Editorial| Volume 139, ISSUE 2, P119-120, August 2008

Editor's highlights

      What is new?Review: Ovarian carcinoma is generally revealed too late, at a time when management is restricted to reducing the size of the tumour by operative treatment followed by chemotherapy. Only a small number of patients are diagnosed during the very early development of the tumour, usually during an abdominal or vaginal ultrasound examination within the framework of a routine check. Thus about 20% of ovarian cancer patients are diagnosed while the disease is limited to one or both ovaries. In cases of early ovarian cancer (EOC) a decision has to be made to remove the adnexal mass and stage the disease either by the traditional method of laparotomy or by laparoscopy, which is controversial because of concerns about intra-abdominal tumour rupture or port site metastases. This difficult topic is the subject of a review on page 121 by Semaan and colleagues from Washington DC. In their article they outline the definition and treatment guidelines for EOC, and discuss the controversies of management and the technical challenges of lymphadenectomy. A simple recommendation cannot be given in the absence of randomised studies but the results of retrospective comparative studies are encouraging. But the authors caution against too optimistic conclusions since the sample sizes in most studies are still too small. Clinical evidence is clearly in favour of a larger role for laparoscopy in the management of EOC, but their conclusion is that larger sample sizes are mandatory to confirm the validity of the laparoscopic approach. It is worth reading this article in full.Obstetrics and Maternal–Fetal Medicine: This section starts with an article on “How to manage HIV-infected women”, evaluating a policy of vaginal delivery in selected cases—an important question of great interest. Suy and colleagues from Barcelona, Spain, present on page 127 their experience of 91 pregnancies with 95 fetuses. Caesarean section was carried out if labour was preterm or if other nationally-agreed criteria were not met, but 47 patients (64%) met the pre-established criteria for vaginal delivery and 21 of them went on to deliver vaginally. Under this management no cases of vertical transmission were observed.
      The use of betamimetic drugs during term labour in cases of acute fetal distress, either to allow the fetus to recover or in preparation for caesarean section, has been a routine procedure over the past 30 years. They may, however, cause maternal side effects such as tachycardia. De hues and colleagues from Utrecht, The Netherlands (page 139) investigated the influence of ritodrine in comparison to atosiban, an oxytocin receptor antagonist, on the cardiovascular parameters of the mother. The effects of both drugs were similar: baseline uterine pressure fell by about 50% and no effect was observed on maternal blood pressure, but the effect on maternal heart rate (MHR) was significant in the ritodrine group. Taking this negative effect on MHR into consideration it would seem logical to use a bolus injection of atosiban to stop labour. In routine practice, however, considerations of cost-effectiveness will also play a certain role.
      Years ago, the increase of caesarean section (CS) rates was paralleled by a continuous fall of perinatal mortality. Since 1995, however, a further rise of CS has not been followed by an additional reduction of perinatal mortality and concern has grown about increasing CS rates. Van Dillen and colleagues from Leiden and Den Haag, The Netherlands, introduced a CS audit in daily report meetings in their large teaching hospital (page 151). The result was a significant decrease in the CS rate during the audit period.
      Twin pregnancy is an interesting natural phenomenon which attracts writers and poets alike. From a medical point of view it has a high risk potential, but this is not the focus of the paper by Faisal and colleagues from UK and USA on page 164. They investigated the incidence of twinning from 1965 until 2004 in South Wales, and observed a fall from 13.1/1000 in 1965–1969 to 10.3/1000 in 1980–1985. This was followed by a gradual increase over the years to 15.7/1000 in 1995–1999 and 2000–2004. After exclusion of iatrogenic cases the rate still showed a significant increase from 10.0 to 13.3/1000. The authors conclude that increase cannot be explained only by maternal age and that other unexplained factors are involved.Reproductive Medicine and Endocrinology: A major step forward in the development of intrauterine devices was the system which liberates levonorgestrel (LNG) continuously, not only preventing pregnancy but also influencing strength and duration of menstrual bleeding. Varma and colleagues from Birmingham, UK (page 169) applied the system in 105 patients with endometrial hyperplasia. The results were convincing: LNG-IUS achieved endometrial regression in 90% of the cases by 2 years, and in 96% of these cases it was achieved within 1 year. The regression rates did not differ between histological types of hyperplasia. The system is highly effective and is likely to reduce the number of hysterectomies performed for non-atypical hyperplasias. It would be interesting to learn the experience of the readers with this method.
