The extracellular matrix protein ITIH5 is a novel prognostic marker in invasive node-negative breast cancer and its aberrant expression is caused by promoter hypermethylation

Inter-alpha-trypsin inhibitors (ITIs) are protease inhibitors stabilizing the extracellular matrix. ITIs consist of one light (bikunin) and two heavy chains (ITIHs). We have recently characterized ITIH5, a novel member of the ITIH gene family, and showed that its messenger RNA is lost in a high proportion of breast tumours. In the present study, an ITIH5-specific polyclonal antibody was generated, validated with western blot and used for immunohistochemical analysis on a tissue microarray; ITIH5 was strongly expressed in epithelial cells of normal breast (n=11/15), while it was lost or strongly reduced in 42% (92/217) of invasive breast cancers. ITIH5 expression in invasive carcinomas was associated with positive expression of oestrogen receptor (P=0.008) and histological grade (P=0.024). Correlation of ITIH5 expression with clinical outcome revealed that patients with primary tumours retaining abundant ITIH5 expression had longer recurrence-free survival (RFS; P=0.037) and overall survival (OS; P=0.044), compared to those with reduced expression (mean RFS: 102 vs 78 months; mean OS: 120 vs 105 months). Methylation-specific PCR analysis frequently showed strong methylation of the ITIH5 promoter in primary breast tumours (41%, n=109) and breast cancer cell lines (n=6). Methylation was significantly associated with mRNA loss (P<0.001; n=39), and ITIH5 expression was induced after treatment of tumour cell lines with the demethylating agent 5-aza-2'-deoxycytidine. Moreover, ITIH5 promoter methylation was significantly associated with reduced OS (P=0.008). The cellular function of ITIH5 was evaluated by forced expression of a full-length ITIH5 complementary DNA in the breast cancer cell line MDA-MB-231, which does not endogenously express ITIH5. ITIH5-expressing clones showed a 40% reduced proliferation rate compared to mock-transfected cells. Overall, these data show that promoter methylation-mediated loss of ITIH5 expression is associated with unfavourable outcome in breast cancer patients, and thus ITIH5 could be used as a prognostic marker, although this marker is not multivariate independent due to its close association with ER expression. Our data indicate that ITIH5 is a candidate class II tumour suppressor gene and could be involved in tumour progression, invasion and metastasis, as its absence is associated with increased proliferation rates and a prognostic value indicating poor clinical outcome.

Expression analysis of mammaglobin A (SCGB2A2) and lipophilin B (SCGB1D2) in more than 300 human tumors and matching normal tissues reveals their co-expression in gynecologic malignancies

BACKGROUND

Mammaglobin A (SCGB2A2) and lipophilin B (SCGB1D2), two members of the secretoglobin superfamily, are known to be co-expressed in breast cancer, where their proteins form a covalent complex. Based on the relatively high tissue-specific expression pattern, it has been proposed that the mammaglobin A protein and/or its complex with lipophilin B could be used in breast cancer diagnosis and treatment. In view of these clinical implications, the aim of the present study was to analyze the expression of both genes in a large panel of human solid tumors (n = 309), corresponding normal tissues (n = 309) and cell lines (n = 11), in order to evaluate their tissue specific expression and co-expression pattern.

METHODS

For gene and protein expression analyses, northern blot, dot blot hybridization of matched tumor/normal arrays (cancer profiling arrays), quantitative RT-PCR, non-radioisotopic RNA in situ hybridization and immunohistochemistry were used.

