Gestación heterotópica abdominal tras fecundación in vitro y transferencia embrionaria. Reporte de un caso y discusión sobre el diagnóstico y manejo / Abdominal heterotopic pregnancy after IVF and embryo transfer. A case report and a review of the diagnosis and management

La coexistencia de una gestación intrauterina y una extrauterina se denomina gestación heterotópica. Es una condición poco frecuente, que ocurre en un 0,001-0,006% de las gestaciones espontáneas y hasta en un 1% de las gestaciones conseguidas mediante técnicas de reproducción asistida.Presentamos un caso de gestación heterotópica con implantación pélvica, una circunstancia extremadamente rara, y discutimos sobre su diagnóstico y su manejo clínico insistiendo en la necesidad de pensar en esta entidad aunque se objetive una gestación intrauterina tras una técnica de reproducción asistida y aunque no existan otros factores de riesgo. Un diagnóstico y tratamiento precoces serán claves para evitar las graves complicaciones asociadas a este tipo de gestación.(AU)

The coexistence of an intrauterine pregnancy and an extra-uterine one is called a heterotopic pregnancy. It is a rare condition that occurs in 0.001-0.006% of spontaneous pregnancies, and in up to 1% of pregnancies achieved through assisted reproduction treatments.The case is presented of a heterotopic pregnancy with pelvic implantation, an extremely uncommon event, followed by a discussion on its diagnosis and clinical management. There must be awareness of this disorder, even if an intra-uterine pregnancy is observed after an assisted reproduction treatment, and although there are no other risk factors.Early diagnosis and treatment is essential to avoid the serious complications associated with this type of pregnancy.(AU)

Estudio piloto sobre el efecto de la vitamina D en la patogenia de los miomas uterinos: influencia de la terapia con vitamina D en el volumen uterino y en la angiogénesis de los miomas determinados por ECO3DPW y niveles séricos de VEGF / Pilot study on the effect of vitamin D on the pathogenesis of uterine fibroids: Influence of vitamin D therapy on volume and vascularisation of uterine fibroids, determined by 3DPW ultrasound and VEGF serum levels

Los miomas uterinos son una de las patologías ginecológicas más comunes encontrándose hasta en el 70% de las mujeres de raza caucásica y en el 80% de las mujeres de raza negra1,2. En los últimos años, la angiogénesis y la vascularización se han convertido en pieza fundamental de estudio del crecimiento de los tumores. En el caso de los miomas uterinos se ha descubierto que existen diferencias en la vascularización cuando se compara con el tejido uterino adyacente. La patogenia de los miomas es multifactorial existiendo varias vías que intervienen en el crecimiento de los mismos como la vía estrogénica, la progestagénica y la de los factores de crecimiento3. Otra de las vías qué influyen en su desarrollo es la vía de la vitamina D. Niveles inadecuados de dicha vitamina pueden favorecer el crecimiento de los mismos. En nuestro trabajo hemos analizado cómo influye la terapia con vitamina D en el volumen de los miomas y en su vascularización mediante el análisis sérico de VEGF y ecografía 3 DPW

Uterine fibroids are one of the most common gynaecological disorders, being found in 70% of Caucasian women and 80% of Afro-Caribbean women 1,2. In recent years, angiogenesis and vascularisation have become a key part of study of tumour growth. Differences in vascularisation have been discovered in uterine fibroids when compared to adjacent uterine tissue. The pathogenesis of uterine fibroids is multifactorial. Several pathways are involved in their growth have been described, such as the oestrogen pathway, the gestagen pathway, and the pathway of the growth factors. Another of the pathways that influences their development is the vitamin D pathway, as inadequate levels of this vitamin may favour the growth of uterine fibroids3. In this work, an analysis is made on how vitamin D therapy influences the volume and vascularity of uterine fibroids, using serum VEGF levels and 3DPW Ultrasound

No todo es lo que parece: miastenia gravis, una rara manifestación paraneoplásica del cáncer de ovario: caso clínico / Not all is what it seems: Myasthenia gravis, a rare paraneoplastic manifestation of ovarian cancer: Clinical case

Los síndromes neurológicos paraneoplásicos son un conjunto de trastornos, raramente asociados a tumores ginecológicos. Su presencia debe alertarnos sobre la posible existencia de un tumor maligno subyacente. Presentamos un caso de miastenia gravis, como manifestación paraneoplásica de un cáncer de ovario primario avanzado

Paraneoplastic neurological syndromes are an unusual diseases rarely associated with gynaecological tumours. Their presence must alert on the possible existence of an underlying malignant tumour. A rare case is presented of myasthenia gravis as a paraneoplastic manifestation of an advanced primary ovarian cancer

[Endometriosis]. / Endometriosis.

