Heinrich Husslein

Plasma Fibrinogen Levels and Prognosis in Patients with Ovarian Cancer: A Multicenter Study

INTRODUCTION To evaluate pretherapeutic plasma fibrinogen levels as a prognostic parameter in patients with epithelial ovarian cancer (EOC). Materials and Methods. In the present multicenter study, pretherapeutic plasma fibrinogen levels were evaluated in 422 patients with EOC. Plasma fibrinogen levels were correlated with clinicopathological parameters and patient survival. RESULTS The mean (standard deviation) pretherapeutic plasma fibrinogen level was 450.0 (150.1) mg/dl. Elevated plasma fibrinogen levels were associated with advanced tumor stage (p = .01) and the presence of a postoperative residual tumor mass (p < .001), but not with histological grade (p = .1) and histological type (p = .8). In a multivariate Cox regression model, tumor stage (p < .001 and p < .001), postoperative residual tumor mass (p = .001 and p = .008), and plasma fibrinogen level (p < .001 and p = .002), but not histological type (p = .8 and p = .2), patient age (p = .9 and p = .9), and serum cancer antigen 125 (p = 0.2 and p = 0.3) and C-reactive protein (p = .2 and p = .3) levels, were associated with disease-free and overall survival, respectively. Histological grade was associated with overall but not with disease-free survival (p = .01 and p = .8), respectively. CONCLUSIONS Pretherapeutic plasma fibrinogen levels can be used as an independent prognostic parameter in patients with EOC.

Enhanced epithelial to mesenchymal transition (EMT) and upregulated MYC in ectopic lesions contribute independently to endometriosis

BackgroundEpithelial to mesenchymal transition (EMT) is a process in which epithelial cells lose polarity and cell-to-cell contacts and acquire the migratory and invasive abilities of mesenchymal cells. These abilities are thought to be prerequisites for the establishment of endometriotic lesions. A hallmark of EMT is the functional loss of E-cadherin (CDH1) expression in epithelial cells. TWIST1, a transcription factor that represses E-cadherin transcription, is among the EMT inducers. SNAIL, a zinc-finger transcription factor, and its close relative SLUG have similar properties to TWIST1 and are thus also EMT inducers. MYC, which is upregulated by estrogens in the uterus by an estrogen response cis-acting element (ERE) in its promoter, is associated with proliferation in endometriosis. The role of EMT and proliferation in the pathogenesis of endometriosis was evaluated by analyzing TWIST1, CDH1 and MYC expression.MethodsCDH1, TWIST1, SNAIL and SLUG mRNA expression was analyzed by qRT-PCR from 47 controls and 74 patients with endometriosis. Approximately 42 ectopic and 62 eutopic endometrial tissues, of which 30 were matched samples, were collected during the same surgical procedure. We evaluated TWIST1 and MYC protein expression by immunohistochemistry (IHC) in the epithelial and stromal tissue of 69 eutopic and 90 ectopic endometrium samples, of which 49 matched samples were analyzed from the same patient. Concordant expression of TWIST1/SNAIL/SLUG and CDH1 but also of TWIST1 and MYC was analyzed.ResultsWe found that TWIST1, SNAIL and SLUG are overexpressed (p < 0.001, p = 0.016 and p < 0.001) in endometriosis, while CDH1 expression was concordantly reduced in these samples (p < 0.001). Similar to TWIST1, the epithelial expression of MYC was also significantly enhanced in ectopic endometrium compared to eutopic tissues (p = 0.008). We found exclusive expression of either TWIST1 or MYC in the same samples (p = 0.003).ConclusionsEpithelial TWIST1 is overexpressed in endometriosis and may contribute to the formation of endometriotic lesions by inducing epithelial to mesenchymal transition, as CDH1 was reduced in ectopic lesions. We found exclusive expression of either TWIST1 or MYC in the same samples, indicating that EMT and proliferation contribute independently of each other to the formation of endometriotic lesions.

Postoperative gum chewing after gynecologic laparoscopic surgery: a randomized controlled trial.

