Anatomy of the pudendal nerve in clinically important areas: a pictorial essay and narrative review

PURPOSE

The pudendal nerve is an anatomical structure arising from the ventral branches of the spinal roots S2-S4. Its complex course may be affected by surrounding structures. This may result in irritation or entrapment of the nerve with subsequent clinical symptoms. Aim of this study is to review the anatomy of the pudendal nerve and to provide detailed photographic documentation of the areas with most frequent clinical impact which are essential for surgical approach.

METHODS

Major medical databases were searched to identify all anatomical studies investigating pudendal nerve and its variability, and possible clinical outcome of these variants. Extracted data consisted of morphometric parameters, arrangement of the pudendal nerve at the level of roots, formation of pudendal nerve, position according to sacrospinal and sacrotuberal ligaments and its terminal branches. One female cadaver hemipelvis was dissected with common variability of separate course of inferior rectal nerve. During dissection photodocumentation was made to record course of pudendal nerve with focus on areas with recorded pathologies and areas exposed to iatrogenic damage during surgical procedures.

RESULTS

Narrative review was done to provide background for photodocumentation. Unique photos of course of the pudendal nerve was made in areas with great clinical significance.

CONCLUSION

Knowledge of anatomical variations and course of the pudendal nerve is important for examinations and surgical interventions. Surgically exposed areas may become a site for iatrogenic damage of pudendal nerve; therefore, unique picture was made to clarify topographic relations.

New staging of endometrial carcinoma - FIGO 2023

AIM

To review the changes in the new version of the FIGO 2023 staging system for endometrial cancer.

METHODS AND RESULTS

The new FIGO 2023 endometrial cancer staging system provides key updates for the diagnosis and treatment of endometrial cancer. An important step in diagnosis is molecular classification, which allows more accurate risk stratification for recurrence and the identification of targeted therapies. The new staging system, based on the recommendations of the international societies ESGO, ESTRO and ESP, incorporates not only the description of the pathological and anatomical extent of the disease, but also the histopathological characteristics of the tumour, including the histological type and the presence of lymphovascular space invasion. In addition, the staging system uses molecular testing to classify endometrial cancers into four prognostic groups: POLEmut, MMRd, NSMP and p53abn. Each group has its own specific characteristics and prognosis. The most significant changes have occurred in stages I and II, in which the sub-staging better reflects the biological behaviour of the tumour. This update increases the accuracy of prognosis and improves individualized treatment options for patients with endometrial cancer.

CONCLUSION

The updated FIGO staging of endometrial cancer for 2023 incorporates different histologic types, tumour features, and molecular classifications to better reflect the current improved understanding of the complex nature of several endometrial cancer types and their underlying bio logic behaviour. The aim of the new endometrial cancer staging system is to better define stages with similar prognosis, allowing for more precise indication of individualised adjuvant radiation or systemic treatment, including the use of immunotherapy.

Preoperative and postoperative staging in endometrial cancer - a prospective study

OBJECTIVE

The aim of this study was to determine how often changes the stage of the tumour in definitive histology against preoperative clinical stage in patient cohort with diagnosed endometrial cancer.

METHODS

We evaluated prospectively a cohort of 166 patients with endometrial cancer. They all underwent abdominal hysterectomy, bilateral salpingo-oophorectomy, sentinel lymph node biopsy. Patients with high-risk tumours also pelvic lymfadenectomy. We collected data of preoperative diagnostic biopsy and postoperative definitive histology. The data were statistically processed.

RESULTS

Detection of sentinel lymph node was successful in 71.1%, bilateral successful detection was in 40.6%. Discrepancy of tumour grade between preoperative biopsy and definitive histology was generally 31.4%. Upgrading of the tumour was in 22 (14.4%) cases, downgrading in 26 (17%) cases. Upgrade from low-risk to high-risk group of tumours was noticed in eight cases. Histopathological tumour type changed in 6.6%, 4.6% moved to histopathologic high-risk group. The tumour stage changed in definite histology in 57.3%, in 19.2% of cases moved from stage low/intermediate-risk group to intermediate-high/high-risk disease group.

CONCLUSION

Correct assessment of preoperative clinical stage and histological grade of endometrial cancer is burdened with a high inaccuracy rate. A lot of cases is up-staged after surgical staging and moved to intermediate-high/high-risk disease group. Results confirm the importance of oncogynaecologic centre II. evaluation of histopathology findings from diagnostic biopsies made in referring hospitals. Sentinel lymph node biopsy should be performed even in clinically low/intermediate-risk disease group.

Human papillomavirus infection (HPV) and pregnancy

Human papillomavirus (HPV) is the most common sexually transmitted viral infection worldwide, which may result in the development in benign lesions or malignant tumors. The prevalence of HPV infection is twice as high in pregnancy as in non-pregnant women. Additionally, there is a risk of vertical transmission of HPV from mother to fetus during pregnancy or childbirth. Various studies have reported an increased risk of adverse pregnancy outcomes in HPV-positive women, including miscarriage, preterm birth, premature rupture of membranes, preeclampsia, fetal growth restriction, and fetal death. HPV vaccination is not currently recommended during pregnancy. On the other hand, there is no evidence linking HPV vaccination during pregnancy with adverse pregnancy outcomes and termination of pregnancy is not justified in this case.

Management of patient with breast carcinoma diagnosed during pregnancy

OBJECTIVE

To present actual complex review of diagnosis and treatment of breast cancer during pregnancy, demonstrated on particular case report.

DESIGN

Case report and review article.

SETTING

University Hospital Královské Vinohrady, Prague Department of Obstetrics and Gynaecology, Department of Radiotherapy and Oncology.

CASE REPORT

Patient with breast cancer diagnosed in early pregnancy, her oncological treatment. Circumstantial finding was endometriosis of rectovaginal septum and dehiscence of uterotomy after C-section.

DISCUSSION

On this case we demonstrate importance of all early diagnosis, prompt examination management and early therapy onset already during the pregnancy.

CONCLUSION

Breast cancer therapy results are equal in pregnant and non-pregnant women, when we compare patients of same age, with same stage and same biological characteristics of tumor. The obstacle during pregnancy is often late diagnosis, which causes bigger size of tumor and more extensive affection of lymphatics in time of therapy onset.