      Raloxifen is a “selective estrogen receptor modulator” (SERM)—a substance which can act as either an agonist or an antagonist on the receptors in different target tissues. Delmanto and colleagues from Sao Paulo, Brazil (page 187) investigated its effect on the vaginal epithelium. They treated 80 postmenopausal women with 60 mg/day raloxifen, while 40 untreated women served as controls. A vaginal maturation value (VMV) was determined. Treatment with raloxifen for 6 months had no effect on the VMV. Therefore when it is used for prevention or treatment of osteoporosis, local estrogens have additionally to be applied if the woman has complaints related to vaginal atrophy.Gynaecology and Gynaecological Oncology: Morita and colleagues from Tokyo (page 199) report on early experience with a new method to treat uterine fibroids: magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS). They describe their investigations in 48 Japanese women who were candidates for surgical intervention. Fifty-five uterine fibroids were treated and followed for 12 months. Two patients required surgical intervention. The average reduction in fibroid volume determined by MR imaging at 6 months after treatment was 33%. It is certainly an interesting method but the authors conclude that long-term results have to be collected to determine whether it can be applied in future as a routine procedure.
      Although the incidence of cervical carcinoma is declining, it still constitutes a burden of disease for women between 30 and 60 years of age. Screening programmes have been introduced but not all women take advantage of this offer. On page 204 Van der Aa and colleagues from Enschede, The Netherlands, describe the results from women taking part in a screening programme (SP) compared with women outside the screening programme (OSP) in the period 1992–2001. Of 263 cases selected from the regional cancer registry during this period 35% were SP tumours, of which 85% were FIGO stage 1, and 65% were OSP tumours, of which 57% were FIGO stage 1. The OSP group had a twofold increase in risk of death. The authors conclude that the SP probably detects the slow growing tumours, and that follow-up of suspicious smears needs to be improved.
      New and promising research on cervical cancer comes from Zhang and colleagues from Shanghai, PR China (page 237). They studied the role of phosphatidylinositol 3-kinase (PI3K), which is involved in many tumour associated signalling pathways. Significant PI3K protein over-expression was observed in tumour tissue and could be inhibited by LY294002, which has antitumour capability in vivo and in vitro. This paper provides an interesting insight into novel targeted therapies for the PI3K/Akt/mTOR signalling pathway components which could provide a useful adjuvant therapeutic strategy for cervical cancer.
      Chronic pelvic pain (CPP), defined as pain in the lower abdomen persisting for more than 6 months, has been reported in up to 15% of all women in the USA between the ages of 18 and 50 years. In the current issue two papers deal with this subject. Tropeano and colleagues from Rome (page 215) investigated ovarian vein incompetence as the potential cause of pelvic pain. Using venography, they studied 22 women with CPP. All 22 received sclerotherapy, which was followed by symptom relief in 17 cases. On page 233 Florido and colleagues from Granada, Spain, investigated 41 women undergoing laparoscopy or laparotomy for CPP and compared their sexual history with women undergoing sterilisation. Women with CPP initiated sexual relations at a later age and had a higher rate of dyspareunia. These two examples show that CCP is not caused by only one disorder but by a number of underlying mechanisms such as adhesions, infections and others.Gynaecological Urology: Polypropylene prostheses are widely used to stabilize the pelvic floor in cases of organ prolapse. De Vita and colleagues from Rome and London (page 245) conducted sacrospinous colposuspension with polypropylene mesh in 80 patients, after excluding a number of patients for various reasons. Only minor complaints were recorded after the operation and the authors conclude that the operative technique is safe and effective. An interesting paper on the composition of periurethral tissue in premenopausal and postmenopausal women is presented on page 252 by Feldner and colleagues from Sao Paulo, Brazil. They investigated sulphated glycosaminoglycans (GAGs) of the extracellular matrix of the periurethral tissue in 44 women. Compared with premenopausal women, postmenopausal women had significantly less total sulfated GAGs, derman sulfate and chondroitin sulphate. It would be interesting to learn which biochemical effects on the tissue are exerted by local administration of estrogens.
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