Placenta percreta com invasão de bexiga: um relato de caso / Percretal placenta with bladder invasion: a case report

O acretismo placentário consiste na aderência anormal da placenta na parede uterina. Ao aderir-se diretamente ao miométrio, denomina-se placenta acreta; ao estender-se mais profundamente, placenta increta, e ao invadir a serosa uterina ou órgãos adjacentes, percreta. O fator de risco mais frequente constitui cesarianas anteriores. Paciente 27 anos, G3P1CA1 (cesariana há 8 anos/ parto prematuro 25 sem há 4 anos), IG: 25sem3d; com alteração da vitalidade fetal e placenta prévia com sinais de acretismo (sugerindo placenta percreta). Foi indicada a interrupção da gestação com 27 semanas e 1 dia. No período intraoperatório foi evidenciada, por meio de ultrassom, presença de acretismo placentário com invasão miometrial e invasão de serosa vesical sendo posteriormente realizado a histerectomia subtotal e rafia das lacerações da mucosa vesical. A placenta percreta é mais frequente em grávidas com placenta prévia no local da cicatriz de cesariana e o órgão mais frequentemente acometido é a bexiga; estando associada a maior morbimortalidade materna. O diagnóstico definitivo é anatomopatológico, porém é presumível durante a cirurgia abdominal com a visualização da invasão placentária, devendo ser confirmado por Histopatologia.

Placental accretism consists of abnormal placental adherence to the uterine wall. When adhering directly to the myometrium it is called placenta accreta; when extending more deeply, placenta increta; and when invading the uterine serosa or adjacent organs, percrete. The most frequent risk factor is previous cesarean sections. The patient is 27 years old with altered fetal vitality and placenta previa with signs of accreation (suggesting percretal placenta). Pregnancy termination at 27 weeks and one day was indicated. In the intraoperative period, the presence of placental accretion with myometrial invasion and bladder serous invasion was evidenced by ultrasound, with subtotal hysterectomy and raffia of lacerations of the bladder afterwards. The percretal placenta is more frequent in pregnant women with placenta previa at the site of the scar of a cesarean section and the organ most frequently affected is the bladder; being associated with higher maternal morbidity and mortality. The definitive diagnosis is anatomopathological, but it is presumed during abdominal surgery with the visualization of the placental invasion and must be confirmed by Histopathology

Junctional zone in infertile women: a three-dimensional ultrasound study / Zona juncional em mulheres inférteis: estudo por ecografia tridimensional

Abstract Objective To analyze the interobserver and intraobserver reproducibility of the visualization and continuity of the juncional zone (JZ) by three-dimensional (3D) ultrasound in infertile women, and to evaluate the sociodemographic, hormonal, and structural factors that influence these assessments. Methods A prospective study conducted at the Assisted Reproductive Technology Unit of Hospital Senhora da Oliveira, in the city of Guimarães, Portugal. Transvaginal 3D ultrasonography was performed, and 2 volumes were generated per case. Two observers who were blinded to each other's work analyzed these volumes, choosing the best coronal section. Four months later, one of the observers performed the same methodology. The JZ visualization was classified as optimal, satisfactory, and unsatisfactory, and the JZ continuity, as continuous and discontinuous. The interobserver and intraobserver agreements were analyzed. The influence of hormonal, structural, and sociodemographic factors on the JZ was evaluated. Results In total, 65 women were included in the present study. The interobserver reproducibility was substantial for JZ visualization and continuity (k = 0.635 and 0.753 respectively), and the intraobserver reproducibility was very good for JZ visualization and continuity (k = 0.884 and 0.816 respectively). Trilaminar endometrial pattern was associated with optimal JZ visualization (p = 0.012). The increase of 1 unit in the level of serum estradiol represents a 9.9% decrease in the odds of unsatisfactory visualization of the JZ (odds ratio [OR] = 0.9; 95% confidence interval [95%CI] = 0.814-0.996; p = 0.042). Endometriosis increases the odds of unsatisfactory visualization by 24 times (OR = 23.7; 95%CI = 1.262-437.057; p = 0.034). The prevalence of discontinuous JZs was of 60%. Myomas and endometriosis were associated with discontinuous JZs (p = 0.034 and 0.016 respectively). Conclusion The assessment of JZ visualization and continuity by 3D ultrasound is reproducible enough to be used in the clinical practice.

