Farnesoid X receptor agonist for the treatment of liver and metabolic disorders: focus on 6-ethyl-CDCA

6-ethyl-chedeoxycholic acid (6E-CDCA) is a farnesoid X receptor (FXR) ligand endowed with agonistic activity under development for treatment of cholestatic liver diseases including primary biliary cirrhosis (PBC) and liver-related metabolic disorders including non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). FXR is a bile sensor that acts in coordination with other nuclear receptors to regulate essential steps of bile acid uptake, metabolism and excretion. 6E-CDCA has been investigated in preclinical models of cholestasis, liver fibrosis and diet-induced atherosclerosis. In a phase II clinical trial in patients with PBC, 6E-CDCA met the primary endpoint of a reduction in alkaline phosphatase levels but safety data indicated that the drug exacerbated pruritus, one of the main symptoms of PBC, suggesting that 6E-CDCA or FXR are mediators of pruritus in humans. Treatment of patients with diabetes and liver steatosis resulted in amelioration of insulin sensitivity despite a reduction a slight reduction in HDL and increased levels of LDL were observed. These side effects on bile acids and lipid metabolism were all predicted by pre-clinical studies, suggesting that potent FXR ligands hold promise but potential side effects might limit their development.

Primary squamous cell carcinoma of the endometrium: a case report

BACKGROUND

Primary endometrial squamous cell carcinoma (PSECC) is a rare neoplasm. Squamous epithelium derived from endometrioid cancer or from cervical squamous cell carcinoma. The prevalence is about 0.1%. The genesis, histogenesis and biological behavior are unknown.

CASE PRESENTATION

A 48-year old woman in postmenopause, referring pelvic pain and vaginal bleeding. Transvaginal ultrasound showed a bulky uterus with the endometrium containing an hyperecogenic area. Endometrial biopsy found an epidermoid carcinoma. MRI showed a 4 x 2 x 1.2 cm mass occupying the uterine cavity. The patient underwent radical treatment. Pathological examination showed features of PSECC. The mutation of p53 tumor suppressor protein was disclosed in 15% of neoplastic cells. PCR revealed the absence of HPV DNA.

CONCLUSIONS

The findings of our case move us to underline that the pathogenesis of this tumor is still unclear. Moreover, preoperative diagnosis and staging of PESCC is extremely difficult. Most patients do not show characteristic symptoms and predisposing factors, making it almost impossible to diagnose the precise localization of tumor origin.

Ovarian metastasis following gallbladder carcinoma: a case report

BACKGROUND

Mucinous ovarian cancer raises problems of differential diagnoses because it is often difficult to distinguish the primary from the metastatic form. Most metastatic ovarian tumors originate from the gastrointestinal tract, mainly colorectal, gastric, pancreatic; the gallbladder is a very rare source of ovarian metastases.

CASE

We report a case of ovarian metastases from a gallbladder cancer, incidentally diagnosed more than 2.5 years earlier during a laparoscopic intervention for biliary lithiasis.

CONCLUSION

The interest of this case lies in the long progression-free survival, the venous thromboembolism syndrome that preceded by a few months the diagnosis of the ovarian mass and the discrepancy between the radiologic and the laparoscopic stage assessment.

Aberrant DNA hypermethylation of hMLH-1 and CDKN2A/p16 genes in benign, premalignant and malignant endometrial lesions

PURPOSE OF INVESTIGATION

aberrant gene function and transcriptional silencing by CpG island hypermethylation have become a critical component in the initiation and progression of endometrial cancer. The aim of this study was to investigate the methylation status of genes associated with aberrant DNA hypermethylation in benign, premalignant and malignant endometrial lesions.

METHODS

using nested methylation-specific PCR, we assessed the methylation of the promoter regions of two genes, hMLH1 and CDKN2A/p16, in tissue samples from endometrial polyps (EP), atypical hyperplasia (AH) and endometrial cancer (EC).

RESULTS

the promoter region of at least one of the two genes was aberrantly methylated in EP (hMLH1 42%, CDKN2A/p16 16%), AH (hMLH1 16%, CDKN2A/p16 50%), EC (hMLH1 50%, CDKN2A/p16 75%). Interestingly, hypermethylation of both genes was found with significant increased frequence in AH and EC, but not in benign lesions.

