Is the sarcomatous component (homologous vs heterologous) the prognostic "driving force" in early-stage uterine carcinosarcomas? A retrospective multicenter study

PURPOSE

Uterine carcinosarcomas (UCSs) are aggressive biphasic malignancies, with a carcinomatous/epithelial component and a sarcomatous/mesenchymal counterpart. The aim of this study was to evaluate the impact of the sarcomatous component (homologous vs heterologous) on the overall survival (OS) and progression-free survival (PFS).

METHODS

This is a multicenter observational retrospective study conducted in patients with stage I and II UCSs.

RESULTS

Ninety-five women with histological diagnosis of early-stage UCSs were retrieved: 60 (63.2%) had tumors with homologous sarcomatous components, and 35 (36.8%) with heterologous. At univariate analysis, a stromal invasion ≥ 50%, the presence of clear cell, serous or undifferentiated carcinomatous component, the heterologous sarcomatous component and FIGO stage IB and II were shown to be variables with a statistically significant negative impact on PFS. Similarly, a depth of invasion ≥ 50%, the heterologous sarcomatous component and FIGO stage IB and II were statistically negative prognostic factors also concerning OS. At multivariate analysis, only the heterologous sarcomatous component was confirmed to be a statistically significant negative prognostic factor both on PFS (HR 2.362, 95% CI 1.207-4.623, p value = 0.012) and on OS (HR 1.950, 95% CI 1.032-3.684, p = 0.040).

CONCLUSION

Carcinomatous and sarcomatous components both played a role in tumor progression and patients' survival. However, only the sarcomatous component retained a statistical significance at the multivariable model suggesting its preeminent prognostic role in early-stage UCSs.

MicroRNA-based signatures impacting clinical course and biology of ovarian cancer: a miRNOmics study

Background

In Western countries, ovarian cancer (OC) still represents the leading cause of gynecological cancer-related deaths, despite the remarkable gains in therapeutical options. Novel biomarkers of early diagnosis, prognosis definition and prediction of treatment outcomes are of pivotal importance. Prior studies have shown the potentials of micro-ribonucleic acids (miRNAs) as biomarkers for OC and other cancers.

Methods

We focused on the prognostic and/or predictive potential of miRNAs in OC by conducting a comprehensive array profiling of miRNA expression levels in ovarian tissue samples from 17 non-neoplastic controls, and 60 tumor samples from OC patients treated at the Regina Elena National Cancer Institute (IRE). A set of 54 miRNAs with differential expression in tumor versus normal samples (T/N-deregulated) was identified in the IRE cohort and validated against data from the Cancer Genoma Atlas (TCGA) related to 563 OC patients and 8 non-neoplastic controls. The prognostic/predictive role of the selected 54 biomarkers was tested in reference to survival endpoints and platinum resistance (P-res).

Results

In the IRE cohort, downregulation of the 2 miRNA-signature including miR-99a-5p and miR-320a held a negative prognostic relevance, while upregulation of miR-224-5p was predictive of less favorable event free survival (EFS) and P-res. Data from the TCGA showed that downregulation of 5 miRNAs, i.e., miR-150, miR-30d, miR-342, miR-424, and miR-502, was associated with more favorable EFS and overall survival outcomes, while miR-200a upregulation was predictive of P-res. The 9 miRNAs globally identified were all included into a single biologic signature, which was tested in enrichment analysis using predicted/validated miRNA target genes, followed by network representation of the miRNA-mRNA interactions.

Conclusions

Specific dysregulated microRNA sets in tumor tissue showed predictive/prognostic value in OC, and resulted in a promising biological signature for this disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40364-021-00289-6.

Pattern of recurrence in patients with endometrial cancer: A retrospective study

INTRODUCTION

Endometrial cancer (EC) known prognostic factors are not sufficient to predict either outcome or recurrence rate/site: to investigate EC recurrence patterns according to ESMO-ESGO-ESTRO risk classes, could be beneficial for a more tailored adjuvant treatment and follow-up schedule.

METHODS

758 women diagnosed with EC, and a 5-years follow-up, were enrolled: they were divided into the ESMO-ESGO-ESTRO risk classes (low LR, intermediate IR, intermediate-high I-HR, and highrisk HR) and surgically treated as recommended, followed by adjuvants therapies when appropriate.

RESULTS

Higher recurrence rate (RR) was significantly detected (p < 0,001) in the HR group (40,3%) compared to LR (9,6%), IR (16,7%) and I-HR (17,1%). Recurrences were detected more frequently at distant sites (64%) compared to pelvic (25,3%) and lymph nodes (10,7%) recurrences (p < 0,0001): only in LR group, no differences were detected between local and distant recurrences. 5-Year distant-free (LR 99%, IR 94%,I-HR 86%, HR 88%) and local-free survivals (LR 99%, IR 100%,I-HR 98%, HR 95%) significantly differ between groups (p < 0,0001 and p = 0,003, respectively). Adjuvant therapy modifies RRs only in LR group (p = 0,01).

CONCLUSION

To identify biological factors to stratify patients at higher risk of relapse is needed. Distant site relapse could be the main reason of endometrial cancer failure follow-up, independently or in addition to their risk class prognosis.

The INTERNATIONAL MISSION study: minimally invasive surgery in ovarian neoplasms after neoadjuvant chemotherapy

OBJECTIVES

The aim of this retrospective multicenter study was to investigate the extent, feasibility, and outcomes of minimally invasive surgery at the time of interval debulking surgery in different gynecological cancer centers.

