Successful laparoscopic resection of retroperitoneal ectopic pregnancy between the abdominal aorta and inferior vena cava: A case report.

Retroperitoneal ectopic pregnancies are extremely rare; only a few cases having been reported. Here, we report laparoscopic removal of an asymptomatic retroperitoneal ectopic pregnancy from a 29-year-old woman who was referred to our hospital for a suspected ectopic pregnancy. Transvaginal ultrasound did not reveal a gestational sac in the uterus or pelvic cavity. However, abdominal contrast-enhanced computer tomography showed a gestational sac between the abdominal aorta and inferior vena cava. On laparoscopy, the gestational sac was confirmed to be in this retroperitoneal location and successfully removed with minimal bleeding. Histopathologic examination revealed chorionic villi surrounded by lymphatic tissue, suggesting lymphatic spread of the retroperitoneal ectopic pregnancy. In summary, contrast-enhanced computer tomography is very useful for locating the site of pregnancy in women suspected of having a retroperitoneal ectopic pregnancy. Timely diagnosis of a retroperitoneal ectopic pregnancy before bleeding occurs can enable their safe laparoscopic removal.

Risk-reducing salpingo-oophorectomy for Japanese women with hereditary breast and ovarian cancer: a single-institution 10-year experience.

BACKGROUND: For women diagnosed with hereditary breast and ovarian cancer, the clinical guidelines recommend risk-reducing salpingo-oophorectomy at age 35-40 years or after completion of childbearing. However, there is limited information regarding the current status of risk-reducing salpingo-oophorectomy in Japan. METHODS: To clarify factors influencing decision-making for risk-reducing salpingo-oophorectomy among Japanese women diagnosed with hereditary breast and ovarian cancer and their clinical outcomes, we analyzed the medical records of 157 Japanese women with germline BRCA pathogenic variants (BRCA1 n = 85, BRCA2 n = 71 and both n = 1) at our institution during 2011-21. Specimens obtained from risk-reducing salpingo-oophorectomy were histologically examined according to the sectioning and extensively examining the fimbriated end protocol. RESULTS: The risk-reducing salpingo-oophorectomy uptake rate was 42.7% (67/157). The median age at risk-reducing salpingo-oophorectomy was 47 years. Older age, married state and parity were significantly associated with risk-reducing salpingo-oophorectomy (P < 0.001, P = 0.002 and P = 0.04, respectively). History of breast cancer or family history of ovarian cancer did not reach statistical significance (P = 0.18 and P = 0.14, respectively). Multivariate analyses revealed that older age (≥45 years) and married state may be independent factors associated with risk-reducing salpingo-oophorectomy. Interestingly, the annual number of risk-reducing salpingo-oophorectomy peaked in 2016-17 and has increased again since 2020. The rate of occult cancers at risk-reducing salpingo-oophorectomy was 4.5% (3/67): ovarian cancer (n = 2) and serous tubal intraepithelial carcinoma (n = 1). CONCLUSION: Age and marital status significantly affected decision-making for risk-reducing salpingo-oophorectomy. This is the first study to suggest possible effects of Angelina Jolie's risk-reducing salpingo-oophorectomy in 2015 and the National Health Insurance introduced for risk-reducing salpingo-oophorectomy in 2020. The presence of occult cancers at risk-reducing salpingo-oophorectomy supports clinical guidelines recommending risk-reducing salpingo-oophorectomy at younger ages.

Acute kidney injury in villous cancer patients treated with vancomycin and tazobactam/piperacillin.

In this report, we present a 37-year-old woman with villous cancer who developed AKI after co-administration of VCM and TAZ/PIPC. Trough concentration of VCM reach a toxic level. Finally, she recovered on day 17.

Preoperative Magnetic Resonance Imaging versus Intraoperative Frozen Section Diagnosis for Predicting the Deep Myometrial Invasion in Endometrial Cancer: Our Experience and Literature Review.

