Clinical consequences of upfront pathology review in the randomised PORTEC-3 trial for high-risk endometrial cancer.

Background: In the PORTEC-3 trial, women with high-risk endometrial cancer (HR-EC) were randomised to receive pelvic radiotherapy (RT) with or without concurrent and adjuvant chemotherapy (two cycles of cisplatin 50 mg/m2 in weeks 1 and 4 of RT, followed by four cycles of carboplatin AUC5 and paclitaxel 175 mg/m2). Pathology review was required before patient enrolment. The aim of this analysis was to evaluate the role of central pathology review before randomisation. Patients and methods: A total of 1295 cases underwent pathology review to confirm HR-EC in the Netherlands (n = 395) and the UK (n = 900), and for 1226/1295 (95%) matching review and original reports were available. In total, 329 of these patients were enrolled in the PORTEC-3 trial: 145 in the Netherlands and 184 in the UK, comprising 48% of the total PORTEC-3 cohort of 686 participants. Areas of discrepancies were evaluated, and inter-observer agreement between original and review opinion was evaluated by calculating the kappa value (κ). Results: In the 1226 pathology reviews, 6356 selected items were evaluable for both original and review pathology. In 43% of cases at least one pathology item changed after review. For 102 patients (8%), this discrepancy led to ineligibility for the PORTEC-3 trial, most frequently due to differences in the assessment of histological type (34%), endocervical stromal involvement (27%) and histological grade (19%). Lowest inter-observer agreement was found for histological type (κ = 0.72), lymph-vascular space invasion (κ = 0.72) and histological grade (κ = 0.70). Conclusion: Central pathology review by expert gynaeco-pathologists changed histological type, grade or other items in 43% of women with HR-EC, leading to ineligibility for the PORTEC-3 trial in 8%. Upfront pathology review is essential to ensure enrolment of the target trial-population, and to avoid over- or undertreatment, especially when treatment modalities with substantial toxicity are involved. This study is registered with ISRCTN (ISRCTN14387080, www.controlled-trials.com) and with ClinicalTrials.gov (NCT00411138).

Imaging in gynecological disease (12): clinical and ultrasound features of invasive and non-invasive malignant serous ovarian tumors.

OBJECTIVES: To describe clinical and ultrasound features of different subclasses of malignant serous ovarian tumors according to the World Health Organization 2014 classification. METHODS: Patients with a histological diagnosis of borderline tumor (BOT), non-invasive and invasive low-grade serous carcinoma (LGSC) and high-grade serous carcinoma (HGSC), who had undergone preoperative ultrasound examination, were retrospectively identified from two ultrasound centers. The masses were described using the terms of the International Ovarian Tumor Analysis Group. RESULTS: Sixty-four (15.8%) women had a serous BOT, 11 (2.7%) a non-invasive LGSC, 31 (7.6%) an invasive LGSC and 300 (73.9%) had a HGSC. The vast majority of BOTs (82.3%) and non-invasive LGSCs (90.9%) were Stage I according to the International Federation of Gynecology and Obstetrics (FIGO) classification scheme, whereas most invasive LGSCs (74.2%) and HGSCs (74.0%) were FIGO Stage III. On ultrasound examination, most borderline lesions were described as unilocular-solid (54.7%) or as multilocular-solid (29.7%) cysts. Papillary projections were present in 52 (81.3%) BOTs. Most non-invasive LGSCs (63.6%) were multilocular-solid cysts and 81.8% had papillary projections. Invasive LGSCs were multilocular-solid cysts in 54.8% of cases, and papillary projections were present in 32.3% of lesions. HGSCs were multilocular-solid (32.7%) or solid (64.0%) masses, with papillary projections in only 7% of cases. CONCLUSIONS: Papillary projections were the most typical ultrasound feature of non-invasive (borderline and low-grade) malignant serous tumors, while the presence of solid components but few, if any, papillations was the most representative feature of invasive (low-grade and high-grade) serous tumors. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Comparison of Onclarity Human Papillomavirus (HPV) Assay with Hybrid Capture II HPV DNA Assay for Detection of Cervical Intraepithelial Neoplasia Grade 2 and 3 Lesions.

