Neoadjuvant chemotherapy and cytoreductive surgery in epithelial ovarian cancer

Ovarian cancer is one of the leading causes of death among gynecological cancers. This is because the majority of patients present with advanced stage disease. Primary debulking surgery (PDS) followed by adjuvant chemotherapy is still a mainstay of treatment. An optimal surgery, which is currently defined by leaving no gross residual tumor, is the goal of PDS. The extent of disease as well as the operative setting, including the surgeon’s skill, influences the likelihood of successful debulking. With extensive disease and a poor chance of optimal surgery or high morbidity anticipated, neoadjuvant chemotherapy (NACT) prior to primary surgery is an option. Secondary surgery after induction chemotherapy is termed interval debulking surgery (IDS). Delayed PDS or IDS is offered to patients who show some clinical response and are without progressive disease. NACT or IDS has become more established in clinical practice and there are numerous publications regarding its advantages and disadvantages. However, data on survival are limited and inconsistent. Only one large randomized trial could demonstrate that NACT was not inferior to PDS while the few randomized trials on IDS had inconsistent results. Without a definite benefit of NACT prior to surgery over PDS, one must carefully weigh the chances of safe and successful PDS against the morbidity and risks of suboptimal surgery. Appropriate selection of a patient to undergo PDS followed by chemotherapy or, preferably, to have NACT prior to surgery is very important. Some clinical characteristics from physical examination, serum tumor markers and/or findings from imaging studies may be predictive of resectability. However, no specific features have been consistently identified in the literature. This article will address the clinical data on prediction of surgical outcomes, the role of NACT, and the role of IDS.

Natural history of epithelial ovarian cancer and its relation to surgical and medical treatment

Epithelial ovarian cancer (EOC) represents approximately 90% of primary malignant ovarian tumors, the sixth most common cancer in women and the second most common gynecologic cancer. Approximately 80%-85% of all ovarian carcinomas in Western society are serous and up to 95% of patients are in advanced stages (FIGO stage III-IV) at diagnosis. Treatment of ovarian cancer is mainly based on three key approaches: surgical removal of neoplasia; chemotherapy to kill cancer cells; direct chemotherapy on peritoneal surfaces. The application of hyperthermic chemotherapy to the peritoneal cavity (HIPEC) after radical surgery may also be an attractive option. We analyzed the natural history of EOC in the literature and identified various time-points where sensitivity to chemotherapy, freedom from disease and overall survival are different. We propose eight time-points in EOC history with homogeneous oncological findings. The effectiveness of HIPEC in EOC treatment should be evaluated based on these eight time-points and we believe that retrospective and prospective studies of HIPEC should be evaluated according to these time-points.

Folic acid supplementation: The new dawn for postmenopausal women with hot flushes

Hot flushes, experienced by 75% of menopausal women, are associated with estrogen deprivation. Estrogen was shown to ameliorate hot flushes by interacting with monoamine neurotransmitters in the brain; reducing noradrenaline and increasing serotonin. Hormone replacement therapy (HRT), the first treatment option, causes concerns over possible increased risks particularly breast cancer. Folic acid is involved in the biosynthesis of serotonin and nordrenaline, which is responsible for its effects on mood and cognition, and degrees of folate inadequacy, not severe enough to produce megaloblastic anaemia, were found to be associated with depression and cognitive malfunctioning. Also, increased age was observed to relate to reduced serum and cerebrospinal fluid folic acid levels. There is emerging evidence that folic acid supplementation ameliorates hot flushes by the same mechanism as estrogen. To explore this hypothesis, a multi-centre, double-blind, placebo-controlled randomized is being set up to compare the effect of 5 mg folic acid vs placebo in reducing the frequency and severity of hot flushes in postmenopausal women, and on the blood level of serotonin and noradrenaline. If folic acid supplementation is demonstrated to be effective, this will be a turning point in the clinical practice since it represents a cheap, safe and well-tolerated alternative to HRT.

Surgical repair of pelvic organ prolapse and follow-up: An institutional multi-center experience

AIM: To investigate the effects of the Elevate Anterior and Posterior transvaginal mesh procedure on 30 patients affected by pelvic organ prolapse (POP) at 12 mo follow-up.

METHODS: Between September 2011 and September 2012, a prospective multicenter observational study enrolled 30 consecutive patients with POP-Q ≥ stage II. After a preoperative evaluation, patients underwent prolapse repair utilizing the Elevate Anterior and Posterior Prolapse Repair System (American Medical Systems, Minnetonka, MN, United States). Operative technique was standardized and performed by the same surgical team under spinal or general anesthesia. Patients were evaluated postoperatively at 1, 3, 6 and 12 mo.

RESULTS: All 30 patients completed the 12 mo follow-up. The mean age was 65.3 years (range 49-81 years) and average hospital stay was 4.5 d. The mean operative time was 65 min (range 40-120 min). Related adverse events reported were mesh extrusions (6.7%) and post void residual urine volume (13.3%). There were no visceral injuries, no infection of the mesh, and no symptoms of recurrent prolapse. All quality-of-life scores significantly improved from baseline.

