The role of sentinel node mapping with indocyanine green and endoscopic near-infrared fluorescence imaging in endometrial and cervical cancer

INTRODUCTION

Endometrial and cervical carcinoma are common neoplasms in gynecological oncology. The prognosis and treatment depend on the stage of the cancer according to the FIGO staging system. Stage IAl may be treated by hysterectomy or even local surgical procedures. For Stage IA2, radical hysterectomy and lymphadenectomy must be performed. Lymph node metastasis is an important prognostic factor in both cancers, however lymphadenectomy is associated with long-term complications. Thanks to the sentinel lymph node biopsy (SLNB), we can more accurately discover the staging of the primary tumor, and in case of sentinel lymph node (SLN) negative patients, can resign regional lymphadenectomy. Some researchers claim that new techniques such as indocyanine green (ICG) and endoscopic near-infrared fluorescence imaging for sentinel node mapping can be used instead of the traditional techniques.

AIM

To establish the role of sentinel node mapping technique in endometrial and cervical cancer.

MATERIAL AND METHODS

A retrospective study of medical records of five patients with cervical cancer (first group) Stage I and nine patients (second group) who underwent laparoscopic radical hysterectomy and SLNB or group of lymph nodes. These procedures were performed at Gynecology Department of the District Hospital in Garwolin.

RESULTS

All lymph nodes were clear of metastases. All patients after histopathological diagnosis were finally referred to the Cancer Centre and Institute of Oncology due to consultation or for further treatment.

CONCLUSION

Based on the present first results and literature review, intracervical ICG injection with fluorescence imaging seems to be the best SLN mapping technique, because of its simplicity, safety, and overall lower cost. More data is required to determine if the nodes identified with this technique are able to predict metastatic disease.

[Severe hemolytic disease of the newborn as a result of late and undiagnosed alloimmunization--case report]

We report a case of a hemolytic disease in a newborn from the first pregnancy due to anti-D antibodies. The maternal blood group was A Rhesus negative. She had an antibody screening test twice during the pregnancy (in the second trimester) and it was negative. The pregnancy was uneventful, without any invasive procedures and bleeding. The infant was born at 39 weeks of gestation in good overall condition. After the delivery the blood group of the neonate was indicated - A Rhesus positive, BOC positive. Anti-D antibodies were detected in maternal blood. Neonatal blood tests revealed severe anemia (hemoglobin level: 6.0g/dl, hematocrit: 22.2%, erythrocytes: 2.01T/L). During the first day of neonatal life, the newborn received two transfusions of red blood cells. Bilirubin level and rate of rise were not recommendation enough for exchange transfusion. The newborn was treated with continuous phototherapy since the delivery The perinatal period was complicated with intrauterine infection and respiratory failure. Hematopoietic vitamins and iron supplementation was initiated in the second week of neonatal life due to persistent anemia. The child remained under medical care of a hematologic clinic and received human recombinant erythropoietin treatment.

Sonohysterography in peri- and postmenopausal women with abnormal uterine bleeding or abnormal endometrial appearance

OBJECTIVES

To assess the usefulness of SIS and to compare its diagnostic accuracy with conventional transvaginal ultrasound (TVS) and hysteroscopy (HSC) to detect intracavitary abnormalities in peri- and postmenopausal women with abnormal endometrial appearance or abnormal uterine bleeding (AUB) prior to admission.

DESIGN AND SETTING

The study group consisted of 40 patients in peri- and postmenopausal period referred to the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw due to AUB or abnormal endometrial appearance on TVS between January 2013 and June 2013. All the participants underwent TVS followed by SIS in order to plan further management. Only the patients with uterine abnormalities on TVS examination, proved by SIS were qualified for HSC. Hysteroscopical guided biopsies were taken in cases with focal lesions. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TVS, SIS and HSC were calculated by comparison with the final pathological diagnosis as the gold standard.

RESULTS

The comparison of the three diagnostic procedures revealed that the diagnostic accuracy of SIS and HSC is superior to conventional TVS. SIS and HSC had identical accuracy for submucosal myomas (PPV and NPV 1.0 for both), while in case of polypoid lesions the accuracy of HSC was higher than of SIS (HSC: PPV 0.8, NPV 1.0; SIS: PPV 0.75; NPV 0.75).

CONCLUSIONS

Due to its accuracy and cost-effectiveness, SIS could be regarded as a primary diagnostic method allowing proper qualification for further invasive diagnostic or therapeutic procedures in the detection of uterine abnormalities among peri- and postmenopausal women.

