Ovarian fibromatosis associated with large pedunculated fibroma in a 30-year-old woman: A rare coincidence or variant?

A 30-year-old nulligravida was referred under suspicion of large subserosal myoma. T2-weighted magnetic resonance imaging revealed multilobulated solid mass in the left lower abdomen measuring 16 cm in longitudinal diameter. The ovarian surface was covered with a marked T2-hypointense thick rim called "black garland sign," forming multiple nodular masses ranging from 1 to 5 cm in diameter in some portions of the bilateral ovaries. By laparoscopic-assisted minilaparotomy, the stalk of pedunculated mass originating from the left ovarian hilum was excised, followed by carrying out of the body after in-bag morcellation using a surgical scalpel. Right ovarian exophytic nodular masses larger than 1 cm were excised using monopolar electrode needle. Pathological examination of excised right and left masses showed fibroblast-like spindle cell proliferation with collagenous stroma; however, differences between right and left masses cannot be distinguished on a histological level. Postoperative diagnosis was ovarian fibromatosis coexisting with large pedunculated fibroma.

Clinical characteristics and laparoscopic surgical outcomes of ovarian dermoid cysts complicated by spontaneous rupture: nine cases and a literature review.

OBJECTIVE: To clarify the clinical characteristics and laparoscopic surgical outcomes of dermoid cysts complicated by spontaneous rupture. METHODS: This was a single-center retrospective observational study of patients with dermoid cysts treated between January 2005 and December 2021. RESULTS: Among 1205 cases of dermoid cysts, spontaneous rupture occurred in nine and torsion occurred in 83 cases. No obvious triggers for rupture were identified, except for one postpartum case with fundal uterine pressure maneuver. Rupture was identified by computed tomography (CT) in six cases. Patients with ruptured cysts had significantly higher serum C-reactive protein (CRP), cancer antigen 125 (CA125), carbohydrate antigen 19-9 (CA19-9), and squamous cell carcinoma antigen (SCC) levels compared with patients with uncomplicated dermoid cysts or cysts with torsion. Laparoscopic management was possible except for one case with severe adhesion, which required laparotomy. Two patients required prolonged postoperative administration of antibiotics due to refractory chemical peritonitis. CONCLUSION: Combined use of CT imaging and elevated levels of CRP, CA125, CA19-9, and SCC may help to differentiate cyst rupture from torsion. Laparoscopic surgery may be a feasible option; however, prompt laparotomic conversion should be considered in cases with difficult adhesiolysis. Refractory chemical peritonitis may occur after successful surgical management.

Conservative endovascular management for intractable delayed hemorrhage after laparoscopic-assisted vaginal hysterectomy: Two case reports.

Delayed hemorrhage from the vaginal stump is a rare complication following hysterectomy. Most cases can be managed by vaginal packing with or without vaginal vault suturing. However, where such initial management fails, the condition is potentially life-threatening and requires immediate intervention. We report two cases successfully managed with transcatheter arterial embolization (TAE). First, a 38-year-old woman presented with lower abdominal pain 12 days after laparoscopic-assisted vaginal hysterectomy (LAVH) for a uterine myoma. Oral antibiotics were administered for pelvic infection. Two days later, she experienced increased bleeding. After failing to achieve hemostasis with vaginal vault suturing, computed tomographic angiography showed extravasation from a pseudoaneurysm in the peripheral branch of the left uterine artery. Hemostasis was achieved with TAE. Second, a 40-year-old woman presented with fever and increased abdominal pain 6 days after LAVH for severe dysplasia of the uterine cervix. Intravenous antibiotics were administered for pelvic infection. Twenty-one days after LAVH, she experienced increased bleeding. Computed tomographic angiography showed extravasation from a peripheral thin branch of the right uterine artery. Temporary hemostasis was achieved with vaginal vault suturing; however, bleeding recommenced 12 h later. Hemostasis was achieved with TAE. We conclude that endovascular management is a feasible option for intractable delayed hemorrhage after hysterectomy, when vaginal vault suturing fails to achieve hemostasis.

