Endometrial regeneration in Asherman's syndrome and endometrial atrophy using Wharton's jelly-derived mesenchymal stem cells.

OBJECTIVES: Reconstruction of the endometrium in patients with endometrial atrophy and Asherman's syndrome using Wharton's jelly-derived mesenchymal stem cells (WJ-MSCs). MATERIAL AND METHODS: Prospective pilot study, with the inclusion of two patients. RESULTS: After administration of WJ-MSCs into the uterine cavity, endometrial reconstruction was achieved in both patients. Pregnancy was achieved in one of them, after transfer of a frozen embryo, completed by delivery around the due date. CONCLUSIONS: Endometrial atrophy and Asherman's syndrome, is one of the most frustrating clinical situations we face in assisted reproductive procedures. The use of Wharton's jelly-derived mesenchymal stem cells in restoring the normal function of the endometrium, could become an easy and accessible therapeutic medal, for this endometrial dysfunction, which is so difficult to treat.

Updating the recommendations of the Working Group for the Preservation of Fertility in Oncological and Hematological Patients and Other Patients Treating Gonadier Therapies "ONCOFERTILITY" (GROF) of the Polish Society of Oncological Gynecology regarding cryopreserves and autologous transplant.

Update of the recommendations of the Fertility Preservation Working Group in Oncological, Hematological and Other Patients Treated with Gonadotoxic Therapies "ONCOFERTILITY" (GROF) of the Polish Society of Oncological Gynecology regarding cryopreservation and autologous ovarian tissue transplantation. The Fertility Preservation Working Group in Oncological, Hematological and Other Patients Treated with Gonadotoxic Therapies "ONCOFERTILITY" (GROF) of the Polish Society of Oncological Gynecology has developed current clinical guidelines and recommendations to improve the quality of healthcare provision in the area of reproductive health in patients undergoing therapy that may impair their reproductive potential. The guidelines are based on current scientific evidence available at the time of writing this document. In the absence of scientific evidence on some aspects, a consensus was reached among GROF stakeholders. The purpose of the guidelines is to assist healthcare professionals in making decisions in specific clinical situations regarding the selection of an appropriate and effective diagnostic and therapeutic process. The document provides practical guidelines for the management of cryopreservation and autologous ovarian tissue transplantation.

Sentinel lymph node in vulvar cancer.

Lymph node removal as a part of surgical management is a standard of care in vulvar cancer patients. Due to patient morbidities and difficulties in treatment of inguinal healing after lymph nodes removal, lymphatic mapping has emerged as an increasingly popular option over the past few years. At this time several different techniques have been described and variety of different dyes were used. In addition, an important aspect of the use of the sentinel lymph node (SLN) technique is the removal of a limited number of lymph nodes, which allows more detailed pathological examination. Moreover, the interpretation of pathological ultra-staging of SLNs, which can identify low-volume metastases for which the clinical significance and the ideal management, remain uncertain. Despite differences in techniques and dyes used, this minimally invasive procedure is currently recommended as an alternative to full inguinofemoral lymph node dissection in selected cases by all major international societies. As for now SLN concept became a standard of care in vulvar cancer. This technique, though simple as a concept, requires a learning curve and should only be used in expert centers. This article provides a review on literature on SLN technique in vulvar cancer, current recommendations and future lines of investigation.

An alternative approach to gynecological wound healing.

An 89-year-old woman was reffered to our Clinic with vulvar cancer. She also suffered from obesity [with body mass index (BMI) 35 kg/m2], persistent hypertension, diabetes mellitus type 2 treated with oral medications. In 2015 she underwent a surgery due to endometrial carcinoma. Total abdominal hysterectomy with bilateral salphingoophorectomy, omentectomy and pelvical node dissection was performed (histopathology revealed adenocarcinoma serosum G2; FIGO stage Ib). In January 2016 after vulvar ulceration biopsy plano-epithelial squamous vulvar cancer was diagnosed. She was referred to surgery. She has undergone an operation in October 2016. She was admitted to gynaecological unit at our institution. Physical examination revealed mutilated vulva with excised labia major, labia minor, and narrowing of vaginal orifice. The right side shown tumor 2.5 cm in diameter, with slough area and no deep infiltration and satellital nodule on the left labia majora 1cm in diameter. The cervix, vaginal wall, rectum and anus appeared normal. There were no enlarged lymph nodes at the inguinal area.

Validation of the Polish version of P-QoL questionnaire.

OBJECTIVE: Pelvic organ prolapse (POP) is a common morbidity that affects many women and significantly decreases quality of life. The severity and the impact of the prolapse on the quality of life are important parameters in the management and follow-up of affected patients. The aim of this validation study was to validate the Polish version of the Prolapse Quality of Life questionnaire (P-QoL). MATERIAL AND METHODS: The P-QOL questionnaire was translated into Polish and administered to women recruited from two gynecological outpatient clinics (n = 231). Both symptomatic and asymptomatic women were included in the study and examined in supine position using the Pelvic Organ Prolapse Quantification System (POP-Q). The validity was assessed by comparing symptom scores and quality-of-life scores between symptomatic and asymptomatic women. RESULTS: A total number of 154 symptomatic and 77 asymptomatic women were included. There was a strong correlation between severity of the disease based on physical findings (POP-Q scale) and the P-QoL scores in main prolapse quality-of-life domains. The overall scores for each life domain were significantly different between symptomatic and asymptomatic women (p < 0.001). All the questions regarding symptoms showed significant differences (p < 0.001) between both groups. CONCLUSIONS: The Polish version of P-QoL is a valid, reliable, and easily comprehensible instrument to assess quality of life and symptoms in Polish-speaking women suffering from urogenital prolapse.

