The utility of artificial neural networks and classification and regression trees for the prediction of endometrial cancer in postmenopausal women.

OBJECTIVE: Artificial neural networks (ANNs) and classification and regression trees (CARTs) have been previously used for the prediction of cancer in several fields. In our study, we aim to investigate the diagnostic accuracy of three different methodologies (i.e. logistic regression, ANNs and CARTs) for the prediction of endometrial cancer in postmenopausal women with vaginal bleeding or endometrial thickness ≥5 mm, as determined by ultrasound examination. STUDY DESIGN: We conducted a retrospective case-control study based on data from analysis of pathology reports of curettage specimens in postmenopausal women. METHODS: Classical regression analysis was performed in addition to ANN and CART analysis using the IBM SPSS and Matlab statistical packages. RESULTS: Overall, 178 women were enrolled. Among them, 106 women were diagnosed with carcinoma, whereas the remaining 72 women had normal histology in the final specimen. ANN analysis seems to perform better with a sensitivity of 86.8%, specificity of 83.3%, and overall accuracy (OA) of 85.4%. CART analysis did not perform well with a sensitivity of 78.3%, specificity of 76.4%, and OA of 77.5%. Regression analysis had a poorer predictive accuracy with a sensitivity of 76.4%, a specificity of 66.7%, and an OA of 72.5%. CONCLUSION: Artificial intelligence is a powerful mathematical tool that may significantly promote public health. It may be used as a non-invasive screening tool to guide clinicians involved in primary care decision making when endometrial pathology is suspected.

Ovarian tumors: Should the cervix be examined first?

There is a controversy regarding ovarian metastasis in early-stage adenocareinoma of the uterine cervix. The authors present the case of a 5 1-year-old woman that at the time of diagnosis was thought to suffer from a Stage II cervical carcinoma and a synchronous ovarian carcinoma, that turned out to be an ovarian metastasis from the endocervical adenocarcinoma, as attested morphologically, histochemically, and immunohistochemically. Radical hysterectomy with oophorectomy, excision of the omentum, lymph node excision, and cytological sampling of the peritoneal cavity were carried out. It is important to always bear in mind that even low-grade adenocarcinomas of the cervix can be metastatic to the ovaries. Clinicians have to be careful when managing those cases, while further investigation is needed in order to determine the exact mechanism of those metastases and the criteria needed in order to preserve the ovaries in young patients.

Cervical length in late second and third trimesters: a mixture model for predicting delivery.

OBJECTIVES: To examine the distribution of cervical length (CL) in the late second and third trimesters of pregnancy and construct survival models for spontaneous delivery. METHODS: This cross-sectional study included 647 women with a singleton pregnancy who had routine CL measurements taken by transvaginal ultrasonography between 24 and 40 weeks' gestation. Only one measurement per patient was included in the analysis. Exploratory data analysis revealed that the distribution of CL measurements was a mixture of two Gaussian distributions, and subsequently a mixture model was applied to describe the distribution of CL. Changes in CL in relation to gestational age were examined by regression analysis and measurements were converted to Z-scores. Survival analysis was applied to the subgroups identified, to describe the probability of delivery throughout gestation. RESULTS: CL was best described by a mixture model of two subgroups with Gaussian distribution, one including women with a long cervix (73.85% of the study population, mean CL of 28.2 ± 4.45 mm) and the other including women with a short cervix (26.15% of the study population, mean CL of 12.3 ± 5.14 mm). CL was dependent on gestational age (GA), therefore conversion to Z-scores was employed in the analysis. Women with a short cervix had a higher probability for spontaneous delivery (hazard ratio (HR), 1.807; P < 0.001) than did women with a long cervix, after adjustment for GA at the time of measurement (GA HR, 1.115; P < 0.001). In both subgroups, the probability of spontaneous delivery was predicted by the GA and CL Z-scores. Survival models for the prediction of spontaneous delivery were constructed separately for the short-cervix subgroup (GA HR, 1.085; P < 0.001 and CL Z-score HR, 0.819; P = 0.003) and the long-cervix subgroup (GA HR, 1.130; P < 0.001 and CL Z-score HR, 0.864; P = 0.005). CONCLUSIONS: CL follows a mixture of two Gaussian distributions, one for a short and one for a long cervix. Late second-trimester/third-trimester CL measurement may be of value in estimating the probability for spontaneous delivery at any given gestational age.

Ovarian carcinosarcoma: a case report, diagnosis, treatment and literature review.

