Secondary cytoreductive surgery for recurrent platinum-sensitive ovarian cancer

Objective

To determine the risks and benefits of secondary cytoreductive surgery for recurrent platinum-sensitive ovarian cancer.

Methods

Data were obtained retrospectively for all women with recurrent platinum-sensitive epithelial ovarian cancer who underwent a second debulking operation between 1998 and 2008 at the University of Texas Southwestern Medical Center. Survival analysis and comparisons were performed using the Kaplan-Meier method, log-rank test, and Cox multivariate proportional hazards model.

Results

Optimal secondary cytoreductive surgery (< 5 mm of residual disease) was achieved in 32 of 40 patients (80%). Nine women (23%) developed major complications. Two variables, residual disease of less than 5 mm vs 5 mm or greater (median 63 months vs 11 months; P = 0.003); and less than 5 vs 5 or more sites of disease relapse (median 63 months vs 22 months; P = 0.009), were independently associated with survival and retained prognostic significance on multivariate analysis.

Conclusions

Optimal secondary cytoreductive surgery was associated with a survival advantage and acceptable risks.     

Uterosacral-cardinal ligament stretching prior to vaginal hysterectomy increases uterine descent: a novel technique

Objective

To examine the effect of uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy on uterine descent.

Study design

A prospective trial of 25 consecutive women undergoing vaginal hysterectomy. Pre-operative, apical, anterior and posterior wall POP-Q measurements were recorded for each patient before and after uterosacral-cardinal ligament complex stretching during general anesthesia.

Results

Uterosacral-cardinal ligament complex stretching yielded a significant increase in mean stage of uterine and anterior wall descent (2.6 ± 0.6 vs. 3.2 ± 0.6 cm, p < 0.001, and 2.5 ± 0.8 vs. 2.9 ± 0.8 cm, respectively, p < 0.004). There was no significant change in posterior wall prolapse measurements (1.3 ± 0.7 vs. 1.4 ± 0.8 cm, p = 0.05).

Conclusion

Uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy increase uterine descent.     

Polycystic ovary syndrome and increased polyp numbers as risk factors for malignant transformation of endometrial polyps in premenopausal women

Objective

To determine the pre-malignant and malignant potential of endometrial polyps and to assess whether different clinical parameters are associated with malignancy in the polyps of premenopausal women.

Methods

The clinical records of operative office hysteroscopic and resectoscopic procedures for endometrial polyps in 417 premenopausal women who attended Baskent University were examined over a retrospective period of 30 months. Only premenopausal patients were included in the study.

Results

In 97.8% of women, histology showed benign endometrial pathology. In 2.2% of women, pre-malignant or malignant conditions were found in the polyp. Polycystic ovary syndrome (PCOS) and the presence of 2 or more polyps were associated with significant pre-malignant or malignant changes.

Conclusion

The presence of irregular vaginal bleeding was not a predictor of malignancy in the polyp. Premenopausal women with PCOS and those with 2 or more polyps had an increased prevalence of polyp malignancy. These groups of patients, whether symptomatic or not, should be evaluated by hysteroscopic resection of the polyps.     

Effect of cervical mucus aspiration before intrauterine insemination

Objective

To determine whether cervical mucus aspiration before intrauterine insemination (IUI) has any effect on clinical pregnancy rates.

Method

The outcomes of 186 IUI cycles in 95 consecutive patients in whom mucus was aspired prior to IUI were compared retrospectively with those of 1057 IUI cycles in 505 women.

Results

The pregnancy rate was 15.1% (28 pregnancies for 186 cycles) in the cervical mucus aspiration group and 9.9% (105 pregnancies for 1057 cycles) in the control group (P = 0.05). Mucus aspiration led to significantly increased pregnancy rates for women with unexplained infertility (24% in the aspiration group vs 9.5% in the control group; P = 0.04).

Conclusion

Cervical mucus aspiration before IUI might improve clinical pregnancy rates by yet-to-be-defined mechanisms.     

