Ingolf Juhasz-Boess

Ovarian ectopic pregnancy: diagnosis, treatment, correlation to Carnegie stage 16 and review based on a clinical case

OBJECTIVE To present a case of a vital ectopic pregnancy after 8 weeks that was located in the right ovary. DESIGN Case study and literature review. SETTING Hospital outpatient clinic. PATIENT(S) A 29-year-old primigravida presented with lower abdominal pain and mild vaginal bleeding at 8 weeks after her last menstrual period. INTERVENTION(S) Wedge resection of the ovary which did not affect subsequent fertility. MAIN OUTCOME MEASURE(S) Conservative treatment options and preservation of patients reproductive capacity. RESULT(S) The embryo was laparoscopically removed in toto and visualized. Therefore, macroscopic correlation to Carnegie stage 16 of development was possible. CONCLUSION(S) Approximately 3% of all ectopic pregnancies are located in the ovaries. Preoperative diagnosis of this extremely rare condition is challenging, because the ectopic tumor often resembles cysts of the corpus luteum. At surgery, the trophoblast tissue or the embryo can rarely be visualized completely.

Genetic polymorphism of the OPG gene associated with breast cancer

BackgroundThe receptor activator of NF-κB (RANK), its ligand (RANKL) and osteoprotegerin (OPG) have been reported to play a role in the pathophysiological bone turnover and in the pathogenesis of breast cancer. Based on this we investigated the role of single nucleotide polymorphisms (SNPs) within RANK, RANKL and OPG and their possible association to breast cancer risk.MethodsGenomic DNA was obtained from Caucasian participants consisting of 307 female breast cancer patients and 396 gender-matched healthy controls. We studied seven SNPs in the genes of OPG (rs3102735, rs2073618), RANK (rs1805034, rs35211496) and RANKL (rs9533156, rs2277438, rs1054016) using TaqMan genotyping assays. Statistical analyses were performed using the χ2-tests for 2 x 2 and 2 x 3 tables.ResultsThe allelic frequencies (OR: 1.508 CI: 1.127-2.018, p=0.006) and the genotype distribution (p=0.019) of the OPG SNP rs3102735 differed significantly between breast cancer patients and healthy controls. The minor allele C and the corresponding homo- and heterozygous genotypes are more common in breast cancer patients (minor allele C: 18.4% vs. 13.0%; genotype CC: 3.3% vs. 1.3%; genotype CT: 30.3% vs. 23.5%). No significantly changed risk was detected in the other investigated SNPs. Additional analysis showed significant differences when comparing patients with invasive vs. non-invasive tumors (OPG rs2073618) as well as in terms of tumor localization (RANK rs35211496) and body mass index (RANKL rs9533156 and rs1054016).ConclusionsThis is the first study reporting a significant association of the SNP rs3102735 (OPG) with the susceptibility to develop breast cancer in the Caucasian population.

Postoperative Quality of Life and Sexual Function in Premenopausal Women Undergoing Laparoscopic Myomectomy for Symptomatic Fibroids: A Prospective Observational Cohort Study.

Introduction Uterine leiomyomas are the most common benign gynecologic tumors. To date laparoscopy myomectomy is the gold standard for treatment of symptomatic fibroids in reproductive-aged women. Detailed counseling about the effects of this procedure on postoperative sexuality and quality of life is important in these patients. However, available data on these subjects are limited and contradictory. The aim of this study was to assess sexual function and quality of life in premenopausal women undergoing laparoscopic myomectomy for symptomatic uterine fibroids. Material and Methods All premenopausal women who underwent laparoscopic myomectomy for symptomatic fibroids between April 2012 and August 2014 at a tertiary university center were enrolled in this prospective observational cohort study. Sexual function and quality of life were assessed for the pre- and postoperative (six months post-operatively) state using two validated questionnaires, the Female Sexual Function Index (FSFI) and the European Quality of Life Five-Dimension Scale (EQ-5D). Results Ninety-five of the 115 (83%) eligible patients completed the study. Overall a significant improvement in quality of life and sexual function was observed in the study cohort: Median FSFI (28 (18.7–35.2)) and EQ-5D scores (1 (0.61–1) after laparoscopic myomectomy were significantly higher than preoperative scores (21.2 (5.2–33.5); 0.9 (0.2–1); p ≤ 0.01). The number, position and localization of the largest fibroids were not correlated with pre- or postoperative sexual function or quality of life. Conclusion Laparoscopic myomectomy might have positive short-term effects on postoperative quality of life and sexual function in premenopausal women suffering from symptomatic fibroids.

