[Primary breast sarcomas: About 30 cases treated at Salah-Azaiez institute in Tunisia]. / Sarcomes mammaires primitifs : à propos de 30 cas traités à l'institut Salah-Azaiez de Tunis.

PURPOSE: To identify retrospectively prognostic factors of primary breast sarcoma and review its treatment modalities. MATERIALS AND METHODS: This is a descriptive study on 30 cases of primary breast sarcoma. We carried out a univariate and multivariate analysis correlating clinical, pathological and therapeutic parameters with disease-free survival and overall survival. RESULTS: The mean age was 46.8 years. The mean tumour size was 10cm. The 30 cases were 18 phyllodes sarcomas, eight angiosarcomas, three liposarcomas and a case of granulocytic sarcoma. Sixteen patients had adjuvant radiotherapy and only seven patients received adjuvant chemotherapy. The median follow-up was 64 months. Overall survival rates at 3 and 5 years were 49.1% and 33.7%. Disease-free survival rates at 3 and 5 years were 22.8% and 15.2% respectively. The analytical study of the following parameters: tumour size and presence or absence of node or distant metastases, showed no correlation with overall survival nor with disease-free survival. Furthermore, adjuvant radiotherapy did not improve overall survival (P=0.298; hazard ratio [HR]=1 [0.982-1.04]) nor disease-free survival (P=0.61; HR=0.942 [0.862-1.029]). By univariate analyses, we identified a correlation between overall survival, surgical margins (>1cm) (P=0005; HR=3.4 [1.217-9.919]) and tumour necrosis (P=0.028; HR=0.099 [0.014-0.682]). We did not find any independent prognostic factor by multivariate analysis. CONCLUSION: The prognosis of primary breast sarcoma seems to depend essentially on optimal surgical excision (margin over 1cm). The only potential histological parameter correlated with the prognosis is the presence of tumour necrosis. The histological subtype should not be considered as a prognostic marker for overall or disease-free survival in patients with primary breast sarcoma.

Iron deficiency in Yemeni patients with sickle-cell disease.

Despite the general view that patients with sickle-cell disease (SCD) have iron overload, there are reports of iron deficiency in a proportion of these patients. We studied Yemeni patients aged 1-30 years with homozygous SCD to determine their iron status using a set of 4 criteria (low serum iron, low transferrin saturation, high total iron binding capacity and low mean corpuscular volume for age). Of the 75 patients, 44 had never been transfused while 31 patients had received blood transfusions but not during the 3-month period prior to the study. Of the patients, 10 (13.3%) met the criteria for iron deficiency, 9 of whom were from the non-transfused patients (20.5%). The sensitivity and specificity were 40% and 98% respectively for reticulocyte count and 80% and 90% respectively for reticulocyte index. We recommend screening non-transfused SCD patients for iron deficiency.

Iron deficiency in Yemeni patients with sickle-cell disease

Despite the general view that patients with sickle-cell disease [SCO] have iron overload, there are reports of iron deficiency in a proportion of these patients. We studied Yemeni patients aged 1-30 years with homozygous SCD to determine their iron status using a set of 4 criteria [low serum iron, low transferrin saturation, high total iron binding capacity and low mean corpuscular volume for age]. Of the 75 patients, 44 had never been transfused while 31 patients had received blood transfusions but not during the 3-month period prior to the study. Of the patients, 10 [13.3%] met the criteria for iron deficiency, 9 of whom were from the non-transfused patients [20.5%]. The sensitivity and specificity were 40% and 98% respectively for reticulocyte count and 80% and 90% respectively for reticulocyte index. We recommend screening non-transfused SCD patients for iron deficiency

A clinicohysteroscopic scoring system of intrauterine adhesions.

We propose a new scoring system for intrauterine adhesions (IUA) that may predict the prognosis after hysteroscopic adhesiolysis. We analyzed hysteroscopic findings and clinical data of patients diagnosed as having IUA by reviewing previously published hysteroscopic classifications of IUA. The data were subjected to evaluation according to the most popular classifications in addition to the proposed classification using a scoring system for different parameters. The results obtained by the proposed scoring system matched well with other classifications regarding grade I and III IUA. But in the cases with moderate IUA (grade II), there was overlap between the classifications (sensitivity 58.3%) which can be attributed to considering the menstrual and reproductive history. Further studies are needed to assess its prognostic value.

The fimbrio-ovarian relation and its role on ovum picking in unexplained infertility: the fimbrio-ovarian accessibility tests.

