SLN biopsy in cervical cancer patients with tumors larger than 2cm and 4cm.

OBJECTIVES: The aim of this study was to assess the detection rate, false-negative rate and sensitivity of SLN in LN staging in tumors over 2cm on a large cohort of patients. METHODS: Data from patients with stages pT1a - pT2 cervical cancer who underwent surgical treatment, including SLN biopsy followed by systematic pelvic lymphadenectomy, were retrospectively analyzed. A combined technique with blue dye and radiocolloid was modified in larger tumors to inject the tracer into the residual cervical stroma. RESULTS: The study included 350 patients with stages pT1a - pT2. Macrometastases, micrometastases, and isolated tumor cells were found in 10%, 8%, and 4% of cases. Bilateral detection rate was similar in subgroups with tumors<2cm, 2-3.9cm, and ≥4cm (79%, 83%, 76%) (P=0.460). There were only two cases with false-negative SLN ultrastaging for pelvic LN status among those with bilateral SLN detection. The false negative rate was very low in all three subgroups of different tumor sizes (0.9%, 0.9%, and 0.0%; P=0.999). Sensitivity reached 96% in the whole group and was high in all three groups (93%, 93%, 100%; P=0.510). CONCLUSIONS: If the tracer application technique is adjusted in larger tumors, SLN biopsy can be equally reliable in pelvic LN staging in tumors smaller and larger than 2cm. The bilateral detection rate and false negative rate did not differ in subgroups of patients with tumors<2cm, 2-3.9cm, and ≥4cm.

Pelvic floor reconstruction by modified rectus abdominis myoperitoneal (MRAM) flap after pelvic exenterations.

OBJECTIVE: To describe the technique and report experiences with pelvic floor reconstruction by modified rectus abdominis myoperitoneal (MRAM) flap after extensive pelvic procedures. METHODS: Surgical technique of MRAM harvest and transposition is carefully described. The patients in whom pelvic floor reconstruction with MRAM after either infralevator pelvic exenteration and/or extended lateral pelvic sidewall excision was carried out were enrolled into the study (MRAM group, n=16). Surgical data, post-operative morbidity, and disease status were retrospectively assessed. The results were compared with a historical cohort of patients, in whom an exenterative procedure without pelvic floor reconstruction was performed at the same institution (control group, n=24). RESULTS: Both groups were balanced in age, BMI, tumor types, and previous treatment. Substantially less patients from the MRAM group required reoperation within 60days of the surgery (25% vs. 50%) which was due to much lower rate of complications potentially related to empty pelvis syndrome (1 vs. 7 reoperations) (p=0.114). Late post-operative complication rate was substantially lower in the MRAM group (any grade: 79% vs. 44%; grade≥3: 37% vs. 6%) (p=0.041). The performance status 6months after the surgery was ≤1 in the majority of patients in MRAM (81%) while in only 38% of patients from the control group (p=0.027). There was one incisional hernia in MRAM group while three cases were reported in the controls. CONCLUSIONS: Pelvic floor reconstruction by MRAM in patients after pelvic exenterative procedures is associated with a substantial decrease in postoperative complications that are potentially related to empty pelvis syndrome.

[Contribution of sentinel lymph-node biopsy to treatment of locally advanced stages of cervical cancers]. / Prínos biopsie sentinelových uzlin pro lécbu lokálne pokrocilých stadií karcinomu delozního hrdla.

OBJECTIVE: Usage of sentinel lymph-node (SLN) concept in locally advanced cervical cancers might help to individualise management. According to SLN status could be patients refered to neoadjuvant chemotherapy (NAC) with subsequent surgery or to primary chemoradiation. The aim of our study was to evaluate sensitivity of SLN detection in locally advanced cervical cancers and to assess the impact of NAC on frequency of their metastatic involvement. DESIGN: Retrospective clinical study. SETTING: Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Medical Faculty, Charles University, Prague. MATERIALS AND METHODS: Included were patients with cervical cancer stages FIGO IB1 (> 3 cm), IB2, IIA2 and selected cases of stages IIB with incipient parametrial involvement. Patients were distributed into two different protocols - patients in group NAC-SLN were refered to radical hysterectomy with SLN biopsy after 3 cycles of NAC, other patients (group SLN) underwent SLN biopsy and NAC was administered only in SLN-negative cases. RESULTS: Altogether 101 patients were included (group SLN = 62, group NAC-SLN = 39). Detection of SLN in whole cohort reached 90.1% per patient and 68.3% bilaterally. No differences were found between SLN group and NAC-SLN group in frequency of per patient SLN detection (90.3% vs 89.7%) and bilateral detection (69.4% vs 66.7%). Prevalence of macrometastases, micrometastases and ITC in the SLN group was 37.1% (23/62), 11.3% (7/62) and 8.1% (5/62), respectively. In the NAC-SLN group macrometastases in SLN were detected in 17.9% (7/39) patients, in 1 patient was detected micrometastis in SLN and no patient had ITC. Difference in frequency of metastases in SLN was significant (p = 0,013). No patient had progressed during NAC, complete response was seen in 15.1% (11/73) patients and reduction of tumour volume > 30% in 84.9% (62/73) patients. CONCLUSIONS: Detection of SLN in locally advanced cervical cancers reached comparable results to early stages. NAC did not influence frequency of SLN detection, but it significantly decreased prevalence of metastatic SLN involvement.

