Clinical analysis of 44 cases of atypical polypoid adenomyoma of the uterus.

BACKGROUND: Atypical polypoid adenomyoma (APA) is a rare intrauterine polypoid lesion that occurs predominantly in premenopausal women. Although APA was previously considered a benign lesion and treated conservatively, an increasing number of cases show that APA has a high rate of recurrence or residual disease and that it precedes the development of carcinoma. The clinical management of APA remains to be established. The aim of this study was to analyse the clinicopathological features of APA and discuss its diagnosis and prognosis. METHODS: Forty-four patients with APA were admitted to Beijing Obstetrics and Gynecology Hospital from 2005 to 2019, and their clinical and histopathologic features were evaluated. B-ultrasound was performed, and all the patients (n = 44) underwent hysteroscopy. Endometrium excision was performed by means of the four-step diagnosis and treatment method. Hysteroscopic transcervical resection (TCR) was performed in 5 patients with APA-H and 11 with APA-L. Except for one patient who underwent transcervical endometrial resection, all the patients underwent hysterectomy and salpingectomy or salpingo-oophorectomy. Data from a median follow-up of 42 months (ranging from 3 to 174 months) were available for these patients. RESULTS: Pathological diagnosis were made according to the degree of abnormality of the APA surface glands, resulting in APA-L in 36 patients and APA-H in 8 patients. Among these patients, 28 (25 APA-L and 3 APA-H) were treated conservatively. The effect of the four-step diagnosis and treatment method as an APA therapy was excellent. During the follow-up, no evidence of recurrence was found. CONCLUSIONS: For patients with intracavitary lesions > 1 cm, the hysteroscopic four-step diagnosis and treatment method and pathological diagnosis are the basis of clinical treatment. More than 30% of APA surface glands have complex structures characterized by branching and budding or other high-risk factors, such as endometrial hyperplasia, which are indications for hysterectomy. For patients who desire to become pregnant or to preserve the uterus, hysteroscopy with complete excision of the lesions should be the preferred treatment method. The patients should be treated and followed up closely with regular hysteroscopy and endometrial biopsy.

Benign polypoid adenomyomatous endometrium associated with hpt-JT syndrome: a case report.

Hyperparathyroidism-jaw tumor (HPT-JT) is an autosomal dominant disorder responsible for benign and/or malignant tumors. Affected women often present life-threatening menorrhagia that leads to the identification of uterine tumors, and experience miscarriages and infertility. Overall though, fewer data concerning gynecological pathologies related to HPT-JT syndrome are available. We report the case of a 32-year-old woman with HPT-JT syndrome, referred for recurrent vaginal bleeding, with a history of repeated endometrial polyps and infertility. We also review the literature that explores medical options for these women.

Atypical polypoid adenomyoma of the endometrium: diagnosis and treatment. A case report.

Atypical polypoid adenomyoma (APA) is a rare uterine lesion that commonly recurs after local excision and is occasionally associated with or anticipates the development of atypical hyperplasia or endometrioid adenocarcinoma. We report a case of a 45-year-old woman affected by APA treated with local resection.

Diagnosing adenomyosis with MRI: a prospective study revisiting the junctional zone thickness cutoff of 12 mm as a diagnostic marker.

