The endogenous oxytocin after manipulative osteopathic treatment in full-term pregnant women

OBJECTIVE

The aim of this study is to assess whether the touch of osteopathic manipulative treatment (OMT) can affect the endogenous production of oxytocin in full-term pregnant women and the assessment of well-being following the treatment.

PATIENTS AND METHODS

In this study have been enrolled 57 pregnant women at full-term pregnancy (37th-41st week) for evaluation of the concentration of salivary oxytocin 2 minutes before and 2 minutes after a single session of OMT by an osteopath lasting for 30 minutes. Pre-OMT and post-OMT saliva samples were collected with the use of Salivette® salivary swabs. 7 salivary swabs were excluded from the analysis. 50 samples were analyzed with an appropriate ELISA kit.

RESULTS

The mean OT salivary concentration pre-OMT was 89.98±16.39, and post-OMT was 100.60±19.13 tends to increase with p=0.0000051. In multivariate analysis, two subgroups show interesting data in the mean difference in OT salivary concentration post-OMT: women with painful contractions (p=0.06) and women under 35 years (p=0.09).

CONCLUSIONS

The results of this study demonstrate that the effectiveness of OMT-increasing endogenous oxytocin is statistically significant in full-term pregnant women. The sensation of well-being found in most women indicates that there has been a predominantly central rather than peripheral oxytocin release after OMT.

The role of peritoneal lavage in benign gynecologic laparoscopic surgery

OBJECTIVE

Laparoscopic surgery offers many advantages compared to invasive surgery but one of the main problems is postoperative pain, partially resulting from the peritoneal inflammatory process mediated by inflammatory cytokines. The rationale of this study is that intraperitoneal washing could remove inflammatory mediators that are the cause of postoperative pain and could help in the removal of CO2 from the abdominal cavity. This article aims to analyze the effects of peritoneal lavage in the reduction of postoperative shoulder pain.

PATIENTS AND METHODS

277 patients enrolled to undergo laparoscopic gynecologic surgery were included in the study. Women are randomized into two groups, according to the use or non-use of peritoneal lavage with saline solution at the end of laparoscopic gynecological major procedures.

RESULTS

Data show that the peritoneal lavage can significantly reduce postoperative pain in the first 36 hours after surgery, as well as patients' requests for analgesics: during the first 3 postoperative days, requests for paracetamol were lower in the YW (Yes Washing) group than the NW (No Washing) group (77 vs. 101; p<0.05); similar results are obtained considering ketorolac administration (62 vs. 71; p<0.05).

CONCLUSIONS

Peritoneal lavage after gynecological laparoscopic procedures may be effective in the reduction of postoperative pain and use of analgesics.

Hemorrhagic cystitis in pregnancy: Case report and review of the literature

Hemorrhagic cystitis is generally a benign self-limited disorder, however there are some severe cases which are associated to a significant blood loss. The etiology may be either bacterial, viral or chemical in origin; though the cause is not identified in most of the cases. Immunocompromised patients or patients who have undergone chemotherapy or radiation constitute the highest risk group. There are only a few articles about hemorrhagic cystitis in pregnancy, frequently associated with preterm labor. We describe, for the first time in literature, one patient with a clinical status of hematuria in two consequent pregnancies, without any identified cause and a medical history negative for recurrent or hemorrhagic cystitis and we report an overview of literature concerning this topic.

[Evolution of electronic fetal monitoring in labor]

Intrapartum fetal hypoxia remains an important cause of neonatal permanent handicap and death, and in many cases it is related to lack of optimal fetal surveillance. In the last 40 years cardiotocography (CTG) has been routinely used for fetal monitoring yet this technique lacks reproducibility and its interpretation by healthcare professionals remains an important variable. Indeed, this technology not only does not improve clinically important outcomes, but also, on the contrary, leads to an increase in the number of caesarean sections carried out. Recent research has focused the attention on specific components of electronic fetal monitoring (EFM) tracings, such as ST-segment analysis (STAN) or fetal pulse oximetry (FPO). Fetal ST-segment analysis and pulse oximetry provide important parameters when used in addition to CTG, but their combined use obviously does not eliminate CTG interpretation limits. Although continuous electronic fetal monitoring is now ubiquitously utilized in modern practice, risks and benefits associated with its use are worth analysing. The analysis of the research and clinical practices carried out in the past several decades may provide useful insights into the current use of electronic fetal monitoring and new system associated procedures (STAN and FPO), which have influenced what has now become a routine modern obstetric practice.

Comparison of cytotoxicity and cell kinetic perturbations of 5 platinum compounds in gynecologic cancer cell-lines

