Abnormal Genital Bleeding Research Articles

Imiquimod for Cervical and Vaginal Intraepithelial Neoplasia: A Systematic Review and Meta-analysis.

To evaluate the treatment efficacy and the risk of adverse events of imiquimod for cervical intraepithelial neoplasia (CIN) and vaginal intraepithelial neoplasia (VAIN), compared with placebo or no intervention. We searched Cochrane, PubMed, ISRCTN registry, ClinicalTrials.gov , and the World Health Organization International Clinical Trials Registry Platform up to November 23, 2022. We included randomized controlled trials and prospective nonrandomized studies with control arms that investigated the efficacy of imiquimod for histologically confirmed CIN or VAIN. The primary outcomes were histologic regression of the disease (primary efficacy outcome) and treatment discontinuation due to side effects (primary safety outcome). We estimated pooled odds ratios (ORs) of imiquimod, compared with placebo or no intervention. We also conducted a meta-analysis of the proportions of patients with adverse events in the imiquimod arms. Four studies contributed to the pooled OR for the primary efficacy outcome. An additional four studies were available for meta-analyses of proportions in the imiquimod arm. Imiquimod was associated with increased probability of regression (pooled OR 4.05, 95% CI 2.08-7.89). Pooled OR for CIN in the three studies was 4.27 (95% CI 2.11-8.66); results of one study were available for VAIN (OR, 2.67, 95% CI 0.36-19.71). Pooled probability for primary safety outcome in the imiquimod arm was 0.07 (95% CI 0.03-0.14). The pooled probabilities (95% CI) of secondary outcomes were 0.51 (0.20-0.81) for fever, 0.53 (0.31-0.73) for arthralgia or myalgia, 0.31 (0.18-0.47) for abdominal pain, 0.28 (0.09-0.61) for abnormal vaginal discharge or genital bleeding, 0.48 (0.16-0.82) for vulvovaginal pain, and 0.02 (0.01-0.06) for vaginal ulceration. Imiquimod was found to be effective for CIN, whereas data on VAIN were limited. Although local and systemic complications are common, treatment discontinuation is infrequent. Thus, imiquimod is potentially an alternative therapy to surgery for CIN. PROSPERO, CRD42022377982.

OP-22 - Efficacy and immune-related adverse events of ipilimumab and nivolumab combination therapy for a vaginal malignant melanoma

Vaginal malignant melanoma is a rare and aggressive tumor, and the standard treatment has not been established. Recently, immune checkpoint inhibitors via PD-1 and CTLA-4 have caused breakthroughs of standard therapy for cutaneous malignant melanoma. However, there are still limited reports of immune checkpoint inhibitors for vaginal malignant melanoma. 50-years-old woman, G1P1. She visited our hospital to evaluate abnormal genital bleeding for several months and vaginal tumors. Her pelvic examination and pelvic MRI showed a 4 cm blackish, polypoid tumor in the vagina. Histological examination of biopsy diagnosed malignant melanoma. Contrast-enhanced CT showed pelvic lymph node metastasis. Finally, she was diagnosed with vaginal malignant melanoma, cT1N1M0. The BRAF gene was wild type. She started ipilimumab (3 mg/kg, tri-weekly) plus nivolumab (1 mg/kg, tri-weekly) combination therapy. At the end of the 3rd course, autoimmune hepatitis (grade 4) and thyroiditis were observed. They were considered immune-related adverse events. Intravenous methylprednisolone pulse and Mycophenolate Mofetil slowly improved liver function. The 4 cm-sized vaginal tumor shrank to under 1 cm, and the enlarged lymph nodes disappeared. Currently, we are considering surgical intervention and/or maintenance chemotherapy with nivolumab alone. We experienced a combination therapy of ipilimumab + nivolumab for vaginal malignant melanoma. While the combination therapy was highly effective, severe immune-related adverse events were observed. There are also reports that cases with immune-related adverse events have a high response rate. It was considered necessary to accumulate experience of immune checkpoint inhibitors for vaginal malignant melanoma in the future.

Small-cell neuroendocrine carcinoma of the cervix accompanied by adenocarcinoma and high-grade squamous intraepithelial lesion.

