Factors associated with dizygotic twinning after IVF treatment with double embryo transfer

BACKGROUND

Dizygotic twin pregnancies after IVF treatment are the result of multiple embryos transferred into the uterine cavity, followed by successful double implantation. Factors that increase the chance of multiple implantation after IVF are relatively unknown. The present study aimed to investigate whether features of body composition, such as maternal height, weight and body mass index (BMI) are associated with an increased chance of dizygotic twinning after IVF with double embryo transfer (DET).

METHODS

This study was conducted using data from a large Dutch nationwide cohort that comprised 19 861 women who had IVF or ICSI treatment between 1983 and 1995 (OMEGA study). First 'fresh' IVF and ICSI cycles with DET resulting in a delivery of a singleton or twin (living as well as stillborn) were selected. A multivariable logistic regression analysis was performed, with the delivery of a singleton or twin as the dependent variable and height, weight, BMI, maternal age, number of retrieved oocytes, use of alcohol, smoking, highest level of education and parity as independent variables.

RESULTS

Of the 6598 women who completed their first IVF or ICSI cycle, 2375 had DET, resulting in 496 deliveries of 371 singletons and 125 twins. Multivariable regression analysis revealed that tall women (>1.74 cm) and women with a high number of retrieved oocytes (>8) had an increased chance of dizygotic twinning [OR: 1.8 (95% CI: 1.0-3.4) and OR: 2.2 (95% CI: 1.3-3.8), respectively].

CONCLUSIONS

Our data demonstrate that tall stature and increased number of retrieved oocytes independently increase the chance of dizygotic twinning after IVF with DET.

Progesterone inhibits epithelial-to-mesenchymal transition in endometrial cancer

BACKGROUND

Every year approximately 74,000 women die of endometrial cancer, mainly due to recurrent or metastatic disease. The presence of tumor infiltrating lymphocytes (TILs) as well as progesterone receptor (PR) positivity has been correlated with improved prognosis. This study describes two mechanisms by which progesterone inhibits metastatic spread of endometrial cancer: by stimulating T-cell infiltration and by inhibiting epithelial-to-mesenchymal cell transition (EMT).

METHODOLOGY AND PRINCIPAL FINDINGS

Paraffin sections from patients with (n = 9) or without (n = 9) progressive endometrial cancer (recurrent or metastatic disease) were assessed for the presence of CD4+ (helper), CD8+ (cytotoxic) and Foxp3+ (regulatory) T-lymphocytes and PR expression. Progressive disease was observed to be associated with significant loss of TILs and loss of PR expression. Frozen tumor samples, used for genome-wide expression analysis, showed significant regulation of pathways involved in immunesurveillance, EMT and metastasis. For a number of genes, such as CXCL14, DKK1, DKK4, PEG10 and WIF1, quantitive RT-PCR was performed to verify up- or downregulation in progressive disease. To corroborate the role of progesterone in regulating invasion, Ishikawa (IK) endometrial cancer cell lines stably transfected with PRA (IKPRA), PRB (IKPRB) and PRA+PRB (IKPRAB) were cultured in presence/absence of progesterone (MPA) and used for genome-wide expression analysis, Boyden- and wound healing migration assays, and IHC for known EMT markers. IKPRB and IKPRAB cell lines showed MPA induced inhibition of migration and loss of the mesenchymal marker vimentin at the invasive front of the wound healing assay. Furthermore, pathway analysis of significantly MPA regulated genes showed significant down regulation of important pathways involved in EMT, immunesuppression and metastasis: such as IL6-, TGF-β and Wnt/β-catenin signaling.

CONCLUSION

Intact progesterone signaling in non-progressive endometrial cancer seems to be an important factor stimulating immunosurveilance and inhibiting transition from an epithelial to a more mesenchymal, more invasive phenotype.