New platinum derivatives were synthesized to overcome problems of cisplatin resistance and nephrotoxicity. Five platinum derivatives were evaluated by using the ATP chemosensitivity assay and flow cytometry in a panel of 10 human gynecologic cancer cell lines: AE7, ECC1, HEC1A, HEC1B, AN3, BG1, CAOV3, SKOV3, SKUT1B and ME180. Five platinum derivatives and their referenced concentrations (X) were: Cisplatin (DDP) 2.5 mug/ml (8.3 muM), Carboplatin (CARBO) 28 mug/ml (75.5 muM), Tetraplatin (TETRA) 2 mug/ml (4.4 muM), 254S at 5 mug/ml (16.5 muM) and NK121 at 5 mug/ml (11.4 muM). Drug exposure was performed at 0, 0.1, 0.2, 0.5, 1, 2 and 5 X for 90 minutes. The ATP chemosensitivity assay was performed on day 7 as previously described. Cell samples were taken at 0, 24, 48, 72, 96 and 168 h timepoints for flow cytometry. Mean IC50s were: DDP 29.1+/-17.4 muM, 254S 18.2+/-6.6 muM, NK121 13.7+/-5.7 muM, CARBO 120.8+/-37.8 muM, and TETRA 30.8+/-20.7 muM. Both 254S and NK121 offered significant improvement of potency over DDP (p=0.02, 0.05 respectively). Similarly, Fell cycle kinetic studies revealed that both 254S and NK121 induced significantly more S and G2 blocks than DDP (p<0.02). Thus, from the chemo-sensitivity and cell kinetic standpoints, both NK121 and 254S appeared more potent and deserve further investigation.

Use of lonidamine to potentiate the effect of cisplatin and carboplatin on platinum resistant human ovarian cancer cells

Lonidamine (LND), an indazole-3-carboxylic-acid derivative, is a new, relatively non-toxic, chemotherapeutic agent. LND, which interferes with energy metabolism, has been shown to potentiate the antineoplastic effects of chemotherapeutic agents and radiation. In this study, we evaluated the effect of LND in combination with cisplatin (DDP) or carboplatin (CARBO) on platinum resistant ovarian cancer cells. The ovarian cancer cell line BG-1 was selected as platinum resistant cell line, defined as cell line with survival fraction >50% at 0.5 peak plasma concentration (PPC). Cells were treated during the proliferative phase of cell growth with DDP and CARBO using doses between 0.1 and 1x (x = PPC). PPC of DDP = 2.5 mu g/ml, PPC of CARBO = 28 mu g/ml. Cells were also treated with LND at doses varying between 10 and 100 mu g/ml (PPC 20-50 mu g/ml). Drugs were used as single agents and in combination. Experiments were performed by treating the cells with DDP or CARBO for 90 min and with LND continuous exposure or 90 min only. The ATP cell viability assay was used to assess the antiproliferative effect of the drugs tested. Experiments were repeated at least 3 times. The synergistic interaction formula for anticancer agents and the t-test were used for the analysis of the results. LND was shown to be effective when used in continuous exposure only (IC50 = 0.58). The IC50 of DDP was 1.1 and the IC50 of CARBO was 0.64. Significant dose related antiproliferative effect of LND alone, as well as DDP and CARBO cytotoxicity potentiation was observed (p<0.05). LND was shown to have synergistic effect when combined with platinum compounds to treat ovarian cancer cells at doses of 20 and 30 mu g/ml. These doses are achievable in patients. LND, a relatively new antineoplastic agent with good clinical tolerance, has been shown to synergistically potentiate the antiproliferative effect of platinum compounds on platinum resistant ovarian cancer cells. LND is an agent of potential use for the treatment of ovarian cancer patients in combination with DDP or CARBO.

[Prevention of postoperative abdominal adhesions in gynecological surgery. Consensus paper of an Italian gynecologists' task force on adhesions]

Adhesions are the most frequent complication of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with considerable morbidity and expense, and an important mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in most patients. There is rising evidence, however, that surgeons can take important steps to reduce the impact of adhesions. A task force of Italian gynecologists with a specialist interest in adhesions having reviewed the current evidence on adhesions and considered the opportunities to reduce adhesions in Italy, have approved a collective consensus position. This consensus paper provides a comprehensive overview of adhesions and their consequences and practical proposals for actions that gynecological surgeons in Italy should take. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be adopted particularly in high risk surgery and in patients with adhesiogenic conditions. Patients also need to be better informed of the risks of adhesions.

[Tubo-peritoneal factor of infertility: diagnosis and treatment]

Infertility, defined as the inability to conceive despite regular unprotected sexual intercourse over 12 years, affects approximately 10% of the fertile population. The commonest cause of tubal damage is pelvic inflammatory disease (PID), which in the developed world is caused mainly by Chlamydia trachomatis infection. The incidence of tubal damage after one episode of pelvic infection is approximately 12%, 23% after two episodes and 54% after three episodes. Other causes of tubal damage include postsurgical adhesions or endometriosis. Tubal patency can be diagnosed by hysterosalpingography (HSG) or laparoscopy with chromopertubation. Surgery represents the best therapeutic approach for tubal pathology, with a term pregnancy rate of 70% after surgery in selected patients, while the latest results in Italy of assisted reproductive technology (ART) report a live birth rate per cycle of 13.8%. In conclusion, tubal reconstructive surgery remains an important option for many couples and surgery should be the fi rst line approach for a correct diagnosis and treatment of tubal infertility.

[Prevention of postoperative adhesions]

Postoperative adhesions represent a common consequence in patients who underwent abdominal or pelvic surgery. Such adhesions can be asymptomatic, but they can cause complications such as chronic abdomino-pelvic pain, secondary infertility, an increase in bowel obstruction risk and more complexity for future surgery, including longer surgery times and an increase in morbidity. Normally, adhesions appear after offences against the peritoneum, causing flogosys, and develop both in new sites, previously not involved, and in sites already interested in adhesiolysis. Previous laparotomy is an important risk factor, as after laparatomy a minimum of 93% of patients present adhesions during a following surgery. Furthermore, the rate of recurrence after adhesiolysis is 85%. Among several strategies employed, valid prevention methods are: using minimally invasive surgery techniques, reducing the incision area, containing tissue dehydration during surgery and an accurate hemostasis. Also, for preventing and reducing adhesions, the usage of NSAIDs, fibrinolytics and anticoagulants, as well as the application of substances acting as a physical barrier, have been proposed. Recently, crystalloid solutions have been introduced, using the hydro-flotation principle for intraperitoneal organs. This research aims to analyze causes and epidemiology for postoperative adhesions, with particular regard to gynecological operations and to describe and compare the means available to prevent them.