Few cytological reports have described small-cell neuroendocrine carcinoma (SCNEC) in the female genital tract. In the present study, we describe a cytological case of SCNEC accompanied by adenocarcinoma, as well as high-grade squamous intraepithelial lesion (HSIL). A Japanese woman (42 years old) presented with abnormal genital bleeding. A conventional Papanicolaou smear revealed an inflammatory condition with three neoplastic components: SCNEC as irregular aggregates of neoplastic small round cells with nuclear molding and granular chromatin; adenocarcinoma as columnar cell clusters with peripherally located large nuclei, and HSIL as sheets or clusters of dysplastic basal-type squamous cells with irregular hyperchromatic nuclei. Accordingly, a cytodiagnosis of SCNEC with adenocarcinoma and HSIL was made. Owing to the rarity of cervical SCNEC, cytological diagnosis may be difficult. Due to its aggressive clinical behavior, the presence of an SCNEC component should be verified in any cytodiagnosis of adenocarcinoma or HSIL.

Uterine stump leiomyosarcoma after sub-total hysterectomy: a case report

Introduction: Uterine sarcomas considered as one of the aggressive tumors of uterine malignancies. It is one of the mesenchymal tumors that originate from smooth muscle of the uterus which is a rare tumor that accounts for 2% to 5% of all uterine malignancies. Very few cases are reported in the literature. Our patient has a unique history of Pelvic-Abdominal swelling reaching xiphisternum level after subtotal hysterectomy one year ago. Abnormal genital bleeding not responding to medical treatment is the usual presentation in uterine sarcoma like in our patient. We report an original case report of an abnormal sequence of this rare tumor arising from the uterine stump after subtotal hysterectomy. Case presentation: A 42-year-old nulliparous woman presented to our gyne-oncology unit in El-Galaa Maternity Teaching Hospital in June 2020 with a significant rapid increase in abdominal circumference, symptoms caused by abdominal pressure (vomiting and constipation) and abnormal genital bleeding after laparotomic sub-total hysterectomy one year ago. Tumor marker CA-125 was raised, LDH was raised and a MRI scan showed a huge mass arising from the pelvis. An exploratory laparotomy was performed and the histopathology report confirmed the diagnosis of uterine leiomyosarcoma weighing around 22kg. Conclusion: Because of their rarity, uterine sarcomas are not suitable for screening. Diagnosis by histopathologic examination and surgery is the only treatment. Pre-operative MRI with contrast for abdomen and pelvis is highly recommended to exclude abdomen metastatic sarcoma if the tumor is confined to the pelvis only.

Profil epidemiologique et etiologique des hemorragies genitales chez la femme en activite genitale en dehors de la grossesse : étude prospective

Genital haemorrhages are a real public health problem. They represent a frequent reason for consultation in gynaecology and obstetrics. Of various origins, they are dominated by pregnancy and hormonal disorders in women of childbearing age. Pelvic ultrasonography is the first-line examination in the exploration of these haemorrhages and guides subsequent investigations either in hysterosonography, hysteroscopy or MRI. The treatment depends on the aetiology. We report 104 patients in the active genital period, presenting abnormal genital bleeding outside of any gravidic state, collected at the Gynecology-Obstetrics II department of Hassan II University of Hospital, Fez, on a prospective study carried out in 2015 whose aim was to we studied the epidemiological and etiological, clinical and paraclinical profile of these cases and compared them to the data of the literature in order to identify a practical behaviour adapted to our Moroccan context.

Racial differences in percentage of Hysterectomy for Common Uterine Conditions among the Hospitalized Women in the US

Background: Hysterectomy is the second most frequently performed operation in the United States, after cesarean section. Approximately 588,000 hysterectomies are performed annually.
 Objectives: To find out the racial differences in percentage of Hysterectomy for Common Uterine Conditions among the Hospitalized Women in the US.
 Methods: The 2001 National Inpatient Sample data was used to estimate the racial differences in the rate of the five most common uterine conditions among the hospitalized women; the same data was also used to estimate the racial differences in the percentage of those who received a hysterectomy. All hospitalized women who had a diagnosis of uterine fibroids, endometriosis, abnormal genital bleeding, genital prolapse and genital malignancy were included. The difference between rate and the percentage was calculated using Z test.
 Results: Of the five, the most common diagnosis, for all hospitalized women regardless of race, was uterine fibroids. But the rate of uterine fibroid diagnosis for hospitalized blacks was nearly two and onehalf times the rate for hospitalized whites (p <0.05). For all single uterine diagnoses except genital prolapse, higher percentage of hospitalized whites had hysterectomy than hospitalized blacks (p <0.05).
 Conclusion: Racial differences exist in the hospitalization and management of different uterine conditions. Whites are more likely to receive hysterectomy for most of the common uterine diagnoses compared to that of blacks. Because blacks have higher rates of uterine fibroid diagnosis and of abnormal genital bleeding, however, the overall hysterectomy rate for hospitalized blacks is similar to that for hospitalized whites.
 Journal of Surgical Sciences (2020) Vol. 24 (1) : 5-10

