Progesterone rise on the day of human chorionic gonadotropin administration impairs pregnancy outcome in day 3 single-embryo transfer, while has no effect on day 5 single blastocyst transfer

Four hundred eighty-two patients undergoing single ET with GnRH-antagonist/recFSH protocol were analyzed. The incidence of premature luteinization (P above 1.5 ng/mL on the day of hCG administration) was 18.2%. Even modest rises of P in the follicular phase have detrimental effect on the implantation potential of a good-quality cleavage stage embryo. On the contrary, premature luteinization in the blastocyst subgroup had no effect on the pregnancy outcome.

Belgian consensus guidelines for follow-up of women with cervical cytological abnormalities

In medical care cervical cancer screening is important because it enables the detection of precancer and cancer at an early stage. By adequate treatment after a screening-detected lesion it helps to reduce the mortality related to cervical cancer. Worldwide, many millions of women have smears taken at a more or less regular base and of these, approximately 7% are abnormal, and follow-up is thus required.As this represents an important cost in medical health care and has serious consequences for the affected women, it is important to have uniform and clear guidelines to allow an optimal follow-up and clinical management. A system for the uniform reporting of cervical cytology has been designed by the National Cancer Institute (U.S.A.) and resulted in the Bethesda System 1991. The present paper and the terminology used are based on the Bethesda System revised in 2001. It explains the guidelines, based on the 2001 Bethesda System and the 2004 consensus guidelines for the management of women with cervical cytological abnormalities, as developed by the members of the Board of the Belgian Society of Clinical Cytology, and adapted to the Belgian situation.

Deconvolution-based dynamic contrast-enhanced MR imaging of breast tumors: correlation of tumor blood flow with human epidermal growth factor receptor 2 status and clinicopathologic findings--preliminary results

PURPOSE

To prospectively determine whether breast carcinomas possess characteristic values of tumor blood flow (TBF) that correlate with pathologic and molecular prognostic markers.

MATERIALS AND METHODS

The institutional ethics committee approved this study. After informed consent was obtained, 57 women (age range, 31-80 years) with histologically proved breast cancer underwent routine magnetic resonance (MR) mammography, which included a whole-breast dynamic contrast material-enhanced (DCE) sequence. A second contrast material bolus was injected during dynamic single-section turbo field-echo imaging of the section where the lesion was maximally enhanced. The relative signal intensity changes were deconvolved in a pixelwise fashion to yield the TBF. Formalin-fixed paraffin-embedded tumor specimens on slides were evaluated for histologic size and grade, as well as for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) protein. In patients with a HER2 protein score of 2+ or 3+, HER2 gene status was assessed. For all prognostic parameters, the Mann-Whitney U test was used to compare median TBF in the HER2-positive group with that in the HER2-negative group.

RESULTS

Significantly higher TBF was observed in tumors larger than 2 cm in diameter and in PR-negative and HER2 gene-amplified tumors (P < .05). In the HER2-positive and HER2-negative groups, ER-positive PR-positive tumors had a lower median TBF than did ER-negative PR-negative tumors, and the difference was significant in the HER2-positive group (P < .05).

CONCLUSION

Pixelwise deconvolution analysis of DCE MR data in patients with breast cancer can provide preoperative information regarding TBF. These results also support the hypothesis that there is increased TBF in HER2-positive tumors.

Tolerance of adjuvant letrozole outside of clinical trials

Recently aromatase inhibitors have become a standard care as an adjuvant treatment for many postmenopausal patients with hormone receptor positive early breast cancer. Adjuvant letrozole was made available either immediately postoperative, after 2-3 years of tamoxifen, or as an extended treatment after 5 years of tamoxifen. Between October 2003 and October 2005, we analyzed the subjective tolerance in 185 postoperative early breast cancer patients receiving letrozole outside of a clinical trial. The most prominent toxicity was musculoskeletal pain. In addition hot flushes, increased fatigue, nausea, vomiting, anorexia, mood disturbances, vaginal dryness, hair loss and rash were also recorded. In contrast to the prospective randomized clinical trials, a high drop-out rate of 20% was documented, mainly due to aromatase inhibitor-associated arthralgia syndrome interfering significantly with the daily life of our patients. Although adjuvant aromatase inhibitors have proven to be generally superior to tamoxifen in the adjuvant setting, it is important to focus attention on the tolerance during the adjuvant therapy and to balance this against the potential benefit in individual patients. Alternative options including switching to tamoxifen remain available.

Genomic activation of the EGFR and HER2-neu genes in a significant proportion of invasive epithelial ovarian cancers

BACKGROUND

The status of the EGFR and HER2-neu genes has not been fully defined in ovarian cancer. An integrated analysis of both genes could help define the proportion of patients that would potentially benefit from targeted therapies.

