Early localized peritoneal mesothelioma as an incidental finding at laparoscopy. Report of a case and implications regarding natural history of the disease

BACKGROUND

Peritoneal mesothelioma is regarded as a fatal disease that presents with progressive ascites in a relatively late stage of its natural history. To the authors' knowledge, prior published articles have not described the early manifestations of this cancer.

METHODS

A 30-year-old asymptomatic woman underwent laparoscopy for an infertility workup. Nodules noted in the pelvis were biopsied and determined to be mesothelioma. Standard immunohistochemical studies were performed. Cytoreductive surgery and heated intraoperative intraperitoneal chemotherapy were used for treatment.

RESULTS

Multiple (approximately 30) tumor nodules up to 2 mm in dimension and limited to the pelvis were observed and resected. No primary tumor focus was evident. These tumor nodules stained positive for Calretinin and negative for carcinoembryonic antigen immunohistochemically.

CONCLUSIONS

In this patient, no incidence for transcoelomic dissemination of mesothelioma from a single primary site was observed. Rather, this patient's clinical presentation suggested that mesothelioma may be multifocal in origin within a limited region of the peritoneal cavity. This hypothesis may support a rationale for aggressive local-regional management of selected patients in whom peritoneal mesothelioma is of limited distribution and mass.

Bleeding and spontaneous abortion after therapy for infertility

OBJECTIVE

To determine the incidence of early-pregnancy bleeding and spontaneous abortion (SAB) after various treatments for infertility and to assess whether bleeding is predictive of SAB.

DESIGN

An historic cohort study of women who conceived after various treatments.

SETTING

Hospital-based private practice.

PATIENT(S)

We studied 418 patients in whom 500 consecutive clinical pregnancies occurred.

INTERVENTION(S)

Patients were grouped according to the method of conception: ovulation induction, IVF, and other. The latter category included interventions not requiring ovulation induction, such as surgery and insemination. A fourth group of subjects who conceived independently of treatment was used as the control.

MAIN OUTCOME MEASURE(S)

Bleeding and pregnancy outcome (SAB, ectopic pregnancy, or ongoing pregnancy).

RESULT(S)

Rates of SAB did not differ among the treatment groups. SAB occurred significantly more often after bleeding than when bleeding did not occur (30.8% versus 19.8%, respectively). Bleeding was predictive of SAB only in patients <35 years old (odds ratio 2.4).

CONCLUSION(S)

Infertile women who conceive after reproductive therapy are not at increased risk for SAB compared with women who conceive naturally. There appears to be no association between previous diagnosis or treatment and the occurrence of SAB in previously infertile women. Bleeding is associated with a twofold relative risk of SAB.

Laparoscopic excision of benign dermoid cysts with controlled intraoperative spillage

Due to the risk of aseptic peritonitis associated with intraoperative rupture of dermoid cysts, many surgeons are reluctant to remove the lesions laparoscopically. In our series, 12 dermoid cysts were removed laparoscopically. Intraoperative spillage occurred in all cases and was managed with copious lavage. None of the patients experienced postoperative morbidity associated with peritonitis, indicating that intraoperative spillage of dermoid cysts is not associated with morbidity as long as vigorous lavage is performed.

Assisted reproduction in contemporary Jewish law and ethics

This article recapitulates and extends a discussion of the position of halakhic Judaism (traditional Jewish law and ethics) on various issues that relate to assisted reproduction, including genetic and legal relationships, disposal of untransplanted embryos, embryo tissue research, multifetal pregnancy reduction, preimplantation genetic screening and sex selection and donor gametes.

Homologous artificial insemination (AIH) and gamete intrafallopian transfer (GIFT) in Roman Catholicism and Halakhic Judaism

While homologous artificial insemination (AIH) and gamete intrafallopian transfer (GIFT) can be viewed as compatible with the teachings of Roman Catholicism and Halakhic Judaism, their permissibility is much more strongly rooted in the latter. Nevertheless, AIH and GIFT cannot be dismissed as unacceptable to Roman Catholics, provided the semen is licitly obtained.

The luteal phase during gonadotropin therapy: effects of two human chorionic gonadotropin regimens

OBJECTIVE

Luteal phase abnormalities are known to complicate ovulation induction with gonadotropins. This study was performed to test the effect of a modified human chorionic gonadotropin (hCG) regimen on the luteal phase during gonadotropin treatment.

DESIGN

Fifteen women from a private practice setting volunteered to be studied during each of two nonconception, gonadotropin-stimulated cycles. After ovarian stimulation with human menopausal gonadotropins (hMG), hCG was administered either as a single dose of 10,000 IU (single dose) or in two divided doses of 5,000 IU given 1 week apart (split dose).

MAIN OUTCOME MEASURES

Early, midluteal, and late luteal estradiol (E2) and progesterone (P) levels and luteal phase lengths were measured, and their median values and intraquartile ranges (IQR) compared using nonparametric analysis.

