Pseudo-Meigs' Syndrome in a Patient With Uterine Fibroids With Massive Pleural Effusion After Starting Gonadotropin-Releasing Hormone Agonist Therapy: A Case Report.

Pseudo-Meigs' syndrome is caused by uterine fibroids, which is often treated using gonadotropin-releasing hormone (GnRH) agonists. Here we report a case of pseudo-Meigs' syndrome that developed with massive pleural effusion after the initiation of GnRH agonist therapy for uterine fibroids. A 48-year-old woman presented with dyspnea. Her medical history included uterine fibroids and GnRH agonist therapy. Contrast-enhanced computed tomography revealed a massive pleural effusion, uterine fibroids, and ascites. A total laparoscopic hysterectomy was performed. The pathologic findings were consistent with those of uterine fibroids. The pleural effusion and ascites resolved completely. The patient was diagnosed with pseudo-Meigs' syndrome due to uterine fibroids.

Consistency between chromosomal status analysis of biopsied human blastocyst trophectoderm cells and whole blastocyst cells.

PURPOSE: This study investigated the consistency between results of preimplantation genetic testing for aneuploidy performed on trophectoderm (TE) cells and remaining blastocyst cells. METHODS: TE biopsy was performed on 29 surplus cryopreserved human blastocysts. Biopsy samples and remaining blastocysts were processed using the VeriSeq PGS kit, and chromosomal statuses were compared by next-generation sequencing. RESULTS: Discordance was observed in the chromosomal status of 11 out of 29 blastocysts between the biopsied TE and remaining blastocysts. Concordance was observed in 11 of 12 blastocysts classified as euploid by TE biopsy and in 7 of 17 blastocysts classified as aneuploid. There was 100% concordance (7/7) in cases diagnosed as aneuploid with no mosaicism by TE biopsy. However, discordance was observed in all 10 cases showing mosaicism or partial chromosomal abnormality. CONCLUSION: Chromosomal status analysis based on TE biopsy does not accurately reflect the chromosomal status of the whole blastocyst. The chromosomal status is usually the same between the TE and remaining blastocyst cells in cases diagnosed as euploid or aneuploid with no mosaicism. However, mosaic blastocysts and those with other types of structural rearrangements have a higher risk of inconsistency, warranting caution during embryo selection.

Effects of localisation of uterine adenomyosis on outcome of in vitro fertilisation/intracytoplasmic sperm injection fresh and frozen-thawed embryo transfer cycles: a multicentre retrospective cohort study.

BACKGROUND: Uterine adenomyosis is a benign disease, common among women in their 40 and 50 s, characterised by ectopic endometrial tissue in the uterine myometrial layer. Adenomyosis causes infertility and has a negative effect on the outcomes of in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) embryo transfer (ET) cycles. It has also been reported to have different characteristics depending on the adenomyotic lesion localisation. The effect of its localisation on IVF/ICSI-ET outcomes is unclear. This study aimed to investigate whether adenomyotic lesion localisation, assessed using magnetic resonance imaging (MRI), was associated with outcomes of IVF/ICSI-ET cycles. METHODS: This multicentre, joint, retrospective cohort study analysed the medical records of 67 infertile patients with adenomyosis who underwent IVF/ICSI with fresh and frozen-thawed ET at five participating facilities from January 2012 to December 2016 and for whom MRI data were available. Fifteen patients were excluded; therefore, the MRI data of 52 patients were evaluated by two radiologists. We assessed the localisation of and classified adenomyotic lesions into advanced (invades the full thickness of the uterine myometrium), extrinsic (localised on the serosal side), and intrinsic (localised on the endometrial side) subtypes. RESULTS: There were 40 advanced, nine extrinsic, and three intrinsic cases, and the outcomes of 100, 27, and nine ET cycles, respectively, were analysed. Pregnancy loss/clinical pregnancy and live birth rates of the advanced, extrinsic, and intrinsic groups were 64 % (16/25) and 9 % (9/100), 33.3 % (3/9) and 22.2 % (6/27), and 50 % (1/2) and 11.1 % (1/9), respectively. A logistic regression analysis adjusted for age, prior miscarriage, and body mass index showed that the extrinsic group had fewer pregnancy losses (odds ratio 0.06; 95 % confidence interval [CI]: 0.00-0.54, p = 0.026) and more live births (odds ratio 6.05; 95 % CI: 1.41-29.65, p = 0.018) than the advanced group. CONCLUSIONS: Adenomyotic lesions exert different effects on IVF/ICSI-ET outcomes. Thus, MRI assessments of adenomyosis in infertile patients are beneficial. Establishment of treatment plans based on adenomyotic lesion localisation should be considered.