METHODS

We determined the tumour mutation status of the entire tyrosine kinase (TK) domain of the EGFR and HER2-neu genes in a cohort of 52 patients with invasive epithelial ovarian cancer as well as the gene copy number and protein expression of both genes in 31 of these patients by DGGE and direct sequecing, immunohistochemistry and Fluorescent in Situ Hybridisation (FISH).

RESULTS

The EGFR was expressed in 59% of the cases, with a 2+/3+ staining intensity in 38%. HER2-neu expression was found in 35%, with a 2/3+ staining in 18%. No mutations were found in exons 18-24 of the TK domains of EGFR and HER2-neu. High polysomy of the EGFR gene was observed in 13% of the invasive epthelial cancers and amplification of the HER2-neu gene was found in 10% and correlated with a high expression level by immunohistochemistry.Mutations within the tyrosine kinase domain were not found in the entire TK domain of both genes, but have been found in very rare cases by others.

CONCLUSION

Genomic alteration of the HER2-neu and EGFR genes is frequent (25%) in ovarian cancer. EGFR/HER2-neu targeted therapies should be investigated prospectively and specifically in that subset of patients.

A case of 'tropical' myelopathy

We present a case of lower limb sensory disturbances and weakness in a patient originating from Mali. MRI showed a diffuse myelopathy of the cervical and thoracic spinal cord. Serological evaluation of blood and cerebrospinal fluid pointed towards schistosomiasis as the cause. Histological confirmation was made on bladder-biopsy. Treatment with praziquantel and steroids brought marked clinical improvement. This case illustrates the need to keep in mind more exotic causes of myelopathy in those patients coming from endemic regions.

Prognostic value of histopathology and trends in cervical cancer: a SEER population study

BACKGROUND

Histopathology is a cornerstone in the diagnosis of cervical cancer but the prognostic value is controversial.

METHODS

Women under active follow-up for histologically confirmed primary invasive cervical cancer were selected from the United States Surveillance, Epidemiology, and End Results (SEER) 9-registries public use data 1973-2002. Only histologies with at least 100 cases were retained. Registry area, age, marital status, race, year of diagnosis, tumor histology, grade, stage, tumor size, number of positive nodes, number of examined nodes, odds of nodal involvement, extent of surgery, and radiotherapy were evaluated in Cox models by stepwise selection using the Akaike Information Criteria.

RESULTS

There were 30,989 records evaluable. From 1973 to 2002, number of cases dropped from 1,100 new cases/year to 900/year, but adenocarcinomas and adenosquamous carcinoma increased from 100/year to 235/year. Median age was 48 years. Statistically significant variables for both overall and cause-specific mortality were: age, year of diagnosis, race, stage, histology, grade, hysterectomy, radiotherapy, tumor size and nodal ratio. The histological types were jointly significant, P < 0.001. Cause-specific mortality hazard ratios by histological type relatively to non-microinvasive squamous cell carcinoma were: microinvasive squamous cell carcinoma 0.28 (95% confidence interval: 0.20-0.39), carcinoma not otherwise specified 0.91 (0.79-1.04), non-mucinous adenocarcinoma 1.06 (0.98-1.15), adenosquamous carcinoma 1.35 (1.20-1.51), mucinous adenocarcinoma 1.52 (1.23-1.88), small cell carcinoma 1.94 (1.58-2.39).

CONCLUSION

Small cell carcinoma and adenocarcinomas were associated with poorer survival. The incidental observation of increasing numbers of adenocarcinomas despite a general decline suggests the inefficiency of conventional screening for these tumors. Increased incidence of adenocarcinomas, their adverse prognosis, and the young age at diagnosis indicate the need to identify women who are at risk.

Combined analysis of three whole genome linkage scans for Ankylosing Spondylitis

OBJECTIVE

Ankylosing spondylitis (AS) is a debilitating chronic inflammatory condition with a high degree of familiality (lambda(s) = 82) and heritability (>90%) that primarily affects spinal and sacroiliac joints. Whole genome scans for linkage to AS phenotypes have been conducted, although results have been inconsistent between studies and all have had modest sample sizes. One potential solution to these issues is to combine data from multiple studies in a retrospective meta-analysis.

METHODS

The International Genetics of Ankylosing Spondylitis Consortium combined data from three whole genome linkage scans for AS (n = 3744 subjects) to determine chromosomal markers that show evidence of linkage with disease. Linkage markers typed in different centres were integrated into a consensus map to facilitate effective data pooling. We performed a weighted meta-analysis to combine the linkage results, and compared them with the three individual scans and a combined pooled scan.

