Diagnosis and treatment of advanced HER2-positive breast cancer in young pregnant female: A case report

RATIONALE

The incidence of pregnancy-associated breast cancer (PABC) is increasing nowadays, and its diagnosis and treatment remain complicated due to the consideration of the fetus. The available data on PABC are primarily derived from case reports since there are ethical restrictions on conducting randomized clinical trials. In the present work, we reported a case of the human epidermal growth factor receptor 2 (HER2)-positive PABC and described the diagnosis and treatment for such type of breast cancer.

PATIENT CONCERNS

A 27-year-old patient was admitted to our hospital with the complaints of right breast mass for 3 days, and she was a first-time pregnant woman with a single live intrauterine fetus at 26 + 3 weeks of gestation. Physical examination of the right breast revealed a palpable and hard mass with obscure boundaries (5.0 cm × 4.0 cm) in the upper outer quadrant. Significant axillary lymph nodes (2.0 cm) were also present.

DIAGNOSIS

PABC.

INTERVENTION

To protect the fetus, breast ultrasonography was used to test her breast mass, a core needle biopsy was adopted to confirm the diagnosis, and abdominal ultrasound and chest X-ray were used to evaluate the metastasis. The patient was scheduled for neoadjuvant therapy using bi-weekly pirarubicin in combination with cyclophosphamide (AC) without anti-HER2 therapy for consideration of the fetus's safety. After 4 cycles of AC, the patient delivered a healthy male infant. After the delivery, all the treatments were carried out according to the standard recommendation for HER2 + breast cancer as non-pregnant patients.

OUTCOMES

After the surgery, the disease-free survival for the patient was 12 months until brain metastasis was diagnosed. She was still undergoing second-line anti-HER2 therapy and currently in a stable situation. Besides, the child was also healthy so far.

LESSONS

The methods for the diagnosis and treatment of PABC that result in teratogenesis should be avoided to protect the fetus. Mammogram and chest X-ray were safe approaches for the fetus. Moreover, chemotherapy-based on pirarubicin in combination with cyclophosphamide had no risk to the fetus.

Pregnancy-induced Cushing's syndrome with an adrenocortical adenoma overexpressing LH/hCG receptors: a case report

BACKGROUND

Pregnancy-induced Cushing's syndrome (CS) with an adrenocortical adenoma overexpressing luteinizing hormone (LH)/human choriogonadotropin (hCG) receptors (LHCGR) has been rarely reported in the literatures. This peculiar condition challenges the canonical diagnosis and management of CS.

CASE PRESENTATION

A 27-year-old woman (G2P0A1) presented at 20 weeks gestational age (GA) with overt Cushingoid clinical features. Adrenocorticotropic hormone (ACTH)-independent CS was diagnosed based on undetectable ACTH and unsuppressed cortisol levels by dexamethasone. Magnetic resonance imaging (MRI) scanning without contrast revealed a left adrenal nodule while pituitary MRI scanning was normal. A conservative treatment strategy of controlling Cushingoid comorbidities was conducted. At 36 weeks GA, a caesarean operation was performed and a live female infant was delivered. At 8 weeks after parturition, our patient achieved normalization of blood pressure, blood glucose, serum potassium, and urinary cortisol level spontaneously. During non-pregnancy period, stimulation testing with exogenous hCG significantly evoked a cortisol increase. The woman underwent resection of the adrenal tumor at 6 months after parturition. Immunohistochemistry (IHC) showed the tumor tissue that stained positive for luteinizing hormone (LH)/human choriogonadotropin (hCG) receptor (LHCGR), whereas negative for both melanocortin 2 receptor (MC2R) and G protein-coupled receptor-1 (GPER-1).

CONCLUSIONS

Stimulation test with exogenous hCG after parturition is necessary for the diagnosis of pregnancy-induced CS. LHCGR plays an essential role in the pathogenesis of this rare condition.

A Narrative Review of Placental Contribution to Adverse Pregnancy Outcomes in Women With Polycystic Ovary Syndrome

CONTEXT

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy of reproductive-aged women. In pregnancy, women with PCOS experience increased risk of miscarriage, gestational diabetes, preeclampsia, and extremes of fetal birth weight, and their offspring are predisposed to reproductive and cardiometabolic dysfunction in adulthood. Pregnancy complications, adverse fetal outcomes, and developmental programming of long-term health risks are known to have placental origins. These findings highlight the plausibility of placental compromise in pregnancies of women with PCOS.

EVIDENCE SYNTHESIS

A comprehensive PubMed search was performed using terms "polycystic ovary syndrome," "placenta," "developmental programming," "hyperandrogenism," "androgen excess," "insulin resistance," "hyperinsulinemia," "pregnancy," and "pregnancy complications" in both human and animal experimental models.

CONCLUSIONS

There is limited human placental research specific to pregnancy of women with PCOS. Gestational androgen excess and insulin resistance are two clinical hallmarks of PCOS that may contribute to placental dysfunction and underlie the higher rates of maternal-fetal complications observed in pregnancies of women with PCOS. Additional research is needed to prevent adverse maternal and developmental outcomes in women with PCOS and their offspring.

Preliminary results of identification and quantification of paclitaxel and its metabolites in human meconium from newborns with gestational chemotherapeutic exposure

Objective

Cancer diagnosis during pregnancy occurs in 1 out of 1000 pregnancies with common malignancies including breast and hematological cancers. Fetal exposure to currently utilized agents is poorly described. We directly assessed fetal exposure by screening meconium from 23 newborns whose mothers had undergone treatment for cancer during pregnancy.

Study design

Meconium was collected from newborns whose mothers were diagnosed with cancer during pregnancy and underwent chemotherapy in the second or third trimester as part of the Cancer and Pregnancy Registry. We conducted screening of 23 meconium samples for chemotherapeutics and known metabolites of chemotherapeutics by liquid chromatography-high resolution mass spectrometry (LC-HRMS). Putative identification of paclitaxel and/or its metabolites was made in 8 screened samples. In positively screened samples, we quantified paclitaxel, 3’-p-hydroxypaclitaxel, and 6α-hydroxypaclitaxel by stable isotope dilution-LC-HRMS.

Results

Mean (standard deviation) levels of paclitaxel in positively screened samples were 399.9 (248.6) pg/mg in meconium samples from newborn born to mothers that underwent chemotherapy during pregnancy. 3’-p-hydroxypaclitaxel and 6α-hydroxypaclitaxel mean levels were 105.2 (54.6) and 113.4 (48.9) pg/mg meconium, respectively.

Conclusion

Intact paclitaxel, 3’-p-hydroxypaclitaxel, and 6α-hydroxypaclitaxel were detected in meconium, providing unambiguous confirmation of human fetal exposure. Variability in meconium levels between individuals may indicate a potential for reducing fetal exposure based on timing, dosing, and individual characteristics. This preliminary study may provide an approach for examining the effects of cancer diagnosis during pregnancy on other outcomes by providing a measure of direct fetal exposure.