One-year dynamic MRI follow-up after vaginal mesh repair: evaluation of clinical, radiological, and quality-of-life results.

BACKGROUND: Pelvic organ prolapse (POP) is a common disorder in elderly women often surgically repaired with alloplastic meshes; yet knowledge of the pelvic floor behavior and multi-compartment defects postoperatively is scarce. PURPOSE: To evaluate the 1-year outcome after mesh repair in patients with POP using clinical examination (CE), dynamic magnetic resonance imaging (dMRI), and the prolapse quality-of-life (P-QOL) questionnaire. MATERIAL AND METHODS: A prospective observational study was conducted of 69 women undergoing pelvic mesh surgery. Clinical examination, dMRI, and the P-QOL questionnaire were applied before and after surgery to evaluate POP. Mean outcome measures were POP outcome as determined on clinical and dMRI examinations and its impact on quality of life. Statistical results were obtained with SPSS version 15.0. ANOVA was used to compare pre-/postsurgical quality of life data. RESULTS: Sixty-nine women (mean age, 64.75 years; BMI, 26.75 kg/m(2); postmenopausal, 89.2%) were recruited and treated with Seratom® or Perigee™ mesh implants. A significant improvement in the position of bladder neck, vaginal vault/uterus, pouch of Douglas, and rectum was found 12 weeks and 1 year after surgery using POP-Q scale and dMRI. Advanced cystoceles and enteroceles seem underestimated by CE using the POP-Q system compared to dMRI results (P = 0.003 and P < 0.001), vice versa dMRI overestimated POP compared to CE. Sixty-four women completed the P-QOL questionnaire, presenting reduced quality of life before surgery which improves postsurgically. Prolapse impact and physical, social, and role limitations correlated strongest with a low quality of life (P < 0.001). CONCLUSION: The 1-year follow-up after mesh repair showed statistical and clinical improvement for all tools employed. dMRI seems a reliable tool for simultaneous assessment of defects in all three compartments, but tends to overestimate POP compared to clinical examination.

Contraception for cancer survivors.

Modern methods of diagnosis and treatment allow for better survival outcomes and, more importantly, for higher curability of cancer. Female cancer survivors often need effective advice concerning the choice of birth control methods. The majority of gynecologists are reluctant to propose anything other than barrier methods due to lack of information concerning safe use of more effective contraceptives. The aim of the paper was to summarize indications and contraindications to different methods of contraception available to cancer survivors in Poland.

[Long-term outcome analysis in the treatment of granulosa cell tumors]. / Retrospeanaliza wyników leczenia ziarniszczaka jajnika.

INTRODUCTION: Granulosa cell tumors of the ovary (GCT) are derived from the sex cords and the ovarian stroma. Their natural history however is indolent with a very favorable long-term prognosis. Their extreme rarity represents a limitation in our understanding of their natural history management, and prognosis. MATERIAL AND METHODS: Retrospective analysis of patient documentation treated for GCT between 1988-2008 at the Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, was performed. Clinical and pathological features of the study group, as well as methods and results of the treatment were analyzed. RESULTS: Medical documentation of 148 patients was analyzed. The majority of patients was classified as FIGO stage 1 (87.5%). Surgery was performed as primary treatment in all cases. Forty eight patients (32,6%) were held for observation stays, whereas 57.1% were qualified to receive adjuvant treatment: chemo- or radiotherapy. Mean progression free survival was 133.5 months (11.1 years) and was significantly longer in patients treated with the chemotherapy regimen when compared to radiotherapy (148 vs. 91 months respectively; p = 0.028). Overall survival was 173,7 months and was significantly longer in patients treated with adjuvant chemotherapy vs. RTH (165 vs. 121 months; p = 0.068). Recurrence of the disease was associated with poorer prognosis. CONCLUSIONS: GCTs are potentially curable neoplasms of the ovary with low treatment failure rates. Quick diagnosis and appropriate treatment in centers experienced in ovarian cancer surgery are the necessary conditions to obtain good results. The stage of the disease remains the most important prognostic factor chemotherapy with the use of bleomycine etoposide and cisplatin should be considered in patients who require adjuvant treatment.

Evaluation of selected ultrasonographic parameters and marker levels in the preoperative differentiation of borderline ovarian tumors and ovarian cancers.

