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Objective Uterine transplantation (UTx) has been proposed as a treatment option for women diagnosed with absolute uterine factor infertility. Allogeneic UTx has been attempted in a number of animal models, but achieving an adequate blood supply for the transplanted uterus still presents the biggest challenge. Microvascular re-anastomosis was unsuccessful in a number of animal models. The aim was to assess whether a large vessel aortic-caval vascular patch technique can bring about long-term graft survival after allogeneic UTx in a rabbit model. Study design A longitudinal study involving uterine cross transplantations ( n =9 donors, n =9 recipients) was performed in New Zealand white rabbits using an aortic-caval macrovascular patch harvested as part of the uterine allograft. All rabbits were allogeneic and of proven fertility , with at least one previous litter each. The end result of the donor graft harvest was a total hysterectomy transecting across the vagina and the most lateral aspects of the uterine horns together with an aortic-caval macrovascular patch (aorta, inferior vena cava, common and internal iliacs, and uterine arterial and venous tree). Tacrolimus (500μg twice daily) was administered for immunosuppression post-transplant. The recipients were closely monitored until death or euthanasia. Results In this case series, long-term rabbit survival was 11% ( n =1). Surgical survival was 56% ( n =5). Three rabbits (UTx #3, #4 and #8) died intra-operatively as a result of blood aspiration, ventricular hematoma, and massive hemorrhage. Three does (#1, #2, #7 and #9) died within the first 24h as a result of the veno-vena and anastomosis breakdown. Does #6 and #9 died secondary to pre-operative pneumonia and a pulmonary embolus , respectively. Only one rabbit survived longer than a month. Conclusion Our method used a macrovascular patch technique to ensure adequate blood supply to the donor uterine graft. We have demonstrated the feasibility of uterine allotransplantation using this technique in the rabbit, but were unable to demonstrate a higher long-term survival percentage because of issues related to using a rabbit model.

Aim To see if: (i) a large vessel aortocaval vascular patch technique may bring about long-term graft survival after allogeneic uterine transplantation (UTn) in a rabbit model; and (ii) fertility can be achieved following natural mating post-allogeneic UTn. Methods Allogeneic uterine cross transplantations were performed in New Zealand white rabbits using an aortocaval macrovascular patch harvested as part of the uterine allograft. Five rabbit recipients received a uterine graft from five unrelated donor rabbits. All female rabbits were unrelated and were of proven fertility with at least one previous litter each. Tacrolimus was administrated for immunosuppression post-transplant. Natural mating was attempted if long-term survival had been achieved. The main outcome measures were: (i) long-term recipient survival; (ii) long-term adequate uterine perfusion; and (iii) successful pregnancy post-UTn. Results All five recipient animals survived the surgery with satisfactory immediate postoperative recovery. Recipients 1, 2 and 4 died within the first 4 postoperative days. Both long-term survivors failed to conceive following introduction of a proven male breeder despite evidence of mating. Necropsy at 9 and 11 months showed a lack of patency of uterine cornua at the point of anastomosis, albeit a small uterus in recipient 3 and a reddish brown amorphous material at the site of the transplanted uterus in recipient 5. Conclusion We have demonstrated the feasibility of uterine allotransplantation using a macrovascular patch technique, but could not demonstrate conception because of blocked cornua. To address this, we propose using embryo transfer techniques in order to achieve conception.

Background: Post-molar pregnancy gestational trophoblastic tumours (GTT) have been curable with chemotherapy treatment for over 50 years. Because of the rarity of the diagnosis, detailed structured information on prognosis, treatment escalations and outcome is limited. Methods: We have reviewed the demographics, prognostic variables, treatment course and clinical outcomes for the post-mole GTT patients treated at Charing Cross Hospital between 2000 and 2009. Results: Of the 618 women studied, 547 had a diagnosis of complete mole, 13 complete mole with a twin conception and 58 partial moles. At the commencement of treatment, 94% of patients were in the FIGO low-risk group (score 0–6). For patients treated with single-agent methotrexate, the primary cure rate ranged from 75% for a FIGO score of 0–1 through to 31% for those with a FIGO score of 6. Conclusion: In the setting of a formal follow-up programme, the expected cure rate for GTT after a molar pregnancy should be 100%. Prompt treatment and diagnosis should limit the exposure of most patients to combination chemotherapy. Because of the post-treatment relapse rate of 3% post-chemotherapy, hCG monitoring should be performed routinely.

