A comparison of maternal and neonatal outcomes of pregnancy with mental disorders: results of an analysis using propensity score-based weighting.

PURPOSE: To assess and compare maternal and neonatal outcomes of pregnancy with or without mental disorders. METHODS: We performed a retrospective cohort study of births at our institution from January 2009 to December 2011, which included all live singleton births during these 3 years. Women emergently transferred to our institution in the middle of their pregnancies were excluded. Associations between mental disorders and perinatal outcomes were estimated using statistical analysis, and multivariable analysis was performed using propensity score-based weighting. RESULTS: A total of 1,166 women were included, 152 (13.0 %) of whom had mental disorders. Comparison of maternal characteristics showed that women with mental disorders were significantly more likely to be multiparous, smokers, recipients of public assistance, unmarried, and to have inadequate perinatal care. Comparison of perinatal outcomes showed that preterm births (PTB) before 37 weeks were significantly increased in women with mental disorders (10.5 vs. 6.0 %, P = 0.037). There were no significant differences in low birth weight (LBW), pregnancy-induced hypertension, and gestational diabetes mellitus. Multivariable analysis using propensity score weighting showed that after adjusting for other factors, women with mental disorders were more likely than women without mental disorders to have PTB before 34 weeks [adjusted odds ratio (OR) 4.79, 95 % confidence interval (CI) 1.49-15.4; P = 0.009], PTB before 37 weeks (adjusted OR 2.46, 95 % CI 1.62-3.69; P < 0.001), or LBW (adjusted OR 1.83; 95 % CI 1.32-2.55; P < 0.001). CONCLUSION: Maternal mental disorders were associated with adverse birth outcomes and socioeconomic disadvantage.

Outcomes of Laser Conization for Cervical Intraepithelial Neoplasia 2-3 and Microinvasive Cervical Cancer.

BACKGROUND: Currently, there is no standardized follow-up protocol for patients who undergo laser conization. Therefore, we retrospectively investigated the clinical outcomes of laser conization in patients with high-grade cervical intraepithelial neoplasia 2-3 (CIN 2-3) and microinvasive squamous cell carcinoma and assessed the risks of residual and recurrent lesions of the cervix uteri. METHODS: The medical and pathological records of 91 patients with CIN 2, 580 with CIN 3 and 73 with microinvasive cervical cancer (MIC) who underwent laser conization between January 2000 and December 2011 were retrospectively reviewed. RESULTS: Positive margins increased with the extent of disease and were observed in 5.5%, 8.9% and 16.4% patients with CIN 2, CIN 3 and MIC, respectively, while residual or recurrent disease was observed in 0%, 3.2% and 13.6% patients, respectively. Examination of specimens obtained through postconization biopsy or hysterectomy revealed that 1.5% and 20% patients with negative and positive margins, respectively, were diagnosed with residual or recurrent lesions. Among patients who were conservatively managed after conization, seven with CIN 3 exhibited residual or recurrent disease, as evidenced by abnormal cytological findings, within 2 years after conization. CONCLUSIONS: Continuous follow-up by cytology and colposcopy, particularly during the first 2 years after conization, can effectively detect early residual or recurrent disease in CIN 3 and MIC patients, regardless of their margin status.

Histopathology predicts clinical outcome in advanced epithelial ovarian cancer patients treated with neoadjuvant chemotherapy and debulking surgery.

OBJECTIVE: To analyze the factors prognostic of survival in patients with advanced epithelial ovarian cancer (EOC) treated with neoadjuvant chemotherapy (NAC) followed by interval debulking surgery. METHODS: Outcomes were retrospectively in patients with advanced EOC or peritoneal cancer who received neoadjuvant paclitaxel and carboplatin chemotherapy every 3 weeks for three to four cycles, followed by interval debulking surgery and three additional cycles of the same regimens from January 2001 to November 2010. Therapeutic response was assessed histopathologically as grade 0 to 3, based on the degree of disappearance of cancer cells, displacement by necrotic and fibrotic tissue, and tumor-induced inflammation. Factors prognostic of progression-free survival (PFS) and overall survival (OS) were calculated. RESULTS: The 124 enrolled patients had a median age of 62 years (range, 35-79 years). Viable cancer cells were observed in specimens resected from 72 patients (58%) at interval debulking surgery after NAC. Multivariate analysis using the Cox proportional hazard model showed that advanced (stage IV) disease (hazard ratio [HR]=1.94, p=0.003), residual cancer at the end of surgery ≥1cm (HR=3.78, p<0.001), and histological grade 0-1 (HR=1.65, p=0.03) were independent predictors of decreased OS. Grade 0-1 was also an independent predictor of increased risk of relapse within 6 months (odds ratio=8.42, p=0.003). CONCLUSIONS: Residual disease of ≥1cm, advanced stage, and the presence of more viable disease in resected specimens are prognostic factors for survival in advanced EOC patients receiving NAC followed by interval debulking surgery.

