Evaluation of lysophosphatidic acid in vaginal fluid as a biomarker for ovarian cancer: A pilot study.

There remains a need to differentiate between women with a benign or a malignant adnexal mass prior to surgery. As part of an ongoing evaluation of vaginal fluid compounds as potential tumor biomarkers we evaluated whether vaginal lysophosphatidic acid (LPA) predicted the subsequent diagnosis of a malignant adnexal mass. In this prospective pilot study vaginal fluid was obtained from 100 post-menopausal women referred for evaluation of a suspicious adnexal mass and tested for LPA by ELISA. Clinical data and serum CA125 results were obtained only after completion of all laboratory testing. Twenty eight of the women were subsequently diagnosed with an ovarian malignancy, four had a borderline tumor and 68 had a benign diagnosis. Among women with a malignant ovarian mass, 11 (39.3%) had an endometrioid adenocarcinoma +/- Clear cell tumor components, 6 (21.4%) had a high grade serous carcinoma, 3 (10.7%) had a mucinous tumor, 2 each (7.1%) had a malignant mixed mesodermal or a granulosa tumor and 1 each (3.6%) had a Clear cell tumor, a mixed cell tumor, leimyosarcoma or metastatic adrenal tumor. Compared to the median vaginal LPA level in women with benign lesions (1.5 µM), LPA was significantly elevated only in women with endometrioid ovarian cancer (7.9 µM) (p = 0.0137). Of the 6 endometrioid tumors in which values for both plasma CA125 and vaginal LPA were available 5 were positive only for LPA while one was only CA125 positive. Detection of LPA in vaginal secretions may be of value for the noninvasive diagnosis of endometrioid ovarian malignancies in post-menopausal women.

Chlamydia trachomatis screening in preterm labor: A systematic review and meta-analysis.

OBJECTIVE: Spontaneous preterm labor (PTL) is responsible for approximately half of all preterm births with intrauterine infection being an important risk factor for PTL. Chlamydia trachomatis infections have been associated with preterm prelabor rupture of membranes (P-PROM) and preterm birth, but its impact on PTL has not previously been specified. The aim of this study was to evaluate the overall prevalence of Chlamydia trachomatis infections in pregnant women with threatened PTL compared to those not in threatened PTL. STUDY DESIGN: A literature search was performed in electronic databases using combinations of: "Chlamydia", "vaginal cervical infection" and "preterm labor." Cohort and case-controlled studies examining threatened PTL and Chlamydia trachomatis infection demonstrated by culture or NAAT methods at time of diagnosis of threatened labor. The Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines for reporting of observational studies for systematic reviews was used. Bias was assessed with the Methodological Index for Non-Randomized Studies (MINORS) score. Meta-analysis was performed using a random effects model. RESULTS: Four studies were identified. A total of 591 women were included, 309 in the threatened PTL, and 282 controls not in threatened PTL. Women presenting in PTL had an increased risk of screening positive for Chlamydia trachomatis compared to the control group (27/308 (9%) vs 3/282 (1%); OR 7.74, 95% CI 2.64-22.71). CONCLUSIONS: The incidence of Chlamydia trachomatis in women with threatened PTL is approximately 9%, and significantly increased compared to asymptomatic controls. Women with threatened PTL should be considered for screening for Chlamydia trachomatis.

Autoimmune progesterone dermatitis following vaginal progesterone exposure in pregnancy.

In the non-pregnant state, exogenous as well as endogenous fluctuations of progesterone have been demonstrated to cause a rare delayed hypersensitivity reaction known as autoimmune progesterone dermatitis. We describe the case of a 20-year-old woman in her second pregnancy who presented to our delivery unit at 31 weeks and 3 days gestation for a cutaneous breakout with pruritic pustules, blisters, and crusts across her chest back and extremities 23 days after the initiation of vaginal progesterone. After suspension of the vaginal progesterone, the patient's cutaneous lesions resolved. Differential diagnosis and management strategies are discussed. With the increased use of progesterone during pregnancy, complications arising from their use will rise. Clinicians should be aware of their potential adverse effects and consider autoimmune progesterone dermatitis in the differential diagnosis of patients presenting with pruritic lesion in pregnancy.

Comparison of Computerized Cardiotocography Parameters between Male and Female Fetuses.