Paraganglioma of the Fallopian Tube Presenting as Isolated Fallopian Tube Torsion.

A 32-year-old woman with no previous disease history was presented with worsening right-lower abdominal pain, which lasted for 4 days. On magnetic resonance imaging, a solid mass measuring 48 mm in longitudinal diameter connected with a tortuous structure that appeared to be a fallopian tube was identified in the right-lower abdomen. Because the right ovary was identified at a slightly distant location, isolated fallopian tube torsion with heterogeneous mass was suspected. The isolated fallopian tube torsion without ovarian involvement was laparoscopically confirmed. After detorsion, solid necrotized mass in the distal portion of the right fallopian tube near the fimbrial end became evident, followed by uneventful right salpingectomy with ovarian preservation. The pathological diagnosis was paraganglioma of the fallopian tube with positive cells for neural cell adhesion molecule, neuron-specific enolase, and S-100 protein in the viable peripheral foci of the massively necrotized hemorrhagic mass. Recurrence was not observed after 1.5 years.

Uterine artery chemoembolization followed by hysteroscopic resection for management of retained placenta accreta with marked vascularity after evacuation of first-trimester miscarriage in angular pregnancy: A case report.

BACKGROUND: Angular pregnancy is a rare form of eccentric intrauterine gestation. To determine the management strategy, angular pregnancy should be differentiated from interstitial pregnancy and cornual pregnancy. CASE: A 37-year-old woman (gravida 5, para 4) with no previous disease history was referred because of a retained placenta with hemorrhage 20 days following the manual vacuum aspiration of an intrauterine pregnancy performed after the diagnosis of miscarriage at 8 weeks of gestation. At the initial examination, a prominent vascular mass was identified in the left lateral portion of the uterus. The patient's serum ß-human chorionic gonadotropin level was 1949 IU/L. Magnetic resonance imaging revealed an enlarged angular space occupied by a suspected retained placenta with expansion of the surrounding myometrium. Three-dimensional computerized tomography showed a prominent vascular mass with a feeding left uterine artery and draining thick left ovarian vein. The diagnosis consisted of retained placenta accreta with marked vascularity after evacuation of a miscarriage in a woman with angular pregnancy. Uterine artery chemoembolization was performed followed by the administration of a single dose of systemic methotrexate. Because the gestational mass persisted and spontaneous expulsion appeared to be unlikely, despite the gradual decline of serum ß-human chorionic gonadotropin levels, hysteroscopic resection of the retained placenta was performed and the patient's subsequent recovery was uneventful.

Rapid regression of microsatellite instability-high/programmed cell death ligand 1-negative recurrent endometrial carcinoma by immune checkpoint blockade with pembrolizumab: A case report and literature review.

In a 53-year-old woman who had a surgical diagnosis of grade 3 endometrioid carcinoma (pT1aN0M0, FIGO 1A), adjuvant chemotherapy with paclitaxel and carboplatin was initiated. However, after the completion of fourth cycle, the patient refused to continue the treatment. At 12 months after surgery, local recurrence was noted near the left posterior portion of the vaginal stump. External radiotherapy to the pelvic cavity achieved marked reduction of the tumor. At 12 months after radiotherapy, regrowth of the tumor was noted. Although the tumor was negative for programmed cell death ligand 1, after the identification of a high level of microsatellite instability, treatment with pembrolizumab, an immune checkpoint inhibitor, was initiated. After 2 cycles of treatment, the recurrent tumor markedly regressed. Four months later, a complete metabolic response was confirmed by positron emission tomography, without any immune-related adverse events; at the time of writing, this has been maintained for 9 months.

Pregnancy outcome after emergency uterine artery embolisation for management of intractable haemorrhage associated with laparoscopic-assisted myomectomy.