Clinical significance of obstructive defecatory symptoms in women with pelvic organ prolapse

Objective

To determine whether the presence of obstructive defecatory symptoms is associated with the site and severity of pelvic organ prolapse. Methods: A cross-sectional study was performed of women with pelvic organ prolapse of grade 2 or greater who had completed a validated questionnaire that surveyed pelvic floor symptoms. Associations between patient characteristics, site and severity of prolapse, and obstructive bowel symptoms were investigated.

Results

Among 260 women with pelvic organ prolapse, women with posterior vaginal wall prolapse were more likely to report obstructive symptoms, such as incomplete emptying (41% vs 21%, P = 0.003), straining at defecation (39% vs 19%, P = 0.002), and splinting with defecation (36% vs 14%, P < 0.001) compared with women without posterior vaginal wall prolapse. There was no significant association between any bowel symptom and increasing severity of prolapse.

Conclusions

Obstructive bowel symptoms are significantly associated with the presence of posterior vaginal wall prolapse, but not with the severity of prolapse.     

Metabolic and endocrine effects of metformin and metformin plus cyclic medroxyprogesterone acetate in women with polycystic ovary syndrome

Objective

To evaluate the metabolic and endocrine effects of treatment with cyclic medroxyprogesterone acetate (MPA) plus metformin compared with metformin alone in women with PCOS.

Methods

In this prospective randomized study of women with PCOS, 20 women received 850 mg of metformin twice a day, and 20 women received 850 mg of metformin plus 5 mg of MPA twice a day. Body mass index, hormonal and lipid blood profiles, homocysteine blood level, and insulin sensitivities assessed by homeostasis model assessment (HOMA) were recorded at baseline and at 3 months.

Results

Total cholesterol levels decreased in the metformin plus MPA group (P = 0.002) but did not change significantly in the metformin group (P = 0.159). While homocysteine levels remained unchanged in the metformin plus MPA group, they increased significantly in the metformin group (P = 0.002).

Conclusion

There were no adverse effects of short-term cyclic MPA plus metformin treatment on metabolic parameters or insulin resistance in patients with PCOS over a 3-month treatment period.     

The risk of caesarean section in obese women analysed by parity

Objective

This study looked at the association between caesarean section (CS) and Body Mass Index (BMI) in primigravidas compared with multigravidas.

Study design

We enrolled women at their convenience, in the first trimester after an ultrasound examination confirmed an ongoing pregnancy. Weight and height were measured digitally and BMI calculated. After delivery, clinical details were again collected from the Hospital's computerised database.

Results

Of the 2000 women enrolled, there were 50.4% (n = 1008) primigravidas and 49.6% (n = 992) multigravidas. Of the 2000 8.5% were delivered by elective CS and 13.4% were delivered by emergency CS giving an overall rate of 21.9%. The overall CS rate was 30.1% in obese women compared with 19.2% in the normal BMI category (p < 0.001). In primigravidas the increase in CS rate in obese women was due to an increase in emergency CS (p < 0.005) and in multigravidas the increase was due to an increase in elective CS (p < 0.01). In obese primigravidas 20.6% had an emergency section for fetal distress. In obese multigravidas 17.2% had a repeat elective CS.

Conclusion

The influence of maternal obesity on the increase in CS rates is different in primigravidas compared with multigravidas.     

Predictors of resolution of complex atypical hyperplasia or grade 1 endometrial adenocarcinoma in premenopausal women treated with progestin therapy

Objective

To identify clinical and pathologic predictors of response to progestin treatment in premenopausal women with complex atypical hyperplasia (CAH) and Grade 1 endometrial adenocarcinoma (Grade 1 EA).

Methods

Forty premenopausal patients with Grade 1 EA or CAH who underwent progestin therapy for a minimum of 8 weeks were retrospectively identified. Patient characteristics and histopathologic features of pretreatment and first follow-up endometrial specimens were evaluated as predictors of resolution, defined as absence of hyperplasia or carcinoma.

