Risk of chemotherapy-induced amenorrhea in patients with breast cancer: a systematic review and meta-analysis.

BACKGROUND: The aim of the study was to calculate the rate of chemotherapy-induced amenorrhea (CIA) after treatment with different adjuvant therapies in patients with breast cancer and to evaluate the risk factors for CIA based on the quality of evidence. PATIENT AND METHODS: A search of PubMed and ISI Web of Science was performed. All published trials with female breast cancer patients who received adjuvant chemotherapy and presented data on the rate of CIA were considered eligible. The pooled rates of CIA were calculated by random effects model. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each potential risk factor for CIA by using the generic inverse weighted method. RESULTS: We identified 580 potentially relevant studies, of which 75 were included in the analysis. Among 75 eligible studies, 19 different definitions of CIA have been used. The pooled rate of CIA was 55% (95% CI 50-60%) including 23 673 patients from 74 studies. The rate of CIA was increased by age with an estimate of 26% (95% CI 12-43%), 39% (95% CI 31-58%), and 77% (95% CI 71-83%) for women <35, 35-40, and >40 years old, respectively. Two risk factors were associated with the occurrence of CIA and were supported by strong level of evidence: older age (>40 years old), and the use of tamoxifen. CONCLUSIONS: This meta-analysis summarized the updated evidence on the impact of different adjuvant treatment regimens for breast cancer in menstruation and could serve as a helpful guide for oncologists during the discussion with their patients on fertility issues before decision on adjuvant therapy is made. A uniform definition of CIA is essential in future studies to make the interpretation of results more reliable.

Misoprostol prior to hysteroscopy in premenopausal and post-menopausal women. A systematic review and meta-analysis.

BACKGROUND: Although several randomized controlled trials (RCTs) have examined the effect of misoprostol prior to hysteroscopy for cervical dilatation, no solid conclusion has been reached. We therefore set out to perform a meta-analysis of RCTs. METHODS: We searched MEDLINE, the ISI Web of Science and the Cochrane Library to identify RCTs comparing misoprostol versus placebo or control prior to hysteroscopy. No restrictions on language or time were applied. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated for all dichotomous outcomes, whereas mean differences (MDs) and 95% CIs were calculated for continuous outcomes using the Mantel-Haenszel or DerSimonian-Laird model according to the heterogeneity. RESULTS: Of the initial 141 potentially relevant articles that were retrieved, 21 RCTs involving 1786 patients were included in the meta-analysis. Subgroup analyses were performed according to menopausal status and according to whether diagnostic or operative hysteroscopy was performed. Premenopausal women treated with misoprostol had a significantly lower risk for further cervical dilatation in the diagnostic setting [RR (95% CI): 0.56 (0.34-0.92)] and a significantly lower risk for cervical laceration in the operative setting [RR (95% CI): 0.22 (0.09-0.54)], compared with placebo. In contrast, post-menopausal patients did not experience any clear benefit from misoprostol compared with placebo regarding the need for further cervical dilatation [RR (95% CI): 0.99 (0.76-1.30)] and the cervical laceration rate [RR (95% CI): 1.15 (0.40-3.29)]. In addition, the mean cervical width prior to hysteroscopy was significantly higher in premenopausal women treated with misoprostol compared with placebo [MD (95% CI): 2.47 mm (1.81-3.13)] but did not differ among post-menopausal patients [MD (95% CI): 0.39 mm (-0.42 to 1.21)]. CONCLUSIONS: Misoprostol prior to hysteroscopy appears to facilitate an easier and uncomplicated procedure only in premenopausal women.

Elimination half-life of anti-Müllerian hormone.

CONTEXT: Anti-Müllerian hormone (AMH) is a glycoprotein that is secreted by the granulosa cells in the human ovary. In the postpubertal female, circulating AMH reflects the number of follicles within the ovary. It is mandatory to know the serum elimination half-life (t(1/2)) of AMH to study in vivo short-term changes of the hormone. OBJECTIVE: Our objective was to determine the kinetics of decay of AMH in the human female. PATIENTS, DESIGN, AND SETTING: Premenopausal women undergoing total abdominal hysterectomy plus bilateral salpingo-oophorectomy participated in this cohort study (n = 21) at an academic tertiary referral center. INTERVENTIONS: Serum samples were obtained immediately before surgery and in 12-h intervals thereafter for 8 d. MAIN OUTCOME MEASURE: AMH elimination was calculated, applying a one-compartment model with first-order kinetics. RESULTS: Mean preoperative AMH levels were 0.67 ng/ml (range, 0.1-1.78 ng/ml) and dropped to 0.08 ng/ml within 84 h after surgery. The AMH decay followed first-order kinetics. The mean terminal t(1/2) of AMH was calculated as 27.6 ± 0.8 h. CONCLUSION: AMH elimination reaches approximately 84% after 3 d, approximately 91% after 4 d, approximately 95% after 5 d, and can be considered complete after 8 d.

