Integrative Medicine for Ovarian Cancer

PURPOSE OF REVIEW

Integrative oncology (IO) services provide a wide range of complementary medicine therapies, many of which can augment the beneficial effects of conventional supportive and palliative care for patients with ovarian cancer. This study aims to assess the current state of integrative oncology research in ovarian cancer care.

RECENT FINDINGS

We review the clinical research both supporting the effectiveness of leading IO modalities in ovarian cancer care as well as addressing potential safety-related concerns. There is growing amount of clinical research supporting the use of IO and implementation of integrative gynecological oncology models of care within the conventional supportive cancer care setting. Additional research is still needed in order to create clinical guidelines for IO interventions for the treatment of female patients with ovarian cancer. These guidelines need to address both effectiveness and safety-related issues, providing oncology healthcare professionals with indications for which these patients can be referred to the IO treatment program.

Resection rectopexy as part of the multidisciplinary approach in the management of complex pelvic floor disorders

Objectives

Pelvic floor disorders are frequently caused by an organ prolapse involving multiple pelvic floor compartments. In such cases, a multidisciplinary strategy for diagnostic work-up and therapy is required.

Methods

All patients who underwent transabdominal rectopexy/resection rectopexy alone or in combination with simultaneous gynecological pelvic floor reconstruction at our institution between 01/2006 and 12/2021 were included in this retrospective study. The study aimed to evaluate the functional outcome and postoperative complications.

Results

Two hundred and eighty seven patients were assigned to one of the following groups: PG1 - patient group one: after resection rectopexy (n=141); PG2 - after ventral rectopexy (n=8); PG3 - after combined resection rectopexy and sacro (cervico)colpopexy (n=62); PG4 - after combined resection rectopexy and trans-vaginal pelvic floor repair (n=76). The duration of follow-up was 14 months for PG1 (median, IQR 37 months), 11 months for PG2 (mean, SD 9 months), 7 months for PG 3 (median, IQR 33 months), and 12 months for PG 4 (median, IQR 51 Months). The surgical procedure resulted in improvement of symptoms related to obstructed defecation in 56.4 % (22/39) of the patients in PG1, 25 % in PG2 (1/4), 62.5 % (20/32) in PG3, and 71.8 % (28/39) in PG4. "De novo" constipation was reported by 2.4 % (2/141) of patients from PG1. Improvement in fecal incontinence symptoms was reported by 69 % (40/58) of patients in PG1, 100 % in PG2 (2/2), 93.1 % (27/29) in PG3, and 87.2 % (34/39) in PG4. The recurrence rate for external rectal prolapse was 7.1 % in PG1, 50 % in PG2 (1/2), 2.7 % in PG3, and 6.3 % in PG4. A significant difference in terms of severe morbidity (grade ≥ IIIb) and mortality could not be determined between the non-interdisciplinary (PG1 with PG2) and interdisciplinary surgery (PG3 with PG4) (p=0.88, p=0.499).

Conclusions

Based on our results, we can assume that combined surgery is as feasible as rectal surgery alone. In our study, combined interventions were effective and not associated with an increased risk of postoperative complications.

Altered protease expression by periarterial trophoblast cells in severe early-onset preeclampsia with IUGR

Adaptation of uteroplacental arteries in patients with early-onset preeclampsia combined with IUGR is compromised due to insufficient invasion of extravillous trophoblast cells (EVT) into the spiral artery wall. The underlying molecular mechanisms are widely unknown. We investigated expression and possible mechanisms of regulation of different matrix-metalloproteases (MMPs) by EVT in placental bed biopsies from patients with early onset preeclampsia combined with IUGR and healthy pregnant women. Expression of MMP-3 and MMP-7 by EVT was markedly reduced in preeclamptic patients, especially close to spiral arteries. In contrast to healthy pregnancies these cells strongly expressed the receptor for leukemia inhibitory factor (LIF). LIF is known to suppress MMP-expression and is produced by uterine natural killer (uNK) cells which we found to be present in higher concentrations in the placental bed of preeclamptic patients, and accumulating aside the spiral arteries. We speculate that in preeclampsia a maternal immune cell network accumulating and interfering in the placental bed leads to an altered cytokine environment, resulting in disturbed trophoblast cell function such as impaired MMP expression and reduced invasiveness.

Patient Refusal of Emergency Cesarean Delivery

OBJECTIVE

To compare the attitudes of a large sample of obstetricians from eight European countries toward a competent woman's refusal to consent to an emergency cesarean delivery for acute fetal distress.

METHODS

Obstetricians' attitudes in response to a hypothetical clinical case were surveyed through an anonymous, self-administered questionnaire. The sample included 1,530 obstetricians (response rate 77%) from 105 maternity units (response rate 70%) in eight countries: France, Germany, Italy, Luxembourg, Netherlands, Spain, Sweden and the United Kingdom.

RESULTS

In every country, the majority of obstetricians would keep trying to persuade the woman, telling her that failure to perform cesarean delivery might result in the fetus surviving with disability, or even that her own life might be endangered. In Spain, France, Italy, and, to a lesser extent, Germany and Luxembourg, a consistent proportion of physicians would seek a court order to protect fetal welfare or avoid possible legal liability or both. In the United Kingdom, Sweden, and Netherlands, several respondents (59%, 41%, and 37%, respectively) would accept the woman's decision and assist vaginal delivery. Only a small minority (from 0 in the United Kingdom to 10% in France) would proceed with cesarean delivery without a court order.

CONCLUSION

Case law arising from a few countries (United States, Canada, and the United Kingdom) and professional guidelines favoring women's autonomy have not solved the underlying ethical conflict, and in Europe acceptance of a woman's right to refuse cesarean delivery, at least in emergency situations, is not uniform. Differing attitudes between obstetricians from the eight countries may reflect diverse legal and ethical environments.