METHODS/MATERIALS

In December 2016, 20 gynecological cancer centers were contacted by e-mail, to participate in the INTERNATIONAL MISSION study. Seven centers confirmed and five were included, with a total of 127 patients diagnosed with advanced epithelial ovarian cancer after neoadjuvant chemotherapy and minimally invasive interval surgery. Only women with a minimum follow-up time of 6 months from interval surgery or any cancer-related event before 6 months were included in the survival analysis. Baseline characteristics, chemotherapy, and operative data were evaluated. Survival analysis was evaluated using the Kaplan-Meier method. RESULTS : All patients had optimal cytoreduction at the time of interval surgery: among them, 122 (96.1%) patients had no residual tumor. Median operative time was 225 min (range 60 - 600) and median estimated blood loss was 100 mL (range 70 - 1320). Median time to discharge was 2 days (1-33) and estimated median time to start chemotherapy was 20 days (range 15 - 60). Six (4.7%) patients experienced intraoperative complications, with one patient experiencing two serious complications (bowel and bladder injury at the same time). There were six (4.7%) patients with postoperative short-term complications: among them, three patients had severe complications. The conversion rate to laparotomy was 3.9 %. Median follow-up time was 37 months (range 7 - 86): 74 of 127 patients recurred (58.3%) and 31 (24.4%) patients died from disease. Median progression-free survival was 23 months and survival at 5 years was 52 % (95% CI: 35 to 67).

CONCLUSIONS

Minimally invasive surgery may be considered for the management of patients with advanced ovarian cancer who have undergone neoadjuvant chemotherapy, when surgery is limited to low-complexity standard cytoreductive procedures.

MetaShot: an accurate workflow for taxon classification of host-associated microbiome from shotgun metagenomic data

Summary

Shotgun metagenomics by high-throughput sequencing may allow deep and accurate characterization of host-associated total microbiomes, including bacteria, viruses, protists and fungi. However, the analysis of such sequencing data is still extremely challenging in terms of both overall accuracy and computational efficiency, and current methodologies show substantial variability in misclassification rate and resolution at lower taxonomic ranks or are limited to specific life domains (e.g. only bacteria). We present here MetaShot, a workflow for assessing the total microbiome composition from host-associated shotgun sequence data, and show its overall optimal accuracy performance by analyzing both simulated and real datasets.

Availability and Implementation

https://github.com/bfosso/MetaShot.

Contact

graziano.pesole@uniba.it.

Supplementary information

Supplementary data are available at Bioinformatics online.

Radical hysterectomy after chemoradiation in FIGO stage III cervical cancer patients versus chemoradiation and brachytherapy: Complications and 3-years survival

BACKGROUND

To compare patterns and rates of early and late complications, and survival outcome in FIGO stage III cervical cancer patients underwent to radical hysterectomy after chemo-radiation (CT-RT) vs. chemo-radiation alone.

METHODS

Between May 1996 and April 2013 150 FIGO stage III cervical cancer patients were treated. We divide patients according to type of treatment: 77 were submitted to standard treatment (Group A), and 73 to completion hysterectomy after chemo-radiation (Group B).

RESULTS

The baseline characteristics of the 2 groups were superimposable. We observed lower intra-operative and treatment-related early urinary and gastro-intestinal complications in Group B with respect to Group A (p < 0.001). Vascular complications were registered only in Group B (p < 0.001). We found a significantly higher rate of local recurrences in the Group A than in the Group B (p < 0.002). We registered 29 deaths in the Group A and 22 in the Group B (p = 0.021). The 3-years disease-free survival rate in the Group A and in the Group B was 62.9% and 68.3%, respectively (p = 0.686), and the 3-years overall survival rate in the Group A and in the Group B was 63.2% and 67.7%, respectively (p = 0.675).

CONCLUSIONS

This study confirms that radical hysterectomy after CT-RT is an effective therapeutic approach for advanced cervical cancer. Further prospective and randomized studies should be performed in order to solve the question about the standard approach, and how the different pattern of complication could impact on the quality of life.

Targeting immune response with therapeutic vaccines in premalignant lesions and cervical cancer: hope or reality from clinical studies

Human papillomavirus (HPV) is widely known as a cause of cervical cancer (CC) and cervical intraepithelial neoplasia (CIN). HPVs related to cancer express two main oncogenes, i.e. E6 and E7, considered as tumorigenic genes; their integration into the host genome results in the abnormal regulation of cell cycle control. Due to their peculiarities, these oncogenes represent an excellent target for cancer immunotherapy. In this work the authors highlight the potential use of therapeutic vaccines as safe and effective pharmacological tools in cervical disease, focusing on vaccines that have reached the clinical trial phase. Many therapeutic HPV vaccines have been tested in clinical trials with promising results. Adoptive T-cell therapy showed clinical activity in a phase II trial involving advanced CC patients. A phase II randomized trial showed clinical activity of a nucleic acid-based vaccine in HPV16 or HPV18 positive CIN. Several trials involving peptide-protein-based vaccines and live-vector based vaccines demonstrated that these approaches are effective in CIN as well as in advanced CC patients. HPV therapeutic vaccines must be regarded as a therapeutic option in cervical disease. The synergic combination of HPV therapeutic vaccines with radiotherapy, chemotherapy, immunomodulators or immune checkpoint inhibitors opens a new and interesting scenario in this disease.

Mini-laparoscopic versus robotic radical hysterectomy plus systematic pelvic lymphadenectomy in early cervical cancer patients. A multi-institutional study

OBJECTIVE

The aim of this study was to verify possible differences in terms of perioperative outcomes and complications between mini-laparoscopic radical hysterectomy with lymphadenectomy (mLRH) and robotic radical hysterectomy with lymphadenectomy (RRH) in patients with early cervical cancer (ECC).

MATERIAL AND METHODS

In this retrospective study, thirty women with early stage cervical cancer who underwent mini-laparoscopic radical hysterectomy plus lymphadenectomy (mLRH) were compared with a cohort of thirty women who underwent robotic multiport radical hysterectomy (RRH). The study involved patients, between August 2010 and December 2012, from three Italian institutions: National Cancer Institute of Rome, University of Insubria, Varese, and the Catholic University of the Sacred Heart of Rome.