CONCLUSION: One year’s follow-up of our 30 patients confirms the safety and the efficacy of the Elevate Anterior and Posterior transvaginal mesh procedure for POP treatment. Our final results are comforting but longer term follow-up is ongoing.

Mirabegron, a novel, non-antimuscarinic drug for the overactive bladder: An up-to-dated review

Mirabegron opened a new era in the treatment of overactive bladder (OAB). For the first time physicians dealing with OAB have an effective alternative to the pharmacological mainstay of the therapy for this disorder, the antimuscarinic drugs. This first-in-class, potent β3-adrenoceptors agonist has recently received approval by regulatory authorities in Japan, United States and Europe, based on the favourable efficacy-tolerability profile demonstrated in multiple randomized, multinational, controlled trials, both short and long-term. There is substantial consistency through the studies in reporting the cardiovascular safety of treatment with mirabegron. The main advantage of mirabegron is the placebo-like incidence of classic adverse effects caused by antimuscarinics, dry mouth and constipation, that is expected to improve long-term adherence of patients to treatment. Mirabegron can be used in patients with contraindications to antimuscarinics and in those who discontinued previous antimuscarinic therapy. Herein, we reviewed the published literature on mirabegron, focusing on the rationale of β3-agonism for OAB treatment and on the preclinical and clinical evidence of efficacy and safety available on this new pharmacological principle.

Pharmacology of cancer chemotherapy drugs for hyperthermic intraperitoneal peroperative chemotherapy in epithelial ovarian cancer

The peritoneal parietal and visceral surfaces of the abdomen and pelvis are an important anatomic site for the dissemination of epithelial ovarian cancer (EOC). The transcoelomic spread of cancer cells gives rise to peritoneal carcinomatosis (PC) which, without special treatments, is a fatal manifestation of EOC. In order to control PC cytoreductive surgery to remove macroscopic disease is combined with perioperative intraperitoneal (IP) and perioperative intravenous chemotherapy to eradicate microscopic residual disease. Chemotherapy agents are selected to be administered by the IP or intravenous route based on their pharmacologic properties. A peritoneal-plasma barrier which retards the clearance of high molecular weight chemotherapy from the peritoneal cavity results in a large exposure of small cancer nodules on abdominal and pelvic surfaces. Tissue penetration is facilitated by moderate hyperthermia (41-42 °C) of the IP chemotherapy solution. Timing of the chemotherapy as a planned part of the surgical procedure to maximize exposure of all peritoneal surfaces is crucial to success.

Comprehensive management of epithelial ovarian cancer with peritoneal metastases

Ovarian cancer has as its predominant pattern of dissemination metastases to the peritoneal surfaces and disease spread within the abdomen and pelvis that most commonly causes the patients demise. To combat peritoneal metastases, cytoreductive surgery with peritoneal and visceral resections is combined with intraperitoneal and systemic chemotherapy. Chemotherapy given in the operating room after the complete visible removal of ovarian cancer is hyperthermic intraperitoneal chemotherapy. The results of the combined treatment are determined by the extent of prior surgery, the extent of disease as established by the peritoneal cancer index, and the quality of the cytoreduction as measured by the completeness of cytoreduction score. Recent clinical information on patients with recurrent ovarian cancer suggest a median overall survival of up to 60 mo. These data are greatly improved over the one year survival observed in the past.

Cytoreductive surgery in primary advanced epithelial ovarian cancer

Epithelial ovarian cancer is one of the most common malignancy and one of the principal causes of death among gynaecological neoplasm. The majority of patients (about 70%) present with an advanced International Federation of Gynaecology and Obstetrics stage disease. The current standard treatment for these patients consists of complete cytoreduction and combined systemic chemotherapy (CT). An increasing proportion of patients undergoing complete cytoreduction to no gross residual disease (RD) is associated with progressively longer overall survival. As a counterpart, some authors hypothesized the improving in survival could be due more to a less diffused initial disease than to an increase in surgical cytoreduction rate. Moreover the biology of the tumor plays an important role in survival benefit of surgery. It’s still undefined how the intrinsic features of the tumor make intra-abdominal implants easier to remove. Adjuvant and hyperthermic intraperitoneal CT could play a decisive role in the coming years as the completeness of macroscopic disease removal increases with advances in surgical techniques and technology. The introduction of neo-adjuvant CT moreover will play a decisive role in the next years Anyway cytoreduction with no macroscopic residual of disease should always be attempted. However the definition of RD is not universal. A unique and definitive definition is needed.