Resumo Objetivo Analisar a reprodutibilidade inter e intraobservador da visualização e continuidade da zona juncional (ZJ) por ecografia tridimensional (3D) em mulheres inférteis, e avaliar os fatores sociodemográficos, hormonais e estruturais que afetam essas avaliações. Métodos Um estudo prospectivo conduzido no Centro de Procriação Medicamente Assistida do Hospital Senhora da Oliveira, em Guimarães, Portugal. Foi realizada ecografia transvaginal 3D e gerados 2 volumes por caso. Dois observadores, cegos às avaliações um do outro, analisaram os volumes obtidos e escolheram o melhor corte coronal. Após quatro meses, a mesma análise foi realizada por um dos observadores. A visualização da ZJ foi classificada como ótima, satisfatória e não satisfatória, e a continuidade, como contínua ou descontínua. Foram avaliadas as reprodutibilidades inter e intraobservador. A influência de fatores sociodemográficos, hormonais e estruturais na ZJ foi analisada. Resultados No total, 65 mulheres foram incluídas no presente estudo. A reprodutibilidade interobservador foi substancial para a visualização e continuidade da ZJ (k = 0,635 e 0,753, respetivamente). A reprodutibilidade intraobservador foi muito boa para a visualização e continuidade da ZJ (k = 0,884 e 0,816, respetivamente). Endométrio trilaminar associou-se à visualização ótima da ZJ (p = 0.012). O aumento de 1 unidade no nível de estradiol diminuiu a chance de visualização não satisfatória da ZJ em 9,9% (razão de probabilidades [RP] = 0,9; intervalo de confiança de 95% [CI95%] = 0,814-0,996; p = 0,042). Endometriose aumentou a chance de visualização não satisfatória da ZJ em 24 vezes (RP = 23,7; CI95% = 1,262-437,057; p = 0,034). A prevalência de ZJs descontínuas foi de 60%. Miomas e endometriose associaram-se a ZJs descontínuas (p = 0,034 e 0,016, respetivamente). Conclusão A avaliação da visualização e continuidade da ZJ por ecografia 3D é reprodutível, podendo ser utilizada na prática clínica.

Opciones terapéuticas para el defecto de cicatriz uterina / Therapeutic options for cesarean scar defect

Resumen La cicatriz uterina es un defecto en la pared anterior del miometrio secundario a la cesárea. Su prevalencia es muy variable, llegando hasta el 84% en algunos estudios, y aumenta según el número de cesáreas previas. La mayoría de las pacientes pueden ser asintomáticas, pero cuando se manifiesta es principalmente con hemorragia uterina anormal. El manejo de esta patología se ha descrito mediante técnicas farmacológicas y quirúrgicas, siendo más estudiadas las técnicas quirúrgicas, dentro de las que se encuentran la histeroscopía, laparoscopia, laparoscopia asistida con histeroscopía, laparotomía y el abordaje vaginal. Se realizó una revisión en PubMed-MEDLINE y LILACS respecto al manejo de este defecto, tomándose artículos publicados en los últimos cinco años, en la cual se encontraron 37 artículos. El manejo depende principalmente de factores como la sintomatología de la paciente, si tiene paridad satisfecha o no, la profundidad del defecto y las preferencias de la paciente. MÉD.UIS.2019;32(3):11-7

Abstract The postcesarean scar defect is a defect in the anterior wall of the myometrium secondary to the cesarean section. Its prevalence is variable, reaching up to 84% in some studies, increasing with the number of previous cesarean sections. Most of the patients can be asymptomatic, but when it manifests, is mostly with abnormal uterine bleeding. Its management has been described with pharmacological and surgical techniques, the latter being the most researched. They include the hysteroscopy, laparoscopy, laparotomy, and the vaginal approach. A revision in PubMed-MEDLINE and LILACS about the management of this defect was done, including articles published in the last five years, resulting in 37 articles. The selection of the treatment depends on different factors such as the patient's symptoms, if she has satisfied parity or not, the depth of the defect and the patient's preferences. MÉD.UIS.2019;32(3):11-7

Evaluation of KI-67 expression in uterine leiomyoma and in healthy myometrium: a pilot study

