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Introduction: The risk for metastasis at primary diagnosis of breast cancer is about 4%. The German guidelines give clear indications on when, who, and how to stage breast cancer patients. Ideally, this should be done via computerized axial tomography (CAT) scan of the thorax and abdomen and an additional bone scan. But daily practice shows that the way health-care providers handle staging recommendations can vary. To objectify adherence to guidelines we started a nation-wide survey., Methods: Between July and September 2020, we sent out a survey via email to all certified and noncertified breast centers and in addition to all Departments of Obstetrics and Gynecology in Germany. We asked for timing of staging, conditions that cause staging, and the applied method. In case we did not get any reply, we sent out a reminder., Results: A total of 220 certified breast centers, 28 noncertified breast centers, and 48 Departments of Obstetrics and Gynecology who care for breast cancer patients took part in our survey. A general pretherapeutic staging was performed in 16.4%, 39.3%, and 66.7% of all institutions and a general postoperative staging was performed in 4.1%, 0%, and 6.3% of each institutional type, respectively. In terms of the applied method, 75% of all certified breast centers used a CAT scan and bone scan, while 23.3% primarily used chest X-ray, ultrasound of the abdomen (27.7%), or MRI. As a potential reason for using X-ray and ultrasound, the presence of a "low-risk" breast cancer was mentioned., Summary: Although certified breast centers show the highest adherence to current guidelines, some still perform a general staging or do not use the recommended staging method. The low probability of primary metastatic breast cancer and the use of a reasonable exposure to radiation warrant a critical discussion., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2022 by S. Karger AG, Basel.)

BACKGROUND: Many studies about the adjuvant endocrine therapy of postmenopausal patients with hormone receptor-positive breast cancer have shown significant superiority of aromatase inhibitors (AIs) compared to tamoxifen only. Within these studies, different AIs (anastrozole, letrozole, exemestane) and treatment strategies (upfront, switch, extended adjuvant) were applied. MATERIAL AND METHODS: The intention of our enquiry was to evaluate the implementation of the results of these studies in German breast cancer centers and university hospitals. Questionnaires were sent to 200 breast cancer centers and university hospitals (returns: 108). RESULTS: Our enquiry showed that most centers preferred anastrozole as upfront therapy in patients with an intermediate or high risk of relapse. Furthermore, during AI therapy, additional bisphosphonate treatment was applied 'always' in only 9% of cases, and in 78% of cases of proved osteopenia/osteoporosis. Surprisingly, 50% of the participating centers do not exclude AIs in premenopausal women. CONCLUSION: At the time of our enquiry, anastrozole as upfront therapy was consistent with the recommendations of the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO) from 2009. Compared to tamoxifen, AIs increase the risk of osteoporosis, which can, however, be prevented and treated with concomitant bisphosphonate therapy. The rare use of bisphosphonates as well as contraindicated AI therapy in premenopausal patients show amongst others the substantial need for more information.

Purpose: This open-label, randomized phase III study was designed to investigate the effects of erythropoietin alfa (EPO) in addition to adjuvant chemotherapy and pelvic radiotherapy (CRT) in patients with stage IB to II cervical cancer who had undergone radical hysterectomy., Patients and Methods: Two hundred fifty-seven patients were randomly assigned to four cycles of carboplatin/ifosfamide chemotherapy followed by external-beam pelvic radiotherapy (CRT group) or four cycles of carboplatin/ifosfamide chemotherapy and EPO followed by pelvic radiotherapy and EPO (CRT + EPO group). The primary end point was recurrence-free survival (RFS). Secondary end points included overall survival (OS), change in hemoglobin levels, and safety, including thromboembolic events., Results: The estimated 5-year RFS rates were 78% for patients receiving CRT + EPO and 70% for patients receiving CRT. There was no statistically significant difference in RFS, although a trend favoring patients treated with CRT + EPO was observed (hazard ratio [HR], 0.66; 95% CI, 0.39 to 1.12; log-rank P = .06). Exploratory analyses suggest a benefit with CRT + EPO for patients with stage IB to IIA disease (HR, 0.39; 95% CI, 0.18 to 0.85; P = .014) or patients with complete resection (HR, 0.55; 95% CI, 0.31 to 0.98; P = .039). OS was similar in both groups (HR, 0.88; 95% CI, 0.51 to 1.50; log-rank P = .63). Patients treated with EPO maintained higher hemoglobin levels throughout CRT. No significant differences in safety profiles were observed between the two groups. Incidence of thrombovascular events was low (2%) and comparable between both groups., Conclusion: This study confirms that EPO can be added safely to CRT in patients with cervical cancer, but it failed to demonstrate a significant benefit in RFS and OS.

