Triplets are not so rare any more.

Triplet gestations present a considerable management challenge due to a high rate of antenatal, intrapartum and neonatal complications. The introduction of ovulation inducing agents resulted in a marked increase of these pregnancies. Consequently, triplet conceptions are not considered a rare phenomenon and have become almost routine high risk pregnancies. In our department the triplet gestation frequency increased 2-4 times in a 10 year period from a rate of 0.07-0.14% during 1978-84 to 0.28% of all deliveries in 1987. This high incidence of triplet deliveries results in a threefold increase in the frequency of triplet neonates and their associated complications. It is reasonable to assume that the wide application of various assisted reproductive techniques will result in continuous increase in the incidence of triplets which will in turn require coordinated management of a high risk pregnancy unit, delivery room and neonatal intensive care unit.     

Conservative management of Caesarean scar pregnancies with systemic multidose methotrexate: predictors of treatment failure and reproductive outcomes

Research questionCaesarean scar pregnancy (CSP) is an increasing concern in modern obstetrics. Early diagnosis and management are of utmost importance. The optimal management approach for CSP is not well established, with various treatment modalities reported. The role of conservative management of CSP has been previously reported, with conflicting results. This study aimed to further evaluate its role and better delineate the subsequent reproductive outcomes.DesignA retrospective cohort study including all patients diagnosed with a CSP and treated by intention of conservative management with systemic methotrexate (MTX). Maternal and gestation characteristics were compared between treatment success and failure groups.ResultsThirty-six cases of CSP were encountered. Overall, 29/36 (80.6%) were treated by systemic injection of MTX while the other 19.4% had combined systemic and local (i.e. intra-sac) MTX treatment. Invasive intervention was needed in five (13.9%) cases (failure group). Among those successfully treated with MTX, the median time to resolution was 22 (interquartile range 13–37) days. Cases who were converted to surgical treatment had a higher number of previous Caesarean deliveries (median 4 versus 2, P = 0.002). In logistic regression modelling, the number of previous Caesarean deliveries was the only factor independently associated with conversion to surgical management (odds ratio 2.02, 95% confidence interval 1.03–3.94). The majority of future pregnancies ended at term pregnancy with only one preterm delivery due to severe intrauterine growth restriction.ConclusionsSystemic MTX therapy is a safe and effective strategy for the treatment of CSP, with favourable subsequent reproductive results and a low conversion rate to surgical management.     

Endometrial carcinoma first presenting as paraneoplastic cerebellar degeneration

BACKGROUND: Paraneoplastic degeneration (PCD) is an immune-mediated disorder affecting the cerebellum, characterized by subacute onset of cerebellar dysfunction progressing to severe disability, and is associated with an underlying malignancy. Ovarian carcinoma and breast carcinoma are commonly implicated. CASE: We report a rare case PCD in an elderly woman, later diagnosed with endometrial carcinoma. CONCLUSION: PCD is an unusual and rare manifestation of gynecological malignancies, including endometrial carcinoma, and a high degree of suspicion is required in these cases in order to make the correct diagnosis.     

Risk factors for recurrent ectopic pregnancy following single-dose methotrexate treatment

Objective: Our study aimed to investigate the predisposing factors for recurrence of an ectopic pregnancy (EP) following single-dose methotrexate (MTX) treatment for a primary EP.

Methods: This was a retrospective cohort study performed in a tertiary care medical centre including all patients diagnosed with primary EP and treated with a single-dose regimen of intramuscular MTX. EPs with future recurrence were compared with first time only EPs, to identify risk factors for recurrent EP. Forward stepwise multivariate logistic regression analyses were subsequently carried out.

Results: The study included 272 women. Of those, 22 (8.1%) had a recurrent EP. Women in the recurrent EP group had a higher rate of abortions (45.5% vs 32.7%; p?=?0.02), previous pelvic surgery (45.5% vs 6.5%; p?<?0.001) and both pelvic and uterine surgery (4.5% vs 1.6%; p?<?0.001). Conception by assisted reproductive technology (ART) was more common among the non-recurrent EP group (23.0% vs 4.5%; p?=?0.04). Success of single-dose MTX treatment was lower in the recurrent EP group compared with the non-recurrent EP group (36.4% vs 65.7%; p?=?0.006). A history of pelvic surgery was independently associated with recurrent EP (adjusted odds ratio [OR] 17.6; 95% confidence interval [CI] 4.9, 63.2; p?=?0.001). Treatment success of single-dose MTX was independently protective for recurrent EP (adjusted OR 0.25; 95% CI 0.08, 0.76; p?=?0.02).

Conclusions: Among women with an EP, attention should be paid to those with previous pelvic surgery. Efforts should be made to achieve medical treatment success to prevent recurrent EP.     

