Influence of laparoscopic surgery for endometriosis and its recurrence on perinatal outcomes.

Purpose: It is unknown whether surgery for endometriosis or recurrence of endometriosis affects obstetric outcomes. Methods: A total of 208 pregnant women with a history of endometriosis were analyzed. Patients who had endometriomas >3 cm and no history of laparoscopic surgery for endometriosis were defined as non-surgery group (n = 60), while those who had a history of surgery for endometriosis (n = 148) were defined as surgery group. We investigated the obstetric outcomes in 208 patients according to with or without postoperative recurrence of endometriosis and the time from surgery to pregnancy. Results: Among 177 cases of on-going pregnancy, in surgery group, there were lower prevalence of placenta previa compared with non-surgery group (8.5% vs. 23.4%; p = 0.020). Subgroup analysis revealed a decreased prevalence of placenta previa in postoperative non-recurrence group (6.0%: p = 0.007) compared with non-surgery (23.4%) and postoperative recurrence group (28.6%). Placenta previa was more prevalent in the patients who got pregnant more than 2 years after surgery (20.0%) than the patients who got pregnant within 2 years (2.4%: p = 0.002). Multivariate analysis revealed that the surgery was associated with a reduction in placenta previa (OR: 0.32, 95% CI [0.11-0.90]; p = 0.032). Conclusions: Pregnancy within two years after laparoscopic surgery for endometriosis may reduce placenta previa.

Case of pituitary stalk transection syndrome ascertained after breech delivery.

Pituitary stalk transection syndrome (PSTS) is a rare complication that can accompany breech delivery. Early diagnosis of this syndrome is difficult, and it may cause a serious delay in the diagnosis. We present a case of PSTS ascertained after breech delivery. A 20-year-old woman presented with primary amenorrhea. The patient was born by breech delivery and had a history of treatment for pituitary dwarfism. Her laboratory findings showed pituitary hypothyroidism, and hormone replacement therapy was initiated. At 28 years old, she became pregnant and had a normal delivery at 38 weeks' gestation. One year after delivery, her thyroid hormone level changed. Laboratory test showed adrenocortical insufficiency, and magnetic resonance imaging of the pituitary gland showed transection of the pituitary stalk and development of an ectopic posterior lobe. These findings were compatible with PSTS. When a patient who has been born by breech delivery presents with symptoms of pituitary deficiency, PSTS should be considered in the differential diagnosis.

Cervical pregnancy: a report of four cases.

Various conservative treatments for cervical pregnancy have been reported. However, unlike tubal ectopic pregnancy, the treatment of cervical pregnancy has not been well established. For patients who desire fertility preservation, treatment with methotrexate chemotherapy carries a high success rate for preservation of the uterus. When methotrexate is injected i.v. or i.m., expulsion of pregnant tissue occasionally takes up to 1 month. In this report, we present four cases of cervical pregnancy which were successfully managed by methotrexate injection into the bilateral uterine arteries. In cases presenting with massive bleeding, embolization of the bilateral uterine arteries was performed. Cervical pregnancy was aborted within 8 days safely, and fertility could be preserved without harmful side-effects.

Kami-shoyo-san, Kampo (Japanese traditional medicine), is effective for climacteric syndrome, especially in hormone-replacement-therapy-resistant patients who strongly complain of psychological symptoms.

AIM: Hormone replacement therapy (HRT) for climacteric symptoms is effective for vasomotor symptoms, such as hot flushes and sweating, but not for various psychological symptoms, such as anxiety, depression, and irritability. In such cases, prescribing Kampo, traditional herbal medicine, is sometimes considered. However, the effectiveness of Kampo has not been clearly shown. We examined the clinical effect of Kami-shoyo-san, a herbal formula commonly prescribed for climacteric symptoms in a Japanese Kampo clinic. METHODS: There were 180 patients who initially consulted our Kampo Outpatient Clinic due to the absence of a response to HRT or unsatisfactory improvement. Out of 180 patients, 45 patients received a Kami-shoyo-san extract for 4 weeks based on patient-centered Kampo diagnosis. We evaluated the severity of climacteric symptoms based on the visual analogue scale (VAS) score before and after 4 weeks of Kami-shoyo-san administration. Furthermore, the severity of each symptom before treatment was compared between the responders and non-responders. RESULTS: Kami-shoyo-san was effective in 33 (73.3%) of the 45 patients. After treatment, on the whole, the VAS score significantly decreased (P < 0.0001). Concerning vasomotor symptoms and psychological symptoms, each VAS score significantly decreased (P<0.0001). When comparing the severity of pretreatment symptoms between responders and non-responders, symptoms, such as 'insomnia', 'depression', and 'vertigo' were significantly more marked in the responders (P<0.05). CONCLUSION: The results of this study suggest that Kami-shoyo-san relieved both vasomotor and psychological symptoms, and especially in patients with marked psychological symptoms, it exhibited potent effects.