RESULTS

In addition to the expected region surrounding the HLA-B27 gene on chromosome 6, we determined that several marker regions showed significant evidence of linkage with disease status. Regions on chromosome 10q and 16q achieved 'suggestive' evidence of linkage, and regions on chromosomes 1q, 3q, 5q, 6q, 9q, 17q and 19q showed at least nominal linkage in two or more scans and in the weighted meta-analysis. Regions previously associated with AS on chromosome 2q (the IL-1 gene cluster) and 22q (CYP2D6) exhibited nominal linkage in the meta-analysis, providing further statistical support for their involvement in susceptibility to AS.

CONCLUSION

These findings provide a useful guide for future studies aiming to identify the genes involved in this highly heritable condition.

Inheritance of arterial lesions in renal fibromuscular dysplasia

We have previously shown that patients with renal fibromuscular dysplasia (FMD) have asymptomatic carotid lesions and that familial forms may occur. The objective of this study was to test whether carotid lesions could be detected in relatives of familial cases. High-resolution echotracking of the carotid artery was performed in 47 relatives of 13 cases from six families. This non-invasive investigation led to a semiquantitative arterial score that was compared with that obtained for 47 controls matched for age and sex and that for 125 sporadic cases. Familial resemblance was tested by using a generalized estimating equation approach taking into account the clustering of scores in families. As expected, FMD cases had a significantly higher score than controls (4.02 vs 2.52, P<10(-5)). Familial cases were not significantly different from sporadic cases. Of interest, the 47 apparently healthy relatives of familial cases had also a high carotid score (4.17), very significantly higher than that of controls (2.52, P<10(-5)) even though lower than the corresponding index FMD cases (4.81, P=0.01). Segregation analysis showed that 52% of the descendants of subjects with a score >4 had a score >4, a proportion consistent with autosomal-dominant transmission of the trait. Altogether these results strengthen the hypothesis of renal FMD being a systemic arterial disease and argue for a familial resemblance that may be due to a major genetic effect. The carotid score obtained by high-resolution echotracking may provide a non-invasive surrogate marker for renal FMD of potential value for use in linkage strategies on large pedigrees.

Effect of oral administration of dydrogestrone versus vaginal administration of natural micronized progesterone on the secretory transformation of endometrium and luteal endocrine profile in patients with premature ovarian failure: a proof of concept

BACKGROUND

We aimed to explore the endometrial histology and endocrine profiles on day 21 of an artificial cycle in patients with premature ovarian failure (POF) treated with oral dydrogesterone (DG) or vaginal micronized progesterone.

METHODS

The study was designed as a prospective pilot study at an academic reproductive medicine unit. Six POF patients were included in the study. After estrogen endometrial priming, patients were randomized to receive DG or progesterone in two subsequent cycles. The main outcome measure was the endometrial histology and the endocrine profiles on day 21 of the cycle.

RESULTS

Development of endometrial glands corresponded to an early secretory phase in five out of six cases supplemented with DG (out-phase). In contrast, five out of six cases treated with micronized progesterone showed an endometrium corresponding to a mid-luteal phase (in-phase) (P = 0.021 versus DG). There was a significant difference in the mean progesterone value [8.6 versus 0.3 microg l(-1) (P = 0.013)], the mean LH value [12.9 versus 22.5 IU l(-1) (P = 0.049)] and the mean FSH value [13.0 versus 23.9 IU l(-1) (P = 0.047)] between the progesterone and DG group, respectively, on day 21 of the cycle.

CONCLUSIONS

After estrogen endometrial priming in POF patients, exogenous vaginal micronized progesterone is more effective than oral DG in creating an 'in-phase' secretory endometrium and induces significantly higher progesterone and lower LH and FSH serum concentrations on day 21 of the cycle.

Breast imaging. Preoperative breast cancer staging: comparison of USPIO-enhanced MR imaging and 18F-fluorodeoxyglucose (FDC) positron emission tomography (PET) imaging for axillary lymph node staging--initial findings

