a Case reportA 32 year old primipara was admitted for premature rupture of the membranes at 37 weeks of gestation. She had a history of miscarriage with curettage in association with previous pregnancy. She delivered a healthy male child. After manual delivery of the placenta, exploration of the uterus and oxytocin was required to control bleeding. Selective uterine artery embolisation was carried out because there was an adherent placental cotyledon in the left uterine horn causing uncontrollable bleeding.Selective catheterisation of the left internal iliac artery and superselective catheterisation of the left uterine arteries were performed using a 5F cobra-shaped catheter (Cobra; Terumo, Tokyo, Japan) and a 0.035-in. diameter hydrophilic polymer-coated guide wire (Radifocus; Terumo) from the contralateral groin. The angiography showed no anastomosis between the uterine and the ovarian artery and demonstrated an arterial tear with massive extravasation of contrast material in the uterine cavity. Bilateral free-flow embolisation was performed under fluoroscopic control using iodinated contrast media mixed with gelatine sponge pledgets (Curaspon; Curaspon Healthcare, Netherlands) particles obtained by scraping a piece of gelfoam with a surgical blade. No vascular spasm was observed.On day 21, the patient was readmitted for pelvic pain and abnormal bleeding. Vaginal examination revealed that half of the uterine cervix presented an abnormal colour suggestive of ischaemia. Pelvic magnetic resonance imaging revealed a bulky uterus with a small peripheral enhancement rim. The central portion of the organ was completely necrotic.Subtotal hysterectomy was performed. Both uterine artery pedicles were filled with thrombus. Surgical exploration also revealed a 5-cm necrotic area on the bladder wall (Fig. 1). Cystoscopic examination demonstrated mucosal deterioration and the necrotic portion was excised. Cystography on day 13 was normal. Two months after surgery, the cervix and the vagina were normal.Histological examination of the surgical specimens showed massive ischaemic necrosis of the whole uterus except the deep myometrium. Plurinuclear and giant cells occupying the vessels in the lower part of the uterus had phagocytosed small foreign bodies. Some vessels contained unusual weakly coloured star-shaped structures probably corresponding to the gelatine sponge particles used for embolisation. Vessels containing those structures were less dilated, smaller in diameter and thicker-walled than other vessels. Examination of bladder tissue demonstrated complete disappearance of the mucosa together with ischaemic changes throughout the wall. DiscussionPostpartum haemorrhage is the leading cause of maternal mortality throughout the world.1 Various management strategies have been proposed including embolisation to preserve the uterus. Selective arterial embolisation allows localisation of the bleeding site even in cases involving coagulopathy and is feasible after ligation of the internal iliac artery. 2Endoluminal embolisation...
► This case is an exceptionally rare primary neuroendocrine carcinoma of the fallopian tube, with a clinical presentation as torsion. ► TTF1 immunoreactivity can be found in neuroendocrine carcinomas originating from the fallopian tube.
8555 Background: BRAF mutation in melanoma has been shown to be associated with a trend in favour of a spontaneous worse outcome after metastases in a series of 197 patients in Australia. Objective: To correlate BRAF status in metastatic melanoma with clinicopathologic features and outcome. Methods: In our department in France 182 patients with metastatic melanoma have been tested for BRAF mutation between September 2009 and September 2011. Survival was assessed by log-rank test. Multivariate analysis was performed with Cox model. Results: From 182 patients, 88 (48.3%) were B-RAF mutant; 77 (87.5%) V600E, 4 (4.5%) V600K, and 7 (8%) other mutation subtypes. BRAF-mutant patients were younger than BRAF wild-type patients at diagnosis of primary melanoma (median age 52.3 vs 60.7 years, respectively, p=0.003), and at diagnosis of distant metastasis (median age 53.6 vs 64.1 years respectively, p=0.002). 34 patients were treated by B-RAF inhibitors. There was no significant difference in other demographic features of patients with metastatic melanoma by mutation status. Features of the primary melanoma significantly associated with a BRAF mutation (p<0.05) were histopathologic subtype (SSM), high mitotic rate (≥1/mm2), lower Breslow thickness (median Breslow: 2.2 vs 3.5 mm for BRAF mutant and BRAF-wild-type patients respectively, p=0.016), truncal location and location on occasionally exposed at sun site.The interval from diagnosis of first ever melanoma to first distant metastasis was not significantly different in BRAF-mutant and wild-type patients. The median overall survival (OS) from diagnosis of primary melanoma was 6.5 years for BRAF wild-type patients. Median OS was not reached in BRAF-mutant patients treated (34 of 88) with a BRAF inhibitor, but also in those not treated (p=0.24, and p=0.06 for treated BRAF-mutant vs BRAF wild-type). The overall survival from diagnosis of first distant metastasis was not significantly different (p=0.75). These results remained unchanged in a multivariate analysis. Conclusions: Our results confirm the characteristics of BRAF-mutant metastatic patients, and the efficacy of B-RAF inhibitors, but not that the presence of mutant-BRAF is per se a pejorative predictive marker.
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