OBJECTIVES: In young patients with borderline tumors the fertility-sparing treatment is indicated, thus the preoperative investigation is important. The aim of this study was to perform a comparative assessment of sensitivity and specificity of selected ultrasonographic and clinical parameters for the diagnoses of borderline tumors and ovarian cancers. METHODS: We retrospectively analyzed 57 patients who underwent surgical treatment in the Maria Sklodowska-Curie Memorial Cancer Center from Jan 01, 2008 to Dec 31, 2009. Ovarian cancers were diagnosed in 41 patients, and borderline ovarian tumors in 16 patients. Statistical model was developed to determine independent predictive factors that would be useful in preoperative differentiation between both tumors. The model included the following factors: menopausal status, tumor morphology, wall thickness (including outgrowths), septal thickness, echogenicity, resistive index, serum CA-125 level, and free fluid in the peritoneal cavity. RESULTS: Based on the statistical model developed, independent predictive factors in the differentiation between ovarian cancers and borderline tumors included the menopausal status (P=0.005), tumor echogenicity (P=0.047) and the presence of free fluid in the Douglas pouch (P=0.043). With the cutoff value of 13 (with scores below 13 indicating a borderline ovarian tumor, and scores of ≥13 indicating ovarian cancer), sensitivity was 90.2% and specificity was 87%. CONCLUSIONS: Our proposed model of preoperative evaluation has a sensitivity of 90% in the differentiation between ovarian cancers and borderline tumors. When combined with intraoperative findings, it allows optimal surgical therapeutic decisions to be made in patients with borderline ovarian tumors.

Clinical and histopathological factors in patients with cervical cancer allowing to identify candidates for less radical surgery.

OBJECTIVE: To determine clinical and histopathological factors in patients with cervical cancer tumors smaller than 2 cm in order to identify those who could be operated less extensively with preservation of reproductive organs and lower morbidity. MATERIAL AND METHODS: We retrospectively reviewed the records of patients with cervical cancer and a maximum tumor of 2cm in diameter who were qualified for primary surgery in the years 2001-2007 at the Department of Gynecologic Oncology Cancer Center in Warsaw. RESULTS: From the group of 110 operated patients, 96 were included into the study Within the analyzed group the infiltration of the parametrium was found in 4 women (4.2%). All of them had squamous cell cancer; stage IB, grade G3. One patient had a tumor 1.5 cm in diameter and 3 patients had tumors up to 2 cm in diameter. The involvement of lymph nodes was observed in 3 patients with squamous cell carcinoma: in one case the tumor was intermediate grade (G2) and in two cases low grade (G3). The lymph nodes were involved only in patients with tumors greater than 0.5 cm. The lymph vascular space invasion was found in 14 patients (14.7%): in 12 with squamous cell cancer and in 2 with adenocarcinoma. The diameter of the tumor was 0.5-1 cm in 4 women, 1-1.4 cm in 3 women and 1.5-2 cm in the majority (7 women accounted for 29% of all patients in that group). No infiltration of the blood vessels could be seen in all 30 women with tumors smaller than 0.5 cm. We found a statistically significant relationship between the size of the tumor and the incidence of lymph vascular space invasion (p=0.024). CONCLUSION: In selective cases fertility organ preserving surgery is possible and safe. In the group of patients with tumor less than 5 mm in diameter no parametrium involvement or lymph metastases were observed. In such situation cervical conisation can be justified. In well-differentiated (G1) tumors less than 2 cm in diameter less radical surgical procedures can also be performed because no treatment failure has been observed.

[Analysis of risk factors for recurrence after treatment of endometrial uterine cancer]. / Analiza czynników ryzyka nawrotu po leczeniu raka blony sluzowej trzonu macicy.

OBJECTIVE: The aim of this study was to evaluate selected clinical, histological and diagnostic factors as prognostics of time and location of endometrial cancer recurrence. We also attempted to design a more efficient follow-up protocols for patients with recurrent endometrial cancer. METHODS: A retrospective review of 196 patients with recurrent endometrial cancer treated at the Department of Gynecologic Oncology, Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, was done. Recurrence was analyzed by site, presence or absence of symptoms and methods of detection. We focused our attention on the impact of specific disease characteristics on pattern and risk of recurrence. RESULTS: Vast majority of recurrences (88%) occurred within the first 3 years after the primary treatment, whereas 71% within the first two years after the completion of the treatment. More than half of the patients (55%) were symptomatic when relapse occurred, while no statistically significant differences were found in time to relapse between the symptomatic and the asymptomatic group. Disease-free time observed when vaginal relapse occurred was significantly shorter compared to distant sites (p = 0.049). Histological maturity of primary tumor seems to be a prognostic of disease-free time (p = 0.039). Also patients with histological type I and II seem to have different courses of the disease (p = 0.064). Among recurrent endometrial cancer cases, pelvic examination, abdominal or pelvic ultrasound and chest x-ray could detect 95% of relapses. CONCLUSIONS: A follow-up program in the first three years after the primary treatment of endometrial cancer is useful in detecting recurrent disease. There is no reason to use an intensive program of follow-up in patients with low risk primary disease. Pelvic examination, vaginal and abdominal ultrasound, chest x-ray are good and not expensive methods in relapse detection. There is no clinical justification for the routine use of the Pap smear in the follow-up of patients with endometrial cancer.