SUMMARY OBJECTIVE Evaluate the expression of KI-67 in uterine leiomyomas and adjacent myometrial tissue and verify the existence of a correlation between clinical parameters and KI-67 expression in tumors. METHODS This is a cross-sectional, controlled, analytical study. Samples of leiomyomas and myometrium were obtained from patients who underwent hysterectomy. The samples were processed by immunohistochemistry using KI-67 antibody, and the expression was evaluated by two blinded observers. Student›s T-test was used for comparison of means, and Pearson›s P test for correlation with clinical parameters. RESULTS A total of 9 patients were included in the study. The mean age was 40.7 years, ranging from 35 to 44 years. The mean expression of KI-67 in myometrium was 1.63%, and, in leiomyomas, 5.96% (p <0.001). The highest expression of KI-67 was moderately related to the severity of anemia, bleeding, and pain level. CONCLUSION The expression of KI-67 in normal myometrium was significantly lower than in leiomyomas. The highest expression of KI-67 was moderately related to the severity of anemia, bleeding, and pain level in the patients of this study.

RESUMO OBJETIVO Avaliar a expressão do KI-67 em leiomiomas uterinos e tecido miometrial adjacente e verificar a existência de correlação entre parâmetros clínicos e expressão do KI-67 em tumores. MÉTODOS Estudo transversal, controlado e analítico. Amostras de leiomiomas e miométrio foram obtidas de pacientes que realizaram histerectomia. As amostras foram processadas por imuno-histoquímica utilizando anticorpo para KI-67 e a expressão avaliada por dois observadores cegos. O teste t de Student foi utilizado para comparação de médias e o teste P de Pearson para correlação com parâmetros clínicos. RESULTADOS Um total de 9 pacientes foi incluído no estudo. A idade média foi de 40,7 anos, variando de 35 a 44 anos. A expressão média do KI-67 no miométrio foi de 1,63% e nos leiomiomas de 5,96% (p <0,001). A maior expressão do KI-67 foi moderadamente relacionada com a gravidade da anemia, sangramento e nível de dor. CONCLUSÃO A expressão do KI-67 no miométrio normal foi significativamente menor que nos leiomiomas. A maior expressão do KI-67 foi moderadamente relacionada à gravidade da anemia, sangramento e nível de dor nos pacientes deste estudo.

Embarazo ectópico en cicatriz de cesárea previa, enfoque terapéutico y revisión de la literatura / Ectopic Pregnancy in Previous Cesarean Section Scar Therapeutic Approach and Literature Review

RESUMEN Introducción: El embarazo ectópico en cicatriz de cesárea previa es una forma novedosa y potencialmente mortal de implantación anormal de un saco gestacional dentro del miometrio y el tejido fibroso de la cicatriz. Se desconoce la historia natural de esta condición para lo cual no existe consenso en su manejo. Presentación de caso: Se presenta un caso que se manejó quirúrgicamente de forma conservadora por minilaparotomía, evacuación del tejido trofoblástico, lográndose preservar el útero. Con edad gestacional de 10 semanas, se aplicó metrotexate localmente e intramuscular. La paciente evolucionó satisfactoriamente hacia la mejoría siendo dada de alta. Métodos: Se realiza una revisión bibliográfica en bases de datos Pub Med y Science Direct con las palabras claves obtenidas del MeSH: "Scar ectopic pregnancy" durante los años 2000 y 2018. Se presentan las alternativas de manejo, tanto médico como quirúrgico, sin embargo, ello estará sujeto a las condiciones de la paciente y a la experiencia del médico tratante(AU)

ABSTRACT Introduction: Ectopic pregnancy in a previous caesarean section is a novel and life-threatening form of abnormal implantation of a gestational sac within the myometrium and the fibrous tissue of the scar. The natural history of this condition is unknown, thus there is no consensus in its management. Case report: We report a case that was surgically managed in conservative way by minilaparotomy, trophoblastic tissue evacuation. The uterus was preserved. The gestational age was 10 weeks. Metrotexate was applied locally and intramuscularly. The patient evolved satisfactorily towards improvement and discharge. Methods: A literature review during the years 2000 and 2018 was carried out in Pub Med and Science Direct databases. The keywords from MeSH used were "Scar ectopic pregnancy". Both medical and surgical management alternatives are presented, however the patient condition and the experience of the attending physician will contribute as well(AU)