AIM: The present study was designed to directly compare the diagnostic performance of preoperative magnetic resonance imaging (MRI) and intraoperative frozen section (FS) diagnoses in predicting deep myometrial invasion (MI) of endometrial cancer. METHODS: Using MRI findings and FS diagnoses, 194 patients with surgically staged endometrial cancer were evaluated for deep MI between 2006 and 2018. Definitive histological diagnosis of paraffin sections of excised tissues was used as the gold standard approach. RESULTS: Of 194 cases, 53 (27.3%) cases were finally diagnosed as having deep MI (≥50%). There was 82% total agreement between MRI and FS diagnoses in predicting deep MI, with a kappa value of 0.54 (95% confidence interval [CI] = 0.40-0.67, moderate agreement). The sensitivity of FS diagnosis (0.66, 95% CI = 0.52-0.78) for predicting deep MI was lower than that of MRI (0.77, 95% CI = 0.63-0.87; p = 0.21), while the specificity of FS (0.98, 95% CI = 0.93-0.99) was significantly higher than that of MRI (0.88, 95% CI = 0.81-0.93; p = 0.001). Overall, the accuracy of FS (0.89, 95% CI = 0.84-0.93) was higher than that of MRI (0.85, 95% CI = 0.79-0.90), although the difference did not reach statistical significance (p = 0.23). The accuracy (0.95, 95% CI = 0.90-0.97) was very high in cases with concordant MRI and FS results. CONCLUSIONS: MRI and FS showed different diagnostic characteristics for predicting deep MI, with a higher specificity observed for FS and the greatest accuracy obtained in concordant cases. Thus, our findings recommend the addition of FS diagnosis, either alone or in conjunction with MRI, to MI evaluation.

Spontaneous regression of quiescent gestational trophoblastic disease after pregnancy: a case report.

BACKGROUND: A persistent low-level elevation of serum human chorionic gonadotropin (hCG) without clinical or radiological evidence of pregnancy or tumors was recently defined as quiescent gestational trophoblastic disease (Q-GTD). Whether patients with Q-GTD should be treated or allowed to become pregnant remains unclear. We herein report a rare case of Q-GTD in which the hCG level spontaneously returned to normal after a successful pregnancy. CASE PRESENTATION: The patient was a 37-year-old primigravida who presented with a persistent low-level elevation of hCG after uterine evacuation of a hydatidiform mole. There was no evidence of neoplasia in the uterus or distant metastasis. The low-level elevation of hCG persisted for at least 2 years but never exceeded 200 mIU/mL. The patient had a successful pregnancy at the age of 40 years. CONCLUSIONS: Interestingly, her hCG level subsequently normalized without chemotherapy. The present case may imply the safety and therapeutic effect of pregnancy in women with Q-GTD.

Whole-Genome Analysis of Human Papillomavirus Type 16 Prevalent in Japanese Women with or without Cervical Lesions.

Recent large-scale genomics studies of human papillomaviruses (HPVs) have shown a high level of genomic variability of HPV16, the most prevalent genotype in HPV-associated malignancies, and provided new insights into the biological and clinical relevance of its genetic variations in cervical cancer development. Here, we performed deep sequencing analyses of the viral genome to explore genetic variations of HPV16 that are prevalent in Japan. A total of 100 complete genome sequences of HPV16 were determined from cervical specimens collected from Japanese women with cervical intraepithelial neoplasia and invasive cervical cancer, or without cervical malignancies. Phylogenetic analyses revealed the variant distribution in the Japanese HPV16 isolates; overall, lineage A was the most prevalent (94.0%), in which sublineage A4 was dominant (52.0%), followed by sublineage A1 (21.0%). The relative risk of sublineage A4 for cervical cancer development was significantly higher compared to sublineages A1/A2/A3 (odds ratio = 6.72, 95% confidence interval = 1.78-28.9). Interestingly, a novel cluster of variants that branched from A1/A2/A3 was observed for the Japanese HPV16 isolates, indicating that unique HPV16 variants are prevalent among Japanese women.

