The outcomes of laparoscopic surgery for uterine endometrial cancer that include para-aortic lymphadenectomy have not been fully elucidated in Japan. The aim of this study was to investigate the feasibility and outcomes of laparoscopic surgery that includes para-aortic lymphadenectomy as an initial treatment of endometrial cancer. Between January 2012 and January 2016, 17 patients with medium- to high-risk endometrial cancer who underwent laparoscopic surgery with para-aortic lymphadenectomy in our department were enrolled and retrospectively reviewed in this study. As controls, 45 patients who underwent open laparotomy for the same disease and at the same period were evaluated. Operation time was similar between the two groups. The amount of blood loss (p<0.0001) and length of hospital stay (p<0.001) were significantly less in the laparoscopy group than in the control group. Among the perioperative complications, lymphocele occurred significantly less frequently in the laparoscopy group (31.1% vs. 0%, p<0.05). Ileus (11.1% vs. 5.9%) and lymphedema (22.2% vs. 5.9%) tended to be less in the laparoscopy group, although the difference did not reach statistical significance. One case was switched from laparoscopy to laparotomy because of intraoperative bleeding from a large vessel injury. Although the number of dissected pelvic lymph nodes was smaller in the laparoscopy group (median, 43 vs. 32, p=0.008), no significant difference in the number of dissected para-aortic nodes (31 vs. 23) was observed. This study excluded cases in which lymph node swelling was observed on preoperative imaging. However, pathological examination revealed lymph node metastasis in nine cases in the laparotomy group (20%) and two cases in the laparoscopy group (12%). Recurrence was observed in three cases in the laparotomy group (6.7%) and one case in the laparoscopy group (5.9%). While operation time strongly correlated with body mass index (BMI) in the control group (p=0.0001), such correlation was not present in the laparoscopy group and deviation was minimal in this group. Similarly, blood loss correlated with BMI in the control group (p=0.01) but not in the laparoscopy group. In conclusion, the laparoscopic approach that includes para-aortic lymphadenectomy did not compromise the treatment outcome in endometrial cancer while reducing operative complications, blood loss, and length of hospital stay. Furthermore, with laparoscopy, long operation duration and large amounts of blood loss might be avoided in obese patients. [Adv Obstet Gynecol, 69 (1) : 1-7, 2017 (H29.2)]
Cervical pregnancy is a rare condition with an estimated incidence of 1 in 10000 deliveries. Although total hysterectomy was previously the only effective treatment for cervical pregnancy, the recent development of conservative treatments such as methotrexate (MTX) administration and uterine artery embolization (UAE) preserved fertility. However, given the rarity of the condition, the most effective management method for cervical pregnancy has not been established. Here, we report a case of cervical pregnancy in which fertility was preserved with systemic MTX administration only, and discuss the management of this rare condition in the context of a literature review. The 27-year-old patient was primipara. At seven weeks gestation, transvaginal ultrasonography examination revealed a 14.5 mm gestational sac in the cervical canal with fetal cardiac activity. Cervical pregnancy was diagnosed, and single-dose intramuscular MTX was administered. We recognized the increase in serum hCG level and enlargement of gestational sac at the seventh day, so administered MTX again on the preparation for UAE. After the second MTX administration, the fetus and chorionic villi were spontaneously aborted without excessive bleeding, and the serum hCG level eventually returned to a negative value. Regarding the criteria for MTX therapy for cervical pregnancy, the lack of a therapeutic effect in the presence of fetal cardiac activity and/or high serum hCG level has been reported. However, in some reported cases of fetal cardiac activity and/or high serum hCG level, including the present case, MTX treatment alone was successful. In the analyses of 23 reported cases in the last ten years from the Japanese literature, the therapeutic effect of MTX was not correlated with neither serum hCG levels nor the presence of fetal cardiac activity. Improvement of the ultrasound technology has enabled the early diagnosis of cervical pregnancy, therefore, MTX administration has been also the first line therapy, regardless of fetal heart beat and/or serum hCG level. [Adv Obstet Gynecol, 69 (1) : 8-12, 2017 (H29.2)]