Risk of micrometastases in non-sentinel pelvic lymph nodes in cervical cancer.

OBJECTIVE: A high sensitivity of sentinel lymph nodes (SLN) for pelvic lymph node (LN) staging has been repeatedly shown in patients with cervical cancer. However, since only SLN are evaluated by pathologic ultrastaging, the risk of small metastases, including small macrometastases (MAC) and micrometastases (MIC), in non-SLN is unknown. This can be a critical limitation for the oncological safety of abandoning a pelvic lymphadenectomy. METHODS: The patients selected for the study had cervical cancer and were at high risk for LN positivity (stage IB-IIA, biggest diameter≥3cm). The patients had no enlarged or suspicious LN on pre-operative imaging; SLNs were detected bilaterally and were negative on intra-operative pathologic evaluation. All SLNs and all other pelvic LNs were examined using an ultrastaging protocol and processed completely in intervals of 150µm. RESULTS: In all, 17 patients were enrolled into the study. The mean number of removed pelvic LNs was 30. A total of 573 pelvic LNs were examined through ultrastaging protocol (5762 slides). Metastatic involvement was detected in SLNs of 8 patients (1× MAC; 4× MIC; 3× ITC) and in non-SLNs in 2 patients (2× MIC). In both cases with positive pelvic non-SLNs, there were found MIC in ipsilateral SLNs. No metastasis in pelvic non-SLNs was found by pathologic ultrastaging in any of the patients with negative SLN Side-specific sensitivity was 100% for MAC and MIC. There was one case of ITC detected in non-SLN, negative ipsilateral SLN, but MIC in SLN on the other pelvic side. CONCLUSIONS: After processing all pelvic LNs by pathologic ultrastaging, there were found no false-negative cases of positive non-SLN (MAC or MIC) and negative SLN. SLN ultrastaging reached 100% sensitivity for the presence of both MAC and MIC in pelvic LNs.

Pregnancy-associated plasma protein A polymorphisms in patients with risk pregnancies.

Pregnant women are often threatened by hypertension, symptoms of preterm labour, hepatopathy, and other. These complications might be the consequence of genetic factors together with involvement of environmental factors. We were searching for three polymorphisms Arg654Lys, Ala678Pro and Thr686Ala in exon 5, and two polymorphisms Phe802Leu, Ser827Ser/Leu in exon 7, and for the new mutations in exons 5 and 7 of the pregnancy-associated plasma protein A gene in the studied group consisting of 203 women - 79 pregnant women in time of preterm labour, 24 pregnant women suffering from preeclampsia, and 100 healthy pregnant and non-pregnant women serving as controls. We did not find any divergence from wild-type form of these polymorphisms in any of the studied groups, which led us to the hypothesis that these polymorphisms are not associated with our studied group of Caucasian origin. However, further studies with a larger group of subjects are needed to confirm our results.

[Progesterone neuroactive metabolites in human pregnancy]. / Progesteron a jeho neuroaktivní metabolity v mechanismu porodu.