RESULTS

No significant differences between groups were observed in terms of age, BMI, previous abdominal surgery or FIGO stage. Operative time, blood loss, need of blood transfusion, risk of intra- and post-operative complications, and lymph nodes yield were similar between mLRH and RRH in patients with ECC. The median length of hospital stay was 2 days in the mLRH group and 3 days in the RRH group (p < 0.05).

CONCLUSIONS

The few differences we registered do not seem clinically relevant, thus making the two procedures comparable. The decision on how to gain best access for radical hysterectomy considers the surgeon's skill and experience with the different possible approaches. Further randomized trials are needed to determine whether mini-laparoscopic techniques truly offer any advantages.

A multicenter phase II randomized trial of docetaxel/gemcitabine versus docetaxel/capecitabine as first-line treatment for advanced breast cancer: a Gruppo Oncologico Italia Meridionale study

OBJECTIVE

To evaluate two docetaxel-based regimens as first-line treatment in advanced breast cancer patients.

METHODS

Patients were randomly assigned to docetaxel/gemcitabine (arm A: docetaxel 75 mg/m(2) on day 1, gemcitabine 1,000 mg/m(2) on days 1 and 8) or docetaxel/capecitabine (arm B: docetaxel 75 mg/m(2) on day 1, capecitabine 1,250 mg/m(2) twice daily on days 1-14); both chemotherapy regimens were repeated every 21 days. The primary objective of the study was to evaluate the response rate.

RESULTS

Seventy-two patients were enrolled (36 each in arms A and B). Responses according to intention-to-treat analysis were as follows: arm A, 41.7% [95% confidence interval (CI) 25.6-57.8]; arm B, 38.9% (95% CI 23-54.8). Median progression-free survival was 10.9 months (95% CI 8.1-13.7) in arm A and 10 months (95% CI 8.8-11.2) in arm B. Overall survival was 26 months (95% CI 22.0-30.0) in arm A and 28 months (95% CI 23.4-32.6) in arm B. Both treatments were well tolerated; myelosuppression was the dose-limiting toxicity, with grade 3-4 neutropenia in 13.8 and 19.4% of the patients in arms A and B, respectively. No relevant differences in other toxicities were observed in the two arms, except for diarrhea (13.9%) and hand-foot syndrome (11.1%), which occurred only in arm B.

CONCLUSIONS

Both regimens were active and well tolerated in advanced breast cancer.

[Specificity of action of anticancer agents]

Since the first cancer chemotherapy use, efforts have been made in identifying drugs with an antitumor specific action, but cancer is a very complex situation to be cured with a single agent, and to increase drugs selective cytotoxicity new agent combinations, or innovative cellular cycle related schedule, or the use of pro-drugs have been developed. Notwithstanding some relevant improvements in results, chemotherapy remains often a palliative approach. The improved knowledge of the biology of cancer, and of molecular mechanisms and specific targets, has recently modified the approach to various tumors. In particular, the identification of a single and specific genetic alteration in some tumors such as myeloid chronic leukaemia or gastrointestinal stromal tumors (GIST) led to the development of imatinib, a "target" drug with a multikinase inhibitor activity towards the specific genetic alteration; this unique opportunity is not applicable to other tumors, because usually tumors have multiple genetic alterations with very complex molecular pathways. The development of drugs with a multitarget action is probably the best approach to the majority of human cancers, but other possibility are the combination of multiple agents, each with known selective activity towards a specific molecular target, or the choice of a chemotherapic drug in combination with one or more molecularly targeted drugs. The knowledge of the multiple and extremely complex molecular pathways of the neoplastic cells will hopefully drive oncologic science towards a more "exact" science, with the use of "personalized" treatment in each cancer patient.

Biological progression of breast cancer and clinical implications

The classic view of tumor progression is that genetic mutation introduced in differentiated or progenitor cells causes tumors, through the acquisition of advantages for survival, and leading to phenotypic heterogeneity. Another theory (stem cell hypothesis) considers that tumor progression derives from cells within the tumor with stem cell characteristics of self-renewal and multiple differentiation potential. It is still unknown the timing of expression of various biological characteristics of breast cancer during the progression cascade, and the existence of clonal heterogeneity within primary tumor and synchronous or asynchronous distant metastases contributes to treatments failures.

Recent advances in the adjuvant treatment of early breast cancer

The majority of breast cancers are actually diagnosed at an early stage. Selection of the best treatment in the adjuvant setting represents a paramount step to reduce the risk of recurrence and cancer-specific mortality. At the present time decision making is based on individualized risk assessment, that takes into account patient and tumor clinical-pathological characteristics. New available tools, such as gene expression profiling, offer the potential to provide accurate prognostic and predictive information, but they require further validation. The present article provides an overview of current strategies in adjuvant breast cancer setting, and addresses a number of unresolved questions related to the role of taxanes, trastuzumab and hormonal treatment.

Endometrial biopsy by means of the hysteroscopic resectoscope for the evaluation of tumor differentiation in endometrial cancer: A pilot study

AIMS

To assess the diagnostic accuracy of endometrial biopsy by means of the hysteroscopic resectoscope (EBHR) in evaluating tumor differentiation in patients with endometrial cancer.

METHODS

Between January and December 2005, all the women with a diagnosis of endometrioid adenocarcinoma of the uterus, when admitted to hospital, were enrolled for this study. Patients eligible for surgical treatment underwent a preoperative work-up consisting in pelvic magnetic resonance imaging (MRI) and EBHR. In all patients submitted to a hysterectomy, a comparison between pre- and postoperative tumor grade was carried out.

