Introduction of gasless laparoscopic surgery as a minimally invasive procedure for endometrial cancer and its usefulness from the viewpoint of the learning curve.

BACKGROUND: We investigated the usefulness of gasless laparoscopic surgery (GLS) using a subcutaneous abdominal wall lifting method for endometrial cancer. METHODS: We studied 105 patients with early endometrial cancer who underwent GLS (55) or open surgery (50). A uterine manipulator was used in all GLS cases. We compared operative time, blood loss, number of lymph nodes removed, hospital stay, perioperative complications, cases converted to laparotomy, and recurrence and survival rates. We also studied the learning curve and proficiency of GLS. RESULTS: The GLS group had significantly longer operative time (265 vs. 191 min), reduced blood loss (184 vs. 425 mL), shorter hospital stay (9.9 vs. 17.6 days), and fewer postoperative complications (1.8 vs. 12.0%) than the open group. No case was converted to laparotomy. Disease-free and overall survival rates at 4 years postoperatively (GLS vs. open groups) were 98.0 versus 97.8 and 100 versus 95.7%, respectively, and there was no significant difference between the groups. Regarding the learning curve for GLS, two different phases were observed in approximately 10 cases. Operator 2, who was not accustomed to laparoscopic surgery, showed a significant reduction in operative time in the later phase 2. CONCLUSIONS: GLS for endometrial cancer results in less bleeding, shorter hospital stay, and fewer complications than open surgery. Recurrence and survival rates were not significantly different from those of open surgery. This technique may be introduced in a short time for operators who are skilled at open surgery but not used to laparoscopic surgery.

Possible Roles of Calreticulin in Uterine Decidualization and Receptivity in Rats and Humans.

Previous in vitro studies have suggested that calreticulin (CALR), which is responsible for the folding and quality control of glycoproteins, may be associated with decidualization. However, its precise role in regulating decidualization has not been explored in vivo. Here, we used pregnant rat models to examine endometrial CALR expression during the peri-implantation period. We also examined whether polypectomy, a procedure that could ameliorate infertility, alters the endometrial expression levels of CALR and several implantation factors in women diagnosed as infertile. In rats, uterine CALR was expressed at a high level at the implantation site, and a marked increase in CALR expression was observed in decidual cells of normal pregnancy. In addition, endometrial CALR expression was enhanced by either administration of estradiol-17ß in the delayed implantation rat model or the artificial induction of decidualization in the pseudopregnant rat. In cultured stromal cells, siRNA-mediated silencing of CALR inhibited the decidual stimulus-induced expression of prolactin, decidual/trophoblast prolactin-related protein, and connexin 43. In humans, the endometrial expression levels of the mRNAs encoding CALR and the implantation-related factor insulin-like growth factor binding protein (IGFBP)-7 tended to increase after polypectomy. The strongest positive correlation between expression levels before polypectomy was observed for IGFBP-7 and CALR, and the strength of this correlation increased after the surgery. Thus, endometrial CALR may play a role in the formation of decidua, and the polypectomy of infertile patients may result in the co-operative expression of endometrial factors, including CALR, that could enhance endometrial receptivity.

Early feasibility surveillance of gynecologic robotic-assisted surgeries in Japan.

AIM: To evaluate the clinical relevance of robotic-assisted surgeries (RAS) for gynecologic malignancies in a Japanese multi-institutional cohort. METHODS: A retrospective review of perioperative outcomes of 357 gynecologic RAS procedures was conducted in 24 hospitals accredited to perform RAS by the Japanese Society of Obstetrics and Gynecology (JSOG) over a 4-year period, January 2014 to December 2017. RESULTS: More than 25 (high), 10-24 (middle) and less than 10 cases (low) were enrolled from 3, 8 and 13 hospitals, respectively. A total of 247 patients underwent RAS for malignant indications. Radical hysterectomy (RH) was conducted for 200 patients, while para-aortic node excision (PAN) for 47 patients. RAS with RH or PAN was more feasible in high-volume centers with significantly shorter operation time and lesser blood loss than that in middle-volume centers. The total rate of perioperative injury and complications in RAS with PAN reached 33.3% in high-volume centers, which was almost equal to those in middle-volume centers (35.5%) but much higher than RAS without PAN (8.5%). CONCLUSION: Perioperative surveillance demonstrated high feasibility of gynecologic RAS procedures conducted in JSOG accredited hospitals for these 4 years. It is mandatory for RAS conducting hospitals to have careful attitudes to realize their learning curves in conducting advanced procedures.

