Conservative treatment of deep infiltrating endometriosis: review of existing options

Endometriosis with its estimated incidence rate of ∼7-10% of women of reproductive age is a disease with the wide spectrum of symptoms depending on form and localization of endometrial foci. One clinical form of endometriosis is deep infiltrating endometriosis (DIE), most difficult to manage and generating a lot of direct and indirect treatment costs. We search the literature from PubMed database to establish the role of conservative treatment of DIE. Randomised controlled trials are lacking but in experts opinion hormonal treatment should be the first-line treatment in DIE. After evaluation of pain or other symptoms, second-line therapy with GnRH analogs or danazol should be offered or minimally invasive surgery. Consensus is not made whether surgery is the best therapeutic treatment for affected patients. Strong depending on surgeon's experience conservative surgery should be offered if the total excision of DIE foci is possible, which is essential for a successful outcome. If available treatment options do not release pain associated with DIE, experimental treatment in clinical trials should be discussed with patients.

Urethral length measurement in women during sonographic urethrocystography - an analysis of repeatability and reproducibility

There has been a rise in the use of sonographic urethrocystography in patients with a full bladder. So far, no publications have been made on the analysis of repeatability and reproducibility of the measurements performed during this procedure.

AIM

An assessment of repeatability and reproducibility of urethral length measurements during sonographic urethrocystography in females with a full bladder in the introital approach, using real-time two-dimensional transvaginal ultrasound.

MATERIAL AND METHODS

The ultrasound was performed in accordance with a standardized technique in female patients with a full bladder containing 200-300 mL of liquid. A total of 92 patients were included in the analysis.

RESULTS

The Intraclass Correlation Coefficient for repeatability and reproducibility of urethral length measurements in sonographic urethrocystography ranged between 0.9217 and 0.9873 (p = 0.0000). The analysis of ultrasound urethral length measurements taken by two different physicians at an interval of several months confirmed their very high compatibility (ICC = 0.81, p = 0.000).

CONCLUSIONS

Very good repeatability and reproducibility of urethral length findings during sonographic urethrocystography performed in accordance with the presented technique support the possible use of this type of examination in both clinical practice and research.

Endometriosis and carcinosarcoma--a hypothetical correlation or a proven pathogenetic pathway? Colon carcinosarcoma with origin in endometriotic foci--a case report

We present the first case of a patient with a synchronic occurrence of three neoplasms: non-small cell lung cancer serous cancer of the ovary and carcinosarcoma of the colon. Moreover, the possible origin of the carcinosarcoma is an endometriotic focus, which is an extremely rare occurrence, especially in women with no history of endometriotic treatment. Immunohistochemical staining of the carcinosarcoma was positive for CD10, estrogen receptors and desmin--typical markers for endometriotic foci. The growth of endometriosis depends on estrogen, which is produced at reduced levels after menopause. However, in some cases endometriosis could be diagnosed de novo in postmenopausal women. On the basis of the reported patient we discuss possible correlations between endometriosis and carcinosarcoma, as well as treatment methods of carcinosarcoma.

[Evaluation of genomic imbalance in endometrial hyperplasia and carcinoma]

OBJECTIVE

The main goal of our study was to identify the earliest and specific genetic changes which could be associated with an increased risk of neoplastic transformation in a group of patients with endometrial hyperplasia. Another goal was to characterize genetic changes associated with advanced forms of cancer.

MATERIAL AND METHODS

The study involved forty-four (44) female patients, including five (5) patients with no histopathologically confirmed hyperplastic features, twenty-six (26) patients with histopathologically confirmed endometrial hyperplasia, and thirteen (13) patients with diagnosed carcinoma of the endometrium. The study was conducted using a custom-made 4x180 K microarray of BlueGnome.

RESULTS

Copy number variations (CNV) were found in the cases without endometrial hyperplasia. Such changes occur with varying frequency in the genome of healthy female population. Significant genome imbalance was identified in the twenty-six (26) (100%) patients with diagnosed hyperplasia and in eleven (11) subjects (84.6%) with diagnosed endometrial cancer. Other not yet reported, changes localized in characteristic regions of the genome were also found.

Evaluation of selected angiogenic and inflammatory markers in endometriosis before and after danazol treatment

Angiogenesis and inflammation are pivotal processes in developing endometriosis in the peritoneal cavity. The aim of the present study was to evaluate these two processes in women with endometriosis who had been treated with danazol to determine the sensitivity of a non-invasive test in diagnosing endometriosis. The clinical follow-up study was conducted in a group of 103 women diagnosed laparoscopically with endometriosis. Thirty-five patients qualified for danazol treatment. Pain was assessed using a visual analogue scale, whereas endometriosis was assessed using the revised American Society of Reproductive Medicine (rASRM) scale. Cancer antigen (CA)-125 and C-reactive protein (CRP) concentrations in plasma and peritoneal fluid were determined by immunoenzymatic methods, whereas vascular endothelial growth factor (VEGF) and interleukin (IL)-1β concentrations in plasma and peritoneal fluid were determined by ELISA. Endometrial expression of IL-8 and platelet-derived growth factor alpha polypeptide (PDGF-A) was determined using real-time polymerase chain reaction (PCR). Women with endometriosis (68.9% of patients) had higher plasma concentrations of CA-125, as well as higher concentrations of both CA-125 and VEGF in the peritoneal fluid. Endometrial expression of IL-8 mRNA was significantly higher, whereas that of PDGF-A was significantly lower, in contrast. After danazol treatment the patients reported lower pain scores; in addition, CA-125 concentrations in the plasma were decreased (P<0.001), whereas VEGF concentration in the plasma increased (P=0.009). For the diagnosis of endometriosis, none of the combinations of given markers had a sensitivity >60%. Danazol treatment is highly effective in relieving pain and decreasing CA-125 concentrations in the plasma. Higher plasma concentrations of VEGF after treatment could imply stimulation of angiogenesis.

Long-term risk of complications after mid-urethral sling IVS implantation

INTRODUCTION

Results of short-term evaluation of multifilament microporous midurethral tape IVS differ a great deal. During the first year of implantation, erosions have been observed in 0%-26% of operated women. Long-term observations are rare. They suggest high risk of extrusion and infection even after years of implantation.

OBJECTIVE

The purpose of the study was to evaluate long-term risk of complications after IVS implantation.

MATERIAL AND METHODS

Between 2001-2005, 72 women were operated on with the use of IVS mid-urethral tape.

RESULTS

Two women had vaginal erosions during the first 3 months after the operation. Twelve women had vaginal erosions, purulent vaginal discharge, with IVS tape sticking out of the abdominal wall or vagina, and abdominal abscess. These complications were diagnosed between 9 months and 6 years after IVS implantation. The patients were operated on vaginally and open abdominally, 1-5 times because of complications after IVS implantation.

CONCLUSIONS

In the case of post-IVS complication, as much tape as possible should be excised. Long-term follow up on patients with IVS implantation should be recommended to the centres where IVS tape was used, even to patients after removal of the tape. Risk of erosion, extrusion and infection after midurethral multifilament microporous IVS tape implantation is too high - which is the reason it should no longer be used.

Standardized modified colposuspension--mid-term results of prospective studies in one centre

INTRODUCTION

Burch colposuspension is still estimated as a 'gold standard' by the Cochrane Collaboration Group in the treatment of operative stress urinary incontinence (SUI) Some urogynecologists agree with this statement, some argue that Burch colposuspension should no longer be used.

OBJECTIVE

The aim of this study was to evaluate mid-term effects and patient's satisfaction with standardized modified colposuspension performed in one centre.

MATERIAL AND METHODS

Modified colposuspension was performed after standardization by 2 trained gynaecologists in 354 women. Data collected from 227 women were added to the final analysis of mid-term results. Average time from the operation to mid-term visit was 19 months (range 9-36 months).

RESULTS

At mid-term visit, 86.3% of patients were cured. There was no case of post-void urine residual over 100 ml. Pain near the operated region was reported by 1 woman from agricultural region. No one reported negative impact of modified colposuspension on sexual activity or dyspareunia.

CONCLUSIONS

Modified colposuspension according to the E. Petri technique seems to be an operation that is safe and well-tolerated by women with preoperative stress urinary incontinence and paravaginal defect without urodynamic signs of ISD in mid-term observation.

[Evaluation of cyclin E expression in endometrial hyperplasia and cancer in postmenopausal women]

OBJECTIVES

The aim of present study was to determine expression of cyclin E in endometrial hyperplasia without atypia, atypical endometrial hyperplasia and endometrial cancers in comparison with expression of cyclin E in atrophic endometrium of postmenopausal women. We have also estimated relationship between cyclin E expression and prognostic factors for endometrial cancer such as: histological type, cancer stage and histological grade.