Individualization of surgical management of cervical cancer stages IA1, IA2

OBJECTIVE

To evaluate the risk of involvement of sentinel lymph nodes in cervical cancer stage IA1 with lymphovascular space invasion and IA2 using the detection of sentinel lymph nodes.

DESIGN

Original article.

SETTINGS

Department of Gynecology and Obstetrics 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague; Oncogynecological centrum; Department of Pathology 3rd Faculty of Medicine, Charles University, Faculty Hospital Kralovské Vinohrady, Prague.

METHODS

The study included women from prospective protocols LAP I and LAP II with cervical cancer stage IA1 with lymphovascular space invasion and stage IA2 from 2002 to 2018 classified according to FIGO 2014 staging, TNM 8. Detection of sentinel lymph nodes throughout this period was performed using ultra-short protocol with Tc and patent blau and also by histopathological examination.

RESULTS

In the first group (28 women) with stage IA1 and lymphovascular space invasion diagnosed from cone biopsy there were two women with positive lymph nodes (7.1%). In the group stage IA2 (34 women) there were 13 women (38.2%) with positive lymphovascular space invasion and two women had positive lymph nodes (5.9%). The risk of positive lymph nodes for stage IA1 with lymphovascular space invasion and for stage IA2 is not statistically significant OR = 0.8125 (95% CI 0.1070-6.172).

CONCLUSION

The detection of sentinel lymph nodes aids to individualize the therapy of early stage cervical cancer and helps to reduce the radicalization of surgery. The risk of positive lymph nodes in stage IA1 with lymphovascular space invasion and stage IA2 with/without lymphovascular space invasion is the same. The results confirm, that the detection of sentinel lymph nodes in stage IA1 with lymphovascular space invasion is fully indicated.

Bladder rupture after a fall on the ground in a patient with total uterine prolapse

OBJECTIVE

The aim of this work is to present a case of traumatic bladder rupture in a patient with total uterine prolapse. Additionally, we provide a brief description of this issue.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynaecology, 3rd Faculty of Medicine, Charles University and Královské Vinohrady University Hospital, Prague; Departement of Radiology, 3rd Faculty of Medicine, Charles University and Královské Vinohrady University Hospital, Prague.

RESULTS

We present a case report of a patient with a total uterine prolapse that has been examined for a lower abdominal pain, hematuria and difficulties with urination. The problems arose suddenly after the fall on the ground. These symptoms are typical for bladder rupture, but other more frequent causes have to be ruled out. CT scan showed a contrast agent leak from the bladder. The patient was indicated for surgical revision and suture of the bladder wall.

CONCLUSION

Separately, rupture of the bladder occurs rarely. Most often, this injury is part of a wider trauma - especially after car crashes. However, our case report suggests that this option should be considered.

Histopathological and clinical features of molar pregnancy

OBJECTIVE

To analyse own set of molar pregnancies and to develop clinically relevant procedures.

TYPE OF STUDY

Review article with analysis of own data.

SETTINGS

Department of Pathology 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague; Department of Obstetrics and Gynecology 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague.

INTRODUCTION

The study monitors the decrease of laboratory values of beta-subunit of hCG gonadotropin (beta-hCG) after evacuation of partial and complete hydatidiform moles in a set of 45 partial and 46 complete moles. Two case reports of invasive moles.

RESULTS

In cases of partial hydatidiform moles there was complete regression of beta-hCG in all cases, 89% regressed in six weeks, none of the women showed no subsequent elevation after reaching negativity. In cases of complete hydatidiform moles the decrease was less gradual, the negativity after six weeks was confirmed in 78%, three complete moles became malignant.

CONCLUSION

The decrease of beta-hCG after molar pregnancy termination is variable. Even if in cases of complete hydatidiform moles the risk of malignization after reaching negativity is low, beta-hCG checks are recommended at monthly intervals for 6 months. Correct diagnosis of complete mole and its differentiation from partial mole can be achieved using immunohistochemistry - p57 antibody.

[Rupture of focal nodular hyperplasia in the 37th week of pregnanacy - case report]

OBJECTIVE

We describe a case of spontaneous hepatic rupture associated with undiagnosed focal nodular hyperplasia of a patient in the third trimester of pregnancy. Additionally, we provide a brief review of literature.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynaecology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague.

RESULTS

We report the case of a 29 year old patient with otherwise physiological pregnancy, who was hospitalized with pain in left hypochondrium. The patient experienced painful respiration, increasing in intensity in supine position. The possibility of lung embolism was considered and ruled out. Based on a suspected haemoperitoneum, caesarean section was performed. During the inspection of peritoneal cavity a ruptured tumor on the liver was identified. Histological examination showed focal nodular hyperplasia.

CONCLUSION

Focal nodular hyperplasia is a benign liver lesion. Complications involving rupture or bleeding are very rare. 17 cases of hepatic rupture associated with focal nodular hyperplasia were described in published reports with only one case related to pregnancy. Our case emphasizes the importance of a close cooperation between a gynaecologist, radiologist and surgeon.

[Ovaria borderline tumor - fertility-sparing surgery; case report]

The borderline tumors are known as low malignant potential tumors. Usually younger women suffer for them, than by the invasive ovarian carcinoma. They often which to be pregnant. The fertility-sparing surgery is posile but contain higher risk of the new disease on contralateral ovary.

The role of trachelectomy in cervical cancer

Cervical cancer is one of the most common cancers in women worldwide. Because it often affects women of childbearing age (19–45 years), fertility-sparing surgery is an important issue. The article reviews current viable fertility-sparing options with a special focus on trachelectomy, including vaginal radical trachelectomy, abdominal radical trachelectomy and simple trachelectomy. Neoadjuvant chemotherapy is also discussed. Finally, the decision to proceed with fertility-sparing treatment should be a patient-driven process.

[Doctors specialty training in obstetrics and gynecology at university medical schools: 2012-2013]

OBJECTIVE

The paper addresses transfer of doctors specialty training from the national Institute of postgraduate medical education (IPVZ) to University Medical Schools (UMS) with the special focus to Obstetrics and Gynecology (OG).

