Charlotte Floridon

Uterine artery embolization of symptomatic uterine fibroids: Initial success and short-term results

Purpose: To evaluate reduction in fibroid volume, the effect on clinical symptoms, adverse events and complications after percutaneous uterine artery embolization (UAE) as primary invasive treatment for symptomatic uterine fibroids. Material and Methods: Sixty-two patients entered the study. Indications for treatment were fibroid-induced menorrhagia, bulk symptoms, pain, and/or large fibroid size. The first 50 patients were evaluated by clinical examination and ultrasonography with measurement of fibroid volume before treament and 1, 6 and 12 months after UAE. The remaining 12 patients were followed 3 and 12 months after treatment. Embolization with microparticles was performed percutaneously in local analgesia by selective catheterization of both uterine arteries. Results: A primary technical success with bilateral UAE was achieved in 60/62 (97%) of the patients. They were treated for postprocedural pain lasting up to 24 h. In 30 of the 62 patients with 6 months follow-up, the mean fibroid volume was reduced 68% 6 months after treatment. Twenty-nine (96%) of the patients experienced reduced bleeding, 21 (70%) reduced pain, and 18 (61%) reduced bulk symptoms at follow-up. Conclusion: UAE is a method with a high technical success rate. The treatment has good effect on fibroid volume reduction and clinical symptoms. Severe post-procedural pain occurs generally in successful bilateral embolizations, but complications and adverse events are otherwise few and minor. UAE represents a promising new method for treating uterine fibroid-related symptoms.

Methotrexate treatment of ectopic pregnancy

The last decade has witnessed an increasing number of reports indicating that ectopic pregnancy (EP) can be successfully and safely treated with methotrexate (MTX). This review summarizes the results. In large series, as many as 45% of a population of women with EP has been treated with MTX. Success rates of 82–95% have been achieved. Tubal patency on the affected side was preserved in 79–91% of the cases. Preliminary assessment of subsequent fertility suggests that 47–69% will obtain an intrauterine pregnancy. Complications have been only few and of minor importance. However, the majority of reports do not include controls. Randomized studies are needed to optimize patient selection, treatment regimens, long‐term toxicity, future fertility, and cost‐benefits.

Success and spontaneous pregnancy rates following systemic methotrexate versus laparoscopic surgery for tubal pregnancies: A randomized trial

Objective. To determine which treatment should be offered to women with a non‐ruptured tubal pregnancy: a single dose of methotrexate (MTX) or laparoscopic surgery. Design. Prospective, randomized, open multicenter study. Setting. Seven Danish departments of obstetrics and gynecology. Sample. A total of 106 women diagnosed with ectopic pregnancy (EP). Methods. Between March 1997 and September 2000, 1,265 women were diagnosed with EP, 395 (31%) were eligible, 109 (9%) were randomized of whom 106 had an EP. The study was originally powered to a sample size of 422 patients. The women were randomized to either medical (MTX; 53) or surgical (laparoscopic salpingotomy; 53) treatment. Follow‐up by questionnaire and through national patient databases for a maximum of 10 years. Main outcome measures. Uneventful decline of plasma‐human chorionic gonadotropin to less than 5 IU/L, rates of spontaneous, subsequent intrauterine, and recurrent ectopic pregnancies. Results. The success rates were 74% following MTX treatment and 87% after surgery (n.s.); the subsequent spontaneous intrauterine pregnancy rate was 73% after MTX and 62% after surgery; and the EP rate was 9.6% after MTX and 17.3% following surgery (n.s.). Conclusions. In women with an EP, who are hemodynamically stable and wishing to preserve their fertility, medical treatment with single dose MTX tends to be equal to treatment with laparoscopic surgery regarding success rate, complications, and subsequent fertility. Although the two treatment modalities seemed to be similar in outcome, it is crucial that the diagnosis is based on a high‐quality ultrasonographic evaluation, as two patients had intrauterine pregnancies despite fulfilling the diagnostic algorithm for EP.

