Post Surgical Management of WHO Grade II Meningiomas: Our Experience, the Role of Gamma Knife and a Literature Review

Purpose: Grade II meningiomas are rarer than Grade I, and when operated on, bear a higher risk of local recurrence, with a 5-year progression free survival (PFS) ranging from 59 to 90%. Radiotherapy (RT) or radiosurgery, such as Gamma Knife radiosurgery (GKRS) can reduce the risk of relapse in patients with residual disease, even if their role, particularly after gross total resection (GTR), is still under debate. Main goal of this study was to compare the outcomes of different post-surgical management of grade II meningiomas, grouped by degree of surgical removal (Simpson Grade); next in order we wanted to define the role of GKRS for the treatment of residual disease or relapse. Methods: from November 2016 to November 2020 all patients harboring grade II meningiomas, were divided into three groups, based on post-surgical management: (1) wait and see, (2) conventional adjuvant radiotherapy and (3) stereotactic GKRS radiosurgery. Relapse rate and PFS were registered at the time of last follow up and results were classified as stable, recurrence next to or distant from the surgical cavity. In the second part of the study we collected data of all patients who underwent GKRS in our Centers from November 2017 to November 2020. Results: A total of 37 patients were recruited, including seven patients with multiple meningiomas. Out of 47 meningiomas, 33 (70.2%) were followed with a wait and see strategy, six (12.7%) were treated with adjuvant radiotherapy, and 8 patients (17.0%) with adjuvant GKRS. Follow up data were available for 43 (91.4%) meningiomas. Within the wait and see group, recurrence rates differed based on Simpson grades, lower recurrence rates being observed in three Simpson I cases (30%) compared to twelve relapses (60%) in patients with Simpson grade II/III. Finally, out of the 24 meningiomas undergoing GKRS (8 residual and 16 recurrence), 21 remained stable at follow up. Conclusions: Gross total resection (GTR) Simpson II and III have a significantly worse outcome as compared to Simpson I. The absence of adjuvant treatment leads to significant worsening of the disease progression curve. Adjuvant radiotherapy, especially GKRS, provides good local control of the disease and should be considered as an adjuvant treatment in all cases where Simpson I resection is not possible.

O-132 Sustained efficacy and safety of relugolix combination therapy in women with endometriosis-associated pain: SPIRIT 52-week data

Study question

To assess the long-term (52-week) efficacy and safety of relugolix combination therapy (Relugolix-CT) in the treatment of endometriosis-associated pain.

Summary answer

Relugolix-CT demonstrated a sustained improvement of endometriosis-associated pain and maintenance of bone mineral density (BMD) over the extension treatment period. It was well tolerated.

What is known already

Endometriosis is a chronic condition characterized by symptoms of menstrual and non-menstrual pain, and dyspareunia, which have a substantial impact on women’s lives. SPIRIT 1 and 2 were Phase 3, randomized, double-blind, placebo-controlled studies of once-daily Relugolix-CT (relugolix 40 mg, estradiol 1 mg, norethindrone acetate 0.5 mg) in premenopausal women (age 18–50 years) with surgically diagnosed endometriosis and moderate-to-severe dysmenorrhea and non-menstrual pelvic pain (NMPP) at baseline. These trials demonstrated a significant improvement of dysmenorrhea, NMPP and dyspareunia in women treated with Relugolix-CT, with a minimal decline in BMD vs placebo over 24 weeks.

Study design, size, duration

Women who completed the 24-week pivotal studies (SPIRIT 1 and 2 trials) were eligible to enroll in an open-label, single-arm, long-term safety and efficacy extension study for an additional 80 weeks. All women received once-daily oral Relugolix-CT. Analyses were done based on original randomization in pivotal studies: Relugolix-CT, delayed Relugolix-CT (relugolix 40 mg alone for 12 weeks, then Relugolix-CT for 12 weeks), or placebo. Here, 52-week efficacy and safety outcomes are presented.

Participants/materials, setting, methods

The primary endpoints were the proportion of dysmenorrhea and NMPP responders at Week 52, based on daily Numerical Rating Scale (NRS) scores (0=no pain, 10=worst pain imaginable). A responder was a woman who achieved a predefined, clinically meaningful reduction from baseline in NRS score with no increase in analgesic use. Secondary efficacy endpoints included change in Endometriosis Health Profile-30 (EHP-30) pain domain scores, and analgesic/opioid use. Safety endpoints included adverse events (AEs) and BMD evaluation.