Individualized misoprostol dosing for labor induction or augmentation: A review

Cesarean birth rates are greater than 20% in many developed countries. The main diagnoses contributing to the high rate of cesarean births in nulliparous women are dystocia and prolonged labor. Traditionally, a policy of vaginal dinoprostone for the treatment of unripe cervix or early amniotomy with oxytocin administration for a ripened cervix has been associated with a modest reduction in the rate of cesarean births due to arrest disorders. However, the course of vaginal dinoprostone is tedious and oxytocin should be administered through an infusion pump, which may be inconvenient in certain settings. Because misoprostol has powerful uterotropic and uterotonic effects, and has become a common agent used in the practice of obstetrics and gynecology, the United States Food and Drug Administration removed the absolute contraindication of the drug during pregnancy from its label in April 2002. However, excessive uterine contractility resulting in tachysystole or fetal distress is always a concern with the oral or vaginal use of fixed-dosage misoprostol. Therefore, misoprostol should be administered with caution to ensure that fetal hypoxia does not occur. A pilot trial examining the use of very small, frequent, titrated oral misoprostol dosages administered every 2 h was first conducted by Hofmeyr et al in 2001. Given women’s different metabolisms and responses to misoprostol, another method of titrating individualized oral misoprostol with dosing administered every hour relative to uterine response was then developed by Cheng in 2006. Based on previous studies, this titration method is potentially an ideal alternative to traditional dinoprostone, oxytocin or the previously established misoprostol dosing method for labor induction or augmentation.

Anesthetic management of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedures

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure are performed with increasing frequency to treat patients with diffused peritoneal carcinomatosis. These procedures have showed to increase life expectancy in what was previously considered a “terminal condition”. Anyway patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. Despite the need of an advanced organ monitoring and support all these derangements seem to be mild and short-lived when timely addressed, at least in the majority of patients. Intensive care physicians are involved in providing surveillance and organ support till the patient is effectively weaned after the operation. Moreover, the anesthesiologist as perioperative physician is involved in pain control, metabolic and nutritional support of this cohort of patients. This task can be challenging considering that part of the patients are already on a long list of pain control medication after previous surgery or chemotherapy. A malnourished state is common too and it is secondary to difficult feeding, wasting syndrome from the tumor and massive ascites. The last issue the anesthesiologists need to be aware of is the impact over the quality of life (QoL) of this procedure. The patient’s underlying pathology is unlikely to be definitively cured so no treatment is an acceptable choice. The possibility to withhold the treatments must be part of the consultation process like the discussion about the QoL in the immediate, as well as in the long-term, after the operation. Careful monitoring and treatment of every aspect that can impact the QoL must be taken and the efforts to be poured into an effective preservation of the QoL must be doubled when compared with a patient scheduled for major abdominal surgery.

Characteristics of semen parameters of Malawian men from couples seeking assisted reproduction

AIM: To profile semen parameters of Malawian men seeking fertility testing.

METHODS: Semen analysis is a key element in the fertility evaluation of men and permits male reproductive potential to be evaluated. Semen samples were collected from consenting men after 3-5 d of sexual abstinence. The samples were collected from 130 males; 78 were male partners of infertile couples while 52 were healthy semen donors. Seminal volume, motility and morphology were assessed. The results were analyzed on Prism 5. All data are expressed as mean ± SD. Student’s t-test was used for statistical analysis. Differences were regarded as statistically significant if P < 0.05.

RESULTS: Semen volume, sperm concentration, progressive motility and normal morphology were significantly higher in the control group when compared to the participant group. On the other hand, no statistically significant difference was found between the control group total sperm motility when compared to the participant group. Oligozoospermia was found in 25 cases, teratozoospermia detected in 17 cases and abnormal seminal plasma in 16 cases. Asthenozoospermia and azoospermia were found in 12 and 8 participants, respectively. This study has shown that most of the infertile patients seeking fertility testing had oligozoospermia. Teratozoospermia was the second most common abnormality found in the patients seeking fertility testing.

CONCLUSION: Our study is in agreement with previous studies which reported that these parameters have been shown to be good predictors for fertilization.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in epithelial ovarian cancer: State of the art

Advanced stage epithelial ovarian cancer (EOC) is difficult to treat with low overall cure rates. A new strategy combining maximal cytoreductive surgery (CRS) with intra-operative hyperthermic intraperitoneal chemotherapy (HIPEC) has been proposed to treat advanced stage EOC in the primary setting. Numerous small, heterogeneous studies have been conducted exploring outcomes in patients with predominantly advanced, recurrent or refractory disease treated with CRS + HIPEC. Although morbidity rates approaching 35% have been reported, oncologic outcomes are promising. Incorporation of HIPEC for the treatment of primary EOC has continued to gain interest. Several prospective phase 2 clinical trials were recently completed evaluating the impact of CRS + HIPEC in the primary setting. This article will briefly discuss the benefits of optimal surgical cytoreduction and the theoretical basis of intraperitoneal chemotherapy in patients with advanced stage EOC, and will then review existing literature describing oncologic outcomes in EOC patients treated with HIPEC in the primary setting.

