The current status of robotic surgery for endometrial cancer in Japan.

The da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) was approved in 2009 by the Japanese Ministry of Health, Labor, and Welfare. In gynecology, robotic surgery for hysterectomy for benign indications and early-stage endometrial cancer has been covered by National Health Insurance since 2018. In a context where the da Vinci surgical system has prevailed in urology departments in Japan, gynecological robotic surgery has spread rapidly once it was covered by insurance. Although minimally invasive gynecologic surgery (minimally invasive surgery, or MIS) in Japan has a specific context, there are several problems with its safety, surgeon education, and cost in Japan. To maximize the many advantages of robotic surgery, its effectiveness needs to be carefully evaluated and this new technology needs to be safely incorporated in practice.

Laparoscopic hemostasis for abdominal brunt massive hemorrhage due to endometriosis.

In the gynecological literature, a limited number of studies have reported intraperitoneal bleeding due to abdominal blunt trauma. In this report, we describe a rare case of massive intraabdominal hemorrhage from the uterine artery triggered by a fall injury without apparent abdominal bruising in the presence of severe endometriosis and a uterine fibroid. A 28-year-old woman who fell from a railway platform was transported to an emergency hospital. Although she did not sustain abdominal bruising and initially had no abdominal symptoms, she complained of gradually worsening abdominal pain. Abdominal CT identified intraabdominal massive hematoma, and emergency exploratory laparoscopy revealed active bleeding from the right uterine artery eroded by endometriosis, which was treated with laparoscopic electrocoagulation. The cause of the intraabdominal bleeding was associated with avulsion of the endometriosis adhesion between the right perimetrium and the right uterine artery due to inertial forces of the uterus during the fall injury. A uterine fibroid discovered during laparoscopy was suspected to strengthen the inertial forces of the uterus. In the case of hemoperitoneum after trauma, gynecological sources of bleeding must be kept in mind, especially for patients with a known history of fibroids or endometriosis.

Effects of maternal and fetal choline concentrations on the fetal growth and placental DNA methylation of 12 target genes related to fetal growth, adipogenesis, and energy metabolism.

AIM: We performed a birth cohort study involving 124 mother-infant pairs to investigate whether placental DNA methylation is associated with maternal choline status and fetal development. METHODS: Plasma choline concentration was assayed longitudinally in the 1st and 3rd trimesters and at term-pregnancy in mothers and cord blood. Placental DNA methylation was measured for 12 target candidate genes that are related to fetal growth, adipogenesis, lipid and energy metabolism, or long interspersed nuclear elements. RESULTS: Higher maternal plasma and cord blood choline levels at term tended to associate with lower birthweight (r = -0.246, P < 0.013; r = -0.290, P < 0.002) and body mass index (BMI) at birth (r = 0.344, P < 1E-3; r = -0.360, P < 1E-3). The correlation between maternal plasma choline level and cord blood choline level was relatively modest (r = 0.049, P = 0.639). There was an inverse correlation between placental DNA methylation at the retinoid X receptor alpha (RXRA) gene and maternal plasma choline level (r = -0.188 to r = -0.452, P = 0.043 to P < 1E-3 at three points). RXRA methylation level was positively associated with birthweight and BMI at birth (r = 0.306, P = 0.001; r = 0.390, P < 1E-3). Further, RXRA methylation was inversely correlated with RXRA gene expression level (r = 0.333, P < 1E-3). CONCLUSION: Our results suggest that the association between maternal choline status and placental RXRA methylation represents a potential fetal programing mechanism contributing to fetal growth.

A Case of Recurrent Ovarian Cancer and Therapy-Related Acute Myeloid Leukemia Treated with Azacitidine.