OBJECTIVE: Review of the physiological role of neuroactive and neuroprotective steroids in human pregnancy. DESIGN: A review article. SETTING: Gynecological-Obstetrical Clinic, 1st Medical Faculty, Charles University and General Hospital, Prague. CONCLUSION: Human parturition is a multi-factorial process. Various mechanisms related to the onset of labor were suggested. Estrogens show accelerating increase in late pregnancy, which probably reflect the increasing activity of fetal zone of the fetal adrenal. This zone is stimulated by progressive increase of placental CRH resulting in excessive production of conjugated 3beta-hydroxy-5-en-steroids, which are transported by circulation to placenta and further metabolized to active hormones. Some progesterone metabolites probably participate in pregnancy sustaining via modulation of ligand-gated ion channels in the CNS and periphery. In this review, the question was addressed whether the catabolism of pregnancy sustaining progesterone metabolites accelerate like the estrogen formation.

Is maternal progesterone actually independent of the fetal steroids?

Progesterone and estradiol are the foremost steroid hormones in human pregnancy. However, the origin of maternal progesterone has still not been satisfactorily explained, despite the generally accepted opinion that maternal LDL-cholesterol is a single substrate for placental synthesis of maternal progesterone. The question remains why the levels of progesterone are substantially higher in fetal as opposed to maternal blood. Hence, the role of the fetal zone of fetal adrenal (FZFA) in the synthesis of progesterone precursors was addressed. The FZFA may be directly regulated by placental CRH inducing an excessive production of sulfated 3beta-hydroxy-5-ene steroids such as sulfates of dehydroepiandrosterone (DHEAS) and pregnenolone (PregS). Due to their excellent solubility in plasma these conjugates are easily transported in excessive amounts to the placenta for further conversion to the sex hormones. While the significance of C19 3beta-hydroxy-5-ene steroid sulfates originating in FZFA for placental estrogen formation is mostly recognized, the question "Which maternal and/or fetal functions may be served by excessive production of PregS in the FZFA?" - still remains open. Our hypothesis is that, besides the necessity to synthesize de novo all the maternal progesterone from cholesterol, it may be more convenient to utilize the fetal PregS. The activities of sulfatase and 3beta-hydroxysteroid dehydrogenase (3beta-HSD) are substantially higher than the activity of cytochrome P450scc, which is rate-limiting for the placental progesterone synthesis from LDL-cholesterol. However, as in the case of progesterone synthesis from maternal LDL-cholesterol, the relative independence of progesterone levels on FZFA activity may be a consequence of substrate saturation of enzymes converting PregS to progesterone. Some of the literature along with our current data (showing no correlation between fetal and maternal progesterone but significant partial correlations between fetal and maternal 20alpha-dihydroprogesterone (Prog20alpha) and between Prog20alpha and progesterone within the maternal blood) indicate that the localization of individual types of 17beta-hydroxysteroid dehydrogenase is responsible for a higher proportion of estrone and progesterone in the fetus, but also a higher proportion of estradiol and Prog20alpha in maternal blood. Type 2 17beta-hydroxysteroid dehydrogenase (17HSD2), which oxidizes estradiol to estrone and Prog20alpha to progesterone, is highly expressed in placental endothelial cells lining the fetal compartment. Alternatively, syncytium, which is directly in contact with maternal blood, produces high amounts of estradiol and Prog20alpha due to the effects of type 1, 5 and 7 17?-hydroxysteroid dehydrogenases (17HSD1, 17HSD5, and 17HSD7, respectively). The proposed mechanisms may serve the following functions: 1) providing substances which may influence the placental production of progesterone and synthesis of neuroprotective steroids in the fetus; and 2) creating hormonal milieu enabling control of the onset of labor.

Pathophysiology of preterm labour.

A specific pathogenic process of premature delivery represents the inflammation. Birth canal infections seem to play a key role in the ethiopathogenesis of premature delivery; the related biochemical changes significantly affect perinatal morbidity and mortality. Other potential causes, particularly hormone metabolism disorders or uteroplacental ischaemia have been intensively studied. This process is related both to the mother and fetus. Fetal inflammatory response (FIRS)--can occur without maternal response--and it is related to a significant increase in perinatal morbidity. FIRS has definite laboratory, histological and clinical criteria. Effective primary prevention of premature delivery does not exist at present. The sensitivity and specificity of so far used laboratory markers is low. Thus, the research is focused on finding new inflammation markers allowing the early identification of pregnant women at a high risk of premature delivery and fetal inflammation. The screening of women at a high risk by means of new laboratory and ultrasound tests belongs to the most important steps in secondary and tertiary prevention of premature delivery. Intensive research of potential trigger mechanisms has been carried out, including a variety of gene types, which are potentially related to the process of premature delivery.

