Dosimetric Parameters Correlate with Taste Alterations in Head and Neck Radiotherapy

PURPOSE/OBJECTIVE(S)

Dysgeusia is an acute and chronic side effect of head and neck chemoradiation, with persistent taste dysfunction 1-2 years post radiotherapy occurring in 23-50% of patients. Several head and neck clinical trials set oral cavity mean doses between 30 to 40 Gy, however, there are no set guidelines accurately defining the composite structure and anatomic boundaries for the oral cavity or separating the tongue into specific quadrants. In this single institution cross sectional study, we sought to determine the effects of radiation doses to specific regions of the oral cavity and tongue on patient-reported long term dysgeusia. We hypothesize that radiation Dose to specific structures in the oral cavity will correlate with long-term dysgeusia in patients who have received head and neck radiotherapy.

MATERIALS/METHODS

Patients with primary head and neck cancer receiving definitive intensity modulated radiation therapy (RT) completed quality of life assessments that included patient-reported gustatory function, 1 year post RT. Dosimetric data from RT plans were collected for specific regions and organs at risk within the oral cavity. These structures included the anterior, posterior, superior and inferior tongue (OT), pharyngeal constrictors (as a surrogate for the corda-tympani) and the oral cavity. A forward binary logistic regression model was performed using these data points with scoring from the QLQ-H&N43 questionnaire subsection on taste (Q45) to determine the most predictive values for dysgeusia and the OR for moderate/severe alterations in taste.

RESULTS

A total of 78 patients were included in this study, of these patients, 63 had dosimetric data for the pharyngeal constrictors. The Oral Cavity Volume percentage receiving 50Gy (OC V50) and Pharyngeal Constrictors Volume percentage receiving 55Gy (PC V55) were the most predictive constraints for dysgeusia. (0.042, p = 0.011 and 0.041, p = 0.033). Holding all other variables constant in a forward binary logistic regression including 78 patients, the odds of having moderate to severe taste alterations increased by 56% (OR 1.045, 95% CI 1.012-1.079) for a 1% increase in OCV50. When analyzing the 68 patients with available pharyngeal constrictors data, taste alteration increased 20% for every 1% increase in PCV55 (OR 1.042, 95% CI 1.003-1.082). There was no correlation with taste alterations in any of the dose parameters tested (Dmax, mean and V50 up to V70) for superior, inferior, anterior or posterior regions of the tongue.

CONCLUSION

Dosimetric parameters for the oral cavity (OC V50) and pharyngeal constrictors (PC V55) were positively correlated with taste alterations, however, no other specific regions within the oral tongue predicted taste disfunction. Normal tissue complication probability modeling curves to identify OC V50 and PC V55 constraints for dysgeusia are needed.

Immune landscape in vulvar cancer-draining lymph nodes indicates distinct immune escape mechanisms in support of metastatic spread and growth

Background

Therapeutic immune intervention is highly dependent on the T-cell priming and boosting capacity of tumor-draining lymph nodes (TDLN). In vulvar cancer, in-depth studies on the immune status of (pre)metastatic TDLN is lacking.

Methods

We have phenotyped and enumerated various T-cell and myeloid subsets in tumor-free (LN−, n=27) and metastatic TDLN (LN+, n=11) using flow cytometry. Additionally, we studied chemokine and cytokine release profiles and assessed expression of indoleamine 2,3-dioxygenase (IDO) in relation to plasmacytoid dendritic cell (pDC) or myeloid subsets.

Results

Metastatic involvement of TDLN was accompanied by an inflamed microenvironment with immune suppressive features, marked by hampered activation of migratory DC, increased cytokine/chemokine release, and closely correlated elevations of pDC and LN-resident conventional DC (LNR-cDC) activation state and frequencies, as well as of terminal CD8⁺ effector-memory T-cell (TemRA) differentiation, regulatory T-cell (Treg) rates, T-cell activation, and expression of cytotoxic T-lymphocyte protein-4 (CTLA-4) and programmed cell death protein-1 (PD-1) immune checkpoints. In addition, high indoleamine 2,3-dioxygenase (IDO) expression and increased frequencies of monocytic myeloid-derived suppressor cells (mMDSC) were observed. Correlation analyses with primary and metastatic tumor burden suggested respective roles for Tregs and suppression of inducible T cell costimulator (ICOS)⁺ T helper cells in early metastatic niche formation and for CD14⁺ LNR-cDC and terminal T-cell differentiation in later stages of metastatic growth.