CONCLUSIONS

our preliminary findings seem to suggest that the association of the two genes hMLH1 and CDKN2A/p16 may allow a differential diagnosis between benign and premalignant/malignant endometrial lesions; this further supports the hypothesis that methylation of such DNA mismatch repair and tumour-suppressor genes may be associated with endometrial carcinogenesis thus representing a valuable target for selective pharmacologic therapy.

Synthesis, structures, and properties of nine-, twelve-, and eighteen-membered N-benzyloxyethyl cyclic alpha-peptoids

N-Benzyloxyethyl cyclic alpha-peptoids of various size were prepared and their conformational features were investigated by means of computational, spectroscopic, and X-ray crystallographic studies.

Huge primary retroperitoneal mucinous cystadenoma of borderline malignancy mimicking an ovarian mass: case report and review

BACKGROUND

Primary retroperitoneal mucinous cystadenoma is a rare tumor only 48 cases have been reported in international literature. Patients affected by primary retroperitoneal mucinous cystadenoma/cystadenocarcinoma ranged in age from 17 to 86 years (median, 42.3 years) and the size of the cystis ranged from 5 to 35 cm (median, 16.1 cm). There is no unanimous opinion on the genesis of these tumors and, due to their extreme rarity, its histogenesis, biological behavior and the optimal management strategy remain at a speculative level.

CASE REPORT

We report the case of a huge borderline primary retroperitoneal mucinous cystadenoma (24 x 25 cm) in a 35-year-old woman and the strategies adopted for the diagnosis and surgical management.

CONCLUSION

Primary mucinous cystic tumor of the retroperitoneum was correctly diagnosed only at the time of surgery. As well as in the majority of cases reported in the literature, preoperative investigations were not able to give information about the tumor site. In spite of the short follow-up (two years), the patient's favorable course supports the hypothesis that primary retroperitoneal mucinous cystadenoma may be treated in the same manner as a primary ovarian tumor of the same grade and comparable stage.

A case of mesonephric adenocarcinoma of the vagina with a 1-year follow-up

Mesonephric adenocarcinoma deriving from remnants of vaginal mesonephric ducts is one of the rarest tumors of the female genital tract with only three cases reported till date in international literature. Differential diagnosis from other aggressive tumors is complex and controversies exist in the literature regarding the biological behavior, prognosis, and optimal management strategies of these tumors. A 58-year-old woman presented with a large mass extending from the right adnexal region to the perineum and labia majora. CA125 was increased. A radical excision of the lesion with pelvic and para-aortic lymphadenectomy was performed. A well-capsulated mesonephric adenocarcinoma in a background of vaginal mesonephric remnants was diagnosed. Tumor cells showed immunoreactivity for pancytokeratin, cytokeratin (CK), CD 10, epithelial membrane antigen, vimentin, and calretinin; indeed they were negative for carcinoembryonic antigen, CK 20, estrogen receptor, and progesterone receptor. No evidence of lymph node involvement or metastatic disease was observed. The patient did not receive any adjuvant therapy and is alive and clinically free of disease at 1-year follow-up. In spite of the aggressive biological behavior attributed in literature to mesonephric carcinomas, which is probably due to the complex differential diagnosis with other müllerian tumors, the favorable course of our patient further supports the hypothesis that malignant mesonephric carcinomas may not behave aggressively and that radical surgery alone may be curative.

Ovarian endometrioma: postoperative adhesions following bipolar coagulation and suture

OBJECTIVE

To compare bipolar coagulation and suturing of the ovary in terms of postoperative ovarian adhesions after laparoscopic ovarian cystectomy for endometriosis.

DESIGN

Prospective, randomized, controlled study.

SETTING

Department of Obstetrics and Gynecology, University of Naples "Federico II."

PATIENT(S)

Thirty-two women with a single endometriotic cyst were randomly divided into two groups of 16 women each (groups A and B).

INTERVENTION(S)

All patients underwent laparoscopic ovarian cystectomy for endometriosis. In group A, hemostasis was performed by closure of the ovary with an intraovarian suture. In group B, complete hemostasis was achieved only with bipolar coagulation on the internal face of the ovary.