AMG 479, a novel IGF-1-R antibody, inhibits endometrial cancer cell proliferation through disruption of the PI3K/Akt and MAPK pathways

Our goal was to evaluate the therapeutic potential of a novel antibody to the insulin growth factor-1 receptor (IGF-1-R; AMG 479) in endometrial cancer cells. The endometrial cancer cell lines, ECC-1/PRAB72 and RL-95-2, were used. Treatment with AMG 479 (0.02-200 nmol/L) resulted in inhibition of cell proliferation at 72 to 120 hours. Insulin growth factor-1 (0.15-7.5 nmol/L) stimulated growth in both cell lines (range of 15%-42%, P = .0025-.0445), which could be blocked by pretreatment with AMG 479 (mean of 29% for ECC-1/PRAB72, P = .006-.007; mean of 36% for RL-95-2, P = .0002-.0045). AMG 479 suppressed IGF-1-R kinase activity in a dose-dependent manner. Cells treated with AMG 479 underwent either G1 (ECC-1/PRAB72) or G2 (RL-95-2) arrest. AMG 479 decreased human telomerase reverse transcriptase (hTERT) mRNA expression in both endometrial cancer cell lines. Treatment with AMG 479 rapidly blocked IGF-1-induced phosphorylation of IFG-1-R, Akt, and p44/42. Thus, manipulation of the IGF-1-R pathway may serve as a promising therapeutic strategy for the treatment of endometrial cancer.

Risk of borderline and invasive ovarian tumours after ovarian stimulation for in vitro fertilization in a large Dutch cohort

BACKGROUND

Long-term effects of ovarian stimulation for IVF on the risk of ovarian malignancies are unknown.

METHODS

We identified a nationwide historic cohort of 19,146 women who received IVF treatment in the Netherlands between 1983 and 1995, and a comparison group of 6006 subfertile women not treated with IVF. In 1997-1999, data on reproductive risk factors were obtained from 65% of women and data on subfertility (treatment) were obtained from the medical records. The incidence of ovarian malignancies (including borderline ovarian tumours) through 2007 was assessed through linkage with disease registries. The risk of ovarian malignancies in the IVF group was compared with risks in the general population and the subfertile comparison group.

RESULTS

After a median follow-up of 14.7 years, the risk of borderline ovarian tumours was increased in the IVF group compared with the general population [standardized incidence ratio (SIR) = 1.76; 95% confidence interval (CI) = 1.16-2.56]. The overall SIR for invasive ovarian cancer was not significantly elevated, but increased with longer follow-up after first IVF (P = 0.02); the SIR was 3.54 (95% CI = 1.62-6.72) after 15 years. The risks of borderline ovarian tumours and of all ovarian malignancies combined in the IVF group were significantly increased compared with risks in the subfertile comparison group (hazard ratios = 4.23; 95% CI = 1.25-14.33 and 2.14; 95% CI = 1.07-4.25, respectively, adjusted for age, parity and subfertility cause).

CONCLUSIONS

Ovarian stimulation for IVF may increase the risk of ovarian malignancies, especially borderline ovarian tumours. More large cohort studies are needed to confirm these findings and to examine the effect of IVF treatment characteristics.

Nomogram for suboptimal cytoreduction at primary surgery for advanced stage ovarian cancer

AIM

Maximal cytoreduction to minimal residual tumor is the most important determinant of prognosis in patients with advanced stage epithelial ovarian cancer (EOC). Preoperative prediction of suboptimal cytoreduction, defined as residual tumor >1 cm, could guide treatment decisions and improve counseling. The objective of this study was to identify predictive computed tomographic (CT) scan and clinical parameters for suboptimal cytoreduction at primary cytoreductive surgery for advanced stage EOC and to generate a nomogram with the identified parameters, which would be easy to use in daily clinical practice.

MATERIALS AND METHODS

Between October 2005 and December 2008, all patients with primary surgery for suspected advanced stage EOC at six participating teaching hospitals in the South Western part of the Netherlands entered the study protocol. To investigate independent predictors of suboptimal cytoreduction, a Cox proportional hazard model with backward stepwise elimination was utilized.

RESULTS

One hundred and fifteen patients with FIGO stage III/IV EOC entered the study protocol. Optimal cytoreduction was achieved in 52 (45%) patients. A suboptimal cytoreduction was predicted by preoperative blood platelet count (p=0.1990; odds ratio (OR)=1.002), diffuse peritoneal thickening (DPT) (p=0.0074; OR=3.021), and presence of ascites on at least two thirds of CT scan slices (p=0.0385; OR=2.294) with a for-optimism corrected c-statistic of 0.67.

CONCLUSION

Suboptimal cytoreduction was predicted by preoperative platelet count, DPT and presence of ascites. The generated nomogram can, after external validation, be used to estimate surgical outcome and to identify those patients, who might benefit from alternative treatment approaches.

