Colon cancer as a complication of pregnancy is rare, with the frequency of occurrence reported to be 1-2 per 100,000 pregnancies. This study describes our experience of one case of sigmoid colon cancer that was detected during the one-month postpartum examination. The patient was 29 years old, gravida 1 parity 1. She was delivered of a boy at 39 weeks 1 day of pregnancy. She complained of constipation, mucous and bloody stool at her one-month postpartum examination. By internal pelvic examination, we found a mass that was soft at the Douglas cavum. Vaginal ultrasonography indicated negative evidence of ovarian tumor. Examining the rectum, approximately 5 cm from the anus, we touched part of a mass whose surface was smooth. An MRI revealed a mass in the rectum, the major axis of which was around 40 mm. Through endoscopy, we recognized a protruding lesion that was mostly covered with a normal mucosa and had an ulceration on the top. The lesion occupied most of the rectal lumen. Rectal tumor causing intussusception was diagnosed, and we referred the patient to a medical institution for surgery. Adenocarcinoma was diagnosed from the biopsy of the ulcer surface, and sigmoid colon resection was performed. The pathological diagnosis was reported as stage IIIb of sigmoid colon cancer. Partial liver resection was later performed, due to liver metastasis. The patient is undergoing chemotherapy 22 months after the first operation, and there is no metastatic lesion seen in the liver. Because both the average age of childbearing and the morbidity rate of colon cancer have been rising in recent years, the frequency of colon cancer with pregnancy may become higher. As this case suggests, because colon cancer might be detected through an internal examination, obstetrician-gynecologists must be attentive as they question and internally examine patients. If colon cancer is suspected, it is important to perform further appropriate examinations in a timely manner. [Adv Obstet Gynecol, 68 (1) : 1-6, 2016 (H28.2)]

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Oral contraceptives/low dose estrogen-progestin (OC/LEP) have been used to alleviate endometriosis, dysmenorrheal, premenstrual tension, abnormal menstrual cycle, and so on, in addition to their contraceptive use. An adverse reaction to OC/LEP is deep vein thrombosis, which can lead to pulmonary embolism if severe. Recently, deaths from thrombosis have been reported among patients who had been orally taking pills. Hence, the Ministry of Health, Labour and Welfare of Japan issued precautions in January 2014 regarding this adverse effect. However, because of the low incidence of thrombosis and secondary favorable effects of OC/LEP (improved quality of life of women and efficacy against some female-specific diseases), the benefits of pills are considered to outweigh their severe adverse effects. We recently encountered three cases of thrombosis that occurred within one year after the start of oral intake of birth control pills. One month before their first visit to our hospital, the three patients began to experience leg pain and crural edema but initially opted not to seek medical care. During the first visit, all three patients were found to have deep vein thrombosis of the lower extremities of varying severity (affecting only the deep leg veins, spreading to the inferior vena cava, or leading to pulmonary embolism). Depending on the clinical condition, different treatment methods have been used, such as anticoagulant therapy, thrombolysis therapy, and insertion of an inferior vena cava filter. All of the patients are currently undergoing outpatient follow-up. Subjective symptoms were present before the onset of thrombosis in all three patients but were left untreated at their own discretion or without detailed evaluation for leg vein thrombosis. Therefore, when OC/LEP are prescribed, patients should be sufficiently advised to pay close attention to possible early symptoms of deep vein thrombosis of the legs for early detection and treatment. [Adv Obstet Gynecol, 68 (1) : 7-12, 2016 (H28.2)]

