Baptist Trimbos

BCL‐2 IMMUNOREACTIVITY INCREASES WITH SEVERITY OF CIN: A STUDY OF NORMAL CERVICAL EPITHELIA, CIN, AND CERVICAL CARCINOMA

The presence of the BCL‐2 protein, a marker for inhibition of programmed cell death, was studied in a series of routinely processed cervical tissues, consisting of normal endocervical (n=40) and ectocervical epithelium (n=27), squamous metaplastic epithelium (n=30), CIN (cervical intraepithelial neoplasia) lesions (n=32), and cervical carcinomas (n=13). BCL‐2 was strongly expressed in the basal cell compartment of normal ectocervical squamous epithelium and in nearly all reserve cells, while in endocervical columnar cells it was moderately expressed. In immature squamous metaplastic epithelium, BCL‐2 expression varied. Half of the cases showed only basal cell staining, while the other half showed staining also in suprabasal layers. BCL‐2 could be detected in all premalignant lesions, showing a striking increase in the number of positive cells with increasing severity of CIN, in combination with a mild increase in staining intensity. All adenocarcinomas were positive (n=5), while five of eight squamous cell carcinomas expressed BCL‐2. Based on these results, it is hypothesized that both the larger number of cells staining with BCL‐2 in higher grades of CIN and the increase in staining intensity imply an increasing protection of these neoplastic conditions against programmed cell death. This protection facilitates not only continuing proliferation, but also the induction of genetic instability in dysplastic epithelial cells; it may thus reflect the greater capacity of the more severe CIN lesions to evolve into cervical carcinoma.

Human papilloma virus specific T cells infiltrating cervical cancer and draining lymph nodes show remarkably frequent use of HLA-DQ and -DP as a restriction element.

Human papillomavirus (HPV)‐induced malignancies are frequently infiltrated by lymphocytes. To comprehend the contribution of HPV‐specific T cells in this anti‐tumor response we developed a method that allowed the analysis of the presence and specificity of cervix‐infiltrating and draining lymph node resident T cells in a group of 74 patients with cervical malignancies, 54 of which were induced by HPV16 or HPV18. We detected the presence of HPV16 or HPV18‐specific T cells in at least 23 of the 54 HPV‐16 or ‐18 positive patients, and not in the 20 controls. Detailed studies resulted in the identification of 17 novel CD4+ and CD8+ T cell epitopes and their HLA‐restriction elements, and also revealed that the HPV‐specific immune response was aimed at both E6 and E7 and showed no preferential recognition of immunodominant regions. Unexpectedly, the vast majority of the CD4+ T cell epitopes were presented in the context of the less abundantly expressed HLA‐DQ and HLA‐DP molecules. Since the identified T cell epitopes constitute physiological targets in the immune response to HPV16 and HPV18 positive tumors they will be valuable for detailed studies on the interactions between the tumor and the immune system. This is crucial for the optimization of cancer immunotherapy in patients with pre‐existing tumor‐immunity.

Cognitive-affective correlates and predictors of superficial dyspareunia

This study investigated the role of cognitive-affective variables related to sexuality, chronic pain, individual and relational well-being in superficial dyspareunia. Although symptomatic women (n = 80) differed from complaint-free controls (n = 62) on all variables, sexuality related measures had the most important contribution into the prediction of group membership. Dyspareunia subgroups based on the presence/absence of a concomitant diagnosis of provoked vestibulodynia were only distinguishable on pain intensity but not on variables related to sexuality and psychological well-being. The present findings underscore the relevance of psychosexual factors in women with superficial dyspareunia.