Magnetic resonance (MR) imaging after ultra-small super paramagnetic iron oxide (USPIO) injection and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) for preoperative axillary lymph node staging in patients with breast cancer were evaluated using histopathologic findings as the reference standard. USPIO-enhanced MR and FDG-PET were performed in ten patients with breast cancer who were scheduled for surgery and axillary node resection. T2-weighted fast spin echo, T1-weighted three-dimensional (3D) gradient echo, T2*-weighted gradient echo and gadolinium-enhanced T1-weighted 3D gradient echo with spectral fat saturation were evaluated. MR imaging before USPIO infusion was not performed. The results were correlated with FDG-PET (acquired with dedicated PET camera, visual analysis) and histological findings. The histopathologic axillary staging was negative for nodal malignancy in five patients and positive in the remaining five patients. There was one false positive finding for USPIO-enhanced MR and one false negative finding for FDG-PET. A sensitivity (true positive rate) of 100%, specificity (true negative rate) of 80%, positive predictive value of 80%, and negative predictive value of 100% were achieved for USPIO-enhanced MR and of 80%, 100%, 100%, 80% for FDG-PET, respectively. The most useful sequences in the detection of invaded lymph nodes were in the decreasing order: gadolinium-enhanced T1-weighted 3D gradient echo with fat saturation, T2*-weighted 2D gradient echo, T1-weighted 3D gradient echo and T2-weighted 2D spin echo. In our study, USPIO-enhanced T1 gradient echo after gadolinium injection and fat saturation emerged as a very useful sequence in the staging of lymph nodes. The combination of USPIO-enhanced MR and FDG-PET achieved 100% sensitivity, specificity, PPV and NPV. If these results are confirmed, the combination of USPIO MR with FDG-PET has the potential to identify the patient candidates for axillary dissection versus sentinel node lymphadenectomy.

Granulomatous lobular mastitis: a rare chronic inflammatory disease of the breast which can mimic breast carcinoma

Granulomatous lobular mastitis is a rare chronic inflammatory disease of the breast. The differential diagnosis with malign breast disease is often not easy. In most cases a surgical biopsy is needed for correct diagnosis. Idiopathic granulomatous mastitis is an exclusion diagnosis, based on the demonstration of a characteristic histological pattern, combined with the exclusion of other possible causes of granulomatous breast lesions. There is still no generally accepted optimal treatment. If surgery forms part of the treatment, a conservative approach seems to be adequate in most cases. Another option is a long-term steroid treatment. It is mandatory to exclude infectious causes of granulomatous mastitis before corticoid therapy is started.

Myomatous erythrocytosis syndrome

Uterine myomas are common but erythrocytosis caused by these is rarely seen. We report a case that illustrates the conjunction of various aetiological factors required for this clinical entity to evolve. A voluminous, retroperitoneally located and focally degenerated myoma was associated with severe secondary erythrocytosis (haematocrit: 65.5%) which resolved after hysterectomy. It has been demonstrated previously that myomatous tissue is the source of excessive production of erythropoietin. Local tissue hypoxia, which is more prone to develop in a pedunculated myoma, stimulates the process. Other prerequisites are a very large size of the myoma and the absence of menometrorrhagia of a severity such as to cause a depletion in iron reserves.

Prolongation of follicular phase by delaying hCG administration results in a higher incidence of endometrial advancement on the day of oocyte retrieval in GnRH antagonist cycles

BACKGROUND

Prolongation of follicular phase by delaying hCG administration has been reported to result in a significantly lower ongoing pregnancy rate that did not seem to be due to an embryonic factor. The aim of this prospective randomized study was to assess the effect of delaying hCG administration on endometrial histology.

METHODS

Ten oocyte donors underwent endometrial biopsy on the day of oocyte retrieval and endometrial histology was assessed by Noyes' criteria. Ovarian stimulation was performed with recombinant (r)FSH and daily GnRH antagonist starting on day 6 of stimulation. Patients were randomized by a computer-generated list to receive 10 000 IU of hCG either as soon as > or =3 follicles > or =17 mm were present on ultrasound (early-hCG group, n = 5) or 2 days after this criterion was met (late-hCG group, n = 5).

RESULTS

When hCG was delayed, endometrial advancement was present in all samples examined (median advancement 3 days, range 2-3 days). On the contrary, no secretory changes were observed when the follicular phase was not prolonged (difference in the proportion of patients with advancement between the early-hCG and the late-hCG group: 100%, 95% CI: 38-100).

CONCLUSIONS

Prolongation of follicular phase by delaying hCG administration results in a higher incidence of endometrial advancement on the day of oocyte retrieval in GnRH antagonist cycles.