Main results and the role of chance

Of 1261 randomized patients, 1044 completed the primary studies; 802 enrolled in the long-term extension and 681 completed 52 weeks of treatment. Baseline demographics and clinical characteristics of the extension population were consistent with those of the original randomized population.

Sustained improvement of endometriosis-associated pain was demonstrated with Relugolix-CT through 52 weeks, the proportion of responders for dysmenorrhea was 84.8% and 73.3% for NMPP.

NRS least squares (LS) mean scores for dysmenorrhea and NMPP decreased from 7.4 (severe) and 6.0 (moderate) at SPIRIT study baseline to 1.3 (mild) and 2.2 (mild) at Week 52, equating to 82.8% and 62.9% reduction in dysmenorrhea and NMPP, respectively. Mean NRS for dyspareunia decreased from 5.9 (moderate) to 2.4 (mild), demonstrating 60.1% reduction with Relugolix-CT.

Daily functioning measured by the EHP-30 pain domain score was improved (–38.1 point) and the majority of women (85.6%) were opioid-free at Week 52. There was no disproportionate increase in the incidence of AEs in the Relugolix-CT group with no new safety signals identified through the 52 weeks. BMD was preserved over the extension period with overall LS mean change from baseline to Week 52 of –0.83% (95% CI: –1.34, –0.32) for lumbar spine in the Relugolix-CT group.

Limitations, reasons for caution

The study was conducted as an open-label study without a control group over the 28 weeks of the extension period.

Wider implications of the findings

Relugolix-CT demonstrated a sustained improvement of dysmenorrhea, NMPP, and dyspareunia, and reduced pain-related functional limitations and the need for opioids over 52 weeks in women with moderate-to-severe endometriosis-associated pain. Relugolix-CT was generally well tolerated and associated with minimal BMD loss after treatment initiation followed by BMD maintenance over 52 weeks.

Trial registration number

NCT03654274

SAT0267 ROLE OF AGGRESSIVE IMMUNOSUPPRESSION ON SUBGLOTTIC STENOSIS IN GRANULOMATOSIS WITH POLYANGIITIS: RETROSPECTIVE ANALYSIS OF A MONOCENTRIC COHORT

Background:

Subglottic stenosis (SGS) is defined as airway narrowing below the vocal cords and is a common and potentially life-threatening manifestation of Granulomatosis with Polyangiitis (GPA), with an estimated prevalence of 16-23% (1). Balloon catheter dilation is effective in GPA-related SGS, but relapses are frequent. Little is known about the role of immunosuppression in this setting.

Objectives:

to analyse the clinical characteristics of a monocentric GPA cohort, describe phenotype differences among patients with and without SGS and investigate the role of surgical and medical treatments on relapse risk and general outcome.

Methods:

Biopsy-proven patients with SGS were identified by review of medical charts among a cohort of patients with GPA, classified according to the algorithm of the European Medicine Agency (2). The clinical characteristics of patients with SGS were retrospectively collected over a median follow-up time of 15.9 years and compared to those of patients without SGS.

Results:

