Long-Term Survival and Clinicopathological Implications of DNA Mismatch Repair Status in Endometrioid Endometrial Cancers in Hong Kong Chinese Women

To investigate the role of DNA mismatch repair status (MMR) in survival of endometrioid endometrial cancer in Hong Kong Chinese women and its correlation to clinical prognostic factors, 238 patients with endometrioid endometrial cancer were included. Tumor MMR status was evaluated by immunohistochemistry. Clinical characteristics and survival were determined. Association of MMR with survival and clinicopathological parameters were assessed. MMR deficiency (dMMR) was found in 43 cases (16.5%). dMMR was associated with poor prognostic factors including older age, higher stage, higher grade, larger tumor size and more radiotherapy usage. Long-term survival was worse in dMMR compared to the MMR proficient group. The dMMR group had more deaths, shorter disease-specific survival (DSS), shorter disease-free survival (DFS), less 10-year DSS, less 10-year DFS, and more recurrence. The 5-year DSS and 5-year DFS in the dMMR group only showed a trend of worse survival but did not reach statistical significance. In conclusion, dMMR is present in a significant number of endometrioid endometrial cancers patients and is associated with poorer clinicopathological factors and survival parameters in the long run. dMMR should be considered in the risk stratification of endometrial cancer to guide adjuvant therapy and individualisation for longer follow up plan.

Short-Form Thymic Stromal Lymphopoietin (sfTSLP) Is the Predominant Isoform Expressed by Gynaecologic Cancers and Promotes Tumour Growth

Simple Summary

Cytokines are a group of small proteins in the body that play an important part in boosting the immune system. Thymic stromal lymphopoietin (TSLP) is a cytokine that plays an important role in the maturation of T cells. Two variants of TSLP, long-form (lfTSLP) and short-form (sfTSLP), have been found, however their roles in cancers are not known. In this study, we discovered that sfTSLP, but not lfTSLP, is predominantly expressed in ovarian and endometrial cancers. The switch that turns the sfTSLP gene on or off is controlled by external modifications of DNA. Our results also found that sfTSLP promotes tumour growth through activating several signal pathways in cancer cells.

Abstract

Thymic stromal lymphopoietin (TSLP) is an epithelial cell derived cytokine belonging to the IL-7 family and a key initiator of allergic inflammation. Two main isoforms of TSLP, classified as long- (lfTSLP) and short-form (sfTSLP), have been reported in human, but their expression patterns and role(s) in cancers are not yet clear. mRNA expression was examined by isoform-specific RT-PCR and RNA in situ hybridisation. Epigenetic regulation was investigated by chromatin immunoprecipitation-PCR and bisulfite sequencing. Tumour progression was investigated by gene overexpression, cell viability assay, cancer organoid culture and transwell invasion. Signals were investigated by proteome profiler protein array and RNA-sequencing. With the use of isoform-specific primers and probes, we uncovered that only sfTSLP was expressed in the cell lines and tumour tissues of human ovarian and endometrial cancers. We also showed the epigenetic regulation of sfTSLP: sfTSLP transcription was regulated by histone acetylation at promoters in ovarian cancer cells, whereas silencing of the sfTSLP transcripts was regulated by promoter DNA methylation in endometrial cancer cells. In vitro study showed that ectopically overexpressing sfTSLP promoted tumour growth but not invasion. Human phosphokinase array application demonstrated that the sfTSLP overexpression activated phosphorylation of multiple intracellular kinases (including GSK3α/β, AMPKα1, p53, AKT1/2, ERK1/2 and Src) in ovarian cancer cells in a context-dependent manner. We further investigated the impact of sfTSLP overexpression on transcriptome by RNA-sequencing and found that EFNB2 and PBX1 were downregulated in ovarian and endometrial cancer cells, suggesting their role in sfTSLP-mediated tumour growth. In conclusion, sfTSLP is predominantly expressed in ovarian and endometrial cancers and promotes tumour growth.

Prevalence and impact of hepatitis B virus infection in ovarian cancer patients in an endemic area-A retrospective cohort study

Hepatitis B virus (HBV) infection is associated with many extrahepatic malignancies, but its association with and impact on ovarian cancer has not been examined. We therefore examined the prevalence of HBV infection among women with primary ovarian carcinoma in an endemic area, and whether this impacts the presentation and survival of these patients. In a retrospective study, we reviewed 523 patients presenting with primary ovarian cancer and known HBV status between 1 January 2006 and 31 December 2017. Patients were divided into HBV-positive and negative groups for the comparison of the patient characteristics and presentation, including staging and histological types, and short term (2 years) mortality from ovarian cancer. Among the 10.1% (53/523) patients screened positive for HBV, more of them presented with advanced staging at FIGO stage 3 or above (OR 1.378, 95% CI 1.063-1.787), although there were no significant differences in patient characteristics. Within 24 months from presentation, there were more deaths due to malignancy in the HBV-positive group (73.3% vs 44.2%, OR 1.659, 95% CI 1.135-2.425). On multivariate analysis after adjusting for nulliparity status, previous use of oestrogens, presence of metastases, histological type (epithelial or others) and grading (high grade or not), whether optimal debulking was performed, and chemotherapy, HBV infection was independently associated with increased death within 24 months of presentation (aOR 2.683, 95% CI 1.015-7.091). In conclusion, the findings of this study suggested an adverse effect of chronic HBV infection on survival within two years of presentation in patients with primary ovarian cancer.

Paclitaxel Induces Immunogenic Cell Death in Ovarian Cancer via TLR4/IKK2/SNARE-Dependent Exocytosis

Emerging evidence shows that the efficacy of chemotherapeutic drugs is reliant on their capability to induce immunogenic cell death (ICD), thus transforming dying tumor cells into antitumor vaccines. We wanted to uncover potential therapeutic strategies that target ovarian cancer by having a better understanding of the standard-of-care chemotherapy treatment. Here, we showed in ovarian cancer that paclitaxel induced ICD-associated damage-associated molecular patterns (DAMP, such as CALR exposure, ATP secretion, and HMGB1 release) in vitro and elicited significant antitumor responses in tumor vaccination assays in vivo Paclitaxel-induced TLR4 signaling was essential to the release of DAMPs, which led to the activation of NF-κB-mediated CCL2 transcription and IkappaB kinase 2-mediated SNARE-dependent vesicle exocytosis, thus exposing CALR on the cell surface. Paclitaxel induced endoplasmic reticulum stress, which triggered protein kinase R-like ER kinase activation and eukaryotic translation initiation factor 2α phosphorylation independent of TLR4. Paclitaxel chemotherapy induced T-cell infiltration in ovarian tumors of the responsive patients; CALR expression in primary ovarian tumors also correlated with patients' survival and patient response to chemotherapy. These findings suggest that the effectiveness of paclitaxel relied upon the activation of antitumor immunity through ICD via TLR4 and highlighted the importance of CALR expression in cancer cells as an indicator of response to paclitaxel chemotherapy in ovarian cancer.

Genomic aberrations in cervical adenocarcinomas in Hong Kong Chinese women

Although the rates of cervical squamous cell carcinoma have been declining, the rates of cervical adenocarcinoma are increasing in some countries. Outcomes for advanced cervical adenocarcinoma remain poor. Precision mapping of genetic alterations in cervical adenocarcinoma may enable better selection of therapies and deliver improved outcomes when combined with new sequencing diagnostics. We present whole-exome sequencing results from 15 cervical adenocarcinomas and paired normal samples from Hong Kong Chinese women. These data revealed a heterogeneous mutation spectrum and identified several frequently altered genes including FAT1, ARID1A, ERBB2 and PIK3CA. Exome sequencing identified human papillomavirus (HPV) sequences in 13 tumors in which the HPV genome might have integrated into and hence disrupted the functions of certain exons, raising the possibility that HPV integration can alter pathways other than p53 and pRb. Together, these provisionary data suggest the potential for individualized therapies for cervical adenocarcinoma based on genomic information.

