Diameter of dominant leiomyoma is a possible determinant to predict coexistent endometriosis

Objective

To identify the frequency and assess risk factors for unexpected discovery of peritoneal endometriotic implants in patients who underwent myomectomy or hysterectomy for symptomatic uterine leiomyomas.

Study design

We retrospectively collected medical records of 829 patients with symptomatic leiomyomas in The University of Tokyo Hospital. All the patients underwent abdominal or laparoscopic surgeries between January 2001 and December 2010 and the presence or absence of endometriosis during surgery was analyzed. Possible determinant to predict coexistent endometriosis was statistically investigated.

Results

In total, 105 leiomyoma cases (12.7% in 829 patients) were diagnosed with endometriosis. Patients with small dominant leiomyomas were significantly complicated by peritoneal endometriotic implants (small leiomyomas were classified as <8 cm). The patients with both diagnoses were more likely to be infertile and at age 39 years or younger than those with leiomyoma alone.

Conclusions

Women undergoing myomectomy or hysterectomy with both endometriosis and leiomyomas have several different clinical features compared with women with only leiomyomas. The size of largest leiomyoma may provide an important clue for coexistent endometriosis. Women with substantial infertility despite a smaller leiomyomas burden may be more likely to have a surgical indication for concomitant endometriosis.     

Clinical and pathological characteristics,pathological reevaluation and recurrence patterns of cellular leiomyomas: a retrospective study in 76 patients

Objectives

To analyze clinical and pathologic features as well as recurrence patterns of cellular leiomyomas (CL) in women who underwent surgical therapy for symptomatic disease.

Study design

This retrospective study was conducted at the Department of Obstetrics and Gynecology, University Women's Clinic, Tuebingen, Germany. We identified all women who had CL on final diagnosis after surgery between January 1, 2000, and December 31, 2010.

Results

Our study sample comprised 76 women with a diagnosis of CL. A single uterine mass was present in 51.3% of the cases; in uteri with both CL and uterine leiomyomas (UL), the CL constituted the largest uterine mass in 20 of 21 (95.2%) cases. Additionally, in 98% of the uteri, CL were either the largest or the only uterine mass. Five women (6.6%; 5/76) had reported surgical procedures for symptomatic leiomyoma before the index surgery in our analysis. Three women underwent hysteroscopic resection of the leiomyomas and 2 women underwent abdominal myomectomy. Mean time to recurrence was 14.0 months (median 6.0; range, 4.0–52.0). Over the follow-up period, 6 women who underwent uterus-conserving surgery (12.0%; 6/50) with CL had leiomyoma recurrence. Five women underwent abdominal myomectomy and one underwent hysteroscopic resection of the CL. One patient had recurrence of a CL 43 months after abdominal myomectomy and underwent vaginal hysterectomy; the other five women had recurrences of UL. Mean time to recurrence was 28.6 months (median 12.5; range, 4.0–83.0).

Conclusions

Recurrence rates of CL in our study group resemble recurrence rates of UL.     

Does vascular endothelial growth factor participate in uterine myoma growth stimulation?

Objective

Peptide growth factors play a role in the rebuilding of extracellular matrix in the course of leiomyoma growth, and exert a regulative effect on the cell only when they bind with a specific membrane receptor and transmit a signal into the cell. A high content of certain peptide growth factors and their receptors in leiomyoma suggests that in the course of the tumour growth hyperstimulation of cells takes place. A combined action of various peptide growth factors causes an amplification of signal paths in cells, inducing gene expression of proteins responsible for cell division and changes of metabolism. We therefore decided to evaluate the amounts and expression of VEGF, their receptor and mRNA levels.

Study design

Studies were performed on human myometrium and uterine leiomyomas of various weights (small: i.e. less than 10 g, and large: i.e. more than 100 g). Expression and content of VEGF-A, D and VEGF R-1, R-2 were analysed with Western blot and ELISA methods, respectively. The RT-PCR method was used to determine VEGF mRNA levels.

