Clinical relevance of the putative stem cell marker p63 in breast cancer.

P63 is a member of the p53 family. This protein is crucial for the maintenance of a stem cell population in the human epithelium and necessary for the normal development of all epithelial tissues including mammary glands. In normal breast tissue, the p63 seems to be a specific myoepithelial cell marker. P63 expression has been described in highly aggressive ER negative basal-like breast tumors. The value of p63 expression in ER positive disease is less clear. The expression levels of p63 mRNA by Affymetrix microarray analysis in a combined cohort of 2,158 ER positive breast cancers and its prognostic and predictive impact were analyzed. Tumor samples containing large amounts of benign breast tissue, which will interfere with p63 measurement, were excluded prior to the analysis. Survival analysis revealed a better prognosis of ER positive breast cancer expressing p63 (n = 410; P < 0.036). No correlation of p63 with standard parameters was observed. In a subgroup analysis, endocrine-treated patients with high p63 expression showed a better prognosis than low p63 expression (P = 0.06; n = 186). In untreated patients, this effect was less clear (n = 148; P = 0.5). P63 is a positive prognostic factor in endocrine-treated ER positive breast cancer and might influence responsiveness to endocrine treatment. Thus, p63 could be helpful as a predictive factor for endocrine therapy.

The erbB2+ cluster of the intrinsic gene set predicts tumor response of breast cancer patients receiving neoadjuvant chemotherapy with docetaxel, doxorubicin and cyclophosphamide within the GEPARTRIO trial.

Gene expression profiling using Affymetrix HG-U133 Arrays (22,500 genes) was performed on fresh frozen pretherapeutic core biopsies from 50 patients undergoing neoadjuvant chemotherapy (NAC) with docetaxel, adriamycin, cyclophosphamide (TAC) within the GEPARTRIO trial. The Sorlie classification based on the "intrinsic gene set" revealed four different subgroups in our cohort (normal-like: 14%, basal-like: 20%, erbB2+: 22% and luminal: 44%), which is in line with the original description. High genomic grade but not histopathological grading was statistically different within the four subgroups (P<0.001). About 45.5% of tumors classified according to erbB2+ cluster showed a pathological complete response compared to 0% in the normal-like, 10.0% in the basal-like and 9.1% in the luminal subgroup (P=0.024). There was a trend to less tumor relapses in the erbB2+ subgroup (0%) compared to the normal-like (28.6%), basal-like (30.0%) and luminal (13.6%) cluster (P=0.215). Our data suggest that the molecular tumor subtypes based on the "intrinsic gene set" can be used to predict tumor response according to NAC.

Ovarian cancer antigen CA 125 enhances the invasiveness of the endometriotic cell line EEC 145.

OBJECTIVE: Ovarian cancer antigen CA 125 is used widely for diagnostic and therapeutic evaluation of ovarian cancer. Although the initial description of CA 125 was in 1981, its function is still unknown. In collagen gel system the invasiveness of the endometriotic cell line EEC 145 is enhanced by a proteinaceous factor in peritoneal fluid mimicking molecular features of CA 125. Therefore we hypothesize that this factor is CA 125. METHODS: The influence of heat-treated peritoneal fluid on the invasiveness of the endometriotic cell line EEC 145 and several human carcinoma cell lines (EJ28, RT112, AN3 CA, RL95-2, HEC-1-A, HeLa, MCF7, T-47D, and SK-OV-3) was investigated in a collagen gel invasion assay by addition of (1); 10% heat-treated peritoneal fluid, (2); peritoneal fluid after immunoprecipitation with antibodies directed to CA 125, and (3); purified CA 125. RESULTS: The invasion index of the endometriotic cell line EEC 145 significantly increased from 4.78 +/- 0.98 to 6.57 +/- 1.58 (P = .0001) by addition of 10% heat-treated peritoneal fluid to the culture medium. The invasion-promoting effect of peritoneal fluid was abolished by reduction of the CA 125 concentration through immunoprecipitation and was mimicked in a dose-dependent manner by addition of CA 125 to the culture medium. The invasiveness of the investigated human carcinoma cell lines was not affected by heat-treated peritoneal fluid of CA 125. CONCLUSION: The results are consistent with the hypothesis that CA 125 can influence invasiveness in a benign endometriotic cell line.

Management of early ectopic pregnancy.

