Obstetric neuraxial analgesia - is it a matter of ethnic disparity?

OBJECTIVE: Pain is an essential element of humane childbirth. Neuraxial analgesia is the most effective method for relieving pain during childbirth. More and more women are using this type of analgesia in childbirth. The aim of the study was to identify ethnic differences in the application of neuraxial analgesia. SUBJECTS AND METHODS: The research was conducted through a face-to-face survey. The respondents are patients after vaginal delivery. The experimental group consists of patients of the ethnic minority, the Romani group (32 women), and the control group consists of patients of the majority, the Serb group (99 women). We investigated the quality and quantity of prenatal care, information about regional anesthesia, and its application in these two groups. RESULTS: There is a significant ethnic disparity between the Serb and Romani ethnic groups. Patients of the Romani ethnic group have qualitatively and quantitatively poorer antenatal care, less information regarding the use of neuraxial analgesia, and use it significantly less often. CONCLUSIONS: Neuraxial analgesia must be available to all patients regardless of ethnicity or social status.

Significance of the Ki-67 proliferation index in the assessment of the therapeutic response to cisplatin-based chemotherapy in patients with advanced cervical cancer.

OBJECTIVE: The purposes of this study were to examine the therapeutic response of advanced cervical cancer to Ki-67 proliferative index (Ki-67 PI) dependent cisplatin chemotherapy, and to determine Ki-67 PI referential value that is expected to provide a satisfactory therapeutic response of cervical cancer to cisplatin chemotherapy. PATIENTS AND METHODS: This prospective study enrolled 59 patients treated for cervical cancer at Clinic for Oncology, Clinical Center Nis, Serbia. According to the obtained Ki-67 PI values, patients were divided into three groups, and all the patients received the same cytostatic, cisplatin. Therapeutic response to chemotherapy was evaluated in relation to disease progression presence or absence and progression-free survival after a year follow-up since the first chemotherapy. RESULTS: Survival rate increases with an increase of Ki-67 PI by Kaplan-Meier survival analysis, meaning that survival rate is statistically significantly shorter in the group of patients with Ki-67 PI < 40% in comparison to patients from other two groups (p=0.010). Mann-Whitney test confirmed a statistically significant increase in survival rate among the groups of patients formed according to Ki-67 PI (p<0.05). Kaplan-Meier survival analysis confirmed that the mean survival rate in the group of patients with Ki-67 PI values over 60% is statistically significantly longer in comparison to patients with Ki-67 PI values below or equal 60% (p<0.001). CONCLUSIONS: Advanced cervical cancer with a high Ki-67 PI expression responds better to cisplatin-based chemotherapy, thus resulting in a longer survival rate. The values of Ki-67 PI were determined: high Ki-67 PI (≥ 60%), moderate Ki-67 PI (40-60%), and low Ki-67 PI (≤ 40%).

Ascites in Ovarian Carcinoma - Reliability and Limitations of Cytological Analysis.

OBJECTIVE: The objective of this study was to examine the validity of ascitic fluid cytology in the detection of pathological findings, to examine the percentage of false positive and false negative results in the cytology of ascitic fluid and to determine the validity of peritoneal cytology in relation to the histopathological type of the ovarian tumour. METHODS: This retrospective study included 170 peritoneal cytology findings. The study was conducted from January 2010 to December 2012. The experimental group included 76 cytology findings obtained from patients diagnosed with ovarian carcinoma, whereas the control group was composed of 94 cytology findings of benign ovarian tumours and liver cirrhosis ascites. The patients with ovarian carcinoma had grades III, as well as grades I and IIc but only in cases where operative and pathological finding indicated a ruptured or perforated tumour capsule. RESULTS: The sensitivity of peritoneal cytology is 68.92%, specificity is 93.61%, positive predictive value is 89.65% and negative predictive value is 78.57%. In 30.02% of patients, the peritoneal cytology showed false negative results, while in 6.38%, the results were false positive. The highest percentage of false negative findings was 77%, found in endometrioid carcinoma. CONCLUSION: Peritoneal cytology of ascitic fluid is highly specific but has relatively low sensitivity, particularly in the case of endometrioid ovarian carcinoma. In order to increase sensitivity, peritoneal cytology should be combined with monoclonal antibodies and other biochemical and immunohistochemical markers.