The feasibility of emergency uterine artery embolisation (UAE) after diagnosis by three-dimensional computed tomographic angiography (CTA) for conservative management of intractable haemorrhage associated with laparoscopic-assisted myomectomy (LAM) was evaluated. In 764 women undergoing LAM, 12 cases were managed by emergency UAE to achieve haemostasis after evaluation by CTA. In two cases, bleeding was diagnosed in the postoperative period, while, in another 10 cases, bleeding was identified at the near-end stage of the surgical procedure. Uterine preservation was achieved in all cases. Among five women desiring child bearing, five spontaneous conceptions and one conception by assisted reproductive technology occurred. Five pregnancies resulted in live birth by caesarean section. Emergency UAE could be a useful minimally invasive option for the salvage of intractable haemorrhage associated with LAM to avoid exploratory laparotomy and/or hysterectomy. In women with fertility wish, pregnancy outcomes were favourable with high number of spontaneous pregnancy rate and without significant negative effects.Impact statementWhat is already known on this subject? Uterine myoma is the most common benign pelvic tumour in women. Myomectomy is indicated as the primary intervention for women with symptomatic myoma, who are of reproductive age and desire uterine preservation, since it can significantly improve symptoms and quality of life and, in some clinical situations, improve reproductive outcomes. Intractable haemorrhage associated with any forms of myomectomy is a potentially life-threatening condition with potential loss of future fertility. However, clear consensus on its management are not well known so far.What do the results of this study add? Emergency uterine artery embolisation after diagnosis by three-dimensional computed tomographic angiography has been effective in preserving the uterus with avoidance of laparotomy and/or life-saving hysterectomy as a salvage therapy for intractable haemorrhage associated with laparoscopic-assisted myomectomy. Significant adverse outcomes were not observed. Furthermore, in women desiring child bearing, a high rate of spontaneous conceptions with live birth by caesarean section was achieved after these combined interventions.What are the implications of these findings for clinical practice and/or further research? Endovascular embolisation could be considered as a minimally invasive alternative with favourable pregnancy outcome to treat intractable haemorrhage associated with myomectomy.

Conservative endovascular and hysteroscopic management of a cesarean scar pregnancy in a woman with previous history of uterine artery embolization for intractable hemorrhage after cesarean section for placenta previa.

Transcatheter arterial chemoembolization (TACE), followed by hysteroscopic resection of the gestational products, could be a feasible option for the conservative management of cesarean scar pregnancy (CSP) in a woman with a previous history of uterine artery embolization (UAE) with coils for intractable hemorrhage after cesarean section.

Superselective microcoil embolization of the vasa recta of sigmoid artery for hemorrhaging after laparoscopic adnexectomy for corpus luteum hematoma with severe adhesion.

A 44-year-old multipara woman was referred because of the sudden onset of left lower abdominal pain. Corpus luteum hematoma was suspected and conservatively managed. Two days later, due to worsening of abdominal symptoms, emergency laparoscopic surgery was performed. Severe pelvic adhesion around the left ovary forming corpus luteum hematoma was identified. After adhesiolysis, which was complicated by massive bleeding, left adnexectomy was performed. Hemostasis was achieved by the coagulation of bleeding vessels, followed by spraying fibrin glue with the placement of oxidized cellulose cotton for bleeding oozing from dissected surface. Two hours after surgery, emergency computed tomography performed due to the development of hemodynamic instability demonstrated extravasation from the versa recta of the sigmoid artery. After the confirmation of hemorrhaging, superselective catheterization to the bleeding vessel followed by embolization by platinum microcoils were performed. Hemodynamic stability was immediately achieved, and the postoperative course was uneventful without manifestation of bowel ischemia.

Multimodal imaging for diagnosis and management of parasitic peritoneal myoma with myxoid degeneration after laparoscopic-assisted myomectomy with electric power morcellation.