A prospective, randomized study was performed in order to evaluate the effect of cefotiam in the prevention of postoperative infectious morbidity in patients undergoing low-risk elective cesarean section. A total of 146 patients were randomly assigned to receive either intraoperative single-shot prophylaxis with 2 g cefotiam (study group, n =76) or no prophylaxis (control group, n=70). Due to a higher rate of urinary tract infections, the incidence of infectious morbidity after cefotiam prophylaxis was higher in the study group than in the control group (16% vs. 9%, P=0.1). Postoperative infectious morbidity following low-risk elective cesarean section cannot be reduced by intraoperative cefotiam prophylaxis.

Background: The aim of this case control study was to investigate the influence of genital Ureaplasma urealyticum colonization on pregnancy outcome., Methods: One hundred and seventy-two women colonized with Ureaplasma urealyticum without co-existing other infections and 123 women with negative cultures for Ureaplasma urealyticum were enrolled. In a multivariate analysis the influence of quantitative Ureaplasma urealyticum colonization level was determined., Results: Compared to the negative women increasing colonization with Ureaplasma urealyticum was associated with a significant decrease of birth weight (p<0.0001) and gestational age (p<0.0001) and with a significant increase of chorioamnionitis (p<0.0001) and preterm delivery (p<0.001). In a multivariate analysis high-density Ureaplasma urealyticum colonization was an independent risk factor for chorioamnionitis and preterm delivery, whereas low colonization levels had no effect on an adverse outcome of pregnancy., Conclusions: The degree of colonization with Ureaplasma urealyticum correlates strongly with an adverse effect on pregnancy outcome.

Objective: To investigate whether the activity of the three mitogen-activated protein kinases (Jun aminoterminal kinase, extracellular regulated kinase, and p38) is altered in placental tissue of women with preeclampsia and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome., Methods: Placental activity (measured by immunoprecipitation-kinase assay) and protein expression (measured by western blot) of Jun aminoterminal kinase, extracellular regulated kinase, and p38 mitogen-activated protein kinase were measured in four groups of eight women each with preeclampsia, HELLP syndrome, and normal vaginal or cesarean deliveries. To further characterize the Jun aminoterminal kinase signal transduction pathway, phosphorylation of c-Jun, a downstream effector of Jun aminoterminal kinase- mitogen-activated protein kinase, was analyzed by western blotting, and the activity of Rac1, an upstream activator of the Jun aminoterminal kinase signaling pathway, was determined by pull-down assay., Results: The activity of Jun aminoterminal kinase was significantly lower in placentas of women with preeclampsia or HELLP syndrome compared with those who had normal vaginal or cesarean delivery, whereas levels of Jun aminoterminal kinase protein expression were similar. Phosphorylation of the transcription factor c-Jun and Rac1 activity also were significantly lower in women with preeclampsia and HELLP than in controls. p38 mitogen-activated protein kinase activity was significantly higher in women with preeclampsia than with HELLP syndrome. There was no change in extracellular regulated kinase activity or protein expression between subgroups., Conclusion: In placentas of women with preeclampsia or HELLP syndrome, a Rac1-Jun aminoterminal kinase-c-Jun-dependent signal transduction pathway was downregulated.

Objective: Our purpose was to examine the impact of immediate postpartum curettage on the recovery of patients with HELLP-syndrome (hemolysis, elevated liver enzymes, and low platelets)., Subjects: Between January 1994 and July 1997 all patients who presented with HELLP-syndrome in our institution underwent immediate postpartum curettage (n=24). Their outcome was compared with the recovery of women with HELLP-syndrome who were delivered without postpartum curettage between 1987 and 1993 (n=20). Clinical and laboratory data were analyzed., Results: No significant difference could be found between both groups in terms of normalization of serum glutamic-oxaloacetic transaminase (GOT), serum glutamic-pyruvic transaminase (GPT), lactic dehydrogenase (LDH), and quantitative platelet count. Postpartum hospitalization time was identical in both groups., Conclusion: In our retrospective study no benefit is achieved by immediate postpartum curettage in patients with HELLP-syndrome. In order to eliminate the possible bias of retrospective analysis, we now plan a randomized study to further investigate the impact of immediate postpartum curettage.