LEVEL OF EVIDENCE

III.

Caesarean section on request: a comparison of obstetricians' attitudes in eight European countries

OBJECTIVE

To explore the attitudes of obstetricians to perform a caesarean section on maternal request in the absence of medical indication.

DESIGN

Cluster sampling cross-sectional survey.

SETTING

Neonatal Intensive Care Unit (NICU) associated maternity units in eight European countries.

POPULATION

Obstetricians with at least 6 months clinical experience.

METHODS

NICU-associated maternity units were chosen by census in Luxembourg, Netherlands and Sweden and by geographically stratified random sampling in France, Germany, Italy, Spain and UK. An anonymous, self-administered questionnaire was used for data collection.

MAIN OUTCOME MEASURES

Obstetricians' willingness to perform a caesarean section on maternal request.

RESULTS

One hundred and five units and 1,530 obstetricians participated in the study (response rates of 70 and 77%, respectively). Compliance with a hypothetical woman's request for elective caesarean section simply because it was 'her choice' was lowest in Spain (15%), France (19%) and Netherlands (22%); highest in Germany (75%) and UK (79%) and intermediate in the remaining countries. Using weighted multivariate logistic regression, country of practice (P<0.001), fear of litigation (P= 0.004) and working in a university-affiliated hospital (P= 0.001) were associated with physicians' likelihood to agree to patient's request. The subset of female doctors with children was less likely to agree (OR 0.29, 95% CI 0.20-0.42).

CONCLUSIONS

The differences in obstetricians' attitudes are not founded on concrete medical evidence. Cultural factors, legal liability and variables linked to the specific perinatal care organisation of the various countries play a role. Greater emphasis should be placed on understanding the motivation, values and fears underlying a woman's request for elective caesarean delivery.

Increased soluble VCAM-1 serum levels in preeclampsia are not correlated to urinary excretion or circadian blood pressure rhythm

OBJECTIVE

Soluble vascular cell adhesion molecule-1 (VCAM-1) is known to be elevated in serum of patients with preeclampsia, but there are no data available on the significance of urinary VCAM-1 excretion in preeclampsia. The aim of our study was to uncover possible circadian rhythms of VCAM-1 plasma levels and urinary VCAM-1 excretion in uncomplicated and hypertensive pregnancies and to ascertain their relation to blood pressure.

STUDY DESIGN

A total of 10 normotensive and 10 preeclamptic pregnant women were included in this study. Venous blood was collected hourly, and urine samples were taken every 2 h over a period of 24 h. VCAM-1 levels were determined by ELISA. We compared these results with the circadian blood pressure rhythm.

RESULTS

The median VCAM-1 plasma levels were significantly (P < 0.01) increased in preeclamptic patients (851.5 ng/mL) in comparison to normotensive pregnant women (659.3 ng/mL) without any circadian rhythm being apparent; however, the urinary excretion of VCAM-1 showed a typical circadian rhythm, with a higher excretion rate during daytime.

CONCLUSION

For the first time we have demonstrated that urinary VCAM-1 excretion in pregnancy shows a circadian rhythm without correlation to plasma levels or the circadian blood pressure rhythm. In contrast, VCAM-1 serum levels did not show a diurnal rhythm. We assume that VCAM-1 serum levels do not correlate with systemic blood pressure or urinary excretion.

Placenta percreta in week 10 of pregnancy with consecutive hysterectomy: case report

Placenta percreta in early pregnancy is rare and has been documented in only a few cases. We report on a patient with abdominal pain in week 10 of pregnancy. Sonography revealed a defective embryonic development and the absence of a border line between trophoblast and myometrium, as well as invasive growth in the region of isthmocervical transition, so curettage was performed. Heavy bleeding at this stage made a hysterectomy necessary. Histological examination revealed a placenta percreta. Because of possible complications, the therapy of choice for a placenta percreta is a hysterectomy, as was performed in this case.

Macrophage-induced apoptosis limits endovascular trophoblast invasion in the uterine wall of preeclamptic women

Impaired invasion of uteroplacental arteries by extravillous trophoblast cells is a key pathogenic mechanism of preeclampsia. We previously demonstrated that reduced trophoblast invasion into uteroplacental spiral arteries was associated with an excess of macrophages in and around these arteries. To explore the significance of these observations, we correlated the extent of extravillous trophoblast apoptosis in placental bed biopsy specimens with macrophage distribution and studied the effect of macrophages upon trophoblast apoptosis in vitro. Extravillous trophoblast hybrid cells were cocultured with activated macrophages exposed to exogenous tumor necrosis factor alpha (TNFalpha), anti-tumor necrosis factor receptor I (TNF-RI), and tryptophan depletion, and the rates of trophoblast apoptosis were measured. Extravillous trophoblast hybrid cells showed increased rates of apoptosis following exposure to exogenous TNFalpha, with tryptophan depletion, and when cocultured with activated macrophages. The proapoptotic effects of macrophages in vitro were completely inhibited only by simultaneous addition of tryptophan and anti-TNF-RI. Our data indicate that macrophages, residing in excess in the placental bed of preeclamptic women, are able to limit extravillous trophoblast invasion of spiral arterial segments through apoptosis mediated by the combination of TNFalpha secretion and tryptophan depletion. The mechanisms by which macrophages are activated and recruited to the placental bed are presently unknown but are likely central to the pathogenesis of preeclampsia.

Detection of prostate-specific antigen immunoreactivity in amniotic fluid

OBJECTIVE

To examine whether prostate-specific antigen (PSA) is present in amniotic fluid, whether the amniotic fluid PSA concentration changes with gestational age, and whether there is an association between amniotic fluid PSA and fetal sex.

