Granulomatous peritonitis caused by iatrogenic spillage of ovarian dermoid cystectomy: a case report and literature review

A 39-year-old nulliparous woman experienced continuous mild fever and abdominal pain since undergoing laparoscopic ovarian dermoid cystectomy 3 months previously in a local hospital. Abdominal computed tomography revealed diffuse heterogeneous fat infiltrations with numerous micronodules in the greater and lesser omentum, combined with ascites with thickening of the parietal peritoneum. The patient underwent exploratory laparoscopy, which included partial pelvic peritonectomy, excision of granulomas, and adhesiolysis with massive irrigation. The patient was treated successfully with laparoscopic surgery and all reproductive structures were spared without operative complications. To avoid peritonitis, complete removal of cyst contents and massive irrigation should be performed during ovarian dermoid cystectomy. Conservative surgical treatment may be a good choice for treating granulomatous peritonitis induced by iatrogenic rupture.

Granulomatous peritonitis caused by iatrogenic spillage of ovarian dermoid cystectomy: a case report and literature review

A 39-year-old nulliparous woman experienced continuous mild fever and abdominal pain since undergoing laparoscopic ovarian dermoid cystectomy 3 months previously in a local hospital. Abdominal computed tomography revealed diffuse heterogeneous fat infiltrations with numerous micronodules in the greater and lesser omentum, combined with ascites with thickening of the parietal peritoneum. The patient underwent exploratory laparoscopy, which included partial pelvic peritonectomy, excision of granulomas, and adhesiolysis with massive irrigation. The patient was treated successfully with laparoscopic surgery and all reproductive structures were spared without operative complications. To avoid peritonitis, complete removal of cyst contents and massive irrigation should be performed during ovarian dermoid cystectomy. Conservative surgical treatment may be a good choice for treating granulomatous peritonitis induced by iatrogenic rupture.

The impact of malnutrition on survival in patients with gynecologic cancer undergoing chemotherapy / 한국영양학회지

PURPOSE: Malnutrition is a major concern in patients with gynecologic cancer receiving chemotherapy. The aim of this study was to evaluate the prognostic significance of malnutrition in patients with gynecologic cancer undergoing chemotherapy. METHODS: A prospective, observational study was conducted on a total of 99 subjects who were treated at a tertiary hospital in Korea. Data regarding demographic, clinical, nutritional, and psychological characteristics at baseline and survival were obtained. RESULTS: Performance status, nutritional status, depression, and annual income were significantly different between survivors and non-survivors. Multivariate Cox modeling after adjusting for other factors showed that a malnourished status in patients with gynecologic cancer undergoing chemotherapy was a significant and independent negative influencing factor for survival. CONCLUSION: These findings provide evidence that adequate nutritional assessment and intervention may assist in improving survival in patients with gynecologic cancer undergoing chemotherapy.

Diagnosis and surgical treatment of isolated rectal endometriosis: long term complication of incomplete treatment for pelvic endometriosis

A 40-year-old woman visited our hospital with cyclic hematochezia for four months. The patient had the history of laparoscopic-assisted vaginal hysterectomy because of severe dysmenorrhea two years ago at another tertiary hospital. According to the medical records, the past surgical treatment was incomplete excision of pelvic endometriotic lesions, especially in rectal serosal lesions.A colonoscopy and abdominopelvic computed tomography showed an isolated tumor mimicking neoplasm, in which a biopsy under colonoscopy was performed and the lesion was endometriosis pathologically. Laparoscopic anterior resection [LAR] was performed. There were no complications during intraoperative and postoperative period and the patient was discharged 7 days after the LAR. It is important for reducing of long-term complication like rectal endometriosis that complete and safe excision of pelvic endometriosis with expert surgical strategy

Monochorionic twin delivery after conservative surgical treatment of a patient with severe diffuse uterine adenomyosis without uterine rupture