Synchronous solid pseudopapillary neoplasm and invasive ductal carcinoma of the pancreas: a case report

BackgroundSolid pseudopapillary neoplasm (SPN) of the pancreas is an extremely rare neoplasm with a favorable prognosis. On the other hand, pancreatic invasive ductal carcinoma (IDC) is known to be an aggressive malignancy. To the best of our knowledge, there is no report of SPN combined with IDC of the pancreas.Case presentationA 66-year-old woman presented with abnormal genital bleeding and was diagnosed with inoperable cervical cancer. During computed tomography for cancer staging, the patient was incidentally diagnosed with pancreatic cancer. After radiation therapy for the cervical cancer, distal pancreatectomy with D2 lymph node dissection was performed. A postoperative pathological examination revealed SPN with ossification and well-differentiated IDC in the pancreatic body. On immunohistochemical staining, SPN tumor cells showed positive β-catenin and CD10 staining, whereas IDC cells were negative for both. The tumor boundaries were clear. Accordingly, the final pathological diagnosis was synchronous SPN and IDC of the pancreas. Moreover, pathological findings such as the ossification and small number of SPN cells suggested that SPN may have existed long before IDC initiation.ConclusionsHere, we report the first case of SPN combined with IDC of the pancreas. They may occur independently, and the long-term presence of SPN may lead to the development of IDC.

A Practical Guide to Gynecologic and Reproductive Health in Women Undergoing Hematopoietic Stem Cell Transplant.

Optimum care of female transplant recipients requires gynecologic care at several stages through the allogeneic hematopoietic stem cell transplantation (HCT) process. Sex-based considerations in women post-HCT span gynecologic sequelae of transplant along with assessment and maintenance of optimal sexual and gynecologic health. Pre-HCT, managing menstruation and abnormal uterine or genital bleeding, considering fertility preservation, and assessing for sexually transmitted infections, including human papillomavirus (HPV)-related disease and cervical cancer, enhance women's health. While inpatient during transplant when women are thrombocytopenic, menstrual bleeding requires suppression. Whenever graft-versus-host disease (GVHD) is assessed, screening for genital GVHD merits consideration. After the first 100 days, periodic assessments include obtaining a menstrual history, assessing ovarian function, and reviewing current hormonal use and contraindications to hormonal methods. Regular assessment for primary ovarian insufficiency, dyspareunia, and intimacy guides provision of contraception and hormone replacement options. As part of ongoing screening for genital GVHD and HPV-related disease, including sexually transmitted infections, periodic pelvic examinations are performed. Once successful long-term survival is achieved, planning for fertility may be considered. This article offers a comprehensive approach to these aspects of gynecologic care of patients throughout the trajectory of HCT and beyond into survivorship. We review the effects of HCT treatment on sexual health, ovarian function, and resulting menstrual changes and fertility challenges. Identification, treatment, and prevention of subsequent malignancies, including breast cancer, are discussed, with a focus on regular assessment of genital HPV disease and GVHD in long-term follow-up.

National point prevalence survey of human papillomavirus infections in Tunisia, 2012–2014: Genotypes and risk factors

