OBJECTIVE

The study aimed to examine the clinical profile, surgical management, and outcomes of patients admitted for ectopic pregnancy.

A five-year retrospective study of ectopic pregnancies admitted in a tertiary training hospital in the Philippines was performed. Data from admission and operating room records were used to obtain the annual cumulative incidence of ectopic pregnancy. Subjects were divided into laparotomy versus laparoscopy groups, and salpingostomy versus salpingectomy groups; differences in the means/medians/mean-ranks and proportions of the different clinical and outcome variables of interest were compared by Student t test/Mann-Whitney U test and chisquare/Fisher exact test of homogeneity, respectively.

The cumulative incidence of ectopic pregnancy ranged from 2.30% to 4.01% from 2017 to 2021. A total of 128 patients were included in the final analysis with a mean age of 27.8 ± 5.73 years. The most common identified risk factors were smoking (17.97%), previous ectopic pregnancy (17.19%), and previous tubal surgery (15.62%). The ampulla was the most common site of tubal involvement. Of the 128 patients, 45.31% underwent laparotomy while 54.69% underwent laparoscopy. Salpingectomy was performed in 76.56% of patients. Tubal rupture was noted in 42.97% of cases. Patients with abdominal pain, back pain, shoulder pain, and dizziness were more likely to undergo laparotomy than laparoscopy (p < 0.05). A lower β-hCG value was noted in patients who underwent salpingostomy compared to salpingectomy (5,569.80 mIU/mL vs 10,555.47, p < 0.05). Salpingostomy was more likely to be performed on patients with previous ectopic pregnancy (p < 0.05) and previous tubal surgery (p < 0.05) than salpingectomy.

The cumulative incidence of ectopic pregnancy in our institution was higher than global estimates. Risk factors and anatomic site of tubal involvement were similar to those reported in literature. Laparoscopy seemed to be underutilized for cases of ruptured ectopic pregnancy. Training on minimally invasive procedures should be provided to point-ofcare trainees or residents for patients to be afforded the benefits of laparoscopy.

Caesarean scar pregnancy (CSP) is a pregnancy where embryo is implanted in the myometrium of a previous caesarean scar and it is a rare type of ectopic pregnancy. Diagnosis and management of CSP is a challenge because caregivers lack awareness about the possibility of implantation in previous caesarean surgery scar. We present here six CSP cases. All patients presented with abdominal pain and/or bleeding per vaginum with history of previous caesarean section. On ultrasonography, caesarean scar pregnancy was diagnosed. We managed them endoscopically at an endoscopic surgery and training center during the year 2019 till the year 2022. The pre-operative and post-operative periods were uneventful and they were discharged on day 2 or 3 of surgery. Hystero-laparoscopic combined approach is a good option for managing CSP in expert hands. Although there are no clear guidelines for managing CSP, we suggest individualizing each patient's treatment plan, depending on their personal characteristics and available facilities at the managing center.

Abstract Ectopic hepatocellular carcinoma (EHCC) is an extremely rare neoplasm, especially in the mediastinum, which shares morphologic characteristics with intrahepatic hepatocellular carcinoma (HCC). Its clinical features remain unclear, posing significant diagnostic and therapeutic challenges. The prognosis is also unclear due to its rarity and potential variability. This study reports the first case of EHCC in the mediastinum with subsequent brain metastasis. A 50-year-old man presented with shoulder and chest discomfort persisting for 5 months, accompanied by progressive weight loss and fatigue over the preceding 2 years. Imaging showed a mediastinal mass initially suspected to be lymphoma due to its malignant characteristics. However, histopathological examination identified the lesion as HCC, supported by characteristic immunohistochemical markers, despite normal abdominal imaging. Two months later, the tumor progressed despite intensive radiotherapy, and the patient experienced recurrent seizures. Subsequent brain imaging confirmed multiple intracranial metastases. Unfortunately, the patient died 6 months after diagnosis. The ectopic liver is more susceptible to hepatocarcinogenesis than the main liver; this is attributed to its incomplete functional structure. EHCC can be considered as differential diagnosis of mediastinal masses, even when no intrahepatic HCC is found. The rarity of EHCC in the mediastinum poses difficulties in developing treatment protocols. This case emphasizes the diagnostic challenges and aggressive nature of ectopic HCC and the need for comprehensive management strategies. There are currently no definite guidelines regarding the diagnosis, treatment, and prognosis of EHCC.
ectopic hepatocellular carcinoma ; mediastinum ; metastasis