METHODS

The PSA concentration was measured in the amniotic fluid of 48 pregnant women. Thirty-four samples were obtained during routine amniotic fluid analyses performed during gestational weeks 16-18, whereas 14 samples were obtained during cesarean section performed after gestational week 36.

RESULTS

PSA was detected in all amniotic fluid samples. The median amniotic fluid PSA was 0.193 ng/ml during gestational weeks 16-18 and 0.39 ng/ml after gestational week 36 (p = 0.1). Furthermore, no significant association was seen between amniotic fluid PSA and fetal sex. The median amniotic fluid PSA level was 0.233 ng/ml for the 21 boys and 0.222 ng/ml for the 27 girls investigated (p = 0.72).

CONCLUSIONS

These results confirm recent literature reports that PSA may serve as a growth regulator during normal fetal development. However, further studies are necessary to elucidate the exact role of PSA during fetal development.

Hormonal interactions in endometrial cancer

Endometrial cancer (EC) is the most frequent malignant tumor of the female genital tract. Increasing evidence suggests that at least two different types of EC exist. Type I is associated with an endocrine milieu of estrogen predominance. These tumors are of endometrioid histology and develop from endometrial hyperplasia. They have a good prognosis and are sensitive to endocrine manipulation. Type II EC is not associated with a history of unopposed estrogens and develops from the atrophic endometrium of elderly women. They are of serous histology, have a poor prognosis, and do not react to endocrine manipulation. Both types of EC probably differ markedly with regard to the molecular mechanisms of malignant transformation. This article reviews reproductive and lifestyle factors modifying the risk of developing type I EC, including the use of hormonal contraceptives, hormone replacement therapy and tamoxifen. The roles of established and novel therapies for precancerous lesions and for invasive EC in the adjuvant and palliative settings are discussed.

Hormonal treatment of endometrial cancer

In developed western countries endometrial cancer is the most common malignant tumor of the female genital tract. 75% of cases are diagnosed in stage I where cure rates of 75-90% are achieved. In stage II, 5-year survival rates amount only to 50%, in stage III up to 30%, and in stage IV to less than 10%. Despite the preponderance of early stage endometrial cancer, about 20-30% of affected patients will die from this disease. As surgical treatment and/or irradiation are not able to control advanced disease, many investigators have been searching for systemic treatment modalities. Cytotoxic chemotherapy achieves high initial response rates of about 40-60%. Recurrence, however, occurs after a median duration of only a few months. As endometrial cancer develops from hormone dependent cells, endocrine treatment has been the traditional palliative therapy of advanced tumor stages. Several studies to date have failed to demonstrate an efficacy of adjuvant hormonal therapy in cases of high-risk endometrial cancer. For the conservative treatment of precancerous, non-invasive hyperplastic lesions of the endometrium, endocrine therapies have been shown to be efficacious.

The production of pro- and anti-inflammatory cytokines in neonates assessed by stimulated whole cord blood culture and by plasma levels at birth

The capability of neonates to achieve cytokine balance was evaluated. Production of the pro-inflammatory cytokines TNF alpha and IL-8, of the natural anti-inflammatory cytokine IL10 and of the regulator of the acute phase response IL6 was assessed after whole blood stimulation by lipopolysaccharide in cord blood (n = 10), adult volunteers serving as control (n = 17). Additionally, circulating cytokines were determined in cord and in maternal blood immediately after delivery (n = 27, respectively). Significant production of TNF alpha, IL8, IL10 and IL6 was observed in cord blood after lipopolysaccharide stimulation and was similar to cytokine production in adult blood. The plasma concentrations of TNF alpha were significantly higher in cord than in maternal blood, while plasma concentrations of IL10 and IL6 were significantly lower. Our results demonstrate fully developed capability of whole cord blood to synthesize pro- and anti-inflammatory cytokines in response to a pro-inflammatory stimulation in vitro. In vivo, however, higher circulating TNF alpha and lower IL10 and IL6 levels in cord blood suggest that the inflammatory stress associated with normal delivery does not induce detectable anti-inflammatory response in neonates at birth.

[Significance of detecting impaired uteroplacental perfusion for diagnosis of antiphospholipid antibody syndrome--a case report]

INTRODUCTION

The antiphospholipid antibody syndrome (APA) is a potentially life-threatening disease in pregnancy, associated with spontaneous abortion, intrauterine growth retardation (IUGR), preeclampsia and foetal death in utero. One of the sequelae of the antiphospholipid-antibodies is an impaired uteroplacental circulation. We present a case where we diagnosed an antiphospholipid antibody syndrome (APA) on the basis of a highly pathological Doppler flow in both uterine arteries.

CASE REPORT

A 35-year-old G2P0 with a history of intrauterine foetal death in the 24th week was seen at 15 weeks in her second pregnancy for an ultrasound scan. The Doppler study of both uterine arteries showed highly pathological resistance indices and bilateral notching. Laboratory studies revealed elevated levels of antibodies against Cardiolipin and phospholipids. Therapy trials with low-dose aspirin, heparin, corticosteroids, hemodilution therapy and immunoglobulin remained unsuccessful. The foetus developed severe IUGR, anhydramnios and foetal distress. In the 26th week the parents insisted on a caesarean section because of a pathological heart rate pattern. The birth weight was 365 grams and the infant died immediately.

DISCUSSION

There are several mechanisms which impair the uteroplacental circulation in an APA syndrome. Therefore it is essential to perform laboratory tests when detecting a pathological blood flow in both uterine arteries. In this case all therapies failed, and the preterm infant died due to severe IUGR and distress. The diagnosis, however, facilitated the introduction of early anticoagulation therapy for the mother, the exclusion of systemic lupus erythematodes and the counselling of the parents with regard to further pregnancies.