Results

Our immunoblotting studies and immunoenzymatic assay, as well as RT-PCR technique, did not detect significant differences in the expression of VEGFs and their receptors in control myometrium and in uterine leiomyomas.

Conclusion

The increase in the amount of some peptide growth factors, especially FGFs and IGF-I, in large leiomyomas without any change in VEGF content means a decrease in the proportional relationship of the latter to other growth factors. Stimulation of extracellular matrix formation seems stronger than angiogenesis during myoma growth.     

Uterine fibroid pseudocapsule studied by transmission electron microscopy

Objective

The fibroid pseudocapsule is a structure which surrounds the uterine fibroid, separates it from the uterine tissue and contains a vascular network rich in neurotransmitters like a neurovascular bundle. The authors examined the composition of the fibroid pseudocapsule using electron microscopy.

Study design

Twenty non-pregnant patients were submitted to laparoscopic myomectomy by the intracapsular method and samples of the removed pseudocapsules were analyzed using transmission electron microscopy.

Results

At the ultrastructural level the pseudocapsule cells have the features of smooth muscle cells similar to the myometrium. So, the pseudocapsules are part of the myometrium which compresses the leiomyoma.

Conclusion

This ultrastructural feature suggests that when removing fibroids their pseudocapsules should be preserved. This study confirms preliminary evidence that pseudocapsules contain neuropeptides together with their related fibers, as a neurovascular bundle. The surgeon's behavior should be directed to carefully control and spare this muscular surrounding tissue during fibroid excision, in order to preserve the myometrium as much as possible.     

Evaluation of prognostic factors and treatment outcomes in uterine carcinosarcoma

Objective

The aims of this study were to determine the prognostic factors, survival outcomes and response to adjuvant therapy in women with uterine carcinosarcoma treated in a single institution.

Study design

This is a cohort study of women diagnosed with carcinosarcoma and treated at the Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, UK. The medical records of all patients diagnosed with carcinosarcoma between January 1960 and July 2002 were reviewed.

Results

A total of 93 women were identified during this period. The median age was 67 years. The most common presentation was abnormal vaginal bleeding, occurring in 85%, followed by pelvic mass in 45%, and abdominal pain in 38%. At surgery there was extra-uterine spread in 54% of women. The median follow-up was 33 months (range 4–146 months). Adjuvant therapy was not associated with survival advantage. Recurrence was diagnosed in 55 patients (59%) and the overall 5-year survival for all stages was 33%. On multivariate analysis depth of myometrial invasion, stage and pelvic nodes metastasis were associated with poor survival.

Conclusion

The poor outcome for these patients may reflect the aggressive nature of carcinosarcoma and that at the time of presentation more than 50% have extra-uterine disease, which was associated with significant poorer survival. Systemic adjuvant therapy has not been associated with significant improvement in the outcome. More studies are needed to better define the appropriate treatment for this rare cancer.     

Robotic Resection of a Symptomatic Parasitic Leiomyoma From the Obturator Fossa

Study Objective

To demonstrate a technique for robotically resecting a parasitic leiomyoma from the obturator fossa.

Lymphatic drainage pathways from the cervix uteri: Implications for radical hysterectomy?

Objective

Radical hysterectomy with pelvic lymphadenectomy is the treatment of choice for early-stage cervical cancer. Wertheim's original technique has been often modified, mainly in the extent of parametrectomy. Okabayashi's technique is considered as the most radical variant regarding removal of the ventral parametrium and paracolpal tissues. Surgical outcome concerning recurrence and survival is good, but morbidity is high due to autonomic nerve damage. While the autonomic network has been studied extensively, the lymphatic system is less understood. This study describes the lymphatic drainage pathways of the cervix uteri and specifically the presence of lymphatics in the vesico-uterine ligament (VUL).

Methods

A developmental series of 10 human female fetal pelves was studied. Paraffin embedded blocks were sliced in transverse sections of 8 or 10 μm. Analysis was performed by staining with antibodies against LYVE-1 (lymphatic endothelium), S100 (Schwann cells), alpha-Smooth Muscle Actin (smooth muscle cells) and CD68 (macrophages). The results were three-dimensionally represented.