A case of ovarian mucinous cystadenoma in a child that recurred 1 year after surgery.

INTRODUCTION AND IMPORTANCE: In children, mature cystic teratomas are the most common ovarian tumors. Mucinous cystadenomas are rarely seen. Further, the recurrence of mucinous cystadenomas is very rare. This report describes a case of ovarian mucous cystadenoma in an adolescent that recurred 1 year after surgery. CASE PRESENTATION: A 13-year-old patient, with a sizable ovarian tumor underwent laparoscopic-assisted cystectomy. On histopathology, the tumor was diagnosed to be an ovarian mucinous cystadenoma. The mucinous cystadenoma recurred 13 months after surgery and subsequently laparoscopic right adnexectomy was performed. CLINICAL DISCUSSION: It has been reported that intraoperative cyst rupture and cystectomy instead of adnexectomy are risk factors for mucinous cystadenoma recurrence. Close follow-up is required for post-cystectomy patients because of the possibility of recurrence. CONCLUSION: The risk of recurrence and the preservation of fertility should be carefully considered when deciding on treatment in young patients with a mucinous cystadenoma.

Cell-free DNA in spent culture medium effectively reflects the chromosomal status of embryos following culturing beyond implantation compared to trophectoderm biopsy.

This prospective study evaluated the accuracy of non-invasive preimplantation genetic testing for aneuploidy (niPGT-A) using cell-free DNA in spent culture medium, as well as that of preimplantation genetic testing for aneuploidy (PGT-A) using trophectoderm (TE) biopsy after culturing beyond implantation. Twenty frozen blastocysts donated by 12 patients who underwent IVF at our institution were investigated. Of these, 10 were frozen on day 5 and 10 on day 6. Spent culture medium and TE cells were collected from each blastocyst after thawing, and the embryos were cultured in vitro for up to 10 days. The outgrowths after culturing beyond implantation were sampled and subjected to chromosome analysis using next-generation sequencing. Chromosomal concordance rate, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), false-positive rate (FPR), and false-negative rate (FNR) of niPGT-A and PGT-A against each outgrowth were analyzed. The concordance rate between the niPGT-A and outgrowth samples was 9/16 (56.3%), and the concordance rate between the PGT-A and outgrowth samples was 7/16 (43.8%). NiPGT-A exhibited 100% sensitivity, 87.5% specificity, 88.9% PPV, 100% NPV, 12.5% FPR, and 0% FNR. PGT-A exhibited 87.5% sensitivity, 77.8% specificity, 87.5% PPV, 75% NPV, 14.3% FPR, and 22.2% FNR. NiPGT-A may be more accurate than PGT-A in terms of ploidy diagnostic accuracy in outgrowths.

Live visualisation of electrolytes during mouse embryonic development using electrolyte indicators.