METHODS

The National Specialty Board (NSB) has been established. NSB tasks include definition of inclusion criteria and process of specialty choice at UMS. In OG specialty there are defined mid-term and final postgraduate training courses and other requirements for final specialty exam (FSE) - in particular trainees scientific work and surgery done with the supervision of NTB member. The system of FSE, its content, application, reimbursement and mechanisms are described in details.

RESULTS

In the whole country in 2012 there have been done 864 FSE in all basic medical specialties, which took place at seven UMS. Autumn semester terms has been utilized significantly more than spring terms (57% vs. 43%). There have been differences in the numbers of specialties and also numbers of candidates in each specialty among different UMS. In total 94% of applicants succeed in the FSE. In 2012 within OG specialty training there has been held 56 FSE - 24 exams on five UMS in spring term and 32 (57%) exams only on two UMS in autumn term. In the spring 2013 FSE were organized on 1st LF UK in Prague with 23 applicants, from which 22 successfully passed. During autumn 2013 the FSE in OG will be held on LF UP in Olomouc with 44 applicants for final postgraduate training course and 39 candidates for FSE.

CONCLUSION

Within OG specialty the transfer of doctors specialty training from IPVZ to UMS has been successfully managed. The NSB in OG specialty closely cooperates with past IPVZ and the Accreditation Commission of the Czech Ministry of Health. Thus continuity, quality and continuous enhancement of specialty training program in OG in Czech Republic is assured.

[Lymphedema after vulvar cancer surgery. A prospective study]

INTRODUCTION

Prospective detection of postoperative lymphedema of the lower limbs (LLL) in patients after surgery for vulvar cancer using different examination methods and their comparison.

DESIGN

Prospective clinical study.

SETTING

Department of Obstetrics and Gynecology, 2nd Medical Faculty of the Charles University and University Hospital Motol, Prague.

METHODS

Totally 36 women were followed after surgery for vulvar cancer. Due to the radicality of surgery the patients were divided into conservative (sentinel lymph node biopsy) and radical (inguinofemoral lymphadenectomy) group. Lower limbs were preoperatively and 3, 6 and 12 months after surgery assessed for the presence of lymphedema by measuring of circumferences, multifrequency bioelectrical impedance analysis (MFBIA) and subjective evaluation of patients.

RESULTS

The prevalence of lower limb lymphedema 12 months after surgery diagnosed by subjective evaluation reached 19,44%, by circumference measurement 38,89% and with MFBIA 66,67%. The prevalence of lymphedema after inguinofemoral lymphadenectomy diagnosed by circumference measurement was in 12 months after surgery higher (45.83%) than after the conservative surgery (25%). Risk factors were evaluated 12 months after surgery (age, BMI, adjuvant radiotherapy, type of surgery) and none of them were found to be statistically significant for the development of the lower limbs lymphedema.

CONCLUSION

The prevalence of lymphedema significantly depends on the diagnostic method, because they capture lymphedema in its various stages. Due to the high sensitivity MFBIA can be used for the detection of early stages of lymphedema. Preoperative measurement of the lower limbs is important for early detection of postoperative lymphedema.

[Pregnancy and multiple sclerosis -outcomes analysis 2003-2011]

OBJECTIVE

The analysis of perinatal results in pregnant women with multiple sclerosis (MS) and the assessment of the influence of pregnancy on this chronic disease in the population of pregnant women in our hospital in the years 2003-2011.

DESIGN

Retrospective analysis.

SETTING

Department of Obstetrics and Gynecology and Department of Neurology, 2nd Faculty of Medicine, Charles University and the Motol Hospital, Prague.

METHODS

Sixty-six women with the diagnosis of MS were included in our study in the years 2003-2011. All these women delivered at our clinic and were neurologically followed until the end of six months post partum. We evaluated the influence of pregnancy on the activity of the disease during the pregnancy and 6 months after delivery, the impact on the disability progression, the influence of the mode of delivery, the analgesia used, and breastfeeding, on the relapse rate post partum. We also assessed the impact of multiple sclerosis on the course of the pregnancy, where we looked for pregnancy complications in patients with multiple sclerosis, differences in the management of labor, and the results of newborns of mothers with this disease. We performed a statistical analysis.

RESULTS

Relapse during pregnancy occurred in 4 of the 66 women (6.1%, relapse rate - RR 0.1);17 women experienced a post partum relapse in the first six months after delivery (25.7%, RR 0.5). From our sample of 44 women breastfed (66.7%), 10 had relapse (10/44, 22.7%) in comparison with the 7 women out of a total of 22 who did not breastfed (7/22, 31.8%). No statistical significance was established, OR = 0.6 (0.2-2.0), p = 0.5518. Epidural analgesia (EDA) was used by 16 women (24.2%). Post partum relapse experienced 3 women that used EDA (3/16, 18.8%) and 14 women that did not use EDA (14/50, 28 %). OR = 0.6 (0.1-2.4), p = 0.5325. Neither breastfeeding, nor epidural analgesia correlated with presence of a post partum relapse. Pregnancy did not influence disability progression, EDSS (Disability status scale, Kurtzke`s scale) before pregnancy and after delivery was stable (EDSS 1.5 or EDSS 1.6). Vaginal delivery had 77% women, post partum relapse had 15 of them (15/50, 30%), 12 women (18.1%) had a caesarean section, relapse occure at 2 of them (2/16, 12.5%), three births (4.5%) were completed by vaginal extraction operations. Five women (7.6%) delivered before 37th week of pregnancy. Birth weight under 2500 g was found in 9 women (13.6%). The incidence of serious pregnancy complications was not increased, intrauterine growth retardation (IUGR) was confirmed in 4 births (6%).

CONCLUSION

There is no need to worry about pregnancy in patients with multiple sclerosis. Therapy provides long-term remission of the disease, and during pregnancy itself due to hormonal changes it is stabilized and the relapse rate decreases. In the post partum period relapse rate increases, however, the pregnancy did not influence disability progression. The mode of delivery in women with this disease is not different from the general population. Neither breastfeeding, nor epidural analgesia correlated with presence of a post partum relapses. The number of complications in pregnancy is not increased and the overall perinatal outcomes are comparable with the general population.