The standard management of placental site trophoblastic tumours (PSTTs) is a radical hysterectomy with pelvic lymph node sampling. We present five cases to demonstrate a modified Strassman procedure (MSP), which is an alternative fertility-sparing technique. Each had a presumed solitary uterine PSTT. Following surgery, one patient remained in remission with her fertility intact. The other four underwent a completion hysterectomy because of incomplete excision of the disease. No residual disease was later found in two of these four uteri. This treatment should only be offered after extensive counselling. We intend to investigate the use of intraoperative frozen section analysis with cold-knife dissection in future.

Objectives: To evaluate the efficacy and toxicity of paclitaxel and cisplatin alternating with paclitaxel and etoposide doublet regimen (TP/TE), for salvage of patients with high-risk gestational trophoblastic neoplasia (GTN).Patients and methods: Twenty-four patients with GTN received TP/TE. Sixteen had failed previous chemotherapy including six with cisplatin-based regimens (group A) and eight changed to TP/TE because of prior treatment-induced toxic effects (group B).Results: In group A, three patients (19%) achieved a complete response (CR) and five (31%) a partial response (PR). All CR and four PR patients remain alive with a median follow-up of 25 months (range 9-48). The eight patients failing TP/TE subsequently died. Thus, the overall survival of the 16 patients in group A was 44% (seven of 16), rising to 70% (seven of 10) if the six patients who had failed prior cisplatin-based chemotherapy were excluded. In group B, four patients were assessable for response (two CR, two PR) and six remain alive (median follow-up 19 months) giving an overall survival of 75%. TP/TE was well tolerated, with only one patient discontinuing therapy because of toxic effects.Conclusion: TP/TE is an effective, well-tolerated, salvage treatment for relapsed patients who are heavily pretreated for GTN. Further studies of this regimen are warranted.

We reviewed 25 cases of gestational trophoblastic tumours referred for surgical management from Charing Cross Hospital (the London centre for gestational trophoblastic disease [GTD]) over a 13-year period. The operation performed was total abdominal hysterectomy, with lymph node sampling in 9/25 (36%) women and bilateral salpingo-oophorectomy in 11/25 (44%) women. Radical hysterectomy and unilateral parametrectomy was required in 3/25 (12%) women. Three of 25 (12%) women failed to survive, i.e. the overall rate of survival was 88%. Management by hysterectomy of primary drug-resistant and relapse cases of GTD is a useful and safe adjunct to chemotherapy.

Summary Gestational trophoblastic neoplasia refers to the spectrum of conditions characterised by proliferation of conceptus-derived trophoblast, and includes partial and complete hydatidiform mole (HM), invasive mole, choriocarcinoma and placental site trophoblastic tumour and its variants. With changes in the management of early pregnancy complications in recent years, the majority of HMs are now evacuated in the late first trimester, at which time, it is now recognised, their histopathological features, although characteristic, may differ from those traditionally described following second-trimester evacuation. In view of these changes in presentation, updated histopathological criteria are presented and specific additional issues discussed, including recent advances in molecular genetics, ancillary investigations, recurrence risk, development of persistent trophoblastic neoplasia, intraplacental choriocarcinoma and mole with coexisting fetus.