Laparoscopic surgical repair of pelvic organ prolapse and female stress urinary incontinence

Pelvic organ prolapse (POP) occurs in a relatively big population of women which is continuously increasing and is associated with a variety of urinary bowel and sexual symptoms. As this problem magnifies, the need for surgical repair is increasing relatively. The main goals of surgical repair for POP include: no anatomic prolapse, no functional symptoms, patient satisfaction and avoidance of complications, goals that cannot always be fully achieved. The decision for the type of surgery depends of various factors such as patient characteristics and prolapsed compartment but also by the surgeon expertise. The laparoscopic approach is already the gold standard procedure for many urologic procedures and can also be used for the treatment of POP and stress urinary incontinence. Herein, we review the literature about the available data concerning laparoscopic surgery techniques for treating POP.

The general surgeon in inter-disciplinary gynaecological cancer care

Gynaecological cancers pose a significant cancer burden globally. In 2008 cancers of the cervix, uterus and ovaries accounted for 529000 (4.2%), 287000 (2.3%) and 225000 (1.8%) cancers, respectively, and together were responsible for 486400 deaths. Inter-disciplinary gynaecological care is an emerging concept aimed at providing more effective care by integrating different disciplines into a team working together to perform the various aspects of management at one time. This model has both advantages and potential shortcomings. In advanced healthcare systems there appears to be little role for the general surgeon. However in developing world, the general surgeon has a valuable, but complementary role in inter-disciplinary gynaecological cancer care. This role depends on the available workforce and includes, but is not limited to, the establishment of a diagnosis and treatment, including the management of complications. There is however little evidence-based research to provide guidance on the general surgeon’s role in inter-disciplinary gynecologic cancer care and more research is needed.

Intrapartum application of the continuous glucose monitoring system in pregnancies complicated with diabetes: A review and feasibility study

Intrapartum maternal normoglycemia seems to play an important role in the prevention of adverse perinatal, maternal and neonatal outcomes. Several glucose monitoring protocols have been developed, aiming to achieve a tight glucose monitoring and control. Depending on the type of diabetes and the optimal or suboptimal glycemic control, the treatment options include fasting status of the parturient, frequent monitoring of capillary blood glucose, intravenous dextrose infusion and subcutaneous or intravenous use of insulin. Continuous glucose monitoring system (CGMS) is a relatively new technology that measures interstitial glucose at very short time intervals over a specific period of time. The resulting profile provides a more comprehensive measure of glycemic excursions than intermittent home blood glucose monitoring. Results of studies applying the CGMS technology in patients with or without diabetes mellitus (DM) have revealed new insights in glucose metabolism. Moreover, CGMS have a potential role in the improvement of glycemic control during pregnancy and labor, which may lead to a decrease in perinatal morbidity and mortality. In conclusion, the use of CGMS, with its important technical advantages compared to the conventional way of monitoring, may lead into a more etiological intrapartum management of both the mother and her fetus/infant in pregnancies complicated with DM.

Smoking and genital human papilloma virus infection in women attending cervical cancer screening in Greece

AIM: To investigate whether smoking is associated with human papilloma virus (HPV) infection.

METHODS: HPV infection is considered to be a necessary condition for cervical cancer development. The study population included 1291 women, aged 25-55 years, attending cervical cancer screening. All women had a Papanicolaou (Pap) test, with liquid-based cytology (Thinprep^®), an HPV-DNA test and an evaluation of smoking habits. The COBAS^® 4800 system was used for HPV-DNA testing, enabling identification of the following high-risk HPV (hrHPV)-types: each of HPVs 16 and 18 separately, and HPVs 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68 as a cocktail. The evaluation of smoking habits was assessed using the smoking intensity index (SII), a variable formed as the product of cigarettes consumed per day by the days (years × 365) that a woman was a smoker, divided by 1000.

RESULTS: There were 136 smokers among 238 women tested positive for hrHPV-types (HPVs 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and/or 68), and 463 smokers among 1053 hrHPV-negative women (OR = 1.7, P < 0.001). This association was attributed to the youngest age group of women, aged 25-34 years (OR = 2.3, P < 0.001), while there was no association in other age groups. The intensity of smoking (increasing SII) showed no statistically significant association with hrHPV infection. Cervical infection with HPV 16 and/or HPV 18 was also not associated with age or smoking habits. Finally, no association was found between Pap test status and smoking habits or smoking intensity.

CONCLUSION: Smoking appears to be associated with hrHPV infection of the uterine cervix, particularly in younger women. Further studies should investigate whether this association is based on causality and evaluate the role of other possible co-factors.

