Publications by authors named "Robert Jach"

104 Publications

Fibrin clot properties among women with endometriosis and the impact of ovarian stimulation.

Reprod Biomed Online 2021 Mar 16. Epub 2021 Mar 16.

Institute of Cardiology, Jagiellonian University Medical College, and John Paul II Hospital Krakow, Poland.

Research Question: Is there a difference in fibrin clot phenotype in women with endometriosis before and after ovarian stimulation?

Design: Prospective study including 73 infertile women in two age-matched groups: (i) with confirmed endometriosis (n = 29); (ii) without endometriosis (n = 44). Assessments of plasma fibrin clot permeability (K), efficiency of fibrinolysis using clot lysis time (CLT), along with thrombin generation (prothrombin fragments 1+2 [F1+2] and endogenous thrombin potential [ETP]) and fibrinolysis inhibitors were performed together with clinical pregnancy rate.

Results: Endometriosis was associated with increased thrombin generation, reflected by both higher F1+2 (+96.1%, P = 0.005) and ETP (+14.2%, P = 0.014) along with unfavourably altered fibrin clot properties represented by lower K (-31%, P < 0.001) and prolonged CLT (+13.5%, P = 0.02), compared with the non-endometriosis group. Moreover, women with endometriosis had higher plasminogen activator inhibitor-1 (PAI-1; +272%, P = 0.004) concentrations and alpha-2-antiplasmin activity (+39.9%, P < 0.001) in contrast to the other group. Ovarian stimulation led to reduction in F1+2 (-48.1%, P < 0.001), improvement of fibrin clot phenotype reflected by higher K (+25.9%, P < 0.001) and shortened CLT (-11.9%, P < 0.001), along with lower PAI-1 (-54%, P = 0.016) compared with the baseline in women with endometriosis.

Conclusions: Endometriosis is associated with the prothrombotic fibrin clot phenotype and increased thrombin generation. Ovarian stimulation favourably alters fibrin clot properties and leads to comparable pregnancy outcomes to those in women without endometriosis.
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http://dx.doi.org/10.1016/j.rbmo.2021.03.008DOI Listing
March 2021

Dendritic Cells Are Associated with Prognosis and Survival in Breast Cancer.

Diagnostics (Basel) 2021 Apr 14;11(4). Epub 2021 Apr 14.

General, Oncological, and Gastrointestinal Surgery, Jagiellonian University Medical College, 30-688 Kraków, Poland.

Dendritic cells (DCs) constitute a part of the tumour microenvironment, but we are still far from understanding their complex role in immune response to the tumour. This study aimed to investigate the density of DCs expressing CD1a, CD83, CD123, DC-LAMP3 (CD208) and DC-SIGN (CD209) in breast cancer. The correlations between DC density and molecular subtype of breast cancer, its hormone receptor status, spatial location and their associations with clinical and pathological prognostic factors were evaluated. We have shown that intratumoural CD1a+ cells were significantly associated with progression-free survival. For LAMP3+ and CD123+ DCs, higher cell densities were associated with non-luminal as compared to luminal cancer phenotype. In contrast, dense CD83+ DC infiltrate was observed in luminal tumours. The number of CD1a+ DCs in both locations was the highest in luminal B/HER2+ cancers. The highest positive cell count of LAMP3+ cells was observed in the triple-negative subtype in both locations. We found higher numbers of LAMP3+ DCs both intratumourally and at the invasive margin, as well as CD123+ DCs intratumourally in tumours with negative expression of oestrogen or progesterone receptors. Our study demonstrates associations between DC subpopulations and histological and clinical characteristics, as well as molecular subtypes in breast carcinoma.
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http://dx.doi.org/10.3390/diagnostics11040702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8070803PMC
April 2021

Cervical cancer screening in Poland in current SARS-CoV-2 pandemic: Interim guidelines of the Polish Society of Gynecologists and Obstetricians and the Polish Society of Colposcopy and Cervical Pathophysiology - a summary January 2021.

Ginekol Pol 2021 ;92(2):165-173

Division of Obstetrics and Gynecology, Poviat Hospital in Zakopane, Poland.

The Polish Society of Colposcopy and Cervical Pathophysiology (PTKiPSM) together with the Polish Society of Gynecologists and Obstetricians (PTGiP) issued a final summary of interim guidelines for secondary cervical cancer prevention during the SARS-CoV-2 pandemic based on the analysis of the latest directional publications and the authors' own experiences. The aim of the summary is to facilitate the implementation of the most effective possible screening of cervical precancerous lesions and cervical cancer due to temporary significant limitation of screening as a consequence of the ongoing epidemiological threat. These final guidelines are taking into account the 2020 call of the World Health Organization (WHO) for global epidemiological elimination of cervical cancer. The guidelines supplement the interim guidelines of PTKiPSM and PTGiP announced in March 2020 on the possible deferral of diagnostic and therapeutic procedures in patients with abnormal screening tests results in secondary prevention of cervical cancer in current pandemic.
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http://dx.doi.org/10.5603/GP.2021.0043DOI Listing
April 2021

Methods for Studying Endometrial Pathology and the Potential of Atomic Force Microscopy in the Research of Endometrium.

Cells 2021 Jan 22;10(2). Epub 2021 Jan 22.

Jerzy Haber Institute of Catalysis and Surface Chemistry, Polish Academy of Sciences, Niezapominajek 8, 30-239 Krakow, Poland.

The endometrium lines the uterine cavity, enables implantation of the embryo, and provides an environment for its development and growth. Numerous methods, including microscopic and immunoenzymatic techniques, have been used to study the properties of the cells and tissue of the endometrium to understand changes during, e.g., the menstrual cycle or implantation. Taking into account the existing state of knowledge on the endometrium and the research carried out using other tissues, it can be concluded that the mechanical properties of the tissue and its cells are crucial for their proper functioning. This review intends to emphasize the potential of atomic force microscopy (AFM) in the research of endometrium properties. AFM enables imaging of tissues or single cells, roughness analysis, and determination of the mechanical properties (Young's modulus) of single cells or tissues, or their adhesion. AFM has been previously shown to be useful to derive force maps. Combining the information regarding cell mechanics with the alternations of cell morphology or gene/protein expression provides deeper insight into the uterine pathology. The determination of the elastic modulus of cells in pathological states, such as cancer, has been proved to be useful in diagnostics.
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http://dx.doi.org/10.3390/cells10020219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7911798PMC
January 2021

A View from the past into our collective future: the oncofertility consortium vision statement.