MAIN OUTCOME MEASURE(S)

Rate and extension of postsurgical ovarian adhesions at 60-90 days follow-up.

RESULT(S)

At follow-up, a significantly lower rate of postsurgical ovarian adhesions was observed in group A than in group B (30.8% vs. 57.1%). The extension of ovarian adhesions was significantly higher in group B than in group A.

CONCLUSION(S)

The use of sutures on ovaries treated for endometrioma is associated with a lower rate of postoperative ovarian adhesion formation compared with bipolar coagulation.

Prevention of adhesions in gynaecological endoscopy

Adhesions resulting from gynaecological endoscopic procedures are a major clinical, social and economic concern, as they may result in pelvic pain, infertility, bowel obstruction and additional surgery to resolve such adhesion-related complications. Although the minimally invasive endoscopic approach has been shown to be less adhesiogenic than traditional surgery, at least with regard to selected procedures, it does not totally eliminate the problem. Consequently, many attempts have been made to further reduce adhesion formation and reformation following endoscopic procedures, and a wide variety of strategies, including surgical techniques, pharmacological agents and mechanical barriers have been advocated to address this issue. The present review clearly indicates that there is no single modality proven to be unequivocally effective in preventing post-operative adhesion formation either for laparoscopic or for hysteroscopic surgery. Furthermore, the available adhesion-reducing substances are rather expensive. Since excellent surgical technique alone seems insufficient, further research is needed on an adjunctive therapy for the prevention and/or reduction of adhesion formation following gynaecological endoscopic procedures.

Primary signet-ring cell carcinoma of the uterine cervix with long term follow-up: case report

BACKGROUND

The uterine cervix represents an exceptional localization of signet-ring cell adenocarcinoma (SRCA). Most commonly, endocervical tumors with such morphology are metastatic from the breast or gastrointestinal tract while primary pure or almost pure tumors are extremely rare. No previous case of primary pure endocervical SRCA with follow-up longer than three years has been found in the literature.

CASE REPORT

The present report describes such a case of a 46-year-old woman without evidence of recurrence eight years after the diagnosis. The patient was referred to the Gynecology Department for persistent abnormal vaginal bleeding of three months duration. Specular examination and colposcopy revealed a cervical polypoid lesion occupying the posterior lip of the cervix and protruding from the external uterine orifice. A biopsy of the lesion was interpreted by the pathologist as SRCA. An extensive search for an extrapelvic primary cancer was undertaken but revealed no evidence of malignancy. The patient underwent radical hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymph node sampling for FIGO Stage 1B1 cervical cancer without any adjuvant chemo- or radiotherapy. The histological diagnosis showed neoplastic signet-ring cells confined in the head of the cervical polyps with minimal stromal infiltration. After surgery the patient underwent close followup including periodic cervicovaginal smears, bimanual vaginal examination, complete laboratory tests, ultrasound and abdominopelvic computed tomography.

CONCLUSIONS

The prognostic relevance of primitive pure SRCA in the uterine cervix is unclear because of the relatively small number of cases. However the two early deaths out of six reported cases and the absence of follow-up longer than three years for the other affected patients, seem to suggest an aggressive behavior. The present case represents an exceptional long-term survival, probably related to an early diagnosis and a prominent polypoid growth of the neoplasia outside the uterus.

Vaginoscopic versus traditional office hysteroscopy: a randomized controlled study

BACKGROUND

A randomized, controlled study was performed to compare vaginoscopic versus traditional (speculum with or without tenaculum) hysteroscopy in terms of pain score and procedure time.

METHODS

Three hundred patients were randomized in two groups: Group A, diagnostic hysteroscopy with vaginoscopic approach (150 patients) and Group B, diagnostic hysteroscopy with traditional approach (150 patients). All procedures were performed using a semi-rigid 3.5-mm minihysteroscope with a 0 degrees grade optic. Patients of each group were divided into three subgroups according to their reproductive status: fertile nulliparous (FN), fertile multiparous (FM) and post-menopausal (MEN) women. Women were asked to rate their degree of pain during four phases of the procedure: introduction of hysteroscope (Group A) or speculum (Group B) into the vagina (Phase I) and progression through cervical canal up to internal uterine orifice (IUO) (Phase II), inspection of uterine cavity (Phase III) and performing of endometrial biopsy (Phase IV). A total pain score was calculated for each group. For each patient, the duration of hysteroscopy was recorded from the introduction to the extraction of the scope (Group A) or of the speculum (Group B).