Hysterectomy for recurrent postmenopausal bleeding revisited: missed sclerosing stromal ovarian tumour

Sclerosing stromal tumour of the ovary is rare. Patients present with menstrual irregularities, pelvic pain, abdominal distension, and presence of a large pelvic mass during their twenties or thirties. We report a rare case of an ovarian sclerosing stromal tumour with an atypical presentation, in that it gave rise to recurrent postmenopausal bleeding.

Abstract 5047: Dysregulated microRNAs in cervical neoplasm

MicroRNAs (miRNAs) play an important role in a variety of physiological processes as well as pathophysiological processes, including cancinogenesis. This study was to identify a distinct miRNA expression signature for cervical intraepithelial neoplasia (CIN) and to reveal individual miRNAs that may be involved in the development of cervical carcinoma. Expression profiling using quantitative real-time RT-PCR of 202 miRNAs was performed on micro-dissected high-grade CIN (CIN 2/3) tissues as compared to normal cervical epithelium. The expression of 12 miRNAs including miR-518a, miR-34b, miR-34c, miR-20b, miR-338, miR-9, miR-512-5p, miR-424, miR-345, miR-10a, miR-193b and miR-203 were significantly different between high-grade CIN and normal epithelium. This miRNA signature was further validated by an independent set of high-grade CIN tissue. The same characteristic signature can also be used to distinguish cervical squamous cell carcinoma (SCC) from normal controls. Target prediction analysis revealed that these dysregulated miRNAs control the apoptosis signaling pathway and cell cycle regulation. These findings contribute to understanding of the pathogenesis of cervical carcinoma at the molecular level.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5047. doi:1538-7445.AM2012-5047

CHD5 Downregulation Associated with Poor Prognosis in Epithelial Ovarian Cancer

BACKGROUND

The CHD5 gene located on 1p36 encodes a protein-chromodomain helicase DNA-binding protein 5. CHD5 has been shown to be a tumor suppressor gene candidate. This study investigated the involvement of CHD5 in ovarian cancer and its clinicopathological significance.

METHODS

CHD5 expression in ovarian cancer and its counterpart were determined by quantitative RT-PCR. The correlation of CHD5 expression to clinicopathological features of the tumor was analyzed.

RESULTS

CHD5 expression was downregulated by at least twofold in 32 of 72 (41%) invasive epithelial ovarian carcinomas when compared to 12 controls in Hong Kong Chinese women. CHD5 downregulation was correlated to clinical status (p < 0.05), but not to patient age, tumor type and grade, recurrence and clinical stage (p > 0.05). Survival analysis showed that patients with CHD5 downregulation in their tumors were associated with shorter disease-free and total survival times compared to those without CHD5 downregulation (p < 0.05). Cox proportional-hazards regression analysis indicated that downregulation of CHD5 is an independent adverse prognostic factor in ovarian cancer.

CONCLUSION

This study shows that CHD5 is downregulated in a certain number of ovarian cancers and appears to be an adverse predictor candidate of ovarian cancer disease-free and total survival.

Dysregulation of microRNA-204 mediates migration and invasion of endometrial cancer by regulating FOXC1

MicroRNAs (miRNAs) regulate mRNA stability and protein expression, and certain miRNAs have been demonstrated to act either as oncogenes or tumor suppressors. Differential miRNA expression signatures have been documented in many human cancers but the role of miRNAs in endometrioid endometrial cancer (EEC) remains poorly understood. This study identifies significantly dysregulated miRNAs of EEC cells, and characterizes their impact on the malignant phenotype. We studied the expression of 365 human miRNAs using Taqman low density arrays in EECs and normal endometriums. Candidate differentially expressed miRNAs were validated by quantitative real-time PCR. Expression of highly dysregulated miRNAs was examined in vitro through the effect of anti-/pre-miRNA transfection on the malignant phenotype. We identified 16 significantly dysregulated miRNAs in EEC and 7 of these are novel findings with respect to EEC. Antagonizing the function of miR-7, miR-194 and miR-449b, or overexpressing miR-204, repressed migration, invasion and extracellular matrix-adhesion in HEC1A endometrial cancer cells. FOXC1 was determined as a target gene of miR-204, and two binding sites in the 3'-untranslated region were validated by dual luciferase reporter assay. FOXC1 expression was inversely related to miR-204 expression in EEC. Functional analysis revealed the involvement of FOXC1 in migration and invasion of HEC1A cells. Our results present dysfunctional miRNAs in endometrial cancer and identify a crucial role for miR-204-FOXC1 interaction in endometrial cancer progression. This miRNA signature offers a potential biomarker for predicting EEC outcomes, and targeting of these cancer progression- and metastasis-related miRNAs offers a novel potential therapeutic strategy for the disease.

Cryotherapy as the treatment modality of postcoital bleeding: a randomised clinical trial of efficacy and safety

BACKGROUND

Postcoital bleeding is a common gynaecological problem that impacts on a woman's quality of life and sexual function. There is little systematic research into its management.

AIMS

To assess the efficacy and side-effects of cryotherapy as treatment for postcoital bleeding.

METHODS

A prospective randomised controlled trial was conducted in a tertiary referral hospital in Hong Kong. A total of 85 women who presented with postcoital bleeding were recruited, and randomised to cryotherapy or no treatment. The treatment group received cryotherapy with compressed carbon dioxide through a cryoprobe placed on the cervix, and controls had cryoprobe on the cervix without compressed carbon dioxide flow. All recruited women were followed up two weeks, three months and six months to review their symptoms and response to the treatment.

RESULTS

The treatment group had a significantly better long-term cure rate and improvement rate. At six months, the cryotherapy group reported a cure rate of 72.1% while that in the control group the cure rate was 50.0% (P = 0.04). The number needed to treat was 5. The mean improvement rate of the cryotherapy group was 82.88% +/- 35.87 but was only 61.62% +/- 55.30 in the control group (P = 0.04). The results were more significant in women with the defined pathological cervix. Apart from the vaginal discharge at second week follow up in the treatment group, there was no statistical significant difference in side-effects and complications among two groups.

CONCLUSION

Our study demonstrated that cryotherapy is a safe and an effective treatment for postcoital bleeding.

Is aortic lymphadenectomy necessary in the management of endometrial carcinoma?

OBJECTIVE

To evaluate the role of aortic lymphadenectomy in the management of endometrial carcinoma.

METHODS

Clinical notes of 163 patients with endometrial carcinoma were reviewed. All patients had peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy with or without aortic lymphadenectomy.

RESULTS

Seventy-five (46.0%) patients had pelvic lymphadenectomy alone whereas 88 (54.0%) had both pelvic and aortic lymphadenectomy. Thirty-five (21.5%) patients had nodal metastases with positive pelvic and aortic nodes in 26 (16.0%) and 24 (27.3%) patients, respectively. Isolated aortic metastases were found in 17 cases (19.3%). Among 35 patients with nodal metastases, recurrence developed in 15 (42.9%) patients and all except one died within five to 50 months. The remaining patients had a median disease-free period of 55 months (13-93 months). The recurrence rate was higher (63.6%) among patients with upper aortic lymph node metastases, and all those who recurred died of disease within seven to 28 months.

CONCLUSIONS

Our data suggest that aortic lymphadenectomy provides both diagnostic and therapeutic value in the management of endometrial carcinoma with high metastatic risk. After surgical removal and adjuvant radiotherapy, patients with nodal metastases achieved a better survival chance.

Gene expression pattern associated with radiotherapy sensitivity in cervical cancer

The objective of the present preliminary study was to determine if a difference in the pattern of gene expression exists between tumors that were subsequently found to be sensitive to radiotherapy and tumors found to be resistant to radiotherapy.

PATIENTS AND METHODS

A total of 16 patients with invasive squamous cell carcinoma of the uterine cervix were included in this study. All patients were treated with standardized radiotherapy alone. Ten of the tumors were clinically radiosensitive and six were radioresistant. Total RNA, extracted from tumor specimens obtained prior to treatment, was hybridized onto an oligonucleotide microarray with probe sets complementary to over 20,000 transcripts. The genes were first subjected to a statistical filter to identify genes with statistically significant differential expression levels between those that were radiosensitive and those that were radioresistant. A back-propagation neural network was then constructed to model the differences so that patterns could be easily identified.