Conclusions

Metastatic spread in vulvar TDLN is marked by an inflamed microenvironment with activated effector T cells, which are likely kept in check by an interplay of suppressive feedback mechanisms. Our data support (neoadjuvant) TDLN-targeted therapeutic interventions based on CTLA-4 and PD-1 blockade, to reinvigorate memory T cells and curb early metastatic spread and growth.

HPV-16 E6/E7 DNA tattoo vaccination using genetically optimized vaccines elicit clinical and immunological responses in patients with usual vulvar intraepithelial neoplasia (uVIN): a phase I/II clinical trial

Background

Usual vulvar intraepithelial neoplasia (uVIN) is a premalignancy caused by persistent infection with high-risk types of human papillomavirus (HPV), mainly type 16. Even though different treatment modalities are available (eg, surgical excision, laser evaporation or topical application of imiquimod), these treatments can be mutilating, patients often have recurrences and 2%–8% of patients develop vulvar carcinoma. Therefore, immunotherapeutic strategies targeting the pivotal oncogenic HPV proteins E6 and E7 are being explored to repress carcinogenesis.

Method

In this phase I/II clinical trial, 14 patients with HPV16+ uVIN were treated with a genetically enhanced DNA vaccine targeting E6 and E7. Safety, clinical responses and immunogenicity were assessed. Patients received four intradermal HPV-16 E6/E7 DNA tattoo vaccinations, with a 2-week interval, alternating between both upper legs. Biopsies of the uVIN lesions were taken at screening and +3 months after last vaccination. Digital photography of the vulva was performed at every check-up until 12 months of follow-up for measurement of the lesions. HPV16-specific T-cell responses were measured in blood over time in ex vivo reactivity assays.

Results

Vaccinations were well tolerated, although one grade 3 suspected unexpected serious adverse reaction was observed. Clinical responses were observed in 6/14 (43%) patients, with 2 complete responses and 4 partial responses (PR). 5/14 patients showed HPV-specific T-cell responses in blood, measured in ex vivo reactivity assays. Notably, all five patients with HPV-specific T-cell responses had a clinical response.

Conclusions

Our results indicate that HPV-16 E6/E7 DNA tattoo vaccination is a biologically active and safe treatment strategy in patients with uVIN, and suggest that T-cell reactivity against the HPV oncogenes is associated with clinical benefit.

Trial registration number

NTR4607.

Delta-Like Ligand-Notch1 Signaling Is Selectively Modulated by HPV16 E6 to Promote Squamous Cell Proliferation and Correlates with Cervical Cancer Prognosis

Human papillomavirus (HPV) drives high-grade intraepithelial neoplasia and cancer; for unknown reasons, this occurs most often in the cervical transformation zone. Either mutation or HPV E6-driven inhibition of Notch1 can drive neoplastic development in stratified squamous epithelia. However, the contribution of Notch1 and its Delta-like ligands (DLL) to site susceptibility remains poorly understood. Here, we map DLL1/DLL4 expression in cell populations present in normal cervical biopsies by immunofluorescence. In vitro keratinocyte 2D monolayer models, growth assays, and organotypic raft cultures were used to assess the functional role of DLL-Notch signaling in uninfected cells and its modulation by HPV16 in neoplasia. An RNA sequencing-based gene signature was used to suggest the cell of origin of 279 HPV-positive cervical carcinomas from The Cancer Genome Atlas and to relate this to disease prognosis. Finally, the prognostic impact of DLL4 expression was investigated in three independent cervical cancer patient cohorts. Three molecular cervical carcinoma subtypes were identified, with reserve cell tumors the most common and linked to relatively good prognosis. Reserve cells were characterized as DLL1-/DLL4+, a proliferative phenotype that is temporarily observed during squamous metaplasia and wound healing but appears to be sustained by HPV16 E6 in raft models of low-grade and, more prominently, high-grade neoplasia. High expression of DLL4 was associated with an increased likelihood of cervical cancer-associated death and recurrence. Taken together, DLL4-Notch1 signaling reflects a proliferative cellular state transiently present during physiologic processes but inherent to cervical reserve cells, making them strongly resemble neoplastic tissue even before HPV infection has occurred. SIGNIFICANCE: This study investigates cervical cancer cell-of-origin populations and describes a DLL-Notch1 phenotype that is associated with disease prognosis and that might help identify cells that are susceptible to HPV-induced carcinogenesis.