OBJECTIVE: Management of early ectopic pregnancy was investigated in a multicenter, prospective study. METHODS: Serum beta-hCG levels were monitored after therapy and correlated to the type of management, gestational age, and initial serum beta-hCG levels in 119 patients with ectopic pregnancies detected at 5-7 postmenstrual weeks. RESULTS: Salpingectomy was performed in 16 patients. No post-operative complications were reported. After conservative laparoscopic surgery of 51 ectopic pregnancies, 9 (18%) had delayed decrease or an increase of serum beta-hCG levels. Re-operations were performed in 4 (7%) patients. Similar findings were noted in 2/6 patients after conservative operations performed by laparotomy. Intrachorionic injection treatment was successful in 17/18 ectopic pregnancies, and expectant management in 7/8 patients with initial serum beta-hCG levels below 250 mIU/ml. CONCLUSIONS: Persistence of trophoblastic activity is a potential complication of conservative surgical treatment of ectopic pregnancy. A detailed diagnosis as early as 6-7 post-menstrual weeks may be the key for future non-surgical management of ectopic pregnancy.

Diagnosis of intrauterine and ectopic pregnancy at 5-7 postmenstrual weeks.

OBJECTIVES: The potential of the combined use of vaginosonography and serum beta-hCG levels for early diagnosis of intrauterine and ectopic pregnancies (5-7 weeks postmenstrual) was investigated in a multicentric study. METHODS: Three hundred and forty-nine patients underwent vaginosonographic examination and determination of serum beta-hCG. When the first examination failed in establishing a precise diagnosis, repeat examinations were performed on alternate days. RESULTS: During the first 3 weeks after the missed menses, vaginosonography can detect practically all viable intrauterine pregnancies, half of the nonviable intrauterine and viable ectopic pregnancies, and one quarter of nonviable ectopic pregnancies, respectively. It was not possible to differentiate intrauterine and ectopic pregnancies by serum beta-hCG levels. CONCLUSIONS: Vaginosonographic screening, ideally at 2 weeks after the missed menses, permits detection, localization, and dating in 80%-90% of suspected pregnancies.

IGF-I and EGF influence on steroid secretion and morphology of human granulosa cells of IVF-cycles and natural cycles in vitro.

The effect of IGF-I, EGF, PDGF and FGF on human granulosa cells of IVF-cycles, and the effect of IGF-I on granulosa cells of natural cycles (day 7 to 13 of cycle) were evaluated in vitro with and without hCG stimulation. At concentrations of 1 ng and 5 ng per ml culture FGF and PDGF did not alter progesterone and estradiol secretion or the morphology of preovulatory granulosa cells. At 1 ng, 2 ng, and 3 ng per ml medium EGF significantly enhanced basal progesterone and estradiol secretion and significantly decreased hCG stimulated estradiol production of preovulatory granulosa cells. While IGF-I treatment with and without hCG stimulation did not alter steroid secretion of preovulatory granulosa cells, the progesterone secretion of granulosa cells of natural cycles was increased by combined treatment with 10 I.U. hCG + 25 ng IGF-I per ml culture medium. Increased steroid secretion was related to reduced cell spreading. Our results provide evidence for the facultative role of IGF-I and EGF as an autocrine/paracrine modulator of ovarian function. IGF-I may play a role in regulation of ovulation induction and luteinisation as IGF-I and hCG act synergistically in increasing progesterone secretion of granulosa cells of natural cycles in vitro and are known to stimulate each other's receptor expression.

Influence of gonadotrophin releasing hormone (GnRH) and a GnRH-agonist on granulosa cell steroidogenesis.

The influence of gonadotropin releasing hormone and Decapeptyl on steroidogenic activity was evaluated at concentrations of 0.1 ng/ml, 1 ng/ml and 10 ng/ml culture medium. In the granulosa cell cultures of 9 out of 18 patients addition of Decapeptyl or gonadotrophin releasing hormone to the culture media caused dose-dependent inhibition of progesterone and oestradiol secretion in vitro. The steroidogenic activity in vitro of the granulosa cells of 84 IVF cycles was correlated to the maximal serum E2 levels of the patients at induction of ovulation. The granulosa cells of patients who were stimulated including Decapeptyl produced on average higher E2 levels in vitro as compared to granulosa cells from hMG stimulation cycles. This may be regarded as an indirect clue to an inhibitory effect of Decapeptyl on oestradiol synthesis in vivo.

Interleukin-6 and soluble interleukin-6 receptor in peritoneal fluid and serum of patients with endometriosis.