RESULTS

Although a number of genes were found to express differentially between radiosensitive and radioresistant tumors; the 10 most discriminating genes were used to construct the model. Using the expressions from these 10 genes, we found that neural networks constructed from random subsets of the whole data were capable of predicting radiotherapy responses in the remaining subset, which appears stable within the dataset.

DISCUSSION

This study shows that such an approach has the potential to differentiate tumor radiosensitivity, although confirmation of such a pattern using other larger independent datasets is necessary before firm conclusions can be drawn.

Identification of molecular markers and signaling pathway in endometrial cancer in Hong Kong Chinese women by genome-wide gene expression profiling

Endometrial cancer is the third most common gynecologic malignancy and the ninth most common malignancy for females overall in Hong Kong. Approximately 80% or more of these cancers are endometrioid endometrial adenocarcinomas. The aim of this study was to reveal genes contributing to the development of endometrioid endometrial cancer, which may impact diagnosis, prognosis and treatment of the disease. Whole-genome gene expression analysis was completed for a set of 55 microdissected sporadic endometrioid endometrial adenocarcinomas and 29 microdissected normal endometrium specimens using the Affymetrix Human U133 Plus 2.0 oligonucleotide microarray. Selected genes of interest were validated by quantitative real-time-polymerase chain reaction (qRT-PCR). Pathway analysis was performed to reveal gene interactions involved in endometrial tumorigenesis. Unsupervised hierarchical clustering displayed a distinct separation between the endometrioid adenocarcinomas and normal endometrium samples. Supervised analysis identified 117 highly differentially regulated genes (>or=4.0-fold change), which distinguished the endometrial cancer specimens from normal endometrium. Twelve novel genes including DKK4, ZIC1, KIF1A, SAA2, LOC16378, ALPP2, CCL20, CXCL5, BST2, OLFM1, KLRC1 and MBC45780 were deregulated in the endometrial cancer, and further validated in an independent set of 56 cancer and 29 normal samples using qRT-PCR. In addition, 10 genes were differentially regulated in late-stage cancer, as compared to early-stage disease, and may be involved in tumor progression. Pathway analysis of the expression data from this tumor revealed an interconnected network consisting of 21 aberrantly regulated genes involved in angiogenesis, cell proliferation and chromosomal instability. The results of this study highlight the molecular features of endometrioid endometrial cancer and provide insight into the events underlying the development and progression of endometrioid endometrial cancer.

Serum vascular endothelial growth factor as a possible indicator of arterial reactivity in postmenopausal women

OBJECTIVE

To determine whether serum vascular endothelial growth factor (VEGF) concentration is correlated with arterial reactivity in postmenopausal women.

METHODS

An observational study was conducted on 24 postmenopausal women who did not receive any hormone therapy in the 6 months preceding the study and had no pre-existing cardiovascular diseases or cardiovascular risk factors. Serum samples were obtained from all participants and analyzed for VEGF concentrations. Arterial reactivity was assessed by the measurement of endothelium-dependent dilatation and endothelium-independent dilatation of the brachial artery, using color duplex Doppler ultrasound.

RESULTS

The study population was aged 50.8 years on average, with about 2 years of menopause. Serum VEGF concentration in postmenopausal women was significantly correlated with both endothelium-dependent dilatation (r = -0.66, p < 0.01) and endothelium-independent dilatation (r = -0.65, p < 0.01) of the brachial artery.

CONCLUSIONS

Serum VEGF level may be a potential indicator of arterial reactivity in postmenopausal women.

Detection of microsatellite instability in endometrial cancer: advantages of a panel of five mononucleotide repeats over the National Cancer Institute panel of markers

The aim of this study was to find the optimal set of microsatellite markers for diagnosis of the microsatellite instability (MSI) phenotype in endometrial cancers. We compared the sensitivity, specificity and ease of use of a reference panel of five markers originally recommended by the National Cancer Institute (NCI) for colorectal cancer and a panel of five quasi-monomorphic mononucleotide repeat markers (pentaplex PCR system). We used these panels for establishing the MSI status of a series of 80 sporadic endometrial adenocarcinomas by comparing the allelic profiles of the markers between tumor and matching germline DNA. Both panels detected the same subset of 21 out of 80 (26%) endometrial MSI carcinomas. However, in the MSI cases, the mean instability of the five mononucleotide repeats was 96.1% as compared with a mean instability of 69.8% for the three dinucleotide repeats of the NCI panel, indicating a superiority of mononucleotide repeats over dinucleotide repeats in detecting MSI. The fact that the two panels of markers detect the same set of MSI tumors is due to the presence of two mononucleotide repeats within the NCI panel. As demonstrated previously in gastric and colon MSI cases, the pentaplex PCR reaction using mononucleotide repeats is thus an easier and more sensitive method than the NCI panel, for the screening of MSI status in endometrial tumors.

Multipopulation analysis of polymorphisms in five mononucleotide repeats used to determine the microsatellite instability status of human tumors

PURPOSE

Human gastrointestinal tumors with inactivated DNA mismatch repair system (microsatellite instability [MSI] tumors) have distinct molecular and clinicopathologic profiles, and are associated with favorable prognosis. There is evidence suggesting that colorectal cancer patients with MSI tumors respond differently to adjuvant chemotherapy as compared with patients with non-MSI tumors. Finally, determination of the MSI status has clinical application for assisting in the diagnosis of suspected hereditary cases. It is thus becoming increasingly recognized that testing for MSI should be conducted systematically in all human cancers potentially of this type. We recently described a pentaplex polymerase chain reaction of five mononucleotide repeats to establish the MSI status of human tumors, and showed that this assay was 100% sensitive and specific. Moreover, these markers are quasimonomorphic in germline DNA of the white population (ie, individuals of Eurasian origin), and could be used for tumor MSI determination without the requirement for matching normal DNA in this group.

PATIENTS AND METHODS

In this study, we analyzed a comparable panel of five mononucleotide markers in germline DNA from 1,206 individuals encompassing 55 different populations worldwide. Results With the exception of two Biaka Pygmies and one San individual for whom three markers showed variant alleles (three cases [0.2%]), the remaining 1,203 individuals showed no alleles of variant size (1,055 cases [87.5%]), or only one (122 cases [10.1%]) or two (26 cases [2.2%]) markers with variant alleles. All 60 MSI tumors investigated display instability in at least four of the five markers.

CONCLUSION

We demonstrated that tumor MSI status can be determined using the pentaplex reaction for all human populations without the need for matching normal DNA.

Transcriptional repression of WEE1 by Kruppel-like factor 2 is involved in DNA damage-induced apoptosis

Human Kruppel-like factor 2 (KLF2) is a Cys(2)/His(2) zinc-finger-containing transcriptional factor, which is involved in multiple cellular pathways. Utilizing gene expression profiling to identify aberrantly expressed genes in ovarian cancer, we found that KLF2 was significantly and specifically downregulated in ovarian tumors. After reintroducing KLF2 into ovarian cancer cell lines, we observed decreased cell growth and increased sensitivity to DNA damage-induced apoptosis. Analysis of genes that could be potential targets of KLF2 revealed that KLF2 negatively regulated WEE1 expression. WEE1 encodes a tyrosine kinase that regulates the G2/M cell cycle transition. Expression of KLF2 markedly repressed the transcription of WEE1 by directly binding to an SP1/CPBP motif located between -252 bp and the start codon of the WEE1 promoter. Both activation and zinc-finger domains of KLF2 were required for this suppression of Wee1 expression. In addition, we demonstrated that Wee1 expression prevents cancer cells from undergoing apoptosis in response to DNA damage; however, this resistance was abolished by coexpression of KLF2, which inhibits WEE1 transcription. Thus, the level of WEE1 is regulated by KLF2 and enhanced KLF2 expression sensitizes cells to DNA damage-induced apoptosis.

