Screening and diagnosis of endometrial cancer in Lynch syndrome

Lynch syndrome (LS) is an autosomal dominant inherited cancer predisposition syndrome caused by a mismatch of DNA repair (MMR system). Lifetime risk of developing endometrial and ovarian cancer in LS is higher than in the general population and gynecologic screening appears interesting. Screening is based on several tests: pelvic ultrasound, endometrial biopsy and hysteroscopy for endometrial cancer, pelvic ultrasound and CA125 for ovarian cancer. Those tests appear efficient for the diagnosis of gynecologic cancers in LS. Nevertheless, screening tests have not proved clinical benefit until now, and potential problems of compliance, risk of false negative cases, and interval cancer associated with screening do justify offering prophylactic surgery to patients. Women with LS should be informed of the potential benefits and risks of screening and the importance of evaluation in case of gynecologic symptoms or abnormal bleeding. Chemoprevention by progestin-containing oral contraceptives and the treatment of premalignant lesion are available options for reducing the risk of endometrial cancer in LS population.

Laparoscopic Burch urethropexy at time of mesh sling removal: A cohort study evaluating functional outcomes and quality of life

AIM: To theorize that performing a laparoscopic Burch urethropexy at time of sling removal would significantly decrease subjective symptoms of stress urinary incontinence (SUI) and improve patient satisfaction.

METHODS: Women who underwent a combined sling removal and laparoscopic Burch procedure between 2009 and 2014 were matched via age and sling-type in a 1:2 ratio to women who only underwent a sling removal. Those who underwent surgery within 6 mo of data collection were excluded from the study, as were women who underwent multi-stage surgery. Preoperative assessment for both groups included a focused clinical exam with or without functional testing and questionnaires including urogenital distress inventory-6 (UDI-6) and incontinence impact questionnaire-7 (IIQ-7) per the standard clinical practice. All non-exempt women were sent a questionnaire that included UDI-6 and IIQ-7 in addition to standard follow-up questions. Research staff contacted participants via email, mail, and telephone using the same questionnaire template and script. Data was analyzed by using χ² test for categorical data, and Student’s t test and Wilcoxon Rank Sum test for continuous data. The measure of effect was determined by logistic regression analysis.

RESULTS: A total of 48 women out of 146 selected patients were successfully recruited with n = 22 in the Burch cohort and n = 26 in the control cohort. The mean age was 54.7 ± 7.8 years and mean body mass index was 22.0 ± 13.9 kg/m². The majority of patients were Caucasian (73.3%), postmenopausal (91.1%), nonsmokers (57.9%), with a history of hysterectomy (81.4%). Six nineteen point six percent of women presented after at least 2 years from placement, which was significantly more common in the Burch cohort. Pain was the most common chief complaint (64.4%) in both groups at the time of initial presentation, and 78.9% of women reported concomitant urinary incontinence. There was no significant difference in pre-operative UDI-6 and IIQ-7 scores between the two cohorts. However, the change in UDI-6 score postoperatively was significantly improved in the Burch cohort with an average drop in score of 28.41 points compared to a decrease of 4.01 points in the control group (P = 0.02, 95%CI: 3.84 to 44.97). Although not statistically significant, the Burch cohort was 58% more likely to show an overall improvement in their score after surgery and 40% more likely to meet the minimal important difference of 11 points (RR = 1.58, 95%CI: 0.97 to 2.57; RR 1.40, 95%CI: 0.79 to 2.46). The difference in IIQ scores was nonsignificant. There was no significant difference in blood loss, complications, or postoperative pain or dyspareunia.

CONCLUSION: Performing a Burch urethropexy during sling removal does not increase complication rates and results in a significant change in validated symptom-related quality of life scores.

Care of survivors of gynecologic cancers

The number of cancer survivors is increasing and most healthcare providers will manage patients who have completed therapy for malignancy at some point. The care of survivors of gynecologic malignancies may seem daunting in a busy general gynecology practice. This paper intends to review the literature and suggest management of these women for the general gynecologist.