A persistently recurring peri-urethral soft tissue lesion of the vulva

Various mesenchymal lesions, some of which have only recently been characterized, may affect the vulva. Because of their apparently shared origin from vulvovaginal mesenchyme, these lesions can resemble one another superficially and can be challenging diagnostically. Clinically, benign lesions and tumor-like conditions may mimic a malignant process because of hypercellularity, mitotic activity, and rapid growth. We report on a 84-year-old diabetic and hypertensive woman who had previously undergone skinning vulvectomy for lichen planus and an embolectomy of the left femoral artery. The patient presented with a rapidly growing vulvar mass. The biopsy showed spindle cell proliferation in a loose myxoid stroma with granulation tissue and a mixed inflammatory infiltrate. Based on histology and immunohistochemistry, the initial diagnosis was that of a benign lesion. In view of the persistent recurrence of the lesion and the absence of metastatic spread, we conclude that the lesion has a low-grade malignant potential and suggest the diagnosis of florid cellular reactive pseudosarcomatous myofibroblastic proliferation.

Steroid receptor expression in late follicular phase endometrium in GnRH antagonist IVF cycles is already altered, indicating initiation of early luteal phase transformation in the absence of secretory changes

BACKGROUND

Ovarian stimulation for IVF profoundly alters the early luteal phase endometrial development. It has been hypothesized that this process has already started in the late follicular phase, as the endometrium has already been exposed to high steroid concentrations since that phase. The aim of the present study was to prospectively investigate the effect of multi-follicular ovarian stimulation for IVF on the late follicular phase endometrium histology and the expression of estrogen receptor (ER) and progesterone receptor (PR).

METHODS

In a cross-over study, 11 infertile women with normal ovulatory function, participating in an IVF programme and treated with GnRH antagonist/recombinant FSH ovarian stimulation, were enrolled in the study. Endometrial biopsies were taken in a natural cycle on the day of the onset of the surge of the LH, and in a subsequent stimulation cycle on the day of hCG administration for final oocyte maturation. Endometrial histological dating was carried out according to Noyes' criteria. Immunohistochemistry was performed, using commercially available antibodies for ER and PR endometrial expression. The immunohistochemical signal was recorded in 1000 epithelial cells in each compartment (glands and stroma). Endometrial expression for each of the two receptors was graded on a scale of 0-3, based on the intensity of nuclear staining. Then a score range between 0 and 3000 was recorded, and expressed as a mean score per 1000 stroma or glandular cells per sample (range: 0-3).

RESULTS

Histological examination of biopsies both in natural and stimulated cycles showed no secretory changes. However, in stimulated cycles, PR expression was significantly up-regulated compared to natural cycles in both glands (1.67 versus 1.34, P < 0.05) and stroma (1.98 versus 1.62, P < 0.05), whereas ER was down-regulated in glands (1.15 versus 1.43, P < 0.05). In IVF cycles, the progesterone measurements, although within normal values (range 0.8-1.4 microg/l), were significantly higher than in natural cycles (0.99 vs 0.63 microg/l, respectively, P = 0.008). An ongoing pregnancy rate of 37.5% was achieved in the stimulated cycles.

DISCUSSION

Although the current study found no early secretory transformation in stimulated endometria before hCG administration, the ER and PR expression in these endometria is similar to the one described during the first days of the luteal phase in natural cycles. Supraphysiological concentrations of estradiol and subtle progesterone rises in the late follicular phase might be responsible for this modulated steroid receptor profile. This phenomenon indicates accentuated maturation of the endometrium in IVF cycles from the pre-ovulatory phase onwards.

Primary lymphoma of the cervix uteri: a diagnostic challenge. Report of two cases and review of the literature

BACKGROUND

Primary non Hodgkin's lymphoma (NHL) of the cervix and vagina is uncommon; the incidence of uterine lymphoma is estimated to be less than 0.5% of all NHL. Patients regularly present with vaginal bleeding. The diagnosis is made on biopsy but this can be difficult on small samples which may not be representative of the lesion. Immunohistochemical analysis and often molecular techniques are required to confirm the diagnosis.

CASES

We report two cases of primary diffuse large B-cell lymphoma of the cervix. In the first case, the diagnosis could only be made on repeat biopsies. The second case presented as a cervical polyp.

CONCLUSION

Gynecologists should be aware of this rare clinical entity in order to apply the proper treatment.

Low-grade endometrial stromal sarcoma treated with the aromatase inhibitor letrozole

BACKGROUND

Low-grade endometrial stromal sarcoma is an indolent steroid responsive tumor. Successful hormonal treatment, most commonly with megestrol acetate, has been reported.

CASE

A 76-year-old woman underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy 25 years earlier allegedly for a benign condition. She presented to us with postrenal kidney failure and a huge pelvic mass compressing both ureters. After transvaginal trough-cut biopsy of the mass, the diagnosis of low-grade endometrial stromal sarcoma with a high expression of alpha-estrogen receptor was made. The patient was treated with letrozole only with a spectacular response.

CONCLUSION

To the best of our knowledge, this is the first case for which letrozole was used on long-term basis as first-line hormonal treatment for a recurrent low-grade stromal sarcoma.