OBJECTIVE: Interleukin-6 (IL-6) and soluble Interleukin-6-receptor (sIL-6R) concentrations were investigated in patients with endometriosis and other benign gynecologic diseases. METHODS: During laparoscopy or laparotomy peritoneal fluid and serum were collected from 29 patients with endometriosis, 31 patients with benign ovarian masses and 4 patients with chronic inflammation or adhesions. Interleukin-6 (IL-6) concentrations were determined by Elisa-technique. RESULTS: Patients with endometriosis stage IV revealed slightly higher IL-6 concentrations in peritoneal fluid when compared to patients with stage I to II disease and ovarian masses/ chronic inflammation. IL-6 serum concentrations were higher in case of stage I and II when compared to stage III and IV and ovarian masses/chronic inflammation. Patients with endometriosis revealed significantly higher sIL-6 receptor concentrations in peritoneal fluid and serum as compared to patients with ovarian cysts and chronic inflammation. CONCLUSION: IL-6 and soluble IL-6 receptor may be considered to be involved in endometriosis. However, the patho-physiologic mechanism must be the subject of further investigation.

Ovarian cancer antigen CA 125 influences adhesion of human and mammalian cell lines in vitro.

Despite the widespread use of CA 125 for diagnostic and therapeutic evaluation of ovarian cancer function, the molecular nature of CA 125 is only poorly understood. It has been shown that CA 125 enhances the invasiveness of a benign endometriotic cell line in vitro. The invasiveness of cells is controlled by proteolytic activity, cell motility and cell adhesion. Therefore, we determined the influence of CA 125 on the cell adhesion of human carcinoma cell lines in vitro. In all tested human and mammalian cell lines (HECIA, AN3-CA, RL95-2, SK-OV-3, OAW-42, PA-1, HeLa, MCF7, T-47D, A-673, RT112, EJ28, EEC 145, CHO, MDBK, MDCK. LLC-PK1) the cell adhesion in vitro was significantly impaired by CA 125 in a time-dependent manner. Treatment of cells with trypsin diminished the effect of CA 125 on cell adhesion for two hours. By inhibition of protein synthesis with cycloheximide (2 microg/ml) the influence of trypsin on the anti-adhesive effect of CA 125 was significantly prolonged. The results suggest that the ovarian cancer antigen CA 125 influences cell adhesion in vitro.

A rabbit model for the evaluation of minimal access treatment of ectopic pregnancy in humans, using intrachorionic injection and local hyperthermia.

Rabbits at mid pregnancy were used as experimental models for investigating the feasibility of intrachorionic injection therapy in human ectopic pregnancy. Also, exposure of rabbit pregnancy to hyperthermia of 45 degrees C was studied. The experiments were followed by serial serum progesterone levels and by light as well as electron microscopy. Intrachorionic injection of different drugs led to demise in 92% of gestations. Application of hyperthermia to the pregnant rabbit uterus led in 94% to demise of gestations. Impairment of the reproductive functions after exposure did not occur. Injection was more effective up to day 15 of pregnancy, while hyperthermia had better results in older gestations. Morphological reactions to injection of different drugs and to hyperthermia were similar. Irreversible damage to the uterine wall was not observed. Intrachorionic injection of drugs may be a suitable treatment of human ectopic pregnancy. Application of hyperthermia may be a promising future therapy.

Prognostic impact of thymidine phosphorylase expression in breast cancer--comparison of microarray and immunohistochemical data.

Contrary findings exist according to the prognostic and predictive impact of thymidine phosphorylase (TP) expression in breast cancer. Goal of our study was to investigate TP expression on the mRNA level by microarray analysis in a large cohort of 1781 breast cancers and to analyse its prognostic impact. Furthermore we compared mRNA expression and immunohistochemical data to explain discrepancies between different studies. The prognostic value of TP mRNA expression was analysed among n=622 untreated patients. Strong expression in the subgroup of n=213 ER-negative cancer correlates with improved survival (P=0.012). In contrast, no difference in survival was detected in the ER-positive group. We also failed to observe a prognostic value of TP mRNA among n=435 endocrine-treated patients as well as n=111 CMF-treated patients. In an unsupervised analysis, TP clustered together with genes expressed in immune cells. Moreover, among normal tissues the highest TP mRNA expression was found in tissues of the immune system. The profile of TP expression in breast cancers correlates to a metagene of interferon induction whereas the expression of TP among normal tissues correlates to a metagene for macrophages. When comparing microarray data with immunohistochemistry from the same n=51 samples, there was no correlation with stained carcinoma cells. In contrast, the correlation with stromal staining was highly significant (P<0.001). Thus TP mRNA from microarray mainly reflects expression in stromal and immune cells. This could account for discrepant results from mRNA and IHC studies. In conclusion, the tumour infiltrating immune cells seem to be a major source of TP expression and predict a favourable prognosis in ER-negative breast cancer. Our data point to a role of TP in host immune response.