OBJECTIVE: To investigate the effect of postoperative gum chewing on bowel motility after laparoscopic gynecologic surgery. METHODS: In this randomized controlled trial, patients were allocated to either postoperative gum chewing every 2 hours for 15 minutes or standard postoperative care without gum chewing. The studys primary end points were time to first regular bowel sounds and time to first passage of flatus after surgery. Secondary end points were time of operation to first defecation, patient satisfaction concerning postoperative gum chewing, potential side effects of postoperative gum chewing, and potential effect of gum chewing on postoperative pain therapy. RESULTS: One hundred seventy-nine patients were included in this trial. We found a significantly shorter interval between surgery and passage of first flatus in the intervention group compared with the control group (median 6.2 hours compared with 8.1 hours; P=.002) and a significantly higher rate of regular bowel sounds 3 hours (76% compared with 47%; P<.001) and 5 hours (91% compared with 78%; P=.01) after surgery. Fewer opioid analgetics were administered to patients allocated to the intervention group (P=.02). There was no significant difference in time to first defecation between groups (median 26.3 hours compared with 29.0 hours, P=.165). Gum chewing was well tolerated and well accepted by patients, and no intervention-related side effects were observed. CONCLUSION: Gum chewing seems to have beneficial effects on bowel motility when used as an adjunct treatment in postoperative care after minimally invasive surgery. Gum chewing should be recommended to patients after gynecologic laparoscopic surgery. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.gov, NCT 01549353. LEVEL OF EVIDENCE: I

Designing a Standardized Laparoscopy Curriculum for Gynecology Residents: A Delphi Approach

BACKGROUND Evidence suggests that simulation leads to improved operative skill, shorter operating room time, and better patient outcomes. Currently, no standardized laparoscopy curriculum exists for gynecology residents. OBJECTIVE To design a structured laparoscopy curriculum for gynecology residents using Delphi consensus methodology. METHODS This study began with Delphi methodology to determine expert consensus on the components of a gynecology laparoscopic skills curriculum. We generated a list of cognitive content, technical skills, and nontechnical skills for training in laparoscopic surgery, and asked 39 experts in gynecologic education to rate the items on a Likert scale (1-5) for inclusion in the curriculum. Consensus was predefined as Cronbach α of ≥0.80. We then conducted another Delphi survey with 9 experienced users of laparoscopic virtual reality simulators to delineate relevant curricular tasks. Finally, a cross-sectional design defined benchmark scores for all identified tasks, with 10 experienced gynecologic surgeons performing the identified tasks at basic, intermediate, and advanced levels. RESULTS Consensus (Cronbach α=0.85) was achieved in the first round of the curriculum Delphi, and after 2 rounds (Cronbach α=0.80) in the virtual reality curriculum Delphi. Consensus was reached for cognitive, technical, and nontechnical skills as well as for 6 virtual reality tasks. Median time and economy of movement scores defined benchmarks for all tasks. CONCLUSIONS This study used Delphi consensus to develop a comprehensive curriculum for teaching gynecologic laparoscopy. The curriculum conforms to current educational standards of proficiency-based training, and is suggested as a standard in residency programs.

Association between pregnancy-associated plasma protein-A and gestational diabetes requiring insulin treatment at 11-14 weeks of gestation.

Objective: To evaluate whether gestational diabetes mellitus (GDM) requiring insulin treatment (White’s classification A2) is associated with an alteration of pregnancy-associated plasma protein-A (PAPP-A) serum levels at first-trimester screening between 11 and 14 weeks of gestation. Methods: We collected data (2007–2010) of all women who developed GDM requiring insulin treatment and completed first-trimester combined screening program including the determination of serum PAPP-A and free β-human chorionic gonadotropin (β-hCG). A total of 288 women were included in this study. Each of the 72 women who developed GDM was matched with three unaffected controls. Results: Women with GDM were significantly older (34.2 ± 5.9 vs. 32.3 ± 5.5 years, P = 0.007) and delivered significantly earlier (38.40 ± 2.25 vs. 39.1 ± 2.2 gestational weeks, P = 0.01). Multiple regression analysis revealed, that PAPP-A and β-hCG were independently associated with each other (P = 0.04) but there was no association between GDM/no GDM and the first-trimester serum markers (P = 0.77). Conclusion: Our data suggest that women who are developing GDM needing insulin treatment do not have altered PAPP-A levels at 11–14 weeks.