A tale of medical shopping or the hazards of repetitious cytological screening of the cervix

A 65-year-old woman had on her own initiative three cervical smears taken at very short intervals. The second smear was taken only 1 day after the first one. It contained necrotic cellular material with atypia due to the scraping on the day before; it was at first mistakenly interpreted as showing malignant features. This led to the performance of various diagnostic procedures, and a considerably greater cost for the medical insurance system.

Number of ovarian follicles in human fetuses with the 45,X karyotype

OBJECTIVE

To evaluate the numbers of ovarian follicles during fetal life in the gonads of human female fetuses with the 45,X karyotype (Turner syndrome, TS) and to compare them with those from age-matched 46,XX fetuses.

DESIGN

Retrospective study.

SETTING

An academic hospital.

PATIENT(S)

Ovarian samples from TS fetuses (aged 17-37 weeks), mainly obtained after induced abortion, and ovaries from eight control fetuses (matching gestational ages).

INTERVENTION(S)

Embedded blocks of ovaries were collected from anatomy-pathology departments of three university hospitals and were sectioned and stained with hematoxylin-eosin.

MAIN OUTCOME MEASURE(S)

Observation of primordial and growing follicles.

RESULT(S)

In the fetal ovaries of controls, numerous oogonia were observed at 18 weeks. Primordial follicles were present in all ovaries from 20 weeks' gestation onward, whereas preantral and antral follicles were observed from 26 weeks onwards. In ovaries from 45,X TS fetuses, oogonia were observed in some ovaries, but no primordial, preantral, or antral follicles were found, even in ovaries from the third trimester of gestation.

CONCLUSION(S)

Follicle formation and growth are severely reduced in ovaries from aborted 45,X TS fetuses.

Reproductive biology and IVF: ovarian stimulation and endometrial receptivity

The influence of ovarian stimulation on endometrium receptivity has been inadequately addressed in medical literature. Hormonal effects of ovarian stimulation on endometrial changes as compared with the natural cycle should be elucidated and correlated with the potential of the embryo to implant. It is important to distinguish between the endometrial effect of induction of ovulation in anovulatory women and those of ovarian (super)ovulation in ovulatory women. Induction of ovulation leads to in vivo conception whereas ovarian stimulation results in in vitro fertilization. The available data in the field indicate that endometrial changes have an impressive negative influence on the potential of embryonic implantation. The aim of this review is to analyse the effects of gonadotropin, GnRH-agonist and GnRH-antagonist administration on endometrial behaviour, to highlight the gaps in current knowledge and to propose areas in which research is needed.

Apport de la biopsie d’endomètre dans l’évaluation de la réceptivité utérine

The histological changes underwent by endometrium during a natural menstrual cycle were described more than 50 years ago. Dating yields several methodological flaws, with intra- and inter-observer variability and shows questionable relationship to endometrial receptivity. The best studied endometrial factors involved in implantation include the formation of luminal epithelial "pinopodes", expression of adhesion molecules and of cytokines. Ovarian stimulation for IVF is known to affect luteal phase function. Factors influencing the endometrial receptivity in such cycles are poorly understood. Studies comparing the endometrium in IVF cycles with natural cycle controls have shown premature secretory changes in the postovulatory and early luteal phase of IVF cycles. These findings suggest a profound modification of luteal endometrial development in stimulated cycles. Studies exploring the endometrium within the cycle of embryo transfer have shown a deleterious effect of severe periovulatory maturation advancement exceeding 3 days, as no clinical pregnancies were observed in this condition.

The endometrium in stimulated cycles for IVF

Ovarian stimulation for IVF is known to affect luteal phase function. The endometrium in IVF cycles is thus subject to an altered endocrinological environment and to a possible direct effect of the ovarian stimulation therapy. Factors influencing the endometrial receptivity in such cycles are poorly understood. Studies comparing the endometrium in IVF cycles with natural cycles as controls have shown premature secretory changes in the post-ovulatory and early luteal phase of IVF cycles, followed by a large proportion of dyssynchronous glandular and stromal differentiation in the mid-luteal phase. These findings suggest a profound modification of luteal endometrial development in stimulated cycles. This hypothesis is further supported by the demonstration of a modified endometrial steroid receptor regulation and a profound antiproliferative effect in IVF cycles. The time of maximal endometrial receptivity is defined as the implantation window and is characterized by the expression of various endometrial products, among which pinopodes, integrins and leukaemia inhibitory factor are best described. Premature expression of pinopodes and integrins are in line with the observation of precocious luteal transformation following ovarian stimulation, although the clinical relevance with respect to the establishment of a clinical pregnancy awaits further validation. Studies exploring the endometrium within the cycle of embryo transfer have shown a deleterious effect of severe peri-ovulatory maturation advancement exceeding 3 days, as no clinical pregnancies were obtained in this condition. Further unravelling of molecules involved in the implantation mechanism is needed for a better comprehension of the link between altered endometrial development and receptivity in IVF cycles.