Exchange protein directly activated by cAMP (EPAC) promotes transcriptional activation of the decidual prolactin gene via CCAAT/enhancer-binding protein in human endometrial stromal cells.

Protein kinase A (PKA) signalling accompanies elevated intracellular cAMP levels during endometrial stromal cell (ESC) decidualisation. Exchange protein directly activated by cAMP (EPAC), an alternate mediator of cAMP signalling, promotes PKA analogue-induced decidualisation; however, the precise mechanism by which EPAC and PKA co-operatively stimulate decidualisation has not been characterised. To examine the role of CCAAT/enhancer-binding protein (C/EBP) in EPAC- and PKA-mediated decidualisation of primary human ESCs, a reporter plasmid containing the 332bp region upstream from the transcription initiation site of the decidual prolactin (dPRL) gene was generated and the promoter activity was evaluated using a luciferase assay. The dPRL promoter activity was increased by treatment of transfected ESCs with the PKA-selective cAMP analogue N6-phenyl-cAMP (Phe) and enhanced further by co-treatment with the EPAC-selective cAMP analogue 8-(4-chlorophenyltio)-2'-O-methyl cAMP (CPT). Treatment with forskolin, an adenylyl cyclase activator, had a similar effect on reporter activity. Site-directed mutagenesis of the C/EBPß- and/or C/EBPδ-binding site in the dPRL promoter abolished Phe/CPT-mediated elevation of the reporter activity. EPAC2 knockdown markedly reduced Phe-stimulated C/EBPß and C/EBPδ mRNA levels, as well as forkhead box O1 (FOXO1) protein levels. These results suggest that EPAC signalling enhances PKA-mediated dPRL expression in ESCs by acting on C/EBP response elements in the promoter region of the gene.

Ultrasound Elastography can Detect Placental Tissue Abnormalities.

BACKGROUND: In this prospective cohort study, we examined the utility of elastography to evaluate the fetus and placenta. PATIENTS AND METHODS: Pregnant women in their third trimester of pregnancy, by which time the placenta has formed, were included in this study. A total of 111 women underwent ultrasound examinations, including elastography. Elastographic evaluation was performed using two protocols. First, the placental index (PI) was measured, which quantitatively assesses the hardness of tissue. Second, regions of interest (ROI) were categorized into 3-step scores according to the frequency of the blue area (hardness of placental tissue score [HT score]), which is a qualitative method. After delivery, 40 of the 111 placentas were pathologically examined. RESULTS: The average PI was 44.3 (± 29.4) in the in utero SGA group, which was significantly higher than that in the normal group (8.8 (± 10.0); p < 0.01) during pregnancy. There was a significant correlation between the PI and z score for estimated fetal weight (EFW) (r = -0.55; p < 0.01). Moreover, a significant positive correlation was observed between the PI and the z score of birth weight (r = -0.39; p < 0.01). Pathological ischemia findings of the placenta were identified in 67% of the HT score 3 group, representing 6 of the 9 patients, and in 20% of the HT score 1 group, representing only 3 of the 15 patients. CONCLUSIONS: Placental hardness, as determined by elastography, correlates with both lower estimated fetal body weight and birth weight. These results suggest that ultrasound elastography in the placenta may be an additional marker of intrauterine fetal well-being.

Efficient production of trophoblast lineage cells from human induced pluripotent stem cells.