Studies have shown that some electrolytes, including Na+ and K+, play important roles in embryonic development. However, these studies evaluated these electrolytes by using inhibitors or knockout mice, with no mention on the changes in the intracellular electrolyte concentrations during embryogenesis. In this study, we used the electrolyte indicators CoroNa Green AM and ION Potassium Green-2 AM to directly visualise intracellular concentrations of Na+ and K+, respectively, at each embryonic developmental stage in mouse embryos. We directly observed intracellular electrolyte concentrations at the morula, blastocyst, and hatching stages. Our results revealed dynamic changes in intracellular electrolyte concentrations; we found that the intracellular Na+ concentration decreased, while K+ concentration increased during blastocoel formation. The degree of change in intensity in response to ouabain, an inhibitor of Na+/K+ ATPase, was considered to correspond to the degree of Na+/K+ ATPase activity at each developmental stage. Additionally, after the blastocyst stage, trophectoderm cells in direct contact with the blastocoel showed higher K+ concentrations than in direct contact with inner cell mass, indicating that Na+/K+ ATPase activity differs depending on the location in the trophectoderm. This is the first study to use CoroNa Green AM and ION Potassium Green-2 AM in mouse embryos and visualise electrolytes during embryonic development. The changes in electrolyte concentration observed in this study were consistent with the activity of Na+/K+ ATPase reported previously, and it was possible to image more detailed electrolyte behaviour in embryo cells. This method can be used to improve the understanding of cell physiology and is useful for future embryonic development studies.

Kinetics of meiotic maturation in oocytes from unstimulated ovaries and duration of pronucleus presence and preimplantation development.

OBJECTIVE: To evaluate the meaning of meiotic maturation kinetics and duration of pronucleus presence (DPP) for parthenogenetic activation outcome. DESIGN: Retrospective study. SETTING: University hospital. PATIENT(S): Eight patients with endometrioid adenocarcinoma and 65 patients who underwent in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). INTERVENTION(S): After collection of oocytes from nonstimulated ovaries of patients with endometrioid adenocarcinoma, in vitro maturation (IVM) and parthenogenetic activation performed with time-lapse imaging; after ICSI, embryos similarly incubated with time-lapse imaging. MAIN OUTCOME MEASURE(S): Timing of the release of the first polar body (fPB), DPP, and developmental stage with IVM and parthenogenetic activation; after ICSI, assessment of DPP and preimplantation developmental stage. RESULT(S): With IVM, 55.2% of oocytes matured; 53.1% of fPBs were released within 24 hours, and 46.9% of fPBs were released after 24 hours. Regarding developmental stage, oocytes that released fPB later during IVM tended to develop more than oocytes that released the fPB within 24 hours. For embryos from parthenogenetic activation the DPP was statistically significantly shorter than the DPP of embryos from ICSI. With ICSI, the DPP was statistically significantly shorter in embryos that developed to ≥8 cells than embryos whose final development included ≤7 cells. The development rate in parthenogenetic activation was statistically significantly lower than that in ICSI. CONCLUSION(S): Embryo development is negatively affected by DPP that is too short or too long. When the DPP was short with parthenogenetic activation, embryo development did not proceed, indicating that DPP is an important determinant of parthenogenetic activation outcomes as with the timing of fPB release.

Oocyte collection and in vitro maturation after train transportation of human follicular fluid aspirated from resected non-stimulated ovaries of patients with endometrial adenocarcinoma.

PURPOSE: Immature human oocytes from resected ovaries can be used for research and fertility preservation, though it is unknown whether it is feasible to transport oocytes for these purposes. This study examined in vitro maturation (IVM) outcomes after the transportation of human follicular fluid (HFF) containing oocytes. METHODS: Fourteen patients with endometrial adenocarcinoma were enrolled. Oocytes obtained from the resected ovaries of seven patients were transported with HFF by railway (transportation group). Samples of HFF from the other seven patients were not transported, and IVM was performed promptly (non-transportation group). The results of oocyte retrieval and IVM were compared. RESULTS: The average ages in the transportation and non-transportation groups were 40.1 ± 2.0 and 39.6 ± 1.8 years, respectively, and the average numbers of collected oocytes were 8.1 ± 8.4 and 5.1 ± 5.1, respectively. There was a significant negative correlation between the number of collected oocytes and age. The proportions of oocytes that reached meiosis II (maturation rate) after IVM were 38.6% and 69.2% in the transportation and non-transportation groups, respectively (P = 0.013). CONCLUSION: In this preliminary study, the usefulness of the transportation of HFF was limited. Further studies on maintaining oocyte normality during transportation are necessary for becoming the effective method for research and clinical use.

