Influence of delayed diagnosis on established prognostic factors in endometrial cancer

To evaluate the influence of delayed diagnosis on prognostic factors in endometrial cancer, we conducted a retrospective chart analysis based on the data of 116 postmenopausal patients with FIGO stage I-IV endometrial carcinoma. The interval from the first episode of post-menopausal vaginal bleeding to definitive, histological diagnosis (bleeding interval) was compared with tumor stage and various histomorphologic features in endometrial cancer. The mean bleeding interval was 12.7 +/- 17.8 weeks in 74 patients with FIGO stage IA, IB endometrial carcinoma and 35.2 +/- 69.3 weeks in 42 patients with stage IC-IV disease (t-test, p: 0.011). FIGO stage IA, IB disease was diagnosed in 23/26 (88%) patients with a bleeding interval <4 weeks, and in 22/34 (64%) and 29/56 (51%) patients with bleeding intervals of 4-8 weeks and >8 weeks, respectively (Chi-square 10.358, p=0.006). The correlation with histologic grade, lymph-node status, vessel invasion and histologic subtypes did not reach statistical significance. Our data confirm the clinical impression that postmenopausal vaginal bleeding is an early symptom in patients with endometrial cancer, and that advanced disease in the majority of cases might come from delayed diagnosis in women with poor compliance.

Hormonal, syndromal and EEG mapping studies in menopausal syndrome patients with and without depression as compared with controls

The aim of the study was to investigate brain function in menopausal depression by EEG mapping, as compared with menopausal syndrome patients without depression and normal controls, and to correlate neurophysiological with clinical and hormonal findings in order to elucidate the pathogenesis of depression in the menopause.

METHODS

One hundred and twenty-nine menopausal women, aged 45-60 years, with no previous hormonal replacement therapy were investigated in regard to hormones (estradiol [E2], follicle stimulating hormone [FSH]), clinical symptomatology (Kupperman Index [KI], Hamilton depression score [HAMD]) and brain function (EEG mapping). Based on KI and DSM-III-R research criteria for major depression, 3 groups were available for statistics (after removal of protocol violators): group A had a KI of <15 and no depression (n = 29); group B had a KI of > or = 15 and no depression (n = 29) and group C had a KI of > or = 15 and fulfilled the criteria for major depression (n = 60).

RESULTS

EEG maps of depressed patients demonstrated less total power and absolute power in the delta, theta and beta band, more relative delta and less alpha power as well as a slower delta/theta and faster alpha and beta centroid than controls, suggesting a vigilance decrement. Group B did not differ from group A. Correlation maps showed significant relationships between estradiol levels and EEG measures (the lower the E2, the worse the vigilance) and between the EEG measures and the Hamilton depression (HAMD) score (the worse the vigilance, the higher the depression score). There were no correlations between the hormones E2 and FSH and the syndromes KI and HAMD. In the target variable, the asymmetry index, depressed patients showed less alpha power over the right than left frontal lobe, whereas normal controls exhibited the opposite. Group B did not differ from group A. The frontal asymmetry index was significantly correlated with the Hamilton depression score and suggests right frontal hyper- and left frontal hypoactivation in depression.

CONCLUSIONS

Although hormonal findings are not directly linked to psychic changes, low estradiol levels do contribute to a decreased vigilance at the neurophysiological level , which is in turn correlated with higher depressive and menopausal symptomatology at the behavioural level. Depression is further correlated to a right frontal hyper- and left frontal hypoactivation.

