Guía clínica para el manejo del nódulo tiroideo y cáncer de tiroides durante el embarazo

Special considerations are warranted in management of thyroid nodule and thyroid cancer during pregnancy. The diagnostic and therapeutic approach of thyroid nodules follows the standard practice in non-pregnant women. On the other hand, differentiated thyroid cancer management during pregnancy poses a number of challenges for the mother and fetus. The available data show that pregnancy is not a risk factor for thyroid cancer development or recurrence, although flare-ups cannot be completely ruled out in women with active disease. If surgery is needed, it should be performed during the second term or, preferably, after delivery. A majority of pregnant patients with low-risk disease only need adjustment in levothyroxine therapy. However, women with increased serum thyroglobulin levels before pregnancy or structural disease require regular thyroglobulin measurements and neck ultrasound throughout pregnancy. Pregnancy is an absolute contraindication for radioactive iodine administration.     

妊娠期乳腺癌的治疗进展

妊娠期乳腺癌是一种特殊类型的乳腺癌。妊娠对乳腺癌的生物学行为可能的影响及诊疗措施对胎儿的影响,使得妊娠期乳腺癌的临床表现、诊断和治疗等有其特殊性。由于妊娠相关的乳腺的生理改变,妊娠期乳腺癌的诊断极具挑战性,导致诊断延误非常普遍。妊娠期乳腺癌患者的治疗策略需要多学科专家一起参与决定,在考虑胎儿安全性的同时尽量与非妊娠乳腺癌患者的标准治疗一致。妊娠期间都可以安全的行乳腺手术。妊娠第一孕期和第二孕期早期可以考虑放疗,但要注意检测胎儿暴露的放射剂量。研究证据越来越支持14孕周后可以安全的行化疗。曲妥单抗和他莫昔芬有潜在的胎儿毒性,不推荐用于妊娠期患者。     

Detection of circulating mammary mucin (Muc1) and MUC1 immune complexes (Muc1-CIC) in healthy women

There is convincing epidemiological evidence that multiparity provides protection against the development of breast cancer. In the present study we evaluated the levels of MUC1 and MUC1 circulating immune complexes (MUC1-CIC) in 135 serum samples obtained from healthy women. The study population included 13 women who had never been pregnant, 31 primiparous pregnant women, 36 multiparous pregnant women who had lactated, 5 multiparous pregnant women who had never lactated, 24 multiparous non-pregnant women who were lactating at the time of the study, 24 multiparous non-pregnant women who had lactated, and 2 multiparous non-pregnant women who had never lactated. The purpose of this work was to detect MUC1 variations during pregnancy and lactation as well as to study the possible induction of a humoral immune response against MUC1 in these conditions. We employed ELISA techniques to measure MUC1 (CASA test) and MUC1-CIC (IgM and IgG) using two anti-MUC1 monoclonal antibodies (MAbs): C595 and SM3. Statistical analysis was performed using the ANOVA test. The pooled results pertaining to pregnant versus non-pregnant women were compared and significant differences were observed in MUC1 and MUC1-CIC-lgM levels detected with both MAbs; the MUC1-CIC-lgG levels detected with C595 were increased in the pregnant group while the MUC1-CIC-lgG levels detected with SM3 did not show any significant differences. When the results were compared between lactating and non-lactating women, no significant differences were found. In conclusion, MUC1 and MUC1-CIC-lgM, detected with both MAbs, and MUC1-CIC-4gG levels detected with the MAb C595 are apparently induced by pregnancy.     

