George Galazios

Vascular endothelial growth factor gene polymorphisms and pregnancy

Vascular endothelial growth factor (VEGF) is a major angiogenic factor and prime regulator of endothelial cell proliferation. During pregnancy, VEGF is essential for the proliferation of trophoblasts, the development of embryonic vasculature and the growth of maternal and fetal blood cells in utero. In cases of pre-eclampsia and in some circumstances of preterm labor-raised umbilical cord serum, VEGF levels might be correlated with the clinical development of the above pathological disorders. Genetic alteration as 936C/T VEGF gene polymorphism has a statistical significant correlation with the severity of pre-eclampsia. The same VEGF gene polymorphism, which has been associated with lower protein production, has an increased risk of spontaneous preterm delivery in a Greek-studied population. Homozygotes were found to carry the greatest risk with a lesser proportionate risk associated with heterozygosity, whereas women with the -1154 allele of the VEGF gene have an increased risk of recurrent pregnancy loss. In this review, we present evidence that demonstrates an implication of VEGF gene polymorphisms in the pathological disorders of pregnancy. However, further genetic studies are needed to confirm these data.

Relation between first trimester maternal serum leptin levels and body mass index in normotensive and pre-eclamptic pregnancies--role of leptin as a marker of pre-eclampsia: a prospective case-control study.

Objective. We measured first trimester plasma leptin concentrations in 37 women who subsequently developed pre-eclampsia and 53 normotensive controls to determine the interrelation between leptin and body mass index (BMI) in both groups. We further investigated the association between the risks for pre-eclampsia with maternal leptin levels. Methods. Bloods samples were collected at 13 weeks. Non-parametric tests, Spearmans correlation, linear regression analysis and multiple logistic regression analysis were applied in our data. Results. 1 kg/m2 increase in pre-pregnancy BMI was related to a 2.747 (95% CI: 3.242–2.252) ng/ml rise in leptin concentration among cases and 2.502 (95% CI: 2.873–2.131) ng/ml rise in leptin concentrations among controls. Increased leptin concentration (≥25.3 ng/ml ) in lean women is associated with a 18.8-fold increased risk of pre-eclampsia (adjusted OR: 18.8, CI: 1.8–194, p = 0.014 ). Leptin treated as a continuous variable is a significant predictor of pre-eclampsia (adjusted OR: 1.08, CI: 1.018–1.133, p = 0.009). Conclusion. Increased leptin concentration can definitely contribute to the prediction of pre-eclampsia in lean women, but this is not the case in overweight women. Further research in terms of longitudinal case–control studies is required to clarify the predictive value of pre-eclampsia.

Imbalance of mononuclear cell infiltrates in the placental tissue from foetuses after spontaneous abortion versus therapeutic termination from 8th to 12th weeks of gestational age