Chemotherapy in pregnancy: exploratory study of the effects of paclitaxel on the expression of placental drug transporters

Introduction The use of paclitaxel in pregnant cancer patients is feasible in terms of fetal safety, but little is known about the effects of paclitaxel on the placenta. Using three experimental models, we aimed to assess the effects of paclitaxel on the expression of placental drug transporters. Methods In the in vitro model (human primary trophoblast culture), trophoblasts were isolated from normal term placentas and subsequently exposed to paclitaxel. The transcriptional regulation of 84 genes encoding for drug transporters, and the protein expression of ABCB1/P-gp and ABCG2/BCRP were assessed. In the in vivo model, placental tissues isolated from pregnant cancer patients treated with paclitaxel were analyzed to assess the protein expression of ABCB1/P-gp and ABCG2/BCRP. The same parameters were assessed in extracts from human placental cotyledons perfused ex vivo with paclitaxel. Results In the in vitro model, the expression of twelve drug-transporters genes was found to be significantly down-regulated after exposure to paclitaxel, including ABCC10, SLC28A3, SLC29A2, and ATP7B (involved in the transport of taxanes, antimetabolites, and cisplatin, respectively). The protein expression of ABCB1/P-gp increased by 1.3-fold after paclitaxel administration. Finally, the protein expression of ABCB1/P-gp and ABCG2/BCRP was higher in cotyledons from mothers treated with multiple doses of paclitaxel during pregnancy than in cotyledons perfused with a single dose of paclitaxel. Discussion Paclitaxel modulates the expression of placental drug transporters involved in the disposition of various anticancer agents. Further studies will be needed to assess the impact of repeated or prolonged exposure to paclitaxel on the expression and function of placental drug transporters.

A comparative analysis of immune privilege in pregnancy and cancer in the context of checkpoint blockade immunotherapy

Despite their abilities to elicit immune responses, both syngeneic tumors and the half-mismatched placenta grow in the host, unlike a tissue allograft that is aggressively rejected. This is because of local and systemic factors that contribute to the immunologic privilege of tumors and the placenta. Checkpoint blockade immunotherapies subvert this privilege, with spectacularly beneficial outcomes in subsets of patients with certain types of cancer. A challenge for the community of scientists and clinicians is to replicate these successes in pregnant patients with cancer, without harm to the placenta. Here we compare and contrast the immunology of cancers and the placenta, and suggest that immunotherapy for pregnant patients with cancer may be a reasonable option, but that this should be explored systematically.

Breast Cancer and Pregnancy

The diagnosis of breast cancer during pregnancy is a rare event, but the young age of the patient together with the emotional impact for both the family and the doctors make therapeutic choices usually very difficult. Until recently, the occurrence of pregnancy associated breast cancer was thought to hold a grave prognosis and therapeutic abortion was very often advised in common practice. The hormonal environment with the increase in estrogens and progesterone was the main factor for the fear of tumor stimulation. The course of breast cancer, however, does not appear to be adversely affected by continuation of pregnancy. In the last years it was realized that potentially curative therapies can be administered even when pregnancy is continued. Of course in the medical literature there is no randomized clinical trial helping in taking decision in this setting; however, a significant experience already exists in some institutions and can guide management in these difficult cases.

The aim of our review is to give an answer to questions usually coming from various specialists who collaborate with the oncologists in treating these patients and furthermore to try and find some basic guidelines which can be used in the information of the patients regarding previous experience in this field.

The problem of a pregnancy after treatment for breast cancer is also analyzed, as this aspect is an emerging issue in clinical oncology. The decision should be evaluated for each single patient, taking into account the prognosis of the patient and her desire of pregnancy.

Long-term Safety of Pregnancy Following Breast Cancer According to Estrogen Receptor Status

Safety of pregnancy in women with history of estrogen receptor (ER)-positive breast cancer remains controversial. In this multicenter case-control study, 333 patients with pregnancy after breast cancer were matched (1:3) to 874 nonpregnant patients of similar characteristics, adjusting for guaranteed time bias. Survival estimates were calculated using the Kaplan-Meier analysis; groups were compared with the log-rank test. All reported P values were two-sided. At a median follow-up of 7.2 years after pregnancy, no difference in disease-free survival was observed between pregnant and nonpregnant patients with ER-positive (hazard ratio [HR] = 0.94, 95% confidence interval [CI] = 0.70 to 1.26, P = .68) or ER-negative (HR = 0.75, 95% CI = 0.53 to 1.06, P = .10) disease. No overall survival (OS) difference was observed in ER-positive patients (HR = 0.84, 95% CI = 0.60 to 1.18, P = .32); ER-negative patients in the pregnant cohort had better OS (HR = 0.57, 95% CI = 0.36 to 0.90, P = .01). Abortion, time to pregnancy, breastfeeding, and type of adjuvant therapy had no impact on patients' outcomes. This study provides reassuring evidence on the long-term safety of pregnancy in breast cancer survivors, including those with ER-positive disease.

Cystic lymphangioma of the lesser omentum in a pregnant woman: a case report and review of the literature

Lymphangiomas are rare benign tumors which are generally seen in pediatric population and the etiopathogenesis has not yet been understood. They occasionally occur in the head and neck or axillary region with only 5% of them being located in the abdominal or mediastinal cavity. These tumors may be asymptomatic or may cause acute abdominal symptoms due to the location and extention. In the English literature, only 4 cases of lymphangioma were reported to have occurred in the pregnancy period. Herein, we report a case of cystic lymphangioma of the lesser omentum detected incidentally on the ultrasonogram of a 21 year-old, 26-week pregnant woman. The patient was followed up uneventfully during pregnancy. Caesarean section was performed due to transverse presentation of the fetus, and the tumor was completely resected during the same session. The patient is recurrence-free after 1 year of postoperative follow-up.

Glycodelin expression in pregnant patients with cervical intraepithelial neoplasia: a case-control study

We aimed to evaluate glycodelin immunostaining in pregnant women with a first diagnosis of cervical intraephitelial neoplasia (CIN) and to correlate the expression of CIN with Ki-67 and glycodelin immunostaining. A retrospective case-control study was performed including 20 patients with natural pregnancy and with first time onset of CIN occurring not later than 16 gestational weeks. The control group included 20 non-pregnant patients matched for age, parity, smoking status and number of previous sexual partners. Exclusion criteria included previous cervical treatment, immunocompromised status and chronic hepatitis B and/or C. Staining for Glycodelin and for Ki-67 was expressed using a classification based on the distribution of positivity on a semi-quantitative three-point scale. An inverse relationship was observed between glycodelin immunostaining and CIN grade in pregnant patients (p = 0.01), with a significantly higher expression in CIN1 than in CIN2 and CIN3, but not in non-pregnant patients (p = 0.81). Positivity for Ki-67 was less intense in pregnant than in non-pregnant patients. A significant inverse relationship was observed between glycodelin immunostaining and Ki-67 expression (p = 0.02). We suggest that the higher expression of glycodelin in pregnancy is related to a lower proliferative activity in CIN, which is probably associated to hormonal status of pregnancy. Further clinical studies are needed to support these findings.