The effect of abdominal radical trachelectomy on ovarian reserve: serial changes in serum anti-müllerian hormone levels.

AIM: To evaluate the effect of abdominal radical trachelectomy on ovarian reserve and compare it with abdominal radical hysterectomy and a control group that did not have surgery. METHOD: We enrolled eighteen women who had abdominal radical trachelectomy with pelvic lymphadenectomy and sixteen patients who had abdominal radical hysterectomy for this study. Ten thousand one hundred eighty-six women were also included as a control group for comparison. The Mann-Whitney U test was used for comparison of patient characteristics and comparison of serum anti-Müllerian hormone levels between the three groups. RESULTS: Serum anti-Müllerian hormone levels in patients with abdominal radical trachelectomy were significantly higher than those of patients with abdominal radical hysterectomy (P<0.05). Serum anti-Müllerian hormone levels in the abdominal radical hysterectomy group were significantly lower than those in the control group (P=0.02), with no significant difference between the abdominal radical trachelectomy and control groups. These data indicated that abdominal radical trachelectomy did not affect ovarian function with respect to ovarian reserve and the response to ovarian stimulation. CONCLUSIONS: Serum anti-Müllerian hormone levels could be useful as a marker of ovarian reserve after abdominal radical trachelectomy. It is important to avoid postoperative complications causing a reduction in ovarian function to accomplish fertility-sparing surgery.

Type II versus type III fertility-sparing abdominal radical trachelectomy for early-stage cervical cancer: a comparison of feasibility of surgical outcomes.

OBJECTIVE: The purpose of this study was to compare surgical outcomes using modified (type II) and traditional (type III) abdominal radical trachelectomy (ART) for fertility-sparing surgery in early cervical cancer. METHODS: A prospectively maintained database of ART procedures was analyzed. Data were collected regarding age, stage, histology, operative outcome, surgical complication, and fertility outcome. RESULTS: We performed 23 fertility-sparing ARTs for patients with International Federation of Gynecology and Obstetrics stages IA to IB1 tumors of less than 2 cm between 2006 and 2010. Type III ART was attempted in 8 patients and modified ART in 15 patients. The median operating time was greater in the type III group compared with that in the type II group (305 vs 247 minutes; P < 0.02). The median surgical blood loss was greater in the type III ART group (580 mL; range, 250-988 mL) compared with that in the modified type II group (366 mL; range, 200-850 mL; P < 0.05). The median time to recovery of bladder dysfunction was less in the type II group (9 days; range, 3-10 days) than that in the type III group (13 days; range, 10-23 days; P < 0.01). There were no recurrences at the time of this report. CONCLUSIONS: Type II ART provides surgical and pathological outcomes with better recovery of bladder function similar to those in type III ART. For patients with early cervical cancer who wish to preserve reproductive function, type II ART is a feasible and safe operation.

Endometrioid adenocarcinoma with high-grade transformation with serous and choriocarcinomatous differentiation - a case report.

A choriocarcinoma component with a malignant tumor is relatively rare. We present a case of an 85-year-old woman with mixed carcinoma, which was endometrioid adenocarcinoma with squamous differentiation, choriocarcinoma and a disseminated peritoneal nodule, which was papillary serous adenocarcinoma. The patient received surgery and conservative treatment. Twenty weeks after surgery, a recurring tumor appeared at the Douglas pouch. Histology showed that the recurring tumor was poorly differentiated carcinoma that was very different from the primary tumor. This case represents an unusual uterine corpus cancer with high-grade transformation with serous and choriocarcinomatous differentiation. This case also demonstrates the capacity of tumor cells to differentiate into divergent elements.

Usefulness of computed tomography in predicting cytoreductive surgical outcomes for ovarian cancer.