Estrogen, progesterone, and Her-2/neu receptor expression discrepancy in primary tumors and in-breast relapse in patients with breast cancer.

To the Editor: Estrogen and progesterone receptors have increasing importance in the management of breast malignancy. 60–70% of primary breast tumors are ER and PR positive. This results in a good prognosis for the patients (1) and allows the use of endocrine therapy which is now a standard in the adjuvant treatment of hormone receptor-positive invasive breast cancers. The hormone receptors are determined by immunohistochemistry on paraffin sections. Her-2/neu is a transmembrane tyrosine kinase receptor which belongs to the family of the EGFR. The most common reason of Her-2/neu overexpression in breast cancer is an amplification of the erbB2 gene. This results in a poor prognosis and occurs in 15–25% of all invasive breast cancers (2). The overexpression of Her-2/neu can be determined using immunohistochemistry and/or fluorescence in situ hybridization. Patients with Her-2/neu overexpressive breast cancer can be treated with the humanized antibody Trastuzumab. Some studies have reported hormone-receptor status discordance rates of 10–54% between primary and recurrent breast tumors (3–8). The mechanisms of change of hormone receptor and Her-2/neu expression have not been explicitly identified. Possible explanations include tumor heterogeneity, genetic instability, or errors in the determination of the receptors. Retrospective analysis was performed on 68 patients diagnosed with an in-breast relapse at the University Breast Center, Homburg/Saar, Germany, between 2001 and 2011. We evaluated the patient’s age at primary diagnosis and relapse, the tumor entity, the TNM stage, the initial grading and the grading at relapse, the ER-, PRand Her-2/neu status in primary cancer and relapse, the therapy received after the primary diagnosis. Primary and recurrent hormone receptor and Her-2/neu receptor data were obtained retrospectively using chart reviews or pathology reports. Sixty-one out of 68 patients showed an invasive carcinoma (89.7%) and seven cases a ductal carcinoma in situ. The patients had received surgical treatment or biopsy between 1982 and 2010 at University Breast Center, Homburg/Saar, in Germany. The age of patients ranged from 31 to 86. The mean time to the first recurrence of breast cancer was 7.7 years after the primary diagnosis. Thirty-three women were premenopausal and 35 were postmenopausal at the time of the first diagnosis. Overall, 64.7% of the primary breast cancers were positive for ER and PR. Only a few patients (3%) were Her-2/neu-positive at the time of the primary diagnosis. At this point of time, 31 patients were lymph node-negative, 32.4% had positive axillary lymph nodes and in 15 cases the nodal status was unknown. Patients had been treated either by lumpectomy in 47 cases or radical mastectomy in 21 cases plus axillary excision in form of axillary dissection in 50 cases or sentinel node dissection in seven cases. Most of the patients had received an adjuvant systemic therapy. Previous therapies included endocrine therapy for 40 out of 68 patients, previous chemotherapy for 38 out of 68 patients and previous radiotherapy for 35 out of 68 patients. Discordance rates between primary and locally recurrent lesions, were 23.5% for ER, 34% for PR, and 7% for Her-2/neu. In 13 cases, there was a switch from ER positive in the primary carcinoma to ER negative in in-breast relapse and in three cases the receptor changed from ER negative to ER positive. 25% of patients showed a PR-switch from positive receptor status in the primary carcinoma to a negative status in cancer relapse, and in 9% the PR status changed from negative to positive. The Her-2/neu receptor status shifted from negative to positive in four out of five patients comparing primary tumor and in-breast Address correspondence and reprint requests to: Russalina Mavrova, Saarland university Homburg Gynecology, obstretics and reproductive medicine, Kirrbergerstr. 100, Homburg Saarland 66421, Germany, or e-mail: r_mavrov@yahoo.de