Human oocytes reversibly arrested in prophase I by phosphodiesterase type 3 inhibitor in vitro

This study addresses the role of cAMP hydrolytic isoenzyme phosphodiesterase type 3 (PDE 3) modulation on human oocyte maturation in vitro. Presence of phosphodiesterase type 3 A (PDE 3A) mRNA was confirmed in human germinal vesicle-stage (GV) oocytes. Making use of a selective PDE 3 inhibitor, Org 9935 (10 microM), oocytes retrieved from immature follicles were arrested in prophase I with a high efficiency for up to 72 h. Cumulus oocyte complexes (COCs) were retrieved in the follicular phase of the cycle before or after exposure to endogenous LH or hCG administration in vivo and randomly distributed into maturation medium with or without the PDE 3 inhibitor. Previous exposure of small follicles to LH activity in vivo had no influence on the arresting capacity of the PDE 3 inhibitor. Reversal from pharmacological arrest leads to a progression through meiosis in a normal time frame with formation of a well-aligned metaphase plate. Ultrastructure analysis of COC derived from follicles between 8 and 12 mm showed that the induced extension of prophase I arrest in vitro resulted in cytoplasm changes but not in apparent nuclear changes during culture.

Endometrial integrin expression in the early luteal phase in natural and stimulated cycles for in vitro fertilization

OBJECTIVE

To investigate the effect of ovarian stimulation on integrin expression in the early luteal phase.

STUDY DESIGN

Seven endometrial biopsies were taken 2 days after the oocyte retrieval from stimulated cycles for IVF and 23 from natural cycles, 2 days after ovulation.

RESULT

Endometrium was in-phase in 22/23 and 7/7 biopsies from the natural and stimulated cycles, respectively. Integrins alpha(1) and alpha(4) were simultaneously positive in 43.4% from the natural and in all (100%) the stimulated cycles (P<0.03). On the day of the endometrial biopsy, progesterone serum values were higher in the stimulated cycles (55.2+/-9.5 microg/l versus 8.5+/-3.8 microg/l) (P<0.001). HSCORE value was significantly higher in stimulated cycles for both integrins.

CONCLUSION

Endometrial integrin expression is more consistently present in the early luteal phase in stimulated cycles than in natural cycles and this may be related to the higher serum progesterone concentration and/or the more advanced endometrial histological features.

Toxic intrathoracic goiter and mediastinal lymphadenopathy: an unusual presentation of systemic primary AL amyloidosis

Mediastinal lymphadenopathy and goiter have been associated with primary amyloidosis, although not in the same patient. One previous case report described the association of an amyloid goiter and hyperthyroidism (due to Graves' disease) with primary amyloidosis. Till now no case reports of patients presenting simultaneously with mediastinal lymphadenopathy, intrathoracic amyloid goiter and hyperthyroidism as the first manifestation of systemic primary (idiopathic) amyloidosis have been described. The present case report describes the clinical, biological radiological and histological features in such a male patient.

Effect of ovarian stimulation with recombinant follicle-stimulating hormone, gonadotropin releasing hormone antagonists, and human chorionic gonadotropin on endometrial maturation on the day of oocyte pick-up

OBJECTIVE

To assess the effect of ovarian stimulation with recombinant FSH, GnRH antagonists, and hCG on endometrial maturation on the day of oocyte pick-up.

DESIGN

Prospective study.

SETTING

Tertiary referral center.

PATIENT(S)

Fifty-five women undergoing controlled ovarian hyperstimulation for IVF/intracytoplasmic sperm injection (ICSI).

INTERVENTION(S)

[1] Ovarian stimulation with recombinant FSH, starting on day 2 of the cycle and GnRH antagonist, starting after a median of 6 days of recombinant FSH stimulation (range, 5-12 days); [2] hCG administration for ovulation induction; and [3] aspirational biopsy of endometrium at oocyte pick-up.

MAIN OUTCOME MEASURE(S)

Endometrial histology at oocyte pick-up by Noyes criteria.

RESULT(S)

Advancement of endometrial maturation (2.5 +/- 0.1 days) as compared to the expected chronological date was observed in all antagonist cycles at oocyte retrieval. Endometrial advancement at oocyte pick-up increased in line with values of LH at initiation of stimulation and the duration of recombinant FSH treatment before the antagonist was started.