J Assist Reprod Genet 2021 Jan 6;38(1):3-15. Epub 2021 Jan 6.

Division of Reproductive Endocrinology & Infertility, University of Pennsylvania, Philadelphia, PA, USA.

Purpose: Today, male and female adult and pediatric cancer patients, individuals transitioning between gender identities, and other individuals facing health extending but fertility limiting treatments can look forward to a fertile future. This is, in part, due to the work of members associated with the Oncofertility Consortium.

Methods: The Oncofertility Consortium is an international, interdisciplinary initiative originally designed to explore the urgent unmet need associated with the reproductive future of cancer survivors. As the strategies for fertility management were invented, developed or applied, the individuals for who the program offered hope, similarly expanded. As a community of practice, Consortium participants share information in an open and rapid manner to addresses the complex health care and quality-of-life issues of cancer, transgender and other patients. To ensure that the organization remains contemporary to the needs of the community, the field designed a fully inclusive mechanism for strategic planning and here present the findings of this process.

Results: This interprofessional network of medical specialists, scientists, and scholars in the law, medical ethics, religious studies and other disciplines associated with human interventions, explore the relationships between health, disease, survivorship, treatment, gender and reproductive longevity.

Conclusion: The goals are to continually integrate the best science in the service of the needs of patients and build a community of care that is ready for the challenges of the field in the future.
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http://dx.doi.org/10.1007/s10815-020-01983-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786868PMC
January 2021

Low-Vacuum Filtration as an Alternative Extracellular Vesicle Concentration Method: A Comparison with Ultracentrifugation and Differential Centrifugation.

Pharmaceutics 2020 Sep 13;12(9). Epub 2020 Sep 13.

Department of Medical Physics, Marian Smoluchowski Institute of Physics, Faculty of Physics, Astronomy and Applied Computer Science, Jagiellonian University, 30-348 Krakow, Poland.

Recent years have brought great focus on the development of drug delivery systems based on extracellular vesicles (EVs). Considering the possible applications of EVs as drug carriers, the isolation process is a crucial step. To solve the problems involved in EV isolation, we developed and validated a new EV isolation method-low-vacuum filtration (LVF)-and compared it with two commonly applied procedures-differential centrifugation (DC) and ultracentrifugation (UC). EVs isolated from endothelial cell culture media were characterized by (a) Transmission Electron Microscopy (TEM), (b) Nanoparticle Tracking Analysis (NTA), (c) Western blot and (d) Attenuated Total Reflection Fourier-Transform Infrared Spectroscopy (ATR-FTIR). Additionally, the membrane surface was imaged with Environmental Scanning Electron Microscopy (ESEM). We found that LVF was a reproducible and efficient method for EV isolation from conditioned media. Additionally, we observed a correlation between ATR-FTIR spectra quality and EV and protein concentration. ESEM imaging confirmed that the actual pore diameter was close to the values calculated theoretically. LVF is an easy, fast and inexpensive EV isolation method that allows for the isolation of both ectosomes and exosomes from high-volume sources with good repeatability. We believe that it could be an efficient alternative to commonly applied methods.
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http://dx.doi.org/10.3390/pharmaceutics12090872DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7558926PMC
September 2020

SUCCOR study: an international European cohort observational study comparing minimally invasive surgery versus open abdominal radical hysterectomy in patients with stage IB1 cervical cancer.

Int J Gynecol Cancer 2020 09 11;30(9):1269-1277. Epub 2020 Aug 11.

Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece.

Background: Minimally invasive surgery in cervical cancer has demonstrated in recent publications worse outcomes than open surgery. The primary objective of the SUCCOR study, a European, multicenter, retrospective, observational cohort study was to evaluate disease-free survival in patients with stage IB1 (FIGO 2009) cervical cancer undergoing open vs minimally invasive radical hysterectomy. As a secondary objective, we aimed to investigate the association between protective surgical maneuvers and the risk of relapse.

Methods: We obtained data from 1272 patients that underwent a radical hysterectomy by open or minimally invasive surgery for stage IB1 cervical cancer (FIGO 2009) from January 2013 to December 2014. After applying all the inclusion-exclusion criteria, we used an inverse probability weighting to construct a weighted cohort of 693 patients to compare outcomes (minimally invasive surgery vs open). The first endpoint compared disease-free survival at 4.5 years in both groups. Secondary endpoints compared overall survival among groups and the impact of the use of a uterine manipulator and protective closure of the colpotomy over the tumor in the minimally invasive surgery group.

Results: Mean age was 48.3 years (range; 23-83) while the mean BMI was 25.7 kg/m (range; 15-49). The risk of recurrence for patients who underwent minimally invasive surgery was twice as high as that in the open surgery group (HR, 2.07; 95% CI, 1.35 to 3.15; P=0.001). Similarly, the risk of death was 2.42-times higher than in the open surgery group (HR, 2.45; 95% CI, 1.30 to 4.60, P=0.005). Patients that underwent minimally invasive surgery using a uterine manipulator had a 2.76-times higher hazard of relapse (HR, 2.76; 95% CI, 1.75 to 4.33; P<0.001) and those without the use of a uterine manipulator had similar disease-free-survival to the open surgery group (HR, 1.58; 95% CI, 0.79 to 3.15; P=0.20). Moreover, patients that underwent minimally invasive surgery with protective vaginal closure had similar rates of relapse to those who underwent open surgery (HR, 0.63; 95% CI, 0.15 to 2.59; P<0.52).

Conclusions: Minimally invasive surgery in cervical cancer increased the risk of relapse and death compared with open surgery. In this study, avoiding the uterine manipulator and using maneuvers to avoid tumor spread at the time of colpotomy in minimally invasive surgery was associated with similar outcomes to open surgery. Further prospective studies are warranted.
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http://dx.doi.org/10.1136/ijgc-2020-001506DOI Listing
September 2020

Possible deferral of diagnostic and therapeutic procedures for patients with abnormal screening tests results in cervical cancer secondary prevention in current SARS-CoV-2 pandemic Interim guidelines of the Polish Society of Gynecologists and Obstetricians and the Polish Society of Colposcopy and Cervical Pathophysiology.