RESULTS

Cancer profiling array data demonstrated that mammaglobin A and lipophilin B expression is not restricted to normal and malignant breast tissue. Both genes were abundantly expressed in tumors of the female genital tract, i.e. endometrial, ovarian and cervical cancer. In these four tissues the expression pattern of mammaglobin A and lipophilin B was highly concordant, with both genes being down-, up- or not regulated in the same tissue samples. In breast tissue, mammaglobin A expression was down-regulated in 49% and up-regulated in 12% of breast tumor specimens compared with matching normal tissues, while lipophilin B was down-regulated in 59% and up-regulated in 3% of cases. In endometrial tissue, expression of mammaglobin A and lipophilin B was clearly up-regulated in tumors (47% and 49% respectively). Both genes exhibited down-regulation in 22% of endometrial tumors. The only exceptions to this concordance of mammaglobin A/lipophilin B expression were normal and malignant tissues of prostate and kidney, where only lipophilin B was abundantly expressed and mammaglobin A was entirely absent. RNA in situ hybridization and immunohistochemistry confirmed expression of mammaglobin A on a cellular level in endometrial and cervical cancer and their corresponding normal tissues.

CONCLUSION

Altogether, these data suggest that expression of mammaglobin A and lipophilin B might be controlled in different tissues by the same regulatory transcriptional mechanisms. Diagnostic assays based on mammaglobin A expression and/or the mammaglobin A/lipophilin B complex appear to be less specific for breast cancer, but with a broader spectrum of potential applications, which includes gynecologic malignancies.

Amniotic Fluid and Maternal Serum Metabolic Signatures in the Second Trimester Associated with Preterm Delivery

Preterm delivery (PTD) represents a major health problem that occurs in 1 in 10 births. The hypothesis of the present study was that the metabolic profile of different biological fluids, obtained from pregnant women during the second trimester of gestation, could allow useful correlations with pregnancy outcome. Holistic and targeted metabolomics approaches were applied for the complementary assessment of the metabolic content of prospectively collected amniotic fluid (AF) and paired maternal blood serum samples from 35 women who delivered preterm (between 29 weeks + 0 days and 36 weeks +5 days gestation) and 35 women delivered at term. The results revealed trends relating the metabolic content of the analyzed samples with preterm delivery. Untargeted and targeted profiling showed differentiations in certain key metabolites in the biological fluids of the two study groups. In AF, intermediate metabolites involved in energy metabolism (pyruvic acid, glutamic acid, and glutamine) were found to contribute to the classification of the two groups. In maternal serum, increased levels of lipids and alterations of key end-point metabolites were observed in cases of preterm delivery. Overall, the metabolic content of second-trimester AF and maternal blood serum shows potential for the identification of biomarkers related to fetal growth and preterm delivery.

Expression analysis and RNA localization of PAI-RBP1 (SERBP1) in epithelial ovarian cancer: association with tumor progression

OBJECTIVE

The plasminogen activator system (PA) plays an important role in invasion and metastasis of solid tumors. The PA Inhibitor type 1 (PAI-1) is the main physiologic regulator of plasminogen activation. A recently characterized protein, PAI-RBP1 (PAI-1 mRNA Binding Protein 1), appears to regulate the stability of PAI-1 mRNA. Expression of PAI-RBP1 (the new, approved gene symbol is SERBP1) has not been previously analyzed in human tumors. We present herein for the first time expression analysis of PAI-RBP1 in epithelial ovarian cancer.

METHODS

PAI-RBP1 was identified as gene overexpressed in ovarian cancer by an in silico approach using EST database mining. A thorough expression analysis of PAI-RBP1 and PAI-1 was performed in normal ovary (n=4), benign (n=6) and malignant (n=42) ovarian lesions using non-radioactive RNA in situ hybridization and immunohistochemistry, respectively.

RESULTS

PAI-RBP1 mRNA and PAI-1 were significantly overexpressed in tumor epithelial cells as compared to benign and normal ovarian tissue. A significant correlation between PAI-RBP1 expression and advanced disease stage (FIGO) was found (p=0.042).

CONCLUSION

In ovarian cancer, PAI-RBP1 is significantly overexpressed in tumor epithelial cells, suggesting a biological role in tumor invasion and metastasis. Its expression is higher in advanced disease, thus the prognostic significance of PAI-RBP1 in ovarian cancer remains to be evaluated in further studies.

Sorafenib in breast cancer treatment: A systematic review and overview of clinical trials

AIM

To evaluate the current role of sorafenib, an oral multikinase inhibitor in the treatment of breast cancer.

