Carcinoma mamario infiltrante tras mastectomía subcutánea / Infiltrating breast cancer alter subcutaneous mastectomy

Aunque la mastectomía subcutánea es una técnica quirúrgica que pretende eliminar todo el tejido mamario macroscópico, conservando el complejo areola-pezón, suele quedar tejido glandular residual en la zona retroareolar, cola de mama y colgajos cutáneos. Por consiguiente, existe la posibilidad de desarrollar carcinoma mamario en este tejido residual. Describimos un caso de carcinoma mamario infiltrante en una paciente en la que previamente se le había realizado una mastectomía subcutánea por presentar un carcinoma intraductal extenso tipo comedo en el seno de un fibroadenoma, que sobrepasaba la cápsula de éste

Although subcutaneous mastectomy aims to remove the entire macroscopic breast gland while conserving the nipple-areola complex, some residual glandular tissue usually remains in the nipple, subareolar region, axillary tail and skin flaps. Consequently, there is a risk of developing breast cancer in the residual tissue. We describe the case of a patient with infiltrating breast cancer who had previously undergone subcutaneous mastectomy for an extensive comedo-type intraductal carcinoma within a fibroadenoma that spread through the fibroadenoma capsule

Influence of the time interval between embryo catheter loading and discharging on the success of IVF.

BACKGROUND: To ascertain the influence of the duration of the 'interval loading-discharging embryos' (ILDE) on the results of embryo transfer. METHODS: The population under study consisted of 450 consecutive fresh embryo transfers. ILDE was measured in all transfers. Pregnancy and implantation rates were analyzed. RESULTS: Conceptional cycles had a lower (mean +/- SD) ILDE than non conceptional cycles (53.5 +/- 43.6 s vs 63.7 +/- 49.3). When only easy transfers--defined as those not requiring cervical tenaculum--were considered, similar differences were observed. The following pregnancy rates were obtained according ILDE duration: 38.9% (ILDE < 30 s), 33.2% (ILDE 31-60), 31.6% (ILDE 61-120) and 19.1% (ILDE > 120) (P < 0.05). When only easy transfers were considered, similar results were obtained: 40.0%, 33.3%, 32.0% and 19.4%, respectively. Similar results were observed regarding implantation rates regarding the whole population (21.2%, 15.4%, 15.9% and 9.4%, respectively; P < 0.01) as well as when only easy transfers were considered. CONCLUSIONS: ILDE duration is a prognostic factor of pregnancy rate and of implantation rate in IVF. The longer the ILDE duration, the lower the pregnancy and implantation rates. The decrease in pregnancy and implantation rates is gradual until an ILDE of 120 s, and decreases sharply afterwards. It is recommended to speed up the embryo transfer process, wherever possible. ILDE > 120 s carries a poor prognosis and should, when possible, be avoided.

Ovarian stimulation in intrauterine insemination with donor sperm: a randomized study comparing clomiphene citrate in fixed protocol versus highly purified urinary FSH.