Autonomous adrenocorticotropin reaction to stress stimuli in human fetus

The aim of the study was to determine whether human fetuses show ACTH response to stress stimuli, to define the gestational age from which these reactions may be present and to analyze the relationship between hormone concentrations and their changes, both in fetuses and in pregnant women. The study included 81 intrauterine transfusions carried out in 19 pregnant women. 52 procedures were performed directly into the umbilical vein, which is not innervated, so neutral for the fetus (the PCI group) and 29 transfusions into the intrahepatic vein -which puncture is stressful for the fetus (the IHV group). ACTH and cortisol concentrations in fetal and maternal plasma obtained during the procedures were assayed. The initial mean plasma ACTH concentration in the PCI group equaled 18.94pg/mL, but in the IHV group it was significantly higher and amounted 75.17pg/mL (p<0.001). There was no significant change in the hormone concentration during the transfusion both in the IHV group (95.8pg/mL, p>0.05) and in the PCI group (22.36pg/mL, p>0.05). The observed hormonal response in the IHV group proves the existence of fetal pituitary reaction to stress. The initial fetal ACTH concentration in the IHV group correlated with the number of transfusions performed on a single fetus (R=0.41; p=0.04). No correlation with parity, gestational weeks or the volume of transfused packed red blood cells was found. There was also no correlation between fetal and maternal ACTH concentrations in any group. Presented data suggest that the human fetus shows autonomous ACTH reaction to stress stimulation.

[First trimester diagnosis of encephalocele--report of two cases and review of the literature]

The authors present two cases of encephalocele, diagnosed at 11(+0)-13(+6) wks scan. Case 1: Occipital encephalocele (max diameter 14 mm) without brain tissue was diagnosed at 12 wks. At 35 wks bilateral ventriculomegaly was additionally found. The course of pregnancy was uneventful. Encephalocele was closed surgically soon after delivery Normal neonatal development at 6 months of age was confirmed. Case 2: Occipital encephalocele (max diameter 34 mm) containing brain tissue was diagnosed at 12 wks. Two weeks later fetal demise was confirmed during ultrasound examination. Uncomplicated induction of abortion was performed locally. The outcome and possible clinical scenarios in both cases, together with review of literature, are presented in the article.

N-terminal pro-B-type natriuretic peptide: a potential marker of fetal heart failure in hemolytic disease

OBJECTIVES

The hemolysis of red blood cells due to isoimmunisation results in fetal anaemia and hypoxia leading to fetal heart failure. An assessment of N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a routine practice in adult heart failure. No studies on this marker have been reported in fetal heart failure. The aim of the current study was to investigate changes in fetal NT-proBNP serum concentrations before and after intrauterine transfusions and to assess its value as a marker of fetal heart failure.

DESIGN

Therapy of Rh immunisations was performed in 14 fetuses with 61 intrauterine transfusions. Hemoglobin concentration, red blood cells count, hematocrit and NT-proBNP concentrations were assessed in samples taken before and after each transfusion.

RESULTS

An increase in the concentrations of blood parameters was strongly correlated with a decrease in the concentration of NT-proBNP. NT-proBNP concentrations were the greatest with the smallest Hb (4.0-5.9 g/dl), hematocrit and red blood cell (RBC) concentrations, respectively. An increase in Hb concentration by 1mg/dl and the RBC count by 1M/µl resulted in a corresponding decrease in NT-proBNP concentration by 659.0 and 2 007.1 pg/ml, respectively. The NT-proBNP concentrations decreased significantly following 52 transfusions.

CONCLUSIONS

The fetal serum concentration of NT-proBNP appears to be a satisfactory marker for heart failure in fetuses inflicted with severe anaemia caused by hemolytic disease. Intrauterine therapy decreases the severity of anaemia and reduces the fetal heart failure index. There appears to be a strong inverse correlation between the pre-transfusion NT-proBNP concentration and morphological parameters.

Placental first trimester's measurements in relation to maternal plasma adiponectin, leptin and insulin concentrations

OBJECTIVE

The dysregulation of adiponectin and leptin is found in insulin resistance. There is evidence that both cytokines and insulin might contribute to the placental development and the fetal growth. The objective of this study was to evaluate the relationship of maternal plasma cytokine and insulin concentrations with the placental dimension in the first trimester of pregnancy.