Background Persistent infection with high-risk Human Papillomavirus (HPV) genotypes may, without treatment, progress to invasive cervical cancer, the second gynecological cancer in Tunisia. This study aims to determine the prevalence of HPV infections, to identify risk factors and main circulating genotypes. Methods National point prevalence survey, between December 2012 and December 2014. Were eligible for inclusion, women aged 18 to 65 years, sexually active, who sought medical attention at their primary health care centre or clinic, the day of the survey, and who gave written consent. Women having an abnormal genital bleeding or a visible lesion in the cervix were not included. A standardized questionnaire on sociodemographic and behavioral factors was orally administered. A liquid-based Pap smear sample was obtained from included women using a cervical brush. If betaglobin positive, samples were analyzed for HPV detection and typing. Multiple logistic regression modeling was done using SPSS 20. Results Out of 1518 women included in the survey with mean age 40.4 ± 0.9 years, 1229 were betaglobin positive. The national prevalence of HPV infection was 7.8% (95% CI [3.4–14.4%]). In multivariate analysis, factors associated to HPV infection were having multiple sexual partners (ORa = 5.2; 95% CI [2.2–11.6]), smoking (ORa = 4.7; 95% CI [2.2–9.8]) and medical history of sexually transmitted infection (ORa = 1.9; 95% CI [1.2–3.1]). Twenty different genotypes of HPV were identified, the most common were HPV6 (25.4%; 95% CI [16.9–36.9%]) and HPV16 (14.1%; 95% CI [16.9–36.9%]). Conclusions T This first national prevalence survey of HPV infection in Tunisia provides important insight into associated factors and main circulating genotypes to improve cervical screening. Next step is a cost-effectiveness analysis of a national HPV immunization programme.

Vaginal Mucosal Implantation After Total Laparoscopic Hysterectomy for an Early Stage Endometrial Cancer

We present an extremely rare case of vaginal implantation of endometrial cancer, which is presumed to have been caused by transvaginal uterine removal during laparoscopic hysterectomy. A 48-year-old woman, nulligravida, had had a bilateral salpingo-oophorectomy due to benign mature cystic teratoma at 46 years old. She presented abnormal genital bleeding and had a total laparoscopic hysterectomy, due to stage Ia endometrial cancer. Postoperative pathology revealed an endometrioid adenocarcinoma G1, showing myometrial invasion, not exceeding the half of the muscular layer. The vascular space invasion and lymphatic space invasion were markedly recognized. Three cycles of combination chemotherapy with paclitaxel and carboplatin, with an interval of 3 weeks, have been postoperatively executed. Four months after the completion of adjuvant chemotherapy, a gross tumor of 6 mm in diameter was found at left vaginal mucosa near hymen. Vaginal biopsy of the lesion revealed a serous adenocarcinoma, and review of the primary endometrial tumor concluded that the primary endometrial carcinoma is corrected to a diagnosis of serous adenocarcinoma. It is considered that the vaginal lesion have been implanted through transvaginal uterine removal during the laparoscopic surgery. The vaginal lesion was surgically resected, however, during the follow-up examination, the other undifferentiated sarcoma was detected at right lung and the treatment was focused on to the sarcoma. And the patient died of the sarcoma, without the further recurrence of endometrial cancer. J Clin Gynecol Obstet. 2018;7(2):57-61 doi: https://doi.org/10.14740/jcgo495w

EP28.02: Two cases of growing inwardly uterine cervical carcinoma that were diagnosed by transvaginal ultrasound guided needle biopsy

In diagnosis of uterine cervical carcinoma growing inwardly with biopsied specimens, accurate pathological diagnosis may not be provided because only an outer layer region of tumour is obtained. We report two cases of uterine cervical carcinoma that was diagnosed by transvaginal ultrasound guided needle biopsy. Two cases were cervical carcinoma which had difficulty in diagnosis by punch biopsied specimens though invasive carcinomas were suspected clinically with MRI findings. Case 1.A 49-year-old 3 gravidas 2 parous woman was referred to our hospital because of abnormal genital bleeding. MRI showed 67mm uterine cervical tumour, and cytology of uterine cervix was SCC. Subsequently, punch biopsy for cervical tumour was performed, but pathological diagnosis with obtained specimens was cervical intraepithelial neoplasia 3(CIN3). Therefore we performed transvaginal ultrasound guided needle biopsy, the result was that the diagnosis of invasive squamous cell carcinoma was obtained in grounds for the existence of atypical squamous cells infiltrating to myometrial layer. Case 2.A 38-year-old 4 gravidas 4 parous woman with past history of tubal ligation was referred to our hospital because of abnormal genital bleeding. MRI showed 38mm uterine cervical tumour, and cytology of uterine cervix was SCC. Subsequently, punch biopsy and diagnostic conisation for cervical tumour were performed, but pathological diagnosis by both examination was cervical intraepithelial neoplasia 3(CIN3). Therefore we performed transvaginal ultrasound guided needle biopsy, the result was that the diagnosis of invasive squamous cell carcinoma was obtained. It was thought that diagnosis by needle biopsied specimens was useful for growing inwardly uterine cervical carcinoma. In addition, it was thought that specimens could be obtained safely even if they were from deep region by performing needle biopsy under transvaginal ultrasound guide.

