Gestational trophoblastic neoplasia (GTN) includes invasive moles, choriocarcinomas, placental site trophoblastic tumours (PSTTs), and epithelioid trophoblastic tumors (ETTs). It is rare to encounter these diseases in routine medical practice as they occur infrequently. In general, GTN responds well to chemotherapy, leading to excellent remission rates. However, some cases require multimodal therapy, including surgical treatment. We retrospectively investigated the treatment course and prognosis of patients with GTN treated over the previous 35 years in our hospital. The subjects included 34 patients with GTN (24 with invasive moles, nine with choriocarcinomas, and one with a PSTT) whose clinical data could be gathered. Of the 24 patients with an invasive mole, 15 (63%) received single-agent chemotherapy, and combination chemotherapy was conducted for seven patients (29%), as the first-line therapy. Of the 15 patients who received single-agent chemotherapy, two patients required combination chemotherapy as the second-line chemotherapy. Seven (29%) required chemotherapy together with surgery and/or endovascular treatment. Remission was ultimately achieved for all 24 patients with invasive moles. Combination chemotherapy was selected for all nine patients with choriocarcinomas, and six (67%) of these patients also underwent surgery. Although three patients (33%) with stage IV choriocarcinomas died of the disease in the early 1980’s, remission was achieved for the other six patients (67%). Surgery was selected for the patient with a PSTT, and the patient progressed favourably. Our data indicates that advances in chemotherapy have resulted in complete remission in a high overall percentage of patients with GTN (91%, 31/34 patients). However, multimodal therapy, including surgery, was selected for 13 (38%) patients. These cases suggest the importance of administering multimodal therapy, depending on the individual case. [Adv Obstet Gynecol, 70 (1) : 1-10, 2018 (H30.2)]

Cervical conization is the standard procedure for the treatment of high-grade cervical intraepithelial neoplasia (CIN), and its use has increased in the recent years. The purpose of this study was to evaluate the diagnosis, complications, and pregnancy outcomes following conization. This retrospective study included 352 patients who underwent conization for CIN between July 2007 and December 2014. The median age was 38 years (range, 17-72 years), and many patients were in their thirties (39.1%). The median observation period was 32.4 months (range, 1-102 months). A comparison between the conization specimen and preoperative biopsy results showed that the pathological diagnosis agreement rate was 58.5% and the rate of under-diagnosis was 15.6%. Positive margins were found in 36 cases (10.2%), with 12 cases consistent with invasive squamous cell carcinoma. Thirteen of these patients were followed up, out of which one patient relapsed. Negative margins were observed in 291 cases (82.0%), of which three cases relapsed. Per a previous report, the frequency of recurrence is high in cases with positive margins; however, in our study, the finding was not significant (p=0.38). Cervical stenosis occurred in six patients (1.7%), for which cervical dilation was performed under anesthesia. Postoperative bleeding that required suturing under anesthesia occurred in two patients. Twenty-nine patients carried on pregnancy and 13 patients were treated for threatened premature delivery. There were two cases of spontaneous miscarriage and seven cases of premature delivery. Premature preterm rupture of membranes occurred in six patients. Seven patients were diagnosed with chorioamnionitis based on the placental pathology. In our study, the diagnosis agreement rate was higher and the recurrence rate was lower than the previous reports. However, the pregnancy outcomes were worse than the previous reports. To avoid CIN recurrence and reduce the complications during future pregnancies, it is necessary to choose the excision range appropriately for patients in the reproductive age. [Adv Obstet Gynecol, 70 (1) : 11-16, 2018 (H30.2)]

We retrospectively analyzed 399 patients who underwent cervical conization from January 2011 to December 2015 at our hospital. After the procedure, the pathological diagnosis of 30 patients (9.6%), who were preoperatively diagnosed with CIN3, were upstaged. Patients with CIN3 should be treated by conization to obtain accurate diagnosis with surgical specimen. Four patients had recurrences after the operations. One of them had clear margin at first conization, but also had a recurrence of CIN3. One patient had a recurrence of IB1 squamous cell carcinoma which had CIN3 margins in the first operation. All patients with recurrent cancer were treated radically by reoperation. After conization, careful observation is recommended especially in first one year, because all recurrences in our cohort were diagnosed in one year after the first operation. 45 patients (11.3%) became pregnant after conization. Among them six cases (13.3%) were with preterm birth. When surgical is performed during lactation period, prevention of cervical stenosis after conization is recommended. [Adv Obstet Gynecol, 70 (1) : 17-23, 2018 (H30.2)]

A-30-year-old primipara conceived using intracytoplasmic sperm injection. The course of her pregnancy was uneventful until she experienced inguinodynia at the 39th week, which made vaginal delivery impossible. On the 40th week of gestation, caesarean section was performed. Immediately following the surgery, the rate of genital bleeding increased rapidly, resulting in the loss of 2959ml of blood. Uterine artery embolization failed to arrest the vaginal bleeding. She eventually developed disseminated intravascular coagulation. Clinical amniotic fluid embolism was strongly suspected and abdominal total hysterectomy was performed. The blood loss during this surgery was 2468ml. On the next day, intra-abdominal bleeding was discovered and laparotomy was again performed to halt the bleeding. The total amount of blood loss during this operation was 4219ml. Negative-pressure wound therapy was instituted with gauze packing in the abdominal cavity through the open surgical wound After the third laparotomy, her clinical course was relatively favorable. One day later, we closed the wound. On the 35th day, she was discharged. The total blood transfusion volume was 36 units of red blood cells, 90 units of fresh frozen plasma, and 90 units of platelet product. Zinc coproporphyrin-1 (ZnCP-1) and sialyl Tn antigen levels in the maternal serum were normal. However, immunostaining of the resected uterus showed numerous C5a receptor-positive cells in the stroma of the cervix and the corpus, suggesting that anaphylactoid reaction occurred. In addition, the specimens in corpus vessels were partially positive for ZnCP-1 staining, suggesting inflow of amniotic fluid into uterine blood vessels. Based on these findings, she was diagnosed with DIC preceding amniotic fluid embolization. Fortunately, through thorough management, the patient recovered without any sequelae. When unexplainable massive bleeding is observed after delivery, we believe that initiating therapeutic intervention as early as possible produces a better prognosis. Furthermore, care coordination among related sections or departments is important. [Adv Obstet Gynecol, 70 (1) : 24-30, 2018 (H30.2)]

