An elevated preoperative serum calcium level is a significant predictor for positive peritoneal cytology in endometrial carcinoma

Objective:To evaluate preoperative serum calcium concentration and investigate the association between calcium level and positive peritoneal cytology in endometrial carcinoma(EC).Methods:A total of 510 patients who were diagnosed with EC and had surgery were initially enrolled in this study at Peking University People's Hospital between January 2012 and December 2016.Clinical characteristics and preoperative serum calcium,albumin,carbohydrate antigen(CA)125,CA19-9,carcinoembryonic antigen(CEA)were extracted from patient records and evaluated according to postoperative peritoneal cytology.Predictive factors were assessed with Cox univariate and multivariate analyses.Factors selected from multivariate analysis results were used to build a predictive model.Results:A total of 510 patients are identified in our database and 444 patients who fulfilled inclusion and exclusion criteria are included in this study.Univariate analysis revealed that ionized calcium concentration was closely related to positive peritoneal cytology,tumor grade and lymph-vascular space invasion(LVSI).Moreover,peritoneal cytology was significantly associated with hypertension,tubal ligation,serum CA125,CA19-9,CEA and ionized calcium level.Multivariate analysis revealed that albumin-adjusted calcium level,CA125 and tubal ligation were independent predictive factors of positive peritoneal cytology(P<0.05).A combination of ionized calcium level with the other two indexes yielded significantly great area under the curve(AUC=0.824).Conclusions:This study enhanced the value of preoperative ionized calcium level.We also identified several potential biomarkers to predict positive peritoneal cytology in EC patients before surgery.

Clinical implications and prognostic value of five biomarkers in endometrial carcinoma

Objective： The aim was to identify the relationship between ER, PR, P53, Ki-67, PTEN, the association with clinicopathological parameters and the correlation with survival. Methods： We studied 190 cases of primary endornetrial carcinoma in which ER, PR, Ki-67, P53, PTEN antigens were investigated with the use of immunohistochemical methods. To evaluate the correlations among immunohistochemical staining and the age, menopause status, histological type, FIGO stage, grading, depth of invasion, lymph nodes involvement and serum tumor marker. Survival analysis was assessed within single and combined biomarkers types. Results： The percentage of Ki-67 and P53 positive endometrial tumors was signifi- cantly higher in ER negative vs ER positive tumors （both P = 0.000）. The same trend was evident in PR positive and nega- tive group. The percentage of PTEN positive tumors was significantly higher in PR positive versus PR negative tumors （P = 0.021） but was no difference in different ER status. ER and PR status were significant predictors with FIGO staging, grading and recurrence. There was no clear association between PTEN positivity and clinicopathological parameters except more relevance with endometrioid histotype （P = 0.013）. Positive Ki-67 or P53 was found to be strictly related to more aggressive features. There was statistically significant difference in different status of P53 and Ki-67 in survival time. Conclusion： ER and PR positive tumors showed a statistically significant association with better clinical outcome, PR has more significant influ- ence on prognosis. The percentage of positive Ki-67 or P53 was significantly higher in hormone-independent group versus in hormone-dependent group and combined Ki-67 and P53 may have more effect on prognosis in former group.

Traction force with extracellular matrix mediated by cytoskeleton influences metastasis through SLC8A1 induced Wnt-b-catenin pathway in endometrial cancer

Endometrial cancer(EC)is one of the most prominent malignancies in gynecology.Unfortunately,despite these advancements in understanding EC pathogenesis,mortality rates have not decreased.Traction force(TF)refers to endogenous mechanical forces exerted by cells.1 These forces act on the extracellular matrix and the extracellular tumor microenvironment through focal adhesions,thereby regulating cell proliferation and migration.However,the TF characteristics of endometrial cancer cells and their heterogeneity remain unclear.

Laparoscopic management of perivascular a retroperitoneal perivascular ectopic pregnancy

Retroperitoneal ectopic_pregnancy(REP)is one of the most special species of abdominal pregnancy.Due to possible invasion of retroperitoneal macrovascular,inconspicuous clinical manifestation and difficulty of diagnosis from imaging,the diagnosis and treatment of REP are easy to be delayed.REP represents a great challenge to surgeons due to the rarity and varying clinical presentations,from asymptomatic patients to patients with unstable haemodynamics,in cases of advanced ruptured ectopic gestation presenting with life-threatening retroperitoneal haemorrhage.Therefore,although REP accounts for only 1%of ectopic pregnancy.