Value of an objective assessment tool in the operating room

BACKGROUND Concerns about the achievement of surgical proficiency during residency are increasing. To objectify surgical skills, the Objective Structured Assessment of Technical Skills (OSATS) was developed and proven valid, feasible and reliable for use in laboratory settings. This study aimed to evaluate the value of this tool for intraoperative use. METHODS Residents were assessed with an OSATS after every procedure they performed as the primary surgeon during a 3-month clinical rotation in gynecological surgery. We mapped individual learning curves (OSATS scores plotted against experience) and established the average procedure-specific learning curve. We used linear mixed models to assess the relation between performance and experience. RESULTS Nine residents were recruited and 319 OSATS analyzed. Individual learning curves revealed progression beyond 24 of 30 OSATS points for 7 residents. Performance on the average procedure improved with experience, and the OSATS score increased by an average of 1.10 points per assessed procedure (p=0.008, 95% confidence interval 0.44-1.77). Median OSATS scores ranged from 18 to 30 among the 21 assessors. CONCLUSION Intraoperative implementation of OSATS seems to offer important advantages: structured feedback is facilitated, and learning curves enable insight into individual progression. However, doubts have been raised about the objectivity of the tool. Therefore, caution is warranted in using it for graduation and certification.

Progressing imbalance between proliferation and apoptosis with increasing severity of cervical intraepithelial neoplasia

The equilibrium between cell proliferation and protection against apoptosis was studied immunohistochemically using monoclonal antibodies against Ki-67-Ag and bcl-2, respectively, in consecutive sections from normal and metaplastic cervical epithelia and cervical intraepithelial neoplasia (CIN) lesions and cervical carcinomas. A high percentage of Ki-67-Ag positive cells was seen in the parabasal cells of normal ectocervical and mature squamous metaplastic epithelium, although the basal cells were virtually negative. In preneoplastic lesions, however, the basal cells showed high proliferative activity and an increasing frequency of Ki-67-Ag positive cells was observed in the higher epithelial layers with increasing severity of CIN. In squamous cell carcinomas, variable numbers of Ki-67-Ag positive cells were observed and in adenocarcinomas expression increased with the degree of anaplasia. bcl-2 expression was observed only in the basal cells of normal endo- and ectocervix including reserve cells. With increasing severity of CIN, staining intensity and number of bcl-2 positive cells gradually increased. Five of eight squamous cell carcinomas were variably positive. All five adenocarcinomas showed extensive bcl-2 expression. Increased expression of both Ki-67-Ag and bcl-2 with increasing severity of CIN indicates an increasing imbalance between cell proliferation and protection from apoptosis. It is therefore proposed that an increasing proliferative fraction combined with a higher number of cells protected from apoptotic cell death contributes to progression of CIN. This phenotype may identify premalignant lesions with the potential to transform to cervical cancer.

Follow‐up after incomplete hysteroscopic removal of uterine fibroids

Background. In this observational study, we analysed whether a period of wait and see was reasonable following incomplete removal of submucous fibroids, with regard to symptoms of abnormal uterine bleeding, and whether factors predicting subsequent surgery could be identified. Methods. In 3 affiliated hospitals, patients with incomplete removal of submucous fibroids, treated with hysteroscopic myomectomy for abnormal uterine bleeding, between January 1997 and January 2005, were followed over time. Using life‐table analysis (Kaplan‐Meier method), the cumulative proportion of women having surgery‐free survival following incomplete removal of submucous fibroids was calculated. Cox‐proportional hazard analyses were used to analyse relationships of variables with recurrence of symptoms. Results. Forty‐one consecutive patients met the inclusion criteria, and were followed over time. The mean age was 42.5 years (range 27–55). The majority of patients with incomplete removal of submucous fibroids were diagnosed with type 2 fibroids. Termination of the procedure before complete removal was achieved, was principally caused by reaching the maximum fluid deficit (90.2%). The surgery‐free percentages were 70.2% (95%‐CI: 55.3–85.1) at 1 year, 54.8% (95%‐CI: 38.1–70.7) at 2 years, and 44.2% (95%‐CI: 26.9–61.5) at 3 years. Size of fibroid (diameter) pre‐operatively turned out to be of statistically significant influence, with a hazard ratio of 1.762 (95%‐CI: 1.114–2.787) per cm increase in diameter (p = 0.016). Conclusions. The results indicate that incomplete removal does not always seem to necessitate subsequent surgery. Instead of subsequent surgery immediately post‐operatively, a wait and see policy is worth considering after incomplete removal.