Ultrasound-based logistic regression model LR2 versus magnetic resonance imaging for discriminating between benign and malignant adnexal masses: a prospective study.

BACKGROUND: The diagnostic performances of the International Ovarian Tumor Analysis (IOTA) ultrasound-based logistic regression model (LR2) and magnetic resonance imaging (MRI) in discriminating between benign and malignant adnexal masses have not been directly compared in a single study. METHODS: Using the IOTA LR2 model and subjective interpretation of MRI findings by experienced radiologists, 265 consecutive patients with adnexal masses were preoperatively evaluated in two hospitals between February 2014 and December 2015. Definitive histological diagnosis of excised tissues was used as a gold standard. RESULTS: From the 265 study subjects, 54 (20.4%) tumors were histologically diagnosed as malignant (including 11 borderline and 3 metastatic tumors). Preoperative diagnoses of malignant tumors showed 91.7% total agreement between IOTA LR2 and MRI, with a kappa value of 0.77 [95% confidence interval (CI), 0.68-0.86]. Sensitivity of IOTA LR2 (0.94, 95% CI, 0.85-0.98) for predicting malignant tumors was similar to that of MRI (0.96, 95% CI, 0.87-0.99; P = 0.99), whereas specificity of IOTA LR2 (0.98, 95% CI, 0.95-0.99) was significantly higher than that of MRI (0.91, 95% CI, 0.87-0.95; P = 0.002). Combined IOTA LR2 and MRI results gave the greatest sensitivity (1.00, 95% CI, 0.93-1.00) and had similar specificity (0.91, 95% CI, 0.86-0.94) to MRI. CONCLUSIONS: The IOTA LR2 model had a similar sensitivity to MRI for discriminating between benign and malignant tumors and a higher specificity compared with MRI. Our findings suggest that the IOTA LR2 model, either alone or in conjunction with MRI, should be included in preoperative evaluation of adnexal masses.

Laparoscopic ultrasound procedure can reduce residual myomas in laparoscopic myomectomy for multiple myomas.

PURPOSE: To clarify whether the use of laparoscopic ultrasound (LUS) during laparoscopic myomectomy could reduce the number of residual myomas after surgery. METHODS: A cohort study was conducted. Subjects were women who underwent laparoscopic myomectomy for multiple uterine myomas for the first time. The subjects were assigned to one of two groups: LUS group or non-LUS group. All subjects underwent pelvic MRI 3 months before and 6 months after surgery, and the number of myomas on MRI was counted by radiodiagnosticians. The extraction rate and residual rate of uterine myomas were compared between the two groups. RESULTS: Fourteen cases with and 30 cases without LUS were analyzed. Median operation times were 171 min (range 75-295) and 141 min (range 50-260) in cases with and without LUS, respectively (p = 0.077). Median extraction rates relative to the total number of myomas were 106 % (range 75-147 %) in subjects with LUS and 100 % (range 71-233 %) in subjects without LUS (p = 0.480). Numbers of residual myomas were 1 (range 0-3) in subjects with LUS and 2 (range 0-9) in subjects without LUS (p = 0.028). Median residual rates of myomas were 6.1 % (range 0-20 %) in subjects with LUS and 20.0 % (range 0-69 %) in subjects without LUS (p = 0.048). Myomas greater than 3 cm in diameter were not observed in either group. CONCLUSIONS: The number and residual rate of myomas were significantly less in subjects with LUS as compared with those without LUS.

RAD-Seq analysis of typical and minor Citrus accessions, including Bhutanese varieties.