Human induced pluripotent stem cells (hiPSCs) are potentially useful in both clinical applications and basic biological research. hiPSCs can differentiate into extra-embryonic cells in the presence of BMP4. However, the differentiation potential of hiPSCs can be affected by culture conditions or genetic variation. In this study, we investigated the effect of various BMP4 concentrations on the expression states of trophoblast markers and the optimal conditions for trophoblast induction. A high-fidelity gene expression assay using hiPSC lines showed that the expression levels of various trophoblast marker genes, such as KRT7, GCM1, CGB, and HLA-G, were upregulated by BMP4 in a dose-dependent manner in all types of hiPSCs used in this study. Treatment with high doses of BMP4 for prolonged periods increased the ratio of cells with trophoblast markers irrespective of the presence of bFGF. We found that the expression states of major pluripotency- and differentiation-related protein-coding genes in BMP4-treated cells depended on culture conditions rather than donor cell types. However, miRNA expression states were affected by donor cell types rather than BMP4 dose. Furthermore, the effect of the presence of bFGF on differentiation potential of KRT7-positive cells differed among iPSC types. Mechanistically, chromatin states around KRT7 promoter regions were comparable among the iPSC types used in this study, indicating that hiPSC chromatin state at these regions is not a parameter for cytotrophoblast differentiation potential. In conclusion, the optimal conditions for trophoblast differentiation from hiPSCs differ according to parental cell line.

MicroRNA and gynecologic cancers.

AIM: Gynecologic malignancies are serious problems in female health. Here we aim to discuss the involvement of microRNA (miRNA) in the pathogenesis of gynecologic cancers and use of miRNA profiles for diagnosis of diseases. METHODS: In order to obtain information needed for this review, we searched the PubMed database with the following keywords: miRNA and ovarian cancer; miRNA and cervical cancer; and miRNA and endometrial cancer. RESULTS: Recent explosive investigations in the field have dramatically expanded our knowledge of the roles of miRNA in the pathology of gynecologic malignancies. In ovarian cancer, miRNA participates in the development of drug resistance. In cervical cancer and endometrial cancer, miRNA play essential roles in important oncogenic processes, including cell proliferation, migration and metastasis. miRNA also have high potentials to be used as biomarkers in these diseases. CONCLUSION: Further validation of the studies and improvement of the methods will result in the broader use of miRNA in the diagnosis of diseases as well as in understanding of the pathomechanisms of gynecologic cancers.

Dienogest compared with gonadotropin-releasing hormone agonist after conservative surgery for endometriosis.

AIM: Although there are various hormone therapies, including gonadotropin-releasing hormone agonist, danazol, levonorgestrel-releasing intrauterine system, dienogest, and low-dose estrogen progestin, no consensus opinion has been reached in terms of which medication should be used and for how long it should be administered. We aimed to determine whether dienogest or goserelin is the better postoperative therapy to prevent recurrence of endometriosis. METHODS: A prospective cohort randomized study were conducted, including 198 patients diagnosed as having endometriosis. A total of 111 patients were randomly assigned into two groups: the dienogest-administered group (n = 56) and the goserelin-administered group (n = 55). Patients were followed for 24 months after laparoscopic surgery. Those who gave consent but desired no postoperative therapy were assigned to the non-treatment group (n = 79). Recurrence, side-effects, degrees of menstrual pain and chronic pelvic pain measured by the Visual Analogue Scale were compared among the three groups: the dienogest, goserelin, and non-treatment groups. RESULTS: No significant difference was observed in the postoperative recurrence rate between the dienogest and goserelin groups. No significant difference was found in the recurrence rate between the goserelin group and non-treatment group; however, a significant difference was found in the recurrence rate between the dienogest group and the non-treatment group (P = 0.027). Menstrual pain and chronic pelvic pain were significantly improved in both treatment groups. Side-effects were markedly observed in the goserelin group as compared with the dienogest group. CONCLUSION: Dienogest is available for prolonged administration of more than 6 months, so it is more useful than goserelin, which is available only for short-term administration.

A retrospective study of urokinase-type plasminogen activator receptor (uPAR) as a prognostic factor in cancer of the uterine cervix.