Results

Kaplan-Meier analysis indicated 63% resolution at 18 months of follow-up. Multivariate classification analysis showed that resolution rates were higher in individuals with a low pre-treatment qualitative abnormal architecture score and a BMI < 35 (Standardized Resolution Ratio (SRR) = 1.48, p = 0.03). The diagnosis of benign endometrium or simple hyperplasia on the first follow-up specimen was highly predictive of resolution (SRR = 2.25, p = 0.002). Resolution rates were lower among subjects with a high pre-treatment qualitative abnormal architecture score (SRR = 0.37, p < 0.03) and lowest in subjects whose first follow-up specimen showed persistent complexity, atypia, or carcinoma with adjacent stromal decidualization (SRR = 0.24, p = 0.002).

Conclusions

Clinical and pathologic parameters can predict response to progestin therapy in premenopausal women with CAH and Grade 1 EA. A low likelihood of resolution is predicted by an unfavorable pre-treatment architectural score and lack of pathological response in the first specimen, despite adjacent stromal decidualization.     

Association of biochemical hyperandrogenism with type 2 diabetes and obesity in Chinese women with polycystic ovary syndrome

Objective

To evaluate the effect of hyperandrogenism on metabolic disorders among patients with polycystic ovary syndrome (PCOS) diagnosed using the Rotterdam criteria.

Methods

A retrospective analysis of the clinical records of 883 women with PCOS and 717 premenopausal controls identified from the general population.

Results

A total of 686 (77.7%) patients were classified with PCOS based on National Institutes of Health (NIH) criteria, and 164 out of 197 (83.2%) additional patients had no hyperandrogenism. Women with normal androgen levels exhibited lower frequencies of obesity, type 2 diabetes, acanthosis nigricans, genetic history of diabetes, and elevated Matsuda index compared with hyperandrogenic patients. Hyperandrogenemia, but not hirsutism, was independently associated with the risk for type 2 diabetes (odds ratio [OR] 5.7; P = 0.028) and obesity (OR 1.7; P = 0.005) among Chinese patients with PCOS.

Conclusions

Hyperandrogenemia is associated with type 2 diabetes and obesity in Chinese women with PCOS and should be considered at first-line management of hyperandrogenism and infertility due to PCOS.     

The administration of metformin during pregnancy reduces polycystic ovary syndrome related gestational complications

Objectives

To prospectively evaluate the safety of metformin administration during pregnancy in a group of PCOS patients by assessing its effect on the prevalence of gestational complications and neonatal outcome.

Study design

Our prospective, single centre study included 98 pregnant women with PCOS treated with metformin throughout pregnancy and 110 normal pregnant controls. All PCOS patients were hyperinsulinemic and received metformin (1700-3000 mg/day) before conception and until 37 weeks’ gestation.

Results

Metformin treatment in the pregnant PCOS patients resulted in significant decrease in miscarriage rate (9.1% vs 20%; p < 0.05), gestational diabetes (0 vs 13%; p < 0.005), and gestational hypertension (0 vs 11%; p < 0.005) and a non-significant decrease in pre-eclampsia (0 vs 3%; p = .24), compared to the control group. Mean neonatal Apgar score, weight and length were comparable between the two groups.

Conclusions

Continuing metformin therapy throughout pregnancy resulted in significant reduction in pregnancy complications with concomitant improved neonatal outcome, with no serious deleterious side effects.     

Pentraxin 3 in amniotic fluid as a marker of intra-amniotic inflammation in women with preterm premature rupture of membranes

Objective

To determine whether amniotic fluid levels of pentraxin 3 (PTX3) are of value in the prenatal diagnosis of acute histological chorioamnionitis in preterm premature rupture of membranes (PPROM).

Methods

Forty pregnant women with PPROM between 24 and 36 weeks of pregnancy without (n = 21) and with (n = 19) histological chorioamnionitis (PPROM group) and 42 women between 16 and 20 weeks of pregnancy (midtrimester group) were included in the study. We compared amniotic fluid PTX3 levels in the PPROM group with versus without histological chorioamnionitis, and between the PPROM and the midtrimester groups using nonparametric tests (Mann-Whitney test), given the non-normal distribution of the analyte.