Expression and tissue localization of collectin placenta 1 (CL-P1, SRCL) in human tissues.

Collectin placenta-1 (CL-P1), also known as scavenger receptor with C-type lectin (SRCL), is a type II membrane glycoprotein that shares structural features with both collectins and type A scavenger receptors. CL-P1 was originally cloned from the placenta and found to be associated with endothelial cells. It binds via its lectin domain to desialyated Lewis X containing glycoproteins and it is able to facilitate internalization of bound ligands. Via positively charged residues in the collagen-like region it binds to negatively charged components of microbial membranes. It has previously been proposed that CL-P1 plays a role in the host defense system and in the clearance of glycoproteins from the blood. With the aims of determining the detailed tissue expression of human CL-P1 we expressed CL-P1 recombinantly in both E. coli and CHO cells, and raised monoclonal antibodies against human CL-P1. Three monoclonal antibodies were characterized and used in immunohistochemical analyses of a panel of cryo- and formalin-fixed sections. We find that CL-P1 mainly associates with cytotrophoblasts and syncytiotrophoblasts of the placenta, alveolar macrophages and to a less degree with macrophage-like and stromal cells of the tonsils. By real-time RT-PCR we verified that the placenta is also the main organ of CL-P1 synthesis. The only source of endothelial cells whereto CL-P1 associates are umbilical cord vein endothelial cells (human umbilical vein endothelial cells, HUVEC). In vitro cultured HUVECs express both the CL-P1 mRNA and show anti-CL-P1 immunoreactivity but CL-P1 locates mainly to the cytosol and not to the membrane of these cells. We conclude that CL-P1 is not a common membrane protein on endothelial cells found in normal tissues under steady state conditions.

Multimeric and trimeric subunit SP-D are interconvertible structures with distinct ligand interaction.

Surfactant protein-D (SP-D) is a calcium dependent lectin in the innate immune system that facilitates clearance of microbes. The protein is associated with mucosal surfaces, and also found in bronchoalveolar lavage, serum and amniotic fluid. Human SP-D includes trimeric subunits and multimeric assemblies of trimeric subunits, which are stabilized by N-terminal interchain disulfide crosslinks. An N-terminal structural polymorphism (Met11Thr) and associated O-glycosylation are previously shown accompanied by incomplete multimerization and with a relative low proportion of multimeric Thr11 SP-D compared to Met11 SP-D. Multimerization has proven important for enhancement of microbial phagocytosis. In the present study defined multimeric forms of Met11Thr SP-D were isolated from human amniotic fluid. Implementation of ManNAc-affinity chromatography allowed high recovery of natural trimeric SP-D subunits. However, affinity chromatography increased the relative proportion of multimers at the expense of natural trimeric subunits. Multimeric SP-D partially disassembled to form trimeric subunits. The resulting distribution of structural forms was independent of the Met11Thr genotype. Trimeric and multimeric SP-D appeared with distinct patterns of disulphide crosslinking, which partly changed according to interconversion between the structural forms. Solid phase assays demonstrated that trimeric SP-D subunits showed greater binding to LPS and PGN, but lower binding to mannan and LTA, than SP-D multimers. Trimeric SP-D subunits also showed greater binding to endogenous lipoproteins: LDL, oxLDL, and HDL, than multimeric SP-D. In conclusion, purified trimeric and multimeric SP-D represent separate and only partly interconvertible molecular populations with distinct biochemical properties.

Pregnancy associated plasma protein-A (PAPP-A) is not a marker of the vulnerable atherosclerotic plaque

OBJECTIVE To investigate if pregnancy associated plasma protein-A (PAPP-A) was present in the vulnerable plaque, and if not, to find alternative hypothesis for the release of PAPP-A. DESIGN AND METHODS Vulnerable plaques and control tissues were examined by immunohistochemistry. Volunteers and patients with non-atherosclerotic disease were examined for release of PAPP-A during ischemia and medical treatment. Non-atherosclerotic tissue samples were examined after incubation with heparins. RESULTS We were not able to detect PAPP-A in vulnerable plaques. Patients and volunteers experiencing ischemic events without atherosclerotic lesions only had elevated PAPP-A when treated with heparin. When tissue from normal artery wall was incubated with heparin, PAPP-A was eluted. This was not the case for non-arterial tissue samples. CONCLUSION Elevation of PAPP-A in patients with acute coronary syndromes seems to be caused by heparin induced release of PAPP-A from the arterial wall and not due to excretion from vulnerable plaques.

