Michael K. Bohlmann

Squamous-cell carcinoma in mature cystic teratoma of the ovary: systematic review and analysis of published data

Up to a quarter of ovarian masses originate from germ cells, and many of these are mature cystic teratomas. The secondary development of malignancy is a rare but well-known phenomenon in patients with ovarian teratomas. Squamous-cell carcinoma accounts for 80% of secondary malignant transformations of ovarian teratomas. We aimed to do an up-to-date systematic review of this rare malignant transformation. 64 suitable studies provided information on 277 patients. Squamous-cell carcinoma in mature cystic teratoma was mainly found in women aged more than 50 years, with high concentrations of squamous-cell-carcinoma antigen and cancer antigen CA125, and with ovarian tumours more than 100 mm in size. Patients with FIGO stage Ia tumours had better survival than those with more advanced disease. Complete resection together with hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy for patients with advanced disease, followed by adjuvant chemotherapy with an alkylating drug was associated with higher survival, radiotherapy was not. We make proposals for investigation and treatment of this rare disorder.

Testosterone and 5α-dihydrotestosterone inhibit in vitro growth of human breast cancer cell lines

Androgens are of biological and clinical importance for the growth and development of breast cancer in women, and the androgen receptor (AR) has been shown to be a predictor of tumor differentiation. In the present study, we investigated the relationship between AR status and testosterone and 5α-dihydrotestosterone (DHT)-dependent proliferation of the human breast carcinoma cell lines MCF-7, T47-D, MDA-MB 435S and BT-20. AR status was studied by means of immunocytochemistry and Western blot analysis. All four cell lines stained positively for AR. Western blot analysis revealed a strong expression of AR in MCF-7, in contrast to BT-20 cells. According to proliferation kinetics, we observed a significant (p ≤ 0.05) dose-dependent inhibition of cell growth by testosterone and DHT treatment in all four cell lines. In the estrogen receptor (ER)-negative cell lines BT-20 and MDA-MB 435S, testosterone was a more potent inhibitor of cell proliferation than DHT (p ≤ 0.05), in contrast to the ER-positive cells lines MCF-7 and T47-D, in which a stronger inhibition of proliferation was achieved by DHT. A partial transformation of testosterone to estrogen in ER-positive cells might be an explanation for this effect. Our data favor a possible role of androgens in growth regulation of breast cancer. Clinical studies are needed to analyze the importance of AR as a possible predictor in response to endocrine therapy of breast cancer.

GnRH analogs do not protect ovaries from chemotherapy-induced ultrastructural injury in Hodgkin’s lymphoma patients

PurposeTo determine the protective effect of gonadotropin-releasing hormone analogs (GnRHa) using several ultrasound and endocrine markers to detect ultrastructural ovarian damage in Hodgkin’s lymphoma patients.MethodsTen patients who had been treated for Hodgkin’s lymphoma and had received GnRHa to protect ovarian function were matched with patients at similar age, who had received the same chemotherapy regimens without GnRHa. In addition, ten healthy women at the same age were matched to the study groups to compare ovarian markers. Blood samples were drawn to determine anti-Müllerian hormone, Inhibin B, follicle-stimulating hormone and transvaginal ultrasound scans were performed to determine antral follicle count and ovarian volume. All women were asked about their menstrual cycle pattern.ResultsNo difference was found when comparing the ovarian parameters of both study groups. Compared with healthy women, all ovarian parameters in the Hodgkin’s lymphoma patients were significantly different.ConclusionsThe results of this study demonstrate ultrastructural ovarian damage in Hodgkin’s lymphoma patients irrespective of GnRHa co-treatment. These findings do not support previous studies, showing GnRHa to protect ovarian function.

