Clinical significance of risk-reducing salpingo-oophorectomy in patients with BRCA1/2 mutation

OBJECTIVE

Serous tubal intraepithelial carcinoma (STIC) is a precursor lesion which is located in the distal fallopian tube and causes high grade serous ovarian carcinoma (HGSOC). The incidence of STIC for women underwent risk reducing salpingo-oophorectomy for BRCA mutation varies from 0.6 to 7% and its clinical outcomes are still unclear. The aim of this study was to demonstrate the incidence of STIC and HGSOC in BRCA1/2 mutation carriers after risk reducing salpingo-oophorectomy (RRSO) and the clinical outcomes of these patients.

MATERIAL AND METHODS

We retrospectively reviewed the records of 48 BRCA1 and/or 2 mutation carriers who underwent prophylactic salpingo-oophorectomy with or without hysterectomy at the Department of Obstetrics and Gynecology, Bursa Uludag University between January 2000 and January 2022.

INCLUSION CRITERIA

BRCA 1 and/or 2 mutation carriers diagnosed by genetic testing, asymptomatic patients with no abnormal findings on pelvic examination.

EXCLUSION CRITERIA

patients with no abnormal findings on pelvic examination and a presence of a personal history of ovarian, fallopian tube or peritoneal cancer.

RESULTS

A total of 48 BRCA 1 and/or 2 mutation carriers underwent RRSO. STIC was diagnosed in 1 (2,0%) patient and restaging surgery was not performed. Primary peritoneal carcinoma (PPC) did not develop during the 20 months follow-up period. One (2.0%) patient was diagnosed with occult ovarian cancer. Restaging surgery was performed and chemotherapy treatments were given after surgery. A pelvic recurrence developed 25 months after the occult cancer diagnosis in the follow up period. One (2.0%) patient with normal histopathological findings after RRSO was diagnosed with peritoneal cancer 57 months after the operation.

CONCLUSION

The risk of PPC continues after RRSO. Therefore, close follow-up procedure is very important for early diagnosis and effective treatment of patients with PPC after RRSO.

The parameters to estimate postoperative severe complications classified through Clavien-Dindo after upper abdominal surgery in patients with primary and recurrent ovarian cancer

OBJECTIVES

The more surgical effort and performing extensive upper abdominal surgery (UAS) are often required to accomplish the highest rates of optimally cytoreduction in patients with ovarian cancer. Nonetheless, the rate of complications increases with extensive surgery. We have studied the upper abdominal surgery complications by Clavien-Dindo Classification (CDC) and analyzed parameters affecting post-operative severe complications classified through Clavien-Dindo.

MATERIAL AND METHODS

A retrospective cohort of patients diagnosed with epithelial ovarian cancer from January 1st 2009 to April 30th 2016 was evaluated. Patients who underwent at least one UAS procedure with or without optimal cytoreduction for epithelial ovarian cancer (stage IIIC-IV or recurrent) were included. Postoperative complications were recorded according to the Clavien-Dindo Classification.

RESULTS

In total, 58 patients were included. There were 120 UAS procedures performed on the 58 patients. Diaphragm peritonectomy was the most performed surgery (50%, 29/58), and then the other UAS procedures were liver surgery (39.7%, 23/58), cholecystectomy (24.1%, 14/58), splenic surgery (24.1%, 14/58), full-thickness diaphragm resection (22.4%, 13/58), pancreatic surgery (19%, 11/58), resection of tumor from porta hepatis (17.2%, 10/58), celiac lymph node excision (8.6%, 5/58), partial gastrectomy (1.7%, 1/58), respectively. Thirteen patients (22.4%) had post-operative grade 3-5 complications according to CDC within 30 days after surgery.

CONCLUSIONS

This current study demonstrated that the addition of extensive upper abdominal surgery procedures were not associated with increased postoperative severe complications in patients with recurrent or advanced ovarian cancer. These procedures are safe and feasible for patients in need and also can be performed with acceptable mortality and morbidity.

Quality of life and sexuality after bilateral sacrospinous fixation with vaginal hysterectomy for treatment of primary pelvic organ prolapse

OBJECTIVE

To investigate the quality of life (QoL) and sexuality in women affected by pelvic organ prolapse (POP) and treated by bilateral sacrospinous ligament fixation (SSLF) with vaginal hysterectomy.