METHODS

An extensive search of the literature until March 2016 was carried out in Medline and clinicaltrials.gov, by using the search terms "sorafenib" and "breast cancer". Papers found were checked for further relevant publications. Overall, 21 relevant studies were found, 18 in advanced breast cancer (16 in stage IV and two in stages III-IV) and three in early breast cancer.

RESULTS

Among studies in advanced breast cancer, there were two trials with sorafenib as monotherapy, four trials of sorafenib in combination with taxanes, two in combination with capecitabine, one with gemcitabine and/or capecitabine, one with vinorelbine, one with bevacizumab, one with pemetrexed and one with ixabepilone, three trials of sorafenib in combination with endocrine therapy and two trials in women with brain metastases undergoing whole brain radiotherapy. In addition, there was one trial of sorafenib added to standard chemotherapy in the adjuvant setting, and two trials in the neoadjuvant setting. In general, sorafenib was well tolerated in breast cancer patients, though its dosage had to be adjusted in some trials, and discontinuation rates were high, particularly for the combination of sorafenib with anastrozole. Sorafenib monotherapy and combinations with taxanes, bevacizumab and ixabepilone showed inadequate efficacy, while efficacy results from combinations with gemcitabine and/or capecitabine and possibly tamoxifen were more promising.

CONCLUSION

At present, sorafenib should not be used for the treatment of breast cancer outside of clinical trials and more clinical data are needed in order to support its standard use in breast cancer therapy.

Systematic characterisation of GABRP expression in sporadic breast cancer and normal breast tissue

The GABRP gene has been previously identified by in silico analysis of four million ESTs as a candidate gene differentially expressed in breast cancer. GABRP is located on chromosome 5q34 and it encodes the pi-subunit of the gamma-aminobutyric acid (GABA) receptor, a transmembrane protein expressed in the brain and several nonneuronal tissues. Using cDNA dot blot hybridisation (cancer profiling array), quantitative RT-PCR and non-radioisotopic in situ hybridisation (ISH), we have analysed GABRP expression in breast cancer and normal breast tissues as well as in nontumorigenic and tumorigenic breast cell lines. Analysis of the cancer profiling array revealed a more than 2-fold downregulation of GABRP (p < 0.001) in 76% of primary breast carcinomas (n = 50) compared to corresponding normal tissues. Quantitative RT-PCR in a panel of 23 normal human tissues showed that the GABRP expression level was most abundant in the normal breast tissues compared to other human tissues. GABRP downregulation in breast cancer was confirmed by quantitative RT-PCR in cryopreserved breast tumour and normal breast tissue specimens (n = 22), in archival formalin-fixed, paraffin-embedded tissue specimens (n = 32), as well as in breast cancer cell lines (n = 8). Furthermore, a significant downregulation of GABRP was noted in large (pT3-pT4) (p = 0.044) primary breast tumours. Non-radioisotopic ISH showed strong GABRP expression in normal epithelial and benign papilloma breast cells, but no signal could be detected in invasive ductal carcinoma. Altogether, these data suggest that GABRP is progressively down-regulated with tumour-progression, and that it may be useful as a prognostic marker in breast cancer.

Endometriotic uterocutaneous fistula after cesarean section. A case report

Endometriosis outside the pelvis is rare and most cases occur in surgical scars after operations involving the female genital tract. Fistulae involving the uterus are also very rare, usually being the result of postpartum and postoperative complications. In the present report, a case of a 44-year-old patient with an endometriotic uterocutaneous fistula is described. The patient presented 6 years after her fourth cesarean section with a painful nodule on the cesarean scar, which was bleeding during menstruation. The lesion extended to the uterine fundus, connecting the endometrial cavity with the skin. This is merely the second case of a uterocutaneous fistula to be reported in the literature and the first case developed on grounds of endometriosis.

Endometriosis and ovarian cancer risk: a systematic review of epidemiological studies

Background: A possible etiological association between endometriosis and ovarian cancer has been repeatedly reported in the literature.

Objective: Our aim was to evaluate published epidemiological data on this issue.

