospital stay, leukocyte count, and CRP and hemoglobin levels were compared.

RESULTS

The operative time was significantly longer in the LAVH group than the other two groups. Blood loss was significantly greater in the TAH group than the LAVH and TVA groups. The rates of intra- and post-operative complications were significantly higher in the TAH group than the LAVH group. The CRP level and leukocyte count were significantly lower in the LAVH group than the TAH and TVH groups.

CONCLUSION

LAVH can be applied to nulligravidas or patients with relatively large uteri and it is proved less invasive than TAH and TVH in this study. We recommend active application of LAVH.

Evaluation of oral etoposide in combination with cisplatin for patients with recurrent cervical cancer: long-term follow-up results of a Japanese multicenter study

AIM

To evaluate the efficacy and toxicities of cisplatin and daily oral etoposide in patients with recurrent cervical cancer.

PATIENTS AND METHODS

Treatment was initiated with oral etoposide 25 mg/day for 21 consecutive days, with intravenous cisplatin at 50 mg/m², on day 1, every 4 weeks, then the etoposide dose was increased to 50 mg/day.

RESULTS

Thirty patients were enrolled in this study. Twenty-seven (90.0%) patients had a history of prior treatment (cisplatin with concurrent chemoradiotherapy in 15, radiation therapy in 3, chemotherapy in 1, and both radiation therapy and chemotherapy in 9), and 22 (73.3%) patients had a treatment-free interval of less than 6 months. NCI-CTC grade 3/4 hematologic toxicities were leukopenia in 19 (63.3%), neutropenia in 17 (58.6%), anemia in 15 (50.0%) and thrombocytopenia in 6 (20.0%). Four patients developed febrile neutropenia. NCI-CTC grade 3 nonhematologic toxicities consisted of nausea/vomiting in 2 (6.7%), anorexia in 4 (13.3%) and fatigue in 2 (6.7%). The overall response rate was 16.7% including one complete response. The median progression-free survival period and overall survival period were 4.5 and 9.7 months, respectively.

CONCLUSION

Combination chemotherapy consisting of oral etoposide and intravenous cisplatin is safe and effective for recurrent cervical cancer.

Expression of the vascular endothelial growth factor (VEGF) gene in epithelial ovarian cancer: an approach to anti-VEGF therapy

AIM

A monoclonal antibody that targeted vascular endothelial growth factor (VEGF) resulted in a dramatic suppression of tumor growth in vivo, which led to the development of bevacizumab, a humanized variant of anti-VEGF antibody, as an anticancer agent. The aims of this study were to clarify the significance of VEGF gene expression in relation to clinicopathological parameters and to identify potential candidates for anti-VEGF therapy with bevacizumab.

PATIENTS AND METHODS

VEGF gene expression was analyzed by real-time quantitative reverse transcription-polymerase chain reaction in 178 surgical epithelial ovarian cancer specimens. This gene expression was correlated with clinicopathological parameters and patient survival.

RESULTS

The median VEGF gene expression level and range relative to GAPDH were 0.147 and 0.016-2.44, respectively. Patients were dichotomized into two groups with low and high expression levels by using the median value as the cutoff. VEGF gene expression did not affect prognosis of patients overall (p = 0.541). Although statistical significance was not noted, we found the prognosis of patients with high VEGF gene expression tended to be worse than that of those with low VEGF gene expression by univariate Cox regression analysis (p = 0.085) in patients with stage III-IV cancer. Macroscopic residual disease (positive; p = 0.012) was significantly associated with poor prognosis in univariate Cox regression analysis in patients with stage III-IV cancer. Moreover, presence of macroscopic residual disease was positively associated with VEGF gene expression (p = 0.030) in patients with stage III-IV cancer.

CONCLUSION

Patients with epithelial ovarian cancer with tumors with positive macroscopic residual disease and high VEGF gene expression could be potential candidates for anti-VEGF therapy with bevacizumab.

Touch preparation of primary uterine pleomorphic rhabdomyosarcoma: report of a case with clinical cytopathologic features

BACKGROUND

Primary pure uterine rhabdomyosarcoma (RMS) is an extremely rare tumor, and no cytopathologic characteristics of this tumor have been reported before.