Isthmocele: from risk factors to management / Istmocele: de fatores de risco ao manejo

Abstract Objective The aim of the present study was to perform a comprehensive review of the literature to provide a complete and clear picture of isthmocele-a hypoechoic area within themyometriumat the site of the uterine scar of a previous cesarean section-by exploring in depth every aspect of this condition. Methods A comprehensive review of the literature was performed to identify the most relevant studies about this topic. Results Every aspect of isthmocele has been studied and described: pathophysiology, clinical symptoms, classification, and diagnosis. Its treatment, both medical and surgical, has also been reported according to the actual literature data. Conclusion Cesarean section is the most common surgical procedure performed worldwide, and one of the consequences of this technique is isthmocele. A single and systematic classification of isthmocele is needed to improve its diagnosis and management. Further studies should be performed to better understand its pathogenesis.

Resumo Objetivo O objetivo do presente estudo foi realizar uma revisão abrangente da literatura a fim de fornecer um quadro completo e claro da istmocele-uma área hipoecoica dentro domiométrio no local da cicatriz uterina de uma cesariana anterior- aprofundando todos os aspectos desta condição Métodos Uma revisão abrangente da literatura foi realizada para identificar os estudos mais relevantes sobre este tema. Resultados Todos os aspectos da istmocele foram estudados e descritos: fisiopatologia, sintomas clínicos, classificação e diagnóstico. Os tratamentos médico e cirúrgico também foram relatados de acordo com os dados reais da literatura. Conclusão A cesárea é o procedimento cirúrgico mais comum realizado em todo o mundo, e uma das consequências desta técnica é a istmocele. Uma classificação única e sistemática da istmocele é necessária para melhorar seu diagnóstico e manejo. Novos estudos devem ser realizados para melhor entender sua patogênese.

Prostaglandin E receptors differentially regulate the output of proinflammatory cytokines in myometrial cells from term pregnant women / 生理学报

Prostaglandin (PG) E plays critical roles during pregnancy and parturition. Emerging evidence indicates that human labour is an inflammatory event. We sought to investigate the effect of PGE on the output of proinflammatory cytokines in cultured human uterine smooth muscle cells (HUSMCs) from term pregnant women and elucidate the role of subtypes of PGE receptors (EP, EP, EP and EP). After drug treatment and/or transfection of each receptor siRNA, the concentrations of inflammatory secreting factors in HUSMCs culture medium were detected by the corresponding ELISA kits. The results showed that, PGE increased interleukin 6 (IL-6) and tumor necrosis factor alpha (TNFα) output, decreased chemokine (c-x-c motif) ligand 8 (CXCL8) output in a dose-dependent manner, but had no effect on IL-1β and chemokine (c-c motif) ligand 2 (CCL-2) secretion of HUSMCs. EP/EP agonist 17-phenyl-trinor-PGE stimulated IL-6 and TNFα whilst suppressing IL-1β and CXCL8 output. The effects of 17-phenyl-trinor-PGE on IL-1β and CXCL8 secretion were remained whereas its effect on IL-6 and TNFα output did not occur in the cells with EP knockdown. The stimulatory effects of 17-phenyl-trinor-PGE on IL-6 and TNFα were remained whereas the inhibitory effects of 17-phenyl-trinor-PGE on IL-1β secretion was blocked in the cells with EP knockdown. Either of EP and EP agonists stimulated IL-1β and TNFα output, which was reversed by EP and EP siRNA, respectively. The inhibitors of phospholipase C (PLC) and protein kinase C (PKC) blocked EP/EP modulation of TNFα and CXCL8 output. PI3K inhibitor LY294002 and P38 inhibitor SB202190 blocked 17-phenyl-trinor-PGE-induced IL-1β and IL-6 output, respectively. The inhibitors of adenylyl cyclase and PKA prevented EP and EP stimulation of IL-1β and TNFα output, whereas PLC and PKC inhibitors blocked EP- and EP-induced TNFα output but not IL-1β output. Our data suggest that PGE receptors exhibit different effects on the output of various cytokines in myometrium, which can subtly modulate the inflammatory microenvironment in myometrium during pregnancy.