Study of dynamic process of acetic acid induced-whitening in epithelial tissues at cellular level

Acetic acid, inducing transient whitening (acetowhitening) when applied to epithelial tissues, is a commonly used contrast agent for detecting early cervical cancer. The goals of this research are to investigate the temporal characteristics of acetowhitening process in cervical epithelial tissue at cellular level and develop a clear understanding of the diagnostic information carried in the acetowhitening signal. A system measuring time-resolved reflectance was built to study the rising and decay processes of acetowhitening signal from the monolayered cell cultures of normal and cancerous cervical squamous cells. It is found that the dynamic processes of acetowhitening in normal and cancerous cells are significantly different. The results of this study provide insight valuable to further understand the acetowhitening process in epithelial cells and to encourage the development of an objective procedure to detect the early cervical cancers based on quantitative monitoring of the dynamic process of acetowhitening.

Prospective self-controlled study on prevention of hysteroscopic dissemination in endometrial carcinoma

Patients diagnosed to have endometrial carcinoma without prior hysteroscopic examination were recruited from March 2000 to August 2003. Normal saline was used to distend the uterine cavity during the hysteroscopic examination to look for endocervical spread before the definitive surgical treatment. We performed laparotomy, clamped both fallopian tubes, and collected peritoneal washing before the hysteroscopic examination was performed. Peritoneal washing was collected once more after the hysteroscopic examination. Hysteroscopic assessment was performed in 103 patients. Of them, 10 patients were excluded from the study due to previous history of tubal sterilization or blockage. The final analysis was confined to 93 patients. Positive peritoneal cytology was found in 10 (10.8%) patients and this finding was significantly related to the tumor grading (P = 0.023), adnexal involvement (P = 0.003), cervical invasion (P = 0.01), and the presence of peritoneal seedlings (P = 0.001). In five of the 10 patients with positive peritoneal cytology before the hysteroscopic examination, malignant cells could also be recovered in the peritoneal washing collected after the hysteroscopic examination. For patients with negative peritoneal cytology before hysteroscopy, none exhibited positive peritoneal cytology after the procedure. Our data suggested that complete occlusion of both fallopian tubes can effectively prevent the dissemination of endometrial malignant cells into the peritoneal cavity during hysteroscopy.

Raloxifene therapy in postmenopausal women is associated with a significant reduction in the concentration of serum vascular endothelial growth factor

OBJECTIVE

To determine whether raloxifene has an effect on serum vascular endothelial growth factor (VEGF) concentration in postmenopausal women.

DESIGN

A randomized, placebo-controlled trial.

SETTING

University-based obstetrics and gynecology unit.

PATIENT(S)

Fifty postmenopausal women who did not receive any hormone therapy in the 6 months preceding the study.

INTERVENTION(S)

The participants were randomly assigned on a one-to-one basis to receive either raloxifene (60 mg daily) or placebo for 36 weeks.

MAIN OUTCOME MEASURE(S)

Serum VEGF concentrations at baseline and at 12 weeks and 36 weeks after the commencement of intervention.

RESULT(S)

The serum VEGF concentrations in the raloxifene group were significantly reduced from 247 +/- 16 pg/mL at baseline to 195 +/- 11 pg/mL at 36 weeks after starting raloxifene. The placebo group showed no significant change in the serum VEGF concentrations throughout the intervention period.

CONCLUSION(S)

Raloxifene therapy in postmenopausal women is associated with a significant reduction in serum VEGF concentration.

Expression genomics of cervical cancer: molecular classification and prediction of radiotherapy response by DNA microarray

PURPOSE

The incidence and mortality rates of cervical cancer are declining in the United States; however, worldwide, cervical cancer is still one of the leading causes of death in women, second only to breast cancer. This disparity is at least partially explained by the absence of or comparatively ineffective screening programs in the developing world. Recent advances in expression genomics have enabled the use of DNA microarray to profile gene expression of various cancers. These expression profiles may be suitable for molecular classification and prediction of disease outcome and treatment response. We envision that expression genomics applied in cervical cancer may provide a more rational approach to the classification and treatment of the disease.

EXPERIMENTAL DESIGN

In this report, we examined the expression profiles of cervical cancer compared with normal cervical tissues in DNA microarrays that contained approximately 11,000 features that correspond to either human transcripts with known function or anonymous expressed sequence tags.

RESULTS

Our results showed that normal cervical tissues were completely segregated from the cancer samples using about 40 genes whose expressions were significantly different between these specimens. In addition, clinical stage IB and stage IIB tumors could also be classified based on their signature expression patterns. Most importantly, some of the tumor samples were further stratified into two major groups based on their response to radiotherapy, and we were able to predict the response of these patients to radiotherapy from their expression profiles.

CONCLUSIONS

Gene expression profiling by DNA microarray may be used for further molecular classification of disease stages and prediction of treatment response in cervical cancer.

The value of pelvic and para-aortic lymphadenectomy in endometrial cancer to avoid unnecessary radiotherapy

The case histories of 95 patients with endometrial carcinoma treated between July 1998 and December 2002 were reviewed. These patients were staged according to FIGO classification and included peritoneal cytology, total abdominal hysterectomy/bilateral salpingo-oophorectomy (TAHBSO), and pelvic with or without para-aortic lymphadenectomy. The FIGO surgical stages were as follow: IA, 9 (9.5%); IB, 35 (36.8%); IC, 16 (16.8%); IIB, 10 (10.5%); IIIA, 5 (5.3%); IIIB, 1 (1.1%); IIIC, 19 (20.0%). In addition to TAHBSO, 47 (49.5%) patients had pelvic lymphadenectomy whereas 48 (50.5%) had both pelvic and para-aortic lymphadenectomy. Nineteen (20.0%) of 95 patients had nodal metastases. Positive pelvic and para-aortic lymph nodes were found in 15 (15.8%) of 95 and 12 (25.0%) of 48 patients, respectively. According to the result of the lymphadenectomy, 19 (20.0%) patients had their surgical stage upgraded to stage IIIC and 61 (64.2%) patients had a change in their management plan. Twelve (12.6%) patients required extended field irradiation due to para-aortic nodal metastases and 49 (51.6%) patients with negative nodes avoided postoperative external radiotherapy. By defining the lymphatic spread via surgical staging, postoperative radiotherapy can be recommended to patients with nodal metastases, while it can be withheld from those patients with negative nodes, irrespective of the presence of risk factors.

A prospective, randomized, placebo-controlled study of the dose effect of oral estradiol on bone mineral density in postmenopausal Chinese women

OBJECTIVES

One of the long-term consequences of estrogen deficiency in postmenopausal women is an increased risk of osteoporosis. Fractures of the hip and lumbar spine are associated with considerable morbidity and mortality. Estrogen replacement therapy reduces the risk of osteoporosis, but there is no clear agreement on the most appropriate doses to be used. The aim of this study was to compare changes in bone mineral density (BMD) measurements using conventional and lower dose estradiol.

METHODS

A prospective, randomized, placebo-controlled 12-month study of the effect of 1 and 2 mg estradiol on BMD in 152 hysterectomized postmenopausal Chinese women with no contraindication to the use of estrogen replacement therapy.

RESULTS

Over 12 months, spinal BMD in placebo treated patients decreased by a mean of 2% from baseline (-0.02+/-0.03 g/cm(2)) while it increased by 2% in the 1 mg (0.02+/-0.03 g/cm(2)) and 3% in the 2 mg group (0.03+/-0.03 g/cm(2)). Mean changes in BMD over 12 months in the hip were -0.02+/-0.02 g/cm(2) (-2%), 0.01+/-0.02 g/cm(2) (+1%) and 0.01+/-0.03 g/cm(2) (+1%) in the placebo, 1 and 2 mg estradiol groups, respectively (P<0.05). Relative to placebo, increases in BMD in both 1 and 2 mg groups were statistically significant for both spine and hip (P<0.05). However, there was no significant difference in the increase in BMD between the 1 and 2 mg doses for either lumbar spine or hip (P=0.82, 0.53, respectively).