CASE

We report the clinicopathologic characteristics, including the cytopathologic findings of touch preparations, of a pleomorphic RMS in a postmenopausal woman.

CONCLUSION

Touch preparations of tumors are a useful diagnostic procedure for detecting sarcoma in a myomatous tumor, and periodic examination using magnetic resonance imaging is recommended for uterine myomatous tumors even in postmenopausal women.

Carbamyl phosphate synthetase deficiency and postpartum hyperammonemia

Carbamyl phosphate synthetase (CPS) is an enzyme that converts ammonia to carbamyl phosphate in the urea cycle. CPS deficiency is a genetic disorder that causes hyperammonemia because of enzyme activity deficiency. It is primarily diagnosed in neonates and infants and has a poor prognosis. We report an adult woman with CPS deficiency who developed hyperammonemia postpartum.

[Gynecologic laparoscopic surgery]

In Japan, endoscopic surgeries are covered by health insurance only when they are performed for benign diseases. Actually, endoscopic surgery is performed for the treatment of benign diseases in most cases. However, it is difficult to precisely know what types of cases are currently treated with laparoscopic procedures in Japan. The Japan Society of Gynecological and Obstetrical Surgery performed a survey to examine the frequency of the use of endoscopic surgery for the first time in Japan, and reported the results. In this article, we described the present situation and problem of gynecologic laparoscopic surgery in Japan from the results.

Emergency cesarean section as a result of acute eosinophilic pneumonia during pregnancy

Acute eosinophilic pneumonia is a disease of unknown etiology characterized by peripheral blood eosinophilia and pulmonary infiltrative shadows on radiography. Acute eosinophilic pneumonia follows an acute course within 1 week and the symptoms include fever, dyspnea, and cough. Acute eosinophilic pneumonia has a good prognosis and responds promptly to steroid treatments. Here we present a critical case of acute eosinophilic pneumonia during pregnancy, which led to emergency cesarean section because of fetal distress. The patient was a 24-year-old gravida at 34 + 6 weeks gestation, with fever, and an elevated CRP; thus antibiotics were started. At 35 + 1 weeks gestation, cardiotocography (CTG) revealed late decelerations, fetal distress was diagnosed, and an emergency cesarean section was performed. The pre-operative maternal blood gas analysis showed a low PaO(2) of 55.7 mmHg and a chest X-ray revealed ground-glass opacities and pleural effusions in the middle lower lung fields bilaterally. A male of 2,336 g in weight was delivered with Apgar scores of 8 and 8 at 1 and 5 min, respectively. Due to the clinical progress and the elevated eosinophil count (532/microl) in the peripheral blood differential leukocyte count, the diagnosis of acute eosinophilic pneumonia was made. With the administration of oxygen and steroid treatment, the patient's general condition recovered. Both the mother and the baby were discharged on the 10(th) post-operative day and the patient has been leading a normal life with no recurrence for > 3 years since delivery.

Benefit of diagnostic laparoscopy for patients with unexplained infertility and normal hysterosalpingography findings

Patients with unexplained infertility following standard infertility screening tests usually undergo timing therapy that coordinates the time of ovulation and coitus, controlled ovarian hyperstimulation, or intrauterine insemination. If the treatment is unsuccessful, diagnostic laparoscopy is performed. However, with recent improvements in the assisted reproductive technology (ART), there has been a growing tendency that bypasses diagnostic laparoscopy and proceeds directly to ART. Therefore, the value of diagnostic laparoscopy in current fertility practice is under debate. In the present study, we evaluated the usefulness of diagnostic laparoscopy for patients with unexplained infertility and normal hysterosalpingography (HSG) findings. Between January 1997 and December 2006, 57 infertile patients with normal HSG findings underwent diagnostic laparoscopy at Kinki University Hospital. In 46 (80.7%) of these patients, diagnostic laparoscopy revealed pathologic abnormalities. Specifically, endometriosis and peritubal and/or perifimbrial adhesions were found in 36 (63.2%) and 5 (8.8%) of the patients, respectively. In 8 patients (14.0%), the management plan was switched to ART because of severe tubal diseases. Among the 57 patients, 29 pregnancies (50.9%) were achieved, including 6 ART-mediated pregnancies. We conclude that diagnostic laparoscopy is beneficial for patients with unexplained infertility and normal HSG findings. Indeed, by diagnostic laparoscopy, we are able to detect the cause(s) of infertility in the pelvic cavity and to design a suitable management plan, which could lead to postoperative pregnancy. Therefore, because of the potential diagnostic and therapeutic benefits, patients with unexplained infertility and normal HSG findings should undergo diagnostic laparoscopy prior to ART.

