[GASTRIC CANCER IN PREGNANCY].

INTRODUCTION: Gastric carcinoma in pregnancy is rare and occurs in only 0.025% to 0.1% of all pregnancies. Due to it's symptoms of abdominal discomfort and nausea, which are common during pregnancy, the diagnosis is usually made in an advanced stage. We present a case of a 37 years old woman who presented at 18 weeks of gestation with abdominal pain, nausea and vomiting accompanied with severe maternal ascites. Her workup included an MRI scan, abdominal and obstetrical ultrasound scans, sampling of the peritoneal fluid, gastroscopy and diagnostic laparoscopy. She was diagnosed with a stage four gastric carcinoma. As seen in this case and in the current literature, diagnosis of gastric carcinoma in pregnancy is difficult. It often tends to be made in stage three or four and usually carries a very poor prognosis. In this paper, we describe our experience with this patient and review the literature.

Maternal and neonatal outcomes following a proactive peripartum multidisciplinary management protocol for placenta creta spectrum as compared to the urgent delivery.

BACKGROUND: Adherent and invasive placenta, termed Placenta Creta Spectrum (PCS), is associated with increased maternal morbidity and mortality. Incidence and risk factors for Placenta Creta are on the rise and call to optimize the obstetric care for this condition. OBJECTIVES: We sought to compare maternal and neonatal outcomes between a ProActive Peripartum Multidisciplinary Approach (PAMA) as compared to the urgent management of the Placenta Creta Spectrum patients. STUDY DESIGN: We conducted a single-center prospective observational study between 2005-2016. PCS patients registered with the implementation of a PAMA protocol 2014-2016 epoch(E2) were compared with the pre-PAMA 2005-2013 epoch(E1), managed by urgent team recruitment. The PAMA protocol is grounded on a continuum of care; A. Antenatal: PCS risk assessment based on clinical history and imaging, surgical, anesthesia, urological consults and designation of a dedicated team to be present at planned surgery; B. Delivery: planned at 34-35 weeks, massive transfusion protocol activation, insertion of ureteral catheters, vertical uterine incision, placement of vessel loops on the iliac vessels, avoidance of active placenta delivery, followed by the decision of hysterectomy or uterine repair; C. Post-operative care: intensive care admission. We evaluated maternal and neonatal outcomes. RESULTS: During the study period 158,438 deliveries were registered in our institution; we identified a total of 72 PCS cases (0.05%): 50(69.4%) in E1 and 22 (30.6%) in E2. Patient characteristics were comparable among epochs. Significantly, patients in E2 vs. E1 had fewer events of massive blood transfusion 36.0% vs. 13.6%, p = 0.05; were transfused less RBC units: median 4 vs. 1.5, p = 0.012, had no transfusion-related respiratory complications and hemorrhage control re-laparotomies. Hysterectomy and hollow visceral injury rates were comparable (72% vs. 63.7%, 26% vs. 22%; respectively). The hysterectomy pathology assessment was available for the majority of the cases in both epochs; percreta diagnosis rate significantly increased in E2. The neonatal outcome was similar among the epochs. CONCLUSIONS: Institution of a PAMA protocol for PCS resulted in eliminating the urgent deliveries and in reducing the associated significant hemorrhagic related maternal morbidity, with no increase in the rate of hysterectomy or adverse neonatal outcome.

Laparoscopic Removal of an Abdominal Pregnancy in the Pelvic Sidewall.