Ginekol Pol 2020;91(7):428-431

2nd Department of Gynecology and Obstetrics, Wroclaw Medical University, Wroclaw, Poland.

The Polish Society of Gynecologists and Obstetricians and Polish Society of Colposcopy and Cervical Pathophysiology Interim Guidelines goal at aiding gynecologists in providing a cervical cancer prevention care during the evolving SARS-CoV-2 pan-demic. Presented guidelines were developed on a review of limited data and updated when new relevant publications were revealed. Timing for deferrals of diagnostic-therapeutic procedures were mostly covered in the guidelines. Also, a support for the existing Polish recommendations on abnormal screening results in a subject of minor and major screening abnor-malities terminology were given. The guidelines are obligatory for the specified COVID-19 pandemic period only and they might be changed depending on the new available evidence.
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http://dx.doi.org/10.5603/GP.2020.0103DOI Listing
August 2020

Enhanced Recovery After Surgery (ERAS) in gynecologic oncology: an international survey of peri-operative practice.

Int J Gynecol Cancer 2020 10 4;30(10):1471-1478. Epub 2020 Aug 4.

Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada.

Introduction: Enhanced Recovery After Surgery (ERAS) programs have been shown to improve clinical outcomes in gynecologic oncology, with the majority of published reports originating from a small number of specialized centers. It is unclear to what degree ERAS is implemented in hospitals globally. This international survey investigated the status of ERAS protocol implementation in open gynecologic oncology surgery to provide a worldwide perspective on peri-operative practice patterns.

Methods: Requests to participate in an online survey of ERAS practices were distributed via social media (WhatsApp, Twitter, and Social Link). The survey was active between January 15 and March 15, 2020. Additionally, four national gynecologic oncology societies agreed to distribute the study among their members. Respondents were requested to answer a 17-item questionnaire about their ERAS practice preferences in the pre-, intra-, and post-operative periods.

Results: Data from 454 respondents representing 62 countries were analyzed. Overall, 37% reported that ERAS was implemented at their institution. The regional distribution was: Europe 38%, Americas 33%, Asia 19%, and Africa 10%. ERAS gynecologic oncology guidelines were well adhered to (>80%) in the domains of deep vein thrombosis prophylaxis, early removal of urinary catheter after surgery, and early introduction of ambulation. Areas with poor adherence to the guidelines included the use of bowel preparation, adoption of modern fasting guidelines, carbohydrate loading, use of nasogastric tubes and peritoneal drains, intra-operative temperature monitoring, and early feeding.

Conclusion: This international survey of ERAS in open gynecologic oncology surgery shows that, while some practices are consistent with guideline recommendations, many practices contradict the established evidence. Efforts are required to decrease the variation in peri-operative care that exists in order to improve clinical outcomes for patients with gynecologic cancer globally.
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http://dx.doi.org/10.1136/ijgc-2020-001683DOI Listing
October 2020

COLPOSCOPY 2020 - COLPOSCOPY PROTOCOLS: A Summary of the Clinical Experts Consensus Guidelines of the Polish Society of Colposcopy and Cervical Pathophysiology and the Polish Society of Gynaecologists and Obstetricians.

Ginekol Pol 2020;91(6):362371

Department of Gynecology and Oncology, Jagiellonian University Medical College, Cracow, Poland.

The Polish Society of Colposcopy and Cervical Pathophysiology and the Polish Society of Gynecologists and Obstetricians provide comprehensive guidelines for colposcopy practice in secondary cervical cancer prevention in Poland. This part of the guidelines, developed by the clinical experts of the Working Group No. 1 (WG1), concerns the colposcopy protocols with the main aim of algorithmizing the procedure, together with all procedure-related processes. The detailed analysis of strong scientific evidence and an extensive literature review of current international colposcopic recommendations were carried out, with also a broad investigation of recently ongoing dynamic changes in national health systems. The attention to colposcopic limitations also occurring in Polish conditions was kept. The overriding goal was the recommended obligatory minimal colposcopy approach introduction. To enhance the standard of colposcopy, adjustment of a precolposcopic assessment, a performance technique, types of used biopsies, as well as the procedure documentation was made. Elements of the risk-based stratification for the increased risk of developing cervical cancer was also included if it was applicable for that part of the guidelines. Comprehensive colposcopy guidelines are a step towards the ongoing era of a precision medicine in cervical cancer prevention in Poland.
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http://dx.doi.org/10.5603/GP.2020.0075DOI Listing
January 2020

Prognostic factors in patients with vulvar cancer: the VULCAN study.

Int J Gynecol Cancer 2020 09 22;30(9):1285-1291. Epub 2020 Jun 22.

Gynecologic Oncology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.

Objective: This study aimed to analyze the prognostic factors for overall and progression-free survival in patients with vulvar cancer.

Methods: This international, multicenter, retrospective study included 2453 patients diagnosed with vulvar cancer at 100 different institutions. Inclusion criteria were institutional review board approval from each collaborating center, pathologic diagnosis of invasive carcinoma of the vulva, and primary treatment performed at the participating center. Patients with intraepithelial neoplasia or primary treatment at non-participating centers were excluded. Global survival analysis and squamous cell histology subanalysis was performed.

Results: After excluding patients due to incomplete data entry, 1727 patients treated for vulvar cancer between January 2001 and December 2005 were registered for analysis (1535 squamous, 42 melanomas, 38 Paget's disease and 112 other histologic types). Melanomas had the worse prognosis (p=0.02). In squamous vulvar tumors, independent factors for increase in local recurrence of vulvar cancer were: no prior radiotherapy (p<0.001) or chemotherapy (p=0.006), and for distant recurrence were the number of positive inguinal nodes (p=0.025), and not having undergone lymphadenectomy (p=0.03) or radiotherapy (p<0.001), with a HR of 1.1 (95% CI 1.2 to 1.21), 2.9 (95% CI 1.4 to 6.1), and 3.1 (95% CI 1.7 to 5.7), respectively. Number of positive nodes (p=0.008), FIGO stage (p<0.001), adjuvant chemotherapy (p=0.001), tumor resection margins (p=0.045), and stromal invasion >5 mm (p=0.001) were correlated with poor overall survival, and large case volume (≥9 vs <9 cases per year) correlated with more favorable overall survival (p=0.05).