Cancer stem cells and early stage basal-like breast cancer

Ductal carcinoma in situ (DCIS) is a category of early stage, non-invasive breast tumor defined by the intraductal proliferation of malignant breast epithelial cells. DCIS is a heterogeneous disease composed of multiple molecular subtypes including luminal, HER2 and basal-like types, which are characterized by immunohistochemical analyses and gene expression profiling. Following surgical and radiation therapies, patients with luminal-type, estrogen receptor-positive DCIS breast tumors can benefit from adjuvant endocrine-based treatment. However, there are no available targeted therapies for patients with basal-like DCIS (BL-DCIS) tumors due to their frequent lack of endocrine receptors and HER2 amplification, rendering them potentially susceptible to recurrence. Moreover, multiple lines of evidence suggest that DCIS is a non-obligate precursor of invasive breast carcinoma. This raises the possibility that targeting precursor BL-DCIS is a promising strategy to prevent BL-DCIS patients from the development of invasive basal-like breast cancer. An accumulating body of evidence demonstrates the existence of cancer stem-like cells (CSCs) in BL-DCIS, which potentially determine the features of BL-DCIS and their ability to progress into invasive cancer. This review encompasses the current knowledge in regard to the characteristics of BL-DCIS, identification of CSCs, and their biological properties in BL-DCIS. We summarize recently discovered relevant molecular signaling alterations that promote the generation of CSCs in BL-DCIS and the progression of BL-DCIS to invasive breast cancer, as well as the influence of the tissue microenvironment on CSCs and the invasive transition. Finally, we discuss the translational implications of these findings for the prognosis and prevention of BL-DCIS relapse and progression.

Urinary incontinence following obstetric fistula repair

Prolonged and/or obstructed labour is the most common cause of genital tract fistula world-wide, in particular, sub-Saharan Africa and parts of Asia where emergency obstetric services are unavailable or suboptimal to afford timely delivery of the baby. This results in pressure necrosis by the fetal presenting part at the level of the obstruction in the maternal pelvis. Other reasons for obstetric fistula include trauma from vaginal deliveries (spontaneous or instrumental) and iatrogenic from cesarean section/hysterectomy. The majority of women develop the fistula during their first labour and most babies are stillborn. Women with a fistula suffer from leakage of urine and/or faeces from the vagina and surgery is the treatment for an established fistula. Long-term complications of fistulas include recurrent fistula, urinary incontinence, reproductive dysfunction, sexual dysfunction, mental health dysfunction, social isolation and orthopaedic complications such as footdrop. Ongoing urinary symptoms are not uncommon after successful fistula closure. There are various reasons for residual urinary incontinence following obstetric fistula repair including urinary stress incontinence, overactive bladder, mixed urinary incontinence and voiding dysfunction. Urinary incontinence after fistula repair requires careful evaluation prior to further surgery, as in some diagnoses, continence surgery is unlikely to treat and may worsen the condition. Initial results from educational and physiotherapy programs demonstrated a positive impact on post-fistula incontinence.

Gynecologic oncologists involvement on ovarian cancer standard of care receipt and survival

AIM: To examine the influence of gynecologic oncologists (GO) in the United States on surgical/chemotherapeutic standard of care (SOC), and how this translates into improved survival among women with ovarian cancer (OC).

METHODS: Surveillance, Epidemiology, and End Result (SEER)-Medicare data were used to identify 11688 OC patients (1992-2006). Only Medicare recipients with an initial surgical procedure code (n = 6714) were included. Physician specialty was identified by linking SEER-Medicare to the American Medical Association Masterfile. SOC was defined by a panel of GOs. Multivariate logistic regression was used to determine predictors of receiving surgical/chemotherapeutic SOC and proportional hazards modeling to estimate the effect of SOC treatment and physician specialty on survival.

RESULTS: About 34% received surgery from a GO and 25% received the overall SOC. One-third of women had a GO involved sometime during their care. Women receiving surgery from a GO vs non-GO had 2.35 times the odds of receiving the surgical SOC and 1.25 times the odds of receiving chemotherapeutic SOC (P < 0.01). Risk of mortality was greater among women not receiving surgical SOC compared to those who did [hazard ratio = 1.22 (95%CI: 1.12-1.33), P < 0.01], and also was higher among women seen by non-GOs vs GOs (for surgical treatment) after adjusting for covariates. Median survival time was 14 mo longer for women receiving combined SOC.

CONCLUSION: A survival advantage associated with receiving surgical SOC and overall treatment by a GO is supported. Persistent survival differences, particularly among those not receiving the SOC, require further investigation.

Laparoscopic surgery in pregnancy

Each year, roughly 2% of pregnant women will undergo non-obstetrical abdominal surgery. Appendicitis, symptomatic cholelithiasis and adnexal masses are some of the common diagnoses encountered. Pregnancy poses challenges in the diagnosis and surgical management of these conditions for several reasons. Since the 1990’s, laparoscopic surgery has gained popularity and in the past few years has become the standard of care for pregnant women with surgical pathologies. The advantages of laparoscopic surgery include shorter hospital stay, lower rates of wound infection, and decreased time to bowel function. This brief review discusses key points in laparoscopic surgery during pregnancy and highlights studies comparing laparoscopic and open approaches in common surgical conditions during pregnancy.