Evidence for non genomic action of 17ß estradiol on transepithelial resistance of human fetal membranes.

BACKGROUND: The role of hormones in the transport mechanisms of human fetal membranes in pregnancy is unclear. Estrogens are essential hormones in pregnancy and they play an important role in the ion transport via membranes. AIM: The aim of this study was to investigate the effect of 17ß-estradiol on transepithelial electrical resistance in the human amniochorion. MATERIAL AND METHODS: Specimens of human fetal membranes were obtained. 17ß-estradiol, tamoxifen and their combination were added in an Ussing chamber. Transepithelial resistance was measured before and after the addition of each solution. RESULTS: An increase in transepithelial resistance was seen after the addition of estradiol to both sides of the membranes. The effect was rapid with a peak at the 1st min of application and dose-depended. Tamoxifen, caused a similar effect but smaller in magnitude and shorter in duration. Tamoxifen in combination with estradiol inhibited only in part the action of estradiol. CONCLUSIONS: These results suggest that estradiol induces a rapid increase of transepithelial resistance in human fetal membranes in vitro via a non-genomic pathway. It is possible those changes in transepithelial resistance play a role in the control of permeability of human amniochorion.

Immature teratoma in pregnancy: a case report and literature review.

BACKGROUND: The management of a Stage I immature teratoma during pregnancy with a review of the literature is reported. CASE REPORT: A growing adnexal mass was removed at 12 weeks of gestation. Although the frozen section was negative, because of intraoperative clinical suspicion, a right salpingo-oophorectomy and surgical staging were performed. Histological examination revealed a Stage Ia, grade 1 immature ovarian teratoma. Appropriate surgical staging enabled avoidance of chemotherapy despite the unexpected histological diagnosis. The pregnancy was terminated because of fetal distress, with cesarean section at 34 weeks of gestation. At that time the peritoneal cavity was inspected and biopsies were taken as in second-look laparotomy. Two years after the first operation the patient remains disease free. CONCLUSION: For adnexal masses removed during pregnancy frozen section is useful but when there is clinical suspicion surgical staging must be performed.

Localisation and surgical treatment of insulinomas.

Most insulinomas are solitary, benign and functional neuroendocrine pancreatic tumours which give rise to manifold symptoms. Their preoperative localisation is often unclear, but the cure rate after their excision is very high. It was the aim of this study to analyse and evaluate our group of patients with regard to preoperative tumour localisation and overall surgical results. Twelve patients with a biochemical diagnosis of organic hyperinsulinism were surgically treated. Diagnosis was made with the combination of magnetic resonance imaging, computed tomography, selective angiography and intraoperative portal vein sampling. In five patients, the tumour was enucleated, in three patients Whipple procedure was performed; while three patients underwent left pancreatectomy with spleen preserving in two cases. The twelfth patient underwent total pancreatectomy following Whipple procedure performed elsewhere. There was no postoperative death. The complications were two pancreatic fistulas and two wound infections. The fasting pre- and postoperative plasma glucose mean value was 2.8 mm/l and 4.9 mm/l, respectively; while the pre- and postoperative plasma insulin mean value was 282 pm/l and 72 pm/l, respectively. Accurate diagnosis, preoperative localisation and diligent surgical exploration by experienced surgeons are the key to a successful outcome in patients with insulinomas.

Upper gastrointestinal bleeding due to primary aortoenteric fistula.

Primary aortoenteric fistula (PAEF) is a rare but clinically important cause of catastrophic gastrointestinal bleeding. "Herald bleeding" is a characteristic symptom which refers to specific case of upper gastrointestinal bleeding that stop temporarily spontaneously and then proceeds to massive bleeding. We present the case report of a 55-year-old male with PAEF who was admitted due to upper gastrointestinal bleeding. Endoscopic studies were unremarkable and patient underwent exploratory laparotomy. The postoperative course was uneventful. A high index of suspicion, early diagnosis and prompt appropriate surgical intervention are crucial for survival of patient with PAEF. Gastrointestinal bleeding combined with a negative endoscopy suggests PAEF. Endovascular operation is an attractive treatment option.