Trial integration of combined ultrasound and laparoscopy tuition in an undergraduate anatomy class with volunteer participation — A pilot study

Anatomy is a cornerstone of medical undergraduate curricula. Due to increasing changes in various medical fields, a lot of new subjects were introduced in undergraduate curricula, while the teaching areas of basic sciences, i.e. anatomy, were reduced. The introduction of advanced diagnostic and therapeutic devices, i.e. ultrasound and laparoscopy, with outstanding imaging quality will be increasingly introduced in basic sciences. In our project, we examined the effect integrating ultrasound and laparoscopy in an anatomy undergraduate course to illustrate the female pelvis. Anatomy students that completed their practicum and cadaver dissection course were enrolled in our project. They received a theoretical introduction followed by a practical course of ultrasound or laparoscopy in the department of obstetrics and gynaecology. Following the course the students had to answer two questionnaires that evaluated their satisfaction, subjective knowledge-gain, problems and content of the course. At the end, a closing briefing was done to discuss the clinical skills and the course. The answers of the questionnaire were summed up in a Likert scale. 25 students were enrolled in the project. 52% attended laparoscopy operations, while 48% attended ultrasound examinations. After analysing the questionnaires using Likert scales (1=strongly agree, 5=strongly disagree) a general satisfaction of 1.5, a subjective knowledge gain of 2.4 and a thrive to extend these clinical skill programs in gynaecology and other specialities in basic science of 1.5 and 1.2, respectively, was reported. There were no statistically significant differences in the Likert scores between both groups (p>0.05). The introduction of ultrasound and laparoscopy in undergraduate basic science teaching programs is a promising method and should be further evaluated, standardized and expanded.

Interdisciplinary Diagnosis, Therapy and Follow-up of Patients with Endometrial Cancer. Guideline (S3-Level, AWMF Registry Nummer 032/034-OL, April 2018) – Part 1 with Recommendations on the Epidemiology, Screening, Diagnosis and Hereditary Factors of Endometrial Cancer

Summary The first German interdisciplinary S3-guideline on the diagnosis, therapy and follow-up of patients with endometrial cancer was published in April 2018. Funded by German Cancer Aid as part of an Oncology Guidelines Program, the lead coordinators of the guideline were the German Society of Gynecology and Obstetrics (DGGG) and the Gynecological Oncology Working Group (AGO) of the German Cancer Society (DKG). Purpose The use of evidence-based, risk-adapted therapy to treat low-risk women with endometrial cancer avoids unnecessarily radical surgery and non-useful adjuvant radiotherapy and/or chemotherapy. This can significantly reduce therapy-induced morbidity and improve the patientʼs quality of life as well as avoiding unnecessary costs. For women with endometrial cancer and a high risk of recurrence, the guideline defines the optimal surgical radicality together with the appropriate chemotherapy and/or adjuvant radiotherapy where required. The evidence-based optimal use of different therapeutic modalities should improve survival rates and the quality of life of these patients. The S3-guideline on endometrial cancer is intended as a basis for certified gynecological cancer centers. The aim is that the quality indicators established in this guideline will be incorporated in the certification processes of these centers. Methods The guideline was compiled in accordance with the requirements for S3-level guidelines. This includes, in the first instance, the adaptation of source guidelines selected using the DELBI instrument for appraising guidelines. Other consulted sources include reviews of evidence which were compiled from literature selected during systematic searches of literature databases using the PICO scheme. In addition, an external biostatistics institute was commissioned to carry out a systematic search and assessment of the literature for one area of the guideline. The identified materials were used by the interdisciplinary working groups to develop suggestions for Recommendations and Statements, which were then modified during structured consensus conferences and/or additionally amended online using the DELPHI method with consent being reached online. The guideline report is freely available online. Recommendations Part 1 of this short version of the guideline presents recommendations on epidemiology, screening, diagnosis and hereditary factors, The epidemiology of endometrial cancer and the risk factors for developing endomentrial cancer are presented. The options for screening and the methods used to diagnose endometrial cancer including the pathology of the cancer are outlined. Recommendations are given for the prevention, diagnosis, and therapy of hereditary forms of endometrial cancer.