Granular cell tumor is a rare, usually benign neoplasm of neural origin that may arise in virtually any site and, when situated in the breast, can mimic breast carcinoma. We describe a case of granular cell tumor of the breast in a 57-yr-old woman. Clinical evaluation, mammography, sonography and MRI suggested a carcinoma with infiltration of skin and muscle. However, the tumor did not display increased glucose metabolism on PET. Clinical findings, imaging results, histological characteristics and surgical management are discussed.

Objective: Our purpose was to determine the levels in plasma of angiogenin in healthy pregnant women and to examine whether there are differences between uncomplicated pregnancies and patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets, preeclampsia-eclampsia, and highly pathologic Doppler flow findings without additional complications., Study Design: Angiogenin was measured with a novel enzyme-linked immunosorbent assay. A case control and observational study was conducted in 68 healthy women from the tenth to fortieth weeks of pregnancy and in 18 patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets, 21 with preeclampsia/eclampsia and 13 with highly pathologic Doppler flow findings at admission for delivery., Results: Between the tenth and fortieth weeks of uncomplicated pregnancy angiogenin plasma levels rose from 150 to 250 ng/ml (significant correlation). In patients with highly pathologic Doppler flow findings angiogenin is significantly reduced compared with healthy pregnant matched pairs (150 vs 219 ng/ml, p < 0.01)., Conclusion: Rising plasma angiogenin levels in pregnancy may reflect persisting placental transformation and remodeling processes: in patients with highly pathologic Doppler flow findings these processes are disturbed and thus placental function is impaired.

Objective: To assess whether various proteolytic factors which are involved in trophoblast invasion show different concentrations in plasma and placenta of patients with HELLP syndrome, pre-/eclampsia and highly pathological Doppler flow measurements but without additional complications (hpD)., Design: Case control and observational study; 18 women with HELLP syndrome, 21 with pre-/eclampsia, 13 with hpD, as well as healthy pregnant women (matched pairs); statistical analysis: sign test and Wilcoxon test., Results: Urokinase-type plasminogen activator (uPA), uPA receptor, tissue-type plasminogen activator (tPA), plasminogen activator inhibitor 1 (PAI-1), matrix metalloproteinases MMP-8, MMP-9 and tissue inhibitor of metalloproteinases TIMP-1 were measured by ELISA. PAI-1 plasma levels are significantly elevated in all three groups studied. In HELLP syndrome, tPA and TIMP-1 are also elevated, and in patients with hpD, MMP-8 is increased, whereas MMP-9, and TIMP-1 are lower. In placenta extract, only pre-/eclampsia shows reduced MMP-9 concentrations., Conclusions: The increased frequency of small-for-gestational-age infants observed in all three study groups is an expression of impaired placental implantation and remodelling processes. These disturbances manifest themselves in the form of changes in some of the factors in plasma and placenta extract that are involved in these processes.

Intracardiac fibrin adhesive was used for selective fetocide in three diamniotic twin pregnancies at 18-24 weeks' gestation (trisomy 21: n = 1; ultrasound evidence of major malformation: n = 2). Two of the three pregnancies were complicated by an intra-amniotic infection leading to pregnancy loss but one patient (with a monochorionic twin gestation) delivered a normal baby prematurely in the 31st week of pregnancy. The technique, complications and pregnancy outcomes are discussed.

Pregnant women and newborn infants were screened for group B streptococcal (GBS) colonization by obtaining paired swabs from the cervix and urethra for the former group and from the ear, nose, umbilical cord, gastric juice and membranes for the latter. One swab was cultured on blood agar; the other was inoculated into serum-starch broth (GBS medium), which allows identification of GBS by production of a characteristic orange-colored pigment. From the 2105 paired swabs obtained, a total of 158 were GBS positive by either method; of these, 154 (97.5%) were recovered by the GBS medium and 89 (56.3%) by blood agar plate. No false positive color reactions were observed with GBS medium. 75% of the positive GBS media could be read within 24 h of incubation. The use of GBS medium proved to be an easy and reliable method for screening of maternal and neonatal GBS colonization.