MATERIAL AND METHODS

154 women were enrolled into study Women were divided into 4 groups. The first group consist of 38 women with endometrial hyperplasia without atypia, the second group consist of 18 women with atypical endometrial hyperplasia. The third group comprise 62 women with endometrial cancer and the forth 36 women with atrophic endometrium. Cyclin E expression was estimated in formalin-fixed, paraffin-embedded tissues obtained from enrolled women with the use of immunohistochemical techniques. We estimated labelling index (LI) - the number of cells that stained for cyclin E in relation to all cells at the certain field of view.

RESULTS

Medians of labelling indices of cyclin E in atrophic endometrium, endometrial hyperplasia with atypia, atypical endometrial hyperplasia end endometrial cancer were 13.7%, 34.7%, 62%, 72.2% respectively These differences were statistically significant. In our study we haven't found relationship between cyclin E expression and histological type of tumour (p = 0.186), cancer stage (p = 0.186) and histological grade (p = 0.539) CONCLUSIONS: In the carcinogenesis of endometrial tumours in postmenopausal women there is a progressive disorder in mechanisms regulating cell cycle. It seems impossible to use cyclin E as prognostic factor for endometrial cancer.

Influence of hypoxia inducible factors on the immune microenvironment in ovarian cancer

BACKGROUND

Ovarian tumors remain immunogenic even at advanced stages, but cancer-induced immunosuppression abrogates immune surveillance. The composition of the immune microenvironment in ovarian tumors was characterized by analyzing selected immunosuppressive factors in specimens from cancer patients. The influence of the hypoxia inducible factors on the immune microenvironment was also addressed.

MATERIALS AND METHODS

Tumor tissue was collected from 21 ovarian cancer patients immediately following tumor excision during surgery. The mRNA expression of selected genes was quantified, and tumor infiltrating leukocytes were characterized by flow cytometry to identify regulatory T-cells, myeloid-derived suppressor cells, and type-2 macrophages.

RESULTS

Overall, a pronounced heterogeneity was found among the analyzed samples. Nevertheless, statistical analysis revealed that the expression of hypoxia inducible factors correlated with the transcription levels of several immunosuppressive molecules.

CONCLUSION

The activity of hypoxia inducible factors contributes to cancer immunosuppression in ovarian cancer patients.

The AgNORs count in predicting long-term survival in serous ovarian cancer

INTRODUCTION

The value of argyrophilic nucleolar organizer regions (AgNORs) to predict survival in patients with ovarian cancer has not been clearly explained yet. The aim of study was to assess the value of analysis of the mean number of AgNORs per nucleus (mAgNOR) and mean percentage of nuclei with five or more AgNORs per nucleus (pAgNOR) in the prediction of disease-free survival (DFS) and overall survival (OS) in patients with serous ovarian cancer.

MATERIAL AND METHODS

The study examined 52 patients treated for serous ovarian cancer with a follow-up period of 2-143 months. After silver staining paraffin specimens from primary surgery, mAgNOR and pAgNOR in cancer cells were counted and analyzed. Age, grading, radicality of surgery and FIGO staging were analyzed as covariates.

RESULTS

Mean mAgNOR equaled 4.4 ±0.9 and pAgNOR equaled 42.2 ±20.8%. Both mAgNOR and pAgNOR were the lowest in G1 tumors. The mAgNOR and pAgNOR were lower in stage I than stage IV cancers. The DFS and OS rates were respectively 15.4% and 21.2%. In univariate analysis FIGO staging, grading, and pAgNOR were associated with worse prognosis, while radicality of surgery remained a significant protective factor in terms of DFS. Higher FIGO staging and older age worsened OS. In multivariate analysis FIGO staging remained significantly associated with both DFS (HR 1.98; 95% CI 1.05-3.71) and OS (HR 1.76; 95% CI 1.00-3.10), while age affected OS rates (HR 1.78; 95% CI 1.04-2.95).

CONCLUSIONS

mAgNOR and pAgNOR are useful markers of cellular kinetics. Prospective studies in larger populations are needed to confirm these results in terms of AgNORs' effects on survival.

[The value of progesterone and estrogen receptors expression in tissue microarray method in prognosis of patients with endometrioid endometrial cancer]

OBJECTIVES

To assess prognostic significance of progesterone receptors (PR) and estrogen receptors (ER) expression in the tissue microarray (TMA) technique for disease free survival (DFS) and overall survival (OS) in endometrioid endometrial cancer (EEC).

MATERIAL AND METHODS

The study included 151 consecutive patients, aged 37-86 years (62.80 +/- 9.99), with the EEC in stages I-III (FIGO), treated surgically at the Pirogow Memorial Hospital of Lodz between 2000 and 2007. Afterwards, they were subsequently treated and examined at the Regional Cancer Center, Copernicus Memorial Hospital of Lodz. Tissue cores 2 mm in size, in duplicate, were taken from the formalin-fixed and paraffin-embedded tissue donor blocks from surgery and constructed into the TMA recipient blocks. Using TMAs, the expression of PR and ER was examined and presented as Total Score (TS). The TS was determined by adding the intensity and marker distribution scores in a given case. The relationship between PR and ER expression, DFS and OS was examined. DFS was defined as the period from primary surgery until relapse. OS was defined as the period from primary surgery until the end of the follow-up (60 months) or until the death of the patient. The study was approved by the Ethics Committee of the Medical University of Lodz (RNN/82/11/KE).

RESULTS

Lack of the PR and ER expression was found in 46 cases (30.46%) and 67 cases (44.37%), respectively. The expression of the PR and ER was weak in 24 cases (15.89%) and 22 cases (14.57%), respectively. Strong PR and ER expression was found in 81 patients (53.65%) and 62 patients (41.06%), respectively. Follow-up after surgery varied from 3 to 60 months (50.95 +/- 16.36). In 30 patients (19.87%) relapse was diagnosed 1-54 months (22.17 +/- 15.59) after surgery. During follow-ups, 29 patients (19.21%) died. In univariate analysis better DFS was related to the presence of PR (p = 0.010), higher TS of PR (HR = 0.81; 95% CI 0.71-0.94), the presence of ER (p = 0.001) and higher TS of ER (HR = 0.88; 95% CI 0.78-0.99). DFS differed significantly between the groups: without PR and ER expression (A), with presence of the PR but not ER expression (B), with the ER but not PR expression (C) and with the PR and ER expression (D) (p = 0.004). In univariate analysis OS was not related to PR expression (p = 0.110), TS of PR (HR = 0.89; 95% CI 0.80-1.02) and ER expression (p = 0.070). TS of ER was connected to better OS (HR = 0.83; 95% CI 0.72-0.96). The OS differed between groups A, B, C and D (p = 0.006). In multivariate analysis variants of PR/ER expression influenced the DFS (p = 0.039) and OS (p = 0.016).

CONCLUSIONS

The expression of the PR and ER can significantly affect therapeutic decisions in selected patients with EEC. In EEC, common assessment of PR and ER expression is of higher prognostic value, than compared to single evaluation of PR and ER receptors.

Membrane expression of the death ligand trail receptors DR4 and DR5 in the normal endometrium, endometrial atypical hyperplasia and endometrioid endometrial cancer

To assess membrane expression of DR4 and DR5 in the normal endometrium (NE), endometrial atypical hyperplasia (EAH) and endometrioid endometrial cancer (EEC), the study examined 101 patients: 20 NE, 14 EAH and 67 EEC. The expression of DR4 and DR5 was examined and presented as the total score (TS). DR4 expression was seen in 18 NE, 11 EAH and 10 EEC. DR5 expression was seen in 20 NE, 13 EAH and 21 EEC. A strong correlation between type of endometrial tissue and TS of both receptors was identified. In EEC TS of DR4 and DR5 was not related to grading, staging or survival. Malignant transformation in the endometrium is related to reduction of membrane DR4 and DR5 expression. The level of membrane staining of the receptors in EEC is not dependent on grading and staging, and is not sufficient to predict survival in EEC patients.

Assessment of the argyrophilic nucleolar organizer region area/nucleus ratio in ovarian serous epithelial adenomas, borderline tumors and cancers

INTRODUCTION

There is a need to assess the value of the novel potentially useful biomarkers in ovarian tumors. The aim of study was to assess the value of sAgNOR analysis in ovarian serous epithelial tumors.