Review Methods: We conducted an extensive search of the literature in MEDLINE, of articles ever published until February 2014, using the key-words “endometriosis” and “ovarian” and one of the following terms in the title: “cancer” or “malignancy” or “malignant” or “tumor” or “neoplasia” or “neoplasm” or “transformation.” Retrieved papers were checked for further relevant publications.

Results: Overall, our search yielded 1 prospective cohort study, 10 retrospective cohort, and 5 case–control studies. A meta-analysis of these studies was not considered to be appropriate, due to differences in data reporting, study design, and adjustment for confounding factors.

Limitations: The main limitation of studies found, with one exception, was the lack of operative confirmation of endometriosis.

Conclusion: An association of endometriosis with clear-cell and endometrioid ovarian cancer was a consistent finding in most studies. On the other hand, existing epidemiological evidence linking endometriosis with ovarian cancer is insufficient to change current clinical practice. Prospective cohort studies, with prior laparoscopic confirmation, localization, and staging of endometriosis are needed, in order to further clarify this issue.

Altered expression pattern of topoisomerase IIalpha in ovarian tumor epithelial and stromal cells after platinum-based chemotherapy

OBJECTIVE

The aim of this study was to evaluate the expression of topoisomerase IIalpha (TOP2A) in epithelial and stromal cells of ovarian cancer.

METHODS

TOP2A expression was analyzed prospectively in normal and tumor epithelial and adjacent stromal cells using quantitative real-time reverse transcription-polymerase chain reaction (RT-PCR) after laser microdissection (n = 38), RNA in situ hybridization (n = 13), and immunohistochemistry (n = 69).

RESULTS

TOP2A mRNA was detected by RNA in situ hybridization in all ovarian cancer samples, with stronger hybridization signals in tumor epithelial cells compared to adjacent stromal cells. The same expression pattern was found by immunohistochemistry (P = .0001). Very interestingly, specific change was found in recurrent ovarian cancer after platinum-based chemotherapy: TOP2A expression decreased in tumor epithelial cells of recurrent ovarian cancer compared to primary ovarian cancer (P = .056), whereas it increased in tumor-adjacent stromal cells in carboplatin-treated recurrent tumors compared to primary ovarian cancer (P = .023).

CONCLUSION

TOP2A mRNA and protein expression in ovarian cancer exhibits specific patterns in tumor epithelial and adjacent stromal cells, which are differentially modulated after platinum-based chemotherapy. These data support the recently discovered importance of the stromal compartment in tumor progression and suggest that tumor stromal cells might be relevant to the development of chemotherapy resistance in ovarian cancer.

Nuchal cord detected by ultrasound at term is associated with mode of delivery and perinatal outcome

OBJECTIVES

To evaluate the clinical relevance of nuchal cord in normal, vertex, singleton pregnancies at term, and its effect on mode of delivery and perinatal outcome.

STUDY DESIGN

Prospective study with 352 normal, singleton pregnancies, with fetuses in the vertex presentation, examined with real-time ultrasound at 37-39 weeks. Health care workers at labour and delivery blinded to previous detection of nuchal cord.

RESULTS

Fetuses of nulliparous women with a nuchal cord were more likely to be delivered with operative vaginal or caesarean delivery (n = 153, p < 0.0001). This was not the case with higher parity (n = 199, p = 0.07). There was no difference between nuchal cord (n = 144) and control groups (n = 208) in amniotic fluid quantity at 37-39 weeks (p = 0.554) or intrapartum CTG (p = 0.9). On the other hand, nuchal cord group had lower Apgar scores at 1 and 5 min (p = 0.001 and 0.027 respectively); this difference remained significant when adjusted for birth weight (p = 0.001 and 0.016), but disappeared when adjusted for mode of delivery (p = 0.048 and 0.319).

CONCLUSIONS

Nuchal cord in normal pregnancies at term is associated with increased rate of operative vaginal and caesarean delivery in nulliparae. The presence of a nuchal cord results in slightly lower Apgar scores at 1 and 5 min, mainly as a consequence of higher operative delivery rates.