Recombinant follicle-stimulating hormone (follitropin alfa) for ovulation induction in Japanese patients with anti-estrogen-ineffective oligo- or anovulatory infertility: results of a phase II dose-response study

Purpose

To determine the optimal regimen of recombinant human follicle-stimulating hormone (r-hFSH) for ovulation induction (OI) in Japanese women with amenorrhea I or anovulatory infertility.

Methods

In this randomized, double-blind, dose-finding study, women aged 20-39 years were enrolled. Patients underwent a chronic low-dose step-up regimen with starting doses of r-hFSH of 37.5 IU (group L; n = 62), 75 IU (group M; n = 62) or 150 IU (group H; n = 60). Primary endpoint was time to achieve a dominant follicle with mean diameter ≥18 mm. Secondary endpoints included percentage of patients producing a dominant follicle ≥18 mm, achieving ovulation, and biochemical pregnancy.

Results

Median time to achieve a dominant follicle ≥18 mm was 14 days (group L; 87.7%), 10 days (group M; 98.4%), and 8 days (group H; 94.5%). In group M, ovulation occurred in 95.1% of patients, with pregnancy in 18.0%, compared with 86.0% and 15.8% in group L, and 50.9% and 9.1% in group H, respectively. Twelve patients developed ovarian hyperstimulation syndrome (nine in group H). Most adverse events in groups L and M were mild in severity.

Conclusions

A starting dose of 75 IU r-hFSH was associated with a favorable efficacy and safety profile for OI in Japanese women.

Retrospective evaluation of CO(2) laser conization in pregnant women with carcinoma in situ or microinvasive carcinoma

BACKGROUND

We evaluated the safety and efficacy of CO(2) laser conization in pregnant women with cervical intraepithelial neoplasia 3/carcinoma in situ (CIN3/CIS) or microinvasive carcinoma (MIC).

OBJECTIVES

A total of 49 pregnant women with biopsy-proven CIN3/CIS (30 patients) or MIC (19 patients) were studied.

METHODS

Retrospective analysis based on clinical records.

RESULTS

Median age and median week of gestation were 31 years (range: 22-39) and 17 weeks (range: 7-33), respectively. The median length of cervix resected by conization, median duration of surgery and median blood loss were 14 mm (range: 5-23), 20 min (range: 7-35) and 78 ml (range: 10-797), respectively. One biopsy-proven CIN3/CIS patient was diagnosed with Federation of Gynecology and Obstetrics (FIGO) Ia2 and 3 biopsy-proven MIC patients were diagnosed with FIGO Ib1 based on conization specimens. A total of 35 patients could be followed until delivery, of which 27 (77.1%) patients delivered transvaginally. Although 8 patients (22.9%) had a cesarean section and 6 patients (17.1%) delivered preterm, no conization-related obstetric complications were observed.

CONCLUSION

Since it results in few obstetric complications, CO(2) laser conization within 20 mm of length can be considered a safe procedure for pregnant women.

Association of metastin/a G-protein-coupled receptor signaling and Down syndrome critical region 1 in epithelial ovarian cancer

It has been revealed that metastin/a G-protein-coupled receptor (AXOR12) signaling enhances the expression of Down syndrome critical region 1 (DSCR1), known to be duplicated in Down syndrome, and suppresses tumor metastasis in in vitro study. The aim of this study was to evaluate whether gene expression of metastin/AXOR12 signaling system is correlated with that of DSCR1 and consequently affect prognosis of patients with epithelial ovarian cancer.