Clear Cell Adenocarcinoma Originated from Adenomyosis / 이화의대지

A 66-year-old postmenopausal woman received routine gynecologic check-up. Transvaginal ultrasonography and abdominal and pelvic computed tomography showed about 5-cm cystic mass in uterus with solid component and the patient had thin endometrium and the serum level of CA 125 was normal. We performed a total hysterectomy and bilateral salpingo-oophorectomy and found tumor which had brownish cystic fluid and about 2 cm sized and colored in light yellowish, polypoid protruding solid mass, located within the myometrial wall. Histopathological examination of frozen section revealed malignancy. The tumor was confined within the myometrium and its histologic type was clear cell adenocarcinoma. Finally we identified that the myometrial mass was clear cell adenocarcinoma originated from adenomyosis pathologically. The malignant transformation of adenomyosis is very rare. When we find a cystic change with solid component in adenomyosis patients, clear cell adenocarcinoma should be suspected as a differential diagnosis and magnetic resonance imaging should be considered for further evaluation.

Anti-inflammatory and utero-relaxant effect of α-bisabolol on the pregnant human uterus

The aim of this study was to evaluate the in vitro anti-inflammatory and utero-relaxant effect of α-bisabolol on the pregnant human myometrium. Samples from the pregnant human myometrium were used in functional tests to evaluate the inhibitory effect of α-bisabolol (560, 860, 1,200 and 1,860 µM) on spontaneous myometrial contractions. The intracellular cyclic adenosine monophosphate (cAMP) levels generated in response to α-bisabolol in human myometrial homogenates were measured by ELISA. The anti-inflammatory effect of α-bisabolol was determined through the measurement of two pro-inflammatory cytokines, tumor necrosis factor-α (TNFα) and interleukin (IL)-1β, and the anti-inflammatory cytokine IL-10, in pregnant human myometrial explants stimulated with lipopolysaccharide (LPS). Forskolin was used as a positive control to evaluate the cAMP and cytokine levels. α-Bisabolol was found to induce a significant inhibition of spontaneous myometrial contractions at the highest concentration level (p 0.05). The anti-inflammatory and utero-relaxant effects induced by α-bisabolol were not associated with an increase in cAMP levels in pregnant human myometrial samples. These properties place α-bisabolol as a potentially safe and effective adjuvant agent in cases of preterm birth, an area of pharmacological treatment that requires urgent improvement.

Effects of corticotropin-releasing hormone on the expression of adenosine triphosphate-sensitive potassium channels (Kir6.1/SUR2B) in human term pregnant myometrium

OBJECTIVE: Corticotropin-releasing hormone (CRH) is a crucial regulator of human pregnancy and parturition. Adenosine triphosphate (ATP)-sensitive potassium (KATP) channels are important for regulating myometrial quiescence during pregnancy. We investigated regulatory effects of different concentrations of CRH on KATP channel expression in human myometrial smooth muscle cells (HSMCs) in in vitro conditions. METHODS: After treating HSMCs with different concentrations of CRH (1, 10, 102, 103, 104 pmol/L), mRNA and protein expression of KATP channel subunits (Kir6.1 and SUR2B) was analyzed by reverse transcription-polymerase chain reaction and western blot. We investigated which CRH receptor was involved in the reaction and measured the effects of CRH on intracellular Ca2+ concentration when oxytocin was administered in HSMCs using Fluo-8 AM ester. RESULTS: When HSMCs were treated with low (1 pmol/L) and high (103, 104 pmol/L) CRH concentrations, KATP channel expression significantly increased and decreased, respectively. SUR2B mRNA expression at low and high CRH concentrations was significantly antagonized by antalarmin (CRH receptor-1 antagonist) and astressin 2b (CRH receptor-2 antagonist), respectively; however, Kir6.1 mRNA expression was not affected. After oxytocin treatment, the intracellular Ca2+ concentration in CRH-treated HSMCs was significantly lowered in low concentration of CRH (1 pmol/L), but not in high concentration of CRH (103 pmol/L), compared to control. CONCLUSION: Our data demonstrated the regulatory effect was different when HSMCs were treated with low (early pregnancy-like) and high (labor-like) CRH concentrations and the KATP channel expression showed significant increase and decrease. This could cause inhibition and activation, respectively, of uterine muscle contraction, demonstrating opposite dual actions of CRH.