BACKGROUND: Hypoxia occurs during the development of uterine cervical cancer and is considered to correlate with its invasion. Hypoxia promotes both the invasiveness and the metastasis of cancer cells through urokinase-type plasminogen activator receptor (uPAR) expression. The aim of this study was to evaluate the correlation between uPAR mRNA level and clinical prognostic factors of uterine cervical cancer. METHODS: We performed a retrospective review of 59 patients with cervical cancer and 9 subjects with normal cervical tissues. Total RNA was isolated from tissues of the uterine cervix surgically removed from patients. The mRNA of uPAR could be measured by real time PCR (RT-PCR). Histopathological factors such as histopathological type, cervical stromal, parametrial, lymphovascular, and uterine corpus invasions, metastasis to the pelvic lymph nodes, and pTNM stage were confirmed by two pathologists. The examined prognostic factors alongside the histopathological ones were FIGO clinical stage, hemoglobin level, serum level of SCC, and the effect on clinical outcomes. These factors were statistically evaluated by Fisher's exact test, log-rank test, and ROC analysis. Immunohistochemical staining with anti-uPAR monoclonal antibody was also performed. RESULTS: In uterine cervical cancer, overexpression of uPAR mRNA was significantly related to shorter disease-free survival (p = 0.0396). However, the other clinical prognostic and histopathological factors were not related to uPAR mRNA expression level. Immunohistochemical staining showed that positive staining for uPAR was histologically localized on the membrane of carcinoma cells. However, the staining was not very intense. CONCLUSIONS: Overexpression of uPAR mRNA may be a prognostic factor in cancer of the uterine cervix.

A lower serum level of middle-molecular-weight adiponectin is a risk factor for endometrial cancer.

BACKGROUND: The present study was undertaken to examine the correlation between serum levels of adiponectin isoforms and the risk for endometrial cancer. METHODS: This retrospective case-control study included 43 Japanese women with endometrial cancer and 62 Japanese women with no history of cancer. Serum levels of total adiponectin and the respective isoforms were determined by enzyme-linked immunosorbent assay. Multivariate logistic regression analysis was performed on the serum levels of total adiponectin and its isoforms, high molecular weight, middle molecular weight, and low molecular weight adiponectins, after adjustment for confounders (age, body mass index, hypertension, and diabetes mellitus). RESULTS: The distribution of body mass index revealed a statistically significant difference between patients and controls (P = 0.001). A statistically significant difference (P < 0.01) was also found in the incidence of diabetes mellitus between the two groups, although there was no significant difference in the incidence of hypertension. In controls, an inverse correlation was observed between body mass index and serum adiponectin levels. However, in patients, an inverse correlation was found only between body mass index and serum middle molecular weight adiponectin level. After adjustment for confounding variables, the factor found to be most closely associated with endometrial cancer was a lower serum level of middle molecular weight adiponectin (adjusted odds ratio 4.89, 95 % confidence interval value 1.25-19.11, P = 0.022). CONCLUSION: Low serum level of middle molecular weight adiponectin was the only independent risk factor for endometrial cancer suggesting that the application of adiponectin might prevent or decrease the risk for endometrial cancer.

[Uterine cancer].

It is thought that robotic surgery is highly useful for uterine malignant tumor such as endometrial cancer and cervical cancer. It is nothing but that robotic surgery enables us the correct and delicate movement of forceps, which is necessary for operative procedures at the deep and narrow space in the pelvic cavity and the perivascular lymphadenectomy. By our experience, significant reduction of blood loss and shortening of the hospital stay were accepted in the cases of endometrial cancer and cervical cancer. At present the robotic surgery in uterine cancer in Japan lags far behind the USA In order not to miss the trend in the world, it is required for the robotic surgery of uterine cancer to spread widely in Japan from now on. For this purpose, it is necessary to accumulate cases on the assumption that advanced medical care and also insurance adaptation.

Validate robot-assisted total laparoscopic hysterectomy with four equally-spaced ports without an assistant port.