Enhancer of the rudimentary gene homologue (ERH) expression pattern in sporadic human breast cancer and normal breast tissue

BACKGROUND

The human gene ERH (Enhancer of the Rudimentary gene Homologue) has previously been identified by in silico analysis of four million ESTs as a gene differentially expressed in breast cancer. The biological function of ERH protein has not been fully elucidated, however functions in cell cycle progression, pyrimidine metabolism a possible interaction with p21(Cip1/Waf1) via the Ciz1 zinc finger protein have been suggested. The aim of the present study was a systematic characterization of ERH expression in human breast cancer in order to evaluate possible clinical applications of this molecule.

METHODS

The expression pattern of ERH was analyzed using multiple tissue northern blots (MTN) on a panel of 16 normal human tissues and two sets of malignant/normal breast and ovarian tissue samples. ERH expression was further analyzed in breast cancer and normal breast tissues and in tumorigenic as well as non-tumorigenic breast cancer cell lines, using quantitative RT-PCR and non-radioisotopic in situ hybridization (ISH).

RESULTS

Among normal human tissues, ERH expression was most abundant in testis, heart, ovary, prostate, and liver. In the two MTN sets of malignant/normal breast and ovarian tissue,ERH was clearly more abundantly expressed in all tumours than in normal tissue samples. Quantitative RT-PCR analyses showed that ERH expression was significantly more abundant in tumorigenic than in non-tumorigenic breast cancer cell lines (4.5-fold; p = 0.05, two-tailed Mann-Whitney U-test); the same trend was noted in a set of 25 primary invasive breast cancers and 16 normal breast tissue samples (2.5-fold; p = 0.1). These findings were further confirmed by non-radioisotopic ISH in human breast cancer and normal breast tissue.

CONCLUSION

ERH expression is clearly up-regulated in malignant as compared with benign breast cells both in primary human breast cancer and in cell models of breast cancer. Since similar results were obtained for ovarian cancer, ERH overexpression may be implicated in the initiation and/or progression of certain human malignancies. Further studies on large breast cancer tissue cohorts should determine whether ERH could function as a prognostic factor or even a drug target in the treatment of human breast cancer.

Apert syndrome: the current role of prenatal ultrasound and genetic analysis in diagnosis and counselling

Apert syndrome is a rare congenital malformation syndrome characterized by the triad of cutaneous and progressive bony syndactyly, midfacial hypoplasia and craniosynostosis. Two missense mutations of the gene encoding the fibroblast growth factor receptor 2 (FGFR2) have been implicated in most cases. We report a case of Apert syndrome detected on prenatal ultrasound. Postnatal genetic analysis showed, for the first time, that the previously reported P253R mutation of the FGFR2 gene is also prevalent in southeast Europe. After prenatal sonographic detection of anomalies suggestive of Apert syndrome, parents should be counselled about prognosis and risk of recurrence, and the option of amniocentesis should be offered.

Immunohistochemical expression pattern of metastasis suppressors KAI1 and KISS1 in endometriosis and normal endometrium

OBJECTIVE

To analyze the expression pattern of metastasis suppressors KAI1 and KISS1 in the endometrium of patients with and without endometriosis.

STUDY DESIGN

In this pilot study, tissue samples were prospectively collected from 38 patients with endometriosis and 29 without endometriosis, undergoing operative laparoscopy in the proliferative phase of the menstrual cycle; diagnosis or absence of endometriosis was confirmed histologically. Protein expression of KAI1 and KISS1 were analyzed immunohistochemically in endometriotic lesions and the eutopic endometrium of patients with endometriosis and without endometriosis.

RESULTS

KAI1 expression was significantly decreased in the glandular eutopic endometrium of endometriosis patients as compared with that of patients without endometriosis (p=0.008). On the other hand, in endometriosis patients, KAI1 expression was significantly increased in the ectopic as compared with the eutopic endometrial stroma (p=0.021). There were no other significant differences in KAI1 expression between different groups. KISS1 expression in the ectopic glandular endometrium was significantly increased as compared with the eutopic glandular endometrium from patients with (p=0.004) and without endometriosis (p=0.008). There was no significant difference in KISS1 protein expression in the stromal endometrium between the three groups.