Endocrinology in pregnancy: management of the pregnant patient with a prolactinoma

A woman with a prolactinoma is usually infertile. Dopamine agonists usually restore ovulation and fertility and such treatment generally is preferred over transsphenoidal surgery because of higher efficacy and safety. Cabergoline is usually preferred over bromocriptine because of its better efficacy with fewer adverse effects. Either drug increases the rates of spontaneous abortions, preterm deliveries, multiple births, or congenital malformations over what may be expected. However, the number of pregnancies reporting such experience is about sevenfold greater for bromocriptine. Tumor growth causing significant symptoms and requiring intervention has been reported to occur in 2.4% of those with microadenomas, 21% in those with macroadenomas without prior surgery or irradiation, and 4.7% of those with macroadenomas with prior surgery or irradiation. Visual fields should be assessed periodically during gestation in women with macroadenomas. If significant tumor growth occurs, most patients respond well to reinstitution of the dopamine agonist. Delivery of the baby and placenta can also be considered if the pregnancy is sufficiently advanced. Transsphenoidal debulking of the tumor is rarely necessary.

Cancer during pregnancy: what is the role of maternal serum and placental biomarkers? A review and commentary

Cancer during pregnancy, referred to as gestational cancer (GC), is infrequent but can occur in 1.0% of pregnant women. Hepatocellular carcinoma (HCC) is often lethal and is the fifth most common cancer worldwide, while breast adenocarcinoma (breast cancer) is the most common cancer seen during pregnancy. Liver and breast carcinomas are two examples of cancer types that present challenges to the obstetrician due to late and/or delayed diagnosis during pregnancy. Delays in diagnosis limit choices available to physicians regarding surgery, radiation, and chemotherapy. In view of such clinical situations, a role for maternal serum and placental biomarker (MSPB) screening results contributing to cancer diagnosis should be recognized; overlooking such data in GC could result from a lack of knowledge and understanding of MSPB biology, chemistry, and physiology. In this report, obstetricians and perinatologists seeking a diagnosis are urged to take advantage of available results from MSPB screening programs obtained from first- and second-trimester patient data. Using liver and breast cancer as examples, the present review and commentary seeks to demonstrate that MSPB levels, profiles, patterns, and cellular responses could provide foundational data in planning invasive or noninvasive methods and procedures (biopsy, imaging, scans, surgery) to attain a diagnosis as soon as possible in pregnancy. Finally, MSPB epidemiological and cancer risk studies could aid in providing baseline information for decisions regarding GC diagnosis from knowledge of their proposed roles in reducing lifetime risk of malignancies such as breast cancer.

p16/Ki-67 dual-stained cytology testing may predict postpartum outcome in patients with abnormal papanicolaou cytology during pregnancy

OBJECTIVE

To evaluate the use of a new immunocytochemical dual-staining protocol, which allows for the detection of coexpression of the p16(INK4a) (p16) and Ki-67 biomarkers in prenatal care. It was hypothesized that dual-staining cytology may predict postpartum outcome in patients with abnormal cervical Papanicolaou (Pap) smears during pregnancy.

STUDY DESIGN

In this retrospective pilot study, 27 abnormal Pap smears collected from women during early pregnancy were destained and subsequently stained for p16/Ki-67. RESULTS were correlated with histologic outcome collected during postpartum follow-up.

RESULTS

Fourteen of 20 abnormal Pap smears during pregnancy showed a positive p16/Ki-67 dual-stained cytology result, whereas 6 specimens tested negative. Seven cases were excluded due to technical reasons. All 14 patients who were positive for p16/Ki-67 dual stain had cervical intraepithelial neoplasia (CIN) on postpartum histology. In contrast, 5 out of 6 patients negative for p16/Ki-67 dual-staining had a negative histology postpartum and during follow-up, and the remaining patient showed a CIN1 (p < 0.001).

CONCLUSION

p16/Ki-67 dual-stained cytology may provide a valuable novel approach to identify pregnant women with persistent or progressing CIN disease and may help improve the management of abnormal Pap cytology results during pregnancy.

Pregnancy stimulates tumor angiogenesis in breast carcinoma

The mechanisms responsible for the poor prognosis of pregnancy-associated breast cancer (PABC) remain not well-understood. We studied angiogenesis and lymphangiogenesis as they are known prognostic factors in breast cancer. We conducted a case control study of breast cancer comparing women with and without PABC matched for age and histological parameters. Surgical specimen sections were immunostained with anti-CD31 for angiogenesis and anti-D2-40 for lymphangiogenesis, then analyzed using vessel density, ratio of the vascular area and the Chalkley count. Seventeen patients with PABC and 22 controls were included. Angiogenesis was significantly increased in tumor tissues, and tended to be higher in healthy breast tissues from the PABC group compared to controls. In contrast, no difference between the two groups was found concerning lymphangiogenesis both in tumor and healthy breast tissues. Pregnancy enhances angiogenesis in breast cancer. This phenomenon appears to explain the poor prognosis of PABC.

Management of prolactinomas during pregnancy

Prolactinomas constitute approximately 40% of hormone-secreting pituitary tumors. In women the main clinical features are menstrual disorders and infertility. Successful treatment with dopamine agonists restores the normal function of the pituitary-gonadal axis, ovulation, and fertility. Adequate management of pregnant prolactinoma patients from the moment of conception is of particular importance for both the mother and the developing fetus. This review article presents current opinions on the course and management of pregnancies in patients with prolactin-secreting pituitary tumors. The introduction contains background information on clinical aspects of the condition, including prolactinoma treatment in women of reproductive age. Physiological changes in the pituitary during normal pregnancy are also described. The next part presents current knowledge on the effect of pregnancy on prolactinoma size, including especially the high risk of prolactinoma growth in patients with pituitary macroadenomas. Safety issues concerning the use of dopamine receptor agonists during pregnancy are also discussed, especially in terms of the risk of congenital defects in the fetus. Moreover, the article presents principles of prolactinoma management in pregnant patients, rare indications for surgical treatment during pregnancy, and the issues concerning pituitary tumor apoplexy in pregnant women, the last being a life-threatening condition. The final part of the article discusses the possible effects of pregnancy on hyperprolactinemia remission as well as on the issue of breastfeeding by mothers with prolactinoma.

Liver diseases in pregnancy: Diseases not unique to pregnancy

Pregnancy is a special clinical state with several normal physiological changes that influence body organs including the liver. Liver disease can cause significant morbidity and mortality in both pregnant women and their infants. Few challenges arise in reaching an accurate diagnosis in light of such physiological changes. Laboratory test results should be carefully interpreted and the knowledge of what normal changes to expect is prudent to avoid clinical misjudgment. Other challenges entail the methods of treatment and their safety for both the mother and the baby. This review summarizes liver diseases that are not unique to pregnancy. We focus on viral hepatitis and its mode of transmission, diagnosis, effect on the pregnancy, the mother, the infant, treatment, and breast-feeding. Autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, Wilson’s disease, Budd Chiari and portal vein thrombosis in pregnancy are also discussed. Pregnancy is rare in patients with cirrhosis because of the metabolic and hormonal changes associated with cirrhosis. Variceal bleeding can happen in up to 38% of cirrhotic pregnant women. Management of portal hypertension during pregnancy is discussed. Pregnancy increases the pathogenicity leading to an increase in the rate of gallstones. We discuss some of the interventions for gallstones in pregnancy if symptoms arise. Finally, we provide an overview of some of the options in managing hepatic adenomas and hepatocellular carcinoma during pregnancy.