Comprehensive study of angiogenic factors in women with endometriosis compared to women without endometriosis

OBJECTIVE Endometriosis is a benign gynaecological disease, affecting women during their reproductive years. Angiogenesis represents a crucial step in the pathogenesis of endometriosis, because endometriotic lesions require neovascularization. In this study several angiogenesis-related genes have been studied in the context of endometriosis. Some of the analyzed angiogenic factors as well as their interactions were studied the first time regarding a possible association with endometriosis. STUDY DESIGN This case-control study consisted of 205 biopsies of 114 patients comprising 61 endometriosis patients and 53 control patients. Among them in 29 cases paired samples were obtained. VEGFA, VEGFR2, HIF1A, HGF, NRP1, PDGFB, FGF18, TNFα, TGFB2, EPHB4, EPO and ANG mRNA expression was analyzed by qRT-PCR in ectopic tissue samples, in eutopic endometrium of women with and without endometriosis, and in unaffected peritoneum of women with and without endometriosis. RESULTS VEGFR2, HIF1A, HGF, PDGFB, NRP1 and EPHB4 are overexpressed in ectopic lesions compared to eutopic tissues. VEGFR2, HGF, PDGFB, NRP1, and EPHB4 showed highest mRNA levels in peritoneal implants, in contrast HIF1A showed the highest expression in ovarian endometriomas. Correlation analyses of angiogenic factors in ectopic lesions revealed the strongest associations between VEGFR2, PDGFB, and EPHB4. We further showed a significant upregulation of VEGFR2, HIF1A and EPHB4 in eutopic endometrium of women with endometriosis compared to that of controls and a trend towards upregulation of HGF. Additionally, a significant downregulation for HIF1A, HGF and EPHB4 was observed in unaffected peritoneal tissues of women with endometriosis compared to controls. CONCLUSION We identified new genes (EPHB4 and NRP1) that may contribute to angiogenesis in endometriosis beside known factors (VEGFA, VEGFR2, HIF1A, HGF, and PDGFB). Correlation studies revealed the putative importance of EBHB4 in association with endometriosis. Our analyses support preliminary reports that angiogenic factors seem to be differently expressed in peritoneal implants, ovarian endometriomas and deep infiltrating endometriosis. Our observation that angiogenic factors are differently expressed in the unaffected peritoneum of women with endometriosis compared to women without endometriosis underlines the importance of the peritoneum in the establishment of endometriosis.

Global and single gene DNA methylation in umbilical cord blood cells after elective caesarean: a pilot study.

OBJECTIVE To evaluate global and single gene methylation patterns as a sign for epigenetic modulation of the immune system in infants born by elective cesarean section (CS) and vaginal delivery (VD). STUDY DESIGN For this prospective pilot study a two step approach was chosen. Initially 41 newborn infants comprising 23 delivered by VD and 18 delivered by elective CS were included. Global DNA methylation of umbilical cord blood was determined. In a second step, methylation status of 96 single genes linked to T cell activation, cytokine production, inflammatory response, and stem cell transcription was evaluated in 48 newborn infants, 20 delivered by VD and 28 delivered by CS. RESULTS Global methylation did not differ significantly between CS and VD (p=0.732). The methylation status was low (threshold: ≤3%) for the majority of single genes (n=92) in both groups. FOXP3, CD7, ELA2, and IRF1 showed hypermethylation in both groups. In the CS group, ELA2 (p<0.001) and IRF1(p =0.017) showed significantly higher methylation compared to the VD group. CONCLUSION We found no difference in global methylation between newborn infants in the VD group compared to the elective CS group. Methylation of single genes was significantly higher in newborn infants delivered by elective CS. Further research is needed to determine the significance of theses findings.

Soluble VCAM-1/soluble ICAM-1 ratio is a promising biomarker for diagnosing endometriosis