Fourteen patients with SGS-GPA were identified, with a female to male ratio of 1:1 and a prevalence of 29.2% among the cohort. The mean ± SD age at GPA onset was 30.8 ± 14.4 years, with a mean time from GPA diagnosis to SGS onset of 4.7 ± 4.2 years. ANCA were positive in 78.6% (54.0% anti-PR3, 18.1% anti-MPO and 27.9% IFI only). The mean Birmingham Vasculitis Activity Score (BVAS) at onset was 10.0 ± 5.6. The main clinical manifestations associated with SGS were crusty rhinitis (100%), sinusitis (78%), pulmonary disease (72.7%), otitis/mastoiditis (50%), glomerulonephritis (42.9%), orbital pseudotumor (28.6%). Six patients (42.9%) received medical treatment only, other six (42.9%) had one to three balloon dilations and two (14.2%) underwent four or more procedures. Eight patients had no SGS relapse (maximum one dilation) and they all received immunosuppression with rituximab (RTX), cyclophosphamide (CYC) or azathioprine (AZA). All patients who received no immunosuppression, methotrexate (MTX) or mycophenolate (MMF) had at least one relapse. Patients treated with MTX or MMF had a mean relapse-free survival of 13.1 months, which was comparable to the one of patients not receiving medical treatment (40.2 months; p=NS) and shorter than the one of patients receiving CYC or RTX (153.2 months; p=0.032). CYC use also inversely correlated with the number of surgical procedures (r=-0.691, p=0.006). Compared to patients without SGS (31 consecutive patients with at least 4 years of follow-up), patients with SGS-GPA had an earlier disease onset (mean age 30.8 vs 50.4 years; p<0.001), but with lower BVAS (mean 10.0 vs 15.3; p=0.013) and showed a higher prevalence of crusty rhinitis (100% vs 67.7%; p=0.019). No difference was observed in damage accrual over time between the two groups.

Conclusion:

Subglottic stenosis is highly prevalent in patients with GPA and may define a milder disease subset occurring more frequently in younger patients. MTX and MMF might be insufficient to prevent SGS relapses requiring balloon dilation. Aggressive immunosuppression (CYC or RTX) might have a non-redundant role in this setting and reduce the risk of relapses.

References:

[1]Quinn KA, et al. Subglottic stenosis and endobronchial disease in granulomatosis with polyangiitis. Rheumatology 2019; 58 (12), 2203-2211.

[2]Watts R, et al. Development and validation of a consensus methodology for the classification of the ANCA associated vasculitides and polyarteritis nodosa for epidemiological studies. Ann Rheum Dis 2007; 66: 222-7.

Disclosure of Interests:

Luca Moroni: None declared, Laura Giudice: None declared, Giuseppe Alvise Ramirez: None declared, Silvia Sartorelli: None declared, adriana cariddi: None declared, Angelo Carretta: None declared, Enrica Bozzolo: None declared, Lorenzo Dagna Grant/research support from: The Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR) received unresctricted research/educational grants from Abbvie, Bristol-Myers Squibb, Celgene, Janssen, Merk Sharp & Dohme, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI., Consultant of: Prof Lorenzo Dagna received consultation honoraria from Abbvie, Amgen, Biogen, Bristol-Myers Squibb, Celltrion, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI.

A multicentre study on epidemiology and prevention of needle stick injuries among students of nursing schools

INTRODUCTION

Among the health professions with a long period of training, the students of the Nursing Bachelor's Degree are the most exposed to biological risk resulting from accidents, in particular with needles and cutting edges. The aim of the study was to estimate the frequency and the circumstances for the occurrence of needle stick injuries, as a knowledge base for targeted prevention interventions.

METHODS

The study was carried out between May and July 2017 in 11 Universities in Italy and 1 in Albania (associated with the "Tor Vergata" University of Rome). An anonymous semi-structured questionnaire was proposed to 1st (second semester), 2nd and 3rd year students of Nursing Bachelor's Degree.

RESULTS

A total of 2742 questionnaires were collected. The average age of participants was 22.9 years (median 22, range 19-60 years), 73% of whom were females. A total of 381 injuries were reported. Three hundred and sixteen students (11.8%) underwent at least 1 injury (12.7% among females, 9.7% among males); 41 students declared two or more injuries; four students did not report the number of injuries occurred. The first injury occurred, as an average, 17 days after the start of the internship (median 15 days) and, in 25% of the cases, during the first 9 days. The highest percentage of accidents occurred during the first internship (25.3% of the total) and decreased with the progress of the training path. The injuries occurred in 38% of cases during drug preparation, 24% when disposing of sharp devices, 15% while re-capping needles, 13% during blood sampling and 10% in other circumstances. In 51.2% of cases, the needle was not sterile. Among the nursing students who suffered a needle stick injury, 58.1% declared that they had performed the post-exposure prophylaxis. 96% of students stated to be vaccinated against Hepatitis B virus. Amongst the students who had their serological status checked (74%), 18% stated the antibody titre was not protective. 49.8% of students answered to have been trained in advance on the correct procedures to avoid needle stick and cutting edges injuries in each clinical ward attended, 41.2% referred that this occurred only in some wards and 10% in no ward at all.