CONCLUSIONS

KAI1 and KISS1 are implicated in the pathogenesis and maintenance of endometriosis. Future studies should investigate whether KAI1 and KISS1 could be used as markers for early and minimally invasive detection of endometriosis based on their differential protein expression pattern in the eutopic endometrium of patients with and without endometriosis.

Ultrasound and MR-imaging in preoperative evaluation of two rare cases of scar endometriosis

Scar or incisional endometriosis is a rare, often misdiagnosed, pathologic condition of the abdominal wall. Two cases of incisional endometriosis are presented. Both patients presented with atypical cyclic pain and palpable nodules on scars of previous cesarean sections. In both cases, the mass was totally excised, after accurate preoperative evaluation with 2-D ultrasound, power Doppler and MRI. Microscopic examination confirmed the preoperatively presumed diagnosis of cutaneous endometriosis. In cases of suspected scar endometriosis, preoperative diagnostic imaging is valuable in determining the extent of disease, thus enhancing accurate and total excision.

The effect of physical exercise on postpartum fitness, hormone and lipid levels: a randomized controlled trial in primiparous, lactating women

PURPOSE

To evaluate the effect of an exercise training program combining low-impact dance aerobic, resistance and stretching exercise on physical fitness, hormone and lipid levels of postpartum, primiparous, lactating women.

METHODS

Thirty seven primiparous, lactating women were randomly assigned at 4-6 weeks postpartum to either follow an exercise training program of 50-60 min aerobic, strengthening and stretching exercise, 3 days a week, for 12 weeks (interventional group; n = 20) or no training program at all (control group; n = 17). The following parameters were measured at baseline and 12 weeks later: (1) for evaluation of physical fitness: VO2max, muscular endurance, joint mobility and body fat; (2) for evaluation of the lipidemic profile: triglyceride, total cholesterol, HDL and LDL levels, and (3) levels of hormones associated with lactation: prolactin, estradiol, cortisol, TSH, fT3 and fT4.

RESULTS

After completion of the exercise training program, comparisons between the interventional and the control group showed statistically significant mean changes in VO2max (p = 0.003), muscular endurance of the upper extremities (p < 0.001), and the abdomen (p < 0.001), flexibility (p = 0.042), and body fat (p = 0.007). There were no significant differences between the two groups in mean changes of lipid and hormone levels.

CONCLUSION

Implementation of a low-impact exercise training program appears to improve physical fitness of postpartum women, while it does not seem to affect lipid levels and lactation-associated hormone levels. Hence, implementation of an exercise training program combining low-impact dance aerobic, resistance and stretching exercise is feasible in postpartum, primiparous, lactating women.

Epidemiology of HPV infection and current status of cervical cancer prevention in Greece: final results of the LYSISTRATA cross-sectional study

The objective of this study was to assess the overall prevalence of the human papilloma virus (HPV) infection and distribution of high-risk HPV (hrHPV) types in Greece and evaluate the participation of women in primary and secondary cervical cancer prevention. This was a prospective, cross-sectional study carried out between October 2005 and January 2011 in Greece; 5379 women filled out the study questionnaire anonymously. 5107 women underwent cervical HPV-DNA testing, either by Hybrid Capture 2, followed by restriction fragment length polymorphism-PCR, or by the Abbott Real-Time High-Risk HPV test. Overall, 5.8% (295/5107) of women were positive for hrHPV infection. The most common hrHPV type was HPV-16 (24.8% among infected women; 1.4% overall), followed by HPV types 31, 35, 53, 18, 51, 56, 58, 52, 39, 66, 45, 33, 59, and 68. In respect to primary prevention of cervical cancer, acceptance of anti-HPV vaccination appeared to decrease over time (from 85-89.9% annually during 2005-2008 to 64.4-60.5% during 2009-2010, P<0.001). In respect to secondary prevention, only 30.3% of women had regular (annually for more than 5 years) Pap smears; regular gynecologic examinations, Papanicolaou testing, and knowledge of HPV were all associated with various demographic parameters (age, education, place of residence, occupation, and income). The prevalence of hrHPV infection in Greece is similar to that in other European countries; the most common type is HPV-16. The initially relatively high acceptance of HPV vaccination decreased after licensing of the vaccine. Demographic parameters appear to influence participation in cervical cancer screening.