RESULTS

42 women were enrolled in the study. Hysteroscopic biopsy was carried out in 39 patients (mean age 62.5 years, range 33-79; FIGO stage I: 34, stage II-IV: 5). No complication related to hysteroscopy was observed. The preoperative tumor grade by hysteroscopy correlated with the final grade in 97.1% of cases. No patient had positive peritoneal washing and after a median follow-up of ten months no intraperitoneal tumor relapse was observed.

CONCLUSION

EBHR is a very accurate diagnostic procedure for assessing the preoperative tumor grade in patients with endometrial cancer.

Analysis of chromosomes 3, 7, X and the EGFR gene in uterine cervical cancer progression

The aim of this study was to investigate the possible role of genetic alterations in the genesis and progression of cervical carcinomas. We analysed the 3, 7, X aneusomy of chromosomes and the status of the epidermal growth factor receptor (EGFR) gene by fluorescence in situ hybridisation (FISH) analysis. Polysomy of chromosomes 3 and X defined the transition from high-grade squamous intraepithelium lesions (HSIL) to cervical carcinoma. Chromosome 7 monosomy and polysomy did not show any statistical significant differences between the groups examined. When we compared the chromosomal aneusomies in all of the specimens using the Kruskal-Wallis test, significant differences (P = 0.0001, P = 0.0001 for chromosomes 3 and X, respectively) were observed. Using a ratio of the EGFR gene signals and chromosome 7 centromeric signals, no samples showed gene amplification. Our results demonstrate the importance of chromosomal 3 and X aneusomies in the development and progression from HSIL to cervical carcinoma, highlighting their usefulness as genetic markers for identifying SILs at high-risk of progression.

Role of pelvic lymphadenectomy in the management of stage I endometrial cancer: our experience

OBJECTIVES

To estimate the prognostic value of pelvic-node removal on survival of patients affected by endometrial carcinoma at presurgical FIGO Stage I.

METHODS

A retrospective analysis was performed on a total of 111 patients recruited from 1990 to 1996 at the S. Carlo di Nancy Hospital. Thirty-nine (35%) of them underwent a total hysterectomy and bilateral salpingo-oophorectomy with removal of the vaginal cuff (group 1), while 72 (65%) underwent a total hysterectomy combined with pelvic lymphadenectomy (group 2). Prognostic features including tumor grade, depth of myometrial invasion and histologic subtype. Survival rates were calculated with Cox and Kaplan analyses.

RESULTS

Overall survival rate at five years was 91.2%. The survival rate of group 1 and group 2 was 89% and 92.8%, respectively which is not statistically significant. Stage, grade, histotype, age at diagnosis, and presence of positive lymph nodes did not show any significant prognostic value on survival probability.

CONCLUSIONS

The survival rate for patients submitted to lymphadenectomy (group 2) was the same of patients who did not undergo this treatment (group 1). Nevertheless, pelvic lymphadenectomy in endometrial carcinoma at presurgical FIGO stage I was worthwhile as it allowed correct staging to be performed. The prediction of nodal disease based only on preoperative investigations (such as TC, NMR) is often inaccurate.

Changes of ovarian microvasculature in hCG stimulated rabbits. A scanning electron microscopic study of corrosion casts

The microvasculature of the ovarian cortex was studied by means of scanning electron microscopy of vascular corrosion casts in estrous and hCG stimulated rabbits in order to establish a better understanding of the structural as well as functional vascular changes which accompany the evolution of the luteofollicular complex. According to the various shape and size seven different morphological types of vascular plexuses corresponding respectively to antral follicles (Types 1-2), atretic follicles (Types 3-4), periovulatory follicles (Type 5), growing pseudopregnant corpora lutea (Type 6) and regressing pseudopregnant corpora lutea (Type 7) were identified. Growing to mature cycling type follicles (Types 1-2) showed a gradual enlargement and proliferation of the theca capillaries. These changes, associated with capillary hyper-permeabilization were observed in ovulatory and post-ovulatory follicles (Types 5), after hCG stimulation. The corpus luteum formation (Types 6) was accompanied by additional capillary dilatation, diffuse angiogenetic sprouts and organization of a more conspicuous venous drainage. The regression of the corpus luteum (Type 7) was characterized by the appearance of avascular areas within the glandular tissue and by regression of vascular dilatation. The atretic follicle (Types 3-4) wall showed large interruptions (avascular areas) and focal invasion of the central cavity by newly formed capillaries randomly arranged. The hCG stimulation did not affect consistently the atretic follicle microvasculature. The present observation shows that both thecal capillary vasodilatation and angiogenetic processes support the gradual increase of ovarian blood flow during follicle growth and corpora lutea formation and that microvascular changes of atretic follicles are possibly related to a type of inflammatory reaction since they seem to be a consequence rather than a primary cause of atresia.

The collagen fibrils arrangement in the Wharton's jelly of full-term human umbilical cord

In the present study, a cell maceration/scanning electron microscopy method is employed in order to reveal the three-dimensional organization of the collagen fibrils in the Wharton's jelly of the human umbilical cord at term. By this method the jelly appears as a three-dimensional network of collagen fibrils that runs continuously from the amniotic membrane to the umbilical vessels. A diverse architecture of the collagen fibrillar network in the inner and outer region of the cord is observed suggesting an anatomical as well as a functional compartmentalization. In fact, the network is soft in the inner part and it is characterized by canalicular structures whereas in the outer region the collagen is dense and the network is characteristically composed by a sponge-like system of cavernous spaces. It is suggested that these cavities might store the ground substance and allow its diffusion during twisting or compression of the cord. Furthermore they may facilitate the flow of metabolites throughout the jelly from and to the umbilical vessels and the amniotic cavity.