To evaluate the usefulness of robot-assisted total laparoscopic hysterectomy with four equally-spaced ports (RA-TLH/4e) without an assistant port. In RA-TLH/4e, four da Vinci ports were placed horizontally at a height of 4 cm above the umbilicus with 8 cm equal spacing. Poor development of the surgical field or difficult forceps manipulations were handled with the endoscope and forceps movement (port-hopping). Patient background, surgical outcomes, complications, port-hopping frequency were compared in three groups: RA-TLH/4e, RA-TLH with four unequally-spaced ports (RA-TLH/4u), and conventional RA-TLH with five ports (RA-TLH/5). There were no significant differences in patient background or surgical outcomes among the three groups except for age, preparation time, and hospital stay, and no cases of laparotomy conversion or serious complications. RA-TLH/4e had fewer port-hoppings than RA-TLH/4u. The minimum abdominal width showed a weak negative correlation with port-hopping frequency in RA-TLH/4u, but not in RA-TLH/4e. RA-TLH/4e allowed for a reduction in personnel and costs compared to RA-TLH/5. The equal placement of four ports allowed sufficient port spacing even for patients with narrow abdominal widths. In addition, the port-hopping technique was able to fully compensate for the lack of an assistant port. RA-TLH/4e is a highly useful technique that not only excels in safety but also reduces costs.

Development and Efficacy of Gasless Reduced-Port Laparoscopic Surgery for Gynecological Diseases.

Objective: To evaluate the efficacy of gasless reduced-port laparoscopic surgery (GRP-LS) using a subcutaneous abdominal wall lifting method for gynecological diseases. Methods: This study included gasless laparoscopic surgeries performed at our hospital between September 1, 1993 and December 31, 2016. The new GRP-LS technique was compared with the conventional gasless three-port laparoscopic surgery (G3P-LS), based on patient background, operative results in patients treated for laparoscopic myomectomy (LM), laparoscopic ovarian cystectomy (LC), and laparoscopic salpingectomy (LT). Surgeons of the two techniques were categorized by the number of surgeries they had performed, and the number of surgeons and surgeries for each technique were compared. Results: GRP-LS was used in 2,338 cases and G3P-LS in 2,473 cases. GRP-LS was used in 980 LM cases, 804 LC cases, 240 LT cases, and 314 cases for other conditions. The operative time required for GRP-LS was significantly less for LM, LC, LT, and the procedure also had less blood loss for LM and LC than G3P-LS. G3P-LS required a transition to open surgery in 0.69% of cases, whereas GRP-LS showed a very low rate of 0.09%. Sixty-seven of the 78 GRP-LS surgeons (85.9%) had performed fewer than 50 GRP-LSs, and these surgeons performed about half of all surgeries. Eighty-three of the 93 GRP-LS surgeons (89.2%) had performed fewer than 50 G3P-LSs, and these surgeons performed 38.9% of all surgeries. Conclusions: GRP-LS is an effective surgery with few complications and less cosmetic damage and can be easily introduced to novice or inexperienced laparoscopic surgeons.

Identification of a novel role of Septin 10 in paclitaxel-resistance in cancers through a functional genomics screen.

Paclitaxel (also known as taxol) is a member of the taxane class of anticancer agents, which has a well-known mechanism that blocks cell mitosis and kills tumor cells, that is often used in clinics to treat cancer. However, some carcinomas such as breast, ovarian and non-small-cell lung cancers are often resistant to paclitaxel treatment. In this study, we used a lentiviral siRNA library against the entire human genomes to identify genes associated with sensitivity to paclitaxel. We isolated two paclitaxel-resistant clones carrying the siRNA specific to septin 10 (SEPT10) and to budding uninhibited by benzimidazoles 3. The relation of budding uninhibited by benzimidazoles 3 to paclitaxel sensitivity has already been established, but that of SEPT10 remains unknown. Interestingly, overexpression of SEPT10 increased cells' sensitivity to paclitaxel; we also found that SEPT10 is an important regulator for microtubule stability. Furthermore, we found that paclitaxel-resistant tumors had decreased expression of SEPT10. Thus, SEPT10 may be a novel candidate molecule that acts as a good indicator of paclitaxel-resistant carcinomas.

Umbilical cord milking stabilizes cerebral oxygenation and perfusion in infants born before 29 weeks of gestation.