METHODS

34 women with singleton pregnancy, between 11th and 14th weeks, were included to the study. Plasma levels of adiponectin, leptin, insulin and glucose were quantified with ultrasound measurements of the placenta. HOMA-IR were calculated to assess the insulin sensitivity.

RESULTS

Mean concentrations of adiponectin, leptin and insulin were 18,39±13.99 µg/ml; 6.99±5.67 ng/ml and 43.98±23.89 pmol/l respectively. The placenta thickness was positively associated with the maternal adiponectin plasma concentration (r=0.36; p=0.037). There were no associations between placental measurements and leptin, fasting insulin, fasting glucose and HOMA-IR. There was not significant correlation between placental measurements and the fetal Crown Rump Length (CRL).

CONCLUSIONS

The results of this study imply that maternal adiponectin plasma concentration may have a role in placental growth.

Maternal plasma cytokines concentrations and insulin resistance in first trimester in relation to fetal growth

OBJECTIVE

Fetal growth is determined by genetic factors and placental supply. There is evidence that insulin might contribute to the up-regulation of placental transporter activity. The dysregulation of adiponectin and leptin is found in insulin resistance. The objective of this study was to evaluate the relation of maternal plasma cytokine and insulin concentrations in the first trimester of pregnancy to fetal growth.

METHODS

55 women with singleton pregnancy, between 12th and 14th weeks of gestation, were included to the study. Plasma concentrations of adiponectin, leptin, insulin and glucose were analyzed together with fetal ultrasound measurements and neonatal birth weight. The HOMA-IR were calculated (fasting insulin (microU/ml) x fasting glucose (mmol/l/22.5) to assess the insulin sensitivity.

RESULTS

Mean concentrations of adiponectin, leptin and insulin were 15.29 +/- 13.83 microg/ml, 6.93+/-5.39 ng/ml and 43.59+/-26.28, respectively. The average insulin resistance defined by HOMA-IR was 1.35+/-0.8. The ratios of adiponectin to leptin, adiponectin to insulin and HOMA-IR were calculated. The percentiles of fetal crown-rump length (CRL) were negatively correlated with adiponectin plasma concentration (r=-0.32; p<0.05), with no relation to leptin and insulin plasma concentration. Correlations between fetus CRL percentile and the ratio of adiponectin to leptin concentration (r=-0.37; p<0.02) and adiponectin to HOMA-IR (r=0.35; p<0.05) were also observed. No association between adiponectin, leptin, fasting insulin, HOMA-IR and neonatal birth weight or birth weight percentile was found. The percentile of fetal CRL in the 1st trimester was positively correlated with neonatal birth weight percentile (r=0.3; p<0.05).

CONCLUSIONS

The results of this study imply that maternal adiponectin concentration may play a role in early determination of fetal growth.

Effects of maternal lipids on the fetal growth in gestational diabetes

OBJECTIVE

The aim of this study was to determine whether there is an association between ultrasound fetal biometry and lipids and glucose profiles at the beginning of gestational diabetes (GDM) treatment.

METHODS

In 98 women with GDM plasma glucose and lipid profile were measured between 27-32 weeks' of gestation. The association between the biochemical parameters and the measurements and percentiles of the biparietal diameter (BPD), femur length (FL) and abdominal circumference (AC), estimated fetal weight (EFW) and the actual birthweight (BW) were analyzed.

RESULTS

There was no significant association between fetal and neonatal biometry measurements and maternal glucose concentrations. Highly significant positive correlation was found between triglicerydes and fetal biometry at the beginning of GDM treatment: AC, BPD, FL and EFW (p=0.007, p=0.018, p=0.018, p=0.013, respectively), as well as between total cholesterol and bi-parietal diameter (p=0.04). Associations between maternal plasma lipids and birthweight or birthweight percentile were not evident.

CONCLUSIONS

These data suggest that maternal lipids and carbohydrates metabolic disturbance are an important determinant for fetal growth in pregnancy before gestational diabetes is diagnosed.

Laparoscopic treatment of uterine myomas in women of reproductive age

OBJECTIVES

To analyze the indications, safety and feasibility of laparoscopic myomectomies performed during the last 10 years.

MATERIAL AND METHODS

The studied material consisted of 187 typically performed laparoscopies, mostly due to uterine myomas. All the patients underwent an ultrasound examination at the time of admission and those with the maximum of 3 tumors, where the largest tumors were less than 10cm in diameter, were qualified for endoscopic surgery.

