Cytoreductive Surgery with the PlasmaJet Improved Quality-of-Life for Advanced Stage Ovarian Cancer Patients.

BACKGROUND: Knowledge of quality-of-life after cytoreductive surgery is important to counsel patients with advanced-stage epithelial ovarian cancer prior to surgery. The aim of this study was to determine whether the use of the PlasmaJet Surgical device during cytoreductive surgery has an effect on the quality-of-life of patients with advanced epithelial ovarian cancer. METHODS: Data included in this prospective observational study were derived from the PlaComOv study, in which patients with advanced epithelial ovarian cancer were randomly assigned to have cytoreductive surgery with or without adjuvant use of the PlasmaJet. Quality-of-life was measured before surgery and one, six, 12, and 24 months after surgery with three questionnaires: the EORTC QLQ-C30, QLQ-OV28, and EQ-5D-5L. RESULTS: Between 2018 and 2020, 326 patients were enrolled in the trial. The overall response rate was high, with the lowest response rate at 24 months of 77%. At 6 months, quality-of-life was higher in the intervention group (95%CI 0.009; 0.081, p = 0.045). At 12 months, quality-of-life was higher in the intervention group with fewer symptoms of fatigue, appetite loss, and diarrhea (95%CI 0.6; 10,0, p = 0.027); similarly, patients in the intervention group reported a better body image (95%CI -14.2; -3.0, p = 0.003) and a higher score on the visual analog scale (95%CI 1.99; 11.15, p = 0.005). At 24 months postoperatively, no further difference was found between the two groups except for pain (95%CI -12.9; -0.8, p = 0.027) and body image (95%CI -13.808; -0.733, p = 0.029). A higher quality-of-life in the intervention group was partially explained by the mediator 'surgery outcome'. CONCLUSIONS: This study demonstrated knowledge of patients' quality-of-life until two years after cytoreductive surgery. The use of the PlasmaJet Surgical device during cytoreductive surgery leads to a higher quality-of-life than conventional surgery with electrocoagulation alone. Even after adjustment for the mediator of surgical outcome, a higher quality-of-life was seen in patients who had surgery with the use of the PlasmaJet device.

Primary care access to radiology: Characteristics of trauma patients referred to the emergency department.

RATIONALE, AIMS AND OBJECTIVES: Low-urgent Emergency Department (ED) attendances are a known contributing factor to ED crowding. In the Netherlands, general practitioners (GPs) have direct access to radiology facilities during office hours. Patients with radiographically confirmed traumatic injuries are subsequently referred to the ED. We analysed these ED trauma patients' characteristics, provided treatments and ED discharge diagnoses to identify the possibility of alternative care pathways. METHODS: Single-centre retrospective observational study of trauma patients referred to the ED by the radiology department during office hours (January 2017-December 2017). Data were obtained from patient records. Descriptive statistics were used to analyse the extracted data. RESULTS: A total of 662 patients were included. The median age was 42 years (range: 1-100, interquartile range (IQR): 15-63) and patients presented to the ED with a median delay of 1 day (range: 0-112 days, IQR: 0-5). Most patients were referred for injuries involving the upper extremities (61.5%) and lower extremities (30%). A total of 48 additional diagnoses were made in the ED. The majority of injuries was classified as 'minor' (29.5%) or 'moderate' (68.3%) on the Abbreviated Injury Scale (AIS). The median length of stay in the ED was 65 min (range: 7-297 min, IQR: 43-102). CONCLUSION: Most patients presented with low acuity injuries and often with a notable delay to the ED. This suggests that the majority of these patients do not necessarily need ED treatment, which may provide an opportunity to counter ED crowding.

Simultaneous interfacility transfer of multiple non-critically ill COVID-19 patients using a single vehicle: the ambulance bus experience.