Loss of APC function in mesenchymal cells surrounding the Müllerian duct leads to myometrial defects in adult mice

The WNT signal transduction pathway plays a rate limiting role in early development of many different organs. To study the functional consequences of constitutive activation of the canonical WNT pathway in the developing uterus, we generated a novel mouse model where loss of the tumor suppressor gene Apc was induced. A mouse model was generated and evaluated where Amhr2(Cre/+) driven loss of Apc exon 15 was induced. The Apc recombination was detected mainly in the myometrial layer of the adult uterus. A significant loss of muscle fibers in myometrium was apparent, though with very few muscle cells earmarked by nuclear β-catenin. The finding was confirmed in the Pgr(Cre/+);Apc(15lox/15lox) mouse model. Loss of APC function in mesenchymal cells surrounding the fetal Müllerian ducts results in severe defects in the myometrial layers of the uterus in adult mice, suggesting that the WNT signaling pathway plays important roles in maintaining myometrial integrity.

The prevalence and factors associated with previous surgery for pelvic organ prolapse and/or urinary incontinence in a cross-sectional study in The Netherlands

OBJECTIVE

To estimate the prevalence and identify the factors associated with previous pelvic organ prolapse (POP) and/or incontinence surgery.

STUDY DESIGN

In a cross-sectional study, all women who were aged 45-85 years and registered in eight general practices were invited to participate. They completed standardised questionnaires (the urinary distress inventory (UDI) and the defaecatory distress inventory (DDI)) and answered questions on previous pelvic floor surgery.

RESULTS

Out of 2979 women eligible for this study, 1380 women were included. Previous surgery had been performed in 119 women. The prevalence of surgery increased with age, with a prevalence of 20.3% in the age group 76-85 years. Pelvic floor symptoms were more prevalent in women who had undergone previous surgery, with higher UDI and DDI scores. Factors associated with previous surgery were age, higher BMI, POP symptoms during pregnancy and previous hernia surgery.

CONCLUSION

In The Netherlands, approximately one in five women will undergo surgery for POP and/or incontinence during her lifetime. The women who underwent surgery were more likely to have symptoms of pelvic floor dysfunction than those who did not undergo surgery.

Chemosensitivity and outcome of BRCA1- and BRCA2-associated ovarian cancer patients after first-line chemotherapy compared with sporadic ovarian cancer patients

BACKGROUND

Because it is insufficiently clear whether BRCA-associated epithelial ovarian cancer (EOC) is more chemosensitive than sporadic EOC, we examined response to chemotherapy, progression-free survival (PFS) and overall survival (OS) in BRCA1- and BRCA2-associated versus sporadic EOC patients.

METHODS

Data about patient characteristics, response to and outcome after primary therapy, including chemotherapy, were collected from 99 BRCA1, 13 BRCA2 and 222 sporadic patients. Analyses were carried out using a chi-square test and Kaplan-Meier and Cox regression methods.

RESULTS

Complete response (CR) or no evidence of disease (NED) was observed in 87% of the BRCA1 patients, progressive disease (PD) in 2%, being 71% and 15%, respectively, in sporadic EOC patients (P = 0.002). In BRCA2 patients, 92% had CR/NED, and none PD (P = 0.27). Median PFS in BRCA1, BRCA2 and sporadic patients was 2.1 [95% confidence interval (CI) 1.9-2.5] years (P = 0.006), 5.6 (95% CI 0.0-11.5) years (P = 0.008) and 1.3 (95% CI 1.1-1.5) years, respectively. Median OS in the three groups was 5.9 (95% CI 4.7-7.0) years (P < 0.001), >10 years (P = 0.008), and 2.9 (95% CI 2.2-3.5) years, respectively. A trend for a longer PFS and OS in BRCA2 compared with BRCA1 patients was observed.

CONCLUSION

Compared with sporadic EOC patients, both BRCA1- and BRCA2-associated patients have improved outcomes after primary therapy, including chemotherapy.

Recurrence rate in vulvar carcinoma in relation to pathological margin distance

OBJECTIVES

This paper describes the results of a retrospective study of surgical approaches and recurrence rates relating to patients with squamous cell carcinoma (SCC) of the vulva. The aim of this study was to analyze the histological margins in relation to recurrence rate and survival.

