Perioperative management of giant ovarian tumors may be complicated by the development of preoperative complications and difficulties in pathologically distinguishing benign from malignant tumors. In this study, we retrospectively evaluated age, body mass index (BMI), tumor diameter, imaging findings, tumor markers, and the histological tumor type and stage in 28 patients who had giant ovarian tumors, defined as those with a maximum diameter of 20 cm or more based on diagnostic imaging, who were managed in our hospital during the 10-year period between 1 January 2005 and 31 December 2014. As to the evaluation of age, giant ovarian tumors were observed in a large number of patients in their 40s and 50s (17 patients), among whom borderline malignancies and malignancies were most common. Preoperative imaging findings showed that 23 giant ovarian tumors (82%) were multilocular, which accounted for a large portion of all tumors evaluated herein. Among seven patients with preoperative complications such as respiratory disorders, deep venous thrombosis and cellulitis, two required preoperative drainage of tumor fluid to improve respiratory function. As to the evaluation of histological types of giant ovarian tumors, eight benign tumors were mucinous cystadenomas (67% of all benign tumors), five borderline malignancies were mucinous borderline tumors (83% of all borderline malignancies), and four malignancies were mucinous adenocarcinomas (40% of all malignancies); the mucinous type was the most predominant in each of the three groups. Neither tumor diameter nor tumor markers were related to whether the tumor was malignant or benign. As to the evaluation of stages of giant ovarian tumors, 5 of 6 (83%) borderline malignant tumors and 7 of 10 (70%) malignant tumors were stage I. In conclusion, over half of giant ovarian tumors were borderline malignant or malignant but the majority of these tumors were stage I. This suggests that appropriate management of perioperative complications can provide relatively favorable outcomes for patients with giant ovarian tumors. [Adv Obstet Gynecol, 68 (2) : 61-68, 2016(H28.5)]
Objective: We aimed to evaluate prognostic factors of outcome in neonates born at less than 29 weeks of gestation (GW) because of threatened premature labor. Patients and Methods: This was a retrospective study including 43 neonates who were born in our hospital between 2005 and 2014. These neonates were divided into two groups according to the outcome: good (healthy) and poor (handicapped or dead). We examined the following factors: GW at delivery, the presence of rupture of the membranes, maximum maternal leukocyte count 15000/μl and serum CRP level 2.0 mg/dl, highest maternal body temperature 37.5 degrees, maternal steroid administration, male sex, standard deviation of birthweight, and stage of chorioamnionitis grade 2. The prognostic factors for poor outcome were determined by uni- and multivariate logistic regression analyses. Results: Logistic regression analyses showed that GW at delivery was an independent prognostic factor of outcome of neonates (OR, 0.5; 95% CI, 0.3-0.9; p=0.03). Conclusions: This study suggests that the prognosis of neonates who are born at less than 29 GW because of threatened premature labor is associated with earlier GW at delivery. [Adv Obstet Gynecol, 68(2) : 69-74, 2016 (H28.5)]
We analyzed 50 autopsy cases of fetal and early neonatal death that were requested by obstetricians at Kansai Medical University. Twenty-seven cases were diagnosed as congenital anomalies, and eight cases were diagnosed as intrauterine fetal death caused by abnormalities of the umbilical cord, such as umbilical cord torsion. Among the congenital anomaly cases, there were eight cases each of Potter syndrome and fetal hydrops. Of these Potter syndrome and fetal hydrops cases, 10 cases were complicated by lung hypoplasia. In 9 of the 50 autopsy cases (18%), the cause of death was unexplained; these cases included macerated fetuses (n=3), macerated and small body weight (under 500g) fetuses (n=3), and cases which were neither macerated nor small body weight fetuses (n=3). The remaining six cases included abnormalities of placenta (n=2), intrauterine infections (n=2), meconium aspiration syndrome (n=1), and discordant twin (n=1). Moribund anatomy has been recognized as a valuable tool in identifying fetal abnormalities and cause of fetal death.[Adv Obstet Gynecol, 68 (2) : 75-81, 2016(H28.5)]