Single incision slings: Are they ready for real life?

AIM: To review of the efficacy and safety outcomes of different single incision slings (SIS) systems, also in comparison with traditional slings.

METHODS: A literature search was conducted in PubMed/MEDLINE database. The research was restricted to randomized and/or prospective trials and retrospective studies, published after 2006, with at least 20 patients with non-neurogenic stress urinary incontinence (SUI). The studies had to assess efficacy and/or safety of the SIS with a minimum follow-up of 12 mo. All the paper assessing the performance of tension free vaginal tape secur were excluded from this review. The final selection included 19 papers fulfilling the aforementioned criteria. Two authors independently reviewed the selected papers.

RESULTS: Four different SIS systems were analysed: Ajust^®, Ophira^®, Altis^® and MiniArc^®. The average objective cure rate was 88%. Overall no statistically significant differences were found between SIS and traditional mid-urethral slings (MUS) in terms of objective cure (all P > 0.005). Only one paper showed a statistically lower success rate in MiniArc^®vs Advantage^® slings (40% vs 90%) and higher rates of failure in the SIS group. Since there was a great variability in terms of tests performed, it was not possible to compare subjective cure between studies. The vast part of the studies showed no major complications after SIS surgery. We also observed very low reported pain rates in SIS patients. The RCTs on Ajust^® and MiniArc^®, showed better outcomes in terms of post-operative pain compared to MUS. None of the patients reported long- term pain complains.

CONCLUSION: SIS showed similar efficacy to that of traditional slings but lower short-term pain, complication and failure rates.

Risks and guidelines for the consumption of alcohol during pregnancy

Daily average intake of alcohol during pregnancy has consistently been associated with short term adverse outcomes such as miscarriage, preterm birth and intrauterine growth restriction, a large variety of malformations, as well as long term adverse outcomes such as foetal alcohol syndrome, mental retardation and general impairment of cognitive functions including intelligence, attention, learning abilities as well as social and behavioural functions. Weekly average consumption and alcohol binge drinking (usually defined as ≥ 5 drinks on a single occasion) independently of high daily average intake has not been consistently associated with short and long term adverse outcomes. Health authorities in most countries recommend that pregnant women completely abstain from alcohol. Even so, many health professionals including doctors, midwives and nurses do not provide information to pregnant women in accordance with the official recommendations, although a large proportion of women of child bearing age and pregnant women drink alcohol, especially before recognition of pregnancy. The discrepancy between guidelines and the information practice of health personnel is likely to continue to exist because guidelines of abstinence are not clearly evidence-based and not in line with current focus on autonomy and informed choice for patients, and because guidelines do not consider the everyday clinical communication situation.

Role of ultrasound imaging in advancing treatment of female patients with pelvic floor mesh complications

Application of vaginal mesh for stress urinary incontinence has seen widespread use due to its relatively short operative time in combination with its efficacy in treatment. However, vaginal mesh is not without its drawbacks and can lead to mesh erosion or extrusion, infection, dyspareunia, and recurrence of incontinence. Vaginal mesh complications can lead to feelings of hopelessness, isolation, shame, and emotional distress. Furthermore, failure to identify and address these complications in a timely manner can be permanently damaging to patient health. It is vital to be able to identify mesh complications early. Various imaging methodologies exist to visualize vaginal mesh placement and complications, including ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT). This invited review paper focuses on the role of ultrasound in mesh visualization, mesh complication identification, and operative planning in the event of subsequent surgical mesh revision. Polypropylene mesh is echogenic on ultrasound, making it a useful tool for visualizing post-operative mesh placement. Transperineal, translabial and endovaginal ultrasound technique use has been described in the pre- and peri-operative setting to identify mesh in complex cases. Efficacy and practicality of CT and MRI use in identifying mesh in these cases is limited.