We analyzed the reduced-representation genome sequences of Citrus species by double-digest restriction site-associated DNA sequencing (ddRAD-Seq) using 44 accessions, including typical and minor accessions, such as Bhutanese varieties. The results of this analysis using typical accessions were consistent with previous reports that citron, papeda, pummelo, and mandarin are ancestral species, and that most Citrus species are derivatives or hybrids of these four species. Citrus varieties often reproduce asexually and heterozygosity is highly conserved within each variety. Because this approach could readily detect conservation of heterozygosity, it was able to discriminate citrus varieties such as satsuma mandarin from closely related species. Thus, this method provides an inexpensive way to protect citrus varieties from unintended introduction and to prevent the provision of incorrect nursery stocks to customers. One Citrus variety in Bhutan was morphologically similar to Mexican lime and was designated as Himalayan lime. The current analysis confirmed the previous proposition that Mexican lime is a hybrid between papeda and citron, and also suggested that Himalayan lime is a probable hybrid between mandarin and citron. In addition to Himalayan lime, current analysis suggested that several accessions were formed by previously undescribed combinations.

Uterine rupture at 10 weeks of gestation after laparoscopic myomectomy.

The patient had a previous history of laparoscopic myomectomy. At 10 weeks of gestation, she visited our emergency center due to sudden abdominal pain. An ultrasound examination and MRI showed complete rupture of the uterine myometrium in the fundal wall and a floating gestation sac in Douglas' fossa with fluid. Emergency abdominal laparotomy was immediately performed due to the diagnosis of uterine rupture. During surgery, a small defect of the myometrium was found in the posterior fundal wall of the uterus. Two-layer suturing was performed at the perforation hole. The occasional occurrence of uterine rupture after surgery of the uterus even in the first trimester should be considered.

Characterization of limes (Citrus aurantifolia) grown in Bhutan and Indonesia using high-throughput sequencing.

Lime [Citrus aurantifolia (Cristm.) Swingle] is a Citrus species that is a popular ingredient in many cuisines. Some citrus plants are known to originate in the area ranging from northeastern India to southwestern China. In the current study, we characterized and compared limes grown in Bhutan (n = 5 accessions) and Indonesia (n = 3 accessions). The limes were separated into two groups based on their morphology. Restriction site-associated DNA sequencing (RAD-seq) separated the eight accessions into two clusters. One cluster contained four accessions from Bhutan, whereas the other cluster contained one accession from Bhutan and the three accessions from Indonesia. This genetic classification supported the morphological classification of limes. The analysis suggests that the properties associated with asexual reproduction, and somatic homologous recombination, have contributed to the genetic diversification of limes.

Amount of hemorrhage during vaginal delivery correlates with length from placental edge to external os in cases with low-lying placenta whose length between placental edge and internal os was 1-2 cm.

AIM: The aim of the present study was to investigate whether amount of hemorrhage during a vaginal delivery associates with the cervical length, length from the placental edge to the os and the sum of the two in cases with a low-lying placenta. MATERIAL AND METHODS: A retrospective study was performed on cases with low-lying placenta diagnosed at 35-36 weeks of gestation based on a distance of 1-2 cm from the lower placental edge to the internal os, and subject to the trial of labor. The total amount of intrapartum hemorrhage in association with the distance from the placental lowest edge to the internal os (placenta-internal os distance, A); cervical length, B; and sum of the two (placenta-external os distance; A + B) were reviewed from our medical records. RESULTS: Twenty-three cases of low-lying placenta that underwent trial of labor were analyzed. Twenty (87%) of 23 patients with low-lying placenta delivered transvaginally and patients underwent emergency cesarean section due to intrapartum bleeding. The length from the placental edge to the external os (length from placental edge to internal os + cervical length) was correlated significantly with the total amount of hemorrhage during delivery (r = -0.598, P = 0.004), though neither the length from the placental edge to the internal os nor the cervical lengths correlated with it. CONCLUSION: Our results suggest that the length from the placental lowest edge to the external os negatively correlated with the amount of hemorrhage during vaginal delivery, but did not correlate with cervical length and distance from the placental edge to the internal os.

Localization of the embryo in the lower part of the gestational sac at 6-7 weeks' gestation is associated with placenta previa.