The role of oestrogen and oestrogencalcium axis in endometrial carcinoma

Unopposed oestrogen is recognised as an inducer of endometrial cancer.Over the past 50 years,the effects of oestrogen on the endometrium and endometrial cancer have been a hot topic in the field of gynaecological oncology.In recent years,a series of studies by our team revealed that the non-genomic transcriptional effects of oestrogen can influence the progression of endometrial carcinoma by regulating calcium ions,suggesting that inhibiting calcium ion channelproteins could serve as an adjuvant therapy for endometrial cancer.In this review,we retrospectively summarise the sources of oestrogen in vivo,the effects of oestrogens on the uterus and endometrium,oestrogen signalling and the clinical application of oestrogen-related compounds,emphasising the significant role of oestrogen-calcium axis inhibition in adjuvant therapy for endometrial cancer.

Rationality of the FIGO2023 staging for early-stage endometrial cancer,compared with the FIGO2009 staging

Objective The International Federation of Gynecology and Obstetrics(FIGO)released a new stagingfor endometrial cancer(EC),which revised the FIG02009 staging to include histopathological andmolecular features.The purpose of this study was to validate the prognostic accuracy of the new staging and discuss its clinical applicability.Methods In this single-centre retrospective study,540 patients with primary surgically treated early-stage EC were enrolled and staged according to FIG02009/2023.Kaplan-Meier survival analysis was used to compare for prognostic differentiation.Cox regression was used to identify potential prognostic indicators.Results A total of 81 patients underwent staging shifts,allstage elevation.The prognosis difference between new stages I and Il was more significant.The new staging was more predictive of death postoperatively.Lesion maximum diameter(LMD)was one of the independent risk factors associated with prognosis.Taking LMD=5.70 cm as the cut-off value could further differentiate patients with divergent prognoseswithin FIG02023stage IIC.Conclusion FIG02023 stagingdemonstrated greater prognostic accuracy.In addition,LMD may be another critical factor affecting prognosis.

Chinese expert consensus on primary prevention for pelvic floor dysfunction during pregnancy

Objective Pregnancy has been identified as a risk factor for pelvic floor dysfunction(PFD).The aim of this study was to establish primary prevention measures for PFD during pregnancy and reduce the overall incidence of PFD.Methods We assembled a panel of 36 experts,including gynecologists,obstetricians,and physiotherapists.Through surveys and expert meetings,the panel reviewed and assessed the safety and effectiveness of various clinical interventions.Based on expert comments from Round 1,a revised list of 8 clinical interventions was developed and submitted for a second round of expert review.Results A consensus was reached on the importance of implementing prevention measures to protect pelvic floor function during pregnancy.Experts particularly emphasized the significance of health education,weight management,pelvic floor muscle training,respiratory training,overall exercise,physical activity,and perineal massage.Conclusion The expert consensus provides comprehensive clinical measures to safeguard pelvic floor function during pregnancy.This paper represents the initial step toward developing scientific recommendations for pregnant women regarding the primary prevention of PFD.Future research should focus on the implementation of these recommendations in clinical practice.

Characteristics of molecular classification in 52 endometrial cancer and atypical hyperplasia patients receiving fertility-sparing treatment