OBJECTIVES: To assess the diagnostic accuracy of a junctional zone (JZ) thickness of ≥ 12 mm and morphological features of the JZ in MRI in diagnosing adenomyosis in a premenopausal study population. METHODS: This single-center, prospective observational study consecutively enrolled 93 premenopausal women suffering from a benign gynecological condition, from September 2014 to August 2016. Institutional review board approval and written consent were obtained. All participants underwent MRI and hysterectomy with a histopathological examination. MR images were evaluated in a blinded fashion by two independent readers. The maximum junctional zone thickness (JZmax), presence of JZmax ≥ 12 mm, and any irregular appearance of the JZ (defined as irregular outer or inner borders, focal thickening, presence of high-intensity signal foci, or fingerlike indentations at the inner border) were documented, and the diagnostic performance was evaluated with the AUC, chi-square test, and multiple regression. RESULTS: Adenomyosis was histopathologically confirmed in 57 (61%) of the women. JZmax was not positively correlated with adenomyosis diagnosis (AUC = 0.57, p = 0.26) and did not differ significantly between those with and without adenomyosis (10.3 vs 10.1 mm, p = 0.88), nor was a cutoff of JZmax ≥ 12 mm (n = 30/57 (53%) vs n = 16/36 (44%), p = 0.29). The presence of an irregular JZ showed the best association with adenomyosis among the evaluated signs (sensitivity 74% (95% CI, 60, 85); specificity 83% (95% CI, 67, 94) (p < 0.001)). CONCLUSIONS: JZmax was not correlated with adenomyosis in the present premenopausal study population, but direct signs of adenomyosis such as irregularities of the JZ provided a good diagnostic accuracy. KEY POINTS: • Measuring the junctional zone thickness is of limited value for diagnosing adenomyosis with MRI and should not be used for diagnosing adenomyosis in premenopausal women with moderate disease severity. • An irregular appearance of the junctional zone, the presence of myometrial cysts, and adenomyoma appear to provide the highest specificity for diagnosing adenomyosis. • A consensus for the definition and reading of the junctional zone is needed.

Use of Augmented Reality in Gynecologic Surgery to Visualize Adenomyomas.

Augmented reality (AR) is a surgical guidance technology that allows key hidden subsurface structures to be visualized by endoscopic imaging. We report here 2 cases of patients with adenomyoma selected for the AR technique. The adenomyomas were localized using AR during laparoscopy. Three-dimensional models of the uterus, uterine cavity, and adenomyoma were constructed before surgery from T2-weighted magnetic resonance imaging, allowing an intraoperative 3-dimensional shape of the uterus to be obtained. These models were automatically aligned and "fused" with the laparoscopic video in real time, giving the uterus a semitransparent appearance and allowing the surgeon in real time to both locate the position of the adenomyoma and uterine cavity and rapidly decide how best to access the adenomyoma. In conclusion, the use of our AR system designed for gynecologic surgery leads to improvements in laparoscopic adenomyomectomy and surgical safety.

Preserving Fertility by Treating the 3 Compartments: Laparoscopic Approach to Deep Infiltrating Endometriosis.

STUDY OBJECTIVE: To describe a laparoscopic technique for the resection of deep endometriosis, treating the 3 compartments. DESIGN: Educational video. SETTING: Tertiary referral center in Strasbourg, France PATIENT: A 37-year-old primiparous woman. INTERVENTION: Adenomyomectomy, partial cystectomy, and bowel resection. Fertility preservation was mandatory because of the patient's desire for future pregnancy. MEASUREMENTS AND MAIN RESULTS: A 37-year-old primiparous woman presented with main symptoms of dysmenorrhea and dyspareunia associated with pollakiuria and macroscopic menstrual hematuria (with emission of endometriotic tissue on analysis). She also complained of dyschezia. Magnetic resonance imaging revealed an endometriotic nodule in the vesicouterine space with an involvement of the anterior wall of the uterus and a suspicion of bladder adenomyosis. There were lateral spicules attracting the ovaries toward the midline and an infiltration of the round ligaments and nodules related to the rectovaginal space's endometriosis. A possible invasion was noted underneath the rectal mucosa. The patient expressed her desire preserve fertility. The local institutional review board has approved the video. Initially, an ultrasonography was performed showing the adenomyoma invading the bladder. The second step was a cystoscopic evaluation by means of a double J probe and a bladder catheter. After surgery the bladder catheter was left in place for 15 days and the double J stents for 6 weeks. The first step was the dissection of the vesicouterine space to dissect the anterior adenomyoma from the bladder. A partial cystectomy was then performed to remove the bladder nodule. The adenomyoma was resected at its uterine portion and the uterus sutured. Surgery was then performed in the posterior compartment. Ureterolysis was performed bilaterally, and the pararectal fossas were then opened. The rectovaginal space was dissected. A rectosigmoid resection was mandatory to remove the bowel nodule. Patient follow-up included regular consultations and a hysterosonography at 6 weeks after surgery. Hysterosonography demonstrated an adequate patency. No adhesions to the uterus were found. We recommended to wait for 6 months to allow pregnancy according to the department's protocols. A clinical improvement was observed. Today, at 8 months she has not attempted pregnancy. CONCLUSIONS: A complete surgery is feasible for severe and deep endometriosis with a multicompartmental disease, using a laparoscopic approach aiming to preserve fertility.

