Safety, feasibility, and short-term-outcome of anal endoscopic submucosal dissection for anal intraepithelial neoplasia: an option for focal lesions?

BACKGROUND

Anal intraepithelial neoplasia (AIN) appears in three different stages. AIN 1 and AIN 2 (p16 negative) are defined as low risk and unlikely to progress to invasive anal cancer. AIN 2 (p16 positive) and AIN 3 are of high risk and should be treated because progression rates to anal cancer are around 10% and treatment significantly reduces this risk. The correct treatment is still a matter of debate. Human papilloma virus (HPV) plays a role in the development of AIN. Our aim was to assess anal endoscopic dissection (aESD) as an intervention for AIN3.

METHODS

We retrospectively evaluated patients who underwent aESD for AIN 3 between December 2017 and March 2023. The interventional technique itself (duration, complications, size of specimen) and patient outcomes (recurrence, progression to anal cancer, re-intervention) were analyzed.

RESULTS

Fifteen patients with a median age of 52 years (23-78) underwent aESD for AIN 3. All tested specimens were positive for HPV. Median duration of intervention was 56.1 min, one delayed postinterventional bleeding occurred, and specimen size was 12.05 cm2. Median follow-up was 11.17 months. Three recurrences (20%) appeared: one was resected via biopsy and two were again treated with aESD. There was no progression to invasive anal cancer in the follow-up period.

CONCLUSIONS

Anal endoscopic submucosal dissection seems to be a safe and feasible treatment for AIN. Recurrences are seldom and can be treated again with the same method. Nevertheless, indications for resection in comparison to radiofrequency ablation, pharmacological therapy, and watch-and-wait strategy are still unclear.

TRIAL REGISTRATION

Ethics commission of Salzburg, Austria, EK-Nr. 1056/2023. Keywords: Endoscopic submucosal dissection, anal intraepithelial neoplasia, anal cancer.

Role of adjuvant therapy in intermediate-risk cervical cancer patients - Subanalyses of the SCCAN study

OBJECTIVE

The "intermediate-risk" (IR) group of early-stage cervical cancer patients is characterized by negative pelvic lymph nodes and a combination of tumor-related prognostic risk factors such as tumor size ≥2 cm, lymphovascular space invasion (LVSI), and deep stromal invasion. However, the role of adjuvant treatment in these patients remains controversial. We investigated whether adjuvant (chemo)radiation is associated with a survival benefit after radical surgery in patients with IR cervical cancer.

METHODS

We analyzed data from patients with IR cervical cancer (tumor size 2-4 cm plus LVSI OR tumor size >4 cm; N0; no parametrial invasion; clear surgical margins) who underwent primary curative-intent surgery between 2007 and 2016 and were retrospectively registered in the international multicenter Surveillance in Cervical CANcer (SCCAN) study.

RESULTS

Of 692 analyzed patients, 274 (39.6%) received no adjuvant treatment (AT-) and 418 (60.4%) received radiotherapy or chemoradiotherapy (AT+). The 5-year disease-free survival (83.2% and 80.3%; PDFS = 0.365) and overall survival (88.7% and 89.0%; POS = 0.281) were not significantly different between the AT- and AT+ groups, respectively. Adjuvant (chemo)radiotherapy was not associated with a survival benefit after adjusting for confounding factors by case-control propensity score matching or in subgroup analyses of patients with tumor size ≥4 cm and <4 cm. In univariable analysis, adjuvant (chemo)radiotherapy was not identified as a prognostic factor in any of the subgroups (full cohort: PDFS = 0.365; POS = 0.282).

CONCLUSION

Among patients with IR early-stage cervical cancer, radical surgery alone achieved equal disease-free and overall survival rates to those achieved by combining radical surgery with adjuvant (chemo)radiotherapy.

Lower-Limb Lymphedema after Sentinel Lymph Node Biopsy in Cervical Cancer Patients

Simple Summary

Lower-limb lymphedema (LLL) is a well-recognized adverse outcome of the surgical management of cervical cancer. Recently, sentinel lymph node (SLN) biopsy has emerged as an alternative procedure to systematic pelvic lymphadenectomy (PLND) aiming to decrease the risk of complications, especially LLL development. Our study represents the first prospective analysis of LLL incidence in cervical cancer patients after a uterine procedure with SLN biopsy, without systematic PLND. In an international multicenter trial SENTIX, the group of 150 patients was prospectively evaluated using both objective and subjective LLL assessments in 6 months intervals for 2 years. Contrary to the expectations, our results showed that SLN biopsy does not eliminate the risk of LLL development which occurred in a mild or moderate stage in about 26% of patients with a median interval to the onset of 9 months.