[The role of laparoscopy in ovarian carcinoma]

The role of minimally invasive surgery in the management of gynecologic cancers is continuously expanding. Although few trials have focused on the safety of laparoscopy in oncology, laparoscopy is now widely used for most gynecological malignancies. Laparoscopy is widely used to manage benign ovarian masses, but its role in managing ovarian cancer still needs to be defined. The role of laparoscopy in ovarian cancer surgery may be divided into three following categories: 1) laparoscopic staging of apparent early ovarian cancer; 2) laparoscopic assessment of disease extent and potential for resectability; 3) laparoscopic reassessment, or second-look operation, or rule out recurrence. Laparoscopic approach has shown several advantages like a reduction in operating time, blood loss, hospital stay, and total hospital charges. The limitations of laparoscopic practice include inadequate port-site metastasis, tumour dissemination due to cyst rupture and incomplete staging. In addition, there were limitations in performing extensive laparoscopic sampling of areas of tumor persistence including retroperitoneal lymph nodes. In literature there are no randomized studies assessing the use of laparoscopy in the management of ovarian cancer. Moreover, most of the studies in literature comparing laparoscopy and laparotomy are carried out by surgeons specialized in one of two approaches, so that the results can not be compared.

[Use of bulking agents in urinary incontinece]

Urinary incontinence consist in voluntary urine leakage. Female affected in the world are about 200 thousand. Urinary incontinence affect severely women quality of life. There are different kinds of urinary incontinence that can be treated in different ways. We can use pelvic floor rehabilitation, drug therapy, invasive and non-invasive surgical treatment. Different treatments are used for different incontinence types. Periurethral injection is the most common procedure between non-invasive surgery. The most recent bulking agents occasionally determine severe adverse reaction or complication. Frequently we can have just pain during injection and a temporary urine retention. During the latest years we used a lot of bulking agents: bovine collagen, autologous fat, carbon particles, macroplastique, calcium hydroxylapatite, ethylene vinyl alcohol copolymer, dextranomer. Urethral injection have success in 40-90%. We can assert that macroplastique is the most efficacy and safe on the basis of literature data and of our experience data. This surgical procedure, in fact, has good percentage of success in accurately selected patients. In our experience Macroplastique can also be used in oncological patients, in elderly women, in patients with important comorbidity and with high surgical risk with good objective and subjective results.

Bulky lymph node resection in patients with recurrent epithelial ovarian cancer: impact of surgery

The aim of this study was to evaluate the role of systematic lymphadenectomy, feasibility, complications rate, and outcome in epithelial ovarian cancer (EOC) patients with recurrent bulky lymph node disease. A prospective observational study of EOC patients with pelvic/aortic lymph node relapse was conducted between January 1995 and June 2005. After a clinical and laparoscopic staging, secondary cytoreduction, including systematic lymphadenectomy, were performed. The eligibility criteria were as follows: disease-free interval ≥6 months, radiographic finding suggestive of bulky lymph node recurrence, and patients' consent to be treated with chemotherapy. Forty-eight EOC patients with lymph node relapse were recruited. Twenty-nine patients were amenable to cytoreductive surgery. Postoperatively, all patients received adjuvant treatment. The median numbers of resected aortic and pelvic nodes were 15 (2–32) and 17 (8–47), respectively. The median numbers of resected aortic and pelvic positive lymph nodes were 4 (1–18) and 3 (1–17), respectively. The mean size of bulky nodes was 3.3 cm. Four patients (14%) experienced one severe complication. No treatment-related deaths were observed. After a median follow-up of 26 months, among cytoreduced patients, 18 women were alive with no evidence of disease, nine were alive with disease. Among the 11 patients not amenable to surgery, five women were alive with persistent disease, six patients died of disease, at a median follow-up of 18 months. Estimated 5-year overall survival and disease-free interval for operated women were 87% and 31%, respectively. In conclusion, patients with bulky lymph node relapse can benefit from systematic lymphadenectomy in terms of survival. The procedure is feasible with an acceptable morbidity rate

Hemoglobin variation and blood transfusion rates in patients affected by locally advanced cervical cancer undergoing neo-adjuvant chemotherapy followed by radical surgery: the role of erythropoietic growth factors

BACKGROUND

The objectives of the present study were to evaluate hemoglobin levels and consequent clinical behaviors related to anemia developed in patients affected by locally advanced cervical cancer treated with neo-adjuvant chemotherapy in the last decade and to evaluate the impact that the introduction of erythropoietic growth factors had in the clinical practice.

PATIENTS AND METHODS

Blood chemistries, prospectively recorded from 98 cervical cancer patients, treated with neo-adjuvant chemotherapy and, if necessary, erythropoietic growth factors, were compared with matched historical controls before the introduction of growth factors in clinical practice.