Role of bariatric surgery in the pelvic floor disorders

Pelvic floor disorders are very frequent among women. Weight loss can help them to achieve urinary and faecal continence again. In this narrative review, the possible mechanisms of pelvic floor disorders in obese women, their symptoms and the role of bariatric surgery in changing their quality of life are presented. We retrieved the included results of our study after performing a systematic, electronic search in PubMed (December 17, 2012) and Scopus (December 17, 2012). The main mechanism causing the development of pelvic floor disorders is chronically increased abdominal pressure as it overts structural damage or neurologic dysfunction predisposing to prolapse and incontinence. The symptoms include a sensation of vaginal fullness or pressure, uterine descent, sacral back pain with standing, vaginal spotting from ulceration of the protruding cervix or vagina, coital difficulty, lower abdominal discomfort, and voiding and defecatory difficulties. Evidence indicates that massive weight loss (45 to 50 kg) improves incontinence in morbidly obese women after bariatic surgery. Faecal incontinence is also improved after bariatric surgery. This review highlights the role of bariatric surgery in weight reduction of obese women that could act as a treatment for the pelvic floor disorders faced by those women offering improvement in incontinence as well as quality of life.

Past, present and future of primary systemic treatment in breast cancer

Primary systemic treatment is a fundamental part of breast cancer therapy, and it is applied to non-surgical and locally advanced tumours as well as surgical tumours to increase the likelihood of conservative treatment. Its aim is to achieve the best possible survival with better cosmetic results and with the lowest number of treatment-related secondary effects. Before treatment is started, it is necessary to attain the best knowledge of the biological features and locoregional extension of the tumour. To do so, it is necessary to obtain a biopsy of the lesion with a wide bore needle, as well as good radiological knowledge of the disease. Therefore, currently, the use of a dynamic magnetic resonance imaging (MRI) of the breast should be included in all cases. In addition, before it is started, especially in those tumours in which conservative treatment is considered, one or several radiopaque markers should be put into place to make it possible to locate the area to be treated if there is a considerable or complete response. Systemic treatment is mainly based on combined chemotherapy with anthracyclins and taxanes, in addition to some biological agents with demonstrated efficiency for increasing the likelihood of complete disease response (trastuzumab in patients with Her-2/neu overexpression). However, there is room for neoadjuvant hormone treatment, in patients with hormone receptor overexpression, especially in those cases in which chemotherapy is contraindicated as well as in elderly patients with a relatively short life expectancy. The assessment of preoperative treatment should be based on adequate radiological tests, and nowad these should include MRI before taking decisions about adequate surgical treatment. The objective of primary treatment is to be able to increase survival and improve the chances of local treatment in the case of locally advanced treatment, achieving results that are at least equal to those of adjuvant treatment in the case of surgical tumours, but with greater chances of conservative surgery. Although the objective is survival, achieving complete pathological response seems to be a reasonable related objective, although these are more closely linked in some tumour subtypes.

Prenatal incarceration of caput succedaneum: A case report

Caput succedaneum is relatively common at birth but infrequently diagnosed in utero. We report the first case of a prenatal incarcerated caput succedaneum after cervical cerclage in a patient with premature rupture of the membranes (PPROM). A 41-year-old woman was referred and admitted to our hospital due to PPROM at 19 wk of gestation. Aggressive therapy, including amnioinfusion, cervical cerclage, and administration of antibiotics and tocolysis, was initiated. At 24 wk of gestation, a thumb tip-sized and polyp-like mass, which was irreducible, was delineated with a vaginal examination, vaginal speculum, and transvaginal ultrasonography, leading to the diagnosis of incarcerated caput succedaneum. Under general anesthesia, the incarcerated caput succedaneum was repositioned with fingers after cutting the string to avoid necrosis, and then, placement of a McDonald cervical cerclage was undertaken again. At 26 wk of gestation, she delivered a 678 g girl through an emergency cesarean section performed due to profuse bleeding and prolonged decelerations. A slight bulge with hair was observed on the head by palpation at birth. Cephalic ultrasonography, X-ray, magnetic resonance imaging and electroencephalogram confirmed no abnormality. Although the baby needed oxygen (0.2 L/min) at the time of hospital discharge, she has grown favorably at three years of corrected age.

New developments of the effect of melatonin on reproduction

In the past decades, a lot of advances in understanding the biochemistry and physiology of the pineal gland have been made. There is evidence that it interacts with many endocrine as well as non-endocrine tissues to influence their metabolic activity modulating many organs and functions. Melatonin is secreted by the pineal gland in the brain and plays an important role in regulating the neuroendocrine system. This hormone is one of the major role players in the regulation of the circadian sleep-wake cycle. It is normally released from the pineal gland during the night in response to environmental changes in light. Studies have shown that melatonin plays a role in the regulation of many reproductive processes such as puberty, gonadal function, and pregnancy. Beside these, melatonin has been shown to be able to directly neutralize a number of free radicals and reactive oxygen and nitrogen species. The main objective of this review is to provide comprehensive information about the new developments in melatonin research regarding its role in reproduction. A review of international scientific literature was done and a question-and-answer format was used in an attempt to convey comprehensive information in a simple manner. This review discusses evidence currently available relating to the effect of melatonin on reproductive processes. It deliberates the mechanism of action of melatonin, its effect on puberty, testicular and ova function, pregnancy, and oxidative stress. A growing body of scientific evidence is suggesting that melatonin plays an important role in reproductive function. It is therefore imperative to highlight the beneficial effects of this hormone in improving the reproductive processes.