Objective To investigate the molecular classification of endometrial cancer(EC)and atypical endometrial hyperplasia(AEH)patients treated with fertility-sparing treatment(FST),and its relationship with clinicopathological factors and treatment efficacy.Methods:A total of 52​EC and AEH patients who received FST and molecular classification tested by next generation sequencing in Peking University People's Hospital from June 2020 to December 2022,were retrospectively collected.We analyzed the relationship between molecular classification and clinicopathological factors and treatment outcomes.Results(1)Of the 52 patients,including 46​EC and 6 AEH patients,42(80.8%)achieved complete remission(CR)after FST,with a median time to achieve CR of 9 months.Ten cases(23.8%)had recurrence.(2)Patients were distributed into 4 molecular subgroups as 39 cases(75%)of copy number low(CNL),7 cases(13.5%)of microsatellite instability-high(MSI-H),4 cases(7.7%)of POLE mutations(POLEmut),and 2 cases(3.8%)of copy number high(CNH).Patients with MSI-H subgroup had more family history of tumor(6/7),more with loss of expression of mismatch repair(MMR)protein(7/7),and higher expression level of Ki-67(3/3).(3)Patients with MSI-H subgroup had the lowest CR rate at 6 months(0/7,P​=​0.014),and survival analysis showed that such patients were less likely to achieve CR than those with CNL(P​=​0.022).For CNL patients,median 6-month CR rate was 40.6%.In addition,CR was obtained in 3(3/4)POLEmut patients and 2(2/2)CNH patients,respectively.Conclusions Molecular classification relates with the treatment response in patients with EC and AEH receiving FST.Patients with MSI-H subgroup have poor treatment efficacy,and patients with CNL need to be further divided to predict treatment benefit.There are also a few successful cases in POLEmut and CNH subtgroups,which needs further research.

Role of steroid receptor-associated and regulated protein in tumor progression and progesterone receptor signaling in endometrial cancer

Background:Steroid receptor-associated and regulated protein(SRARP)suppresses tumor progression and modulates steroid receptor signaling by interacting with estrogen receptors and androgen receptors in breast cancer.In endometrial cancer(EC),progesterone receptor(PR)signaling is crucial for responsiveness to progestin therapy.The aim of this study was to investigate the role of SRARP in tumor progression and PR signaling in EC.Methods:Ribonucleic acid sequencing data from the Cancer Genome Atlas,Clinical Proteomic Tumor Analysis Consortium,and Gene Expression Omnibus were used to analyze the clinical significance of SRARP and its correlation with PR expression in EC.The correlation between SRARP and PR expression was validated in EC samples obtained from Peking University People’s Hospital.SRARP function was investigated by lentivirus-mediated overexpression in Ishikawa and HEC-50B cells.Cell Counting Kit-8 assays,cell cycle analyses,wound healing assays,and Transwell assays were used to evaluate cell proliferation,migration,and invasion.Western blotting and quantitative real-time polymerase chain reaction were used to evaluate gene expression.The effects of SRARP on the regulation of PR signaling were determined by co-immunoprecipitation,PR response element(PRE)luciferase reporter assay,and PR downstream gene detection.Results:Higher SRARP expression was significantly associated with better overall survival and disease-free survival and less aggressive EC types.SRARP overexpression suppressed growth,migration,and invasion in EC cells,increased E-cadherin expression,and decreased N-cadherin and Wnt family member 7A(WNT7A)expression.SRARP expression was positively correlated with PR expression in EC tissues.In SRARP-overexpressing cells,PR isoform B(PRB)was upregulated and SRARP bound to PRB.Significant increases in PRE-based luciferase activity and expression levels of PR target genes were observed in response to medroxyprogesterone acetate.Conclusions:This study illustrates that SRARP exerts a tumor-suppressive effect by inhibiting the epithelial-mesenchymal transition via Wnt signaling in EC.In addition,SRARP positively modulates PR expression and interacts with PR to regulate PR downstream target genes.

Pregnancy outcomes after fertility preservation in women with endometrial carcinoma and atypical endometrial hyperplasia:A systematic review and meta-analysis

