Total Hysteroscopic Treatment of Cervical Pregnancy: The 2-step Technique

Study ObjectiveTo evaluate the efficacy of total surgical treatment of ectopic cervical pregnancy [1] with a minimally invasive approach performed by hysteroscopy [2].DesignStep-by-step video demonstration of the surgical technique using 5 mm hysteroscopy followed by 10 mm resectoscopy.SettingA research and university hospital (IRCCS Burlo Garofolo, Trieste, Italy).PatientsA 41-year-old woman with an ultrasound diagnosis of ectopic cervical pregnancy at 6 + 6 weeks of gestation with a beta human chorionic gonadotropin serum level of 55.951 mUI/mL.InterventionsWe performed a 2-step technique using 5- and 10-mm hysteroscopy (Video 1). During the first step, a 5-mm Bettocchi hysteroscope (Karl Storz, Tuttlingen, Germany) with a 5F bipolar electrode Versapoint Twizzle (Gynecare, Menlo Park, CA) was used. In this phase, the gestational sac was identified in order to confirm the diagnosis and its site of implantation. Later, the gestational sac was opened, and the pregnancy was terminated by cord section under an embryoscopic view (Fig. 1). Finally, a partial vessel coagulation was performed. Afterward, the cervix was dilated, and a resectoscopy was performed. During the second step, a 10-mm Gynecare resectoscope with the bipolar Gynecare Versapoint was used and the gestational sac with the embryo was removed; subsequently, a complete chorial villi resection was achieved. At last, a coagulation of bleeding vessels on the implantation site in order to control the hemostasis was performed (Fig. 2).Measurements and Main ResultsThe study was approved by the institutional review board. The patient was discharged 24 hours after the procedure with an uneventful postoperative course, and the beta human chorionic gonadotropin serum level became negative in 20 days. After 40 days, the ultrasound cervical findings were regular, whereas office hysteroscopy showed the implantation site scar. After 5 months, the patient was pregnant with regular intrauterine implantation (Fig. 3).ConclusionThe total hysteroscopic approach with a 2-step technique offers an effective, safe, and minimally invasive surgical treatment to ectopic cervical pregnancy. Considering that our method, in contrast with the recent literature 3, 4, 5, is performed without any medical treatment, we reported for the first time an approach, that deserve more clinical data to confirm its effectiveness.     

细胞因子IL-2、IL-10与高危型HPV感染和宫颈癌关系的

宫颈上皮内瘤变与宫颈癌关系密切,是宫颈癌癌前病变的统称,高危型人乳头瘤病毒（HR-HPV）感染是宫颈癌和癌前病变的最重要原因。机体通过增强抗感染免疫和抗肿瘤免疫,可使绝大多数妇女清除病毒和病变细胞,防止宫颈癌的发生。免疫细胞及其分泌的细胞因子在其中发挥了重要作用。细胞因子白细胞介素2（IL-2）、IL-10是由免疫原或其他因子刺激免疫细胞后所产生并分泌的低分子质量的可溶性蛋白质,且与受体的亲和力极高,为其发挥生物学效应提供了结构基础。IL-2、IL-10参与机体的细胞免疫和体液免疫,在宫颈病变的发生、发展中起到了重要的调控作用。但其在宫颈癌和癌前病变中发挥的具体作用及作用机制还不明确,尚存争议。本文综合相关文献报道,对细胞因子IL-2、IL-10与HR-HPV感染和宫颈癌的关系进行综述。     

根治性同步放化疗前淋巴结清扫在局部晚期宫颈癌诊疗中的意义

宫颈癌是威胁女性健康的第四大肿瘤,分期主要基于临床检查。2018年10月国际妇产科联盟(FIGO对宫颈癌分期进行了修改,强调了盆腔及腹主动脉旁淋巴结的转移情况。对于根治性同步放化疗的患者,淋巴结转移与放疗肿瘤控制率密切相关。由于腹主动脉旁淋巴结转移的情况决定了是否扩大放疗照射野,放疗对于较大的淋巴结控制效果不理想,因此在根治性放化疗前手术评估淋巴结情况、切除增大的淋巴结,有助于分期及减瘤,进行个体化的治疗。但手术分期为有创操作,存在相关风险,可能推迟放疗起始时间,缺乏前瞻性的随机对照研究,此治疗方式并未被广泛认可。综述根治性放化疗前手术清扫淋巴结分期的相关文献。     