Results

Two major pathways drained the cervix uteri: a supra-ureteral pathway, running in the cardinal ligament superior to the ureter, and a dorsal pathway, running in the utero-sacral ligament towards the rectal pillars. No lymph vessels draining the cervix uteri were detected in the VUL. In the paracolpal parametrium lymph vessels draining the upper vagina fused with those from the bladder.

Conclusions

The VUL does not contain lymphatics from the cervix uteri. Hence, the favorable survival outcomes of the Okabayashi technique cannot be explained by radical removal of lymphatic pathways in the ventrocaudal parametrium.     

A comparison of uterine peristalsis in women with normal uteri and uterine leiomyoma by cine magnetic resonance imaging

Objective

The non-pregnant uterus shows wave-like activity (uterine peristalsis). This pilot study was intended to determine: (1) whether uterine peristalsis during the menstrual cycle is detectable by cine magnetic resonance imaging (MRI); (2) the effects of leiomyoma on uterine peristalsis.

Study design

Mid-sagittal MRI was performed sequentially with T2-weighted single-shot fast spin-echo (SSFSE) in 3 normal ovulatory volunteers and 19 premenopausal women with uterine leiomyoma. Direction and frequency of movement of the junctional zone were evaluated using a cine mode display.

Results

Junctional zone movement was identified in all subjects. Direction of uterine peristalsis in normal volunteers was fundus-to-cervix during menstruation, cervix-to-fundus during the periovulatory phase, and isthmical during the mid- and late-luteal phases. Abnormal peristaltic patterns were detected in three of five patients with uterine leiomyoma during menstruation and in the mid-luteal phase of the cycle, respectively.

Conclusion

Cine MRI is a novel method for evaluation of uterine peristalsis. Results of this pilot study suggest that abnormal uterine peristalsis during menstruation and the mid-luteal phase might be one of the causes of hypermenorrhea and infertility associated with uterine leiomyoma.     

Leiomyoma pseudocapsule after pre-surgical treatment with gonadotropin-releasing hormone agonists: Relationship between clinical features and immunohistochemical changes

Objective

To evaluate if pre-operative GnRH-a modify uterine leiomyoma pseudocapsule and the possible clinical effects of these changes.

Study design

The study was performed at the University Federico II of Naples on 33 premenopausal patients submitted to laparotomic myomectomy after treatment with triptorelin depot. 29 untreated patients formed the control group. The operating time, the intraoperative bleeding and the prompt identification of the cleavage plan between myoma and myometrium were evaluated. The pseudocapsule features and the immunoexpression of PCNA and CD34 in this area were studied.

Results

Treated patients showed lower blood loss and not clearly identifiable cleavage plan, but without any significant increase in the operating time. Treated lesions showed less evident border between myoma and myometrium and lower PCNA and CD34 pseudocapsule immunoexpression than untreated ones.

Conclusion

We propose the changes of leiomyoma pseudocapsule as partial explanations of the reported clinical and surgical findings after pre-operative GnRH-a.     

Midwives' use of complementary/alternative treatments

Background

in recent years, several surveys have suggested that many midwives use some form of complementary/alternative therapy (CAT), often without the knowledge of obstetricians.

Objective

to systematically review all surveys of CAT use by midwives.

Search strategy

six electronic databases were searched using text terms and MeSH for CAT and midwifery.

Selection criteria

surveys were included if they reported quantitative data on the prevalence of CAT use by midwives.

Data collection and analysis

full-text articles of all relevant surveys were obtained. Data were extracted according to pre-defined criteria.

Main results

19 surveys met the inclusion criteria. Most were recent and from the USA. Prevalence data varied but were usually high, often close to 100%. Much use of CATs does not seem to be supported by strong evidence for efficacy.

Conclusion

most midwives seem to use CATs. As not all CATs are without risks, the issue should be debated openly.     