Ectopic pregnancy: histopathology and assessment of cell proliferation with and without methotrexate treatment.

OBJECTIVE To evaluate tubal morphology, trophoblast proliferation, and inflammatory reaction in response to methotrexate (MTX) treatment of ectopic pregnancy (EP). DESIGN Nonrandomized controlled study. SETTING Academic hospital. PATIENTS Archival specimens from 10 EP unsuccessfully treated with MTX and 10 cases primarily treated by surgery. INTERVENTIONS Ki67/hCG and Ki67/human placental lactogen double immunohistochemical methods were used to examine trophoblastic spread, placentation, hormone production, decidualization, vascular invasion, hemorrhage, rupture, and proliferative index of the cytotrophoblast. B and T-lymphocyte responses were evaluated by CD3 and CD20. RESULTS Trophoblastic spread and placentation were confined to the tubal mucosa after MTX treatment, whereas invasion of the muscularis and subserosa was common in the controls. The proliferative index was reduced (19 percent versus 93 percent), although a high proliferative index was found in two of three cases complicated by rupture. Polar proliferation of Ki67-positive cytotrophoblast toward the implantation site was abolished in MTX-treated cases. Decidual reaction was not observed. No correlation was observed between the above-mentioned findings and gestational age, level of beta-hCG, dose of MTX, or interval to surgery. CONCLUSION Trophoblastic spread, differentiation, and invasion were compromised by MTX treatment. Methotrexate seems to decrease cytotrophoblast proliferation. Whether a missing decrease in proliferation index reflects treatment failure awaits a larger population-based study.

Alternative treatment for symptomatic fibroids.

The present review discusses treatment options for symptomatic fibroids. Although the standard treatment of fibroids has been surgical hysterectomy, an increasing number of reports indicate that uterine artery embolization with preservation of the uterus is a promising alternative. Other surgical and medical approaches reported during the past year are also addressed. The review summarizes patient selection, contraindications, results, complications and future considerations. Complications following uterine artery embolization treatment for symptomatic fibroids have been minor in comparison with those following hysterectomy. Although patient satisfaction is good, none of the studies included control individuals and further studies are needed to optimize patient selection and to evaluate long-term results of treatment.

Fibroids treated by uterine artery embolization

An increasing number of reports indicate that uterine fibroids can be successfully treated with uterine artery embolization (UAE). UAE seems to be a promising treatment for women who want to retain their uterus. This review summarizes the technical considerations and the results. UAE is a radiological procedure using angiography for visualization of the blood circulation. Subsequently, the flow through the uterine arteries is blocked resulting in infarction of fibroids. Success rates of 87% have been achieved with an average 57% reduction of fibroid volume. Complications have been few compared to hysterectomy and patient satisfaction is high. However, none of the reports include controls. Further studies are needed to optimize patient selection and to evaluate long‐term results.

Fibroids treated by uterine artery embolization: A review

An increasing number of reports indicate that uterine fibroids can be successfully treated with uterine artery embolization (UAE). UAE seems to be a promising treatment for women who want to retain their uterus. This review summarizes the technical considerations and the results. UAE is a radiological procedure using angiography for visualization of the blood circulation. Subsequently, the flow through the uterine arteries is blocked resulting in infarction of fibroids. Success rates of 87% have been achieved with an average 57% reduction of fibroid volume. Complications have been few compared to hysterectomy and patient satisfaction is high. However, none of the reports include controls. Further studies are needed to optimize patient selection and to evaluate long-term results.