Objectives To examine the accuracy of sonographic findings of routine ultrasound examinations in patients with a proven histological diagnosis of complete or partial hydatidiform mole referred to a supra-regional referral center, and to examine the relationship of sonographic findings to gestational age across the first and early second trimesters. Methods Review of consecutive cases referred to a trophoblastic disease unit from June 2002 to January 2005 with a diagnosis of possible or probable hydatidiform mole in whom results of a pre-evacuation ultrasound examination were documented. Ultrasound detection rates for partial and complete hydatidiform moles were calculated and comparison of detection rates between complete and partial mole, and gestational age groups carried out. Results 1053 consecutive cases were examined. The median maternal age was 31 (range, 15–54) years and the median gestational age was 10 (range, 5–27) weeks. 859 had a final review diagnosis of partial or complete hydatidiform mole (82%), including 253 (29%) complete moles and 606 (71%) partial moles. Non-molar hydropic miscarriage was diagnosed following histological review in 194 (18%). Overall, 378 (44%) cases with a final diagnosis of complete or partial hydatidiform mole had a pre-evacuation ultrasound diagnosis suggesting hydatidiform mole, including 200 complete moles and 178 partial moles, representing 79% and 29%, respectively, of those with complete (253) or partial (606) moles in the final review diagnosis. The ultrasound detection rate was significantly better for complete versus partial hydatidiform moles (Z = 13.4, P < 0.001). There was a non-significant trend towards improved ultrasound detection rate with increasing gestational age, with an overall detection rate of 35–40% before 14 weeks' gestation compared to around 60% after this gestation. The sensitivity, specificity, positive predictive value and negative predictive value for routine pre-evacuation ultrasound examination for detection of hydatidiform mole of any type were 44%, 74%, 88% and 23%, respectively. Conclusions Routine pre-evacuation ultrasound examination identifies less than 50% of hydatidiform moles, the majority sonographically appearing as missed or incomplete miscarriage. Detection rates are, however, higher for complete compared to partial moles, and improve after 14 weeks' gestation. Histopathological examination of products of conception remains the current gold standard for the identification of gestational trophoblastic neoplasia. Copyright © 2005 ISUOG. Published by John Wiley & Sons, Ltd.

Adenomatoid tumors of the uterus are uncommon benign lesions derived from mesothelium, with a prevalence of 1.2% in one study of 1 000 unselected hysterectomy specimens. They are usually small and near the serosal surface; however, they may be large and diffuse (giant adenomatoid tumors). They coexist with leiomyomas in 60% of cases. A 33-year-old nulliparous woman was referred for severe menorrhagia and dysmenorrhea, thought to be due to a submucosal fibroid on ultrasound. This transpired to be an adenomatoid tumor, and she underwent three transcervical resections of the tumor (TCRT) over a period of 12 months for tumor recurrence and failure of symptom resolution. The last TCRT was performed with ultrasound guidance and laparoscopic visualization of the uterus to the resection point of blanching of the serosal surface. She failed to respond to a GnRH analogue throughout. A specialist opinion on the suitability of vascular embolization of the tumor judged that it would be ineffective for this lesion. She then underwent a Strassman procedure and removal of the adenomatoid tumor. This involved dissection of ureters and pelvic vasculature, selective temporary ligation of uterine arteries, hemisection of the uterus, and excision of the tumor with frozen sections to ensure clear tumor margins and resuturing of the uterine halves. Temporary vascular occlusion of the uterine arteries and ovarian vessels allowed a Strassman procedure, which resulted in successful resection of a recurrent giant adenomatoid tumor of the uterus, with fertility preservation in a young nulliparous woman. Two and a half years on there is no evidence of tumor recurrence.

The development of persistent gestational trophoblastic disease following an apparently uncomplicated term pregnancy is well-recognized; however, reports of confirmed intraplacental choriocarcinoma are rare. We report four cases of histologically reviewed intraplacental choriocarcinoma occurring in third-trimester pregnancies from the files of a regional trophoblastic disease unit. In all cases, macroscopic examination of the placenta appeared unremarkable, with small nondescript lesions being identified, thought to be fresh infarcts or intervillus thrombi. Histological examination demonstrated the presence of focal intraplacental choriocarcinoma. Review of the literature demonstrates primary intraplacental choriocarcinoma rarely may be associated with obstetric complications such as intrauterine death or fetal distress. But in most cases, the disease is initially asymptomatic, the diagnosis only being made following histopathological placental examination for other indications. Intraplacental choriocarcinoma may therefore manifest as a spectrum of clinical disease ranging from an incidental lesion diagnosed on placental pathological examination with no adverse effects on mother or baby, through to metastatic maternal disease that is present in about half of the cases, to disseminated fatal infantile choriocarcinoma.

Please cite this paper as: Saso S, Chatterjee J, Yazbek J, Thum Y, Keefe K, Abdallah Y, Naji O, Lindsay I, Savage P, Seckl M, Smith J. A case of pregnancy following a modified Strassman procedure applied to treat a placental site trophoblastic tumour. BJOG 2012; DOI: 10.1111/j.1471-0528.2012.03501.x.