-CA-125 antigen as a prognostic factor for survival in patients with epithelial ovarian carcinoma of FIGO stage I--preliminary results-

The tumour marker CA 125 has proved useful in monitoring the course of disease and in indicating responsiveness to therapy in patients suffering from epithelial ovarian cancer. Due to its poor sensitivity, however, attempts to improve early detection by screening with this tumour marker have been unsuccessful to date. This study was performed to evaluate whether there was a relation between pre-operative CA 125 levels and the survival of patients with epithelial ovarian cancer FIGO stage I. If such a relation exists, CA 125 may be an effective variable in singling out those subsets of patients with stage I disease for whom adjuvant chemotherapy would bring an additional therapeutic benefit. Our results suggest CA 125 may be a significant prognostic factor. With a 5-year survival of 43%, marker-positive ovarian cancer carries a poor prognosis. Since the question as the whether follow-up treatment is required in this early, potentially curable stage of disease, is contingent upon numerous factors and since an individualised therapeutic regimen may lead to increased survival rates, the prognostic influence of CA 125 and its relationship to other prognostic factors should be evaluated by multivariate analysis.

Effects of cisplatin on urinary thromboxane B2 excretion

PURPOSE

Thromboxane A2 (TxA2) is implicated in the pathogenesis of various forms of drug-induced renal damage. Based on previous functional studies, we postulated that cis-dichlorodiammineplatinum (cisplatin) induces intrarenal TxA2 synthesis. To test this hypothesis, we measured urinary excretion of thromboxane B2 (TxB2), the stable inactive metabolite of TxA2, during and after cisplatin administration.

PATIENTS AND METHODS

The study included 16 patients with malignant disease who were scheduled to receive cisplatin (100 mg/m2) and 11 healthy subjects who received the same amount of fluid loading and the same concomitant medication as the patients but no cisplatin. Total urine output was collected in seven intervals from 24 hours before until 72 hours after the start of prehydration. Urinary immunoreactive TxB2 was measured.

RESULTS

There was a marked increase (4.5 +/- 1.6-fold; mean +/- SEM) in urinary TxB2 excretion in patients during and immediately after cisplatin infusion. This increase was significant compared with baseline and the control group.

CONCLUSION

High-dose cisplatin causes an acute increase in urinary excretion of TxB2. This likely represents enhanced intrarenal synthesis of TxA2, in response to an acute damaging effect of cisplatin on the kidneys. These findings warrant further studies to evaluate the renoprotective effect of anti-TxA2 intervention in patients receiving high-dose cisplatin.

[Difficulties in becoming a woman and staying a woman. On the problems of female identity in menopause]

With a very few exceptions, the sparse psychoanalytic literature on menopause has regarded it almost exclusively as a kind of ailment, a process of decay and loss. By contrast, recent feminist discourse has demonstratively set itself apart from Freud's theory of femininity and emphasized the opportunities that the menopause brings, albeit at the expense of female sexual desire. Hettlage-Varjas and Kurz suggest that critical review of Freud's theories and more recent concepts of femininity can be integrated into psychoanalytical theory on the psychology of conflict and instinctual drives. They thus avoid the equally dangerous temptations either of classifying the female climateric as pathological or else denying the anxieties and sense of loss that involves and declaring it a conflict-free zone.

The influence of obesity on the disease-free survival in primary breast cancer

Hyper-estrogenism is more common in obese than in non-obese women. Consequently obesity has been shown to increase the risk of hormone department tumors. Some investigators have claimed that obesity at the time of primary treatment may be an independent prognostic factor for breast cancer, but this issue is still controversial. Therefore, we conducted a retrospective analysis to assess the influence of obesity at the time of primary treatment on disease-free survival (DFS). Obesity was defined as an excess of more than 25% of ideal weight according to Broca's index ([Height (cm) -100])-10%). The Cox-model was used for multivariate analysis. Mean follow-up was 61 (range 6-126) months. 295 (62.3%) patients were classified as of normal weight and 178 (37.6%) as obese. Mean excess of ideal weight was 8.9 kilograms (kg) in premenopausal and 13.9 kg in postmenopausal patients (non-parametric t-test p < 0.00001). Patients with tumor size < 20mm, 20-50mm and > 50mm had a means excess of the real weight of 10.6kg, 12.5kg and 16.1kg, respectively (non-parametric t-test p < 0.0001). Percentual excess of real weight compared to ideal weight was 22.4 [+/-21.2] kg in patients without recurrence and 21.5 [+/-21.9] in patients with recurrent disease (nonparametric t-test p = 0.7256). Univariate analysis revealed no significant association between obesity and the DFS. Multivariate analysis identified axillary lymph node involvement as the only statistically significant prognostic factor for disease-free survival (RR 1.55; 95%-confidence interval 1.02-2.36; p:0.0368). Because of the high correlations and node-status, tumor size and histological grading, the other factors failed to be prognostically relevant in this analysis. Obesity was not found to influence DFS of patients with primary breast cancer and is therefore unlikely to constitute an independent prognostic factor. It may, however, contribute to delayed diagnosis, since a significant proportion of obese patients were diagnosed with local advanced disease.