METHODS

A retrospective chart review of 93 cases of vulvar cancer. The data collected included clinicopathological and surgical characteristics and the following potential risk factors: pathological margin distance, less than 8 mm; stromal invasion depth, more than 2.5 mm; tumor size; and presence of benign or premalignant epithelial disorders.

RESULTS

Ninety-three patients (median age, 74 years) underwent modified radical vulvectomy, hemi-vulvectomy, or local wide excision for SCC of the vulva from 2000 to 2005. The tumor was radically removed in 80 patients (86%), although the histopathological margin was less than 8 mm in 50 patients (54%). Eighteen patients (23%) developed a local recurrence. The recurrence rate did not differ between patients in whom the margin distance was 8 mm or more and those in whom the margin distance was less than 8 mm, (23% and 22%, respectively). The median follow-up was 31 months (range, 2-90 months).

CONCLUSIONS

Several studies showed that pathological margin distance of more than 8 mm is an important predictor for local recurrence. This finding was not confirmed in the present study.

Prevalence of double incontinence, risks and influence on quality of life in a general female population

BACKGROUND

Urinary incontinence (UI) and anal incontinence (AI) are complaints with impact on quality of life (QOL). Few data are available on prevalence of double incontinence (DI) in the general female population.

OBJECTIVE

To determine prevalence of UI, AI, and DI, their associations with age, parity, and effects on QOL.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study on a general female population, aged 45-85 years.

MEASUREMENTS

Validated questionnaires measuring pelvic floor dysfunction and QOL. A short questionnaire was used for non-responders. Analyses were performed with Chi-square tests, ANOVA, and logistic regression.

RESULTS

Response rate was 62.7% (1,869/2,979); 59% of non-responders filled in the short questionnaire (620/1,051). No significant differences in stress urinary incontinence, vaginal bulging, solid stool incontinence and parity were found between responders and non-responders. DI with and without flatal incontinence were reported by 7.7% and 35.4%, respectively. Women with urge urinary incontinence (UUI) alone had an OR of 4.3 (95% CI 2.4-7.9) for liquid stool incontinence, 1.6 (95% CI 0.5-4.9) for solid stool incontinence and 2.4 for flatal incontinence (95% CI 1.5-3.8). Women with AI had an OR of 5.8 (95% CI 1.8-18.2) for UUI. Women with DI including flatus reported significantly poorer QOL. Limitation of the study was the lack of objective clinical validation of symptoms, which may have influenced the real prevalence data.

CONCLUSIONS

Most important relation was found between UUI and liquid stool incontinence (OR 4.3). We recommend that clinicians take the history of patients with UUI or mixed urinary incontinence to exclude the co-existence of AI.

Assessment of posterior compartment prolapse: a comparison of evacuation proctography and 3D transperineal ultrasound

INTRODUCTION

Evacuation proctography (EP) is considered to be the gold standard investigation for the diagnosis of posterior compartment prolapse. 3D transperineal ultrasound (3DTPUS) imaging of the pelvic floor is a noninvasive investigation for detection of pelvic floor abnormalities. This study compared EP with 3DTPUS in diagnosing posterior compartment prolapse.

METHOD

In a prospective observational study, patients with symptoms related to posterior compartment prolapse participated in a standardized interview, clinical examination, 3DTPUS and EP. Both examinations were analysed separately by two experienced investigators, blinded against the clinical data and against the results of the other imaging technique. After the examinations, all patients were asked to fill out a standardized questionnaire concerning their subjective experience.

RESULTS

Between 2005 and 2007, 75 patients were included with a median age of 59 years (range 22-83). The Cohen's Kappa Index for enterocole was 0.65 (good) and for rectocele it was 0.55 (moderate). The level of correlation for intussusception was fair (kappa = 0.21).

CONCLUSION

This study showed moderate to good agreement between 3DTPUS and EP for detecting enterocele and rectocele.

Abstract 4208: Constitutive activation of Wnt/beta-catenin signaling induces uterine developmental defects

Background: Wnt/beta-catenin signaling plays a regulatory role in uterine development and function. To study this role of Wnt/beta-catenin signaling during embryogenesis in more detail, we employed an AmhR2 promoter-driven C-recombinase (Jamin et al., 2002) to conditionally inactivate the Apc gene in mesenchymal cells surrounding the müllerian duct. As a consequence of Apc inactivation, defects in the destruction complex are expected to result in the intracellular accumulation of beta-catenin and the subsequent constitutive activation of canonical Wnt signaling.