Recent developments in chemotherapy have improved the prognosis of patients with cancer. However, affected patients may still experience long-term chemotherapy-induced complications. We herein report a case that developed myelodysplastic syndrome (MDS) after undergoing long-term chemotherapy for ovarian cancer. A 72-year-old female (gravida 1, para 1) diagnosed with ovarian cancer was treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and partial omentectomy. The histopathological diagnosis was ovarian serous carcinoma of stage IIC. The patient received two courses of intraperitoneal chemotherapy and six courses of cyclophosphamide, therarubicin and carboplatin as adjuvant chemotherapy. The patient also received six courses of dose-dense TC (carboplatin and paclitaxel), and six courses involving the weekly administration of irinotecan for disease recurrence. Eleven years after the primary surgery, a blood examination revealed anemia and neutropenia under dose-dense TC therapy and a bone marrow examination showed MDS. After sixth course of dose-dense TC, however, the patient developed acute myeloid leukemia and died of sepsis and cerebral hemorrhage. [Adv Obstet Gynecol, 68 (2) , 82-87, 2016 (H28.5)]
Persistent cloaca is a complex malformation in which the rectum, vagina, and urinary tract share a common channel. It is a rare condition with an incidence of 1 in 20000 to 50000 live births. As it is a complex malformation with a wide spectrum of severity, we are faced with great difficulties in treatment. We report a case of persistent cloaca with uterus didelphys, including a hypoplastic single-sided cervix after reconstruction of an imperforate anus, an ectopic ureter opening, and a vesicorectal fistula. A 16-year-old girl, menarche at 12 years old, showed dysmenorrhea for several years. A large cystic tumor was found by computed tomography and uterus didelphys was detected by magnetic resonance imaging (MRI). Her left uterine cervix was not observed by MRI. She was suspected to have hematometra and hematosalpinx because of dysgenesis of the uterine cervix. She had a laparotomy to remove the cystic tumor and left uterus. We did not locate the left ovary during surgery. A part of the cystic tumor was found to be a left ovary after surgery. She has regular menstruation without menstrual cramps. [Adv Obstet Gynecol, 68 (2), 88-92, 2016 (H28.5)]
Klippel-Trenaunay-Weber syndrome (KTWS) is a rare disorder characterized by extensive cutaneous vascular malformation, venous varicosities, hemangiomas, and hypertrophy of soft or bony tissue. We herein report a case of a pregnant woman complicated with KTWS. A 23-year-old woman (gravida 1, para 0) underwent anticoagulation therapy with low-dose aspirin and unfractionated heparin from the first trimester because of the presence of hemangiomas. We assessed the location of the hemangiomas by pelvic and spinal magnetic resonance imaging (MRI) at gestational age (GA) of 27 and 35 weeks. A cesarean delivery with spinal anesthesia was supposed to be done based on the initial assessment of hemangiomas at GA of 27 weeks. However, MRI at GA at 35 weeks revealed hemangiomas developed newly around the lumbar. We therefore performed a cesarean delivery under general anesthesia at GA at 37 weeks. During the operation, we examined the location of the hemangiomas in abdominal wall by transabdominal ultrasound and avoided injuring the hemangiomas. The patient delivered a 2518g healthy female infant and received anticoagulation therapy for six weeks after delivery, preventing thrombosis and embolism. In conclusion, anticoagulation therapy and decision of style and method of parturient based on the assessment of the location of hemangiomas by MRI, ultrasonography and bronchoscopy may enable safer perinatal management for pregnancies complicated by KTWS. [Adv Obstet Gynecol, 68 (2) : 93-98, 2016 (H28.5)]