The expression of Müllerian inhibiting substance/anti-Müllerian hormone type II receptor in myoma and adenomyosis

OBJECTIVE: We compared the expression levels of Müllerian inhibiting substance (MIS)/anti-Müllerian hormone type II receptor (AMHRII) in uterine myoma and adenomyosis to evaluate the possibility of using MIS/anti-Müllerian hormone (AMH) as a biological regulator or therapeutic agent in patients with uterine leiomyoma and adenomyosis. METHODS: We studied normal uterine myometrium, leiomyoma, endometrial tissue, and adenomyosis from 57 patients who underwent hysterectomy for uterine leiomyoma (22 cases) or adenomyosis (28 cases) and myomectomy for uterine myoma (7 cases). Immunohistochemical staining was used to confirm the MIS/AMHRII protein expression level in each tissue. Reverse transcription-polymerase chain reaction was performed to quantify MIS/AMHRII mRNA expression. RESULTS: The MIS/AMHRII protein was more strongly expressed in uterine myoma (frequency of MIS/AMHRII expressing cells: 51.95%±13.96%) and adenomyosis (64.65%±4.85%) tissues than that in the normal uterine myometrium (3.15%±1.69%) and endometrium (31.10%±7.19%). In the quantitative analysis of MIS/AMHRII mRNA expression, MIS/AMHRII mRNA expression levels in uterine myoma (mean density: 4.51±0.26) and adenomyosis (6.84±0.20) tissues were higher than that in normal uterine myometrial tissue (0.08±0.09) and endometrial tissue (1.63±0.06). CONCLUSION: This study demonstrated that MIS/AMHRII was highly and strongly expressed on uterine myoma and adenomyosis. Our data suggest that MIS/AMH may be evaluated as a biological modulator or therapeutic agent on MIS/AMHRII expressing uterine myoma and adenomyosis.

Three-dimensional power doppler angiography characteristic in validating the preoperative accuracy of myometrial and cervical involvement in women with endometrial cancer / Philippine Journal of Obstetrics and Gynecology

Background@#The Lead Vessel and Infitrating Vessels are findings in endometrial cancer that are well visualized by three-dimensional power Doppler angiography. Vessel diameter and length may be utilized as markers for deep myometrial and or cervical involvement.@*Objective@#To determine the accuracy of Lead vessel and Infiltrating vessel dimensions in assessing the depth of myometrial invasion in endometrial cancer and its cervical involvement.@*Participants and Methods@#All women histopathologically diagnosed with endometrial cancer, undergoing surgical staging, with informed consent were included. Sonography using GE Voluson S8 system for describing the uterus and endometrial thickness were followed by a 3D power Doppler Angiography to analyze the depth of myometrial invasion and presence or absence of cervical involvement. Vessel diameter and length in transverse and sagittal plane were measured by calipers. Predictive values and operating characteristics (sensitivity, specificity, positive and negative predictive values) were computed.

Fertility preserving treatment with hysteroscopic resection followed by progestin therapy in young women with early endometrial cancer / 부인종양

OBJECTIVE: To report our 15-year institutional experience of fertility-sparing treatment in young patients with early endometrial cancer (EC) treated by combined hysteroscopic resection and progestin therapy. METHODS: Twenty-eight patients (stage IA, G1 and 2 endometrioid EC) wishing to preserve their fertility were enrolled into this prospective study. Hysteroscopic resection was used to resect the tumor, endometrium adjacent to the tumor and myometrium underlying the tumor. Adjuvant hormonal therapy consisted of oral megestrol acetate or levonorgestrel intrauterine device for 6 months or more. RESULTS: After 3 months from the progestin start date, 25 patients (89.3%) showed a complete regression (median time to complete regression, 3 months [range, 3-9 months]), two (7.1%) showed persistent disease, while one patient (3.6%) presented with progressive disease and underwent definitive surgery (stage IA, G3 endometrioid). At 6 months, one of the two patients with persistent disease underwent definitive surgery (stage IA, G1 endometrioid), while the other one was successfully re-treated. Two recurrences were observed (7.7%) both involving the endometrium and synchronous ovarian cancer. The median duration of complete response was 94.5 months (range, 8-175 months). More than half of the responders (57.7%) attempted to conceive with 93.3% and 86.6% pregnancy and live birth rates, respectively. CONCLUSION: The addition of a standardized three-step resectoscopy to progestin would seem to improve the efficacy of progestin alone. High pregnancy and live birth rates were observed in women attempting to conceive.