Advanced age is a risk factor for higher grade perineal lacerations during delivery in nulliparous women

PurposeTo identify risk factors for the development of severe perineal lacerations and to give recommendations for their prevention in nulliparous women.MethodsA retrospective case–control analysis of deliveries at our University Hospital was performed. Multiparae, Caesarean sections, twin pregnancies, fetal breech position and preterm deliveries were excluded. Univariate and multivariate step forward regression analyses were performed; correlations between contributors were further analyzed by Spearman Rank Correlation. Differences between the degree of lacerations and maternal age were further analyzed with Friedman ANOVA followed by Dunn’s Multiple Comparison Test.ResultsA total of 2,967 deliveries fitted our inclusion criteria, 50 (1.7%) mothers had higher-grade lacerations. Mediolateral and median episiotomy, advanced maternal age, vaginal operative delivery, higher fetal birth weight and abnormal cephalic presentation were associated with severe lacerations.ConclusionsAdvanced maternal age plays an important role in the development of anal sphincter tears in nulliparous women. Episiotomy and operative vaginal deliveries should be restrictively performed when possible. To identify further preventive approaches in patients with accumulated risk factors prospective randomized studies are needed.

Laparoscopic nerve-sparing radical hysterectomy: Description of the technique and patients’ outcome

OBJECTIVE The radical hysterectomy type three can be accompanied by postoperative morbidity, such as dysfunction of the lower urinary tract with loss of bladder or rectum sensation. We describe the technique of laparoscopic nerve-sparing radical hysterectomy and patients outcome. METHODS Thirty-two patients underwent laparoscopic nerve-sparing radical hysterectomy with pelvic lymphadenectomy. Both the hypogastric and the splanchnic nerves were identified bilaterally during pelvic lymphadenectomy. RESULTS The median age of the patients was 52 years, and the average operating time was 221 min. There were no intraoperative or postoperative complications considering the nerve-spring radical hysterectomy. Postoperatively, in all patients spontaneous voiding was possible on the third postoperative day with a median residual urine volume of <50 ml. CONCLUSIONS Laparoscopic identification (neurolysis) of the inferior hypogastric nerve and inferior hypogastric plexus is a feasible procedure for trained laparoscopic surgeons who have a good knowledge not only of the retroperitoneal anatomy but also of the pelvic neuro-anatomy as this qualification could prohibit long-term bladder and voiding dysfunction during nerve-sparing radical hysterectomy.

Induction of estrogen receptor-α and -β activities by synthetic progestins

The cellular action of steroid hormones is mediated by specific receptors. Recently, two different estrogen receptors (ER), α and β, have been cloned with a specific tissue distribution. Active estrogen as well as active progestin are compounds of oral hormonal contraceptives and hormone replacement therapy. To examinate the regulation of ER-α and -β activities after treatment with synthetic progestins and synthetic and natural estrogens, COS 7 cells were transfected with the vector expressing ER-α and -β in combination with a luciferase reporter vector. ER-α activity was upregulated in the presence of synthetic progestins in a dose-dependent manner. Norethisterone, norethynodrel and desogestrel proved to be the most potent stimulatory agents of ER-α expression. On the other hand, not all progestins exhibited a stimulatory action on ER-β activity. Only norgestrel, levonorgestrel, norethynodrel and norethisterone induced ER-β-activating functions in a dose-dependent manner. Luciferase activity due to estrogen stimulation served as a positive control. Our results indicate that progestins have different effects on the activities of ER-α and -β.

Hysteroscopic findings in women with two and with more than two first-trimester miscarriages are not significantly different