Effects of laparoscopic radical surgery for deep endometriosis on endometriosis-related pelvic pain.

Deep endometriosis is associated with severe painful symptoms that sometimes impair the quality of life in women of reproductive age. Medical therapy does not provide for adequate pain relief, and an effective management option to reduce pelvic pain appears to be complete laparoscopic removal of as many endometriotic lesions as possible. In this study, we investigated the usefulness and risks of radical laparoscopic removal of deep endometriosis for patients diagnosed as stage III/IV endometriosis during laparoscopic surgery. Forty-seven consecutive patients undergoing conservative laparoscopic surgery alone (adhesiotomy and cystectomy of ovarian endometriosis but not removal of deep endometriotic lesion; non-DEL removal group) and 151 consecutive patients undergoing radical laparoscopic removal of deep endometriotic lesions combined with conservative surgery (DEL removal group) were compared. As a result, significant improvements in pain were obtained in both groups, however, the degree of improvement was significantly higher and the rate of recurrence was significantly lower in the DEL removal group. The addition of radical removal of deep endometriotic lesions to conservative laparoscopic surgery markedly reduces the severity of dysmenorrhea and the rate of recurrent pelvic pain. Although the surgical procedure is technically demanding, the levels of peri-operative complications and morbidity are acceptable.

Ovarian squamous cell carcinoma which metastasized 8 years after cervical conization for early microinvasive cervical cancer: a case report.

Squamous cell cervical carcinoma that metastasized to the ovary is common in patients with bulky tumors or locally advanced disease; however, ovarian squamous cell carcinoma that metastasized after cervical conization surgery for early microinvasive uterine cervical carcinoma is very rare. We present a case of ovarian squamous cell carcinoma that metastasized 8 years after cervical conization surgery for early microinvasive cervical carcinoma. She had no sign of recurrence in the uterine cervix. We detected human papillomavirus type 16 DNA in both cervical tissue and ovarian tissue, suggesting that ovarian squamous cell carcinoma is derived from microinvasive cervical cancer. Although there are very few cases of early microinvasive squamous cell carcinoma that metastasized to the ovary with delayed recurrence, we should pay attention strictly not only to the cervical condition but also to the ovarian condition on regular post-operative follow-up.

Anti-N-methyl-D-aspartate receptor encephalitis associated with ovarian immature teratoma.

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a treatment-responsive encephalitis associated with anti-NMDAR antibodies. Unlike classic paraneoplastic encephalitis, this disorder usually develops in young women with ovarian teratoma who typically present with marked neuropsychiatric symptoms, followed by prolonged respiratory failure, clouding of consciousness, and bizarre dyskinesia. This disorder is often treatable by resection of ovarian tumor and immunotherapy, but, delayed diagnosis results in a worse condition and sometimes fatal outcome. However, some gynecologists are not familiar with this disorder. When physicians encounter a female patient with encephalitis showing marked neuropsychiatric symptoms, search for an ovarian tumor should be promptly initiated. We present a case of anti-NMDAR encephalitis associated with ovarian immature teratoma. The symptoms were dramatically relieved by tumor resection and immunotherapy.

Stage I ovarian cancer cases during early, mid and late pregnancy periods: three case reports and review of the literature.