Methods: [Apc15Lox/15lox;AmhR2-Cre] conditional Apc knockout mice were generated. Cre expression and AmhR2 promotor activity was verified by staining for beta-galactosidase activity in [AmhR2-LacZ] and [AmhR2-Cre;ROSA26-LacZlox] reporter mice. Furthermore, recombination of the Apc gene was verified for different laser micro-dissected regions of the uterus, from 8-week-old mice, by PCR. Uterine defects were examined by immunohistochemical staining for various uterine markers.

Results: It was observed that the Cre-mediated Apc gene deletion mainly took place in the myometrial layers of the uterus. Recombination in the stroma and epithelium of the lumen and glands was low. Microscopically, the affected mice showed a significant reduction in the number of glands and a somewhat disorganized stroma. The main defects, however, were observed in the myometrial layer of the uterus, where clear disorganization of muscle fibres and in 50% of cases visible loss of musculature was apparent. As a consequence of these defects, the mice displayed reduced litter sizes and some mice were incapable of normal delivery.

Conclusion: AmhR2-Cre driven embryonic knock-down of Apc results in a defect of the myometrial layer of the uterus. Effects on the endometrium were observed to be less profound.

Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4208.

Prediction of 30-day morbidity after primary cytoreductive surgery for advanced stage ovarian cancer

OBJECTIVE

Treatment in advanced stage epithelial ovarian cancer (EOC) is based on primary cytoreductive surgery followed by platinum-based chemotherapy. Successful cytoreduction to minimal residual tumour burden is the most important determinant of prognosis. However, extensive surgical procedures to achieve maximal debulking are inevitably associated with postoperative morbidity and mortality. The objective of this study is to determine predictors of 30-day morbidity after primary cytoreductive surgery for advanced stage EOC.

METHODS

All patients in the South Western part of the Netherlands who underwent primary cytoreductive surgery for advanced stage EOC between January 2004 and December 2007 were identified from the Rotterdam Cancer Registry database. All peri- and postoperative complications within 30 days after surgery were registered and classified according to the definitions of the National Surgical Quality Improvement Programme (NSQIP). To investigate independent predictors of 30-day morbidity, a Cox proportional hazards model with backward stepwise elimination was utilised. The identified predictors were entered into a nomogram.

RESULTS

Two hundred and ninety-three patients entered the study protocol. Optimal cytoreduction was achieved in 136 (46%) patients. 30-day morbidity was seen in 99 (34%) patients. Postoperative morbidity could be predicted by age (P=0.007; odds ratio [OR] 1.034), WHO performance status (P=0.046; OR 1.757), extent of surgery (P=0.1308; OR=2.101), and operative time (P=0.017; OR 1.007) with an optimism corrected c-statistic of 0.68.

CONCLUSION

30-day morbidity could be predicted by age, WHO performance status, operative time and extent of surgery. The generated nomogram could be valuable for predicting operative risk in the individual patient.

Prediction of residual disease after primary cytoreductive surgery for advanced-stage ovarian cancer: accuracy of clinical judgment

OBJECTIVES

Treatment of patients with an advanced-stage epithelial ovarian cancer (EOC) is based on cytoreductive surgery and platinum-based chemotherapy. Amount of residual disease after primary cytoreductive surgery is an important prognostic factor. The objectives of the present study were to evaluate the accuracy and reproducibility of preoperative clinical judgment of residual disease after primary cytoreductive surgery and to compare the predictive performance of the offhand assessment to the predictive performance of prediction models.

MATERIALS AND METHODS

Fifteen observers (5 gynecologic oncologists, 5 gynecologists, and 5 senior residents) were offered preoperative data of 20 patients with advanced-stage EOC who underwent primary cytoreductive surgery. The observers were asked to predict residual disease after cytoreductive surgery (<or=1 or >1 cm). Their estimation was compared with the performance of 2 prediction models.

RESULTS

Overall, suboptimal cytoreduction was predicted with a sensitivity of 50% and a specificity of 56%. The intraclass correlation coefficient was 0.27. chi(2) Test showed no significant difference in prediction of suboptimal cytoreduction between the different subgroups and prediction models.