Early ovarian cancer surgery with indocyanine-green-guided targeted compartmental lymphadenectomy (TCL, pelvic part) / 부인종양

OBJECTIVE: Para-aortic indocyanine-green (ICG)-guided targeted compartmental lymphadenectomy is feasible in early ovarian cancer; systematic pelvic and para-aortic lymphadenectomy could potentially be avoided if thoroughly investigated sentinel nodes could predict whether residual nodes will be involved or free of disease. In contrast to advanced ovarian cancer, where the therapeutic potential of lymphadenectomy will soon be clarified by the results of the Arbeitsgemeinschaft Gynäkologische Onkologie lymphadenectomy in ovarian neoplasms (AGO LION) trial, systematic lymphadenectomy seems to be mandatory for diagnostic and also therapeutic purposes in early ovarian cancer. Sentinel node biopsy or resection of the regional lymphatic network may reduce morbidity compared to systematic lymphadenectomy as shown already for other entities. Apart from the ovarian mesonephric pathway, a second Müllerian uterine pathway exists for lymphatic drainage of the ovary. Lymphatic valves apparently do not exist at this level of the utero-ovarian network since injection of radioactivity into the ovarian ligaments also labelled pelvic nodes. METHODS: We applied ICG using 4×0.5 mL of a 1.66 mg/mL ICG solution for transcervical injection into the fundal and midcorporal myometrium at each side instead of injection into the infundibulopelvic ligament, since the utero-ovarian drainage was intact. RESULTS: In this case a 1.8 cm cancer of the right ovary was removed in continuity with its draining lymphatic vessels and at least the first 2 sentinel nodes in each channel “en bloc” as shown in this video for the pelvic part, consistent with the loco-regional ontogenetic approach. CONCLUSION: This could potentially avoid most of systematic lymphadenectomies in early ovarian cancer.

Transvaginal ultrasound versus magnetic resonance imaging for preoperative assessment of myometrial infiltration in patients with endometrial cancer: a systematic review and meta-analysis / 부인종양

OBJECTIVE: To compare the diagnostic accuracy of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) for detecting myometrial infiltration (MI) in endometrial carcinoma. METHODS: An extensive search of papers comparing TVS and MRI in assessing MI in endometrial cancer was performed in MEDLINE (PubMed), Web of Science, and Cochrane Database from January 1989 to January 2017. Quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. RESULTS: Our extended search identified 747 citations but after exclusions we finally included in the meta-analysis 8 articles. The risk of bias for most studies was low for most 4 domains assessed in QUADAS-2. Overall, pooled estimated sensitivity and specificity for diagnosing deep MI were 75% (95% confidence interval [CI]=67%–82%) and 82% (95% CI=75%–93%) for TVS, and 83% (95% CI=76%–89%) and 82% (95% CI=72%–89%) for MRI, respectively. No statistical differences were found when comparing both methods (p=0.314). Heterogeneity was low for sensitivity and high for specificity for TVS and MRI. CONCLUSION: MRI showed a better sensitivity than TVS for detecting deep MI in women with endometrial cancer. However, the difference observed was not statistically significant.

Current Medical Therapy for Uterine Leiomyomas / 고신대학교의과대학학술지

Uterine leiomyomas are benign tumors arising from the myometrium and largely prevalent in the woman's reproductive years. The majority of women with leiomyomas either remain asymptomatic or develop symptoms gradually over time. When patients are symptomatic, the nature of their complaints is often attributable to the number, size, and/or location of their fibroids. Depending on a patient's symptomatology and reproductive plans, treatment options include expectant management, medical management (hormonal and non-hormonal), or surgical management (myomectomy or hysterectomy).

Persistent low-level elevation of serum human chorionic gonadotropin after termination of pregnancy: a rare case of peritoneal trophoblastic implant

Peritoneal trophoblastic implant can occur after treatment of ectopic pregnancy. Similarly, after termination of intrauterine pregnancy, trophoblastic implants are rare but can be a complication of perforation during dilatation and curettage. We report an extremely rare case of trophoblastic implant on the myometrium, ovarian surface, and peritoneal wall 4 months after uncomplicated dilatation and curettage. To the best of our knowledge, this is the first case of peritoneal trophoblastic implant following dilatation and curettage without uterine perforation. Knowledge of this case is useful for the management of patients with persistent low-level elevation of serum human chorionic gonadotropin after termination of pregnancy.