Current approach to epithelial ovarian cancer based on the concept of cancer stem cells.

Epithelial ovarian cancer (EOC) is the most common ovarian malignancy. EOCs comprise a diverse group of neoplasms, exhibiting a wide range of morphological characteristics, genetic alterations, and biological behaviors. Currently, there is no effective screening for early detection of EOCs and more than two-thirds of EOC patients are diagnosed with advanced stage disease. The major limiting factors in the treatment of EOC patients are recurrence and chemoresistance. Recent studies suggest that EOCs, like other solid tumors, contain distinct populations of cells that are responsible for tumor initiation, maintenance and growth. These cells, termed cancer stem cells (CSCs), display some of the features of normal stem cells and are thought to evade current chemotherapeutic strategies for the treatment of EOCs. Distinguishing CSC-associated antigen profiles may elucidate novel, more sensitive biomarkers for early detection of EOCs and provide molecular targets for the development of new treatment modalities. This review summarizes the current approaches to EOCs based on the concept of CSCs and evaluates their clinical relevance.

The application of magnetic resonance imaging in preoperative evaluation of patients with endometrial carcinoma.

PURPOSE: The aim of this paper was to assess the usefulness of the preoperative application of magnetic resonance (MRI) imaging in patients with confirmed endometrial carcinoma. METHODS: This prospective study included 50 patients with endometrial cancer. MRI was used for preoperative disease staging and in planning the operative treatment. The parameters monitored by MRI were compared with the findings of curettage pathological examination. Estimated were the depth of myometrial invasion, the involvement of the cervix by the tumor, the presence of adnexal metastases and regional lymph nodes. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV) of the MRI in relation to the aforementioned clinicopathological parameters were assessed. RESULTS: The presence of myometrial invasion was estimated with 100% specificity, 86% sensitivity, 100% PPV and 40% NPV. The estimation of the depth of myometrial invasion (>or<50%) was defined with 89% sensitivity, 54% specificity, 83% PPV and 60% NPV. MRI provided valuable data about cervical invasion (100% PPV for the presence of cervical invasion and 55% PPV for the depth of cervical invasion), thereby helping to decide on the kind of surgical intervention, the choice of approach (open or laparoscopic surgery) and the choice of the surgeon. CONCLUSION: MRI is useful and reliable in preoperative evaluation. The information obtained by MRI provides space and time for planning the treatment modality.

Recurrence of cervical intraepithelial neoplasias with negative cone margins: risk factors.

PURPOSE: The percent of young patients treated for cervical intraepithelial neoplasias (CIN) has been increasing, thus it is very important to define patients in high risk for relapse. The aim of this study was to establish any possible association of persistent human papillomavirus (HPV) infection, age, smoking, parity, use of oral contraceptives, and Chlamydia infection, with relapse of CIN. METHODS: Between March 2006 and March 2009 a prospective clinical study was performed at the Clinic of Obstetrics and Gynecology in Nis, with the study group comprising the first 35 patients with disease relapse after conization and the control group consisting of 30 patients with more than one year after treatment without relapse. HPV typization was done at the Laboratory for Molecular Biology and Cytogenetics of the Clinical Centre Nis using polymerase chain reaction (PCR). RESULTS: A statistically significant higher percentage of recurrences with lower pathologic stage (CIN I) was found in younger women (below 29 years) (p<0.01). Women in the control group were more commonly non smokers (56.66 vs. 40%) but without statistical significance (p>0.05). The distribution of smoked cigarettes in the study and control subjects showed no statistically significant difference (p>0.05). Patients with recurrences were more commonly HPV-positive compared to controls (68.57 vs. 6.66%; p <0.05). In the study group, HPV-positive smokers recurred with more advanced grades (CIN III and microinvasive carcinoma/MIC; p<0.01). In non smokers, the severity of recurrence was not statistically correlated with HPV positivity. CONCLUSION: Persistent HPV infection, smoking associated with HPV infection and more advanced age were demonstrated to be of statistical significance for CIN recurrence. Parity, use of oral contraceptives, Chlamydia infection, and smoking as independent etiologic factors were not significantly associated with CIN relapse.