PATIENTS AND METHODS

The expression levels of metastin, AXOR12, DSCR1 isoform 1 (DSCR1-1), DSCR1 isoform 4 (DSCR1-4), calcineurin, and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) gene expression were analyzed by real-time quantitative reverse transcription-polymerase chain reaction in 102 epithelial ovarian cancer surgical specimens.

RESULTS

Patients were dichotomized into two groups having low and high expressions by using the median value as the cut-off A good agreement was noticed between metastin and AXOR12 gene expression levels (kappa coefficient; 0.73), however, the gene expression of metastin/AXOR12 signaling system was not significantly correlated with that of DSCR1-4. By univariate Cox regression analysis, the prognosis of the patients with low metastin and low AXOR12 gene expression was significantly worse than that of those with high metastin and high AXOR12 gene expression, respectively (p = 0.04 and 0.018). Combination of metastin and AXOR12 gene expression also had significant impact on patient prognosis (p = 0.045). The DSCR1-1, DSCR1-4 and calcineurin gene expressions did not significantly affect the prognosis.

CONCLUSION

The precise mechanism of metastin/ AXOR12 signaling for suppression of the invasive phenotype in vivo, especially in epithelial ovarian cancer, is still uncertain. Genes such as DSCR1 that are duplicated in Down syndrome might not play an important role in tumorigenesis of epithelial ovarian cancer.

Favourable prognosis with modified dosing of docetaxel and cisplatin in Japanese patients with ovarian cancer

BACKGROUND

The long-term efficacy and safety of docetaxel/cisplatin as first-line chemotherapy in Japanese patients was evaluated in order to find an optional regimen for ovarian cancer.

PATIENTS AND METHODS

Women with surgically resected stage Ic-IV epithelial ovarian cancer were treated with docetaxel 70 mg/m2 and cisplatin 60 mg/m2 every 4 weeks.

RESULTS

Ninety women were enrolled of whom 89 (median age, 54 years) received a median of 6 cycles (range 1 to 9). With a median 38 months'follow-up, median progression-free survival was 28 months (95% lower confidence interval, 24 months) in 60 patients with stage III-IV disease. The overall response rate for 20 patients was 45%. Neutropenia was the most common (67%) grade 3/4 toxicity. Major grade 3/4 nonhaematological toxicities were gastrointestinal toxicities (< or = 11%) and fatigue (8%). No grade 3/4 neurotoxicity was observed.

CONCLUSION

The combination of docetaxel/cisplatin is a regimen with favourable progression-free survival for ovarian cancer.

Radical hysterectomy for invasive cervical cancer during pregnancy: a retrospective analysis of a single institution experience

PURPOSE

To evaluate long-term prognosis and patient safety for a radical hysterectomy in pregnant women with invasive cervical cancer.

PATIENTS AND METHODS

We retrospectively analyzed 12 cases of radical hysterectomy (RH) performed for invasive cervical cancer during pregnancy. Four patients underwent RH with the fetus in situ and another eight patients underwent RH followed by cesarean section.

RESULTS

The median treatment period was 17 weeks of gestation (range: 9 to 39), the mean blood loss was 550.1 +/- 162.5 g (range: 275 to 850). Pelvic lymph node metastases were observed in three patients and parametrial invasion was observed in one patient. Although one patient experienced a recurrence at the vaginal stump, all patients were alive at a median follow-up interval of 105 months (range: 61 to 234).

CONCLUSION

RH during pregnancy can be safely performed even with the fetus in situ and a subsequent cesarean section.

Laparoscopic mucin removal in patients with pseudomyxoma peritonei

BACKGROUND AND OBJECTIVES

Pseudomyxoma peritonei results from ovarian and appendiceal mucinous tumors. Cyst rupture results in intraabdominal mucin accumulation, leading to abdominal distension. No effective treatment has yet been established. Pseudomyxoma peritonei is generally associated with a poor prognosis. In a recent Mayo Clinic report, the 5-year survival rate for this disease was 53% and the 10-year survival rate was 32%, while the Memorial Sloan-Kettering Cancer Center reported 5- and 10-year survival rates of 75% and 10%.