Human myometrial interstitial cajal like cell [Telocyte] in preterm and full term labour: histological and immunohistochemical studies

Introduction: Preterm labour is a common obstetric problem. The human myometrium is formed of two types of cells namely smooth muscles and interstitial Cajal like cells or telocytes which express both estrogen and progesterone receptors

Aim of the work: This study aimed to know how many telocytes are present in the pregnant uteri at time of labour in the different gestational ages and the possible role of telocytes in preterm labour

Patients and methods: 10 pregnant women were included in the study planned to do cesarean section. They were divided into two groups: Group I: included 5 cases whose gestational age was less than 37 weeks [preterm]. Group II: included 5 cases whose gestational age was more than 37 weeks [full term]. Specimens were obtained from the myometrium at the time of the operation and processed for histological and immunohistochemical study

Results: H and E stained sections revealed hypertrophied smooth muscle fibers with different orientations. Methylene blue stain revealed telocytes between the smooth muscle fibers as a branched cell with small cell body and thin long processes. CD 117 [ckit] immunostaining revealed an apparent increase in the number of telocytes in preterm cases [Group I] compared to full term cases [Group II]. Morphometric study revealed a significant increase in the number of ckit positive telocytes in preterm cases compared to the full term one

Conclusion: Telocytes are present in the pregnant uteri at different gestational ages with a significant increase in their number in the preterm cases; they may have a possible role in preterm labour

Ileo-uterine fistula in a degenerated posterior wall fibroid after Caesarean section / 대한생식의학회지

Uterine fibroids are benign tumors of the myometrium with a diverse range of manifestations. Fibroids can dramatically increase in size during pregnancy due to the increase in estrogen levels. After delivery, the fibroids usually shrink back to their pre-pregnancy size. Uterine myomas may have many complications, including abnormal uterine bleeding, infertility, pressure on nearby organs, degeneration, and malignant transformation. No previous reports have indicated that a fistula may develop between a uterine fibroid and the bowel loops, although previous studies have documented the occurrence of fistulas from the uterus to the bowel following myomectomy or uterine artery embolization performed to treat a myoma. In our case report, we document the rare complication of a fistula occurring between a degenerated myoma in the posterior wall and the ileum 1 week postoperatively in a patient who underwent a Caesarean section but did not have a history of uterine artery embolization.

Identification of interacting proteins with NF-κB in different status of uterine smooth muscle in labor / 中南大学学报(医学版)

To analyze the differentially expressed proteins which interacted with NF-kappaB in the uterine lower segment smooth muscle tissues under different status of labor onset, and to provide a new foundation on the mechanisms for labor onset.
 Methods: NF-κB P65 protein expression in smooth muscle tissues from the term non-labor group, natural term labor group and drug-induced term labor group was analyzed by Western blot. Co-immunoprecipitation and SDS-PAGE (sodium dodecyl sulfate polyacrylamide gel electrophoresis) were performed to detect the proteins interacting with NF-κB p65 in the NF-κB p65 complexes. The components of the complex were identified by LC-ESI-MS/MS (liquid chromatography-tandem electrospray mass spectrometry) and database analysis. The identified differentially expressed proteins were confirmed by Western blot.
 Results: Positive expression of NF-κB was detected in all of the three groups. 10 differentially expressed proteins were identified by LC-ESI-MS/MS in human lower segment myometrium tissues in the term non-labor group and natural term labor group, mean while, 5 differentially expressed proteins were identified in the term non-labor group and the drug-induced labor group. 3 differential expression proteins were detected in all of the 3 groups, including Heat shock 70, Annexin A6 and Desmin, which were verified by Western blot. These proteins were mainly involved in chaperone, signal transduction, cell structure, and energy metabolism process, respectively.
 Conclusion: NF-κB expressed in uterine smooth muscle cells is involved in the process of initiation and regulation of labor onset through a number of proteins relevant to signal transduction, cell structure and energy metabolism.