PURPOSE: The objective of this study was to identify features of preoperative computed tomography (CT) scans that can best predict outcomes of primary cytoreductive surgery in ovarian cancer patients. METHODS: Preoperative CT scans of 98 patients were evaluated retrospectively. Multiple logistic regression analysis was used to develop two models. RESULTS: Although optimal surgical reduction was attempted in 98 patients, 12 had suboptimal results. Having tumor implants on the small or large bowel mesenteries (any size) or at other sites (cutoff index: ≥ 1 cm) was found to be significant (p < 0.001) for predicting a suboptimal cytoreduction outcome. Two predictive models were created using multiple logistic regression analysis; both consider diffuse peritoneal thickening (DPT), infrarenal para-aortic or pelvic lymph node involvement, a bowel encasement tumor (≥ 2 cm), and any tumor implants in the cul-de-sac as significant. Model 1 adds consideration to any tumors in the pelvic or retroperitoneum and has an accuracy of 90.8% for predicting a suboptimal surgery. Model 2 (accuracy of 93.9%) adds to the core of predictors the presence of tumor implants on the bowel mesenteries (≥ 2 cm), omental caking (≥ 2 cm), and ascites fluid. CONCLUSION: Using specific CT findings from patients with ovarian cancer, we have devised two predictive models that have an accuracy of greater than 90% for predicting whether cytoreductive surgery will completely remove all tumor tissue, which should greatly aid in the differential decision-making as to whether to attempt cytoreductive surgery first, or to advance directly to neoadjuvant chemotherapy.

Squamous cell carcinoma of the uterine cervix producing granulocyte colony-stimulating factor: a report of 4 cases and a review of the literature.

Granulocyte colony-stimulating factor (G-CSF)-producing malignant tumor has been reported to occur in various organs, and most of which has been associated with poor clinical outcome. However, because of the rarity of the reported cases, information regarding the G-CSF-producing gynecological malignancies is limited. We report 4 cases of G-CSF-producing cervical cancers. At initial diagnosis, all of the 4 patients exhibited marked leukocytosis without an obvious sign of infection. Of the 4 patients, 3 had their disease initially treated with definitive radiotherapy, and one was treated with radical surgery. Despite the aggressive treatments, all of these patients experienced recurrences within 6 months. In all cases, the white blood cell count returned to the normal range in response to the initial treatment and then increased again with recurrences. Based on the facts that the tumor cells were positive for G-CSF, the serum level of G-CSF was elevated, and their clinical course correlated well with the white blood cell count, we concluded that these tumors were G-CSF-producing cancers. All patients died from disease progression in less than 15 months. These cases strongly indicate the aggressive nature of the G-CSF-producing cervical cancer.

Postpartum outcome of cervical intraepithelial neoplasia in pregnant women determined by route of delivery.

Cervical intraepithelial neoplasia (CIN) has its highest incidence during women's reproductive years. During 2 sequential 7-year periods, 1994 to 2000 and 2001 to 2007, 3695 and 3894 deliveries were performed, respectively, at Osaka University Hospital. CIN was detected in 21 cases (0.57%) during 1994-2000 and in 43 cases (1.1%) during 2001-2007. By comparison, cervical intraepithelial neoplasia-complicated pregnancies increased significantly in the latter period (P = .015 by Fisher exact test, Odds ratio = 1.95; 95%CI: 1.16-3.30). We observed CIN regression in 34 (76%) of 45 cases of vaginal delivery and in 6 (50%) of 12 cases of cesarean delivery, indicating that the outcome of an initially diagnosed CIN and the delivery routes appeared not to be significantly related. However, a different result was obtained when only those patients whose CIN lesions persisted until the delivery were analyzed. Among the 35 such cases in the vaginal delivery group, 24 cases (69%) regressed after the delivery; in 8 such cases from the cesarean delivery group, only 2 cases (25%) regressed afterward. Our study clearly shows that pregnancy complicated with CIN is increasing rapidly in Japan. We also find that there is a significantly more frequent postpartum regression of biopsy-proven CIN lesions following a vaginal delivery compared to cesarean section (P = .042 by Fisher exact test, Odds ratio = 6.55; 95% CI: 1.13-37.8).

Cesarean scar pregnancies successfully treated with methotrexate.

Three cases of cesarean scar pregnancy successfully treated with methotrexate are described. The diagnosis was confirmed by transvaginal sonographic examinations showing a well-formed gestational sac in the myometrium of the lower uterine segment. Initial treatment with a systemic injection of 50 mg of methotrexate was not sufficient, and multiple doses were required to obtain a complete remission in two cases. In a case with a beta-hCG level of more than 20,000 mIU/mL with a viable embryo in a gestational sac, a combination of systemic and local treatment with methotrexate was required. It took 7-11 weeks for the beta-hCG level to become undetectable and 12-17 weeks for the cesarean scar pregnancy mass to disappear completely.