CONCLUSION

The results of this study show a high percentage of needle stick injuries in students of the Nursing Bachelor's Degree. Therefore, there is a need for careful reflection on the most effective methods of targeted training acquisition of knowledge, skills and behavioural models useful for the exercise of the profession.

Bone resorption in autologous cryopreserved cranioplasty: quantitative evaluation, semiquantitative score and clinical significance

BACKGROUND

Changes after reimplantation of the autologous bone have been largely described. However, the rate and the extent of resorption in cranial grafts have not been clearly defined. Aim of our study is to evaluate the bone flap resorption (BFR) after cryopreservation.

METHODS

We retrospectively reviewed 27 patients, aged 18 years or older, subjected to cranioplasty (CP) adopting autologous cryopreserved flap. The BFR was derived from the percentage of decrease in flap volume (BFR%), comparing the first post-operative computed tomography (CT) and the last one available (performed at least 1 year after surgery). We also proposed a semiquantitative scoring system, based on CT, to define a clinically workable BFR classification.

RESULTS

After a mean ± SE follow-up of 32.5 ± 2.4 months, the bone flap volume decreased significantly (p < 0.0001). The mean BFR% was 31.7 ± 3.8% and correlated with CT-score (p < 0.001). Three BFR classes were described: mild (14.8% of cases) consisting in minimal bone remodelling, CT-score ≤ 6, mean BFR% = 3.5 ± 0.7%; moderate (51.9% of cases) corresponding to satisfactory cerebral protection, CT-score < 13, mean BFR% = 25.6 ± 2.2%; severe (33.3% of cases) consisting in loss of cerebral protection, CT-score ≥ 13, mean BFR% = 54.2 ± 3.9%. Females had higher BFR% than males (p = 0.022). BFR classes and new reconstructive surgery were not related (p = 0.58).

CONCLUSIONS

BFR was moderate or severe in 85.2% of re-implanted cryopreserved flaps. The proposed CT-score is an easy and reproducible tool to define resorption extent.

Safety of transsphenoidal microsurgical approach in patients with an ACTH-secreting pituitary adenoma

PURPOSE

Patients affected by Cushing's disease often have important comorbidities directly linked to hypercortisolism that might enhance the operative risk. We report the safety of transsphenoidal surgery in patients affected by Cushing's disease as compared with patients with nonfunctioning pituitary adenoma.

METHODS

We have retrospectively analyzed 142 patients with Cushing's disease and 299 patients with nonfunctioning pituitary adenoma who underwent transsphenoidal surgery performed by a single experienced neurosurgeon between September 2007 and December 2014. For all of them, an intraoperative computerized anesthetic record for the automatic storage of data was available.

RESULTS

The intraoperative vital parameters and the frequency of drugs administered during anesthesia were comparable between Cushing's disease and nonfunctioning pituitary adenoma groups. The duration of surgery was similar between the two groups (41.2 ± 11.8 vs. 42.9 ± 15.6 min), while the duration of anesthesia was slightly shorter in Cushing's disease patients (97.6 ± 18.1 min) than in nonfunctioning pituitary adenoma patients (101.6 ± 20.6 min, p = 0.04). The total perioperative mortality rate was 0.2% (0% in Cushing's disease vs. 0.3% in nonfunctioning pituitary adenoma). Cushing's disease patients had surgical and medical complication rates of 3.5% each, not different from those occurring in nonfunctioning pituitary adenoma. The postoperative incidence of diabetes insipidus (10.6%) and isolated hyponatremia (10.6%) in Cushing's disease patients was significantly higher than in nonfunctioning pituitary adenoma patients (4.4 and 4.1%; p = 0.02 and p = 0.01, respectively).

CONCLUSIONS

In a large series of unselected and consecutive patients with Cushing's disease, transsphenoidal surgery performed by one dedicated experienced neurosurgeon had a reasonably low risk of complications. In particular, despite the higher burden of comorbidities typically associated with hypercortisolism, medical complications are rare and no more frequent than in patients with nonfunctioning pituitary adenoma.