Search for photon-linelike signatures from dark matter annihilations with H.E.S.S

Gamma-ray line signatures can be expected in the very-high-energy (E(γ)>100 GeV) domain due to self-annihilation or decay of dark matter (DM) particles in space. Such a signal would be readily distinguishable from astrophysical γ-ray sources that in most cases produce continuous spectra that span over several orders of magnitude in energy. Using data collected with the H.E.S.S. γ-ray instrument, upper limits on linelike emission are obtained in the energy range between ∼ 500 GeV and ∼ 25 TeV for the central part of the Milky Way halo and for extragalactic observations, complementing recent limits obtained with the Fermi-LAT instrument at lower energies. No statistically significant signal could be found. For monochromatic γ-ray line emission, flux limits of (2 × 10(-7) -2 × 10(-5)) m(-2) s(-1) sr(-1) and (1 × 10(-8) -2 × 10(-6)) m(-2) s(-1)sr(-1) are obtained for the central part of the Milky Way halo and extragalactic observations, respectively. For a DM particle mass of 1 TeV, limits on the velocity-averaged DM annihilation cross section ⟨σv⟩(χχ → γγ) reach ∼ 10(-27) cm(3)s(-1), based on the Einasto parametrization of the Galactic DM halo density profile.

[Active cellular immunotherapy of ovarian cancer using dendritic cells]

OBJECTIVE

Overview and comparison of current results of studies dealing with the development and application of anti-cancer vaccines based on dendritic cells in ovarian cancer.

DESIGN

Review.

SETTING

Department of Obstetrics and Gynaecology Charles University, Prague, 2nd Faculty of Medicine and University Hospital Motol, Department of Immunology 2nd Faculty of Medicine and University Hospital Motol.

SUMMARY

Ovarian carcinoma (OVCA) is highly sensitive to chemotherapy; however despite this results from treatment are fairly unsatisfactory. Bearing this in mind, it is important to look for new ways to better understand the immunological mechanisms which could affect reactivation of the disease. It is likely that new knowledge in the field of the immunology of ovarian carcinoma could improve monitoring of the disease and help to ameliorate prognosis of the disease. One strategy in development is creation of anti-OVCA vaccines. Theese vaccines are made by the fusion of dendritic cell (DC) and tumor cells or its parts (NA, peptides). DC are bone-marrow derived leukocytes that are critical in the initiation of T cell mediated immunity. DC are fused to patient-derived ovarian carcinoma cells. The fusion cells induces cytotoxic T cell against autologous OVCA cells.

[Gynaecological precanceroses from the clinical perspective - today and tomorrow]

During the last twenty-five years an enormous shift in our knowledge of cancerogenesis in all gynaecological precancerous and cancerous diseases can be seen. Early diagnosis of these lesions of the lower genital tract (vulva, vagina and cervix) is enabled mainly due to easy access. The major role in the pathogenesis of most precancerous lesions can be accounted to high risk human papillomavirus. Recently, new information about HPV genotypisation of single precancerous lesions and single histological cancer types were revealed. Thus we can better estimate the effect of vaccines on different age groups of women in relation to different types of cancer. The development and introduction of prophylactic vaccines into clinical practice was one of the major improvements of current medicine. Precancerous and cancer lesions of endometrium make themselves known by early symptoms such as perimenopausal and postmenopausal bleeding. Optimal diagnostic and therapeutic procedures have to be based on close cooperation between the clinician and pathologist.

[Review of precancerous vulvar lesions]

Classification of squamous vulvar precancerous lesions is based on the concept of vulvar intraepithelial neoplasia (VIN) and incorporates a three grade evaluation of the intensity of dysplastic changes (VIN I, II and III). On the basis of histological features, VIN has been subdivided into the usual VIN (u-VIN) and differentiated VIN (d-VIN), which represent the two basic pathways of the pathogenesis of vulvar squamous cell carcinoma. Although u-VIN is etiologically associated with the human papillomavirus (HPV) infection and histologically corresponds to cervical intraepithelial neoplasia, d-VIN represents the HPV-negative sequence of vulvar carcinogenesis, which is linked to lichen sclerosus (LS) and lichen simplex chronicus (LSC). u-VIN preferentially occurs in relatively young women with a history of cervical, vaginal or vulvar premalignant lesions. On the other hand, d-VIN usually affects postmenopausal women without anamnestic data of other dysplastic lesions of the lower female genital tract. d-VIN is characterized by a higher tendency of stromal invasion than u-VIN and its malignant potential is analogous to carcinoma in situ (VIN III). The histological appearance of d-VIN is subtle with basal atypia and a well-preserved differentiation of the superficial parts of the squamous epithelium, therefore it is frequently misdiagnosed for u-VIN I, LS or LSC in vulvar biopsies. Primarily because of the low diagnostic reproducibility of the u-VIN I category and the doubts about its precancerous potential as well as due to the questionable differentiation between u-VIN II and III, a revised VIN classification was proposed in 2004. The grading of vulvar precancerous lesions was abandoned, the u-VIN I category was discontinued and u-VIN II and III were merged. In the revised terminology, the term u-VIN represents HPV-associated high grade precancerous vulvar lesions (formerly u-VIN II and III) and d-VIN encompasses HPV-negative high grade dysplasias.

[Guideline for treatment of gynaecological malignant tumours 2010---endometrial carcinoma]

OBJECTIVE

To develop guideline for primary surgical treatment of endometrial carcinoma.

DESIGN

Review, consensus of expert group.

SETTING

Dept. of Gynaecology and Obstetrics, 3rd Medical Faculty of Charles University in Prague.

METHOD

A retrospective review of published data, analysis of statistic data from Czech Republic, consensus among proposers and opponents.