Cushing's syndrome in pregnancy: a diagnostic conundrum

A 31 year old woman who was 16 weeks pregnant was admitted because of headache, blurred vision, excessive weight gain, and hirsutism. Laboratory tests showed low adrenocorticotropic hormone (ACTH) and elevated serum and urinary cortisol. Magnetic resonance imaging showed a left adrenal mass. Left adrenalectomy was done, and histopathology showed an adrenal adenoma. The patient had an uncomplicated delivery after 37 weeks of gestation. Cushing's syndrome is very rare in pregnancy. It may be difficult to diagnose because the clinical and laboratory signs of Cushing's syndrome may be similar to those of pregnancy.

[Pregnancy-Associated Breast Cancer: An analytical observational study]

BACKGROUND AND OBJECTIVE

Pregnancy-associated breast cancer is defined as breast cancer diagnosed during pregnancy and up to one year postpartum.

PATIENTS AND METHOD

A retrospective, analytical, observational study comparing 56 cases of breast cancer and pregnancy (PABC) diagnosed 1976-2008 with 73 patients with breast cancer not associated with pregnancy (non-PABC) was performed. Demographic data, prognostic factors, treatment and survival were reviewed and compared.

RESULTS

The prevalence of PABC in our center is 8.3/10,000. The highest frequency (62%) appeared during the postpartum period. The stages are higher in PABC, being 31.3% advanced (EIII and EIV) in PABC versus 13.3% in non-PABC (P < .05). Regarding prognostic factors, 27.3% in PABC had a tumoral grade 3 versus 15.8% of non-PABC. Among women with PABC, 33.3% had negative estrogen receptors, 48.7% negative progesterone receptors and 34.5% positive Her2Neu compared with 22.2, 24.1 and 31%, respectively of non-PABC patients. Finally, positive lymph nodes were found in 52.8% of PABC, versus 33.8% non-PABC (P < .05). Overall and disease-free survival rate at 5 years for PABC was 63.7 and 74.2%, respectively.

CONCLUSIONS

The poorer survival observed is possibly due to the presence of adverse prognostic features such as lymph node metastases, negative hormone receptors, tumoral grade iii, as well as a delay in diagnosis with a higher rate of advanced stages.

HIF-1α, VEGF and WT-1 are protagonists in bilateral primary angiosarcoma of breast: a case report and review of literature

Bilateral primary angiosarcoma of breast is an extremely rare disease. Only 4 cases had been described in the literature. Hypoxia inducible factor- 1 α (HIF-1α) is a transcription factor that binds to hypoxia response elements in the promoters of target genes. Vascular endothelial growth factor (VEGF) is an important signaling protein involved in angiogenesis. Wilms tumor -1 protein (WT-1) is a transcription factor that plays an important role in angiogenesis. We present a 29-year old female with bilateral primary angiosarcoma of breast. Five-μm sections were stained with CD31, FLI-1, HIF-1α, WT-1, VEGF, VEGF-R, D2-40, estrogen receptor, and progesterone receptor. The neoplastic cells show diffuse immunoreactivity to CD31, FLI-1, HIF- 1α, VEGF, VEGFR, and WT-1 protein. The neoplastic cells show no immunoreactivity to estrogen receptor, progesterone receptor and D2-40. In conclusion, HIF- 1α, WT-1 and VEGF are possible protagonists in the development of bilateral primary angiosarcoma of breast. The neoplastic process involves endothelial cell of blood vessels lineage rather than lymphatic lineage. Painless breast tumors in young women that are highly vascular at the time of biopsy should be considered as malignant until proven otherwise. Tissue biopsy is the gold standard in the diagnosis of primary angiosarcoma of breast.

Epigenetic mechanism underlying the development of polycystic ovary syndrome (PCOS)-like phenotypes in prenatally androgenized rhesus monkeys

The pathogenesis of polycystic ovary syndrome (PCOS) is poorly understood. PCOS-like phenotypes are produced by prenatal androgenization (PA) of female rhesus monkeys. We hypothesize that perturbation of the epigenome, through altered DNA methylation, is one of the mechanisms whereby PA reprograms monkeys to develop PCOS. Infant and adult visceral adipose tissues (VAT) harvested from 15 PA and 10 control monkeys were studied. Bisulfite treated samples were subjected to genome-wide CpG methylation analysis, designed to simultaneously measure methylation levels at 27,578 CpG sites. Analysis was carried out using Bayesian Classification with Singular Value Decomposition (BCSVD), testing all probes simultaneously in a single test. Stringent criteria were then applied to filter out invalid probes due to sequence dissimilarities between human probes and monkey DNA, and then mapped to the rhesus genome. This yielded differentially methylated loci between PA and control monkeys, 163 in infant VAT, and 325 in adult VAT (BCSVD P<0.05). Among these two sets of genes, we identified several significant pathways, including the antiproliferative role of TOB in T cell signaling and transforming growth factor-β (TGF-β) signaling. Our results suggest PA may modify DNA methylation patterns in both infant and adult VAT. This pilot study suggests that excess fetal androgen exposure in female nonhuman primates may predispose to PCOS via alteration of the epigenome, providing a novel avenue to understand PCOS in humans.

[Glassy cell carcinoma of cervix: a clinicopathologic analysis of 5 cases]

OBJECTIVE

To investigate the clinicopathological characteristics, histological diagnosis, immunohistochemistry and prognosis of cervical glassy cell carcinoma (GCC).

METHODS

The clinical characteristics, cytology, histology and immunohistochemistry were analyzed in 5 cases of GCC.

RESULTS

The average age of the five patients was 34.4 years (31 - 41 years). Abnormal vaginal bleeding and/or watery discharge were clinical presentations. One case was complicated with pregnancy and another one had a seven-year history of using contraceptives. All patients had an obvious mass in the cervix. Characteristic morphological features of GCC were present in 2 cases. Morphologically, the tumors consisted of clusters of tumor cells with distinct cell bounders, a large amount of eosinophilic granules in the cytoplasm imparting ground glass appearance, and thin nuclear membrane and prominent nucleoli. Nuclear enlargement and multinucleation were frequently noted. Mitosis and apoptosis were common. Numerous eosinophils and plasma cells were present in the stroma. Immunohistochemically, GCC expressed markers for both squamous cell carcinoma (p63 and CK34βE12) and adenocarcinoma (CAM5.2, MUC1, MUC2 and CEA). Ki-67 proliferation index was high (≥ 70%). All the five patients were treated with radical hysterectomy, followed by radiation and chemotherapy. The tumor-free survival time ranged from 25 days to 33 months.

CONCLUSIONS

GCC is a distinct variant of adenosquamous carcinoma of the cervix with high proliferation index and expression of markers of both squamous cell carcinoma and adenocarcinoma. The tumor has characteristic cytological and histological features.

Primary fallopian tube cancer in term pregnancy: a case report

PURPOSE

This work aimed to study the features of primary fallopian tube carcinoma during pregnancy and to improve the understanding of clinical gynecologists.

