New Surgical Approach to Treat Fibroids and Solid Tumors - Thermal and Nonthermal Ablation.

There is a trend toward more minimally invasive treatment for symptomatic uterine fibroids. They are image-guided ablation surgery with focused ultrasound, microwave, and radiofrequency ablations that are becoming tested and used in some medical centers or hospitals. Nevertheless, these image-guided ablation surgeries involve thermal ablation to the fibroids, which might lead to thermal injury to the surrounding tissues, for example, nerve injury, vessel injury, and skin burn due to heat diffusion. A new technology - irreversible electroporation (IRE) - is a new paradigm for treating solid tumors. This nonthermal ablation process does not induce high temperatures when treating cancers or solid tumors. The IRE treatment may soon be used for treating fibroids or other solid tumors. In a few clinical trials, IRE is currently used in experimental studies for treating gynecological cancers. This paper will present the minimally invasive thermal ablation treatments for fibroids, introduce this new nonthermal IRE ablation in treating gynecological cancer, and propose its future uses in uterine fibroids.

A Journey from Learning a Noninvasive High-intensity Focused Ultrasound Surgical Treatment for Gynecological Diseases to Providing High-intensity Focused Ultrasound Services in Hong Kong.

This paper reflects a Hong Kong doctors group's journey to learn the high-intensity focused ultrasound (HIFU) ablation treatment for gynecological diseases in China. The procedures of HIFU ablation for fibroids, adenomyosis, and other gynecological diseases are described. After completing our training, the authors applied the HIFU ablation techniques they have learned to establish an outpatient HIFU clinic and provided HIFU ablation treatment in Hong Kong. This paper describes their early experience in providing HIFU services.

Nano-Enhanced Drug Delivery and Therapeutic Ultrasound for Cancer Treatment and Beyond.

While ultrasound is most widely known for its use in diagnostic imaging, the energy carried by ultrasound waves can be utilized to influence cell function and drug delivery. Consequently, our ability to use ultrasound energy at a given intensity unlocks the opportunity to use the ultrasound for therapeutic applications. Indeed, in the last decade ultrasound-based therapies have emerged with promising treatment modalities for several medical conditions. More recently, ultrasound in combination with nanomedicines, i.e., nanoparticles, has been shown to have substantial potential to enhance the efficacy of many treatments including cancer, Alzheimer disease or osteoarthritis. The concept of ultrasound combined with drug delivery is still in its infancy and more research is needed to unfold the mechanisms and interactions of ultrasound with different nanoparticles types and with various cell types. Here we present the state-of-art in ultrasound and ultrasound-assisted drug delivery with a particular focus on cancer treatments. Notably, this review discusses the application of high intensity focus ultrasound for non-invasive tumor ablation and immunomodulatory effects of ultrasound, as well as the efficacy of nanoparticle-enhanced ultrasound therapies for different medical conditions. Furthermore, this review presents safety considerations related to ultrasound technology and gives recommendations in the context of system design and operation.

Magnetic Resonance Imaging in the Evaluation of Cesarean Scar Defect.

The incidence of Cesarean scar defect (CSD) would increase with the increasing trends of cesarean section delivery. The actual incidence of this condition is unknown, but it had been estimated by hysteroscopy, sonohysterography, or transvaginal ultrasound to be around 50% of patients with cesarean section. CSD is often asymptomatic, but it may produce common symptoms such as abnormal uterine bleeding, infertility, and pelvic pain. Adverse pregnancy outcomes with scar ectopic pregnancy, uterine rupture had been reported. The use of magnetic resonance imaging (MRI) imaging of this condition is seldom performed and reported. This paper is to analyze retrospectively the MRI finding of 158 women, so as to review the MRI findings of CSD, their appearances and measurements.

A false positive fluorodeoxyglucose positron emission tomography/computed tomography diagnosis of pelvic lymph node recurrence following surgical treatment of Stage 1 endometrial cancer-a case report.

A 47 year old patient with a G3, FIGO stage 1A endometrial cancer was treated by hysterectomy. Her two ovaries were conserved because of the pre-operative diagnosis of endocervical cancer. On follow up PET-CT follow up investigation, she had a benign ovarian corpus luteal cyst mistaken as a metastatic pelvic lymph node which was later removed and proven benign histologically. This paper is to raise the clinical awareness of possible false positive PET finding from a benign ovarian cyst, such that a misinterpretation of "recurrence" as in this case can be avoided.

Regulatory Effect of Peptidoglycan on the Expression of Toll-Like Receptor 2 mRNA and Proteins in Trophoblast Cell Line TEV-1 Cells.