BACKGROUND/AIM: This report aims to present a rare case of ovarian carcinosarcoma and its current, optimal diagnosis and therapy strategy. DESCRIPTION OF CASE: We report the case of a 70-year-old patient, who presented at the Obstetrics and Gynecology Department of the University Hospital of Mainz, with a short history of increased abdominal circumference. CONCLUSION: The symptoms, diagnosis, and therapy of carcinosarcoma follow the pattern of a high grade epithelial ovarian cancer, fallopian cancer and primary peritoneal cancer. The rarity of this disease is a barrier to conducting prospective trials and establishing guidelines for high-quality evidence data. Hippokratia 2015; 19 (3): 256-259.

Reactive oxygen species in the follicular fluid of subfertile women undergoing In Vitro Fertilization: a short narrative review.

Reactive Oxygen Species (ROS) are produced as a normal product of aerobic metabolism. Naturally, there is an array of protective mechanisms that neutralize ROS, while any potential imbalance between ROS and antioxidants results in oxidative stress. In an In Vitro Fertilization (IVF) setting, existing literature suggests a favorable outcome in terms of oocyte quality/maturation and fertilization rate with increased ROS levels, while other study groups have presented significant data on the detrimental effect of increased ROS concentration in the quality of embryos exposed and their potential to advance. In this study, we examine the conflicting views of the role of ROS in fertilization and embryo quality, especially through their concentration in the follicular fluid of subfertile women undergoing IVF. The current debate could possibly be attributed to the different assay methods and end-point outcomes employed by each research group, along with the noted limited number of the relevant studies published on the subject. Properly conducted studies can further validate and elicit the exact role of ROS as well as their association to female reproduction, and especially to women undergoing IVF.

The prevalence of phenotypic subgroups in Greek women with polycystic ovarian syndrome.

BACKGROUND: Since 2003, when the American Society for Reproductive Medicine (ASRM) and European Society of Human Reproduction and Embryology (ESHRE) sponsored consensus established criteria for polycystic ovarian syndrome (PCOS) diagnosis, the phenotypic spectrum of the syndrome has been significantly broadened. PURPOSE OF THE STUDY: This survey makes an effort to distinguish PCOS according to phenotypic expression and to estimate its prevalence in a Greek population. MATERIALS AND METHODS: Greek women from 18 to 35 years of age, who visited the outpatient department, claiming either irregular menstruation (oligo- or anovulation, OA) or clinical manifestations of hyperandrogenemia (HA) were recruited. They gave full disease history and underwent clinical examination, including transvaginal ultrasound (TVUS) scan to identify PCO morphology. Blood samples were collected to perform hormonal and metabolic analyses. Acute or chronic disorders were excluded. Finally, 266 PCOS women constituted the study population. CONCLUSIONS: The full-blown phenotype (HA+OA+PCO) is the predominant phenotype in this Greek population.

Liquid based cytology and HPV DNA testing in a Greek population compared to colposcopy and histology.

Screening for cervical cancer in Greece is still unorganised and based on self- motivation. The purpose of this study was to evaluate the accuracy of cytological findings from a large observational population sample, originating from Western Athens, in association with reflex DNA test, colposcopic estimation, and final histologic diagnosis. The rate of invasive carcinoma, both squamous cell and adenocarcinoma, is indicative of a largely unscreened population. In this study, the estimated overall prevalence of human papilloma virus (HPV) was 41.1%, with HPV positivity at 37.4% of cytologically normal women. HPV testing did not seem to improve sensitivity of cytology for atypical squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LGSIL) cases in identifying CIN 2+ lesions, but outperformed cytology in detecting CIN3+ for cytological high-grade squamous intraepithelial lesion (HGSIL) cases. For HGSIL cases sensitivity of colposcopy for detecting CIN3+ was comparable to cytology.

The practical role of anti-Müllerian hormone in assisted reproduction.

The objective of this study was to offer a brief critical summary of the literature on the role of AMH in the subfertility work up and during ART, while exploring its role in predicting ART success.

Comparing classic and newer phenotypes in Greek PCOS women: the prevalence of metabolic syndrome and their association with insulin resistance.