Clinical value of detecting microalbuminuria as a risk factor for pregnancy-induced hypertension in insulin-treated diabetic pregnancies

OBJECTIVE

We evaluated the role of clinical non-overt stage III diabetic nephropathy concerning the development of more frequent hypertensive complications during pregnancies of women requiring insulin.

METHODS

122 unselected pregnant women treated with insulin were enrolled in the study, of whom 56 were type-1 diabetic patients and 66 patients had gestational diabetes. In 24-h urine samples, excretion rates of albumin (UAE) and beta(2)-microglobulin were determined by nephelometric analysis and a radioimmunoassay, respectively. These parameters were also measured in the serum as well as HbA(1c), fructosamine and daily blood glucose profiles.

RESULTS

Sixteen (15.7%) women had an elevated UAE (>30 mg/24 h), of whom three had macroalbuminuria (UAE>300 mg/24 h). Thirteen (12.7%) insulin-treated women showed microalbuminuria during pregnancy, eight with type-1 diabetes and five with gestational diabetes requiring insulin. In the entire group hypertension was observed in seven (6.9%) women of whom six had microalbuminuria. The sensitivity and specificity were 85.7% and 92.6%, respectively. The positive predictive value reached 46.2%, whereas the negative predictive value was 98.9%.

CONCLUSION

Measurement of UAE in diabetic pregnancies seems to be an useful additional parameter for risk evaluation of hypertensive disorders.

[Lethal osteochondrodysplasias: prenatal and postnatal differential diagnosis]

PURPOSE

Lethal osteochondrodysplasias show an abnormal maturation and a disturbed growth of cartilage and bones. They represent a heterogeneous group of rare genetic diseases. Their incidence is 1 to 3 in 10,000 births.

MATERIAL AND METHODS

We report altogether 5 cases: two of thanatophoric dysplasia, one of achondrogenesis type II and two cases of the rare fibrochondrogenesis. The differential diagnosis in respect to ultrasonographic, morphologic, radiographic and histopathologic criteria of the most common of these diseases are discussed together with a review of the literature.

RESULTS

On the basis of the ultrasound finding of the short-rib-syndrome, it is possible to differentiate between viable and lethal osteochondrodysplasias at 19 to 22 weeks of gestation. The short-rin-syndrome leads to pulmonary hypoplasia.

CONCLUSIONS

It is essential to obtain an exact diagnosis postnatally by radiographic and histopathological examinations to counsel the parents concerning the risk of recurrency. The risk in this heterogeneous group of genetic diseases ranges between less than 1% up to 50% depending on the final diagnosis. Our two cases of fibrochondrogenesis in a consanguineous couple strongly suggest an autosomal recessive inheritance in this disease.

[Trophoblast invasion in pre-eclampsia]

It is generally accepted that insufficient invasion of trophoblast cells into the myometrial portions of the spiral arteries is thought to play a crucial role in the development of preeclampsia. As a consequence, uteroplacental vessels fail to undergo adaptive changes which are imperative to provide a sufficient blood supply to the placenta. Consecutive placental hypoxia is supposed to cause secretion/shedding of still unidentified placental metabolites resulting in different forms of pregnancy-induced hypertension. This review presents published data concerning the causes of insufficient trophoblast invasion in preeclampsia. Expression of HLA-G by extravillous trophoblast cells seems to be altered, resulting in activation of the maternal immune system. The pattern of integrin expression as well as the secretion of proteases is reported to be disturbed, which could lead to a reduced invasive potential of the trophoblast cells. Recent data indicate a pathophysiological role of NK-cells and macrophages in the altered trophoblast invasion. Also angiotensinogen Thr235 polymorphism seems to alter early physiologic changes in spiral arteries. In summary, preeclampsia seems to be induced by a multifactorial disturbance of trophoblast invasiveness which is characterized by reduced invasiveness of the trophoblast cells themselves and by an activated maternal immune response blocking the invasion by the semiallogenic trophoblast.

[Pre-eclampsia--endothelial damage of endothelial activation?]

There is considerable evidence that endothelial damage, followed by the release of vasoactive substances contributes to the pathophysiology of preeclampsia. Because of controversial experiences in literature we wanted to evaluate the potential cytotoxic effect of preeclamptic sera on cultured endothelial cells. Therefore cultured human umbilical vein endothelial cells (HUVEC) were stimulated with sera obtained from preeclamptic patients, while sera from normotensive pregnant and nonpregnant women served as controls. To prove the viability of these cells we performed ethidiumbromide/acridinorange immunostaining and determined t-PA/PAI-1 release into the supernatant. These experiments could not show any cytotoxic effect on endothelial cells. In ongoing studies we measured the concentrations of adhesion molecules, markers of endothelial activation, in maternal sera, in the supernatant of cultured endothelial cells, and on cell surface after stimulation with the above mentioned sera. In the supernatant we couldn't determine any different concentrations of adhesion molecules after stimulation with the different sera, but using immunofluorescence-microscopy an increased concentration of those molecules could be detected on the endothelial surface after stimulation with preeclamptic sera than compared to sera from normotensive controls. In conclusion, our experiments support the hypothesis that sera from preeclamptic women may cause endothelial activation.