[EN] Objective: Uterine transplantation (UTx) has been proposed as a treatment option for women diagnosed with absolute uterine factor infertility (AUFI). The goal of UTx remains achieving pregnancy and live birth of a healthy neonate following allogeneic UTx. Our aim was to assess whether fertility was possible following allogeneic uterine transplantation (UTx), when the recipient had demonstrated long-term survival and had been administered immunosuppression. Study design: Nine allogeneic UTx in New Zealand White rabbits were performed using a pre-determined protocol. Tacrolimus was the immunosuppressant selected. Embryos were transferred into both cornua of the sole living recipient via a mini-midline laparotomy. The pregnancy was monitored with regular reproductive profiles and serial trans-abdominal ultrasound to measure conceptus growth (gestation sac and crown rump length (CRL)). Results: In the sole surviving doe a gestation sac was visualised on ultrasound from Day 9 (D9) after embryo transfer. Gestation sac diameter and CRL increased from D9 to D16 but by D18 the gestation sac had reduced in size. The fetus was no longer visible, suggesting fetal resorption had occurred. Subsequent scans on D22 and D25 did not demonstrate a gestation sac. Scheduled necropsy on D27 and histopathology confirmed evidence of a gravid uterus and presence of a gestational sac. A single episode of acute rejection occurred on D13. Conclusion: Pregnancy was achieved after rabbit allogeneic UTx but serial ultrasound suggested that fetal demise occurred prior to scheduled necropsy. The study represents only the third example of conception and pregnancy following an animal allogeneic UTx., The authors would like to thank all the staff and veterinarians at the Royal Veterinary College (London, UK) who have been with us from the beginning and have worked tirelessly at ensuring we had the best possible conditions to carry out our transplant work. ALD receives funding at UCLH/UCL via the Department of Health's NIHR Biomedical Research Centres funding scheme.

Placental site trophoblastic tumors (PSTT) are the rarest form of gestational trophoblastic disease (GTD). The clinical management of PSTT differs from the other forms of GTD as surgery plays a more important role. The most common metastatic sites are the lung, liver, and vagina while spread to the adnexa is relatively unusual. We describe a case of a 35-year-old woman presenting with PSTT and ovarian metastasis who was successfully treated with radical hysterectomy, bilateral oophorectomy, pelvic lymph node dissection, and postoperative chemotherapy. The case highlights the possibility of ovarian metastases despite normal preoperative imaging and confirms the value of multidisciplinary management of this rare illness.

Eleven years after developing idiopathic ovarian failure in herearly twenties, a 32-year-old woman underwent in vitro fer-tilisation (IVF) in which her partner was the sperm donor andher own sister the oocyte donor. This treatment resulted inthe delivery of a healthy girl in January 2004. However, 12months later, she presented to her GP with left iliac fossa painand a positive home pregnancy test.Assessment by the local gynaecology team demonstrateda serum human chorionic gonadotrophin (hCG) level varyingbetween 190 and 260 iu/l, while an ultrasound demonstrateda 2-cm uterine mass, which was initially thought to be afibroid. After further investigations demonstrated a rise inthe hCG level, a laparoscopy and dilatation and curettagewere performed.Histopathological examination demonstrated fragments ofendometrium and myometrium with infiltration of the myo-metrium by sheets of mitotically active cells with eosinophiliccytoplasm and ovoid nuclei highly suggestive of the diagnosisof placental site trophoblastic tumour (PSTT) (Figure 1).At this point, she was referred to Charing Cross Hospital,London, one of the national centres in the UK for treatmentof trophoblastic tumours. Updated investigations demon-strated the hCG level to remain elevated at 111 iu/l. A pelvicDoppler ultrasound confirmed the presence of a 3-cm mass oflow vascularity, while pelvic magnetic resonance imaging anda computed tomography (CT) of the chest and abdomen didnot show any evidence of distant spread.Following investigations, she was treated surgically witha hysterectomy plus bilateral salpingo-oophorectomy. Thepathology confirmed the diagnosis of PSTT confined tothe uterus, although malignant cells were found adjacent tothe serosal surface.Fluorescent microsatellite genotyping was performed onDNA from tumour cells obtained by microdissection offormalin-fixed, paraffin-embedded sections and from bloodsamples from the patient, her partner and sister. The genotypeof the tumour was disomic, with one allele from the partnerand one from the patient’s sister for five informative alleles(Table 1). No maternal alleles was identified at any informa-tive loci.Postoperatively, the hCG level fell to normal. However, asmalignant cells were present at the serosal resection surface,she received 8 weeks of adjuvant chemotherapy using thepaclitaxel/etoposide paclitaxel/cisplatin regimen.