Endometriosis is a common gynaecological disease of unknown aetiology which affects an estimated 10% to 15% of all premenopausal women. It is defined as the presence of endometrial tissue, consisting of both glandular epithelium and stroma, outside the uterine cavity. Three different clinical entities of endometriosis can be distinguished: peritoneal endometriosis, ovarian endometriosis and deep invasive endometriosis. There are several theories to explain their pathogenesis: metaplasia of the mesothelium, in situ development of Müllerian remnants in the rectovaginal area (deep-invasive lesions) or retrograde transplantation of shed menstrual effluent (peritoneal implants). The most widely accepted hypothesis for the development of endometriosis is retrograde menstruation. However, some other factor renders certain women susceptible to the implantation and growth of this ectopic endometrium.

[Proposal for a new microsurgical model for the study of induced endometriosis in Wistar rats. Preliminary results]. / Propuesta de un nuevo modelo microquirúrgico para el estudio de la endometriosis inducida en rata Wistar. Resultados preliminares.

The current knowledge status on the patogenesis of endometriosis as well as devastating consequences of disease evolution in women's reproductive health, have promoted researchers advances in a great manner during last years. The immunologic and neangiogenesis systems implication have opened new ways of knowledge over classic theories from the beginning of the xx century. The experimental resesearch, using animal induction models. Below we explain the first steps a new induction model ("PGR1-HotDog"), based on Wistar rats using a new disease autogeneration system, created for te study of the early stages of the endometriosis.

Ultrasound study of the myoendometrial border.

Abnormal thickening of the Endometrial Subendometrial Myometrium Unit (ESEMy Unit, including basal endometrium and inner myometrium) has been detected on imaging and referred to as "diffuse adenomyosis" in infertile patients with proven endometriosis. However, no robust relationship exists between enlargement of the ESEMy Unit and adenomyosis proven on hysterectomy specimen examination; moreover, if any correlation exists, it lacks histological validation in women wishing to preserve fertility. While adenomyosis effects on fertility, if any, remain elusive, thickening of the ESEMy Unit have been consistently linked to fertility impairment in both experimental and clinical models. The hypothesis tested herein is that a novel condition exists, called "ESEMy Unit disruption disease"; it is epidemiologically different from adenomyosis, diagnosable on imaging and bears a clear impact on human fertility through various mechanisms. A new wave of good quality studies may be elicited by a clear distinction between adenomyosis and the "ESEMy Unit disruption disease".

[Diagnosis of endometriosis]. / Diagnóstico de la endometriosis.

There are no sufficiently sensitive and specific signs and symptoms or diagnostic tests for the clinical diagnosis of endometriosis, and no diagnostic strategy is supported by evidence of effectiveness. Pelvic and rectal examinations should be performed, although the yield of the physical examination is low. Laboratory tests and radiological examinations are usually not warranted. Measurement of CA 125 levels may be useful for monitoring disease progress, and MRI has a high sensitivity in detecting endometrial cysts but poor diagnostic accuracy for endometriosis in general. Patients with persistent symptoms after empirical treatment should be referred for laparoscopy, the preferred method for diagnosis of endometriosis.

[Angiogenesis and endometriosis]. / Angiogenesis y endometriosis.

Endometriosis is a common gynaecological disease of unknown aetiology. Angiogenesis appears to be one of the processes involved in its pathogenesis. Angiogenic factors are increased in the peritoneal fluid of patients with endometriosis (McLaren 1996 et al; Taylor et al, 2002), in peritoneal implants (Ferriani et al, 1993) and in ovarian endometriomas. On the other hand, some researchers have found that angiogenesis is related to pelvic pain. We speculated that ovarian endometriomas in patients presenting with pelvic pain would be more angiogenic than those in asymptomatic women and that their vascular features would therefore be different.