Placental macrophages (Hofbauer cells) are located close to trophoblastic cells and foetal capillaries, which make them perfect candidates for involvement in regulatory processes within the villous core. Their capacity of producing several cytokines and prostaglandin-synthesising enzymes, and expressing vascular endothelial growth factor, indicate a possible role in placental development and angiogenesis in order to support pregnancy. Common cells to Hofbauer macrophages sharing similar cell surface markers (HLA-A, -B, -C and leukocyte common antigen) have been reported in the stroma, decidua and amnion, indicating additional foetal protection. Yet this is not always the case. Most spontaneous abortions occur before 12 weeks’ gestation, and most are due to chromosomal errors in the conceptus. Relatively few truly spontaneous abortions take place between 12 and 20 weeks’ gestation. Thereafter, between 20 and 30 weeks, another type of premature spontaneous termination becomes prevalent, which is due to ascending infection. The numbers of cells expressing the various markers of the monocytemacrophage lineage change throughout pregnancy. In the present study, we investigated the immunohistochemical expression of mononuclear infiltrations in paraffin-embedded placentas, from foetuses after spontaneous abortion (8th, 10th and 12th weeks of gestational age), and those after therapeutic abortion at the same time, using a panel of monoclonal antibodies for the identification of leukocytes (CD45/LCA), B-lymphocytes (CD20/L-26), T lymphocytes (CD45RO/UCHL1), CD68 and CD14 cells. Immunologic factors in human reproductive failure are plausible mechanisms of infertility and spontaneous abortion. Approximately 25% of cases of premature ovarian failure appear to result from an autoimmune aetiology. Unfortunately, current therapeutic options for these women are limited to exogenous hormone or gamete substitution. Local inflammations at the sites of endometriosis implants are postulated to mediate the pain and reduced fecundability associated with this clinical syndrome. The recruitment of immune cells, particularly monocytes and T-cells, neovascularisation around foci of invading peritoneal lesions, and the possible development of antiendometrial autoantibodies support an immunologic basis of this disorder. To date, treatment of pain and infertility associated with endometriosis is primarily surgical, although immune-based adjuvants are theoretical possibilities for the future. Finally, although hypotheses supporting immunologic mechanisms of recurrent pregnancy loss have been popular over the past decade, most clinical investigations in this area do not provide compelling evidence for this position. Reputable specialists in reproductive medicine use experimental immunotherapies judiciously in selected cases of repetitive abortion. For example, the use of anticoagulation therapy can be beneficial in cases with documented antiphospholipid antibodies. At present, however, efficacious immunotherapy protocols for general application have not been established. Despite these caveats, continued strides in our understanding of human reproductive immunology should yield considerable future progress in this field. During the physiological changes that occur in the first and in the beginning of the second trimester of pregnancy, spiral arteries of the placental bed are converted into the uteroplacental arteries. The essence of this conversion consists of losing the muscular elements in the vessel walls, making them unable to respond to vasomotor influences. Cells that infiltrate the walls of spiral arteries and replace their normal elements are called migratory, non-villous or intermediate trophoblastic cells. Besides infiltrating and replacing the anatomic structures of spiral arteries, intermediate trophoblastic cells also penetrate into the lumina of these vessels forming endovascular plugs. These plugs are one of the reasons why early uteroplacental blood flow cannot be visualised, even with transvaginal ultrasound, during the first 12 weeks of gestation. In uncomplicated pregnancies, the endovascular trophoblast is bound to disappear by the end of the second trimester of pregnancy, but the literature on this topic is scarce. Here we describe the detection, isolation and characterisation of CD45RO-, L26- and CD68/CD14-positive cells from human early pregnancy deciduas. These cells were found in close vicinity to endometrial glands, with preference to the basal layer of the decidua. We conclude that (1) maternal cells, apparently CD45RO/UCHL1-positive cells, cross the maternofoetal barrier and participate in spontaneous (involuntary) abortions, and (2) a small proportion of maternal cells (approximately 30%), apparently CD68/CD14-positive cells, also cross the maternal-foetal barrier and cause growth delay and recurrent reproductive failure. Further investigation of involvement of the intercellular adhesion molecules 1 and 2, platelet endothelial cell adhesion molecule, vascular cell adhesion molecule and E-selectin in leukocyte accumulation will be needed to support the passage of maternal cells to the foetus. The results were statistically significant (P<0.0001, Student’s t-test).

Correlation between maternal first trimester plasma leptin levels and birth weight among normotensive and preeclamptic women

Objective. To determine the connection between maternal first trimester serum leptin levels and newborn weight. Methods. The study included 37 preeclamptic women and 53 normotensive women who considered the control group. Maternal blood samples were withdrawn at 13 weeks of gestation for the measurement of leptin concentrations. Birth weights were transformed to z-scores according to maternal and obstetrical features, based on customised centiles. Non-parametric tests, students t-test, Pearsons correlation, Spearmans correlation and linear regression analysis were performed in our analysis. Results. Pre-pregnancy body mass index and first trimester maternal plasma leptin levels were significantly higher among women with preeclampsia (p = 0.015 and p < 0.001, respectively). Birth weight z-score was negatively correlated with leptin levels (r = −0.570, p < 0.001), in preeclamptic group and in control group (r = −0.477, p < 0.001). The regression modelling demonstrated a significant negative association between birth weight z-scores and leptin for both groups. Conclusion. Maternal first trimester serum leptin demonstrates a significant negative association with neonatal weight in preeclamptic pregnancies and to a lesser extent in normotensive pregnancies. A possible leptins involvement in pathophysiological adaptations that define the foetal growth potential can be supported.

Cytologic diagnosis of axillary lymph node metastasis in breast cancer.

