Ultrasound-guided thoracic paravertebral block by the paralaminar in-plane approach using a microconvex array transducer: methodological utility based on anatomical structures.

OBJECTIVE: We evaluated the analgesic feasibility of paralaminar in-plane (PL) approach for ultrasound-guided thoracic paravertebral block (USG-TPVB). As the needle trajectory was expected to be closely affected by the distance from the skin to the lamina-transverse process junction (LTPJ), we examined the correlativity between them on computed tomography (CT) or ultrasonography. METHODS: Thirty-two patients undergoing thoracotomy were recruited. We measured the distances between the skin and LTPJ using preoperative CT (S-L) and procedural ultrasonography (US-L). At the beginning and the end of the surgery, 20 ml of 0.5% ropivacaine was injected. The level of sensory block and postoperative numerical pain rating scale (NRS) was assessed. Relationships among the measured parameters and the agreement of the needle depth (ND) with S-L and US-L were evaluated using Pearson's correlation coefficient and Bland-Altman analysis. RESULTS: S-L and US-L were strongly correlated with ND (r = 0.72 and r = 0.81, respectively) but not with BMI. The Bland-Altman analysis showed that the mean percent differences between the ND and S-L or ND and US-L were -9.6 and 20.1%, respectively. Catheters were inserted 18.6 mm lateral from the midline on average. Analgesia extended to 3-5 dermatomes in 29 patients, and the median NRS was 2 at 1, 6, 12, and 24 h after surgery, respectively. CONCLUSIONS: We demonstrated that PL approach provided feasible analgesia for thoracotomy and the ND was significantly correlated with the morphometric values. This technique allowed for inner catheter insertion route targeting longer anteroposterior thoracic paravertebral space length; this may reduce potential risk of pleural puncture for USG-TPVB. Trial registry number This study was registered in the UMIN Clinical Trials Registry (UMIN-CTR). (URL: http://umin.ac.jp/ctr/ , ID:UMIN000014821).

A patient group at negligible risk of para-aortic lymph node metastasis in endometrial cancer.

OBJECTIVE: The objective of this study was to identify a group at negligible risk of para-aortic lymph node metastasis (LNM) in endometrial cancer and its presumed prognosis. METHODS: We enrolled 555 patients with endometrial cancer who underwent preoperative endometrial biopsy, pelvic magnetic resonance imaging, and determination of serum cancer antigen (CA)125, and surgical treatment including lymphadenectomy. Three risk factors for LNM confirmed in previous reports were grade 3/non-endometrioid histology, large tumor volume, and a high CA125 value. Pelvic LNM rate, para-aortic LNM rate, and 5-year overall survival rate were assessed in four groups according to the number of these risk factors. RESULTS: LNM was noted in medical records of 74 patients (13.3%). Of 226 patients in the no risk factor group, pelvic LNM was noted in the medical records of five (2.2%), but no para-aortic LNM was noted. The 3-year/5-year survival rates in the no risk factor group were 97.2/96.6%, with a median follow-up period of 65.5 months. Of 186 patients in the one risk factor group, 21 (11.2%) had pelvic LNM. Of 113 patients undergoing para-aortic LN dissection in the one risk factor group, six (5.3%) had para-aortic LNM. CONCLUSION: Patients with grade 1/2 histology based on endometrial biopsy, small tumor volume assessed by magnetic resonance imaging, and low CA125 value are supposed to have negligible risk of para-aortic LNM. In such patients, the para-aortic region might not be considered as a target to be assessed by staging procedure.

FDG PET/CT diagnostic criteria may need adjustment based on MRI to estimate the presurgical risk of extrapelvic infiltration in patients with uterine endometrial cancer.