The extracellular matrix of normal human placental villi at term: a scanning electron microscopy study

The three-dimensional organisation of the extracellular fibrillar matrix in normal human placental villi at term is investigated by scanning electron microscopic after 2N-NaOH-maceration technique. The latter method consists of a chemical digestion of cellular components of the villi that allows the visualisation of the extracellular fibrillar network in a real three-dimensional fashion by scanning electron microscope. By this approach, the extracellular fibrillar matrix, mainly composed by collagen fibrils, forms a continuous skeleton within the whole villous system of the placenta. This sort of collagenous fibrillar skeleton forms the axis of chorionic villi and connects them with the basal plates. Significant differences in quantity and arrangement of the extracellular matrix are observed at the various levels of the villous ramification. In fact, in the stem villi, the fibrillar extracellular matrix is considerable and the fibres are arranged longitudinally at the villous surface (outer fibrils) and circularly in the inner core of the villous around the wall of the fetal vessels (inner fibrils). On the contrary, in mature intermediate and terminal vili, the extracellular fibrillar matrix is significantly reduced and the fibrils are mainly arranged in a thin circular layer around the capillaries and sinusoids. The present study confirms morphologically the existence of a diverse organization of the extracellular matrix specific for the various levels of the villous ramification as suggested by previous immunohistochemical studies. Moreover, the presence of a highly organized collagenous fibrillar skeleton as observed in our study, stress the important mechanical role of the extracellular matrix in sustaining the chorionic fetal vessels and the trophoblastic layer. Furthermore, the fine reticular-meshed network of this skeleton observed in the terminal villi suggests an additional role of the extracellular matrix to ensure a favorable milieu for active feto-maternal exchanges at this level of the villous tree.

Extracellular fibrillar matrix architecture of human placental villi at term

The spatial organisation of the extracellular fibrillar matrix of normal human placental villi at term can be directly visualised by scanning electron microscopy after 2N-NaOH maceration technique. By these methods, the extracellular fibrillar matrix of placental villi appears as a continuous network of isolated collagen fibrils and/or small fibrillar bundles interwoven each other. This sort of "collagenous fibrillar skeleton" forms the axis of chorionic villi and connects them with the basal plates running through the whole villous system of the placenta. Significant variations in the spatial arrangement as well as in the quantity of the extracellular matrix is observed at different levels of the villous ramification. Within the stem villi, the fibrillar extracellular matrix are abundant and, whereas the fibrils near the villous surface run parallel to the longitudinal axis of the villous (outer fibrils), those located in the inner core of the villous are arranged circularly around the wall of the fetal vessels (inner fibrils). In mature intermediate and terminal villi, viceversa, the extracellular fibrillar matrix is significandy reduced and the fibrils are mainly organised in a thin circular layer around the capillaries and sinusoids. The present study demonstrated the existence of a diverse spatial architecture of the extracellular matrix that results to be peculiar to the various levels of the ramification of the villous tree. Therefore, these morphological data strongly suggest a "compartmentalisation" of the villous tree as suggested by previous immunohistochemical study. Such a highly organised "collagenous fibrillar skeleton" stresses the important mechanical role of the extracellular matrix in sustaining the chorionic fetal vessels and the trophoblastic layer. Furthermore, the fine reticular-meshed network observed within the terminal villi suggests that at this level an additional role ensuring a favourable milieu for active feto-maternal exchanges may exist.

How to increase the proportion of hysterectomies performed vaginally

OBJECTIVES

The main purpose of our study was to identify the patient characteristics of women undergoing hysterectomy and to estimate the proportion of hysterectomies that could be done vaginally by recognized surgical techniques.

STUDY DESIGN

The records of 500 women who underwent hysterectomy were reviewed. The characteristics of patients without an absolute contraindication to vaginal hysterectomy were analyzed.

RESULTS

Overall, 96 (19.2%) of our study group underwent vaginal hysterectomy. A total of 382 (76.4%) women were judged not to have an absolute contraindication to this route. The most frequent characteristics of this group were lack of uterine prolapse (76.4%), a myomatous uterus (44.5%), and a need for oophorectomy (43.2%). We did not exclude women who did not have significant uterine prolapse or a history of pelvic surgery or pelvic tenderness and we included those requiring oophorectomy or with a uterine size up to that of 14 weeks' gestation; with these criteria more than two thirds of the entire study population could undergo vaginal surgery.

CONCLUSIONS

To maximize the proportion of hysterectomies performed vaginally, gynecologists need to be familiar with surgical techniques for dealing with nonprolapsed uteri, uterine leiomyomas, and vaginal oophorectomy.

Microanatomy of the female reproductive organs in postmenopause by scanning electron microscopy

The detailed three-dimensional ultrastructural features of the reproductive organs of menopausal and postmenopausal women were studied by means of integrated transmission and scanning electron microscopy (SEM) and reported in a new colored microtopographical fashion. These methods revealed significant alterations in the microanatomy of the various reproductive organs specifically related to the decline of plasma estrogen levels. In particular, the ovary progressively showed characteristic wide areas of loss of epithelium with consequent exposure of the underlying connective tissue. Both endometrial and tubal mucosa demonstrated a gradual but often dramatic decrease in the number of ciliated cells which was more evident in the tube. In addition, the non-ciliated (microvillous secretory) cells of the uterus, including both endocervix and tubal mucosa, became flattened and, in some instances, their apical poles developed unusual wrinkles (microridges or microplicae). The ectocervix and vaginal squamous cells presented a reduction in the number of their microridges and changes in the typical structural organization. These microtopographical results showed that the decline of estrogen during the menopause and postmenopause induces important and complex structural changes of the woman's reproductive system, much more detailed than those revealed to date by the use of only conventional optical and transmission electron microscopy (TEM). The three-dimensional findings offer the opportunity to re-evaluate the classic histopathology of the above aging organs using more refined microtopographical and morphophysiopathological parameters.