The frequency of malignant lymphoma is approximately 1 in 6000-10000 pregnant women. A malignant lymphoma involving the myometrium was diagnosed at 35 weeks of gestation in a 38-year-old woman (gravida 1, para 0) who presented to our hospital with rapidly worsening refractory lower back pain that was resistant to analgesics. Computed tomography (CT) revealed, a large number of swollen lymph nodes, which led us to suspect a malignant lymphoma. We planned to start therapy as soon as possible after delivery, therefore, we performed a caesarean section at 36 weeks and five days of gestation, during which intrapelvic lymph node and myometrium tumour biopsy specimens were obtained. The final pathological diagnosis was a diffuse large B-cell lymphoma of clinical stage IV and a malignant lymphoma involving the myometrium. The patient received six cycles of R-CHOP therapy starting from postpartum day 12. At the time of writing, the patient was healthy with no evidence of recurrence 1.5 years after chemotherapy, and her child had no developmental disorders. Diagnosis of malignant lymphoma in pregnant women is challenging, because of an overlap of the disease with gestation-related symptoms and hesitation to perform CT during pregnancy. As a result, malignant lymphoma is often diagnosed late and at an advanced stage. Though the present case was diagnosed at an advanced stage, CT findings were obtained early, which allowed us to suspect malignant lymphoma, we were able to promptly treat the primary disease. The low back pain during pregnancy is popular symptom. Especially if symptom is strong, we should performe actively imaging studies to distinguish malignant tumor. [Adv Obstet Gynecol, 68 (2), 99-105, 2016 (H28.5)]
Hyperreactio luteinalis (HL) is a condition associated with bilateral ovarian enlargement due to theca lutein cysts. It occurs commonly in pregnant patients with trophoblastic disease, occasionally in multiple pregnancies, and rarely in normal singleton pregnancy. We present an unusual case in which a 45-year-old nulliparous patient was found to have bilateral multicystic adnexal masses at 19 weeks of gestation. Due to severe preeclampsia and fetal growth restriction, she delivered by cesarean section. The ovaries had an anaplastic appearance, and a biopsy was taken during the cesarean section. Pathology revealed multiple benign theca lutein cysts. As a rare benign disease, HL is usually self-limited. However, some cases are diagnosed by unnecessary operation. Accordingly, it is important to exclude these from the differential diagnosis via magnetic resonance imaging and wedge biopsy in to avoid unnecessary surgical excision. [Adv Obstet Gynecol, 68 (2) : 106-111, 2016 (H28.5)]
An intraperitoneal pregnancy is an extremely rare condition, and its early diagnosis is difficult due to subtle early symptoms compared with those of ectopic pregnancies in other locations. We encountered a woman with an intraperitoneal pregnancy that occurred in the serosa of the posterior uterine wall. She was referred to our hospital for investigation of an increase in the urinary hCG level after a diagnosis of a miscarriage at another hospital. A 30-year-old para one woman had discharged pieces of deciduous membrane eigtht weeks and six days after the last menstrual period, and subsequently underwent evacuation of the uterus after a diagnosis of incomplete abortion was made. However, due to persisting genital bleeding and an increase of urinary hCG level (from 1092 mIU/ml to 3224 mIU/ml in nine days), she was referred to our hospital. On initial examination, ultrasound showed an approximately 2cm cystoid-like lesion in the uterine posterior wall. Color Doppler confirmed blood circulation in this site, and CT demonstrated enhancement along the tumor wall at the early stage of the arterial phase. MRI T2-weighted image confirmed a tumor of high-signal intensity, but a clear image of a gestational sac could not be observed. Because the initial examination did not detect genital bleeding and sign of the abdominal cavity hemorrhage, we opted for conservative chemotherapy (MTX 17.5 mg/body × 5 days) to treat a possible clinical invasive mole or a ectopic pregnancy, at 15 weeks and two days after the last menstrual period. However, the treatment strategy was altered because of severe adverse reactions such as stomatitis and digestive symptoms and an increase in serum hCG. As there was a slight increase in tumor size, open surgery was performed 16 weeks and six days after the last menstrual period. Although the morphological effect of chemotherapy made the judgment difficult, pathological examination of the surgical specimen showed the prominent presence of intermediate trophoblasts and the absence of marked invasion into the muscle layer. Based on these findings combined with the clinical course and changes in serum hCG levels, the diagnosis of an ectopic pregnancy was reached. The serum hCG levels dropped gradually after surgery and hysterosalpingography performed three months after surgery did not reveal any abnormalities in the passage through both tubes. [Adv Obstet Gynecol, 68 (2) : 112-117, 2016 (H28.5)]