Primary carcinoma of the vagina.

In this paper we reviewed the risk factors for primary carcinoma of the vagina (PCV), diagnostic and therapeutic modalities, and principles leading to rational decision-making in the individualized management of vaginal carcinoma patients. The review was based on the recent literature and our own years- long experience with the disease. PCV is a rare gynecologic malignancy accounting for about 2% of all neoplasms of the female genitals. Most of the affected women are over 60 years of age, peaking between 70 and 80 years. Only 10-15% of patients are below 50 years. Histopathologically, most common are squamous cell carcinoma (80-90%) and adenocarcinoma (4-10%). The leading risk factor for vaginal intraepithelial neoplasia (VAIN) and subsequent squamous cell vaginal carcinoma is long-lasting infection with human papillomavirus (HPV) type 16. Prognosis of the disease depends on several factors, the most important of which are age, histologic type, and tumor stage. Survival depends on the disease stage. Five -year survival rates are about 95% for stage 0, 75% for stage I, 60% for stage II, 35% for stage III, 20% for stage IVa, and 0% for IVb stage. Due to its being a rare entity, there are still controversies as to the most optimal treatment. Individualized treatment approaches have been increasingly used. In most centres, standard treatment for this cancer is radiotherapy. Some reports have shown that surgery might also be an option, while in some centres radiation is supplemented by cisplatin-based chemotherapy. The supposed advantage of radiotherapy is the preservation of the anatomy and function of the vagina. We believe that there are certain psychologic benefits with the preservation of the vagina, regardless of its function. However, preservation of the vaginal function after treatment of invasive vaginal cancer is a rare phenomenon, both in the literature and from our own experience.

Risk factors and adjuvant chemotherapy in the treatment of endometrial cancer.

Endometrial carcinoma is the most common and potentially curable gynecologic malignant neoplasm. The staging of endometrial cancer, according to the International Federation of Gynecology and Obstetrics (FIGO), is surgical. Recent studies suggest a therapeutic benefit associated with extensive retroperitoneal lymph node evaluation to determine the disease extent and thereby more effectively direct potentially life-saving adjuvant therapy. Due to the increasing number of endometrial cancer patients who undergo surgical staging, some independent prognostic factors have been identified in early stages (stage I-II), including lymph-vascular space involvement, histologic grade 3, aggressive histologic subtypes (uterine papillary serous carcinoma, clear cell carcinoma), depth of myometrial invasion, cervical invasion and the age of patients. Adjuvant radiation therapy, known to offer survival benefit in advanced-stage disease, may also offer survival benefit in intermediate-risk surgical stage I, but this is followed by a significant risk of serious complications. Based on randomized clinical trials, this review identified that only a limited body of evidence is available which can help clinicians make decisions about adjuvant chemotherapy of patients with high-risk stage I and II, as well as stage IIIA endometrial cancer. Further investigations are required to define the subgroup of patients who benefit from postoperative adjuvant chemotherapy. In addition, the optimal regimen remains to be defined as all of them (doxorubicin/cisplatin--AP, cyclophosphamide/ doxorubicin/cisplatin--CAP, paclitaxel/carboplatin--TC, paclitaxel/doxorubicin/cisplatin--TAP) cause significant toxicity. Thereby, combination of carboplatin plus paclitaxel represents an efficacious, low-toxicity regimen for managing intermediate-risk surgical stage I, as well as advanced or recurrent endometrial cancer.