METHODS AND RESULTS

In this report, we describe 4 patients with a laparoscopically confirmed recurrence of pseudomyxoma peritonei who subsequently underwent repeated laparoscopic mucin removal.

CONCLUSION

Because laparoscopic surgery can be performed frequently, it appears that laparoscopic surgery, a minimally invasive procedure, greatly improves the quality of life of patients with pseudomyxoma peritonei.

Phase II study of single-agent gemcitabine in heavily pretreated Japanese patients with recurrent ovarian cancer

BACKGROUND

Gemcitabine has been recommended as an active agent for salvage chemotherapy in patients with recurrent epithelial ovarian cancer, but no clinical study of this agent has been conducted for Japanese women with ovarian cancer. To evaluate the efficacy and feasibility of gemcitabine for heavily pretreated Japanese patients with recurrent epithelial ovarian cancer, we conducted a single-institute phase II clinical trial.

METHODS

All patients had received a minimum of two previous chemotherapy regimens, In this study, gemcitabine was administered at 1000 mg/m(2) on days 1, 8, and 15 of a 28-day cycle.

RESULTS

A total of 28 patients participated in this study. Although 5 patients (17.9%) needed dose reduction to 800 mg/m(2) because of thrombocytopenia and granulocytopenia, all patients completed an average of 6.7 courses (range, 2-24 courses). The overall response rate, including five partial responses, was 17.9% (95% confidence interval [C I], 6.0-36.9). The median time to progression was 8.8 months and the median survival period was 11.2 months. Grade 3/4 hematological toxicities included leucopenia, 35.7%; granulocytopenia, 39.3%; anemia, 46.4%; and thrombocytopenia, 10.7%. However, no grade 3/4 nonhematological toxicity was observed. The mean delay in treatment was 5.0 +/- 7.7 days (range, 0-15 days) in a total of 562 cycles.

CONCLUSION

Single-agent gemcitabine is an effective salvage chemotherapy regimen in heavily pretreated Japanese patients with recurrent epithelial ovarian cancer.

Feasibility study of docetaxel and nedaplatin for recurrent squamous cell carcinoma of the uterine cervix

BACKGROUND

To determine a new taxane plus platinum treatment regimen for squamous cell carcinoma of the uterine cervix (CSCC), a phase I feasibility study of docetaxel (DTX) plus nedaplatin (CDGP) combination therapy was conducted.

PATIENTS AND METHODS

Twenty consecutive patients were enrolled into the study. The starting dose of DTX/CDGP was 60 mg/m2 / 80 mg/m2, every 4 weeks for at least three courses and the dose was escalated to 70 mg/m2 / 100 mg/m2. DTX 60 mg/m2 / CDGP 100 mg/m2 was also evaluated as an extra dose level.

RESULTS

Dose-limiting toxicity was granulocytopenia and the maximum tolerated dose was determined as 70 mg/m2 / 100 mg/m2. All 20 patients had measurable disease and a partial response was achieved in 8 (40.0%) patients.

CONCLUSION

DTX/CDGP therapy appears to be a tolerable regimen for cervical squamous cell carcinoma, even in patients previously treated by cisplatin concurrent chemoradiotherapy. The recommended doses of DTX and CDGP were determined to be 60 mg/m2 and 100 mg/m2, respectively.

Definitive diagnosis of primary adenocarcinoma of the appendix by laparoscopic appendectomy

We report a 62-year-old woman with a primary adenocarcinoma of the appendix mimicking ovarian tumor. We had diagnosed it definitively by laparoscopic appendectomy, and additional surgery was required in this case. However, the present case suggests that, in some cases, if cancer of the appendix can be diagnosed early, laparotomy can be avoided and the cancer treated with minimally invasive laparoscopic surgery alone.

A change in promoter methylation of hMLH1 is a cause of acquired resistance to platinum-based chemotherapy in epithelial ovarian cancer

BACKGROUND

Acquired resistance to platinum-based chemotherapy (Pt-chemo) is a major problem for improving the prognosis for patients with advanced epithelial ovarian cancer (EOC). However, the molecular mechanism of acquired resistance to Pt-chemo is not well understood.