Therapy-related myelodysplastic syndrome (tMDS) and acute myeloid leukemia (tAML) are lethal complications of chemotherapy. The incidence rates are expected to increase owing to improvements of cancer treatment. Early diagnosis of tMDS/AML is crucial because AML progresses rapidly. Hematopoietic stem cell transplantation (HSCT) is the only current treatment to prolong survival; however, patients with tMDS/AML are more likely to be intolerable to HSCT if they have other active solid tumors. An effective treatment for patients with tMDS/AML who are not candidates for HSCT is not established. We present a case of tAML that developed during chemotherapy for treating active ovarian cancer. The patient presented with thrombocytopenia that was initially suggested to be chemotherapy-induced thrombocytopenia. The patient was not a candidate for HSCT because of active cancer. However, she was able to receive azacitidine because her ovarian cancer responded well to chemotherapy. Pancytopenia is a common symptom of both chemotherapy-induced bone marrow suppression and tMDS/AML; thus, it may be difficult to distinguish between them at the first presentation. Given the prediction that the tMDS/AML incidence will increase as the survival of cancer patients improves, oncologists should be aware of the risks of tMDS/AML in patients with a history of cytotoxic chemotherapy. Although the indications for intensive care of tAML for patients with active solid tumors are poor, some patients might be able to receive cytotoxic treatment for tAML if the active solid tumors remain stable. Further studies focused on tMDS/AML with active solid tumors are needed to develop an effective treatment.

Severely fluctuating blood glucose levels associated with a somatostatin-producing ovarian neuroendocrine tumor.

CONTEXT: Somatostatin-producing tumors are a rare type of neuroendocrine tumor. Their effects on blood glucose levels have been variously reported, and detailed reports have been scarce. OBJECTIVE: The aim of this study was to identify the reasons for the extraordinary blood glucose fluctuations in a case with no previous history of diabetes. PATIENTS AND METHODS: A 68-yr-old nondiabetic woman with an ovarian tumor was suffering from hyper- and hypoglycemia. Based on the results of an oral glucose tolerance test and continuous glucose monitoring, we speculated that the fluctuating blood glucose level was accompanied not only by a low insulin level but also by low counter-regulatory hormones levels, and that those broad hormonal suppressions were caused by a high somatostatin level produced in the ovarian tumor. We performed an oophorectomy and assessed the pathology of the tumor and changes in the blood glucose profile as well as hormonal levels postoperatively. RESULTS: The blood glucose level was completely normalized after the oophorectomy. Insulin secretion was also normalized. Histological examination showed that the tumor comprised a mature cystic teratoma and a stromal carcinoid. Immunohistochemically, the stromal carcinoid component was positive for somatostatin. The somatostatin level was 8505 pmol/liter preoperatively, which dropped down to 71.5 pmol/liter postoperatively. We found two previous reports of somatostatin-producing ovarian neuroendocrine tumors. Somatostatin levels among cases of ovarian origin were much higher than those among cases of gastrointestinal origins, and cases of ovarian origin all experienced blood glucose fluctuations. CONCLUSION: Extremely high somatostatin levels and blood glucose fluctuations may be characteristics of somatostatin-producing ovarian neuroendocrine tumors.

Effect of Social Service Prenatal Care Utilization on Perinatal Outcomes among Women with Socioeconomic Problems in the Tokyo Metropolitan Area.

Background. To investigate the effect of social service prenatal care (PNC) utilization on perinatal outcomes among women with socioeconomic problems in the Tokyo metropolitan area. Methods. Retrospective study. The study enrolled all women at our hospital who either attended PNC utilizing social services (attenders) or who did not attend PNC (nonattenders) between January 1, 2007, and December 31, 2010. We compared the maternal characteristics and perinatal outcome of attenders with those of nonattenders. Results. A total of 83 attenders and 45 nonattenders were enrolled. The mean gestational age at the first PNC visit was 31.1 weeks in the attenders. Attenders were found to have a lower incidence of preterm delivery, pregnancy-induced hypertension, emergency cesarean section, low birth weight, and the NICU admission than nonattenders (P < 0.05). Conclusions. The utilization of social service PNC greatly improved perinatal outcomes among women with socioeconomic problems problems in the Tokyo metropolitan area.