RESULTS

Although the median total pain scores were 2 in each group, the 95% confidence interval for vaginoscopic hysteroscopy (1.86-2.01) was significantly (P < 0.05) lower than that for traditional hysteroscopy (2.10-2.26). Comparison between the corresponding phases of the procedure showed the only significant difference during Phase I of the procedure [Group A: 1 (95% CI 1.0-1.18) versus Group B: 2 (95% CI 2.3-2.8); P < 0.05]. No significant differences in terms of duration of the procedure were observed between the two approaches.

CONCLUSIONS

When surgeons using vaginoscopic hysteroscopy with a semi-rigid minihysteroscope were compared with those using traditional approach and the same instrumentation, the operating times and the patients' pain scores were similar.

Effects of neridronate treatment in elderly women with osteoporosis

Osteoporosis is a common disorder, especially among elderly post-menopausal women. Elderly women are often affected by co-morbidities, impaired gastrointestinal function and reduced mobility; therefore, the treatment strategy for their osteoporosis can be difficult. In this randomized pilot study, we have investigated the effects of a 12-month treatment with neridronate on bone mineral density (BMD), bone turnover markers and quality of life (QoL). The study included 40 women (age, 65-80 yr; post-menopausal period, >15yr) from a single osteoporosis centre. Twenty women received a monthly im injection of 25 mg of neridronate associated with a daily dose of 500 mg of calcium and 400 U of vitamin D. Twenty women received calcium plus vitamin D supplements alone. Changes in BMD at the lumbar spine and femoral neck were measured by dual energy X-ray absorptiometry. Serum type I collagen C-telopeptide (sCTX), urinary free-deoxypyridinoline (ufDPD), bone alkaline phosphatase (ALP) and serum osteocalcin levels were determined. For the QoL assessment, the Italian version of the SF-36 test was administrated. Spine and hip BMD rose by 6.6 +/- 3 and 4.2 +/- 2.3%, respectively (p < 0.05), after 12 months of neridronate treatment. Markers of skeletal turnover significantly fell already after 3 months of neridronate treatment and decreased progressively thereafter within 12 months. The mean decrease at 12 months ranged from 38 +/- 11% for sCTX to 25.2 +/- 15% for ufDPD (p < 0.001, all). The mean improvement in QoL in the treated group was 45.7% for bodily pain, 37.5% for general health perception, 23.1% for vitality, 18% for emotional role functioning and 12% for physical role functioning. The changes observed in BMD, turnover markers and QoL in the untreated group were ns. The intermittent neridronate administration was easily manageable and well tolerated. In conclusion, neridronate currently represents a valid option for the treatment of osteoporosis, since it helps just as much as oral BPs in the improvement of BMD and in particular conditions it can be even more effective.

Serum leptin levels and uterine Doppler flow velocimetry at 20 weeks' gestation as markers for the development of pre-eclampsia

Altered Doppler flow velocimetry of the uterine arteries during the second trimester is correlated with the risk of developing pre-eclampsia. Serum levels of leptin, a protein regulating body weight and secreted by the placenta, are higher in women with severe pre-eclampsia. We investigated whether alterations of uterine arteries' Doppler flow velocimetry during the early second-trimester scan were accompanied by changes in leptin levels, and whether these changes might be an early risk factor for pre-eclampsia. We retrospectively selected 50 women with altered uterine artery velocimetry at the second-trimester scan who subsequently developed pre-eclampsia (group A) and 100 women who did not develop pre-eclampsia, divided into two groups: 50 women with normal velocimetry at the second-trimester scan (group B) and 50 women with altered velocimetry at the second-trimester scan (group C). Serum leptin levels during the second and third trimesters and bilateral uterine artery resistance index during the second trimester were evaluated. No differences were observed in serum leptin levels in the second trimester among the three groups. During the third trimester, women in group A showed significantly higher serum leptin levels in comparison with women in groups B and C (p < 0.01). Serum leptin levels do not seem to be a useful early marker for the development of pre-eclampsia in the presence of altered uterine blood flow, and may be a late compensatory mechanism or reflect a generalized response of the trophoblast to hypoxic stimuli.