Fronto-orbitozygomatic approach: functional and cosmetic outcomes in a series of 169 patients

OBJECTIVE Advantages of the fronto-orbitozygomatic (FOZ) approach have been reported extensively in the literature; nevertheless, restoration of normal anatomy and the esthetic impact of surgery are increasingly important issues for patients and neurosurgeons. The aim of this study was to analyze functional and cosmetic outcomes in a series of 169 patients with different pathologies who underwent surgery in which the FOZ approach was used. METHODS Between January 2000 and December 2014, 250 consecutive patients underwent surgery with an FOZ approach as the primary surgical treatment. Follow-up data were available for only 169 patients; 103 (60.9%) of these patients were female and 66 (39.1%) were male, and their ages ranged from 6 to 77 years (mean 46.9 years; SD 15.6 years). Mean follow-up time was 66 months (range 6-179 months; SD 49.5 months). Evaluation of clinical outcomes was performed with a focus on 4 main issues: surgical complications, functional outcome, cosmetic outcome, and patient satisfaction. The additional time needed to perform orbitotomy and orbital reconstruction was also evaluated. RESULTS The permanent postoperative complications included forehead hypesthesia (41.4%) and dysesthesia (15.3%), frontal muscle weakness (10.3%), exophthalmos (1.4%), enophthalmos (4.1%), diplopia (6.6%; 2% were related to surgical approach), and persistent periorbital and eyelid swelling (3%). Approximately 90% of the patients reported subjectively that surgery did not affect their quality of life or complained of only minor problems that did not influence their quality of life significantly. The mean time needed for orbitotomy and orbital reconstruction was approximately half an hour. CONCLUSIONS Comprehensive knowledge of the potential complications and overall clinical outcomes of the FOZ approach can be of great utility to neurosurgeons in balancing the well-known benefits of the approach with potential additional morbidities.

The use of platelet gel in postero-lateral fusion: preliminary results in a series of 14 cases

Over the last few years, some hemocomponents have been used advantageously in clinical neurosurgical practice, not systemically via transfusion but topically as a sealant (fibrin glue). This has diverted the attention of many authors to the role of platelets in the healing process. The combination of hyper-concentrated platelets and fibrin glue (fibrinogen, XIII factor, fibronectin) with activated thrombin produces a platelet gel that can be easily applied to "difficult" wounds. This topical use of hemocomponents has gained an important role in regenerative medicine. The authors have considered the possibility of using a preparation with a high autologous platelet concentration applied in addition to autologous bone during vertebral postero-lateral fusion. The aim of the procedure is to induce a higher rate of vertebral fusion. Between November 2007 and November 2008, 14 patients (9 men and 5 women, mean age 58.9) underwent laminectomy, vertebral stabilization and postero-lateral fusion. The number of vertebral levels involved in stabilization was: 1 in 2 patients, 2 in 5 patients, 3 in 5 patients, 4 in 1 patient and 5 in 1 patient. Platelet gel was obtained by taking 16 ml of peripheral venous blood from the patient. For this procedure two patented test tubes were used for each patient, with a capacity of 8 m each. These make up the REGEN-THT(®) (Thrombocyte Harvesting Tube) system that makes it possible to obtain 8 ml of autologous platelet gel in 40-45 min. The addition of Ca gluconate and ethanol at 95% makes it possible to obtain a preparation of plasma rich in platelets and activated thrombin with a platelet concentration five times superior to the haematic one. The platelet gel is combined with fragments of autologous bone and synthetic bone during surgical operation. To allow a comparative assessment of the degree of fusion achieved with and without application of the platelet preparation in each patient, it was arbitrarily decided to use it in only one half of the operative field. All patients underwent serial CT scans 3 and 6 months after surgery as well as plain X-rays to evaluate bone fusion. The reconstructed CT images, especially in sagittal and axial planes, permitted an evaluation of the degree of vertebral fusion and "bone growth". The fusion rate was calculated measuring the increment of bone density on CT images, by means of an evaluation of the ROI (HU) in the newly formed bone, and comparing bone density within the bone callus formed by autologous and synthetic bone alone in the one to which the platelet preparation had been added. A good rate of fusion was observed in all patients. Furthermore, a comparative analysis of ROI at 3 and 6 months after surgery demonstrated a high increase in the fusion rate during the first 3 months after surgery. After 6 months the differences in ROI between the two sides had balanced out. However, at 6-month follow-up examination, bone density in the half of the surgical field in which platelet gel had been added to autologous-heterologous bone was higher in comparison to the contralateral one. Bony neoformation after posterior-lateral arthrodesis is well-evident 3 months after surgery and usually continues gradually for the following 18-24 months. The autologous platelet preparation used seems to accelerate bony deposition and to promote tissue healing, increasing bone density at the level of posterior-lateral arthrodesis. Moreover, this preparation has low production costs and is easy to apply.