BACKGROUND: The study was conducted to compare the results of intrauterine donor insemination (DI) under ovarian stimulation with either clomiphene citrate (CC), in a fixed protocol, or FSH, with ovarian monitoring. METHODS: Forty-nine patients were randomized using a computer-generated list to receive highly purified urinary FSH (starting dose of 150 IU) and were subjected to periodic vaginal ultrasound and estradiol determinations. HCG was given when > or =2 follicles (> or =17 mm) were identified and estradiol reached >400 pg/ml. Intrauterine insemination (IUI) was performed 36 h later. The other 51 received CC on a fixed protocol (100 mg/day from the day 5-10 of the ovarian cycle) with HCG being administered on the day 12, and IUI performed 36 h later. Up to six IUI cycles were performed on all patients if pregnancy was not reached before. Women failing to conceive in the CC group underwent IUI with FSH. The main outcome measures were intrauterine gestational sac observed by transvaginal ultrasound, per cycle and per woman pregnancy rate (PR) and multiple PR. RESULTS: The per cycle PR was significantly higher in the FSH group, 14.4% (30/209) versus 6.1% (16/261), as well as the per woman PR, 61.2% (30/49) versus 31.4% (16/51). 12.5% (2/16) of pregnancies obtained in the CC group were multiple, compared with 20% (6/30) in the FSH group. There were no triplets or higher order pregnancies in CC versus two in FSH (6.7% of pregnancies). Patients failing to conceive with CC, who later underwent intrauterine DI with FSH, had similar results to the primary FSH group: 54.3% PR per patient (19/35) and 16.0% per cycle (19/118), with a multiple PR of 31.6% (6/19). The PR for women starting with CC cycles and, if pregnancy was not obtained, continuing with six FSH cycles, was 69.2%. CONCLUSIONS: The PR obtained with CC stimulation was approximately half that obtained with FSH. There was a trend to lower multiple PR with CC. It is recommended that each case should be considered on an individual basis and the treatment options discussed with patients. In our opinion, CC could be a reasonable approach for young women with good prognosis, whereas in the remaining cases FSH would be the preferable method.

Ultrasound-guided embryo transfer improves pregnancy rates and increases the frequency of easy transfers.

BACKGROUND: Recent reports have suggested that ultrasound (US) guidance during embryo transfer might improve pregnancy rates. METHODS: A prospective randomized (computer-generated random table) trial was performed to compare embryo transfer under abdominal US guidance (n = 255 women) with clinical touch embryo transfer (n = 260). RESULTS: The clinical pregnancy rate was 26.3% (67/255) in the US-guided transfer group compared with 18.1% (47/260) in the clinical touch transfer group (P < 0.05). The implantation rate was 11.1% (100/903) in the US group compared with 7.5% (66/884) in the clinical touch group (P < 0.05). US-guided transfer was associated with a decrease in the difficulty of the transfers: 97% of transfers were easy in the US-guided group compared with 81% in the clinical touch group (P < 0.05). CONCLUSIONS: US-guided embryo transfer increased pregnancy and implantation rates in IVF cycles, as well as the frequency of easy transfers. It is suggested that the decrease in cervical and uterine trauma can play a role in the increase in pregnancy rates associated with US-guided transfer. It is recommended that embryo transfer should be performed under US guidance.

Cystosarcoma phyllodes maligno metastásico en muslo / Malignant metastasis of a phyllodes tumour in the thigh

Describimos las características clínicas de un tumor phyllodes maligno en una mujer de 41 años de edad que metastatizó en los tejidos blandos del muslo. Relacionamos estos hallazgos con los criterios histopatológicos asociados con el comportamiento clínico y metastásico de este tumor. El sobrecrecimiento estromal es el criterio histológico más importante para predecir el comportamiento metastásico del tumor phyllodes maligno (AU)

Evolución de los resultados del tratamiento del cáncer de endometrio en España entre 1980 y 1999. análisis de las casuísticas nacionales de la sociedad española de ginecología y obstetricia / Evolution of the results of treatment of endometrial cancer in Spain between 1980 and 1999. Analysis of the national casuistic of the Spanish Society of Obstetrics and Gynecology

