Xanthogranulomatous inflammation (XGI), an uncommon form of granulomatous inflammation, consists of infiltration by foamy histiocytes intermixed with other inflammatory cells. It is rare in female genital organs. We report a case of XGI, which was difficult to distinguish from the uterine malignant tumor. The patient was 78-year-old para three. She contracted pneumonia and treated with Tazobactam/Piperacillin. Computed tomography revealed an enlarged uterus in a short period, and she was referred to our department. There was no genital bleeding or abdominal pain, but the discharge was cloudy. Endometrial histopathology revealed atypical cells, and Klebsiella pneumoniae was detected in her vaginal culture. Magnetic resonance imaging revealed a highly enhanced mass showing high signal intensity on diffusion-weighted imaging from uterus to the right adnexa. She underwent hysterectomy and small intestinal resection. The uterus and right adnexa formed a solid mass, and they adhered to the small intestine and colon. Klebsiella pneumoniae was detected in her peritoneal fluid. Microscopically, a fair number of foamy histiocytes and inflammatory cells ware observed, and the diagnosis was XGI. XGI was infiltrated to the submucosal layer of the small intestine. Further research is needed to establish appropriate diagnostics and a treatment. [Adv Obstet Gynecol, 72 (1) : 1-7, 2020 (R2.2)]

A favorable outcome can be obtained in the majority of cases of villoglandular adenocarcinoma (VGA), a rare subtype of adenocarcinoma that develops in the uterine cervix, though the prognosis of advanced cases is worse. We report experience with a case of VGA diagnosed during pregnancy. A 34-year-old nulliparous woman was referred to our hospital because of abnormal cervical cytology results indicating HSIL. We performed a colposcopy-directed biopsy, though nothing remarkable was revealed. The patient revisited our hospital six months later and was found to have a normal pregnancy at eight weeks of gestation, while abnormal cervical cytology results indicating HSIL were seen once again. In addition, colposcopic findings revealed a minute polypoid lesion with a diameter of approximately 2-3 mm in the cervix and directed biopsy results suggested an early stage VGA of the uterine cervix. We performed cervical conization and cerclage procedures at 15 weeks of gestation, and pathological findings revealed an intraepithelial VGA and HSIL of the uterine cervix, while the cut margin was negative. The pregnancy was continued with repeated cervical cytology examinations. The patient delivered a healthy newborn vaginally at 39 weeks of gestation. At 10 months after conization, there was no evidence of recurrence. [Adv Obstet Gynecol, 72 (1) : 8-13, 2020 (R2.2)]

Correctly diagnosing uterine sarcomas preoperatively is very difficult. We examined the usefulness of magnetic resonance imaging (MRI) for distinguishing between uterine sarcomas and leiomyomas. From April 2012 to July 2018, MRIs were used to distinguish between uterine sarcomas and leiomyomas in a total of 159 patients with preoperatively identified uterine tumors. All patients underwent total hysterectomy and the uterine tumors were pathologically assessed for malignancy. Preoperatively, seventeen tumors were uterine sarcomas, but postoperatively, only 10 were uterine sarcomas. The characteristic findings of uterine sarcomas on MRI are: (1) high-intensity T1-weighted images, (2) spread beyond the muscular layer, (3) high-intensity diffusion-weighted images, and (4) high contrast effects. In our evaluation, we assigned a point value of 1 to each of the characteristic findings for a total possible finding rating of 4. For all patients, the average of the finding scores was 3.1 for uterine sarcoma and 0.63 for uterine leiomyoma. For uterine sarcomas vs. leiomyoma, the high-intensity T1-weighted images were 90.0% vs. 15.4%; spread beyond the muscular layer was 60.0% vs. 2.0%; high-intensity diffusion-weighted images were 100% vs. 33.6%; and high contrast effects were 60% vs. 18.1%. The likelihood of malignancy was increased in the cases with tumor spread beyond the muscular layer or with more than 3 separate tumors. Thus, the four characteristic findings of MRI could be very useful for distinguishing uterine leiomyomas from sarcomas. [Adv obstet gynecol, 72 (1) : 14-20, 2020 (R2.2)]