MATERIAL AND METHODS

The analysis was performed in ovaries from 113 patients treated operatively due to serous ovarian tumors (30 adenomas, 14 borderline tumors and 69 cancers). After silver staining of paraffin specimens from surgery, sAgNOR in tumor cells was analyzed. Additionally, the value of the argyrophilic nucleolar organizer region area/nucleus ratio (sAgNOR) in the prediction of disease-free survival (DFS) and overall survival (OS) in 52 patients with serous ovarian cancer with complete follow-ups in November 2009 was evaluated. Age, grading, radicality of surgery and FIGO staging were analyzed as additional factors.

RESULTS

SAGNOR IN ADENOMAS, BORDERLINE TUMORS AND CANCERS WAS IN THE FOLLOWING RANGES: (0.73 ±0.23) × 10(6), (0.81 ±0.18) × 10(6) and (0.96 ±0.33) × 10(6) [AgNOR/cm(2)] respectively. In cancers from G1 to G3 sAgNOR was (1.02 ±0.32) × 10(6) (G1), (0.98 ±0.37) × 10(6) (G2) and (0.82 ±0.24) × 10(6) (G3) [AgNOR/cm(2)] respectively. In univariate analysis, but not in multivariate analysis, staging negatively correlated with better DFS and OS. sAgNOR, age of patients, grading and radicality of surgery were not associated with DFS or OS in either univariate or multivariate analysis.

CONCLUSIONS

sAgNOR analysis is not sufficient to precisely characterize cellular kinetics in serous ovarian tumors, and the analysis of sAgNOR, mAgNOR and pAgNOR should be performed commonly. The prognostic significance of sAgNOR in patients with serous ovarian cancer was not proven.

Construction of a tissue microarray with two millimeters cores of endometrioid endometrial cancer: factors affecting the quality of the recipient block

The tissue microarray (TMA) method currently is not used to render a primary diagnosis of cancer, but its scientific value has been proved in studies of various cancer types. TMA technology still is not used often for uterine tumors, however. We investigated the repeatability of histological diagnosis of endometrioid endometrial cancer (EEC) using conventional histology and TMA using 2 mm cores. We examined EEC tissues from 171 patients. Formalin fixed, paraffin embedded tissue donor blocks from EEC specimens were selected and examined histologically. Duplicate 2 mm tissue cores were inserted into a TMA recipient block. EEC tissues were examined as hematoxylin-eosin stained sections from the TMAs. EEC tissue was identified in the TMAs in 158 cases (92.4%) and not found in 13 cases (7.6%). On the TMA slides, both EEC positive cores were identified in 129 cases (75.4%), but only one core in 29 cases (17.0%). Among 342 biopsies of the donor blocks (each case in duplicate), EEC was found in 287 cases (83.9%) using the TMA: 124/146 (84.9%) with superficial infiltration, 153/178 (86.0%) with deep myometrial infiltration, and 10/18 (55.6%) without myometrial infiltration. We concluded that two 2 mm tissue cores from a biopsy of a donor block inserted into a TMA recipient block were sufficient to diagnose EEC in more than 90% of cases. EEC was identified in the TMAs with similar frequency with respect to superficial and deep myometrial infiltration. Cases without myometrial infiltration were identified less often.

CA-125 concentration in serum and peritoneal fluid in patients with endometriosis - preliminary results

INTRODUCTION

Cancer antigen 125 (CA-125), known as a biomarker for women genital tract malignancies, could be also useful in detecting and monitoring endometriosis. The aim of this study was to evaluate CA-125 in serum and peritoneal fluid (PF) as an indicator of endometriosis.

MATERIAL AND METHODS

Fifty-six patients admitted to the First Department of Obstetrics and Gynaecology for diagnostic or therapeutic laparoscopy conducted for infertility, pelvic pain, suspected endometriosis or ovarian cysts entered the study. Those with laparoscopically confirmed endometriosis were assigned to group A, those without this condition to group B. Blood for CA-125 was taken prior to surgery, centrifuged and assayed in accordance with the manufacturer's instructions (VIDAS CA-125 II). Peritoneal fluid and an endometrial biopsy were taken during laparoscopy. Statistical comparisons were performed using Statistica 7.1.

RESULTS

Group A consisted of 44 women with laparoscopically confirmed diagnosis; 15 patients served as a control group. The mean value of CA-125 concentration in the endometriosis group was 33.98 U/ml, vs. 9.3 U/ml in the control group. The mean value of CA-125 in peritoneal fluid was 1241.88 U/ml in the non-endometriosis group versus 2640.23 U/ml in the study group; both results were statistically significant (p < 0.05). There was a significant correlation between the stage of endometriosis and CA-125 plasma concentration (R = 0.5993, p < 0.001). Cancer antigen 125 concentration in serum was a moderate predictor to distinguish between patients with and without endometriosis (AUC 0.794; 95% CI 0.668-0.921; p = 0.001).

CONCLUSIONS

Cancer antigen 125 is a well-known biomarker for endometriosis and helpful in daily clinical practice when endometriosis is suspected. The cut-off value in serum suggesting endometriosis with 68% sensitivity is 11 U/ml. This value is normal range for Ca-125 concentration.

[Effectiveness of tissue microarray technique for the assessment of estrogen and progesterone receptors expression in endometrioid endometrial cancer--preliminary report]

OBJECTIVES

To assess the effectiveness of the donor-block biopsies with a 2 mm-size needle in endometrioid endometrial cancer (EEC) in the tissue microarray (TMA) technique and the application of the TMA for estrogen receptors (ER) and progesterone receptors (PR) expression in EEC.

MATERIAL AND METHODS

The study examined EEC tissues from 60 patients. Tissue cores, 2 mm in size, in duplicate, were taken from the formalin-fixed and paraffin-embedded tissue donor blocks and constructed into the TMA recipient block. The presence of EEC tissue in the TMAs was analyzed, and the ER and PR expressions were examined.

RESULTS

EEC tissue in TMAs was confirmed in 56 cases (93.33%). In 49 of them (81.67%), both cores presented with cancer tissues. In 4 cases (6.67%) EEC tissue was absent. All cases with ECC present on the TMA slides were appropriate for the ER and PR analysis. In 29 EEC cases (51.98%) both ER and PR were expressed. In 3 cases (5.36%) only ER was expressed, in 8 cases (14.29%) only PR was expressed, and in 16 cases (28.57%) ER and PR were assessed as negative.

CONCLUSIONS

Two 2 mm-sized tissue cores from donor-block biopsies constructed into the TMA recipient block were sufficient to diagnose EEC and enabled the assessment of ER and PR expression in 93.3% of the cases. The use of the described TMA technique makes the immunohistochemical study of EEC easier and more time-efficient.

[Expert panel recommendations on therapeutic and diagnostic management of urinary incontinence and overactive bladder in women]

The expert panel recommendations are issued in order to increase the number of patients with urinary incontinence and overactive bladder receiving appropriate care. The expert panel recommends that urologists, gynecologists and other physicians interested in the field of incontinence should Incontinence question should be actively asked during each physician visit and if the answer is positive it should be followed by detailed questionnaire aiming at disclosing at which occasion patient is loosing urine. The next step should be urogynecological examination and cough stress test. The panel recommends urine dipstick in all women and post void residual urine measurement only in women with voiding difficulties. Other tests, such as ultrasound, cystoscopy urodynamics are not recommended during initial diagnostic procedure. The indications for referral are significant pelvic organ prolapse, haematuria, pain during micturition, recurrent incontinence and infections, suspicion of fistula. The initial management of stress urinary incontinence should include lifestyle interventions, and physiotherapy Use of pessaries is acceptable in women who are not fit or do not want surgical therapy Local estrogen therapy should only be used in women with urogenital atrophy Duloxetin is an option in the pharmacological therapy of stress incontinence, but it doesn't cure the disease. The ineffectiveness of initial procedure should be indication to surgery Alphaadrenomimetic drugs are not recommended in the therapy of urinary incontinence. The initial management of overactive bladder and urgency incontinence should include lifestyle interventions, however fluid restrictions (if fluid load is less than 3000 ml) are not recommended. The cornerstone of overactive bladder and urgency incontinence therapy remains the treatment with anticholinergic drugs. Drugs are only effective when used accordingly to the registered doses. The new generation anticholinergics are recommended over the old ones, especially in frail elderly patients and in patients with concomitant diseases, due to their better safety profile. The evaluation of anticholinergics efficacy should be performed after 2-3 months, then after 6 months.

[The effects of operative SUI treatment established using Burch colposuspension and IVS tape and evaluated through various urogynecologic tests]

OBJECTIVES

Numerous diagnostic instruments have been used in modern urogynecology; alas, sufficient comparative analysis between most of them has not been carried out in world literature.