CONCLUSION

The results of our study show that a 1 mg dose of oral estradiol is effective in preventing bone loss in postmenopausal Chinese women.

The role of microsatellite instability in cervical intraepithelial neoplasia and squamous cell carcinoma of the cervix

OBJECTIVES

This study was conducted to define the role of microsatellite instability (MSI) in cervical intraepithelial neoplasia (CIN) and squamous cell carcinoma (SCC) of the cervix. We also tested the validity of using markers recommended for MSI study in colonic carcinoma by the National Cancer Institute (NCI) for cervical neoplasm.

METHODS

Twenty normal cervical, 24 low-grade CIN (CIN-L), 59 high-grade CIN (CIN-H), and 93 SCC tissues were examined for MSI after microdissection. A polymerase chain reaction based MSI detection was performed using five markers recommended by the NCI for colonic cancer (panel one) as well as five other markers (panel two) found to be informative in earlier studies. High-frequency MSI (MSI-H) was defined as instability in > or = 2 of 5 loci if one panel was used and > or = 30% of loci when more than five loci were used. Low-frequency MSI (MSI-L) was diagnosed if instability was noted but did not meet the criteria of MSI-H. Findings were correlated with clinicopathologic information.

RESULTS

The combined use of panel one and two markers showed no MSI in normal cervical or CIN-L tissue, MSI-L in 1 CIN-H (1.7%), MSI-L in 16 (17.2%), and MSI-H in 11 (11.8%) SCC, respectively. The NCI-recommended panel alone detected 19 of 27 MSI-positive SCC. MSI-positive was not related to patient age, disease stage, and tumor grade. The overall survival of MSI-positive patients was significantly worse than that of microsatellite stable patients (P = 0.02). An increasing trend of MSI-H rate with higher disease stages was noted (P = 0.035) but MSI-H was not associated with poor prognosis.

CONCLUSIONS

The NCI recommended panel of markers might not be useful in MSI study for SCC and using more than five markers improves the MSI detection. MSI is rare in cervical dysplasia but is present in a subset of SCC. The association between MSI-positivity and prognosis awaits future confirmation.

A prospective, randomized, placebo-controlled study of the dose effect of oral oestradiol on menopausal symptoms, psychological well being, and quality of life in postmenopausal Chinese women

OBJECTIVES

Hypoestrogenism occurring in association with the menopause may result in the development of vasomotor symptoms and it may also have a detrimental effect on psychological well being and quality of life (QOL). The aims of this study were to measure menopausal symptoms, mood and QOL in postmenopausal Chinese women and to assess the effect of different doses of oestrogen on these outcome indicators.

METHODS

A prospective, randomized, placebo-controlled study of the effect of 1 and 2 mg oestradiol on menopausal symptoms, anxiety and depressive symptoms, and QOL in 152 postmenopausal women over a 12 month study period. Menopausal symptoms were measured using a modified Kupperman's scale. Anxiety and depressive symptoms and QOL were measured using the Hospital Anxiety and Depression Scales and a modification of the World Health Organization Quality of Life questionnaire, respectively.

RESULTS

Baseline scoring of vasomotor symptoms in our population was low whilst QOL scoring was relatively high. Over 12 months, after adjustment for differences in baseline scoring, there was a significant reduction in menopausal symptom scores in the 2 mg oestradiol group compared with placebo but not in the 1 mg group. There were no statistically significant changes in levels of anxiety and depression or QOL in either the 1 or the 2 mg group compared with placebo.

CONCLUSIONS

These results suggest that relatively few Chinese women will be expected to benefit from hormone replacement in terms of either QOL or mood. In addition, the overall benefit of treatment for vasomotor symptoms will be less for a given number of Chinese women than for Caucasians. Therefore, when considering the reasons for prescribing hormone replacement therapy in this population, protection against osteoporosis will for most women be the prime consideration.

Expression of apoptotic regulators and their significance in cervical cancer

Insufficient apoptosis is implicated in many human cancers, including cervical carcinoma. The objectives of this study were to explore changes of apoptosis-regulating gene expression and their clinical significance in cervical cancer. The expression of apoptosis-regulating genes, including five Bcl-2 family and two caspase family members, was evaluated in 43 cervical invasive squamous cell carcinomas, using immunohistochemistry. Specimens in which >or=10% of the neoplastic cells showed cytosolic immunoreactivity were considered to be immunopositive. Results were correlated with clinico-pathologic characteristics of the subjects. All seven apoptotic regulators examined were positive in a proportion of the tumors. The percentage of cases expressing Bax was higher in the patients without evidence of disease after treatment than in the patients alive with disease or who died of disease (P<0.05). A significant difference in disease-free survival was detected between Bax-positive and -negative groups (P<0.05), and in overall survival between Mcl-1-positive and -negative groups (P<0.05). Significant association between the seven markers tested was only found for caspase 3 and Bak immunoreactivity in cervical carcinoma (P<0.05). The results demonstrate expression of multiple apoptosis-modulating proteins in cervical cancer. There appears to be complex regulation of apoptosis protein levels in association with clinical behavior of cervical squamous cell carcinoma.

Hysteroscopic dissemination of endometrial carcinoma using carbon dioxide and normal saline: a retrospective study

OBJECTIVE

The aim of this study was to compare the likelihood of disseminating endometrial carcinoma cells into the peritoneal cavity by hysteroscopic examination using carbon dioxide (CO(2)) or normal saline (NS) as the distension medium.

METHODS

A retrospective study of 162 consecutive patients with endometrial carcinoma treated at a university teaching hospital from 1994 to 1999 was undertaken. All patients had a hysteroscopic examination, using either CO(2) or NS as the distension medium, as part of the investigation for abnormal uterine bleeding or in determining whether the uterine cervix was invaded by tumor. Peritoneal fluid for cytology was collected immediately upon entry into the abdominal cavity. Positive peritoneal cytology was considered the primary statistical endpoint.

RESULTS

Among 162 patients, 39 cases were excluded from the study because of macroscopic intraperitoneal diseases (n = 32) or pathology other than endometrioid adenocarcinoma (n = 7). Another 3 cases were excluded because both distension mediums had been used in the hysteroscopy. Analysis was therefore based on the data of 120 patients. There was no statistically significant difference between the two groups of patients undergoing hysteroscopy using either CO(2) (n = 70) or NS (n = 50) with regard to age, pathologic stage, International Federation of Gynecology and Obstetrics grading, myometrial invasion, tumor size, cervical involvement, nodal involvement, and 2-year progression-free survival. However, there was a mean of 13.0 plus minus 5.0 days (range 3-21 days) time gap between laparotomy for definitive surgery and CO(2) hysteroscopy compared to immediate laparotomy after NS hysteroscopy (P < 0.001). Positive peritoneal cytology was noticed in 8 (6.7%) patients of which 7 were in the NS group and 1 was in the CO(2) group. Positive cytology was significantly more common among patients after hysteroscopy using NS than CO(2) (14.0% versus 1.4%, odds ratio = 11.2, 95% confidence interval = 1.3-94.5, P = 0.009). The presence of positive peritoneal cytology was not associated with age, tumor grade, tumor size, myometrial invasion, cervical involvement, or nodal metastasis. All 8 patients with positive cytology received no additional treatment and are disease free at 12 to 34 months of follow-up.

CONCLUSIONS

Our data suggested that endometrial malignant cells were introduced into the peritoneal cavity during hysteroscopy and might be more likely after the use of NS rather than CO(2). This report emphasizes the need for prospective evaluation for further clarification of this hypothesis. The clinical significance of the dissemination awaits the long-term follow-up of these patients.

Cervical intraepithelial neoplasia is associated with increased polyamine oxidase and diamine oxidase concentrations in cervical mucus

OBJECTIVE

The aim of this study was to establish whether reactive oxygen species, generated during oxidation of amines, catalyzed by polyamine oxidase (PAO) and diamine oxidase (DAO) in cervical secretions may play a role in the etiology of cervical cancer.