Results

Patients with histological chorioamnionitis had a significantly higher median amniotic fluid PTX3 concentration than patients without the histological signs of chorioamnionitis (3.69 ng/mL [0.51-106.8] versus 0.8 ng/mL [0.36-121.0]; P = 0.015). Patients in the PPROM group reached a significantly higher median amniotic fluid concentration of PTX3 compared with those in the midtrimester group (1.0 ng/mL [0.36-121.0] versus 0.67 ng/mL [0.4-2.8]; P = 0.007).

Conclusion

Histological chorioamnionitis is associated with a significant increase of amniotic fluid pentraxin 3 levels. Amniotic fluid pentraxin 3 appears to be a marker of intra-amniotic inflammation.     

Thyroid function in the third trimester of pregnancy and after delivery in an area of adequate iodine intake

Objective

To establish whether the higher thyroid stimulating hormone (TSH) levels and lower levels of the 2 free thyroid hormones noted toward the end of pregnancy are in relation with iodine supply.

Methods

We compared these hormones’ levels in the third trimester of pregnancy and 4 months after delivery in 116 consecutive women without thyroid disease and otherwise healthy. The study was conducted in Slovenia, an iodine-sufficient area. The Mann-Whitney test, the Kruskal-Wallis rank test, and Spearman analysis were used for statistical analysis.

Results

In the third trimester TSH was significantly higher and both free thyroid hormones were significantly lower than after delivery (P = 0.003 and P < 0.001), but the free thyroxine to free triiodothyronine ratios in the third trimester and 4 months after delivery did not significantly differ. Urinary iodine concentration (UIC) was significantly higher during pregnancy than after delivery (P = 0.044). We found no significant correlations between UIC and TSH or between UIC and both free thyroid hormones during pregnancy or after delivery.

Conclusion

The decrease of both free thyroid hormones in the third trimester of pregnancy is most likely due to reasons that are not related to iodine supply.     

Prevalence of HPV infection by cytologic diagnosis and HPV DNA extraction and prevalence of the HPV genotypes detected in urban Turkish women

Objective

To evaluate the prevalence of the different human papillomavirus (HPV) genotypes in women seen at 2 Marmara University Hospital gynecologic outpatient clinics in Istanbul, Turkey.

Methods

From May 1 through August 31, 2008, specimens were obtained from 500 women for cytologic evaluation by the split-sample method. HPV types were identified by PCR and hybridization using a microarray that identifies 35 types.

Results

The overall prevalence of HPV was 16.5%, multiple genotypes were found in 35.8% of the infected women, and 75% of the types were high risk; 79% of the infected women had negative cytologic results, 3.7% had ASCUS, 10% had LSIL, and 6% had HSIL; the highest infection rates were 36% for women aged 20 to 30 years and 35% for those aged 31 to 40 years; 65.2% of the infected women were university graduates; and 34% were single.

Conclusion

HPV infection involved numerous types, most of them high risk, even in women with negative cytology results. Further studies with larger groups will provide more information on HPV distribution in Turkey, which may guide the development of local vaccination programs.     

Influence of LH and high-density lipoprotein cholesterol (HDL-C) on metformin response in women with polycystic ovary syndrome

Objective

To search for predictors of metformin response in women with polycystic ovary syndrome (PCOS) through a detailed analysis of clinical and laboratory parameters.

Study design

We designed a prospective study to investigate clinical and laboratory parameters to search for predictors of metformin response in women with PCOS. A total of 53 PCOS patients were given metformin 850 mg twice a day for 6 months, after which patients were classified as responders or non-responders. Parameters analyzed for comparison between the two groups were: plasma fasting insulin glucose/insulin ratio; oral glucose tolerance test (OGTT) with insulin (120 min); HOMA and QUICKI tests; total cholesterol and fractions, triglycerides; LH, FSH, estradiol, progesterone, testosterone, androstenedione, 17-OH progesterone, and DHEAS.