A 45-year-old multipara woman was referred due to the rapid enlargement of an asymptomatic pelvic mass that was detected during a regular check up. She had undergone laparoscopic-assisted myomectomy 15 years previously. At the time, the uncontained extraction of an intraligamental myoma with electric power morcellation had been performed. Multimodal imaging revealed a heterogeneous mass in the vesicouterine pouch that was found to be supplied by the left gastro-omental and superior vesical arteries. Although malignancy could not be completely denied, parasitic peritoneal myoma with myxoid degeneration was the most probable diagnosis. Single-port laparoscopic excision of the peritoneal mass was performed along with laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy. The excised peritoneal mass was placed into a retrieval bag and extracted through the vagina. The pathological diagnosis was a parasitic peritoneal myoma with myxoid degeneration. The postoperative course was uneventful, and there was no recurrence of parasitic myoma in the 1-year follow up after surgery.

Conservative endovascular management of retained placenta accreta with marked vascularity after abortion or delivery.

OBJECTIVE: To report our experience on the value of transcatheter arterial embolization (TAE) or transcatheter arterial chemoembolization (TACE) for the uterus-preserving management of retained placenta accreta with marked vascularity after abortion or delivery. STUDY DESIGN: Thirty-eight consecutive women with retained placenta accreta were retrospectively analyzed over a 5-year period. When elevated levels of serum ß-hCG (> 25 mIU/mL) were detected, TACE with dactinomycin was chosen for devascularization along with cytotoxic effects on active trophoblasts; in contrast, if the serum ß-hCG level was low (≤ 25 mIU/mL), TAE was chosen. After confirming devascularization, the additional need for hysteroscopic resection and systemic methotrexate administration was individually determined. RESULTS: The most frequent sign and symptom in the abortion group was significant hemorrhaging, while a hypervascular mass detected at a regular check-up was the most frequent in the delivery group. The median time elapsed between abortion and endovascular management was 36 days, and the median time elapsed after delivery was 31.5 days. TACE was performed more frequently than TAE in the abortion group, while TAE was the more frequent procedure in the delivery group. In 10 and 11 cases, after abortion and delivery, respectively, hysteroscopic resection was performed. Systemic methotrexate administration was additionally done in three and one cases after abortion and delivery, respectively. Uterine preservation was achieved in all cases. CONCLUSION: This case series emphasizes that endovascular embolization is an effective key intervention with or without additional therapies for uterus-preserving management of retained placenta accreta with marked vascularity after abortion or delivery.

Magnetic resonance imaging for diagnosis and management of unruptured interstitial pregnancy.

AIM: The aim of this study was to evaluate the value of magnetic resonance imaging (MRI) for the diagnosis and management of suspicious unruptured interstitial pregnancy. MATERIAL AND METHODS: Only patients with unruptured interstitial pregnancy evaluated by MRI and observed for at least a year after surgery were included. Initial evaluation was performed by measurement of serum ß-human chorionic gonadotrophin level and ultrasonography. In suspicious cases, emergency MRI was performed to diagnose interstitial pregnancies with the exclusion of rudimentary horn pregnancy and angular pregnancy. Three-dimensional computed tomographic (CT) angiography was additionally performed if the uteroplacental neovascularization needed to be evaluated. Then, management procedures were individually determined along with the need for preoperative transcatheter arterial chemoembolization for immediate devascularization, and for the local or systemic administration of methotrexate. Either laparoscopic cornuostomy or cornual resection was chosen to excise the gestational mass. RESULTS: Five consecutive women with unruptured interstitial pregnancy were enrolled. One case each of rudimentary horn pregnancy and angular pregnancy was excluded. Three-dimensional CT angiography was performed in three cases due to increased vascular flow on color Doppler ultrasonography. Preoperative devascularization by transcatheter arterial chemoembolization was performed in two cases, in which a prominent neovascularized gestational mass was identified. Uterine preservation was achieved by cornuostomy or cornual resection in all cases. Two patients with a desire to become pregnant conceived spontaneously thereafter, followed by successful cesarean birth. CONCLUSION: This small case series emphasizes that precise localization of gestational products in the interstitial portion of the fallopian tube by MRI can facilitate the minimally invasive management of unruptured interstitial pregnancy for uterine preservation.