Objective:The objective of the study was to compare the effects of assisted reproductive technology(ART)and spontaneous pregnancy on pregnancy outcomes in women with endometrial carcinoma(EC)and atypical endometrial hyperplasia(AEH)following fertility-sparing treatments.Methods:Relevant studies published through July 2020 were identified from PubMed and Web of Science literature searches.The pregnancy outcomes of ART and spontaneous pregnancy were summarized and compared for women with complete remission of EC/AEH after fertility-sparing treatments.A subgroup analysis was performed based on whether patients had received in vitro fertilization and embryo transfer(IVF-ET)treatment.The complete remission and recurrence rates of EC/AEH following fertility-sparing treatments were estimated.The effect of pregnancy on recurrence rates of EC/AEH was also calculated.Results:Sixteen observational studies reporting pregnancy outcomes or recurrence with ART or spontaneous pregnancy for women with EC/AEH after fertility-sparing treatments were included.The complete remission rate of EC/AEH was 81.5%(95%CI,78%–85%).Compared with spontaneous pregnancy,the pregnancy rate of ART was significantly higher(66.8%vs.43.7%,OR=2.64,95%CI 1.71–4.05,P<0.00001,I^(2)=14%).Subgroup analysis showed that the pregnancy rate of IVF-ET was significantly higher than that of spontaneous pregnancy(62.7%vs.35.1%,OR=2.85,95%CI 1.44-5.63,P=0.003,I^(2)=29%).The live birth rate of ART was significantly higher than that of spontaneous pregnancy(75.3%vs.47.8%,OR=3.96,95%CI1.76-8.77,P=0.0009,I^(2)=45%).The recurrence rate of EC/AEH was 31%(95%CI 24%–39%).Clinical pregnancy could reduce the recurrence rate of EC/AEH,but there was no significant evidence of an association.Conclusions:ART,especially IVF-ET,could significantly improve pregnancy outcomes in women with EC/AEH receiving fertility-sparing treatments.Following complete remission,ART treatment might be a better option for women with EC/AEH than spontaneous pregnancy.

Urinary catheterization management after vaginal prolapse surgery:A national survey among Chinese urogynecologists and nurses

Background:Urinary catheterization after vaginal prolapse surgery can cause inconvenience for patients,elevate the risk of urinary tract infections,and potentially prolong the hospitalization.In China,there is no consensus on the optimal time to remove the urinary catheter after vaginal prolapse surgery.Thus,it will be valuable to gain insight into the nationwide catheterization management after the vaginal prolapse surgery.Methods:From March to May 2020,an online questionnaire was shared and purposive non-probabilistic sampling was used to recruit the participants.The urogynecologists currently performing vaginal prolapse surgery and involved nurses were included in this study.Results:1363 urogynecologists and 436 nurses responded and 99.5%of them reported using transurethral indwelling catheters(TIC)for post-operative bladder drainage in their practices.The duration of initial catheterization after vaginal prolapse surgery was generally 1–7 days,with a median duration of 3 days for anterior colporrhaphy(AC)and anterior&posterior colporrhaphy(APC),and 2 days for other procedures.For the same type of surgery,the median duration of catheterization varied by region.For AC,it was shorter by 1 day in West China and South China(P<0.001);for PC,it was 2 days in most regions,while 1 day in East China(P<0.05);and for APC,it was 3 days in most regions,while 4 days in Northeast China(P<0.05).No statistically significant difference was found in duration of catheterization in hospital levels.Conclusions:The findings suggested that duration of catheterization after prolapse surgery varied greatly in China,potentially resulting in unnecessary prolonging of catheterization.Well-designed studies are urgently needed to optimize catheterization management after vaginal prolapse surgery in China.

Chinese expert consensus on fertility-preserving treatment for young women with early stage well differentiated endometrial cancer

For young women with early stage well differentiated endometrial cancer who have fertility desire,it is import to give comprehensive assessment before initiation of conservative treatment.Progestin based therapy with regular assessment of treatment efficacy can achieve a promising outcome.After complete remission patients are suggested with assisted reproductive technology or maintenance therapy depending on their immediate pregnancy plan.Hysterectomy is recommended for patients who have finished reproduction while re-treatment for recurrent cases should be carefully informed.

Efficacy and safety of hospital-based group medical quarantine for dialysis patients exposed to coronavirus disease 2019

To the Editor:The coronavirus disease2019(COVID-19)outbreak developedinto a pandemic.Patientsundergoing hemodialysis(HD)are more susceptible to COVID-19,and isolating patients undergoing HD after exposure are extremely challenging since they frequently travel between their homes and dialysis centers,during which they share a hall for dialysis sessions that may last for hours.We successfully quarantined one infected HD patient and other potentially exposed patients.This experience might serve as an important reference for dialysis centers or for people in similar situations across the country to reduce the spread of COVID-19.