METHODS

The clinical features of a case of primary fallopian tube carcinoma during pregnancy were analyzed.

RESULTS

The final diagnosis was Stage IA fallopian tube cancer after cesarean delivery.

CONCLUSIONS

It is helpful to detect CA-125 level and employ B-mode ultrasound imaging. Patients should undergo routine celiac examinations before gynecological and obstetric procedures (including cesarean section and abdominal hysterotomy) are performed.

[Ovarian ginandroblastoma as a transcesarean incidental finding. A case report and literature review]

The gynandroblastoma is an extremely rare sexual cord stromal tumor, which contains both male and female elements, characterized by Sertoli or Leydig cells and granulose cells. We describe an ovarian gynandroblastoma in a 28 year-old female patient, found accidentally during a cesarean section operation. There is only one reported case in world literature occurring in a pregnant woman. The principal component we found was adult granulose cells, with a microfollicular pattern, and the presence of luteinized cells in some areas; besides we found the presence of well differentiated Sertoli cells elements, in addition to Leydig cells groups, in over 10% of the tumoral surface. Inmunohistochemical stainings were performed: citokeratin, which resulted positive in Sertoli cells and negative in granulose cells; and inhibin, which was positive in both components showing its mixed origin.

Pregnancy and estrogen receptor beta expression in a large congenital nevus

BACKGROUND

Large congenital nevi carry a slightly increased risk of melanoma. Pregnancy poses an additional challenge in the monitoring of these patients because little is known regarding the effects of increased estrogen levels on congenital nevi.

OBSERVATIONS

A young woman was observed to have clinical lightening of her garment nevus and satellite nevi during 2 sequential pregnancies. Postpartum, the patient experienced darkening and repigmentation in her large garment nevus, with continued lightening of nearby satellite lesions. In addition to photographic documentation of these changes, biopsy samples taken during pregnant and nonpregnant periods underwent immunohistochemical evaluation for estrogen receptor beta (ERbeta), the predominant estrogen receptor in nevi and melanomas. Biopsy samples collected during pregnancy showed a decrease in nuclear staining for ERbeta compared with samples collected after pregnancy. These changes in ERbeta expression were not associated with histologic atypia during pregnancy or after delivery.

CONCLUSIONS

Congenital nevi may be unique in their response to altered estrogen levels. Given the slightly increased risk of melanoma in giant congenital nevi and the dearth of information available regarding the effects of pregnancy on congenital nevi, this case illustrates the need for further study of these pigmented lesions.

Tumor Markers In Biological Fluids Associated With Pregnancy

Proteins that are expressed by both malignant and healthy fetal tissues are recognized as oncofetal. These antigens are associated with cell proliferation and differentiation and are produced in high concentrations in pregnancy and malignancy. Their biological role in malignancy is the suppression of the host's immune system, while in pregnancy they affect the maternal immune response, generating maternal tolerance toward the embryo. This review describes the levels of alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), carcinoembryonic antigen (CEA), cancer antigen 125 (CA 125), squamous cell carcinoma antigen (SCC), cancer antigen 15-3 (CA 15-3), mucin-like carcinoma-associated antigen (MCA), tissue polypeptide-specific antigen (TPS), carbohydrate antigen 19-9 (CA 19-9), and prostate-specific antigen (PSA) in maternal serum (MS), umbilical cord serum (UC), and amniotic fluid (AF) and outlines their roles in the assessment of pregnancy and malignancy. All antigens studied, except CA 15-3, are oncofetal. The presence of considerable concentrations of AFP, hCG, CEA, CA125, SCC, MCA, TPS, CA 19-9, and PSA in AF during pregnancy may be attributed to their involvement in biological functions associated with fetal development, differentiation, and maturation. MS CEA, CA 15-3, and CA 19-9, in contrast to all the others, are not influenced significantly by pregnancy and thus remain reliable tumor markers in monitoring malignancy in pregnant patients.

Pregnancy and post-partum breast cancer: a prospective study

BACKGROUND

The concomitant occurrence of breast cancer and pregnancy remains a challenging clinical situation combining ethical and medical problems. There are few prospective data on pregnancy-associated breast cancer (PABC) whose incidence continuously increases.

PATIENTS AND METHODS

Forty patients with PABC were compared with 61 non-pregnant, age-matched patients with infiltrative breast carcinomas (BC) diagnosed and followed since 1982.

RESULTS

Although PABC and BC tumor size, grade and type, and lymphovascular and lymphnode invasion were similar, the BC cases showed better overall--(p=0.0001) and disease-free (p-0.015) survival. Moreover, the outcome of pregnant patients was worse than post-partum patients (p=0.017). Importantly, the number of PABC patients receiving hormonotherapy was lower than the BC patients (p<0.0004), due to lower estrogen receptor (ER) (p=0.038) and progesterone receptor (PR) (p=0.008) immunohisto-chemical (IH) levels. Retrospective estrogen-regulated pS2/trefoil factor 1 (pS2/TFF1) immunohistochemitry showed no difference between PABC and BC. All the children delivered were healthy.

CONCLUSION

Pregnancy and the post-partum period increase breast cancer aggressiveness, pregnancy being the most detrimental. PABC hormone-dependence is under-estimated using ER and PR, and pS2/TFF1 might help in its determination. Appropriate treatment does not impair child outcome.

Viral regulation of aquaporin 4, connexin 43, microcephalin and nucleolin

The current study investigated whether human influenza viral infection in midpregnancy leads to alterations in proteins involved in brain development. Human influenza viral infection was administered to E9 pregnant Balb/c mice. Brains of control and virally-exposed littermates were subjected to microarray analysis, SDS-PAGE and western blotting at three postnatal stages. Microarray analysis of virally-exposed mouse brains showed significant, two-fold change in expression of multiple genes in both neocortex and cerebellum when compared to sham-infected controls. Levels of mRNA and protein levels of four selected genes were examined in brains of exposed mice. Nucleolin mRNA was significantly decreased in day 0 and day 35 neocortex and significantly increased in day 35 cerebellum. Protein levels were significantly upregulated at days 35 and 56 in neocortex and at day 56 in cerebellum. Connexin 43 protein levels were significantly decreased at day 56 in neocortex. Aquaporin 4 mRNA was significantly decreased in day 0 neocortex. Aquaporin 4 protein levels decreased in neocortex significantly at day 35. Finally, microcephalin mRNA was significantly decreased in day 56 neocortex and protein levels were significantly decreased at 56 cerebellum. These data suggest that influenza viral infection in midpregnancy in mice leads to long-term changes in brain markers for enhanced ribosome genesis (nucleolin), increased production of immature neurons (microcephalin), and abnormal glial-neuronal communication and neuron migration (connexin 43 and aquaporin 4).