Conclusions: Advanced patient age, number of positive inguinal lymph nodes, and lack of adjuvant treatment are significantly associated with a higher risk of relapse in patients with squamous cell vulvar cancer. Case volume per treating institution, FIGO stage, and stromal invasion appear to impact overall survival significantly. Future prospective trials are warranted to establish these prognostic factors for vulvar cancer.
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http://dx.doi.org/10.1136/ijgc-2019-000526DOI Listing
September 2020

Survey of Fertility Preservation Options Available to Patients With Cancer Around the Globe.

JCO Glob Oncol 2020 2;6. Epub 2020 Mar 2.

Northwestern University, Chicago, IL.

Purpose: Oncofertility focuses on providing fertility and endocrine-sparing options to patients who undergo life-preserving but gonadotoxic cancer treatment. The resources needed to meet patient demand often are fragmented along disciplinary lines. We quantify assets and gaps in oncofertility care on a global scale.

Methods: Survey-based questionnaires were provided to 191 members of the Oncofertility Consortium Global Partners Network, a National Institutes of Health-funded organization. Responses were analyzed to measure trends and regional subtleties about patient oncofertility experiences and to analyze barriers to care at sites that provide oncofertility services.

Results: Sixty-three responses were received (response rate, 25%), and 40 were analyzed from oncofertility centers in 28 countries. Thirty of 40 survey results (75%) showed that formal referral processes and psychological care are provided to patients at the majority of sites. Fourteen of 23 respondents (61%) stated that some fertility preservation services are not offered because of cultural and legal barriers. The growth of oncofertility and its capacity to improve the lives of cancer survivors around the globe relies on concentrated efforts to increase awareness, promote collaboration, share best practices, and advocate for research funding.

Conclusion: This survey reveals global and regional successes and challenges and provides insight into what is needed to advance the field and make the discussion of fertility preservation and endocrine health a standard component of the cancer treatment plan. As the field of oncofertility continues to develop around the globe, regular assessment of both international and regional barriers to quality care must continue to guide process improvements.
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http://dx.doi.org/10.1200/JGO.2016.008144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853877PMC
March 2020

Survey of Third-Party Parenting Options Associated With Fertility Preservation Available to Patients With Cancer Around the Globe.

JCO Glob Oncol 2020 2;6. Epub 2020 Mar 2.

Northwestern University, Chicago, IL.

Purpose: In the accompanying article, "Survey of Fertility Preservation Options Available to Patients With Cancer Around the Globe," we showed that specific fertility preservation services may not be offered at various sites around the world because of cultural and legal barriers. We assessed global and regional experiences as well as the legal status of third-party reproduction and adoption to serve as a comprehensive international data set and resource for groups that wish to begin oncofertility interventions.

Methods: We provide data on the legalities of third-party assisted reproductive technologies and other family-building options in the 28 oncofertility-practicing countries surveyed.

Results: We found regional and country differences that will be important in the development of tailored resources for physicians and for patient brochures that are sensitive to these local restrictions and cultural norms.

Conclusion: Because many patients first consult Web-based materials, the formal assessment of the availability of these options provides members of the global oncofertility community with data to which they might otherwise not have ready access to better serve their patients.
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http://dx.doi.org/10.1200/JGO.2017.009944DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853875PMC
March 2020

Investigation of the role and chemical form of iron in the ovarian carcinogenesis process.

J Trace Elem Med Biol 2020 Jul 17;60:126500. Epub 2020 Mar 17.

Deutsches Elektronen-Synchrotron, Petra III Extension, P65, Hamburg, Germany.

Background: Ovarian cancer is one of the most frequent types of gynaecological malignancy among women. Despite the advances in diagnostic techniques, ovarian tumours are still detected at a late stage, thus the survival rate is very low. Iron is an essential metal in the human body, yet its potential role in ovarian carcinogenesis is yet to be determined. The aim of this study was to check if iron oxidation state in tissue and cystic fluid can be treated as an indicator of the malignancy of the ovarian tumours. Another aspect of this study was to investigate the role of iron in carcinogenesis mechanism in ovarian tumour transformation.

Methods: Synchrotron radiation X-ray absorption near edge structure (SR-XANES) spectroscopy was used to analyze the human ovarian tumour tissues and cystic fluids of different types and grades of malignancy. Fresh, non-fixed, frozen samples were used to analyze the state of iron oxidation in all the biological materials. The samples were obtained from patients requiring surgical intervention. The High Energy X-ray Absorption Spectroscopy (XANES) measurements were performed at the beamline P65 at Petra III Extension, DESY - Deutsches Elektronen - Synchrotron.

Results: Fe XANES spectra were collected at selected points of a few different regions of the samples. For each specimen, an average of these points was probed. Having been measured, the spectra were compared with organic and inorganic reference materials. Also, the position of the absorption edge was calculated using the integration method. In all specimens, iron occurred in the oxidation states, Fe2+ and Fe3+, although the fraction of iron in the third oxidation state was substantial, especially in malignant cases. The results also show differences in the chemical form of iron in the tissue and cystic fluids of the same patient.

Conclusions: The cryo-XANES measurement carried out for ovarian cancer tissues and cystic fluids showed changes in the chemical form of iron between non-malignant and malignant tumours. For both types of sample can be observed that they contain iron on second and iron on third oxidation state. Moreover, the tendency was observed that malignant tumours of the ovary contain a larger fraction of iron in the second oxidation state compared to non-malignant ones.
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http://dx.doi.org/10.1016/j.jtemb.2020.126500DOI Listing
July 2020

Ovarian Sertoli-Leydig cell tumour with α-fetoprotein-producing intestinal glandular cells. Clinical case and short review of basic literature.

Pol J Pathol 2019 ;70(3):226-231

Department of Pathomorphology, Jagiellonian University Medical College, Krakow, Poland.