Dialysis and pregnancy--a case report and review of the literature

We report on a patient with an eight-year history on maintenance hemodialysis treatment without residual renal function in whom pregnancy was successfully managed through to the 29th week. During this time, under carefully modified dialysis treatment, the nephrologic course, as well as materno-fetal flow relationships were unremarkable. Fetal development was appropriate for gestational age. However, pregnancy was complicated by polyhydramnios, which necessitated i.v. tocolysis. In the 28 + 6th week of gestation, cesarean section was performed because of an antibiotic-resistant fever of unclear origin which ceased within two days of delivery. Although the postnatal course of the adequately developed baby was complicated by the respiratory distress syndrome, normal development continued. We emphasize that the intensive interdisciplinary cooperation of nephrologists and obstetricians is imperative for the successful management of pregnancy under these conditions. In these pregnancies, the main fetal problems consist of premature labor because of polyhydramnios, preterm delivery, intrauterine growth retardation and stillbirth. The mother is threatened by the development of superimposed pre-eclampsia, left ventricular failure because of volume overload and progressive anemia. In order to maintain a well-balanced homeostasis, intensification of dialysis therapy by an increase in frequency and duration is the most important therapeutic approach. Accurate fetal monitoring including frequent examination of the feto-maternal circulation by Doppler sonography as well as attentive surveillance of the mother is required to recognize the above mentioned complications.

Elevated soluble adhesion molecules in women with pre-eclampsia. Do cytokines like tumour necrosis factor-alpha and interleukin-1beta cause endothelial activation

OBJECTIVE

The purpose of the present study was to evaluate the clinical significance of tumour necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) for endothelial cell activation in pre-eclampsia. Therefore, we determined and compared the correlations between these cytokines and circulating adhesion molecules in the sera of pre-eclamptic pregnant women, normotensive pregnant women and nonpregnant women.

METHODS

The soluble adhesion molecules VCAM-1, ICAM-1, E-selectin, and P-selectin were determined in the serum of 38 pre-eclamptic pregnant women and 40 normotensive pregnant and nonpregnant controls using ELISA-techniques. We correlated these serum concentrations with the serum levels of TNF-alpha and IL-1beta, respectively, also determined by ELISA.

RESULTS

Elevated serum levels of VCAM-1 and E-selectin could be detected in pre-eclamptic patients, with and without HELLP-syndrome. In contrast, no increased serum concentration of ICAM-1, P-selectin, TNF-alpha and IL-1beta were found in these patients. While significant correlation between VCAM-1 and E-selectin could be determined (r=0.604; p<0.001) no unambiguous correlations, however, were found between TNF-alpha or between IL-1beta and the examined adhesion molecules or the selectins.

CONCLUSIONS

In contrast to in vitro investigations on cultured umbilical vein endothelium, our experimental results indicate that the cytokines TNF-alpha and IL-1beta can not explain endothelial cell activation, and that their measurement in serum is not useful for the detection of pre-eclampsia.

Immunohistochemical analysis of prostate-specific antigen does not correlate to other prognostic factors in breast cancer

BACKGROUND

Prostate-specific antigen (PSA) is found in 30-40% of female breast tumors, as recently described. Diamandis and co-workers could demonstrate that PSA correlate significantly to a relapse-free survival and lower tumor stages in patients with breast cancer using a time-resolved immunofluorometric analysis. The presence of PSA in these tumors seems to reflect a favourable prognostic marker for that disease. The aim of our study was to evaluate the role of PSA as a prognostic factor in breast cancer using an immunohistochemical technique.

MATERIALS AND METHODS

The PSA immunoreactivity of tissues from one-hundred women with malignant breast tumors was correlated to tumor staging, histomorphological tumor type, and biochemical estrogen and progesterone receptor content. Additionally, survival analysis was performed according to Kaplan and Meier.

RESULTS

49% of the tumors revealed positive staining for PSA. No significant correlation between PSA and the other parameters, or the mean survival time (PSA pos.: 5.3 years, PSA neg.: 5.4 years) could be demonstrated.

CONCLUSIONS

As there were no significant correlations between PSA and other prognostic markers, PSA detected by immunohistochemistry seems not to be helpful in prognostic evaluation of breast cancer.

The distribution of macrophages in spiral arteries of the placental bed in pre-eclampsia differs from that in healthy patients

Placental bed biopsies taken during caesarean section from 10 patients with pre-eclampsia and six healthy pregnancies were studied. We applied antibodies against cytokeratin and different macrophage markers to analyse the distribution of invasive extravillous trophoblast cells as compared to that of macrophages in myometrial segments of uteroplacental arteries. The data were evaluated quantitatively. We found a clear inverse relationship between local infiltration with macrophages and trophoblast invasion. In pre-eclampsia, vessel cross-sections prevailed which were characterized by large numbers of macrophages but a low degree of trophoblast invasion. In contrast, in normal third trimester pregnancies the respective arterial segments had a high degree of trophoblast invasion but were largely void of macrophages. These data suggest causal links between macrophages and inhibition of intra-arterial trophoblast invasion in pre-eclampsia.

The role of soluble adhesion molecules in evaluating endothelial cell activation in preeclampsia

OBJECTIVE

Adhesion molecules, such as vascular cell adhesion molecule 1, are known to be increased in the serum of patients with preeclampsia, indicating that these molecules are possible markers of endothelial cell activation. We investigated the influence of serum from women with preeclampsia on the expression of adhesion molecules by cultured endothelial cells.

STUDY DESIGN

Human umbilical vein endothelial cells were cultured in Ham/Iscove modified Dulbecco's medium containing 20% pooled human serum, l -glutamine (200 mmol/L), penicillin, and streptomycin. We stimulated these cells for 24 hours with sera from patients with preeclampsia and then determined the levels of vascular cell adhesion molecule 1, intercellular cell adhesion molecule 1, E-selectin, and P-selectin in the supernatant and in the maternal serum by means of enzyme-linked immunosorbent assay. These results were compared with those of sera obtained from normotensive pregnant and nonpregnant women. In addition, the expressions of these adhesion molecules on the endothelial surface were determined by immunofluo-rescence microscopy.