Burden of gynaecological cancers in developing countries

Approximately 1:4 of all cancers in women in developing countries (excluding non-melanoma skin cancer) is a gynaecological cancer. The gynaecological cancer burden in developing countries is huge primarily due to the high incidence and mortality of cervical cancer. Cervical cancer accounts for over 60% of the gynaecological cancer burden in developing countries despite being preventable by current technologies. This is due to the absence of effective nationally organized screening programmes in most developing countries. Institution of such programmes, therefore, has the potential to dramatically reduce gynaecological cancer burden in these countries. Subsidized human papilloma virus (HPV) vaccine and HPV typing as well as cheap screening techniques such as visual inspection aided with acetic acid hold the key to effective prevention of cervical cancer in these countries. This is because a significant proportion of patients in developing countries are unable to access and avail themselves of the few available preventive, diagnostic and treatment services because of poverty. Although, advocacy and the political will to invest in the development of human resources and healthcare infrastructure appear critical to gynaecological cancer control and reducing the burden of disease in many developing countries, the proposition assumes that resources are truly available for this investment. This may not be true. Many developing countries rely on foreign aids for developmental programmes and these aids have dwindled significantly with the current global economic meltdown.

Why hypertension is good new and preeclampsia bad news-demonstrating the failure of prevention

Hypertensive disorders in pregnancy continue to be an intriguing and potentially lethal complication in humans and some other primates. In a simplistic way the current hypothesis is that the genesis of preeclampsia starts at 12 to 14 wk gestation with failure of trophoblast invasion in the spiral arteries, resulting in some degree of hypoxemia in the placenta. The hypoperfused placental tissue starts to secrete variable amounts of angiogenic and antiangiogenic factors which eventually cause endothelial damage all over the pregnant women’s body with one of the many signs of preeclampsia as the clinical endpoint. For some incomprehensible reason a major interest has existed for decades concerning the early prediction of preeclampsia, most commonly tested using uterine artery Doppler (the earlier the better) and various serum markers, alone or in combination. Any new model for detection has been welcomed enthusiastically, although nothing has changed in the outcome of women presenting with preeclampsia.

Mucinous cystadenocarcinoma of ovary: Changing treatment paradigms

Traditionally, all carcinomas arising from the surface epithelial layer of the ovary have been grouped together. This grouping has led to a single therapeutic strategy that is used for all epithelial ovarian cancers. However mucinous cancers appear to be distinct from serous cancers in their clinical behaviour and molecular signatures. In comparison to serous tumours, early stage mucinous tumours tend to be localised at diagnosis with a higher overall survival. But when metastatic at presentation or after recurrence, the outcome of mucinous tumours is far inferior to serous tumours. With standard platinum based chemotherapy the response rate and survival is far worse in mucinous cancers. The precise biological and molecular explanation for this difference remains unanswered. There is urgent need for testing and adoption of therapeutic approaches tailored to molecular characteristics of mucinous carcinomas so that patient survival can be optimised.

Advanced ovarian cancer: Neoadjuvant chemotherapy plus surgery and HIPEC as up-front treatment

Epithelial ovarian cancer (EOC) is one of the most common malignancies and one of the principal causes of death in gynecological neoplasms. The majority of EOC patients present with an advanced International Federation of Gynecology and Obstetrics stage disease. The current standard treatment for these patients consists of complete cytoreduction and combined systemic chemotherapy of a platinum agent and paclitaxel. Even if the majority of patients with EOC respond to first-line platinum based chemotherapy, almost 20% of them are resistant or refractory. According to these data, the main risk is for a certain number of patients to have undergone cytoreductive surgery (CRS) and subsequent hyperthermic intraoperative peritoneal chemotherapy (HIPEC) in a useful way. Radical surgery, especially in advanced cases, is associated with a high incidence of postoperative morbidity and mortality, which could be increased by the HIPEC. Every effort should be made for previously selected patients to improve outcome and optimize resources. Over the last decade, new options have been introduced to prolong survival. Improved long-term results can be achieved using CRS in combination with intraoperative HIPEC. This combination has also been used in an up-front setting. Controversial outcomes have been reported for neoadjuvant platinum-based chemotherapy. Different papers have been published reporting discordant results. Further studies are needed.