Sertoli Leydig cell tumor of the ovary, is a rare neoplasm from the group of sex cord-stromal tumors of the ovary, accounting for less than 1% of all ovarian tumors. Among the Sertoli Leydig cell tumors, we distinguish a separate group of tumors secreting α-fetoprotein (AFP). The young 24-year-old woman presented to the Clinical Department of Gynaecological Endocrinology at the University Hospital in Krakow due to secondary amenorrhea, hirsutism and worsening abdominal pain for several months. During the admission draws attention was drawn to the abnormal level of testosterone, AFP and the revised structure of the ovary in the ultrasound. After a preliminary diagnosis, expanded pelvic MRI was performed, which found an isolated tumor derived from Sertoli Leydig cells. The patient was enrolled to unilaterally remove the right ovary by laparotomy. Histopathological examination and immunohistochemical staining confirmed the diagnosis of Sertoli Leydig cells tumor, and in pathological examination we found glandular mucosa cells of the colon. Owing to scientific reports on the stromal tumors of the ovary, we decided to perform genetic testing and verify the patient's karyotype. In the follow-up 90 days after the surgery, levels of testosterone and AFP were correct. In case of Sertoli Leydig cell tumors, especially in young women of childbearing potential, special attention should be paid to Anti-Mullerian hormone testing before surgery, as well as genetic diagnostics to exclude disorders of sex development.
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http://dx.doi.org/10.5114/pjp.2019.90402DOI Listing
January 2020

Cesarean scar pregnancy - various methods of treatment.

Folia Med Cracov 2019 ;59(2):5-14

Department of Gynaecological Endocrinology and Gynaecology, Jagiellonian University Medical College Kraków, Poland.

Ectopic pregnancy constitutes 2% of all pregnancies. In the last decades, due to the rising amount of caesarean sections, new localization of ectopic pregnancy has been observed - caesarean scar pregnancy (CSP). Cesarean scar pregnancy is an iatrogenic disease and a life-threatening condition which frequency will systematically rise. Because of possible serious complications, CSP should be swiftly diagnosed and treated. The purpose of this retrospective study was to demonstrate different methods of CSP treatment performed between 2015-2018 in the Clinic of Endocrinological Gynaecology and Gynaecology Jagiellonian University Medical College in Cracow. The clinical characteristics, diagnosis, various methods of treatment and clinical outcomes were analysed. Definitive algorithm of CSP treatment is still not established. Pharmacological and operative methods are approved while expectant observation is considered unsafe due to possible risk of complications for the patient, including death.
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April 2020

Quiz. What is your diagnosis?

Pol J Pathol 2019;70(2):153-154

Department of Pathomorphology, Jagiellonian University Medical College, Krakow, Poland.

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http://dx.doi.org/10.5114/pjp.2019.87109DOI Listing
January 2019

Challenging iatrogenic menopause. Oncofertility programme in Poland - a single-centre experience.

Prz Menopauzalny 2019 Jun 14;18(2):63-67. Epub 2019 Jun 14.

Clinic of Gynaecological Oncology, Jagiellonian University Medical College, Krakow, Poland.

Introduction: Menopause is defined as a 12-month period of time when menstruation permanently ceases. In some cases, menopause may be caused by external factors - for example gonadotoxic treatment that irreversibly damages ovarian tissue leading to loss of its hormonal and reproductive function. Oncofertility is a discipline that merges oncology and reproductive medicine, giving patients a chance to experience parenthood after gonadotoxic treatment is finished.

Aim Of The Study: The purpose of the study is to present the implementation and first outcomes of the Oncofertility Programme in the University Clinic of Endocrinological Gynaecology and Gynaecology, University Hospital in Krakow, Poland.

Material And Methods: Patients interested in fertility preservation have been consulted in the University Clinic of Endocrinological Gynaecology and Gynaecology in Krakow since April 2016. Preliminary qualification to one of the available methods (embryo cryopreservation, oocyte cryopreservation, ovarian tissue cryopreservation) was conducted. Patients declaring a wish to join the programme were then referred to one of the three infertility treatment centres cooperating with the University Clinic, in order to undergo the chosen procedure.

Results: During a period of 24 months, 18 patients were consulted. The youngest consulted patient was 20 years old, the oldest 39. Two years after the first consultation, a telephone survey among consulted patients was carried out to verify whether the patients finally underwent oncofertility procedures, and to ask about their reproductive status.

Conclusions: The problem of fertility issues being inadequately addressed results in low referral rates to oncofertility programmes. Attempts to raise awareness of oncofertility possibilities among oncologists should be undertaken because critically few patients are being referred to oncofertility centres.
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http://dx.doi.org/10.5114/pm.2019.85787DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6719631PMC
June 2019

Indications for sexology consultation in women after surgical treatment due to breast cancer.

Ann Agric Environ Med 2019 Jun 11;26(2):379-384. Epub 2018 May 11.

Department of Gynaecologic Oncology, The Jagiellonian University Medical College, Kraków, Poland.

Introduction And Objectives: Surgical treatment due to brest cancer have an impact on women sexuality. There is a need for research about effective indications for sexology consultation in women after such treatment. The aim of this study is to determine the indications for sexology consultation in women after surgical treatment for breast cancer.

Material And Methods: We tested 42 women patients diagnosed with breast cancer who had undergone mastectomy 3 months before the study. 3 months after the surgery the women were surveyed using the Polish version of FSFI assessing sexual functioning in women. The result of PL-FSFI were compared with the control group.

Results: It was found that the mean score of PL-FSFI in the study group 3 months after the surgery was 13.33 points (score range: 1.2-31.7; median 8.3 points) with a statistically significant difference in terms of areas: desire, arousal, lubrication and orgasm in favour of the control group. The total score of PL-FSFI was significantly lower in women after mastectomy than in women after breast-conserving surgery. It has been shown that sexually active women in whom the surgery concerned the right breast (on the side of the dominant hand) scored lower on the scale "sexual functioning" of QLQ-BR-23 than women with surgery of the left breast, with this difference being statistically significant. There was a statistically significant correlation between the baseline performance status on the Zubrod scale and the scales: desire, lubrication and satisfaction of PL-FSFI. Living in a small town proved to be statistically significant for predicting a lower risk of sexual dysfunction among the surveyed women.

Conclusions: The women who underwent surgery due to breast cancer had a higher risk of sexual dysfunction compared to the general population. Higher risk of sexual dysfunction especially concerns women after mastectomy, those who underwent breast surgery on the side of the dominant hand, and those with a worse preoperative overall level of functioning of > = 1 point on the Zubrod scale. A lower risk of disorders was observed in women living in smaller towns. The above factors indicate the advisability for sexology consultation in women with breast cancer.
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http://dx.doi.org/10.26444/aaem/89733DOI Listing
June 2019

Unique Roles of Sphingolipids in Selected Malignant and Nonmalignant Lesions of Female Reproductive System.