妊娠合并宫颈癌患者继续妊娠的治疗方法研究进展

妊娠合并宫颈癌虽然不常见,但却是临床上棘手的问题,随着妊娠年龄的推迟,未来妊娠合并宫颈癌的发病率会更高。治疗过程中,不仅要考虑患者的健康,同时要兼顾胎儿,若选择继续妊娠要尽量减小对胎儿的不良影响,同时采取措施延缓肿瘤进展,达到与非妊娠宫颈癌患者相同的治疗结局。目前妊娠合并早期宫颈癌继续妊娠可选择的治疗方案有期待治疗、手术治疗和化学药物治疗,手术方式包括广泛性宫颈切除术、单纯宫颈切除术和宫颈锥切术,化疗药物则以铂类为基础,单药化疗或联合化疗。通常ⅠA1期妊娠合并宫颈癌患者可进行期待治疗,ⅠA2~ⅠB1期妊娠合并宫颈癌患者可选择手术治疗,ⅠB1期以上妊娠合并宫颈癌患者推荐新辅助化疗,发现淋巴结转移的患者理论上应停止妊娠。现对妊娠合并宫颈癌继续妊娠的治疗方法的最新研究进展进行总结。     

绝经后女性宫颈癌前病变筛查方法的比较

目的：探讨绝经后女性宫颈细胞学与人乳头瘤病毒（HPV）检测在宫颈癌前病变筛查中的作用。方法：回顾性分析2017年10月—2018年9月于天津市第一中心医院妇科门诊因宫颈筛查异常行阴道镜下活检的113例绝经后女性,分析不同宫颈液基薄层细胞学检查（TCT）及高危型HPV（HR-HPV）结果对宫颈病变检出的情况,比较组织学高度鳞状上皮内病变（HSIL）中宫颈TCT和HPV检测的敏感度、特异度、阳性预测值和阴性预测值。结果：绝经后女性HR-HPV感染分布与宫颈病变分布差异无统计学意义（χ2=0.809,P=0.303）。细胞学高风险组中组织学CINⅡ+的检出率高于低风险组（χ2=29.018,P=0.000）;宫颈活检组织学病变程度与宫颈细胞学严重程度呈弱正相关（r=0.389,P=0.000）。免疫组织化学（免疫组化）阳性组中宫颈高级别病变分布情况高于阴性组,差异有统计学意义（P=0.000）。绝经后女性宫颈TCT和HR-HPV筛查方法的敏感度、特异度、阳性预测值和阴性预测值分别为78.38%、75.00%、60.42%、87.69%和94.59%、10.13%、33.98%、80.00%。结论：宫颈TCT级别高、免疫组化阳性的绝经后女性有宫颈高级别病变的风险,需引起临床医师的关注。     

The feasibility and accuracy of ultrasound assessment in the labor room

Objective: Vaginal examination is widely used to assess the progress of labor; however, it is subjective and poorly reproducible. We aim to assess the feasibility and accuracy of transabdominal and transperineal ultrasound compared to vaginal examination in the assessment of labor and its progress.

Methods: Women were recruited as they presented for assessment of labor to a tertiary inner city maternity service. Paired vaginal and ultrasound assessments were performed in 192 women at 24–42 weeks. Fetal head position was assessed by transabdominal ultrasound defined in relation to the occiput position transformed to a 12-hour clock face; fetal head station defined as head-perineum distance by transperineal ultrasound; cervical dilatation by anterior to posterior cervical rim measurement and caput succedaneum by skin-skull distance on transperineal ultrasound.

Results: Fetal head position was recorded in 99.7% (298/299) of US and 51.5% (154/299) on vaginal examination (p?¹). Bland–Altman analysis showed 95% limits of agreement, ?5.31 to 4.84 clock hours. Head station was recorded in 96.3% (308/320) on vaginal examination (VE) and 95.9% (307/320) on US (p?=?.79¹). Head station and head perineum distance were negatively correlated (Spearman’s r?=??.57, p?p?p?p?Conclusions: We describe comprehensive ultrasound assessments in the labor room that could be translated to the assessment of women in labor. Fetal head position is unreliably determined by vaginal examination and agrees poorly with US. Head perineum distance has a moderate correlation with fetal head station in relation to the ischial spines based on vaginal examination. Cervical dilatation is not reliably assessed by ultrasound except at dilatations of less than 4?cm. Caput is readily quantifiable by ultrasound and its presence is associated with lower fetal head station. Transabdominal and transperineal ultrasound is feasible in the labor room with an accuracy that is generally greater than vaginal examinations.     