Torsion of pedunculated subserous uterine leiomyoma: A rare complication of a common disease

Objective

To evaluate the clinical presentations, diagnosis, management, and outcomes of torsion of the pedunculated subserous uterine leiomyoma.

High expression of cyclooxygenase-2 in uterine fibroids and its correlation with cell proliferation

Objective

To investigate the expression of cyclooxygenase-2 (COX-2) in uterine fibroids and healthy uterine smooth muscle as well as its role in the pathogenesis of uterine fibroids.

Methods

We collected uterine fibroid tissues and their paired adjacent healthy uterine smooth muscle tissues from 30 cases of uterine fibroids. We used immunohistochemistry and quantitative real-time PCR, as well as western blot to detect COX-2 expression. Using the COX-2 inhibitors NS-398 and celecoxib, we observed the response to the inhibitors in the healthy and fibroid smooth muscle cell pairs.

Results

COX-2 was detected by immunohistochemistry in both uterine fibroids and uterine smooth muscle, with higher immunoreactivity in uterine fibroids; the positive index of the smooth muscle cells was 11.90 and the positive index of uterine fibroids cells was 46.50 (P < 0.05). The expression of COX-2 mRNA in uterine fibroids was higher (0.122 ± 0.062) than in normal smooth muscle tissue (0.025 ± 0.009; P < 0.05). Also, the western blot results showed that COX-2 expression was significantly higher in uterine fibroid cases, as compared to the expression in uterine smooth muscle. Immunofluorescence showed that the occurrence of COX-2 was obviously higher in smooth muscle cells of uterine fibroids than in the healthy smooth muscle cells. NS-398 or celecoxib significantly inhibited the proliferation of smooth muscle cells of uterine fibroids, but did not inhibit the proliferation of healthy smooth muscle cells. Accordingly, NS-398 or celecoxib significantly reduced the expression of the downstream metabolite of COX-2, PGE2, in the smooth muscle cells of uterine fibroids, but not in healthy smooth muscle cells.

Conclusion

COX-2 expression in uterine fibroids was significantly higher than in healthy uterine smooth muscles. The inhibition of COX-2 activity significantly reduced the proliferation of smooth muscle cells of the uterine fibroids, suggesting that COX-2 plays an important role in the pathogenesis of uterine fibroids.     

Rectovesical ligament and fusion defect of the uterus with or without obstructed hemivagina and ipsilateral renal agenesis

Objective

The rectovesical ligament is a peritoneal band in women with failure of fusion of the two Müllerian ducts. The aim was to evaluate existence of this abnormal structure in women with dysfused uterus and its possible relations to concomitant vaginal and renal anomalies.

Study design

The study group comprised 47 women with uterine fusion defect (37 didelphic and 10 bicornuate uterus). They had undergone laparoscopy or laparotomy to visualize the pelvic cavity, and imaging for renal evaluation. The rectovesical ligament was present if inspection of the pelvic cavity revealed a broad peritoneal band between the two hemiuteri, attached anteriorly to the bladder and posteriorly to the sigmoid. Presence or absence of the ligament was reported, and concomitant renal and vaginal anomalies were evaluated.

Results

The rectovesical ligament was not visualized in 14 patients with didelphic or complete bicornuate uterus associated with unilateral renal agenesis: of these 13 had a previously treated obstructive longitudinal vaginal septum. A peritoneal band was found in 27 women with didelphic uterus with longitudinal vaginal septum with no obstruction and normal bilateral kidneys. Six women with bicornuate uterus had normal kidneys and an identified rectovesical ligament between the uterine hemicorpora, except for one with partial bicornuate uterus.

Conclusion

The rectovesical ligament is not merely a consequence of the failed fusion of two Müllerian ducts, but its relation to uterine malformation with or without vaginal and renal anomalies indicates some share of this structure in the early development of the urogenital system.     

The value of re-exploration in patients with inadvertently morcellated uterine sarcoma

Objective

To describe the role of immediate re-exploration in patients with inadvertently morcellated uterine leiomyosarcoma (ULMS) and smooth muscle tumors of uncertain malignant potential (STUMP).