RESULTS

Hemoglobin level in the study group did not differ significantly during chemotherapy. At the third cycle of chemotherapy and at the end of chemotherapy, hemoglobin level was significantly higher in the study group compared with the control group. Transfusion rates in the study group were significantly lower. The analysis within the study group revealed that hemoglobin level in patients who suffer at diagnosis from anemia tends to increase whereas hemoglobin level in nonanemic patients tends to decrease.

CONCLUSIONS

Erythropoietic growth factors increase hemoglobin level and reduce blood transfusions in cervical cancer patients undergoing neo-adjuvant chemotherapy followed by radical surgery. An appropriate autologous blood donation program can noticeably reduce homologous blood transfusions.

Liposome-encapsulated doxorubicin citrate in previously treated recurrent/metastatic gynecological malignancies

The aim of this study was to evaluate the safety and efficacy of liposome-encapsulated doxorubicin citrate (LEDC) in patients affected by recurrent/metastatic gynecological malignancies scheduled for palliative chemotherapy. Inclusion criteria were proven recurrent/advanced gynecological neoplasms, measurable/assessable disease, adequate organ function, left ventricular ejection fraction >50% as determined by echocardiography, informed consent. LEDC was administered intravenously over 1 h at the dose of either 75 mg/m(2) or 60 mg/m(2) (every 3 weeks until disease progression or toxicity prohibiting further therapy). From May 2003 to September 2005, 36 patients were enrolled. Primary disease was ovarian, endometrial, and cervical cancers in 15 (42%), 11 (30%), and 10 (28%) patients, respectively. LEDC was employed as third- or fourth-line chemotherapy in 25 (70%) and 11 (30%) patients, respectively. The median number of courses of LEDC received was 3 (range 2-9). Six patients (17%) achieved a partial response to treatment lasting 27 weeks and 10 patients (28%) experienced stable disease lasting 18 weeks. The predominant toxicity was hematological, especially neutropenia. Among patients receiving a dose of 75 mg/m(2), two (11%) suspended therapy for febrile neutropenia, and nine (50%) required a dose reduction of 25%. As a result, the next 18 patients were treated at a reduced dose (60 mg/m(2)) of LEDC. Severe neutropenia (G3-G4) was significantly less common in this group (61% versus 22%; P= 0.04). LEDC has shown antineoplastic activity in previously treated recurrent/metastatic gynecological cancer patients and the toxicity profile could be considered acceptable at a 60 mg/m(2) dosage.

Gynecological cancers in developing countries: the challenge of chemotherapy in low-resources setting

The epidemiologic pattern of cancers in developing countries differs in many aspects from that of industrialized nations. Cancer natural history, microbiologic environment, patient's immune system, and drug availability may differ as well. Four of five new cases of cervical cancer and most of cervical cancer deaths occur in developing countries. Where chemoradiation and supportive care facilities are unavailable, it would be logical to consider an inexpensive effective drug. In locally advanced cases, neoadjuvant chemotherapy followed by surgery should be considered the treatment of choice. For ovarian cancer, it may be reasonable to maintain a secure supply of platinum and/or taxanes. For endometrial cancer, platinum compounds are proved active chemotherapic single agents. Oral medroxyprogesterone acetate (MPA) may represent a good chance for treating an advanced or recurrent disease. For vulvar/vaginal cancer, the role of chemotherapy alone is currently considered limited, and it is mostly used as palliative treatment in advanced or recurrent cases. Whenever possible, standard western chemotherapic regimens should be applied in developing countries as well. When standard therapies are unavailable, drugs of choice should be easily accessible, inexpensive, and effective. The most commonly used drugs are cisplatin, cyclophosphamide, and MPA.

[Up-date on cytoreductive surgery in the management of advanced ovarian cancer]

Epithelial ovarian cancer represents the most aggressive neoplasm of women genital apparatus with a total 5-year survival rate ranging from 17% to 35% if the disease is in the metastatic phase. Its aggressiveness derives from the fact that it is an asymptomatic disease until it spreads in abdominal cavity. Therefore, in 70% of the cases, the diagnosis is done when tumor is already in advanced phase (Stage FIGO IIB-IV). Data from international literature suggest that standard treatment for advanced ovarian cancer is optimal cytoreductive surgery with adjuvant chemotherapy platinum-based. However, in the last decades, many authors have described the enthusiastic results of neoadjuvant chemotherapy and interval debulking surgery. Griffiths, first, underlined the importance of residual mass after cytoreductive surgery as a prognostic factor. Currently, cytoreduction is defined optimal when residual mass is microscopical or absent. Nevertheless, surgery for ovarian cancer turns out to be a particularly aggressive surgery that needs an operator's remarkable technical ability and a cultural Background: Many studies demonstrated that the frequency of feasibility of optimal cytoreductive surgery also varies within the gynecologic oncology specialized centers. During the last few years, new technologies (such as Cavitron Ultrasonic Surgical Aspirator, CUSA, and argon's coagulator) and new surgical techniques have been introduced. Ovarian cancer turns out to be a particularly chemosensitive tumor. Its responsiveness has been the object of numerous studies and protocols in literature, such as European Organisation of Research and Treatment of Cancer (EORTC) and Gynecologic Oncology Group (GOG) trials.