METHODS

This is a prospective observational study carried out at Isparta City Hospital from July 2017 to December 2018. A total of 26 sexually active women with symptomatic uterine prolapse POP-Q (Pelvic Organ Prolapse Quantification) stage II or higher requiring surgery were included in the study. Short Form Health Survey (SF-36) was used preoperatively and at 6 months to examine the impacts of vaginal reconstruction on QoL. To assess sexual functioning, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) was used preoperatively and at 6 months.

RESULTS

A significant improvement of POP-Q landmarks was found between pre- and posttreatment at 6 months of follow-up. The patients reported QoL improvement at the follow-up for all the categories of physical functioning, bodily pain, physical health, general health, vitality, social activity, emotional state, and mental health with respect to the baseline values (P < .001). The results of PISQ-12 demonstrated a significant improvement for all the three fields: behavioral emotive factor, physical factor, and partner-related factor, and the total score at 6 months after surgery (P < .001).

CONCLUSION

This study clearly demonstrates that bilateral SSLF is able to significantly improve both QoL and sexual function in patients with POP. Improvement in sexuality and QoL after surgery may be explained by correction of avoidance of sexual intercourse due to prolapse and physical recovery.

Perioperative outcomes of bipolar energy instruments in total laparoscopic hysterectomy

OBJECTIVES

To compare conventional and advanced bipolar energy instruments in terms of perioperative outcomes inpatients who underwent total laparoscopic hysterectomy (TLH).

MATERIAL AND METHODS

The data of 101 patients who underwent TLH between June 2017 and December 2018 for benigngynecological disorders were analyzed retrospectively. Conventional bipolar forceps (Robi forceps) were used in 37 patientsand advanced bipolar instruments (LigaSure) were used in 64 patients. Data about the characteristics of the patients, operationtime, estimated blood loss, length of hospital stay and other perioperative outcomes were compared.

RESULTS

The mean ages of the patients in the conventional bipolar and LigaSure groups were 47.6 ± 6.5 and 48.1 ± 7 years,respectively (p > 0.05). There was no statistically significant difference between the two groups with regard to all otherpatient characteristics; body mass index, parity, previous pelvic operation and indications of hysterectomy (p > 0.05). Themean operation time (41 ± 13.2 vs 37 ± 11.5 min), estimated intraoperative blood loss (70 ± 22 vs 65 ± 21 mL) and absolutechange in hemoglobin (-1.23 ± 1.12 vs -1.11 ± 1.14 g/dL) were slightly higher in the conventional bipolar group. However,there was no statistical significance with respect to these differences between the groups (p > 0.05).

CONCLUSIONS

Our findings indicate that a conventional bipolar system is as safe and effective as LigaSure, and it may beused as an alternative option for patients undergoing TLH in low-income hospitals.

Prenatal sonographic diagnosis of cephalopagus conjoined twins at 14 weeks of pregnancy

Conjoined twins are extremely rare and are a type of monozygotic twins that occur due to an incomplete embryonic division on postconception day 13 to 15. Eight different types of conjoined twins have been described in the literature. Management of the condition depends on the site and extent of the union. We present a case of cephalopagus twins diagnosed at 14 weeks of gestation.

Evaluation of the Ki-67 Proliferation Index and Urocortin Expression in Women with Ovarian Endometriomas

OBJECTIVE

The reasons why endometriosis is more aggressive and invasive in some patients are unknown. Despite the importance of population-based clinically defined risk factors in the prediction of recurrence, biochemical markers obtained from the patient are more valuable for prediction on an individual basis. Therefore, the discovery of significant potential biomarkers could be useful to clinicians for shedding light on the pathogenesis of endometriosis and in the monitoring recurrence.

MATERIALS AND METHODS

This study included 50 patients who underwent surgery for ovarian cysts that were diagnosed as endometrioma. The age of the patients, stage of the endometriosis, diameter and localization of endometriomas, type of surgery, and pre- and postoperative cancer antigen 125 (CA125) levels were compared between patients with and without recurrence. The archived pathology slides were stained with Ki-67 and anti-urocortin antibodies for reevaluation. By comparing the pathology parameters of the patients with and without recurrence, the association between these parameters and recurrence was investigated.

RESULTS

The median Ki-67 proliferation index of the patients with recurrence (7.5±6.5) was statistically significant compared with that of the patients without recurrence (1±4) (p=0.003). The urocortin epithelial staining intensity and percentage were not found to be statistically significant in comparison. A statistically significant difference was determined between postoperative CA125 median levels of patients without recurrence (10±17.6) and those of patients with recurrence (29.9±18.1) (p=0.003).

CONCLUSION

The Ki-67 proliferation index may be useful for predicting prognosis and recurrence risk.