Differentially expressed genes of reprogrammed human pluripotent stem cells in breast cancer.

Reprogramming of human somatic cells into pluripotent cell types gives insight in the pathophysiology of diseases. We analysed genes recently shown to be differentially expressed in induced pluripotent stem cells (iPS) in 95 breast cancer samples. This analysis reveals two breast cancer subgroups with stem cell-like features, differing in ER-status and proliferation as well as in their clinical course of disease.

[Management of abnormal uterine bleeding]. / Ursachen und Therapie von uterinen Blutungsstörungen.

Bleeding disorders are one of the most frequent gynecological problems. The causes of bleeding disorders, and their frequency in particular, vary depending on the age of the woman affected. In premenopause and perimenopause, the most frequent causes are hormonal, in up to 90 % of cases, as well as organic changes in the uterus such as myomas, adenomyosis uteri, or endometrial polyps, in up to 70 % of cases. Coagulation defects cause increased bleeding, particularly in girls and young women, with no other recognizable cause. The treatment of bleeding disorders is causally based, although if the woman does not wish to have children, the therapeutic algorithm in many cases leads to similar symptomatic measures. The following therapeutic approaches, listed in order of increasing efficacy, are mainly used in the treatment of increased bleeding: gestagen, estrogen-gestagen combination, levonorgestrel (Mirena) and endometrial ablation or myoma enucleation, with comparable success rates, and finally hysterectomy. Embolization of the uterine artery in myomas or adenomyosis uteri, nonsteroidal anti-inflammatory drugs, and antifibrinolytic agents represent alternatives that may be useful in individual cases. The paper provides an overview of the various causes, useful diagnostic measures, and treatment options in uterine bleeding disorders.

[Clinical management of an androgen insensitivity syndrome]. / Klinisches Management beim Androgeninsensivitätssyndrom.

The seldom occurring androgen insensitivity syndrome is characterised by male karyotype in a phenotypical women. We report on a complete androgen insensitivity syndrome with the rare coincidence of bilateral Fallopian tubes and a testicular intraepithelial neoplasia. Additionally we discuss aspects of incidence, molecular background, characteristics, diagnostic pitfalls and therapy against the background of the current literature.

[Integrin expression in eutopic and ectopic endometrium]. / Integrinexpression im eutopen und ektopen Endometrium von Endometriosepatientinnen.

The significance of retrograde menstruation as a risk factor for endometriosis has been confirmed by numerous clinical observations. Integrins mediate both cell-cell and cell-matrix adhesion, and it is therefore suspected that integrins are involved in the development of endometriosis. Using immunohistochemistry, integrin expression in eutopic and ectopic endometrium is examined in endometriosis patients and control individuals. In nearly all cases, the glandular epithelial cells in the endometrium showed expression of alpha (2-), alpha (3)-, alpha (6)- and alpha (v)- integrin and a low percentage of expression of alpha (1)-, alpha (4)-, and alpha (5)-integrin. In comparison with eutopic endometrium, ectopic endometrium shows reduced expression of alpha (2)- and alpha (v)-integrin. Since no differences in alpha (2)- and alpha (v)-integrin expression were observed in eutopic endometrium between endometriosis patients and control individuals, it may be suspected that the reduced expression of these in ectopic endometrium is explained by influences in the altered environment -- e. g., in the peritoneal fluid -- on the ectopic endometrium.

Uterotubal transport disorder in adenomyosis and endometriosis--a cause for infertility.