Fetal sex has been identified as an important factor influencing pregnancy outcomes, but its impact on fetal heart rate (FHR) variability in uncomplicated pregnancies is still unclear. The objective of the study was to assess short-term variability (STV) and other computerized cardiotocography (cCTG) parameters in relation to fetal sex during fetal antepartum surveillance. We retrospective compared cCTG parameters of male and female fetuses in uncomplicated singleton pregnancies at term. In addition to univariate analysis, a multivariate analysis was performed taking into account maternal characteristics. A total of 689 cCTG recordings were analyzed: 335 from male fetuses and 354 from female fetuses. Analysis of cCTG results by fetal sex showed no significant difference in percentage of signal loss, number of contractions, movements, accelerations and decelerations, long-term variability (LTV), and STV at both uni-and multivariate analysis. There was a statistically significant difference for baseline FHR at the univariate analysis, which was not confirmed by a multivariate analysis. Our results suggest that fetal sex did not affect cCTG parameters in uncomplicated term singleton pregnancies, and therefore it does not need to be taken into account when interpreting cCTG in physiological conditions.

Dyslipidemia in pregnancy and maternal-fetal outcome.

Hyperlipidemia is a known cause of atherosclerosis and directly contributes to the current epidemic in cardio-vascular disease. Pregnancy is typified by an increase in serum levels of total cholesterol and triglycerides pushed by the rise in estrogen, progesterone and lactogen. Mobilization of stored fat depots in late pregnancy may provide a reservoir of fatty acids for fetal growth and placental tissue steroid synthesis. This physiologic increase in lipids performs an essential role during pregnancy; however, elevated levels of lipids in predisposed women or with familiar forms of hyperlipidemia can carry increased risk for maternal-fetal complications. The present treatment of pregnant women with hyperlipidemia is the suspension of medications. However, hyperlipidemia during pregnancy is associated with preeclampsia, preterm birth and gestational diabetes and offspring of these mothers show a propensity to enhanced fatty streak formation and an increased risk of progressive atherosclerosis. This current evidence may motivate the further study on the potential benefits of treatment of hyperlipidemia in pregnancy and its effects on maternal-fetal outcomes.

The role of predictive vaginal biomarkers in women with cervical cerclage.

Cervical cerclage is currently one of the primary methods of treatment for cervical insufficiency (CI). Identifying methods in order to selectively apply cerclage may allow us to further limit unnecessary procedures. In this regard, a limited number of inflammatory and extracellular matrix biomarkers measurable non-invasively at the level of the cervix have been examined. In this review we summarize the current research on the use of cervical biomarkers in predicting cerclage failure and propose potential objectives for future research.

Epidemiology of Second Primary Tumors in Women With Ovarian Cancer.

OBJECTIVE: The last large study of second primary tumors (SPTs) in women with ovarian cancer was published in 1996, prior to major changes in the differential diagnosis and treatment. The present study reports on the incidence of SPTs in a contemporary cohort of patients with a diagnosis of ovarian cancer. METHODS: Ovarian cancer patients with a diagnosis of an ovarian malignancy between 1992 and 2012 were identified and characterized from 13 registries of the Surveillance, Epidemiology, and End Results database. RESULTS: Of 41,073 women with a diagnosis of an ovarian malignancy between 1992 and 2012, 1831 (4.5%) developed a microscopically confirmed SPT. There was no significant difference in the risk of developing an SPT at all sites between women with an ovarian cancer and the general population. There was an elevated risk of site-specific SPTs of the small intestine, vagina, thyroid gland, and acute nonlymphocytic leukemia in ovarian cancer patients compared with the general Surveillance, Epidemiology, and End Results population. Conversely, the risk of lung and non-Hodgkin lymphoma was significantly decreased in women with ovarian cancer. An elevated risk of SPTs was observed in women with mucinous, endometrioid, and germ cell tumors. White women had an overall decreased risk of developing a second primary solid tumor, whereas American Indian and Asian/Pacific Islander women had an overall increased risk of an SPT at any site. CONCLUSIONS: The incidence of SPTs in women with ovarian cancer was not significantly different as compared with the general population. However, divergent rates of SPTs in relation to histology, latency, age, and race were observed.

The Role of Hsp70 in the Regulation of Autophagy in Gametogenesis, Pregnancy, and Parturition.