A 31-year-old nulliparous woman with severe diffuse uterine adenomyosis, which replaced nearly the whole uterine myometrium, visited our hospital due to severe dysmenorrhea, menorrhagia, and a desire to have a baby. The patient had a history of two spontaneous abortions. Laparotomic adenomyomectomy with transient occlusion of uterine arteries (TOUA) was performed safely and the patient tried in vitro fertilization and achieved a intrauterine twin pregnancy after recovery time of the operation. At 31+6 weeks of gestation, a male neonate baby weighing 1,620 g and a male neonate baby weighing 1,480 g were born by transverse lower segment cesarean delivery. There was no complication after the operation. The babies were discharged after receiving routine neonatal intensive care for neonatal respiratory distress syndrome. Adenomyomectomy with TOUA technique would be an option for conservative surgical treatment in patients with severe diffuse whole uterine adenomyosis. This is the first report of twin pregnancy after diffuse whole uterine adenomyomectomy with TOUA.

Successful term delivery cases of trans-abdominal cervicoisthmic cerclage performed at more than 18 weeks of gestation

A 38-year-old nulliparous woman was referred to our clinic because of cervical incompetence at 19 weeks of gestation. Trans-abdominal cervicoisthmic cerclage was performed after failure of modified Shirodkar cerclage operation in the patient at 21 weeks of gestation via a laparotomic approach. Another 38-year-old patient, who underwent loop electrosurgical excision procedure conization for treatment of cervical dysplasia 4 years ago, presented for cervical incompetence. At 18 weeks of gestation, we performed trans-abdominal laparotomic cervicoisthmic cerclage without any post-operative complications. During antenatal follow-up, there were no obstetrical co-morbidities and finally she gave birth to a healthy infant at full term by cesarean section. We report two cases of women who underwent trans-abdominal cervicoisthmic cerclage surgery because of cervical incompetence as they were not suitable for transvaginal cervical cerclage. Both patients successfully maintained their pregnancy until full term after undergoing transabdominal cervicoisthmic cerclage at more than 18 weeks of gestation.

Intraoperative bleeding control during cesarean delivery of complete placenta previa with transient occlusion of uterine arteries

There are few methods to control heavy intra-operative bleeding during cesarean delivery of placenta previa. Transient occlusion of uterine arteries (TOUA) during operation has previously been reported as a quick and safe method to control intra-operative uterine bleeding. We reported 2 cases of cesarean delivery with complete placenta previa in which TOUA was performed to safely reduce intra-operative complication, especially heavy intra-operative bleeding. In the 2 cases, cesarean deliveries were safe and without any complications under the TOUA method. TOUA can be a good method to control heavy intra-operative bleeding during cesarean delivery of complete placenta previa with risk of heavy bleeding.

Relationships among Malnutrition, Depression and Quality of Life in Patients with Gynecologic Cancer receiving Chemotherapy

PURPOSE: The purpose of this study was to identify nutritional status, and relationships among malnutrition, depression and quality of life in patients with gynecologic cancer who were receiving chemotherapy. METHODS: For this study a descriptive cross-sectional design was used. Participants were 111 women who were enrolled and agreed to undergo a face-to-face interviews including administration of the structured questionnaires: Patient-Generated Subjective Global Assessment (PG-SGA), Beck Depression Inventory (BDI), Simplified Nutritional Appetite Questionnaire (SNAQ), and Functional Assessment of Cancer Therapy-General (FACT-G). RESULTS: Mean body mass index was 23.3 and mean body weight was 56.5 kg. Sixty-three (57%) of the 111 patients were malnourished according to the PG-SGA. The malnourished patients showed higher levels of depression and lower quality of life compared to the non-malnourished patients. In addition, malnutrition was associated with BMI level, depression, appetite and quality of life. CONCLUSION: The findings indicate that the prevalence of malnutrition is high and malnutrition in patients with gynecologic cancer influences depression and adversely affects the quality of life of these women. To improve the patient's quality of life, nutritional assessment and appropriate management is important to decrease malnutrition in patients with gynecologic cancer.