Randomised study of systematic lymphadenectomy in patients with epithelial ovarian cancer macroscopically confined to the pelvis

No randomised trials have addressed the value of systematic aortic and pelvic lymphadenectomy (SL) in ovarian cancer macroscopically confined to the pelvis. This study was conducted to investigate the role of SL compared with lymph nodes sampling (CONTROL) in the management of early stage ovarian cancer. A total of 268 eligible patients with macroscopically intrapelvic ovarian carcinoma were randomised to SL (N=138) or CONTROL (N=130). The primary objective was to compare the proportion of patients with retroperitoneal nodal involvement between the two groups. Median operating time was longer and more patients required blood transfusions in the SL arm than the CONTROL arm (240 vs 150 min, P<0.001, and 36 vs 22%, P=0.012, respectively). More patients in the SL group had positive nodes at histologic examination than patients on CONTROL (9 vs 22%, P=0.007). Postoperative chemotherapy was delivered in 66% and 51% of patients with negative nodes on CONTROL and SL, respectively (P=0.03). At a median follow-up of 87.8 months, the adjusted risks for progression (hazard ratio [HR]=0.72, 95%CI=0.46–1.21, P=0.16) and death (HR=0.85, 95%CI=0.49–1.47, P=0.56) were lower, but not statistically significant, in the SL than the CONTROL arm. Five-year progression-free survival was 71.3 and 78.3% (difference=7.0%, 95% CI=–3.4–14.3%) and 5-year overall survival was 81.3 and 84.2% (difference=2.9%, 95% CI=−7.0–9.2%) respectively for CONTROL and SL. SL detects a higher proportion of patients with metastatic lymph nodes. This trial may have lacked power to exclude clinically important effects of SL on progression free and overall survival.

Gynecological cancers in developing countries: the challenge of chemotherapy in low-resources setting

The epidemiologic pattern of cancers in developing countries differs in many aspects from that of industrialized nations. Cancer natural history, microbiologic environment, patient's immune system, and drug availability may differ as well. Four of five new cases of cervical cancer and most of cervical cancer deaths occur in developing countries. Where chemoradiation and supportive care facilities are unavailable, it would be logical to consider an inexpensive effective drug. In locally advanced cases, neoadjuvant chemotherapy followed by surgery should be considered the treatment of choice. For ovarian cancer, it may be reasonable to maintain a secure supply of platinum and/or taxanes. For endometrial cancer, platinum compounds are proved active chemotherapic single agents. Oral medroxyprogesterone acetate (MPA) may represent a good chance for treating an advanced or recurrent disease. For vulvar/vaginal cancer, the role of chemotherapy alone is currently considered limited, and it is mostly used as palliative treatment in advanced or recurrent cases. Whenever possible, standard western chemotherapic regimens should be applied in developing countries as well. When standard therapies are unavailable, drugs of choice should be easily accessible, inexpensive, and effective. The most commonly used drugs are cisplatin, cyclophosphamide, and MPA.

Gynecologic oncology specialty

In general, the gynaecologic oncologists should be fully equipped to manage primary treatment and most complications related to the care of patients with gynaecologic neoplasms. During the subspecialty trianing program the fellow in trianing should learn to understand and perform radical pelvic surgery, including intestinal and urology procedures, and in addition a deep knowledge of chemotherapy and radiation therapy is important for the complete treatment of gynaecologic neoplasms. The subspecialty of gynaecologic oncology has made many advances over the last few decades; there have been several changes to the management of gynaecologic cancers, which have led to improved outcome and well-being of patients.

The role of neoadjuvant chemotherapy followed by radical surgery in the treatment of locally advanced cervical cancer

In 1984 the first pilot study on neoadjuvant chemotherapy in cervical cancer was reported. Since then, many investigators have studied the possible role that this therapeutic strategy could achieve in patients. Different chemotherapic combinations are constantly being attempted in order to obtain the maximum tumour response. At the same time few randomised studies have demonstrated the superiority of this treatment when adopted before radical surgery, in terms of overall survival compared to radiotherapy alone. Recently a detailed meta-analysis has been performed and the results confirmed what previously was achieved by the randomised trials. Since the beginning of all the phase III trials, the standard treatment of locally advanced disease has been modified from radiotherapy alone to concomitant radio-chemotherapy. For this reason the EORTC group has launched a trial with the objective of comparing neoadjuvant chemotherapy followed by radical surgery versus concomitant chemo-radiotherapy.

Systemic therapy for gynecological neoplasms: ovary, cervix and endometrium

Early-stage endometrial carcinomas should be treated by total abdominal hysterectomy and bilateral salpingo-oophorectomy. In a small subset of patients, who wish to have children, conservative treatment (hormonal therapy) could be considered. The most effective agents for palliation of advanced disease are doxorubicin plus cisplatin.

GLUT-1 expression in ovarian carcinoma: association with survival and response to chemotherapy

BACKGROUND

Cancer cell growth is an energy-related process supported by an increased glucose metabolism. The objective of this study was to investigate the association of GLUT-1 with response to chemotherapy and outcome in patients with ovarian carcinoma.

METHODS

Histologic sections of formalin fixed, paraffin embedded specimens from 113 primary ovarian carcinomas were stained for GLUT-1 by using polyclonal GLUT-1 antibody (Dako Co., Carpinteria, CA) and the labeled streptavidin biotin procedure. Intensity of GLUT-1 staining was compared with disease free survival (DFS), chemotherapy response, and other clinicopathologic characteristics.