Objective: Impaired trophoblast invasion plays a major role in the development of preeclampsia. Therefore various factors that are involved in invasion were investigated in gestational disease., Methods: In pregnant women with HELLP-syndrome (n = 18), pre-/eclampsia (n = 21) and highly pathological Doppler flow measurements (hpD) (n = 13), plasma and placental tissue extract concentrations of uPA, uPA-receptor, tPA, PAI-1, MMP-8, MMP-9, TIMP-1, thrombomodulin, and angiogenin were measured using ELISA., Results: In all three collectives, PAI-1 plasma concentrations were significantly higher (p < 0,05) than in normal pregnancies, in patients with HELLP-syndrome, tPA and TIMP-1 plasma levels were also elevated. MMP-9 concentrations in placental tissue extracts were lower in pre-/eclampsia than in normal pregnancies., Conclusions: Impaired placental implantation and remodelling in gestational disease is reflected by changes in plasma and placental tissue extract concentrations of various factors that are involved in these processes.

Various parameters associated with fibrinolysis were examined in plasma and placenta tissue extract in 18 patients with HELLP syndrome (haemolysis, elevated liver enzymes, and low platelet count). A significant increase in plasma concentrations of tPA and PAl-1 was observed in the HELLP patients in comparison to 18 pregnant women of the control group (equal duration of pregnancy). In contrast, there was no difference in plasma concentrations of uPA, uPA-receptor and D-dimer. In placenta tissue extract, significant differences were found just as rarely for uPA, uPA-receptor and PAl-1 as for tPA and D-dimer. Our findings indicate, that endothelial damage with release of tPA may be involved in the pathophysiological pathway of HELLP syndrome. Increased plasma levels of PAl-1 may reflect deficient fibrinolysis resulting in impairment in microcirculation. Clinical relevance of tPA and PAl-1 plasma concentration as possible predictor of hypertensive pregnancy complications will have to be studied further.

Puerperal ovarian vein thrombophlebitis (POVT) is a rare but severe complication of the post partum period. We report on a patient, who developed a POVT based on an infection with Ureaplasma urealyticum and Mycoplasma hominis. Problems of diagnostic procedures in cases of POVT and the role of ureaplasma and mycoplasma in infectious obstetric complications are discussed.

A rising Caesarean delivery rate is the reason, why the obstetrician should be very well informed about the management of vaginal birth after Caesarean section: It is feasible in almost all women with nonrecurrent indication for the preceeding Caesarean section. Suspected foetal macrosomia, twin gestation and breech presentation represent relative contraindications. External cephalic version is a reasonable option. In case of history of uterine scar dehiscence or rupture and in women with vertical uterine scar, repeat section should be performed.

Despite the fact, that acute pseudo-obstruction of the colon (Ogilvie's syndrome) is a rare entity, many of the reported cases have occurred after gynaecologic and obstetric surgical procedures. In order to avoid life-threatening complications, such as caecal perforation, early detection and initiation of conservative treatment is necessary. We report on three cases with Ogilvie's syndrome after caesarean section. Symptoms and treatment are discussed.

The aetiology of preterm rupture of membranes is not yet completely understood. Local infections of the vagina and cervix have attracted special attention during the last years. Ascending infection with subsequent chorioamnionitis is a common complication of preterm rupture of membranes. Recognition of the beginning of a chorioamnionitis is usually based on clinical symptoms and laboratory findings like white blood cell count and C-reactive protein. The purpose of this study was to find out the diagnostic value of elastase, a protease of polymorphonuclear granulocytes, which is known to be involved in inflammatory processes. Fifteen out of thirty-three patients with preterm rupture of membranes developed a chorioamnionitis. Elastase plasma concentration levels > or = 32 ng/ml one day before delivery showed a significant correlation (p = 0.02) to the development of a chorioamnionitis. At this time neither white blood cell count, nor rectal body temperature showed significant correlations. Low elastase levels do not exclude an infection, whereas high levels indicate an infectious process. We conclude that elastase is a relevant marker of chorioamnionitis.

Since the introduction of anti-D gamma-globulin prophylaxis non-immune hydrops fetalis (NIHF) has become the relevant and more common form of fetal hydrops. A case of an NIHF with chylothorax, diagnosed in the 36th week of pregnancy, is discussed with regard to obstetrical and neonatological management.