Objective. To investigate the regulatory effect of peptidoglycan on the expression of human Toll-like receptors 2 (TLR2) mRNA and proteins in the human extravillous trophoblast cell line (TEV-1). Methods. TEV-1 cells were incubated with different doses of peptidoglycan. The expression of TLR2 mRNA and protein was detected by reverse transcriptase-polymerase chain reaction (RT-PCR) and immunocytochemistry SP staining. Results. TLR2 was expressed in TEV-1 cells and localized to both the cytoplasm and plasma membrane. Compared with the untreated control, TEV-1 cells incubated with 30 µg/ml peptidoglycan significantly upregulated the expression of TLR2 mRNA and protein after 12 hours of treatment (P < .01). However, the expression of TLR2 mRNA and protein was decreased but had no significant difference compared with the control (P > .05) after 24 hours of treatment. On the other hand, 10 µg/ml peptidoglycan did not seem to have regulatory effect on mRNA and protein expression of TLR2 (P > .05). Conclusion. Peptidoglycan has a role in regulating the expression of TLR2 mRNA and protein in TEV-1 cells. It suggests that the trophoblast cells may play important role in the immune response at the fetal-maternal interface and affect the result of pregnancy by expressing TLR2.

Inguinal endometriosis: an uncommon differential diagnosis as an inguinal tumour.

Inguinal endometriosis can present as a rare tumor when it occurs outside the abdomen and pelvis. We present a patient with a painful tumor in the right inguinal region, where its diagnosis was made before the operation. This enabled a conservative excisional surgery to be performed. The literature is reviewed and the diagnosis as well as management are discussed.

A retrospective study of laparoscopic-assisted vaginal hysterectomy (LAVH) in virgins and nulliparae.

OBJECTIVE: To study the feasibility and result of LAVH performed in virgins and nulliparae. STUDY DESIGN: Retrospective review of 297 consecutive cases of LAVH using the Biswas Uterine Vaginal Elevator (BUVE) in a private hospital in Hong Kong for benign gynaecological conditions between July 2006 and February 2009. Variables analysed included patient demographics, operative times, uterine weight, hospital stay, intraoperative blood loss, and operative complications. Patients who were virgins and nulliparae were compared to each other and to a control group of patients receiving LAVH during the same period of time. RESULTS: All 297 cases of LAVH were successfully performed without any conversion. Ninety-seven LAVHs were performed on 31 virgins and 66 nulliparae, while 200 LAVHs were performed on parous patients during the same study period. The uterine sizes in the virgin group were significantly larger than those in the other two groups. The operation times in the virgin and nullipara groups were significantly longer than those in the control group. The complication rates of LAVH in these three groups were 6.4%, 12.1% and 3% in the virgin, nulliparous and control groups respectively. The overall complication rate of this series was low at 5.3%. CONCLUSIONS: LAVH is feasible with acceptable safety in virgins and nulliparae in spite of their narrow and tight vaginas.

Novel Vaginal "paper roll" uterine morcellation technique for removal of large (>500 g) uterus.

At laparoscopic-assisted vaginal hysterectomy with a novel "paper roll" vaginal morcellation technique, large uteri (> or = 500 g) can be removed via the vagina with safety, speed, and ease. The technique provides protection for the bladder and rectum, and large uteri can be removed in 1 piece, allowing the pathologist to reconstruct the entire uterus.

Hysteroscopic appearance of endometrial cavity after microwave endometrial ablation.

STUDY OBJECTIVE: To assess the appearance of the endometrial cavity after microwave endometrial ablation. DESIGN: Prospective observational study. SETTING: GuangDong Women's and Children's Hospital, GuangDong, China. PATIENTS: A total of 349 patients who underwent microwave endometrial ablation from January 2000 through August 2008 were followed up for 1 month to 8 years. At follow-up in 2007 and 2008, patients were advised of this clinical study and were randomly selected for participation if they agreed to undergo outpatient hysteroscopy to assess the uterine cavity during follow-up visits. Fifty three patients (median [range] age, 43.1 [33-53] years) were recruited into the study at the time of endometrial ablation. INTERVENTION: Outpatient hysteroscopy. MAIN RESULTS: Within the first 3 months after ablation, outpatient hysteroscopy revealed varying amounts of necrotic tissue from the endometrium and superficial myometrium of the uterus. Six months postablation, a granulomatous reaction and fibrosis were present. A fibrotic cavity was also evident, and menstrual flow was reduced or had ceased. One year after ablation, hysteroscopy demonstrated a fibrotic cavity with myofibrous scars. Most patients developed amenorrhea at this time. Two years or more postablation, a second hysteroscopy demonstrated various types of intrauterine adhesions in 28 of the 53 women (52.8%). A cervical adhesion was observed in 1 patient (1.9%), focal adhesions in the fundal area in 12 (22.6%), a narrowed and scarred uterine cavity with bilateral stenotic tubal ostia in 11 (20.7%), and complete obliteration of the cavity in 4 (7.5%). Of these 28 women, 22 had amenorrhea, 3 had vaginal spotting during menstruation, and 2 had hypomenorrhea. Of those without intrauterine adhesions, only 5 had amenorrhea, 10 had vaginal spotting, and 8 had hypomenorrhea. CONCLUSION: The hysteroscopic appearance of the uterine cavity after microwave endometrial ablation varies considerably. In this study, the menstrual outcome was correlated with postablation uterine cavity appearance.

Effect of acupuncture on induction of labor.