[Initial experiences with ambulatory irrigation hysteroscopy]

During one year, 120 patients were referred for outpatient diagnostic hysteroscopy. The most common indications were abnormal uterine bleeding (67%), followed by sterility and infertility, respectively (18%). The uterine cavity was visualised in 103 patients, and about half of the patients (50.5%) had demonstrable uterine pathology. 75 patients (72.8%) did not experience any pain during or after the examination and 28 women (27.2%) reported varying levels of pain. In 17 cases (14%) passage through the internal cervical os was either not possible for anatomical reasons or was not tolerated by the patients. However, diagnostic hysteroscopy, combined with directed biopsy where appropriate, is now considered the method of choice for identifying intrauterine pathology. Performed in an outpatient setting, diagnostic hysteroscopy using a fluid distention medium is largely pain-free and hardly accompanied by side effects, provided patients are thoroughly counseled beforehand. Essential preliminaries for a successful examination are careful patient selection, a clear clinical indication and, above all, the skilled coordination between eye and hand. More widespread use of diagnostic hysteroscopy may spare numerous women the stress of curettage while at the same time facilitating optimal selection of those cases really requiring further medical examination or therapy.

Microvessel density and vessel invasion in lymph-node-negative breast cancer: effect on recurrence-free survival

Microvessel density (MVD) and blood and lymphatic vessel invasion (BLVI) were investigated with regard to their influence on the disease-free survival (DFS) in node-negative breast cancer patients. Paraffin embedded microsections of 230 patients with T1,2 N0 breast cancer were immunohistochemically stained for factor VIII-related antigen. Every cluster consisting of more than highlighted endothelial cells was considered a countable microvessel. MVD was counted in 4 fields of 0.25 mm2 each. All MVD values are given as value for the sum of 4 fields of 0.25 mm2 each, that is, I mm2. BLVI was considered positive, when at least one tumor cell could be identified in a stained lumen. Out of 230 patients, 49 experienced local or distant recurrence and had a mean MVD of 72.4/mm2, whereas 181 patients who lived without recurrent disease had a mean MVD of 45.3/mm2. BLVI was negative in 6.2% of the cases with and in 93.8% of the cases without recurrent disease. BLVI was positive in 59.4% of the cases without and 40.6% of the cases with recurrent disease. MVD and BLVI remained the only significant prognostic factors of DFS in the Cox-Model. Tumor size, histological grade, and hormonal-receptor status were not prognostically relevant in the Cox-model. 10-year-DFS was 93.3% in BLVI-negative/MVD < or = 40/mm2 patients, 88.1% when MVD was high or BLVI was positive and 48.9% in BLVI positive/MVD < or = 40/mm2 patients. Our present data indicate that MVD and BLVI identify a very-low risk group among node-negative breast cancer patients, who will not benefit from systemic adjuvant therapy. MVD and BLVI should be used as stratification criteria in clinical trails on node-negative breast cancer patients.

