Retromesenteric para-aortic lymphadenectomy in gynecologic malignancy

In gynecologic oncology lymphadenectomy is of prognostic and therapeutic importance because recurrence-free time and survival depend on the metastatic involvement of lymph nodes. Lymphadenectomies are not performed to such an extent as they are indicated. This might be due to a laborious or problematic preparation. The authors therefore report their experience in a seldom taught preparation of the left para-aortic compartment in the form of a learning curve.

MATERIALS AND METHODS

To access the left para-aortic area, the descending colon is lifted to open the retroperitoneum along the line of Toldt. The mesentery of the descending colon was separated from the kidney along the fascia of Gerota by blunt preparation. Time was measured from the incision of the peritoneum until the renal vein was clearly visible.

RESULTS

The authors collected the data from the first 25 preparations. Mean duration for the left para-aortic preparation was 7.8 minutes compared to 5.9 minutes for the right side. Duration of preparation of the left area dropped from 11.0 minutes within the first patients (#1 to #5) to 3.8 minutes in the last patients (#20 to #25). No complications were observed in the study group linked to the retromesenteric approach described.

CONCLUSION

Retromesenteric para-aortic lymphadenectomy is quick to learn. The authors needed 20 preparations to observe a significant drop in the time needed for preparation. Retromesenteric para-aortic lymphadenectomy offers an excellent overview that lightens lymphadenectomy and therefore reduces the risks for patients.

Cold-shock domain family member YB-1 expression in endometrium and endometriosis

BACKGROUND

The Y-box-binding protein (YB-1) is described as a potential oncogene highly expressed in tumors and associated with increased cell survival, proliferation, migration and anti-apoptotic signaling. The aim of our study was to examine the expression and role of YB-1 in human endometriosis (Eo) and its association with cell survival, proliferation and invasion.

METHODS

We analyzed the gene and protein expression levels of YB-1 by quantitative real-time RT-PCR and immunoassays, respectively, in peritoneal macrophages, ovarian endometrioma and eutopic endometrial tissues/cells derived from women with (n= 120) and without (n= 91) Eo. We also evaluated the functional consequences of YB-1 knockdown in the Z12 Eo cell line by measuring cell proliferation [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazoliumbromid cell proliferation assay], invasion (Matrigel invasion assay) and spontaneous and tumour necrosis factor (TNFα)-induced RANTES (regulated upon activation, normal T-cell expressed and secreted chemokine) expression and apoptosis (ELISA-based assay).

RESULTS

YB-1 gene and protein expression was statistically significantly higher in ovarian lesions, eutopic endometrium and peritoneal macrophages of patients with Eo in comparison with the control group. Interestingly, the strongest YB-1 expression was observed in the epithelial compartment of endometrial tissues. In the Z12 cell line, YB-1 knockdown resulted in significant cell growth inhibitory effects including reduced cell proliferation and increased rates of spontaneous and TNFα-induced apoptosis. Significantly, higher RANTES expression and decreased cell invasion in vitro were also associated with YB-1 inactivation.

CONCLUSION

High YB-1 expression could have an impact on the development and progression of Eo. This study suggests the role of YB-1 as a potential therapeutic target for Eo patients.

Reduced pelvic pain in women with endometriosis: efficacy of long-term dienogest treatment

Purpose

To investigate the efficacy and safety of dienogest as a long-term treatment in endometriosis, with follow-up after treatment discontinuation. The study included women with endometriosis, who had previously completed a 12-week, placebo-controlled study of dienogest, who participated in an open-label extension study for up to 53 weeks. Thereafter, a patient subgroup was evaluated in a 24-week follow-up after treatment discontinuation.

Methods

A multicenter study performed in Germany, Italy and Ukraine. Women with endometriosis were enrolled at completion of the placebo-controlled study (n = 168). All women received dienogest (2 mg once daily, orally) and changes in pelvic pain (on a visual analog scale), bleeding pattern, adverse events and laboratory parameters were evaluated during and after treatment.

Results

The completion rate among women who entered the open-label extension study was 90.5% (n = 152). A significant decrease in pelvic pain was shown during continued dienogest treatment (P < 0.001). The mean frequency and intensity of bleeding progressively decreased. Adverse events, rated generally mild or moderate, led to withdrawal in four patients (2.4%). No clinically relevant changes in laboratory parameters were observed. During treatment-free follow-up (n = 34), the reduction in pelvic pain persisted, while bleeding frequency and intensity returned to normal patterns.

Conclusions

Long-term dienogest showed a favorable efficacy and safety profile, with progressive decreases in pain and bleeding irregularities during continued treatment; the decrease of pelvic pain persisted for at least 24 weeks after treatment cessation.

Innovations in conservative endometriosis treatment: an updated review

Endometriosis is a common, benign and chronic gynecological disorder. It is also an estrogen-dependent disorder that can result in intractable dysmenorrhea, heavy and/or irregular periods, painful bowel movements and urination during menstruation and infertility and ultimatively in repeated surgeries. Although surgery to remove endometriotic lesions is effective in relieving endometriosis-associated pain, recurrence rates are high and many women require continuous medical therapy to control symptoms. Symptom relief with palliation of pain and optimization of the quality of life should be the main aim of the medical therapy. Different pharmacologic treatment options are currently available. The most widely exerted medical therapy for endometriosis involves gonadotropin-releasing hormone (GnRH) agonists and oral contraceptives. Also progestogens and androgen derivates are used. New treatment options that are currently under investigation are selective progestogen receptor modulators (SPRMs), aromatase inhibitors (AI), GnRH- antagonists, cyclooxygenase (COX)-2 inhibitors, angiogenesis disruptor's und immune modulators. Although these new agents are promising, further confirmation in randomized clinical trials is required.