Maternal and perinatal outcomes in pregnancies with multiple sclerosis: a case-control study

OBJECTIVE

To assess whether maternal multiple sclerosis (MS) is associated with adverse pregnancy outcomes by determining the clinical course of disease during pregnancy and postpartum throughout a 10-year-period in a single tertiary center.

METHODS

We conducted a case-control study that included pregnancies with a definitive diagnosis of MS (n=43), matched with 100 healthy pregnant women with similar characteristics. Maternal and perinatal data were retrieved from hospital files. Groups were compared with the Mann-Whitney and χ2 tests. Logistic regression models were constructed to determine independent effects.

RESULTS

Maternal demographic and baseline laboratory data were similar across the groups. Rates of preterm delivery, fetal growth restriction, preeclampsia, gestational diabetes, stillbirth, cesarean delivery, congenital malformation, and 5-min Apgar score were comparable (P>0.05 for all). General anesthesia during cesarean delivery (96% vs. 39%, P=0.002), urinary tract infection (UTI) (12% vs. 3%, P=0.04), low 1-min Apgar score (21% vs. 9%, P=0.04), and nonbreastfeeding (33% vs. 2%, P=0.001) were more frequent in women with MS. The low 1-min Apgar score and breastfeeding rates were independent of general anesthesia and UTI in regression models.

CONCLUSION

MS during pregnancy was not associated with adverse maternal and perinatal outcomes except UTI, low 1-min Apgar scores, and decreased breastfeeding rates.

The Value of Preoperative CA 125 Levels in Prediction of Myometrial Invasion in Patients with Early-stage Endometrioid- type Endometrial Cancer

AIM

To evaluate the relationship between pre-operative CA-125 levels and myometrial invasion in patients with early-stage endometrioid-type endometrial cancer.

MATERIALS AND METHODS

Two-hundred and sixty patients were diagnosed with endometrial cancer between January 2007 and December 2012. Of these, 136 patients with stage 1 endometrioid histologic-type and documented pre-operative serum CA-125 levels were included in the study. Age, preoperative CA-125 level, histologic grade, surgical grade, and presence of deep myometrial invasion were recorded. Additionally, 16, 20, and 35 IU/ml cutoff values were used and compared to evaluate the relationship between pre-operative CA-125 levels and myometrial invasion.

RESULTS

The average serum CA-125 level was 35.4±36.7 in patients with deep myometrial invasion, and 21.5±35.8 in cases without deep myometrial invasion. The relationship between the presence of deep myometrial invasion and CA-125 cut-off values (16, 20, 35 IU/ml) was statistically significant, although the correlation was weak (p<0.05). When the relationship between 16, 20 and 35 IU/ml CA-125 cut-off values and the presence of deep myometrial invasion was studied, specifity and sensitivity values were identified as: 0.60-0.68 for 16 IU/ml; 0.73-0.48 for 20 IU/ml; and 0.89-0.33 for 35 IU/ml. The sensitivity of 16 IU/ml cut-off value was higher when compared to other values.

CONCLUSIONS

This study demonstrates that preoperative serum CA-125 values maybe used as a predictive test in patients with early stage endometrioid-type endometrium cancer, and as a prognostic factor alone. Further studies should be conducted to identify different CA-125 cut-off values in patients with low risk endometrial cancer.

Surgical staging of low-risk Stage IA endometrioid endometrial cancers

PURPOSE

Surgical staging in early endometrial cancer is not universally done and lymphadenectomy in early-stage disease is controversial. Aim of the present study was to evaluate surgical staging in patients with endometrioid histology, FIGO Stage IA endometrial cancer.

MATERIALS AND METHODS

Eighty-seven patients with FIGO Stage IA, low-risk patients were included in the study. Staging surgery group included patients who had comprehensive surgical staging (hysterectomy, oophorectomy, and pelvic lymph node dissection with or without para-aortic lymph node dissection). Non-staging surgery group included patients who had hysterectomy, and bilateral oophorectomy with or without lymph node sampling. Two groups were compared for lymph node status, occult cervical involvement, other prognostic factors, and outcome were analyzed.

RESULTS

In total 17.2% of patients were upstaged in final pathological examination; 12.9% in non-staging surgery group and 24.2% in staging surgery group. Upstaging was due to lymph node involvement (6%), cervical stromal invasion (13.7%), and myometrial invasion greater than 50% (1.1%). Median pelvic lymph node number was 23 and pelvic lymph node metastases was found in 3% of the patients. Median para-aortic lymph node number was 11.5 and there was one isolated para-aortic lymph node metastases (5.8%).