CONCLUSIONS

Clinical judgment of residual disease after primary cytoreductive surgery in patients with advanced-stage EOC shows limited accuracy. Given the poor interobserver reproducibility, prediction models could attribute to uniform treatment decisions and improve counseling.

Miscarriage risk for IVF pregnancies in poor responders to ovarian hyperstimulation

The increasing miscarriage rate with advancing female age is attributed to a decline in oocyte quality. A poor response to ovarian hyperstimulation is often an expression of a decrease in oocyte quantity. Although oocyte quality and quantity both decrease as a result of ovarian ageing, it is unclear whether these two processes are related to each other. To investigate the relationship between oocyte quantity and quality, we compared miscarriage rates between IVF treated women with a poor and normal response, respectively. Data were studied from a retrospective nationwide cohort of Dutch women undergoing IVF treatment from 1983 to 1995. Women achieving an ongoing pregnancy after their first complete IVF cycle (n=1468) were compared with those experiencing miscarriage (n=357) with respect to their ovarian response. Logistic regression analysis showed a statistically significant association between poor response (fewer than four retrieved oocytes) and miscarriage (P=0.001). Due to interaction, this association became stronger with increasing female age. Among women < 36 years, miscarriage rates between poor and normal responders did not differ, whereas among women 36 years poor responders had a statistically significant increased miscarriage rate compared with normal responders (P=0.001). These results support the hypothesis of a relationship between quantitative ovarian reserve and oocyte quality.

Progesterone inhibition of Wnt/beta-catenin signaling in normal endometrium and endometrial cancer

PURPOSE

Wnt signaling regulates the fine balance between stemness and differentiation. Here, the role of Wnt signaling to maintain the balance between estrogen-induced proliferation and progesterone-induced differentiation during the menstrual cycle, as well as during the induction of hyperplasia and carcinogenesis of the endometrium, was investigated.

EXPERIMENTAL DESIGN

Endometrial gene expression profiles from estradiol (E(2)) and E(2) + medroxyprogesterone acetate-treated postmenopausal patients were combined with profiles obtained during the menstrual cycle (PubMed; GEO DataSets). Ishikawa cells were transfected with progesterone receptors and Wnt inhibitors dickkopf homologue 1 (DKK1) and forkhead box O1 (FOXO1), measuring Wnt activation. Expression of DKK1 and FOXO1 was inhibited by use of sequence-specific short hairpins. Furthermore, patient samples (hormone-treated endometria, hyperplasia, and endometrial cancer) were stained for Wnt activation using nuclear beta-catenin and CD44.

RESULTS

In vivo, targets and components of the Wnt signaling pathway (among them DKK1 and FOXO1) are regulated by E(2) and progesterone. In Wnt-activated Ishikawa cells, progesterone inhibits Wnt signaling by induction of DKK1 and FOXO1. Furthermore, using siRNA-mediated knockdown of both DKK1 and FOXO1, progesterone inhibition of Wnt signaling was partly circumvented. Subsequently, immunohistochemical analysis of the Wnt target gene CD44 showed that progesterone acted as an inhibitor of Wnt signaling in hyperplasia and in well-differentiated endometrial cancer.

CONCLUSION

Progesterone induction of DKK1 and FOXO1 results in inhibition of Wnt signaling in the human endometrium. This Wnt inhibitory effect of progesterone is likely to play a rate-limiting role in the maintenance of endometrial homeostasis and, on its loss, in tumor onset and progression toward malignancy.

Pelvic floor muscle function in a general female population in relation with age and parity and the relation between voluntary and involuntary contractions of the pelvic floor musculature

Introduction and hypothesis

The objective of this study is to describe pelvic floor muscle function (PFMF) in relation to age and parity in a general female population and to test whether strength/endurance measurements represent all functions of the pelvic floor musculature.

Methods

A cross-sectional study was performed on 95% of the women aged 45–85 years from a small Dutch town. Validated questionnaires were used to obtain general information, and vaginal examination to test PFMF was performed on 649 women. Chi-square tests were used to analyse the relation between PFMF versus age and parity. Analysis of variance was used to compare muscle strength and endurance to the other PFMF items.

Results

Response rate to the questionnaire was 62.7% (1,869/2,979). PFM strength and endurance are not positively associated with the effective involuntary muscle contractions during coughing.

