Recurrence during pregnancy of a conservatively treated early-stage cervical squamous cell carcinoma

OBJECTIVE

To evaluate the safety of conservative management of early cervical cancer.

DESIGN

Case report and analysis of literature guidelines.

SETTING

Academic teaching hospital.

PATIENT(S)

A 35-year-old, nulliparous woman treated by simple trachelectomy and pelvic lymphadenectomy for a well-differentiated, 12-mm squamous cell carcinoma infiltrating to a depth of 3 mm (stage Ib1) without lymphovascular space involvement.

INTERVENTION(S)

Follow-up.

MAIN OUTCOME MEASURES(S)

Recurrence and disease evolution.

RESULT(S)

Sixteen months after surgery, at 32 weeks' gestation, a local recurrence of 5 cm in diameter was diagnosed, associated with pelvic and interaortocaval lymph node involvement. Despite extensive radiotherapy, chemotherapy, and radical surgery, disease progression could not be halted.

CONCLUSION(S)

We report a case of early-stage cervical cancer, conservatively treated by simple trachelectomy and lymphadenectomy, that recurred although none of the known risk factors for recurrence were initially present, and despite the fact that literature guidelines were followed.

Immunohistochemical localization of growth factors after cryopreservation and 3 weeks' xenotransplantation of human ovarian tissue

OBJECTIVE

To compare early follicular growth after fresh and frozen-thawed human ovarian tissue xenografting and to investigate whether expression of c-kit, kit ligand (KL), and growth differentiation factor-9 (GDF-9) is maintained after freezing and xenografting of human ovarian tissue.

DESIGN

Prospective experimental study.

SETTING

Gynecology research unit in a university hospital.

ANIMAL(S)

Ten nude (Swiss nu/nu) 6-week-old female mice.

INTERVENTION(S)

The ovarian biopsy samples were obtained from six women, aged 20 to 30 years. Fresh and frozen-thawed ovarian fragments intraperitoneally grafted into nude mice for 3 weeks.

MAIN OUTCOME MEASURE(S)

Histologic analysis and immunohistochemical evaluation of c-kit, KL, and GDF-9 expression before and after grafting.

RESULT(S)

The integrity and proportion of growing follicles increased similarly in both fresh (64%) and frozen-thawed (59%) xenografts compared with non-grafted tissue (fresh: 40%; frozen-thawed: 21%). Both C-kit and KL staining were detected in the oocytes and granulosa cells of preantral follicles, and GDF-9 expression was observed in the oocytes of preantral follicles in all groups.

CONCLUSION(S)

Freezing does not appear to have a major impact on early follicular growth after transplantation. This study shows, for the first time, expression of c-kit, KL, and GDF-9 in human preantral follicles after ovarian tissue cryopreservation and xenotransplantation.

Current achievements and future research directions in ovarian tissue culture, in vitro follicle development and transplantation: implications for fertility preservation

BACKGROUND Female cancer patients are offered 'banking' of gametes before starting fertility-threatening cancer therapy. Transplants of fresh and frozen ovarian tissue between healthy fertile and infertile women have demonstrated the utility of the tissue banked for restoration of endocrine and fertility function. Additional methods, like follicle culture and isolated follicle transplantation, are in development. METHODS Specialist reproductive medicine scientists and clinicians with complementary expertise in ovarian tissue culture and transplantation presented relevant published literature in their field of expertise and also unpublished promising data for discussion. As the major aims were to identify the current gaps prohibiting advancement, to share technical experience and to orient new research, contributors were allowed to provide their opinioned expert views on future research. RESULTS Normal healthy children have been born in cancer survivors after orthotopic transplantation of their cryopreserved ovarian tissue. Longevity of the graft might be optimized by using new vitrification techniques and by promoting rapid revascularization of the graft. For the in vitro culture of follicles, a successive battery of culture methods including the use of defined media, growth factors and three-dimensional extracellular matrix support might overcome growth arrest of the follicles. Molecular methods and immunoassay can evaluate stage of maturation and guide adequate differentiation. Large animals, including non-human primates, are essential working models. CONCLUSIONS Experiments on ovarian tissue from non-human primate models and from consenting fertile and infertile patients benefit from a multidisciplinary approach. The new discipline of oncofertility requires professionalization, multidisciplinarity and mobilization of funding for basic and translational research.

Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules

BACKGROUND

The debate continues between advocates of the shaving technique and supporters of bowel resection in case of deep endometriosis with rectal muscularis involvement, despite little evidence for better improvement with bowel resection.

METHODS

We analyzed complication, pregnancy and recurrence rates after deep endometriotic nodule excision by shaving surgery. This is a prospective analysis of 500 cases (<40 years old) of deep endometriotic nodules.

RESULTS

Laparoscopic nodule resection was performed successfully in all cases. Major complications included: (i) rectal perforation in seven cases (1.4%); (ii) ureteral injury in four cases (0.8%); (iii) blood loss >300 ml in one case (0.2%); and (iv) urinary retention in four cases (0.8%). The median follow-up duration was 3.1 years (range 2-6 years). In our prospective series of 500 women, 388 wished to conceive. Of this number, 221 (57%) became pregnant naturally and 107 by means of IVF. In total, 328 women (84%) conceived. The recurrence rate was 8% among these 500 women, and it was significantly lower (P < 0.05) in women who became pregnant (3.6%) than in those who did not (15%). In women who failed to conceive, or were not interested in conceiving, severe pelvic pain recurred in 16-20% of patients.

CONCLUSION

In young women, conservative surgery using the shaving technique preserves organs, nerves and the vascular blood supply, yielding a high pregnancy rate and low complication and recurrence rates. There is a need, however, for further strong and energetic debate to weigh up the benefits of shaving (debulking surgery) versus rectal resection (radical surgery).

Xenotransplantation of human ovarian tissue to nude mice: comparison between four grafting sites

BACKGROUND

This study was designed to assess the impact of different ovarian tissue transplantation sites on the follicular pool and ovarian tissue integrity after short-term grafting, since there is no consensus in the literature as to the optimal grafting site in experimental models.

METHODS

Frozen-thawed ovarian tissue from eight patients was grafted for 1 or 3 weeks to the peritoneum, inside the ovarian bursa, under the skin and into the muscle of 16 nude mice. Assessment of follicular density and follicle classification was carried out by histological analysis. Proliferative activity was evidenced by immunostaining with anti-Ki-67 antibodies, and fibrotic areas were analyzed by morphometry on histological slides.

RESULTS

One week post-transplantation, the proportion of Ki-67-positive primordial follicles was higher (20-42%) than in controls (1.7%), demonstrating follicular activation in all four sites. Despite this activation, primordial follicles were still found 3 weeks post-grafting, (34.1-66.9% of the follicle population), most of them quiescent, as indicated by the absence of Ki-67 immunostaining. Cryopreservation and grafting resulted in extensive fibrosis in the stroma. This fibrosis was significantly less pronounced in intramuscular (IM) grafts, representing 18.8% of the surface versus 44.7-60.5% for other sites, after 3 weeks of grafting.

CONCLUSIONS

All four grafting sites equally supported early follicular growth and preserved some quiescent follicles after short-term frozen-thawed human ovarian tissue transplantation. The extensive fibrosis observed does not appear to have a major impact on early follicle development, but its long-term effects must be investigated. The graft environment may be implicated in the preservation of the stroma, as suggested by a lower degree of fibrosis in the IM site.

Fertility preservation in girls during childhood: is it feasible, efficient and safe and to whom should it be proposed?

BACKGROUND

In prepubertal and adolescent girls, fertility may be impaired by gonadotoxic treatments, repeat ovarian surgery or genetic disorders. Cryopreservation of ovarian cortex is an existing option to preserve fertility in these young girls at risk of premature ovarian failure (POF). The efficacy, feasibility and risks of ovarian cryopreservation in children must be assessed in order to validate the technique.

METHODS

Here, we conducted a review of ovarian cryopreservation in adults and, more specifically, in children using the PubMed databases. In addition, our own experience with ovarian cryopreservation in children was evaluated and compared with the literature.