Biomed Res Int 2019 2;2019:4376583. Epub 2019 May 2.

Jagiellonian University Medical College Gynecology and Obstetrics, Krakow, Poland.

Cancer develops as a result of the loss of self-control mechanisms by a cell; it gains the ability to induce angiogenesis, becomes immortal and resistant to cell death, stops responding to growth suppressor signals, and becomes capable of invasion and metastasis. Sphingolipids-a family of membrane lipids-are known to play important roles in the regulation of cell proliferation, the response to chemotherapeutic agents, and/or prevention of cancer. Despite the underlying functions of sphingolipids in cancer biology, their metabolism in different malignant tumors is poorly investigated. Some studies showed marked differences in ceramide content between the tumor and the respective healthy tissue. Interestingly, the level of this sphingolipid could be either low or elevated, suggesting that the alterations in ceramide metabolism in cancer tissue may depend on the biology of the tumor. These processes are indeed related to the type of cancer, its stage, and histology status. In this paper we present the unique roles of bioactive sphingolipid derivative in selected gynecologic malignant and nonmalignant lesions.
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http://dx.doi.org/10.1155/2019/4376583DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521305PMC
December 2019

Oncological outcome of surgical management in patients with recurrent uterine cancer-a multicenter retrospective cohort study-CEEGOG EX01 Trial.

Int J Gynecol Cancer 2019 05;29(4):711-720

Department of Obstetrics and Gynecology, Gynecologic Oncology Center, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic.

Objectives: To assess the survival of patients who have received an operation for recurrent cervical and endometrial cancer and to determine prognostic variables for improved oncologic outcome.

Methods: A retrospective multicenter analysis of the medical records of 518 patients with cervical (N = 288) or endometrial cancer (N = 230) who underwent surgery for disease recurrence and who had completed at least 1 year of follow-up.

Results: The median survival reached 57 months for patients with cervical cancer and 113 months for patients with endometrial cancer after surgical treatment of recurrence (p = 0.036). Histological sub-type had a significant impact on overall survival, with the best outcome in endometrial endometrioid cancer (121 months), followed by cervical squamous cell carcinoma, cervical adenocarcinoma, or other types of endometrial cancer (81 vs 35 vs 35 months; p <0.001). The site of recurrence did not significantly influence survival in cervical or in endometrial cancer. Cancer stage at first diagnosis, tumor grade, lymph node status at recurrence, progression-free interval after first diagnosis, and free resection margins were associated with improved overall survival on univariate analysis. On multivariate analysis, the stage at first diagnosis and resection margins were significant independent predictive parameters of an improved oncologic outcome.

Conclusion: Long-term survival can be achieved via secondary cytoreductive surgery in selected patients with recurrent cervical and endometrial cancer. An excellent outcome is possible even if the recurrence site is located in the lymph nodes. The possibility of achieving complete resection should be the main criterion for patient selection.
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http://dx.doi.org/10.1136/ijgc-2019-000292DOI Listing
May 2019

The thin red line - postmenopausal abnormal uterine bleeding with endometrial thickness less than 4 mm.

Contemp Oncol (Pozn) 2019 5;23(1):43-46. Epub 2019 Apr 5.

Department of Gynecological Endocrinology, Jagiellonian University Medical College, Krakow, Poland.

Aim Of The Study: To evaluate the risk of endometrial malignancy in postmenopausal women with abnormal uterine bleeding (AUB) with endometrial thickness ≤ 4 mm.

Material And Methods: Histological assessment of endometrial samples obtained via hysteroscopy or curettage was performed in 57 women.

Results: Women with premalignancy or malignancy (24.6%) had higher endometrial thickness (by 9.7%, = 0.01) compared to women with benign condition. Out of 12 women with atypical hyperplasia (21.1%), 5 women (8.8%) were diagnosed with simple and 7 women (12.3%) had complex hyperplasia, whereas 2 (3.5%) were diagnosed with malignancy.

Conclusions: Postmenopausal women with AUB and endometrial echo ≤ 4 mm are less likely to have a malignant condition. However, the role of histological evaluation cannot be undermined, especially in women at high risk of endometrial cancer, and routine endometrial biopsy should be considered. We recommend a change in the cut-off to 2 mm in routine practice.
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http://dx.doi.org/10.5114/wo.2019.83816DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500390PMC
April 2019

The value of the free androgen index depends on the phenotype of polycystic ovary syndrome - a single-centre experience.

Endokrynol Pol 2019 2;70(4):330-335. Epub 2019 Apr 2.

Department of Gynaecological Endocrinology and Gynaecology, Jagiellonian University Medical College, Cracow, Poland.

Introduction: The free androgen index (FAI) values differ among patients with polycystic ovarian syndrome; however, the differences are not fully understood or known. The aim of the study was to evaluate FAI in women with polycystic ovary syndrome (PCOS) in regard to the phenotype of the PCOS and insulin resistance status.

Material And Methods: Anthropometric, hormonal, and biochemical parameters were assessed in 312 recruited women with PCOS. The FAI values were calculated in the reproductive and metabolic phenotypes of PCOS in groups of insulin resistance status based on the homeostasis model assessment-insulin resistance (HOMA-IR) > 2.0 or fasting insulin (FI) > 10 mmol/L. To test the relationship between individual variables, Spearman's correlation analysis, the Kolmogorov-Smirnov test, and Student's t-test were used.

Results: The correlation between FAI values and HOMA-IR and FI was 0.42 and 0.47, respectively, in PCOS patients. A two fold higher FAI value was observed in metabolic PCOS phenotype when compared to the reproductive one (8.51 ± 5.56 vs. 4.40 ± 2.45 for HOMA-IR and 8.73 ± 6.09 vs. 4.31 ± 3.39 for FI, respectively; p < 0.05).