Gestational trophoblastic neoplasia (GTN) encompasses several entities including complete (CHM) and partial (PHM) hydatidiform mole (HM) and the malignant gestational trophoblastic tumors (GTTs), choriocarcinoma (CC), and placental-site trophoblastic tumor (PSTT), including epithelioid trophoblastic tumor (ETT). To detect pGTN, postmolar surveillance by measurement of maternal human chorionic gonoadotropin (hCG) levels should be performed. With such a protocol, many cases of pGTN are identified early at a presymptomatic stage based on plateuing or rising hCG concentrations and subsequently treated successfully with chemotherapy. In such cases, histopathological confirmation of the precise nature of the pGTN usually is not available. However, GTT also may present clinically with primary or metastatic disease, either following and unrecognized HM or developing from a nonmolar gestation. Due to their distinctive clinical and histological features, malignant GTTs are generally clearly subdivided into CC and PSTT (including ETT). CC essentially represents malignant trophoblastic tumors with differentiation toward villous trophoblast, with extensive hematogenous spread and high hCG levels, which are highly chemoresponsive. However, PSTTs, represent malignant differentiation toward implantation-site type trophoblast, with lower hCG levels and less response to chemotherapy. Current issues regarding the clinical and histological features of CC and PSTT/ETT are discussed.

Placental-site trophoblastic tumours are a rare form of gestational trophoblastic disease and consequently information about optimum management or prognostic factors is restricted. We aimed to assess the long-term outcome of stage-adapted management by surgery, chemotherapy, or both for patients with the disorder.35 550 women were registered with gestational trophoblastic disease in the UK (1976-2006), of whom 62 were diagnosed with placental-site trophoblastic tumours and included, retrospectively, in the study. Patients were treated by surgery, chemotherapy, or both. We estimated the probabilities of overall survival and survival without recurrence of disease 5 and 10 years after the date of first treatment, and calculated the association of these endpoints with prognostic factors, including time since antecedent pregnancy, serum concentration of beta-human chorionic gonadotropin, and stage of disease, with both univariate and multivariate analyses.Probabilities of overall and recurrence-free survival 10 years after first treatment were 70% (95% CI 54-82) and 73% (54-85), respectively. Patients with stage I disease had a 10-year probability of overall survival of 90% (77-100) and did not benefit from postoperative chemotherapy. By contrast, patients with stage II, III, and IV disease required combined treatment with surgery and chemotherapy; probability of overall survival at 10 years was 52% (3-100) for patients with stage II disease and 49% (26-72) for stage III or IV disease. Outcome for patients who had recurrent or refractory disease was poor: only four (22%) patients achieved long-term survival beyond 60 months. Multivariate analysis showed that the only significant independent predictor of overall and recurrence-free survival was time since antecedent pregnancy. A cutoff point of 48 months since antecedent pregnancy could differentiate between patients' probability of survival (48 months) or death (/=48 months) with 93% specificity and 100% sensitivity, and with a positive predictive value of 100% and a negative predictive value of 98%.Stage-adapted management with surgery for stage I disease, and combined surgery and chemotherapy for stage II, III, and IV disease could improve the effectiveness of treatment for placental-site trophoblastic tumours. Use of 48 months since antecedent pregnancy as a prognostic indicator of survival could help select patients for risk-adapted treatment.National Commissioning Group.

Background Teratomas are the commonest germ cell tumours and are most frequently found in the testes and ovary. Extragonadal teratomas are rare and mainly occur in midline structures. Uterine teratomas are extremely rare with only a few previous case reports, usually involving mature teratomas of the uterine cervix. Case Presentation We report an 82-year-old lady presenting with post-menopausal bleeding. Initial investigations revealed a benign teratoma of the uterus which was removed. Her symptoms persisted and a recurrent, now malignant, teratoma of the uterine corpus was resected at hysterectomy. Six months after surgery she relapsed with para-aortic lymphadenopathy and was treated with a taxane, etoposide and cisplatin-containing chemotherapy regimen followed by retroperitoneal lymph node dissection. Conclusion In this report we discuss the aetiology, diagnosis and management of uterine teratomas, and review previous case studies.