OBJECTIVE: The objective of this study is to review the existing scientific evidence on the potential role of acupuncture on induction of labor during pregnancy. DESIGN: The Medline, EMBASE, Cochrane Central Register of Controlled Trials, AMED (Allied and Complementary Medicine), and NCCAM (The National Center for Complementary and Alternative Medicine) databases were searched to identify relevant monographs from 1970 to 2008. INCLUSION CRITERIA: These criteria included all available human acupuncture studies on pregnant women carrying a viable fetus due for third trimester induction of labor. EXCLUSION CRITERIA: These criteria included studies not meeting the inclusion criteria, in languages other than English, or animal studies. RESULTS: Ten (10) studies on labor induction were identified. The duration of labor as a result of acupuncture treatment ranged from 10 hours 20 minutes to 29.1 hours. All of the studies demonstrated labor induction by acupuncture treatment. However, because two randomized controlled trials reported that there was no statistically significant effect of acupuncture, these results are more suggestive than definitive. Furthermore, although the relationship between cervical ripening and interleukin-8 (IL-8), prostaglandin F(2alpha) (PGF(2alpha)), and beta-endorphin is well documented in the literature, there is no evidence to suggest that acupuncture alters these mediators. Serum levels of IL8, beta-endorphin, and PGF(2alpha) were not found to be significantly influenced by acupuncture. CONCLUSIONS: Although the definitive role of acupuncture in inducing labor is still yet to be established, the existing studies suggest that acupuncture may be beneficial in labor induction. Further randomized clinical trials are needed to investigate this further.

Polycystic ovarian syndrome in adolescence.

BACKGROUND: Polycystic ovarian syndrome (PCOS), which is a common endocrinopathy seen not only in adult women but also in female adolescents nowadays, is associated with reproductive, metabolic and cardiovascular problems. OBJECTIVE: This article aims to review the current evidence on managing PCOS in adolescence. In addition, the pathophysiology, risk factors, clinical presentations and existing diagnostic criteria of PCOS will also be discussed. DISCUSSION: Certain risk factors are available to assist the clinicians to identify adolescents at risk of PCOS as the signs can be masked by the normal physiological changes during puberty. It is important to screen and diagnose adolescent PCOS in order to prevent the development of future infertility, type II diabetes mellitus, cardiovascular disease, and even endometrial cancer. Lifestyle modification is of the greatest benefit for adolescents in terms of management, with the condition that full support is available from both the clinicians and their families. The psychological impact of PCOS also constitutes a major concern in adolescent PCOS.

Current alternative and complementary therapies used in menopause.

OBJECTIVE: To determine the efficacy and safety of common complementary and alternative medicine (CAM) therapies used to relieve the menopausal symptoms. DESIGN: Comprehensive literature search was conducted through the databases Medline, EMBASE, Cochrane, AMED (Allied and Complementary Medicine), NCCAM (The National Centre for Complementary and Alternative Medicine) to identify relevant monographs in English language. RESULTS: Studies have shown that some therapies such as clonidine, selective serotonin receptor inhibitors (SSRIs) and gabapentin are effective in decreasing the degree and frequency of somatic symptoms in menopause, while phytooestrogens and black cohosh have shown mixed results. Use of Ginseng, evening primrose, Dong Quai or vitamin E appears not to be efficacious for the relieving hot flushes. Other effects of these therapies including possible improvements in mood are yet to be substantiated. INCLUSION CRITERIA: All available human complementary medicine studies on menopausal women with regard to the relief of menopausal symptoms. EXCLUSION CRITERIA: Studies not meeting the inclusion criteria, published in languages other than English or animal studies. CONCLUSION: There is a general lacking of longer-term follow-up beyond the trial lengths of 6-12 weeks in the use of CAM, although women may be taking these medications for many years. Well-designed, randomised control trials are needed to elucidate the true effect of these therapies above the placebo effect.

Heterotopic pregnancy following in vitro fertilization and embryo transfer: 12 cases report.

OBJECTIVE: To evaluate the incidence, predisposing factors, early diagnosis and treatment options of heterotopic pregnancy (HP) following in vitro fertilization and embryo transfer (IVF-ET) procedure. METHODS: A retrospective review study was performed to identify the HP cases after IVF-ET at the Reproductive Centre in Guangdong Women and Children's Hospital in China between the years of 2002-2007. RESULTS: Twelve out of 1,476 pregnancies (0.81%) were diagnosed for HP, of which nine patients elected for exploratory salpingectomy, two patients received selective fetal reduction by embryo aspiration under ultrasound guidance, and one patient opted for expectant treatment. Postoperatively, four intrauterine pregnancies were continued to develop until term while two were delivered at 35 weeks of gestation. The achievement ratio of continuous pregnancy was 66.7% (6/9). CONCLUSION: The incidence of HP is increasing due to the widespread use of assisted reproductive technology. An early transvaginal sonography performed by experienced radiologist/radiographer is considered to be essential and beneficial in establishing early diagnosis of HP. Both salpingectomy and selective fetal reduction by embryo aspiration can be administered as one of the effective therapies for HP with the optimal outcome of intrauterine pregnancy.