CONCLUSION

Of the patients, 17.2% had stage migration. Until the issue is solved by future studies, surgical staging might be considered standard surgery for endometrial cancer.

Uterine tumors resembling ovarian sex cord tumors: a case report with adenomyosis and complex hyperplasia with atypia

Uterine tumors resembling ovarian sex cord tumors (UTROSCTs) are very rare uterine neoplasms. They mostly behave in a benign fashion but cases were reported with extra-uterine spread. There are less than 50 cases reported in the literature so far according to the present authors' knowledge. We report a case of 45-year-old woman with UTROSCT concurrent with adenomyosis and complex hyperplasia with atypia of endometrium and her three-year follow up.

Hypoxia-inducible factor-1α, adrenomedullin and Bcl-2 although expected are not related to increased uptake of fluorine-18-fluorodeoxyglucose in endometrial cancer

OBJECTIVE

To study the relation between SUVmax, hypoxia inducible factor 1α (HIF-1α), angiogenetic factor adrenomedullin (AM) and antiapoptotic factor Bcl-2 in endometrial cancer.

SUBJECTS AND METHODS

Thirthy eight patients who were diagnosed after a preoperative endometrial biopsy with endometrium cancer underwent pre-operative positron emission tomography/computed tomography (PET/CT) utilizing fluorine-18-fluorodeoxy glucose (¹⁸F-FDG). Maximum standardized uptake values (SUVmax) of the primary tumor were measured. After hysterectomy and bilateral salpingo-oophorectomy, microscopic slides of the 38 endometrial adenocarcinoma patients were evaluated by a surgical pathologist to confirm the diagnosis. Immunohistochemical staining for AM, Bcl-2 and HIF-1α was studied.

RESULTS

In all patients, ¹⁸F-FDG uptake was detected. The mean SUVmax of the tumors was 11.8 ± 5.9. Although SUVmax was higher in HIF-1α positive tumors, this finding was not statistically important. No correlation was found between SUVmax and HIF-1α positivity. Mean SUVmax was 6.4 ± 3 and 12.3 ± 1.4 in AM negative and AM positive patients, respectively. Mean SUVmax was 10.6 ± 4.9 and 12.3 ± 1.4 in Bcl-2 negative and Bcl-2 positive patients, respectively. We found no correlation between SUVmax, AM or Bcl-2 expression. Allred scores were not related with SUVmax in regression analysis.

CONCLUSION

Our study in a small number of patients is the first to show that SUVmax, although expected is not associated with HIF-1α, AM or with Bcl-2 in endometrial cancer. Increased uptake of ¹⁸F-FDG in endometrial cancer seems to be independent of HIF-1α and its downstream factors.

Clinical presentation of Von Hippel Lindau syndrome type 2B associated with VHL p.A149S mutation in a large Turkish family

Von Hippel Lindau (VHL) syndrome is an autosomal dominant disorder characterized by benign and malignant tumors. This study presents the clinical and genetic features of VHL syndrome in a Turkish family. For the diagnosis of pheochromocytoma-related diseases, 49 family members from three generations were evaluated between March 2008 and January 2013. Family members were examined to identify components of pheochromocytoma-related genetic syndromes through physical examination, laboratory tests, and imaging methods. For the causative mutation, sequence analysis of VHL gene was performed. Nine patients were diagnosed with pheochromocytoma. Lumbal spinal hemangioblastoma and pancreatic neuroendocrine tumor without pheochromocytoma were detected in one patient. In patients with pheochromocytoma, additional tumors, such as retinal angioma, renal cell carcinoma, pancreatic serous cystadenoma, and pancreatic neuroendocrine tumors were detected. All patients were diagnosed as VHL syndrome type 2B. Sequence analysis of VHL gene revealed heterozygous p.A149S mutation in all symptomatic patients and in seven of the asymptomatic family members. This is the first study that identified VHL p.A149S mutation in a Turkish family with VHL syndrome. However, VHL p.A149S mutation was identified in an American family by Atuk et al. (J Clin Endocrinol Metab, 83:117-120, 14) and the family was defined as VHL type 2A. In our study, the family was identified as VHL type 2B. This variability in the phenotypic features suggests that further studies are required to beter assess the genotype-phenotype correlation in such cases.