Trends in cervical cancer screening in developing countries

Developing countries suffer the highest burden of cervical cancers but have the lowest resources. Effective cervical cytology screening programme, along with a network of diagnostic and therapeutic colposcopy centres, like developed countries, is almost impossible to be reproduced in developing countries. Visual inspection methods [e.g., Visual inspection with Lugol’s iodine (VILI) and Visual Inspection with Acetic Acid (VIA)] which are cheaper, require less expertise and have the advantage of possible treatment in one setting have been shown to be effective alternatives. The sensitivity to detect CIN2+, by VIA and VILI, have been shown to be 80% and 91% respectively, with a specificity rate of 92% and 85% respectively. Screening by human papillomavirus (HPV) testing has high sensitivity (96.4%) but low specificity (94.1%) to detect CIN2+, when compared to Pap Smear (sensitivity, 55.4% and specificity, 96.8%). A single lifetime HPV testing in a large unscreened population has been shown to significantly reduce cervical cancer incidence and mortality when compared to cervical cytology, VIA or no screening. HPV testing of self-collected vaginal specimens also helps to overcome religious and socio-cultural barriers towards pelvic examination amongst women in developing countries. Current HPV testing methods are expensive, skill/infrastructure demanding and takes time to produce results. A cheaper HPV test, called careHPV™, which is able to provide results within 2.5 h and requires minimal skill/infrastructure to operate, was designed for use in developing countries. One stop screen and treat facilities using VIA or rapid HPV testing, and cryotherapy, can overcome non-compliance to follow-up which is a major issue in developing countries. Cure rates of 81.4% for CIN1, 71.4% for CIN2 and 68.0% for CIN3 at 6 mo after treatment have been reported. Incorporating telemedicine with cervicography of VIA or VILI or even telecolposcopy, has great potential in cervical cancer screening, especially in countries with vast geographical areas.

Ethnic disparities: Genetics vs (social) environment

To define “ethnicity” in the context of perinatal care is a tough job. The word makes us think: “racial, social, cultural, national…”. An ethnic group is generally considered a group of people with a common history, usually (but not always) a common religion and language, sharing aspects of culture such as nutrition and traditions concerning pregnancy, childbirth, the way they care for children. As procreation occurs mostly in-group, every ethnic group will demonstrate a higher prevalence of, more or less well-known, genes and their connected diseases. For some populations, such as Ashkenazi Jewish people, the prevalence and associated risks of these autosomal diseases are well known, as in the case of “Jewish genetic disease”, and specific screening programs are available.

Intrauterine growth restriction and genetic determinants - existing findings, problems, and further direction

Fetal growth is determined largely by the nutrient supply, placental transport function, and growth hormones. Recently, gene mutation and expression, especially of those genes associated with the proteins that are related to the fetal growth, have been reported to play an important role in the development of intrauterine growth restriction (IUGR). Fetal growth epigenetics, a new concept in fetal growth, has resulted from studies on fetal programing. This paper outlines the findings of our serial studies on IUGR, and summarizes data on IUGR animal models, placental function in transferring nutrients, cell proliferation dynamics in IUGR, and experimental treatment of IUGR. We review genetic approaches to IUGR, especially those relating to growth factor genes, angiotensinogen genes and other gene mutations. We also discuss the epigenetics of fetal growth and future study directions on fetal growth restriction. These should be valuable in elucidating the mechanisms employed by the fetus and in helping to develop interventional strategies that might prevent the development of IUGR.

Prevention and not merely prediction of preterm labor and delivery

Different methods have been proposed to screen for preterm labor and delivery; most of these aim to predict the risk that preterm delivery is going to take place. However, interesting though this knowledge might be, knowing the future is of no use when no changes can be made. Recent publications have suggested new and exciting modalities to actually diminish the frequency of preterm birth in patients selected by transvaginal cervical length measurement; these modalities include vaginal progesterone and vaginal pessaries. Although promising, many questions remain to be answered; not least about the long term outcome for both neonates and mothers, but also on the eventual introduction of such strategies to the general obstetric population. One of the main problems that urgently needs clarification is how we are going to offer this best of medicine to those needing it most: deprived and socially isolated women who have the highest risk for preterm labor and delivery, probably not due to any congenital cervical problems, but to a combination of environmental, microbiological and social factors, including transgenerational poverty and deprivation.

Free radicals generation in an in vitro fertilization setting and how to minimize them

Several studies report an increase in both male and female factors in infertility worldwide. In recent years there has been a tremendous increase in couples seeking assisted reproductive technology (ART) procedures in order to have children. However, the success rates of these procedures still remain very low. One of the major contributing factors to the low success rate in ART has been the damage caused by free radicals to the gametes and the developing embryo. The manipulation of gametes and embryos in an in vitro environment when performing assisted reproductive techniques carries the risk of exposure of these cells to supraphysiological levels of free radicals; namely, reactive oxygen species (ROS) and reactive nitrogen species. Oxidative stress can originate from the early steps of ART involving the oocyte, sperm and embryo, as well as in the endometrial environment later on following embryo transfer. The common sources of free radicals in an in vitro fertilization setting include the developing embryo, spermatozoa and leukocytes, semen centrifugation, oxygen partial pressure, light, culture media and cryopreservation/thawing. These free radicals are measured using different techniques, such as the cytochrome C reduction method and chemiluminescence-based techniques. Different efforts are being employed to minimize the excess generation of free radicals in the ART setting, with the aim of improving the success rate, and antioxidant supplementation has emerged as one of the viable routes. Moreover, it is very important to inform ART personnel about the sources of ROS in the laboratory so that they can stop the use of procedures that are deleterious and start to use safer procedures.