DESIGN

The aim of the study was to compare the results of selected urogynecology tests, used to analyze the effectiveness of SUI treatment, using Burch colposuspension and IVS tape.

MATERIAL

The study was conducted among 76 patients selected for operative treatment of SUI II and III degree, using of Burch colposuspension (I group, n=47) and IVS tape, Tyco (II group, n=29).

METHODS

The following investigations: urogynecologic anamnesis and examination with cough test, miction diary, pad test, urodynamic exam and UDI-6 questionnaire, have been used to evaluate SUI symptoms before and half a year after the operation.

RESULTS

The percentage of the cured, depending on the adopted urogynecology investigation, oscillated in group I between 56.8% to 91.5%, and 56.5% to 86.2% in group II. The best results were obtained in anamnesis and cough test.

CONCLUSIONS

1. The analyzed methods of urogynecology tests correlate with anamnesis as far as SUI symptoms after operative treatment are concerned. 2. There are relevant differences between several tests, in case of the estimation of SUI cure rate after colposuspension, as well as when using IVS tape.

One-year endometrial safety evaluation of a continuous combined transdermal matrix patch delivering low-dose estradiol-norethisterone acetate in postmenopausal women

OBJECTIVE

To evaluate the safety and endometrial protection of low-dose transdermal estradiol (E2)/norethisterone acetate (NETA) patches (Estalis 25/125) in terms of post-treatment incidence of endometrial hyperplasia/cancer after 1 year of treatment in postmenopausal women with intact uteri.

METHODS

Patients were randomized to receive either transdermal E2/NETA (delivering daily doses of E2 25 microg and NETA 125 microg; applied every 3-4 days) or oral E2/NETA (E2 1mg and NETA 0.5 mg; given daily) in this open-label study. The primary variable was the incidence of endometrial hyperplasia/cancer based on endometrial biopsies; secondary variables included vaginal bleeding/spotting patterns, patch adhesion, safety and tolerability.

RESULTS

Six hundred and seventy-seven patients were randomized (507 in the transdermal group and 169 in the oral group; one did not receive study drug) and >80% completed the study. There were no cases of endometrial hyperplasia or cancer in either group and the upper limit of the one-sided 95% confidence interval in the transdermal group was 0.85%. Over time, both treatments were associated with a decreasing frequency of spotting/bleeding days. The overall incidence of adverse events (AEs) was comparable in both groups, and the majority was mild-to-moderate in intensity. Breast tenderness was the most frequently reported AE (transdermal 19.9% versus oral 28.4%). AEs related to the gastrointestinal system were more frequent with oral E2/NETA, and episodes of spotting and bleeding were more frequent with transdermal E2/NETA. Local skin tolerability of the transdermal matrix system was good.

CONCLUSIONS

Transdermal E2/NETA (25 and 125 microg) provided adequate endometrial protection in postmenopausal women when evaluated according to CPMP/CHMP criteria, achieved a high rate of amenorrhea, and was well tolerated.

[The influence of SUI operative treatment with use of IVS tape on quality of life]

OBJECTIVES

Real influence of urinary incontinence symptoms and adopted modes of treatment on patient's quality of life is not known.

DESIGN

Assessment of influence of operative SUI treatment with the use of IVS tape on patient's quality of life.

MATERIAL AND METHODS

Prospective study was conducted among 57 patients with SUI symptoms II and III degree (type III according to Blavais), who were classified to apply IVS tape. Diagnostic investigations were completed by questionnaires: IIQ-7 and UDI-6, which were filled by patients. In analysis there were included results obtained before the operation and 6 months after procedure.

RESULTS

We recognized women as cured: based on physicians anamnesis--80.7% of patients, according to UDI-6 --71.93%. Half year after operation relevant improvement of quality of life, evaluated by IIQ-7 questionnaire, showed 89.47%. Improvement of quality of life correlated with lack of SUI symptoms in anamnesis (r = 0.631; p < 0.001) and in UDI-6 questionnaire (r = 0.597; p < 0.001).

CONCLUSIONS

(1) Operation with the use of IVS tape is effective according to improvement of quality of life in majority of patients treated due to SUI. (2) Efficacy of operative treatment in domain with SUI symptoms correlates with influence of procedure on quality of life. (3) Assessment of SUI operative treatment should include analysis of SUI symptoms and their influence on quality of life, achieved upon standardized questionnaires filled by patients.

[The efficacy of SUI treatment with Burch colposuspension evaluated with use of ITT analysis]

OBJECTIVES

Search for methods of assessment of effects of SUI treatment, which goal is to minimize risk of bias, are inconclusive and remain the subject of investigation.

DESIGN

The aim of the study was to analyze the influence of application of different methods of efficacy measurement of SUI treatment with use of Burch colposuspension on final conclusions concerning the treatment effects.

MATERIAL AND METHODS

Prospective investigation was carried out among 50 women with SUI symptoms II or Ill degree, scheduled for Burch colposuspension. The analysis of obtained results was carried out with use of ITT and modified ITT. To compare, therapy effects were explored with the use of principles which have been, until quite recently, most often used in urogynecology.

RESULTS

Differences in percentage of cured, based on results of several urogynecologic examinations according to method of analysis (previously used method, ITT, modified ITT), have oscillated between 3% to 20%.

CONCLUSIONS

(1) While selecting diagnostic methods to analyze SUI treatment effectiveness, potential problems with obtaining complete data after the treatment should be taken into account. (2) In order to minimize statistic bias, the usage of few methods of analysis of obtained results is highly recommended.

[Burch colposuspension--analysis of complications on our own material]

OBJECTIVES

Literature describing complications after colposuspension and analyses of the learning curve is scarce. Knowledge concerning this topic may lower the frequency of complications, improve the effectiveness of the procedure and increase patients' satisfaction.

DESIGN

The purpose of the study was to evaluate types and frequency of complications which occur during modified Burch colposuspension and shortly after the procedure (to the moment of admission home), aiming at the optimization of the operative technique.

MATERIALS AND METHODS

Indications for colposuspension were: genuine stress incontinence II and III degree and paravaginal defect medium to large degree (type II stress incontinence according to Blaivais). We have analyzed first 400 procedures, performed by 3 gynecologists. A complex analysis of the course of the operation and postoperative period (till patient's withdrawal from hospital) has been performed. Colposuspension has been conducted according to professor's Petri's tips.

RESULTS

The most common complications during the first procedures were: bleeding into Retzius space, transient haematuria and residual of urine after miction. Their incidence diminished with the increasing of number of procedures. The presence of highly experienced team during the operation lowered the risk of complications.

CONCLUSIONS

Percentage of complications during and after modified Burch colposuspension is low and it decreases with the number of procedures.

[Abdominal sacrocolpopexy in the enterocoele treatment--analysis of the surgical technique and the course of the initial procedures]

OBJECTIVES

Abdominal sacrocolpopexy is one of the most effective treatments of enterocoele. Alas, little is known about complications resulting from the procedure.

DESIGN

The aim of the study was to analyze the course of the operation, the perioperative period and the outcome of abdominal sacrocolpopexy.

MATERIALS AND METHODS

8 women, aged 60-75, have undergone the operation. The sacrocolpopexy procedure has been performed through abdominal access on patients with considerable enterocele (III and IV degree on POP-Q scale). Polypropylene multifilament tape Surgipro (Tyco) has been applied in all cases.

RESULTS

All of the procedures have run without any complications. The patients did not complain about any major ailments during postoperative period and have been released from the hospital according to schedule. One month after the operation, the check-up proved the outcome was good. After six months, III degree POP has been diagnosed again in two patients with previously performed Richter operation and, additionally, vaginal erosion has been found in one of them.

CONCLUSIONS

Abdominal sacrocolpopexy procedure involves a low risk of complications. Detailed evaluation will only be possible after assessing higher number of procedures and estimating the results after a longer period of time.

[Sacrospinous colposacrofixation in the treatment of female pelvic organ prolapse (POP)--analysis of the operation course and complications]

OBJECTIVES

Richter operation is used for the enterocele and high rectocoele treatment. There are many modifications of the procedure. Alas, not much data concerning complications and the learning curve of Richter operation is currently at our disposal.

DESIGN

The aim of the study is to analyze the course of sacrospinous colposacrofixation and the postoperative period of time in order to optimize surgical technique.

MATERIAL AND METHODS

The first 200 procedures, performed by two surgeons, have been investigated. Women with II, III and IV degree of pelvic organ prolapse, according to POP-Q scale, recommended by ICS, have undergone the operation. In accordance with the protocol, we have analyzed the course of the operation and postoperative period of time during the patients' stay in the hospital, as well as the first month after their leaving the hospital.

