Uterine leiomyosarcomas with osteoclast-like giant cells associated with high expression of RUNX2 and RANKL.

Uterine leiomyosarcoma (ULMS) with osteoclast-like giant cells (OLGCs) has been reported as a rare phenomenon in ULMS, and its clinico-pathological features and tumorigenesis remain unclear. We recently reported high expression of receptor activator of nuclear factor κB ligand (RANKL) in ULMS with OLGCs. As osteoblasts produce RANKL, in this study, we analyzed the expression of Runt-related transcription factor 2 (RUNX2), a critical transcription factor for osteoblasts, and osteoclast-related proteins in three cases of ULMS with OLGCs as well as five conventional ULMSs and nine leiomyomas. Immunohistochemistry and real-time reverse transcription quantitative polymerase chain reaction analyses showed high expression of RUNX2 and RANKL in ULMS with OLGCs. In these cases, macrophages expressed receptor activator of nuclear factor κB (RANK), and OLGCs expressed osteoclast-related proteins (nuclear factor of activated T cells, cytoplasmic 1 (NFATc1), and cathepsin K). Accumulation sites of cathepsin K-positive OLGCs showed hemorrhagic appearance and degraded type IV collagen. We reviewed reported cases of ULMS with OLGCs, including ours, and found that they presented an aggressive course even at stage I. Furthermore, metastatic lesions showed similar histological features to those of OLGC association in ULMS. Here, we show that tumor cells in ULMS with OLGCs highly express RUNX2 and RANKL and that osteoclastic differentiation of macrophages occurs in the tumor tissue.

The Trained Sniffer Dog Could Accurately Detect the Urine Samples from the Patients with Cervical Cancer, and Even Cervical Intraepithelial Neoplasia Grade 3: A Pilot Study.

(1) Background: Previous reports have indicated that cancers of the stomach, lung, and pancreas can be detected by dog sniffing, but results have been varied. Here, a highly trained dog was used to determine whether urine from patients with cervical premalignant lesions and malignant tumors have a cancer-specific scent. (2) Methods: A total of 195 urine samples were collected from patients with cervical cancer, cervical intraepithelial neoplasia grade 3 (CIN3), benign uterine diseases, and healthy volunteers. Each test was performed using one urine sample from a cancer patient and four samples from different controls. Each of the five urine samples was placed in a separate box. When the cancer sniffing dog stopped and sat in front of the box with a sample from a cancer patient, the test was considered as positive. (3) Results: 83 patients with cervical cancer (34 cases of cervical cancer and 49 cases of cervical intraepithelial neoplasia grade 3), 49 patients with uterine benign diseases, and 63 healthy volunteers were enrolled, and their urine samples were collected. In 83 times out of 83 runs in a double-blind test, the trained dog could correctly identify urine samples of cervical cancer patients. (4) Conclusion: A trained dog could accurately distinguish the urine of all patients with cervical cancer or CIN3, regardless of the degree of cancer progression.

A nationwide survey on gynecologic endoscopic surgery in Japan, 2014-2016.

AIM: Since 2014, Japan Society of Gynecologic and Obstetric Endoscopy and minimally invasive therapy (JSGOE) conducted a nationwide survey on gynecologic endoscopic surgery. We aimed to evaluate the current status and complications associated with endoscopic surgery by Japan gynecologic and obstetric endoscopy-database registry system (JOE-D). METHODS: Electrical medical records concerning the endoscopic surgery were generated from the daily use of reporting system. The subjects were all patients who underwent gynecologic endoscopic surgery. In addition to assessment of actual numbers, diagnosis, and operative methods, adverse events were registered. RESULTS: Total 203 970 patients performed laparoscopic, hysteroscopic and falloposcopic surgery for 3 years, 2014-2016. The numbers of endoscopic surgeries conducted in 2016 were increased more than 67 000, 13 000 or 450 cases, respectively. Incidence rates of complications involving these three types of surgeries in each year were approximately 3.1%. Incidences of intraoperative complications were relatively high in malignant diseases, laparoscopic-assisted vaginal hysterectomy (LAVH) and myomectomy (LAM). In total laparoscopic hysterectomy/laparoscopic hysterectomy (TLH/LH) performed from 2014 to 2016, ureteral injury as intra and postoperative complication occurred in 0.35%. In the past 3 years, the rates of vascular injury, urinary tract, and bowel injury as intraoperative complications caused by laparoscopic surgery were approximately 0.1%. In the hysteroscopic surgery, the rates of total intra- and postoperative complications were 0.78%. CONCLUSION: We exhibited the current status by the nationwide survey of gynecologic endoscopic surgery all over Japan. Severe intra or postoperative complications were identified over the 3 years at a rate of 0.04%.