Abstract

Background: To prospectively assess LLL incidence among cervical cancer patients treated by uterine surgery complemented by SLN biopsy, without PLND. Methods: A prospective study in 150 patients with stage IA1–IB2 cervical cancer treated by uterine surgery with bilateral SLN biopsy. Objective LLL assessments, based on limb volume increase (LVI) between pre- and postoperative measurements, and subjective patient-perceived swelling were conducted in six-month periods over 24-months post-surgery. Results: The cumulative incidence of LLL at 24 months was 17.3% for mild LLL (LVI 10–19%), 9.2% for moderate LLL (LVI 20–39%), while only one patient (0.7%) developed severe LLL (LVI > 40%). The median interval to LLL onset was nine months. Transient edema resolving without intervention within six months was reported in an additional 22% of patients. Subjective LLL was reported by 10.7% of patients, though only a weak and partial correlation between subjective-report and objective-LVI was found. No risk factor directly related to LLL development was identified. Conclusions: The replacement of standard PLND by bilateral SLN biopsy in the surgical treatment of cervical cancer does not eliminate the risk of mild to moderate LLL, which develops irrespective of the number of SLN removed.

Sentinel lymph node mapping and intraoperative assessment in a prospective, international, multicentre, observational trial of patients with cervical cancer: The SENTIX trial

BACKGROUND

SENTIX (ENGOT-CX2/CEEGOG-CX1) is an international, multicentre, prospective observational trial evaluating sentinel lymph node (SLN) biopsy without pelvic lymph node dissection in patients with early-stage cervical cancer. We report the final preplanned analysis of the secondary end-points: SLN mapping and outcomes of intraoperative SLN pathology.

METHODS

Forty-seven sites (18 countries) with experience of SLN biopsy participated in SENTIX. We preregistered patients with stage IA1/lymphovascular space invasion-positive to IB2 (4 cm or smaller or 2 cm or smaller for fertility-sparing treatment) cervical cancer without suspicious lymph nodes on imaging before surgery. SLN frozen section assessment and pathological ultrastaging were mandatory. Patients were registered postoperatively if SLN were bilaterally detected in the pelvis, and frozen sections were negative.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02494063).

RESULTS

We analysed data for 395 preregistered patients. Bilateral detection was achieved in 91% (355/395), and it was unaffected by tumour size, tumour stage or body mass index, but it was lower in older patients, in patients who underwent open surgery, and in sites with fewer cases. No SLN were found outside the seven anatomical pelvic regions. Most SLN and positive SLN were localised below the common iliac artery bifurcation. Single positive SLN above the iliac bifurcation were found in 2% of cases. Frozen sections failed to detect 54% of positive lymph nodes (pN1), including 28% of cases with macrometastases and 90% with micrometastases.

INTERPRETATION

SLN biopsy can achieve high bilateral SLN detection in patients with tumours of 4 cm or smaller. At experienced centres, all SLN were found in the pelvis, and most were located below the iliac vessel bifurcation. SLN frozen section assessment is an unreliable tool for intraoperative triage because it only detects about half of N1 cases.

Diagnostic Reliability, Accuracy and Safety of Ultrasound-guided Biopsy and Ascites Puncture in Primarily Inoperable Ovarian Tumours

BACKGROUND/AIM

To compare the diagnostic reliability, accuracy and safety of ultrasound-guided biopsy (Tru-Cut biopsy) and ascites puncture in patients with a primarily inoperable malignant ovarian tumor.

PATIENTS AND METHODS

This is a retrospective analysis of the studied methods in consecutively examined patients and a prospective validation of these methods. 79 women with a suspected primarily inoperable ovarian tumor underwent Tru-Cut biopsies and were included in the ultrasound-guided biopsy group. In addition, 55 patients after ascites puncture were enrolled in the comparison group. Both procedures were performed in 48 patients for the prospective validation.