Objectives. The diagnosis of a gestational trophoblastic tumour (GTT) should be considered in all women presenting with a malignancy and an elevated human chorionic gonadotrophin (hCG) level. Whilst some non-gestational malignancies can also produce hCG, most non-gestational tumours can be distinguished from GTT on the basis of histopathological examination. However, some non-gestational tumours can exhibit trophoblastic differentiation and so make establishing the definitive diagnosis difficult. In these cases, molecular genetic investigation can establish the differential diagnosis between gestational and non-gestational tumours and facilitate optimal management. The objective of this study is to demonstrate the clinical value of distinguishing these two diagnoses by genetic analysis in patient care at a major GTT treatment centre. Methods. Between 1994 and 2005, fluorescent microsatellite genotyping was used to examine the genetic origin of 35 cases of metastatic hCG-producing tumours with trophoblastic differentiation, three cases of atypical uterine tumours, three cases of uterine choriocarcinoma with a very long interval and one atypical ovarian tumour. Results. Of the 42 cases examined, 24 were proved to be of gestational origin, 14 were non-gestational and in 4 cases genetic analysis was inconclusive. We illustrate the clinical value of this diagnostic technique by presenting five individual cases in which molecular genetic results helped determine the appropriate clinical management. Conclusion. Analysis of the genetic origin of atypical hCG-producing tumours in women allows the optimisation of individual patient care and should be considered in the management of these unusual cases.

Hurthle cell carcinoma, a variant of follicular carcinoma of the thyroid, has been regarded as an aggressive type of differentiated thyroid cancer. It is diagnosed histologically and regarded as a carcinoma by the presence of vascular invasion or capsular invasion. In this case report, a patient with a history of thyroid Hurthle cell carcinoma presented with what seemingly appeared to be a pelvic mass of gynecological origin, with a raised risk-of-malignancy index of 567. She underwent a laparotomy which revealed the presence of multiple masses in the form of nodules and lumps attached to her small bowel, sigmoid colon, omentum, and infracolic region, without the involvement of her pelvic organs or para-aortic lymph nodes. At frozen section, the masses were reported to be high-grade metastatic tumor, possibly a melanoma, unlikely to be a female genital tract tumor. These masses were resected along with a 15-cm section of small bowel and analyzed. They were diagnosed to be secondary lesions of Hurthle cell carcinoma of the thyroid. Hurthle cell carcinoma of the thyroid has not been known to be associated with the elevation of CA125 nor has it been known to metastasize to the small bowel and sigmoid colon.

While developing the technique of abdominal radical trachelectomy for conservative cervical cancer management, the vascular supply of the uterus was thoroughly examined. The question of how many vessels the uterus requires to ensure its viability arose. Following an abdominal radical trachelectomy for stage IB cervical carcinoma, blood supply of the body of the uterus is successfully maintained by only the two infundibulopelvic vessels (n= 34). Pregnancy has resulted following this technique (n= 2). Selective ligation of the pelvic vasculature has been utilized in the abdominal radical trachelectomy procedure. The objectives of this study were to investigate the vasculature of the infundibulopelvic and broad ligaments, to assess the contribution of the ovarian and uterine vessels to overall uterine perfusion, and to consider the clinical applications of selective pelvic vessel ligation. Ten fresh dissections of the infundibulopelvic vessels, broad ligaments of benign total abdominal hysterectomy, and bilateral salpingo-oophorectomy specimens were performed. Perfusion index (PI) and oxygen saturation (O(2)Sat) measurements using a modified probe were taken at specified intervals at the uterine cornu during ten routine benign abdominal hysterectomies to assess the contribution of the ovarian and uterine vessels to overall uterine perfusion and the concepts studied were utilized in certain gynecological procedures. The ovarian/infundibulopelvic vessels course medially through the broad ligament toward the uterine cornu and consistently give off a branch to the ovary on its lateral border. In addition, further vessels were noted to run laterally from the uterine cornu along the ovarian ligament to the medial aspect of the ovary. PI and O(2)Sat measurements imply that the uterine and ovarian vessels contribute almost equally to uterine perfusion. Clinical application by selective ligation of the pelvic vasculature has been utilized in certain gynecological procedures often prone to torrential life-threatening uterine hemorrhage. Selective temporary ligation of the uterine and ovarian vessels has proven useful in the surgical management of chemoresistant gestational trophoblastic disease, in the Strassman procedure, fertility-sparing surgery in ruptured cornual ectopic pregnancies, and unrelenting postpartum hemorrhage. Of the six supplying vessels (ovarian, uterine, and vaginal) to the uterus only two (ovarian or uterine or a combination thereof) are required for uterine viability.