Successful laparotomy tumor resection and levonorgestrel-releasing intrauterine system for atypical polypoid adenomyoma.

Hysteroscopic transcervical resection (TCR) is often performed as fertility sparing treatment for atypical polypoid adenomyoma (APA) patients. However, TCR has the risk of uterine wall perforation, especially when the tumor extends deeply into the uterine muscle layer. We report an APA patient in whom it was impossible to completely resect the tumor by TCR, but laparotomy tumor resection followed by levonorgestrel-releasing intrauterine system (LNG-IUS) was successful. The patient was a 35-year-old nulligravida woman. We performed laparotomy tumor resection and inserted the LNG-IUS into uterine cavity just after surgery. Microscopic residual tumor was suspected based on histopathological findings. However, the patient has not relapsed for 26 months, even though the LNG-IUS was removed after 6 months. Laparotomy tumor resection may be one fertility sparing treatment option for APA patients. Furthermore, it may be effective to use the LNG-IUS after surgery for two purposes that are adhesion prevention and tumor disappearance.

Adenomyoma With Pseudoinvasive Growth Pattern and Serosal Penetration Mimicking Endometrial Carcinoma.

We present a novel case of a 48-yr-old female with a uterine adenomyoma with an unusual pseudoinvasive growth pattern displaying full-thickness penetration beyond the serosal surface in association with a dehisced Caesarian scar. Before hysterectomy, magnetic resonance imaging findings showed an infiltrative lesion suggestive of endometrial carcinoma. An endometrial biopsy was benign but definitive operative management was pursued given the concerning imaging. Gross examination of the uterus demonstrated a 7.2 cm, relatively well-circumscribed polypoid neoplasm with pushing borders extending through the full thickness of the myometrium. A serosal defect with protruding red tissue was noted where the neoplasm penetrated the exterior surface of the uterus. Histologic examination demonstrated benign endometrial glands, associated endometrial stroma, thick-walled vessels, and a prominent smooth muscle component consistent with an adenomyoma. To our knowledge, this unique presentation of a pseudoinvasive adenomyoma extending beyond the serosa is extremely rare and is the first time reported in the literature.

Hysteroscopic Transcervical Resection for Atypical Polypoid Adenomyoma of the Uterus: A Valid, Fertility-Preserving Option.

STUDY OBJECTIVE: To evaluate hysteroscopic transcervical resection (TCR) for atypical polypoid adenomyoma of the uterus (APA). DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Single tertiary hospital. PATIENTS: Women who underwent TCR for APA at Kawasaki Municipal Hospital between 2003 and 2015. INTERVENTIONS: Clinical records were obtained. MEASUREMENTS AND MAIN RESULTS: Thirty-five patients with APA were evaluated. The median patient age was 35 years (range, 23-43 years), and the median tumor diameter was 22 mm (range, 9-51 mm). The median duration of observation after the first TCR was 34.0 months (range, 4.2-133.7 months). In 19 patients, the tumor recurred after the first TCR. A second TCR was performed in 13 patients, 11 of whom experienced recurrence. A third TCR was performed in 7 patients, all 7 of whom experienced recurrence. A fourth TCR was performed in 4 patients, 3 of whom experienced recurrence. The recurrence rate after the second TCR was higher than that after the first TCR (71.4%-84.6% vs 54.3%; p < .01, t test). The median disease-free interval was 12.4 months after the first TCR, 15.3 months after the second TCR, 10.5 months after the third TCR, and 10.9 months after the fourth TCR. Seven patients progressed to endometrial cancer; however, there was no mortality. Six of the 35 patients conceived, and 4 had a normal spontaneous delivery. CONCLUSION: Owing to disease-free intervals that follow treatment, TCR is a promising treatment modality as a fertility-preserving option for patients with APA under careful observation. Twenty percent of patients with APA develop cancer; however, the present study showed no mortality.