RESULTS

Significant differences in favour of ultrasound-guided biopsy were found in all studied variables (malignancy confirmation 72.9% vs. 95.8%, tumor origin 52.1% vs. 89.6%, histologic subtype 43.8% vs. 85.4% and accuracy, i.e. agreement of preoperative and definitive diagnosis 43.7% vs. 95.4%).

CONCLUSION

Ultrasound-guided biopsy is an accurate, reliable, safe and minimally invasive method. Owing to the high reliability and accuracy, it has the capacity to replace ascites puncture with cytologic examination or a more invasive method (laparoscopy, laparotomy) for adequate tumor sampling.

Central Pathology Review in SENTIX, A Prospective Observational International Study on Sentinel Lymph Node Biopsy in Patients with Early-Stage Cervical Cancer (ENGOT-CX2)

The quality of pathological assessment is crucial for the safety of patients with cervical cancer if pelvic lymph node dissection is to be replaced by sentinel lymph node (SLN) biopsy. Central pathology review of SLN pathological ultrastaging was conducted in the prospective SENTIX/European Network of Gynaecological Oncological Trial (ENGOT)-CX2 study. All specimens from at least two patients per site were submitted for the central review. For cases with major or critical deviations, the sites were requested to submit all samples from all additional patients for second-round assessment. From the group of 300 patients, samples from 83 cases from 37 sites were reviewed in the first round. Minor, major, critical, and no deviations were identified in 28%, 19%, 14%, and 39% of cases, respectively. Samples from 26 patients were submitted for the second-round review, with only two major deviations found. In conclusion, a high rate of major or critical deviations was identified in the first round of the central pathology review (28% of samples). This reflects a substantial heterogeneity in current practice, despite trial protocol requirements. The importance of the central review conducted prospectively at the early phase of the trial is demonstrated by a substantial improvement of SLN ultrastaging quality in the second-round review.

Coincidence of giant uterine myomatosis and detection of two advanced malignancies in 77-year-old female patient

OBJECTIVE

Our aim is to emphasize the importance of patient participation in screening programs available in the Czech Republic and in preventive gynaecological examinations. As an example, we present a case report of a 77-year-old female patient with the accumulation of serious gynaecological diseases (extreme uterine myomatosis, breast cancer) and non-Hodgkin´s B-lymphoma.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynaecology, Faculty Hospital in Pilsen, Charles University Medical Faculty in Pilsen.

CASE REPORT

Our case report of a 77-year-old patient is a rare case of the simultaneous detection of giant uterine myomatosis causing voluminous ventral hernia, invasive ductal breast cancer, and non-Hodgkin´s B-lymphoma. The patient was not gynecologically examined for last 20 years and did not undergo any screening examinations. In the postoperative period, the patient was diagnosed with invasive ductal breast cancer and follicular lymphoma. All the diseases were diagnosed in advanced stage.

CONCLUSION

The occurrence of bulky fibroids is very rare in postmenopause. Long-term neglect of clinical symptoms and adverse health signals allows their gradual progression. Especially in older patients, other serious illnesses may complicate the situation.

Calreticulin exposure correlates with robust adaptive antitumor immunity and favorable prognosis in ovarian carcinoma patients

BACKGROUND

Adjuvanticity, which is the ability of neoplastic cells to deliver danger signals, is critical for the host immune system to mount spontaneous and therapy-driven anticancer immune responses. One of such signals, i.e., the exposure of calreticulin (CALR) on the membrane of malignant cells experiencing endoplasmic reticulum (ER) stress, is well known for its role in the activation of immune responses to dying cancer cells. However, the potential impact of CALR on the immune contexture of primary and metastatic high-grade serous carcinomas (HGSCs) and its prognostic value for patients with HGSC remains unclear.

METHOD

We harnessed a retrospective cohort of primary (no = 152) and metastatic (no = 74) tumor samples from HGSC patients to investigate the CALR expression in relation with prognosis and function orientation of the tumor microenvironment. IHC data were complemented with transcriptomic and functional studies on second prospective cohort of freshly resected HGSC samples. In silico analysis of publicly available RNA expression data from 302 HGSC samples was used as a confirmatory approach.

RESULTS

We demonstrate that CALR exposure on the surface of primary and metastatic HGSC cells is driven by a chemotherapy-independent ER stress response and culminates with the establishment of a local immune contexture characterized by TH1 polarization and cytotoxic activity that enables superior clinical benefits.