Sturge-Weber syndrome (SWS) is a neurocutaneous syndrome marked by a typical facial 39 port-wine stain and leptomeningeal angioma. We present a case of SWS whose mother had 40 hydramnios in the third trimester with bibliographic consideration. A 32–year-old woman, gravida 3, para 2 was diagnosed with mild hydramnios (amniotic fluid index, AFI, 20.3) using ultrasound at 35 weeks of gestation without any fetal anomalies. AFI increased to 36.4 at 38 weeks and the estimated fetal body weight was above the 97.7 percentile. Therefore, labor was induced at 38 weeks gestation. A baby boy was born at 39 weeks gestation weighing 4078g, with Apgar scores of 7 at 1 min and 9 at 5 min. He had breathing difficulty initially, which improved with immediate resuscitation. He had a large port-wine facial stain and swelling of the lower jaw, and was admitted to the neonatal intensive care unit (NICU) for further investigations. Magnetic resonance imaging (MRI) of the brain showed a leptomeningeal capillary-venous malformation in the left temporal lobe and SWS was suspected. He was transferred to a pediatric hospital at 32 days of age and was diagnosed with SWS. Treatment with propranolol was initiated. [Adv Obstet Gynecol, 70 (1) : 31-36, 2018 (H30.2)]

Pseudomyxoma peritonei (PMP) is a rare (1.5/1,000,000) clinical entity that is characterized by the diffuse intra-abdominal accumulation of gelatinous material and the development of mucinous implants on the peritoneal surface and omentum. The long-term outcomes of most patients with PMP remain poor because PMP progresses to massive abdominal distension and nutritional compromise. In most cases, PMP is unexpectedly encountered during laparotomy because it exhibits few distinctive symptoms in its early stages. Here, we report a case of very early stage PMP, which was diagnosed during laparoscopic surgery for a right-sided ovarian cystic mass in a patient with an elevated carcinoembryonic antigen (CEA) level. A 67-year-old, gravida 0, para 0, female with history of a mastectomy for breast carcinoma five years ago was referred to us in order to have a right-sided ovarian cystic mass investigated. The mass was detected by positron emission tomography-computed tomography, which was performed because the patient’s CEA level was elevated (14.6 ng/ml). Transvaginal ultrasonography and magnetic resonance imaging also showed a right-sided ovarian cystic mass (diameter: 6 cm) without any signs of malignancy together with a small amount of ascites in Douglas’ pouch. Intra-laparoscopic-operatively, mucinous ascites and a right-sided ovarian cyst were found in the pelvis, which suggested PMP. Therefore, abdominal total hysterectomy, bilateral salpingo-oophorectomy, resection of the pelvic peritoneal implants, appendectomy, and omentectomy were performed, and the abdominal cavity was washed out with 3000 ml saline and 500 ml 5% glucose in order to minimize the amount of residual mucin. A pathological examination revealed that the PMP originated from a low-grade atypical mucinous tumor of the appendix and exhibited peritoneal implantation, and that a mucinous cystadenoma of the right ovary existed independently. No metastatic tumors were found in the omentum. This case was diagnosed at such an early stage that it would not have been possible to preoperatively diagnose based on radiological imaging. Exploratory laparoscopy might facilitate the early diagnosis of PMP. [Adv Obstet Gynecol, 70 (1) : 37-43, 2018 (H30.2)]

Metastasis of cancer to an inguinal hernia sac is very rare. We herein report the first known case of an undifferentiated uterine sarcoma metastasized to an inguinal hernia sac. A 65-year-old woman was admitted to our hospital because of swelling of the lower right abdomen. Ultrasound examination and magnetic resonance imaging diagnosed a 10-cm degenerating uterine leiomyoma and a right inguinal hernia entrapping the small intestine. Considering the risk of strangulation, we performed abdominal total hysterectomy, bilateral salpingo-oophorectomy, and hernioplasty soon after admission. Two white masses were found in the inguinal hernia sac during the operation. Histological examination proved to be an undifferentiated uterine sarcoma with two peritoneal metastatic lesions in the hernia sac. Exploration of the entire body after the operation showed no other metastases, therefore, the postoperative diagnosis was undifferentiated uterine sarcoma pT3bNXM0. Postoperative adjuvant chemotherapy with gemcitabine and docetaxel was performed. On postoperative day 50, ultrasonography and computed tomography revealed the presence of ascites and peritoneal dissemination throughout the abdomen, confirming progression of the disease. Palliative care was given, and the patient died on postoperative day 205. [Adv Obstet Gynecol, 70 (1) : 44-51, 2018 (H30.2)]