Human granulosa cells use high density lipoprotein cholesterol for steroidogenesis

This study examines the ability of human high density lipoproteins (HDL3) to deliver cholesteryl esters to human granulosa cells and describes the selective cholesterol pathway by which this occurs. Luteinized cells obtained from subjects undergoing in vitro fertilization-embryo transfer procedures were incubated with native HDL3 (or radiolabeled or fluorescently labeled HDL cholesteryl esters) to determine whether cells from humans (in which HDL is not the primary circulating lipoprotein species) can nevertheless interiorize and appropriately process cholesteryl esters for steroidogenesis. The results indicate that hormone-stimulated granulosa cells actively and efficiently use human HDL-derived cholesterol for progesterone production. More than 95% of the mass of HDL cholesteryl esters entering cells does so through the nonlysosomal (selective) pathway, i.e. cholesteryl esters released from HDL are taken up directly by the cells without internalization of apoproteins. Once internalized, the cholesteryl esters are either hydrolyzed and directly used for steroidogenesis or stored in the cells as cholesteryl esters until needed. The utilization of the internalized cholesteryl esters is a hormone-regulated event; i.e. luteinized human granulosa cells internalize and store large quantities of HDL-donated cholesteryl esters when available, but further processing of the cholesteryl esters (hydrolysis, re-esterification, or use in steroidogenesis) does not occur unless the cells are further stimulated to increase progesterone secretion.

Laparoscopic management of a noncommunicating uterine horn in a patient with an acute abdomen

A 13-year-old girl with a history of cloacal anomalies presented with acute abdominal pain. Abdominal ultrasound was not definitive, and vaginal probe ultrasound was precluded by the patient's stenotic vagina. Magnetic resonance imaging delineated a left hematometra and hematosalpinx as well as a more normal-appearing right hemiuterus. Operative laparoscopy was used to lyse the extensive pelvic adhesions in a patient with a history of an imperforate anus and to resect a left rudimentary uterine horn with outflow obstruction. A review of cases in the world literature reveals that operative laparoscopy can be used to treat these patients successfully.

Insulin-like growth factor binding proteins in peritoneal fluid of women with minimal and mild endometriosis

This prospective cohort study was carried out in a university-based infertility clinic to determine the profile of insulin-like growth factor binding proteins (IGFBPs) in patients with mild endometriosis and no obvious mechanical factor contributing to infertility. A total of 26 patients with minimal and mild endometriosis and 10 controls contributed peritoneal fluid at surgery. The variety, expression and levels of IGFBPs were determined by radio-immunoassay and Western ligand blots (WLBs) with quantitation by laser densitometer. A 27 kDa species was significantly lower and 31 kDa species tended to be lower in patients with endometriosis as determined by quantitative laser densitometer. The levels of IGFBP-3 detected by radioimmunoassay and by WLB were correlated in the control group and in the patients with endometriosis in the follicular phase but not in patients with endometriosis in the luteal phase. The level of 27 kDa species seen on WLBs did not appear to correspond to IGFBP-1 determined by radioimmunoassay and IGFBP-3 levels in luteal phase endometriosis patients also departed from values determined by radioimmunoassay. These discrepancies suggest a complex system to control levels of IGF in the peritoneum involving multiple binding proteins and proteases. The IGFBPs of patients with endometriosis may contribute to reproductive dysfunction and be able to serve as markers.