CONCLUSIONS

Our data indicate that CALR levels in primary and metastatic HGSC samples have robust prognostic value linked to the activation of clinically-relevant innate and adaptive anticancer immune responses.

[One-Step Nucleic Acid Amplification method - what is the future of sentinel lymph node management?]

OBJECTIVE

The article summarizes current possibilities of usage of the One-Step Nucleic Acid Amplification method (OSNA) in the perioperative management of sentinel lymph nodes in oncologic surgery. The principle of this method is the detection of cytokeratin 19 (CK19) in the lymphatic tissue as a marker of the metastatic spread.

DESIGN

Review article.

SETTINGS

Department of Obstetrics and Gynaecology, University Hospital Pilsen, Faculty of Medicine in Pilsen, Charles University, Prague; Department of Biology, Faculty of Medicine in Pilsen, Charles University, Prague; Department of Immunochemistry, University Hospital Pilsen, Faculty of Medicine in Pilsen, Charles University, Prague; Sikl´s Department of Pathology, University Hospital Pilsen, Faculty of Medicine in Pilsen, Charles University, Prague.

METHODS

The review of the literature published until the end of April 2017 available on the PubMed database was performed. The official abbreviation OSNA and the full name of the method One-Step Nucleic Acid Amplification was used for search in this database.

CONCLUSION

The usage of the OSNA method with the detection of CK 19 in the sentinel lymph nodes as a marker of metastatic spread to the lymphatic tissue currently represents an acceptable form of perioperative sentinel lymph node management in patients with breast and colorectal cancer. Until now published data are pointing towards possible successful application of this method in sentinel lymph node management in patients with some other malignancies, such as thyroid carcinoma, gastric cancer, uterus cancer and head and neck cancer. More data is needed to establish this method also in those neoplasms.

CD44 as a cancer stem cell marker and its prognostic value in patients with ovarian carcinoma

The aim of our study was to clarify whether the CD44 adhesion molecule as a cancer stem cell marker could also serve as a prognostic factor in patients with epithelial ovarian cancer (EOC). A retrospective study was performed on 87 patients with histologically verified EOC. Specimens of both primary tumour and implantation metastases were tested from 48 of them. CD44 expression was detected by immunohistochemistry. We looked for the cut-off levels of CD44 expression using the Cox regression model. We confirmed statistically significant prognostic factors for overall survival (OS) and disease-free interval (DFI) to be: stage of the disease, postoperative residual tumour and papillary serous histological type. We demonstrated a statistically significant correlation between low CD44 expression and serous papillary carcinoma histotype, tumour recurrence and chemoresistance at a value below 2%. CD44 was neither a prognostic factor of OS nor of DFI. IMPACT STATEMENT What is already known about this subject: Epithelial ovarian cancer is the second most common gynaecological cancer in developed countries. Despite great efforts devoted to ovarian cancer research during past decades, levels of patient mortality have changed very little. Cancer stem cells (CSCs) are subpopulations of cells with typical characteristics of stem cells - i.e. the ability to self-renew and differentiate in a variety of cell types. The main surface marker typical for CSCs is CD44. The aim of our study was to clarify whether the CD44 as a CSCs marker could serve as a prognostic factor in patients with epithelial ovarian cancer. Previous studies published on this topic revealed controversial results. The novelty of our study lies in looking for the cut-off using the Cox regression model.

WHAT THIS STUDY ADDS

We demonstrated a statistically significant correlation between low CD44 expression and serous papillary carcinoma histotype, tumour recurrence and chemoresistance at a value below 2%, however, CD44 was neither a prognostic factor of overall survival nor of disease-free interval. We propose to investigate other markers including other CSCs as a prognostic factors or potential aims for targeted therapy in ovarian cancer.

Importance of Preoperative Knowledge of the Biomarker HE4 in Early-stage Endometrial Cancer Regarding Surgical Management

AIM

To analyze the utility of HE4 assessment in preoperative management of patients with early-stage endometrial cancer for stratification into low-risk and high-risk groups.

PATIENTS AND METHODS

The following data were prospectively collected from patients operated for endometrial cancer from 05/2012 till 9/2016; age, HE4, CA125, expert ultrasound examination of the pelvis, histotype, grade, FIGO stage.