Since ovarian cancer during pregnancy is rare, the decisions regarding pregnancy discontinuation or fertility preservation are often difficult. We report three ovarian cancer cases detected at early, mid and late pregnancy periods in which both babies and mothers were saved. In particular, case 2 is the first reported instance of a sertoliform endometrioid carcinoma of the ovary during pregnancy. In addition, we review the clinical characteristics of previously reported patients with stage I ovarian cancer diagnosed during pregnancy. Even with stage Ia ovarian cancer, restaging laparotomy at cesarean section or post-delivery may be important to determine the treatment plan because staging during pregnancy is rarely complete.

Prediction of exact delivery time in patients with preterm labor and intact membranes at admission by amniotic fluid interleukin-8 level and preterm labor index.

AIM: To examine whether delivery time for preterm labor can be predicted by clinical and biochemical markers at admission. METHODS: It has previously been reported that interleukin (IL)-8 and glucose in the amniotic fluid, fetal fibronectin (fFN) in vaginal secretions and the preterm labor index (PLI) are independent risk factors for delivery before 34 weeks' gestation. Using these four markers, we developed an equation model to predict the remaining gestation period after amniocentesis by step-wise multiple regression analysis in 126 preterm delivery cases (retrospective section of the study). We also evaluated whether this equation model could predict delivery time in 65 new preterm labor patients (prospective section of the study). Finally, we investigated the risk factors for delivery within three days after amniocentesis. RESULTS: The period from amniocentesis until delivery was calculated using the following equation by step-wise multiple regression analysis: predicted period until delivery (days) = 77.1 - 15.8 × log (amniotic IL-8 level [ng/mL]) - 9.2 × PLI (points). The calculated period until delivery correlated significantly with the actual period until delivery in the prospective study. When a high score of PLI (≥5 points) and a high level of vaginal fFN (≥90 ng/mL) or a high level of amniotic IL-8 (≥25.5 ng/mL) were present, the positive predictive values were 88.2% and 80.9% in predicting delivery within three days, respectively. CONCLUSIONS: Using markers reflecting inflammation in the uterus (amniotic IL-8 or vaginal fFN) and clinical symptoms (PLI), we may be able to predict the exact delivery time in preterm labor patients with intact membranes.

Endometrioid adenocarcinoma of the vagina with a microglandular pattern arising from endometriosis after hysterectomy.

Primary endometrioid adenocarcinoma rarely occurs in the vagina. Occasionally, endometrioid adenocarcinoma has a microglandular pattern. Herein, a case of primary endometrioid adenocarcinoma of the vagina with a microglandular pattern arising from pre-existing endometriosis long after a hysterectomy, is described. A 57-year-old postmenopausal woman developed a vaginal discharge over one decade after undergoing a hysterectomy. Microscopic examination of the vaginal smear and a biopsy specimen demonstrated an atypical glandular proliferation composed of columnar cells with occasional intracytoplasmic mucin and bland nuclear morphology, showing microcysts and numerous neutrophils within and around cysts. Immunohistochemically, the neoplastic cells were diffusely positive for CK7, MUC1, ER, and PR, and focally positive for vimentin, CEA, CK5/6, p63, p16(INK4a), and p53. A portion of residual endometrioid adenocarcinoma was identified adjacent to foci of endometriosis in the vaginectomy specimen. The patient has done well without evidence of recurrent disease for 1 year after surgery. Pathologists are encouraged to be aware of the occurrence of endometrioid adenocarcinoma associated with endometriosis in the vaginal stump after hysterectomy, and microglandular morphology which might be a source of misinterpretation.

Carcinomatous meningitis associated with ovarian cancer complicated by SIADH.

We experienced a case of carcinomatous meningitis originating from stage IIIc ovarian cancer complicated by syndrome of inappropriate antidiuretic hormone secretion (SIADH). A 51-year-old woman had been treated with multiple chemotherapy regimens after an initial operation for ovarian cancer. During the last chemotherapy regimen, she suffered headache, mood changes and ataxia. After one week, she had a convulsive seizure and lost consciousness. Laboratory studies showed hyponatremia, low serum osmolality, elevated urinary sodium level and urine osmolality. Cranial-enhanced magnetic resonance imaging (MRI) revealed abnormal meningeal enhancement. A lumbar puncture examination revealed that numerous atypical cells were present. Carcinomatous meningitis complicated by SIADH was diagnosed and treatment for hyponatremia and whole brain radiotherapy were performed; however, she died two weeks after the radiation therapy. Clinicians should consider carcinomatous meningitis when there are findings of SIADH.