Enlarging ovarian cysts mimicking malignant or borderline tumors during pregnancy

Background:Ovarian cysts are uncommon gestational complications.Because of high-level progesterone,ovarian endometriomas may undergo decidualization during pregnancy,manifesting as enlarging cysts with papillae and rich blood flow.Such cases can mimic malignant or borderline tumors,causing dilemmas in clinical management.Here,we present two cases of enlarging ovarian cysts during pregnancy with evidence suggesting decidualized endometrioma.The diagnosis and treatment are further discussed,which add to our limited knowledge and might help future clinical practice.Case summary:In the first case,a right ovarian cyst was detected by ultrasound in a 32-year-old pregnant woman.The cyst measured 4.2 cm in diameter at 7t6 weeks of gestation,and gradually increased to 9.6 cm7.6 cm5.6 cm at 37t5 weeks,with multiple solid papillae lining the inner wall.During cesarean section,an ovarian mass of approximately 9 cm in diameter was surgically removed,which was later identified by pathological review as an endometrioma with decidualization.The second case also presented as an enlarging ovarian mass during the first and second trimester.The size of the cyst peaked at 24t5 weeks of gestation,measuring 6.9 cm5.6 cm4.1 cm.But in the third trimester,the tumor slightly regressed.Careful follow-up was adopted after successful vaginal delivery,and the cyst was found to have undergone quick regression shortly after pregnancy.Both patients recovered well after delivery with no further complications.Conclusion:Endometriomas with decidualization during gestation may resemble borderline or malignant tumors.Close monitoring and proper management are essential for guiding clinical management.

Reconsider the safety of laparoscopic surgery in endometrial cancer

General introduction The 20th century witmessed the development of laparoscopic surgical technologies and its successful applications in gynecological and general surgeries.In 1901,Russian doctor Dimitri Ott,for the first time,inspected the human a bdominal cavity with a speculum through a small incision,which marked the origin of the concept of minimally invasive techniques."During the following decades,clinical diagnosis of intra-abdominal lesions was performed by some doctors in Europe and the US.with instuments similar to modern laparoscopy.But it was until 1980s that modem sense laparoscopic surgeries,induding laparoscopic appendicectomy and laparoscopic cholecystectomy,were conducted.In 1989,Dr.Reich Harry performned the first laparoscopic hysterectomy,'which is regarded as a comerstone in the history of gynecologic surgery.Afterwards,laparoscopic surgery rapidly stepped into the mainstream of gynecology practice during the 1990s,delivered for both benign and malignant diseases.Starting from the 2000s,the master-slave mode ro-botic system,exemplified by the da Vinci@robot,has been accepted wordwide,and currently,robot assisted laparoscopic approaches have taken up a major proportion of general,urologic and gynecologic sur-geries,especially in developed countries.5 From a historical perspective,the broad application of laparoscopic surgeries nowadays stands on solid foundations established in decades of technical revolutions and refinements.

Using a needle for sacrospinous ligament fixation for pelvic organ prolapse based on the Miyazaki technique

Background:Approximately 7%of all women will require surgery to correct pelvic organ prolapse during their lives.Of these,approximately 10%-13%will require another operation within 5 years due to recurrence of the disease.Increases in life expectancy and elderly individuals with estrogen deficiencies will mean higher rates of pelvic organ prolapse,significantly reducing the quality of life for millions of people.This study introduces technologies that can help treat pelvic prolapse while reducing the rate of recurrence.Methods:This paper outlines how to properly perform sacrospinous ligament fixation using the Miyazaki technique.Results:A needle was used to successfully perform a sacrospinous ligament fixation using Miyazaki's technique.Conclusions:Considering the Food and Drug Administration’s 2019 decision to permit surgeries with native tissue,this method can be used with sacrospinous ligament fixation as the primary treatment option for pelvic organ prolapse.