BACKGROUND: During the COVID-19 pandemic, hospital capacity in the Netherlands has been pushed to its limits. In order to prevent hospitals from collapse due to capacity issues, hospitalized COVID-19 patients were redistributed throughout the country. The numerous individual interfacility transfers further increased the pressure on emergency medical services (EMS), which simultaneously had to serve the community during the pandemic. In this report, we evaluate the interfacility transport of multiple non-critically ill COVID-19 patients using one single vehicle: a coach converted into an ambulance bus. DISCUSSION: Between March 28, 2020, and July 17, 2021, the ambulance bus was dispatched 22 times. In total, 102 patients were transferred over a mean distance of 79.6 km. No technical or patient-related adverse events were reported. The primary benefits of the ambulance bus were its time and staff reducing potential, as well as the ability to provide relief to overwhelmed hospitals. Furthermore, it could be assembled from existing equipment in a relatively short time span. However, the efficiency of dispatches and matching between hospitals could be improved. CONCLUSION: The simultaneous interfacility transfer of multiple non-critically ill COVID-19 patients using an ambulance bus was feasible. No technical or patient-related adverse events were reported during 22 dispatches, involving a total of 102 patients. This mode of transport may also be useful in non-pandemic situations, such as hospital and nursing home evacuations.

A Swift and Dynamic Strategy to Expand Emergency Department Capacity for COVID-19.

Emergency departments (EDs) worldwide struggled to prepare for coronavirus disease 2019 (COVID-19) patient surge and to simultaneously preserve sufficient capacity for "regular" emergency care. While many hospitals used costly shelter facilities, it was decided to merge the acute medical unit (AMU) and the ED. The conjoined AMU-ED was segregated into a high-risk and a low-risk area to maintain continuity of emergency care. This strategy allowed for a feasible, swift, and dynamic expansion of ED capacity without the need for external tent facilities. This report details on the technical execution and discusses the pearls and potential pitfalls of this expansion strategy. Although ED preparedness for pandemics may be determined by local factors, such as hospital size, ED census, and primary health-care efficacy, the conjoined AMU-ED strategy may be a potential model for other EDs.

Recurrence and survival after laparoscopy versus laparotomy without lymphadenectomy in early-stage endometrial cancer: Long-term outcomes of a randomised trial.

BACKGROUND: Laparoscopic hysterectomy is accepted worldwide as the standard treatment option for early-stage endometrial cancer. However, there are limited data on long-term survival, particularly when no lymphadenectomy is performed. We compared the survival outcomes of total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH), both without lymphadenectomy, for early-stage endometrial cancer up to 5 years postoperatively. METHODS: Follow-up of a multi-centre, randomised controlled trial comparing TLH and TAH, without routine lymphadenectomy, for women with stage I endometrial cancer. Enrolment was between 2007 and 2009 by 2:1 randomisation to TLH or TAH. Outcomes were disease-free survival (DFS), overall survival (OS), disease-specific survival (DSS), and primary site of recurrence. Multivariable Cox regression analyses were adjusted for age, stage, grade, and radiotherapy with adjusted hazard ratios (aHR) and 95% confidence intervals (95%CI) reported. To test for significance, non-inferiority margins were defined. RESULTS: In total, 279 women underwent a surgical procedure, of whom 263 (94%) had follow-up data. For the TLH (n = 175) and TAH (n = 88) groups, DFS (90.3% vs 84.1%; aHR[recurrence], 0.69; 95%CI, 0.31-1.52), OS (89.2% vs 82.8%; aHR[death], 0.60; 95%CI, 0.30-1.19), and DSS (95.0% vs 89.8%; aHR[death], 0.62; 95%CI, 0.23-1.70) were reported at 5 years. At a 10% significance level, and with a non-inferiority margin of 0.20, the null hypothesis of inferiority was rejected for all three outcomes. There were no port-site or wound metastases, and local recurrence rates were comparable. CONCLUSION: Disease recurrence and 5-year survival rates were comparable between the TLH and TAH groups and comparable to studies with lymphadenectomy, supporting the widespread use of TLH without lymphadenectomy as the primary treatment for early-stage, low-grade endometrial cancer.

When disasters strike the emergency department: a case series and narrative review.