HPV16 E7 DNA tattooing: safety, immunogenicity, and clinical response in patients with HPV-positive vulvar intraepithelial neoplasia

BACKGROUND

Usual type vulvar intraepithelial neoplasia (uVIN) is caused by HPV, predominantly type 16. Several forms of HPV immunotherapy have been studied, however, clinical results could be improved. A novel intradermal administration route, termed DNA tattooing, is superior in animal models, and was tested for the first time in humans with a HPV16 E7 DNA vaccine (TTFC-E7SH).

METHODS

The trial was designed to test safety, immunogenicity, and clinical response of TTFC-E7SH in twelve HPV16+ uVIN patients. Patients received six vaccinations via DNA tattooing. The first six patients received 0.2 mg TTFC-E7SH and the next six 2 mg TTFC-E7SH. Vaccine-specific T-cell immunity was evaluated by IFNγ-ELISPOT and multiparametric flow cytometry.

RESULTS

Only grade I-II adverse events were observed upon TTFC-E7SH vaccination. The ELISPOT analysis showed in 4/12 patients a response to the peptide pool containing shuffled E7 peptides. Multiparametric flow cytometry showed low CD4+ and/or CD8+ T-cell responses as measured by increased expression of PD-1 (4/12 in both), CTLA-4 (2/12 and 3/12), CD107a (5/12 and 4/12), or the production of IFNγ (2/12 and 1/12), IL-2 (3/12 and 4/12), TNFα (2/12 and 1/12), and MIP1β (3/12 and 6/12). At 3 months follow-up, no clinical response was observed in any of the twelve vaccinated patients.

CONCLUSION

DNA tattoo vaccination was shown to be safe. A low vaccine-induced immune response and no clinical response were observed in uVIN patients after TTFC-E7SH DNA tattoo vaccination. Therefore, a new phase I/II trial with an improved DNA vaccine format is currently in development for patients with uVIN.

Abstract 1746: Rational molecular assessment and innovative drug selection (RAIDs): Paving the way to personalized medicine in cervical cancer

Cervical cancer (CC) is the fourth most common cause of cancer deaths in women worldwide, for which prognostic and predictive biomarkers are largely lacking. RAIDs is a EU-funded project on cervical cancer that spans seven European countries. The main objective of the RAIDs project is to use this tumor type, which is easily accessible for repeated biopsies, to learn how to stratify patients into targeted therapies. The project includes: 1) a cognitive cohort study (BioRAIDs), one of the first prospective trials intended to define patient stratification for targeted therapies, 2) a targeted clinical trial using an HPV directed vaccine and 3) preclinical studies aiming at assessing new treatment strategies. Molecular analysis on quality controlled tumor and sera samples from 400 patients include Next Generation Sequencing at SeqOmics (Hungary), PIK3CA mutations detection in circulating tumor DNA at Erasmus MC (Netherlands), Reverse Phase Protein array and HPV insertion sites analyses at Institut Curie (France) and immune-microenvironment analyses at CGOA (Netherlands). In addition, 20 CC cell lines have been profiled pharmacologically using a panel of drugs which potentially synergize with “standard treatment”.

The present poster will mainly focus on the Reverse Phase Protein Array (RPPA) results of BioRAIDs and how these relate to the genomic profiling and to patient outcome. More than 150 cryopreserved baseline (before treatment) samples and 23 CC cell lines have been screened by RPPA. From these, whole exome sequencing is available for 92 patient samples. Stratification of patients based on proteomics and genomics has evidenced different subgroups (clusters) of patients displaying specific molecular characteristics. Genomics data and proteomics data both demonstrate that these clusters differ notably in the pathways of oxidative phosphorylation, glycolysis and DNA repair. Patient response to treatment is assessed by the presence or absence of residual tumor at six months after treatment. The correlation of proteomics and genomics data with these clinical data is ongoing and will identify putative predictive biomarkers. Correlation of protein data with response to drugs treatment in 20 CC cell lines has identified several potential biomarkers, some of which again relate to (glucose) metabolism.