Review of the current surgical management of vulval cancer

Currently in the United Kingdom, 1200 cases of vulval cancer are diagnosed per annum accounting for 6% of female genital cancers. Although classically a condition that affects older women and associated with lichen sclerosus, there has been a greater incidence of vulval squamous tumours in young women due to the increasing prevalence of promoting human papillomavirus (HPV). The advent of a vaccination programme against HPV 16 and 18, the main aetiological causes of vulval intraepithelial neoplasia and cervical intraepithelial neoplasia, may reduce the incidence in future generations. Primary surgery is the current gold standard treatment and although mortality rates have reduced by 40% since the 1970s, radical vulval resections are associated with significant morbidity such as wound breakdown, infection, lymphoedema and psychosexual consequences. Over the past decade there has been a move to less mutilating procedures in women diagnosed with early vulval cancer. This is in combination with the introduction of new surgical methods such as sentinel lymph node testing, more directed radiotherapy and chemotherapy options. These treatment methods are being assessed in clinical trials to determine their associated recurrence rates, survival rates and morbidity. Most vulval cancers are squamous cell in origin but, there are other histological subtypes including Paget’s disease and vulval melanoma which can require different management approaches. The objective of this paper is to review the current literature on the management of vulval cancer, summarise the new treatments which are being developed and the associated evidence.

Human papilloma virus vaccination: Review article and an update

Human papilloma virus (HPV) is sexually transmitted and associated with uterine cervix, vaginal, and vulvar cancers in females, oropharyngeal and anal cancer in both genders, and penile cancer in males. Moreover, genital warts are benign tumors which are HPV-related and can occur in both genders. This is a review of HPV structure, HPV infection transmission, the global impact of HPV and its associated diseases, HPV vaccines and their efficacy and safety, public acceptance of HPV vaccines, the obstacles for its acceptance and strategies to address the barriers. Cervarix (a bivalent vaccine with protection against HPV types 16 and 18) and Gardasil (a quadrivalent vaccine with protection against HPV types 6, 11, 16 and 18) are 2 recommended vaccines. The longest follow up of 9.4 years has shown efficacy and protection of the vaccine against HPV types 16 and 18. The adverse effects have been minimal and the vaccine is considered safe. Numerous studies are conducted to follow the vaccinated individuals to better understand the effect of HPV vaccine on incidence of HPV-related cancers and precancerous lesions.

Pathobiological role of MUC16 mucin (CA125) in ovarian cancer: Much more than a tumor biomarker

MUC16 (CA125) has remained the mainstay for ovarian cancer assessment and management since the early 1980’s. With the exception of HE4, it is the only reliable serum biomarker for ovarian cancer. MUC16 belongs to a family of high-molecular weight glycoproteins known as mucins. The mucin family is comprised of large secreted transmembrane proteins that includes MUC1, MUC4 and MUC16. These mucins are often overexpressed in a variety of malignancies. MUC1 and MUC4 have been shown to contribute to breast and pancreatic tumorigenesis. Recent studies have uncovered unique biological functions for MUC16 that go beyond its role as a biomarker for ovarian cancer. Here, we provide an overview of the literature to highlight the importance of MUC16 in ovarian cancer tumorigenesis. We focus on the growing literature describing the role of MUC16 in proliferation, migration, metastasis, tumorigenesis and drug resistance. Accumulating experimental evidence suggest that the C-terminal domain of MUC16 is critical to mediate theses effects. The importance of MUC16 in the pathogenesis of ovarian cancer emphasizes the need to fully understand the signaling capabilities of MUC16 C-terminal domain to develop more efficient strategies for the successful treatment of ovarian cancer.

Variation in use of menopausal hormone treatment on risk of health outcomes

AIM: To determine the relative risk of selected serious outcomes with variations in use of menopausal hormone treatment (MHT).

METHODS: A cohort of 489 women, randomly recruited at age 40-79 years, from a longitudinal study of urbanised population was a study group and was followed for 14 years. Four selected outcomes (coronary artery disease, stroke, peripheral artery disease, breast cancer) were tested. Each woman on entry to the study was interviewed by a dedicated medical practitioner, and data on menstrual and menopausal history and health status were obtained. Outcome information was ascertained by questionnaire and medical reports from attending medical practitioners. In case of death, cause of death was checked with the Registry of Births, Deaths, Marriages and Divorce. This information was available for all women. An ever-user of MHT was defined as use for 6 mo or more at any time during the study. A late start of MHT was defined as 3 years or more from onset of menopause. The generalised linear statistical package was used to examine the data; univariate logistic regression models were used to describe the relationship between patient characteristics and a disease outcome, followed by stepwise multi variate analysis, controlling for age, lifestyle factors and co-morbidities.