Conclusions: PCOS patients are not a homogenous group in terms of FAI value. Patients with metabolic PCOS phenotype are characterised by two-fold higher FAI values compared with reproductive PCOS phenotype. Further studies on the metabolic and androgenic status of different types of PCOS phenotypes should be carried out.
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http://dx.doi.org/10.5603/EP.a2019.0017DOI Listing
February 2020

Significance of BRCA1 expression in breast and ovarian cancer patients with brain metastasis - A multicentre study.

Adv Med Sci 2019 Sep 26;64(2):235-240. Epub 2019 Feb 26.

Department of Gynecology and Gynecologic Oncology, Medical University of Bialystok, Bialystok, Poland.

Purpose: Cerebral metastases develop in 10-30% of patients with breast cancer (BC) and in around 3.3 to 4% of patients with ovarian cancer (OC). The aim of the multicenter study is to investigate the correlation between the expression of estrogen alpha receptors (ERα), progesterone receptors (PR), human epidermal growth factor receptor 2 (HER2), stromal cell-derived factor 1 (SDF1) and its receptor C-X-C chemokine receptor type 4 (CXCR4), breast cancer metastasis suppressor 1 (BRMS1), astrocyte elevated gene 1 (AEG1), depending on the status of BRCA1 protein, in patients suffering from OC and BC with brain metastases.

Patients And Methods: The analysis included 51 patients: 29 with BC and 22 with OC, in whom brain metastases were disclosed.

Results: In most patients (65.5% of BC patients and 68.2% of patients with OC tumors) BRCA1 protein loss was found. No correlation was disclosed between the levels of ERα, PR receptors, HER2, SDF1, CXCR4, AEG1, BRMS1 and BRCA1 status, patient age, stage of disease advancement, grade of histological maturity of the cells, presence of metastases to lymph nodes. A statistically significant correlation was disclosed between the negative expression of PR receptors and a high expression of CXCR4 in patients with BC. High values of the AEG1 protein (linked to metastases) were detected alongside a high expression of BRMS1 (a suppressor of metastases).

Conclusions: Patients with BC and OC and brain metastases have a frequent loss of BRCA1 expression. The role of ERα, PR, HER2, SDF1, CXCR4, AEG1, BRMS1 in metastatic process needs further studies.
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http://dx.doi.org/10.1016/j.advms.2018.12.007DOI Listing
September 2019

Current management of cervical cancer in Poland-Analysis of the questionnaire trial for the years 2002-2014 in relation to ASCO 2016 recommendations.

PLoS One 2019 31;14(1):e0209901. Epub 2019 Jan 31.

Department of Gynecology and Obstetrics, Jagiellonian University Medical College, Krakow, Poland.

Objectives: To assess the survival of patients with cervical cancer (CC). Since the recommendations concerning cervical cancer management adopted by Polish medical societies do not differ significantly from the ESGO or non-European guidelines, and the fact that evaluation of the system for CC treatment in Poland, as well as the mortality rate of Polish women with CC, which is 70% higher than the average for European Union (EU) countries, justifies the hypothesis that treatment of CC in Poland deviates from the Polish and international recommendations. This article puts forward the current management of cervical cancer in Poland and discusses it in the context of ASCO guidelines.

Material And Methods: A survey retrospective multicenter analysis of the medical records of 1247 patients with cervical cancer who underwent treatment for disease and who had completed at least two years of follow-up.

Results: Although concurrent radiotherapy and chemotherapy is a standard treatment of FIGO IB to IVA cervical cancer patients in enhanced- and maximum-resources settings, in our analysis, we found that the percentage of women subjected to chemotherapy was lower than in countries where total survival rates were lower.

Conclusion: Within the IA to II A cervical cancer patients studied group, the methods of treatment remained in line with ASCO guidelines for countries with the highest standard of care. Although concurrent radiotherapy and chemotherapy is a standard treatment of FIGO IB to IVA cervical cancer patients in enhanced- and maximum-resources settings, in our analysis, we found that the percentage of women subjected to chemotherapy was lower than in countries where total survival rates were lower. Our findings, together with the inconsistencies within the cervical cancer screening program, may be one of the explanations of poorer survival rate of women with cervical cancer in Poland.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0209901PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6354992PMC
September 2019

The relationship between surgical treatment (mastectomy vs. breast conserving treatment) and body acceptance, manifesting femininity and experiencing an intimate relation with a partner in breast cancer patients.

Psychiatr Pol 2018 Oct 27;52(5):859-872. Epub 2018 Oct 27.

Klinika Ginekologii Onkologicznej Uniwersytet Jagielloński Collegium Medicum.

Objectives: The aim of the study was to verify the following hypotheses: (1) Do women who have undergone surgical treatment for breast cancer differ from healthy women in the way they experience their body (body self)?; (2) Does the surgical technique (mastectomy vs. breast conserving treatment) differentiate the group in terms of experiencing their body after the surgery?; (3) Do demographic variables, BMI, breast size and the evaluation of the scar differentiate the group in terms of experiencing their body self after the surgery?

Methods: In order to gain some insight into how women experience their body after breast surgery, the Body Self Questionnaire designed in 2005 by Beata Mirucka was used. The analysis included data from 50 women who completed surveys. This data were compared to the control group. Data were analyzed using IBM SPSS Statistics package, version 24, with a one-way analysis of variance (ANOVA).

Results: Statistically significant differences were obtained between the entire group of women after breast surgery (mastectomy and BCT, jointly) and the control group of healthy women in three aspects of the Body Self Questionnaire: body acceptance, manifesting femininity and experiencing an intimate relation with a partner.

Conclusions: Surgical treatment of breast cancer is significantly associated with the way patients experience their body, which is expressed in three dimensions of the body self in treated women.
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http://dx.doi.org/10.12740/PP/91916DOI Listing
October 2018

Exploring the relationship between the body self and the sense of coherence in women after surgical treatment for breast cancer.

Psychooncology 2019 01 25;28(1):54-60. Epub 2018 Oct 25.

Department of Gynaecology and Oncology, Jagiellonian University Medical College, Cracow, Poland.

Objective: Analysis of the relationship between the body self (BS) and the sense of coherence (SOC) in women after breast surgery due to cancer in comparison with a control group.

Methods: A cross-sectional study in a group of 78 women using the body-self questionnaire (BS-Q), and the life orientation questionnaire (SOC-29). Statistics based on the IBM SPSS v.25.