In conclusion, we here present new evidence for molecular subgroups of cervical cancer that could benefit from different treatment options. Notably, our data suggest that the metabolism/glycolysis pathways are a major effector in CC and constitute a potential therapeutic target in a subset of patients.

This project has received funding from the European Union’s Seventh Program for research, technological development and demonstration under grant agreement No 304810.

Citation Format: Leanne de Koning, Bérengère Ouine, Aurélie Cartier, Els M. Berns, Kirsten Ruigrok-Ritstier, Corine Beaufort, Balazs Balint, Attila Kereszt, Gemma Kenter, Sanne Samuels, Ekaterina S. Jordanova, Emmanuelle Jeannot, Heiko von der Leyen, Marina Popovic, Windy Luscap-Rondof, Vonick Sibut, Choumouss Kamoun, Isabel Britto, Claudia Rincon, Philippe Hupé, Maud Kamal, Suzy M. Scholl. Rational molecular assessment and innovative drug selection (RAIDs): Paving the way to personalized medicine in cervical cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1746. doi:10.1158/1538-7445.AM2017-1746

Impact of (chemo)radiotherapy on immune cell composition and function in cervical cancer patients

New treatments based on combinations of standard therapeutic modalities and immunotherapy are of potential use, but require a profound understanding of immune modulatory properties of standard therapies. Here, the impact of standard (chemo)radiotherapy on the immune system of cervical cancer patients was evaluated. Thirty patients with cervical cancer were treated with external beam radiation therapy (EBRT), using conventional three-dimensional or intensity modulated radiation therapy without constraints for bone marrow sparing. Serial blood sampling for immunomonitoring was performed before, midway and at 3, 6 and 9 weeks after EBRT to analyze the composition of lymphocyte and myeloid-cell populations, the expression of co-stimulatory molecules, T-cell reactivity and antigen presenting cell (APC) function. Therapy significantly decreased the absolute numbers of circulating leukocytes and lymphocytes. Furthermore, the capacity of the remaining T cells to respond to antigenic or mitogenic stimulation was impaired. During treatment the frequency of both CD4⁺ and CD8⁺ T cells dropped and CD4⁺ T cells displayed an increased expression of programmed cell death-1 (PD-1). In vitro blocking of PD-1 successfully increased T-cell reactivity in all five samples isolated before radiotherapy but was less successful in restoring reactivity in samples isolated at later time points. Moreover, (chemo)radiotherapy was associated with an increase in both circulating monocytes and myeloid-derived suppressor cells (MDSCs) and an impaired capacity of APCs to stimulate allogeneic T cells. T-cell reactivity was slowly restored at 6–9 weeks after cessation of therapy. We conclude that conventional (chemo)radiotherapy profoundly suppresses the immune system in cervical cancer patients, and may restrict its combination with immunotherapy.

From prospective biobanking to precision medicine: BIO-RAIDs - an EU study protocol in cervical cancer

Background

Cervical cancer (CC) is -second to breast cancer- a dominant cause of gynecological cancer-related deaths worldwide. CC tumor biopsies and blood samples are of easy access and vital for the development of future precision medicine strategies.

Design

BIO-RAIDs is a prospective multicenter European study, presently recruiting patients in 6 EU countries. Tumor and liquid biopsies from patients with previously non-treated cervical cancer (stages IB2-IV) are collected at defined time points. Patients receive standard primary treatment according to the stage of their disease. 700 patients are planned to be enrolled. The main objectives are the discovery of -dominant molecular alterations, -signalling pathway activation, and -tumor micro-environment patterns that may predict response or resistance to treatment. An exhaustive molecular analysis is performed using 1° Next generation sequencing, 2° Reverse phase protein arrays and 3° Immuno-histochemistry.

Discussion

The clinical study BIO-RAIDs is activated in all planned countries, 170 patients have been recruited till now. This study will make an important contribution towards precision medicine treatments in cervical cancer. The results will support the development of clinical practice guidelines for cervical cancer patients to improve their prognosis and their quality of life.

Trial registration

Clinicaltrials.gov: NCT02428842, registered 10 February 2015.

Integration of geriatric mental health screening into a primary care practice: a patient satisfaction survey

OBJECTIVE

Colocation of mental health screening, assessment, and treatment in primary care reduces stigma, improves access, and increases coordination of care between mental health and primary care providers. However, little information exists regarding older adults' attitudes about screening for mental health problems in primary care. The objective of this study was to evaluate older primary care patients' acceptance of and satisfaction with screening for depression and anxiety.