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Here, we report our experience with a patient in whom massive ascites developed and malignancy was detected 10 months after the laparoscopic enucleation of a mature cystic teratoma in the right ovary complicated by an endometrial cyst. A right ovarian tumor was detected during an examination of a 32-year-old nullipara. Ultrasonography revealed that the tumor consisted of two 8 cm polycystic masses. Blood tests revealed neither elevated levels of carcinoembryonic antigenor the carbohydrate antigens CA19-9 or CA125. However, magnetic resonance imaging (MRI) showed the presence of a mature cystic teratoma complicated by endometriosis. We performed laparoscopic enucleation, and pathology tests resulted in a final diagnosis that was consistent with the preoperative diagnosis. However, 10 months post-surgery, symptoms of abdominal distension appeared. Diagnostic imaging revealed the presence of massive ascites accumulation and multiple pelvic metastases. A hematological cytodiagnosis of the ascitic fluid was negative. Further blood tests revealed marked increases in alpha-fetoprotein (AFP) and CA125. MRI showed that the multiple masses were diffusely confined, particularly to the area around the right ovary. Positron emission tomography and computed tomography imaging of the pelvis also indicated abnormal mass accumulation, with a maximum standard uptake value of 10.6-15.9. Although esophagogastroduodenoscopy showed no malignancy, ovarian or possibly peritoneal cancer was suspected and surgery was performed. Intraoperative observations confirmed the presence of multiple pelvic tumors. The right ovary was enlarged by a round walnut-sized tumor, and a quick intraoperative inspection revealed it to be an immature teratoma. The cytological examination result of the ascites was false positive, and right adnexal surgical excision was performed to reduce the tumor size in order to preserve her fertility. Our final diagnosis based on pathology tests rated the right ovary, disseminating factor in the pelvis, and immature teratoma at grade 3. Moreover, four courses of bleomycin, etoposide, and cisplatin chemotherapy were initiated on postoperative day 11. Seven months have elapsed since the final cancer drug administration, and no tumor or ascites retention recurrence has been detected. AFP and CA125 levels have normalized, and the cancer is in remission. Reanalysis of the primary surgical tissue samples revealed the slight presence of Sal-like protein 4 and transcription factor Oct3/4-positive immature nerve tissue, suggesting that the immature teratoma may have already been developing within the pelvis at the time of the first surgery. Mature cystic teratomas are highly indicative of ovarian tumors, and most of them are treated with laparoscopic enucleation. However, the existence of tiny malignant lesions, as in this case, can be diagnosed by exercising sufficient caution. [Adv Obstet Gynecol, 68 (1) : 13-19, 2016 (H28.2)]

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Androgen insensitivity syndrome (AIS) is a 46, XY disorder of sex development (DSD), and characterized by a female phenotype associated with complete or partial resistance to the effects of androgens. We experienced two cases of complete AIS (CAIS), with different outcomes. The typical presentation of CAIS is primary amenorrhea. Prophylactic gonadectomy is indicated because of the risk of gonadal germ cell tumor. In case one, the patient was diagnosed with CAIS because of the lack of menarche, and prophylactic gonadectomy was performed in early adulthood. In the case two patient, Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome was suspected, because she presented with amenorrhea in puberty. When she developed abdominal distension in adolescence, ovarian cancer was suspected, and a surgery was performed. The findings of a pathological examination led to the diagnosis of AIS. In the differential diagnosis of CAIS, attention should be particularly focused on MRKH syndrome because of its frequency. Primary amenorrhea, absence of the uterus, and a vagina with a blind end are present in both MRKH syndrome and CAIS. However, CAIS differs in that it does not involve an organ of Müllerian origin, though patients with MRKH syndrome show normal ovaries and traces of the uterus. These features are not helpful in distinguishing between both syndromes because the testes can be misidentified as the ovaries, as seen in case two. Growth of underarm hair and pubic hair, hormone levels, and imaging findings should be taken into consideration for a comprehensive judgment. CAIS is a rare disorder; however, its incidence is high in girls with inguinal hernias. The prevalence of CAIS in girls with inguinal hernias is 1.1%, which is more than 40 times the natural incidence. AIS should be suspected in patients with primary amenorrhea and a history of inguinal hernias. Recognition of DSD has increased after the Chicago consensus on DSD, and clinical guidelines have been developed in several western countries. DSD should be managed by a multidisciplinary team (MDT), comprising experts in various fields, mainly endocrine internal medicine, urology, obstetrics and gynecology, and psychiatry, if necessary; moreover, the MDT should include clinical psychologists, neonatologists, clinical geneticists, biochemists, experts in medical ethics, and experts in welfare. MDTsare widespread in Europe and the United States. However, in Japan, it is still under the formative stage and requires immediate attention. [Adv Obstet Gynecol, 68 (1) : 20-28, 2016 (H28.2)]