Endometrial Stromal Sarcomas: a clinico-pathological analysis of 27 patients

To evaluate clinico-pathological features and prognostic valuses of Endometrial stromal sarcomas [ESS] through comparison of the two grade groups [low- and high-grade disease]. We retrospectively analyzed the medical records of 27 patients who were diagnosed with ESS at a single institute between March 1988 and November 2009. Our retrospective chart review was approved by our local institutional Review Board [IRB]. The median age of the patients was 44.0 years, the median follow-up period was 101.0 months and the 10-year survival rate was 74.2%. The median uterine weight was 215.0 gm. Twenty-three [70.4%] and four patients [29.6%] had low- and high-grade disease, respectively. As primary treatment, twenty-four [70.4%] and three patients [11.1%] underwent type I hysterectomy and type III hysterectomy, respectively. Total six cases were recurred and two cases of the six-recurred patients were distant metastasis [lung] and four cases were died of the disease. Univariate analysis revealed that the histologic grade and the uterine tumor weight were significantly related with longer disease-free survival [p=0.025 and 0.043 respectively]. ESSs with high-grade or larger tumor size have to be carefully and sufficiently managed, because of its rarity and aggressive behavior. To determine the proper adjuvant treatment of ESS with high risks, further clinical data should be collected and studied

Conservative surgical treatment combined with GnRH agonist in symptomatic uterine adenomyosis

To investigate the safety and therapeutic outcomes of conservative surgery combined with GnRH agonist for uterine adenomyosis. Eighteen women with symptomatic uterine adenomyosis were analyzed retrospectively at Cheil General Hospital and Women's Healthcare Center, Seoul, Korea, between March 2008 and November 2009. We used the mean numerical rating scale [MRS] for dysmenorrhea and the Mansfield-Voda-Jorgensen menstrual bleeding scale [MVJ] for menorrhagia before and after the treatment. The mean follow-up period was 9.7 months [6-16 months]. The mean surgical time was 92.5 min, the mean estimated blood loss was 238.9 ml, and the mean hospital stay after operation was 3.4 days. The mean decrease of hemoglobin was 2.0 g/dL After combination of surgery and GnRH agonist, the mean MRS of dysmenorrhea decreased significantly from 8.1 to 1.9 [P < 0.001], and the mean MVJ score also decreased from 4.3 to 3.2 [P < 0.05]. This conservative surgery should be considered as a therapeutic option for women with symptomatic adenomyosis who wish to preserve the uterus

Co-occurrence of an adenoma malignum and an endocervical-type adenocarcinoma of the uterine cervix in a woman with Peutz-Jeghers syndrome / 부인종양

We report a rare co-occurrence of an adenoma malignum and an adenocarcinoma in a 30-year-old woman with Peutz-Jeghers syndrome. The woman was diagnosed with Peutz-Jeghers syndrome based on an endoscopic biopsy after vaginal bleeding. A pelvic examination and an MRI revealed the co-occurrence of a 4x5 cm protruding adenocarcinoma of FIGO stage Ib2 based on a punch biopsy and a 4.5x5.7 cm multilocular cystic mass above the solid cancer. The patient received two courses of neoadjuvant chemotherapy, followed by a laparoscopic radical hysterectomy with pelvic lymph node dissection. Pathologic findings were consistent with adenocarcinoma (40%) and adenoma malignum (60%) confined to the cervix. Three courses of adjuvant chemotherapy were performed and no clinical evidence of recurrence was seen during a 12 month follow-up period. This study will contribute to defining the best diagnosis and treatment for these rare complicating tumors.