[News in pathophysiology and management of preterm labour]. / Novinky v patofyziologii a managementu predcasného porodu.

OBJECTIVE: To summarize available data concerning pathophysiology and management of preterm labour and their use in clinical practice. SETTING: Department of Obstetrics and Gynecology od the First Faculty of Medicine, Charles University, and General Teaching Hospital, Prague. DESIGN: Review article. METHODS: Compilation od published data from scientific literature. CONCLUSION: Birth canal infections seem to play a key role in the ethiopathogenesis of premature delivery; the related biochemical changes significantly affect perinatal morbidity and mortality. Other potential causes, particularly hormone metabolism disorders or uteroplacental ischaemia have been intensively studied. The particular pathogenetic process of premature delivery is inflammation. This process is related to both mother and fetus. Fetal inflammatory response (FIRS)--can occur without maternal response--is connected with significant increase in perinatal morbidity. FIRS is characterised by defined laboratory, histological and clinical criteria. Effective primary prevention of premature delivery does not exist at present. The sensitivity and specificity of the laboratory markers having been used so far is low. Thus, the research is focused on finding new inflammation markers to allow early identification of pregnant women at a high risk of premature delivery and fetal inflammation. The screening of women at a high risk by means of new laboratory and ultrasound tests belongs to the most important steps in secondary and tertiary prevention of premature delivery. Intensive research of potential trigger mechanisms has been carried out, including a variety of gene types, which are potentially related to the process of premature delivery. We try to exercise new informations about pathophysiology of preterm labour in prenatal care, firstly about thrombophillias and gestagens. We also use a principles of "evidence based medicine" and revalue importance of steroids, tocolytics and antibiotics.

Prenatal and perinatal management of preterm labour.

New knowledge of the pathophysiology of premature birth enables us to introduce new approaches in prenatal care as well as the management of premature delivery. These apply for the patients with subclinical risk factors, particularly with thrombophilias, chronic infections or other latent chronic infections. The peri- and pre-conceptional dispensarisation of these women might help reduce the development of premature delivery. Secondary prevention with the administration of gestagens is highly important for women with anamnestic or existing risk of premature delivery. During the underlying premature delivery, it is advisable to re-evaluate the significance of the administration of antibiotics and tocolytics as well as timing of corticoid dosage in the induction of foetal lung maturity. Using new diagnostic and therapeutic methods, the aim of present premature delivery management is to prolong the duration of pregnancy to the maximum with the lowest risk of the development of foetal inflammatory response possible and, therefore, with a low risk of long-term handicaps in children.

Advanced glycoxidation end products in patients with multiple sclerosis.

Advanced glycoxidation end products (AGEs) play an important role in the pathogenesis of neurodegenerations and we studied if AGEs could represent a useful marker in patients with multiple sclerosis (MS). AGE-products were assessed in cerebrospinal fluid (CSF) and serum of 31 patients with MS and 8 controls. We did not find any statistically significant differences in patients with MS and controls either in CSF or in serum. We have observed a significant association between pentosidine and total AGEs as well as a relationship of both to the protein content in CSF in MS patients. Despite of the involvement of both oxidative stress and RAGE (receptor for AGEs) in the pathogenesis of MS and its experimental model, neither pentosidine nor total AGE were shown as useful markers in this indication. Other compounds and ligands of RAGE are probably of higher significance in MS.

Results obtained in short-term experiments and their application prospects in prognosticating threshold levels of chronic exposure to chemical compounds.

Joint studies carried out by toxicologists of CMEA countries have led to the development of new ways of approach to the problem of rapid establishment of toxicometric parameters and hygienic standards (TSEL, MAC) for the working-zone atmosphere. One of the most promising approaches is the rapid establishment of MAC from the threshold of acute specific effect. Upon this principle, methodical directives for determining MAC values for specifically active irritants were elaborated. A study of the quantitative relations between toxicometric parameters and the physicochemical properties of substances in the working-zone atmosphere furnished methods for calculating TSEL values for noxious substances in this atmosphere. The essential possibility was confirmed of using isolated mitochondria as a model for preliminarily estimating the toxicity and establishing safe concentration levels of noxious substances in the working-zone atmosphere. The application of a complex of functional, biochemical and morphometric indices made it possible to foretell from short-term experiments minimal effective concentrations of a substance on chronic exposure. Ways of further research in the field of prognosticating toxicometric parameters and hygienic regulations for chemical compounds are outlined.