Cancer arising in the gastric stump. Occurrence following resection for benign peptic ulcer disease

Two patients developed adenocarcinoma of the gastric stump 20 to 30 years following gastric resection for benign peptic ulcer disease. The bulk of the medical literature supports a small but definite increased incidence with a latency period of 20 years or more. The risk is greatest following operations that lead to greater reflux of bile and pancreatic juices into the gastric remnant. The diagnosis may be inapparent by upper gastrointestinal tract roentgenograms, and changes may not even be obvious at endoscopy. Five-year survival rates are low (2% to 4%). Because the prognosis is poor once the disease is diagnosed, the high-risk patient should be considered for intermittent endoscopic surveillance.     

Chromosomal analysis of pregnancy losses in patients undergoing assisted reproduction

Chromosomal analysis was performed on products of conception from 18 patients having early pregnancy loss after assisted reproduction. Sonographic findings prior to obtaining tissue varied from gestational sacs consistent with a blighted ovum to fetal poles with cardiac activity. The mean age of the patients was 36.3 years. There were nine (50%) normal karyotypes, five (28%) autosomal trisomies, two cases of tetraploidy, one case of monosomy, and a case with two pericentric inversions. The results of this study suggest that patients undergoing assisted reproduction are not at an increased risk for chromosomal abnormalities.     

Serum progesterone concentrations on the day after human chorionic gonadotropin administration and progesterone/oocyte ratios predict in vitro fertilization/embryo transfer outcome

Purpose In gonadotropin-releasing hormone analogue-pretreated in vitro fertilization-embryo transfer cycles, pregnancy rates are inversely related to serum progesterone levels on the day of administration of human chorionic gonadotropin. The relationship of the progesterone concentration on other days in the periovulatory period to pregnancy rates in such cycles is little studied. We therefore retrospectively analyzed the relationship between progesterone concentrations on the day after human chorionic gonadotropin and pregnancy in 114 cycles, 28 and 23 of which produced clinical and ongoing/delivered pregnancies, respectively. To assess the effect of the extent of follicular luteinization on success, we also studied the relationship between the progesterone concentration per oocyte retrieved and pregnancy for the day of and day after human chorionic gonadotropin.Results Progesterone concentrations on the day after human chorionic gonadotropin were inversely associated with clinical pregnancy by multiple logistic regression analysis (P<0.05). Progesterone/oocyte ratios were inversely associated with clinical pregnancy (P<0.05) and ongoing/delivered pregnancy (P<0.02) for both the day of and the day after human chorionic gonadotropin.Conclusion The study results extend the window of time during which elevated progesterone concentration is associated with poor outcome to at least 2 days. This finding is consistent with hypothetical mechanisms attributing the link between progesterone concentration and outcome to either endometrial or follicle/oocyte events. The association of lack of follicular luteinization (low progesterone per oocyte ratios) and favorable outcome suggests a predominant effect of progesterone on follicle/oocyte quality. Further studies are needed to clarify the mechanisms underlying the association between progesterone and in vitro fertilization-embryo transfer outcome.     

Gonadotropin-releasing hormone analogs in the treatment of endometriomas

A limited number of small studies have assessed the efficacy of gonadotropin-releasing hormone agonists in the treatment of ovarian endometriomas. Most of these trials have not used quantitative measurements to evaluate the effects of therapy on disease resolution. The results available thus far suggest that nafarelin, buserelin, and histrelin offer modest degrees of efficacy, similar to that of danazol, in the management of patients with ovarian endometriotic cysts. Gonadotropin-releasing hormone agonists appear to be most efficacious when endometriomas are less than 1 cm in size.     

Effects of tamoxifen on corpus luteum function and luteal phase length in cynomolgus monkeys

Previous data in nonhuman primates have demonstrated that tamoxifen prolongs the luteal phase without altering reproductive hormone levels. A small study in humans found no effect on menstrual cycle length, but an increase in luteal ovarian steroid levels. In view of these conflicting results, we studied the effect of tamoxifen on corpus luteum (CL) function in monkeys (n = 20). Blood was obtained daily beginning cycle day 8, and sera assayed for estradiol (E2), progesterone (P), luteinizing hormone, and follicle-stimulating hormone. Four days after the midcycle E2 peak, laparoscopy confirmed CL formation, and the animals were administered (1) lactose (n = 7), (2) tamoxifen, 0.5 mg.kg-1.d-1 (n = 6), or (3) tamoxifen, 3.0 mg.kg-1.d-1 (n = 7) for 12 consecutive days. Serum collection continued until cycle day 50 or menses, whichever came first. Results indicate a biphasic response among tamoxifen-treated animals, with 7 of 13 developing prolonged luteal phases. There was, however, no significant difference in luteal phase length among the three groups, although when the two groups given tamoxifen were combined, the difference in luteal phase length versus controls approached significance. No differences were found among peak P levels, mean luteal phase P levels, or mean luteal phase gonadotropin levels. No variables were found to correlate significantly with luteal phase length. These results suggest that luteal phase administration of the antiestrogen tamoxifen does not alter pituitary gonadotropin secretion or CL function. However, tamoxifen does prolong luteal phase length in a subset of monkeys, perhaps via a direct effect on the endometrium.