Sarcoma de Ewing extraóseo de origen ginecológico: tumor neuroectodérmico primitivo de localización infrecuente. Reporte de caso y revisión de la literatura

Objetivo: presentar el caso de una paciente con diagnóstico de sarcoma de Ewing extraóseo cer­vicovaginal y realizar una revisión de la literatura, con especial atención al diagnóstico histopatológico y las posibilidades terapéuticas de estas neoplasias. Materiales y métodos: caso de una paciente de 53 años de edad, en seguimiento por antecedente de cáncer de mama ductal infiltrante, que presenta un sangrado genital anómalo. Tras la exploración física y los estudios con pruebas de imagen se obser­va una tumoración cervicovaginal que se extiende hacia la pelvis, de la cual se toma una biopsia. El resultado de la misma es compatible con sarcoma de Ewing / tumor neuroectodérmico primitivo cer­vical. Se realizó una búsqueda en las bases de datos Medline vía PubMed, con los términos: “sarcoma; ewing”, “neuroectodermal tumors”, “primitive”, “peripheral” y “uterine cervical neoplasms”, ras­treando artículos de revisión bibliográfica, reportes y series de casos clínicos en inglés y español publi­cados desde 2009. Resultados: se hallaron doce artículos correspon­dientes a revisiones de literatura, reportes y series de casos clínicos, donde se describen los aspectos más importantes referentes al tratamiento, las ma­nifestaciones clínicas y el diagnóstico molecular, inmunohistoquímico e histopatológico de esta patología.Conclusiones: el tumor de Ewing extraóseo gine­cológico es una lesión extremadamente rara, cuyo diagnóstico se basa en el estudio de la morfología histopatológica, el examen inmunohistoquímico y las pruebas genéticas. La combinación de cirugía, quimioterapia y radioterapia se considera actual­mente el tratamiento de elección.

A retrospective clinical analysis of 5 cases of vaginal melanoma

Vaginal melanoma is a rare tumor, accounting for <1% of all melanomas and ~1-5% of all vaginal malignant tumors. The prognosis of vaginal melanoma is extremely poor, as it is often resistant to chemotherapy and radiotherapy, and metastases may develop in the early stages of the disease. The present study investigated 5 patients with vaginal melanoma treated at the Department of Gynecology of Osaka City University Hospital (Osaka, Japan) between October, 2000 and April, 2014. All the cases presented with abnormal genital bleeding as the main complaint. Notably, in 3 of the 5 cases the tumors appeared as non-pigmented polyps. Local resection was performed as the primary treatment in all 5 cases. After surgery, dermal injection of interferon β (feron maintenance therapy) was performed in 3 cases, and dacarbazine, nimustine, vincristine and interferon β (DAVFeron therapy) was administered in 1 case as adjuvant therapy. All 5 cases recurred within 1 year. The site of recurrence varied, and included the vaginal wall, liver, brain and lung. The median overall survival was 419 days and the median progression-free survival 177 days. In this cohort, all the cases presented with abnormal genital bleeding as the main complaint. Therefore, malignant melanoma of the vagina must be considered along with other gynecological malignancies in patients with abnormal genital bleeding. In this study, over half of the cases had a non-pigmented polypoid lesion of the vagina. Therefore, malignant melanoma of the vagina must be considered when a polypoid lesion is identified on the vaginal wall.

Adult granulosa cell tumors of the ovary: a retrospective study of 30 cases with respect to the expression of steroid synthesis enzymes.

ObjectiveSome, but not all, granulosa cell tumors are characterized by estrogen production. This study was designed to determine whether there are clinical or pathological variations in granulosa cell tumors in relation to the expression of sex steroid synthesis enzymes.MethodsClinical symptoms, serum hormonal values, and histology of 30 granulosa cell tumor patients who underwent surgery between 2002 and 2014 were retrospectively reviewed.ResultsMost patients presented with abnormal genital bleeding including abnormal menstrual cycles. Eight of 16 patients older than 50 years had endometrial hyperplasia and one had endometrial cancer. Serum 17β-estradiol (E2) levels tended to be higher in patients over 50 years of age (p=0.081). Serum follicle-stimulating hormone (FSH) levels were low in all patients irrespective of serum E2 levels. Magnetic resonance imaging revealed a thicker endometrium in older as compared to younger patients (p<0.05). Tumor cells in the majority of cases were positive for inhibin α and P450 aromatase, irrespective of age and serum E2 levels. P450 17α-hydroxylase (P450c17) expression varied among cases. P450c17 was strongly positive in luteinized tumor cells and weakly positive in theca cells and fibroblasts. High E2 levels were associated with P450c17-positive cells in the tumor (p<0.05).ConclusionThe expression of hormone-synthesizing enzymes divides granulosa cell tumors into 2 distinct types; tumors with P450c17-positive cells show elevated serum E2 and related clinical symptoms, while tumors without these cells show symptoms related to FSH suppression by inhibin.