The purpose of this study was to analyse hysteroscopic results in patients with recurrent miscarriages and to compare the frequency of uterine anomalies in women with a history of exactly two and with more than two consecutive miscarriages. A retrospective analysis of 206 patients undergoing hysteroscopy for repeated early pregnancy losses was performed at two university centres. Late miscarriages were excluded, terminations of pregnancy were not counted. Eighty-seven patients had suffered from exactly two early miscarriages and 119 from more than two. Both groups were comparable with respect to age at admission (32.95+/-4.46 versus 34.06+/-5.02 years) and at first miscarriage (30.43+/-4.24 versus 29.08+/-5.38 years). The prevalence of acquired (adhesions, polyps, fibroids) and congenital uterine anomalies (septate or bicornuate uterus, etc.) did not differ significantly (acquired: 28.7 versus 27.7%; congenital: 9.2 versus 16.8%). The rates of uterine anomalies did not differ significantly overall (36.8 versus 42.9%). In conclusion, uterine anomalies are frequently found in patients with two and with more than two early miscarriages. Due to the high rate of anomalies, their risk for adverse pregnancy outcome and a possible therapeutic approach, hysteroscopy might be a diagnostic option even after two early miscarriages.

Medical prevention and treatment of postpartum hemorrhage: a comparison of different guidelines

BackgroundPostpartum hemorrhage (PPH) remains a common cause of maternal mortality worldwide, mainly caused by uterine atony. Medical intervention plays an important part in prevention and therapies of PPH. Prophylactic interventions include the use of uterotonic drugs. We elaborated the consistency of national and international guidelines on those medical approaches.Materials and methodsMedical approaches in PPH were extracted from recent publications. Furthermore, the current guidelines of the World Health Organization, the FIGO and of the American, British, Canadian and German Societies of Obstetricians and Gynecologists on PPH were analyzed.ResultsOxytocin is considered as therapy of first choice. However, the examined guidelines fail to give unequivocal recommendations on further uterotonics in PPH, which may partially be attributed to differing publication dates of the guidelines.ConclusionInternational guidelines on PPH are characterized by differing recommendations. However, recent publications suggest that adhering to local guidelines significantly reduces the prevalence of severe PPH.

Spontaneous uterine rupture at the 21st week of gestation caused by placenta percreta.

AbstractPurposeTo describe the management of a ruptured uterus caused by placenta percreta in the 21st week of gestation.Methods We present a case report of a 33-year-old patient with a ruptured uterus in the 21st week of gestation who presented at the Department of Gynecology and Obstetrics, University of Schleswig-Holstein, Campus Luebeck. Therapeutic management was performed by laparoscopy, and consecutive laparotomy and hysterectomy.Results A 33-year-old patient presented with severe abdominal pain in the 21st week of gestation at the department of abdominal surgery. A laparoscopy was performed to exclude appendicitis. There was about one liter of blood in the peritoneal cavity and a small, bleeding lesion in the fundus uteri was found which was coagulated. The blood was evacuated and the patient returned to department of gynecology. One hour after the first operation, the patient developed signs of hypovolemic shock and ultrasound showed absent fetal heart beat. An immediate laparotomy was performed and a ruptured uterus was detected. The fetus was removed and a hysterectomy performed. Pathology results showed a placenta percreta. After a few days in hospital and transfusion of 4 liters of blood the patient was discharged in a healthy condition.Conclusions In a pregnant woman with severe abdominal pain even in the 21st week of gestation a placenta percreta has to be considered as a differential diagnosis. If there is no evidence of other causes, laparoscopy may help to confirm the diagnosis and hysterectomy is a life saving intervention.

Seven years' experience in laparoscopic dissection of intact ovarian dermoid cysts

A large case series on laparoscopic removal of dermoid cysts with a diameter between 3 and 12 cm, via an endobag, is reported (127 cysts in 121 premenopausal women). The incidence of spillage and recurrence rate of laparoscopic ovarian dermoid cystectomy, the duration of the surgical procedure, the length of hospitalization, the incidence of recurrence and pregnancies was evaluated. In 2.5% of cases, the endobag ruptured during removal, and a total spillage rate of 12% was seen. No signs or symptoms of peritonitis were observed regardless of cystic spillage or not. Laparoscopic cystectomy of dermoid cysts in premenopausal women is safe and effective and appears to be a valuable alternative to laparotomy. Controlled intraperitoneal spillage of cyst contents does not increase postoperative morbidity as long as an endobag is used and the peritoneal cavity is washed out thoroughly.