La Sección de Ginecología Oncológica de la Sociedad Española de Obstetricia y Ginecología (SEGO) ha analizado en los últimos años las casuísticas conjuntas de numerosos hospitales del país, sobre adenocarcinoma de endometrio, por medio de dos encuestas hechas en 1991 para los casos diagnosticados y tratados entre 1980 y 1985, y en 1999 para los casos de 1993. En los aspectos fundamentales los resultados parecen ser notoriamente superiores en la encuesta más reciente, lo que debería significar que se han producido cambios importantes en el diagnóstico y en el tratamiento de estos procesos. Sin embargo, el análisis comparado de ambas encuestas, en cuya realización existen algunas deficiencias, indica que los cambios pueden haber sido menos pronunciados de lo esperado. Tanto la supervivencia global a 5 años (el 59,1 frente al 71,4 por ciento) como la supervivencia libre de enfermedad (el 55,6 frente al 63,1 por ciento) fueron estadísticamente superiores en la casuística más moderna (p = 0,0000). Los casos de la primera casuística fueron más avanzados que los de la segunda y en ellos hubo más casos diagnosticados como adenocarcinomas exclusivamente y con grado de diferenciación histológico significativamente peor. Los casos de 1993 fueron tratados primariamente con cirugía en el 88,9 por ciento de las ocasiones frente a solamente el 76,4 por ciento de los de la casuística más antigua (p = 0,0000). Solamente el 28,9 por ciento de los casos fue tratado en hospitales que atendían 25 casos o más en la primera casuística, mientras que este porcentaje ascendió al 50,5 por ciento en la casuística de 1993. En el primer período estudiado hubo más pacientes perdidas para el seguimiento que en el segundo (el 24,2 frente al 7,0 por ciento; p = 0,0000). La clasificación quirúrgica de la FIGO (1988) no parecía estar implantada todavía en 1993 pues solamente se realizó en el 27,2 por ciento de las pacientes. Estos hechos, junto con la apreciación de que las pacientes son diagnosticadas a edades tardías (61,0 ñ 9,7 años en la primera casuística y 64,0 ñ 10,5 años en la segunda), hacen considerar que la atención sobre el cáncer de endometrio en España es todavía mejorable (AU)

Women who are not exposed to spermatozoa and infertile women have similar rates of stage I endometriosis.

OBJECTIVE: To compare the prevalence of endometriosis and its different stages in infertile women and women not exposed to spermatozoa. DESIGN: Prospective study. SETTING: Artificial insemination donor program at a university hospital. PATIENT(S): One hundred fifty women unable to conceive because they had not been exposed to spermatozoa (134 with azoospermic partner, 10 with an HIV-positive partner, and 6 without a male partner). Controls were 750 women in infertile couples in which the male partner had normal sperm. INTERVENTION(S): Laparoscopy was systematically performed in a blinded manner in both groups as part of the infertility work-up. MAIN OUTCOME MEASURE(S): Diagnosis of endometriosis. RESULT(S): In unexposed women and controls, the prevalence of endometriosis was similar (32% and 34.5%). Rates of stage I disease were also similar in both groups (26% and 19.3%). There was a significant trend toward higher stages of endometriosis in infertile women (stage II disease, 3.3% vs. 5.7%; stage III disease, 1.3% vs. 3.1%; stage IV disease, 1.3% vs. 6.4%). Endometriosis was not associated with the few demographic characteristics that differed between groups. CONCLUSION(S): From an epidemiologic point of view, stage I endometriosis is not more common in infertile women than in unselected women. However, stage II to IV endometriosis was more frequent in infertile women. Whereas a relation between stage I endometriosis and infertility seems unlikely, the relation between stages II to IV endometriosis and infertility seems possible.

Carcinoma primario de apéndice diagnosticado como cáncer de ovario avanzado / Primary carcinoma of the appendix diagnosed as advanced ovarian cancer

Se presenta un caso de cistoadenocarcinoma mucinoso del apéndice, diagnosticado preoperatoriamente como un cáncer de ovario avanzado. Se discute su presentación clínica, variedades histopatológicas y su tratamiento (AU)

Recombinant human FSH versus highly purified urinary FSH: a randomized study in intrauterine insemination with husbands' spermatozoa.

A randomized trial was carried out comparing recombinant FSH (rFSH) and highly purified urinary FSH (uFSH) in intrauterine insemination (IUI) with husbands' spermatozoa. A total of 45 women received rFSH (139 cycles), while 46 women received uFSH (155 cycles). The starting dose was 150 IU/day s.c., beginning on the second day, and on days 6-7 the dose was adjusted according to ovarian response, assessed by vaginal ultrasound and plasma oestradiol concentration. The pregnancy rate according to the intention to treat was 57.8% in rFSH versus 52.2% in uFSH, the corrected pregnancy rates 56.8% and 52.2%, and the cumulative pregnancy rates 69.6% and 61.0%, but the differences were not statistically significant. The per cycle pregnancy rate was 18.12% in rFSH and 15.48% in u-FSH, also not statistically significant. In the rFSH group, the consumption of FSH ampoules per cycle was significantly lower (19.20 +/- 7.02 versus 23. 80 +/- 10.78; P < 0.0001). The ratio of oestradiol/FSH ampoules was significantly higher in rFSH (56.45 +/- 31.26 versus 46.41 +/- 29. 25; P < 0.001). These data indicate that, in IUI cycles, rFSH has a higher potency than uFSH.