Human beta-casomorphin-8 immunoreactive material in the plasma of women during pregnancy and after delivery

A method for the extraction of human beta-casomorphin-8 immunoreactive material from human plasma and a radioimmunoassay for its determination in the plasma extracts were developed. Blood was collected from 34 men, from 35 non-pregnant women, from 35 pregnant women and from 138 women after delivery and plasma extracts were assayed for the presence of human beta-casomorphin-8 immunoreactive materials. No human beta-casomorphin-8 immunoreactive material was detected in the plasma of men or non-pregnant women, whereas such material was found in the plasma of 26 out of 35 pregnant women and in the plasma of 100 out of 138 women after parturition. Material collected from women after delivery was characterized by gel filtration and high-performance liquid chromatography (HPLC) and was found to be of different composition in various individuals; its components, one of which coeluted with human beta-casein from the HPLC column, have apparently higher molecular weights than human beta-casomorphin-8. Some of these compounds seem to be very stable against enzymatic degradation at 37 degrees C in human plasma, whereas human beta-casomorphin-8 proved to be degraded very fast under identical conditions. A physiological significance of mammary products of the beta-casomorphin type during pregnancy or after parturition is suggested.     

Effects of early pregnancy on regional adipose tissue metabolism

Adipose tissue metabolism was studied in needle biopsies from femoral and abdominal subcutaneous depots, in 12 healthy young women, during early (9-11 weeks) pregnancy, and 6 weeks after a legal abortion. Both during pregnant and non-pregnant conditions, a higher lipoprotein lipase (LPL) activity was seen in the femoral compared to the abdominal region, but the LPL activity was not influenced by early pregnancy. Rates of fatty acid esterification and acylglyceride synthesis were not different between regions, nor affected by pregnancy. The stimulatory effect of norepinephrine (10(-7) M) on lipolysis was significantly greater in the abdominal than in the femoral region in both the pregnant and non-pregnant condition. This difference was apparently due to higher alpha-adrenergic activity in the femoral region. Pregnancy per se had no effect on lipolytic response to norepinephrine. These findings indicate that lipid accumulation is favoured in the femoral region in young women both during pregnant and non-pregnant conditions.     

Pregnancy in women with hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is increasingly being diagnosed in pregnant women. Women with HCM generally tolerate pregnancy well. The risk is however higher in women who are symptomatic before pregnancy or in those with severe left ventricular outflow tract obstruction. The incidence of arrhythmias does not appear to be increased during pregnancy and maternal mortality is low. Prior to conception, women with HCM should have a risk assessment as well as genetic counselling. During pregnancy beta-blockers should be continued and the judicious use of diuretics may be required to treat symptoms of dyspnoea. A vaginal delivery with regional anaesthesia is usually appropriate. Women should be managed by a specialist multidisciplinary team.     

Annexin A8 Identifies a Subpopulation of Transiently Quiescent c-Kit Positive Luminal Progenitor Cells of the Ductal Mammary Epithelium

We have previously shown that Annexin A8 (ANXA8) is strongly associated with the basal-like subgroup of breast cancers, including BRCA1-associated breast cancers, and poor prognosis; while in the mouse mammary gland AnxA8 mRNA is expressed in low-proliferative isolated pubertal mouse mammary ductal epithelium and after enforced involution, but not in isolated highly proliferative terminal end buds (TEB) or during pregnancy. To better understand ANXA8’s association with this breast cancer subgroup we established ANXA8’s cellular distribution in the mammary gland and ANXA8’s effect on cell proliferation. We show that ANXA8 expression in the mouse mammary gland was strong during pre-puberty before the expansion of the rudimentary ductal network and was limited to a distinct subpopulation of ductal luminal epithelial cells but was not detected in TEB or in alveoli during pregnancy. Similarly, during late involution its expression was found in the surviving ductal epithelium, but not in the apoptotic alveoli. Double-immunofluorescence (IF) showed that ANXA8 positive (+ve) cells were ER-alpha negative (−ve) and mostly quiescent, as defined by lack of Ki67 expression during puberty and mid-pregnancy, but not terminally differentiated with ∼15% of ANXA8 +ve cells re-entering the cell cycle at the start of pregnancy (day 4.5). RT-PCR on RNA from FACS-sorted cells and double-IF showed that ANXA8+ve cells were a subpopulation of c-kit +ve luminal progenitor cells, which have recently been identified as the cells of origin of basal-like breast cancers. Over expression of ANXA8 in the mammary epithelial cell line Kim-2 led to a G₀/G₁ arrest and suppressed Ki67 expression, indicating cell cycle exit. Our data therefore identify ANXA8 as a potential mediator of quiescence in the normal mouse mammary ductal epithelium, while its expression in basal-like breast cancers may be linked to ANXA8’s association with their specific cells of origin.     