Disseminated carcinomatosis of the bone marrow (DCBM) is a form of metastasis of the carcinoma to the bone marrow, which has a very poor prognosis. Gastric, breast, and prostate cancer are the most common causes of this syndrome, which can lead to disseminated intravascular coagulation, leukoerythroblastosis, and microangiopathic hemolytic anemia. Here we report a rare case of DCBM in association with endometrioid adenocarcinoma of the corpus uteri. A 72-year-old woman, gravida 4 para 3, was referred to our office with a uterine tumor. Transvaginal ultrasound and magnetic resonance imaging revealed a solid tumor with accompanying fluid collection in the corpus uteri. Aspiration biopsy led to a diagnosis of a grade 3 endometrioid adenocarcinoma, and computed tomography scans revealed multiple metastases to the lung and lymph nodes. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed for tumor reduction. The final diagnosis was grade 3 endometrioid adenocarcinoma with squamous differentiaton of the corpus uteri, StageIVB (pT2NXM1). Patient was followed up without chemotherapy because of concomitant Alzheimer’s disease. At one month after surgery bone marrow biopsy was performed because of acute elevation of serum lactate dehydrogenase (LDH), alkalinephosphatase (ALP), and D-dimer levels and thrombocytopenia. Microscopic bone marrow sections included cells resembling the endometrial stromal and epithelia cells, thus, the patient was diagnosed with DCBM. Despite the enlargement of lung and liver metastases, her family elected to continue the best available supportive care, and the patient died on postoperative day 55. DCBM has a poor prognosis, and established treatment approaches are lacking. In patients with acute elevation of serum LDH or ALP levels, thrombocytepenia, and multiple bone metastases, bone marrow biopsy might help in its diagnosis and facilitate earlier intervention. [Adv Obstet Gynecol, 69 (1) :13-20, 2017 (H29.2)]
Peritoneal inclusion cysts (PIC) can occur as a consequence of past abdominal surgeries, trauma, pelvic inflammatory disease, or endometriosis. Various therapeutic modalities have been advocated including adhesiolysis, sclerotherapy, oral contraceptives/low dose estrogen-progestin (OC/LEP), or GnRH agonists. We hereby report a case of persistent PIC successfully treated using the levonorgestrel-releasing intrauterine system (LNG-IUS). The patient was a 44-year-old woman who had undergone surgery on her ileum at the age of nine months. At the age of 31, she complained of pain with abdominal blow and was found to have a large amount of ascites associated with multiple intrapelvic cysts along with uterine fibroids. She then underwent exploratory laparotomy which showed no ovarian cysts but revealed ascites sequestered in an enclosed space formed by abdominal adhesions. On a diagnosis of PIC was made and adhesiolysis was performed on this patient. However, abdominal pain and distension was not improved. The peritoneal-venous shunt surgery was impossible for the risk of shunt closure with viscosity of ascites and absorption has been continued. At the age of 42, ascites was found to be hemorrhagic during her menses. This finding prompted us to recommend the use of the LNG-IUS in this patient on the assumption that the regurgitation of menstrual blood might have been increasing the ascites in the PIC. Shortly after initiating the LNG-IUS therapy the ascites disappeared, and absorption has not been required for over a year. This case report indicates that the use of the LNG-IUS might constitute a conservative treatment option for patients with PIC associated with the regurgitation of menstrual blood.[Adv Obstet Gynecol, 69 (1) : 21-25, 2017 (H29.2)]
Mycoplasma hominis is a microbe existing at vagina of almost 50% of reproductive women. It happens to infect genitourinary tract or uterine muscular wound of Caesarean section. M. hominis is Gram-negative and its isolation needs prolonged incubation in routine blood culture. M. hominis is resistant to β-lactam antibiotics because it lacks a cell wall. No response to these antibiotics results in more serious symptoms than other bacteria. We report a case of bacteremia that progressed from postpartum endometritis with M. hominis after cesarean section in a 33-year-old woman. Magnetic resonance imaging was suspicious for an abscess at the surgical site at seven days after cesarean section, and reoperation was undertaken at the same time. Although we provided an intraperitoneal drainage tube for withdrawing liquids from the vesicouterine excavation during reoperation, and treated her with several antimicrobial agents, her bacteremia symptoms persisted. At 15 days after cesarean section (day seven of reoperation), M. hominis was considered to be the primary causative organism. The clinical symptoms have improved by the 11th day of re-operation after administration of levofloxacin sensitive to M. hominis.[Adv Obstet Gynecol, 69 (1) : 26-31, 2017 (H29.2)]
We report a case of torsion of a rare fallopian tube lipoma. The patient was a 62-year-old woman who had been pregnant and borne a child once. She was referred to our hospital because of lower abdominal pain for four days. When she was first diagnosed, adnexal tenderness was present on the left side. T1 and T2 enhanced images of MRI showed a 6 cm sized tumor with high signal intensity on the left side of adnexa. This signal pattern was attenuated with fat suppression T1 enhanced image. We performed a laparotomy, suspecting torsion of a left ovarian mature cystic teratoma. The left adnexa had a dusky-red tumor mass emerging from the fimbriae of the fallopian tube; it was about the size of a goose egg and was twisted counterclockwise five times. A normal atrophic ovary was confirmed close to the tumor. The tumor on the fallopian tube was solid and lobulated, weighing 95g. Histopathological diagnosis confirmed that the tumor was composed of normal adipose cells. It also had connective tissue walls and fat lobules. Lipoma of the fallopian tube can be distinguished from ovarian mature cystic teratoma because the walls of its lobules are visible in MRI. As the walls of the lobules of the present tumor lesion could be seen in MRI scans, we diagnosed it as lipoma of the fallopian tube. [Adv Obstet Gynecol, 69 (1) : 32-36, 2017 (H29.2)]