A prospective, randomized, double-blind clinical trial to study the efficacy and efficiency of a fixed dose of recombinant follicle stimulating hormone (Puregon) in women undergoing ovarian stimulation.

A prospective, randomized, double-blind, multicentre (n = 5) study was conducted to compare the influence of either a 100 or 200 IU daily fixed-dose regimen of recombinant follicle stimulating hormone (FSH) on the number of oocytes retrieved and the total dose used in down-regulated women undergoing ovarian stimulation. Fertilization was done by intracytoplasmic sperm injection or conventional in-vitro fertilization. A total of 199 women were treated with FSH, 101 subjects with 100 IU and 98 subjects with 200 IU. In subjects of the 200 IU treatment group, significantly more oocytes were retrieved compared to the 100 IU group (10.6 versus 6.2 oocytes, P < 0.001). The total dose needed to develop at least three follicles with a diameter of > or = 17 mm was significantly lower in the 100 IU treatment group (1114 IU versus 1931 IU, P < 0.001). In the low-dose group, significantly lower serum concentrations of oestradiol, progesterone and FSH were observed at the day of human chorionic gonadotrophin administration. Although more cycle cancellations due to low response were seen in the 100 IU group (n = 24 versus n = 3), the clinical pregnancy rate per started cycle was similar (24.7% in the 100 IU group versus 23.3% in the 200 IU group). In the high-dose group, more side-effects, in particular more cases of ovarian hyperstimulation syndrome, were noted. It is concluded that compared to 200 IU, the use of a 100 IU fixed dose is less efficacious in terms of the number of oocytes retrieved, but more efficient as indicated by a lower total dose.

Fatty acid composition of fertilization-failed human oocytes.

The aim of the study was to assess the fatty acid composition of human fertilization-failed oocytes. A total of 150 unfertilized oocytes from 43 women undergoing in-vitro fertilization (IVF) were analysed using capillary gas chromatography. The majority of fatty acids were saturated (79.22%), of which stearic (38.65%) and palmitic (32.66%) acids were the most abundant. Of the monounsaturated fatty acids (14.27%) oleic acid was the most abundant (9.77%). Polyunsaturated fatty acids comprised 6.50% of fatty acids, the n-6:n-3 ratio being 7.73. The ratio of eicosapentaenoic acid:docosahexaenoic acid was approximately 5. It is concluded that the most common fatty acids in human unfertilized oocytes are either saturated or monounsaturated fatty acids, whose main function is to provide an energy source. A number of differences in fatty acid composition were observed, in comparison with other biological samples. In particular, stearic and eicosapentaenoic acids were more prominent, and oleic and linoleic acids were less prominent; this may reflect some specific peculiarity of oocyte metabolism.

Agreement between hysterosalpingography and laparoscopic chromopertubation in assessment of tubal patency.

BACKGROUND: To assess the agreement between tubal patency assessed by laparoscopy with chromopertubation and by hysterosalpingography using contrast media. SETTING: University Medical School. PATIENTS: 314 consecutive women subjected to laparoscopy and hysterosalpingography for an infertility study. DESIGN: Prospective study. METHODS: Chromopertubation using Methylen blue dye, performed on days 20-24. Hysterosalpingography performed on days 7-10 with water soluble contrast. MAIN OUTCOME MEASURE: Kappa coefficient calculation. RESULTS: Kappa coefficient ranged from 0.40 to 0.36, depending on the categories analyzed, corresponding to a fair agreement. CONCLUSION: The diagnosis of tubal factor requires that both tubal patency tests (Hysterosalpingography and laparoscopy) show an abnormal patency. When one of the aforementioned tests is normal, performing the second one has little clinical advantage. However, it is suggested that when there is a discordant patency the pregnancy rates could be somewhat reduced.