Results: Multivariate analysis of variance (MANOVA) has shown significant differences based on groups in experiencing intimacy, manifesting femininity, body acceptance, and manageability. In particular, manifesting femininity and body acceptance showed a big effect size (0.30 < partial ɳ  < 0.32). Correlation analysis between the BS-Q and SOC-29 subscales and Fisher's r to z transformation determines that the differences between groups were significant in favour of healthy women in two sets of variables: experiencing intimacy/meaningfulness and attitude to food and weight/manageability.

Conclusions: Breast cancer survivors are at greater risk of developing decreased body acceptance and problems in intimacy, and have less correlation than the healthy control group between manageability and meaningfulness with an appropriate attitude to food and intimate relationship with their partner, respectively. A higher manifestation of femininity in the treated group can be considered a positive but socioculturally conditioned coping strategy.
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http://dx.doi.org/10.1002/pon.4909DOI Listing
January 2019

Frequency of and causative founder variants in ovarian cancer patients in South-East Poland.

Hered Cancer Clin Pract 2018 27;16. Epub 2018 Feb 27.

5Department of Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Połabska 4 St, 70-115 Szczecin, Poland.

Background: Causative variants in and are well-established risk factors for breast and ovarian cancer. In Poland, the causative founder variants in the are responsible for a significant proportion of ovarian cancer cases, however, regional differences in the frequencies of various mutations may exist. The spectrum and frequency of mutations between ovarian cancer patients have not yet been studied in the region of South-East Poland.

Methods: We examined 158 consecutive unselected cases of ovarian cancer patients from the region of Podkarpacie. We studied 13 Polish causative founder variants in (c.5266dupC, c.4035delA, c.5251C > T, c.181 T > G, c.676delT, c.68_69delAG, c.3700_3704delGTAAA, c.1687C > T, c.3756_3759delGTCT) and in (c.658_659delGT, c.7910_7914delCCTTT, c.3847_3848delGT, c.5946delT).

Results: A causative founder variants were detected in 10 of the 158 (6.3%) ovarian cancer cases. causative founder variants were not observed. The c.5266dupC mutation was detected in 6 patients, c.181 T > G mutation in 3 patients and the c.676delT mutation in 1 patient. The median age of diagnosis of the 10 hereditary ovarian cancers was 55.5 years of age.

Conclusions: The frequency of 13 causative founder variants in Podkarpacie was lower than in other regions of Poland. Testing of three mutations (c.5266dupC, c.181 T > G, c.676delT) should be considered a sensitive test panel.
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http://dx.doi.org/10.1186/s13053-018-0089-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828315PMC
February 2018

The relationship between breast cancer treatment, tumour type and vitamin D level in pre- and postmenopausal women.

Neuro Endocrinol Lett 2017 Dec;38(6):437-440

Department of Gynecology and Oncology, Chair of Gynecology and Obstetrics, Jagiellonian University Medical College, Cracow, Poland.

Objective: Vitamin D deficiency has been linked to a higher risk of cancer. There is insufficient data regarding the influence of treatment on vitamin D status. The aim of this study was to compare pre- and post-treatment levels of 25(OH)D in premenopausal and postmenopausal women with breast cancer with a different receptor status (ER-estrogen receptors, PR-progesterone receptors) and in healthy controls.

Methods: 49 patients with breast cancer (23 premenopausal), and 28 healthy controls matched for age, menopausal status and BMI.

Results: The pre-treatment levels of 25(OH)D in patients with breast cancer were significantly lower in comparison to the control group (19 ng/mL vs. 30 ng/mL, p<0.001), the lowest in premenopausal women (18.4 ng/mL). After the treatment period, a significant decrease in 25(OH)D level (mean 15.8 ng/mL) was observed. The pre-treatment level of 25(OH)D was significantly lower in patients with ER (16.1 vs. 23.9 ng/mL, p=0.02) and with PR (15 vs. 24.4 ng/mL, p=0.003). The mean pre- and post-treatment levels of 25(OH)D were lower in patients with Ki67 <21% (16.7 vs. 20.1 ng/mL, p=0.15; 12.5 vs. 18.1 ng/mL, p=0.02 respectively).

Conclusions: 25(OH)D level is lower in patients with breast cancer in comparison to healthy women, regardless of their menopausal status. The lowest levels are found in patients with ER and PR positive tumours. While a significant decrease in 25(OH)D level during the course of therapy is observed, the supplementation of vitamin D should be considered.
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December 2017

Evaluation of quality of life in women with breast cancer, with particular emphasis on sexual satisfaction, future perspectives and body image, depending on the method of surgery.

Psychiatr Pol 2017 Oct 8;51(5):871-888. Epub 2016 Oct 8.

Klinika Ginekologii Onkologicznej UJ CM.

Objectives: Both because of the large number of women undergoing surgery and a high cure rates, psychological rehabilitation of the consequences of breast cancer and side effects of their treatment is a major challenge of modern psychooncology. Aim. The study analyzed the quality of life in women with breast cancer, with particular emphasis on indicators of sexual satisfaction, future perspectives and body image, depending on the method of surgery.

Methods: The study included 42 women aged 35-70 years, 3 months after surgery due to early breast cancer, treated with adjuvant chemotherapy. The following research tools were used in the study: two EORTC questionnaires: QLQ-C30, BR23, and sexual function questionnaire: PL-FSFI.

Results: There was no significant difference in the overall quality of life, depending on the type of surgery. The greatest local complaints were reported by patients after breast conserving surgery (BCT) with axillary lymphadenectomy. A higher level of cognitive functioning but a greater severity of systemic side effects was found in women undergoing mastectomy compared to BCT-patients. Women who underwent surgery of the right breast reported increased problems in sexual functioning (p = 0.034). Multiple regression analysis showed a positive correlation of the emotional functioning variable with the assessment of future perspectives (p = 0.01) and body image (p = 0.007).

Conclusions: The type of surgical technique does not affect the overall quality of life and sexual satisfaction. Problems with memory and attention do not correlate directly with the side effects, and as such require an independent diagnostics. Women undergoing treatment of the dominant-side breast should be the candidates for sexology consultation. There is a risk of disturbances in the body image and in the assessment of future perspectives in patients with emotional disorders observed within 3 months after surgery.
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http://dx.doi.org/10.12740/PP/OnlineFirst/63787DOI Listing
October 2017