Traditional epidemiologic data suggest that persistent gestational trophoblastic disease (pGTD), may follow, and be derived from, either molar pregnancy, non-molar term pregnancy or first-trimester non-molar miscarriage. We examined a database of cases of possible or probable hydatidiform moles and proven pGTD derived from the Regional Trophoblastic Disease Unit, Charing Cross Hospital, London. There were 424 cases (6%), in whom the initial registered diagnosis was that of PHM or CHM but central histopathological review diagnosed a definite non-molar hydropic abortion (HA). In eight of the 424 (2%), although the histology of the most recent index pregnancy was that of non-molar miscarriage, there was a previous history of pregnancy affected by hydatidiform mole; two of these developed subsequent pGTD. Of a further 86 cases referred for a histopathological opinion prior to registration which demonstrated definite non-molar HA, none developed pGTD (zero of 510 (0%, 95% CI 0-0.7%)). During the same period there were 352 cases with pGTD requiring chemotherapy. In 31 cases, the only known pregnancy was the preceding apparent non-molar HA. However, of these, there were only three cases in whom the preceding histological products of conception had been centrally reviewed and were suggestive of non-molar pregnancy. However, in all three of these cases, the specimens were inadequate for definite exclusion of molar pregnancy. In one case in whom no material was available for review, molecular genetic analysis using restriction fragment length polymorphisms was carried out, and the choriocarcinoma was genetically derived from a previous molar pregnancy rather than the preceding HA. There were therefore no cases identified on the database of the trophoblastic disease unit of pGTD requiring treatment in whom the trophoblastic tumour could be genetically proven to have arisen from the preceding first trimester non-molar HA. We suggest that the risk of pGTD developing from a histologically confirmed non-molar HA is less than 1 in 50,000 and that the majority of pGTD cases previously reported to have been caused by a non-molar miscarriage probably represent disease due to an unrecognised early molar pregnancy.

Traditionally radical hysterectomy has formed the mainstay of treatment for early stage cervical carcinoma. More recently radical trachelectomy and laparoscopic lymphadenectomy have been introduced to allow preservation of fertility. We present a new approach to fertility-sparing surgery, namely abdominal radical trachelectomy. The technique is similar to a standard radical hysterectomy and lymphadenectomy. In our technique the ovarian vessels are not ligated and, following lymphadenectomy and skeletonisation of the uterine arteries, the cervix, parametrium and vaginal cuff are excised. The residuum of the cervix is then sutured to the vagina and the uterine ateries re-anastomosed.

The majority (95%) of patients indicated that collaboration between different healthcare professionals resulted in better patient care. Seventy-five percent of patients indicated that collaboration between different healthcare professionals results in less repeated information. The majority of patients indicated that the different healthcare professionals involved in their care worked well (90%) and communicated well (85%) as a team. Almost all respondents (87%) identified themselves as part of their healthcare team. Patient perspectives regarding collaboration in healthcare were uniformly viewed, with 35% ‘‘mostly’’ agreeing and 65% ‘‘strongly’’ agreeing to the statement ‘‘collaboration between different healthcare professions is important to me’’. Conclusions: IPC was found to be important to the majority of respondents. It was also well rated at the Odette Cancer Centre, as anticipated. Patient experiences were almost uniformly positive, with high praise for the radiation therapists, radiation oncologists and radiation nurses. Surprisingly, a significant number of patients did not think repeating health information to multiple healthcare professionals was negative or redundant. On the contrary, they found it more beneficial and would rather repeat themselves, as it could decrease human error.