METHODS

The study was conducted at an urban, academically affiliated primary care practice serving older adults. Study patients (N = 107) were screened for depression/anxiety and underwent a post-screening survey/interview to assess their reactions to the screening experience.

RESULTS

Most patients (88.6%) found the length of the screening to be "just right." A majority found the screening questions somewhat or very acceptable (73.4%) and not at all difficult (81.9%). Most participants did not find the questions stressful (84.9%) or intrusive (91.5%); and a majority were not at all embarrassed (93.4%), upset (93.4%), or uncomfortable (88.8%) during the screening process. When asked about frequency of screening, most patients (72.4%) desired screening for depression/anxiety yearly or more. Of the 79 patients who had spoken with their physicians about mental health during the visit, 89.8% reported that it was easy or very easy to talk with their physicians about depression/anxiety. Multivariate results showed that patients with higher anxiety had a lower positive reaction to the screen when controlling for gender, age, and patient-physician communication.

CONCLUSIONS

These results demonstrate strong patient support for depression and anxiety screening in primary care.

High levels of soluble MICA are significantly related to increased disease-free and disease-specific survival in patients with cervical adenocarcinoma

Downregulation of major histocompatibility complex class I chain-related molecule A (MICA) and upregulation of human leukocyte antigen G (HLA-G) on the tumor cells are important immune escape mechanisms for different epithelial tumors. In addition, upregulation of the soluble forms of the latter molecules in serum leads to peripheral T-cell and natural killer (NK)-cell tolerance. As for cervical cancer, it remains unknown whether soluble MICA (sMICA) and soluble HLA-G (sHLA-G) concentrations are related to tumor characteristics or patient survival rates. We measured sMICA and sHLA-G in pre-treatment sera of a large cohort of cervical cancer patients (n = 366) by enzyme-linked immunosorbent assay (ELISA). We detected a median sMICA of 174.73 pg/ml and a median sHLA-G of 5.35 U/ml. We did not find an association between sHLA-G levels and clinicopathological characteristics. In adenocarcinoma, low sMICA concentration was positively related to recurrent disease, a higher International Federation of Gynecology and Obstetrics (FIGO) stage and vaginal involvement (Mann-Whitney U-test; P = 0.018, P = 0.042 and P = 0.013, respectively). In the latter patient group, high sMICA levels were associated with better disease-free survival (DFS) and disease-specific survival (DSS) (P = 0.011 and P = 0.047). After adjusting for confounding factors, high sMICA proved to be an independent predictor for a better DFS and DSS [HR 0.16; 95% confidence interval (CI) 0.04-0.64; P = 0.009 and HR 0.12; 95% CI 0.03-0.50; P = 0.004]. sHLA-G did not influence survival in cervical cancer patients, regardless of histology. We conclude that cervical adenocarcinoma patients with high sMICA levels have an increased DFS and DSS. This data warrants a prospective trial to study the functional role of sMICA in cervical adenocarcinoma.

High and interrelated rates of PD-L1+CD14+ antigen-presenting cells and regulatory T cells mark the microenvironment of metastatic lymph nodes from patients with cervical cancer

A better understanding of the microenvironment in relation to lymph node metastasis is essential for the development of effective immunotherapeutic strategies against cervical cancer. In the present study, we investigated the microenvironment of tumor-draining lymph nodes of patients with cervical cancer by comprehensive flow cytometry-based phenotyping and enumeration of immune-cell subsets in tumor-negative (LN(-), n = 20) versus tumor-positive lymph nodes (LN(+), n = 8), and by the study of cytokine release profiles (n = 4 for both LN(-) and LN(+)). We found significantly lower CD4(+) and higher CD8(+) T-cell frequencies in LN(+) samples, accompanied by increased surface levels of activation markers (HLA-DR; ICOS; PD-1; CTLA-4) and the memory marker CD45RO. Furthermore, in LN(+), we found increased rates of a potentially regulatory antigen-presenting cell (APC) subset (CD11c(hi)CD14(+)PD-L1(+)) and of myeloid-derived suppressor cell subsets; the LN(+) APC subset correlated with significantly elevated frequencies of FoxP3(+) regulatory T cells (Treg). After in vitro stimulation with different Toll-like receptor (TLR) ligands (PGN; Poly-IC; R848), we observed higher production levels of IL6, IL10, and TNFα but lower levels of IFNγ in LN(+) samples. We conclude that, despite increased T-cell differentiation and activation, a switch to a profound immune-suppressive microenvironment in LN(+) of patients with cervical cancer will enable immune escape. Our data indicate that the CD14(+)PD-L1(+) APC/Treg axis is a particularly attractive and relevant therapeutic target to specifically tackle microenvironmental immune suppression and thus enhances the efficacy of immunotherapy in patients with metastasized cervical cancer.