Ovarian Cancer during Pregnancy: Clinical and Pregnancy Outcome

The aim of this study is to evaluate the clinical feature and pregnancy outcome in patients with ovarian cancer diagnosed during pregnancy. We retrospectively analyzed the medical records of 27 patients diagnosed with ovarian cancer during pregnancy at Cheil General Hospital & Women's Healthcare Center from January 1996 to December 2006. Mean age of the patients was 29.1 yr (range 23-40), and a mean follow-up period was 57 months (range 7-112 months). Of 27 patients, 15 (55.5%) had borderline malignancies, 7 (25.9%) had epithelial malignancies and 5 (18.6%) had germ cell tumors. A total of 26 patients received a conservative surgery preserving pregnancy. The mean time for surgical intervention during pregnancy was 20 weeks of gestational age. Of the 27 patients, 26 had full term delivery of a healthy baby without any congenital malformation. Only one patient with epithelial ovarian cancer had a relapse at 19 months after the first conservative operation with adjuvant chemotherapy. There were few data for managing patients with ovarian cancer diagnosed during pregnancy. This study results could help establish a guideline for management of ovarian malignancy complicating pregnancy.

High malignant female adnexal tumor of probable wolffian origin (FATWO): A case report / 대한산부인과학회지

Female adnexal tumors of probable Wolffian origin (FATWO) are rare. Although the histological features of the benign tumors are recognized, features of malignancy are not well defined in published work because these tumors are particularly rare. In this study, we report a 52-year-old woman with a High malignant FATWO. The frozen biopsy of the fragile uterine mass, located at the left broad ligament, revealed a malignant FATWO with high mitotic figure (up to 36/10 HPF). The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, and paraaortic and pelvic lymph node dissection. Pathologic findings were consistent with malignant FATWO infiltrating to the unilateral salpinx without lymph node metastasis. The patient received three cycles of adjuvant treatment with paclitaxel and carboplatin. There was no clinical evidence of recurrence during the 12 months of follow-up; the patient is currently still being followed-up.

Comparison of surgical approach to staging operation for endometrial cancer including pelvic and paraaortic lymphadenectomy / 대한산부인과학회지

OBJECTIVE: To compare laparoscopic surgery with laparotomy in comprehensive surgical staging of endometrial cancer. METHODS: We retrospectively analyzed the medical records of 272 patients with endometrial adenocarcinoma treated by staging operation including pelvic and paraaortic lymphadenectomy between January, 1996 and December, 2007. RESULTS: There was no significant difference between the two groups in terms of age, body mass index, or histologic type, but in the laparotomy group, grade and surgical stage were significantly higher. All the patients, 182 in the laparotomy and 90 in the laparoscopy group, had lymphadenectomy, and the mean number of pelvic and paraaortic lymph nodes (LNs) obtained were 33.1+/-13.2 and 16.1+/-11.6 in the laparoscopy group, and 32.5+/-14.5 and 19.0+/-12.7 in the laparotomy group, respectively; these differences were not statistically significant. In the laparoscopy group, the operating time and postoperative hospital length of stay were shorter than in the laparotomy group, as were the pre- and post-operative hemoglobin changes. There were no significant differences between the two groups in terms of intra- or post-operative complications, but positive lymph nodal metastasis and conducting of postoperative adjuvant therapy were highter in the laparotomy group. The operative technique did not influence overall or disease-free survival after adjusting for several confounding factors. CONCLUSION: Laparoscopic-assisted surgical staging for endometrial cancer required a shorter operating time, shorter postoperative hospital stay, and lower blood loss compared to traditional laparotomy staging, and can be a good therapeutic option for staging operation including lymphadenectomy of endometrial cancer.