The three-dimensional architecture of the myosalpinx in the rat (Rattus norvegicus) as revealed by scanning electron microscopy

The three-dimensional (3-D) architecture of myosalpinx in the rat has been investigated by means of scanning electron microscopy after microdissection and removing interstitial connective tissue with 6N NaOH digestion. In the extramural portion of tube-uterine junction the myosalpinx shows circularly arranged fibers originating from the uterus, together with oblique fibers typical for the salpinx, which occur more frequently in the deeper layers. As fibers approach the mucous folds they assume a plexiform arrangement, which is maintained through all tubal segments. In the isthmus surface fibers form wide muscle rings around the elbow of loops, peculiar to the rat tubal morphology. Surface fibers in the ampulla and pre-ampulla have an even circular course. Our 3-D results reveal that the muscular architecture of rat tube is mainly organized in concentric, monolayered shells with a plexiform arrangement tightly fastened together. Functionally, this muscular arrangement seems to be capable of stirring rather than pushing the embryo and gametes. Finally, such a plexiform network might work as a mechanism of "tube locking" in proximity of isthmic loops as well as at the level of the ampullary-isthmic junction.

The collagen skeleton of the cat testis. A scanning electron microscopy study after 2N-NaOH maceration

Testes from adult cats were studied by means of scanning electron microscopy (SEM) after 2N-NaOH maceration method which selectively digests cells and tissue compounds. As seen by this technique, the testis appears covered by a dense fibroconnective tunica albuginea that divides partially the organ by sending septa into the parenchyma. The interstitium is made up by a rich connective tissue composed by randomly-arranged fine collagen bundles that clearly outline the spaces occupied by the seminiferous tubules. The basement membrane of the seminiferous tubules consists in two rough layers of collagen fibers that in some places leave small fenestrations. The three-dimensional arrangement of collagen fibers in the interstitium outlines a system of cavities likely to be lacunar spaces for Leydig cells and vascular imprints. Especially, the above chemical technique followed by deep observations under the SEM allowed a clear and complete view of the real three-dimensional microarchitecture of the connective tissue of the testis. Therefore, the collagen component was revealed to actually form a unique and complex skeleton for the whole organ. This three-dimensional figure closely follows indeed the classical histological compartmentalization of the testis with a better insight of its spatial microtopographical features. Moreover, this structural pattern is also likely to give rise to very fine morphofunctional subcompartmentalization, especially regarding the basement membrane of the seminiferous tubules and the lacunar spaces for Leydig cells including satellite vessels.

Collagen fibrillar skeleton in pregnant rabbit endometrium at term: a SEM study after NaOH maceration

This paper describes the spatial organization of the collagen fibrillar skeleton in pregnant rabbit endometrium at term, employing an alkali/low temperature/maceration technique followed by scanning electron microscopic (SEM) observations. Parallel light microscopic (LM) and transmission electron microscopic (TEM) investigations were made to identify the location and possible changes in the endometrial collagen network. Two different types of NaOH maceration were applied, demonstrating separately: 1) the collagen structures (2N-NaOH maceration removes the cells and basal laminae); and 2) the cellular elements (6N-NaOH maceration removes the collagen fibrils). After 2N-NaOH maceration, the collagen network of the endometrium is seen in a superficial compartment around the glands and a deep compartment situated near the endometrial-myometrial junction. Significant changes are observed only in the superficial compartment. The luminal mucosal surface is characterized by numerous thin projections reducing the uterine cavity which, as a consequence, further appears very irregular and highly convoluted. The subepithelial collagen network is composed of densely packed fibrils with a woven course. It contains many tubular or channel-like invaginations (100-150 microns in width and 200-300 microns in length) where endometrial glands are located. These invaginations, corresponding to the glandular impressions, are extremely dilated, enlarged and variable in shape. The collagen fibrils are arranged concentrically around the glandular orifices without forming bundles. At the bottom of the spaces between the mucosal projections, small fenestrations (4-8 microns in diameter each) are present. They form small groups of about 10-20 in number and are due to the endometrial blood capillaries. The deep compartment of the endometrial collagen network is little altered, preserving its general lamellar arrangement. The changes in the endometrial collagen skeleton are due to a variety of complex mechanical and hormonal stimuli affecting the uterus during pregnancy. These may be significant for correct implantation, placentation and delivery.

The collagen skeleton of the human umbilical cord at term. A scanning electron microscopy study after 2N-NaOH maceration

The organization of the collagen fibrils in the human umbilical cord at term is directly visualized by means of a scanning electron microscopy cell maceration method. This technique clearly reveals that there is a much more extensive collagen fibrillar architecture within the umbilical cord than that reported in the classical histological descriptions. The Wharton's jelly, in fact, appears as a spongy network of interlacing collagen fibres and small woven bundles apparently arranged at random and forming a continuous soft skeleton that encases the umbilical vessels. The collagen fibrillar network shows the presence of a wide system of interconnected cavities consisting of canalicular-like structures as well as cavernous and perivascular spaces. This system of cavities might play a mechanical role allowing the storing of the ground substance of the jelly and its diffusion during twisting or compression. Furthermore, it may have an important role facilitating the diffusion throughout the jelly of diffused materials (i.e. water and trophic metabolites) either from or to the umbilical vessels and the amniotic cavity, thus overcoming the lace of a proper vasculature with the jelly.

The three-dimensional organization of the smooth musculature in the ampulla of the human fallopian tube: a new morpho-functional model

The three-dimensional organization of the smooth musculature around the human ampulla is revealed by means of scanning electron microscopy after NaOH maceration and ultrasonic microdissection of the interstitial connective tissue. The muscular wall of the ampulla appears as a continuous network of randomly anastomosed smooth muscle cell bundles that showed a multidirectional arrangement. The smooth muscle cell bundles modify their orientation along their course, intertwine repeatedly with each other and dichotomize, generating new bundles with a different orientation from that at the origin. These results demonstrate that the myosalpinx of the human ampulla is not organized into clear cut longitudinally, circularly or spirally arranged layers, as suggested in previous light microscopy studies. In contrast, the presence of a network of multidirectional smooth muscle cell bundles revealed in this study suggests that there is no morphological evidence for unidirectional peristalsis, and that the musculature is probably structurally designed to stir rather than push the tubal contents. These morphological findings better explain the random pattern of propagation of the contraction waves and the electrical impulses through the smooth musculature of the human ampulla, as postulated in early experimental physiological studies. Further, they suggest a specific function for the ampullar musculature which may not be only strictly related to tubal content transport.