OBJECTIVE: Recently, it has been debated whether the new polycystic ovary syndrome (PCOS) phenotypes, according to the Rotterdam criteria, share the same metabolic risk with the classic ones (National Institutes of Health 1990). Our study sought to compare the prevalence of metabolic syndrome (MS) and glucose homeostasis disorders in Greek women with classic and new PCOS phenotypes. MATERIALS AND METHODS: Two hundred and sixty-six Greek PCOS women were recruited and divided into groups according to two of the three Rotterdam criteria that they fulfilled. Two subgroups were formed; the first represented the classic phenotypes and the second the new phenotypes. The clinical, biochemical, and ultrasound characteristics of both groups were explored. All subjects were evaluated for MS and underwent a 2-h glucose tolerance test to assess insulin resistance (IR) as measured by the homeostasis model assessment (HOMA-IR), quantitative insulin sensitivity check index (QUICKI), and MATSUDA indices. RESULTS: 62.4% of PCOS women were classified as classic NIH phenotypes of which 32 women had MS (prevalence 19.6%). Only 4 patients categorized in the newer phenotypic groups had MS (prevalence 4.1%). Among the subjects with classic phenotypes, 11.7% exhibited impaired glucose tolerance (3-fold higher percentage compared to patients with newer phenotypes). Regarding IR indices, HOMA-IR was significantly higher and QUICKI significantly lower for classic phenotypes. CONCLUSIONS: Greek PCOS women with classic phenotypes are at increased risk for MS and impaired glucose homeostasis compared to women with newer phenotypes. A subclassification of PCOS permits the earlier recognition and closer surveillance of women whose metabolic profile indicates potential risks for adverse health outcomes.

Clinical complications after transvaginal oocyte retrieval: a retrospective analysis.

There are little systematic data reported in the literature on complications observed after transvaginal oocyte retrieval (OR) guided by ultrasound. We report our experience in 542 in vitro fertilisation cycles. The frequency of severe complications in our patients was 0.72%; of these, two cases were bronchospasm during anaesthesia (0.36%) and two were cases of intraperitoneal bleeding (0.36%); minor vaginal bleeding was the most frequent complication (18.08%), which was treated easily. Through this retrospective analysis, it is evident that clinical suspicion is of particular importance in detecting post-OR complications on one hand, but on the other these complications are rare and most are treated conservatively.

Endometrioid ovarian cancer arising from an endometriotic cyst in a young patient.

OBJECTIVE: To present a case of a young woman with ovarian endometrioid adenocarcinoma arising from an endometriotic cyst and review of the literature. CASE REPORT: A 33-year-old woman, gravid 2, para 2 was admitted to our department with a 5 cm adnexal mass. Diagnostic laparoscopy was performed and pathological examination demonstrated an endometriotic cyst with an area of an ovarian endometrioid adenocarcinoma well differentiated, with no capsular invasion. One month after the operation the patient underwent MRI which revealed a 6 cm mass in the Douglas pouch. The multidisciplinary oncology council decided on exploratory laparotomy, which revealed no pathology. After that the multidisciplinary oncology council decided on adjuvant chemotherapy and the patient received four cycles of carboplatin/taxol. CONCLUSION: It should always be considered that even when there are no risk factors for malignancy occurrence, a high index of suspicion is necessary and will help to prevent delay in the diagnosis of this rare neoplasm.

Prenatal diagnosis of fetal left ventricular non-compaction cardiomyopathy.

Isolated left ventricular non-compaction (LVNC) is a rare disorder, classified as a primary genetic cardiomyopathy by the American Heart Association or as an unclassified cardiomyopathy by the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. The key features are the prominent trabeculae and deep intratrabecular recesses resulting in thickened myocardium with the two layers consisting of compacted and non-compacted myocardium. These recesses are in continuity with the left ventricular cavity and are filled with blood without evidence of communication to the epicardial coronary artery system. We present a case of LVNC detected prenatally at 25 + 4 weeks of gestation.

Prevalence of severe pelvic inflammatory disease and endometriotic ovarian cysts: a 7-year retrospective study.

INTRODUCTION: The purpose of this study was to delineate the association between endometriosis and pelvic inflammatory disease (PID) and the prevalence of this coexistence. MATERIALS & METHODS: The records of all patients with endometriotic ovarian cysts treated at the 3rd Department of Obstetrics and Gynecology of the University of Athens and in "Lito" Maternity Hospital of Athens from 2000 through 2007 were reviewed. RESULTS: During this 7-year period 720 women underwent surgery due to endometriotic ovarian cysts. The average age was 40.9 years (range: 17-70). Median diameter of the cysts was 4.495 cm and 59% were located in the right ovary. PID was identified in 21 (2.9%) cases. The average age of these women was 31 years (range: 21-39). Half of the women presented with fever (10/21; 47.6%). Ultrasound examination was performed in all women, followed by laparoscopy. In 47.6% (10/21) the PID abscess was located in the right ovary and the rest (52.38%) in the left. The mean diameter of the endometriotic cysts in these women was 3.52 cm. Laparoscopy was the treatment of choice in all the women with the exception of five cases, where due to technical difficulties during laparoscopy, a laparotomy was performed. In all the cases with PID, abscesses were evacuated laparoscopically. No operative complications were observed. CONCLUSIONS: Endometriosis and PID are two conditions that can easily confuse the physician in setting the diagnosis, especially in the situation where they co-exist. In our study we report that the prevalence of PID in women with endometriosis is sufficiently higher than the prevalence in the general population.