PURPOSE: The staging of endometrial cancer requires surgery which carries the risk of morbidity. FDG PET/CT combined with anatomical imaging may reduce the number of unnecessary lymphadenectomies by demonstrating the risk of extrapelvic infiltration. The purpose of this study was to optimize FDG PET/CT diagnostic criteria for risk assessment in endometrial cancer after first-line risk triage with MRI. METHODS: The study population comprised 37 patients who underwent curative surgery for the treatment of endometrial cancer. First, the risk of extrapelvic infiltration was triaged using MRI. Second, multiple glucose metabolic profiles of the primary lesion were assessed with FDG PET/CT, and these were correlated with the histopathological risk of extrapelvic infiltration including lymphovascular space invasion (LVSI) and high-grade malignancy (grades 2 and 3). The results of histological correlation were used to adjust FDG PET/CT diagnostic criteria. RESULTS: Presurgical assessment using MRI was positive for deep (>50 %) myometrial invasion in 17 patients. The optimal FDG PET/CT diagnostic criteria vary depending on the results of MRI. Specifically, SUVmax (≥16.0) was used to indicate LVSI risk with an overall diagnostic accuracy of 88.2 % in patients with MRI findings showing myometrial invasion. High-grade malignancy did not correlate with any of metabolic profiles in this patient group. In the remaining patients without myometrial invasion, lesion glycolysis (LG) or metabolic volume were better indicators of LVSI than SUVmax with the same diagnostic accuracy of 80.0 %. In addition, LG (≥26.9) predicted high-grade malignancy with an accuracy of 72.2 %. Using the optimized cut-off criteria for LVSI, glucose metabolic profiling of primary lesions correctly predicted lymph node metastasis with an accuracy of 73.0 %, which was comparable with the accuracy of visual assessment for lymph node metastasis using MRI and FDG PET/CT. CONCLUSION: FDG PET/CT diagnostic criteria may need adjustment based on the anatomical information provided by MRI. The optimized criteria can predict the risk of pathology-proven LVSI correctly in 83.8 % of patients before surgery, and thus would improve presurgical treatment planning.

Relationship between removal of circumflex iliac nodes distal to the external iliac nodes and postoperative lower-extremity lymphedema in uterine cervical cancer.

OBJECTIVE: This study aimed to determine if there is a causal relationship between removal of the circumflex iliac nodes distal to the external iliac nodes (CINDEIN) and postoperative lower-extremity lymphedema (POLEL) after systematic lymphadenectomy in patients with cervical cancer. METHODS: A retrospective chart review was performed for all living cervical cancer patients who underwent lymphadenectomy and were managed at Hokkaido Cancer Center between 1993 and 2013. The type of lymphadenectomy gradually shifted from lymphadenectomy with removal of CINDEIN to without CINDEIN dissection during this period. The study period was divided into two phases: from 1993-2007 (first phase) and from 2008-2013 (second phase). We identified patients with POLEL. Logistic regression analysis was used to select the risk factors for POLEL. RESULTS: Implementation of CINDEIN-dissection lymphadenectomy (94.0% vs. 20.6%, p<0.0001) and adjuvant radiotherapy (26.1% vs. 4.5%, p<0.0001) was significantly higher in the first phase than in the second phase. Of 398 patients evaluated, POLEL was noted in medical records of 80 (20.1%) patients with a median follow-up period of 78.0months. The occurrence rate of POLEL was significantly higher in the first phase than in the second phase (32.2% vs. 8.0%, p<0.0001), despite no change in the number of dissected lymph nodes between the two phases. Multivariate analysis showed that adjuvant radiation therapy (odds ratio=2.6, 95% confidence interval=1.4-4.8) and removal of CINDEIN (odds ratio=4.6, 95% confidence interval=2.4-9.0) were independent risk factors for POLEL. CONCLUSION: Elimination of CINDEIN dissection is helpful for reducing the incidence of POLEL.

Close relationship between removal of circumflex iliac nodes to distal external iliac nodes and postoperative lower-extremity lymphedema in uterine corpus malignant tumors.

OBJECTIVE: The aim of this study was to confirm a causal relationship between removal of circumflex iliac nodes to the distal external iliac nodes (CINDEIN) and lower-extremity lymphedema after systematic lymphadenectomy in patients with uterine corpus malignancies. METHODS: A retrospective chart review was carried out for all patients with uterine corpus malignant tumor managed at Hokkaido Cancer Center between 1991 and 2013. All 318 patients underwent CINDEIN dissection as a part of initial surgery and 217 patients did not. Patients had undergone hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy and their medical records were reviewed. The type of lymphadenectomy gradually shifted from pelvic lymphadenectomy with removal of CINDEIN to full lymphadenectomy without CINDEIN dissection during this period. We identified patients with postoperative lower-extremity lymphedema (POLEL). Logistic regression analysis was used to select the risk factors for POLEL. RESULTS: Of 535 patients evaluated, POLEL was noted in the medical records of 126 patients (23.6%), with median follow-up of 71months. The occurrence of POLEL was significantly higher in the CINDEIN-dissection group than in the CINDEIN-sparing group (34.3% vs. 7.8%, P<0.0001). Multivariate analysis confirmed that adjuvant radiation therapy [odds ratio (OR)=6.3, 95% confidence interval (CI)=2.6-14.9], resection of more than 31 lymph nodes (OR=2.0, 95% CI=1.2-3.5), and removal of CINDEIN (OR=5.4, 95% CI=3.1-9.3) were independent risk factors for POLEL. CONCLUSIONS: Elimination of CINDEIN dissection can be helpful in reducing the incidence of POLEL.