Robot-assisted laparoscopic adenomyomectomy of adenomyotic nodule implanted in the uterine endometrium manifesting as endometrial cancer: a case report and literature review.

Thickened uterine endometrium with abnormal uterine bleeding highly suggests endometrial hyperplasia or endometrial carcinoma. A case of 35-year-old nulliparous woman came to our department with endometrial mass manifesting as endometrial cancer. Transrectal ultrasonography and magnetic resonance imaging (MRI) showed an 8x6 cm multicystic, ill-defined mass compacted at the uterine endometrium, the anterior wall of the uterus, and 3x3 cm heterogenous mass at the left adnexa. The edometrial mass showed multiple septations with enhancement and low-signal intensity on T2-weighted images. After endometrial biopsy was done and simple hyperplasia without atypia was observed at the histopathologic finding, the patient underwent robot-assisted laparoscopy and diagnosed as adenomyoma at the frozen pathology. After adenomyomectomy, permanent pathologic analysis revealed the same result and she recovered without any complications and responded well to gonadotropin-releasing hormone (GnRH) agonist therapy.

[Atypical polypoid adenomyoma of the uterus: a clinicopathological review of 27 cases].

Objective: To investigate the clinical and pathological characteristics of atypical polypoid adenomyoma (APA) for improvement of the diagnosis, different diagnosis and treatment of the disease. Methods: The clinical data, pathological characteristics, and the follow-up information were retrospectively analyzed in 27 cases of APA admitted in Peking Univeristy People's Hospital from 2007 to 2016. Results: The median age was 42.6 years old (range 25-60 years old). Fifteen patients were nullipara, 2 patients were postmenopausal. The most common presenting symptom was abnormal uterine bleeding (81%, 22/27) . Leisions were obtained by using hysteroscopy in 23 cases, hysterectomy 3 cases and dilatation and curettage 1 case. Fertility preserving treatments were performed in 10 patients who had strong desire for fertility, among which 1 case progressed into endometrial carcinoma. Among 15 patients underwent hysterectomy and (or) bilateral salpingo-oophorectomy, 9 cases of them had endometrial atypical hyperplasia. Endometrial carcinoma along with APA were found in three patients, 2 cases of them underwent hysterectomy and bilateral salpingo-oophorectomy and pelvic lymphadenectomy, the other one received medication for fertility preservation. Follow up information were available in 24 cases (89%, 24/27) with a median follow up of 46 months (range 4-108 months), 1 case recurred and 1 case progressed into endometrial carcinoma. One case died of other malignancy, while the other patients were alive. Conclusions: APA is a rare uterine neoplasm mixed with epithelial and mesenchymal component. It occurs mostly in childbearing-age women and its diagnosis is dependent on pathology. Although it's clinical course is benign, there is risk of co-existance of endometrial carcinoma and endometrial atypical hyperplasia. For those who has desire of fertility, the treatment strategy is completely removed the lesion and closely followed up. For those who do not desire to preserve fertility, hysterectomy may be an option.

Diffuse Adenomyomatosis of the Gallbladder in a Child.