RESULTS

The guideline recognizes endometrial carcinoma patients based on their risk and recommends type of surgical treatment for certain group. It emphasizes the importance of centralized oncogynaecological treatment. Surgical staging remains the basic principle for treatment of endometrial carcinoma patients. The aim of pre-operative diagnostics is to estimate the extent of the disease--"interim staging", that can be different from definitive histopathological staging. Based on risk factors patients are divided into low or high risk group. Standard procedure for low risk patients is hysterectomy and bilateral salpingoophorectomy. It is advisable to use peroperative biopsy in these patients that can shift the patient to high risk group. High risk patients are recommended for hysterectomy, bilateral salpingoophorectomy, and systematic aortopelvic lymphadenectomy. The guideline contains recommendation for young patients wishing to preserve their fertility, for cases of inadequate surgery and for follow-up.

CONCLUSION

Guideline for treatment of endometrial carcinoma is recommendation for clinicians and other subjects who participate on the process of the diagnostics/treatment of endometrial carcinoma patients. All points of the guideline were discussed and voted about by all participants of expert group.

Search for a dark matter annihilation signal from the galactic center halo with H.E.S.S

A search for a very-high-energy (VHE; ≥100  GeV) γ-ray signal from self-annihilating particle dark matter (DM) is performed towards a region of projected distance r∼45-150  pc from the Galactic center. The background-subtracted γ-ray spectrum measured with the High Energy Stereoscopic System (H.E.S.S.) γ-ray instrument in the energy range between 300 GeV and 30 TeV shows no hint of a residual γ-ray flux. Assuming conventional Navarro-Frenk-White and Einasto density profiles, limits are derived on the velocity-weighted annihilation cross section (σv) as a function of the DM particle mass. These are among the best reported so far for this energy range and in particular differ only little between the chosen density profile parametrizations. In particular, for the DM particle mass of ∼1  TeV, values for (σv) above 3×10(-25)  cm(3) s(-1) are excluded for the Einasto density profile.

Re-evaluation of cord blood arterial and venous reference ranges for pH, pO(2), pCO(2), according to spontaneous or cesarean delivery

Umbilical cord blood gas analysis (pO(2) and pCO(2)) is now recommended in all high-risk baby deliveries and in some centers it is performed routinely following all deliveries. The aim of this study was to re-evaluate cord blood arterial and venous reference ranges for pH, pO(2), pCO(2) in newborns, delivered by spontaneous vaginal delivery (SVD) and by cesarean section (CS) performed in Faculty Hospital Motol. Two groups of subjects were selected for the study. Group I consisted of 303 newborns with SVD. Group II consisted of 189 newborns delivered by cesarean section. Cord blood samples were analyzed for standard blood gas and pH, using the analytical device Rapid Lab 845 and Rapid Lab 865. We obtained reference values expressed as range (lower and upper reference value expressed as 2.5 and 97.5 percentiles) for cord blood in newborns with SVD: arterial cord blood: pH=7.01-7.39; pCO(2)=4.12-11.45 kPa; pO(2)=1.49-5.06 kPa; venous cord blood: pH=7.06-7.44; pCO(2)=3.33-9.85 kPa; pO(2)=1.80-6.29 kPa. We also obtained reference values for cord blood in newborns delivered by CS: arterial cord blood: pH=7.05-7.39; pCO(2)=5.01-10.60 kPa; pO(2)=1.17-5.94 kPa; venous cord blood: pH=7.10-7.42; pCO(2)=3.88-9.36 kPa; pO(2)=1.98-7.23 kPa. Re-evaluated reference ranges play essential role in monitoring conditions of newborns with spontaneous and caesarean delivery.

[Czech version of EORTC QLQ-CX24 questionnaire for patients with cervical cancer]

OBJECTIVE

Translation and validation of the EORTC QLQ-CX24 questionnaire on quality of life into the Czech language and literature.

TYPE OF STUDY

Prospective study.

SETTING

Dept. of Obstetrics and Gynaecology, 2nd Medical Faculty, Charles University and Faculty Hospital Motol, Prague.

METHODS

In concordance with the EORTC guidelines a questionaire for patients with cervical cancer was translated and validated. A group of 14 women who underwent the treatment for cervical cancer filled in the questionaire. T-test was used for the evaluation of the patient's characteristics and the differences in quality of life.

RESULTS

We present a Czech version of the questionaire EORTC QLQ-CX24 and the description how to evaulate it. In comparison of the two treatment groups no statistically significant differences have been found.

CONCLUSION

EORTC QLQ-CX24 is an internationally accepted questionnaire focused on patients with cervical cancer which should be incorporated into the projects dealing with women undergoing treatment for this disease.

[Thrombotic thrombocytopenic purpura in pregnancy. Case report]

OBJECTIVE

Description of case of patient with rare thrombotic thrombocytopenic purpura in pregnancy.

SUBJECT

Case report.

SETTING

Department of Gynecology and Obstetrics, Charles University and University Hospital Motol, Prague.

CONCLUSION

Thrombotic thrombocytopenic purpura (TTP) is a rare and substantial disorder characterized with combination of microangiopathic haemolytic anemia, consumption trombocytopenia and symptoms of organs dysfunction--especially kidneys and neurological deficiency. It's caused by production of microthrombi affecting small blood vessels. These palatelets-rich microtrombi are formed due to deficiency of the enzyme ADAMTS13--metalloprotease which is responsible for cleaving of ultralarge multimers of von Willebrand factor into smaller units. In our case report we describe patient with TTP in pregnancy. Therapy with corticosteroids and immunoglobulines was not effective, improvement of thrombocytopenia appeared after plasmapheresis (total count 14). The delivery was induced at term without complications. Target examination confirmed diagnosis of secondary TTP.

[Burkitt lymphoma in pregnancy--case report]

OBJECTIVE

The aim of the study is to show the possible variations of early symptoms of haematological malignity during pregnancy and to summarize data about treatment modalities and possible management of gravidity in case of the disease.

DESIGN

Case report.

SETTING

Department of Obstetrics and gynaecology, Charles University, 2nd Medical Faculty; 1st internal clinic - department of hematology, Charles University, 1st Medical Faculty, Prague.

METHODS

Pubmed database was searched between years 1989 and 2009. The data we used focused on non- Hodgkin's lymphomas diagnosed during pregnancy, especially on Burkitt lymphoma. The treatment modalities, neonate outcomes and prognosis of the mothers were emphasised.