RESULTS

Difficulties in reaching the sacrospinous ligament have occurred during the initial procedures. The incidence of the problem has been gradually reducing with the increasing number of performed operations. None of the patients was in need of blood transfusion. Granulation in the vagina, resulting in the necessity of its, and parts of sutures, evacuation, occurred in case of 6 (3%) patients.

CONCLUSIONS

Sacrospinous colposacrofixation equals a low risk of complications, even during the initial procedures. With the rise of the number of performed operations and better ability recognition of anatomic properties of the operating area, technical problems decrease significantly.

Ultrasound diagnostic schema for the determination of increased risk for chromosomal fetal aneuploidies in the first half of pregnancy

The aim of the study was to develop an early ultrasound diagnostic schema for the determination of increased risk for fetal chromosomal aneuploidies. The study was conducted on a population of 1318 pregnant women divided into 2 groups: 1255 women with the normal course of pregnancy and 63 women with diagnosed fetal abnormalities. There were 34 cases of chromosomal abnormalities (trisomy 21, 18, 13; triploidy; unbalanced inversion 9; deletion 16) and 29 cases of structural malformations. The estimation of the range of normal values was performed for the nuchal translucency (NT) measurement between 11 and 13 weeks and the nasal bone length (NB) measurement between 12 and 20 week. The results obtained in the collective set of normal pregnancies constituted the basis for the calculation of the range of normal values. The measurements of NB and NT showed a linear value increase with the pregnancy course. The following test characteristics (correlation to CRL) were recorded: NB - sensitivity 60%, specificity 98%, positive predictive value (PPV+) 43%, negative predictive value (NPV-) 98.9%. For the assumption that the test outcome means the presence or absence of the nasal bone in the ultrasound scan the sensitivity was 40%, but specificity 100%; NT - sensitivity 63.6%, specificity 98.2%, PPV+ 38.9%, NPV - 98.2%; NT + NB - presents similar characteristic to the NB or NT alone - sensitivity 55.6%, specificity 98.6%, PPV+ 50%, NPV - 98.9%. The following test characteristics for chromosomal aberration markers (correlation to BPD) were observed: NB - sensitivity 68.4%, specificity 97.4%, PPV+ 56.5%, NPV - 98.4%; NT - sensitivity 73.9%, specificity 97.9%, PPV+ 54.8%, NPV- 99.2%; NT + NB - sensitivity 94.7%, specificity 98.9%, PPV+ 90%, NPV - 99.7%, respectively. The "genetic sonogram" protocol for the structural defect detection was analysed: sensitivity was 80%, specificity 100%, PPV+ 100%, NPV - 99.7%. It is concluded that the new biometric parameter--nasal bone length (NB) and the corrected one--nuchal translucency thickness (NT) are useful markers for fetal abnormalities, especially for chromosomal aberrations. High predictive values of the diagnostic schema for the detection of aneuploidies and structural defects indicate that its application in correlation with the biparietal diameter (BPD) is highly recommended. The proposed schema is an effective algorithm for prenatal diagnostics characterised by high prognostic values. The possible introduction of the schema could result in a decrease of the invasive procedure rates, which could minimise the rate of miscarriages as a complication of amniocenteses.

[Efficacy of burch colposuspension in the stress urinary incontinence treatment evaluated with he use of consort diagram]

Different results of stress urinary incontinence (SUI) treatment may be caused by methodological bias. A group of specialists have introduced a new way of clinical results analysis, called CONSORT (The Consolidated Standards of Reporting Trial).

OBJECTIVE

The aim of the study was to evaluate CONSORT diagram usefulness to objectivize analysis of effectiveness of operative urinary stress incontinence (SUI) treatment with the use of Burch colposuspension.

MATERIAL AND METHODS

Prospective analysis was provided among 50 women planned for Burch colposuspension because of SUI II and III degree. Before treatment and half year later there were performed urogynecological exams according to protocol.

RESULTS

With use of CONSORT diagram we evaluated the percentage of cured patients between 42% to 70% according to diagnostic method and possibility to obtain complete data.

CONCLUSIONS

The use of CONSORT diagram allows detailed analysis of data completeness. It is useful to minimize the bias effect resulting from lack of results of particular exam. It is useful to objectivize estimation of effectiveness of SUI treatment with use of Burch colposuspension.

Serum melatonin circadian profiles in women suffering from cervical cancer

Although there is an increasing evidence that the pineal gland may play a role in human malignancy, the studies on melatonin concentrations in different types of malignant tumors brought about controversial results. However, changes in melatonin concentrations have been observed in some types of human malignant tumors. Therefore, we decided to study the circadian melatonin rhythm in patients suffering from cervical cancer in different stages of progression and to compare them with those in subjects free from neoplastic disease. A total of 45 women were analyzed in this study. The subjects were divided into two groups. The first group consisted of 31 patients [mean age 52.1 +/- 1.8 yr (mean +/- S.E.M.), range 32-77 yr] with cervical cancer in various stages of the disease. The second group consisted of 14 healthy volunteers [mean age 53.5 +/- 2.0 yr (mean +/- S.E.M.), range 42-63] who served as the control group. Blood samples were collected at 08:00, 12:00, 16:00, 20:00, 22:00, 24:00, 02:00, 04:00, 06:00, and 08:00 hours. Melatonin concentration was measured by immunoenzymatic method. There were significant differences in circadian melatonin profiles as well as in the area under curve among the two studied groups. Melatonin concentrations were significantly lower in cancer patients in comparison with healthy individuals. Taking into consideration stage of the cervical cancer significantly lower melatonin secretion has been found in all subgroups of patients in comparison with that of tumor-free control group. Additionally, nocturnal melatonin concentrations as well as area under curve were significantly lower in advanced stage of cancer (stages 3 and 4) in comparison with patients with preinvasive cancer (stage 0) at 24:00, 02:00, and 04:00 hours and patients with stage 1 disease at 02:00 and 04:00 hours. The results of the present study indicate that the presence of cervical cancer influences melatonin levels in women. Moreover, stage dependence in reduction of melatonin concentrations has been found.

[The usefulness of uterine artery doppler velocimetry in high risk pregnancy diagnostic (PIH and/or IUGR)]

OBJECTIVES

High risk pregnancy was defined as developing of pregnancy induced hypertension or/and growth retardation in the course of gestation.

DESIGN

The main aim of the study is to analyze the usefulness of uterine artery doppler velocimetry in high risk pregnancy diagnostic.

MATERIALS AND METHODS

610 single pregnancies were included in the study. First group of normal pregnancies where -530 single normal pregnancies between 19 and 39 gestation weeks. S/D, RI & PI in both uterine arteries were assessed. There were assessed flow velocity waveforms also for detection of notches. At the next stage an examined group with 80 pregnant women was formed where in the course of gestation pregnancy induced hypertension and/or fetal growth retardation. 24 hour monitoring of the blood pressure in the examined group was performed. Obtained data from both groups was calculated and statistically analyzed.

RESULTS

Mean values for flow velocity waveform indices were estimated for both groups: controls S/D 2,35 (SD 0,61), RI 0,56 (SD 0,11), PI 0,96 (SD 0,32), examined group S/D 2,99 (SD 1,16), RI 0,63 (SD 0,12), PI 1,26 (SD 0,51). There is significant difference between values for all flow parameters p < 0,001. In the control group we observed notches in 11,8% of all women and in the examined (hypertension and/or growth restriction) group in 81,3% (p<0,001). The sensitivity is 81,3% and specificity 88,2%. MoMRIs for both uterine arteries were calculated to compare data from control and examined group. In the examined group 41,3% RI results were above calculated MoM and there is significant difference between both groups (p <0,001). The sensitivity is 41,3% and specificity 89,5%. In the group of the hypertensive pregnant women where mean systolic blood pressure in 24 hour monitoring was above 130 mm Hg we observed notches in 61,1% of flow velocity waveforms in uterine arteries. In the group of normal pregnancies there were 11,8% notches and there is significant difference between both groups (p<0,001).

CONCLUSIONS

The uterine artery velocimetry values of S/D, RI, PI decrease with the progression of gestation. There are no significant differences between right and left uterine artery doppler velocimetry. There are significant differences for values and percentage of notches in both groups. Extremely high rate of notches is observed in the group with most elevated blood pressure (daily mean value over 130mm Hg). It is possible to calculate obstetrical risk assessing values for blood flow in uterine arteries in pregnancy. It can be helpful to estimate methods detecting elevated risk for hypertension and/or growth retardation in pregnancy.