Magnetic Resonance Imaging and 3-dimensional Computed Tomographic Angiography for Conservative Management of Proximal Interstitial Pregnancy by Hysteroscopic Resection After Transcatheter Arterial Chemoembolization.

Ectopic pregnancy implanted in the interstitial portion of the fallopian tube is a rare potentially life-threatening disorder. A case of unruptured interstitial pregnancy with prominent neovascularization in a 37-year-old woman was precisely localized in the proximal interstitial portion of the fallopian tube with a dilated proximal tubal ostium by magnetic resonance imaging and 3-dimensional computed tomographic angiography. After devascularization by transcatheter arterial chemoembolization, hysteroscopic resection of the interstitial gestational products was performed with single-port laparoscopic assistance. Postoperatively, 3 rescue doses of systemic methotrexate were administered to accelerate the resolution of gestational products followed by uneventful recovery. The uterine wall structure around the interstitial portion was well preserved at the cesarean delivery in the subsequent spontaneous gestation.

Cervico-isthmic pregnancy: early diagnostic imaging and successful dual therapy for uterine-sparing treatment.

Cervico-isthmic pregnancy is a rare and potentially life-threatening form of ectopic gestation in which the blastocyst implants in the uterine cervico-isthmus between the histological and anatomical internal os, followed by subsequent extension to the lower uterine segment. Early diagnosis may allow a conservative therapeutic approach that avoids catastrophic hemorrhage requiring hysterectomy. Here we report the case of a 43-year-old primigravida woman whose cervico-isthmic pregnancy complicated by massive hematometra was diagnosed at 6 weeks gestation by multimodal imaging and successfully treated by hysteroscopic resection, securing adequate hemostasis, after transcatheter arterial chemoembolization.

Conservative management of uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy and subsequent pregnancy outcome: case series and review of the literature.

OBJECTIVE: Uterine artery pseudoaneurysm is a rare potentially life-threatening complication after myomectomy. Its clinical characteristics and management, and the outcomes of subsequent pregnancy, are not well understood. The purpose of this study was to clarify these important issues. STUDY DESIGN: Retrospective analysis of a case series of uterine artery pseudoaneurysm detected after laparoscopic-assisted myomectomy (LAM) in a single center over a 13-year period. During the early postoperative course, gray scale ultrasonographic evaluation was carried out routinely by searching for an anechoic or hypoechoic well-defined cystic structure in the post-myomectomy scar. In suspicious cases, further evaluation was performed by color Doppler flow analysis and three-dimensional computerized tomographic angiography. After finally confirming the diagnosis by digital subtraction angiography, uterine artery pseudoaneurysm was conservatively managed by angiographic intervention. In cases achieving successful conception, cesarean delivery was chosen and the uterine scar was evaluated. RESULTS: Uterine artery pseudoaneurysm was diagnosed in 9 out of 854 cases of LAM. One case was undiagnosed until massive uterine hemorrhage occurred in the late postoperative period, while the other eight cases were diagnosed in the early postoperative course without hemorrhagic complication. Eight cases were managed by uterine artery embolization, but spontaneous resolution of pseudoaneurysm was observed in one case during a difficult prolonged attempt to superselect the offending branch of the uterine artery. Postembolization course was uneventful, except in a 41-year-old woman who developed oligomenorrhea. Among five women desiring preserved fertility, three women including one after spontaneous miscarriage achieved live birth by cesarean section. One woman experienced spontaneous miscarriage and one did not become pregnant by fertility treatment. In a case with elective cesarean delivery, severe early postpartum hemorrhage occurred from the placental bed and was conservatively managed by emergency uterine artery embolization. CONCLUSION: The development of uterine artery pseudoaneurysm after myomectomy may be more common than previously considered, and should be carefully monitored to avoid potentially life-threatening hemorrhage and loss of fertility. Although spontaneous resolution may occur, conservative management by angiographic intervention could be a feasible management option for future fertility preservation, once a diagnosis has been made.