Relationship of prenatal alcohol use with maternal and prenatal factors in American Indian women

Demographic factors and patterns of substance use among women who did not consume alcohol during pregnancy were compared to women who did consume alcohol during pregnancy. One-hundred seventy-seven Northern Plains Indian women who received prenatal care at an urban clinic in a rural state were screened for substance use as part of the validation study with a self-administered questionnaire. Women who drank during pregnancy were more likely to be single and have less education than women who did not drink. While most of the women in the study had available transportation resources, the women who drank during pregnancy were less likely to have transportation than the women who did not drink. Women who drank during pregnancy consumed more alcohol more frequently before pregnancy than did women who drank before but not during pregnancy. Compared to women who did not drink during pregnancy, women who drank during pregnancy were more likely to smoke cigarettes and use illicit drugs, to have parents who drank, to feel they drank the same or more than other pregnant women, or to have experienced more relationship breakups and physical and emotional abuse. Prenatal patients who drink alcohol during pregnancy need more intensive counseling regarding their multiple risk behaviors.     

Proliferation and differentiation in the human breast during pregnancy

Using multiple immunofluorescence labelling on human breast tissues obtained and freshly frozen at the 12th, 15th, and 18th weeks of pregnancy, we have shown that markers of mammary functional differentiation, milk proteins (beta-casein and kappa-casein), are synthesised by actively cycling (Ki67 positive) as well as non-cycling (Ki67 negative) cells. These results demonstrate that functional differentiation/maturation does not coincide with loss of proliferative potential in human mammary luminal epithelial cells. In addition, we have examined expression patterns of integrin subunits (alpha1, alpha2, alpha3, alpha6, beta1, and beta4) and extracellular matrix components (laminin, fibronectin, collagen I, and collagen IV), since they have been shown to exert influences on mammary differentiation and morphogenesis in vitro. Compared to human breast tissues obtained from non-pregnant women, a decrease in alpha2 labelling on luminal epithelial cells was observed, particularly in expanding acini that showed abundant Ki67 positivity. The expression patterns of other integrin subunits, however, did not change, indicating that the expression patterns of most integrins existing prior to pregnancy are sufficient to support the morphological and functional development associated with milk protein synthesis.     

Association of cytokines in hepatitis E with pregnancy outcome

AimsThe aim of this study was to evaluate tumour necrosis factor-alpha (TNF-α), interleukin (IL)-6, interferon gamma (IFN-γ) and transforming growth factor-beta1 (TGF-β1) in hepatitis E infection during pregnancy and its relation with pregnancy outcome.MethodsA total of 272 pregnant and 219 non-pregnant women with hepatitis and 262 age and gestational age matched healthy pregnant women and 208 age matched, healthy non-pregnant women were evaluated on the basis of history, clinical examination, liver function profile. Serological tests of hepatitis A, B, C and E and cytokines using commercially available (ELISA) kits. The patients with hepatitis E were further evaluated for viral load by Real Time PCR. All these were followed till delivery for pregnancy outcome.ResultsHEV viral load in acute viral hepatitis (AVH) and fulminant hepatic failure (FHF) of pregnant women were comparatively higher than non-pregnant women. Significantly higher levels of TNF-α, IL-6, IFN-γ and TGF-β1 were present in HEV infected pregnant women compared to non-pregnant women and controls. TNF-α, IL-6 and IFN-γ had significant positive correlation with viral load, serum bilirubin and prothrombin time in pregnant women. Higher levels of all four cytokines were found in pregnant women with HEV infection having adverse pregnancy outcome compared to that of pregnant women with non-HEV infection and controls.ConclusionIn conclusion, severity of HEV infection and associated adverse pregnancy outcome might be mediated by cytokine in pregnancy.     