Serum CA 125 Level after Neoadjuvant Chemotherapy is Predictive of Prognosis and Debulking Surgery Outcomes in Advanced Epithelial Ovarian Cancer.

Recently, neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) has been recommended for selected patients with International Federation of Gynecology and Obstetrics (FIGO) stage III or IV disease and bulky tumors. The aim of this study was to evaluate associations between post-NACT serum CA 125 levels, surgical outcomes, and clinical outcomes in patients with advanced epithelial ovarian cancer. We retrospectively analyzed 107 patients with FIGO stage III or IV ovarian cancer who were treated with NACT-IDS at the Gynecology Department of Kanagawa Cancer Center between January 2001 and December 2012. Serum CA 125 levels after NACT were significantly lower in the complete/optimal IDS group compared to the suboptimal IDS group (mean±standard deviation: 48.1±27.6 vs. 346.5±295.2 U/mL, p<0.01). Patients with low preoperative CA 125 levels (<35 U/mL) had a higher probability of optimal IDS (78.1±41.9% vs. 33.3±19.2%, p<0.01) and longer progression-free survival (mean±standard deviation: 30.4±14.3 months vs. 21.3±7.3 months, p<0.05) than patients with high CA 125 levels (>100 U/mL). Patients with low CA 125 levels (<35 U/mL) had a higher probability of complete/optimal IDS and longer progression-free survival compared to patients with high CA 125 levels (>100 U/mL).

Allelic Imbalance in Regulation of ANRIL through Chromatin Interaction at 9p21 Endometriosis Risk Locus.

Genome-wide association studies (GWASs) have discovered numerous single nucleotide polymorphisms (SNPs) associated with human complex disorders. However, functional characterization of the disease-associated SNPs remains a formidable challenge. Here we explored regulatory mechanism of a SNP on chromosome 9p21 associated with endometriosis by leveraging "allele-specific" functional genomic approaches. By re-sequencing 1.29 Mb of 9p21 region and scrutinizing DNase-seq data from the ENCODE project, we prioritized rs17761446 as a candidate functional variant that was in perfect linkage disequilibrium with the original GWAS SNP (rs10965235) and located on DNase I hypersensitive site. Chromosome conformation capture followed by high-throughput sequencing revealed that the protective G allele of rs17761446 exerted stronger chromatin interaction with ANRIL promoter. We demonstrated that the protective allele exhibited preferential binding affinities to TCF7L2 and EP300 by bioinformatics and chromatin immunoprecipitation (ChIP) analyses. ChIP assays for histone H3 lysine 27 acetylation and RNA polymerase II reinforced the enhancer activity of the SNP site. The allele specific expression analysis for eutopic endometrial tissues and endometrial carcinoma cell lines showed that rs17761446 was a cis-regulatory variant where G allele was associated with increased ANRIL expression. Our work illuminates the allelic imbalances in a series of transcriptional regulation from factor binding to gene expression mediated by chromatin interaction underlie the molecular mechanism of 9p21 endometriosis risk locus. Functional genomics on common disease will unlock functional aspect of genotype-phenotype correlations in the post-GWAS stage.

P16-positive continuous minimal deviation adenocarcinoma and gastric type adenocarcinoma in a patient with Peutz-Jeghers syndrome.

We report a case of Peutz-Jeghers syndrome (PJS) in a 33-year-old female patient with synchronous uterine cervical minimal deviation adenocarcinoma (MDA) and gastric type adenocarcinoma (GTA). The patient was diagnosed with PJS at the age of 10. At the time of consultation, she complained of watery discharge. Magnetic resonance imaging of the pelvis showed a poorly circumscribed mass in the uterine cervix. Histologically, both MDA and GTA components, as well as their transitional area, were observed. Both components were diffusely positive for MUC6, CK7 and, robustly, for p16. Moreover, the components were negative for ER, PgR and CEA, while HIK1083 and CK20 positive cells were found focally. Ki-67 labeling index in the MDA component was 5% while that in the GTA component was 50%. This case of GTA accompanied by MDA in a patient with PJS is distinct from the single previously-reported comparable case of which we are aware, with respect to the overexpression of p16 protein, an event considered rare in these tumors, and the continuity between the MDA and GTA components. This continuity favors the hypothesis that GTA arises from the dedifferentiation of MDA.

miR-200a, miR-200b and miR-429 are onco-miRs that target the PTEN gene in endometrioid endometrial carcinoma.