Immunotherapeutic strategies for cervical squamous carcinoma.

Progress in developing preventive and therapeutic vaccines for HPV-associated diseases has been made in the last few years, but continued studies are needed to evaluate the clinical feasibility of different vaccination approaches and to determine a clinically effective and safe one. The perfect HPV vaccine will have both preventive and therapeutic capabilities, and because it is likely to be used world-wide, especially in developing countries, it must also have low production costs.

Synergistic effects of the sesquiterpene lactone, EPD, with cisplatin and paclitaxel in ovarian cancer cells

BackgroundOvarian cancer remains still the leading cause of death of gynecological malignancy, in spite of first-line chemotherapy with cisplatin and paclitaxel. Although initial response is favorably, relapses are common and prognosis for women with advanced disease stays poor. Therefore efficacious approaches are needed.MethodsPreviously, an anti-cancer agent, EPD exhibited potent cytotoxic effects towards ovarian cancer and not towards normal cells. Cell viability and cell cycle analysis studies were performed with EPD, in combination with cisplatin and/or paclitaxel, using the ovarian carcinoma cell lines: SK-OV-3, OVCAR-3, JC, JC-pl and normal fibroblasts. Cell viability was measured using Presto Blue and cell cycle analysis using a flow cytometer. Apoptosis was measured in JC and JC-pl , using the caspase 3 assay kit.ResultsIn JC-pl, SK-OV-3 and JC, synergistic interactions between either EPD and cisplatin or EPD and paclitaxel were observed. For the first time the effects of EPD on the cell cycle of ovarian cancer cells and normal cells was studied. EPD and combinations of EPD with cisplatin and/ or paclitaxel showed cell cycle arrest in the G2/M phase. The combination of EPD and cisplatin showed a significant synergistic effect in cell line JC-pl, while EPD with paclitaxel showed synergistic interaction in JC. Additionally, synergistic drug combinations showed increased apoptosis.ConclusionsOur results showed a synergistic effect of EPD and cisplatin in an ovarian drug resistant cell line as well as a synergistic effect of EPD and paclitaxel in two other ovarian cell lines. These results might enhance clinical efficacy, compared to the existing regimen of paclitaxel and cisplatin.

Cosmetic results of lower midline abdominal incision: Donati stitches versus a continuous intracutaneous suture in a randomized clinical trial

Background. The objective of this study was to compare the cosmetic outcome of two different closing techniques for lower midline abdominal incisions: a continuous intracutaneous suture versus interrupted Donati stitches.Methods. Eighty patients undergoing gynecological surgery through a lower midline abdominal incision were randomized. The cosmetic outcome of the scar was assessed by independent observers and the patients at 8 days and 4–6 months after the operation using visual analog scales and a validated scoring system for hypertrophy, width, color, and cross‐hatching. Patients also completed a visual analog scale for postoperative pain on both occasions. The accumulated data were statistically evaluated using two‐sided χ2, Students t, or Mann–Whitney tests with a confidence interval of 95%. Results. Closing a lower midline abdominal laparotomy wound with an absorbable intracutaneous suture did not take more time than using Donati stitches. Laparotomy scores were only significantly better in the intracutaneous group at the first assessment, one week after the operation. The cosmetic visual analog scale scores by both independent observers and patients were slightly better in the intracutaneous group but the difference was not statistically significant. There was also no significant difference between visual analog scale scores for pain felt around the scar. Conclusions. This study shows that in the opinion of both independent observers and patients, scar cosmetics are not significantly different when using Donati skin sutures or an intracutaneous suture to close a lower midline laparotomy wound. The two methods do not differ either in time‐consuming aspects or postoperative pain perception.

Detection of cervical intraepithelial neoplasia in women with atypical squamous or glandular cells of undetermined significance cytology: A prospective study

Background.  (1) To assess the prevalence of histologically confirmed cervical intraepithelial neoplasia in patients with cervical smears diagnosed as atypical squamous or glandular cells of undetermined significance. (2) To evaluate the role of colposcopy and the presence of human papillomavirus in detecting underlying cervical intraepithelial neoplasia.