Platinum-resistant ovarian cancer: Prematurely stopped phase II Austrian AGO chemotherapy studies

AIM: To report the results of two phase II studies of chemotherapy in patients with platinum-resistant and platinum-refractory ovarian cancer and discuss the current status of systemic therapy in this disease.

METHODS: Two subsequent Austrian Arbeitsgemeinschaft für Gynäkologische Onkologie (AGO) phase II studies have been carried out. Patients either had platinum-refractory or platinum-resistant disease, i.e., disease progression during first line platinum-based therapy or recurrence within 6 mo following the last platinum-containing chemotherapy, respectively. In the first study, 6 cycles of irinotecan at 55 mg/m² and docetaxel 25 mg/m² were both administered on days 1, 8 and 15 of a 4 wk cycle. In the second phase II study, either non-pegylated (PEG) liposomal doxorubicin (L-DXR) 60 mg/m² monotherapy on day 1 and PEG filgrastim on day 2 (arm A) or L-DXR at 50 mg/m² and gemcitabine (GEM) at 650 mg/m² on day 1 and GEM on day 8 (arm B) were administered every 4 wk. Patients in arm B received prophylactic filgrastim 5 μg/kg per day from days 3 to 6 and from days 9 to 12, respectively.

RESULTS: Response rates in studies were 14% and 17%, respectively. The progression-free survival was less than 3 mo. Diarrhea was most prevalent in patients treated with irinotecan + docetaxel, while stomatitis/mucositis occurred in a quarter of patients treated with L-DXR +/- GEM + granulocyte colony stimulating factor, respectively. Following treatment with the latter regimen, a total of 11 serious adverse events were recorded among the 12 patients included. The rate of remissions of the regimens used in these two Austrian AGO studies was low and their toxicity significant. Due to their low therapeutic index, neither of these regimens can be recommended in this heavily pretreated patient population with platinum-resistant ovarian cancer exhibiting a high tumor-associated symptom burden.

CONCLUSION: The two reported phase II studies of the Austrian AGO in platinum-resistant disease had to be terminated prematurely due to a low therapeutic index. Treatment of this disease remains a clinical dilemma. Bevacizumab seems to be active at this late-stage disease but may be associated with significant bowel toxicity.

Sexuality after childbirth: Gaps and needs

Childbirth is a stressful event for a majority of women and can have many consequences one of which is female sexual dysfunction. The main aim of pre- and postnatal health services is to fulfil physical and emotional needs of mothers and babies but not sexual function of women. Also, the fact that sexual satisfaction is part of general well being and mental health is generally neglected. Sexual function of women not only is affected by childbirth, but also is influenced by many other factors. One of these factors is culture and religion. Women’s sexual life after childbirth has different meaning in different cultures. In many conservative societies with certain cultural and religious beliefs women are prohibited from having sex after childbirth. In these societies, women hear conflicting stories about risks and benefits of having sexual intercourse during postpartum period the majority of which may not be true. It has been reported that some women may be at greater risk of postpartum sexual dysfunction as neurobiological factors and genetics have been recently suggested to impact female sexual functioning. Considering the multidimensional nature of female sexual dysfunction, this problem cannot be resolved by a simple solution and not all postpartum women can be treated by the same protocol. Various treatment options, such as the use of medications, behavioural interventions and psychotherapy have been investigated in research studies and there is still controversy over the issue. Regarding the fact that sexually satisfied women are more mentally healthy, routine screening during prenatal, antenatal and postnatal visits are suggested to uncover hidden difficulties with sexual functioning of women and improve their quality of life.

Survey of the management of borderline ovarian tumors in the United Kingdom

Borderline ovarian tumors (BOTs) represent approximately 10% of ovarian neoplasms and are a heterogeneous group of tumors with variable biological behaviour. The majority present with disease confined to the ovary and have an excellent prognosis after surgical removal. A small proportion subsequently has recurrent disease or progression to invasive cancer. Tumor recurrence can occur up to 20 years after surgical resection. There are no robust clinical, histological or molecular markers that distinguish high risk cases and no satisfactory treatment for patients with progressive disease. This results in great variability in management in different centres. We conducted a national survey on the management of borderline ovarian tumors in cancer centres representing different regions in the United Kingdom. In this article we review the literature for the current concepts in diagnosis, treatment and follow up of BOTs and we report the results of the survey of current practice in the United Kingdom. On that basis we provide recommendations for the management of patients with BOTs.

What is the purpose of launching the World Journal of Obstetrics and Gynecology?

World Journal of Obstetrics and Gynecology (WJOG) is a new member of the World Series journals and is launched in June 10, 2012. WJOG is an open access peer-reviewed bimonthly journal that will cover obstetrics and gynecology including reproductive medicine. The intention of WJOG is to publish papers that describe and influence the situation all around the world. The journal will publish both basic research and well as clinical findings. The focus shall be on translational work. Please send your important findings and comments to WJOG.