STUDY OBJECTIVE: To describe the presentation, diagnosis, and management of a patient with abdominal pregnancy and to illustrate the laparoscopic technique used to manage this patient. DESIGN: A descriptive study approved by our local Institutional Review Board. Consent was given from the patient. SETTING: A university hospital in Ashdod, Israel. PATIENT: On May 15th 2018, a gravida 3, para 2, 37-year-old asymptomatic patient was referred to our hospital's gynecologic emergency department due to a suspected ectopic pregnancy. The patient had no relevant medical or surgical history. Her obstetric history consisted of 2 spontaneous vaginal deliveries with no other significant gynecologic history. Her menses were regular every month. Her last menstrual period was 6 weeks before presentation. Her ß-human chorionic gonadotropin (hCG) level measured on the day before presentation was 24,856 IU/L. Physical examination was unremarkable except for a small amount of brownish vaginal discharge. A transvaginal ultrasound (TVUS) exam on presentation did not demonstrate an intrauterine gestational sac, but revealed a gestational sac and a fetus next to the right adnexa, with a crown-rump length of 1.3 cm, consistent with 7+3 gestational weeks. There was a minimal amount of fluid in the pouch of Douglas. INTERVENTION: Owing to an extrauterine pregnancy with high ß-hCG value, laparoscopic operative management was chosen. On entrance to the abdominal cavity, a normal uterus and 2 ovaries and fallopian tubes were observed. A small to moderate amount of blood was present in the pouch of Douglas. a 3- to 4-cm distension was noted over the right uterosacral ligament. Following delicate probing of the area, moderate to severe bleeding commenced, which was initially controlled with local pressure and oxidized regenerated cellulose. An intraoperative TVUS identified an abdominal pregnancy in the right pelvic sidewall. The gestational sac was completely dissected and removed following ureterolysis and separation of the right ureter from the specimen. Local injection of vasopressin was also used. The ß-hCG level before surgery of 19,008 IU/L decreased to 6339 IU/L on postoperative day 1. The patient was discharged in good condition on postoperative day 2. A final histopathological report confirmed a gestational sac. MEASUREMENT AND MAIN RESULTS: This patient referred for a tubal ectopic pregnancy was eventually diagnosed with an abdominal pregnancy and was treated operatively with complete excision of the abdominal pregnancy, which was located at the right pelvic sidewall. CONCLUSION: Abdominal pregnancy is a rare type of ectopic pregnancy with a reported incidence of 1:10,000 to 1:30,000 pregnancies, and accounts for approximately 1% of ectopic pregnancies [1]. It carries a high risk for maternal morbidity and mortality. Many different locations at different gestational ages have been reported in the literature, including the pouch of Douglas, pelvic sidewall, bowel, broad ligament, omentum, and spleen [2-4]. These varied locations and the rarity of this type of pregnancy make diagnosis and treatment challenging. The location of the growing fetal tissue may endanger the patient's life if it impinges on vital anatomic structures. In the present case, the gestational sac was very close to the right ureter, and we opted to surgically excise the gestational sac in its entirety.

Isolated tumor cells identified by sentinel lymph node mapping in endometrial cancer: Does adjuvant treatment matter?

OBJECTIVE: To evaluate the outcome and the role of adjuvant treatment in the management of patients with endometrial cancer and isolated tumor cells (ITCs) identified by SLN mapping. METHODS: This single center study identified all patients undergoing hysterectomy, salpingo-oophorectomy, lymphadenectomy and SLN mapping for endometrial cancer between November 2010 and December 2015. Data was prospectively collected. Progression-free survival was analyzed according to the Kaplan-Meier method and compared using the log-rank test. RESULTS: A total of 519 patients were included. Overall, 85 patients (16.4%) were found to have SLN metastases of which 43 (51%) were macrometastasis, 11 (13%) micrometastasis (MM) and 31 (36%) ITC. Eleven (35%) of patients with ITCs received adjuvant chemotherapy±whole pelvic radiation therapy (WPRT), 10 (32%) received WPRT, and 10 (32%) received either no adjuvant treatment or vault brachytherapy (VBT) only. ITC patients received significantly less chemotherapy (p=0.0001) and WPRT (p=0.007) compared to patients with macrometastasis. Of note, ITC were not considered node positive in our study. With a median follow-up of 29months (range: 0-67), the progression free survival (PFS) at 3-years for the ITC patients was 95.5%, similar to node negative (87.6%) and micrometastasis patients (85.5%), but statistically better than patients with macrometastasis (58.5%) (p=0.0012). Only 1/31 patient with ITC recurred (IB, 7cm carcinosarcoma) despite adjuvant treatments. None of the ITC patients with endometrioid histology recurred (0/28) and none of the ITC patients who did not receive adjuvant treatment or VBT recurred (0/10). CONCLUSIONS: Patients with endometrial cancer found to have SLN ITCs have an excellent outcome. The use of adjuvant treatment should be tailored to uterine factors and histology and not solely based on the presence of ITCs. Patients with ITCs and otherwise low-risk uterine disease probably derive little benefit from receiving additional treatments. More studies are needed to confirm our results.

Canonical Wnt activity regulates trunk neural crest delamination linking BMP/noggin signaling with G1/S transition.

Delamination of premigratory neural crest cells depends on a balance between BMP/noggin and on successful G1/S transition. Here, we report that BMP regulates G1/S transition and consequent crest delamination through canonical Wnt signaling. Noggin overexpression inhibits G1/S transition and blocking G1/S abrogates BMP-induced delamination; moreover, transcription of Wnt1 is stimulated by BMP and by the developing somites, which concomitantly inhibit noggin production. Interfering with beta-catenin and LEF/TCF inhibits G1/S transition, neural crest delamination and transcription of various BMP-dependent genes, which include Cad6B, Pax3 and Msx1, but not that of Slug, Sox9 or FoxD3. Hence, we propose that developing somites inhibit noggin transcription in the dorsal tube, resulting in activation of BMP and consequent Wnt1 production. Canonical Wnt signaling in turn stimulates G1/S transition and generation of neural crest cell motility independently of its proposed role in earlier neural crest specification.