Conclusions

Voluntary muscle contractions decreased with age, but there was no relation with parity. Muscle strength and endurance measurements alone are not sensitive enough to determine PFMF.

Causes of postoperative mortality after surgery for ovarian cancer

Residual disease after cytoreductive surgery is an important prognostic factor in patients with advanced stage epithelial ovarian cancer (EOC). Aggressive surgical procedures necessary to achieve maximal cytoreduction are inevitably associated with postoperative morbidity and mortality. To determine causes of postoperative mortality (POM) after surgery for EOC all postoperative deaths in the southwestern part of the Netherlands over a 17-year period were identified and analysed by reviewing medical notes. Between 1989 and 2005, 2434 patients underwent cytoreductive surgery for EOC. Sixty-seven patients (3.1%) died within 30 days after surgery. Postoperative mortality increased with age from 1.5% (26/1765) for the age group 20-69 to 6.6% (32/486) for the age group 70-79 and 9.8% (18/183) for patients aged 80 years or older. Pulmonary failure (18%) and surgical site infection (15%) were the most common causes of death. Only a quarter of deaths resulted from surgical site complications. Our results suggest that causes of postoperative mortality after surgery for EOC are very heterogeneous. Given the impact of general complications, progress in preoperative risk assessment, preoperative preparation and postoperative care seem essential to reduce the occurrence of fatal complications.

Prediction model and prognostic index to estimate clinically relevant pelvic organ prolapse in a general female population

INTRODUCTION AND HYPOTHESIS

Estimation on prevalence and distribution of pelvic organ prolapse (POP) signs in a general female population is difficult. We therefore developed and validated a prediction model and prognostic instrument.

METHODS

Questionnaires were sent to a general female population (45-85 years). A random sample underwent vaginal examination for POP (POPQ). A prediction model was developed using multivariate analysis and validated in a subgroup of participants.

RESULTS

Positive questionnaire-response rate was 46.8% (1,397 of 2,979). From the questionnaire group, 649 women were vaginally examined (46.5%). Prevalence of clinically relevant POP was 21%. Multivariate analysis demonstrated significantly higher odds ratios on the report of vaginal bulging, parity > or = 2 and a mother with POP. The receiver operating characteristic curve showed areas under the curve of 0.672 and 0.640.

CONCLUSIONS

The prevalence of POP at or beyond the hymen could be estimated in a general female population using our prediction model with 17 questions and our POP score chart with eight questions.

Vaginal noise: prevalence, bother and risk factors in a general female population aged 45-85 years

INTRODUCTION AND HYPOTHESIS

Vaginal noise (VN) is a symptom of pelvic floor (PF) dysfunction and has been described in a few studies. No other risk factors have been described besides parity and pelvic organ prolapse (POP). Underlying mechanisms of VN are unclear. Aims of this study were to describe prevalence, bother and relation between VN and PF (muscle)(dys)function.

METHODS

A cross-sectional study was performed on a general population of 2,921 women (aged 45-85 years). Questionnaires were filled in by 1,397 women, and 800 were selected at random to undergo vaginal examination for POP Quantification and PF muscle function assessment. Chi-square tests, Student's t test and multivariate logistic regression were performed (P < 0.05).

RESULTS

Response rate was 62.7%. Prevalence of VN was 12.8%; 72.1% reported only a little bother. Odds ratios for parity and solid stool were high.

CONCLUSIONS

VN was strongly related to many symptoms of pelvic floor dysfunction, but it was only causing a little bother.

Postoperative mortality after primary cytoreductive surgery for advanced stage epithelial ovarian cancer: a systematic review

OBJECTIVE

Accurate estimation of the risk of postoperative mortality (POM) is essential for the decision whether or not to perform cytoreductive surgery in a patient with advanced stage ovarian cancer. To ascertain modern reference figures, a systematic review of studies reporting POM after primary cytoreductive surgery for advanced stage epithelial ovarian cancer (EOC) was performed.

MATERIALS AND METHODS

A Medline search was performed to retrieve papers on primary cytoreductive surgery for advanced stage EOC. Twenty-three papers met the inclusion criteria and were reviewed.