OBJECTIVE: Uterine hyperperistalsis and dysperistalsis are common phenomena in endometriosis and may be responsible for reduced fertility in cases of minimal or mild extent of disease. Since a high prevalence of adenomyosis uteri has been well documented in association with endometriosis, we designed a study to examine whether hyperperistalsis and dysperistalsis are caused by the endometriosis itself or by the adenomyotic component of the disease. DESIGN: A prospective observational study. SETTING: University hospital, Department of Obstetrics and Gynaecology, Division of Reproductive Medicine and Gynaecologic Endocrinology with 300 in vitro fertilisation/intracytoplasmatic sperm injection cycles and 350 intrauterine insemination cycles/year. POPULATION: Forty-one subjects with infertility and with laparoscopically proven endometriosis and patent fallopian tubes. Thirty-five subjects (85%) additionally showed signs of adenomyosis. METHODS: All subjects underwent T2-weighed magnetic resonance imaging (MRI) and hysterosalpingoscintigraphy (HSSG) during the subsequent menstrual cycle. MRI revealed the extent of the adenomyotic component of the disease and the integrity of uterotubal transport capacity was evaluated by HSSG. MAIN OUTCOME MEASURES: Influence of adenomyosis on uterotubal transport capacity in endometriosis. RESULTS: In 35 of the 41 subjects (85%) with endometriosis, signs of adenomyosis were detected using T2-weighed MRI. Two of six (33%) subjects with no adenomyosis (group I) showed dysperistalsis and hyperperistalsis, compared with 14 of 24 (58%) women with focal adenomyosis (group II) and 10 of 11 (91%) women with diffuse adenomyosis (seven showed a failure in transport capacity and two contralateral transport). CONCLUSIONS: Our data suggest that endometriosis is associated with impeded hyperperistaltic and dysperistaltic uterotubal transport capacity. However, adenomyosis is of even more importance, especially when diffuse adenomyosis is detected. Both forms of adenomyosis are commonly found in subjects with mild to moderate endometriosis. We suggest that the extent of the adenomyotic component in subjects with endometriosis explains much of the reduced fertility in subjects with intact tubo-ovarian anatomy.

[Suspicion for intraabdominal adhesions -- is open laparoscopy the gold standard?]. / Verdacht auf intraabdominelle Verwachsungen -- ist die offene Laparoskopie der Königsweg?

Laparoscopy is used for most surgical procedures in gynaecology. In general complications are rare. However, one of the most critical steps is the initial laparoscopic entry into the peritoneal cavity. According to the literature serious complications occur in approximately 1-2/1 000 cases. Whereas major vascular injuries are mainly recognised immediately, delayed recognition of bowel injuries is frequent. Complication rates of different entry procedures used in gynaecological laparoscopy are similar even in high risk patients (intraperitoneal adhesions, obesity). Utilising an open - instead a closed - entry (either by Veress needle or first trocar) technique or alternativ entry positions are suggested by some authors. This review presents data available in the literature and highlights that open laparoscopy is no gold standard.

The congruity between urine and cervical swab cultures in pregnant women with versus without amniotic fluid infection.

INTRODUCTION: We observed the congruity of bacteria found in urine and cervix of pregnant women with amniotic fluid infection (AFI) compared to healthy controls. PATIENTS AND METHODS: Over three years, we prospectively analysed urine and cervical swabs cultures in 120 pregnant women in gestational week 16-20. The patient population was divided in two groups: group I patients had clinical symptoms of AFI. The rest of the patients were designated as healthy controls (group II). Congruity between findings in both groups was observed. In patients with bacterial growth, antibiotic treatment was initiated as recommended and once ended - culture probes were repeated. RESULTS: The rates of nonsignificant and significant bacteriuria were doubled in group I. Fifty-five percent (n = 33) of patients in group I had identical bacteria cultured both from the urine sample and cervical swab, in contrast to only 13.3 % in group II. Congruity was most pronounced for Klebsiella species and E. coli, the later being single most dominant isolate in regards to both cultures. After antimicrobial treatment, microbial eradication occurred in 15 patients (45.5 %). The observed incidences of abortions and preterm deliveries were significantly lower in patients with microbial eradication versus patients with microbial persistence. CONCLUSION: Patients with clinical symptoms of AFI have high risk for bacteriuria identical to bacterial culture from cervical swab. Antimicrobial treatment was effective only partially where indicated. Screening for eradication is recommended and consensus on the most appropriate therapy is needed.

[Alternatives to hysterectomy: a review]. / Organerhaltene Therapiemöglichkeiten beim Uterus myomatosus.

Total hysterectomy is considered as gold standard in the treatment of symptomatic uterine fibroids in women without reproductive wishes. However an increasing number of patients asked for alternatives to hysterectomy. Myomectomy, endometrial ablation, hormonal treatment, uterine artery embolization, and supracervical hysterectomy may be useful in the treatment uterine fibroids in an individual patient.