Impact of different prenatal management strategies in short- and long-term outcomes in monochorionic twin pregnancies with selective intrauterine growth restriction and abnormal flow velocity waveforms in the umbilical artery Doppler: a retrospective observational study of 108 cases

OBJECTIVES

To review perinatal and neurodevelopmental outcome (NDO) following selective fetoscopic laser coagulation (SFLC), cord coagulation (CC) or expectant management of monochorionic diamniotic twin pregnancies complicated with selective intrauterine growth restriction (sIUGR) and absent or reverse end-diastolic flow (AREDF) in the umbilical arteries (UA).

DESIGN AND SETTING

Single-centre retrospective observational study.

POPULATION

108 cases of sIUGR diagnosed before 26⁺⁶  weeks' gestation with AREDF in the UA.

METHODS

Survival rate and potential risk factors were analysed. NDO was assessed using parental questionnaires.

MAIN OUTCOMES MEASURES

Survival, gestational age at delivery and NDO.

RESULTS

SFLC, CC and EM were performed in 13, 50 and 45 cases, respectively, with an overall survival of 23.1, 40 and 77.8% and intrauterine demise of the co-twin of 30.8, 10 and 6.7% respectively. Intrauterine demise of the sIUGR twin occurred in 76.9 and 17.8% following SFLC and EM, respectively. The discordance in EFW at diagnosis was higher and absent/negative a-wave in the ductus venosus (DV) was more prevalent in the surgical groups. NDO in survivors at follow up was abnormal in 0 and 18% in the smaller twin following SFLC and EM, respectively, and in 25, 24 and 21% in the larger twin following SFLC, CC and EM, respectively.

CONCLUSION

SFLC yielded a poor result. EM seems a valid option when EFW discordance is <30% and a-wave in DV is positive. Otherwise, CC should be considered to protect the AGA co-twin. The long-term outcome of both small and large twins seems unaffected by the choice in primary prenatal management strategy.

TWEETABLE ABSTRACT

In type II sIUGR in MC twins, long-term neurodevelopment is normal in over 80% of the survivors.

Chemotherapy (platinum and pemetrexed) in combination with erlotinib in non-small cell lung cancer induces major gastrointestinal toxicity: two case reports from the FLARE/GFPC 03-2013 study

WHAT IS KNOWN AND OBJECTIVE

A randomized phase III study was designed to assess the efficacy and safety of second-line platinum-based chemotherapy with or without erlotinib in non-small cell lung cancer (NSCLC) with EGFR-activating mutation after secondary resistance to EGFR-TKIs (epidermal growth factor receptor tyrosine kinase inhibitors).

CASE SUMMARY

We report herein two of the first three patients who presented with major gastrointestinal toxicities in the experimental arm of the trial.

WHAT IS NEW AND CONCLUSION

Pending further data, it would seem safer to administer EGFR-TKIs and chemotherapy sequentially rather than concomitantly.

[Exclusive surgical treatment of Mycobacterium xenopi infection of a pulmonary cavity]

The diagnosis of pulmonary infection due to Mycobacterium xenopi was retained in a 48-year-old immunocompetent patient. The lesion was isolated in a peripheral region and was well limited. Exclusive surgical treatment was undertaken. Cure was complete without recurrence at three years. This case illustrates that in certain cases environmental mycobacteriosis with a very limited lesion may respond very well to surgical resection, an interesting alternative to medication.

[Lung cancer and peritoneal mesothelioma: two complications of asbestos exposure in the same patient]

INTRODUCTION

Association of a lung cancer and a malignant peritoneal mesothelioma is reported in a 78-year-old patient with significant asbestos exposure.

OBSERVATION

After exploration of an intra-pulmonary opacity, with inspissated pleura, the diagnosis of primary pulmonary adenocarcinoma was obtained by thoracotomy in April 1999. In February 2002, the diagnosis of peritoneal mesothelioma was made by laparoscopy. The course was marked by irreducible ascites and was fatal 7 months after the diagnosis of peritoneal mesothelioma.

CONCLUSION

Malignant mesothelioma is a rare disease and even rare in association with lung cancer.

[Hyperplasia of the thymus in Graves' disease. A case report]

Graves' disease is rarely associated with hypertrophy of the thymus which takes on a pseudotumor aspect. We observed a case in a 40-year-old woman who presented clinical and biological hyperthyroidism with anti-TSH receptor antibodies, favoring the diagnosis of Graves' disease which was confirmed by scintigraphy. The chest x-ray performed because of chest pain revealed enlargement of the mediastinum. The thoracic CT-scan without contrast injected showed a pseudotumor aspect of the thymus. Medical treatment with anti-thyroid drugs and beta blockers led to regression of the thymus mass. Knowledge of this type of association can avoid unnecessary thymus surgery. The clinical course is favorable irrespective of the type of anti-thyroid drug given.

[Thymoma and autoimmune thyroiditis. A case report]

We report an association between a thymus tumor and autoimmune thyroiditis. This association is probably related to loss of immune control secondary to loss of thymus integrity. A 48-year-old woman was hospitalized for thoracic pain. Her past history included thyroiditis treated by L-thyroxin for two years. The chest x-ray demonstrated a mediastinal opacity which was confirmed by computed tomography. Surgical resection was performed and histological analysis of the surgical specimen confirmed the diagnosis of lympho-epithelial thymoma. Thyroid immunity tests demonstrated the presence of anti-peroxidase antibodies confirming the diagnosis of Hashimoto's thyroiditis. Chest x-ray and CT-scan are indicated in patients with autoimmune thyroiditis to search for a thymic mass. Conversely, search for autoimmune thyroiditis is warranted in patients with an identified thymic mass.

[Rare association of hypoparathyroidism and mediastinal-pulmonary sarcoidosis]

We report the case of a 52-year-old woman who presented hypoparathyroidism and sarcoidosis. The hypoparathyroidism developed 8 years after the diagnosis of sarcoidosis. No element in favor of an autoimmune disease of the parathyroid could be evidenced. Pathology and immunology blood tests were equally noncontributive. Another pathophysiological mechanism, possibly sarcoidic granulomatous infiltration of the parathyroid glands, was suspected. The patient also presented apparently coincidental vitiligo.

[Right heart failure caused by thiamine deficiency (cardiac beriberi)]

BACKGROUND

Vitamin B1 deficiency (beriberi) is very uncommon in France. It leads to high output cardiac failure totally different from the situation observed in alcoholic patients. We report a typical case of cardiac beriberi.

CASE REPORT

The patient was referred for dyspnea with high output cardiac failure. Echocardiography evidenced severe pulmonary hypertension and high cardiac output. The more common causes of heart failure were ruled out. The dietary habits of the patient (suggested beriberi which was confirmed by the low serum thiamin and therapeutic test with vitamin B1.

DISCUSSION

High output cardiac failure should suggest possible Shoshin beriberi, particularly in subjects with imported dietary habits living in a precarious socioeconomic situation.