Total immunoreactive alpha-inhibin in human seminal plasma, sperm quality, and in vitro fertilization rates.

OBJECTIVE: To assess the relationship between the concentrations of total immunoreactive alpha-inhibin in human seminal plasma, sperm quality, and in vitro fertilization (IVF) rates. SETTING: Medical school hospital. DESIGN: Prospective study. PATIENTS: 72 consecutive couples undergoing IVF with husband's sperm in which at least 4 oocytes were obtained. MAIN OUTCOME MEASURES: Alpha-inhibin determination by means of enzyme-linked immunosorbent assay, sperm analysis for density and motility, IVF rates. RESULTS: Total immunoreactive alpha-inhibin levels were not correlated with IVF rates. Nor were there any differences in fertilization rates in the different groups. Lower inhibin levels were found in oligozoospermic cases. Lower sperm counts were found in cases with inhibin values below the median value, and also with respect to various other cutoffs. No correlation was found between inhibin levels and any of the sperm variables measured. CONCLUSION: Total immunoreactive alpha-inhibin is not a prognostic factor in IVF cycles. However, an association was found between inhibin and sperm concentration, suggesting that alpha-inhibin in the human seminal fluid could be a marker for some aspects of spermatogenesis.

Endometriosis and spontaneous abortion rate: a cohort study in infertile women.

OBJECTIVE: To ascertain if there is an association between endometriosis and spontaneous abortion. DESIGN: Prospective cohort study. SETTING: Medical School Hospital. POPULATION: 174 infertile women laparoscopically diagnosed with endometriosis and 174 infertile women in which endometriosis was ruled out by laparoscopy, in the same period of time. MAIN OUTCOME MEASURE: Spontaneous abortion. Non-progressive gestational sac and/or histological study. RESULTS: Per woman abortion rate was 7.47% (13/174) in the endometriosis group, similar to 5.74% (10/174) in the infertile women without endometriosis (RR=1.32: CI=0.53-3.36). Nor were there any differences in the per pregnancy abortion rate: 20.96% (13/62) in endometriosis vs. 16.94% (10/59) in non-endometriosis (RR=1.3; CI=0.47-3.57). The abortion rate was similar in the different AFS stages: 22.86% (8/35) in stage I, 16.67% (3/18) in II, 25% (1/4) in III and 20% (1/5) in IV. In stage I no differences were observed in patients who were managed expectantly or with medical treatment. CONCLUSION: Endometriosis is not associated with an increased abortion rate. The severity of disease expressed by AFS staging is not associated with an increase in the abortion rate. In stage I the treatment of endometriosis did not decrease abortion rates.

Correlation of MDR1 expression and oncogenic activation in human epithelial ovarian carcinoma.

The expression of the MDR1 gene has been shown to correlate with tumor aggressiveness and oncogenic activation both in experimental tumor models and in human clinical specimens In order to verify whether this association also takes place in ovarian carcinoma, we studied tumor samples from 39 patients by means of immunohistochemistry for the overexpression of P-glycoprotein (MDR1), nm23, c-erb-B2 and p53. MDR1 (p = 0.023), nm 23 (p = 0.037) and c-erb-B2 (p = 0.015) were expressed significantly more in specimens from patients with advanced stage of disease. There were no differences in p53 expression between both groups of patients. Furthermore, we found a significant coexpression of MDR1 and nm23 (p = 0.028), and of MDR1 and c-erb-B2 (p = 0.0077). There was no association between the expression of the MDR1 gene and p53. These results parallel those previously reported by us for mammary carcinoma, and seem to indicate that expression of the multidrug resistance gene (MDR1) is inherent to the development of the malignant phenotype in several human tumors.