RESULTS: The risk of ever-use of MHT was significantly increased only for peripheral artery disease (RR = 2.16; 0.99, 4.71; P = 0.05), and not for coronary artery disease, stroke and breast cancer. A late start of MHT (three years or more from onset of menopause) was associated with significantly increased risks for coronary artery disease (RR = 2.56; 1.15, 5.72; P = 0.02) and peripheral artery disease (RR = 4.42; 1.55, 12.64; P = 0.005), and use after age 60 years with significantly increased risks for coronary artery disease (RR = 4.98; 2.19, 11.55; P < 0.001), stroke (RR = 2.99; 1.11, 8.08; P = 0.03) and peripheral artery disease (RR = 4.18; 1.24, 14.14; P = 0.02). Use up to 10 years was not associated with significant risk for all outcomes. These risks were confirmed by stepwise multi variate analysis, adjusting for age at recruitment, body mass index, smoking, physical activity and alcohol use, and existing diabetes, mellitus, hypertension and hypercholesterolaemia. Regardless of variations in use, risk for breast cancer was not found.

CONCLUSION: The study confirms ever-use of MHT affected only risk of peripheral artery disease; but some use variations could have adverse effects.

Implications of multigene testing for hereditary breast cancer in primary care

Approximately 1 in 8 women will develop breast cancer during their lifetime and the risk factors include age, family history, and reproductive factors. In women with a family history of breast cancer, there is a proportion in which a gene mutation can be the cause of the predisposition for breast cancer. A careful assessment of family and clinical history should be performed in these women in order to determine if a genetic counseling referral is indicated. In cases of hereditary breast cancer, genetic testing with a multigene panel can identify specific genetic mutations in over 100 genes. The most common genes mutated in hereditary breast cancer are the high-penetrance BRCA1 and BRCA2 genes. In addition, other mutations in high-penetrance genes in familial cancer syndromes and mutations in DNA repair genes can cause hereditary breast cancer. Mutations in low-penetrance genes and variants of uncertain significance may play a role in breast cancer development, but the magnitude and scope of risk in these cases remain unclear, thus the clinical utility of testing for these mutations is uncertain. In women with high-penetrance genetic mutations or lifetime risk of breast cancer > 20%, risk-reducing interventions, such as intensive screening, surgery, and chemoprevention, can decrease the incidence and mortality of breast cancer.

Imperative for improvements and international convergence of intrapartum fetal monitoring: A bird’s eye view

Intrapartum fetal monitoring has been criticized for the lack of evidence of improvement in fetal outcome despite causing increased operative intervention. Paradoxically, cardiotocography (CTG) has been a major driver for litigation for neonatal neurological injury. This analytical review tries to explore why extensive clinical studies and trials over 50 years have failed to demonstrate or bring about significant improvement in intrapartum fetal monitoring. There seems a need for significant reform. International congruence on most aspects of CTG interpretation [definitions of fetal heart rate (FHR) parameters, CTG recording speed, 3-tier systems, etc.] is highly desirable to facilitate future meaningful clinical studies, evaluation and progress in this field. The FHR changes are non-specific and poor surrogate for fetal well-being. As a compromise for maintaining low false-negative results for fetal acidemia, a high false-positive value may have to be accepted. The need for redefining the place of adjuvant tests of fetal well-being like fetal blood sampling or fetal electrocardiography (ECG) is discussed. The FHR decelerations are often deterministic (center-stage) in CTG interpretation and 3-tier categorization. It is discussed if their scientific and physiological classification (avoiding framing and confirmation biases) may be best based on time relationship to uterine contractions alone. This may provide a more sound foundation which could improve the reliability and further evolution of 3-tier systems. Results of several trials of fetal ECG (STAN) have been inconclusive and a need for a fresh approach or strategy is considered. It is hoped that the long anticipated Computer-aided analysis of CTG will be more objective and reliable (overcome human factors) and will offer valuable support or may eventually replace visual CTG interpretation. In any case, the recording and archiving all CTGs digitally and testing cord blood gases routinely in every delivery would be highly desirable for future research. This would facilitate well designed retrospective studies which can be very informative especially when prospective randomised controlled trials are often difficult and resource-intensive.

Clinical applicability of immunotherapy of cervical intraepithelial neoplasia

Immunotherapy for cervical intraepithelial neoplasia (CIN) has not yet reached clinical applicability, but seems sensible and shows promising preliminary results. One of the most promising forms of immunotherapy for CIN may currently be imiquimod, because of its established role in other human papillomavirus (HPV)-induced genital conditions, its promising treatment efficacy in high-grade CIN, and its off-label availability. Although imiquimod cannot yet replace the current gold standard treatment for CIN [i.e., large loop excision of the transformation zone (LLETZ)] in all patients, it may be considered in subgroups of patients; for example, young women who may wish to become pregnant in the future, or patients with recurrent CIN lesions in whom a second LLETZ is to be avoided. Immunotherapy of CIN could be extended to post-treatment vaccination, in order to prevent new HPV infections and disease recurrence.