MATERIALS AND METHODS

hMLH1 promoter methylation (hMLH1 MET) and hMLH1 protein expression was examined in 36 paired samples of primary and secondary resected tumors by methylation-specific polymerase chain reaction (PCR).

RESULTS

No primary tumors exhibited hMLH1 MET, while 56.3% of secondary tumors showed hMLH1 MET. Moreover, no significant correlation was observed between hMLH1 MET and histological subtype, while hMLH1 MET was significantly greater (p < 0.001) in partially responsive secondary tumors compared with no change or progressive disease, and hMLH1 MET also occurred more frequently (p = 0.059) in tumors treated with four or more courses of Pt-chemo.

CONCLUSION

A change in hMLH1 MET is a major molecular cause of acquired resistance to Pt-chemo in EOC.

Expression of metastin and a G-protein-coupled receptor (AXOR12) in epithelial ovarian cancer

BACKGROUND

Metastin, a product of the KiSS-1 gene, is a ligand for a G-protein-coupled receptor (AXOR12) and is a strong suppressant of metastasis. The aim of this study was to evaluate whether metastin and AXOR12 gene expressions affect prognosis of patients with epithelial ovarian cancer.

METHODS

The expression levels of metastin, AXOR12 and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) gene expression were analysed by the real-time quantitative reverse transcription-polymerase chain reaction in 76 epithelial ovarian cancer surgical specimens. Their expression (metastin/GAPDH and AXOR12/GAPDH ratios) was correlated with the clinical findings. Furthermore, cellular distribution of metastin and AXOR12 mRNA was examined by in situ hybridisation on tissue sections.

RESULTS

The median and range of mRNA expression for metastin and AXOR12 were 0.047 and 0.01-13.57, and 4.00 and 0.011-135.13, respectively. Patients were dichotomised into two groups having low and high expressions by using the median value as the cutoff. A good agreement was noticed between metastin and AXOR12 gene expression levels (kappa coefficient; 0.74). The presence of residual tumour following resection was negatively associated with metastin (P=0.0084) and AXOR12 (P=0.0148) gene expressions indicating an association of low expression of these genes in more aggressive, and advanced tumours. By univariate Cox regression analysis, the prognosis of the patients with low AXOR12 gene expression was significantly worse than those with high AXOR12 gene expression (P=0.030). The combination of metastin and AXOR12 gene expression level was also significantly associated with the prognosis (P=0.049). Transcripts for both metastin and AXOR12 were detected in the epithelial ovarian carcinoma cells.

CONCLUSIONS

These results present a new insight into the understanding of the biological behaviour of epithelial ovarian cancer. Metastin/AXOR12 signalling may suppress the invasive phenotype of epithelial ovarian cancer.

Hypoxia inducible factor 1-alpha expression as a factor predictive of efficacy of taxane/platinum chemotherapy in advanced primary epithelial ovarian cancer

To investigate the impact on survival of HIF 1-alpha expression on primary advanced epithelial ovarian cancer (EOC), we examined the correlations between prognosis and HIF 1-alpha expression by Western blot analysis in 52 cases of stage III/IV EOC. HIF 1-alpha expression was confirmed in 36 cases (69.2%) of EOC, and HIF 1-alpha-expressing tumors had a significantly higher rate of response (p<0.01) to postoperative paclitaxel/carboplatin combination chemotherapy (TC) than tumors without HIF1-alpha expression. Moreover, patients with HIF 1-alpha-expressing tumors with suboptimal resection of stage III/IV tumors indicated for postoperative TC exhibited significantly better survival (p<0.01).

Feasibility of concurrent cisplatin use during primary and adjuvant chemoradiation therapy: a phase I study in Japanese patients with cancer of the uterine cervix

BACKGROUND

Although the prognostic advantages of concurrent cisplatin (CDDP) chemoradiation therapy (CCRT), for uterine cervical cancer (UCC) has been demonstrated, the feasibility of concurrent CDDP administration has not yet been evaluated. We determined the optimal CDDP dose for both weekly and monthly schedules during primary and adjuvant CCRT in patients with UCC.