RESULTS

According to population-based studies, POM after primary cytoreductive surgery for EOC is 3.7% on average. Single centre studies report an average rate of 2.5%. The overall mean POM is 2.8%. POM is more frequent for elderly women and after extensive procedures. Accurate information on age-specific and procedure-specific rates could not be obtained.

CONCLUSION

POM rates after surgery for EOC are satisfactorily low. There is a clear need for reliable reference figures for mortality after debulking surgery in the elderly.

Management of Surgical Stage III and IV Endometrioid Endometrial Carcinoma: An Overview

This paper covers an overview of the literature on the management of advanced endometrial cancer, concentrating on patients with histopathologic endometrioid type of tumors. The different treatment modalities are described and management recommendations are proposed.

The standard surgical procedure includes an extrafacial total hysterectomy with bilateral salpingo-oophorectomy, collection of peritoneal washings for cytology, and exploration of the intraabdominal contents. In cases of extensive disease in the abdomen, an optimal surgical cytoreduction is associated with improved survival. Further treatment with radiotherapy may be indicated based on the pathological staging information to improve loco-regional control. Primary radiotherapy is indicated in cases where surgery is contraindicated. Systemic treatment can either be hormone therapy or chemotherapy. Progesterons are the cornerstone of hormone therapy. Prognostic factors for response are the presence of high levels of progesterone and estrogen receptors and low grade histology. Paclitaxel is the most active single agent drug. The combination therapy with paclitaxel and carboplatin is adopted as first choice in patients with endometrial cancer because of the efficacy and low toxicity, although not proven in a randomized trial.

The literature on the management of patients with advanced endometrial cancer is discussed in detail. Each stage of advanced disease is presented separately, and management recommendations are proposed, and alternative approaches are given.

Ongoing clinical trials are described, and the focuses of ongoing research are mentioned.

Management of Recurrent Endometrioid Endometrial Carcinoma: An Overview

In this paper, an overview of the literature on the management of recurrent endometrial cancer is presented, focusing on patients with histopathologic endometrioid type of tumors. The different treatment modalities are described, and a management recommendation scheme is presented. Indications for surgical treatment depend on resectability, site and size of the tumor, and performance status of the patient. Indications for radiotherapy depend on the site of the recurrence and also on the initial therapy received. When considering systemic treatment for patients with recurrent endometrial cancer, it is important to take into account the general health status and condition of the patient as well as which prior therapy the patient has received. The treatments of choice for patients with hormone-sensitive tumors (positive receptor levels, low-grade tumors, and long disease-free interval) are progestagens as first-line treatment and tamoxifen as second-line treatment. Patients with high-grade tumors, negative hormone receptor levels, and short treatment-free interval are best treated with chemotherapy. Paclitaxel, doxorubicin, and cisplatin are the most active combination therapy for these patients but with significant toxicity. In phase II studies, the combination therapy with paclitaxel and carboplatin seems to be as effective but less toxic and can be administered in outpatient clinic. The literature on the management of patients with recurrent endometrial cancer is discussed in detail. The different sites of recurrent disease (ie, local, regional, and/or distant) are evaluated separately; management recommendations are proposed, and alternative approaches are given.

Reduced local immunity in HPV-related VIN: expression of chemokines and involvement of immunocompetent cells

Usual type VIN is a premalignant disorder caused by persistent HPV infection. High prevalence of VIN in immuno-suppressed women suggests that a good innate and adaptive immune response is important for defense against HPV. Here, we explored expression levels of chemokines and related these to the presence or absence of immuno-competent cells (dendritic and T-cells) in affected (HPV-positive VIN) and non-affected (HPV-negative) vulvar tissues from the same patients. Combining microarray data with quantitative real-time RT-PCR, it was observed that several important chemokines were differentially expressed between VIN and control samples (up-regulation of IL8, CXCL10, CCL20 and CCL22 and down-regulation of CXCL12, CCL21 and CCL14). Furthermore, an increased number of mature dendritic cells (CD208+) seemed to be bottled up in the dermis, and although a T-cell response (increased CD4+ and CD8+ cells) was observed in VIN, a much larger response is required to clear the infection. In summary, it seems that most mature dendritic cells do not receive the proper chemokine signal for migration and will stay in the dermis, not able to present viral antigen to naive T-cells in the lymph node. Consequently the adaptive immune response diminishes, resulting in a persistent HPV infection with increased risk for neoplasia.