CD10 Expression in Pure Stromal and Sex Cord-Stromal Tumors of the Ovary

CD10 has been recently advocated as a good immunohistochemical marker for endometrial stromal tumors. Metastatic endometrial stromal tumors to the ovary and primary endometrioid stromal sarcomas may show overlapping histological features with pure stromal and sex cord-stromal tumors (SCSTs). We investigated CD10 expression in a large series of pure stromal and SCSTs of the ovary to ascertain whether CD10 may aid in this differential diagnosis. Archival material from 11 fibromas, 10 thecomas, 10 sclerosing stromal tumors (SSTs), 10 adult granulosa cell tumors (AGCTs), 4 luteinized AGCTs, 9 juvenile granulosa cell tumors (JGCTs), 9 Sertoli cell tumors, 9 Sertoli-Leydig cell tumors, 11 sex cord tumors with annular tubules, 10 steroid cell tumors (StCTs), and 8 fibrosarcomas of the ovary were immunostained for CD10. The percentage of cells stained (<5%, 5%-39%, 40%-75%, and >75%) and intensity of staining (1+, 2+, 3+) were evaluated. CD10 was expressed in 7 of 10 thecomas (4 with 5%-75% and mostly 1+), 9 of 10 SSTs (7 with 5%-39% + cells, mostly 1+), 9 of 10 AGCTs (<5%-39%, four 1+, five 2+), 1 of 4 luteinized AGCTs (<5% and 1+), 8 of 9 JGCTs (mostly <5% to 39% and +1), 4 of 9 Sertoli cell tumors (either focal or >75% with variable intensity), 4 of 9 Sertoli-Leydig cell tumors (mostly <10% with variable staining), with the Leydig cells being positive in only 1 tumor (1+ and <5%), and 7 of 10 StCTs (4 tumors with more than 75% + cells, from 1+ to 3+). All fibromas, all but 1 fibrosarcoma (<5% and 1+), and all sex cord tumors with annular tubules were CD10 negative. CD10 expression was frequently seen in StCTs, SSTs, and thecomas of the ovary, although the latter 2 categories usually showed only faint immunoreactivity. In conclusion the frequency and intensity of CD10 immunoreactivity in pure stromal and sex cord-stromal ovarian tumors are low and contrast with the typical strong and diffuse immunostaining seen in endometrial stromal tumors; however, faint CD10 positivity is consistent with the diagnosis of ovarian SCST. Steroid cell tumors are often positive for CD10, but these tumors do not pose problems in differential diagnosis with endometrial stromal tumors. CD10 may play a useful role in aiding the differential between endometrial stromal tumors in the ovary and SCST and stromal tumors.

Targeted treatment using monoclonal antibodies and tyrosine-kinase inhibitors in pregnancy

An expanding knowledge of the signalling pathways involved in the cell cycle has led to great improvements in the understanding of the molecular events involved in carcinogenesis. The past decade has seen substantial advances with the introduction of several classes of targeted therapeutics for the treatment of various cancers and autoimmune disorders. However, the question arises as to whether pregnant women can take advantage of these new treatments in view of the potential risks to the fetus. Published work suggests that biological agents, like traditional treatments, have the potential to affect the fetus, and should, therefore, be used with caution during pregnancy. However, when targeted treatment is clearly indicated the magnitude of the risk to the fetus might not reach that of standard chemotherapy. In circumstances where better alternative treatments do not exist, or where failure to use targeted treatments would result in suboptimum patient care or survival, the risk-benefit analysis might favour the use of potentially effective molecular treatment during pregnancy.

Spectrophotometric analysis of melanocytic naevi during pregnancy

Malignant melanoma is the most common cancer during pregnancy, but it is unknown whether melanocytic naevi in general are activated. A total of 381 melanocytic naevi in 34 Caucasian primigravidae were examined using spectrophotometric intracutaneous analysis (SIAscopy) technology in early pregnancy and prior to delivery. The Siagraphs of each naevus were then compared in order to evaluate changes over time. A total of 163 melanocytic naevi in 21 nulliparous women served as an additional control group. At the first visit none of the Siagraphs examined for the case or control groups aroused suspicion of dysplastic naevus or melanoma and no significant structural changes were noted during the observation period. However, 2.1% of the melanocytic naevi in the pregnant group increased and 1.3% decreased in size. Corresponding figures in the non-pregnant group were 1.8% and 0%, respectively. Only one naevus in a pregnant woman increased slightly in epidermal pigmentation, and a decrease in pigmentation was noted in 3.7% of the melanocytic naevi in the cases and 1.8% in the controls. None of the differences within or between the groups was statistically significant. We conclude that pregnancy does not influence the appearance of pigmented naevi. A changing naevus during pregnancy should be examined carefully and considered for excision and histopathology.

Mucinous cystadenocarcinoma of the pancreas diagnosed in postpartum

BACKGROUND

Cystic tumors of the pancreas are uncommon. They account for 10-15% of all pancreatic cystic masses and only 1% of pancreatic malignancies. Mucinous cystadenocarcinoma is the most frequent pancreatic cystadenocarcinoma and it is mainly seen in women, suggesting a sex hormone influence. Its presentation during pregnancy is infrequent and entails difficult diagnostic and therapeutic decisions. We report the case of a 31-year-old woman who presented a pancreatic cystadenocarcinoma 2 months after delivery.

MATERIALS AND METHODS

A 31-year-old woman was referred to our service because of abdominal pain and mass. She had given birth to her first child 2 months previous. Abdominal ultrasound demonstrated a poorly circumscribed cystic mass in the left upper abdominal quadrant, and the computed tomography scan showed a multilocular cystic lesion located in the body of pancreas. There was no seric alteration of specific pancreatic enzymes or tumor markers.

RESULTS

Laparoscopic examination showed a large cystic tumor (12 x 11 x 5.5 cm) in the pancreas involving the body and the tail. It extended to the spleen and was highly vascularized, precluding a minimal invasive resection. An open body-tail pancreatectomy and splenectomy was performed. The resection margins were free of tumor, and the histological study showed a mucinous pancreatic cystadenocarcinoma with mucin-producing columnar epithelium and associated papillae patterns, reminiscent of ovarian stroma. Immunohistochemical studies were negative for hormonal receptors. The patient had no post-surgical complications and was discharged home in 4 days.

CONCLUSIONS

Cystic tumors of the pancreas are infrequent, and cancer of the pancreas during pregnancy is extremely rare. Insidious symptoms and bodily changes due to pregnancy may mask diagnosis. Aggressive surgery is currently the only chance of cure.

Increased AFP as an indicator of ovarian carcinoma and fetal kidney carcinoma--case report

We examined a young primipara with increased alpha-fetoprotein (AFP) values and cystic tumefaction of the right ovary. Having in mind a mild decrease in ovarian artery resistance index (RI) and suspected findings of fetal kidney, this situation was delicate due to its double pathology which was later confirmed. Wilms' tumor is the most common urogenital tumor in childhood, and it is detectable in the prenatal period by ultrasound examination. In utero kidney biopsy confirms diagnosis and facilitates decisions concerning the course of pregnancy. Relative risk of intervention limits this diagnostic procedure for indicated cases.