Hexamethylmelamine as Consolidation Treatment for Patients with Advanced Epithelial Ovarian Cancer in Complete Response after First-Line Chemotherapy

The aim of this study was to assess the efficacy of consolidation therapy with hexamethylmelamine (HMM) in patients with advanced epithelial ovarian cancer (EOC). Patients treated at our hospital between January 1997 and November 2006 and in documented clinical complete response from advanced ovarian cancer following front-line platinum-based therapy were retrospectively analyzed. The patients treated with HMM were compared to the patients of matched counterpart without consolidation therapy. Of 102 patients enrolled, 49 were treated with HMM and 53 received no consolidation treatment. For patients with HMM and observed patients, the mean age were 54.6 and 55.6 yr; the distribution of stage was similar (P=0.977); the optimal surgery was performed in 36 (73.5%) and 44 (83%) (P=0.336); the recurrence rate were 27 (55.1%) and 33 (62.3%) (P=0.463); and the median progression-free survival were 38 months and 21 months for patients with HMM and observed patients (P=0.235). No treatment-related adverse events were reported during the follow-up period. Although this study failed to show the significant survival benefit of consolidation therapy with HMM in patients with advanced EOC, we consider that our study can contribute data to investigate the effectiveness of consolidation therapy in epithelial ovarian cancer.

The clinical approach for endometrial biopsies with atypical endometrial hyperplasia for further management / 대한산부인과학회지

OBJECTIVE: To evaluate the proper approach in women diagnosed with atypical endometrial hyperplasia (AEH) by endometrial biopsy. METHODS: We retrospectively analyzed the medical records of 108 patients who underwent hysterectomies for AEH diagnosed by endometrial biopsy from 2000 to 2007. The results of the endometrial biopsies were graded on an ordinal scale and were compared with pathologic features obtained at the hysterectomy. RESULTS: AEH was initially diagnosed by dilatation and curettage (87 cases) or endometrial biopsy with a Z-sampler (17 cases). The remaining four cases were diagnosed by hysteroscopic polypectomy. In patients preoperatively diagnosed with AEH by biopsy, hysterectomy specimens revealed a rate of simple or complex endometrial hyperplasia without atypia of 33.3% with AEH and normal endometrium found in 52.8 and 3.7% of specimens, respectively. The incidence of endometrial carcinoma was considerably high (11/108, 10.2%). All cases were confined to the endometrium and two of those were located at the adenomyosis without myometrial invasion. All patients with endometrial carcinoma displayed coexisting atypical complex hyperplasia following hysterectomy. CONCLUSION: Biopsy specimens showing AEH, particularly atypical complex hyperplasia, are associated with an increased risk of coexisting endometrial carcinoma. When considering management strategies for women with a biopsy diagnosis of AEH, clinicians should take into account the considerable rate of concurrent endometrial cancer and the discrepancy with pathologic diagnosis.

Fertility preservation in patients with early epithelial ovarian cancer / 부인종양

OBJECTIVE: To assess the role of fertility preservation in the treatment of patients with early epithelial ovarian cancer (EOC). METHODS: We retrospectively analyzed the medical records of 21 patients with early EOC from January 1995 to December 2006. All eligible patients with a strong desire to preserve fertility were younger than 35 years and underwent fertility-sparing surgery with or without adjuvant chemotherapy. RESULTS: Twenty-one eligible patients with a median age of 26.7 years (range, 20 to 33 years) were identified, and the mean follow-up period was 43 months (range, 5 to 86 months). Only one patient with stage IC recurred 34 months after the first operation. A total of five patients were able to become pregnant at least once after the first fertility preserving treatment, with or without adjuvant chemotherapy. All five patients succeeded in full-term vaginal delivery with healthy infants. No patients died of their disease. CONCLUSION: Fertility preserving treatment in patients with early EOC can be considered as a proper treatment strategy in patients with early EOC, who have the strong desire for fertility preservation.