Apoptosis and endometrial receptivity: Relationship with in vitro fertilization treatment outcome

Apoptosis is an important process in the reconstruction of endometrium within the menstrual cycle. The balance between cell proliferation and apoptosis regulates the periodic repair and shedding of endometrial cells and leads to the menstruation or prepare the mucosal layer of endometrium for the implantation of the embryo. Many factors with pro- and antiapoptotic action, such as B cell lymphoma/leukemia-2 and inhibitors apoptosis proteins families, caspases, tumor necrosis factor receptors, phosphatase and tensin homolog, proliferator-activated receptor gamma, microRNAs and others are differently expressed in the endometrial tissue at phases of menstrual cycle. Receptivity of the endometrium at the period of “window of implantation” is associated with the significant increase of apoptosis in endometrium to allow the embryo to be successfully implanted. The impairment of apoptosis regulation in the endometrium at this period often is observed in infertile women with endometriosis, tubal factor, polycystic ovary syndrome, etc.. In many cases the impairment of apoptosis regulation in the endometrium is the main cause of in vitro fertilization (IVF) treatment failure in these patients. As of today, the exact mechanisms and factors mediating the apoptotic process in normal endometrium and in infertile women are not fully understood. Herein, the literature data concerning the endometrial apoptosis regulation in general, and in light of the influence of apoptosis upon IVF treatment outcome are reviewed. The possibility to use some parameters of endometrial apoptosis for prediction of the successful pregnancy achievement in women participating in IVF protocols also is discussed.

Alpha1B adrenoceptor expression is a marker of reduced survival and increased tumor recurrence in patients with endometrioid ovarian cancer

AIM: To investigate the expression patterns of different adrenoceptor isoforms in ovarian cancer and their association with survival and tumor recurrence.

METHODS: The protein expression levels of α1B, α2C and β2 adrenoceptor were assessed in unselected ovarian cancer using immunohistochemistry on microarrayed archival tissue samples. A database containing clinical and pathology parameters and follow-up was used to investigate the association between adrenoceptor isoform expression with ovarian specific survival and tumor recurrence, using univariate and multivariate statistical analysis.

RESULTS: Expression of α1B showed an association with reduced ovarian specific survival (P = 0.05; CI: 1.00-1.49) and increased tumor recurrence (P = 0.021, CI: 1.04-1.69) in the whole patient group. On sub-analysis the expression of α1B in endometrioid cancers (χ² = 5.867, P = 0.015) was found to predict reduced ovarian specific survival and increased tumor recurrence independently of tumor grade, clinical stage and chemotherapy. An association with clinical outcome was not seen for α2C or β2 AR.

CONCLUSION: Alpha1B adrenoceptor protein was found to predict increased risk of tumor recurrence and reduced mortality in patients with endometrioid type ovarian cancer and should be investigated as a biomarker for identifying patients at increased risk of disease progression. Furthermore, α adrenergic receptor antagonists with α1B selectivity should be investigated as a possible adjuvant therapy for treating patients with endometrioid cancer. Proof of principle could be tested in a retrospective population study.

Evaluation of sentinel lymph nodes in vulvar, endometrial and cervical cancers

Sentinel lymph node (SLN) biopsies are a sensitive tool in evaluating lymph nodes for multiple cancers, and in some diseases they decrease morbidity in both the short- and long-term. SLN detection in gynecologic malignancies has been studied extensively over the past decade. We review the current literature on SLN dissection in vulvar, endometrial and cervical cancers. Large, well-designed trials in each of the three types of cancer have demonstrated high sensitivity and low false-negative rates when SLN biopsy is performed in the correct patients and with an appropriate technical approach. In all of these cases the addition of ultra-staging to conventional pathology yields increased detection of micrometastatic disease. Biopsy of the sentinel nodes is feasible and safe in early vulvar malignancies, with multiple studies describing low recurrence rates in those women who have with negative SLNs. There does not appear to be a survival benefit to lymphadenectomy over SLN biopsy and quality of life is improved in women undergoing SLN biopsy. Optimal treatment strategies for women with positive nodal biopsies, particularly in cases with micrometastatic disease, remain unclear. Multiple large studies investigating the utility of SLN biopsy in endometrial malignancy have found that sentinel nodal status is a reliable predictor of metastases in women with low-risk disease. Prospective studies are ongoing and suggest sentinel nodal detection may soon become widely accepted as an alternative standard of care for select cases of endometrial cancer. In cervical cancer, SLN biopsy is accurate for diagnosing metastatic disease in early stage tumors (≤ 2 cm diameter or stage ≤ IB2) where the risk of metastasis is low. It is unknown if women who undergo SLN biopsy alone will have different survival outcomes than women who undergo complete lymphadenectomy in these cases. In a specific population of women with vulvar cancer, SLN dissection is an effective and safe alternative to complete dissection. It can be offered as an alternative management strategy in these women. In women who do undergo SLN biopsy, it is associated with improved quality of life. Promising evidence supporting the utility of SLN dissection in endometrial and cervical cancer continues to emerge, and it may soon become a reasonable option for select patients. However, continued research and refinement of appropriate patient selection and long-term follow-up are necessary.