Endometrioid endometrial carcinoma (EEC) is a common malignancy of the female genital tract. However, no adequate biomarker is currently available for predicting the prognosis of this cancer. Recent studies have revealed dysregulated expression of several microRNAs (miRNAs) in various cancer tissues, and therefore, these cancer-associated miRNAs (also called onco-miRs) could be promising prognostic biomarkers of cancer progression or metastasis. In this study, in order to identify onco-miRs and their possible targets involved in EEC, we performed microarray-based integrative analyses of miRNA and mRNA expression in specimens excised from EEC lesions and adjacent normal endometrial tissues. Using integrated statistical analyses, we identified miR-200a, miR-200b and miR-429 as highly up-regulated onco-miRs in EECs. Conversely, we detected expression of a tumor-suppressor gene, phosphatase and tensin homolog (PTEN), which was predicted in silico using a miRNA-targeting mRNA prediction algorithm, as a target of the three miRNAs and which was down-regulated in EECs. Furthermore, these miRNAs were validated to target PTEN experimentally using luciferase assays and real-time polymerase chain reaction. These results suggest that the occurrence of EEC is, at least in part, mediated by miRNA-induced suppression of PTEN expression.

Proteomic identification of autoantibodies in sera from patients with ovarian cancer as possible diagnostic biomarkers.

BACKGROUND/AIM: Accumulating evidence shows that various types of cancers induce a specific immune response resulting in the production of antibodies against self-components (autoantibodies). The aim of the present study was to identify antigens for autoantibodies in sera from patients with ovarian cancer, especially clear cell carcinoma (CCC), as novel diagnostic markers for the disease. MATERIALS AND METHODS: The reactivity of individual sera from patients was examined by two-dimensional (2-D) immunoblotting using lysates of CCC cell lines, ES-2 and RMG-1, as antigens to identify autoantigens. ELISA was established to quantitatively measure autoantibody titer of patients' sera. RESULTS: Autoantibodies against RhoGDI were induced in sera of ovarian cancer patients. Elevated levels of autoantibodies against heterogeneous nuclear ribonucleoprotein L (hnRNPL) and a mitochondrial protein, dihydrolipoamide dehydrogenase (DLD), were detected in patients with CCC. CONCLUSION: Autoantibodies against RhoGDI and hnRNPL and DLD may serve as novel diagnostic markers for ovarian cancer and CCC, respectively.

Novel hybrid laparoscopic sacrocolpopexy for pelvic organ prolapse with a severe paravaginal defect.

Abdominal sacrocolpopexy is the gold standard for treating pelvic organ prolapse (POP) because of safety and durable good results. More recently laparoscopic sacrocolpopexy (LSC), a less invasive approach, has become popular. Although these surgeries are versatile and can treat almost all patients with POP, these techniques have shortcomings. Specifically, reinforcement of lateral vaginal defects are not very strong, thus patients with POP and a severe paravaginal defect are not good candidates for abdominal or laparoscopic sacrocolpopexy. To overcome this problem, we developed a novel type of LSC, which can reinforce severe paravaginal defects by using a reversed T-shaped anterior mesh combining the advantage of transvaginal mesh surgery. We refer to this novel surgery as 'hybrid LSC'. Thus far, eight patients have successfully undergone this surgery. Hybrid LSC is a simple and secure method, and is an alternative treatment for POP with a severe paravaginal defect.

Novel hybrid mesh surgery combines sacrocolpopexy with transvaginal mesh placement for pelvic organ prolapse.