RESULTS

GLUT-1 cytoplasmic membrane staining was observed in 89 of 104 (85.6%) malignant tumors. Poorly differentiated tumors showed a trend to overexpress the GLUT-1 protein compared with the more differentiated counterparts (27.6% vs. 8.7%; P = 0.08). Patients who experienced a complete clinical response to chemotherapy were more frequently GLUT-1 positive than GLUT-1 negative (80% vs. 51.5%; P = 0.036). In multivariate analysis of advanced stage disease, residual tumor (P = 0.0001) and high GLUT-1 expression levels (P = 0.028) were the only independent variables that maintained a significant association with response to chemotherapy (P = 0.0001; chi-square = 38.13). In the subgroup of Stage III-IV (International Federation of Gynecology and Obstetrics patients showing a complete clinical response, GLUT-1 overexpression was associated with a shorter DFS. The median time to progression was 30 months in GLUT-1 strongly positive cases (> 50% of cancer cells positive) versus 60 months in GLUT-1 weakly positive cases (< or = 50% of cancer cells positive; P = 0.024).

CONCLUSIONS

GLUT-1 status is an independent prognostic factor of response to chemotherapy in advanced stage ovarian carcinoma. Moreover, patients overexpressing GLUT-1 show a significantly shorter DFS. These results suggest that the assessment of GLUT-1 status may provide clinically useful prognostic information in patients with ovarian carcinoma.

History of gynecologic oncology subspecialty

During the past quarter-century, progress has occurred in the area of coordinated care of the patient with gynecologic cancer. This progress is the result of the refined surgical techniques and perioperative management of patients requiring intensive care after radical pelvic surgery. Furthermore, the addition of radiation therapy and chemotherapy has made major contributions to the improvement and quality of life for patients with gynecologic cancer. All formal training programs in gynecologic oncology now include appropriate rotations and experience with these newer techniques and treatment modalities. The gynecologic oncologist should be fully equipped to manage primary treatment and most of the complications related to the care of patients with gynecologic neoplasms. Formal training programs in gynecologic oncology have been fundamental in the attainment of this goal and provide the infrastructure for future developments. It is anticipated that continued worldwide surgical studies in the area of gynecologic oncology will improve the well-being of women who may have cancer.

Urinary diversion in gynecologic oncology

Urinary diversion in gynecology is performed primarily in conjunction with cancer surgery, but at times, it is required for women with intractable urinary fistulas or other urologic disorders. After 1950, ileal conduits replaced ureterosigmoidostomies as the most widely used form of urinary diversion. Transverse colon conduits have gained popularity because these nonirradiated bowel segments offer less risk for postoperative urinary leaks and small bowel complications associated with bowel and ureteral anastomoses. In 1978, Kock et al described the use of detubularized segments of ileum and the intussuscepted nipple valves to create a continent pouch that is still advocated by urologists in some centers. Ileocolonic continent pouches, originally suggested in 1908, have received considerable attention in the past 10 to 15 years because of ease of construction, lower revision rates, and higher continence rates compared with the Kock ileal pouches. At the Division of Gynecologic Oncology at the University of Miami, the authors have been using the Miami pouch as the preferred form of continent urinary diversion since 1988, with acceptable results. Women who need urinary diversion can be offered at least two major choices: (1) the traditional bowel (ileum or colon) conduit, which requires an external ostomy appliance, or (2) a continent pouch, such as the Miami ileocolonic reservoir. In choosing between non-continent and continent conduits, the patients must be made aware that the continent pouches are available in only a few centers in the United States and carry a slightly higher risk for complications because of the relatively higher complexity. Nonetheless, data strongly suggest that most of these complications can be managed noninvasively and that these patients retain a closer to normal quality of life. The age, disease status, and general health of the woman and the likelihood of her long-term survival after diversion weigh heavily in the final decision.

Radical vaginal hysterectomy: classic and modified

RVH offers significant advantages to the corresponding abdominal procedure, including: the possibility for regional anesthesia, particularly in patients with poor medical conditions; reduced surgical trauma because of the absence of an abdominal incision; applicability in obese patients; shorter surgical time when performed by an experienced surgeon; decreased need for blood transfusions; lower risk for complications; faster postoperative recovery period; shorter hospitalization. The primary drawback to the use of RVH for early stage cervical cancer has always been the lack of lymph node dissection. This has now been modified by the widespread use of laparoscopic lymphadenectomy. The increasing reliability of noninvasive radiologic techniques has provided and will continue to provide greater possibilities for preoperative staging to best determine the needs of the patient. The authors believe that an oncologic surgeon familiar with advanced laparoscopic techniques and RVH is able to take advantage of the benefits of both routes. Furthermore, a surgeon skilled in these techniques and RAH has the tools to ideally care for the specific needs, of each patient. The authors encourage individualization of surgical management, with special emphasis on the revision of the role of RVH in gynecologic oncology.

Low colorectal anastomosis after radical pelvic surgery: a risk factor analysis

OBJECTIVE

This study was conducted to analyze our experience with low (8-12 cm above the anal verge) and very low (<6 cm above the anal verge) colorectal resection and primary anastomosis at the time of radical en bloc resection of pelvic malignancies.

STUDY DESIGN

A retrospective review of 77 patients undergoing supralevator pelvic exenteration with low colorectal resection and primary anastomosis in our gynecologic oncology service was carried out. Data were obtained from patient medical records and from the tumor registry. Univariate statistical analysis of the data was used.