INTRODUCTION: Emergency departments (EDs) are reasonably well prepared for external disasters, such as natural disasters, mass casualty incidents, and terrorist attacks. However, crises and disasters that emerge and unfold within hospitals appear to be more common than external events. EDs are often affected. Internal hospital crises and disasters (IHCDs) have the potential to endanger patients, staff, and visitors, and to undermine the integrity of the facility as a steward of public health and safety. Furthermore, ED patient safety and logistics may be seriously hampered. METHODS: Case series of 3 disasters within EDs. Narrative overview of the current IHCD-related literature retrieved from searches of PubMed databases, hand searches, and authoritative texts. DISCUSSION: The causes of IHCDs are multifaceted and an internal disaster is often the result of a cascade of events. They may or may not be associated with a community-wide event. Examples include fires, floods, power outages, structural damage, information and communication technology (ICT) failures, and cyberattacks. EDs are particularly at-risk. While acute-onset disasters have immediate consequences for acute care services, epidemics and pandemics are threats that can have long-term sequelae. CONCLUSIONS: Hospitals and their EDs are at-risk for crises and their potential escalation to hospital disasters. Emerging risks due to climate-related emergencies, infectious disease outbreaks, terrorism, and cyberattacks pose particular threats. If a hospital is not prepared for IHCDs, it undermines the capacity of administration and staff to safeguard the safety of patients. Therefore, hospitals and their EDs must check and where necessary enhance their preparedness for these contingencies.

Marizomib sensitizes primary glioma cells to apoptosis induced by a latest-generation TRAIL receptor agonist.

Due to the absence of curative treatments for glioblastoma (GBM), we assessed the efficacy of single and combination treatments with a translationally relevant 2nd generation TRAIL-receptor agonist (IZI1551) and the blood-brain barrier (BBB) permeant proteasome inhibitor marizomib in a panel of patient-derived glioblastoma cell lines. These cells were cultured using protocols that maintain the characteristics of primary tumor cells. IZI1551+marizomib combination treatments synergistically induced apoptotic cell death in the majority of cases, both in 2D, as well as in 3D spheroid cultures. In contrast, single-drug treatments largely failed to induce noticeable amounts of cell death. Kinetic analyses suggested that time-shifted drug exposure might further increase responsiveness, with marizomib pre-treatments indeed strongly enhancing cell death. Cell death responses upon the addition of IZI1551 could also be observed in GBM cells that were kept in a medium collected from the basolateral side of a human hCMEC/D3 BBB model that had been exposed to marizomib. Interestingly, the subset of GBM cell lines resistant to IZI1551+marizomib treatments expressed lower surface amounts of TRAIL death receptors, substantially lower amounts of procaspase-8, and increased amounts of cFLIP, suggesting that apoptosis initiation was likely too weak to initiate downstream apoptosis execution. Indeed, experiments in which the mitochondrial apoptosis threshold was lowered by antagonizing Mcl-1 re-established sensitivity to IZI1551+marizomib in otherwise resistant cells. Overall, our study demonstrates a high efficacy of combination treatments with a latest-generation TRAIL receptor agonist and the BBB permeant proteasome inhibitor marizomib in relevant GBM cell models, as well as strategies to further enhance responsiveness and to sensitize subgroups of otherwise resistant GBM cases.

A scoping review of internal hospital crises and disasters in the Netherlands, 2000-2020.