METHODS

Cervical mucus was obtained from women attending the gynecological outpatient department: 139 with and 154 without cytological evidence of cervical intraepithelial neoplasia were recruited. The mucus was freeze dried in liquid nitrogen, weighed, and later resuspended for assay of PAO and DAO concentrations using a chemiluminescence method. The two groups were compared by group sequential analysis using PEST3 software.

RESULTS

Patients with a colposcopic diagnosis of a high-grade squamous intraepithelial lesion (SIL) had significantly higher enzyme activities than control cases (L(N)PAO 1.37 (0.37) versus 1.18 (0.35): Student t test: P < 0.001; L(N)DAO 1.37 (0.36) versus 1.15 (0.37): Student t test: P < 0.001).

CONCLUSION

It is probable that this rise in enzyme activity precedes cytological changes and plays some part in the etiology of cervical cancer, as the cells that undergo premalignant change are normally squamous in origin, whereas mucus is a product of columnar epithelium. Higher enzyme activity in patients with SIL than in controls may be a reflection of higher risk of exposure to amine substrates in semen through multiple sexual partners.

Entrapment of viable trophoblastic tissue in a uterine hematoma after surgical evacuation. A case report

BACKGROUND

Postevacuation uterine perforation is a common event. Early diagnosis and management are important to minimize the associated morbidity and mortality.

CASE

A woman presented with persistent vaginal bleeding for two weeks following surgical uterine evacuation for missed abortion at 7 weeks' gestation. She had a persistently elevated serum human chorionic gonadotropin level. Ultrasonography revealed a 3-cm, heterogeneous mass with high vascularity at the left anterior uterine fundal region; the endometrial echo was normal. Cornual pregnancy was suspected, and surgical resection was planned. Intraoperatively, a uterine hematoma with evidence of previous uterine perforation was diagnosed. Hysterotomy, removal of the hematoma and repair of the uterus were performed. Histologic examination revealed entrapment of trophoblastic tissue in the specimen. The patient had an uneventful recovery.

CONCLUSION

Entrapment of trophoblastic tissue in a uterine hematoma is a rare sequel of uterine perforation after evacuation and might be confused with cornual pregnancy.

The effect of continuous combined hormone replacement therapy on arterial reactivity in postmenopausal women with established angina pectoris

Most epidemiological studies have suggested that the administration of estrogen reduces cardiovascular risk in healthy postmenopausal women. More recently, however, in the large Heart Estrogen/progestin Replacement Study (HERS), it was unexpectedly found that in women with established cardiovascular disease, there was overall no difference in cardiovascular events between those treated with combined oestrogen/progestin hormone replacement therapy and those on placebo. The aim of this study was to examine the effect of combined hormone replacement therapy on arterial reactivity in women with existing angina pectoris. Seventy-four postmenopausal women with angina pectoris were recruited into a 16 week double-blind, placebo-controlled study of treatment with 2 mg of estradiol combined with 1 mg of norethisterone acetate daily. The median endothelium-dependent change in arterial relaxation increased from 5.00 to 7.69% in the treatment group and decreased from 5.57 to 3.64% in the controls. The median endothelium-independent change in arterial relaxation increased from 6.49 to 7.27% in the treatment group and decreased from 4.39 to 2.07% in the controls. The changes in arterial relaxation between the treatment and control groups were not statistically significant. The administration of estrogen/progestin did not significantly improve either endothelium-dependent or -independent arterial relaxation in postmenopausal women with established cardiovascular disease. We have previously shown that estrogen/progestin treatment improves endothelium dependent relaxation in healthy women. The results of our study provide one possible explanation for the clinical findings of the HERS study. In women with established cardiovascular disease, arterial relaxation does not increase significantly in response to treatment with combined hormone replacement therapy.

Aberrant expression of p21(WAF1/CIP1) and p27(KIP1) in cervical carcinoma

An immuno-histochemical study of p21 and p27 expression in cervical carcinoma was performed in 73 patients. Positive p21 and p27 staining was detected in 35.6 and 11% of tumour tissues, respectively. p21 expression was significantly correlated with advanced disease stage and negative human papilloma virus infection whilst positive p27 staining was not correlated with any clinical and pathological parameters studied. Kaplan-Meier estimation indicated that survival might be related to disease stage, tumour grade and p21 expression. Cox regression analysis confirmed that advanced stage disease and poorly differentiated tumour are independent prognostic factors for cervical carcinoma.

Anti-ischemic action of estrogen-progestogen continuous combined hormone replacement therapy in postmenopausal women with established angina pectoris: a randomized, placebo-controlled, double-blind, parallel-group trial

The benefit of treating postmenopausal women with established cardiovascular disease with combined estrogen-progestogen hormone replacement therapy (HRT) is controversial. This study investigated the effect of treatment with estradiol and norethisterone acetate on exercise tolerance and on the frequency and severity of ischemic attacks in postmenopausal women with stable angina pectoris. A total of 74 Chinese women were recruited for this 16-week double-blind, placebo-controlled trial. They were randomly allocated into two groups; one group received placebo/placebo/placebo and the other group received placebo/estrogen-progestogen/placebo. Estrogen-progestogen continuous combined HRT increased both time to 1-mm ST depression (99.1 s, p < 0.05) compared with a mean decrease of 22.9 s with placebo (p < 0.05), and total exercise duration also showed a significant increase (32.7 s, p < 0.05) after treatment compared with placebo (2.5 s, p < 0.05). In addition, the total number of ischemic events/24 h during ambulatory electrocardiographic monitoring decreased by 0.82 events after treatment (p < 0.05) compared with an increase in the placebo group (0.94), a highly significant difference (p = 0.006). These results suggest that the administration of this particular combined hormone replacement preparation may have a beneficial effect on myocardial ischemia in postmenopausal women with established coronary disease.

Preoperative hysteroscopic assessment of cervical invasion by endometrial carcinoma: a retrospective study

OBJECTIVE

The aim of this study was to evaluate the efficacy of hysteroscopy, using normal saline (NS) or carbon dioxide (CO2) as the distention medium, in assessing tumor invasion of the uterine cervix by endometrial carcinoma.

METHODS

A retrospective study was conducted in 200 consecutive patients with endometrial carcinoma diagnosed from 1993 to 2000. Prior to definitive surgical treatment, hysteroscopy was performed using either NS or CO2 as the distention medium to determine whether the tumor had spread to the cervix. The uterine specimens obtained after hysterectomies were cut open for gross examination. Tumor invasion of the cervix as determined by hysteroscopy and gross examinations was compared with the pathological findings.

RESULTS

Tumor invasion of the cervix was found in 41 (20.5%) cases on pathological examination. Hysteroscopy has an accuracy of 92.5% (185/200), a sensitivity of 68.3% (28/41), and a specificity of 98.7% (157/159), with a PPV of 93.3% (28/30) and a NPV of 92.4% (157/170) in determining cervical involvement. Assessment by gross inspection had 93.0% (186/200) accuracy, 68.3% (28/41) sensitivity, 99.4% (158/159) specificity, 96.6% (28/29) PPV, and 92.4% (158/171) NPV. There was no significant difference between the two assessment methods. When the results of hysteroscopy performed with different distention mediums were compared, the use of NS had a higher accuracy in determining tumor spread to the cervix (96.8% vs 88.7%, P = 0.03) and NPV (96.4% vs 88.4%, P < 0.05) than the use of CO2.

CONCLUSIONS

Hysteroscopic assessment and gross examination of the uterine specimen had similar efficacy in detecting cervical invasion by endometrial carcinoma. Hysteroscopic examination using NS is more accurate than that which uses CO2.

Alteration of cyclin D1 and CDK4 gene in carcinoma of uterine cervix

Amplification and overexpression of cyclin D1 and CDK4 genes in cervical carcinoma were studied by semi-quantitative differential polymerase chain reaction assay and an immunostaining technique, respectively. Amplifications of cyclin D1 and CDK4 genes were found in 24% (27/113) and 26% (29/112) of tumors, respectively. Overexpression of cyclin D1 and CDK4 was demonstrated in 32% (21/66) and 73% (45/62) of tumors, respectively. No tumor showed CDK4 gene mutation on single strand conformational polymorphism. Sixteen percent (8/49) of the tumor specimens showed neither amplification nor overexpression. Disease stage, tumor grade and overexpression of cyclin D1 were found to be independent poor prognostic factors in cervical carcinoma.