Availability of tissue rinse liquid-based cytology for the rapid diagnosis of sentinel lymph node metastasis and improved bilateral detection by photodynamic eye camera.

OBJECTIVE: On sentinel lymph node navigation surgery for early invasive cervical cancers, to gain high sensitivity and specificity, the sentinel nodes should be detected bilaterally and pathological diagnosis should be sensitive to detect micrometastasis. To improve these problems, we tried tissue rinse liquid-based cytology and the photodynamic eye. METHODS: From 2005 to 2013, 102 patients with Stage Ib1 uterine cervical cancer were subjected to sentinel lymph node navigation surgery with Technetium-99 m colloid and blue dye. For the recent 11 patients with whom bilateral sentinel node detection was not available, the photodynamic eye was selectively examined. The detected sentinel node was cut along the minor axis into 2 mm slices, soaked in 10 ml CytoRich red and then subjected to tissue rinse liquid-based cytology at the time of surgery. RESULTS: With the accumulation of 102 Ib1 patients subjected to sentinel lymph node navigation surgery, the bilateral sentinel node detection rate was 67.7%. The photodynamic eye was examined for the recent 11 patients who did not have bilateral signals. Out of the 11, 10 patients obtained bilateral signals successfully. During the period of examining the photodynamic eye, a total of 34 patients were subjected to sentinel lymph node navigation surgery. Thus, the overall bilateral detection rate increased to 97% in this subset. Two hundred and five lymph nodes were available as sentinel nodes. The sensitivity of tissue rinse liquid-based cytology was 91.7%, and the specificity was 100%. False positivity was 0% and false negativity was 8.3%. Detection failure was observed only with one micrometastasis and one case of isolated tumor cells. CONCLUSION: Combination of photodynamic eye detection and tissue rinse liquid-based cytology pathology can be a promising method for more rewarding sentinel node detection.

[Comparison of Analgesic Efficacy between Posterior and Lateral Transversus Abdominis Plane Block Techniques for Laparoscopic Gynecological Surgery].

BACKGROUND: Posterior transversus abdominis plane (TAP) block has been considered as a useful technique for lower abdominal postoperative analgesia, but in ultrasound-guided block, its efficacy and usability are still unknown. We prospectively compared the analgesic efficacy among posterior and lateral TAP block and with control group in laparoscopic gynecological surgery. METHODS: 29 patients were randomly assigned to a study group. Ultrasound-guided TAP block was performed before the operation. In the posterior group (n =10), a needle was inserted from posterior to the middle axillary line, and its tip was centrally positioned at the origin of the transversus abdominis muscle. In the lateral group (n=10), a needle was inserted from the middle axillary line, and the tip was peripherally positioned at the surface of the transversus abdominis muscle. Visual analog scale (VAS), the use frequency of fentanyl rescue dose, and the period of time until initial rescue use after the operation were measured. RESULTS: In posterior group, pain scores both at rest and on movement were significantly lower than other groups at early phase (P<0.05). The number of uses of the fentanyl rescue dose was smaller in posterior group than in control group in the first 6 postoperative hours (1±1.2 vs 3±1.5, P<0.05). CONCLUSIONS: Ultrasound-guided posterior TAP block could become a more useful tool for postoperative analgesia. We presumed that its additional effect is caused from reduction of visceral pain related to sympathetic nerve block.

Identification of KLF17 as a novel epithelial to mesenchymal transition inducer via direct activation of TWIST1 in endometrioid endometrial cancer.