Adenomyomatosis of the gallbladder (ADMG) is characterized by proliferation of the mucosal epithelium and hypertrophy of the muscularis. ADMG is predominantly diagnosed by using ultrasonography. Although ADMG is benign in nature, lithiasis, and chronic inflammation secondary to it may lead to dysplastic changes and cancer. Mucosal invagination through the hypertrophied muscularis results in large intramural diverticula or sinus tracts which are visible at radiology, known as Rokitansky-Aschoff sinuses. Histologically, ADMG manifests with hyperplasia of the muscular layer and proliferation of mucosal glandular tissues. We describe a case of ADMG in an 8-year-old girl presenting with recurrent abdominal pain. Diagnosis was made using ultrasound, and the condition was successfully treated with open cholecystectomy. Ultrasound scanning in children presenting with recurrent abdominal pain may lead to more accurate diagnosis of ADMG during childhood.

Laparoscopic radical cholecystectomy for suspected early gall bladder carcinoma: thinking beyond convention.

BACKGROUND: Gall bladder cancer (GBC) is the most common and aggressive malignancy of the biliary tract with extremely poor prognosis. Radical resection remains the only potential curative treatment for operable lesions. Although laparoscopic approach is now considered as standard of care for many gastrointestinal malignancies, surgical community is still reluctant to use this approach for GBC probably because of fear of tumor dissemination, inadequate lymphadenectomy and overall nihilistic approach. Aim of this study was to share our initial experience of laparoscopic radical cholecystectomy (LRC) for suspected early GBC. METHODS: From 2008 to 2013, 91 patients were evaluated for suspected GBC, of which, 14 patients had early disease and underwent LRC. RESULTS: Mean age of the cohort was 61.14 ± 4.20 years with male/female ratio of 1:1.33. Mean operating time was 212.9 ± 26.73 min with mean blood loss of 196.4 ± 63.44 ml. Mean hospital stay was 5.14 ± 0.86 days without any 30-day mortality. Bile leak occurred in two patients. Out of 14 patients, 12 had adenocarcinoma, one had xanthogranulomatous cholecystitis and another had adenomyomatosis of gall bladder as final pathology. Resected margins were free in all (>1 cm). Median number of lymph nodes resected was 8 (4-14). Pathological stage of disease was pT2N0 in eight, pT2N1 in three and pT3N0 in one patient. Median follow-up was 51 (14-70) months with 5-year survival 68.75 %. CONCLUSIONS: Laparoscopic radical cholecystectomy with lymphadenectomy can be a viable alternative for management of early GBC in terms of technical feasibility and oncological clearance along with offering the conventional advantages of minimal access approach.

Endocervical Atypical Polypoid Adenomyoma.

Atypical polypoid adenomyomas (APAMs) are rare uterine tumors that occur predominantly in premenopausal women, with less than 250 cases reported so far, worldwide. They may recur after treatment, and they may coexist with, or precede development of an endometrial adenocarcinoma. For this reason cases managed with conservative surgery or medical therapies require long-term follow-up. We report the case of a 41 years old nulliparous patient who during a diagnostic hysteroscopy was found with an endocervical atypical polypoid adenomyoma (APAM). The patient was desirous of a pregnancy, reported menometrorrhagia, and had a coexistent 5 cm, grade 2, submucous myoma, 3 endometrial polyps, and diffuse adenomyosis. She was treated with hysteroscopic resection of the APAM and polyps, plus laparoscopic myomectomy and wedge resection of adenomyosis. She is on an IVF list and after 4 months she is symptoms-free.

Parasitic Myomas and an Adenomyoma Obstructing the Ureter After Power Morcellation of Myomas and Endometriotic Nodule Resection.

BACKGROUND: The use of power morcellation (PM) in abdominal and pelvic surgery has been discouraged and even banned in some institutions because of the risk of spreading malignant cells, although some authorities maintain that PM can be an appropriate tool for selected patients deemed to be at low risk of malignancy. CASE: A 42-year-old woman developed parasitic myomas and an adenomyoma obstructing the right ureter after laparoscopic excision of multiple myomas and deep infiltrating endometriosis using PM. Laparoscopic excision of the parasitic myomas and removal of the adenomyoma relieved the obstruction of the ureter. CONCLUSION: Although there is reasonable concern about the use of PM spreading malignant disease, benign disease can also be spread by PM and can cause significant complications. Use of PM should be restricted as much as possible.