Doubling time calculations for lung cancer by three-dimensional computer-aided volumetry: effects of inter-observer differences and nodule characteristics.

INTRODUCTION: The purpose of this study was to investigate doubling time (DT) differences among solid, part-solid (PS) and non-solid (NS) types of lung cancers. We also compared inter-observer differences in size measurements between diameter and three-dimensional (3D) volume measurements of lung cancers, including PS- and NS-type nodules, using 3D computer-aided volumetry (3D-CAV). METHODS: The long-axis diameters and 3D volumes of lung tumours were measured using CAV by two chest radiologists for 71 consecutive patients with peripheral lung cancer who underwent at least two CT examinations before surgical resection. We evaluated the inter-observer variability for the ratio of diameter change (RCdiameter) and volume change (RCvolume), which were based on two CT images obtained at different times prior to resection. Inter-observer agreement was evaluated by Bland-Altman plots. Based on the volumes obtained from 3D-CAV, we calculated the DTs and compared DT differences between solid, PS and NS types of lung tumours. RESULTS: The inter-observer Spearman's rank correlation coefficients were 0.87 for RCvolume and 0.64 for RCdiameter (p < 0.001). For all internal appearance types, the rs values for RCvolume were greater than those for RCdiameter. The median DT values for solid, PS and NS were 278, 347 and 584 days, respectively. NS- and PS-type tumours had significantly longer DTs (p = 0.024; by Spearman's rank correlation coefficient). CONCLUSIONS: DT determinations using 3D-CAV had good correlations with the internal appearances of lung cancers. Lung tumour volume measurements by 3D-CAV exhibited better inter-observer correlations than did diameter measurements.

Pulmonary lobar volumetry using novel volumetric computer-aided diagnosis and computed tomography.

OBJECTIVES: To compare the accuracy of pulmonary lobar volumetry using the conventional number of segments method and novel volumetric computer-aided diagnosis using 3D computed tomography images. METHODS: We acquired 50 consecutive preoperative 3D computed tomography examinations for lung tumours reconstructed at 1-mm slice thicknesses. We calculated the lobar volume and the emphysematous lobar volume < -950 HU of each lobe using (i) the slice-by-slice method (reference standard), (ii) number of segments method, and (iii) semi-automatic and (iv) automatic computer-aided diagnosis. We determined Pearson correlation coefficients between the reference standard and the three other methods for lobar volumes and emphysematous lobar volumes. We also compared the relative errors among the three measurement methods. RESULTS: Both semi-automatic and automatic computer-aided diagnosis results were more strongly correlated with the reference standard than the number of segments method. The correlation coefficients for automatic computer-aided diagnosis were slightly lower than those for semi-automatic computer-aided diagnosis because there was one outlier among 50 cases (2%) in the right upper lobe and two outliers among 50 cases (4%) in the other lobes. The number of segments method relative error was significantly greater than those for semi-automatic and automatic computer-aided diagnosis (P < 0.001). The computational time for automatic computer-aided diagnosis was 1/2 to 2/3 than that of semi-automatic computer-aided diagnosis. CONCLUSIONS: A novel lobar volumetry computer-aided diagnosis system could more precisely measure lobar volumes than the conventional number of segments method. Because semi-automatic computer-aided diagnosis and automatic computer-aided diagnosis were complementary, in clinical use, it would be more practical to first measure volumes by automatic computer-aided diagnosis, and then use semi-automatic measurements if automatic computer-aided diagnosis failed.