Impact of adjuvant chemotherapy on survival of women with T1N0M0, hormone receptor negative breast cancer

BackgroundThe benefit of adjuvant chemotherapy in women with T1N0M0 breast cancers is unclear. While gene expression-based prognostic assays may aid management of women with early estrogen receptor (ER) positive tumors, therapeutic decision-making in women with early stage ER negative tumors remains fraught with difficulties. We investigated the association between adjuvant chemotherapy and overall survival in women with T1N0M0, hormone receptor negative breast cancers.MethodAll newly diagnosed breast cancer patients with node-negative and hormone receptor negative tumors measuring ≤ 2 cm at the University Malaya Medical Centre (Malaysia) from 1993 to 2013 were included. Mortality of patients with and without adjuvant chemotherapy were compared and adjusted for possible confounders using propensity score.ResultsOf 6732 breast cancer patients, 341 (5.1%) had small (≤2 cm), node-negative and hormone receptor negative tumors at diagnosis. Among them, only 214 (62.8%) received adjuvant chemotherapy. Five-year overall survival was 88.1% (95% confidence interval (CI): 82.0%–94.2%) for patients receiving chemotherapy and 89.6% (95% CI: 85.1%–94.1%) for patients without chemotherapy. Chemotherapy was not associated with survival following adjustment for age, ethnicity, tumor size, tumor grade, HER2 status, lympho-vascular invasion, type of surgery and radiotherapy administration. However, chemotherapy was associated with a significant survival advantage (adjusted hazard ratio: 0.35, 95%CI: 0.14–0.91) in a subgroup of women with high-grade tumors.ConclusionAdjuvant chemotherapy does not appear to be associated with a survival benefit in women with T1N0M0, hormone receptor negative breast cancer except in those with high-grade tumors.     

Postpartum mammary gland involution drives progression of ductal carcinoma in situ through collagen and COX-2

The prognosis of breast cancer in young women is influenced by reproductive history. Women diagnosed within 5 years postpartum have worse prognosis than nulliparous women or women diagnosed during pregnancy. Here we describe a mouse model of postpartum breast cancer that identifies mammary gland involution as a driving force of tumor progression. In this model, human breast cancer cells exposed to the involuting mammary microenvironment form large tumors that are characterized by abundant fibrillar collagen, high cyclooxygenase-2 (COX-2) expression and an invasive phenotype. In culture, tumor cells are invasive in a fibrillar collagen and COX-2-dependent manner. In the involuting mammary gland, inhibition of COX-2 reduces the collagen fibrillogenesis associated with involution, as well as tumor growth and tumor cell infiltration to the lung. These data support further research to determine whether women at high risk for postpartum breast cancer would benefit from treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) during postpartum involution.     

Some Physiological Adjustments Relating to Nutrition in Pregnancy

Information from human and animal studies clearly indicates that a number of adjustments in protein, fat, iron and calcium metabolism occur during pregnancy. Recognition of these adjustments has led to a reappraisal of nutrient requirements during pregnancy. The existence of significant protein storage during pregnancy is called into question; in contrast, the evidence suggests that the major storage component is fat, perhaps in anticipation of the energy costs of lactation. In women who will not lactate, this storage is of no benefit and is an etiologic factor in obesity. From a consideration of iron metabolism in pregnancy, it is concluded that it is better to prevent iron depletion in non-pregnant women, especially that associated with excessive menstrual loss, than to administer iron therapy to pregnant women.     

Antibodies to rubellavirus, herpes simplex virus and Toxoplasma gondii in serial serum samples of pregnant and non-pregnant women.