Krüppel-like factor 17 (KLF17), a member of the KLF transcription factor family, has been shown to inhibit the epithelial-mesenchymal transition (EMT) and tumor growth. However, the expression, the cellular function and the mechanism of KLF17 in endometrioid endometrial cancer (EEC; a dominant type of endometrial cancer) remain elusive. Here, we report that among the KLF family members, KLF17 was consistently upregulated in EEC cell lines compared with immortalized endometrial epithelial cells. Overexpression of KLF17 in EEC cell lines induced EMT and promoted cell invasion and drug resistance, resulting in increased expression of TWIST1. In contrast, KLF17 suppression reversed EMT, diminished cell invasion, restored drug sensitivity and suppressed TWIST1 expression. Luciferase assays, site-directed mutagenesis and transcription factor DNA-binding analysis demonstrated that KLF17 transactivates TWIST1 expression by directly binding to the TWIST1 promoter. Knockdown of TWIST1 prevented KLF17-induced EMT. Consistent with these results, both KLF17 and TWIST1 levels were found to be elevated in EECs compared with normal tissues. KLF17 expression positively correlated with tumor grade but inversely correlated with estrogen and progesterone receptor expression. Thus, KLF17 may have an oncogenic role during EEC progression via initiating EMT through the regulation of TWIST1.

MicroRNA-106b modulates epithelial-mesenchymal transition by targeting TWIST1 in invasive endometrial cancer cell lines.

Type II endometrial carcinoma is an aggressive subtype of endometrial cancer (EC). TWIST1, a helix-loop-helix transcription regulator, is known to induce epithelial-mesenchymal transition (EMT) and promote tumor metastasis. MicroRNAs (miRNAs) also serve as important regulators of EMT and metastasis by regulating EMT-related genes. In this study, we sought to explore the role of TWIST1 in inducing EMT in representative type II EC cell lines, and to determine the miRNAs involved in regulating TWIST1 gene expression. Functional analysis suggested that TWIST1 contributes to the EMT phenotypes of EC cells, as evidenced by the acquisition of fibroblast-like properties, enhanced invasiveness, and induction of an EN-switch (downregulation of epithelial marker E-cadherin and upregulation of mesenchymal marker N-cadherin). Conversely, silencing of TWIST1 by siRNA inhibited cell invasion and the mesenchymal phenotype, which was accompanied by a reversion of the EN-switch. We also observed a novel post-transcriptional regulatory mechanism of TWIST1 expression mediated by miR-106b via its direct interaction with TWIST1 mRNAs at the 3'-untranslated region. Our data suggest that TWIST1 is a critical inducer of EMT in invasive EC cells and that miR-106b could suppress EC cell invasion by downregulating TWIST1 expression.

Distribution of lymph node metastasis sites in endometrial cancer undergoing systematic pelvic and para-aortic lymphadenectomy: a proposal of optimal lymphadenectomy for future clinical trials.

PURPOSE: The aim of this study was to demonstrate the precise mapping of lymph node metastasis (LNM) sites in endometrial cancer. METHODS: A total of 266 patients who underwent primary radical surgery including systematic pelvic and para-aortic lymphadenectomy for endometrial cancer from 1993 to 2010 were enrolled in this study. We removed lymph nodes from the femoral ring to the para-aortic node up to the level of renal veins. We analyzed the distribution of positive-node sites according to their anatomical location. RESULTS: Overall, 42 of 266 patients (15.8 %) showed LNM. The median number of nodes harvested was 62.5 (range 40-119) in pelvic nodes (PLN), and 20 (range 3-47) in para-aortic nodes (PAN). Among 42 cases with positive-nodes, 16 cases (38.1 %) showed positive PLN alone, 7 cases (16.7 %) in PAN alone, and 19 cases (45.2 %) in both PLN and PAN. The most prevalent site of positive-nodes was PAN (9.8 %) followed by obturator nodes (9.4 %), internal iliac nodes (7.1 %), and common iliac nodes (5.6 %). Six of 19 cases (31.6 %) of positive PAN above the inferior mesenteric artery (IMA) showed negative PAN below IMA. Metastasis to the deep inguinal nodes was found to be extremely rare (0.38 %). Single-site LNM was the most frequently observed in obturator nodes, followed by PAN above IMA. CONCLUSION: Routine resection of deep inguinal nodes is not recommended, whereas para-aortic lymphadenectomy should be extended up to the level of renal veins for endometrial cancer.