BACKGROUND: Internal hospital crises and disasters (IHCDs) are events that disrupt the routine functioning of a hospital while threatening the well-being of patients and staff. IHCDs may cause hospital closure, evacuations of patients and loss of healthcare capacity. The consequences may be ruinous for local communities. Although IHCDs occur with regularity, information on the frequency and types of these events is scarcely published in the medical literature. However, gray literature and popular media reports are widely available. We therefore conducted a scoping review of these literature sources to identify and characterize the IHCDs that occurred in Dutch hospitals from 2000 to 2020. The aim is to develop a systematic understanding of the frequency of the various types of IHCDs occurring in a prosperous nation such as the Netherlands. METHODS: A systematic scoping review of news articles retrieved from the LexisNexis database, Google, Google News, PubMed and EMBASE between 2000 and 2020. All articles mentioning the closure of a hospital department in the Netherlands were analyzed. RESULTS: A total of 134 IHCDs were identified in a 20-year time period. Of these IHCDs, there were 96 (71.6%) emergency department closures, 76 (56.7%) operation room closures, 56 (41.8%) evacuations, 26 (17.9%) reports of injured persons, and 2 (1.5%) reported casualties. Cascading events of multiple failures transpired in 39 (29.1%) IHCDs. The primary causes of IHCDs (as reported) were information and communication technology (ICT) failures, technical failures, fires, power failures, and hazardous material warnings. An average of 6.7 IHCDs occurred per year. From 2000-2009 there were 32 IHCDs, of which one concerned a primary ICT failure. Of the 102 IHCDs between 2010-2019, 32 were primary ICT failures. CONCLUSIONS: IHCDs occur with some regularity in the Netherlands and have marked effects on hospital critical care departments, particularly emergency departments. Cascading events of multiple failures transpire nearly a third of the time, limiting the ability of a hospital to stave off closure due to failure. Emergency managers should therefore prioritize the risk of ICT failures and cascading events and train hospital staff accordingly.

Utility of Shock Index for Suspected Rupture of Abdominal Aortic Aneurysms.

BACKGROUND: A ruptured abdominal aortic aneurysm (rAAA) is a life-threatening condition, with high mortality rates. The Shock Index (SI) is an easy tool and a useful predictor of hemodynamic instability in trauma patients. We aimed to assess the predictive and prognostic value of the SI for patients with a suspected rAAA in the prehospital and hospital setting. METHODS: This was a retrospective, observational, single-center study. Patients >18 years old who visited the emergency department with a suspected rAAA between January 2009 and December 2018 were included. Prehospital and hospital SI were calculated and analyzed for its predictive value on the presence of a rAAA, need for packed cells (PCs) and mortality. RESULTS: A total of 313 patients met the inclusion criteria, of which 71 patients (22.6%) presented with a rAAA. Prehospital and hospital SI were significantly increased in the rAAA group. A SI ≥ 1.0 was estimated as an optimal cutoff point for the presence of a rAAA (AUROC 0.74, 95% CI 0.67-0.82; p < 0.001) with an adjusted Odds Ratio (OR) of 5.3 (95% CI 2.13-13.39) for the prehospital SI and an adjusted OR of 18.2 (95% CI 5.83-56.73) for the hospital SI. Both prehospital and hospital SI ≥ 1.0 were associated with a higher need for PCs and amount of PCs (p < 0.05). A hospital SI ≥ 1.0 was associated with higher in-hospital mortality rates (39.0% vs 68.0%, p = 0.022). CONCLUSIONS: The prehospital and hospital SI were significantly elevated in the rAAA group. As such, the SI showed promising results as a predictive and prognostic tool, with SI ≥ 1.0 as cutoff point.

Convergence of pathway analysis and pattern recognition predicts sensitization to latest generation TRAIL therapeutics by IAP antagonism.

Second generation TRAIL-based therapeutics, combined with sensitising co-treatments, have recently entered clinical trials. However, reliable response predictors for optimal patient selection are not yet available. Here, we demonstrate that a novel and translationally relevant hexavalent TRAIL receptor agonist, IZI1551, in combination with Birinapant, a clinically tested IAP antagonist, efficiently induces cell death in various melanoma models, and that responsiveness can be predicted by combining pathway analysis, data-driven modelling and pattern recognition. Across a panel of 16 melanoma cell lines, responsiveness to IZI1551/Birinapant was heterogeneous, with complete resistance and pronounced synergies observed. Expression patterns of TRAIL pathway regulators allowed us to develop a combinatorial marker that predicts potent cell killing with high accuracy. IZI1551/Birinapant responsiveness could be predicted not only for cell lines, but also for 3D tumour cell spheroids and for cells directly isolated from patient melanoma metastases (80-100% prediction accuracies). Mathematical parameter reduction identified 11 proteins crucial to ensure prediction accuracy, with x-linked inhibitor of apoptosis protein (XIAP) and procaspase-3 scoring highest, and Bcl-2 family members strongly represented. Applied to expression data of a cohort of n = 365 metastatic melanoma patients in a proof of concept in silico trial, the predictor suggested that IZI1551/Birinapant responsiveness could be expected for up to 30% of patient tumours. Overall, response frequencies in melanoma models were very encouraging, and the capability to predict melanoma sensitivity to combinations of latest generation TRAIL-based therapeutics and IAP antagonists can address the need for patient selection strategies in clinical trials based on these novel drugs.