RESULTS

Only for vascular cell adhesion molecule 1 and E-selectin were elevated plasma levels found in hypertensive patients, whereas intercellular cell adhesion molecule 1 and P-selectin showed similar plasma levels in all the patients. No differences in the levels of the adhesion molecules were found between the supernatants of endothelial cell cultures after stimulation with sera from patients with preeclampsia and those after stimulation with normotensive control sera. In contrast, with immunofluorescence microscopy we could detect higher amounts of vascular cell adhesion molecule 1, intercellular cell adhesion molecule 1, and E-selectin on the endothelial surface after stimulation with sera from women with preeclampsia.

CONCLUSION

Although vascular cell adhesion molecule 1 and E-selectin were elevated in maternal serum samples from women with preeclampsia and on the endothelial surface after stimulation with such sera, there were no detectable increases in the levels of both of these adhesion molecules in the supernatant of cultured endothelial cells. We therefore assume that sera from women with preeclampsia may cause endothelial cell activation. Because we could not detect elevated concentrations of any of the investigated adhesion molecules in the supernatant of endothelial cells, we believe that factors other than sera from women with preeclampsia seem to play a major role in the release of soluble forms of adhesion molecules from the endothelial membrane.

Pulsation of blood flow in the umbilical vein during the second trimester of pregnancy correlated to fetal malformation and chromosomal abberation

In the present study the flow profile of the umbilical vein between the 14th and 24th weeks of pregnancy was examined for the first time in connection with pathological pregnancies and chromosomal/fetal anomalies, and compared with the flow pattern of normal pregnancies. The aim of our study was to clarify whether at this early stage in gestation the diagnosis of the fetal condition should be extended to include the monitoring of the umbilical vein and to assess the possibility of making predictions about the further course of pregnancy. 50 pregnant patients without complications, 21 patients later developing pregnancy-induced hypertension/intrauterine growth retardation, 16 pregnancies with fetal anomalies, and 4 pregnancies with chromosomal aberrations were scanned with color Doppler sonography to determine the flow spectra of the umbilical vein in a free loop. Admission criteria were single-child pregnancies and precise knowledge of the duration of gestation. Pulsations of the venous blood flow, which are physiological during the first three months of pregnancy, cease in normal pregnancies from the beginning of the second trimester. In cases where pregnancy-induced hypertension/intrauterine growth retardation developed, 2 out of 21 patients showed pulsations. In the pregnancies in which fetal and/or chromosomal anomalies occurred, pulsations in the flow pattern of the umbilical vein were detected in 14 out of 20 cases. The pulsations of the venous blood flow, which are attributable to a late diastolic reflux component in the venous circulation, are common finding in fetal/chromosomal anomalies. In our opinion, the flow spectrum of the umbilical vein should therefore be incorporated in sonographic screenings, and if pulsations are detected, we advise careful sonographic abnormality diagnostics and an investigation of the karyotype.

Uteroplacental and fetoplacental blood flow in a patient with renal anemia

We report on Doppler sonographic findings of a dialysis patient with renal anemia during otherwise uncomplicated pregnancy. Uteroplacental and fetoplacental flow relationships before, as well as after the dialysis treatments during the course of the pregnancy were in the normal range. The favorable flow condition in the utero- and fetoplacental circulation was associated with a low hematocrit. This in accordance with previous reports indicates a more favorable maternal and fetal outcome in association with a low hematocrit/hemoglobin concentration.

[Sirenomelia--prenatal diagnosis and clinical consequences of a rare abnormality]

Sirenomelia or the mermaid syndrome is a rare birth defect, often combined with severe malformations of the urogenital system and the lower gastrointestinal tract. The incidence is about one case in 60,000. Ultrasound can be very important in early detection of this deformity. Because of the high incidence of oligohydramnios amnioninfusion could be helpful. Also a magnetic resonance radiographia in the prenatal period could be performed. We report three cases of sirenomelia and in addition the literature is reviewed and discussed.

The Cantrell-sequence: a result of maternal exposure to aminopropionitriles?

The characteristic features of the Cantrell-sequence--anterior thoraco-abdominal wall defect with ectopia cordis and diaphragm, sternum, pericardium, and heart defects--have been observed in animals following maternal administration of beta-aminopropionitrile, a toxic amino-acid derivative. We report on an unusual case of the Cantrell-sequence in a premature infant with associated dysmelia, aplasia of the right kidney, cerebellar hypoplasia and circumscribed aplasia of the cutis, which has not been reported previously. Maternal history suggested an occupational exposure to aminopropionitriles prior to pregnancy. Prenatal ultrasound, differential diagnosis, perinatal management, and the teratogenic role of aminopropionitriles in this rare genetic disorder are discussed.

Evaluation of the success of hemodilution therapy for fetal growth retardation by Doppler sonography

The aim of our study was to evaluate the success of a hemodilution therapy in patients with intrauterine growth retardation (IUGR) using Doppler sonography. Therefore, 22 patients with IUGR were subjected to hemodilution therapy using infusions of 500 ml hydroxyethylstarch in combination with 500 ml Ringer solution on 14 successive days. The 22 patients were divided into two groups on the basis of the actual birth weight, whereas 13 patients gave birth to an eutrophic infant (AGA group) while 9 infants remained dystrophic (SGA group). The following parameters were determined: hematocrit, prolongation of gestation, pulsatility and resistance index of the umbilical artery, the fetal aorta, the uterine arteries and the middle cerebral artery as well as the fetal outcome. Although the hematocrit decreases in both groups were almost identical, the Doppler sonographic examinations in the AGA group revealed in all cases more favorable improvements in perfusion under therapy in comparison with the SGA group. Considering the fetal aorta we could determine a worsening of perfusion in the SGA group. In the course of our investigations we have found that hemodilution therapy with hydroxyethylstarch represents a promising approach to counteract retarded fetal growth. Doppler sonography progress monitoring appears to be highly suitable for evaluating the response to therapy, especially since it can be assumed that the absence of an improvement in flow indicates only a slight advantage for the child.