RESULTS

In total, 124 patients were enrolled. A cut-off of ≥113 pmol/l HE4 demonstrated 40.3% sensitivity and 83.9% specificity for detection of high-risk patients. Correlations of HE4 with age (p<0.001), depth of myometrial invasion (p=0.001), clinical stage of the disease according to ultrasound - T1a vs. T1b (63.6 pmol/l vs. 110.6 pmol/l, p<0.001) were found. However, no correlation of HE4 with lymph node invasion (p=0.07) and tumor grade (p=0.212) was identified.

CONCLUSION

HE4 levels correspond to clinical and FIGO stage of the disease. The sensitivity and specificity does not reach the transvaginal ultrasound results in preoperative assessment of the extent of the disease. Combination of HE4 with ultrasound does not improve the stratification of patients into low-risk and high-risk groups. Preoperative assessment of HE4 is useful providing no imaging method is available.

[Carcinosarcoma of the endometrium with melanocytic differentiation, case report]

OBJECTIVE

The case report presents a case of 60-year old woman with a rare malignant mixed Müllerian tumor with melanomatous differentiation diagnosed from a histology after cervical polyp ablation and curettage.

DESIGN

Case report.

SETTING

Department of gynecology and obstetrics, University Hospital in Pilsen.

CONCLUSION

Carcinosarcoma, previously malignant mixed Müllerian tumor, is a very rare aggressive endometrial carcinoma with low incidence, which typically occurs among older women and commonly affects the uterine body and cervix. Clinically, the carcinosarcoma is impossible to be distinguished from endometrial carcinoma or uterine sarcoma and the definitive diagnosis can only be made based on histological examination.

Incidence of uterine sarcomas in West Bohemia, at the Department of Gynaecology and Obstetrics, University Hospital in Pilsen, Czech Republic

OBJECTIVE AND SETTING

A retrospective review of women of the West Bohemian population was performed at the Department of Gynaecology and Obstetrics, University Hospital in Pilsen, Czech Republic from 1/2005 - 1/2017.

METHODS

The following data was analysed: patients age, histological type, tumour size, FIGO stage, body mass index, previous irradiation, Tamoxifen usage, and other possible risk factors. A total number of 20 uterine sarcoma patients were detected in the period from 1/2005 to 1/2015, and these cases were followed until 1/2017.

RESULTS

The histological types identified were: leiomyosarcoma in 12 cases, endometrial stromal sarcoma in 7 cases and one case of high-grade undifferentiated uterine sarcoma. This only patient diagnosed with high-grade undifferentiated uterine sarcoma showed distant metastases 12 months after the surgical treat-ment and died one month later. The whole group of uterine sarcoma patients regardless histological subtype reached two years in 50% of cases, with the median disease-free interval 18 months and the median follow up of 38 months. The diagnosis of sarcoma was already known in 25% of cases from dilatation and curettage histology. There were suspicious sonographic findings suggestive of sarcoma in 10% of cases. Multiparity was associated with 48.2% of endometrial stromal sarcoma cases. The leading clinical symptom was postmenopausal bleeding in 55% of patients.

CONCLUSION

We confirmed uterine sarcomas to be rare malignancies, even in the Czech population with high uterine malignancy incidence. Uterine cold knife morcellation during the vaginal part of laparoscopically assisted vaginal hysterectomy didnt worsen the prognosis of our patients.

[Agressive small cell carcinoma of the ovary, hypercalcemic type, surgery and oncological treatment: case report]

Small cell carcinoma of the ovary (SCCOHT) is a rare tumor typically affecting young women. It is a highly malignant tumor accompanied with poor prognosis, early relapse and low survival rates. The most significant prognostic factor is stage of the disease. Due to above mentioned factors there are no guidelines for therapy of this rare tumor. We present a case of 22-years-old patient initially treated with antibiotics under diagnosis of pelvic inflammatory disease. Due to persistent mass at left adnexa, she was indicated for diagnostic laparoscopy, converted to laparotomy and left adnexectomy with frozen section revealing unspecified malignant tumor of left ovary. A conservative operation was performed and, after diagnosis of SCCOHT was established, the patient was indicated for adjuvant chemotherapy.

CA125 and HE4 levels in a Czech female population diagnosed with endometrial cancer in preoperative management

AIM

The aim of the present study was to compare the use of cancer antigen 125 (CA125) and human epididymis protein 4 (HE4) biomarkers in patients with endometrial cancer for preoperative management and to particularly focus on relationship between CA125 and HE4 and disease stage in predicting myometrial invasion or intrauterine tumor spread.