Update on human papillomavirus vaccination: Where are we now?

Infection with human papillomavirus (HPV) is the major cause of pre-invasive and invasive lesions of the urogenital tract, resulting in morbidity and mortality worldwide. HPV-related infection is responsible for most cases of cervical cancer, a leading cause of cancer death in women worldwide. Developed countries have screening programs in place to detect precancerous lesions at early stages; in resource-limited settings however, HPV related diseases are often identified in advanced stages. This is due to limitations in the availability and roll out of effective screening programs. The relatively recent availability of the HPV vaccine has provided a new public health opportunity to decrease the incidence of HPV-related disease. The high mortality rates seen in developing countries could be reduced through effective implementation of HPV vaccination programs. Large trials have proven the efficacy of bivalent, quadrivalent vaccine and most recently 9-valent vaccine. Uptake in vaccination remains low due to multiple barriers including lack of education, lack of access, and costs. New strategies are being assessed to increase access, increase knowledge and reduce costs that may result in feasible vaccination programs worldwide. The goal of this article is to review the effectiveness and safety of the current HPV vaccines available, vaccine delivery strategies, cost effectiveness, and efforts to improve the acceptability. A literature search was conducted through PubMed using the terms “HPV vaccination, and safety, and males, and acceptability and strategies, and cost effectiveness,”focusing on articles published between 2006 and 2015. The most relevant and larger scale trials were evaluated for discussion.

Amniocentesis: A contemporary review

Amniocentesis is an essential tool in obstetrics. Invasive testing remains the only modality for diagnostic genetic testing and the only way to provide comprehensive testing for chromosomal abnormalities. Despite increasing use of cell free fetal deoxyribonucleic acid (DNA) testing, amniocentesis should still be offered to all women who desire more complete and accurate genetic testing. Counseling patients on the limitations of screening tests is of the upmost importance and amniocentesis should continue to be recommended to confirm positive results from cell free fetal DNA testing or in the case of failed cell free fetal DNA test. As cell free fetal DNA screening has not adequately been studied in multiple gestations, its use is not recommended in this population and invasive testing should be offered. Amniocentesis is also very useful in providing additional information in settings other than genetic testing the second and third trimester. If intraamniotic infection is suspected, but the clinical findings are not enough to guide management, amniocentesis can provide testing that can both immediately clarify the picture (interleukin-6, gram stain, glucose levels) and finally confirm the presence of infection (culture). It can also be used to detect the presence of intrauterine viral infections. Additionally, amniocentesis may be used to test for markers of fetal lung maturity. The American Congress of Obstetricians and Gynecologists recommends that amniocentesis for this indication not be used in cases where late preterm delivery is indicated. It may be useful in guiding decision-making, however, when late preterm delivery is indicated, but when exact timing is unclear. Regardless of the indication, amniocentesis appears to be a relatively low risk procedure with minimal risk to the patient. Additional randomized controlled trials are not likely, as they are not feasible to due extremely high number of participants that would be needed to detect a difference in loss rates. Based on current literature, however, the risk of pregnancy loss from second trimester amniocentesis is low in both singleton and twin gestations. We counsel patients that technique has changed since the original studies in the 1970s and feel comfortable quoting a loss rate of 1/500-1/1000 based on contemporary data.