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Mature cystic teratomas commonly arise from the ovaries. In addition to ovaries, these teratomas are the known to originate from the testis, sacrococcygeal region, retroperitoneum, mesentery, mediastinum, and intracranial space. However, a mature cystic teratoma of the omentum is rare. We report a case of an omental mature cystic teratoma that was preoperatively diagnosed to have an ovarian origin and was removed with laparoscopic operation. A 39-year-old woman, gravida 1 para 1, visited our hospital owing to a diagnosis of ovarian tumor. Magnetic resonance imaging (MRI) revealed a cystic tumor of 6 cm diameter, adjacent to the left front of the uterus. The right ovary was also normal sized, whereas the left ovary was not identified in the MRI image. Laparoscopic operation was indicated for the removal of the left ovarian teratoma. Intraperitoneal observation revealed a cystic tumor, fibrously attached to the omentum and had no association with both ovaries. The feeding vessel to the omental tumor was not clearly identified. The right ovary had a normal appearance, and the left ovary was atrophic with a streak appearance. There were no other tumors nor other disseminated lesions in the peritoneum. The laparoscopic operation was completed with the resection of the omental tumor. The postoperative pathological result indicated a mature cystic teratoma of the omentum. The literature reports on omental mature cystic teratomas in Japan are limited to a dozen cases. There are two hypotheses on the occurrence of a teratoma from the omentum: primary origin from the omental supernumerary ovary and ovarian origin with autoamputation. To our knowledge, this is the first report on the laparoscopic management of an omental teratoma in Japan. Mature cystic teratomas can cause malignant transformation and should be treated carefully and surgically removed. [Adv Obstet Gynecol, 68 (1) : 29-35, 2016 (H28.2)]

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Sertoli-Leydig cell tumor belongs to the group of sex cord-stromal tumors of the ovary. They are very rare tumors and account for about 0.2-0.6 % of all ovarian tumors. Age at diagnosis averages 25 years, with 75% of these tumors occurring during the second and third decade of life, and less than 10% occurring either prior to menarche or after menopause. We present a case of a Sertoli cell tumor in a postmenopausal woman with signs of virilization. A 67-year-old nulliparous woman presented to our attention with the chief complaint of abdominal distension. Her past history was endometriosis, gout, hypertension and hepatitis C. Cervical cytology was NILM. A magnetic resonance image scan of the pelvic area revealed a 25 cm complex cystic and solid right pelvic mass. As well, the endometrium of the uterus was unusually thick. Serum estradiol was 163.6 pg/ml and serum testosterone was 5.6 ng/ml. We suspected a hormone producing ovarian tumor and performed an abdominal total hysterectomy, bilateral salpingo-oophorectomy and partial omentectomy. The tumor was cystic and solid right ovarian tumor. The predominant microscopic pattern was albeit or retiform. A mitotic count was 1-2/10 HPFs. The immunohistochemical findings showed α-inhibin, vimentin and PgR were positive, EMA, CEA, AE1/AE3, CK7, CK20, CD30, AFP, ER were negative, MIB-1 was positive in 1% of tumor. Leydig cells were not observed. Final diagnosis was right ovarian tumor, Sertoli cell tumor (intermediate differentiation, borderline malignancy) pT1a NX M0, FIGO stage1A. After the surgery, the level of serum estradiol and testosterone decreased rapidly. The patient was started on follow-up visits without adjuvant therapy and was found to be with no evidence of disease. [Adv Obstet Gynecol, 68(1) : 36-41 , 2016(H28.2)]

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