Extreme polycythemia in recipient twin with twin-to-twin transfusion syndrome: a case report.

UNLABELLED: We report a case of severe polycythemia in the recipient twin of a pregnancy with twin-to-twin transfusion syndrome (TTTS). Stage I TTTS was suspected at initial presentation (24 weeks) due to discordant growth associated with a twin oligo-polyhydramnios sequence. Increasing peak systolic velocity (PSV) in the middle cerebral artery (MCA) of the donor twin indicated fetal anemia. In addition, we observed a decreasing MCA-PSV of the recipient twin, indicating polyglobulia. Close follow-up without intervention showed a stable course of TTTS without progression to higher stages.Following caesarean section at 31 2/7 weeks due to preterm premature rupture of membranes of the leading donor twin, the donor twin showed anemia (hematocrit 28%) whereas the recipient twin demonstrated severe polycythemia (hematocrit 88%). Inter-twin difference of reticulocyte counts was high (38% for the donor and 5% for the recipient twin). Transfusion and partial exchange transfusion (PET) were performed in the donor and in the recipient twin, respectively. Normal hematocrit levels were achieved without complication. Perinatal outcome of both twins was good. CONCLUSION: Even in a stable course of pregnancy with stage I TTTS, severe polycythemia of the recipient twin can occur and can require careful PET in a specialized center.

Topographic distribution of sentinel lymph nodes in patients with cervical cancer.

BACKGROUND: Since the introduction of the sentinel concept in cervical cancer in 1999, various studies have been demonstrated the feasibility, detection rate and sensitivity and rate of false-negative sentinel lymph nodes (SLN). There are only limited data regarding the mapping of the removed SLN. A correlation between the localization of SLN and the tumor stage, histology or marker substance has never been investigated. METHODS: Between 2/2000 and 6/2005, the SLN distribution of 151 patients with histologically confirmed cervical cancer (FIGO stages IA n = 21, IB n = 95, IIA n = 14, IIB n = 18, IIIB n = 2, IVA n = 1), who participated in the ongoing "Uterus 3" sentinel study of the German Association of Gynecologic Oncologists (AGO), was retrospectively analyzed with respect to the histology, tumor stage and detection substance. The tumors comprised mostly of squamous cell carcinomas (75.5%) with a smaller fraction of adenocarcinomas (24.5%). RESULTS: Altogether, 406 SLN, an average of 2.7 (1-7) SLN per patient, were removed. More than one SLN was detected in 111 patients (73.5%). SLN were found unilaterally in 70 patients (46.4%) und bilaterally in 81 patients (53.6%). SLN sites were paraaortic in 4%, common iliac in 5%, external iliac in 5%, internal iliac in 8%, interiliac in 71% and parametric in 7%. Irrespective of the detection drug applied, most SLN were interiliac (blue 70%, TC 67%, TC and blue 71%). Combined application of technetium and blue dye revealed significantly more SLN in the paraaotic region (P = 0.006). Adenocarcinomas and squamous carcinomas did not differ in the distribution of SLN (P = 0.205). The majority of SLN are interiliac in all tumor stages (FIGO IA 76%, IB 68%, IIA 61%, IIB 83%, III and IV 88%). CONCLUSIONS: Removal of SLN in the external iliac, interiliac and obturator area enables evaluation of more than 80% of all SLN. The pattern of SLN is independent from histology and tumor stage. Combined use of technetium and blue dye detects sentinels more frequently in the paraaortic region than a single marker.

Clinical implication of laparoscopic pelvic lymphadenectomy in patients with vulvar cancer and positive groin nodes.

OBJECTIVE: At present, no clear guidelines for the treatment of patients with vulvar cancer and positive groin nodes exist. In general, the decision for additional pelvic radiation is based on findings by imaging techniques and/or the number of groin nodes involved. The aim of this case series was to demonstrate that histologic result of laparoscopic removed pelvic lymph nodes can be used to select patients who should not undergo pelvic irradiation. METHODS: From July 1997 to October 2004, 12 consecutive patients with primary or recurrent vulvar cancer underwent laparoscopic pelvic lymphadenectomy following primary or secondary surgical treatment. RESULTS: There were 8 patients with primary cancer of the vulva and 4 patients with recurrent disease in the inguinal and/or pelvic lymph nodes. The mean age was 61 (26-83) years and the mean body-mass-index was 27.1 (20.8-36.6). Positive groin nodes were found in five patients on the right side and in five patients on the left side; in one patient, positive groin nodes were present in both sides. In another patient with a history of vulvar cancer and positive groin nodes the CT-scan indicated the presence of positive iliac and paraaortic lymph nodes. Only in two patients tumor involved lymph nodes were diagnosed by laparoscopic pelvic lymphadenectomy (one left-sided, one right-sided). The number of harvested pelvic lymph nodes was 13.7 (5-20) in unilateral and 27.8 (16-37) in bilateral lymphadenectomy. The histologic examination of removed pelvic lymph nodes confirmed pelvic radiation in only 2 out of 12 patients, whereas 10 patients were spared from whole pelvis irradiation. CONCLUSION: With respect to small sample size, laparoscopic lymphadenectomy seems to be a good tool to avoid unnecessary pelvic radiation in patients with vulvar cancer and confirmed positive groin nodes.