Dose-finding study for the use of long-acting gonadotrophin-releasing hormone analogues prior to ovarian stimulation for IVF

Gonadotrophin-releasing hormone (GnRH) analogues improve the outcome of treatment with IVF by increasing the number and quality of oocytes retrieved and by reducing cycle cancellation rates. Whilst short-acting GnRH analogues are most commonly used, depot preparations are now available that are more convenient for patient use. Some studies have reported that pregnancy rates with depot GnRH analogues are similar to those of short-acting preparations, but others have suggested that the more profound down-regulation seen with depot GnRH analogues results in inferior embryo quality. The purpose of this study was to determine whether a lower than conventional dose of a depot GnRH analogue may be more appropriate for use in ovarian stimulation prior to IVF. Sixty patients were randomized to receive either 3.75 mg (conventional dose) or 1.87 mg (low dose) triptorelin prior to ovarian stimulation for IVF. Suppression was measured using serum concentrations of LH measured 2 and 3 weeks after the administration of the GnRH analogues, the dose of gonadotrophin used and the time to resumption of menses. Mean concentrations of LH were 2.2 +/- 1.0 and 1.1 +/- 0.6 IU/l in the conventional dose group and 3.5 +/- 5.5 and 2.7 +/- 1.9 IU/l in the low dose group (P < 0.05 at 2 and 3 weeks). There were no significant differences between the doses of gonadotrophins used, the number of oocytes and embryos available and the time to resumption of menses, nor in the pregnancy rates. Although the degree of suppression as measured biochemically was more profound with the conventional dose, this did not affect the IVF outcome. The use of a lower dose therefore appears to be equally effective and could contribute to a reduction in the cost of treatment.

The effects of follicular fluid and platelet-activating factor on motion characteristics of poor-quality cryopreserved human sperm

PURPOSE

To evaluate the effects of follicular fluid and platelet-activating factor on sperm motion characteristics of cryopreserved oligospermic and normospermic samples.

METHODS

Sperm motion characteristics were evaluated prior to cryopreservation, immediately after thawing and following incubation in human tubal fluid, follicular fluid, or 1-microM platelet-activating factor cultures. Sixteen oligospermic samples and 20 normospermic samples were examined. Sperm motion characteristics were analyzed manually according to WHO criteria (1999) and also with an automated videomicrography system.

RESULT(S)

Incubation in follicular fluid increased overall motility and the percentage of sperm with fast progressive motility in normospermic but not oligospermic samples. Incubation with platelet-activating factor increased overall motility and the percentage of sperm showing nonprogressive motility in both oligospermic and normospermic samples.

CONCLUSION(S)

The stimulatory effects of culture in follicular fluid as seen in normospermic samples do not show a significant benefit in oligospermic cryopreserved samples. Platelet-activating factor and follicular fluid increase motility via different mechanisms. Incubation of oligospermic cryopreserved sperm with PAF increases the number of motile sperm, thereby enabling easier identification of viable sperm for intracytoplasmic sperm injection in samples with severe asthenozoospermia.

Randomized double-masked comparison of radially expanding access device and conventional cutting tip trocar in laparoscopy

OBJECTIVE

To compare postoperative wound pain associated with the radially expanding access device and the conventional disposable cutting-tip trocar.

METHODS

Our randomized, double-masked, self-controlled study involved 34 women scheduled for laparoscopic adnexal surgery. In each, a 10-mm radially expanding access device was inserted laterally on one side of the lower abdomen and a size-matched disposable cutting-tip trocar was placed on the other side, using random assignment. Postoperative pain for each studied wound and patient satisfaction toward the wounds were assessed using a visual analog scale. Any bleeding complication associated with insertion of the trocar was also recorded.

RESULTS

The radially expanding access device was associated with significant reduction in severity (median 1.4 versus 5.0, P <.001) and duration (median 11 versus 21 days, P <.001) of postoperative wound pain, shorter wound scars (14 versus 17 mm, P <.001), a lower incidence of wound induration (0 versus 9, P <.01), and a higher patient satisfaction (median 9.7 versus 6.2, P <.001). There were four inferior epigastric artery injuries, all at the conventional trocar wound.

CONCLUSION

The radially expanding access device was associated with less postoperative wound pain and more patient satisfaction than the conventional cutting-tip trocar.

Whole blood mercury concentrations in sub-fertile men in Hong Kong

We aimed to investigate the association between whole blood mercury concentrations and semen quality in sub-fertile men. Fifty-nine male partners of infertile couples attending the Assisted Reproduction Unit of the Chinese University of Hong Kong between 1997 and 1998 were recruited into our study. Blood was taken from each subject for whole blood mercury concentration and hormone profile. Semen samples were obtained for computer assisted semen analysis using the Hobson sperm tracker. The semen parameters and hormone profile were compared between subjects with normal and those with elevated mercury concentrations. Twenty-one subjects (35.6%) had a whole blood mercury concentration higher than the normal range (0-50 nmol/l). All parameters of the semen analysis including the concentration of sperm, percentage of morphologically normal sperm, percentage of motile sperm, curvilinear velocity, straight-line velocity, average path velocity, and amplitude of lateral head displacement, were reduced in those with elevated blood mercury concentrations, although the difference was not statistically significant. We failed to demonstrate a statistically significant effect on the measurement of semen quality, but other adverse effects cannot be excluded. From a public heath perspective, these findings confirm that mercury toxicity is a potentially serious problem affecting the local community.

Intramyometrial abscess complicating pregnancy. A report of two cases

BACKGROUND

Intramyometrial abscess in pregnancy is a rare event. Little information is available on the presentations and potential complications.

CASES

Two asymptomatic patients underwent complications with failed instrumental delivery in the second stage of labor. Intramyometrial abscesses were found during lower segment cesarean section. In the first case, incision and drainage was done, and the culture of the pus revealed multiple organisms, including Escherichia coli, group B Streptococcus and Klebsiella species. The patient was successfully treated with antibiotics, while the infant did not show any evidence of infection. In the second case, removal of the abscess was performed, and pathology showed evidence of chronic abscess, but the culture did not reveal any organisms. The patient was treated with prophylactic antibiotics. The infant was treated with antibiotics for clinical sepsis, but no organism was revealed.

CONCLUSION

Intramyometrial abscess complicating pregnancy can be asymptomatic. Obstructed labor can be a potential complication when the abscesses are located in the lower uterine segment. Antibiotics, together with incision and drainage or removal of the abscess, is the first choice for treatment.

Prospective randomized study of the effect of "add-back" hormone replacement on vascular function during treatment with gonadotropin-releasing hormone agonists

BACKGROUND

Gonadotropin-releasing hormone agonists (GnRHas) are a group of drugs that with long-term use induce a pseudomenopausal state in which estrogen production is suppressed. They are commonly used in the treatment of sex steroid-dependent conditions. "Add-back" hormone replacement therapy is used to prevent menopause-like symptoms and bone loss during GnRHa treatment, but it is also recognized that hypoestrogenism adversely affects vascular function. The aim of this study was to examine the effect of GnRHa and add-back therapy on vascular reactivity. This model serves as a paradigm for the effect of hormone replacement therapy in postmenopausal women.

METHODS AND RESULTS

Measurements of endothelium-dependent and endothelium-independent vascular reactivity were compared in 2 groups of women treated with a GnRHa for 6 months. One group received estrogen/progestogen add-back therapy during the second 3 months of GnRHa treatment. Vascular reactivity was examined by use of ultrasound measurements of changes in brachial artery diameter. Endothelium-dependent changes were assessed during reactive hyperemia, whereas endothelium-independent changes were measured after the administration of glyceryl trinitrate sublingual spray. Treatment with the GnRHa alone had an inhibitory effect on endothelium-dependent relaxation. However, endothelium-dependent relaxation significantly improved in the group receiving add-back therapy (14.6%) compared with the group treated with GnRHa alone (8.6%) (P<0.01). There were no significant endothelium-independent changes in either group.