OBJECTIVE: To evaluate whether placenta previa is associated with ultrasonographic findings during the first trimester. METHODS: A case-control study with 1:5 (34 and 170 cases with placenta previa and normal placenta) matched pairs was conducted to compare ultrasonographic findings, including the position of the gestational sac (GS), that of the embryo in the GS, and placental cord insertion from 5-11 weeks of gestation. RESULTS: Embryos located in the lower part of the GS at 6-7 weeks of gestation were observed in 83.3 and 17.1% of the cases and the controls, respectively. Placental cord insertion in the lower third of the uterus at 9-11 weeks of gestation was observed in 38.3 and 6.7% of the cases and the controls, respectively. CONCLUSION: Low embryo localization and low placental cord insertion during the first trimester was associated with placenta previa.

Can ultrasonography of the placenta previa predict antenatal bleeding?

PURPOSE: To evaluate the abnormal sonographic (US) findings in patients with placenta previa and bleeding. METHODS: A total of 182 cases of singleton pregnancies with placenta previa were reviewed. The US findings including the type of placenta previa, placental location, presence of placenta lacunae, lack of clear zone, sinus venosus at the margin of the placenta, velamentous cord insertion, sponge-like echo in the cervix and cervical length were evaluated in relation to episodes of bleeding that required in-patient treatment during pregnancy and/or emergency cesarean section. RESULTS: Episodes of antenatal bleeding occurred in 102/182 (56%) patients with placenta previa. An emergency cesarean section was performed in 66 (64.7%) of these 102 patients. In the 80 patients without episodes of antenatal bleeding, an emergency cesarean section was performed in only 1 (1.3%). Detection of US findings just prior to cesarean section was not associated with the need for emergency cesarean section due to uncontrollable bleeding from the placenta previa. Frequencies of each US finding at 20 weeks of gestation were not different between the patients who underwent emergency cesarean sections and the others. Frequency of marginal sinus was slightly higher in cases with bleeding episode (16% versus 0%, p < 0.05), but the other US findings were not associated with the occurrence of bleeding episodes during pregnancy. CONCLUSIONS: No US finding could predict bleeding episodes and the eventual need for an emergency cesarean section. The obstetrician should be aware that sudden bleeding during pregnancy may occur in patients with placenta previa, even in the absence of any other US findings.

Correlation between the cervical length and the amount of bleeding during cesarean section in placenta previa.

AIM: To investigate the association between the amount of bleeding during a cesarean section and the effacement of the uterine cervix in patients with placenta previa. METHODS: This study reviewed 115 singleton pregnancies with placenta previa. In cases of placenta previa, the thickness of the uterine muscle and cervical length were retrospectively measured and compared with the amount of bleeding during the cesarean section. RESULTS: No correlation was found between the amount of bleeding during the cesarean operation and the thickness of the uterine isthmus. There was a significantly negative correlation between the amount of bleeding and cervical length (r = -0.344, P < 0.001). The threshold cervical length associated with massive bleeding (>2500 mL) was 25 mm, based on an ROC curve. The relative risk for massive bleeding in cases with a short cervical length (<25 mm) was 7.2 (95% CI, 2.3-22.3) in comparison to cases with a long cervical length. CONCLUSIONS: This study demonstrated that a short cervical length in cases with placenta previa was associated with massive bleeding during the operation. Short cervical length seems to be one of the warning signs for massive bleeding during the operation for placenta previa.

Evaluation of placental function using near infrared spectroscopy during fetal growth restriction.

OBJECTIVES: To investigate whether a near infrared spectroscopy (NIRS) system is useful for evaluation of the placental function in cases of fetal growth restriction (FGR). METHODS: Subjects included 282 delivered neonates of appropriate for gestational age (AGA) and 44 small for gestational age (SGA) babies. The measurement of the concentration of oxyhemoglobin (HbO(2)) and deoxyhemoglobin (HHb) was conducted using transabdominal NIRS targeting the placenta at around 20 weeks, 30 weeks and after 36 weeks of gestation and calculated tissue oxygen indexes (TOI=HbO(2)/total Hb). We correlated between TOIs and causes of FGR. RESULTS: TOIs measured immediately before delivery in the SGA group with severe pre-eclampsia (79.2+/-3.8 (%+/-standard deviation (SD); P=0.002)) and placental abnormalities (78.2+/-3.6; P=0.043) were higher than in the AGA group (74.0+/-4.5). TOIs in the SGA group with umbilical cord abnormalities were lower (69.7+/-7.7; P=0.024) than in the AGA group. CONCLUSION: NIRS might provide information about blood oxygen level of the intervillous space and thus explain the cause of FGR.