[Basic research into endometriosis. Are we going in the right direction?]. / Investigación básica en endometriosis. ¿Estamos en el camino correcto?

Endometriosis is a common gynaecological syndrome of unknown aetiology. The most widely accepted hypothesis for the development of endometriosis is retrograde menstruation. However, some other factor renders certain women susceptible to the implantation and growth of ectopic endometrium. Angiogenesis appears to be one of the process involved in the pathogenesis of endometriosis. Angiogenic factors are increased in the peritoneal fluid of patients with endometriosis in peritoneal implants and in ovarian endometriomas. We believe that the optimal serum marker should be used to monitor the response of new antiangiogenic agents in endometriosis treatment.

[Treatment for endometriosis]. / Tratamiento de la endometriosis.

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, which induced a chronic inflammatory reaction. Endometriosis is associated with severe dysmenorrhea, deep dyspareunia, chronic pelvic pain, ovulation pain, cyclical, or perimenstrual symptoms, with or without abnormal bleeding, infertility, and chronic fatigue. Therapies can be useful to relieve and sometimes solve the symptoms, encourage fertility, eliminate endometrial lesions, and restore the anatomy of the pelvis. For medical therapy, several different preparations (oral contraceptives, progestogenics, gestrinone, danazol, and GnRHa) and new options (GnRH antagonists, aromatase inhibitors, estrogen receptor beta agoinist, progesterone receptor modulators, angiogenesis inhibitors, and COX-2 selective inhibitors) are available.

Endometriosis / Endometriosis

La endometriosis es una de las enfermedades más enigmáticas queafecta a las mujeres en edad reproductiva. Esta enfermedad se defi ne porla presencia de tejido endometrial (epitelio glandular y estroma) fuerade la cavidad uterina, localizándose habitualmente sobre la superfi cieperitoneal y sobre el ovario. Desde un punto de vista epidemiologico,se describen varios factores de riesgo como la edad, las caracteristicasreproductivas, los habitos personales y los factores hereditarios comodirectamente relacionados con el desarrollo de la enfermedad.En la actualidad existen cuatro teorías para explicar la patogénesis dela endometriosis: metaplasia celómica, restos de células embrionarias,diseminación linfática y vascular y trasplante de tejido endometrial.Sin embargo, no podemos concluir que conozcamos el origen de laenfermedad (AU)

Endometriosis is a common gynaecological disease of unknown aetiologywhich affects an estimated 10% to 15% of all premenopausal women.It is defi ned as the presence of endometrial tissue, consisting of bothglandular epithelium and stroma, outside the uterine cavity.Three different clinical entities of endometriosis can be distinguished:peritoneal endometriosis, ovarian endometriosis and deep invasiveendometriosis. There are several theories to explain their pathogenesis:metaplasia of the mesothelium, in situ development of Müllerianremnants in the rectovaginal area (deep-invasive lesions) or retrogradetransplantation of shed menstrual effl uent (peritoneal implants). Themost widely accepted hypothesis for the development of endometriosisis retrograde menstruation. However, some other factor renders certainwomen susceptible to the implantation and growth of this ectopicendometrium (AU)

Propuesta de un nuevo modelo microquirúrgico para el estudiode la endometriosis inducida en rata Wistar. Resultados Preliminares / Proposal for a New Microsurgical Model for the Study of Induced Endometriosis in Wistar Rats. Preliminary Results

El desconocimiento actual sobre la patogenia de la endometriosis ylas devastadores consecuencias que conlleva esta enfermedad paralas mujeres en edad reproductiva, han sido las grandes promotorasde los esfuerzos de los investigadores en los últimos años. La implicaciónpatogénica del sistema inmunológico, así como de los procesosneoangiogénicos ha abierto una gran vía de conocimiento sobre lasteorías clásicas conocidas desde principios del siglo XX. Todo ello, pasapor la investigación experimental de la endometriosis, en modelosanimales, con sistemas de inducción de la enfermedad. A continuaciónexplicamos los primeros resultados de un nuevo modelo experimentalde autogeneración de endometriosis en rata Wistar (“PGR1-HotDog”),creado con una fi nalidad, el conocimiento de las fases más precocesde la enfermedad (AU)