Induction of the 70 kDa heat shock protein (hsp70) and autophagy are two major mechanisms that promote cell homeostasis during the rapid cell growth and differentiation characteristic of reproduction. Hsp70 insures proper assembly, conformation, and intracellular transport of nascent proteins. Autophagy removes from the cytoplasm proteins, other macromolecules, and organelles that are no longer functional or needed and recycles their components for synthesis of new products under nutritionally limiting conditions. Hsp70 inhibits autophagy and so a proper balance between these two processes is essential for optimal germ cell production and survival and pregnancy progression. A marked inhibition in autophagy and a concomitant increase in hsp70 at term is a trigger for parturition. Excessive external or endogenous stress that induces a high level of hsp70 production can lead to a non-physiological inhibition of autophagy, resulting in altered spermatogenesis, premature ovarian failure, and complications of pregnancy including preeclampsia, intrauterine growth restriction, and preterm birth.

Prevalence of lymph node metastasis and prognostic significance of lymphadenectomy in apparent early-stage malignant ovarian sex cord-stromal tumors.

OBJECTIVE: The aim of this retrospective population-based study was to investigate the prevalence of lymph node metastasis in patients with apparent early stage malignant sex cord-stromal tumors (SCSTs) and the effect of regional lymph node sampling/lymphadenectomy (LND) on their survival. METHODS: A cohort of patients diagnosed with malignant SCSTs between 1988 and 2012 was drawn from the National Cancer Institute's Surveillance, Epidemiology, and End Results database. Overall and Cancer Specific Survival, stratified by performance of LND, were calculated following generation of Kaplan-Meier curves. Comparisons were made using the log-rank and Breslow tests. A multivariate Cox proportional analysis was performed to determine the effect of LND on overall mortality. RESULTS: A total of 1156 patients with SCST met the inclusion criteria; 1000 (86.5%) and 156 (13.5%) patients had apparent stage I and II disease, respectively. LND was performed in 572 (49.5%) patients. Lymph node metastases were pathologically confirmed in 19 patients (3.3%). Five-year cancer specific survival (CSS) was similar, 92.7% and 94.7%, for patients who did or did not undergo LND, respectively. According to multivariate analysis overall mortality did not differ between the two groups after controlling for age, histology and apparent stage. CONCLUSIONS: Regional lymphatic mode metastasis in patients with apparent early stage SCSTs is uncommon and lymphadenectomy did not confer a survival benefit in this cohort.

Prognostic Significance of Transitional Cell Carcinoma-Like Morphology of High-Grade Serous Ovarian Carcinoma: A Comparative Study.

OBJECTIVES: This was a retrospective population-based study investigating the demographic characteristics, clinical characteristics, and prognosis of patients with ovarian high-grade serous carcinoma displaying transitional cell carcinoma-like (TC-like) morphological features. MATERIALS AND METHODS: A cohort of patients diagnosed with ovarian high-grade serous carcinoma from 1988 to 2012 was drawn from the National Cancer Institute's Surveillance Epidemiology and End Results Database. Patients with transitional cell histology were included in the study group, whereas patients with other serous tumors served as controls. Demographic and clinical characteristics between the study and the control groups were compared using χ test. For surgically treated patients, survival was estimated by generation of Kaplan-Meier curves. Multivariate analysis was performed using the Cox regression method. RESULTS: A total of 29,716 patients met the inclusion criteria. From these, 264 patients (0.9%) were included in the TC-variant group, whereas 29,452 (99.1%) composed the control group. Patients with TC-variant tumors were younger and more likely to present with larger, unilateral tumors at an early disease stage. Surgically treated patients with advanced stage had a median disease-specific survival of 50 months compared with 40 months in the control group (P = 0.013). In that group, multivariate analysis confirmed that TC-like morphological features were an independent predictor of survival. CONCLUSIONS: High-grade serous carcinoma with TC-like morphological features was associated with unique demographic and clinical characteristics. For patients with advanced stage-disease, the presence of TC-like morphological features was associated with a superior survival.

Autophagy induction by sera from women undergoing an in vitro fertilization cycle varies with subsequent outcome.