RESULTS

Analysis of the literature and six published series on ovarian cryopreservation in children, as well as our own series of 58 cases, show that there is no reason to doubt its efficacy in this young population. However, no consensus has yet been reached on the indications for the technique. Indeed, with existing models, the real risk of POF may be over- or underestimated.

CONCLUSION

Our review suggests that ovarian cortex cryopreservation is feasible and as safe as comparable operative procedures in children. Although no births have yet resulted from freeze-thawing of prepubertal ovarian cortex, the results of this approach in adults are encouraging. However, the absence of consensus on the indications for fertility preservation, as well as the optimal timing and quantity of ovarian cortex for cryopreservation, should be taken into consideration when discussing fertility issues with girls at risk of POF and their parents.

Involvement of the nuclear factor-κB pathway in the pathogenesis of endometriosis

OBJECTIVE

To evaluate the role of nuclear factor-κB (NF-κB) in the pathogenesis of endometriosis.

DESIGN

A literature search was conducted in PubMed to identify all relevant citations.

RESULT(S)

Our findings highlight the important role of NF-κB in the pathophysiology of endometriosis. In vitro and in vivo studies show that NF-κB-mediated gene transcription promotes inflammation, invasion, angiogenesis, and cell proliferation and inhibits apoptosis of endometriotic cells. Constitutive activation of NF-κB has been demonstrated in endometriotic lesions and peritoneal macrophages of endometriosis patients. Agents blocking NF-κB are effective inhibitors of endometriosis development and some drugs with known NF-κB inhibitory properties have proved efficient at reducing endometriosis-associated symptoms in women. Iron overload activates NF-κB in macrophages. NF-κB activation in macrophages and ectopic endometrial cells stimulates synthesis of proinflammatory cytokines, generating a positive feedback loop in the NF-κB pathway and promoting endometriotic lesion establishment, maintenance and development.

CONCLUSION(S)

NF-κB transcriptional activity modulates key cell processes contributing to the initiation and progression of endometriosis. Because endometriosis is a multifactorial disease, inhibiting NF-κB appears to be a promising strategy for future therapies targeting different cell functions involved in endometriosis development, such as cell adhesion, invasion, angiogenesis, inflammation, proliferation, and apoptosis. Upcoming research will elucidate these hypotheses.

Differential expression of genes from the homeobox A cluster in deep endometriotic nodules and peritoneal lesions

OBJECTIVE

To compare expression of homeobox A (HOXA) genes involved in the differentiation of the female reproductive tract in deep endometriotic nodules and peritoneal lesions.

DESIGN

Prospective experimental study.

SETTING

Academic gynecology research unit.

PATIENT(S)

Thirty patients undergoing laparoscopy.

INTERVENTION(S)

During laparoscopy, deep endometriotic nodules (n=30) and peritoneal lesions (n=11) were recovered. Eutopic endometrium and vaginal tissue (n=30) were collected for control purposes.

MAIN OUTCOME MEASURE(S)

Quantification of HOXA-9, HOXA-10, HOXA-11, and HOXA-13 in deep nodules, peritoneal lesions, and control samples by real-time reverse-transcription polymerase chain reaction, and localization of HOXA-10 and HOXA-13 proteins by immunohistochemistry.

RESULT(S)

The HOXA-13 transcripts were detected in 29 out of 30 nodules, and their expression was significantly higher than in vaginal tissue, but they were barely detectable in endometrium and peritoneal lesions. Expression of HOXA-10 and HOXA-11 transcripts in deep nodules was similar to eutopic endometrium, and HOXA-10 expression was significantly lower in peritoneal endometriotic lesions. The HOXA-10 immunostaining was mainly localized in the stroma of deep endometriotic nodules, HOXA-13 in glandular structures and stroma, and neither of these proteins were detected in fibromuscular areas.

CONCLUSION(S)

Marked expression of HOXA-10 and HOXA-13 in the endometrium-like tissue of nodules but low expression in peritoneal endometriotic lesions supports the theory of differential origin of these two types of endometriosis.

Expression of eicosanoid biosynthetic and catabolic enzymes in peritoneal endometriosis

BACKGROUND

Increased peritoneal eicosanoid concentrations have been reported in endometriosis patients and might be important in disease-associated pain and inflammation. Here, we evaluated the expression of key biosynthetic and catabolic enzymes involved in this abnormal eicosanoid production in peritoneal macrophages and endometriotic lesions.