Methods

All patients with ULMS/STUMP who were managed or referred to the participating institutions from January 2005 to January 2012 following minimally invasive gynecology surgery with morcellation were detected through the pathology database. The diagnosis was confirmed by gynecologic-pathologists following post-surgery pathology review.

Results

Twenty-one patients with the diagnosis of ULMS (N = 15) and STUMP (N = 6) after morcellation were identified. The median age of occurrence was 46 years (range, 25–58 years). Median follow-up duration was 27 months (range, 1.8–93.1 months). None of the 21 patients had documented evidence of extra-uterine disease at the time of original surgery. Ultimately 12 patients were immediately re-explored to complete staging. The median time to the staging surgery was 33 days (range 15–118 days). Two (28.5%) out of seven patients with presumed stage I ULMS and one (25%) out of four patients with presumed stage I STUMP had significant findings of disseminated intraperitoneal disease detected at immediate surgical re-exploration. One of the 8 patients with confined early ULMS and STUMP at the second surgery had intraperitoneal recurrence, while the remaining 7 patients have had no recurrence and remain disease free.

Conclusion

Surgical re-exploration is likely to show findings of disseminated peritoneal sarcomatosis in a significant number of patients diagnosed with ULMS after a morcellation procedure. Findings from re-exploration can contribute to the knowledge of natural history of morcellated ULMS/STUMP and allow for accurate prognostication.     

Recognition of parametrial invasion, an important landmark when treating cervical cancer

Purpose

Histological assessment of parametrial invasion in uterine cervical cancer is often subjective due to the parametrium being a loosely defined structure without apparent definitive landmarks. This study defines a precise and consistent histological landmark for the parametrium.

Methods

Based on study of cervico-parametrial junctions in 22 type III radical hysterectomy specimens from FIGO stage IB/IIA patients, three candidate histological landmarks were tested for ease in determination and reliability in 66 hysterectomy specimens with FIGO stage IIB tumors. The candidate landmarks were abrupt narrowing point of vascular branches, adipose/loose connective tissue of parametrium, and presence of a distinct smooth muscle layer in the outermost cervical wall.

Results

All uteri had a distinct smooth muscle layer in outermost cervical wall. The layer was compact, circumferential, and continuous with the corpus above and vagina below. It clearly distinguished parametrium from cervical wall, especially when the Masson trichrome stain was used which differentiated fibrous tissue from smooth muscle. Smooth muscle bundles are also present in the parametrium, but course perpendicularly or diagonally to the cervical wall, clearly distinguishable from the circular smooth muscle in the outer wall. With clear histological criteria, concordance rates among three pathologists rose from 55% to 98%.

Conclusion

Clear histological criteria together with the use of Masson trichrome stains to distinguish smooth muscle from fibrous tissue improved concordance rates in identifying parametrial invasion by tumor to near 100%.     

Ultrasound guided core needle biopsy prior to thermo ablative treatment of uterine tumors: first results

Purpose

This study aimed at evaluating the diagnostic yield for core needle biopsies of uterine fibroids before laparoscopic radiofrequency volumetric thermal ablation (RFVTA) with the aim of sonographic imaging. This study was in the context of a randomized, prospective, single-center, longitudinal comparative study in which RFVTA and laparoscopic myomectomy for symptomatic uterine fibroids were compared.

Methods

All patients of the RFVTA-arm received a core needle biopsy under the guidance of an intraoperative laparoscopic ultrasound system. The Tissue samples were observed histologically.

Results

24 patients were included and received in the median 3.17 biopsies (range 2–7). 45.8% of the fibroids were intramural. In 92% uterine leiomyoma was detected, in 4% a cell rich leiomyoma and in 4% a smooth muscle tumor with uncertain malignant potential (STUMP). There were no complications caused by core needle biopsy.

Conclusions

Ultrasound guided core needle biopsy can be used to receive a histological result before treating uterine fibroids with thermo surgical methods like RFVTA.