Mesh surgeries, such as sacrocolpopexy and transvaginal mesh surgery, are commonly used to treat pelvic organ prolapse. Although mesh surgeries have a high success rate, they are unsuitable for some patients. For a patient with pelvic organ prolapse and highly calcified multiple fibroids, we performed hybrid sacrocolpopexy combined with transvaginal mesh surgery with a method modified for the patient's condition. Three months after surgery, the results were highly satisfactory. This approach is simple, secure, and versatile for patients who are not good candidates for conventional mesh surgeries. This novel hybrid mesh surgery is an option for treating various types of pelvic organ prolapse.

Evaluation of laparoendoscopic single-site gynecologic surgery with a multitrocar access system.

OBJECTS: Laparoendoscopic single-site surgery (LESS) is an ideal approach for gynecologic surgery and yields better cosmetic results. However, a standard umbilical approach with LESS is not appropriate for gynecologic surgery requiring intra-abdominal suturing and dissection requiring traction. Therefore, we have developed a new multitrocar access system for gynecologic LESS. The purpose of this study was to evaluate the efficacy of gynecologic LESS using this access system. METHODS: This access system consists of one 12-mm trocar, two 5-mm trocars, and a 5-mm flexible laparoscope. Two 5-mm trocars with small port heads were inserted cross-wise on opposite sides of the sleeve of the centrally positioned 12-mm trocar to maintain triangulation. Thirty-eight patients with various gynecologic conditions underwent LESS with this access system. The results of these surgeries were retrospectively compared to those of conventional laparoscopic procedures. RESULTS: Of the 38 LESS procedures performed with this access system, none was up-converted, converted to an open laparotomy, or required blood transfusion. The Salpingo-oophorectomy with LESS had several benefits, such as no extension of the skin incision of the trocar site and no leakage of the contents of the ovarian cyst into the peritoneal cavity, over that with conventional laparoscopy. A comparison of LESS (11 patients) and conventional laparoscopy (16 patients) for total hysterectomy showed no significant difference in total blood loss (234.0 mL vs. 221.6 mL) or the weight of the resected uterus (276.0 g vs. 285.0 g), although the mean total operative time was greater with LESS (199.0 min vs. 168.5 min). CONCLUSION: Our multitrocar access system is safe and secure, and can be adapted for various gynecologic surgeries involving complicated procedures. LESS with this access system achieves results comparable to those of conventional laparoscopy with 4 ports, although the operative time is longer.

A case of tumor lysis syndrome following chemotherapy for a uterine epithelioid leiomyosarcoma with focal rhabdomyosarcomatous differentiation.

Tumor lysis syndrome (TLS) is a potential complication characterized by hyperuricemia, hyperphosphatemia, hyperkalemia and hypocalcemia due to massive necrosis of malignant cells after cytotoxic therapy. This fatal complication occurs frequently in tumors with hematological malignancies, such as acute lymphoblastic leukemia and Burkitt's lymphoma, and in other tumors with high proliferative rates and tumor burdens. TLS is rarely associated with the treatment of solid tumors. Herein, we report a case of TLS following the initial administration of effective chemotherapy for an epithelioid leiomyosarcoma with focal rhabdomyosarcomatous differentiation of the uterus.

Endometrial aspiration cytology for diagnosis of peritoneal lesions in extrauterine malignancies.

OBJECTIVE: To evaluate the usefulness of endometrial aspiration cytology for assessing malignant cells of extrauterine origin. STUDY DESIGN: Endometrial cytology was performed on 224 patients with primary ovarian cancer, 10 with fallopian tube cancer and 45 with peritoneal tumors. RESULTS: Of 224 patients with ovarian cancer, 53 (23.7%) had positive endometrial cytology. Positive rates were: stage I, 4.3%; stage II, 25.0%; stage III, 39.7%; stage IV, 34.5%. Histologic positive rates were: serous, 28.7%; mucinous, 11.4%; clear cell, 23.1%; endometrioid and unclassifiable adenocarcinomas, 28.0%. Of 5 patients with ovarian cancer, 2 were asymptomatic, but aspiration cytology was positive. Of 10 patients with fallopian tube cancer, 9 (90.0%) had positive endometrial cytology. The positive rate on endometrial cytology was 56.7% in stomach cancer, 60.0% in breast cancer and 20.0% in colon cancer. Of 1,209 women with stomach cancer, 30 (2.4%) displayed ovarian metastasis. Of these, 7 (23.3%) had Krukenberg's tumor; endometrial cytology was positive in 1 (14.3%). In 7 of 17 patients with positive endometrial cytology, clinical diagnosis was made before stomach cancer therapy. CONCLUSION: Endometrial aspiration cytology is useful for identifying nongynecologic malignant cells, diagnosing ovarian and fallopian tube cancers, and determining peritoneal dissemination and metastasis originating from gastrointestinal and breast cancers.