A case of gradually manifesting McCune-Albright syndrome with a 10-year follow-up.

McCune-Albright syndrome (MAS) is characterized by fibrous dysplasia (FD) of bone, café-au-lait skin pigmentation, and precocious puberty. Here we report a case of a 12-year-old girl with MAS presenting sexual precocity as initial signs, followed by FD of bone with her growth. She was referred to our hospital because of breast budding and abnormal genital bleeding at the age of 2.8 years. On physical examination, her height and weight were greater than two standard deviations of the mean ranges. Hormonal analysis revealed an elevated serum estradiol and suppressed luteinizing hormone and follicle-stimulating hormone production. Her bone age had advanced, and a 16-mm monocystic lesion was observed on her right ovary by pelvic ultrasonography. Considering the clinical and paraclinical findings, precocious pseudopuberty was suspected and periodic observations were started. Her estrogen "flare up" was transient and she had repeated similar episodes three times in the following 7 years. She complained of pain in her right hip at the age of 9.6 years, which was diagnosed as FD of bone by fluorodeoxyglucose-positron emission tomography. Although no café-au-lait skin pigmentation was observed, we made a preliminary diagnosis of MAS. Because clinical evidence for MAS can appear later in the course of recurrent autonomous cysts, careful observation and periodical assessments of patients with suspected MAS is necessary.

Magnetic resonance imaging findings and prognosis of gastric-type mucinous adenocarcinoma (minimal deviation adenocarcinoma or adenoma malignum) of the uterine corpus: Two case reports.

Our group previously documented the first, very rare case of primary gastric-type mucinous adenocarcinoma of the uterine corpus. Although this type of endometrial cancer appears to be similar to the gastric-type adenocarcinoma of the uterine cervix, its main symptoms, appearance on magnetic resonance imaging (MRI) and prognosis have not been fully elucidated due to its rarity. We herein describe an additional case of gastric-type mucinous adenocarcinoma of the endometrium and review the relevant literature. The two cases at our institution (Kyoto University Hospital, Kyoto, Japan) involved postmenopausal women with a primary complaint of abnormal genital bleeding. Microscopic examination of the hysterectomy specimens indicated a highly differentiated mucinous adenocarcinoma with a desmoplastic stromal reaction. Immunohistochemistry for HIK1083 and/or MUC6 was positive in both cases, suggesting a gastric phenotype. Both patients were diagnosed at an advanced stage, they relapsed or recurred immediately after adjuvant chemotherapy, and eventually succumbed to the disease. The main symptom of gastric-type mucinous adenocarcinoma of the uterine cervix is watery discharge, whereas abnormal genital bleeding in addition to watery discharge is mainly observed in the mucinous type of endometrial adenocarcinoma. Cystic cavities in the tumor are present on MRI in cases of endometrial origin, and prognosis is very poor due to resistance to chemotherapy. Thus, gastric-type mucinous adenocarcinoma of the uterine endometrium exhibits a clinical behavior that is similar to tumors originating from the uterine cervix, but is associated with distinguishing clinical symptoms. The incidence of gastric-type endometrial adenocarcinoma may be higher than expected.

Minilaparotomy Hysterectomy as a Suitable Choice of Hysterectomy for Large Myoma Uteri: Literature Review.