The current knowledge status on the patogenesis of endometriosis aswell as devastating consequences of disease evolution in women´sreproductive health, have promoted researchers advances in a greatmanner during last years. The immunologic and neangiogenesis systemsimplication have opened new ways of knowledge over classic theoriesfrom the beginning of the XX century. The experimental resesearch,using animal induction models. Below we explain the fi rst steps a newinduction model (“PGR1-HotDog”), based on Wistar rats using a newdisease autogeneration system, created for te study of the early stagesof the endometriosis (AU)

Angiogenesis y Endometriosis / Angiogenesis and endometriosis

La endometriosis se produce por un proceso de implantación y crecimientode las células endometriales sobre la superfi cie peritoneal yovárica. Al igual que los procesos tumorales los implantes de células endometrialesno son capaces de proliferar a menos que exista un procesode neoangiogénesis. Se ha propuesto que la angiogénesis endometrialexcesiva pudiera ser un importante mecanismo en la patogénesis de laendometriosis. El proceso de angiogénesis implica la interacción de unelevado número de factores de crecimiento entre los que se encuentrael factor de crecimiento vascular (VEGF), el cual es reconocido como elprincipal factor angiogénico. En un reciente investigación hemos estudiadoel papel del VEGF sérico en pacientes con endometriosis ováricadividas en dos grupos en funcion de si presentaban o no síntomas dedolor pélvico crónico y/o dismenorrea (AU)

Endometriosis is a common gynaecological disease of unknown aetiology.Angiogenesis appears to be one of the processes involved in itspathogenesis. Angiogenic factors are increased in the peritoneal fl uid ofpatients with endometriosis (McLaren 1996 et al; Taylor et al, 2002), inperitoneal implants (Ferriani et al, 1993) and in ovarian endometriomas.On the other hand, some researchers have found that angiogenesis isrelated to pelvic pain. We speculated that ovarian endometriomas inpatients presenting with pelvic pain would be more angiogenic thanthose in asymptomatic women and that their vascular features wouldtherefore be different (AU)

Pregnancy associated breast cancer.

BACKGROUND: Breast carcinoma during pregnancy put the health of the mother in conflict with that of the foetus. The aim is to give optimal treatment to the mother to maximise the chances of survival, whilst minimising the risk of harm of the foetus. We report the epidemiology, pathology, clinical picture, therapeutic management and foetal outcome of pregnant women with breast cancer treated in our institution. PATIENTS AND METHODS: Twenty-two pregnant breast cancer patients were treated in our hospital from January 1996 to October 2006. Parents were surveyed by mail or telephone regarding outcomes of children exposed to chemotherapy in uterus. RESULTS: The treatment of breast cancer pregnancy should conform as closely as possible to standardised protocols for patients without concomitant pregnancy. Most of the patients underwent surgery during pregnancy In four cases diagnosed during the first trimester chemotherapy was initiated during the 10th week when organogenesis period was finished. None of the children exposed to chemotherapy during this trimester presented congenital malformations. All 11 cases diagnosed during second and third trimester were treated with Doxorrubicin, Fluoracil and Cyclophosphamide and four cases were treated with taxanes. No congenital malformations were detected. CONCLUSION: Breast cancer can be treated with FAC chemotherapy during the second and third trimesters without significant complications for the children exposed to chemotherapy in uterus. We report four cases treated with taxanes after the first trimester and no congenital anomalies were observed.

Triage for surgical management of ovarian tumors in asymptomatic women: assessment of an ultrasound-based scoring system.

OBJECTIVES: To prospectively evaluate an ultrasound-based scoring system as a method for triaging asymptomatic women presenting with an adnexal mass for surgical treatment. METHODS: Two hundred and four adnexal masses in 189 asymptomatic women undergoing elective surgical treatment at our institution were included in this prospective study. Patients were evaluated by transvaginal power Doppler ultrasound imaging before surgery. Patients were classified as low risk or high risk for malignancy according to an ultrasound-based scoring system. Women with a low risk for malignancy were scheduled for laparoscopy and patients with a high risk for malignancy were scheduled for laparotomy. However, patients classified as low risk by the ultrasound scoring system, but with a tumor size >or= 10 cm or clinical suspicion of pelvic adhesions, were instead considered to be at intermediate risk and were scheduled for laparotomy. Some patients classified as high risk were scheduled for an operative laparoscopy by an expert in gynecological oncology. RESULTS: One hundred and thirty-four (65.7%) masses were considered to be low risk and were treated by a laparoscopically guided procedure. All these tumors were benign. Forty-seven (23%) masses were classified as high risk, of which 39 tumors were malignant and eight benign. Twenty-three (11.3%) tumors were considered to be intermediate risk and were scheduled for primary laparotomy. In this group, 21 (91.3%) tumors proved to be benign and two (8.7%) were malignant. CONCLUSIONS: Ultrasound-based triage of asymptomatic women diagnosed with a persistent adnexal mass is effective for selecting the surgical approach.