CONCLUSION

The diagnostics of haematological malignities in pregnancy is difficult. The most frequent symptoms are subfebris, fever of unknown etiology, lymphadenopathy, night sweats, infirmity and the weight lost. According to the literature the Burkitt lymphoma is potencialy currable disease during pregnancy. The close cooperation of the gynecologists and hematooncologists and the individualization of treatment based on the stage of pregnancy, localization of the tumorous mass and the agresivity of disease is needed.

[Treatment of recurrent ovarian cancer]

OBJECTIVE

The description of current treatment possibilities in recurrent ovarian cancer.

DESIGN

Review article.

SETTING

Obstetrics and Gynecology Department, Charles University 2nd Medical Faculty and University Hospital Motol, Prague.

METHODS

The review of literature on treatment of recurrent ovarian cancer. Current data on chemotherapy, surgery and targeted biological therapy in recurrent ovarian cancer.

CONCLUSIONS

Chemotherapy is indicated in most cases of recurrent ovarian cancer, surgery does not play an important role. Standard treatment of platinum-sensitive recurrent ovarian cancer is based on platinum combination chemotherapy. Standard treatment of platinum-refractory ovarian cancer represents non-platinum monotherapy. Targeted biological therapy should be still used only in the studies.

[Chemotherapy during pregnancy]

OBJECTIVE

The aim of the study is to summarize current data on chemotherapy administered during pregnancy.

TYPE OF STUDY

Review article.

SETTING

Dept. of Obstetrics and Gynaecology of the Charles University in Prague, 2nd Medical Faculty, University Hospital.

SUBJECT AND METHOD

Pubmed database was searched between the years 1980 and 2009 with the combinations of key words concerning cytostatics, therapy and pregnancy. Cisplatin administration was identified in 38 cases. Eight cases of administration of carboplatin during pregnancy were found with normal neonatal outcome Twenty-one case reports were found on the use of taxanes during pregnancy: 14 on paclitaxel and 7 on docetaxel.

CONCLUSION

Based on the literature the administration of cytostatics during pregnancy can be considered under a close supervision and long-term follow-up in dedicated teams.

[Bioimpedance analysis--a new method in prediction and early detection of ovarian hyperstimulation syndrome?]

OBJECTIVE

The aim of the study was to establish a new method of the multiple-frequency bioimpedance analysis (MFBIA) for patients with controlled ovarian hyperstimulation (COH) and to determine the significance of this method in prediction and early diagnosis of severe forms of ovarian hyperstimulation syndrome (OHSS).

DESIGN

Prospective case control study.

SETTING

Department of Obstetrics and Gynecology, 2nd Medical Faculty, Charles University and University Hospital Motol, Prague.

METHODS

53 patients were recruited into the case control study. The surface body impedances for the frequencies of the current 1, 5, 50 and 100 kHz were measured. Study group included 13 patients with developed OHSS grade III.-V. according Golans classification. The control group included 40 women undergoing COH without developed OHSS. Measurements of impedances were performed by MFBIA device.

RESULTS

The decrease of the values of impedance between the day of oocyte retrieval and the day of embryotransfer significantly increases relative risk of OHSS grade III.-V. development. The best correlation was found for the frequency of 5 kHz (9.08 p<0.0001). The study suggests, the predictive value of MFBIA in OHSS development might be higher than the number of retrieved oocytes (>20 oocytes-RR 5,71).

CONCLUSION

Patients in risk of OHSS development are those with decreasing impedances. The highest predictive value of OHSS development is for the impedances at frequency of 5 kHz. Greater multicenter studies should be done to confirm our preliminary results.

Energy spectrum of cosmic-ray electrons at TeV energies

The very large collection area of ground-based gamma-ray telescopes gives them a substantial advantage over balloon or satellite based instruments in the detection of very-high-energy (>600 GeV) cosmic-ray electrons. Here we present the electron spectrum derived from data taken with the High Energy Stereoscopic System (H.E.S.S.) of imaging atmospheric Cherenkov telescopes. In this measurement, the first of this type, we are able to extend the measurement of the electron spectrum beyond the range accessible to direct measurements. We find evidence for a substantial steepening in the energy spectrum above 600 GeV compared to lower energies.

[The clinical significance of sentinel lymph node micrometastases in breast cancer]

OBJECTIVE

The advent of sentinel lymph node biopsy and improvements in histopathological and immunohistochemical analysis has increased the rate at which micrometastases are identified. However their significance has been the subject of much debate. Published studies have reported divergent results regarding the significance and implications of axillary lymph node micrometastases. Some studies demonstrate no associations, whilst others have found these to be indicators of poor prognosis, associated with non-SLN involvement, in addition to local and distant failure. The objective of our study was to evaluate the impact of sentinel lymph node micrometastatic cancer to prognosis of the disease.

DESIGN

Retrospective study.

SETTING

Departments of Gynecology and Obstetrics, Faculty Hospital, Prague.

METHODS

From January 2000 to December 2006 in 87 cases with sentinel axillary node negative cancer we reexamined the axillary tissue blocks by serial sectioning, haematoxilin-eosin staining and immunohistochemistry. Additional 15 cases of micrometastatic sentinel node involvement detected by frozen section were included. The overall and disease free survivals of patients with sentinel negative status (N0-67 cases) and with sentinel node micrometastases (Nmic-35 cases) were evaluated. The median follow-up was 60 months (24-96 months).

RESULTS

Micrometastases (Nmic) were found in 20 cases (23%). From the group of 67 nodes negative patients (N0) in 7 cases (10.5%) developed tumor recurrence and from the group of 35 Nmic in 5 cases developed five tumor recurrences (13.3%). In the group of N0 patients developed 2 regional recurrences and 3 patients died, but 2 patients died of other causes. In the group of Nmic developed one regional recurrence and 3 patients died of generalization of disease.

CONCLUSION

Our study demonstrated that the presence of sentinel node micrometastases is associated with risk of development of distant metastases and generalization of the disease, but not with higher risk of regional recurrence.