Multiplexed quantitation of endogenous estrogens and estrogen metabolites in human peritoneal fluid

Endogenous estrogens and estrogen metabolites (EM) in human peritoneal fluid may play an important role in health and disease, yet little is known regarding their types and levels present in human peritoneal fluid, primarily due to the lack of an analytical method that is capable of directly quantifying their absolute abundances. In this report, we describe the application of a capillary LC-MS/MS method for identifying and quantifying biologically active and total endogenous EM in human peritoneal fluid. The method requires only 50 muL of peritoneal fluid, yet can quantify 13 distinct EM. Calibration curves for each EM were linear over a 10(3)-fold concentration range and the lower LOQ was 50 fg on-column. For a charcoal stripped human peritoneal fluid sample containing 10 pg/mL of each EM, accuracy ranged from 83 to 118%, and intrabatch precision ranged from 0.2 to 4.4% RSD and interbatch precision ranged from 5.5 to 15.5% RSD. The analyses of human female peritoneal fluid shows that at least 10 biologically active and 11 total endogenous EM can be positively identified and quantitatively measured. Many of the biologically active forms are present in high abundance and possess distinct biological activities which warrant further study. Although micellar EKC gave baseline separation of a standard mixture of 10 EM, the LOQs using UV detection were not suitable for the assay of the low level estrogens in biological samples.

Mass spectrometry and serum pattern profiling for analyzing the individual risk for endometriosis: promising insights?

OBJECTIVE

To evaluate whether distinct patterns of serum proteins in symptomatic women are of value to predict endometriosis before laparoscopy.

DESIGN

Prospective exploratory cohort study.

SETTING

Tertiary care center.

PATIENT(S)

A total of 91 consecutive symptomatic patients suffering from dysmenorrhea, dyspareunia, chronic pelvic pain, or unexplained infertility.

INTERVENTION(S)

Collection of serum samples and a standardized protocol for patients' history before laparoscopic diagnosis.

MAIN OUTCOME MEASURE(S)

Protein expression was analyzed by mass spectrometric analysis according to surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF MS) standards. The analysis of data was performed using a genetic algorithm (ClinProTools 2.0 software) and a rule-based decision-tree algorithm (XLminer software).

RESULT(S)

A total of 90 out of 91 samples were eligible for analysis. At laparoscopy, 51 of 90 patients (56.7%) exhibited endometriosis and 39 of 90 (43.3%) were disease free. Analyzing the serum samples, the software revealed a unique selection of mass peaks between 2,000 and 20,000 Da, which allowed for discrimination between patients suffering from endometriosis and control subjects. Overall recognition capacity was 70.8%, exhibiting a sensitivity of 81.3% (95% confidence interval [CI] 66.5-92.5) and a specificity of 60.3% (95% CI 46.1-74.2]) using the genetic algorithm, and a sensitivity of 78.4% and a specificity of 59.0% using the rule-based decision-tree algorithm.

CONCLUSION(S)

These findings provide direct evidence that screening for serum protein patterns using SELDI-TOF MS before laparoscopy might be of discriminative value in the prediction of disease and partly confirms recently published data. However, in this prospective setting, we found both low sensitivity and low specificity, which disqualifies the screening for serum protein patterns by SELDI-TOF MS as a "quick fix" diagnostic test.

Laparoscopic management of early primary omental pregnancy

OBJECTIVE

To describe the successful laparoscopic management of an omental pregnancy.

DESIGN

Case report.

SETTING

University of Schleswig-Holstein, Campus Luebeck, Department of Gynecology and Obstetrics.

PATIENT(S)

A 25-year-old patient with an omental pregnancy.

INTERVENTION(S)

Laparoscopic partial omentectomy.

MAIN OUTCOME MEASURE(S)

Successful laparoscopic management of an omental pregnancy.

RESULT(S)

A 25-year-old woman reported having abdominal pain. Her urine pregnancy test was positive. She had been using an intrauterine copper device for a period of 2.5 years. Gynecologic examination revealed normal results, in the uterus and fallopian tubes especially, where no signs of pregnancy were found through clinical and sonographic examination. Because the patient had had increasing pain, a laparoscopy was performed. There was approximately 500 mL of dark blood found in the cul de sac. The uterus and fallopian tubes appeared normal and without any signs of pregnancy. However, there was a cavity detected in the omentum majus. A partial omentectomy then was performed laparoscopically. An omental pregnancy was confirmed by beta-hCG-positive trophoblast cells in the omentum majus.

CONCLUSION(S)

Omental pregnancy can be rather difficult to identify. If there is no evidence of tubal pregnancy, laparoscopy may help to confirm the diagnosis of omental pregnancy and simultaneously offer minimal invasive therapy.

Peroxisome proliferator-activated receptors: new players in the field of reproduction

Peroxisome proliferator-activated receptors (PPAR) are members of the nuclear hormone receptor superfamily. Synthetic ligands to one family member, PPARgamma, are currently widely used as treatment for chronic diseases such as diabetes type II and other insulin resistances, e.g. as seen in polycystic ovary syndrome (PCOS). Moreover, novel approaches employing knock-out mice demonstrated that PPARgamma seems to play a key role in placental and fetal development. This review describes recent insights into the role of PPARs in human reproduction with specific reference to infertility, placental maturation and fetal development as well as disturbed pregnancy. Further, we highlight the current knowledge on synthetic ligands to PPARgamma used as a treatment in women with PCOS.