Hormonal manipulations and breast cancer

Breast cancer is the most common cancer among women and the leading cause of death in women, 40 to 55 years of age. The lifetime odds of developing breast cancer are apparently up to 1 in 8 women in North America and 1 in 12 in Western Europe. According to the American Cancer Society, some 200,000 women (and 1,500 men) will be diagnosed with breast cancer this year. Although the incidence of breast cancer in women has been rising since the mid-1940s, the mortality has dropped modestly over the past decade, probably due to earlier and improved diagnosis and treatment.Evidence from both epidemiological and experimental studies points to an important role of reproductive variables in the development and promotion of human breast neoplasia. Hormonal manipulations, in the form of contraceptives, hormone replacement therapy, or antiestrogens, affect the incidence and course of breast cancer and may be useful in prevention and treatment of the tumor. In this review we summarize the current status of the use of hormones and antihormones in regard to breast cancer and outline possible areas of additional development and investigation. TARGET AUDIENCE: Obstetricians and Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to summarize the effects of estrogen and progestogens on the breast and to list the effects of other hormonal modulators on the breast.     

Growing teratoma syndrome vs chemotherapeutic retroconversion: case report and review of the literature

BACKGROUND: Immature ovarian teratoma is the third most common germ cell tumor (GCT) following dysgerminoma and endodermal sinus tumor. The treatment of choice during childbearing age for immature teratoma composes of unilateral oophorectomy and in case of metastatic disease postoperative chemotherapy (BEP). Finding a solid mass in the peritoneal or chest cavity during routine follow up raises the suspicion of distance recurrence. DiSaia was the first to describe the appearance of benign distant metastasis during routine follow up. He termed this phenomenon "chemotherapeutic retroconversion". Latter, Logothetis described what seems to be a similar phenomenon in testicular non-seminomatous germ cell tumor (NSGCT) that he called the "growing teratoma syndrome". CASE: We present a case of a 12-year-old girl treated for growing teratoma syndrome after primary ovarian GCT. CONCLUSION: Review of the literature shows that this syndrome and the "chemotherapeutic retroconversion" are probably the same phenomenon.     

Invasion of interstitial matrix by a novel cell line from primary peritoneal carcinosarcoma,and by established ovarian carcinoma cell lines: role of cell-matrix adhesion molecules,proteinases, and E-cadherin expression

OBJECTIVE: Primary peritoneal carcinosarcomas are similar to ovarian carcinomas in that they can metastasize by intraperitoneal dissemination; therefore, invasion of the submesothelial interstitial (stromal) matrix is an integral part of the pathology. Our objective was to study cell-matrix interactions that may influence invasive behavior of a novel, primary peritoneal carcinosarcoma cell line (PC880), and to assess how these cell-matrix interactions are different from frequently studied cultured ovarian carcinoma cells NIH:OVCAR-3, SKOV-3, and ES-2. We also wanted to determine how the expression of the cell-cell adhesion molecule E-cadherin is related to invasive behavior. METHODS: The PC880 cell line was established from ascites fluid of a patient diagnosed with primary peritoneal carcinosarcoma. Adhesion assays were done in titer plates coated with individual matrix components. Cell migration in monolayer cultures was assessed by the scratch wound assay method. Invasion assays were done using a three-dimensional type I collagen gel. Cytokeratin, vimentin, and E-cadherin were detected by Western blotting. E-cadherin mRNA was detected by RT-PCR. RESULTS: PC880 cells adhered well to fibronectin, laminin, and vitronectin in an integrin-dependent manner. The cells also adhered to type I collagen and invaded a three-dimensional type I collagen matrix. The invasiveness of the PC880 cells was moderated by pretreatment of the collagen matrix with heparin or chondroitin sulfate (82 and 63% of control invasiveness, respectively), indicating a role of cell surface proteoglycans in promoting invasive phenotype. Treatment of PC880 cells with sodium chlorate also decreased invasiveness (80% of control), further confirming the role of cell surface proteoglycans. Treatment of PC880 cells with function-blocking antibody to alpha2 integrin decreased invasiveness (57% of control), indicating the role of integrins in promoting the invasive phenotype. The protease inhibitors GM6001, E-64, and AEBSF decreased invasiveness (35, 57, and 37% of control, respectively) of PC880 cells. The ES-2 cells also adhered to type I collagen, and invaded the three-dimensional type I collagen matrix; however, inhibitors such as heparin, chondroitin sulfate, function-blocking antibody to alpha2 integrin, E-64, and AEBSF were less effective in moderating the invasiveness. Inhibition of invasiveness with sodium chlorate was the same as in PC880 cell, while GM6001 did not inhibit invasiveness at all. The NIH:OVCAR-3 and SK-OV-3 cells were previously found to adhere to type I collagen, but these cells did not invade the three-dimensional type I collagen matrix. In a monolayer culture PC880 and ES-2 cells had significantly higher motility than NIH:OVCAR-3 and SK-OV-3 cells. Only these noninvasive cell lines expressed E-cadherin protein or mRNA. CONCLUSIONS: PC880 is the first cell line established from primary peritoneal carcinosarcoma, and the cytoskeletal composition indicated that these cells represent the sarcomatous elements of the tumor. PC880 cells, similar to ES-2 cells, adhered to type I collagen, and invaded a three-dimensional collagen matrix. The invasion of the interstitial matrix by both the peritoneal carcinosarcoma and the ovarian carcinoma cell line was mediated by cell surface proteoglycans, alpha2 integrin, and proteases. The invasive cell behavior of PC880 and ES-2 cells correlated with a high degree of motility, and with the lack of expression of the cell-cell adhesion molecule E-cadherin.