RESULTS

Early and midluteal E2 and P levels were similar regardless of which hCG regimen was administered. The median late luteal E2 level was 1,146.0 pg/mL (the IQR ranged from 633 to 1,650, IQR = 1,017) with the split-dose regimen and 240.0 pg/mL (the IQR ranged from 150 to 460, IQR = 310) with the single-dose regimen. The median late luteal P level was 108.0 ng/mL (the IQR ranged from 58.5 to 129, IQR = 70.5) with the split-dose regimen and 4.2 ng/mL (the IQR ranged from 1.9 to 11.7, IQR = 9.8) with the single-dose regimen. Median luteal phase lengths were 16 days (the IQR ranged from 15 to 17, IQR = 2) for the split-dose regimen and 11 days (the IQR ranged from 10 to 12, IQR = 2) for the single-dose regimen.

CONCLUSION

In hMG-stimulated cycles, a second dose of hCG given during the midluteal phase significantly increases late luteal E2 and P levels and consistently lengthens the luteal phase.

Detection of premature luteinization with serum progesterone levels at the time of the postcoital test

Poor cervical mucus (CM) may be caused by a number of factors, including premature luteinization, local cervical effects, and inadequate folliculogenesis. In an attempt to distinguish between these causes of poor CM, we obtained progesterone (P) levels at the time of postcoital tests (PCTs) in infertile women during spontaneous or clomiphene citrate (CC)-stimulated cycles. The amount of CM, viscosity, ferning, spinnbarkeit, and cellularity were each scored from 0 to 3 points on the day after detection of the urinary luteinizing hormone surge (luteal day 1). The charts of 46 such patients were retrospectively reviewed. Eleven control patients with good CM scores (greater than 10) had low P levels (less than 2.5 ng/mL). Of the remaining 35 cycles, 19 were marked by low P levels, and 16 were accompanied by P levels of greater than 2.5 ng/mL. Overall, 94.4% of CC-stimulated cycles versus 64.3% of spontaneous cycles had abnormal CM scores (less than 9). On the basis of these inappropriately elevated P levels, premature luteinization can be cited as the cause of poor mucus quality. In fact, premature luteinization may be responsible for some of the purported antiestrogenic effects of CC. Therefore, it is appropriate to draw a P level at the time of a poor PCT, particularly in cycles stimulated by CC.

Synergistic effect of relaxin and progesterone on cyclic adenosine 3',5'-monophosphate levels in the rat uterus

Cyclic adenosine 3',5'-monophosphate is known to modulate smooth muscle contractility. Because both relaxin and progesterone have been demonstrated to affect myometrial cyclic adenosine monophosphate activity, we questioned whether the previously observed synergism of these two hormones in inhibiting uterine contractility is mediated via cyclic adenosine monophosphate. Immature rats were treated with estradiol benzoate (n = 7) or a combination of estradiol benzoate and progesterone (n = 7). Uterine horns were isolated, each horn was divided into two segments, and these horn segments were incubated in Ringer-Locke solution, either alone (control) or with 3-isobutyl-1-methylxanthine (MIX) 0.5 mM, MIX 0.5 mM + relaxin 10 ng/ml, or MIX 0.5 mM + relaxin 50 ng/ml. When compared with uterine segments incubated in MIX alone, treatment with MIX + relaxin 50 ng/ml significantly increased cyclic adenosine monophosphate levels in animals treated with estradiol benzoate alone or in combination with progesterone. Relaxin 10 ng/ml was sufficient to significantly elevate mean (+/- SEM) uterine cyclic adenosine monophosphate levels above that of control MIX-treated uteri in animals receiving both estradiol benzoate and progesterone (2.49 +/- 0.39 pm/micrograms deoxyribonucleic acid [DNA] versus 1.08 +/- 0.16 pm/microgram DNA, p less than 0.05) but not in animals receiving estradiol benzoate alone (2.08 +/- 0.32 pm/micrograms DNA versus 1.28 +/- 0.16 pm/micrograms DNA, NS). Compared with treatment with MIX only, MIX + relaxin 10 ng/ml and MIX + relaxin 50 ng/ml produced greater increases in uterine cyclic adenosine monophosphate in the steroid combination group than in the estradiol benzoate controls (144.8% and 233.7% versus 71.7% and 156.6%, respectively). These results suggest that the synergism of relaxin and progesterone in inhibiting uterine contractility may be mediated by intracellular cyclic adenosine monophosphate.

Ruptured tubal pregnancy with contralateral tubal infarction. A case report

We treated a woman for tubal infarction complicating a contralateral tubal pregnancy. This is the first published report of such a case.

Offspring of teenage mothers: congenital malformations, low birth weights and other findings

Teenage mothers were found to have congenitally malformed infants with a significantly higher frequency when compared to a published control population. Low birth weight and perinatal death were common among the infants of mothers 17 and younger. No chromosomal anomalies were found among the infants of this population, but this result does not unequivocally rule out an increased frequency of these disorders.