RESULTS

Out of 187 women, 39 patients had laparoscopy performed twice, with a 3-4 months interval for GnRH analogues treatment. Among 164 operative laparoscopies myomas were enucleated in 132 of the women (80.5%). In the case of 18 patients (9.6%) there was a need for laparoconversion resulting from the difficulties with enucleation, adhesions, and the size or localization of the tumor. There were also 62 cases of diagnostic laparoscopy, where myomas were either too large or too small to be enucleated. On analyzing the number and size of the tumors it occurred that a single myoma was the most frequent finding, while more than half of all the enucleated uterine tumors found during diagnostic and operative endoscopies were up to 2cm in diameter.

CONCLUSIONS

Laparoscopic myomectomy is a safe and reliable surgical alternative for women suffering from symptomatic myomas and is a method of choice in young patients of reproductive age. Beside skillful surgical techniques, a proper qualification for the operation is essential for the desired outcome.

Anti-Co(a) implicated in severe haemolytic disease of the foetus and newborn

The Colton (Co(a)) antigen is of high frequency; its incidence in Caucasians is about 99.8%. Reports on haemolytic transfusion reactions and haemolytic disease of the foetus/newborn (HDFN) due to anti-Co(a) are rare. We report a severe HDFN due to anti-Co(a). The first child of the mother was healthy. The second died a few hours after delivery because of hydrops fetalis, likely due to HDFN; anti-Co(a) in the maternal serum, the father typed as Co(a+). The third pregnancy was followed up by the measurements of anti-Co(a) titre (additional antibodies were excluded), its functional activity by the chemiluminescence test (CLT) and the Doppler flow in the middle cerebral artery of the foetus. Increased values of antibody titre up to 128, the CLT to 30% and multiplex of median of the peak systolic velocity to 1.71 indicated haemolytic disease and the necessity for an intrauterine transfusion. The foetus received the maternal red blood cells (RBCs). Delivery had to be by Caesarean section for obstetrical reasons at 34-week gestation. The newborn (anti-Co(a) on red cells and in plasma, the rise of the bilirubin concentration up to 333 micromol L(-1)) had four exchange transfusions: the first of maternal RBCs, the remaining of donor's Co(a+) cells and one top-up transfusion. The baby was discharged in good health. Anti-Co(a) was responsible for severe HDFN. Proper monitoring during pregnancy and antenatal and post-natal therapy were successful. This is the second severe published HDFN due to anti-Co(a).

The usefulness of laparoscopy and hysteroscopy in the diagnostics and treatment of infertility

OBJECTIVES

The aim of the study was to analyze the use of endoscopic procedures in the group of infertile patients.

MATERIAL AND METHODS

The study material consisted of 636 patients, aged 20-41. They all had endoscopic procedures performed (laparoscopy and/or hysteroscopy) due to infertility, and were qualified for the procedure after a gynecological examination and ultrasound scan. The study group was divided into subgroups of primary and secondary sterility and endoscopic procedures were then analyzed.

RESULTS

A total of 724 endoscopic procedures were performed on 636 patients. Eighty eight women had both hysteroscopy and laparoscopy performed, 476 had only laparoscopy, while 72--only hysteroscopy. Women diagnosed due to primary sterility more often had no visible abnormalities in the pelvic region (30%) and patent oviducts than those with secondary sterility. The remaining 70% more often had ovaries typical for polycystic ovarian syndrome and endometriosis. However, periadnexal adhesions and tubal impotency were more common in the group of secondary sterility. As to hysteroscopy, women with primary sterility more often had congenital uterine malformations, while submucosal myomas and intrauterine adhesions were less common in that group. All the surgical procedures performed during laparoscopies were analyzed. Tubal patency assessment and ovarian drilling were significantly more often performed in the subgroup of primary sterility. All intrauterine pathologies were treated during hysteroscopy.

CONCLUSIONS

Laparoscopy and hysteroscopy play an important role as both diagnostic and therapeutic tools in the infertility treatment centers.

The evaluation of uterine cavity with saline infusion sonohysterography and hysteroscopy in infertile patients

OBJECTIVES

The preliminary study was performed to evaluate the diagnostic accuracy of saline infusion sonohysterography (SIS) in the detection of intrauterine pathologies in infertile women The SIS findings were compared to the results of two widely used procedures: transvaginal sonography (TVS) and hysteroscopy (HS).

MATERIAL AND METHODS

68 infertile women, aged 27-42 were enrolled in the study. TVS, SIS and diagnostic HS were consecutively performed in every patient. The results of each method were compared. Sensitivity, specificity, positive predictive value and negative predictive values for TVS and SIS were obtained.