Granular cell astrocytoma

Granular cell astrocytoma (GCA) is a rare morphologic variant of astrocytomas, characterized by a prominent component of plump granular tumor cells. It has an aggressive clinical course as compared with conventional astrocytoma of the same grade. As its cytologic feature resembles that of a foamy histiocyte and, histologically, the tumor is rich in arborizing capillaries, it can be difficult to distinguish GCA from non-neoplastic diseases such as infarct or demyelinating disease. In this paper, a case of a GCA in a 28-year-old full-term pregnant woman suffering from a sudden episode of seizure during delivery is described, focusing on histopathological, immunohistochemical, and ultrastructural features. Histopathology and immunohistochemical phenotype of this tumor were identical to the previous reports. Ultrastructurally, secondary lysosome (so-called lipofuscin bodies) granules were present but not numerous; instead, many mitochondria and unusual paracrystalline inclusions were found in each tumor cell. In our case, the light microscopic granular appearance might be produced not only by phagolysomes but also by numerous mitochondria and paracrystalline inclusions.

Sustained trophism of the mammary gland is sufficient to accelerate and synchronize development of ErbB2/Neu-induced tumors

Epidemiological studies indicate that parity enhances HER2/ErbB2/Neu-induced breast tumorigenesis. Furthermore, recent studies using multiparous, ErbB2/Neu-overexpressing mouse mammary tumor virus (MMTV-Neu) mice have shown that parity induces a population of cells that are targeted for ErbB2/Neu-induced transformation. Although parity accelerates mammary tumorigenesis, the pattern of tumor development in multiparous MMTV-Neu mice remains stochastic, suggesting that additional events are required for ErbB2/Neu to cause mammary tumors. Whether such events are genetic in nature or reflective of the dynamic hormonal control of the gland that occurs with pregnancy remains unclear. We postulated that young age at pregnancy initiation or chronic trophic maintenance of mammary epithelial cells might provide a cellular environment that significantly increases susceptibility to ErbB2/Neu-induced tumorigenesis. MMTV-Neu mice that were maintained pregnant or lactating beginning at 3 weeks of age demonstrated accelerated tumorigenesis, but this process was still stochastic, indicating that early pregnancy does not provide the requisite events of tumorigenesis. However, bitransgenic mice that were generated by breeding MMTV-Neu mice with a luteinizing hormone-overexpressing mouse model of ovarian hyperstimulation developed multifocal mammary tumors in an accelerated, synchronous manner compared to virgin MMTV-Neu animals. This synchrony of tumor development in the bitransgenic mice suggests that trophic maintenance of the mammary gland provides the additional events required for tumor formation and maintains the population of cells that are targeted by ErbB2/Neu for transformation. Both the synchrony of tumor appearance and the ability to characterize a window of commitment by ovariectomy/palpation studies permitted microarray analysis to evaluate changes in gene expression over a defined timeline that spans the progression from normal to preneoplastic mammary tissue. These approaches led to identification of several candidate genes whose expression changes in the mammary gland with commitment to ErbB2/Neu-induced tumorigenesis, suggesting that they may either be regulated by ErbB2/Neu and/or contribute to tumor formation.

Breast Cancer and Pregnancy

This article addresses a challenging diagnostic and treatment dilemma encountered in the care of pregnant women-breast cancer. The treatment of a breast cancer is significantly affected by an ongoing pregnancy and may result in an increased risk for a poor outcome in the mother. The definition, incidence, mechanism, diagnosis, and treatment of breast cancer associated with pregnancy and the normal physiologic and endocrine changes in the breast during pregnancy that contribute to the difficulty encountered by practitioners in diagnosing and treating the disorder are reviewed. The risks associated with pregnancy after breast cancer treatment and the effect of pregnancy on lifetime risk for breast cancer in the general population and for women with mutations in BRCA1 and BRCA2 are also discussed.

A case of unilateral gravid macromastia in 23-year-old Japanese woman associated with elevated serum CA19-9

We report a rare case of gravid macromastia (GM) treated after delivery. A 23-year-old woman with left breast enlargement was referred to our hospital. Laboratory investigations revealed an elevated serum CA19-9 level of 200.3 U/ml. Gravid macromastia was diagnosed by clinical examination (US, MRI) and 11G mammotome biopsy. Tumorectomy of the left breast and mammoplasty were performed. The mass had proliferated to the exclusion of normal gland. Histological examination revealed abundant proliferation of stromal loose connective tissue and interposed fat cells surrounding normal and lactating lobules. The epithelial cells were positive for CA19-9 on immunohistochemical staining. Serum CA19-9 decreased to normal levels 3 months after operation. GM is exceedingly rare and occurs in less than 0.001-0.003% of all pregnant women. Once established, the condition is likely to continue to successive pregnancies. This benign tumor is sometimes difficult to distinguish from malignant tumors since it shows few histological characteristics and grows rapidly. Attention is necessary to diagnose tumors of the breast during pregnancy.

Importance of the detection method for intact dimeric human chorionic gonadotropin without interference with the free human chorionic gonadotropin beta subunit for pregnancy exclusion before liver transplantation in a woman with cholangiocarcinoma

Assay of human chorionic gonadotropin (hCG) is mainly used for the detection and monitoring of pregnancy, and for the follow-up of trophoblastic tumors. The serum free beta-hCG subunit (hCGbeta) is also a tumor marker in many non-trophoblastic tumors, including gastrointestinal cancers. In this work, we compared the performance of several immunoassays for pregnancy exclusion before liver transplantation and in the follow-up of a woman with cholangiocarcinoma. Serum hCG was detected with the Abbott Testpack plus hCG-Combo and measured with four automated sandwich immunoassays: ADVIA-Centaur, ACS:180, AxSYM and Dimension. hCGbeta was determined by an automated fluorescence sandwich immunoassay (Kryptor-Free beta hCG) and with a specific immunoradiometric assay (ELSA-F beta hCG, Schering). The expression of hCG was also evaluated by immunohistochemistry on sections of intrahepatic cholangiocarcinoma cells and on peritoneal metastases. Before transplantation, discordant results were observed for pregnancy exclusion. Qualitative Testpack and Dimension tests detected no hCG-like immunoreactivity, whereas the ADVIA-Centaur, ACS:180 and AxSYM tests revealed positive levels. The same discrepancy was obtained in follow-up of the patient after liver transplantation. hCGbeta assay and immunohistochemical staining revealed tumor cell secretion of hCGbeta. In conclusion, a specific serum immunoassay for intact dimeric hCG without cross-reaction with hCGbeta should be adopted as routine policy for pregnancy exclusion before liver transplantation.

Pregnancy improves neutropenia in T-cell large granular lymphocyte leukaemia

The effect of pregnancy on T-cell large granular lymphocyte (LGL) leukaemia has not been previously described. We retrospectively reviewed the clinical features of three patients with T-cell LGL leukaemia; each of them had one or more pregnancies during disease evolution. Pregnancy was associated with sustained improvement in neutrophil count and concurrent reduction in lymphocytosis. Neutropenia returned in the non-pregnant state in all cases. A similar effect, induced by exogenous progesterone in one patient, suggests a role for progesterone in overcoming mechanisms of neutropenia in this disease. Pregnancy thus appears to have a beneficial effect on neutrophil count in T-cell LGL leukaemia.