[New horizons in breast surgery. Radioguided surgery and selective sentinel node biopsy]. / Nuevos horizontes en cirugía mamaria. Cirugía radioguiada y biopsia selectiva de ganglio centinela.

Although needle-wire localization is the most commonly used localization technique for nonpalpable breast lesion biopsy, the technique of radioguided occult lesion localization (ROLL), is becoming increasingly used for open-surgery diagnosis in such cases. Sentinel lymph node biopsy(SLNB) is based on the hypothesis that lymphatic drainage from a tumor reaches the sentinel node(SLN) first and that it can be identified accurately and removed. If SLN exactly reflects the lymph-node status, a negative SLN for metastasis might allow complete axillary lymph node dissection (ALDN) to be avoided.

[Breast cancer during pregnancy]. / Cáncer de mama durante el embarazo.

As women in western countries delay childbearing, it has been hypothesized that the incidence of breast cancer diagnosed during pregnancy will increase. Breast carcinoma during pregnancy(BCP) put the health of the mother in conflict with that of the fetus. The aim is to give optimal treatment to the mother to maximise the chances of survival, whilst minimising the risk of harm of the fetus. Few breast surgeons or oncologist develop expertise in this area owing the rarity of the association. We report the epidemiology, pathology, clinical picture, therapeutic management and fetal outcome of pregnant women with breast cancer treated in our institution.

[New developments in the surgical treatment of breast cancer]. / Novedades en el tratamiento quirúrgico del cáncer de mama.

Adecuate surgical treatment is mandatory in order to achieve cure in patients with breast cancer. Breast surgeons have to choice the best surgical technique over the breast and over the axillary nodes. Two new surgical aproaches have been implemented in the last decade: oncoplastic conservative surgery and sentinel lymph node biopsy. Oncoplastic surgery provides oncologic safety results and good cosmetic outcome. In this paper the technical steps and indications of different oncoplastic techniques in conservative breast surgery are review. Concerning to axillary surgery sentinel lymph node biopsy is the gold standard. However there are several controversial points in sentinel node biopsy referring to indications, identification and histological findings.

Nuevos horizontes en cirugía mamaria. Cirugía radioguiada y biopsia selectiva de ganglio centinela / No disponible

La frecuencia de lesiones mamarias ha aumentado debido a los programasde screening poblacional con técnicas como la mamografía. Tradicionalmente,la localización de esas lesiones se ha realizado mediantela colocación de guías metálicas. En la actualidad, la cirugía radioguiadasupone un avance en el tratamiento de dichas lesiones favoreciendoun mejor acceso a la lesión, disminuyendo la cantidad de tejido sanoextirpado y en defi nitiva, logrando un resultado cosmético óptimo.La biopsia de ganglio centinela se encuadra dentro de las técnicas decirugía radioguiada con exéresis del primer ganglio linfático que recibeel drenaje linfático de la glándula mamaria. El análisis intraoperatoriode dicho ganglio permite conocer la presencia o no de diseminaciónlinfática y evita realizar linfadenectomías innecesarias(AU)

Although needle-wire localization is the most commonly used localizationtechnique for nonpalpable breast lesion biopsy, the technique ofradioguided occult lesion localization(ROLL), is becoming increasinglyused for open-surgery diagnosis in such cases.Sentinel lymph node biopsy(SLNB) is based on the hypothesis thatlymphatic drainage from a tumor reaches the sentinel node(SLN) fi rstand that it can be identifi ed accurately and removed. If SLN exactly reflects the lymph-node status, a negative SLN for metastasis might allowcomplete axillary lymph node dissection (ALDN) to be avoided(AU)