Treatment of the male with follicle-stimulating hormone in intrauterine insemination with husband's spermatozoa: a randomized study.

We have examined the potential of follicle-stimulating hormone (FSH) therapy for the male to improve pregnancy rates in intrauterine insemination (IUI) with husband's spermatozoa. A prospective randomized trial was performed in 148 couples undergoing IUI because of male subfertility. In the treatment group, 150 IU FSH were administered to the husbands, either i.m. or s.c., three times a week, starting 3 months before the beginning of IUI cycles and maintained until the fifth IUI cycle. In the control group no treatment was given. FSH therapy did not change semen parameters. The pregnancy rate per cycle was 13.47% in the FSH group versus 10.07% in the non-FSH group; the pregnancy rate per woman was 44.38% in the FSH group versus 37.18% in the non-FSH group. Although the pregnancy rate increase was > 30% per cycle and > 20% per woman, statistical significance was not achieved. The cumulative pregnancy rate was 59.20% in the FSH group versus 42.91% in the non-FSH group. The pregnancy rate outside the IUI cycle was 14.70% (10/68) in the FSH group versus 2.5% (2/80) in the non-FSH group, the difference being statistically significant. In conclusion, a non-significant trend towards higher pregnancy rates in IUI was observed in the FSH group.

Spontaneous pregnancy in couples waiting for artificial insemination donor because of severe male infertility.

OBJECTIVE: To assess the spontaneous fertility in couples with severe seminal conditions while waiting for artificial insemination donor. STUDY DESIGN: Prospective follow-up during a period of 24 months. SETTING: University Medical School. PARTICIPANTS: There were 285 couples in which the male had a very severe seminal pathology: 166 azoospermia, 86 oligozoospermia and 33 severe asthenozoospermia. OUTCOME MEASURES: Pregnancy rates after being included on waiting list. RESULTS: The spontaneous pregnancy rate was 3.2% (9/285), per month spontaneous pregnancy rate being 0.13%. Spontaneous pregnancy rate was 0% in azoospermia (0/166). versus 7.6% (9/119) in non-azoospermia cases. Spontaneous pregnancy rate was 8.5% (4/47) in the group with less than 0.1 million motile sperm/cc, 6.5% (3/46) in the group between 0.1 and 1 million/cc and 7.7% (2/26) in the group with 1-2 million/cc. CONCLUSION: In a 2-year follow-up, pregnancy rate among non-azoospermic couples before undergoing artificial insemination was 7.6%. Extramatrimonial pregnancy (based on anamnesis and sperm analysis) seemed to be uncommon. Even in cases with less than 0.1 million of motile sperm/cc there was not a negligible spontaneous pregnancy rate.

Infertile women with and without endometriosis: a case control study of luteal phase and other infertility conditions.

OBJECTIVE: To assess the relationship in infertile women between endometriosis and luteal phase defects and other infertility conditions. SETTING: University Medical School. DESIGN: Case-control study. PATIENTS: One hundred and seventy-four infertile women with endometriosis and 174 infertile women without endometriosis, all of them studied by laparoscopy. The inclusion criteria were failure of six cycles of ovulation stimulation or abnormal preliminary study (abnormal pelvic physical, hysterosalpingographic or ultrasound findings). RESULTS: The frequency of out-of-phase biopsies (16.1% vs 16.7%) as well as other endometrial abnormalities were similar in endometriosis associated infertility (EAI) and in non-endometriosis infertility (NEI). Mean progesterone and prolactin levels, as well as the proportion of abnormal progesterone levels (37.4% vs 44.3%) and of hyperprolactinemia (12.9% vs 13.2%) were similar in EAI and NEI. The frequency of uterine myomas was similar in both groups. Sperm characteristics were not better in EAI than in NEI. Higher endometriosis stages were not associated with a higher frequency of the aforementioned conditions. CONCLUSION: Luteal phase defects, sperm abnormalities and myomas are no more common in EAI than in NEI or in advanced stages of endometriosis.