Ultrasound evaluation of intrauterine growth restriction therapy by a nitric oxide donor (L-arginine)

OBJECTIVE

There are numerous methods available of treating intrauterine growth restriction but their results are still not satisfactory. Currently, we are conducting a research project whose main aim is based on the use of the nitric oxide (NO) donor L-arginine in growth restriction therapy. The main aim of this study was the ultrasound evaluation of the efficacy of this therapy based on biometric measurements (the estimated fetal weight) compared with the estimated weight of newborn children.

STUDY DESIGN

The investigated group comprised two randomly chosen groups of pregnant women with ultrasound-diagnosed intrauterine growth restriction (biometry < 10th centile for gestation age): 78 patients were treated by L-arginine 3 g daily orally for 20 days; and 30 patients, not treated, acted as the control group.

RESULTS

The ultrasound estimation of fetal weight at the start and at the end of the treatment showed a mean increase of 642 g (SE 90 g) using the Shepard method, and 648 g (SE 94 g) using the Hadlock method, respectively. By comparison, within the control group a mean value increase of 395 g (SE 77 g) was found, using the Shepard method, and 404 g (SE 82 g) using the Hadlock method, respectively. There was a significant statistical difference when comparing the estimated fetal weight increase in both methods: p=0.008 for the Shepard calculation and p=0.012 for the Hadlock calculation. The weight of the newborn infants was also evaluated: in the treated group the mean value was 2823 g (SE 85 g) and in the untreated group the mean value was 2495 g (SE 147 g). There was a significant (p=0.027) difference, showing a positive effect of the treatment on the weight of newborns. In the treated group the percentage of growth-retarded newborns was 29% while in the untreated group it was 73%. A significant difference has been found (p < 0.01) between both of the groups of newborns.

CONCLUSIONS

The ultrasound evaluation of the estimated fetal weight and the birth weight of the newborns showed an improvement: there was an acceleration of fetal development in the L-arginine-treated group of pregnant women as compared with the untreated group. The ultrasound evaluation of the estimated fetal weight is a good diagnostic tool, properly monitoring the efficacy of the L-arginine treatment of the growth-retarded fetuses.

[Ultrasound evaluation of NO-donor (L-arginine) therapy for intrauterine growth retardation]

There are many methods of the growth restriction therapy, but the results are still not satisfactory. Actually, we are conducting a project which main conception is based on the use of the NO donor (L-arginine) in growth retardation therapy. This amino acid is an effective NO donor and has a vasodilating effect on the vessels and anti-aggregation effect on platelets, which plays a great role in improving feto-maternal blood flow. The main aim of this paper is the ultrasound evaluation of the effectiveness of NO-donor (L-arginine) therapy for intrauterine growth retardation based on biometrical measurements (estimated fetal weight) compared with newborns weight estimation.

METHODS

The investigated group comprised two groups of pregnant women with ultrasonographically diagnosed intrauterine growth retardation (biometry <10th percentile for the gestation age): --78 patients were treated by L-arginine 3 g daily p.o. in 20 days period. --30 patients not treated (no agreement for therapy) as controls.

RESULTS

Ultrasound estimation of fetal weight at the start and at the end of the treatment showed a mean value increase of 642 g (SE 90g) using Shepard method and 648g (SE 94g) using Hadlock method respectively. Comparing not treated group there was assessed a mean value increase of 395 g (SE 77 g) using Shepard method and 404g (SE 82g) using Hadlock method respectively. There is statistical significant difference comparing an estimated fetal weight in both methods: p = 0.008 for Shepard calculation and p = 0.012 for Hadlock calculation. There was analyzed newborn weight also--in a treated group mean value was at 2823 g and in not treated group mean value was at 2495 g. There was no significant difference found but a positive tendency for treated group newborns weight is visible. In the treated group number of the growth retarded newborns was at 29% and in the not treated group was at 73%. There was found a significant difference comparing both newborns groups at p < 0.05.

CONCLUSIONS

The ultrasound evaluation of the estimated fetal weight and after-birth weight estimation of the newborns showed an increased dynamic of the fetal development in the L-arginine treated group of pregnant women comparing to the not treated group. The ultrasound evaluation of the estimated fetal weight is a good diagnostic tool for properly monitoring the effectiveness of treatment with L-arginine for growth retarded fetuses.

[Assessment of the AgNORs count in serous ovarian cancer]

OBJECTIVE

The survival rate of patients with ovarian cancer strongly depends on staging and grading. The next potential, independent prognostic factor might be the amount of nucleolar organizer regions (AgNORs) in cancer cells.

DESIGN

To assess the relationship between AgNORs count in serous ovarian cancer and grading, the size of primary tumor, the evaluation of peritoneal fluid and clinical staging.

MATERIAL AND METHODS

69 women who underwent surgical procedure due to serous ovarian cancer between 1998-2002 were included into the study. In each case the clinical and histopathological assessment of neoplastic disease was made. In all cases the specimens were prepared according to the method described by Howell and Ploton. In cancer cells the mean number of AgNORs per nucleus (mAgNOR) and the mean percentage of nuclei with five or more AgNORs per nucleus (pAgNOR) were counted.

RESULTS

The mAgNOR in cancer cells varied from 3.22 to 7.19 (mean 4.31+/-0.81), and the pAgNOR varied from 5% to 84% (mean 39.74+/-20.58%). According to the grading of cancers it was as follows: 3.74+/-0.25 and 22.12+/-10.03 in G1 tumors, 4.13+/-0.56 and 35.52+/-13.94 in G2 tumors, and 4.75+/-0.92 and 52.26+/-20.65 in G3 tumors. All the differences were statistically significant. We did not find any correlation between the size of primary tumor and mAgNOR as well as pAgNOR. There were no correlations between the presence as well as the amount of ascitic fluid, and mAgNOR as well as pAgNOR. The positive correlation between the presence of cancer cells in peritoneal fluid and pAgNOR, but not mAgNOR was found. The values of mAgNOR and pAgNOR in clinical stages were respectively: 3.94+/-0.44 and 27.11+/-15.71 for stage I, 4.14+/-0.62 and 39.25+/-22.53 for stage II, 4.27+/-0.79 and 38.76+/-19.79 for stage III, 4.55+/-0.92 and 46.42+/-20.71 for FIGO stage IV. The positive correlations between staging and mAgNOR as well as pAgNOR were found.

CONCLUSIONS

The number of AgNORs per cell is one of the sensitive methods in the assessment of ovarian cancer agressiveness and positively correlates with grading and staging of the disease.

[Obstetric hysterectomy--analysis of indications in years 1992-2001]

AIM OF THE STUDY

Analysis of indications and post-operative course in patients after obstetric hysterectomy.

MATERIAL AND METHODS

45 cases of obstetric hysterectomy were analysed.

RESULTS

Mean age of operated woman was 32.18 +/- 4.31 years. Mean gestational age was 35.9 +/- 1.76 weeks. The estimated rate of obstetric hysterectomy was 2.5 per 1000 deliveries. The most frequent indication for urgent hysterectomy were placentation disorders. Elective hysterectomy was performed because o invasive cervical cancer and uterine myomas. Mean time of duration of surgery was 91.67 min.

CONCLUSIONS

1. Indications for obstetric hysterectomy should be stated very carefully and the operation should be performed by the most experienced staff. 2. In case of severe intraoperative bleeding internal iliac artery ligation should be performed.

[Combination of screening tests for fetal abnormalities in the first and second pregnancy trimesters]

OBJECTIVE

Screening for fetal abnormalities in the second trimester of pregnancy, based on the concentrations of various markers in serum and maternal age, has become widely used in the past decade. In the first trimester fetal malformations are associated with high values for fetal NT.

DESIGN

We propose a new screening method in which measurements obtained during both trimesters are integrated to provide a single estimate of a woman's risk of having a pregnancy affected by genetic syndrome.

MATERIAL AND METHODS

Study groups comprised 775 pregnant women where examinations were done between 11th-14th and 15th-19th pregnancy weeks. Nuchal translucency thickness was measured by ultrasound examination in both trimesters of pregnancy. AFP, -HCG and oestriol were measured by ELISA assays. Derived risks were then calculated.

RESULTS

Eight fetal aneuploidies were diagnosed. When we used a risk of 1:250 as the cutoff to define a positive result on the integrated test, the rate of detection of fetal abnormalities was 100%, with a false positive rate of 0.6%.

CONCLUSION

Integrated test, which is a combination of the ultrasound examination and the triple test allows to achieve high sensitivity and the decrease in the percentage of false positive results, which leads to the reduction in the number of amniocentesis to be performed.