[Diabetic nephropathy and pregnancy]

With a percentage of 20% diabetic nephropathy represents one of the most common causes of end-stage renal failure. During pregnancy it is associated with an increased perinatal morbidity as a striking result of the consistently high rate of 50% preterm deliveries mainly due to the frequent development of pre-eclampsia ranging between 35-55%. Perinatal mortality (0-11%) seems to be less increased in recent years. Simple and reliable screening methods by means of test-strips are available in order to detect microalbuminuria, which characterizes incipient diabetic nephropathy (stage III). Strict maternal metabolic control achieving normoglycemic blood glucose levels represents the basic of treatment. Furthermore, an adequate diet and control of blood pressure are fundamental issues of sufficient therapy. Currently, there are no data available to assess definitely the influence of pregnancy on the clinical course of diabetic nephropathy.

Prophylaxis and treatment of bladder dysfunction after Wertheim-Meigs operation: the positive effect of early postoperative detrusor stimulation using the cholinergic drug betanecholchloride

The efficacy of betanecholchloride in the postoperative treatment of bladder dysfunction is controversial. We therefore performed a comparative study on the effect of this therapy for the prophylaxis of detrusor hypotonia after Wertheim-Meigs operation. Forty patients with cervical cancer FIGO stage Ib/IIa were divided into two study groups. The control group (24 patients) only received betanecholchloride if the residual urine persisted above 50 ml after the 10th postoperative day. The study group (16 patients) received 50 mg betanecholchloride three times a day from the 3rd postoperative day onward. In this group postoperative catheter treatment, and consequently hospital stay, were significantly shorter (9.6 versus 13.3 days and 15.5 versus 18.6 days). The residual urinary volume normalized faster (8.0 versus 13.0 days) and the rate of cystitis was lower (18.8 versus 25%). According to our study, a prophylactic application of the parasympathomimetic drug betanecholchloride diminishes postoperative complications associated with bladder dysfunction after Wertheim-Meigs operation.

[Prostaglandin-induced labor--is the prostaglandin E2 vaginal gel a "new" alternative?]

In Germany, intracervical application of 0.5 mg PGE2 gel and the 3 mg PGE2 vaginal tablet are registered for induction of labour. Both methods are highly effective; however, the are associated with several problems in practice. Major problems of the intracervical route are the strict application of the gel into the cervical canal, not spreading it to the vaginal and/or extra-amniotic space, the "technical" difficulties of application in cases of an unfavourable cervix in a posterior position and the risk of artificial rupture of the membranes. The problems with the PGE2 vaginal tablet are the incalculable release and absorption, the unpredictable clinical response and the unclear definition of CTG monitoring intervals. The application of the 2 mg PGE2 vaginal gel has proved an efficient and practicable method for induction of labour in both the unfavourable and the favourable cervix. The advantages over the intracervical procedure are in particular the practicability and safety of administration, even in "anatomically" difficult situations (e.g., narrow cervical canal); the advantages over the PGE2 vaginal tablet are greater bioavailability with a quicker release and absorption, the more predictable clinical response and the closer correlation with the subsequent changes in cervical scores. Since well-defined comparative studies are lacking, no definite conclusions can so far be drawn regarding the method of choice for induction of labour. Recently, a prospective, randomised multi-centre study has gone under way to clarify this question.

[Does lung maturation therapy with 16-methylene-prednisolone modify maternal infection parameters in threatened premature labor?]

Silent intrauterine infection is a frequent cause of preterm labour. Maternal C-reactive protein (CRP) and leukocyte count are important predictors of such infections. Treatment with corticosteroids is known to elevate leukocyte count and in this manner can possibly interfere with its accuracy as a predictor of infection. Therefore, we investigated the impact of antenatal administration of 16-methylene-prednisolone (Decortilen solubile) on the maternal serum level of CRP and leukocyte count. Furthermore, we determined the haptoglobin, the platelet count as well as the percentage of stab cells and lymphocytes.

PATIENTS AND METHODS

20 patients with preterm labour between 25 + 6 and 34 + 2 weeks of gestation were enrolled in a prospective study. Premature rupture of the membranes, uterine bleeding, infection and treatment with antibiotics were criteria for exclusion. Three doses (60 mg) of Decortilen solubile were given intravenously 24 h apart. Blood samples were obtained before, twice a day (8.00 a.m. and p.m.) during treatment and until the day 4 after termination of corticosteroid treatment. For statistical analysis the Wilcoxon rank sum test was used.

RESULTS

Before corticosteroid treatment the medians (range) were: CRP: 5.2 ( < 5.0-28.0) mg/l, haptoglobin: 1.4 (0.7-2.0) g/l, leukocytes: 10.5 (5.2-16.0) G/l, platelets: 246 (128-424) G/l, stabs: 9.5 (3.0-14.0)% and lymphocytes: 28.5 (16.0-50.0)%. During the after termination of corticosteroid administration no significant changes in the CRP and haptoglobin levels were seen. The leukocyte count was unchanged during treatment and decreased on day 1-2 after termination of treatment. The platelet count remained unchanged during corticosteroid treatment and increased significantly thereafter. The stab cell percentage increased slightly from day 1-2 to day 3-4 after termination of treatment. The lymphocyte percentage increased during treatment and decreased significantly from day 1-2 to day 3-4 after treatment.

CONCLUSION

Decortilen solubile treatment is not associated with an increase in maternal CRP-level and leukocyte count. We emphasise that the accuracy especially of the CRP for early prediction of silent infection in preterm labour does not seem to be impaired by this corticosteroid in a dosage usually administered for prevention of respiratory distress syndrome.