New revised FIGO 2008 staging system for endometrial cancer produces better discrimination in survival compared with the 1988 staging system.

BACKGROUND AND OBJECTIVES: The aim of this study was to analyze the stage migration and survival of endometrial cancer by the revised FIGO 2008 staging system compared with the 1988 staging system. METHODS: A total of 355 patients with endometrial cancer, who underwent complete surgical staging, were enrolled. We compared the surgical stages and survival by FIGO 1988 staging system with those by FIGO 2008 staging system. RESULTS: 2008 FIGO staging system resulted in an increase of stage I patients and decrease of stage II and IIIa patients. The 5-year overall survival (OS) rates for patients with 2008 FIGO stage IA and IB disease were 98.2% and 91.9%, respectively (P = 0.004). Five-year OS rate of new stage II (82.6%) was significantly worse than that of new stage IA (98.2%, P = 0.003). Patients with positive washing cytology alone revealed a 5-year OS rate similar to that of patients with new stage IIIA disease (96.2% vs. 90.9%, respectively; P = 0.53). The 5-year OS rate for patients with stage IIIC1 disease was improved compared with that for patients with stage IIIC2 disease (85.7% vs. 63.0%, respectively; P = 0.08). CONCLUSION: New revised FIGO 2008 staging system for endometrial cancer produced better discrimination in OS outcomes compared with the 1988 system.

MicroRNA-194 inhibits epithelial to mesenchymal transition of endometrial cancer cells by targeting oncogene BMI-1.

BACKGROUND: Epithelial-mesenchymal transition (EMT) is the key process driving cancer metastasis. Oncogene/self renewal factor BMI-1 has been shown to induce EMT in cancer cells. Recent studies have implied that noncoding microRNAs (miRNAs) act as crucial modulators for EMT. The aims of this study was to determine the roles of BMI-1 in inducing EMT of endometrial cancer (EC) cells and the possible role of miRNA in controlling BMI-1 expression. METHODS AND RESULTS: We evaluated the expression of BMI-1 gene in a panel of EC cell lines, and detected a strong association with invasive capability. Stable silencing of BMI-1 in invasive mesenchymal-type EC cells up-regulated the epithelial marker E-cadherin, down-regulated mesenchymal marker Vimentin, and significantly reduced cell invasion in vitro. Furthermore, we discovered that the expression of BMI-1 was suppressed by miR-194 via direct binding to the BMI-1 3'-untranslated region 3'-UTR). Ectopic expression of miR-194 in EC cells induced a mesenchymal to epithelial transition (MET) by restoring E-cadherin, reducing Vimentin expression, and inhibiting cell invasion in vitro. Moreover, BMI-1 knockdown inhibited in vitro EC cell proliferation and clone growth, correlated with either increased p16 expression or decreased expression of stem cell and chemoresistance markers (SOX-2, KLF4 and MRP-1). CONCLUSION: These findings demonstrate the novel mechanism for BMI-1 in contributing to EC cell invasion and that repression of BMI-1 by miR-194 could have a therapeutic potential to suppress EC metastasis.

Initial failure site according to primary treatment with or without para-aortic lymphadenectomy in endometrial cancer.

OBJECTIVE: The objective of this study was to compare the initial failure sites in patients with endometrial cancer who underwent surgical treatment including pelvic lymphadenectomy with or without para-aortic lymphadenectomy. METHODS: A retrospective chart review was carried out for 657 endometrial cancer patients with no residual disease after initial treatments including lymphadenectomy at two tertiary centers between 1987 and 2004. Surgical treatment at one institute included pelvic lymphadenectomy (PLX) without para-aortic lymphadenectomy (PALX), while surgical treatment including PLX+PALX was routinely performed at the other institute. We identified patients with recurrence and evaluated initial failure sites. Rates of recurrence in the respective sites were compared according to the type of lymphadenectomy. RESULTS: Of the 657 patients, 103 (15.7%) suffered recurrence. There was no significant difference between the rate of intrapelvic recurrence in the PLX alone group and that in the PLX+PALX group (4.7% vs. 2.9%, p=0.22). The rate of extrapelvic recurrence in the PLX alone group was significantly higher than that in the PLX+PALX group (16.1% vs. 6.2%, p<0.0001), and the rate of para-aortic node (PAN) recurrence in the PLX alone group was also significantly higher than that in the PLX+PALX group (5.1% vs. 0.6%, p=0.0004). In the analysis of patients who received adjuvant chemotherapy, the rate of PAN recurrence in the PLX alone group was significantly higher than that in the PLX+PALX group (9.5% vs. 1.3%, p=0.0036). CONCLUSION: PAN recurrence was a failure pattern peculiar to the PLX alone group. Adjuvant chemotherapy might not be able to replace surgical removal as a treatment for metastatic lymph nodes.