An ultrastructural study of the fibromuscular capsule of the corpus luteum in mice

The presence and distribution of contractile cells in mature corpora lutea (CL) of pregnant and normal cycling mice were studied by transmission (TEM) and scanning (SEM) electron microscopy. In the connective tissue surrounding the CL, SEM observations made after maceration in alkali, revealed long, flat, spindle-shaped elements arranged parallel to each other, forming a continuous capsule. TEM of these elements revealed ultrastructural features of mature smooth muscle cells (SMC), as well as structures intermediate between fibroblasts, fibrocytes and SMC. Discrete bundles of SMC were seen to exit the external capsule of the CL and to penetrate the luteal tissue. The extensive branches of these bundles of SMC appeared to make contact with numerous vessels. Therefore, three-dimensional reconstruction, based on TEM and SEM analysis, revealed that the SMC of the CL were organized such that they form a wide fibromuscular skeleton around and within the luteal mass. It is possible that pulsatile or tonic contraction of this structure may help to regulate the secretory activity of the luteal tissue by modifying the pressure inside the CL.

Collagen fibrillar network in estrous and hCG-stimulated rabbit uterus: a SEM study after NaOH maceration

The three-dimensional (3-D) organization of the collagen fibrillar network in rabbit uterus was studied by cell maceration/scanning electron microscopy (SEM) method, both during estrus and after stimulation with 100 I. U. of human chorionic gonadotropin (hCG). The cellular elements of glutaraldehyde-fixed tissue were effectively removed with 2N-NaOH at 25 degrees C for 5-7 days, followed by rinsing in distilled water. Correlative light microscopy (LM) and transmission electron microscopy (TEM) observations were also made in order to better clarify the natural location and distribution of collagen structures in the uterine layers. In estrous and ovulatory rabbits the superficial compartment of the endometrial stroma was composed of diffusely organized individual collagen fibrils and thin bundles of fibrils, forming specific supporting structures around the uterine glands. The deeper stroma showed a more condensed lamellar arrangement, particularly in the central part of the endometrial folds (plicae). Two distinct collagen networks, detected in the circular and longitudinal muscle layers of the myometrium, represented plexuses of anastomosing fine sheaths around the individual smooth muscle cells. A condensation of the fibrillar framework was observed around the large blood vessels between these two layers. Little alteration in uterine fibrillar network could be noticed in ovulatory animals 12 h after stimulation with hCG. Marked changes indicating collagen reorganization occurred in progestational animals 7.5 days after hCG administration. In this case, the collagen fibrillar network of the endometrium showed an irregular pattern consisting of slender elongations surrounding the labyrinthine spaces of the epithelium and corresponding to numerous, extremely attenuated plicae. Such a rearrangement of fibrils is very likely a response to hormonal stimulation of the uterus. To further identify the location of the blood vessels in the uterine collagen skeleton, vascular casts were also prepared. The collagen fibrillar network not only provides a mechanical support for the structural components of the uterus but also creates a favourable milieu for their activities.

Microvasculature of growing and atretic follicles in the rabbit ovary: a SEM study of corrosion casts

Rabbit ovarian microvasculature, with particular regard to developing and atretic follicles, was studied by scanning electron microscopy (SEM) of vascular corrosion casts. The microvascular network of the follicles was arranged in typical round plexuses of varying shape and size. Four different morphological types of vascular plexuses supplied the follicles: Type 1 (100-250 microns in diameter) consisted of a simple net of thin capillaries that delimited a small empty central cavity. Type 2 (diameter > 250 microns) consisted of a multilayered capillary wall delimiting a large empty central cavity. This wall presented an inner layer made of uniformly distributed dilated and tortuous capillaries with numerous angiogenetic sprouts. Type 3 (diameter of 100-300 microns) lacked the central cavity and comprised randomly arranged thin capillaries. Type 4 (diameter > 250 microns) consisted of a multilayered capillary wall delimiting a central cavity. Its inner layer was made of capillaries not homogeneous in size and course (thin in some areas, sinusoidal in others, sometimes highly dilated). In addition, the wall showed large interruptions (avascular areas) and focal invasion of the central cavity by newly formed vessels. Types 1 and 2 showed the gradual transformation of thin capillaries into sinusoids as has been demonstrated in evolutive follicles. Types 3 and 4, described here for the first time, probably represent the vascular supply to atretic follicles. In particular, Type 3 supplied follicles undergoing obliterating atretic degeneration, whereas Type 4 supplied atretic follicles with hypertrophy of the theca layer. In fact, follicular atresia is a pleiomorphic phenomenon which ends in a regression of the follicles (obliterant atresia), but which may induce a temporary follicular hyperactivation (luteinizing atresia). These changes in the microvasculature prelude the formation of the so called "interstitial gland of the ovary". Furthermore, these data prove that: 1) both thecal capillary vasodilatation and angiogenetic processes basically support the gradual increase of ovarian blood flow during follicle growth; 2) microvascular changes of atretic follicles are possibly related to a type of inflammatory reaction since they seem to be a consequential rather than primary cause of atresia.