METHODS

Peritoneal macrophages, endometriotic lesions and matched eutopic endometrium were collected from endometriosis patients (n = 40). Peritoneal macrophages and eutopic endometrium samples were also collected from disease-free women (n = 25). Expression of type IIA secretory phospholipase A(2) (sPLA(2)-IIA), cyclooxygenase-2 (COX-2), microsomal prostaglandin E synthase-1 (mPGES-1), 15-hydroxyprostaglandin dehydrogenase (15-PGDH) and 5-lipoxygenase (5-LO) was quantified by real-time PCR, and these five key enzymes were localized by immunohistochemistry.

RESULTS

sPLA(2)-IIA, COX-2 and mPGES-1 mRNA was significantly increased in peritoneal macrophages of endometriosis patients compared with controls (P = 0.006, P = 0.016 and P = 0.025, respectively). In endometriosis patients, sPLA(2)-IIA, mPGES-1 and 15-PGDH mRNA was significantly enhanced in peritoneal lesions compared with matched eutopic endometrium (P < 0.001, P < 0.001 and P = 0.005, respectively). In eutopic endometrium, a significant decrease in 15-PGDH mRNA was found in the endometriosis group compared with controls (P = 0.023). Finally, sPLA(2)-IIA, COX-2, mPGES-1 and 15-PGDH immunostaining was found mainly in endometrial glands, whereas 5-LO was distributed throughout the glands and stroma.

CONCLUSIONS

Our study highlights an imbalance between eicosanoid biosynthesis and degradation in endometriosis patients. Both peritoneal macrophages and endometriotic lesions may be involved. Research into new molecules inhibiting biosynthetic enzymes (such as sPLA(2)-IIA and mPGES-1) and/or activating catabolic enzymes (such as 15-PGDH) may prove to be a major field of investigation in the development of targeted medical therapies.

Cryopreservation of ovarian tissue: an overview

Advances in the diagnosis and treatment of childhood, adolescent and adult cancer have greatly increased the life expectancy of premenopausal women with cancer. The ovaries are very sensitive to cytotoxic treatment, especially to alkylating agents. The only established method of fertility preservation is embryo cryopreservation according to the Ethics Committee of the American Society for Reproductive Medicine (2005), but this option requires the patient to be of pubertal age, have a partner or use donor sperm, and be able to undergo a cycle of ovarian stimulation, which is not possible when the chemotherapy has to be initiated immediately or when stimulation is contraindicated according to the type of cancer. For patients who need immediate chemotherapy, cryopreservation of ovarian tissue is the only possible alternative. This manuscript reports the techniques and results of orthotopic transplantation of cryopreserved ovarian tissue. Among almost 30 cases reported in the literature, seven live births have been achieved to date.

Evaluation of estrogen treatment in an immunodeficient mouse endometriosis model

BACKGROUND/AIMS

Endometriosis is known to be an estrogen-dependent disease. However, only a few studies have analyzed the effect of estrogen treatment in mice xenotransplanted with human endometrium. The objective of this study was to adapt a previously developed heterologous murine model to the study of estrogens and test the impact of estrone treatment on endometriosis development.

METHODS

Human proliferative endometrium was xenotransplanted into the peritoneal cavity of castrated immunodeficient mice. These mice were treated with estrogens by means of subcutaneous estrone-releasing pellets. The effect of estrone on estradiol level, uterine histology and endometriosis development was evaluated after 21 days.

RESULTS

Bioactivity of estrone pellets and their metabolization into estradiol were demonstrated. However, there was no impact on endometriosis development (no difference in lesion number, weight, size or fluorescence). This lack of response was not due to absence of estrogen receptor expression, since strong expression was found in all lesions harvested. Surprisingly, castrated nontreated mice presented with lesions showing high proliferative activity, similar to lesions found in treated mice (around 30%).

CONCLUSION

The high proliferation observed in lesions recovered from ovariectomized nontreated mice questions the utility of using estrogens in heterologous murine models.