Insulin receptor mediates inhibitory effect of insulin, but not of insulin-like growth factor (IGF)-I, on IGF binding protein 1 (IGFBP-1) production in human granulosa cells

Insulin-like growth factor binding proteins (IGFBPs) may participate in regulating ovarian function by modifying effects of insulin-like growth factors (IGFs) or by directly affecting ovarian steroidogenesis in both normal and pathological circumstances. The latter include hyperinsulinemic insulin resistant states, such as polycystic ovary syndrome. We examined regulation of IGFBP-1 production in human granulosa cells by insulin and IGF-I. The cells were obtained during in vitro fertilization, plated in McCoy-5A tissue culture medium supplemented with 10% fetal calf serum (10(5) cells/0.5 mL), and incubated at 37 C, 90% humidity, 5% CO2 for 48 h. After additional 24 h incubation without fetal calf serum, 1, 10, or 100 ng/mL of insulin or IGF-I were added with or without 2 h preincubation with 10 micrograms/mL monoclonal anti insulin receptor antibody IR-47-9. After 48 h incubation with insulin or IGF-I, the medium was collected and IGFBP-1 and progesterone concentrations were measured, using kits from Diagnostic Systems Laboratories, Webster, TX. Progesterone concentration ranged between 50-100 ng/mL/10(5) cells, without consistent stimulatory effect of either insulin or IGF-I. Control cells produced 7.0 +/- 1.7 ng/mL of IGFBP-1. Incubation with 1 or 10 ng/mL of insulin resulted in culture medium IGFBP-1 concentrations of 7.1 +/- 1.3 ng/mL and 5.4 +/- 0.7 ng/mL, respectively (P = NS). Incubation with 100 ng/mL of insulin reduced IGFBP-1 culture medium concentration to 1.6 +/- 0.3 ng/mL (P < 0.01, compared with controls). 1, 10, and 100 ng/mL of IGF-I inhibited IGFBP-1 concentrations in the conditioned culture medium to 1.3 +/- 0.3 ng/mL, 0.4 +/- 0.1 ng/mL and 0.3 +/- 0.1 ng/mL, respectively (P < 0.01, compared with controls). Preincubation with antiinsulin receptor antibody IR-47-9 alleviated inhibitory effect of insulin, but not of IGF-I on IGFBP-1 production. After preincubation with IR-47-9, IGFBP-1 culture medium concentrations were 5.9 +/- 0.8 ng/mL, 4.9 +/- 1.2 ng/mL, and 4.8 +/- 1.3 ng/mL for 1, 10, and 100 ng/mL of insulin, respectively. The latter number was significantly higher than IGFBP-1 concentration in the medium collected from cells incubated with 100 ng/mL of insulin without IR-47-9 (1.6 +/- 0.3 ng/mL, P < 0.01) and not significantly different from the control cells. For cells preincubated with IR-47-9 and then incubated with 1, 10, or 100 ng/mL of IGF-I, the IGFBP-1 conditioned culture medium concentrations were 1.7 +/- 0.1 ng/mL, 0.5 +/- 0.2 ng/mL, and 0.3 +/- 0.1 ng/mL, respectively. None of these were significantly different from the IGFBP-1 concentrations in the medium collected from cells incubated with the respective concentrations of IGF-I without preincubation with IR-47-9. We conclude that 1) both insulin and IGF-I inhibit IGFBP-1 production by cultured human granulosa cells; 2) IGF-I is a more potent inhibitor of IGFBP-1 production than insulin; 3) in the range of hormone concentrations tested, insulin exerts its inhibitory effect on IGFBP-1 production via insulin receptor, while IGF-I appears to exert its effect via another receptor.

Radiation-induced premature menopause: a misconception

PURPOSE

To disprove the common view that women who have undergone irradiation to fields excluding the pelvis are at risk for radiation-induced premature menopause, we reviewed menstrual function and fertility among women treated with subtotal lymphoid irradiation for Hodgkin's Disease.

METHODS AND MATERIALS

Treatment and follow-up records of all women less than age 50 at the time of diagnosis of Stage I or II supradiaphragmatic Hodgkin's Disease, treated with subtotal lymphoid irradiation alone and enrolled in radiotherapy trials from 1967 to 1985, were reviewed. In addition, patients were surveyed regarding their menstrual status and fertility history.