Vaginal reconstruction by skin grafts: a scanning electron microscopic evaluation

In order to evaluate the morphofunctional pattern of transplanted skin structural and ultrastructural studies on biopsies taken from surgically created neovaginae in three cases of vaginal agenesis were performed one and two years postoperatively. Two of the cases were associated with a rudimentary uterus, while the remaining one involved testicular feminization. Neovaginae were constructed by directly prolonging a pre-existing perineal introitus, to form a vesicorectal pouch, which was lined inside with gluteal skin autografts. All three patients reported satisfactory psychosexual behavior one year after operation. Light microscopy of the bioptic fragments demonstrated, even two years after surgery, features generally similar to those of the normal dermis and epidermis, and a keratinization rate as a rule, that did not range significantly from the norm. Scanning electron microscopy also confirmed the maturation of the cornified cells, since these were often seen to be desquamating and exhibited structures usually found in normal skin, such as double edges on the luminal surface--usually considered to be the morphological expression of squamous cell overlapping--and microwrinkles on disrupted apical and basal cytoplasmic flaps, which are considered reciprocal cell-gearing devices. Our results seem to indicate, therefore, that the transplanted skin, maintaining, on the whole, its integrity and viability despite an environment differing somewhat from the external one with regard to moisture, pH and temperature, shows a good adaptability, at least until the above mentioned time lapses.

Scanning electron microscopy of the rabbit gallbladder mucosal microvasculature

The arrangement of the microvasculature of the rabbit gallbladder was studied by means of scanning electron microscopy (SEM) of vascular corrosion casts and parallel uncorroded samples, together with correlated light microscopy (LM) observations. The outer layers of the gallbladder wall possess a coarse capillary network supplied by long and straight vessels which also give off numerous smaller twigs for the mucosal layer. Thin richly branched and anastomosing capillaries originate from the mucosal twigs. The mucosal capillaries are arranged in structures having a bowl-like configuration with the convexity facing towards the serosal layer, and the concavity corresponding to the epithelial lacunae seen by SEM of uncorroded samples. These structures were polygonal or irregularly rounded, and limited by vessels arranged in folds. The vessels running in these folds were capillaries and/or venules. The vascular folds corresponded to the epithelial folds demonstrated by SEM and LM of uncorroded samples.

The three-dimensional architecture of the myosalpinx in mammals: an anatomical model for a functional hypothesis

Direct visualization of the three-dimensional architecture of the tubal musculature (myosalpinx) was made possible by a technique involving chemical digestion of interstitial connective tissue, followed by ultrasonic microdissection and final observations under the scanning electron microscope. The isthmic myosalpinx in the guinea pig, rabbit and in humans consists of muscular bundles that tend to lie longitudinally, circularly or oblique. The muscular bundles along the tubal wall change direction, branch and intermingle with one another, giving rise to an irregular network in which distinct layers are not readily distinguishable. In the ampulla, the muscle bundles form a very irregular three-dimensional network of fibres that follow different orientations. The authors suggest a primary role for such a structure in the random pendular transport of the gametes as well as in the denudation of the egg by deformation of the myotubal wall.

Cellular and microvascular changes of the ovarian follicle during folliculogenesis: a scanning electron microscopic study

In order to study the three-dimensional topographic arrangement of the oocyte and zona pellucida, follicular cells and follicle microvasculature, this study applied alkali maceration methods for tissue exposure, the ruthenium red-detergent method for the extracellular matrix visualization, and the vascular corrosion cast technique to rabbits, guinea-pigs and mice ovaries at different stages of follicular development. Macerated samples showed a gradual differentiation of the oocyte surface. This, in primordial follicles, appeared rather smooth, but, with the follicular development, displayed a gradual increase of blebs and microvilli. The latter widely covered the surface of oocytes contained in large or mature follicles. The outer surface of the zona pellucida showed numerous fenestrations, whereas the inner one was smooth. The ruthenium red-detergent method permitted a well detailed view of the filamentous texture of the zona pellucida. The three-dimensional distribution of the contacts between oocyte and neighbouring follicular cells was clearly evaluated in macerated samples. Follicular cells of primary follicles were characterized by their short cytoplasmic processes reaching the oocyte surface. In secondary follicles, these processes issued secondary processes. In larger follicles, the secondary processes of the corona cells were much longer and thinner, and took a tortuous course to reach the oocyte surface, which ran among the numerous oocyte microvilli. This microvillous arrangement greatly increases contact between the oocyte and corona cells, and suggests a coordinated reciprocal control of the activities of both cell types. These data also showed that the spongy and filamentous nature of the zona pellucida is closely dependent upon the temporal differentiation and enormous increase in number of follicular cell projections and their ramifications. Maceration revealed the theca cells surface. In smaller follicles these appeared as fusiform cells which resembled fibroblasts. In larger or mature follicles, many theca cells differentiated to possess morphological features of steroidogenic cells. In addition, these cells delimited a series of intercellular communicating lacunae, continuous with wide pericapillary spaces. The gradual differentiation of the follicle towards a structure having an endocrinal role was further emphasized in vascular corrosion casts. A simple microvascular net made of thin capillaries supplying primary follicles was seen to transform into an elaborate sinusoidal network made of thick permeable capillaries, supplying mature follicles.

Three-dimensional architecture of the human myosalpinx isthmus. Scanning electron microscopy after NaOH digestion and ultrasonic microdissection

The three-dimensional architecture of the human isthmic myosalpinx is directly visualized by means of scanning electron microscopy after removal of interstitial connective tissue through NaOH maceration and ultrasound microdissection. These investigations show that the myosalpinx is composed of irregularly running bundles of smooth muscle cells, changing their orientation within the myosalpinx and displaying longitudinal, oblique and circular directions. The muscular bundles anastomose and intermingle with other bundles running at different levels in the oviduct wall, and actually give rise to a wide and complex muscular network in which no distinct layers are readily discernible. These morphological data are consistent with the physiological findings that the transport of gametes and embryo in very early stages in the isthmic portion of the oviduct tube is the result of a discontinuous pattern of forward and backward movements.