Obstructive sleep apnea syndrome and its association with vitamin D deficiency

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) is a widespread disorder characterized by recurrent, partial or complete episodes of apnea due to upper airway tract obstruction during sleeping period. Deficiency of vitamin D has roles in development of many diseases. Association between presence and severity of OSAS and vitamin D has recently gained research interest.

AIM

The aim of our study was to investigate the association between serum 25-hydroxy [25 (OH)] vitamin D levels and severity of disease in patients with OSAS.

MATERIAL AND METHODS

One hundred and fifty OSAS patients (50 patients with mild, 50 with moderate, 50 with severe OSAS) who were diagnosed by polysomnography (PSG) and 32 non-OSAS controls who were referred to the Health Ministry Ankara Numune Training and Research Hospital, Endocrinology and Metabolism Department, from January 2010 to May 2011 were included in the study. Serum 25(OH)D, PTH, calcium and phosphorus levels were evaluated in all the patients who were recruited to the study.

RESULTS

There was no statistically significant difference in serum 25(OH)D levels between OSAS and controls (p>0.05). However, in subgroup analysis of OSAS, we found that the patients with severe OSAS had significantly lower levels of 25(OH)D as compared with other groups (p=0.003). Also, the number of patients with serum 25(OH)D deficiency (<10 μg/dl) were higher in OSAS group than in controls (p<0.05).

CONCLUSIONS

We found that when the severity of OSAS increases, 25(OH)D deficiency becomes more pronounced.

Regulation of Na/K-ATPase gene expression by thyroid hormone and hyperkalemia in the heart

Hypothermic hyperkalemic circulatory arrest has been widely used for myocardial protection during heart surgery. Recent data showed that administration of triiodo-L-thyronine (T3) postoperatively enhanced ventricular function. The effect of hyperkalemic arrest in conjunction with thyroid hormone on the plasma membrane enzyme sodium/potassium-adenosine triphosphatase (Na/K-ATPase), was determined in cultured neonatal rat atrial and ventricular myocytes. Exposure of ventricular myocytes to hyperkalemic medium (50 mM KCl) in the absence of T3 increased expression of the Na/K-ATPase catalytic subunit mRNAs, alpha1 and alpha3 isoforms, by 1.9- and 1.5-fold, respectively (p<0.01), which were accompanied by similar increases (1.4- and 1.8-fold) in protein content. Addition of T3 to the hyperkalemic cultures attenuated these increases in Na/K-ATPase mRNA isoforms to levels of expression observed in cells treated with T3 (10(-8) M) alone. Similarly, expression of the alpha1 mRNA isoform in atrial myocytes was increased (p<0.05) by hyperkalemic conditions, and T3 treatment attenuated this effect. In contrast, although expression of the Na/K-ATPase beta1 mRNA in both atrial and ventricular myocytes was significantly increased by hyperkalemia, addition of T3 did not prevent the hyperkalemic response, and in atrial myocytes T3 significantly increased beta1 mRNA expression 1.8-fold. These results show that expression of cardiac Na/K-ATPase is regulated by T3 and hyperkalemia in an isoform and chamber specific manner, and suggest that use of hyperkalemic cardioplegia during heart surgery may alter plasma membrane ion function.

Ethylene provides positional information on cortical cell division but is not involved in Nod factor-induced root hair tip growth in Rhizobium-legume interaction

Nod factors secreted by Rhizobium leguminosarum bv. viciae induce root hair deformation, involving a reinitiation of tip growth, and the formation of nodule primordia in Vicia sativa (vetch). Ethylene is a potent inhibitor of cortical cell division, an effect that can be counteracted by applying silver ions (Ag+) or aminoethoxy-vinylglycine (AVG). In contrast to the inhibitory effect on cortical cell division, ethylene promotes the formation of root hairs (which involves tip growth) in the root epidermis of Arabidopsis. We investigate the possible paradox concerning the action of ethylene, putatively promoting Nod factor induced tip growth whilst, at the same time, inhibiting cortical cell division. We show, by using the ethylene inhibitors AVG and Ag+, that ethylene has no role in the reinitiation of root hair tip growth induced by Nod factors (root hair deformation) in vetch. However, root hair formation is controlled, at least in part, by ethylene. Furthermore, we show that ACC oxidase, which catalizes the last step in ethylene biosynthesis, is expressed in the cell layers opposite the phloem in that part of the root where nodule primordia are induced upon inoculation with Rhizobium. Therefore, we test whether endogenously produced ethylene provides positional information controlling the site where nodule primordia are formed by determining the position of nodules formed on pea roots grown in the presence of AVG or Ag+.