[Balloon dissection of the cavum retzii--an innovative preparatory technique for endoscopic, extraperitoneal Burch colposuspension-plasty]

Colposuspension is known as "Gold Standard" in incontinence surgery; however, a variety of different techniques exist for performing this measure. Minimal invasive surgery offers new treatment possibilities. Besides the intraperitoneal approach, there is also an extraperitoneal technique for the Burch procedure. We describe an innovative technique, namely, balloon dissection, which is well known in endoscopic hernioplasty for an atraumatic approach to the cavum retzii. This technique that was used in six patients with urinary stress incontinence has the following advantages: minimal blood loss, better visualisation of the operative field, and a shortened hospital stay and recovery period than with abdominal colposuspension.

[Intrapartum therapy-resistant fetal bradycardia--color Doppler sonographic diagnosis of umbilical cord compression due to fetal grasping]

Fetal heart rate pathology is seen in up to 40% of complications of the umbilical cord. We report a case in which long lasting bradycardia was associated with fetal grasping of the umbilical cord. Using colour doppler, the reason for the bradycardia could be detected. After vibro-acoustic stimulation the fetus released the grasp of the umbilical cord, following by a normalisation of the fetal heart rate and a spontaneous delivery two hours later. This case report underlines the importance of colour doppler for the diagnosis of fetal heart rate pathology.

[HELLP syndrome in the 21st week of pregnancy in mosaic trisomy 9]

We report for the first time the case of postabortional HELLP-syndrome in the 21st week of gestation. In this case mosaic trisomy 9 was confirmed by amniocentesis prior to induction. Pertinent history, clinical course and pathoanatomical morphology are described. We emphasize the early onset of the HELLP-syndrome in association with trisomy 9 after abortion. The possibility of interconnections between trisomy 9 and the occurrence of HELLP-syndrome (sparse blood, vessels in the villi, circulatory deficit on the fetal side of the placenta, increased production of e.g. vasopressive substances) is discussed.

[Subpartal diagnosis of umbilical cord encirclement using color-coded Doppler ultrasonography and correlation with cardiotocographic changes during labor]

Umbilical cord complications are the most common cause of pathologic fetal heart tones during delivery. The inauguration of colour-coded Doppler ultrasound in obstetrics has made the definite diagnosis of umbilical cord encirclement during delivery possible. The prospective study introduced here examines the question of how exactly an encirclement can be seen by Doppler during delivery, its influence on cardiotocographic results, delivery mode, and fetal outcome. 107 patients in labour with cervical dilatation were examined in a prospective study using colour-coded Doppler ultrasound to determine cases of umbilical cord encirclement. In 50 cases, encirclement could be visualised, 48 of which were confirmed post partum. Encirclement could be ruled out in 57 other cases. A sensitivity of 96% and specificity of 100% resulted. No significant differences could be found with regard to mode of delivery and fetal outcome. However, the umbilical cord in cases of encirclement was significantly longer than when no encirclement occurred. Assessment of fetal heart tones demonstrated a significantly higher rate of variable decelerations in the patient group with umbilical cord encirclement compared to that without. In conclusion, our results show that the early diagnosis of umbilical cord encirclement during delivery allows appropriate assessment of fetal heart tone changes,justifying temporising management under continuous monitoring with possible micro-blood analysis.

[Monitoring the pregnant diabetic patient]

Despite improved surveillance of pregnant diabetic women perinatal mortality and morbidity remains higher than in the general population. Low detection rates of patients with gestational diabetes represent one of the main reasons as screening programs based upon the presence of risk factors only comprise 30% of all women with gestational diabetes. Concerning maternal risks in patients with insulin-dependent diabetes mellitus the incidence of pregnancy induced hypertension is increased up to 12-28%. Macrosomia (6-32%) and malformations (1.5-6%) are the most frequent fetal complications and depend on the quality of controlling the blood glucose level. However, the decrease of fetal and maternal risks requires a general screening program for gestational diabetes as well as an intensive surveillance of the mother and the fetus by an obstetrician and internal specialist, respectively. Delivery of pregnant diabetic women should preferable be performed in specialized hospital units.

[The course of pregnancy and fetal outcome in diabetic patients with anamnestic fetal death]

Of 116 pregnant patients with diabetes mellitus type 1 or gestational diabetes, 12 (10.3%) had previously suffered stillbirth, while in four (3.4%) cases spontaneous abortion after the 6th month had occurred. In these 16 cases, we examined the mean daily blood glucose concentration, glycosylated hemoglobin (HbA1c), fructosamine as well as glucose and albumin elimination via urine. These control data on carbohydrate metabolism were correlated with the intensity of gestational monitoring in relation to course of pregnancy and neonatal morbidity and/or mortality. In addition, we retrospectively analyzed the cause of prior intrauterine death. In six of eight cases evaluable, we could hereby demonstrate disturbed carbohydrate metabolism. Pregnant women with diabetes mellitus type 1 were hospitalized twice as often (on average four times) as patients with gestational diabetes (2.1 admissions on average). While five of seven type 1 diabetics were primarily admitted prior to the 20th week of gestation, the majority of gestational diabetics (7/9) were first examined by qualified medical personnel trained in the care of gestational diabetes after the 28th week of gestation. Two of nine were first diagnosed post partum. 13 of 14 patients with prepartally known diabetes demonstrated mean blood glucose values under 110 mg/dl. While one of the two patients with postpartally diagnosed diabetes suffered stillbirth once again, the other had to be delivered by emergency C-section because of fetal distress (pH art. 7.08). Our results show that adequate monitoring of carbohydrate metabolism and proper care of diabetic pregnant women can lower obstetrical/neonatal risks to more acceptable levels, especially in those patients who have had stillbirth in their prior medical history.