Proteasome activity is altered in skeletal muscle tissue of tumour-bearing rats a leucine-rich diet

Leucine can modulate skeletal muscle metabolism by enhancing protein synthesis and decreasing proteolysis. In this study, we investigated the effects of leucine on the ubiquitin-proteasome system in skeletal muscle of pregnant tumour-bearing rats fed a leucine-rich diet. Pregnant Wistar rats were distributed into three groups that were fed a semi-purified control diet (C, control; W, Walker tumour-bearing; P, pair-fed) and three other groups of pregnant rats fed a semi-purified leucine-rich diet (L, leucine; WL, Walker tumour-bearing; PL, pair-fed). The tumour-bearing rats were injected subcutaneously with a suspension of Walker 256 tumour cells. Protein synthesis and degradation were measured in gastrocnemius muscle; the total protein content and tissue chymotrypsin-like and alkaline phosphatase enzyme activities were also determined. Muscle protein extracts were run on SDS-PAGE to assess the expression of the myosin heavy chain (MHC), 20S alpha proteasome subunit, 19S MSSI ATPase regulator subunit and 11S alpha subunit. Although tumour growth decreased the incorporation of [3H]-Phe, the concomitant feeding of a leucine-rich diet increased the rate of protein synthesis. Muscle proteolysis in both tumour-bearing groups was increased more than in the respective control groups. Conversely, the leucine-rich diet caused less protein breakdown in the WL group than in the W group. Only the W group showed a significant reduction (71%) in the myosin content. In WL rats, the 20S proteasome content (32 kDa band) was reduced, while the expression of the 19S subunit was 3-fold less than in the W group and the 11S proteasome subunit reduced, to around 32% less than in the W group. These findings clearly indicate that leucine can stimulate protein synthesis and inhibit protein breakdown in pregnant rats, probably by modulating the activation of the ubiquitin-proteasome system during tumour growth.

The Safety of Lymphatic Mapping in Pregnant Breast Cancer Patients Using Tc-99m Sulfur Colloid

This investigation was undertaken to assess the risk to the embryo/fetus associated with sentinel lymph node biopsy and lymphoscintigraphy of the breast performed in pregnant patients. Approximately 92.5 MBq (2.5 mCi) of filtered Tc-99m sulfur colloid was injected peritumorally the day before surgery in two nonpregnant women with breast cancer. The whole-body distribution of the radiopharmaceutical was evaluated using a gamma camera 1 hour after injection. We then calculated the absorbed dose to the embryo/fetus for three theoretical extreme scenarios of biodistribution and pharmacokinetics: 1) all of the injected radiopharmaceutical remains in the breast and is eliminated only by physical decay; 2) all of the injected radiopharmaceutical is instantaneously transported to the urinary bladder, where it remains and is eliminated only by physical decay; and 3) the injected radiopharmaceutical behaves as though it were administered intravenously, that is, it has the biodistribution and pharmacokinetics of Tc-99m sulfur colloid injected for a liver/spleen or bone marrow scan. The fetal radiation absorbed dose was then estimated for two Tc-99m dosages: 18.5 MBq (0.5 mCi) and 92.5 MBq (2.5 mCi). The Medical Internal Radiation Dosimetry (MIRD) program was used to estimate the absorbed doses to the embryo/fetus for the first two scenarios. Published data were used to calculate the doses for the third scenario. A single breast is not among the source organs in the MIRD program, so the heart was used as a surrogate in the first scenario. In the two breast cancer patients, whole-body gamma-camera images obtained 1 hour after radiopharmaceutical injection revealed no radioactivity except in the vicinity of the injection site. In the theoretical scenarios, with 92.5 MBq, the highest absorbed doses to the embryo/fetus were as follows: scenario 1, 7.74 x 10(-2) mGy at 9 months of pregnancy; scenario 2, 4.26 mGy during early pregnancy; and scenario 3, 0.342 mGy at 9 months of pregnancy. The maximum absorbed dose to the fetus of 4.3 mGy calculated for the worst-case scenario is well below the 50 mGy that is believed to be the threshold absorbed dose for adverse effects. Thus breast lymphoscintigraphy during pregnancy appears to present a very low risk to the embryo/fetus.

Progression of pregnancy-dependent mouse mammary tumors after long dormancy periods. Involvement of Wnt pathway activation

Mouse mammary tumor virus (LA) induces pregnancy-dependent mammary tumors that progress toward autonomy. Here we show that in virgin females, pregnancy-dependent tumor transplants are able to remain dormant for up to 300 days. During that period, these tumors synthesize DNA, express high levels of estrogen and progesterone receptors (ER+PR+) and are able to resume growth after hormone stimulation. Surprisingly, in a subsequent transplant generation, all these tumors are fully able to grow in virgin females, they express low levels of ER and PR (ER-PR-) and have a monoclonal origin; i.e., show all of the features we have described previously in pregnancy-independent tumors. Histologically, mouse mammary tumor virus (LA)-induced tumors are morphologically similar to genetically engineered mouse (GEM) mammary tumors that overexpress genes belonging to the Wnt pathway. Interestingly, in the virus-induced neoplasias, pregnancy-independent passages arising after a dormant phase usually display a lower level of glandular differentiation together with epithelial cell trans-differentiation, a specific feature associated to Wnt pathway activation. In addition, dormancy can lead to the specific selection of Int2/Fgf3 mutated and overexpressing cells. Therefore, our results indicate that during hormone-dependent tumor dormancy, relevant changes in cell population occur, allowing rapid progression after changes in the animal internal milieu.

Breast carcinoma with choriocarcinomatous features

Although breast carcinomas have been shown to produce various ectopic substances, including human chorionic gonadotropin, it is rare to identify morphologic differentiation compatible with the hormone produced by a tumor. Presently, only eight cases of breast carcinoma with focal choriocarcinomatous differentiation have been reported in the literature. This article describes the pathologic findings, immunohistochemical profile, and clinical course in two additional cases of this unusual variant of breast carcinoma. In the first case, the tumor had morphologic features suggestive of medullary carcinoma, and the patient is doing well 12 months after presentation. In the second case, the tumor was locally advanced at presentation with histologic features consistent with metaplastic carcinoma having squamous, sarcomatoid, and choriocarcinomatous elements. The patient presented with extensive multifocal metastases 6 months after the initial presentation and is not responding well to standard or experimental treatment regimen. Immunostaining for the beta subunit of human chorionic gonadotropin was localized mostly, but not entirely, to multinucleated syncytiotrophoblast-like giant cells within both tumors.

mRNA-expression of often used house-keeping genes and the relation between RNA and DNA are sex steroid-dependent parameters in human myometrium and fibroids

The content of RNA and DNA in human myometrium and fibroids obtained at different endocrine conditions varied, with the highest RNA/DNA ratio in tissues from pregnant patients, intermediate ratios in women during the menstrual cycle and the lowest in tissues from postmenopausal and GnRHa-treated patients. mRNA expression of two house-keeping genes, gamma-actin and GAPDH, was highest in myometrium from pregnant women, intermediate in untreated women of fertile age and lowest in tissues from GnRHa-treated and postmenopausal women. To control for degradation of nucleic acids when measuring mRNA expression, we suggest additional analysis of gene(s), where the expression pattern is known, and that expression, whenever possible, is related to DNA, which is a more stable parameter than RNA and total nucleic acids, when there are differences in proliferation between tissues and/or groups of patients.