Pelvic echinococcus mimicking multicystic ovary

An unusual case of pelvic echinococcus cyst is presented, appearing initially on transvaginal ultrasound as a pelvic mass mimicking a multicystic ovary. A similar mass in the liver raised preoperatively the suspicion of echinococcosis, making an open surgical procedure preferable to laparoscopy. Diagnosis was confirmed pathologically after removal of the cyst. Though their location in the pelvis is rare, echinococcal cysts should be considered in the differential diagnosis of pelvic masses, especially in patients from endemic areas. Evaluation of previous medical history and current symptoms, together with the ultrasonographic findings, is important for correct diagnosis and appropriate management.

Multifetal pregnancy reduction in pregnancies with a monochorionic component

We conducted a retrospective, cross-sectional study to evaluate the efficacy, safety, and effect of first-trimester multifetal pregnancy reduction on procedure-related complications and obstetrical outcome in multiple pregnancies with a monochorionic component. Although procedure-related complications were relatively common, the obstetrical outcome was favorable in most cases when the monochorionic twin component was reduced.

Mucocele of the vermiform appendix with sonographic appearance of an adnexal mass

Mucocele of the vermiform appendix is caused by mucus retention in its lumen, due to obstruction or hyperproduction. Appendiceal malignancy can be the underlying cause, making accurate preoperative diagnosis imperative. In women, it can sometimes present as an adnexal mass. A rare case of an appendiceal mucocele is presented, mimicking a cystic tumor of the right adnexum, both clinically and ultrasonographically. In addition, serum levels of CA-125 were increased. This is the first case of a mucocele of the appendix simulating an adnexal mass on ultrasound with increased levels of CA-125 to be reported. This clinical entity should be considered in patients presenting on ultrasound with a right-sided adnexal mass as a rare potential diagnosis.

Fetal nasal bone length in the second trimester: comparison between population groups from different ethnic origins

OBJECTIVE

To compare normal ranges of ultrasonographically measured fetal nasal bone length in the second trimester between different ethnic groups.

METHOD

A prospective, non-interventional study in order to establish normal ranges of fetal nasal bone length in the second trimester in a Greek population was conducted in 1220 singleton fetuses between 18 completed weeks and 23 weeks and 6 days of gestation. A literature search followed in order to identify similar studies in different population groups. Fetal nasal bone length mean values and percentiles from different population groups were compared.

RESULTS

Analysis of measurements in the Greek population showed a linear association, i.e., increasing nasal bone length with increasing gestational age from 5.73 mm at 18 weeks to 7.63 mm at 23 weeks. Eleven studies establishing normal ranges of fetal nasal bone length in the second trimester were identified. Comparison of fetal nasal bone length mean values between the 12 population groups showed statistically significant differences (P<0.0001).

CONCLUSION

Normal ranges of fetal nasal bone length in the second trimester vary significantly between different ethnic groups. Hence, distinct ethnic nomograms of fetal nasal bone length in the second trimester should be used in a given population rather than an international model.

Prenatal Management and Postnatal Separation of Omphalopagus and Craniopagus Conjoined Twins

Two cases of prenatally diagnosed conjoined twins are presented: a set of omphalopagus twins sharing a common liver, and a set of craniopagus with involvement limited to the skull. In both cases, prenatal diagnosis allowed accurate planning of pre- and postnatal management. Prenatal management involved serial imaging and counseling with participation of different specialists according to imaging findings. In the rare case of conjoined twins, an interdisciplinary approach is required, with feto-maternal specialists playing a pivotal role in co-ordinating teamwork and planning successive stages of management.