Introduction: Ectopic ACTH secretion (EAS) is a rare cause of Cushing’s syndrome, accounting for 5–15% of cases. Pulmonary neuroendocrine tumors are the most frequent cause. However, primary tumor localization remains a significant diagnostic challenge, delaying effective treatment. Case: A 59-year-old female with diabetes mellitus presented with refractory hypertension and hypokalemia. Initial laboratory findings revealed a baseline cortisol of 1,164 nmol/L and morning adrenocorticotropic hormone (ACTH) of 19.5 pmol/L (normal <10.2 pmol/L), with an overnight dexamethasone suppression test cortisol of 624 nmol/L. Pituitary magnetic resonance imaging (MRI) and computed tomography (CT) scans of the thorax, abdomen, and pelvis were initially unremarkable. A PET scan identified mild hypermetabolism in the left adrenal gland and gastrointestinal tract, though colonoscopy revealed only chronic colitis. An intravenous desmopressin stimulation test demonstrated a 181% rise in ACTH and a 35% rise in cortisol, pointing toward pituitary Cushing’s. However, repeat pituitary MRI remained normal. A high-dose dexamethasone suppression test showed approximately 34% cortisol suppression (cortisol 1,128 nmol/L to 745 nmol/L), suggesting ectopic Cushing’s syndrome. Bilateral inferior petrosal sinus sampling demonstrated a peak central-to-peripheral ACTH ratio of 1.8 on the right and 1.6 on the left, pointing toward ectopic Cushing’s. Localization with DOTATATE PET-CT identified a 7 × 9 × 8 mm nodule in the right middle lobe. A wedge resection was performed. Histopathology confirmed a typical carcinoid tumor with clear resection margins. Immunohistochemistry revealed tumor cells positive for CK AE1/ AE3, synaptophysin, chromogranin, and INSM-1, with weak positivity for ACTH. The latest 8 am cortisol was 117 nmol/L and ACTH 1.74 pmol/L, confirming biochemical cure. Hypokalemia resolved, with improvement in her metabolic profile. Conclusion This case highlights the diagnostic complexities of EAS, particularly when initial imaging is inconclusive and biochemical tests yield conflicting results. Timely, precise localization of the causative tumor is crucial for successful surgical intervention and to prevent severe complications of hypercortisolism, thereby improving patient outcomes.
ACTH Syndrome, Ectopic

Objective: To investigate the clinical characteristics, treatments and fertility recovery of rudimentary horn pregnancy (RHP). Methods: The clinical data of 12 cases with RHP diagnosed and treated in Peking University Third Hospital from January 1, 2010 to December 31, 2022 were retrospectively analyzed. Clinical informations, diagnosis and treatments of RHP and the pregnancy status after surgery were analyzed. Results: The median age of 12 RHP patients was 29 years (range: 24-37 years). Eight cases of pregnancy in residual horn of uterus occurred in type Ⅰ residual horn of uterus, 4 cases occurred in type Ⅱ residual horn of uterus; among which 5 cases were misdiagnosed by ultrasound before surgery. All patients underwent excision of residual horn of uterus and affected salpingectomy. After surgery, 9 patients expected future pregnancy, and 3 cases of natural pregnancy, 2 cases of successful pregnancy through assisted reproductive technology. Four pregnancies resulted in live birth with cesarean section, and 1 case resulted in spontaneous abortion during the first trimester of pregnancy. No uterine rupture or ectopic pregnancy occurred in subsequent pregnancies. Conclusions: Ultrasonography could aid early diagnosis of RHP while misdiagnosis occurred in certain cases. Thus, a comprehensive judgment and decision ought to be made based on medical history, physical examination and assisted examination. Surgical exploration is necessary for diagnosis and treatment of RHP. For infertile patients, assisted reproductive technology should be applied when necessary. Caution to prevent the occurrence of pregnancy complications such as uterine rupture, and application of cesarean section to terminate pregnancy are recommended.
Pregnancy ; Humans ; Female ; Young Adult ; Adult ; Cesarean Section/adverse effects* ; Retrospective Studies ; Pregnancy, Ectopic/surgery* ; Pregnancy, Cornual/surgery* ; Uterus/surgery* ; Uterine Rupture/etiology* ; Abortion, Spontaneous