OBJECTIVE To compare imprint cytology with histology as a method for rapid intraoperative diagnosis of axillary lymph node metastasis in breast cancer. STUDY DESIGN We evaluated imprint cytology, comparing it with histopathology. A sample of 635 axillary lymph nodes was studied by imprint cytology using both Giemsa stain and hematoxylin-eosin. The results were compared with each other and with those of histopathologic examination. RESULTS The Giemsa stain method, as compared to histopathology, had 94% accuracy, 97% sensitivity, 90% specificity and 94% positive prognostic value. The hematoxylin-eosin stain method was less accurate than the Giemsa stain method as compared to histopathology (accuracy 91%, sensitivity 96%, specificity 83% and positive prognostic value 92%). CONCLUSION These data confirm the value of imprint cytology as a rapid, reliable method of intraoperative assessment of axillary lymph node metastasis in breast cancer. It results in better staging of the disease. It can be used intraoperatively, as an alternative to frozen section, if a pathology laboratory is not available, to exclude stage I patients from further treatment.

Incidence and Detection of Contralateral Breast Cancer

Abstract: In this study we estimated the efficacy of contralateral breast biopsy as a subsidiary method of early detection of bilateral breast cancer. We performed blind biopsies in the upper outer quadrant of the opposite breast in 195 patients undergoing surgical treatment for primary breast cancer. The histologic examination of the biopsy specimens showed 12 malignant lesions, which accounts for an incidence of 6.1%. In detail, we had two infiltrating ductal cancers, two infiltrating lobular cancers, three ductal in situ cancers, and five lobular in situ cancers. The overall incidence of invasive disease was 2.05%. We concluded that contralateral breast biopsy should be reconsidered as a method for enhancing early detection of contralateral breast cancer in high‐risk groups, especially when it meets the emotional needs of patients. Permission given, it is included in the main surgical treatment of patients, avoiding the cost and complications of anesthesia, and it is cosmetically acceptable, without being an emotional burden for the woman.

Induction of hepatic haematopoiesis with fibronectin expression by EMT stromal cells during the second trimester of development

In an initial period of vertebrate phylogeny (bone marrow-less vertebrates), lymphohaematopoiesis takes place in numerous organs containing a suitable microenvironment. Among other organs (i.e., gonads, kidney and spleen), the liver is apparently the most appropriate site for homing and differentiation of haematopoietic cell precursors. Interaction between haematopoietic cells and stromal cells is important for regulation of haematopoiesis. Numerous soluble and membrane-bound factors directly regulating haematopoiesis have been documented, but little is known about the effect of the foetal hepatic epithelial-to-mesenchymal transition (EMT) stromal cells’ activity and their product-fibronectin, on foetal hepatic haematopoiesis. The binding of late-stage erythroid cells to FN has been well characterised and is believed to be critical for the terminal stages of erythroid differentiation. The intention of this article is to provide a quantitative overview of FN, produced by hepatic EMT stromal cells, in foetal hepatic haematopoiesis during the first and second trimester of development. Paraffin-embedded specimens from the liver of 30 human embryos in the first and second trimesters of gestation were investigated by conventional histology and immunohistology for the presence of FN and specific haematopoietic cell types. The staining intensity, and localisation of FN and haematopoietic markers in sequential sections were examined. Furthermore, double immunohistochemical staining was performed to assess simultaneous detection of FN and haematopoietic markers. FN was expressed in the EMT stromal cells of the hepatic portal triads more strongly during the second trimester than the first. Furthermore, an intense immunostaining for haematopoietic lineages, and especially for erythropoiesis, was observed in the second trimester compared to the first. The results of the double immunostaining disclosed an intimate co-expression of the FN and CD haematopoietic markers. Foetal hepatic EMT stromal cells provide a unique microenvironment that supports the emergence, expansion and maintenance of human foetal haematopoietic development during the mid-gestational stage. FN produced by the EMT stromal cells follows a time course parallel to that of haematopoiesis. We suggest that in foetal liver, phenotypic modifications of EMT stromal cells expressing FN concerning the cell adhesion capacity of the protein are associated with proliferation and differentiation of specific haematopoietic cell lineages during the second trimester of gestation, probably reflecting the increasing demand of the growing foetus for mature erythroid and myeloid cells.