Emergency Department Ceiling Collapse: Response to an Internal Emergency.

Hospital disaster resilience is often conceived as the ability to respond to external disasters. However, internal disasters appear to be more common events in hospitals than external events. This report describes the aftermath of a ceiling collapse in the emergency department of VieCuri Medical Center in Venlo, the Netherlands, on May 18, 2017. By designating the acute medical unit as a temporary emergency department, standard emergency care could be resumed within 8 hours. This unique approach might be transferrable to other hospitals in the developed world. In general, it is vital that hospital disaster plans focus on both external and internal disasters, including specific scenarios that disrupt vital hospital departments such as the emergency department. (Disaster Med Public Health Preparedness. 2019;13:829-830).

Superior Treg-Expanding Properties of a Novel Dual-Acting Cytokine Fusion Protein.

Autoimmune diseases are caused by uncontrolled endogenous immune responses against healthy cells. They may develop due to an impaired function of regulatory T cells (Tregs), which normally suppress self-specific effector immune cells. Interleukin 2 (IL-2) and tumor necrosis factor (TNF) have been identified as key players that promote expansion, function, and stability of Tregs. In vivo, both low-dose IL-2 therapy and TNF receptor 2 (TNFR2) agonism were shown to expand Tregs and alleviate autoimmunity. We here designed a novel dimeric dual-acting fusion cytokine, where mouse IL-2 is genetically linked to a TNFR2-selective single-chain TNF mutein (IL2-EHD2-sc-mTNFR2). IL2-EHD2-sc-mTNFR2 showed high affinity to TNFR2 and efficiently activated IL-2 and TNFR2-selective signaling pathways. Further, IL2-EHD2-sc-mTNFR2 promoted superior Treg expansion, with both the IL-2 and the TNFR2 agonist (sc-mTNFR2) component necessary for this biological response. Ultimately, we propose that IL2-EHD2-sc-mTNFR2 is a dual-acting cytokine that efficiently promotes Treg expansion and might have a superior therapeutic window than conventional IL-2-based drugs.

Selective Activation of Tumor Necrosis Factor Receptor II Induces Antiinflammatory Responses and Alleviates Experimental Arthritis.

OBJECTIVE: Treg cells modulate immune responses and can suppress the development of autoimmune diseases. Tumor necrosis factor receptor II (TNFRII) has been recognized as a key receptor on these cells that facilitates expansion and stabilization of CD4+ Treg cells. The purpose of the present study was to investigate the therapeutic activity of a novel TNFRII agonist in experimental arthritis as well as the role of different Treg cell subsets. METHODS: A novel mouse TNFRII-selective fusion protein (EHD2-sc-mTNFR2 ) was generated by genetic engineering. Mouse T cells were incubated together with interleukin-2 and/or EHD2-sc-mTNFR2 , and the effects on Treg cells were analyzed by flow cytometry. Mice with collagen-induced arthritis (CIA) were treated with EHD2-sc-mTNFR2 or saline, and the therapeutic effects were monitored and characterized. RESULTS: Selective activation of TNFRII was found to expand both CD4+ and CD8+ Treg cells. Moreover, TNFRII activation elevated the number of CD4+CD25+ and CD8+CD25+ Treg cells and increased the number of FoxP3-expressing cells in CD8+, but not CD4+, Treg cells, indicating different mechanisms of TNFRII-induced expansion of diverse T cell subsets with suppressive activity. In the CIA model, we demonstrated that administration of the TNFRII agonist EHD2-sc-mTNFR2 led to the expansion of both CD4+ and CD8+ Treg cells in vivo and induced antiinflammatory responses that alleviated arthritis. CONCLUSION: Our findings support the use of TNFRII-selective therapeutics as an effective approach to the treatment of arthritic disease and possibly other inflammatory and autoimmune diseases.