RESULTS

Intrauterine pathologies were diagnosed in 25% of patients. TVS detected 6 (37.5%) and SIS revealed 11 (87.5%) of 13 intrauterine pathologies finally visualized at diagnostic hysteroscopy. TVS failed to visualize three submucous myomas, one endometrial polyp and two cases of septate uteri. All three cases of intrauterine synechiae were not detected with this method One submucous myoma and one endometrial polyp were not identified with SIS. The study group was, however, too limited to show statistically significant differences in diagnostic accuracy among TVS, SIS and HS.

CONCLUSIONS

Saline infusion sonohysterography is simple, sensitive and inexpensive diagnostic method. The procedure is not time-consuming, causes minimal discomfort to the patient and may be performed without anesthesia in office settings. The method may be recommended for the diagnosis of intrauterine pathologies in infertile women.

[Accuracy of transvaginal sonography, sonohysterography and hysteroscopy in diagnosis of intrauterine pathology]

OBJECTIVES

Sonohysterography (SHG) is a relatively new technique in evaluation of intrauterine disorders. We compared the diagnostic accuracy of this method with that of transvaginal sonography(TVS) and diagnostic hysteroscopy (DH) in diagnosis of intracavitary abnormalities in women with abnormal uterine bleeding, inconclusive endometrial view at TVS and thickened endometrium.

METHODS

In prospective study, pre- and postmenopausal women underwent TVS, SHG, and DH. The findings at TVS and SHG were compared with hysteroscopic and histologic findings (obtained from operative hysteroscopy, hysterectomy and d&c). Sensitivity, specificity, positive and negative predictive values were calculated for focally growing lesions.

RESULTS

150 patients were included in the study. There was very good agreement between SHG and DH in the diagnosis of focally growing lesions. SHG was more sufficient in detecting intracavitary abnormalities than TVS. Problems with distention of the uterine cavity were due to cervical stenosis and endometrial carcinoma.

CONCLUSION

SHG is more accurate in the diagnosis of intracavitary abnormalities than is TVS. SHG is almost as good as DH at detecting focally growing lesions in the uterine cavity.

[Transvaginal ultrasonography and diagnostic hysteroscopy in infertile women]

Sensibility and specificity of transvaginal ultrasonography and diagnostic hysteroscopy were compared in 211 infertile women. Examinations were performed between 1996-2000 in I-st Department of Obstetrics and Gynecology Warsaw Medical University--Poland. Comparing results we concluded high compatibility of transvaginal ultrasound and hysteroscopic examinations. In the future--as we suppose--the number of diagnostic hysteroscopies in infertile women will decrease and will be at least partially replaced by transvaginal ultrasound as less invasive and less expensive method.

Diagnosis and treatment of sigmoidal endometriosis--a case report

Intestinal endometriosis is a rare but clinically significant complication. The most commonly involved sites are the rectosigmoid (up to 73%) and rectovaginal septum (13%). A case of a 53-year-old woman with intestinal endometriosis located in the sigmoid colon is presented with symptoms of pelvic pain and rectal bleeding. The diagnosis was established by means of colonoscopy which was performed 3 times before laparotomy. Bowel resection and pathologic study are necessary to relieve the symptoms and avoid neglecting a malignant tumor or other lesions. The postoperative course was uneventful and the patient was discharged after 13 days.

[Computer-assisted analysis of cardiotocographic recordings in the course of fetal hemolytic disease]

OBJECTIVES

The aim of this study was to assess the usefulness of computerized cardiotocography in the diagnostics of fetal hemolytic disease.

STUDY DESIGN

50 invasive diagnostic and therapeutic procedures proceeded by computer assisted CTG recording were analysed. The values of particular parameters of CTG were compared with adequate values obtained in uncomplicated pregnancy. The correlation between both cardiotocographic and hematological parameters was estimated. The common relationship between all analyzed features was examined using multidimensional analysis of variancy.

RESULTS

The most significant correlation was determined in case of short-term variation and hematocrite of fetal blood. The five-feature algorhythm, containing short- and long-term variation, number of accelerations, fetal movements and gestational age, was established for the prognosing of the most probable level of fetal hematocrite.

CONCLUSION

Computerized cardiotocography seems to be the useful diagnostic method which enable to decrease the number of invasive intrauterine procedures in case of fetal hemolytic disease.