2 patients with fast and 4 with medium varieties of Gaucher's syndrome were treated by displacement bone marrow transplantation to install a donor enzyme factory for life. Immunoprophylaxis was given to prevent host impairment of normal enzymes. 5 patients showed rapid and remarkable improvement and were leading fully active lives at 310-1207 days postgraft. Hypersplenism caused the death of 1 patient and a stormy time for another. Pre-transplant elective splenectomy hastened recovery.

A young Caucasian woman is described in whom obstructive jaundice was caused by a granular cell myoblastoma of the common bile duct. She was treated by percutaneous transhepatic biliary drainage for 10 days, before radical removal. Granular cell myoblastomas are benign lesions of disputed histogenesis, rare among biliary neoplasms, the excision of which is curative.

A review of results of therapy for acute myocardial infarction was undertaken because the decline in the rate of mortality from this disease has not been commensurate with the general advancement of medical technology. Conscientious general care and early chair rest are emphasized. A retrospective study of the use of anticoagulants revealed a slightly decreased incidence of thromboembolism and of mortality in the cases in which anticoagulants were used. Although anticoagulant drugs are probably of some benefit, their use should not detract from the search for better methods of salvaging life after myocardial infarction. Intensive-care units which utilize modern electronic monitoring, therapeutic devices, and medical personnel trained and drilled in the procedures for cardiac resuscitation are considered to be an urgent need. Intensive-care units are likely to be the best means now available to clinicians for decreasing the rate of mortality from acute myocardial infaction. The use of thrombolytic agents, now quite new, may become a widely employed and useful means of helping the patient who has acute myocardial infarction. At present, the need in this area is for further clarification of the biochemical effects of thrombolytic agents, the development of more practical means of administration and control of the agents, the search for improved agents, and the evaluation of thrombolytic agents in animals and in the various thromboembolic diseases of man under careful investigational conditions.

Summary A patient with chronic pancreatitis presented with a series of massive upper gastrointestinal haemorrhages due to bleeding into the pancreatic duct. This report emphasizes the value of intensive investigation before surgery, since it may be impossible to identify the site of bleeding at laparotomy.

One hundred and six consecutive chronic hepatitis B virus (HBV) carriers were studied for the prevalence of delta markers in serum and tissue, and the clinical and histological features of those with and without delta infection were compared. Twenty (18.9%) patients were positive for anti-delta in serum or delta antigen in the liver or both. They presented at a younger age (30.3 v 38 years). All of them were symptomatic at the time of biopsy, in contrast to 35% of patients without delta infection who were not symptomatic. Those with delta infection had higher serum transaminase values and showed more severe liver damage on biopsy: chronic active hepatitis in 45% and cirrhosis in 55%. There was more pronounced disease activity both within the parenchyma and in the portal and periportal zones. The histological diagnosis of the 86 patients without delta infection included minimal disease (10%), chronic persistent hepatitis (9%), chronic active hepatitis (62%), and cirrhosis (19%). Delta infection in chronic HBV carriers is associated with a more active and progressive liver disease.

Pneumonia is more likely to complicate influenza in the elderly and those with chronic disease but can strike the previously healthy younger person as well. Age and previous state of health also strongly influence prognosis. Appropriate therapy depends on careful initial assessment of the pneumonia and includes antibiotic treatment as well as intensive respiratory care for patients manifesting acute respiratory failure.

During an epidemic, in November and December 1968, the influenza A Hong Kong/68 virus was isolated from 127 adult patients. The procedures for isolation and identification of this virus are described. The clinical manifestations were similar to those of Asian influenza in 1957. Pneumonia was a complication in 20 cases. Based on roentgenograms, these cases were separated into the following two distinct syndromes: localized pneumonia (ten cases), either bacterial or viral, with low mortality (two deaths); and bilateral or diffuse pneumonia (ten cases), a primary influenza virus pneumonia, with high mortality (six deaths). Staphylococcus aureus or Pseudomonas aeruginosa infection was present in six of the eight fatal cases. Patients who were elderly, had associated chronic disease, or were hospitalized with other illnesses were most prone to develop pneumonia. Current methods of influenza control are discussed.