Analytical and clinical performance validation is essential before introduction of a new human papillomavirus (HPV) assay into clinical practice. This study compares the new BD Onclarity HPV assay, which detects E6/E7 DNA from 14 high-risk HPV types, to the Hybrid Capture II (HC2) HPV DNA test, to concurrent cytology and histology results, in order to evaluate its performance in detecting high-grade cervical lesions. A population of 567 women, including 325 with ≥ASCUS (where ASCUS stands for atypical cells of undetermined significance) and any HC2 result and 242 with both negative cytology and negative HC2 results, were prospectively enrolled for the study. The overall agreement between Onclarity and HC2 was 94.6% (95% confidence intervals [CI], 92.3% to 96.2%). In this population with a high prevalence of disease, the relative sensitivities (versus adjudicated cervical intraepithelial neoplasia grades 2 and 3 [CIN2+] histology endpoints) of the Onclarity and HC2 tests were 95.2% (95% CI, 90.7% to 97.5%) and 96.9% (95% CI, 92.9% to 98.7%), respectively, and the relative specificities were 50.3% (95% CI, 43.2% to 57.4%) for BD and 40.8% (95% CI, 33.9%, 48.1%) for HC2. These results indicate that the BD Onclarity HPV assay has sensitivity comparable to that of the HC2 assay, with a trend to an increased specificity. Moreover, as Onclarity gives the chance to discriminate between the different genotypes, we calculated the genotype prevalence and the absolute risk of CIN2+: HPV 16 was the most prevalent genotype (19.8%) with an absolute risk of CIN2+ of 77.1%.

Yoctomole electrochemical genosensing of Ebola virus cDNA by rolling circle and circle to circle amplification.

This work addresses the design of an Ebola diagnostic test involving a simple, rapid, specific and highly sensitive procedure based on isothermal amplification on magnetic particles with electrochemical readout. Ebola padlock probes were designed to detect a specific L-gene sequence present in the five most common Ebola species. Ebola cDNA was amplified by rolling circle amplification (RCA) on magnetic particles. Further re-amplification was performed by circle-to-circle amplification (C2CA) and the products were detected in a double-tagging approach using a biotinylated capture probe for immobilization on magnetic particles and a readout probe for electrochemical detection by square-wave voltammetry on commercial screen-printed electrodes. The electrochemical genosensor was able to detect as low as 200 ymol, corresponding to 120 cDNA molecules of L-gene Ebola virus with a limit of detection of 33 cDNA molecules. The isothermal double-amplification procedure by C2CA combined with the electrochemical readout and the magnetic actuation enables the high sensitivity, resulting in a rapid, inexpensive, robust and user-friendly sensing strategy that offers a promising approach for the primary care in low resource settings, especially in less developed countries.

CD4 quantification based on magneto ELISA for AIDS diagnosis in low resource settings.

The Acquired Immune Deficiency Syndrome (AIDS) affects the life of millions of people around the world. Although rapid and low cost screening tests are widely available for the diagnosis of HIV infection, the count of CD4+ T lymphocytes remains a drawback in the areas mostly affected by the HIV, being this control imperative for assessing the deterioration of the immunological system and the progression towards AIDS, when the counting of cells falls down 200cellsµL(-1). This paper describes a high-throughput, simple and rapid method for CD4+ T lymphocytes quantification, directly in whole blood, based on a magneto ELISA. The CD4 cells are separated and preconcentrated from whole blood in magnetic particles, and labeled with an enzyme for the optical readout performed with a standard microplate reader. The magneto ELISA is able to reach the whole CD4 counting range of medical interest, being the limit of detection as low as 50 CD4+ cells per µL of whole blood, without any pretreatment. This method is a highly suitable alternative diagnostic tool for the expensive flow cytometry at the community and primary care level, providing a sensitive method but by using instrumentation widely available in low-resource settings laboratories and requiring low-maintenance, as is the case of a microplate reader operated by filters.

Electrochemical magneto-actuated biosensor for CD4 count in AIDS diagnosis and monitoring.

The counting of CD4(+) T lymphocytes is a clinical parameter used for AIDS diagnosis and follow-up. As this disease is particularly prevalent in developing countries, simple and affordable CD4 cell counting methods are urgently needed in resource-limited settings. This paper describes an electrochemical magneto-actuated biosensor for CD4 count in whole blood. The CD4(+) T lymphocytes were isolated, preconcentrated and labeled from 100 µL of whole blood by immunomagnetic separation with magnetic particles modified with antiCD3 antibodies. The captured cells were labeled with a biotinylated antiCD4 antibody, followed by the reaction with the electrochemical reporter streptavidin-peroxidase conjugate. The limit of detection for the CD4 counting magneto-actuated biosensor in whole blood was as low as 44 cells µL(-1) while the logistic range was found to be from 89 to 912 cells µL(-1), which spans the whole medical interest range for CD4 counts in AIDS patients. The electrochemical detection together with the immunomagnetic separation confers high sensitivity, resulting in a rapid, inexpensive, robust, user-friendly method for CD4 counting. This approach is a promising alternative for the costly standard flow cytometry and suitable as diagnostic tool at decentralized practitioner sites in low resource settings, especially in less developed countries.

Endometrial reconstruction after hysteroscopic incisional metroplasty.

Endometrial reconstruction after hysteroscopic metroplasty of a septate uterus was studied by light microscopy and scanning electron microscopy when the uterus was removed 13 days after metroplasty for a histologic diagnosis of leiomyosarcoma. We observed a retraction of the margins of the incised septum, which could prevent the formation of intrauterine adhesions. Reepithelialization of the cut surface seemed to proceed both centripetally, by proliferation of the surrounding normal endometrium, and centrifugally from the bottom of the glands present at the base of the septum.