RESULTS

Thirty-six women, aged 10 to 40 years, with normal menstrual function at the time of Hodgkin's diagnosis, were identified. Mean follow-up was 14 years, with a range of 1.25-22.75 years. The average radiation dose to mantle and paraaortic fields was 40-44 Gy; the calculated scatter radiation dose to the pelvis at the ovaries was 3.2 Gy. There were 38 pregnancies in 18 women; all offspring are normal. One of 36 women (2.7%) experienced premature menopause. The reported rate of premature menopause in women who have not undergone irradiation is 1-3%; not significantly different than the rate in our study. There is a syndrome whereby antibodies to several endocrine organs occur (including the ovary), which is associated with premature ovarian failure. This syndrome may be associated with prior radiation to the thyroid, such as that given by mantle irradiation for Hodgkin's Disease. We report such a case.

CONCLUSION

There is little risk of premature menopause in women treated with radiation fields that exclude the pelvis. Women with presumed radiation-induced premature menopause warrant an evaluation to exclude other causes of ovarian failure, such as autoimmune disorders.

Ovulatory function in epilepsy

Women with epilepsy have lower fertility rates than women without epilepsy. We hypothesized that limbic dysfunction in temporal lobe epilepsy (TLE) alters the release of hypothalamic trophic hormones that secondarily affect release of the pituitary gonadotropins, causing ovulatory failure. We assessed ovulatory function over three consecutive menstrual cycles in 17 women with partial seizures arising from the temporal lobe (TLE), 7 women with primary generalized epilepsy (PGE), and 12 controls. We devised scores to reflect ovulatory function that were based on daily basal body temperature and monthly serum progesterone levels. Seizure frequency, antiepileptic drugs (AEDs), and depressive symptomatology were also evaluated. Anovulation was more frequent in subjects with TLE (35.3%) than in subjects with PGE (0%) or in controls (8.3%). Anovulatory cycles tended to occur more frequently in subjects with TLE who were treated with polytherapy than in those receiving monotherapy, but this result was not statistically significant. Seizure frequency and symptoms of depression did not affect ovulatory function. Although AED polytherapy may increase the likelihood of anovulation, our results suggest a mechanism of infertility related to temporal lobe dysfunction.

Ethics of fetal tissue transplantation

Now that the Clinton Administration has overturned the ban on federal funding for fetal tissue transplantation, old ethical issues renew their relevance and new ethical issues arise. Is fetal tissue transplantation necessary and beneficial? Are fetal rights violated by the use of fetal tissue in research? Is there a moral danger that the potential of fetal tissue donation will encourage elective abortions? Should pregnant women be allowed to designate specific fetal transplant recipients? What criteria should be used to select fetal tissue transplants? Whose consent should be required for the use of fetal tissue for transplantation? We review the current state of clinical research with fetal tissue transplantation, the legal history of fetal tissue research, the major arguments against the use of fetal tissue for transplantation, and the new postmoratorium ethical dilemmas. We include recommendations for guidelines to govern the medical treatment of fetal tissue in transplantation.

Angiographic arterial embolization to control hemorrhage in abdominal pregnancy: a case report

A case is described in which heavy postoperative bleeding from the placental bed after removal of the fetus in an abdominal pregnancy was managed by selective arterial embolization of the placental vascular bed. Selective angiographic embolization is a useful tool in both obstetric and gynecologic complications when hemorrhage fails to respond to other modes of therapy.

Pregnancy following nonsurgical donor ovum transfer to a functionally agonadal woman

We report this country's first nonsurgical donor ovum transfer pregnancy in a functionally agonadal woman who had received chemotherapy and radiation for Hodgkin's lymphoma. For women with ovarian failure, nonsurgical uterine lavage and ovum transfer may provide an opportunity for motherhood that was not possible previously.

[Alpha fetoprotein in non-neoplastic liver diseases]

Seric alfa-FP has been studied in acute and chronic hepatitis and in hepatocellular carcinoma. Sixty five normal subjects, 62 cirrhoses, 10 active chronic hepatitis, 12 chronic persistent hepatitis, 4 primary biliary cirrhoses and 9 hepatomas have been examined for seric alfa-FP. Abnormal seric alfa-FP (> 10 ng/ml) values agree with literature data. It is likely that hepatocellular regeneration due to viral or inflammatory disorders, can produce formation of alfa-FP and other abnormal proteins fro a depression mechanism of sue regulator gene.