OBJECTIVE: To study the ovum pickup mechanism and the fimbrio-ovarian relation in fertile women and cases of unexplained infertility and to design a method for investigation and anticipation of the state of ovum pickup. DESIGN: Prospective clinical study. SETTING: Department of Obstetrics and gynecology Kasr El Aini Hospital, Cairo University, Egypt. PATIENTS: Fifty fertile and 25 cases of unexplained infertility. INTERVENTIONS: In all of cases the fimbrio-ovarian relation is studied by determining the length of the free ovarian border between the ovarian ligament and the fimbria ovarica that contains the corpus luteum (the ovulation border), the site of ovulation on that border and the length of the fimbria ovarica. It is also determined by a simple test "The fimbrio-ovarian accessibility test." The fimbriae are held by non-traumatizing grasper and their ability to reach and/or to cover the ovulation site are taken as a prove for successful ovum pickup. In addition, cases having suspected failed ovum picking are treated by controlled superovulation, also by drilling of the ovary at an accessible site to the fimbria ovarica and by freeing short fimbria ovarica with or without its advancement on the ovulation border. RESULTS: The ovulation site is found to be usually accessible to the fimbrial end of the tube (94%) in the fertile cases and not accessible (92%) in the infertile cases. Correction of the fimbrio-ovarian relation in the infertile cases was associated with a cumulative ongoing pregnancy rate of 68%. CONCLUSION: Failed ovum pickup should be considered one of the important causes of unexplained infertility. The suggested "fimbrio-ovarian accessibility" test may be useful for the elucidation of the state of ovum pickup in infertile cases. Correction of the fimbrio-ovarian relation, to make ovum pickup possible, should be considered a method for treating such cases.

Endocrinologic and psychologic aspects of galactorrhea associated with normal menstrual cycles.

Twelve cases of galactorrhea in women with normal menstrual cycles who were radiologically free of any pituitary adenomas were investigated. Determinations were made for serum thyroid-stimulating hormone (TSH), T3 resin uptake (T3RU), total thyroxine by radioimmunoassay (T4), free thyroxine index (FT4I), norepinephrine, epinephrine, prolactin and urinary luteinizing hormone, total estrogens, pregnanediol and total catecholamines. Psychologic evaluation and assessment were also done using the Middlesex Hospital Questionnaire and the Eysenk, manual dexterity, Bender Gestalt and trial-making scales. Hypothyroidism associated with moderate hyperprolactinemia and anovulation were the main features in eight cases. Associated psychologic disturbances were reported. The other four cases showed significant elevations in serum epinephrine, norepinephrine and urinary total catecholamines with concomitant pathologic scales of anxiety and neuroticism. Thyroxine replacement and psychotherapy are recommended in the treatment of such cases.

The diagnostic value of hysterosalpingography in infertility cases: part 2, the radiological appearance of tubal pick-up mechanism "hand pointing sign.".

PIP: Hysterosalpingography was used to determine the appearance of the fallopian tubes at the time of ovulation. 47 of 50 normal fertile patients showed a characteristic radiological sign, designated the tubal hand pointing sign, at the time of expected ovulation. 6 figures depict this tubal alteration. The tubal hand pointing sign is seen as the normal tube spreads laterally from the uterine corne. The proximal part of the tube is nearly straight, followed by a convoluted intermediate part. The infundibulum and fimbria ovarica are seen pointing to the ovary and ovarian bed. The tubal pick=up mechanism was suggested as the cause of the radiological appearance described. In 2 cases depicted, the distal part of the tube is creeping, snake-like, over the ovarian surface and bed. Hence, it is suggested that absence or distortion of this tubal hand pointing sign may be helpful in the diagnosis of infertility.^ieng

Genital tract bleeding in IUD users and its relation to the device state.

PIP: The relationship between the device state of an IUD and genital tract bleeding was investigated. The investigation was based on data collected from a random 1075 insertions of 30-mm Lippes Loops, which constituted a general incidence of bleeding of 15% in IUD users. In 21% of these cases, the bleeding could not be halted by standard treatments, and the IUD was removed. X-ray, hysterography, and ultrasonography were used to diagnose the IUD state in situ. 75% of the cases requiring IUD removal showed abnormal radiological findings, whereas only 20% of the treatable bleeding cases showed radiological device abnormality. Use-duration was the main factor in the findings; users of IUDs for less than 1 year had abnormal radiological findings in 58.3% of resistant cases and in 29.6% of treatable cases. The corresponding figures among users for periods of time varying from 1-3 years and greater than 3 years were 49.6 and 11.4, respectively, and 86.6 and 66, respectively. Device displacement, distortion, and fractures were the most common radiologically detected abnormalities. In the 2 groups studied, the bleeding pattern varied in amount and type. In resistant cases, metrorrhagia was significant. The increase of vaginal discharge (40.4%), uterine colic (88%), tenderness (25.8%), and RVF (35.5%) was detected in the resistant as opposed to the treatable groups. This increase suggests a uterine factor, i.e., the IUD itself.^ieng

Serum sialic acids in the normal menstrual cycle: a possible test for the prediction of ovulation.