The objective of this paper is to propose minilaparotomy hysterectomy as the suitable choice for large uterus on the basis of our experienced case of performed minilaparotomy hysterectomy to 4,500 g myoma uteri and review published cases about this clinical condition. We presented a 44-year-old woman (gravida 0, virgin) who consulted our hospital because of the chief complaints of abnormal genital bleeding and hypermenorrhea. Transabdominal ultrasonography revealed that abdominal solid tumor reached over the navel. Her tumor was an indication of surgery; to do minilaparotomy hysterectomy with laparoscope was decided because her informed consent was obtained. A 6 cm transverse incision (Maylard incision) was made to the skin above the pubic hairline. At the end of surgery, the length of abdominal wound was 8.5 cm, operating time was 128 min, weight of resected myoma uteri was 4,500 g, and intraoperative blood loss was 895 mL. Blood transfusion was not done; postsurgical course was not a problem without anemia. We propose that a large uterine case in which it is difficult to perform vaginal or laparoscopic hysterectomy should be considered in order to select minilaparotomy hysterectomy up to around 5 kg weight of uterus, and the length of skin incision in minilaparotomy hysterectomy is necessarily <9 cm particularly in large uterus.

Successful treatment of atypical cesarean scar defect using endoscopic surgery

BackgroundCesarean scar syndrome results from a postoperative defect of the uterine isthmus, also known as an isthmocele. Patients present with gynecological symptoms, such as abnormal genital bleeding or infertility, after cesarean delivery. Although the cesarean rate is increasing worldwide, this syndrome is not widely known.Case presentationA 43-year-old G2P1 Japanese woman with atypical cesarean scar syndrome had a 3-year history of secondary infertility and postmenstrual brown discharge. Laparoscopic and hysteroscopic exploration revealed a cesarean scar defect connected to a small cavity in the myometrium: this was not an endometrial cavity or a uterine diverticulum. After endoscopic excision of the cavity, the brown discharge resolved, and the patient achieved ongoing pregnancy on her third attempt at intrauterine insemination.ConclusionConsensus is still lacking regarding the diagnosis and treatment of cesarean scar defect. However, the gynecologists should be aware that cesarean scar syndrome can have scar defects forming cavities of unusual shapes and features. Surgical correction of these defects will often improve postmenstrual bleeding and subfertility in these cases.

子宮腺筋症の術前診断で腹腔鏡下子宮全摘出術を施行し子宮体癌と判明した1例

We present a case of endometrial cancer detected incidentally after a total laparoscopic hysterectomy for adenomyosis. A 45-year-old woman was referred to our department with the chief complaint of hypermenorrhea, abnormal genital bleeding, and anemia. Cytological and histological examinations of the uterus showed no evidence of malignancy. Magnetic resonance imaging and pelvic ultrasonography revealed an indistinct tumor in the posterior wall of the uterus. We made a diagnosis of adenomyosis and performed total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. The histopathological findings revealed that it was an endometrioid adenocarcinoma G2. We additionally performed computed tomography (CT)/positron emission tomography CT and found swelling of a para-aortic lymph node. Therefore, she underwent a pelvic/para-aortic lymphadenectomy via an abdominal operation 61 days after the initial operation. The cancer had spread to 11 lymph nodes. Then, she received adjuvant chemotherapy. We found no evidence of recurrence 1 year after the second surgery.

Uterine metastasis of lung adenocarcinoma revealed by the same epidermal growth factor receptor mutation in both lung and endometrial biopsies

Abstract We experienced a rare case of uterine metastasis of non-small cell lung cancer in an 82-year-old Japanese woman revealed by detecting the same epidermal growth factor receptor (EGFR) gene mutation in both lung and endometrial biopsy specimens. The patient noticed abnormal genital bleeding at the first presentation. Further examination revealed huge masses in both lung and uterus. Biopsies from the lung and endometrium were performed. Although the pathological findings of both specimens showed similar adenocarcinomatous features including intracytoplasmic luminas, immunohistochemical analyses could not clarify whether these two tumors are lung metastasis of endometrial adenocarcinoma, uterine metastasis of lung adenocarcinoma or double primary adenocarcinomas of the lung and endometrium. Mutational analyses of EGFR gene using genomic DNA revealed that both lung and endometrial tumors had the same substitution mutation (L858R) at exon 21 which is often observed in lung adenocarcinomas. Since EGFR mutations are rarely detected in primary endometrial cancers and especially L858R mutation has not been reported in them, detection of the same L858R EGFR gene mutation in both lung and endometrial tumors strongly suggested that uterine tumor is the metastasis of lung adenocarcinoma. Mutational analyses might be useful to determine whether the tumor is primary or metastatic when the particular mutational types are observed in particular tumor types and/or particular organs.