Endometrial injury for RIF patients undergoing IVF/ICSI: a prospective nonrandomized controlled trial.

Abstract To evaluate the effect of endometrial injury on clinical outcomes in subfertile women with repeated implantation failures (RIF) undergoing assisted reproduction. In this prospective nonrandomized controlled trial, 103 subfertile women with RIF were included. Fifty-one underwent endometrial injury through hysteroscopy in the early follicular phase of the previous cycle and 52 underwent the standard protocol without any intervention. Live birth and miscarriage were the primary outcomes. Clinical and in vitro fertilization (IVF) cycle characteristics, were also compared between groups. Both groups were comparable in terms of baseline and cycle characteristics. Live birth rates were significantly higher in the study, compared with the control group (18/51 vs. 8/52, odds ratio (OR) = 0.25; 95% confidence interval (CI) = 0.10–0.64; p = 0.020), although miscarriage rates were similar (7/51 vs. 10/52, OR= 0.25; 95%CI= 0.12–0.66; p = 0.452). The rest of the outcomes parameters were comparable between groups. Logistic regression analysis revealed that endometrial injury and duration of subfertility were independent predictors of live birth after control of other variables (OR = 2.818; 95%CI = 1.044–7.605; p = 0.041 and OR = 0.674; 95%CI = 0.461–0.985, p = 0.042, respectively). Endometrial injury induced through office hysteroscopy in the preceding cycle in subfertile women with RIF improves live birth rates.

Postoperative accelerated radiotherapy with cytoprotection followed by three-dimensional conformal boost in patients with early endometrial/cervical cancer

AIMS AND BACKGROUND Adjuvant external beam radiotherapy is highly recommended for uterine carcinomas invading beyond the inner half of the myometrium or cervical stage IIa carcinomas. The addition of a booster intracavitary dose is widely used. METHODS We assessed the feasibility and toxicity of a hypofractionated accelerated conformal radiotherapy scheme (2.7 Gy per fraction, for 14 consecutive fractions to the pelvis) supported with the cytoprotective agent amifostine (HypoARC). The amifostine dose was individualized (500-1000 mg daily subcutaneously). A booster dose of radiation was given to the vagina and stump using a 6-field 3D-conformal technique (3 x 4 Gy or 4 x 3 Gy) instead of intracavitary radiotherapy. RESULTS Grade 2 diarrhea appeared in 9/25 (36%) and grade 1 cystitis in 7/25 (28%) cases. Analysis according to the amifostine dose level clearly showed reduced toxicity in patients receiving a daily dose of 750-1000 mg (P < 0.009). Within a median follow-up of 31 months (range, 11-52), there was only one case with grade 2 colitis (the patient had received no amifostine). None of the patients treated has relapsed locally or to distant organs within a median of 31 months of follow-up. CONCLUSIONS It is concluded that HypoARC followed by 3D-conformal booster dose to the vagina is feasible and convenient for patients and for busy radiotherapy departments, as it reduces the overall time by 50%. When supported by high-dose daily amifostine, it has an impressively low rate of early and late radiation toxicity.

Ten Years of Experience in Contraception Options for Teenagers in a Family Planning Center in Thrace and Review of the Literature

Introduction: The goal of our study was to investigate and evaluate the contraceptive behavior in teenagers from our family planning centre that services two different religious and socioeconomic populations living in the Thrace area. Methods: During the last 10 years 115 Christian Orthodox (group A) and 53 Muslim teenagers (group B) were enrolled in our retrospective study. Contraceptive practice attitudes were assessed by a questionnaire. Religion, demographics, socio-economic characteristics were key factors used to discuss contraception and avoid unplanned pregnancy in each group and to compare with the contraceptive method used. Results: The most used contraceptive method—about two times more frequently—among Christian Orthodox participants was the oral contraceptive pill (p = 0.015; OR = 1.81, 95% CI = 1.13–2.90), while in the other group the use of condoms and IUDs was seven and three times more frequent, respectively. Our family planning centre was the main source of information for contraception. Conclusions: During adolescence, the existence of a family planning centre and participation in family planning programs plays a crucial role to help the teenagers to improve their knowledge and choose an effective contraception method.