[Topical administration of oxybutynin hydrochloride in women with urge incontinence. Results of a prospective randomized double-blind study]

Detrusor instability is the second most common cause of femal urinary incontinence. Oxybutynin chloride anticholinergic action with direct muscle-relaxant properties. 39 women with persistent-urgeincontinence participated in a pilot study of intravesical oxybutynin application. Patients received either 20 mg oxybutynin or placebo as 40 ml sterile sodium chloride solution administered intravesically over a period of 10 days. Urodynamic assessment as well as micturition protocols were performed before and after treatment. The intravesical oxybutynin-application was significantly better than the placebo application concerning reduction of pollakisuria and nycturia. Oxybutynin also increased bladder capacity more than in the placebo-treated group (p < 0.01) and provided an improvement of bladder compliance (p < 0.05). No local or systemic side effects were observed which would have immediately terminated the oxybutynin treatment.

Gemeprost for first trimester missed abortion

In 87 patients with a missed abortion prior to 13 weeks, the application of a prostaglandin (PG) E1 derivative (1 mg gemeprost, Cergem) was compared to conventional surgical termination of pregnancy by cervical dilatation and curettage. In 33 patients with PGE1 application, complete expulsion of the abnormal pregnancy occurred after an average of 2.8 +/- 1.5 vaginal suppositories. PGE1 treatment was effective in 76.7%, and surgical management was effective in 90.9% of patients. Sixty percent of the patients in the PGE1 group required analgesia because of uterine pain in comparison to 4.5% in the surgical group. The possibility of medical termination with synthetic PG derivatives should be further investigated.

The role of prolactin in the menopause

Within a study on menopausal discomforts, 2322 women were seen for the first time at the Outpatients Department for Climacteric Disturbances and Prophylaxis of Osteoporosis at our clinic. Amongst routine hormonal examination we measured prolactin levels. We found hyperprolactinemia in 23 women. Furthermore, in 224 women who initially had normal hPRL values, an estrogen-gestagen replacement therapy was administered and within this we found a significant increase of the prolactin levels (P < 0.005). The role of prolactin in the climacteric period as well as the mechanism of the estrogen effect upon prolactin secretion are subjects of discussion.

[Tumor vascular invasion in breast carcinoma. Hematoxylin-eosin versus immunohistochemical staining for factor VIII antigen]

Blood vessel invasion was investigated with haematoxylin-eosin (HE) staining and immunohistochemical staining for factor VIII antigen (F VIII) in 106 patients with primary carcinoma of the breast, in order to compare their value in prognosticating the probability of recurrence. Blood vessel invasion was diagnosed in 65 cases (61.9%) by HE, but in only 45 (43.4%) by F VIII staining. Lymph-node status and blood vessel invasion correlated positively on HE (r = 0.73; P = 0.0001), but not so on F VIII staining. Multivariate logistic regression showed blood vessel invasion to be a strongly independent prognostic factor for recurrence-free survival with F VIII staining (odds ratio: = 7.19; P = 0.0001), while HE staining was not independent from other prognostic factors. These preliminary data thus suggest that demonstrating vascular invasion by F VIII staining may identify those patients with a very high risk of recurrence, independent of lymph-node status.

Pregnancy and spontaneous delivery 13 months after heart transplantation

This case report is about a 23-year-old female patient who underwent heart transplantation because of dilatative cardiomyopathy. Four months after transplantation she conceived. Thirteen months postoperatively, the patient had spontaneous vaginal delivery and gave birth to a child in good physical condition.

[Tumoral vascular density in breast tumors and their effect on recurrence-free survival]

Angiogenesis quantitation of 106 patients with primary breast cancer and 35 patients with adenofibroma of the breast was compared and examined to its prognostic relevance for five-years disease-free survival in breast cancer patients. Immunocytochemical staining for Factor VIII-related antigen was performed to outline vascular endothelium. We found a significant higher vessel density in breast cancer patients who experienced recurrence (17.4) than in those with no recurrence (9.4) or with adenofibroma (8.7) [p < 0.0001]. The probability of five-years recurrence-free survival for patients with a primary tumor of high vessel density was at 52.3% and 86.4% for tumors of low microvessel density (p < 0.0011). Microvessel density proved to be an independent prognostic factor for breast cancer recurrence in the Cox-Model (relative risk 2.047, p = 0.0002).