Separation of polyvinyl chloride (PVC) from automobile shredder residue (ASR) by froth flotation with ozonation.

The purpose of this study is to develop froth flotation to separate polyvinyl chloride (PVC) from automobile shredder residue (ASR) plastic mixtures of variable composition. Some polymers in ASR polymer mixtures have similar density and hydrophobicity with PVC and thus selective flotation of PVC from ASR polymer mixtures cannot be achieved. The present study focused on the surface modification of PVC with ozonation, and then the modified PVC can be separated from other polymers by the following froth flotation. The results of this study indicate that the selective recovery of PVC from real ASR polyethylene tetra pethelate (PET), polymethyl methacrylate (PMMA), polybutyl methacralate (PBMA), ethyl acrylate (EA), polycarbonate (PC) and rubber mixtures can be accomplished in a three-step process involving a gravity separation, ozonation and froth flotation. The rubber was removed from other heavy ASR (PVC, PET, PMMA, PBMA, EA and PC) polymers by froth flotation without mixing. It was found that ozonation process produced the desired difference in contact angle required (from 89.5 to 73.0 degrees ) for separation of PVC from other heavy ASR polymers, whereas the contact angles of other polymers was slightly decreased. The most of the load ASR, i.e. about 72.4% is floated away and 27.6% was settled down. The highest component 96.7% of PVC was recovered in the settled fraction. As a result of this research effort, the surface modification of PVC with ozonation can be efficiently useful to separate the PVC from other similar density ASR mixed polymers.

Heavy metals removal from automobile shredder residues (ASR).

The fate of heavy metals during a separation process for automobile shredder residues (ASR) was investigated. A washing method to remove heavy metals from the ASR was also investigated. Although the separation process was not designed for removal of heavy metals, but for the recovery of reusable materials, the heavy metal content in the ASR was efficiently decreased. The concentrations of Pb, Cr and Cd in ASR were effectively reduced by a nonferrous metals removal process, and the As concentration was reduced by the removal of light dusts during the separation process. Five heavy metals (As, Se, Pb, Cr, Cd) remaining in the ASR after the separation process satisfied the content criteria of the Environmental Quality Standards for Soil (EQSS), while the concentrations of As, Se, Pb in the leachate from the remaining ASR did not satisfy the elution criteria of the EQSS. After additional washing of the remaining ASR with a pH 1 acid buffer solution, the As, Se, and Pb concentrations satisfied the EQSS for elution. These results indicate that an ASR residue can be safely recycled after a separation process, followed by washing at acidic pH.

Gasless laparoscopic surgery using a new intra-abdominal fan retractor system: an experience of 500 cases.

AIM: The aim of this study is to report the feasibility of a newly developed intra-abdominal fan retractor system for use in gynecologic laparoscopic surgery. METHODS: Five hundred women undergoing gasless laparoscopic surgery using the abdominal wall lifting device were included in the study. The intraoperative and postoperative courses, and complications were examined. RESULTS: The intra-abdominal retractor system provided adequate exposure in all cases, except for one patient with morbid obesity. Neither the presence of the intra-abdominal retractor blades nor the mechanical arm interfered with the placement of instruments during surgery. No complications related to the use of gasless laparoscopy were encountered in this study period. CONCLUSION: The new intra-abdominal fan retractor system is feasible in gynecologic laparoscopic surgery.

Frequent somatic mutations in PTEN and TP53 are mutually exclusive in the stroma of breast carcinomas.

We have recently shown that loss of heterozygosity of specific markers, including those at 10q23, 17p13-p15 and 16q24, can occur in the stromal and epithelial compartments of primary invasive breast carcinomas. Here, we demonstrate high frequencies of somatic mutations in TP53 (encoding tumor protein p53) and PTEN (encoding phosphate and tensin homolog) in breast neoplastic epithelium and stroma. Mutations in TP53 and PTEN are mutually exclusive in either compartment. In contrast, mutations in WFDC1 (16q24, encoding WAP four-disulfide core domain 1) occur with low frequency in the stroma.