By testing serial serum samples of 213 pregnant women for rubellavirus, of 196 for herpes simplex virus and of 134 for Toxoplasma gondii, it was found that during pregnancy there was a fall in the humoral antibody level. Presence and titre of antibodies were lower in sera of pregnant than of non-pregnant women. Alteration of the humoral antibody level during pregnancy may influence serological studies aimed at clarifying the role of infections in fetal malformations. Serial serum samples (4 samples from each pregnant woman involved) should be tested for obtaining reliable data regarding the frequency of infections during pregnancy.     

The effect of steroid sex hormones on the biosynthesis of alpha 2-macroglobulin and pregnancy-associated alpha 2-glycoprotein in cultures of peripheral blood mononuclear cells]

The peripheral blood mononuclears are capable of intense biosynthesis of alpha 2-macroglobulin and of weak biosynthesis of pregnancy-associated alpha 2-glycoprotein. Sex hormones of men and non-pregnant women exert no influence on the protein biosynthesis. During pregnancy alpha 2-macroglobulin biosynthesis is shortly activated, although it does not depend on the influence of sex hormones. All the steroid sex hormones provide a short-term biosynthesis of this protein during the II trimester of pregnancy, while testosteron inhibits it during the III trimester. Possible mechanisms of control of biosynthesis of these proteins are discussed.     

Lower prevalence of chromosome aberrations and SCEs in self-poisoned pregnant women

A cytogenetic investigation was conducted in 18 self-poisoned pregnant and 16 self-poisoned non-pregnant women and in 31 pregnant and non-pregnant controls. Blood samples for analysis of chromosomal aberrations and SCEs were collected from women who were at different early stages of pregnancy. The difference between self-poisoned women and controls was very highly significant in the case of chromatid-type and unstable chromosome-type aberrations and highly significant in the case of SCEs. Further, the frequency of chromatid aberrations in pregnant women relative to non-pregnant ones was significantly lower suggesting a possible protective effect of pregnancy.     

Erythema infectiosum and pregnancy-related complications.

Erythema infectiosum, an acute, communicable viral disease with a highly distinctive exanthem, follows the usual course of a self-limiting benign disease. In pregnant women, however, it may be associated with fetal death and nonimmune hydrops fetalis. Because of the association of human parvovirus (HPV) B19 infection with fetal damage we reviewed the current knowledge of the clinical aspects of erythema infectiosum, focusing on pregnancy and fetal outcome, to determine the magnitude of fetal risk and offer recommendations for management. Among 180 infected pregnant women 44 fetal deaths (24%) occurred, 1 to 12 weeks after the infection was noted. Pregnant women should be advised that (a) because of the high prevalence (up to 65%) of anti-HPV B19 IgG antibody among adults most of them are not at risk and (b) if maternal infection does occur therapeutic abortion is not indicated since intrauterine infection causes fetal death more often than abnormal development. Infection should be suspected in pregnant women who exhibit the symptoms of erythema infectiosum with or without arthropathy. They should be monitored for an elevated serum alpha-fetoprotein level (indicating fetal aplastic crisis) and undergo serial ultrasonography for the detection of hydrops fetalis. Although the incidence of congenital malformation is no higher than the expected rate in the general population (3% to 5%), the precise incidence of fetal adverse outcomes remains unknown and requires investigation in larger, prospective studies.     