RESULTS

The distribution of primary malignancies in this cohort was as follows: 33 (43%) recurrent or primary cervical carcinomas, 27 (35%) primary or recurrent ovarian carcinomas, 7 (9%) recurrent vaginal carcinomas, 4 (5%) endometrial carcinomas, 3 (4%) colon carcinomas, and 3 (4%) cases of stage IV endometriosis. Forty patients underwent total pelvic exenteration, and 37 patients underwent posterior exenteration. Thirty-six patients in the total pelvic exenteration group had a history of pelvic irradiation. Twelve (30%) of these patients had development of breakdown or fistulas of the anastomosis. Six of the 12 patients (50%) had undergone protective colostomy. Thirty-seven patients underwent posterior exenteration with primary anastomosis for ovarian cancer, endometrial cancer, colon cancer, or endometriosis, and only 1 of these had received pelvic irradiation. This patient did not have a protective colostomy, and a rectovaginal fistula developed. In addition, there were 3 other breakdowns in the posterior exenteration group. Finally, the presence of preoperative ascites did not appear to alter the breakdown rate of the anastomosis among the patients with ovarian cancer who underwent cytoreductive surgery.

CONCLUSION

Radical resection of pelvic tissue remains a crucial part of the armamentarium of the gynecologic oncologist. Previous pelvic irradiation appears to be a major risk factor (35% vs 7.5%) for anastomotic breakdown and fistulas, independent of the presence of a protective colostomy. The overall results appear to be better for patients undergoing this procedure as part of a posterior exenteration.

Expression of GLUT-1 glucose transporter in borderline and malignant epithelial tumors of the ovary

OBJECTIVE

Cancer cells have increased rates of glucose metabolism when compared to normal cells. One of the mechanisms proposed for the accelerated glucose use in malignant cells is the overexpression of glucose transporters. In this study we evaluated the expression of the GLUT-1 glucose transporter in borderline and malignant epithelial neoplasms of the ovary.

METHODS

Histologic sections of tumor tissues from 21 borderline and 82 malignant epithelial neoplasms of the ovary were stained for GLUT-1 using polyclonal GLUT-1 antibody (Dako, Carpinteria, CA) and the labeled streptavidin biotin procedure. DAB was used as chromagen and tissues were counterstained with hematoxylin.

RESULTS

Normal ovarian surface epithelial cells were either negative or weakly positive. Of the 82 carcinomas, 81 (98.8%) were positive for GLUT-1. The staining intensity was significantly associated with the grade of tumor (P = 0.001). Of the 21 borderline neoplasms, 20 (95.2%) were positive for GLUT-1. Carcinomas had a significantly stronger stain than borderline tumors (P = 0.0001). The intensity of the stain was also stronger in serous carcinomas compared to other subtypes (P = 0. 0001). Positive cells demonstrated a cytoplasmic membrane staining that was more intense in tumor cells farther away from blood supply.

CONCLUSION

Overexpression of the GLUT-1 transporter is associated with the histology and grade of the tumors. Our findings show a progressive increase in the expression of the GLUT-1 transporter from the borderline tumor to the high-grade carcinomas. These data suggest that the expression of this transporter may be closely related to the malignant transformation of epithelial ovarian tumors.

Severe perineal lacerations during vaginal delivery: the University of Miami experience

OBJECTIVE

After childbirth-related third- or fourth-degree perineal lacerations, the estimated incidence of wound disruption, fecal incontinence, or fistula ranges from 1% to 10%. Risk factors associated with severe laceration were analyzed at a single large teaching institution.

STUDY DESIGN

This study consisted of an analysis of data from the delivery database of Jackson Memorial Hospital, University of Miami, from 1989 through 1995. Included were vaginal deliveries for which complete information was available on maternal age, parity, ethnicity (white, black, or Hispanic), birth weight, episiotomy versus no episiotomy, type of episiotomy, and delivery (normal spontaneous, vacuum, or forceps). Multiple gestations, cases of shoulder dystocia, cesarean deliveries, patients with a history of cesarean delivery, and babies weighing <500 g at birth were excluded from this study. Both univariate and multivariate analyses were performed with variables such as maternal age, race, birth weight, type of episiotomy if any, and type of vaginal delivery.

RESULTS

Among the 71,959 women who were delivered at our institution during the 7-year study period, 50,210 met the inclusion criteria. Through time there had been a decline in the use of episiotomy in general and of midline episiotomy in particular. The annual total number of deliveries also decreased. The episiotomy procedure per se and the type of episiotomy as well as birth weight, assisted vaginal delivery, and older maternal age were identified as independent risk factors associated with third- and fourth-degree perineal lacerations.

CONCLUSION

Although episiotomy is an important risk factor for severe lacerations after vaginal delivery, there are other significant independent risk factors, such as maternal age, birth weight, and assisted vaginal delivery, that should be considered in counseling and making decisions regarding delivery modality. Older patients who are being delivered of a first child are at higher risk for severe laceration. Midline episiotomy and assisted vaginal delivery should therefore be avoided in this population whenever possible, especially in the presence of a large baby.

Antitumor activity of a novel glyco-nitric oxide conjugate in ovarian carcinoma

BACKGROUND

Several studies have shown that nitric oxide (NO)-releasing agents can kill tumor cells. Unfortunately, currently available NO delivery molecules do not target tumor cells preferentially. To exploit the overexpression of glucose transport proteins and the high level of glucose transport characteristics of tumor cells, glucose was conjugated to S-nitroso-N-acetyl-penicillamine (2-gluSNAP) and evaluated for cytotoxicity in human ovarian carcinoma cells.