Pediatric differentiated thyroid carcinoma in stage I: risk factor analysis for disease free survival.

BACKGROUND: To examine the outcomes and risk factors in pediatric differentiated thyroid carcinoma (DTC) patients who were defined as TNM stage I because some patients develop disease recurrence but treatment strategy for such stage I pediatric patients is still controversial. METHODS: We reviewed 57 consecutive TNM stage I patients (15 years or less) with DTC (46 papillary and 11 follicular) who underwent initial treatment at Ito Hospital between 1962 and 2004 (7 males and 50 females; mean age: 13.1 years; mean follow-up: 17.4 years). Clinicopathological results were evaluated in all patients. Multivariate analysis was performed to reveal the risk factors for disease-free survival (DFS) in these 57 patients. RESULTS: Extrathyroid extension and clinical lymphadenopathy at diagnosis were found in 7 and 12 patients, respectively. Subtotal/total thyroidectomy was performed in 23 patients, modified neck dissection in 38, and radioactive iodine therapy in 10. Pathological node metastasis was confirmed in 37 patients (64.9%). Fifteen patients (26.3%) exhibited local recurrence and 3 of them also developed metachronous lung metastasis. Ten of these 15 achieved disease-free after further treatments and no patients died of disease. In multivariate analysis, male gender (p = 0.017), advanced tumor (T3, 4a) stage (p = 0.029), and clinical lymphadenopathy (p = 0.006) were risk factors for DFS in stage I pediatric patients. CONCLUSION: Male gender, tumor stage, and lymphadenopathy are risk factors for DFS in stage I pediatric DTC patients. Aggressive treatment (total thyroidectomy, node dissection, and RI therapy) is considered appropriate for patients with risk factors, whereas conservative or stepwise approach may be acceptable for other patients.

Treatment strategy of papillary thyroid carcinoma in children and adolescents: clinical significance of the initial nodal manifestation.

BACKGROUND: Risk factors and treatment strategy in younger patients with papillary thyroid carcinoma are still controversial. METHODS: We reviewed 120 consecutive papillary thyroid carcinoma patients younger than 20 years who underwent initial surgery between 1977 and 2004 (14 male and 106 female subjects; mean age, 16.3 years; mean follow-up, 11.6 years). Outcomes were evaluated initially, and risk factors for disease-free survival (DFS) were analyzed statistically. Cox proportional multivariate analysis revealed that initial nodal manifestation (P < .001, hazard ratio 2.97) was the most statistically significant risk factor for DFS. The outcomes were then compared between four subgroups on the basis of the initial nodal manifestation and node dissection: 17 patients in group A (no lymphadenopathy, no or only prophylactic central dissection), 30 patients in group B (no lymphadenopathy, prophylactic modified neck dissection, MND), 46 patients in group C (nonpalpable lymphadenopathy detected by radiological or operative findings, therapeutic MND), and 27 patients in group D (palpable lymphadenopathy, therapeutic MND). RESULTS: Subtotal/total thyroidectomy and radioactive iodine therapy were performed for 47.1 and 0% in group A, 33.3 and 0% in group B, 43.4 and 10.9% in group C, and 85.1 and 48.1% in group D, respectively. In groups A, B, C, and D, 0%, 3.3%, 28.3%, and 48.1% developed recurrence, respectively (P < .001). DFS Kaplan-Meier curves differed significantly among the four subgroups (P < .0005). CONCLUSIONS: Initial nodal manifestation is useful to predict DFS in younger papillary thyroid carcinoma patients. Our findings will be beneficial to determine the treatment strategy. Conservative therapy is considered acceptable for patients without risk factors.