Chemical pleurodesis with autologous blood and freeze-dried concentrated human thrombin improved spontaneous pneumothorax and thoracic endometriosis: The first case involving a pregnant woman.

OBJECTIVE: Spontaneous pneumothorax combined with thoracic endometriosis is a rare condition during pregnancy. We present a case of chemical pleurodesis with autologous blood and freeze-dried concentrated human thrombin during pregnancy. CASE REPORT: This report presents a case of spontaneous pneumothorax combined with thoracic endometriosis that arose at 22 weeks' gestation in a 35-year-old female. The initial chest drainage was unsuccessful. At 25 weeks' gestation, video-assisted thoracoscopic surgery was performed and revealed endometriosis in the thoracic cavity. Since the leak persisted, chemical pleurodesis was performed with autologous blood and freeze-dried concentrated human thrombin at 28 weeks' gestation. The leak improved markedly and did not recur. CONCLUSION: This is the first case report about chemical pleurodesis with autologous blood and freeze-dried concentrated human thrombin during pregnancy. This procedure might contribute to the management of pneumothorax in pregnant women.

Successful Pregnancies and Deliveries in a Patient With Evolving Hypopituitarism due to Pituitary Stalk Transection Syndrome: Role of Growth Hormone Replacement.

We herein report a 31-year-old Japanese woman with evolving hypopituitarism due to pituitary stalk transection syndrome. She had a history of short stature treated with growth hormone (GH) in childhood and had hypothyroidism and primary amenorrhea at 20 years old. Levothyroxine replacement and recombinant follicle stimulating hormone-human chorionic gonadotropin (FSH-hCG) therapy for ovulation induction were started. GH replacement therapy (GHRT) was resumed when she was 26 years old. She developed mild adrenocortical insufficiency at 31 years old. She succeeded in becoming pregnant and delivered twice. GHRT was partially continued during pregnancy and stopped at the end of the second trimester without any complications.

Selective inhibition of the epidermal growth factor receptor by ZD1839 decreases the growth and invasion of ovarian clear cell adenocarcinoma cells.

The mechanism that regulates the growth of ovarian clearcell adenocarcinoma (CCA) are not well understood. We investigated the role of several growth factors that bind to membrane tyrosine kinase receptors and added them to the ovarian CCA cell lines KK, RMG-1, and HAC-II to evaluate their effect on growth and cellular invasion. Epidermal growth factor and transforming growth factor-alpha significantly stimulated the growth and invasion of CCA cell lines in vitro. ZD1839, an epidermal growth factor receptor-tyrosine kinase inhibitor, decreased the growth and invasion of CCA cell lines in vitro and in vivo inhibited the growth of xenografts of the CCA cell line RMG-1. Severe combined immunodeficient mice bearing RMG-1 xenografts treated with ZD1839 survived for longer than the untreated control group. From these findings, we conclude that ZD1839 may offer a new and effective treatment for ovarian CCA.

Cisplatin enhances the p53-independent apoptosis induced by a topoisomerase I inhibitor (CPT-11) in the lens epithelial tumors in transgenic mice.

We reported that CPT-11 could induce apoptosis in mouse lens epithelial tumors when it was administered to pregnant alphaT3 mice which developed epithelial cell carcinoma in situ in the lens in the perinatal period. p53-deficient alphaT3 mice were generated to analyze the influence of p53 status on tumor cells under combined chemotherapy. On the 16-18th gestational day, alphaT3 received a single i.p. administration of both CPT-11 and Cisplatin, and fetal lens epithelial tumors were examined two days later. Apoptosis in the p53-wild-type alphaT3 tumors was observed in a Cisplatin dose-dependent manner. In addition, it was found that Cisplatin augmented CPT-11-induced p53-independent apoptosis in p53-deficient alphaT3 mice.

A case of myomatous erythrocytosis syndrome associated with a large uterine leiomyoma.