A retrospective analysis of postoperative complications with or without para-aortic lymphadenectomy in endometrial cancer.

INTRODUCTION: Although para-aortic lymphadenectomy (PALX) has not been accepted as a standard treatment for patients with endometrial cancer, it is possible that systematic lymphadenectomy including PALX has therapeutic significance for patients with intermediate-/high-risk endometrial cancer. On the other hand, a consensus regarding the safety of PALX has not been reached. The aim of this study was to compare the incidence rates of postoperative complications after pelvic lymphadenectomy (PLX) with or without PALX in patients with uterine corpus cancer. METHODS: A retrospective chart review was carried out for all patients with endometrial cancer treated at 2 tertiary centers between 1998 and 2004. Surgery at one institute included both PLX and PALX, whereas PLX alone was routinely performed at the other institute. A total of 142 patients underwent PLX + PALX and 138 patients underwent PLX alone. We evaluated postoperative complications including intraoperative injury, ileus, lymphedema, lymphocyst, and thrombosis. RESULTS: There was no fatal accident associated with surgery. Lymphedema was the most frequent complication. Comparing the PLX + PALX group and the PLX group, there were no significant differences in the rate of cases of lymphedema (23.2% vs 28.3%), lymphocyst (9.2% vs 9.4%), and thrombosis (4.9% vs 2.2%). The rate of cases of mild/moderate ileus in the PLX + PALX group was significantly higher than that in the PLX group (10.5% vs 2.9%; P = 0.011). However, no significant difference in the rates of cases of severe ileus was found between the 2 groups (1.4% vs 0.7%). There were also no significant differences between the 2 groups in the rates of intraoperative organ injury (2.8% vs 2.2%) and secondary operation for postoperative complications (4.9% vs 4.3%). CONCLUSIONS: Para-aortic lymphadenectomy can be performed with an acceptable morbidity under the conditions in which it is performed by experienced surgeons, and measures to prevent complications are properly taken.

Risk factors for lower-limb lymphedema after surgery for cervical cancer.

BACKGROUND: Lower-limb lymphedema (LLL) is a prevalent complication that is encountered after treatment for gynecological malignancies. The aim of this study was to evaluate the risk factors for postoperative LLL in patients with cervical cancer. METHODS: We conducted a retrospective chart review for patients who had undergone surgery, including systematic lymphadenectomy, for cervical cancer. Patients who died of cancer, were evaluated for short periods of time (<2 years), had missing medical records, or were suffering from deep venous thrombosis were excluded. We utilized the International Society of Lymphology staging of lymphedema severity as the diagnostic criteria for LLL, and patients with stage II or III lymphedema, as objectively determined by physicians, were included in the group of patients with LLL. Multivariate analysis was performed to confirm independent risk factors. RESULTS: A total of 155 patients with cervical cancer were evaluated. Thirty-one patients (20.0%) contracted LLL with a median follow-up of 6.1 years. Suprafemoral node dissection (odds ratio, 9.5; 95% confidence interval, 1.2-73.3; P = 0.031) and adjuvant radiotherapy (3.7; 1.2-10.9; P = 0.019) were identified as independent risk factors. CONCLUSION: Given that the effectiveness of the above two therapeutic options for cervical cancer is currently controversial, the clinical benefits of these therapies should be reevaluated specifically to conserve the quality of life for patients with this disease.

The hedgehog-patched signaling pathway and function in the mammalian ovary: a novel role for hedgehog proteins in stimulating proliferation and steroidogenesis of theca cells.