PATIENTS AND METHODS

Thirty-four patients diagnosed with endometrial cancer and 32 healthy controls were enrolled into the pilot study in the period between May 2012 and March 2013. Blood from all the females was collected and examined for CA125 and HE4. Based on standardized ultrasound examination, including gynecological examination, the clinical disease stage was determined.

RESULTS

We found a significant difference (p<0.0001) for means of serum levels of HE4: females with endometrial cancer, 75.5 pmol/l, versus healthy females, 40.0 pmol/l. A non-significant statistical difference was found for mean serum CA125 levels (p=0.4442): females with endometrial cancer 19.0 IU/l, versus healthy females, 15 IU/l. A significant correlation with histopathological disease stage was found for both biomarkers (Spearman correlation). Sensitivity and specificity, and the related cut-off for HE4 suggest that HE4 would be a more appropriate biomarker for differential diagnosis between benign and malignant states.

CONCLUSION

Based on our pilot study, we found that parallel examination of HE4 and CA125 may support endometrial ultrasound finding verification prior to biopsy. This study is ongoing and we expect that results on a larger population may enable HE4 measurement to be implemented in routine practice.

[HE4 a biomarker of ovarian cancer]

OBJECTIVE

Verification of the importance of determination of HE4 and calculation of ROMA index for increasing the efficiency of diagnosis of ovarian cancer in a population of Czech women.

DESIGN

Prospective study.

SETTING

Department of Gynaecology and Obstetrics, Faculty Hospital in Pilsen.

METHODS

In the period from 06/24/2010 to 12/01/2011 was at the Department of Gynaecology and Obstetrics, University Hospital Pilsen examined 552 patients with abnormalities in the pelvis. Patients were divided into two groups. There were 30 women with histologically confirmed malignant ovarian tumors. Another 522 women had benign findings. According to the levels of FSH were women in both groups divided into premenopausal and postmenopausal. At all women were measured CA 125, HE4 and FSH. HE4 and CA125 were determined using the chemiluminescent device Architect 1000 (Abbott, USA), FSH chemiluminescent method on the device DXI 800 (Beckman Coulter, USA). At all premenopausal women was calculated ROMA1 index and at all postmenopausal women ROMA2 index. SAS statistical software 9.2 were used for all statistical calculations.

RESULTS

The highest diagnostic efficiency was achieved by a combination of HE4 and CA125 markers with the calculation ROMA2 index for postmenopausal women. In determining of menopausal status according to the values of FSH cut-off for menopause 40 IU/L and cut-off at 26.4% for ROMA2 reaches ROMA2 sensitivity of 92.3%, specificity of 88.5% and PV- of 99.3%. If we reduce the cut-off for laboratory diagnosis of menopause using FSH at 22 IU/L, and cut-off for ROMA2 was 26.3% reaches ROMA2 sensitivity of 95.2%, specificity of 87.8% and PV- of 99.5%.

CONCLUSION

HE4 in combination with CA125 and current ROMA index calculation is a suitable methodology to improve the detection of ovarian cancer.

HE4 and ROMA index in Czech postmenopausal women

AIM

The first aim of the project was to evaluate the benefits of the determination of human epididymis protein 4 (HE4) and the risk of ovarian malignancy algorithm (ROMA) index for primary detection of ovarian cancer in a population of Czech women. The second aim was to study the advantages HE4, cancer antigen 125 (CA125) and ROMA index for distinguishing between benign and malignant tumors. Aware of the age distribution of ovarian cancer, we focused on postmenopausal patients.

PATIENTS AND METHODS

Our group of patients consisted of 256 females, 21 with ovarian cancer and 235 with benign ovarian tumors. All diagnoses were histologically verified. We determined the serum levels of HE4 and CA125 and calculated the ROMA2 index for postmenopausal women. Serum levels of the analytes were measured using an Architect 1000i instrument. Serum samples were collected prior to surgery or any other form of treatment and the results of the two groups of patients were compared (malignant vs. benign).