Prenatal diagnosis of hemifacial microsomia and ipsilateral cerebellar hypoplasia in a fetus with oculoauriculovertebral spectrum

Oculoauriculovertebral spectrum, or Goldenhar syndrome, is characterized by varying degrees of prevalently unilateral underdevelopment of craniofacial structures (orbit, ear, mandible) and spinal anomalies. We report the prenatal ultrasonographic diagnosis made at 24 weeks' gestation in a family with a negative history. The prenatal diagnosis was suspected due to the presence of marked hemifacial microsomia and moderate ipsilateral cerebellar hemisphere hypoplasia in the absence of facial clefting.

Nucleophilic Cyclopropane Ring Opening in Duocarmycin SA Derivatives by Methanol under Acid Conditions: A Quantum Mechanical Study in the Gas-Phase and in Solution

We present a quantum-mechanical study of the S(N)2 acid-catalyzed solvolysis with methanol of seven simplified duocarmycin SA (DNA alkylating agent) derivatives characterized by spirocyclic systems of increasing complexity, all containing the cyclopropyl/cyclohexadienone substrate. The reaction has been studied at the DFT-PBE0/6-31G(d) level in the gas phase and in methanol solution, using in the latter case the polarizable continuum model (PCM) to describe solvent effects. The results delivered by this computational protocol are in full agreement with the available experimental evidences and are not modified by extension of the basis set or by using a second-order many-body treatment (MP2) in place of DFT. This allows investigation of substituent effects in terms of structure/reactivity relationships and evaluation of the role of stereoelectronic effects. Furthermore, reactivity indices (hardness, electrophilicity) have been computed and shown to correlate well with activation energies. Together with their intrinsic interest, the details of the mechanism of the acid-catalyzed nucleophilic addition to the activated cyclopropane issuing from the present study pave the route for a deeper understanding of the molecular basis for the remarkable profile of the DNA-alkylation by DSA derivatives.

Molecular mechanisms involved in GnRH analogue-related apoptosis for uterine leiomyomas

GnRH agonist therapy is known to reduce uterine leiomyoma volume, although the molecular mechanisms responsible for this effect remain poorly understood. In this study, we have investigated the molecular mechanisms involved in the anti-proliferative effect of a GnRH agonist, leuprolide acetate (LA), in uterine leiomyomas obtained from six patients treated with LA for 3 months before surgery (group B), compared with tumours from six untreated patients (group A). To this end, we have evaluated the expression and the activity of molecules involved in the regulation of cell survival and proliferation. In group B, the total activity of PI3K was reduced by 60% compared with control samples. Furthermore, LA caused a reduction of PKB activation of approximately 50%, measured as serine 473 phosphorylation. In parallel with PKB reduction in LA samples, we observed a 60% reduction in the phosphorylation of its substrate BAD. While Bcl-xL/BAD association was not significantly modified in LA-treated leiomyomas, BAD/14.3.3 interaction was reduced, due to a 50% decreased 14.3.3 expression. In addition, LA was able to reduce the expression of the antiapoptotic proteins FLIP and PED/PEA15 by 70 and 50% respectively, compared with control samples. We next evaluated the activation of MAP kinases in leiomyomas. Activation of p42 and p44 MAP kinase isoforms was increased by 30% in group B. However, the phosphorylation of the transcription factor Elk1 was not increased in a similar fashion in LA-treated leiomyomas compared with group A. Thus, these data suggest that LA reduction of leiomyoma volume is mediated at least in part by a decreased activation of the PI3K/PKB survival pathway and by the suppression of antiapoptotic factors.