Study question Do cell adhesion molecules play a role in endometriosis, and can they be used as a biomarker for diagnosing endometriosis? Summary answer Altered expression of vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1) in the endometrium and peritoneum may play a key role in endometriosis and the soluble VCAM-1/soluble ICAM-1 ratio is a promising biomarker. What is known already Cell adhesion molecules are cell surface proteins that mediate cellular adherence, inflammatory and immune responses, and cancer-related biological processes. Altered expression of VCAM-1 and ICAM-1 in women with endometriosis has been investigated previously; however, gene expression levels in tissues and protein levels in the serum have not been investigated in the same patients. Study design size, duration We performed a prospective, longitudinal study (the Endometriosis Marker Austria) in patients who underwent a laparoscopy for benign gynecological pathology in a university-based tertiary referral center for endometriosis. From a total of 138 women who were included in the study from July 2013 through September 2014, 97 had not received hormonal treatment for at least 3 months prior to recruitment and were included in the analysis; 49 (50.5%) of these women had endometriosis, and the 48 (49.5%) who did not have endometriosis served as a control group. Participants/materials setting methods During laparoscopy, tissue samples were obtained from ectopic and eutopic endometrium, and from normal pelvic peritoneum. In addition, serum samples were collected immediately before and 6-10 weeks after surgery. The mRNA levels of VCAM-1, ICAM-1 and epithelial cell adhesion molecule (EpCAM) were measured using quantitative real-time PCR, and serum protein levels of soluble VCAM-1 (sVCAM-1), ICAM-1 (sICAM-1) and EpCAM (sEpCAM) were measured using ELISA and correlated with endometriosis status. Main results and the role of chance The mRNA levels of both VCAM-1 and ICAM-1 were higher in ectopic endometriotic lesions than in eutopic endometrium (P < 0.001). Moreover, the mRNA levels of both VCAM-1 and ICAM-1 were higher in normal peritoneum samples obtained from women with endometriosis compared to those from controls (P = 0.038 and P = 0.009). The mRNA levels of VCAM-1 were also higher in the eutopic endometrium samples obtained from women with endometriosis compared to controls (P = 0.018). With respect to serum protein levels, compared to controls, the women with endometriosis had lower serum levels of sICAM-1 (P = 0.042) and higher levels of sVCAM-1 (P < 0.001). Our analysis revealed that the serum levels of sVCAM-1 were not affected by lesion entity, menstrual cycle phase or disease severity. An receiver operating characteristics curve, calculated to determine whether preoperative serum sVCAM-1 concentration can be used to predict endometriosis, found an AUC of 0.868 with 80% specificity and 84% sensitivity at a cutoff value of 370 pg/ml. This predictive performance can be further improved by calculation of the sVCAM-1/sICAM-1 ratio, leading to an AUC of 0.929 with 86.7% specificity and 90.3% sensitivity at a cutoff ratio value of 1.55. Large scale data Not applicable. Limitations reasons for caution The relatively small sample size in the expression analyses is a possible limitation of this study. Wider implications of the findings Our findings could contribute to an improved understanding of the pathogenesis of endometriosis and the role of cell adhesion molecules. In addition, the results may lead to the development of new, non-invasive tools for diagnosing endometriosis. The ability to diagnose patients by measuring serum sVCAM-1 levels or the sVCAM-1/sICAM-1 ratio would have considerable clinical value. Study funding/competing interest(s) The Ingrid Flick Foundation (Grant no. FA751C0801), which played no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors declare no competing interests.

Prospective evaluation of the learning curve of fertiloscopy with and without ovarian drilling

Fertiloscopy represents an alternative to laparoscopy in the diagnostic evaluation of unexplained infertility or for the purpose of ovarian drilling. The learning curve of fertiloscopy in an experienced laparoscopic surgeon was evaluated in a prospective multicentre observational trial. A total of 110 fertiloscopies were carried out. At Centre 1, a beginner, and at Centre 2, an expert in fertiloscopy, performed the procedures. In three cases in Centre 1, and in 0 cases in Centre 2, the procedure was converted to transabdominal laparoscopy owing to intraoperative complications. Median operating time was longer at Centre 1 during the first 40 procedures (P < 0.001) and equal thereafter. Analyzing fertiloscopies with and without ovarian drilling separately, operating time was only longer for the first 20 procedures in each group (P < 0.001 and P = 0.002). In a multivariate analysis, intraoperative complications and fertiloscopy with ovarian drilling (compared with diagnostic fertiloscopy) were associated with longer duration of surgery (P < 0.001 for both parameters). An increasing consecutive number of fertiloscopies was associated with shorter duration of surgery (P < 0.001). Experienced laparoscopists should consider a transition towards fertiloscopy in the diagnostic workup of unexplained infertility or for the purpose of ovarian drilling.

A Tool to Support Surgical Quality Assessment

In the domain of medical endoscopy an increasing number of surgeons nowadays store video recordings of their interventions in a huge video archive. Among some other purposes, the videos are used for post-hoc surgical quality assessment, since objective assessment of surgical procedures has been identified as essential component for improvement of surgical quality. Currently, such assessment is performed manually and for selected procedures only, since the amount of data and cumbersome interaction is very time-consuming. In the future, quality assessment should be carried out comprehensively and systematically by means of automated assessment algorithms. In this demo paper, we present a tool that supports human assessors in collecting manual annotations and therefore should help them to deal with the huge amount of visual data more efficiently. These annotations will be analyzed and used as training data in the future.