The expression of hedgehog (Hh) genes, their receptor, and the co-receptor in mice, rat, and bovine ovaries were investigated. RT-PCR of ovarian transcripts in mice showed amplification of transcripts for Indian (Ihh) and desert (Dhh) Hh, patched 1 (Ptch1), and smoothened (Smo) genes. Semi-quantitative RT-PCR and northern blot analyses showed that whole ovarian Ihh and Dhh transcripts decreased 4-24 h after hCG versus 0-48 h after pregnant mares serum gonadotrophin treatment in mice, whereas mouse Ptch1 and Smo transcripts were expressed throughout the gonadotropin treatments. Quantitative real-time RT-PCR (qRT-PCR) revealed that the expression of the Hh-patched signaling system with Ihh mRNA abundance in granulosa cells was greater, whereas Smo and Ptch1 mRNA abundance was less in theca cells of small versus large follicles of cattle. In cultured rat and bovine theca-interstitial cells, qRT-PCR analyses revealed that the abundance of Gli1 and Ptch1 mRNAs were increased (P<0.05) with sonic hedgehog (SHH) treatment. Additional studies using cultured bovine theca cells indicated that SHH induces proliferation and androstenedione production. IGF1 decreased Ihh mRNA abundance in bovine granulosa cells. The expression and regulation of Ihh transcripts in granulosa cells and Ptch1 mRNA in theca cells suggest a potential paracrine role of this system in bovine follicular development. This study illustrates for the first time Hh activation of Gli1 transcriptional factor in theca cells and its stimulation of theca cell proliferation and androgen biosynthesis.

Survival and failure pattern of patients with endometrial cancer after extensive surgery including systematic pelvic and para-aortic lymphadenectomy followed by adjuvant chemotherapy.

We investigated the survival and the failure pattern of 288 patients with endometrial cancer treated with extensive surgery including systematic pelvic and para-aortic lymphadenectomy followed by cisplatin-based chemotherapy from 1982 to 2002. We correlated the failure pattern with various clinicopathologic factors to find the predictors of recurrence sites. The 5-year overall survival rates were 97.5% for stage I, 87.5% for stage II, 85.2% for stage III, and 12.5% for stage IV. Notably, the 5-year survival rate was 76.5% for patients with stage IIIC disease. Among patients with a low risk (n = 92) for recurrence who received no adjuvant chemotherapy, 2 (2.2%) showed recurrent disease. Among those with intermediate (n = 98) and high (n = 98) risks for recurrence who received adjuvant chemotherapy, 9 (9.2%) and 20 (20.4%) showed recurrent disease, respectively. The recurrence sites were described as follows: distant (n = 12), vaginal (n = 8), peritoneal (n = 7), pelvic (n = 2), and lymphatic (n = 2). Lymphatic failure was found beyond the area of lymphadenectomy. Architectural and nuclear grades; myometrial, lymph-vascular space, and cervical invasions; and lymph node metastasis were predictors of distant failure. Cervical invasion and lymph node metastasis were predictors of vaginal failure. For patients with stage I/II cancer, the architectural and nuclear grades were related to distant failure. Seven (63.6%) of 11 patients with a low or intermediate risk survived after relapse, whereas only 1 (4.8%) of 21 patients with a high risk survived after a recurrence. We conclude that we need to further test the efficacy of systemic adjuvant therapy using new chemotherapeutic regimens to prevent distant failure and to improve the survival of patients with endometrial cancer.

Bioactivity of human chorionic gonadotropin produced in frozen-thawed embryo transfer cycles with exogenous hormone replacement.

Human chorionic gonadotropin (HCG) is the glycoprotein hormone in pregnancy. It is known that hCG molecule has a variety of isoforms showing different potency in bioactivity. Taking advantage of rat Leydig cell assay to evaluate hCG bioactivity, we first tried to predict the prognosis of pregnancy in hormone replacement (HR)-cryopreserved embryo transfer cycles. There was no significant difference in serum estradiol (E2) level, immuno-hCG, or bioactive to immunoreactive hCG ratio (b/i) between normal pregnancies and miscarriages at 4 weeks of gestation. Linear regression did not show a significant correlation in E2 or b/i between normal pregnancies and miscarriages. The same analysis was performed on serum samples collected from spontaneously pregnant patients. In normal pregnancies b/i was significantly lower than that in miscarriages while serum E2 was significantly higher. The linear regression analysis was also performed to clarify the correlation between E2 and b/i, and no significant correlation was observed. To confirm the effect of E2 on hCG production, we treated trophoblastic cells with E2. E2 increased the immunoreactivity of hCG to a non-physiologically high concentration; however, it did not change its bioactivity, suggesting that E2 did not change hCG bioactivity by affecting trophoblasts directly. In this study, we presumed it possible to speculate the prognosis of the pregnancy in spontaneous cycles from b/i of hCG, but not in HR cycles. It is suggested that process of hCG secretion could undergo different endocrine regulations between the artificial sex steroid replacement cycles and spontaneous cycles with corpus luteum function.