Anti-NMDA receptor encephalitis is a paraneoplastic encephalitis associated with ovarian teratoma. It is a non-herpetic limbic form that occurs most frequently in young women. Here we present a difficult-to-diagnose case of ovarian mature cystic teratoma associated with anti-NMDA receptor encephalitis. A 25-year-old nulligravid woman presenting with fever, headache, vomiting, and neck stiffness was admitted to our neurology department. Although she was initially treated for aseptic meningitis, she experienced consciousness disturbance and convulsive seizures. We suspected encephalitis based on her symptoms and steroid pulse therapy was initiated. However, her condition suddenly deteriorated and she was transferred to the ICU with intratracheal intubation. An abdominal MRI revealed a 33 × 25 mm multi-cystic ovary. She underwent a left adnexectomy on the 36th day in the hospital. Histopathological examination of the excised specimen revealed a 2 cm mature cystic teratoma. Anti-NMDA receptor antibodies were detected in spinal fluid collected at admission, which led to a definitive diagnosis. She gradually regained consciousness after the operation and was discharged 114 days after admission. Anti-NMDA receptor encephalitis is usually severe and can be fatal, but is potentially reversible. Management of anti-NMDA receptor encephalitis should be initially focused on immunotherapy, and the detection and removal of a teratoma. [Adv Obstet Gynecol, 69 (1) : 37-44, 2017 (H29.2)]
Pseudomyxoma peritonei is a rare clinical condition characterized by the perforation of mucinous tumors and the intra-abdominal accumulation of a jelly-like mucin. The primary site is commonly the appendix. Because the presenting symptoms are similar to those of ovarian cancer, patients are occasionally referred to gynecologists; the differential diagnosis is difficult. We report a patient with a preoperative diagnosis of right ovarian tumor and an operative diagnosis of pseudomyxoma peritonei of the appendix with an ovarian tumor. The 61-year-old woman had been followed for 11 years due to an ovarian cyst. Serum levels of CA125 and CEA had elevated, and gastrointestinal endoscopy and CT studies did not reveal malignancy. During follow-up of her ovarian tumor, her serum CEA increased, and transvaginal ultrasound and MRI revealed enlargement of the ovarian tumor, with ascites. Diagnostic laparoscopic surgery was performed, revealing a pelvis filled with mucinous ascites and an enlarged and perforated appendix close to the right ovarian cyst. Bilateral salpingo-oophorectomy and appendectomy were performed. The pathological diagnosis was a mature cystic teratoma of the right ovary and a low-grade atypical mucinous tumor of the appendix. The patient was recommended to undergo complete cytoreductive surgery, including peritonectomy and hyperthermic intraperitoneal chemotherapy, with a high risk of morbidity and mortality; she was referred to a specialized institution. As in this case, differentiating ovarian tumors from pseudomyxoma peritonei of the appendix is difficult. The consideration of simultaneous pseudomyxoma peritonei is mandatory in cases involving elevated serum CEA levels and ascites. [Adv Obstet Gynecol, 69 (1) : 45-50, 2017 (H29.2)]
Impaction of uterine fibroid into pelvis sometimes causes acute urinary retention.Wallace ring pessary insertion into vagina is effective for pelvic organ prolapse by pushing up the drooping organs. Therefore we guessed that a pessary was also effective for acute urinary retention with uterine fibroids by pushing up the uterus impacted into pelvis. We experienced three successful cases treated as outpatients without relapse after the pessary insertion. The first patient, (30 years old, 1 gravid, 1 para) a 65-mm diameter Wallace ring pessary was inserted immediately after urinary retention occurred. This patient could control urination and was followed up as an outpatient. However, since the patient preferred to undergo myomectomy as soon as possible, we could not follow up the pessary effect for a short term. The second patient, a 50-year-old 2 gravid 2 para, experienced acute urinary retention during follow-up for uterine fibroids. Although she could temporarily control urination after resting, we inserted a 59-mm diameter Wallace ring pessary due to relapse in a short time, because she experienced relapse after a short period. Because the patient intended to retain her uterus, she has been treated only with replacement of a pessary without trouble for more than two years. The third patient, a 45-year-old nullipara, also had acute urinary retention and was treated with a Wallace ring pessary (55-mm diameter). Comparison of magnetic resonance images (MRI) taken before and after the treatment showed that the pessary pushed up the uterus . She has had no relapse or symptoms for more than three months. In summary, acute urinary retention with uterine fibroids may be restored by inserting a Wallace ring pessary into the vagina, and this procedure may be effective for preventing relapses over a long term. [Adv Obstet Gynecol, 69 (1) : 51-55, 2017 (H29.2)]
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