Viable Pregnancy in a patient with metastatic melanoma treated with double checkpoint immunotherapy.

Metastatic cancers during pregnancy have historically been associated with dismal outcomes, with greater rates of tumor progression in part because of diminished treatment alternatives. Immunotherapy with T-cell checkpoint inhibitors has significantly impacted the survival of several metastatic tumors. However, given their mechanism of action, immune-related adverse events can occur, especially with combined immunotherapy treatments. During pregnancy, checkpoint pathways have a major role, providing immune tolerance to the fetal allograft. Furthermore, evidence suggests that inhibition of this pathway may be associated with an increased risk of miscarriage. We describe, to our knowledge, the first case reported in the literature of a patient 7 weeks pregnant, diagnosed with metastatic melanoma and treated with nivolumab plus ipilimumab. We also present the associated immune-related side effects and their treatment, as well as the oncologic results that lead to favorable pregnancy outcome.

The cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy.

OBJECTIVE: We sought (1) to describe an anatomic defect of the uterine cavity in the anterior isthmus diagnosed by transvaginal sonography in a group of premenopausal women with previous cesarean deliveries, (2) to establish whether there is an association between the presence of the pouch and a bleeding disturbance, and (3) to compare the diagnostic efficacy of transvaginal sonography versus hysteroscopy for the detection of this defect. METHODS: We performed a retrospective study of 92 premenopausal women with histories of at least 1 cesarean delivery. Age, number of previous cesarean deliveries, time elapsed between last cesarean delivery and first consultation, and total area of the pouch were recorded in groups of women with and without abnormal bleeding. Hysteroscopy was also performed in 43.8% of the patients who had abnormal bleeding. RESULTS: In all women, transvaginal sonography revealed the presence of a pouch on the anterior uterine segment at the site of the expected previous cesarean delivery scar. Hysteroscopy showed 100% correlation with transvaginal sonography in detection of this pouch. CONCLUSIONS: The high correlation between bleeding disturbances and the presence of a pouch, in the absence of other pathologic entities, suggests this anatomic defect as the possible cause, especially in view of the fact that women who had heavier and longer bleeding episodes tended to have a larger pouch. Transvaginal sonography is a very simple, noninvasive, low-cost examination that should be considered as the first choice for screening, because it highly correlates (100%) with hysteroscopy in the diagnosis of this defect and may help rule out other causes.