Arteriovenous fistulae of the uterus are rare. We report on a patient with a vascular malformation of the uterus complicated by hypermenorrhea. Symptoms, possible complications and therapy are discussed.

Lupus erythematosus first diagnosed in pregnancy or puerperium is a problem both for the obstetrician and for the internist. We report on a case of lupus manifestation with signs and symptoms similar to sepsis diagnosed in the puerperium.

The stromal Leydig cell tumour of the ovary is a very rare benign neoplasm which usually occurs in postmenopausal women. Due to a significant production of androgens by the tumour, it is frequently associated with symptoms of virilization. To our knowledge only 7 cases have been reported in the literature, one of them with bilateral manifestation. We report an additional case affecting both ovaries in a 59-year-old nun with long-standing virilism, review the literature, and discuss the histomorphological features for differential diagnosis.

Androgen-producing tumours of the ovary are uncommon in postmenopausal women. We report on symptoms of two patients with androgenization due to a stromal-Leydig cell tumour and a steroid-cell tumour, respectively. Clinical signs and symptoms, laboratory findings and therapeutic consequences are discussed.

The clinical relevance of foetal macrosomia (i.e. birth weight greater than or equal to 4000 gms) was investigated retrospectively using the 1987 figures of the "Bayerische Perinatalerhebung". 8591 (total n = 101931; 8.4%) newborns met the criterion for macrosomia and were compared with two groups of normosomic newborns (birth weight 2500-2999 gms and 3000-3999 gms). The problems, which may obscure correct prenatal diagnosis are discussed. The incidence of operative deliveries and birth injuries was increased. The duration of the deliveries was not prolonged in our study in contrast to published reports. The neonatal transfer-rate to a neonatal centre was higher in newborns, delivered by Caesarean section, compared with newborns delivered by the vaginal route. The perinatal and the maternal morbidity was higher, the perinatal mortality lower in the macrosomic newborn. According to our data, macrosomia represents and elevated perinatal risk.

The reported study investigates the relationship of genital infections, pathobiochemical findings and demographic data to preterm labor, premature rupture of membranes (PROM) and premature delivery. The predictability of chorioamnionitis, puerperal and neonatal infections by these parameters was evaluated concurrently. 301 patients were included in this study between July 1985 and June 1986. 147 of these patients were studied longitudinally during pregnancy, delivery and puerperium (longitudinal group). A second group consisted of 154 women who presented themselves on start of labor to the labor and delivery unit of our Department (peripartal group). The incidence of preterm labor and of PROM was 26%. The incidence of premature delivery, chorioamnionitis, puerperal and neonatal infection was 11.4%, 5.5%, 7.6% and 3% respectively. Cervical colonization with Mycoplasma hominis correlated positively with PROM (relative risk 2.2), premature delivery (3.9) and neonatal infection (6.9). Chorioamnionitis, premature delivery and puerperal infection were also significantly increased in patients with positive vaginal Ureaplasma urealyticum cultures during pregnancy and delivery. Premature delivery (2.8) and puerperal infection (4.0) were associated with a vaginal group B-Streptococci (GBS) colonization during pregnancy, as was a positive GBS culture during delivery associated with puerperal infection. Bacterial vaginosis also correlated positively with premature delivery (5.6) and puerperal infection. Preterm labor correlated negatively with the socioeconomic level, PROM correlated negatively with the marital status, positively with age, a history of cervical cerclage, conization or PROM during former pregnancies. Sexual intercourse more often than once weekly during the last month of pregnancy was also associated with an increased number of PROM. Gardnerella vaginalis, Candida and Trichomoniasis during pregnancy and delivery were associated with preterm labor and puerperal infections. Levels of maternal plasma fibrinogen concentrations in patients with PROM were elevated 48 hours after delivery in accordance to the characteristics of acute phase proteins. In contrast, the maternal PMN-granulocyte-elastase concentration was significantly elevated at time of delivery and 24 hours thereafter in those patients who developed puerperal infections. The derived positive predictive value was 26%, the negative 94.7%, respectively. The overall accuracy of the prediction was 83.1%. Six out of seven mothers with neonates treated because of neonatal infection showed significantly elevated plasma concentration of PMN-granulocyte-elastase.(ABSTRACT TRUNCATED AT 400 WORDS)