Clinical characteristics of Lynch-like cases collaterally classified by Lynch syndrome identification strategy using universal screening in endometrial cancer.

OBJECTIVE: Lynch syndrome (LS), an autosomal-dominant inherited disorder, increases the risk for LS-associated cancers (LS-AC). Molecular LS assessment for all cases is referred to as universal screening (U/S) and is recommended for endometrial cancer (EC) and colorectal cancer. Lynch-like cases (LL) lack LS-pathogenic mutations despite being suspected as LS by U/S, but have been poorly investigated in EC. The aim of this study was to capture the features of LL in EC and to devise LL management in EC. METHODS: U/S, consisting of immunohistochemistry and reflex methylation analysis, was applied to 348 Asian ECs, and sporadic cancer (SC) cases were screened out. Genetic testing was offered to "suspected-LS" cases selected by U/S. The features of the LS, LL, and SC groups were recorded and compared. RESULTS: U/S screened 306 ECs as SC. The recurrence rates of suspected-LS and SC cases were 14.3% (6/42) and 26.5% (81/306), respectively. Of the 42 suspected-LS cases, 10 were identified as LS, 17 were classified as LL, and 15 did not undergo genetic testing. In the LS group, the frequency of personal history (50%) and family history (100%) of LS-AC were prominent. Of note, the prevalence of family history of LS-AC and gastric cancer was significantly higher in the LL group than in the SC group (76.5% vs. 38.6% and 47.1% vs. 25.2%, respectively). CONCLUSIONS: Herein, we report the features of LL classified by LS identification via U/S in Asian EC. LL should be candidates for tailored surveillance based on regionality and family history.

A case of placental site trophoblastic tumor complicating nephrotic syndrome in which hysteroscopic biopsy did not yield a definitive diagnosis.

Placental site trophoblastic tumor (PSTT) is the rarest subtype of gestational trophoblastic neoplasm. We present a case of PSTT complicating nephrotic syndrome. A 32-year-old woman experienced irregular menstrual bleeding and lower extremity edema 18 months after delivery. She was diagnosed with nephrotic syndrome and exaggerated placental site based on the hysteroscopic biopsy results. During follow-up, transvaginal color Doppler ultrasound showed an enlarged uterus filled with a hypervascular mass. Positron emission tomography-computed tomography showed diffuse accumulation in the entire uterus. The patient was diagnosed with PSTT only after total hysterectomy. Postoperatively, serum ß-human chorionic gonadotropin decreased to within the normal range and her nephrotic syndrome resolved. She has remained without evidence of recurrence for 15 months. It is difficult to diagnose PSTT definitively. Most patients with PSTT are of reproductive age, therefore, to maintain fecundity, therapy development is expected.

In vitro maturation and cryopreservation of oocytes retrieved from intra-operative aspiration during second enucleation for ovarian tumor: A case report.

•We reported oocyte collection from an ovarian tumor with a single ovary.•Intra-operative retrieval of oocytes may be useful for preserving fertility.•We have done in vitro maturation for immature oocytes with ovarian enucleation.

Isolated Loss of PMS2 Immunohistochemical Expression is Frequently Caused by Heterogenous MLH1 Promoter Hypermethylation in Lynch Syndrome Screening for Endometrial Cancer Patients.

