Conjoined twins in a monochorionic triplet pregnancy after in vitro fertilization: a case report

Background: Monozygotic monochorionic triplet pregnancy with conjoined twins is a very rare condition and is associated with many complications

Case: In this study, we describe a monochorionic-diamniotic triplet pregnancy after in vitro fertilization with an intracytoplasmic sperm injection. At a gestational age of 6 weeks and 4 days of pregnancy one gestational sac was observed, and at a gestational age of 12 weeks and 2 days, triplets with conjoined twins were diagnosed. After consulting with the parents, they chose fetal reduction of the conjoined twins. Selective feticide was successfully performed by radiofrequency ablation at 16 weeks of pregnancy. Unfortunately, the day after the procedure, the membrane ruptured, and 1 week later, all fetuses and placenta were spontaneously aborted

Conclusion: Monochorionic triplet pregnancy with conjoined twins is very rare. These pregnancies are associated with very serious complications. Intra cytoplasmic sperm injection increases the rate of monozygotic twinning and conjoined twins. Counseling with parents before IVF is very important

Variable number tandem repeat [VNTR] genotyping of hydatidiform mole in Iranian patients

Classification of molar gestation into Complete Hydatidiform Mole [CHM] and Partial Hydatidiform Mole [PHM] is done according to clinical, ultrasonographic, histologic and genetic criteria. However, making a distinction between CHM and PHM using histologic criteria alone may be difficult and several studies have shown that misclassifications are frequent, even for experienced pathologists. CHM is the most common precursor to choriocarcinoma and heterozygous moles carry an increased predisposition to transformation. Formalin-fixed, paraffin-embedded tissue sections of patients as well as peripheral blood of patients and their partners' were collected in EDTA tubes. Tissue samples were obtained by curettage. Histological evaluation was performed on routine section stained with Hematoxylin and Eosin. Variable Number Tandem Repeats [VNTRs] genotyping was performed for 30 cases in two groups of CHM [n=21] and PHM [n=9], with Polymerase Chain Reaction [PCR] amplification of 2 different polymorphic loci, namely the Col2A1 and D1S80. The results of DNA analysis by VNTR genotyping showed that in 16 cases of CHM, amplification of the VNTR polymorphic loci showed androgenetic mono-spermic moles [homozygote] and in 5 cases of CHM androgenetic dispermic moles [heterozygote] in molar tissue. In cases of PHM, 6 samples were triploid dispermic and 3 samples were diploid biparental. This study confirmed that VNTR genotyping can identify the parental source of polymorphic alleles in hydatidiform mole. Compared to STR genotyping, VNTR genotyping was performed by PCR amplification of several minisatellite markers of DNA. This method significantly requires less time and is cost-effective

[Comparison of radiological and pathological results in gestational trophoblastic diseases]

Gestational trophoblastic disease [GTD] is a heterogenous group of neoplastic lesions that is derived from placental trophoblastic epithelium. According to World Health Organization [WHO] classification they include: Hydatidiform mole [complete and partial], invasive mole, choriocarcinoma and placental site trophoblastic tumor. Hydatidiform mole is the most common and the diagnosis is achieved by preevacuation ultrasonographic evaluation, laboratory tests and finally histological assessment as gold standard. Since these disorders show varying potential for local invasion and metastasis, the accurate diagnosis, follow up and recommendations given to patients may differ. Consecutive cases with diagnosis of GTD from archive of pathology department of women [Mirza Kochak Khan] hospital were reviewed in whom results of clinical presentation and pre-evacuation ultrasound examination were documented. There were overall 220 cases for which the following clinical features were determined: gravidity, parity, history of previous abortion and gestational trophoblastic disease, the clinical symptoms such as vaginal bleeding and hypertension. Finally concordance between pre-evacuation ultrasonographic and histological diagnosis by kappa test is calculated. Out of 220 cases with clinically gestational trophoblastic disease diagnosis, 197 cases were confirmed by histological diagnosis. The concluding histological diagnosis includes: 98 cases of complete mole [CM], 84 partial mole [PM], 4 invasive mole and 11 cases of choriocarcinoma. Outside 98 cases with histological diagnosis CM only in 4 cases misdiagnosed by ultrasonoghraphy [4.1%] and high degree of concordance between ultrasonography and histological diagnosis is seen. Ultrasonographic examination accompanied with clinical examination, beside histological assessment as gold standard have high efficacy in diagnosing complete mole. This study did not show this finding for partial mole.