Limits on an energy dependence of the speed of light from a flare of the active galaxy PKS 2155-304

In the past few decades, several models have predicted an energy dependence of the speed of light in the context of quantum gravity. For cosmological sources such as active galaxies, this minuscule effect can add up to measurable photon-energy dependent time lags. In this Letter a search for such time lags during the High Energy Stereoscopic System observations of the exceptional very high energy flare of the active galaxy PKS 2155-304 on 28 July 2006 is presented. Since no significant time lag is found, lower limits on the energy scale of speed of light modifications are derived.

High-dose density chemotherapy followed by simple trachelectomy: full-term pregnancy

We report five patients with early-stage cervical cancer who do not fulfill criteria of fertility-sparing surgery (tumor more than 2 cm in the biggest diameter or infiltrating more than half of stroma). Five patients received three cycles of dose density neoadjuvant chemotherapy (NAC) at a 10-day interval: cisplatin plus ifosfamide in squamous cell cancer or plus doxorubicin in adenocarcinoma with good tolerance. After NAC, they underwent laparoscopic pelvic lymphadenectomy and vaginal simple trachelectomy. Two patients had no residual tumor, two had only microscopic residual disease, and one had macroscopic residual disease. Two women became pregnant 5 and 8 months after surgery, one delivered in term healthy baby and one is now in the second trimester of pregnancy without any complications. NAC followed by fertility-sparing surgery seems to be feasible treatment for women with tumor bigger than 2 cm or infiltrated more than half of the stroma.

[Abdominal sacrocolpopexy--simple and still actual method in the treatment of vaginal vault prolapse?]

OBJECTIVE

To evaluate the effectiveness and complications of abdominal sacrocolpopexy in the treatment of vaginal vault prolapse.

DESIGN

Review article.

SETTING

Obstetrics and Gynecology Department, Charles University 2nd Medical Faculty and Teaching Hospital Motol, Prague.

METHODS

Review from biomedical database Medline from 1960 till 2006. The articles were found under the key words: vaginal vault prolaps, abdominal sacrocolpopexy, effectiveness, complications, urinary incontinence, female sexual dysfunctions.

RESULTS

The effectiveness of surgery is getting near to 100 percent in the smaller groups between 11 and 21 women. The larger groups are presenting greater success rate variability from 85 to 97 percent. The studies with up to 2 years of follow up are giving representative results of the effectiveness of surgery. Prolapse recurrence and cystocele, rectocele, enterocele and stress urinary incontinence occurrance belong among the characteristic failure signs. Studies evaluating abdominal sacrocolpopexy argue low incidence of complications. Complications connected with surgery can be divided to intraoperative and early and late postoperative. Bleeding from injured medial sacral artery, cystotomy, enterotomy and ureterotomy are the most common intraoperative complications. Wound infection, ileus and urinary tract infection are the most often early postoperative complications. Stress urinary incontinence, anterior or posterior vaginal wall descent, recurrence of vaginal vault prolapse and mesh erosion through vaginal wall are characteristic late postoperative complications.

CONCLUSIONS

Abdominal sacrocolpopexy can be a method of choice in the treatment of vaginal vault prolapse, mainly because of the low morbidity and high success rate. Polypropylene mesh is the prefered suspension structure but the accurate surgical technique is the most important for the abdominal sacrocolpopexy success and safety.

Preoperative transforming growth factor-beta 1 (TGF-beta 1) plasma levels in operable breast cancer patients

OBJECTIVES

The aim of this project was to search for new risk prognostic markers in the early stage of breast cancer. We tested preoperative plasma transforming growth factor - beta 1 (TGF- beta 1) levels in patients with operable breast cancer. Correlation with traditional prognostic markers and with positivity/negativity sentinel lymph node was evaluated.

MATERIALS AND METHODS

Between 2003 and 2005, 36 patients with operable breast cancer (T1-2, N0-1, M0) with positive or negative sentinel lymph nodes were evaluated for their plasma TGF-beta 1. Twenty-seven healthy individuals (9 premenopausal and 18 postmenopausal) served as controls. Patients were evaluated for the traditional prognostic markers including tumor characteristics, positivity and negativity of sentinel lymph node, TNM, tumor grade, expression of tumor markers CA 15-3 and CEA, hormonal status (pre- or postmenopausal patients, estrogen and progesteron receptor expression), ERB and p53 expression. Predictive value of TGF-beta 1 level and correlation with either of the assessed parameters was tested by one way ANOVA analysis.

RESULTS

Measurements of preoperative plasma TGF-beta 1 levels in patients with operable breast cancer were significantly higher compared with healthy individuals (median 15293 and 3983 pg/ml p < 0.0001). TGF-beta 1 level in plasma of patients with a positive sentinel lymph node was significantly higher than in patients with negative sentinel lymph nodes (high vs low, median 18,9 and 14,5 ng/ml, respectively, p = 0.05).

CONCLUSION

The determination of TGF-beta 1 status might help to identify a high-risk population early in tumor progression, for which a more appropriate therapy should be established. In the node-negative population, the up-regulation of TGF-beta 1 might constitute an early event that promotes further progression of breast tumors.

[Progression and regression low grade intraepitelial squamous lesions in context of positivity of high risk human papillomavirus]

OBJECTIVE

Evaluation of regression and progression of histologically confirmed low grade squamous intraepithelial lesions (LG SIL) in women under the age of 35 in context of positivity of high risk human papillomavirus (HPV HR). Evaluation of sensitivity of PAP smear and HPV HR test in women with LG SIL.

DESIGN

Prospective study.

SETTING

Department of Obstetrics and Gynecology, Charles University Prague, 2nd Medical Faculty, University Hospital Motol.

PATIENTS AND METHODS

166 women with SIL low or repeated ASC-US PAP smear were included to the study. 1 to 3 punch biopsy under the expert colposcopy and HPV HR test were performed in all women. Follow up were done every 6 month in all women with histologically confirmed LG SIL.

RESULTS

LG SIL was detected in 120 women. Sensitivity of PAP smear was 72.3% and sensitivity of HPV HR test 60.2 % in women with LG SIL. 84 women (70 %) were HPV HR positive. Regression of LG SIL was detected in 20 (23 %) HPV HR positive women and in 18 (50%) HPV HR negative women. This difference is statistically significant (p = 0.0094). Progression of LG SIL was detected in 24 (29 %) HPV HR positive women and in 4 (11%) women HPV HR negative women. This difference is borderline statistically significant (p = 0.058). Progression of LG SIL to the carcinoma in situ or invasive cancer had not been detected during follow up period.