Overview of embryonal rhabdomyosarcoma of cervix in women over 40-year-old

The literature on cervical embryonal rhabdomyosarcoma (RMS) is reviewed here to identify management guidelines for middle-aged women diagnosed with this rare type of gynecologic cancer. Specifically, the PubMed, Web of Science and Google Scholar databases, were searched to find published case series on cervical embryonal RMS reporting on four or more patients, of whom at least one was > 40-year-old. The χ² test was used to assess heterogeneity. Five articles published between 1986 and 2013 were identified, reporting on a total of 47 patients, of whom 22 (46.8%) were older and 25 (53.2%) younger than 40-year-old. Although the two age groups did not differ significantly by stage of disease or radiotherapy treatment, the older age group received less chemotherapy (55% vs 90%, P = 0.008) and had more hysterectomy (86% vs 43%, P = 0.009). Follow-up data was missing for 18/47 (38.3%) patients. Among the 29 patients with follow-up data, survival was shorter in the older group, with 8/12 (67%) alive and 3 with disease at a median follow-up of 2.6 years, as compared with the younger group that had 15/17 (88%) alive and none with disease at a median follow-up of 3.5 years. The longest survivals among the older women were observed in those who received radiotherapy, including one case with a resected lung metastasis. A prospective multi-institutional collaboration and better follow-up are needed to determine the optimal management of cervical embryonal RMS. Long-term survival appears feasible if management is accompanied by chemotherapy and radiotherapy.

Postpartum intrauterine device contraception: A review

AIM: To review the safety (infection, perforation) and efficacy (expulsion, continuation rates, pregnancy) of intrauterine device (IUD) insertion in the postpartum period.

METHODS: MEDLINE, PubMed and Google Scholar were searched for randomized controlled trials and prospective cohort studies of IUD insertions at different times during the postpartum period. Time of insertion during the postpartum period was documented specifically, immediate post placenta period (within 10 min), early post placenta period (10 min to 72 h), and delayed/interval period (greater than 6 wk). Other study variables included mode of delivery, vaginal vs cesarean, manual vs use of ring forceps to insert the IUD.

RESULTS: IUD insertion in the immediate postpartum (within 10 min of placental delivery), early postpartum (10 min up to 72 h) and Interval/Delayed (6 wk onward) were found to be safe and efficacious. Expulsion rates were found to be highest in the immediate postpartum groups ranging from 14% to 27%. Immediate post placental insertion found to have expulsion rates that ranged from 3.6% to 16.2%. Expulsion rate was significantly higher after insertion following vaginal vs cesarean delivery. The rates of infection, perforation and unplanned pregnancy following postpartum IUD insertion are low. Method of insertion such as with ring forceps, by hand, or another placement method unique to the type of IUD did not show any significant difference in expulsion rates. Uterine perforations are highest in the delayed/interval IUD insertion groups.Breastfeeding duration and infant development are not affected by delayed/interval insertion of the non-hormonal (copper) IUD or the Levonorgestrel IUD. Timing of the Levonorgestrel IUD insertion may affect breastfeeding.

CONCLUSION: IUD insertion is safe and efficacious during the immediate postpartum, early postpartum and delayed postpartum periods. Expulsion rates are highest after vaginal delivery and when inserted during the immediate postpartum period. IUD associated infection rates were not increased by insertion during the postpartum period over interval insertion rates. There is no evidence that breastfeeding is negatively affected by postpartum insertion of copper or hormone-secreting IUD. Although perforation rates were higher when inserted after lactation was initiated. Randomized controlled trials are needed to further elucidate the consequence of lactation on postpartum insertion. Despite the concerns regarding expulsion, perforation and breastfeeding, current evidence indicates that a favorable risk benefit ratio in support of postpartum IUD insertion. This may be particularly relevant for women for whom barriers exist in achieving desired pregnancy spacing.

MicroRNAs: New players in endometriosis

Endometriosis is an estrogen-dependent inflammatory disorder that limits the quality of life of affected women. This pathology affects 10% of reproductive-age women, although the prevalence in those patients experiencing pain, infertility or both is as high as 35%-50%. Endometriosis is characterized by endometrial-like tissue outside the uterus, primarily on the pelvic peritoneum, ovaries and the pouch of Douglas. Despite extensive research endeavours, a unifying theory regarding the exact etiopathogenic mechanism of this high prevalent and incapacitating condition is still lacking, although it has been suggested that epigenetics could be involved. MicroRNAs (miRNAs), one of the epigenetic players, are small non-coding RNAs that can act as post-transcriptional regulators of gene expression, reducing the expression of their target mRNAs either inhibiting its translation or promoting its degradation. MiRNA expression profiles are specific of tissue and cell type. Abnormal miRNA expression has been described in different pathological conditions, such as a myriad of oncological, cardiovascular and inflammatory diseases and gynecological pathologies. In endometriosis, miRNA expression patterns of eutopic endometrium from patients and control women and from different endometriotic lesions have been described. These small non-coding molecules have become attractive candidates as novel biomarkers for an early non-invasive diagnosis of the disease, which could suppose a valuable benefit to the patients in terms of improvement of prognosis and reduction of the ratio of recurrence. In this systematic review we will focus on the role of miRNAs in the pathophisiology of endometriosis.