Autophagy maintains intracellular homeostasis during placental development and embryogenesis. We evaluated if differences in the autophagy-inducing capacity of sera from women undergoing an in vitro fertilization (IVF) cycle predicted subsequent pregnancy outcome. In this retrospective study, sera collected from 94 women at the time of intrauterine embryo implantation were incubated with peripheral blood mononuclear cells (PBMCs) from healthy donors. The PBMCs were lysed and autophagy induction measured by determination of the p62 concentration. A reduced capacity for autophagy induction was associated with defective implantation while an elevated level of autophagy was associated with ectopic pregnancy.

The serum brain-derived neurotrophic factor concentration prior to initiation of an in vitro fertilization cycle predicts outcome.

Our objective was to determine if the concentration of circulating brain-derived neurotrophic factor (BDNF) prior to cycle initiation predicts outcome in women undergoing in vitro fertilization (IVF). Stored serum samples from 226 women - 54 with a live birth, 45 with a spontaneous abortion, 38 with a biochemical pregnancy, 54 who did not become pregnant and 35 with an ectopic pregnancy- were retrospectively blindly tested for BDNF by ELISA. The median serum concentration of BDNF was highest in women with an extrauterine ectopic pregnancy (7.3ng/ml), intermediate in women whose embryos did not implant (5.5ng/ml) and lowest in women with a spontaneous abortion (4.2ng/ml), biochemical pregnancy (3.8ng/ml) or a live birth (3.6ng/ml) (P<0.0001). Among women with a positive pregnancy test an elevated BDNF level predicted an ectopic pregnancy with a sensitivity of 0.853 (0.689, 0.950) and a specificity of 0.949 (0.897, 0.979). We conclude that elevated BDNF in serum obtained before IVF cycle initiation is predictive of an extrauterine pregnancy.

Epidemiology and outcomes of squamous ovarian carcinoma; a population-based study.

OBJECTIVE: Squamous ovarian carcinoma (SOC) is a rare tumor. Scarcity of information about the epidemiology and prognosis of SOC hinders attempts at optimal patient management. This retrospective study of a large cohort details the clinicopathological and demographic characteristics and prognosis of women with SOC. METHODS: A cohort of patients drawn from the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) database who were diagnosed with SOC between 1988 and 2012 were analyzed. Observed and disease-specific survival was estimated by Kaplan-Meier plots in women who underwent surgery as part of their cancer-related treatment. A Cox hazard regression analysis was performed to determine independent predictors of cancer-specific survival in patients with SOC. RESULTS: We identified 341 patients with SOC with a median age at diagnosis of 55 years. Stage I, II, III and IV tumors were noted in 34%, 15%, 20.5% and 24.9% of patients, respectively. Five-year cancer-specific survival was 86% for stage I, 54.3% for stage II, 36.3% for stage III and 2.8% for stage IV disease patients. Observed and cancer-specific survival was better for patients that underwent lymphadenectomy (p=0.031). Postoperative radiotherapy was not associated with improved survival. In a multivariate analysis, independent predictors of improved cancer-specific survival were younger age, lower disease stage and lymphadenectomy. CONCLUSIONS: SOC is typically a unilateral malignancy with a tendency toward loco-regional spread. Stage I patients have a relatively high survival rate; however, the prognosis is poor for women with abdominal or distant spread. Lymphadenectomy, but not postoperative radiotherapy, is associated with improved survival.

Induction of the 70 kDa heat shock protein stress response inhibits autophagy: possible consequences for pregnancy outcome.

AIM: The induction of heat shock protein synthesis and activation of autophagy are intracellular processes stimulated under adverse conditions. We evaluated the relationship between intracellular concentrations of the inducible 70 kDa heat shock protein (hsp70) and autophagy induction in human peripheral blood mononuclear cells (PBMCs) following exposure to sera from pregnant and non-pregnant women. METHODS: Autophagy was induced in PBMCs by incubation for 48 h with sera from 42 pregnant women at mid-gestation and 45 non-pregnant women. Intracellular concentrations of hsp70 and p62 were measured by ELISA. p62 is a cytoplasmic protein that is consumed during autophagy induction. Its concentration in the cytoplasm is inversely proportional to the extent of autophagy induction (high p62 = low autophagy). RESULTS: The p62 concentration was highly correlated with the hsp70 level utilizing sera from both pregnant (Spearman r = 0.4731, p = 0.0015) and non-pregnant (Spearman r = 0.6214, p < 0.0001) women. Median p62 (7.4 ng/ml versus 2.7 ng/ml, p < 0.0001) and hsp70 (7.0 ng/ml versus 3.5 ng/ml, p = 0.0022) levels were higher when PBMCS were incubated with sera from pregnant women. CONCLUSION: The extent of autophagy in PBMCs is inversely proportional to the intracellular hsp70 concentration and sera from pregnant women induces hsp70 and inhibits autophagy to a greater extent than does sera from non-pregnant women. A stress response that induces hsp70 has the potential to interfere with autophagy-related events.

