Invasive mole presenting as a heavily bleeding vaginal lesion 3 weeks after uterine evacuation

Gestational trophoblastic disease occurs in 1–3:1000 gestations worldwide. Up to one-fifth of complete hydatidiform moles undergo malignant transformation, with 2%–4% manifesting as metastatic disease. Of these, a third present with vaginal metastases, which can cause bleeding and discharge. We describe the case of a 49-year-old primiparous woman presenting with syncope and intense bleeding from an anterior vaginal lesion, 3 weeks after uterine evacuation for a presumed spontaneous abortion. A vaginal metastatic nodule was suspected; haemostasis was achieved with vaginal packing, precluding the need for surgical intervention. The patient was ultimately diagnosed with invasive mole with vaginal and lung metastases (stage III high-risk gestational trophoblastic neoplasia (GTN)) and started on multiple-agent chemotherapy. Two months later the lesion had regressed completely, and remission was reached 2 weeks later. Clinicians should consider the possibility of metastatic GTN with vaginal involvement whenever heavy vaginal bleeding follows a recent history of failed pregnancy.

Strategic issue diagnosis by top management teams: A multiple-agent model

This study proposes an explanation for the accuracy of top management teams’ diagnoses of strategic issues. Key determinants are the number of members on the management team, as well as the span of managers’ attention and its allocation to the environment and to other managers. Depending on the nature of the issues faced, managers who reason analogically from past experience to draw inferences about current strategic issues may arrive at accurate or inaccurate diagnoses. We specify and analyze a multiple-agent model that encompasses individual, top management team, and context characteristics relevant to classifying strategic issues as opportunities or threats based on learning from experience. Results from our model indicate that attending to the environment improves the accuracy of strategic issue diagnoses, whereas attending to other managers’ inferences proves detrimental. Adding members can enhance issue diagnosis accuracy for a team that makes decisions according to majority-rule voting, despite leaving the accuracy of individual managers’ diagnoses unchanged.

The Use of Single-agent Versus Multiple-agent Concurrent Chemoradiotherapy in the Treatment of Locally Advanced Rectal Cancer

Purpose: The use of concurrent chemoradiotherapy is frequently recommended in the treatment of locally advanced rectal cancer however the ideal chemotherapy regimen remains unknown and there is variability in chemotherapy agents used among different institutions. We sought to examine differences in overall survival between patients receiving single versus multiple-agent concurrent chemoradiotherapy.Methods: The National Cancer Database was used to identify 31,025 patients with rectal cancer who received concurrent chemoradiotherapy between 01/2006 through 12/2016. We compared patients who received single-agent chemotherapy with those who received multiple-agent concurrent chemoradiotherapy. The primary outcome of interest was overall survival. The groups were compared using univariate analysis and Cox proportional hazard models to adjust for potential confounding factors. Results: 18,544 patients received single-agent and 12,481 patients received multiple-agent chemotherapy. The former were older with more comorbidities as evidenced by their higher Charlson-Deyo Scores. Those receiving multiple-agent chemotherapy were more likely to have clinical Stage III disease (52.9% vs 43.3%, p<0.001) and less likely to have well-differentiated cancer (6.9% vs 7.7%, p<0.001). The rates of negative resection margin were identical (p=0.225) between the two groups. On multivariable analysis after adjusting for comorbidities, radiation dose, and resection margins, single-agent chemotherapy was associated with worse overall survival (HR 1.09, 95% CI 1.057-1.124, p<0.001). Conclusion: Multiple-agent chemoradiotherapy is associated with improved overall survival in locally advanced rectal cancer, however chemotherapy regimen does not affect resection margins. The modest overall survival benefit with multiple agent chemotherapy must be balanced with the potential associated toxicity.