Gestational trophoblastic diseases are histologically different types of tumors originating from the placenta with an incidence of 0.2–5.8/1000 pregnancies. Ectopic pregnancy is the implantation of the fertilized ovum outside the uterine cavity, and a 0.64% incidence is reported. Ectopic cornual pregnancy and molar pregnancy are rare cases, and a combination of these two rare entities occurring simultaneously is even rare and very few cases have been reported in the literature. A cornual pregnancy refers to the implantation and development of a gestational sac in one of the upper and lateral portions of the uterus, whereas an interstitial pregnancy is a gestational sac that implants within the proximal, intramural portion of the fallopian tube that is enveloped by the myometrium. We present one of the rare combinations of molar pregnancy and cornual/interstitial ectopic pregnancy in a 30‑year‑old G3 P1 who presented with a triad of amenorrhea, vaginal bleeding, and abdominal pain. Laparotomy was done in view of an ultrasound which was suggestive of a well‑defined complex thick‑walled lesion of size 3.2 × 3.3 with a gestational sac and no cardiac activity in the right fallopian tube/adnexa suggesting tubal ectopic pregnancy. Beta‑human chorionic gonadotropin (β‑hCG) levels were done and noted to be as high as 9998 mIU/mL. Intraoperatively, a cornual ectopic pregnancy was found with no hemoperitoneum which was excised. Histopathology showed chorionic villi with variable size and hydropic change, myxoid stromal changes, and cistern formation with polar trophoblastic proliferation, based on which a diagnosis of molar pregnancy was made. Although ultrasonography and higher than usual serum β‑hCG levels are diagnostic of uterine molar pregnancy, they do not yield a proper diagnosis in ectopic molar pregnancy, hence, making it difficult to distinguish between an early ectopic molar pregnancy from a nontrophoblastic tubal pregnancy. The final diagnosis is usually made only after histopathology. A high degree of clinical suspicion of cornual pregnancy followed by histopathological examination of the products of conception is the standard for arriving at an appropriate diagnosis. Serial serum β‑hCG level follow‑up is recommended to rule out its malignant potential.
Pregnancy, Cornual ; Pregnancy, Ectopic ; Hydatidiform Mole

Gestational trophoblastic neoplasia (GTN) in itself is an uncommon condition, much so is primary extrauterine GTN. The incidence of GTN in the Philippines is at 22.4/40,000 pregnancies. However, no report has been made for primary extrauterine GTN. Only two cases of primary vaginal choriocarcinoma are reported in literature. This is a case of a 26 year old G1P0 (0010) who came in for profuse vaginal bleeding. Serum beta‑human chorionic gonadotropin (β‑hCG) was elevated and ultrasound showed hypervascular vaginal mass and an empty uterus. A primary vaginal GTN was considered and the patient was treated with etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMACO) regimen. During the course of chemotherapy, there was a note of profuse vaginal bleeding which was controlled by angiographic uterine artery embolization. A normal β‑hCG level was achieved after six cycles of EMACO. The patient was able to have three successful pregnancy outcomes thereafter. Primary vaginal GTN is a rare condition that requires a high index of suspicion. In a nulliparous patient complicated with profuse vaginal bleeding, angiographic embolization is an effective fertility‑sparing procedure that can manage the said complication.
Trophoblastic Neoplasms ; Embolization, Therapeutic ; Pregnancy, Ectopic

Cuspid ; Digital Technology ; Humans ; Maxilla ; Tooth Eruption, Ectopic ; Tooth, Impacted ; Transplantation, Autologous

Ectopic eruption of the maxillary permanent first molar refers to its deviation from the normal position due to some factors during the eruption process, which will lead to root resorption and early loss of the adjacent second primary molar, mesial movement itself, or serious malocclusion. To solve these problems, the Society of Pediatric Dentistry of Chinese Stomatological Association organized pediatric dental experts from 16 universities and hospitals, including West China Hospital of Stomatology, Sichuan University, Peking University School and Hospital of Stomatology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine to carry out a panel discussions. The research, and diagnosis and treatment experiences of ectopic eruption of maxillary permanent first molar at home and abroad in recent years were also referred to. The present guideline was eventually developed for the reference of dental clinicians.
Child ; China ; Consensus ; Humans ; Maxilla ; Molar ; Tooth Eruption, Ectopic/therapy*

Cushing’s syndrome due to ectopic adrenocorticotrophic hormone (ACTH) secretion is uncommon, accounting for 9 to 18% of cases; approximately 10% of ACTH producing tumours are caused by thymic carcinomas.1 We describe a young lady who presented with Cushing’s syndrome secondary to a primary neuroendocrine tumour (NET) arising from the thymus. She had surgical resection of her primary tumour with remission of her Cushing’s syndrome however subsequently went on to have locoregional recurrence followed by distant metastases to her bilateral ovaries. She underwent 6 surgeries including bilateral adrenalectomy and had 3 cycles of chemotherapy over the course of the 8 years since her diagnosis. Due to the rarity and highly aggressive nature of this disease, we highlight the need for a multidisciplinary team approach and use of multiple modalities in the management of our patient. Timely use of bilateral adrenalectomy particularly in young patients is important to prevent further complications and facilitate other treatment modalities.
Adrenalectomy ; ACTH Syndrome, Ectopic