[Nuchal translucency measurement--non invasive ultrasound screening for fetal abnormalities. Part I]

OBJECTIVE

Fetal abnormalities are the most common cause of perinatal and postnatal death and infant handicap. In the last years came into being many diagnostic methods making possible--precise and accurate diagnosis of fetal malformation.

DESIGN

Estimation the value of the screening test for fetal abnormalities based on the nuchal translucency measurement between 10-14th week of pregnancy.

MATERIAL AND METHODS

A group of 675 women with singleton pregnancies undergoing first trimester nuchal translucency measurement. Nuchal translucency thickness was measured by transvaginal ultrasound examination according to Nicolaides. Derived risks were then calculated.

RESULTS

When we used a risk of 1:250 as the cutoff to define a positive result on the screening test, the rate of detection of fetal abnormalities was 100%, with a false positive rate of 1.3%.

CONCLUSION

First trimester nuchal translucency measurement is an effective method of screening for fetal abnormalities (obstetrical high-risk group).

[Low-grade endometrial stromal sarcoma firstly localized in colonic mesentery]

There are only few papers describing extrauterine localisation of endometrial tumor sarcoma. Pathogenesis of this tumor is still not clear. Most of the authors suggest the heterotopic Mullerian ducts to be the origin of such tumors. We describe a case of 53 year old woman with endometrial tumor sarcoma localized in the mesenterium of the colon. Diagnostic problems and differential diagnosis is presented. The authors suggest to immunohistochemical methods (CK desmin) to facilitate diagnosis.

[Plasma carbonyl group concentration in pregnant women with IUGR treated by L-arginine and acetylsalicylic acid]

OBJECTIVES

Carbonyl groups are the elements connecting protein structure, they influent into biological activity. High concentration of carbonyl groups means high risk of protein destruction.

DESIGN

The aim of this study was the evaluation of carbonyl group concentration in blood serum in normal pregnancy and in women with IUGR treated by L-arginine and acetylsalicylic acid.

MATERIAL AND METHODS

The study was done at the Department of High Risk Pregnancy, Department of Gynaecology and Obstetrics, Medical University of Łódź, in 1999-2002. The study group included 80 pregnant women hospitalised due to foetal growth restriction, between the 32-th and 38-th weeks of pregnancy. The treatment was conducted for twenty days and consisted of everyday low dose aspirin (Acard) and L-arginine (NO precursor). The ultrasound and laboratory examinations were done on the first day of hospitalisation in both groups, and at 20-th day of treatment in the group of IUGR. The carbonyl groups concentration was measured by Levine method and expressed in mmol/1 mg proteins.

RESULTS

In controls mean value of carbonyl groups concentration was 1.848 +/- 0.291 mmol/1 mg proteins and after 20 days of observation 1.897 +/- 0.439. In the group with IUGR before treatment was 2.193 +/- 0.658. After 20 day of the therapy and the value decreased to 2.078 +/- 0.679. There is a significant difference between the value of carbonyl-groups concentration in normal pregnancy and IUGR. The carbonyl-groups concentration decreased after 20 days of treatment by L-arginine, and the value is still higher than in normal pregnancy.

CONCLUSIONS

Oxidative protein damage in IUGR decreased in the process of treatment.

[Diagnostic methods for fetal malformations in the first half of pregnancy]

INTRODUCTION

Fetal abnormalities are the most common cause of perinatal and postnatal death and infant handicap. For this reason prenatal screening (for fetal malformation) has become a routine part of obstetric care in many countries. Most often used are biochemical tests and continuously developing ultrasound diagnostics which makes possible precise analysis of the fetal morphology. There is interesting to establish a noninvasive test for the early detection of fetal malformation in pregnancy which is based on ultrasound examination (NT measurement from the 10th to the 19th weeks, presence of nasal bone in the first trimester ultrasound), correlated with serum concentration of AFP, beta-HCG and oestriol in the second trimester of pregnancy (triple test). The main aim of the study was to establish a diagnostic schema for detection of fetal malformations based on NT measurement in the first and second trimester coupled with triple test performed in the second trimester.

MATERIALS AND METHODS

A group of 775 pregnant women from the 10-th week of pregnancy until childbirth has been put under examination. Between the 10th and the 14th and than between 15th and 19th week of pregnancy ultrasound examination with fetal biometry and NT measurement was done. NT measurements have been performed in accordance with the standards worked out by professor K. Nicolaides. At the first ultrasound examination the presence of the nasal bone was observed. The next step was performing the triple test between the 15th and 19th week of pregnancy. On the same day as second ultrasound examination blood was taken to determine the results of the triple test (ELISA method). The obtained results have undergone statistical analysis.

RESULTS

The age of women qualified for the examination oscillated between 15 and 45 (over 35 -9.4%). There were 8 fetal malformations recognized all connected with the chromosomal anomalies, namely, 4 Downs syndrome, 2 fetuses with trisomy of the 18th pair of chromosomes and 2 with triploidy. At all physiologic pregnancies nasal bone was seen during first ultrasound examination. The obtained results of nuchal fold measurements and concentrations for the parameters of the triple test have been the basis to calculate medians in the particular weeks of pregnancy. In all the cases of genetic malformations the widening of the nuchal fold above 99 percentile (MoM NT) has been observed. Fetal nasal bone were absent in 62.5% first trimester ultrasound examinations. The risk of the occurrence of a genetic malformation resulting from the mother's age combined with the risk connected with the NT measurements and the results of the triple test for the cut-off point 1:250 (which seems to be the best for this population) gave 100% sensitivity, 0.6% % of false positive results and the positive predictive value of 80%. The above mentioned results are better than the ones which were obtained within the triple test only, where for the previously fixed cut-off point 1:250 sensitivity reached 63%, positive predictive value 25% and 4.4% false positive rate. Performing the so-called integrated test in which the risk of the occurrence of any malformation is estimated on the basis of the NT measurement in the first and the second term of pregnancy seems to be far more useful.

CONCLUSIONS

Diagnostic schema for detection of fetal malformations in the first half of pregnancy which is based on ultrasound examination (NT measurement from the 10th to the 19th weeks), correlated with serum concentration of AFP, beta-HCG and oestriol in the second trimester of pregnancy (triple test) is very sensitive and safe method of the prenatal diagnosis leading to significant decrease of the invasive procedures (amniocentesis).

[Total antioxidative activity measured by ABTS method in pregnant women treated with L-arginine for IUGR]

Elevated concentration of free radicals is observed in IUG and it is connected with high rate of prematurity and perinatal mortality too. The total antioxidative serum activity is one of the oxidative stress defence system parameter. The main aim of the study was to find the correlation between the L-arginine therapy and total antioxidative concentration.

MATERIAL AND METHODS

The study was done in Dep. of Obstetrics and Gynaecology Medical University in Lodz in 2000-20003 y. The study group consist of 45 women with ultrasound diagnosed IUGR, the control group consist of 30 healthy pregnant women at the same gestational age. The IUGR therapy consist of L-arginine 3 x 1 g oral dose daily. The total antioxidative activity was measured in maternal blood on first and 20-th day of treatment. The Wayner method was used to measure total antioxidative activity by reduction of ABTS. The results were expressed in microM of serum.

RESULTS

The value of the total antioxidative activity at the first day of observation in women with IUGR was 225.9 microM and after 20 days increased to 231.8 microM. In women in normal pregnancy at the first day the value was 249.6 ng/ml microM and after 20 days of observation 247.8 microM.

CONCLUSIONS

The total antioxidative activity in blood serum decreased in pregnancy connected with IUGR. The L-arginine treatment decreased the oxidative stress risk.

[Analysis of 8-isoprostane concentration as a marker of oxidative stress in pregnant women diagnosed with IUGR]

Intrauterine growth restriction is connected with high rate of prematurity and perinatal mortality. 8-isoprostane is one of the oxidative stress indices, similar to the prostaglandins and connected with vessels restriction. The main aim of the study was to find the correlation between the L-arginine and acetylsalicylic acid therapy and 8-isoprostane concentration.

MATERIAL AND METHODS

The study was done in Dep. of Obstetrics and Gynaecology Medical University in Lodz in 2000-2002 y. The study group consist of 50 women with diagnosed IUGR, the controls: 30 healthy pregnant women at the same gestational age. The IUGR therapy consisted of L-arginine 3 x 1 g and acetylsalicylic acid--Acard 1 x 1 daily. 8-isoprostane was measured in maternal blood in first and 20-th day of observation. The Oxis Immunoassay for 8-epi prostaglandin was used. The results were expressed in ng/ml of serum.