Results

From all patients, 30 (56.6%) were responders and 23 (43.3%) were non-responders. Multinomial analysis showed that the positive response to metformin was associated with higher levels of basal LH (p = 0.038) and lower levels of high-density lipoprotein cholesterol (HDL-C) (p = 0.015).

Conclusion

In weight-matched PCOS subjects, laboratory markers might predict the metformin response. Higher levels of basal LH and lower levels of HDL-C are correlated with a positive response to metformin treatment in PCOS subjects.     

A qualitative study of the information needs of premenopausal women with breast cancer in terms of contraception, sexuality, early menopause, and fertility

Objectives

To evaluate the information needed and received by premenopausal Turkish women with breast cancer regarding contraception, early menopause, infertility, fertility preservation, and sexuality.

Methods

A qualitative exploratory methodology was used whereby an interviewer met on 2 occasions with women with breast cancer. The participants—who were recruited from the oncology clinic of Adnan Menderes University Hospital, Ayd?n, Turkey—were premenopausal, younger than 50 years of age, and had been diagnosed with breast cancer within the past year. Raw data were sorted under themes.

Results

Premenopausal women with breast cancer received insufficient counseling on contraception, early menopause, infertility, fertility preservation, and sexuality, despite their willingness to receive information.

Conclusion

In Turkey, premenopausal women with breast cancer should receive comprehensive information and counseling from oncology staff on the issues studied. The present study may guide future research on this topic.     

Postpartum evaluation of stress urinary incontinence among primiparas

Objective

To assess the prevalence of postpartum stress urinary incontinence (SUI); the relationship between postpartum SUI and mode of delivery; and the association between SUI and other obstetric factors.

Method

In this prospective study, 1000 primiparas with no history of UI were recruited and followed up for 4 months after delivery. The χ² and Fisher's Exact tests were used to calculate the effects of the nominal variables.

Result

The prevalence of postpartum SUI was 14.1%, and the mode of delivery was significantly associated with SUI. The prevalence rates were 15.9% after vaginal delivery, 10.7% after elective cesarean section (CS), and 25% after CS performed for obstructed labor. The prevalence of postpartum SUI was similar following spontaneous vaginal delivery and CS performed for obstructed labor (P = .21). Meanwhile, elective CS with no trial of labor was found to be associated with a significantly lower prevalence of postpartum SUI (P = .01; χ² = 12.42). A maternal body mass index greater than 30 before pregnancy and fetal weight higher than 3000 g appeared to be associated with an increased rate of SUI (P = .001; χ² = 17.6 and P = .000; χ² = 22.5, respectively).

Conclusion

Elective CS significantly reduced the rate of postpartum SUI.     

Wide genital hiatus is a risk factor for recurrence following anterior vaginal repair

Objective

To determine if a wide genital hiatus is a risk factor for recurrence of anterior vaginal wall prolapse following anterior vaginal repair.

Methods

A retrospective cohort study was performed on patients who had undergone an anterior vaginal wall repair. Patients were placed into 1 of 2 groups: wide genital hiatus (≥ 5 cm) or normal genital hiatus (< 5 cm). The wide genital hiatus group (n = 35) was compared with the normal genital hiatus group (n = 30) for surgical failure.

Results

There were no significant differences between the 2 groups in demographic data, additional operative procedures, or apical suspensions. The rate of postoperative anterior vaginal wall prolapse was greater in patients with a wide genital hiatus compared with those with a normal genital hiatus (34.3% vs 10% respectively; odds ratio 4.7 [95% confidence interval, 1.0-24.1]; P = 0.02).

Conclusion

The rate of recurrent anterior vaginal wall prolapse is higher in patients with a wide genital hiatus.     

Goserelin versus leuprolide before hysterectomy for uterine fibroids

Objective

To compare goserelin and leuprolide given before hysterectomy for symptomatic large fibroid uteri.