Novel strategies to mimic transmembrane tumor necrosis factor-dependent activation of tumor necrosis factor receptor 2.

Tumor necrosis factor receptor 2 (TNFR2) is known to mediate immune suppression and tissue regeneration. Interestingly, the transmembrane form of tumor necrosis factor (tmTNF) is necessary to robustly activate TNFR2. To characterize the stoichiometry and composition of tmTNF during TNFR2 activation, we constructed differently oligomerized single chain TNF ligands (scTNF) comprised of three TNF homology domain (THD) protomers that mimic tmTNF. Using a variety of cellular and in vivo assays, we can show that higher oligomerization of the scTNF trimers results in more efficient TNF/TNFR2 clustering and subsequent signal transduction. Importantly, the three-dimensional orientation of the scTNF trimers impacts the bioactivity of the oligomerized scTNF ligands. Our data unravel the organization of tmTNF-mimetic scTNF ligands capable of robustly activating TNFR2 and introduce novel TNFR2 agonists that hold promise as therapeutics to treat a variety of diseases.

Prospective evaluation of the added value of imaging within the Dutch National Diagnostic Appendicitis Guideline--do we forget our clinical eye?

BACKGROUND: Annually 16,000 appendectomies are performed in the Netherlands, of which 15-20% are negative. In 2010, to reduce this unacceptable percentage of superfluous appendectomies, the Dutch Association for Surgery introduced the 'Appendicitis Guideline'. This guideline recommends the use of imaging. In this observational prospective study the added value of imaging in everyday clinical practice is evaluated. METHODS: All patients with suspected appendicitis were included at the emergency department of a Dutch teaching hospital during the period from September 2011 to May 2012 (n = 350; 237 adults and 113 children under 18 years). Adherence to the guideline was evaluated. RESULTS: 75 Patients (21%) were not referred for imaging because of a low suspicion or alternative diagnosis. In 16 patients (5%) the guideline was not followed. Of the 259 patients (74%) who underwent ultrasonography, 105 (30%) also underwent computed tomography (CT). 127 appendectomies were performed, showing appendicitis in 112 patients (88%); 15 appendectomies (12%) were negative. In the latter group, 12 were performed after false positive imaging results, and 3 following inconclusive imaging results. CONCLUSION: When using imaging in the diagnosis of appendicitis, the percentage of negative appendectomies remains close to the percentage declared as unacceptable by the publishers of the guideline.

Low vacuum and discard tubes reduce hemolysis in samples drawn from intravenous catheters.

OBJECTIVES: In-vitro hemolysis is a great challenge to emergency departments where blood is drawn from intravenous catheters (IVCs). Although high quality samples can be obtained by straight needle venipuncture, IVCs are preferred for various reasons. The aim of this study was to identify blood collection practices that reduce hemolysis while using IVC. DESIGN AND METHODS: The study was conducted at an emergency department where blood is drawn in ≥ 90% of patients from IVC. Hemolysis, measured spectrophotometrically, was compared between syringe and vacuum tubes. The following practices were tested in combination with vacuum collection; a Luer-slip adapter, a Luer-lock adapter, discard tubes and low vacuum tubes. Each intervention lasted 1 week and retrieved 154 to 297 samples. As reference, hemolysis was also measured in vacuum tubes retrieved from departments where only straight needle venipuncture is performed. RESULTS: Vacuum collection led to more hemolytic samples compared with syringe tubes (24% versus 16% respectively, p=0.008). No difference in hemolysis was observed between the Luer-slip and the Luer-lock adapter. The use of discard (17% hemolytic, p=0.045) and low vacuum tubes (12% hemolytic, p<0.001) substantially decreased hemolysis. None of the interventions reduced the hemolysis rate to the level observed when drawing blood by straight needle venipuncture (3%, p<0.02). CONCLUSIONS: In summary, both discard and low vacuum tubes reduce hemolysis while drawing blood from IVC. Of these practices the use of a low vacuum tube is preferred considering the less volume of blood and the amount of tubes drawn.

[Vulvar basal cell carcinoma with destructive consequences]. / Vulvair basaalcelcarcinoom met destructieve gevolgen.