RESULTS

There was a significant difference in the serum levels for all parameters studied between the groups of patients with malignant and those with benign diagnoses (Wilcoxon test, p<0.0001). When all parameters were evaluated at 95% specificity, the HE4 cut-off was 112 pmol/l at a sensitivity of 71.42%, a positive predictive value (PPV) of 55.56%, a negative predictive value (NPV) of 97.14% and an area under the curve (AUC) of 0.9152. The CA125 cut-off was 81 IU/l at a sensitivity of 80.95%, a PPV of 58.62%, a NPV of 98.23% and an AUC of 0.9731. ROMA2 index had a cut-off 37.70% at a sensitivity of 85.71%, a PPV of 62.06%, a NPV of 98.65% and an AUC of 0.9803. The highest diagnostic efficiency was achieved by the ROMA2 index.

CONCLUSION

Determination of HE4 along with CA125 and ROMA2 index calculation is a suitable method for the improvement of the primary detection of ovarian cancer. This approach also improves the differential diagnostic possibilities for distinguishing between malignant and benign tumors.

Short report: HIV infection among commercial sex workers and injecting drug users in the Czech Republic

Since the first HIV case was diagnosed in the Czech Republic in 1985, there is a lack of information regarding the epidemiology of HIV infection in most high-risk groups. To determine the prevalence of, and risk factors for, HIV among female and male commercial sex workers (FCSW and MCSW, respectively) and injecting drug users (IDUs), cross-sectional studies were conducted in the cities of Cheb, Usti nad Labem, Ostrava, and Prague of the Czech Republic. A total of 1,277 subjects were enrolled, which included 585 FCSWs, 230 MCSWs, and 462 IDUs. The HIV prevalences were 0.7% (95% CI: 0.2-1.7%), 0.9% (95% CI: 0.1-3.1%), and 0.2% (95% CI: 0.005-1.2%) among FCSWs, MCSWs, and IDUs, respectively. Although low HIV prevalences were found, ongoing sentinel surveillance studies, which address modifiable behavioral and biologic risk factors among high-risk groups, are necessary to guide strategies to stem the tide of the epidemic in this country.

Clinical findings with the oral contraceptive combination ethinylestradiol/dienogest in the Czech Republic

The efficacy and safety of the low dose monophasic oral contraceptive (OC) combination containing 30 micrograms of ethinylestradiol (EE) and 2.0 mg of dienogest (DNG) (EE/DNG) was evaluated in a prospective, open-label, multicenter, uncontrolled, phase III trial. The trial was carried out in six hospitals by 36 investigators in the Czech Republic, and included 557 healthy women (aged 18-35 years), over 12 cycles, with a total of 6051 cycles. EE/DNG provided a reliable ovulation inhibition. The contraceptive efficacy study showed an adjusted Pearl index of 0.198 on the basis of three pregnancies occurring during 6051 cycles. EE/DNG provided good cycle control, reduced the incidence of intermenstrual bleedings, the intensity of menstrual bleeding and frequency of dysmenorrhea. Due to the antiandrogenic properties of the progestogen component DNG, EE/DNG improved androgen-related conditions, such as skin blemishes, hair greasiness and acne vulgaris. From 108 women with acne, 62 (57%) improved after the 6th cycle, and 16 (15%) were healed. Similar changes were found after cycle 12. Breast tenderness and headache were the most frequent of the common complaints due to treatment with EE/DNG. The frequency of all complaints decreased steadily over time. Only 7.7% of subjects discontinued due to adverse reactions. No thrombophlebitic events were noticed.

[Long-term follow-up of the health status of opiate abusers treated with methadone--pilot study]

BACKGROUND

Examination of the health status of patients abusing opiates can be substantiated by their high morbidity. The aim of the work was to describe the actual health status and the extent and seriousness of the affliction before the substitution therapy with opioid receptors agonist--methadone.

METHODS AND RESULTS

The group of drug abusers consisted of 101 persons (average age was 28.5 years, within the range of 20 to 47 years, 77 men and 24 women). Among the pathological findings, values of the levels of hepatic enzymes ALT, AST (35 and 31%), GMT (9%), low haemoglobin levels (24%) and elevated values of IgM (38%) and CRP (25%) belonged to the most frequent ones. Because of the simultaneously positive tests for hepatitis (C and B, 70% and 61%), the alteration is fully obvious. Low testosterone levels in males (63%) indicate the dysfunction of the hypothalamus-hypophysis-gonadas axis. Increased values of thyroxin (14%), P (20%) and atherogenity index (19%) remain unexplained. Several other laboratory-biochemical parameters remained within the physiological range. Imaging methods revealed hepatomegaly in 28% and splenomegaly in 27%, echotexture indicating steatosis was found in 15% of studied persons.