Methods

A randomized study of 66 premenopausal women with fibroid uteri at least 14 weeks of gestation in a gravid uterus. Women were randomized to receive either subcutaneous depot 3.6 mg goserelin or 3.75 mg leuprolide every 4 weeks for a total of 3 doses. Hysterectomy was performed within 1 month of the last dose.

Results

A total of 34 women randomized to the goserelin group and 31 women to the leuprolide group were available for analysis. Preoperative hemoglobin level (P = 0.89), operative blood loss (P = 0.72), and operating time (P = 0.39) were not different between the 2 groups. Postoperative hemoglobin was higher in the leuprolide group (P = 0.003), but blood transfusion requirement was not different between the groups (P = 1.0). Other outcomes and side effects of the drugs were similar.

Conclusions

Goserelin and leuprolide administered before hysterectomy for uterine fibroids have similar perioperative outcomes.     

Carcinosarcoma of the ovary: a case-control study

Introduction

Carcinosarcoma of the ovary is a rare tumor with a grim prognosis. Chemotherapy for these tumors is chosen according to guidelines established for epithelial ovarian cancer (EOC). The purpose of this study is to compare response to chemotherapy and survival in patients with advanced stage carcinosarcoma of the ovary.

Methods

We identified women with advanced carcinosarcoma of the ovary who underwent first-line platinum and taxane-based chemotherapy. Each case was matched to two women with serous EOC. Cases and controls were matched by age, stage, and year of diagnosis. The Kaplan-Meier method was used to generate overall survival (OS) data. Factors predictive of outcome were compared using the log-rank test and Cox proportional hazards model.

Results

Fifty women treated with first line platinum and taxane-based chemotherapy had advanced carcinosarcoma of the ovary and were selected as cases. The response rates to chemotherapy for cases and controls were 62% and 83% (P = 0.03), respectively. Median progression-free survival was 11 months (95% CI, 8 to 14 months) versus 16 months (95% CI, 12 to 21 months; P = 0.02) and median overall survival was 24 months (95% CI, 18 to 29 months) versus 41 months (95% CI, 33 to 49 months; P = 0.002) for cases and controls, respectively.

Conclusion

Patients with advanced carcinosarcoma of the ovary have a poorer response to platinum and taxane-based first-line chemotherapy and worse survival, compared to patients with serous EOC. Aggressive surgical treatment may play an important role. However, other alternative systemic therapeutic approaches should be sought for patients with carcinosarcoma of the ovary.     

Aurora-A overexpression and aneuploidy predict poor outcome in serous ovarian carcinoma

Objective

Aurora-A is a potential oncogene and therapeutic target in ovarian carcinoma. It is involved in mitotic events and overexpression leads to centrosome amplification and chromosomal instability. The objective of this study was to evaluate the clinical significance of Aurora-A and DNA ploidy in serous ovarian carcinoma.

Methods

Serous ovarian carcinomas were analysed for Aurora-A protein by immunohistochemistry (n = 592), Aurora-A copy number by CISH (n = 169), Aurora-A mRNA by real-time PCR (n = 158) and DNA ploidy by flowcytometry (n = 440).

Results

Overexpression of Aurora-A was found in 27% of the tumors, cytoplasmic overexpression in 11% and nuclear in 17%. The cytoplasmic and nuclear overexpression were nearly mutually exclusive. Both cytoplasmic and nuclear overexpression were associated with shorter survival, high grade, high proliferation index and aberrant p53. Interestingly, only cytoplasmic expression was associated with aneuploidy and expression of phosphorylated Aurora-A. DNA ploidy was associated with poor patient outcome as well as aggressive clinicopathological parameters. In multivariate analysis, Aurora-A overexpression appeared as an independent prognostic factor for disease-free survival, together with grade, stage and ploidy.

Conclusions

Aurora-A protein expression is strongly linked with poor patient outcome and aggressive disease characteristics, which makes Aurora-A a promising biomarker and a potential therapeutic target in ovarian carcinoma. Cytoplasmic and nuclear Aurora-A protein may have different functions. DNA aneuploidy is a strong predictor of poor prognosis in serous ovarian carcinoma.