Incidence of metastasis in circumflex iliac nodes distal to the external iliac nodes in cervical cancer.

OBJECTIVE: A causal relationship between removal of circumflex iliac nodes distal to the external iliac nodes (CINDEIN) and lower leg edema has been recently suggested. The aim of this study was to elucidate the incidence of CINDEIN metastasis in cervical cancer. METHODS: A retrospective chart review was carried out for 531 patients with cervical cancer who underwent lymph node dissection between 1993 and 2014. CINDEIN metastasis was pathologically identified by microscopic investigation. After 2007, sentinel lymph node biopsy was performed selectively in patients with non-bulky cervical cancer. The sentinel node was identified using (99m)Tc-phytate and by scanning the pelvic cavity with a γ probe. RESULTS: Two hundred and ninety-seven patients (55.9%) underwent CINDEIN dissection and 234 (44.1%) did not. The percentage of International Federation of Gynecology and Obstetrics stage IIb to IV (42.4% vs. 23.5%, p<0.001) was significantly higher in patients who underwent CINDEIN dissection than those who did not. CINDEIN metastasis was identified in 1.9% overall and in 3.4% of patients who underwent CINDEIN dissection. For patients with stage Ia to IIa disease, CINDEIN metastasis was identified in 0.6% overall and in 1.2% of patients who underwent CINDEIN dissection. Of 115 patients with sentinel node mapping, only one (0.9%) had CINDEIN detected as a sentinel node. In this case, the other three lymph nodes were concurrently detected as sentinel lymph nodes. CONCLUSION: CINDEIN dissection can be eliminated in patients with stage Ia to IIa disease. CINDEIN might not be regional lymph nodes in cervical cancer.

Heterodimeric fly glycoprotein hormone-alpha2 (GPA2) and glycoprotein hormone-beta5 (GPB5) activate fly leucine-rich repeat-containing G protein-coupled receptor-1 (DLGR1) and stimulation of human thyrotropin receptors by chimeric fly GPA2 and human GPB5.

Glycoprotein hormones play important roles in thyroid and gonadal function in vertebrates. The glycoprotein hormone alpha-subunit forms heterodimers with different beta-subunits to activate TSH or gonadotropin (LH and FSH) receptors. Recent genomic analyses allowed the identification of another alpha-subunit, GPA2, and another beta-subunit, GPB5, in human, capable of forming heterodimers to activate TSH receptors. Based on comparative genomic searches, we isolated the fly orthologs for human GPA2 and GPB5, each consisting of 10 cysteine residues likely involved in cystine-knot formation. RT-PCR analyses in Drosophila melanogaster demonstrated the expression of GPA2 and GPB5 at different developmental stages. Immunoblot analyses further showed that fly GPA2 and GPB5 subunit proteins are of approximately 16 kDa, and coexpression of these subunits yielded heterodimers. Purified recombinant fly GPA2/GPB5 heterodimers were found to be glycoproteins with N-linked glycosylated alpha-subunits and nonglycosylated beta-subunits, capable of stimulating cAMP production mediated by fly orphan receptor DLGR1 but not DLGR2. Although the fly GPA2/GPB5 heterodimers did not activate human TSH or gonadotropin receptors, chimeric fly GPA2/human GPB5 heterodimers stimulated human TSH receptors. These findings indicated that fly GPA2/GPB5 is a ligand for DLGR1, thus showing the ancient origin of this glycoprotein hormone-seven transmembrane receptor-G protein signaling system. The fly GPA2 also could form heterodimers with human GPB5 to activate human TSH receptors, indicating the evolutionary conservation of these genes and suggesting that the GPA2 subunit may serve as a scaffold for the beta-subunit to activate downstream G protein-mediated signaling.