Predictive biomarkers of preterm delivery in women with ongoing IVF pregnancies.

In vitro fertilization (IVF) pregnancies potentially have a higher rate of preterm delivery (PTD) than do spontaneously conceived gestations, and differences persist following adjustment for multiple gestation, maternal age, and parity. The reasons for this increased susceptibility to PTD remain incompletely elucidated. To identify potential biomarkers predictive of PTD in IVF subjects, we performed a retrospective analysis of multiple markers in sera obtained during early gestation that have been suggested to be associated with peri-implantation events. Sera from 35 women with a preterm birth and 68 women with a term delivery, obtained between 9 and 11 days after embryo transfer, were tested blindly for concentrations of interleukin (IL)-1ß, IL-6, IL-13, IL-17, human epididymal protein 4 (HE4), secretory leukocyte protease inhibitor (SLPI), insulin-like growth factor (IGF)-I, IGF-II, IGF binding protein (BP)-1, and interferon-γ. Concentrations of HE4 (p=0.001) and IL-13 (p=0.029) were reduced, and levels of IGF-II (p=0.023) and SLPI (p=0.043) were increased, in women who subsequently delivered preterm. By receiver operator curve analysis, the combination of HE4 and IL-13 levels best predicted the outcome preterm birth. The association between deficiencies in circulating HE4 and IL-13 levels during early pregnancy and subsequent PTD suggest that factors contributing to sub-optimal embryo implantation influence length of gestation in women undergoing IVF.

Inhibition of autophagy in peripheral blood mononuclear cells by vaginal fluid from women with a malignant adnexal mass.

Inhibition of autophagy is a characteristic of ovarian cancer. We determined whether inhibition of autophagy by vaginal fluid could provide a non-invasive test for cancer risk stratification in women presenting with an adnexal mass. Vaginal fluid supernatants from 90 women undergoing evaluation for a suspicious adnexal mass were incubated with peripheral blood mononuclear cells (PBMCs) obtained from healthy women under conditions that induce autophagy. Rapamycin, an autophagy inducer, was added to some cultures. After 48 hr the cells were collected, lysed and assayed by ELISA for intracellular p62 concentration. p62 is a cytoplasmic protein that is consumed during autophagy induction. Its concentration is inversely proportional to the extent of autophagy induction. Clinical information including pathological diagnoses was obtained after completion of laboratory studies. Mean p62 levels were 9.4 ng/ml in the 21 women with a subsequent malignant diagnosis, 4.5 ng/ml in the eight women with a borderline tumor diagnosis and 3.6 ng/ml in the 61 women with benign disease (p < 0.0001, malignant vs. others). When rapamycin was added to the vaginal fluid-PBMC co-incubation, p62 levels in samples from women with a malignant diagnosis decreased to 3.3 ng/ml, a level comparable to what was observed with the nonmalignant samples. Vaginal fluid inhibition of autophagy can differentiate between women with malignant and benign adnexal masses.

Interaction between the inducible 70-kDa heat shock protein and autophagy: effects on fertility and pregnancy.

A consequence of hsp70 (HSPA1A) induction is the inhibition of autophagy. Evidence of autophagy involvement in all aspects of the reproductive process is reviewed, and possible consequences of hsp70 induction at each developmental stage are postulated. It is proposed that aberrant external or internal stimuli that result in high levels of hsp70 production interfere with normal autophagy-related functions and lead to a decrease in the number of functional ova and spermatozoa, impaired pre- and post-implantation embryo development, and increased susceptibility to premature labor and delivery. The purpose of this review is to increase understanding of hsp70-autophagy interactions during reproduction. Interventions to modulate this interaction will lead to development of novel protocols to improve fertility and pregnancy outcome.