Pregnancy diagnosis in urine of Iberian lynx (Lynx pardinus)

Diagnosis of pregnancies is an important management tool for the Iberian lynx Conservation Breeding Program, a program geared to recover the world's most endangered felid. Non-invasive methods such as fecal hormone analyses are not applicable to the lynx, since fecal progestin does not follow the typical pregnancy pattern of felids. Therefore, we aimed to test whether urine can be used as an alternative substance for pregnancy diagnosis in the Iberian lynx.Progesterone immunoreactive metabolites were determined in urine samples of pregnant and non-pregnant females before and during breeding season. Additionally, we used the Witness^®Relaxin test to determine relaxin in blood and urine. No differences were found in progestin concentrations determined in urine samples collected from pregnant and non-pregnant animals between day 1 and 65 following mating. Although the Witness^®Relaxin test was positive in serum samples collected from animals between day 32 and 56 of pregnancy, it failed in both fresh and frozen urine samples collected from the same stage of pregnancy. A weak relaxin reaction in urine samples collected from animals between day 29 and 46 of pregnancy was detectable after urines were concentrated by ultrafiltration (>50×). Concentrated samples obtained from non-pregnant and early pregnant animals yielded negative test results. In conclusion, the Witness^®Relaxin test can be applied for pregnancy diagnosis in Iberian lynx in both serum and concentrated urine samples obtained during the second half of pregnancy. A positive relaxin test indicates an ongoing pregnancy, whereas negative tests must be judged carefully as hormone concentrations might be below detection thresholds.     

Estradiol, progesterone and prolactin modulate mammary gland morphogenesis in adult female plains vizcacha (Lagostomus maximus)

We studied for the first time the mammary gland morphogenesis and its hormonal modulation by immunolocalizing estradiol, progesterone and prolactin receptors (ER, PR and PRLR) in adult females of Lagostomus maximus, a caviomorph rodent which shows a pseudo-ovulatory process at mid-gestation. Mammary ductal system of non-pregnant females lacks expression of both ERα and ERβ. Yet throughout pregnancy, ERα and ERβ levels increase as well as the expression of PR. These increments are concomitant with ductal branching and alveolar differentiation. Even though mammary gland morphology is quite similar to that described for other rodents, alveolar proliferation and differentiation are accelerated towards the second half of pregnancy, once pseudo-ovulation had occurred. Moreover, this exponential growth correlates with an increment of both progesterone and estradiol serum-induced pseudo-ovulation. As expected, PR and PRLR are strongly expressed in the alveolar epithelium during pregnancy and lactation. Strikingly, PRLR is also present in ductal epithelia of cycling glands suggesting that prolactin function may not be restricted to its trophic effect on mammary glands of pregnant and lactating females, but it also regulates other physiological processes in mammary glands of non-pregnant animals. In conclusion, this report suggests that pseudo-ovulation at mid-gestation may be associated to L. maximus mammary gland growth and differentiation. The rise in P and E2-induced pseudo-ovulation as well as the increased expression of their receptors, all events that correlate with the development of a more elaborated and differentiated ductal network, pinpoint a possible relation between this peculiar physiological event and mammary gland morphogenesis.     

晚期肝癌和复发性肝癌治疗的研究进展

肝细胞癌(HCC)是我国最常见的恶性肿瘤之一,70%继发于肝炎、肝硬变。虽然诊断技术的提高,使肝癌的早期发现成为可能,然而由于肝癌早期症状隐匿,大多数肝癌确诊时已处于中晚期。肝切除术是治疗肝细胞癌最常用的手段。对于一些不可切除的晚期肝细胞癌,可采用动脉化疗栓塞以及系统化疗等手段使肿瘤降期,当转变成可切除肝癌后,再行补救性肝切除延长患者的生存期。此外,对于剩余肝体积不足而无法行一期肝切除的患者,可以采用PVE、ALPPS等方法,在剩余肝脏体积增大后再行二期肝切除术。肝内肿瘤复发率高也是导致肝细胞癌预后差的重要因素。在局部治疗后,建议在保留肝功能的前提下重复治疗。相比局部消融和动脉化疗栓塞治疗等多种手段,肝切除术有最好的远期疗效。联合和重复不同的治疗手段可达到很好的总生存期。对于患有晚期不可切除肿瘤或复发癌的患者,应积极的发挥肝切除的作用,并联合其他非手术治疗手段以取得较好的预后。