Nongestational ovarian choriocarcinoma (NGOC) is a very rare germ cell tumor that normally appears alongside other malignant germ cell tumors. We present a case of NGOC that occurred in the absence of any other malignant germ cell tumor. A 17-year-old virgin girl was referred to our hospital after experiencing atypical genital bleeding for two months. Magnetic resonance imaging revealed a 140×90 mm multilocular cystic mass with a partly solid portion in the left adnexal region, as well as a cystic mass, 30 mm in diameter, in the right adnexal region. Laparotomy was performed after the preliminary diagnosis of a bilateral mature cystic teratoma of the ovaries, and included a left salpingo-oophorectomy, right cystectomy, and resection of a mass in the pouch of Douglas. Histological examination of the tumor confirmed an ovarian choriocarcinoma, with no other malignant germ cell tumor, coexisting with a mature cyctic teratoma. The mass in the pouch of Douglas was a metastatic tumor arising from the choriocarcinoma. After surgery, the patient’s serum human chorionic gonadotropin (hCG) level showed 1211 mIU/mL and computed tomography (CT) revealed multiple lung metastases. The final postoperative diagnosis was made as NGOC, stage IV. A combination chemotherapy regimen of methotrexate, etoposide, and actinomycin-D (MEA) was administered five times. After the second course, serum hCG level dropped to within normal range. CT after completion of chemotherapy showed that the lung metastases had disappeared. Tumor recurrence in the uterus and multiple lung metastases were detected one year later. Four cycles of chemotherapy with bleomycin, etoposide, and cisplatin (BEP) were administered, but were ineffective. Thoracoscopic partial lung resection for the lung metastases, as well as total abdominal hysterectomy, were performed. Afterwards, adjuvant chemotherapy regimen was administered; however, the patient died 43 months after her initial presentation because of diffuse lung metastases. [Adv Obstet Gynecol, 68 (2) : 118-125, 2016 (H28.5)]
The coexistence of ovarian and endometrial cancer in young women is not uncommon. We herein report a case of fertility-sparing treatment for heterochronous primary ovarian and endometrial malignant tumors that resulted in a pregnancy and normal delivery. A 33-year-old married nullipara was referred to our hospital for fertility-sparing treatment for endometrial cancer. Her older brother had died of leukemia at 16 years of age. When the patient was 28 years old, she was diagnosed with stage Ia endometrioid grade 2 adenocarcinoma of the ovary. She underwent six cycles of chemotherapy after left adnexectomy, right ovarian segmental resection, and pelvic lymphadenectomy at a previous hospital. She started infertility therapy immediately after completion of the chemotherapy, but she did not become pregnant. Four years and four months later, a cervical polyp was resected and pathological examination revealed an endometrioid Grade 1 adenocarcinoma. She strongly desired fertility preservation and was referred to our hospital. Myometrial invasion of tumor was not detected by magnetic resonance imaging, but dilatation and curettage revealed endometrioid Grade 1 adenocarcinoma. She underwent high-dose progesterone therapy for six months and achieved a pathological complete response. Two months later, she became pregnant with in vitro fertilization-embryo transfer and had a normal vaginal delivery at 38 weeks of gestation. She received Holmstrom therapy because of postpartum amenorrhea for one year and three months. There was no evidence of recurrence for two years and nine months after delivery. She desired another child, but we recommended that she receive standard therapy for the following reasons: 1) recurrence of endometrial cancer after delivery, recurrence of ovarian cancer, and new carcinogenesis of the opposite ovary are not rare; 2) a screening test for early detection of ovarian cancer has not been established. [Adv Obstet Gynecol, 68 (2) : 126-130, 2016 (H28.5)]
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