     

The prevalence of metabolic syndrome in pre- and post-menopausal women attending a tertiary clinic in Turkey

Objective

To determine the prevalence of metabolic syndrome among pre- and post-menopausal women attending a tertiary clinic in Turkey.

Study design

This is a cross-sectional study consisting of one hundred and eighty healthy postmenopausal women and fifty-three healthy premenopausal women evaluated for presence or absence of metabolic syndrome. The t test and Fischer exact test were used for continuous variables and chi-square test was used for categorical variables.

Results

The prevalence of metabolic syndrome among pre-menopausal women was 15.09% according to NCEP criteria. The prevalence of metabolic syndrome among postmenopausal women was 19.44% according to NCEP criteria. There was no significant difference in the prevalence of metabolic syndrome between premenopausal and postmenopausal women in our study population.

Conclusion

There was no significant difference in the prevalence of metabolic syndrome between premenopausal and postmenopausal women attending a tertiary clinic in Turkey.     

A systematic review of the effect of daily panty liner use on the vulvovaginal environment

Background

Whether panty liners predispose to vulvovaginitis is unclear.

Objectives

To clarify the effects of the use of panty liners on the female genital tract.

Search strategy

Several electronic databases (including PubMed and Embase) were searched to identify studies published in English before May 3, 2012.

Selection criteria

Case–control studies, randomized controlled trials, and cohort studies comparing young women who did and did not use panty liners in the intermenstrual period were included.

Data collection and analysis

The quality of the studies was assessed using the Newcastle–Ottawa Scale or the Jadad Scale. Data from suitable studies were extracted for analysis.

Main results

Five articles met the inclusion criteria. Four studies—all of which included only healthy women—found no significant clinical implications arising from the use of panty liners. The fifth study was of women with recurrent candidiasis and showed that use of panty liners was associated with new candidiasis episodes.

Conclusions

The intermenstrual use of panty liners does not seem to have a negative effect on the vulvovaginal area.     

The role of the alcohol dehydrogenase-1 (ADH1) gene in the pathomechanism of uterine leiomyoma

Objective

To describe alterations of gene expression patterns of the alcohol dehydrogenase-1 (ADH1) gene in human leiomyoma tissue. We correlated changes in ADH1 gene activity with several clinical and demographic variables.

Study design

We compared gene expression patterns of ADH1 in leiomyoma tissue samples obtained from 101 hysterectomy cases to 110 cases of hysterectomy performed for non-oncological indications. Gene expression was determined by standard PCR technique. Clinical and epidemiological data were extracted from the computerized database of the 1st Department of Obstetrics and Gynecology of Semmelweis University and from patient questionnaires.

Results

Median age in the leiomyoma group was significantly lower than in the control group (47.5 ± 12.1 vs. 54.7 ± 10.2 years). The incidence of uterine leiomyoma was highest (48%) in the 41–50 year age group. In the obstetric history, cumulative gestational age in the leiomyoma group was significantly lower (105.1 ± 8.2 weeks) than in the control group (127.2 ± 9.1 weeks) and cumulative lactation length was also significantly shorter (2.4 ± 1.2 months vs. 5.1 ± 2.2 months). Surgical treatment of the fibroid was myomectomy in 39.6% of the cases and hysterectomy in 60.4%. The ADH1 gene was significantly underexpressed in the leiomyoma group compared to the control group. There was no significant association between ADH1 gene expression and family history. Within the leiomyoma group, there was no significant difference in ADH1 gene expression between subgroups of cases with different number of fibroid tumors found in the hysterectomy sample, but individual tumor number did correlate with the degree of underexpression of the ADH1 gene. There was no significant association between ADH1 gene expression and cumulative history of lactation.

Conclusions

Underexpression of the ADH1 gene, which influences the transformation of the extracellular matrix, plays a probable role in the etiology of uterine fibroid. Although significant differences in ADH1 gene activity were not seen, a negative correlation between tumor number and degree of ADH1 underexpression was found. Neither family history nor cumulative lactation length was a significant predictor of uterine leiomyoma.