Lynch syndrome (LS) is an autosomal-dominant inherited disorder mainly caused by a germline mutation in the DNA mismatch repair (MMR) genes (MLH1, MSH2, MSH6, and PMS2) and is associated with increased risk for various cancers, particularly colorectal cancer and endometrial cancer (EC). Women with LS account for 2% to 6% of EC patients; it is clinically important to identify LS in such individuals for predicting and/or preventing additional LS-associated cancers. PMS2 germline mutation (PMS2-LS) is the rarest contribution to LS etiology among the 4 LS-associated MMR germline mutations, and its detection is complicated. Therefore, prudent screening for PMS2-LS is important as it leads to an efficient LS identification strategy. Immunohistochemistry is recommended as a screening method for LS in EC. Isolated loss of PMS2 (IL-PMS2) expression is caused not only by PMS2-LS but also by MLH1 germline mutation or MLH1 promoter hypermethylation (MLH-PHM). This study aimed to determine the association between MLH1-PHM and IL-PMS2 to avoid inappropriate genetic analysis. We performed MLH1 methylation analysis and MLH1/PMS2 germline mutation testing on the IL-PMS2 cases. By performing MMR-immunohistochemistry on 360 unselected ECs, we could select 8 (2.2%) cases as IL-PMS2. Heterogenous MLH1 staining and MLH1-PHM were detected in 4 of 8 (50%) IL-PMS2 tumors. Of the 5 IL-PMS2 patients who underwent genetic analysis, 1 had PMS2 germline mutation with normal MLH1 expression (without MLH1-PHM), and no MLH1 germline mutation was detected. We suggest that MLH1 promoter methylation analysis for IL-PMS2 EC should be performed to exclude sporadic cases before further PMS2 genetic testing.

CRP 1846C>T Genetic Polymorphism Is Associated with Lymph Node Metastasis and/or Severe Lymphatic Invasion in Endometrial Cancer.

Endometrial cancer (EC) rates are rising in Japan. Lymph node (LN) metastasis is an important prognostic factor in EC, and its risk is increased with higher tumor grade, deep myometrial invasion, larger tumor size, and lymphovascular space invasion (LVSI). Current methodologies to assess these factors are unreliable. We previously showed the association between C-reactive protein (CRP) 1846C>T (rs1205) polymorphism and LN metastasis in esophageal, non-small cell lung, and breast cancers. The CRP gene is located on chromosome 1q21-q23, and the polymorphism in the noncoding region (1846C>T) of this gene decreases serum CRP levels. We investigated the relationship between CRP 1846C>T genetic polymorphism and LN metastasis or LVSI in 130 EC patients using polymerase chain reaction-restriction fragment length polymorphism. The CRP 1846C/T genotype was C/C in 11 patients, C/T in 58 patients and T/T in 61 patients. The patients were divided into two groups based on their CRP 1846 genotypes: "C/C" and "C/T + T/T". Nine (7%) and 18 (13%) patients, all with the polymorphism, had LN metastasis and moderate or prominent lymphatic invasion, respectively. LN metastasis and/or severe lymphatic invasion were observed in the C/T + T/T group, while patients with the C/C genotype had no LN metastases or severe lymphatic invasion. Univariate and multivariate logistic regression models revealed that the C/T + T/T patients had a significant likelihood of developing LN metastasis and/or severe lymphatic invasion. Our results suggest that CRP genetic polymorphism is a novel risk predictor of LN metastasis and/or lymphatic invasion in EC.

Retrieval and in vitro maturation of human oocytes from ovaries removed during surgery for endometrial carcinoma: a novel strategy for human oocyte research.

PURPOSE: To collect human oocytes from ovaries removed as part of surgical treatment for endometrial carcinoma, and to induce in vitro maturation of such oocytes to obtain material for research on human ovarian aging. DESIGN: Prospective clinical study. SETTING: University Hospital. PATIENTS: Eight patients aged 35-44 years with a preoperative diagnosis of Stage I endometrial cancer agreed to participate in this project. INTERVENTIONS: Surgically removed ovaries were punctured; oocytes were collected from follicular fluid and matured in vitro. Immunofluorescent detection of microtubules and DNA labeling were performed after in vitro maturation. MAIN OUTCOME MEASURES: Number of oocytes collected and their in vitro maturation stage. RESULTS: In total, 87 oocytes were collected, 11 of which had completed metaphase II. Of the oocytes collected, 75 % were from three patients in their 30s, while the remaining 25 % were from five patients in their 40s. Several stages of oocytes were collected and the detection of microtubule arrangement and chromatin in various stages using fluorescence was possible. CONCLUSION: Material for research on human ovarian aging can be obtained from ovaries removed during surgery for endometrial cancer.