Alteration of the K-ras gene expression in atypical and nonatypical hyperplastic endometrium

Endometrial cancer is the most common gynecologic malignancy that has often proceeded by a premalignant phase. Modern molecular and immunostaining methods for precancerous lesions diagnosis have been expanded. One of the genetic alternations in the endometrial cancer carcinogenesis is the mutational activation of the K-ras oncogene. K-ras mutation has recognized to occur at an early stage of neoplastic progression in the endometrium. The purpose of this study is to investigate the expression pattern of K-ras gene in atypical and nonatypical hyperplastic endometrium. In a prospective study in the referral gynecologic hospital in Tehran, immunohistochemical evaluation of K-ras has performed on 72 consecutive specimens in two following groups: endometrial hyperplasia without atypia [n: 36], and endometrial hyperplasia with atypia [n: 36]. Staining of cells has evaluated in arbitrary quantitative methods in regards to both slides area staining and intensity of color reaction. K-ras immunoreactivity has seen in 3/36 [8.3%] cases of non atypical hyperplasia and in 2/36 [5.6%] cases of atypical hyperplasia [P: 0.64]. We have not establish any significant differences in K-ras expression between the atypical and nonatypical hyperplastic endometrium, and our data has supported this view that K-ras mutation is a very rare event in human endometrial carcinogenesis

[Immunohistochemical expression of estrogen and progesterone receptors in endometrial hyperplasia and endometrioid carcinoma]

Endometrial carcinoma [EC] is the most common gynecologic malignancy; however, mechanisms underlying its pathogenesis remain obscure. Endometrial carcinoma has been classified into two major categories: type I [related to estrogen or endometrioid adenocarcinoma] and type II [unrelated to estrogen]. Estrogen is the main trigger for the abnormal proliferation in the endometrial epithelium but progesterone can inhibit this process. The aim of this study was to analyze the expression of estrogen and progesterone receptors in all types of endometrial hyperplasia in comparison to endometrioid adenocarcinoma of endometrium. Forty-seven specimens including 23 cases of histopathologically confirmed hyperplastic endometrium [12 simple hyperplasia, 5 complex hyperplasia without atypia, and 6 complex hyperplasia with atypia] and 24 cases of endometrial carcinoma were studied. Immunohistochemical staining of estrogen and progesterone receptors was performed in paraffin-embedded blocks and expression of estrogen and progesterone receptors were scored according to the proportion of positive staining cells. Overexpression of progesterone receptors was seen in 18 [75%] out of 24 cases of endometrial carcinoma and 23 [100%] of all types of endometrial hyperplasia. The aforesaid differences were statistically significant [P=0.023]. 70.8% of cases with endometrial carcinoma were 3+ for immunohistochemical staining of progesterone receptors as were 85.7% of the cases with endometrial hyperplasia; the difference being also statistically significant [P=0.02]. Considering the increased proportion of progesterone receptor expression in all types of hyperplastic endometrium in comparison to endometrial carcinoma, hormonal therapy by progestinal agents is recommended as a treatment of choice

[Determining the interobserver reproducibility of pap smears in the diagnosis of epithelial cell abnormalities]

Cancer of uterine cervix is the second cause of death in women in the world and the most common cause in developing countries. Because the majority of women with invasive cervical cancer of the uterine have not previously undergone screening, many clinicians assume that Pap smear has a high degree of accuracy; but problems such as false positive and false negative interpretations, as well as interobserver variability have questioned its validity. We retrieved 162 positive cervical smears that had been originally interpreted as ASC-US, ASC-H, LSIL, HSIL, SCC, AGC and adenocarcinoma from the cytology archives of Women's Hospital in Tehran, Iran. The slides were rescreened by an experienced pathologist and reclassified in the mentioned categories. All the 162 slides were reviewed by three more pathologists in a blind study using interpretative criteria utilized in their daily routine to evaluate interobserver reproducibility. To increase the level of interobserver agreement, the diagnostic categories were reduced to squamous Vs. glandular abnormalities and invasive [SCC and adenocarcinoma] Vs. non-invasive abnormalities. The results obtained in this study indicated slight interobserver agreement [k=0.26]. The most reproducible category was the invasive category [SCC in addition to adenocarcinoma] and the least agreement was seen for HSIL [k=0.19]. This study showed that reproducibility of cytological interpretation of conventional Pap smears varies among interpretive categories and the overall interobserver agreement is slight. Since convening on the reduction of interobserver discrepancy in Pap smear interpretations necessitates more reliable information of interpretative variability, larger studies need to be undertaken