Prevalence of acute hemoperitoneum in patients with endometriotic ovarian cysts: a 7-year retrospective study.

INTRODUCTION: Endometriosis is a quite common condition in women of reproductive age. The purpose of this study is to delineate the association between hemoperitoneum and endometriosis. MATERIALS & METHODS: The records of all patients with endometriotic ovarian cysts treated at the 3rd Department of Obstetrics and Gynecology of the University of Athens and at "Lito" Maternity Hospital of Athens from 2000 through 2007 were reviewed. RESULTS: During this 7-year period 720 women underwent surgery due to endometriotic ovarian cysts. The average age was 40.9 years (range: 17-70). The median diameter of the cysts was 4.49 cm and 59% were located in the right ovary. Hemoperitoneum was identified in 16 (2.22%) of them. The average age of these women was 28.5 years (range: 22-44). Ten (62.5%) of these women presented with acute and strong abdominal pain and moderate signs of cardiovascular shock. The rest presented with abdominal pain and distension worsening at the onset of menses, nausea and/or vomiting and hemorrhagic fluid in the pelvis. Ultrasound examination was performed in all women and afterwards they underwent laparoscopy to identify the source of bleeding. In all cases a ruptured endometriotic cyst was found. In 68.8% (11/16) the ruptured cyst was located in the left ovary and the rest (31.2%) in the right. A thorough examination did not reveal any other sources of bleeding. No operative complications were observed. DISCUSSION: The simultaneous occurrence of ascites and endometriosis is rare. A physician, though, must always take into consideration endometriosis in the differential diagnosis of ascites and acute abdominal pain or pelvic mass.

Ultrasound assessment of endometrial thickness: correlation with ovarian stimulation and pregnancy rates in IVF cycles.

PURPOSE: To study the correlation between endometrial thickness and IVF outcome and factors affecting this relation. METHODS: Transvaginal ultrasound evaluation of endometrial thickness on hCG administration day in 112 IVF-ET cycles and comparison to indices of ovarian stimulation. Outcome was considered positive when fetal sac and fetal heart pulse were present at ultrasound. GnRH-agonist and antagonist protocols were also compared. Statistical analysis was performed by the SPSS system, chi-square and t-test. RESULTS: 38 cycles displayed clinical pregnancy. In cases of higher endometrial thickness, pregnancy rates, mean serum estradiol levels, oocyte and mature oocyte numbers as well as mean large follicle numbers were higher, while the mean age was lower. CONCLUSIONS: In 38 cycles resulting in pregnancy, mean endometrial thickness was higher compared to cycles with negative outcomes. Higher serum estradiol is associated with higher endometrial thickness and pregnancy rates. Women achieving pregnancy and pregnant women with endometrium thicker than 9 mm were younger. Follicle stimulation was better with higher endometrial thickness. After adjustments for age, no statistical difference was found in endometrial thickness between agonist and antagonist protocols.

Successful full-term pregnancies with assisted reproduction supported with prednisolone, acetylsalicylic acid and high progesterone doses in a lupus patient.

We present two rare cases of successful full-term pregnancies in a young woman suffering from lupus erythematosus for two years, who had subfertility problems and two missed abortions, before and after the diagnosis of lupus, with assisted reproduction. She received 10 mg of prednisolone daily from ovulation induction (with recombinant FSH--50 IU) until delivery, together with acetylsalicylic acid from ovulation induction until the 37th week of gestation and finally progesterone in high doses from the last insemination until the 12th week of gestation.

Intra/extra-amniotic administration of prostaglandin F2a in fetal death, missed and therapeutic abortions.

Prostaglandin F2a was used for termination of pregnancy in two groups of patients. The first included eighteen patients with either missed abortion or intrauterine fetal death, and were treated by intrauterine-extraamniotic infusion of 20 mg prostaglandin F2a. The treatment was successful in 14 patients (mean induction-abortion interval 6.7 hours). Four patients, where the above method failed to induce labor, were given intravenously prostaglandin F2a or oxytocin simultaneously or separately; the expulsion time ranged from 12 to 48 hours. The second group included twelve patients who underwent a therapeutic abortion following either a diagnosis of fetal congenital abnormality or because of a maternal indication. The therapeutic abortion was performed using prostaglandin F2a (25-40 mg) via amniocentesis. The treatment was successful in all patients (mean induction-delivery interval 10.6 hours).