Several etiologies have been proposed for erythrocytosis associated with uterine leiomyoma. We report a case of erythrocytosis associated with a large uterine leiomyoma, in which specific immunostaining for erythropoietin was positive. A 55-year-old woman, gravida 0, para 0, was referred to our hospital for treatment for a large uterine myoma and erythrocytosis. She had no vaginal bleeding after she reached menopause at 50 years old. She had severe polycythemia: hemoglobin (Hb), 19.9 g/dL; red blood cell count (RBC), 6.65 × 10(6)/mm(3); hematocrit, (Hct) 59.1%. An abdominal simple hysterectomy was performed, and a pathological examination confirmed the diagnosis of leiomyoma of the uterus. In addition, immunostaining demonstrated that the cytoplasm of the leiomyoma cells was strongly positive for erythropoietin. After the operation, the patient's hemoglobin and hematocrit levels normalized, and we diagnosed her condition as myomatous erythrocytosis syndrome.

Systemic lymphadenectomy cannot be recommended for low-risk corpus cancer.

Objective. The objective of this study is to ascertain whether omission of lymphadenectomy could be possible when uterine corpus cancer is considered low-risk based on intraoperative pathologic indicators. Patient and Methods. Between 1998 and 2007, a total of 83 patients with low risk corpus cancer (endometrioid type, grade 1 or 2, myometrial invasion <==50%, and no intraoperative evidence of macroscopic extrauterine spread, including pelvic and paraaortic lymph node swelling and adnexal metastasis) underwent the total abdominal hysterectomy and bilateral salpingo-oophorectomy without lymphadenectomy. A retrospective review of the medical records was performed, and the disease-free survival (DFS), overall survival (OS), peri- and postoperative morbidities and complications were evaluated. Results. The 5-year DFS rates and the 5-year OS rates were 97.6% and 98.8%, respectively. No patient presented postoperative leg lymphedema and deep venous thrombosis. Conclusion. Omission of lymphadenectomy did not worsen the DFS or OS. The present findings suggest that systemic lymphadenectomy could be omitted in low-risk endometrial carcinoma.

Circulating and decidual Th17 cell levels in healthy pregnancy.

PROBLEM: The Th1/Th2 paradigm has recently been reconstituted to include a third population, Th17 cells. It has been reported that Th2 type immunity is predominantly present in normal pregnancy. However, the level of Th17 cells during pregnancy is still unclear. We investigated the level of peripheral Th17 cells in healthy pregnancy subjects. METHOD: of study To evaluate the levels of Th17 cells, we investigated the proportion of peripheral blood mononuclear cells that produced IL-17 in the first, second, and third trimester pregnancy subjects using flow cytometry. We further studied the proportion of decidual lymphocytes that produced IL-17 in early pregnant subjects. RESULTS: Most of the IL-17-producing cells were CD4(+) T cells. The number of circulating Th17 cells did not change during pregnancy. In a paired t-test of early normal pregnant subjects, the proportion of IL-17(+) decidual lymphocytes was significantly higher than that of peripheral blood lymphocytes. CONCLUSION: Th17 levels in peripheral blood lymphocytes do not change during normal pregnancy.

Accumulation of IL-17-positive cells in decidua of inevitable abortion cases.

PROBLEM: Th17 cells, a new subset of helper T cells, have been focused on as a producer pro-inflammatory cytokines. It is, however, still unknown how Th17 cells affect pregnancy outcome. We investigated the expression of IL-17-producing cells in human spontaneous abortion. METHOD OF STUDY: IL-17 expression was analyzed in decidual tissues among normal pregnancy, missed abortion, and inevitable abortion cases by immunohistochemistry and flow cytometry. RESULTS: IL-17+ cells were accumulated in decidua and were detected in decidual CD4+ T cells and few decidual CD8+ T cells in spontaneous abortion cases. The number of decidual IL-17+ cells in inevitable abortion cases involving active genital bleeding was significantly higher than that in normal pregnancy cases (P < 0.05). On the other hand, there were no significant differences in the numbers of decidual IL-17+ cells between missed abortion cases and normal pregnancy subjects. Furthermore, the number of IL-17+ cells was positively correlated with the number of neutrophils in spontaneous abortion cases. CONCLUSION: IL-17+ cells might be involved in the induction of inflammation in the late stage of abortion, but not in the early stage of abortion.