CONCLUSIONS

In chronic drug abusers before the onset of the substitution therapy, it is possible to expect frequent alterations, namely that of hepatic functions, positive test for hepatitis B and C, alteration of immunoglobulines level and testosterone deficits (in males).

[Laboratory indicators in drug addicts and tertiary prevention of narcotic dependence]

BACKGROUND

The authors report on some laboratory indicators in opiate abusers dependent for prolonged periods on opiates. The objective of the study is a proposal for an examination pattern in adepts during oral substitution therapy and emphasis on the necessity of systematic follow up of the health status.

METHODS AND RESULTS

In 27 opiate abusers with a varying period of dependence on opiates the hematology laboratory tests was assessed, plasma levels of some minerals, renal and hepatic functions, some enzymes and metabolic indicators and vitamin D metabolites. For statistical evaluation Student's t-test was used and simultaneous testing.

CONCLUSIONS

Long-term opiate abuse damages in 30 and 35% resp. liver functions. Therefore vitamin D deficiency develops. The authors recommend to follow up the health status of opiate abusers during oral substitution treatment (tertiary prevention).

[Coronary heart disease with a marked vasospastic component associated with the menstrual cycle and its treatment]

The authors describe the case of a 46-year-old patient with serious manifestations of ischaemic heart disease-repeated myocardial infarctions, malignant arrhythmias, the algic form of angina pectoris, whose complaints were markedly linked to the menstrual cycle. The authors mention also the individual solution, i.e. elimination of ovarian activity by actinotherapy.

[The early androgen syndrome--effect on the hormonal and immune system]

Administration of 1 mg testosterone propionate to neonate mice of both sexes on the 4th day after birth causes marked and prolonged changes in some parameters of the immune and hormonal system. At the age of one month the oestradiol level in males and females is markedly elevated, but not the testosterone level. There is a marked increase in the metabolic activity of peritoneal macrophages stimulated by zymosan and at the same time also in the percentage of cells phagocytizing inert HEMA particles. There was a marked increase in the amount of haemoglobin in females and of the bone marrow cellularity (in particular in males). Obviously also changes in cell differentiation occur, the ratio of different cell types in the peripheral blood stream changes. There is a decline of neutrophil granulocytes with a divided nucleus (in particular in males, where also the number of lymphocytes rises). The cell-mediated immune response is also altered as the graft response to the host is more intense. The humoral immunity against T-dependent antigen is also affected. The titre of IgG antibodies is reduced and the titre of IgM antibodies elevated. The results are discussed, but so far it is difficult to decide whether the observed changes of the immune system are primary, i.e. directly induced by testosterone, or whether they are secondary, i.e. induced by an elevated testosterone level.

[Glycosaminoglycans in the peritoneal fluid of infertile women with endometriosis]

The authors examined the glycosaminoglycan level in the peritoneal fluid of 54 infertile women with or without endometriosis. The peritoneal fluid was collected during a routine laparoscopic examination. Glycosaminoglycans were assayed in complexes with Alcian blue. There was a higher concentration of glycosaminoglycans in peritoneal fluid during the follicular phase of women with endometriosis. The authors did not prove a statistically significant difference between women with and without endometriosis.

Melatonin rhythm in human milk

The pineal hormone melatonin exhibits a circadian rhythm in body fluids. No data are available on melatonin in human milk. The present study was undertaken to determine whether melatonin is detectable in human milk and, if so, whether it exhibits a daily rhythm. Blood and milk were sampled between 1400-1700 h and again between 0200-0400 h from 10 mothers 3-4 days after delivery. Melatonin in both fluids was beyond the limit of detection during the day, whereas during the night, its concentration was 280 +/- 34 pmol/L in serum and 99 +/- 26 pmol/L in milk. Six mothers collected milk after each feeding throughout 1 24-h period within 3 months after delivery. Melatonin in the milk of all subjects exhibited a pronounced daily rhythm, with high levels during the night and undetectable levels during the day. The presence of the rhythm in milk suggests that melatonin fluctuations in milk might communicate time of day information to breast-fed infants.