Beneficial treatment with risedronate in long-term survivors after allogeneic stem cell transplantation for hematological malignancies

In this prospective randomized study we evaluated the effect of risedronate, an aminobisphosphonate, on bone mass and turnover in patients who had undergone allogeneic stem cell transplant (SCT) for hematological malignancies. Thirty-four patients (18 females, 16 males, age 32+/-10 years) with bone mineral density (BMD) </=-1.5 SD as a T-score at least 6 months after SCT were treated with calcium 1 g/day and vitamin D 800 IU/day and randomized to receive ( n=17, group 1) or not receive ( n=17, group 2) oral risedronate 5 mg/day. The duration of treatment was 12 months. After 6 months, lumbar BMD increased by 4.4+/-1.6% in patients of group 1 and decreased by 4.3+/-1.5% in those of group 2 ( P<0.05); at the femoral neck, BMD did not change significantly in patients of group 1 (+1.2+/-1.2%), while it decreased in those of group 2 (-4.3+/-2.1%; P<0.05). After 12 months, lumbar BMD further increased (+5.9+/-1.7%, P<0.05), compared to baseline in group 1 and slightly increased (+1.1+/-1.4%) in group 2. No further changes were observed at femoral neck in both groups. In conclusion, treatment with risedronate for 12 months increased BMD significantly at the lumbar spine and prevented further bone loss at the femoral neck in long-term survivors after allo-SCT.

Effectiveness and mechanism of action of desmopressin in the treatment of copper intrauterine device-related menorrhagia: a pilot study

BACKGROUND

Desmopressin, a synthetic analogue of the natural hormone vasopressin, stimulates endogenous haemostasis and exerts a powerful myometrial and vasoconstrictor action in a variety of pharmacological preparations. Both mechanisms of action may have therapeutic value for the treatment of intrauterine device (IUD)-related menorrhagia, which is believed to be caused not only by altered local haemostasis but also-according to a new hypothesis-by decreased vascular uterine resistance. The aim of this prospective study was to evaluate the effect of vasopressin drug on menstrual blood loss and on changes, if any, in uterine flow impedance. Mefenamic acid, which is commonly used to treat IUD-related menorrhagia, was administered as a comparison.

METHODS

Twenty-four women with IUD-induced menorrhagia were recruited and randomly allocated to treatment with either desmopressin or mefenamic acid. Menstrual blood loss (measured by pictorial blood loss assessment chart) and uterine artery resistance (measured with transvaginal colour Doppler) performed in two pretreatment periods were compared with 3-month treatment periods.

RESULTS

Menstrual blood loss was significantly reduced in both treatment groups. In the desmopressin group, the effect was clinically useful in all subjects, but in the mefenamic group menstrual blood loss was consistently menorrhagic in two patients. No significant differences were observed in the uterine artery pulsatility index before and during treatment.

CONCLUSIONS

Desmopressin may be a useful therapeutic tool for many women with IUD-related menorrhagia. Its mechanism of action lies in an ability to enhance local haemostasis, without affecting uterine blood flow.

Vanadate regulates the insulin mitogenic effect by modulating SHP-2 association with insulin receptor substrate 1 in JAr human choriocarcinoma cells

Maternal hyperglycemia alters placental glucose metabolism and induces placental hypercellularity. In this study we investigated, in JAr cells, the effect of a protein tyrosine phosphatase inhibitor, vanadate, on the insulin receptor substrate 1 (IRS1)-mitogen-activated protein kinase (MAPK) pathway and on cell proliferation in the presence of normal or high glucose concentration. When JAr cells were cultured in the presence of 25 mmol/l glucose, treatment with vanadate completely prevented SHP-2 association with IRS1. However, vanadate treatment reverted the effect of high glucose on basal and insulin-stimulated insulin receptor and IRS1 phosphorylation. Similar effects were observed on MAPK activation. These events determined a related modification in cell proliferation. Indeed, after high glucose and vanadate treatment, thymidine incorporation levels were comparable to those observed in the presence of normal glucose concentration and in the absence of vanadate. Therefore, in JAr cells, vanadate exerts an inhibitory effect on cell proliferation. This action is related to a modulation of the SHP-2 association with IRS1 that in turn might regulate the phosphorylation state of the main substrates involved in mitogenesic signaling of the insulin receptor.