Serous endometrial intraepithelial carcinoma (SEIC) is presumed to be a precursor lesion of serous uterine carcinoma, characterized by overexpression of p53 in the nucleus, common sheddings to the peritoneal cavity and poor prognosis. Because the endometrium is thin and the biopsy sampling amount small, preoperative diagnosis of SEIC is often tricky. In this report, we feature three cases of SEIC and detail the role of endometrial cytology in its preoperative diagnosis. Case one was a 59-year-old woman and exhibited adenocarcinoma in endometrial cytology and atypical endometrial hyperplasia in the endometrial biopsy. A hysterectomy was undergone, and the prognosis was death due to intraperitoneal seeding 34 months after hysterectomy. Case two was a 67-year-old woman and showed adenocarcinoma in endometrial cytology, which was positive for p53 staining; the biopsy was of low specimen volume. The prognosis was disease-free survival at 26 months after hysterectomy. Case three was a 72-year-old woman with liquid-based endometrial cytology indicating adenocarcinoma; endometrial biopsy was benign. The prognosis was disease-free survival at 21 months after hysterectomy. From the above cases, preoperative diagnosis of SEIC may be insufficient through endometrial biopsy alone, but a combined use of liquid-based endometrial cytology and p53 staining proves effective. [Adv Obstet Gynecol, 72 (1) : 21-28, 2020 (R2.2)]

A 29-year-old, gravida 1 para 0, woman was diagnosed with diarrhea and frequent bleeding since 21 weeks of pregnancy and admitted to the Department of Gastroenterology at 23 weeks, three days of pregnancy with suspected ulcerative colitis. Ulcerative colitis was diagnosed by lower gastrointestinal endoscopy and treatment was initiated. Administration of five-aminosalicylic acid (5-ASA 4800 mg) formulation was not sufficiently effective; hence, steroid administration (prednisolone [PSL] 60 mg) was also initiated. From the next day, the symptoms improved gradually, and steroid dosage was gradually tapered. Even after that, remission was maintained without symptom exacerbation, and she was discharged at 32 weeks, three days of pregnancy. The disease was stable even after discharge, and fetal growth was unremarkable. The patient experienced labor at 38 weeks, four days of pregnancy and delivered vaginally. The mother and baby were healthy and were discharged on the 6th day. She remained in remission after discharge; PSL was discontinued and remission was maintained only with 5-ASA. There are only a few studies regarding the development of ulcerative colitis during pregnancy , so further research is necessary; however, good disease control can be achieved for both the mother and baby by careful cooperation with the physicians. [Adv Obstet Gynecol, 72 (1) : 29-33, 2020 (R2.2)]

A retroverted uterus in the first trimester occurs in 10 to 20% of all pregnancies. Entrapment of the gravid uterus in the pelvis even after 14 to 16 weeks of gestation is defined as incarceration of the retroverted uterus. A 35-year-old woman (gravida one, para zero) was referred to our hospital for a regular prenatal checkup at nine weeks of gestation. She had undergone abdominal right ovarian cystectomy after rupture of a right ovarian endometriotic cyst 13 years ago. At 19 weeks of gestation, incarceration of the retroverted gravid uterus was confirmed by transvaginal ultrasonography. She underwent pelvic magnetic resonance imaging at 33 weeks of gestation, which showed that the uterus was excessively flexed backward, the bottom of the uterus fit into the small pelvis, and the cervix was elongated and stretched up to the anterior abdomen. At 38 weeks of gestation, a selective cesarean section was performed. We made an incision in the uterine wall based on intraoperative ultrasonic examination. She delivered a boy weighing 3656g. After delivery, ultrasound examination showed the uterus in a retroverted flexion. She was discharged from hospital on the eighth postoperative day. Preoperative recognition of incarceration of the retroverted gravid uterus is important to prevent intrapartum complication. [Adv Obstet Gynecol, 72 (1) : 34-39, 2020 (R2.2)]

A 53-year-old woman, G4P1 (three artificial abortions, including 1 mid-term abortion), who had a past history of diverticulitis that was treated conservatively, visited our hospital presenting stool-like discharge. Colonoscopy revealed diverticulitis of the sigmoid colon, and a fistula extending from the sigmoid colon to the lower uterus or vagina was found on barium enema examination. From these findings, she was diagnosed as sigmoid-vaginal fistula secondary to diverticulitis of the sigmoid colon, and laparoscopic hysterectomy and partial sigmoidectomy were performed. The fistula was located between the sigmoid colon and vaginal fornix, forming an adhered abscess. The postoperative course was uneventful and no recurrence has been reported. Sigmoid-vaginal fistula is rare and radical operation can be difficult because of inflammation or adhesion. However, laparoscopic surgery is possible for such inflammatory fistulas. This report presents the case with a discussion of previous reports. [Adv Obstet Gynecol, 72 (1) : 40-45, 2020 (R2.2)]