[The value of the "vascular invasion" factor for prognosis of breast cancer]

The histological sections of 106 patients, who underwent a primary breast cancer operation in the years 1986 and 1987, were inspected for the presence of tumour vascular invasion. With immunohistochemical methods, tumour vessels were tomographed and the paraffin sections were stained with an antibody, which is sensitive to factor VIII-antigen. A tumour embolus was considered present, if a malignant cell was established within a positively stained lumen. The question of possible influence on the pathogenesis of breast cancer was examined in case of vascular invasion in the histological preparation. In 46 of the 106 patients (43.4%), tumour emboli were found. After an average observation period of 59 months, no tumour progression was seen in 60 patients, 46 patients developed a recurrence of the tumour at the check-up date. The presence of vascular invasion correlates with undifferentiated tumour grading. The probability of relapse- free survival after 5 years was 83.9% within the group without vascular invasion, compared with 47.9% (p = 0.0001) within the group with established vascular invasion. In the multivariate analysis of the factors lymphonodular status, grading and vascular invasion, it was found, that the presence of tumour vascular invasion with a relative risk of 3.68 (95% CI 1.93-7.03) was the strongest statistically significant prognostic factor for relapse-free survival (p = 0.0001).

[Abdominal hysterectomy without internal peritonealization: primary vaginal closure with stapler or open and drained vagina]

The purpose of this study was to compare the postoperative course in 127 patients undergoing abdominal hysterectomy without closure of the visceral peritoneum, who were assigned to either staple closure of the vaginal cuff or drain use. In 31 patients, the vaginal cuff was closed with absorbable staples, and in the 96 patients of the control group, vaginal drain was used. Both, the rate of postoperative complications requiring antibiotic treatment and febrile morbidity were significantly lower in the staple group. This may be attributable to the fact that primary closure of the vaginal cuff prevents bacterial contamination of the peritoneal cavity. In the drain group, two patients had to undergo laparotomy immediately postoperatively due to ileus. Because of pelvic discomfort as a late complication, one patient had to undergo pelvic reexploration, and the other patient laparoscopy-assisted adhesiolysis. It is interesting to note, that, at the time of second-look intervention, adhesion in the region of the peritoneal defect was seen in only one of these 4 patients. In the staple group, both, the surgical procedure and anaesthesia time were shorter than in the drain group; the postoperative course was comparatively uneventful, and the period of hospitalisation was reduced. Thus, we conclude, that there is a clear advantage of the use of staples over drainage for vaginal cuff treatment in abdominal hysterectomy without closure of the visceral peritoneum.

[Topical use of oxybutynin hydrochloride in women with urge incontinence]

In 36 women with cystometric evidence of bladder instability we investigated the efficacy of intravesical instillation of oxybutynin. The intravesical application of oxybutynin had a significant effect regarding the reduction of pollakiuria and nocturia and an improvement of bladder capacity. No local or systemic side effects were noted.

[L-carnitine-betamethasone combination therapy versus betamethasone therapy alone in prevention of respiratory distress syndrome]

In this prospective randomised study the effects of antenatal treatment with a low dose betamethasone (2 mg/1 day)-L-carnitine (4 g/5 days) combination were compared with those of a high dose betamethasone, given alone (8 mg/2 days) on the prevention of respiratory distress syndrome (RDS) and mortality in preterm infants. One-hundred women entering the trial gave birth to 109 liveborn infants, 55 in the betamethasone group (A), 54 in the betamethasone-L-carnitine combination group (B). Eight of the 55 (14.5%) infants in group A developed RDS, four of the 54 (7.3%) in group B, which was significantly more (p < 0.05), although in group B the betamethasone dose was dramatically reduced. The mortality also was significantly lower after treatment with a betamethasone-L-carnitine combination compared to betamethasone alone (4 of 55 infants or 7.3% in group A versus 1 of 54 infants or 1.8% in group B, p < 0.05). The present results demonstrate that in combination with L-carnitine, the betamethasone dose is markedly reducible with a concomitant significant reduction of the incidence of RDS and mortality of premature newborns.