RESULTS

The concentration of 8-isoprostane at the first day of observation in women with IUGR was 0.0587 ng/ml, and after 20 days decreased to 0.0569. In women in normal pregnancy at the first day was 0.0539 ng/ml and after 20 days 0.0547 ng/ml.

CONCLUSIONS

The 8-isoprostane concentration increased in blood serum due to the pregnancy duration. The therapeutic method decreased the concentration of this oxidative stress marker.

[Hysteroscopic evaluation of the uterine cavity in postmenopausal women with uterine bleeding]

Postmenopausal uterine bleeding is the most characteristic and frequent endometrial adenocarcinoma symptom. Patient with uterine bleeding appeared at least 12 months after the last menstruation needs diagnostic management before initiation of any treatment.

OBJECTIVES

Evaluation of hysteroscopy for the recognition of pathologies causing postmenopausal uterine bleeding.

MATERIALS AND METHODS

Seventy-nine women aged 48-80 without hormonal replacement therapy hospitalized in the 1st Department of Gynecology and Gynecological Oncology of the Medical University of Łódź between 1998-2002 because of postmenopausal uterine bleeding were included in the study. In each case diagnostic hysteroscopy with visualisation of the uterine cavity was performed and then histopathologic biopsy by a curretage was taken. Hysteroscopic images were analyzed and compared with the histopathological results.

RESULTS

2 women had the oncologically suspected hysteroscopic images. In both cases endometrial adenocarcinoma was histopathologically confirmed. Among 5 patients with hysteroscopic images suggesting non-malignant endometrial proliferation 4 cases of endometrial hyperplasia were found. 11 times hysteroscopic visualisation of endometrial polyps enabled their complete deletion. In 8 cases intrauterine adhesions were found and dissected: 11 patients presented submucous myomas during hysteroscopy. In 3 cases visualisation of the uterine cavity was not possible because of technical failure. Any patient with absence of hysteroscopically found uterine abnormalities had a poor histopathological result.

CONCLUSIONS

Hysteroscopic investigation in postmenopausal women with uterine bleeding reduce the risk of false negative histopathological result. Hysteroscopy is useful method of the uterine cavity visualisation. Thanks to localization and elimination of the pathologies like endometrial polyps and intrauterine adhesions the repeated bleeding and the second time admission of the patient for the same reason can be avoided.

[Photodynamic diagnosis of vulvar precancerous conditions and invasive cancers using 5-aminolevulinic acid]

BACKGROUND

Photodynamic therapy (PDT), in particular Photodynamic diagnosis (PDD) is a modern, non-invasive technique using photosensitizer like 5-aminolevulinic acid (5-ALA) in detection of the vulvar diseases. Photodynamic therapy gives the possibilities to differentiate inflammatory diseases from precancerous lesions and invasive vulvar cancer.

OBJECTIVE

To assess accuracy of the PDD in detection, localisation and differentiation of precancerous diseases and invasive cancer of the vulva.

MATERIAL AND METHODS

This study included 107 patients with vulvar disorders, 30 patients with VIN I, 31 patients with VIN II, and 46 patients with VIN III and vulvar carcinoma. All women underwent a standard gynaecologic examination. 5-ALA was topically applied to the vulva. After 180-360 minutes the vulvar skin was illuminated by a short--are xenon lamp at 380-440 nm and an output of 200 mW (D-Light; Karl storz). A filter to select the emitted wavelength range 630-670 nm was used in order to achieve differentiation's of the fluorescence--positive and negative areas. After the PDD, biopsies were taken from patients with multifocal VIN lesions. Macroscopic appearance, fluorescence pattern in scale of three degrees (zero, +, ++) and histology of the lesions were compared.

RESULTS

The sensitivity, specificity, positive and negative predictive value for the detection of VIN I were 85.7%, 81.2%, 80.0%, 86.6% respectively, for VIN II there were 93.3%, 93.7%, 93.3% and 93.7%, and for VIN III and invasive vulvar cancer there were 96.3%, 94.7%, 96.3% and 94.7% respectively. The sensitivity, specificity, positive and negative predictive value for the detection of all VIN and invasive vulvar cancer common were 92.9%, 90.2%, 91.2%, 92.0 respectively.

CONCLUSION

The Photodynamic therapy becomes a valuable, non-invasive diagnostic tool that lowers the amount of false negative diagnosis in cases of VIN and vulvar cancer.

[Assessment of the influence of chemotherapy on the nucleolar organizer regions (AgNORs) count in serous ovarian cancer cells]

OBJECTIVE

When planning treatment of ovarian cancer, the prognostic factors should be considered. One of them is the amount of nucleolar organizer regions (AgNORs) in cancer cells, which reflects proliferative activity of the tumor.

DESIGN

To estimate the influence of chemotherapy on the AgNORs count in serous ovarian cancer cells.

MATERIAL AND METHODS

26 women who underwent surgical procedure and then chemotherapy between 1998-2002 due to serous ovarian cancer were included into the study. During the initial surgery the cancer stage I was detected in 1 case, stage II in 2 cases, stage III in 12 cases, and stage IV in 11 cases. In all cases during second-look laparotomy, which was performed after 6 courses of chemotherapy (paclitaxel, cisplatinum), the persistent disease was found. In 17 out of 26 cases it was disseminated neoplasmatic disease. In all cases the specimens were prepared according to one-step AgNORs method described by Howell and Ploton. In cancer cells the mean number of AgNORs per nucleus (mAgNOR) and the mean percentage of nuclei with five or more AgNORs per nucleus (pAgNOR) were counted.

RESULTS

The mAgNOR and pAgNOR mean number before chemotherapy were respectively: 4, 22 +/- 0.94 and 35.62 +/- 19.90. After treatment the mAgNOR and pAgNOR were significantly lower, and the data were respectively: 3.67 +/- 0.91 and 24.15 +/- 19.53. In 4 cases (15.4%) the mAgNOR increased, in 7 cases (26.9%) the change was not significant, and in 15 cases (57.7%) the mAgNOR decreased. In 6 cases (23.1%) the pAgNOR increased, in 5 cases (19.2%) the change was not significant, and in 15 cases (57.7%) the pAgNOR decreased. We did not found any correlation between the tendency to change the number of AgNORs and staging, the amount of persistent neoplasmatic tissue, the range of primary surgery, as well as grading.

CONCLUSIONS

The number of AgNORs per nucleus in most cases of ovarian cancer after chemotherapy was lower. The tendency to change the number of AgNORs was not connected with staging as well as grading.

[Nitric oxide activity in women with intrauterine growth restriction treated by L-arginine]

OBJECTIVES

The aim of the study was to find correlation between the nitric oxide metabolites such nitrite in healthy pregnant women and in intrauterine growth restriction. The decrease of nitric oxide metabolites production may be linked to endothelial cells deficiency.

DESIGN

High risk of destruction of biological function of cells by free radical processes is observed in IUGR. It depends on NO deficiency and lipid peroxidation processes. Concentration of NO metabolites measured in pregnancy can show the correlation between oxidative stress and NO metabolism.

MATERIAL AND METHODS

The study was undertaken in Medical University in Lodz in 2000-2002. The study group consisted of women with IUGR, the control one of healthy women. The group of IUGR was treated with L-arginine-nitric oxide precursor and acetylsalicylic acid. The nitrite activity was measured by Oxis kit, in Grees reaction and was expressed in mumol/l.

RESULTS

In group of IUGR low concentration of NO metabolites was observed before treatment. After 20 days of treatment the concentration decreased. In the control group the value was higher than IUGR group/significant difference/and after 20 days of observation decreased as well.

CONCLUSIONS

We found the difference between the two groups and the decrease of NO metabolite concentration in the course of pregnancy.

[Ductus venosus blood flow in normal pregnancy outcome]

OBJECTIVE

Doppler studies of the fetal circulation have demonstrated the importance of ductus venosus velocimetry in the monitoring abnormal course of pregnancy.

DESIGN

Estimation of the ductus venosus Doppler reference ranges between 10-19th week of pregnancy.

MATERIAL AND METHODS

The ductus venosus blood flow has been studied in 140 consecutive fetuses between 10 and 19 week of pregnancy. When a midsagittal view of the fetus was obtained, color Doppler was used to visualize the ductus venosus. The pulsed Doppler sample volume was then placed on it, in the isthmic portion.

RESULTS

The mean PIV ranged from 1.09 in the first trimester of pregnancy to 0.96 in the second trimester.

CONCLUSION

A decrease in mean PIV values was observed in the course of pregnancy. In the normal course of pregnancy A-wave was observed.