METHODS

The study was conducted as a phase I, dose-escalation trial. Concurrent CDDP was started at the dose of 30 mg/m(2) for the weekly schedule and at 50 mg/m(2) for the monthly schedule, and the doses were steadily escalated to the maximum tolerated dose (MTD).

RESULTS

A total of 45 patients with UCC (25 receiving primary CCRT and 20 receiving adjuvant CCRT) were entered in the study. In both the primary and adjuvant CCRT patients, the MTD was observed to be 40 mg/m(2) for the weekly schedule and 80 mg/m(2) for the monthly schedule. Dose-limiting toxicity was observed in 10 patients (granulocytopenia in 9 patients and diarrhea in 1 patient). Disease recurrence was confirmed in 6 patients in the primary CCRT group during a mean follow-up period of 22.4 +/- 13.2 months, and in patients 3 in the adjuvant CCRT group during a mean follow-up period of 17.7 +/- 6.8 months.

CONCLUSION

For Japanese patients with UCC receiving primary or adjuvant CCRT therapy, the recommended CDDP dose was determined to be 30 mg/m(2) for the weekly schedule and 75 mg/m(2) for the monthly schedule.

Inhibition of Oct4 expression in mouse preimplantation embryos using morpholino antisense oligonucleotides

Morpholino oligonucleotides (MO) can induce gene silencing by binding to a target mRNA and inhibiting its translation, and this technique has been especially successful in studies of embryonic development in various vertebrates. But in mice MO-induced downregulation of target genes has not been widely reported. In this study, we examined whether MO delivery using ethoxylated polyethylenimine (EPEI) delivery reagent is useful for silencing gene expression in the mouse preimplantation embryo, by targeting endogenous gene Oct4. To optimize the conditions for MO delivery, we examined the MO concentration, the EPEI concentration, the treatment time, and the number of MO treatments. The MO treatment was performed at the 2-cell, the morula, the blastocyst, and the hatched blastocyst stage. We first determined the optimal conditions for MO delivery into the nucleus using fluorescein isothiocyanate (FITC)-labeled MO, and demonstrated that treatment with a combination of 20 microM MO and 0.56 microM EPEI for 3 hrs produced effective MO delivery. MO-induced downregulation of Oct4 was then examined. Two-step MO treatment at the 2-cell and blastocyst stages successfully suppressed Oct4 expression. This MO treatment resulted in marked reduction of Oct4 protein at the blastocyst stage. After cultivation of blastocysts for further 4 days, derivatives of embryos either differentiated to trophoblastic cells or showed developmental arrest at the blastocyst. This phenocopy is similar to Oct4-deficient embryos. Overall, our results indicate that MO delivery with EPEI is an effective tool for analyzing gene function in mouse preimplantation embryos.

Preoperative diagnosis of ovarian tumors, focusing on the solid area based on diagnostic imaging

AIM

The objectives were to attempt to differentiate between benignancy and malignancy by focusing not on macroscopic finding of tumor sections, but on the solid areas by diagnostic imaging. To investigate the usefulness of diagnostic imaging for ovarian tumors, we examined the solid areas in the tumor and their shape and analyzed the relationship between these factors and the malignant potential.

METHODS

Subjects were 921 surgical cases (1074 tumors) over a period of 7 years. Diagnostic images (ultrasonography, computed tomography and magnetic resonance imaging) were reread, focusing on the solid area. Tumors were classified into four groups according to the prominence of the solid area, and the findings were compared with the postoperative diagnosis.

RESULTS

Of the cases, 718 indicated benign, borderline malignancy in 29 and malignancy in 174. The malignant potential of tumors with solid areas was significantly higher than those with no solid area. However, upon comparison among the different groups with solid areas, no significant differences were detected in terms of the frequency at which malignancies were detected, despite the differences between the groups with respect to size and shape.

CONCLUSION

It is important for the treatment strategy that solid areas, even if small, should not be neglected, and that malignancies are found at high frequency regardless of shape, size and prominence.