Working across boundaries: clinical outcomes for an integrated mental health service for people with intellectual disabilities

BACKGROUND

The Mental Health Service for People with Learning Disabilities (MHSPLD) is a service development in keeping with UK government policy that promotes cross agency working and access to mainstream mental health services for people with intellectual disabilities. We aimed to show whether the service model brought about improvements in people's mental state and level of functioning.

METHODS

Community and inpatient groups were compared across three time points using a range of clinical outcome measures that assessed psychiatric symptoms, risk, needs and level of functioning.

RESULTS

Inpatients and community groups had similar mental health problems, but inpatients had higher unmet needs and lower functioning, and were at greater risk. There were significant improvements across the range of outcome measures in both groups.

CONCLUSIONS

Working with mainstream mental health services and across health and social service boundaries delivers effective mental health care for people with intellectual disabilities.

Occupational Health Survey of Farm Workers by Camp Health Aides

Little is known about the magnitude of occupational health problems among migrant farm workers. A community-based cross-sectional survey was conducted in two migrant farm worker communities: Homestead, Florida, and Kankakee, Illinois. Camp Health Aides (CHAs) interviewed 425 workers about job tasks, personal protective equipment (PPE), field sanitation, work exposures, and selected health conditions. Limited provision of personal protective equipment was reported among those reporting early re-entry tasks: 35% in Kankakee and 42% in Homestead were provided gloves, and 22% in Homestead and 0% in Kankakee were provided protective clothing. About two-thirds were provided toilet facilities and water for hand-washing. Workers reported high prevalences of health conditions consistent with exposure to ergonomic hazards and pesticides. The prevalence of back pain in the past 12 months was 39% in Homestead and 24% in Kankakee. Among Homestead participants, 35% experienced eye symptoms, while 31% reported skin symptoms. These symptoms were less prevalent among Kankakee participants (16% for both eye and skin symptoms). Specific areas of concern included back pain associated with heavy lifting and ladder work; eye and skin irritation associated with fertilizer application tasks and with working in fields during or after spraying of chemicals, especially early re-entry of sprayed fields; and skin irritation associated with a lack of access to hand-washing facilities. In both Kankakee and Homestead, better adherence to safety standards is needed, as well as greater efforts to implement solutions that are available to help prevent work-related musculoskeletal problems.

Uterine leiomyoma and menstrual cycle characteristics in a population-based cohort study

BACKGROUND

We examined the association of uterine leiomyoma with menstrual cycle characteristics in a population of non-care-seeking women.

METHODS

This cross-sectional study uses data from the Seveso Women's Health Study (SWHS), a population-based cohort in Italy. Participants included 341 premenopausal women, 30-60 years old, who had an intact uterus and were not pregnant, lactating, or using oral contraception or intra-uterine devices. We examined the presence of any ultrasound-detected uterine leiomyoma in relation to self-reported menstrual cycle length, flow length and heaviness of flow. The association of leiomyoma number, volume, tissue layer location and axial position with menstrual cycle characteristics was also examined.

RESULTS

Uterine leiomyomata were detected in 73 women (21.4%). After adjustment for covariates, the presence of a leiomyoma was not significantly related to menstrual cycle length, flow length or heaviness of flow [odds ratio (OR) for scanty flow =1.9, 95% confidence interval (CI) 0.8-4.3; OR for heavy flow =1.3, 95% CI 0.7-2.5; relative to moderate flow]. Number, volume, tissue layer location (subserosal or intramural) and axial position (anterior or posterior) of the leiomyoma were also not related to menstrual cycle characteristics.

CONCLUSION

In this Italian population of women not seeking gynaecological care, menstrual characteristics are not related to leiomyoma.