Clinicopathologic study of ovarian granulosa cell tumors / 대한산부인과학회지

OBJECTIVE: The aim of this study was to evaluate the clinicopathologic characteristics of granulosa cell tumor of the ovary (OGCT). METHODS: We retrospectively reviewed the medical records of 27 patients with OGCT at our hospitals from January 1995 to December 2003. RESULTS: The mean age was 48.3 years (24~70) and mean follow up period was 56.7 months (12~102). The most common symptom was vaginal bleeding (n=11, 40.7%). The tumors were ranging from 3 cm to 21 cm in diameter (mean: 9.9). Post-surgical FIGO stage was stage I in 20 (74.1%), stage II in 6 (22.2%), and stage III in 1 (3.7%). Endoemetrial samples were available in 21 patients and the results were endometrial carcinoma in 1 and endometrial hyperplasias in 5. Staging operation was performed in 17, unilateral salpingo-oophorectomy in 6, total hysterectomy and bilateral salpingo-oophorectomy in 2, and fertility sparing operation in 2. Postoperative chemotherapy was administered in 13 patients (48.2%). Two patients had recurred and recurrence rate was 7.4% (2/27). Two recurred patients finally died of the disease at 42 months and 103 months after first operation respectively. During follow-up period, 2 patients had 3 pregnancies and all of them delivered at term. CONCLUSION: These results shows that most OGCT is detected in early stage and have relatively excellent survival. However, because OGCT is a slow-growing tumor and has a late recurrence, long time follow-up is required.

Pure Basaloid Squamous Cell Carcinoma of the Uterine Cervix: A Case Report

Basaloid squamous cell carcinoma of the uterine cervix is an extremely rare malignancy of the female genital tract with a poorer clinical outcome than squamous cell carcinoma of the uterine cervix. We report a case of pure basaloid squamous cell carcinoma of the uterine cervix. A 70-yr-old woman with vaginal bleeding was referred to our institute. A basaloid squamous cell carcinoma of the uterine cervix, of International Federation of Gynecology and Obstetrics (FIGO) stage Ib1, was diagnosed by a loop electrosurgical excision procedure cone biopsy. A radical hysterectomy was performed, along with bilateral salpingo-oophorectomy, pelvic lymph node dissection, and para-aortic lymph node sampling. Pathologic findings were consistent with a basaloid squamous cell carcinoma confined to the cervix without an extracervical tumor. No further treatment was administered and there was no clinical evidence of recurrence during the 12 months of follow-up. Follow-up for the patient is ongoing. Although basaloid squamous cell carcinoma of the uterine cervix is thought to behave aggressively, accumulation of data on these rare tumors is necessary to determine whether their behavior differs significantly from that of conventional cervical squamous cell carcinoma of similar clinical stage. These data would be useful for defining the best diagnosis and treatment for these rare tumors.

The effect of lymph-vascular space invasion on clinicopathologic features in patients with endometrial cance / 대한산부인과학회지

OBJECTIVE: The aim of this study was to evaluate the effect of lymph-vascular space invasion (LVSI) on clinicopathologic features and outcomes in patients with endometrial cancer. METHODS: All women who were surgically treated for endometrial cancer at the Cheil General Hospital & Women's Healthcare Center between January 2000 and December 2003 were eligible. One hundred-forty one patients underwent retrospective review of medical record. Pathologic findings of LVSI were reviewed and divided in LVSI-positive group and LVSI-negative. Statistical analysis was performed by dBSTAT-4. RESULTS: Fifty-five patients (39%) were LVSI-positive and eighty-six patients (61%) were LVSI-negative. LVSI-positive patients were statistically older than LVSI-negative. LVSI-positive patients had more abnormal cytology, poorer differentiation, larger tumor size (diameter>2 cm), more myometrial invasion. more pelvic nodal metastasis, more paraaortic nodal metastasis, and more advanced stage. There was no difference between the two groups in the percentage of patients with gravidity, parity, histologic types (endometrioid vs nonendometrioid). CONCLUSION: LVSI-positive patients with endometrial cancer are generally older, consistent with more abnormal cytology, poorer differentiation, larger tumor size, more myometrial invasion, more lymph-node metastasis, and more advanced-stage disease. So, LVSI should be a consideration in appropriate treatment in endometrial cancer.