Brain-derived neurotrophic factor/tyrosine kinase B signaling regulates human trophoblast growth in an in vivo animal model of ectopic pregnancy.

Although medical treatment of unruptured ectopic pregnancy using methotrexate has been established, development of more potent and safer medical treatment is needed due to limited indications and side effects of methotrexate. Brain-derived neurotrophic factor (BDNF) signals through its receptor tyrosine kinase B (TrkB) to regulate the growth of malignant trophoblastic, choriocarcinoma cell. We investigated possible involvement of this signaling system in nonmalignant human trophoblast growth in both ectopic and intrauterine pregnancy. Here, we demonstrated the expression of BDNF in syncytiotrophoblasts and extravillous trophoblasts (EVTs) together with TrkB in cytotrophoblasts and EVTs in human placental villi during both normal and ectopic pregnancies. Treatment of cultured villous explants with soluble TrkB ectodomain or a Trk receptor inhibitor K252a suppressed cytotrophoblast differentiation by inhibiting EVT outgrowth reflected by decreased levels of an EVT marker, human leukocyte antigen-G. These inhibitors also decreased cytotrophoblast proliferation and cellular viability based on histopathological analyses and monitoring glucose metabolism, together with increased apoptosis in cytotrophoblasts based on in situ terminal deoxynucleotidyl transferase-mediated 2'-deoxyuridine 5'-triphosphate nick end-labeling and caspase-3/7 assays. After xenotransplantation of human placental villi into SCID mice as an in vivo model of ectopic pregnancy, treatment with K252a suppressed transplanted villi growth as reflected by decreased cytotrophoblast differentiation and proliferation, reduced tissue levels of chorionic gonadotropin-ß, and increased apoptosis and caspase-3/7 activities. Thus, paracrine signaling by the BDNF/TrkB system is important for human cytotrophoblast differentiation, proliferation, and survival, and inhibition of BDNF/TrkB signaling in cytotrophoblasts could provide a novel medical treatment for ectopic pregnancy.

Mayer-Rokitansky-Kustner Hauser syndrome complicated by either uterine leiomyoma or ovarian tumor.

A 50-year-old Japanese woman with Mayer-Rokitansky-Kustner-Hauser syndrome and two pelvic tumors underwent laparotomy. Laparotomy revealed that no torsion of the right ovarian tumor had occurred, with uterine leiomyoma originating from the right side of a rudimentary uterus. Histopathological examination demonstrated leiomyoma of the rudimentary uterus with positive staining for estrogen and progesterone receptors, and mucinous cyst adenoma of the right ovary. Uterine leiomyoma is rare in this syndrome and the present report represents the first published case complicated by ovarian tumor.

HCG up-regulates survivin mRNA in human granulosa cells.

The apoptosis of granulosa cells is involved in follicular atresia and degeneration of the corpus luteum. The mechanisms that regulate follicular atresia and luteal degeneration remain obscure. Survivin is a member of the family of inhibitors of apoptosis protein that is expressed during fetal development and in cancer tissues. The present study investigates the expression of survivin, as well as its regulation and function in granulosa cells. We identified survivin at the protein level in granulosa cells and detected not only survivin but also splice-variant transcripts in human and mouse granulosa-luteal cells. One-step real-time PCR analysis revealed that HCG increases the amount of survivin mRNA expressed in cultured human granulosa cells. These results suggest that survivin is involved in supporting luteal function, and that HCG contributes to this role.