OBJECTIVE: To investigate the effects of umbilical cord milking at birth on cerebral perfusion and systemic perfusion in very low birth weight (VLBW) infants. STUDY DESIGN: Cerebral tissue oxygenation index and cerebral fractional tissue oxygen extraction were monitored in 50 stable VLBW infants (gestational age <29 weeks, birth weight <1250 g), with 26 allocated to the milked group and 24 to the control group. We used near-infrared spectroscopy 3-6, 12, 18, 24, 36, 48, and 72 hours after birth. Left ventricular end-diastolic dimension, left ventricular ejection fraction, left ventricle (LV) Tei index (measurement of left ventricular systolic and diastolic function), left ventricular cardiac output, and superior vena cava flow were measured concurrently using echocardiography. RESULTS: There were no significant differences in gestational age and birth weight between the 2 groups. Hematocrit, left ventricular end-diastolic dimension, left ventricular cardiac output, and superior vena cava flow were higher in the milked group than in the control group, with improvement in the LV Tei index despite the absence of left ventricular ejection fraction changes within 24 hours after birth. Tissue oxygenation index increased and cerebral fractional tissue oxygen extraction decreased in the milked group within 24 hours after birth. CONCLUSION: Umbilical cord milking stabilized cerebral oxygenation and perfusion in VLBW infants by improving LV diastolic function by increasing LV preload.

Does the use of a uterine manipulator in robotic surgery for early-stage endometrial cancer affect oncological outcomes?

BACKGROUND: To investigate the impact of the use of a uterine manipulator in robot-assisted surgery for early-stage endometrial cancer on oncological outcome. METHODS: Eighty six robotic surgeries and sixty seven open surgeries were performed for early-stage endometrial cancer. Disease-free survival and overall survival at 5 years, and surgical results and postoperative complications were compared between surgeries. In robotic surgery, a uterine manipulator was used in all cases. RESULTS: There was no significant difference in oncological outcome between surgeries. Robotic surgery showed significantly longer operative time, less blood loss, and shorter hospital stay compared to open surgery. In robotic surgery, complications occurred significantly less frequently, and no patients required conversion to laparotomy. There were no clear correlations of positive lavage cytology with The International Federation of Gynecology nd Obstetrics stage, recurrence, and site of recurrence in either surgery. CONCLUSIONS: The use of a uterine manipulator during robotic surgery for early-stage endometrial cancer did not influence recurrence or survival.

Establishment of three cisplatin-resistant endometrial cancer cell lines using two methods of cisplatin exposure.

Using the endometrial cancer cell line EI established in our department, we attempted to establish cisplatin (CDDP)-resistant cell lines by incremental exposure and high concentration exposure methods. Three CDDP-resistant cell lines were isolated, which could be distinguished by morphological differences. 1. Upon acquiring CDDP resistance, the cells tended to become small and grow in a floating state. This tendency was especially marked when using incremental exposure method. Using the incremental exposure method, a cell line obtained by isolating and culturing only adherent cells was designated EICR-Ia, and a cell line established by culturing only floating cells was designated EICR-If. A cell line obtained by the high concentration exposure method was designated EICR-II. 2. Upon acquiring CDDP resistance, tumor markers such as TPA and LDH increased, while proliferative capability of the cells was lowered. 3. The invasion capability was diminished in EICR-If cells, but was increased in EICR-Ia and EICR-II cells. 4. Following exposure to CDDP, the intracellular platinum concentrations were markedly elevated in EI and EICR-If cells, whereas the increase was mild in EICR-Ia and EICR-II cells and the concentration was lower than that in parent EI cells. 5. Studies of drug resistance gene expression revealed increased expression of MDR1, GSTπ, and Topo-II in EICR-If cells; increased expression of GSTπ in EICR-II cells; but no expression of any of the genes in EICR-Ia cells. 6. Analyses of cancer- and apoptosis-related genes showed increased expressions of Bcl-2, c-Myc, p53, and ICE in EICR-If cells. 7. Upon acquiring CDDP resistance, sensitivity to mitomycin and adriamycin decreased, but sensitivity to etoposide and 5-fluorouracil increased. The findings indicate that the mechanisms of CDDP resistance are different in the three cell lines.