PIP: A test for predicting ovulation is described which is based on measurement of serum sialic acids in normal menstrual cycle. In this study of 7 healthy, fertile women, free, bound, and total sialic acids were determined during various menstrual cycle phases. A second experiment was performed on 109 oral contraceptive pill users who were taking combined formulations for less than 1 year, 1-2 years, and 3-5 years. In addition, urinary luteinizing hormone determinations were made throughout the menstrual cycles. Bound and total sialic acids showed significant drops from Day 9-13 of the menstrual cycle, whereas they were at an almost constant level during the remainder of the cycle. Based on luteinizing hormone determinations, this drop was seen to coincide with the preovulatory estrogen peak, and just preceded the luteinizing hormone peak. Pill users, with anovular cycles, did not show such a drop in bound and total sialic acids. Hence, determination of serum sialic acids may be a useful tool for ovulation detection.^ieng

Serum cryoglobulins and sialic acids in cervical erosion.

PIP: Serum cryoglobulins and sialic acid levels were determined in 101 women grouped as follows: 1) 25 normal women (control); 2) 36 women with cervical erosion who were pill users; and 3) 40 women with inflammatory cervical erosion. At the same time, 36 normal pregnant women were tested to detect any cryoglobulins in their sera. The level of serum cryoglobulins in those with cervical erosion was 20 times greater than that of the control group, and proved to be highly significant (p 0.005). Twice the normal values were detected in those cases of hormonal erosion. 55% of the pregnant women showed serum cryoglobulins but this was not significant (p 0.05) when compared with those values for hormonal erosion. Insofar as the serum sialic acids were concerned, no significant changes were noted in those cases of hormonal erosion while a signficant rise was seen in those with inflammatory cases (p 0.05). A S.A./C.G. (sialic acid/cryoglobulin) ratio was deduced and based on the discrepancy in serum cryoglobulins and this ratio in the 2 groups displaying erosion, it is possible that these parameters might be useful in diagnosing the inflammatory nature of cervical lesions.^ieng

Prognostic value of certain enzymatic and hormonal assays in threatened abortion.

PIP: The following biochemical indices were evaluated comparatively as predictors of the course of threatened abortion: serum oxytocinase, heat stable alkaline phosphatase, leucine aminopeptidase, urinary pregnanediol, and urinary estriol. 36 cases, grouped into controls and pathological cases, were studied. In normal pregnancy, there was a progressive rise in the levels of the serum oxytocinase, leucine aminopeptidase, urinary estriol, and pregnanediol. Serum heat stable alkaline phosphatase showed an undifferentiated range of results in nonthreatened pregnancies. In the group of threatened abortion cases, results were, therefore, considered abnormal if 2 or more successive determinations showed progressive reduction in enzyme or hormonal levels, and abnormality was also diagnosed if the results were below the normal range (published tabularly, per gestational week). The prognostic value of these biochemical indices was as follows: of 16 cases with normal serum oxytocinase values, 31.2% aborted, whereas of 10 with abnormal values, 70% aborted. Of 16 cases with serum leucine normal values, 37.5% aborted, whereas Of 10 abnormal cases, 60% aborted. Of 18 cases with normal heat stable alkaline phosphatase values, 55.5% aborted, whereas of 8 cases with abnormal values, 25% aborted. Of 17 cases with normal urinary estriol determinations, 45% aborted, whereas of 9 cases with abnormal values, 44.5% aborted. And of 17 cases with normal pregnanediol levels, 41% aborted, whereas of 9 cases with abnormal values, 55.5% aborted. These results show that combined estimation of serum oxytocinase and urinary pregnanediol is a reliable parameter in anticipating pregnancy outcome in cases of threatened abortion.^ieng

Enzymatic and hormonal assessment of foetoplacental unit in normal and complicated pregnancies.

PIP: This study compared and correlated the relationship and dependability of serum oxytocinase, leucine amino peptidase, and heat stable alkaline phosphatase levels as well as urinary estriol and pregnanediol excretion values as placental function tests. 2 groups were studied, those with normal (25 cases) and those with abnormal pregnancies (84 cases). There were 84 cases of pregnancy complications which were matched with control, uncomplicated pregnancies after determining the normal range of the factors under study. Of no significance in predicting fetal status at birth were serum heat stable alkaline phosphatase determinations. Serial assays of urinary estriol were useful predictors of fetal status at birth in 80% of complicated cases; 50% of complicated case outcomes were correctly predicted using the serum oxytocinase value. In complications of diabetes mellitus, the urinary estriol assays were sensitive and reliable indicators of the pregnancy state, whereas in preeclampsia complications, both the serum oxytocinase and urinary estriol assays were of prognostic value. However, serum leucine amino peptidase was of less prognostic significance than the oxytocinase determinations. Pregnanediol assays showed insignificant results as diagnostic aids. For assessing the status of the feto-placental unit, combined urinary estriol and serum oxytocinase assays are the most reliable prognostic indicators.^ieng