ⅠB1期肿瘤直径≥2cm的年轻子宫颈癌：保留生育功能手术“复旦标准”存在的争议和证据

腹式广泛性宫颈切除术（ART）因其宫旁切除根治度广,常被用于肿瘤较大的患者。复旦大学附属肿瘤医院于2011年提出ⅠB1期肿瘤直径≥2cm的子宫颈癌患者接受ART手术的适应证--“复旦标准”。此标准逐步被临床接受,但仍存在争议。文章就ⅠB1期肿瘤直径≥2cm患者ART术后安全性结局、微创广泛性宫颈切除术的应用以及新辅助化疗联合保育手术等问题进行阐述。     

Prevalence of lymph nodes in the parametrium of radical vaginal trachelectomy (RVT) specimen

Objective

In order to evaluate radicality in fertility preserving surgery in women with early invasive cervical cancer we analyzed the parametrium of specimens of patients treated by radical vaginal trachelectomy for the presence of lymph nodes. We tried to identify morphologic factors associated with the presence of parametrial lymph nodes.

Methods

We analyzed surgical specimens of 112 patients who underwent radical trachelectomy between June 2004 and April 2009 at the Department of Gynecologic Oncology at Charité Campus Benjamin Franklin and Campus Mitte. All parametrial tissue was step sectioned and a total of 1878H&;E stained histological sections were analyzed.

Results

In 8 patients (7.1%) a total of 13 lymph nodes were detected. Five lymph nodes in four patients had been primarily detected by routine histological examination. In one of these patients (0.9%) a 2 mm lymph node metastasis was found. Serial sectioning revealed additional seven lymph nodes in four patients. The thickness of parametrium correlated significantly with the presence of lymph nodes in the parametrium.

Conclusion

The presence of small lymph nodes in the parametrium of specimens of radical trachelectomy is low. In patients with early-stage cervical cancer, the incidence of metastasis is less than 1%. Preoperative assessment of the volume of the parametrium may indicate which patients need parametrial resection.     

探讨三维能量多普勒超声在宫颈癌与重度宫颈上皮内瘤变的应用价值

目的评价应用三维能量多普勒超声在重度宫颈上皮内瘤变（CIN3）及宫颈癌的诊断价值。方法对宫颈CIN3患者37例、宫颈癌患者37例（Ⅰ期患者21例,Ⅱ期患者16例）及对照组患者34例（宫颈细胞学正常）进行阴道三维能量多普勒超声检查并测量相关数据（宫颈体积、血管化指数VI、血流指数FI、血管化血流指数VFI及阻力指数RI）,同时对宫颈血管进行分型。结果Ⅰ期、Ⅱ期宫颈癌组宫颈体积、VI、FI、VFI均明显大于CIN3组及对照组,RI明显小于CIN3组及对照组,差异有统计学意义（P〈0.05）;Ⅱ期宫颈癌组宫颈体积、VI、VFI大于Ⅰ期宫颈癌组,有统计学差异（P〈0.05）;CIN3组与对照组比较宫颈体积、VI、FI、VFI及RI均无明显差异（P〉0.05）。血管分型显示,宫颈癌以Ⅲ、Ⅳ型血管为主,CIN3以Ⅱ型血管为主,对照组以Ⅰ型血管为主。结论三维能量多普勒超声能客观地反映宫颈的血供状态,为CIN3及宫颈癌分期提供重要参考信息,有较高的应用价值。     

大蒜素对宫颈癌细胞生长的影响及作用机制

目的探讨大蒜素对体外培养的人宫颈腺癌Hela、鳞癌Cask i细胞半胱氨酸蛋白酶(Caspase)-3、8、9的表达和活性变化对宫颈癌细胞生长的影响及其作用机制。方法2008年1月至2009年1月在河北医科大学附属第二医院通过体外培养的人宫颈腺癌Hela、鳞癌Cask i细胞,MTT法检测大蒜素作用后细胞的生长抑制率,分光光度法和RT-PCR方法分别检测大蒜素对细胞Caspase-3、8、9活性和表达的影响。结果用6.25、12.5、25、50、75、100mg/L的大蒜素处理Hela、Cask i细胞24、48、72h后,随着药物浓度和作用时间的增加,抑制率增高。分光光度法检测大蒜素作用48h后,Hela细胞Caspase-3、8、9活性的OD实验组/OD对照组分别是对照组的2.32、2.26、1.53倍;Cask i细胞是对照组的2.28、1.69、2.08倍(P<0.05)。RT-PCR法检测大蒜素作用12h后,Caspase-3、8、9mRNA基因扩增产物与β-actin基因扩增产物电泳带的吸光度比值明显升高,Hela细胞为对照组的1.92、1.47、1.57倍,Cask i细胞为对照组的1.87、1...