[Intravesical administration of estriol in sensory urge incontinence--a prospective study]

Local intravaginal application of oestriol is part of the therapeutical programme of sensory urge-incontinence. The effectiveness of a new method--intravesical administration of 1 mg oestriol versus a placebo--has been proved in a prospective randomised study. 21 patients each were treated over a period of three weeks with oestriol or with the placebo-substance intravesically. The effectiveness of the administered therapy was checked with clinical and urodynamic parameters. The intravesical administration of 1 mg oestriol proved to be efficient and free of side effects in respect of the parameters such as imperative micturition, bladder capacity, of the maximum urethral closure pressure as well as the number of micturitions per diem. The intravesical administration of oestriol may be considered as additional method of therapy for treatment of sensory urge-incontinence.

[Surgical treatment of recurrent stress incontinence: Burch versus lyodura sling operation--a prospective study]

This prospective randomised study involved 52 female patients suffering from recurrent stress urinary incontinence, objectively confirmed by means of clinical incontinence tests and urodynamic examinations. They alternatively underwent colposuspension according to Burch or suburethral sling procedure surgery. Urodynamic and sonographic examinations were carried out before and 2.5 years (i.e. within a range of 2-3) after surgery according to Burch or suburethral sling procedure. There was no significant difference between the two methods with respect to subjective and objective rate of cure, which amounted to 85% of the cases involving colposuspension and 88% of cases involving the suburethral sling procedure. Both methods resulted in a significant improvement of the depression quotient and a significant elevation of the internal urethral meatus (p < 0.05). Apart from an aggravation of urge symptoms in both groups, the patients with surgery according to Burch tended towards enterocele and rectocele in the medium range, whereas urination disorders had to be accepted in the patients operated on according to the sling procedure in the long term.

Prognostic factors related to recurrent endometrial carcinoma following initial surgery

Site of recurrence and histological type are significant prognostic factors for survival in recurrent endometrial carcinoma. The aim of this retrospective analysis of 56 patients suffering from recurrences of endometrial carcinoma following initial surgery was to establish the prognostic relevance that the following factors had on the survival rate: age, primary tumor stage, histological assessment (papillary vs non-papillary), postoperative adjuvant radiation therapy, recurrence free interval (< 24 months, > 24 months) and localisation of recurrence. The univariate analysis showed a significantly longer median survival time after recurrence for the following parameters: local recurrence vs extra vaginal recurrence (77.5 months vs 15.7 months, p = 0.02), non-papillary vs papillary carcinoma (36.1 months vs 7.7 months, p = 0.02), no adjuvant irradiation vs adjuvant irradiation (82.0 months vs 8.8 months, p = 0.007). Patients after adjuvant radiation treatment and patients suffering from papillary carcinomas have a significantly higher proportion of patients with distant metastasis (patients with adjuvant radiation treatment: Chi-square test: p = 0.001; patients suffering from papillary carcinomas: p = 0.033). In the case of local recurrences, a three year survival rate of 54% can be achieved with radiation treatment. Recurrences of papillary endometrial carcinomas and patients suffering from distant metastasis on the other hand, show very low survival rates if they are treated with radiation therapy (papillary carcinomas: three-year survival rate of 18%, patients suffering from distant metastasis: 19%). These patients should be included in randomised studies with a view to examining the therapeutic effects of either additional or exclusive treatment with chemotherapy.