Inguinal endometriosis: pathogenetic and clinical implications.

In six women with a preoperative diagnosis of incarcerated hernia, surgical exploration of the groin revealed inguinal endometriosis and no hernia. The affected structure was always the extraperitoneal portion of the round ligament. Six of the seven lesions were on the right. Intraperitoneal endometriosis was demonstrated in all patients. Catamenial pain was the pathognomonic symptom in the differential diagnosis of the inguinal mass. Gynecologists and surgeons should bear in mind the possibility that endometriosis may be the cause of symptoms of a suspected incarcerated inguinal hernia. Should this disease be detected at inguinal exploration, a laparoscopy is indicated during the same operation.

Endometrium of cavitary rudimentary horns in unicornuate uteri.

The rudimentary horns removed from ten patients with unicornuate uterus, subclass A1b, were studied by light and scanning electron microscopy. Seven of the horns removed were small in volume (range 7.5-15.7 mL) and three were larger (range 20.8-39.7 mL). In four cases the endometrial cavity communicated with the tubal lumen, hematometra was present in three cases, and endometriosis was diagnosed in six. In six of the seven rudimentary horns without hematometra, the endometrial mucosa did not correspond to the cycle phase of the endometrium of the hemiuterus; however, in the three rudimentary horns with hematometra, the endometrium presented cycle-phase characteristics similar to those of the hemiuterus. The endometrio-myometrial junction, the underlying myometrium, and the arcuate arterioles were always altered. We consider that the absence of cyclic changes in the endometria of the smaller horns may be attributed to reduced vascular supply, to the absence of any isthmocervical structure, and to the qualitative and/or quantitative differences in endometrial mucosal receptors.

Reliability of the visual diagnosis of ovarian endometriosis.

The visual diagnosis of endometrioma at laparotomy in 245 women operated on for ovarian cysts demonstrated a sensitivity of 97%, specificity of 95%, positive and negative predictive value of 98% and 94%, respectively, and overall accuracy of 96%. Because the visual detection of endometriomas is remarkably accurate, ovarian biopsy, although desirable in some cases, would seem dispensable for a correct laparoscopic diagnosis and staging of the disease.

Repair of the uterine cavity after hysteroscopic septal incision.

We performed a follow-up hysteroscopy with multiple biopsies at different intervals after surgery in 19 women who underwent hysteroscopic septal incision. Seven days after operation the sectioned areas were very evident and not epithelialized (3 patients). At 14 days, the incised zone was depressed with scattered epithelialization (5 subjects). At 1 month, the sectioned surfaces were still depressed and uniformly covered by thin endometrium (5 cases). After 2 months the uterine cavity was almost normal with minimal tendency to central fundal adhesions (6 women). Thus, spontaneous healing processes after hysteroscopic metroplasty progressed regularly and completely and there is probably no reason to delay attempts at pregnancy for longer than two cycles after surgery.

Transvaginal ultrasonography in the diagnosis of diffuse adenomyosis.

OBJECTIVE: To evaluate the diagnostic capability of transvaginal ultrasonography in detecting diffuse adenomyosis. DESIGN: We compared the preoperative transvaginal ultrasound (US) findings and the pathological findings of the surgical specimen in a series of women who underwent hysterectomy for menorrhagia. PATIENTS: Forty-three women (mean [+/- SD] age of 46 +/- 5) with recurrent menorrhagia and enlarged uterus, without evidence of uterine leiomyomas at abdominal US and of endometrial disease at vabra curettage. SETTING: Tertiary care center, university medical school. MAIN OUTCOME MEASURES: Sensitivity, specificity, predictive positive and negative values of transvaginal US in the diagnosis of diffuse adenomyosis. RESULTS: The sonographer diagnosed adenomyosis in 22 patients, whereas the pathologist found adenomyosis in 20 women, confirming the US findings in 16 cases and making an ex novo diagnosis in 4. The sensitivity of transvaginal US was 80%, the specificity 74%, the predictive value of a normal test 81%, and that of an abnormal test 73%. CONCLUSIONS: Transvaginal US seems to represent a real advance in the preoperative diagnosis of diffuse adenomyosis.

Sclerosing stromal tumor of the ovary. Report of eight cases and review of the literature.

In this article, we describe eight cases of sclerosing stromal tumors (SST) of the ovary and review the literature. We could not demonstrate unequivocal hormonal activity in any of the cases, although suggestive evidence for it has been reported in the literature in the form of clinical, histologic, electron microscopic and immunohistochemical findings.

Growth and rupture of an ovarian endometrioma in pregnancy.

Pregnancy has long been considered to have beneficial effects on endometriosis. We describe a patient who underwent emergency exploratory laparotomy at gestation week 35 for rupture of an ovarian endometrioma.