CONCLUSION(S)

The higher the values of LH at initiation of stimulation and the longer the duration of recombinant FSH treatment before the antagonist is started, the more advanced the endometrial maturation at oocyte pick-up.

Endometrial hormone receptors and proliferation index in the periovulatory phase of stimulated embryo transfer cycles in comparison with natural cycles and relation to clinical pregnancy outcome

OBJECTIVE

To investigate the endometrial steroid receptors and proliferation index in GnRH analogue/hMG-stimulated cycles in comparison with natural cycles and their relation to clinical pregnancy outcome.

DESIGN

Prospective observational study.

SETTING

Tertiary referral center.

PATIENT(S)

Twenty-seven stimulated patients with GnRH agonist and hMG. Twenty normo-ovulatory patients were the natural cycle controls.

INTERVENTION(S)

Endometrial aspiration biopsies: in stimulated cycles on the day of oocyte retrieval within the ET cycle (Day OPU) (n = 20) or 2 days later (Day OPU + 2) (n = 7); in natural cycles on the natural day of ovulation (Day NO) (n = 10) or on the day of ovulation + 2 (Day NO + 2) (n = 10).

MAIN OUTCOME MEASURE(S)

Comparison of endometrial maturation, estrogen (ER) and P receptor (PR), and proliferation index by immunohistochemistry in natural and stimulated cycles, correlation with pregnancy outcome in stimulated cycles.

RESULT(S)

Stimulated cycles Day OPU showed significantly advanced endometrial maturation compared to natural cycles Day NO; stromal ER and glandular and stromal PR staining was lower in stimulated than in natural cycles, but higher on Day OPU than on Day NO + 2; proliferation index was lower in all stimulated cycles. Steroid receptors and proliferation index in stimulated cycles were unrelated to clinical pregnancy occurrence.

CONCLUSION(S)

Compared to natural cycles, ovarian stimulation induced an imbalance in endometrial ER and PR and led to a profound antimitotic effect in the peri-ovulatory phase. These parameters were, however, not predictive of clinical pregnancy in cycles with ET.

CD80 (B7-1) and CD86 (B7-2) genes and genetic susceptibility to coeliac disease

The role of the costimulatory molecules B7-1 (CD80) and B7-2 (CD86) in T-cell activation makes them good candidates for coeliac disease susceptibility genes. We conducted a genetic linkage study of the CD80/86 gene region in the general Finnish population and in a local subisolate. No linkage was found in either population.

Maximum identity length contrast: a powerful method for susceptibility gene detection in isolated populations

We report the results of our analysis of the Genetic Analysis Workshop 12 simulated data set. Focusing on the isolated populations, we compare the efficiency of a new method, the maximum identity length contrast statistic (MILC) with the maximum likelihood score (MLS) in a genome screen strategy. MILC is a method based on the contrast of haplotype identity between transmitted and nontransmitted haplotypes in trios. It uses information on linkage and association. We found that MILC allows the detection of a risk factor corresponding to candidate gene 1 where the MLS fails, though the same population replicates were used. Interestingly, the association between this risk factor and the disease could not have been detected with the TDT at a genome-wide level.

Loss of nuclear BRCA1 localization in breast carcinoma is age dependent

Abstract. Patients carrying a germ line mutation in the BRCA1 gene are predisposed to breast cancer. Somatic BRCA1 mutations were almost never reported in sporadic breast tumors, but several authors have described a decrease in BRCA1 mRNA and protein. In order to further investigate the possible role of BRCA1 in sporadic breast cancer, an improved immunohistochemical protocol was developed and applied on tissue sections obtained from 102 cancer patients belonging to two nonoverlapping age groups (less than 40 and more than 60 years). Based on the obtained BRCA1 specific nuclear staining we could distinguish two categories of breast cancer. The staining was present in almost all the nuclei of the normal and the cancer cells in about 50% of young (less than 40 years old) as well as older patients (more than 60 years old). Thus, BRCA1 does not seem to be involved in the genesis of these cancers. In the second category of patients, either a fraction of, or all tumor cells showed no nuclear staining. In this category, no nuclear BRCA1 staining could be observed in the tumor cells of 14 (27%) young and 3 (6%) older patients. Among six young patients bearing a breast tumor showing no BRCA1 nuclear staining at all, one was found to carry a BRCA1 germline mutation. Taken together, our results suggest that the molecular pathway in which the BRCA1 protein participates is disturbed in about 50% of sporadic breast cancer, this effect being more pronounced in tumors of young patients.