BACKGROUND: Basal cell carcinoma is the most common form of skin cancer. Generally, the prognosis is relatively good and curative surgical treatment is accomplished in the great majority of patients. CASE DESCRIPTION: Here we report a case that illustrates the natural course of a vulvar basal cell carcinoma. It concerns an 80-year-old woman who was diagnosed with a so-called 'giant' vulvar basal cell carcinoma causing severe destruction of the anogenital anatomy. At the time of diagnosis, haematogenous metastases were strongly suspected and curative therapy was not possible. CONCLUSION: This case description illustrates that a basal cell carcinoma can transform into a 'giant' basal cell carcinoma if it is left untreated for many years. 'Giant' basal cell carcinomas carry a significantly higher risk of metastases than basal cell tumours smaller than 5 cm. In addition, 'giant' basal cell carcinoma is associated with higher morbidity and mortality rates.

A robust ex vivo model for evaluation of induction of apoptosis by rhTRAIL in combination with proteasome inhibitor MG132 in human premalignant cervical explants.

Development of medical therapies for high-grade cervical intraepithelial neoplasia (CIN II/III) is hampered by the lack of CIN II/III cell lines. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) induces apoptosis upon binding to its receptors DR4 or DR5. Proteasome inhibition by MG132 sensitized cervical cancer cell lines to recombinant human (rh)TRAIL. In our study, we aimed to develop an ex vivo model for CIN II/III and to investigate the apoptosis-inducing effect of rhTRAIL and/or MG132 in cervical explants from CIN II/III patients. A short-term ex vivo culture system was optimized for cervical biopsies, in which explants from normal cervix and CIN II/III lesions were exposed to either rhTRAIL (1 microg/ml), MG132 (5 microM) or the combination and compared to untreated explants for apoptosis induction. Normal cervix (n = 90) and CIN II/III (n = 24) explants could be reproducibly put in culture and kept viable for up to 7 days using a transwell membrane system. CIN II/III explants (n = 5) were highly sensitive to rhTRAIL plus MG132 (mean % apoptosis: 91 +/- 5) compared to normal cervix (n = 10) treated with rhTRAIL plus MG132 (mean % apoptosis: 24 +/- 10, p < 0.0001), while monotherapy with either rhTRAIL, MG132 or medium resulted in a mean % apoptosis <10 in both CIN II/III and normal cervix. Our ex vivo model system allows preclinical evaluation of (topical) medical therapies for CIN II/III. A strong synergistic apoptosis-inducing effect of the combination of rhTRAIL and MG132, especially in CIN II/III lesions indicates that rhTRAIL combined with proteasome inhibitors deserves exploration as medical treatment for CIN II/III.

An overview of innovative techniques to improve cervical cancer screening.

Although current cytomorphology-based cervical cancer screening has reduced the incidence of cervical cancer, Pap-smears are associated with high false positive and false negative rates. This has spurred the search for new technologies to improve current screening. New methodologies are automation of Pap-smear analysis, addition of new biological or molecular markers to traditional cytology or using these new markers to replace the current screening method. In this overview we will summarize data on cervical cancer epidemiology and etiology and the current cervical cancer screening approach. Available data on new screening approaches, such as quantitative cytochemistry, detection of loss of heterozygosity (LOH) and hypermethylation analysis will be reviewed. We discuss the potential of these approaches to replace or augment current screening. When available, data on cost-effectiveness of certain approaches will be provided. In short, Human Papillomavirus (HPV) DNA detection stands closest to implementation in nation-wide screening programs of all markers reviewed. However, specificity is low in women aged <35 years and the psychological effects of knowledge of HPV positivity in absence of cervical (pre) malignant disease are important drawbacks. In our opinion the results of large clinical trials should be awaited before proceeding to implement HPV DNA detection. New technologies based on molecular changes associated with cervical carcinogenesis might result in comparable sensitivity, but improved specificity. Hypermethylation analysis is likely to be more objective to identify patients with high grade squamous intra-epithelial lesions (HSIL) or invasive cancer with a higher specificity than current cytomorphology based screening.