CONCLUSION

PAP smear is a standard for LG SIL detection in women under the age of 35 and HPV HR test is not so important for LG SIL detection in this group of women. HPV HR test could be useful for prediction of the risk of progression, but positivity of HPV HR in LG SIL cannot indicate surgical treatment (conisation) in this cohort of women under the age of 35.

[Detection of postoperative lymphoedema in patients with breast cancer]

OBJECTIVE

Lymphoedema is a severe postoperative complication after treatment of many malignancies. It is a pathological accumulation of extracellular water (ECW). Early diagnostic tool is needed. Multifrequency bioimpedance analysis (MFBIA) is a method for detection of changes in ECW.

TYPE OF STUDY

Prospective study.

SETTING

Dept. of Obstetrics and Gynaecology of the 2nd Medical Faculty, Charles University, Prague.

METHODS

We measured a control group of 72 women and a group of 74 patients undergoing a breast cancer surgery during 18 month after the surgery by MFBIA and circumferency. Characteristics of the patients were recorded. The detection of lymphoedema was done using MFBIA, circumferency measurement and upon the symptoms of the patients.

RESULTS

The average age in the controll and tested group was 40,1 and 58,9 years. The average size of the tumour, grade and positivity if oestrogen receptors was 15,1 mm, 2,04 and 43%. In 23 patients (21%) complete lymphadenectomy was performed, in 51 patients (79%) a detection of sentinel lymph node was performed. Lymphoedema was detected in 8 women (11%). In these patients MFBIA detected lymphoedema 9 month earlier in total than other methods.

CONCLUSION

MFBIA is a low-cost and precise method for the detection od early stage postoperative lymphoedema. We recommend to incorporate MFBIA into standard dispensatory plan of every patient combined with circumferency measurement.

Endodermal sinus tumor diagnosed in pregnancy: a case report

Pure endodermal sinus tumor (EST) of the ovary is an uncommon germ cell tumor characterized by rapid growth. Its occurrence during pregnancy is extremely rare. The case of a 34-year-old woman with EST stage IC diagnosed in the 22nd week of gestation is presented. She received four cycles of cisplatin monotherapy during pregnancy. Further, three cycles of combination chemotherapy (cisplatin, bleomycin, and etoposide) were administered. Twenty-eight months posttreatment the patient was in complete remission with good health. A healthy female infant was delivered by cesarean section in the 35th week of pregnancy. The child showed normal laboratory, pediatric, and neurologic examination at the time of discharge from hospital and during the first and second years of her life. We conclude that the prognosis of EST is very good if patient receives adjuvant therapy. Cisplatin monotherapy seems to be effective and safe during pregnancy.

[A set of patients with breast cancer associated with pregnancy]

OBJECTIVE

The aim of our study is to follow patients diagnosed with breast cancer associated with pregnancy.

DESIGN

Prospective follow-up study.

SETTING

Department of Obstetrics and Gynecology of the 2nd Medical Faculty of the Charles University and Faculty Hospital Motol, Prague.

METHODS

Between the year 2002 and 2006 12 women were reffered to our department, seven with the diagnosis of breast cancer during pregnancy, three within one year after the delivery, two pregnant after the therapy for breast cancer. A managment was sellected individually with respect to the age of pregnancy, the stage of the disease and to the decision of the women. The average age of the diagnosis, managment, way of delivery, fetal and maternal outcome were recorded.

RESULTS

The average age was 31.7 years. Two patients underwent a termination of the pregnancy, other delivered a healthy newborn. Two of our patients are dead, three have a metastatic disease, one was lost for follow-up, the rest are further followed.

CONCLUSIONS

Breast cancer diagnosed during pregnancy is a special and rare situation, which needs to be managed individually as there is a lack of information about such patients. These patients should be concentrated in specialized centers.

[Transforming growth factor-beta 1 as a marker in patients with operable breast cancer]

OBJECTIVE AND DESIGN OF STUDY: Determination of TGF-beta 1 levels in plasma of patients with operable breast cancer. The correlation of TGF levels with the stage of disease and other prognostic markers. Prospective study.

METHODS

There were 36 patients fulfilling the entrance criteria included in the study. The blood samples were taken to set the plasma levels of TGF-beta before the operation, with no adjuvant therapy. 27 age matched healthy volunteers served as controls. The study was approved by ethical board and patients signed informed consent regarding blood sampling and results presentation. Differences between groups were determined using the Mann-Whitney U-test.

RESULTS

We proved that TGF-beta 1 levels are elevated in patients with operable breast cancer. Moreover, TGF-beta in plasma of patients with positive sentinel lymph node was significantly higher as compared to patients with negative sentinel node. Most important is the fact that patients involved in our study were in very early stages of disease.

CONCLUSION

TGF-beta 1 is marker correlating with breast cancer disease risk factors, especially with positive sentinel lymph node. We conclude that TGF is one of the early markers which may help define the risk of disease progression already before the operation.

Langerhans cell histiocytosis of vulva in adolescent

Langerhans cell histiocytosis (LCH) affecting child vulva alone is a very rare disease. Only 13 cases of primary vulvar LCH have been previously reported in the medical literature. We describe an additional case in which the LCH was confined to the vulva, with review of the literature. A 16.5-year-old girl presented with papulous and ulcerative lesions on her labia majora and minora. The biopsy revealed a typical histopathologic finding consistent with LCH. A metastatic work-up did not reveal any evidence of the disease except on the vulva. Treatment was carried out according to LCH II protocol. The patient was diagnosed with a recurrent disorder in the vulva 8 months after the completion of primary chemotherapy. For this reason, she underwent second line treatment with 2-chlorodeoxyadenosine. Eighteen months after the second line chemotherapy, the patient has no signs of a local or systemic recurrence. Primary LCH of vulva is very unusual, but we have to keep in mind this possibility when an adolescent girl presents with an atypical chronic lesion on the vulva. This patient appears to be the first case of adolescent 16.5 year old having a solely cutaneous lesion of the vulva