CONCLUSIONS

These results suggest that the administration of add-back therapy has a protective effect on vascular function in GnRHa-induced hypoestrogenism. As a model for the menopause, these results also suggest that the long-term administration of hormone replacement therapy would result in endothelium-dependent arterial relaxation, an observation previously attributed only to the acute administration of estrogen.

Prospective, randomized, controlled study of the effect of hormone replacement therapy on peripheral blood flow velocity in postmenopausal women

OBJECTIVE

To investigate the effect of different types and methods of delivery of hormone replacement therapy (HRT) on peripheral vascular flow velocity in postmenopausal women.

DESIGN

A prospective, randomized, operator-blinded, controlled study.

SETTING

A hormone replacement clinic in a university teaching hospital.

PATIENT(S)

Sixty-eight women who had undergone surgical menopause.

INTERVENTION(S)

No treatment, oral estrogen, continuous combined estrogen and progestogen, or percutaneous estrogen.

MAIN OUTCOME MEASURE(S)

The pulsatility indices of the brachial, dorsalis pedis, popliteal, and radial arteries were measured under standardized conditions before the commencement of HRT and after 2 and 6 months of treatment. Serum E2 levels were measured at each visit.

RESULT(S)

There was an inverse correlation between the serum E2 levels and the pulsatility indices. There was a significant reduction in the pulsatility index in at least one of the four arteries after 2 months of HRT in all the treatment groups but not in the control group. The effect of HRT on the pulsatility index persisted until the completion of the study in all the treatment groups.

CONCLUSION(S)

These results confirm that the administration of HRT is associated with a reduction of the pulsatility index, and hence an increase in blood flow in the peripheral arteries; this change in the pulsatility index is related directly to serum E2 levels. The percutaneous route of administration of estrogen was at least as effective as oral treatment in improving peripheral vascular flow velocity. The beneficial effect of estrogen was not affected by the addition of a progestogen.

Metabolic and inflammatory responses after laparoscopic and abdominal hysterectomy

OBJECTIVE

Our purpose was to quantify and compare the metabolic and inflammatory changes after laparoscopic and abdominal hysterectomy.

STUDY DESIGN

Forty-four patients with no major medical disease requiring abdominal hysterectomy for benign disorders were randomly assigned to have laparoscopic hysterectomy (n = 20) and abdominal hysterectomy (n = 24). Venous blood and 24-hour urine samples were collected the day before and for each of the first 3 postoperative days.

RESULTS

No differences were present in demographic characteristics, operating time, and uterine weight between the two groups. No major complications were encountered. The laparoscopic hysterectomy group had a significantly lower postoperative morphine consumption (median 5.5 vs 14 mg, P < .05), lower febrile morbidity rate (15% vs 45.8%, P < .05), and shorter hospital stay (median 4 vs 6 days, P < .001) and demonstrated a less intense stress response in terms of serum interleukin-6 (median 50.6 vs 73.9 pg/mL x hour x 10, P = .01), C-reactive protein (median 28.1 vs 44.7 mg/L x hour x 10(2), P = .005), cortisol (median 23.4 vs 27.2 mg/mL x hour x 10(3), P = .04), white blood cell count (median 59.5 vs 69.8 10(9)/L x hour x 10, P = .009), 24-hour urinary excretion of cortisol (median 34.8 vs 44.2 nmol/L x hour x 10(3), P = .02), and norepinephrine (median 80.8 vs 132.4 nmol/L x hour x 10(2), P = .001). No significant difference was detected in plasma glucose (median 41.5 vs 45.6 mmol/L x hour x 10, P = 6) and 24-hour urinary excretion of epinephrine (median 32.2 vs 34.1 nmol/L x hour x 10(2), P = .3).

CONCLUSION

Laparoscopic hysterectomy is associated with a lower morbidity and a less intense stress response than abdominal hysterectomy for benign diseases.

p16INK4 and p15INK4B alterations in primary gynecologic malignancy

Chromosome 9 abnormalities have been found in primary tumors and cell lines from human gynecologic malignancy. Alterations of p16INK4 and p15INK4B genes mapped on the band p21 of chromosome 9 have been detected in various human tumors, but the role of these genes as tumor suppressors in vivo appear to be dependent on tumor type. Polymerase chain reaction (PCR)-based analysis was performed to search for lesions of these genes in 202 primary gynecologic malignancies. Homozygous deletions of p16INK4 were detected in 7 of 128 (5%) cervical, 1 of 41 (2%) endometrial, 2 of 27 (7%) ovarian, and 3 of 6 (50%) vulvar carcinomas, while homozygous deletions of p15INK4B were detected in 19 of 128 (15%) cervical, 1 of 41 (2%) endometrial, 9 of 27 (33%) ovarian, and 3 of 6 (50%) vulvar carcinomas, respectively. No mutations were found in exon 2 of p16INK4 from 161 cases of gynecologic malignancy without deletion of p16INK4. All 3 cases of vulvar carcinoma showing homozygous deletions of p16INK4 and p15INK4B were at advanced clinical stage (stage III-IV), while all 7 cases of cervical carcinoma and 2 cases of ovarian carcinoma showing homozygous deletion of p16INK4 were at early stage (stage I-II). The results indicate that homozygous deletions of p16INK4 and/or p15INK4B genes may play a role in a subset of primary gynecologic malignancy.

C-myc mutation detected by polymerase chain reaction--heteroduplex in cervical cancer

To evaluate both the incidence of c-myc gene mutation and the relationship of this finding to the clinico-pathologic characteristics of patients with cervical cancer, a polymerase chain reaction (PCR)-based heteroduplex gel electrophoresis method was used to screen DNA extracted from 102 cervical invasive carcinomas referred to the Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong. C-myc mutation was detected and then characterised by sequencing of PCR products in 4 cases (4%). The incidence of c-myc mutation in patients with advanced stage tumours (stage III-IV, 11% was statistically higher than in those with early stages (stage I-II, 1%, p = 0.05). There was also a significant difference in the incidence of c-myc mutation among the patients who had died of their disease (10%), were alive with evidence of disease (25%), and those without evidence of disease (0%, p = 0.0003). These findings indicate that the c-myc mutation is not common in cervical cancer, but where it exists, it may be associated with cancer progression and poorer outcome. Whether the c-myc mutation is an adjunct prognostic indicator in cervical cancer remains to be established in a larger study.

Iatrogenic cardiac tamponade during pregnancy

A 26-year-old primigravida who presented to us with threatened preterm labour which was suppressed successfully with sulindac, was found to have a pericardial effusion. Pericardiocentesis was performed because of evidence of right ventricular compression. However, it was complicated by inadvertent puncture of the left ventricle causing cardiac tamponade, and hypovolaemic shock shortly afterwards. An emergency pericardiotomy was performed to rescue the patient.

A randomised double blind comparison of Syntometrine and Syntocinon in the management of the third stage of labour

OBJECTIVE

To compare the effect of intramuscular Syntometrine and Syntocinon in the management of the third stage of labour.

DESIGN

A randomised double blind prospective study.

SETTING

Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Hong Kong.

SUBJECTS

One thousand consecutive patients with singleton pregnancy and vaginal delivery in February and March 1993.

RESULTS

The use of Syntometrine in the management of the third stage not only reduced the blood loss after delivery but was associated with a 40% reduction in the risk of postpartum haemorrhage (odds ratio 0.60; 95% CI 0.21-0.88), and the need for repeat oxytocic injections (odds ratio of 0.63; 95% CI 0.44-0.89). The two drugs did not differ in their effect on the duration of the third stage. However, the incidence of manual removal of the placenta was higher when Syntometrine was used (odds ratio 3.7; 95% CI 1.03-12.5), although the overall incidence remained low. Side effects from both drugs, such as nausea, vomiting, headache and hypertension, were uncommon.

CONCLUSION

Intramuscular Syntometrine is a better choice than Syntocinon in the management of the third stage of labour.