METHODS

The cytotoxicity of 2-gluSNAP and SNAP was assessed by clonogenic cell survival assays performed in A2780S (cisplatin sensitive) and A2780cP (cisplatin-resistant) ovarian carcinoma cells in vitro. Immunoblotting and immunohistochemistry were used to assess the expression of Glut-1 hexose transport protein in the cell lines as well as in paraffin blocks from 28 surgical specimens of epithelial ovarian carcinoma. Apoptosis was assessed by an end-labeling assay.

RESULTS

The ovarian carcinoma cell lines consistently were more sensitive to 2-gluSNAP than SNAP alone. The median effective doses (MEDs) for 2-gluSNAP and SNAP in the A2780s cell line were 0.0042 microM and 20.4 microM, respectively. Therefore, 2-GluSNAP was nearly 5000-fold more potent than the NO-donating moiety (SNAP) alone. In the A2780cP cells, the MED for 2-gluSNAP (0.38 microM) was 250-fold lower than that for SNAP alone (100 microM). Immunoblotting and immunohistochemistry studies showed overexpression of Glut-1 in the cell lines and in 23 of 28 epithelial ovarian carcinoma specimens.

CONCLUSIONS

The novel glyco-NO conjugate 2-gluSNAP exhibits a much greater cytotoxicity than the parent NO donor without the hexose moiety. These agents have the potential to target tumor cells preferentially, that overexpress Glut-1. This transporter is expressed highly in epithelial ovarian carcinoma.

The impact of intraoperative autologous blood transfusion during type III radical hysterectomy for early-stage cervical cancer

OBJECTIVE

The aim of this study was to determine the effects on transfusion rates, perioperative complications, and survival of using intraoperative autologous blood transfusions for patients undergoing type III radical hysterectomy and lymphadenectomy.

STUDY DESIGN

A retrospective analysis was conducted on 156 patients treated with type III radical hysterectomy and lymphadenectomy at the University of Miami School of Medicine from 1990 to 1997. One group of patients (n = 50) had intraoperative autologous blood transfusions and the other (n = 106) did not.

RESULTS

The group that received intraoperative autologous blood transfusion had a significant reduction in homologous blood transfusions (12% vs 30%; P =.02). Patient demographic data, histologic parameters, and operative factors were similar between the 2 groups. There was a higher percentage of patients with positive pelvic lymph nodes in the group that did not receive intraoperative autologous blood transfusion (10% vs 30%; P =.02). Seven patients in the intraoperative autologous blood transfusion group (14%) died with disease present and all the recurrences in this group were local.

CONCLUSION

The use of intraoperative autologous blood transfusions during type III radical hysterectomy and lymphadenectomy appears to be safe and effective without compromising rates and patterns of recurrence.

Primary uterine angiosarcoma

OBJECTIVE

The aim of this study was to report the first case of primary uterine angiosarcoma described in a Hispanic American woman and to review the literature on uterine angiosarcomas. We review characteristic presenting symptoms, gross and microscopic pathologic findings, and treatment outcomes where available.

METHODS

A case report is presented with a review of the English language literature via a Medline search. The key phrases used in the search were uterine angiosarcoma, hemangiosarcoma, hemangioendothelioma, and primary uterine neoplasm.

RESULTS

Since the first report in 1902, there have been 19 reported cases of primary uterine angiosarcoma considered valid. Many early cases are questioned due to the lack of ultrastructural and immunohistochemical evidence available in later cases. Seventy-four percent (14 of 19) of these patients are perimenopausal with a mean age of 55 years (range 17-76 years). The common presenting findings are a pelvic mass, menorrhagia, and weight loss. Varying regimens of surgery, chemotherapy, and radiation have been utilized with limited success.

CONCLUSIONS

Primary uterine angiosarcomas tend to exhibit a highly malignant behavior. The predominant prognostic factor seems to be the size of the tumor at diagnosis and the presence of extrapelvic disease. Recurrence occurs on average at 8.2 months. Of evaluable patients (n = 14), at 12 months the survival was only 43%. Although radiation and chemotherapy are options being utilized, no consensus exists for optimal therapy given the few cases from which to draw conclusions. Regardless of treatment, outcome is usually poor.

Primary malignant melanoma of the uterine cervix: case report and review of the literature

This is a case report and review of the literature on primary melanoma of the cervix. There have been only 26 published cases of primary cervical melanoma and most are poorly documented and doubtful. The patients' ages ranged from 26 to 78 years old with a mean age of 55 +/- 13 years. The main presenting symptom was vaginal bleeding (83.0%). The majority of the patients, 88%, presented in stage I or II. Treatment varied from a simple excision of a cervical mass to a radical hysterectomy with lymph node dissection and adjuvant radiation or chemotherapy. Our patient presented with vaginal bleeding and was diagnosed as having stage IIa cervical melanoma. She underwent a radical hysterectomy, partial vaginectomy, and pelvic and paraaortic lymph node dissection. She received adjuvant radiation therapy and her survival was 29 months. The prognosis of primary cervical melanoma is usually poor and unpredictable. We recommend a radical hysterectomy and vaginectomy, if necessary, to obtain negative surgical margins of at least 2 cm. We advocate lymphadenectomy only for grossly positive nodes.