Minimally invasive Fothergill-Manchester operation with connective tissue conservation

Poor cure rates for prolapse repair reported by the PROSPECT TRIAL1 and total mesh bans after the Cumberlage Report,2 leave few options for vaginal surgery for urogynecologists worldwide.One remaining option,the Fothergill-Manchester Repair began as a modification of the Donald operation.3 Fothergill emphasized the role of cardinal ligament(CL)and uterosacral(USL)ligaments in uterine prolapse repair.4 The classical Manchester operation involves full thickness inverted V-shaped vaginal excisions(Fig.1).The cervix is dilated and if elongated,it is amputated.CLs are severed and sutured to the anterior part of cervix.USLs may also be severed.Sturmdorf sutures bring vaginal flaps into the cervical canal.Vagina is repaired.The operation can be traumatic,some even reported a large quantity blood loss as high as 850 ml,5 possibly related to severing of CLs which contains uterine artery branches and also,failure of Sturmdorf sutures to control bleeding from cervical amputation.

Can minimally invasive surgery still be done for cervical cancer patients considering the LACC trial?

1.Background For the past several decades,minimally invasive surgery(MIS)has been advantageous for the treatment of cervical cancer compared to open surgery.MIS is favored due to reduced blood loss,decreased postoperative complications,rapid recovery,and shorter hospitalization time.In 2018,results from the Laparoscopic Approach to Cervical Cancer(LACC)trial,an international multicenter randomized phase III trial of women with early-stage cervical cancer comparing the survival outcomes among different surgical approaches1 and a real-world study published in the New England Journal of Medicine.

Clinical features and outcome of 15 patients with recurrent endometrial cancer or atypical endometrial hyperplasia received primary fertility-sparing therapy followed by hysterectomy

Objective To investigate the clinical features and outcome of recurrent endometrial cancer(EC)or atypical endometrial hyperplasia(AEH)patients who underwent hysterectomy after fertility-sparing therapy.Methods Clinical data was retrospectively collected for 15 recurrent endometrial cancer or atypical endometrial hyperplasia patients who underwent hysterectomy in six hospitals from 2003 to 2019.According to the indicators of hysterectomy,patients were divided into four groups:7 patients who underwent direct hyesterectomy after the first relapse,4 due to re-treatment failure,1 after full term live birth,and 3 because of multiple recurrence.Clinical coexisting conditions,regimen and outcome of fertility-sparing therapy,pre-and post-operative pathological results,and prognosis were analyzed.Results(1)Fertility-spraring treatment was given to a total of 15 eligible patients,including 6 with EC and 9 with AEH.Median time interval from remission to recurrence was 12 months(range 3–92).Oral progestin-based medicine was the main fertility-sparing therapy in both primary treatment and re-treatment after recurrence.Six(6/8)patients received progestin combined with gonadotrophin releasing hormone agonist or metformin in three re-treatment groups.(2)Nine patients underwent hysterectomy and 6 staging surgery.Three patients had pathological upgrade after surgery.Five(5/10)EC patients had superficial myometrial invasion in postoperative pathology.All patients showed no evidence of disease in the median follow-up of 17 months(range 3–118).(3)Among seven patients who failed to re-treatment and had multiple recurrence,six were overweight/obesity and six had insulin resistance.Two of these patients had synchronous ovarian cancer in the postoperative pathology.Conclusion For the patients with recurrent EC or AEH after primary fertility-sparing therapy,overweight/obesity and insulin resistance might be the risk factors for re-treatment failure.Hysterectomy is recommended when patients had re-treatment failure or multiple recurrence;and generally the prognosis is favorable.

Expert consensus on the management process of gynecological emergency under the regular epidemic prevention and control of COVID-19

At present,China is in the stage of the COVID-19 epidemic where regular prevention and control measures are required to contain the spread of disease.Reports of new sporadic cases are still widespread across China and medical personnel remain at high risk of exposure to infection.This is especially the case for medical staff working within emergency departments.Most gynecological emergency cases are complex and a high proportion require emergency surgical treatment.By referring to national regulations and requirements on COVID-19 prevention and control,and by summarizing our experiences in the battle against COVID-19 within Wuhan,this consensus report provides recommendations on the triage,reception,consultation,admission and surgical management of gynecological emergency patients.We also make suggestions for the environmental layout and disinfection and the medical waste management.This consensus aims to optimize the diagnosis and treatment process of gynecological emergency patients and reduce the exposure risk of medical staff within the current context of routine COVID-19 prevention and control.