Incisional hernia formation and associated risk factors on a gynecologic oncology service: an exploratory analysis.

PURPOSE: The aim of this study is to identify the rate of incisional hernias and associated risk factors following a vertical midline laparotomy on a gynecologic oncology service. METHODS: This is a retrospective cohort study of patients that underwent a laparotomy through a vertical midline abdominal incision between September 1998 and November 2012. Hernias and various factors were identified including demographics, disease comorbidities, intraoperative variables, and suture technique. Assessment of association with hernia formation was performed using Cox regression and log-rank test. RESULTS: Two hundred and fifty-two patients with follow-up of at least 30 days were identified. Mean age was 59 years (range 21-88 years) and mean BMI was 35.9 kg/m(2) (range 17.2-84.4 kg/m(2)). Sixteen (6.3 %) developed incisional hernias with a median follow-up of 1.7 years (range 1 month to 13 years). The estimate of the 5-year probability of being hernia-free is 86 % (95 % CI 76.5-91.9). Average age of patients who developed a hernia was 66.2 years while average age of those without hernia was 58 years (p < 0.05). There was a significant association of hypertension with incisional hernia occurrence (p = 0.0035, log-rank test). Cancer was present in 100 % of patients that developed hernias and 73 % (172/236) of those that were hernia-free (p = 0.0041, log-rank test). By univariate analysis the risk of developing an incisional hernia was higher, if the abdominal fascia was closed with loop sutures (HR 4.6, 95 % CI 1.49-13.94; p = 0.008). By multivariable analysis incisions closed with loop suture had more than a fivefold increased risk of developing a hernia (HR 5.2, 95 % CI 1.65-16.39; p = 0.005). Presence of both hypertension and utilization of loop sutures had the highest risk of incisional hernia development (HR 7.1, 95 % CI 2.28-22.4; p = 0.001). CONCLUSION: Wound complications including incisional hernias contribute to morbidity in gynecologic oncology patients. Older age, hypertension, utilization of loop sutures, and cancer were found to be associated with hernia formation after laparotomy through a vertical midline abdominal incision. The use of loop sutures to close the abdominal fascia should be investigated further.

Glassy cell carcinoma of the cervix: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this study is to summarize the data on the incidence, clinical behavior and overall survival of patients with glassy cell cervical carcinoma (GCCC). METHODS: Twenty-four case series and fifteen case reports identified by searching PubMed database qualified for inclusion in this study. The published cases were combined with data from a retrospective chart review of patients with GCCC in two major teaching hospitals in Brooklyn, NY. RESULTS: A total of 292 cases were collected through our literature and chart review. Median age at diagnosis was 45 years old (range 12-87 years of age). GCCC incidence ranges from 0.2 to 9.3% of all cervical cancers and 2 to 30.2% of cervical adenocarcinomas. The stage distribution is similar to squamous cell carcinoma with 79% of the patients being diagnosed with Stage I or II disease. Most common sites of recurrence for Stage I patients are the vagina and pelvis. In Stage II patients locoregional and distant metastases are equally common. Recurrence rate was higher among patients treated only with surgery (32.7%), as compared to patients treated with surgery followed by radiation (11%) or patients treated with radiation only (10%). Median overall survival (OS) was 25 months (95% CI 8.4-41.6). Overall 5-year survival for all stages is lower when compared to all cervical cancers (54.8% vs 75%). There was no interaction between race and OS (p=0.66). CONCLUSION: GCCC is a rare histologic type of cervical cancer that presents at a younger age, is associated with high risk for distant failure and carries worse prognosis as compared to the squamous cell type. Radiation therapy is associated with decreased risk of recurrence.

Interactions of Wnt/beta-catenin signaling and sonic hedgehog regulate the neurogenesis of ventral midbrain dopamine neurons.

Signaling mechanisms involving Wnt/beta-catenin and sonic hedgehog (Shh) are known to regulate the development of ventral midbrain (vMB) dopamine neurons. However, the interactions between these two mechanisms and how such interactions can be targeted to promote a maximal production of dopamine neurons are not fully understood. Here we show that conditional mouse mutants with region-specific activation of beta-catenin signaling in vMB using the Shh-Cre mice show a marked expansion of Sox2-, Ngn2-, and Otx2-positive progenitors but perturbs their cell cycle exit and reduces the generation of dopamine neurons. Furthermore, activation of beta-catenin in vMB also results in a progressive loss of Shh expression and Shh target genes. Such antagonistic effects between the activation of Wnt/beta-catenin and Shh can be recapitulated in vMB progenitors and in mouse embryonic stem cell cultures. Notwithstanding these antagonistic interactions, cell-type-specific activation of beta-catenin in the midline progenitors using the tyrosine hydroxylase-internal ribosomal entry site-Cre (Th-IRES-Cre) mice leads to increased dopaminergic neurogenesis. Together, these results indicate the presence of a delicate balance between Wnt/beta-catenin and Shh signaling mechanisms in the progression from progenitors to dopamine neurons. Persistent activation of beta-catenin in early progenitors perturbs their cell cycle progression and antagonizes Shh expression, whereas activation of beta-catenin in midline progenitors promotes the generation of dopamine neurons.