Torsed retroperitoneal leiomyomas: A case report and review of literature.

BACKGROUND: Retroperitoneal leiomyomas (RLs) are rare benign tumours that can occur in the pelvic and/or abdominal parietal retroperitoneum. Once torsion occurs, it causes acute abdominal pain and can even lead to serious consequences such as gangrene, peritonitis, haemoperitoneum and shock if not identified and treated promptly. Therefore, a better understanding of the characteristics of RL torsion is needed. Here, we present a case of acute pedicle torsion of an RL in the posterior peritoneum followed by a literature review. CASE SUMMARY: Herein, we report the case of a 42-year-old woman with RL torsion. The patient visited our hospital complaining of lower abdominal pain for 6 d. Pelvic examination revealed a tender mass superior to the uterus. Pelvic magnetic resonance imaging (MRI) revealed an anterior uterine mass, multiple uterine fibroids and slight pelvic effusion. MRI suggested the possibility of a subserosal myoma of the anterior uterine wall with degeneration. Intraoperative exploration revealed a 10 cm pedunculated mass arising from the posterior peritoneum, with the pedicle torsed two times. Pathological examination confirmed a torsed RL. CONCLUSION: In the case of a pelvic mass complicated with acute abdomen, the possibility of torsion should be considered.

Efficacy and Safety of Sanjie Analgesic Capsule in Patients with Endometriosis-Associated Pain: A Multicenter, 3:1 Randomized, Double-Blind, Placebo-Controlled Trial.

OBJECTIVE: To assess the efficacy and safety of Sanjie Analgesic Capsule (SAC) in Chinese patients with endometriosis-associated pain. METHODS: This was a multicenter, randomized, double-blind, placebo-controlled trial conducted at 15 centers between November 2013 and July 2017 in China. Eligible 323 patients with endometriosis were randomized at a 3:1 ratio to the SAC group (241 cases) and placebo group (82 cases) by stratified block randomization. Patients in the SAC or placebo groups were given SAC or placebo 1.6 g 3 times per day, orally, respectively since the first day of menstruation for 3 consecutive menstrual cycles. The primary endpoint was clinical response to dysmenorrhea evaluated using a 10-point Visual Analogue Scale at 3 and 6 months. The secondary endpoint was the pain score evaluated by VAS (chronic pelvic pain, defecation pain, and dyspareunia) at 3 and 6 months, and the pain recurrence rate at 6 months. Adverse events (AEs) were recorded during the study. RESULTS: A total of 241 women were included in the SAC group, and 82 were in the placebo group. Among these women, 217 (90.0%) and 71 (86.6%) completed the intervention, respectively. At 3 months, overall response rate (ORR) was significantly higher in women administered SAC (80.1%) compared with those who received a placebo (30.5%, P<0.01). Six months after treatment, the ORR for dysmenorrhea was 62.7% in the SAC group and 31.7% in the placebo group (P<0.01). Chronic pelvic pain and defecation pain were significantly improved by SAC compared with placebo (both P<0.05). The incidence rates of total AEs events in the SAC and placebo groups were 6.6% and 9.8%, respectively, and no significant difference was shown between the two groups (P=0.339). CONCLUSION: SAC is well-tolerated and may improve dysmenorrhea in women with endometriosis-associated pain. (Trial registration: ClinicalTrials.gov, No. NCT02031523).

[Role of mast cells in estrogen-mediated experimental endometriosis in rats].

OBJECTIVE: To investigate the role of mast cells in the pathogenesis of estrogen-mediated experimental endometriosis in rats. METHODS: Endometriosis model was established by transplanting autologous fragments of uterus to the inner surface of the abdominal wall in 24 un-pregnant female Sprague Dawley rats. The rats were divided randomly into three groups (n=8 in each group), and were injected with different doses of estrogen: high-dose group (200 µg·kg⁻¹·d⁻¹), low-dose group (100 µg·kg⁻¹·d⁻¹) and the control group (0 µg·kg⁻¹·d⁻¹). The ovaries were surgically removed in high-dose and low-dose groups. Four rats were sacrificed in each group at 2 and 4 weeks after surgery. Their serum estradiol levels, size of lesions, total number of mast cells and degranulations, serum TNF-α levels, expression of tryptase and NGF in tissues were analyzed and compared among groups. RESULTS: The mean levels of serum estradiol 2 weeks and 4 weeks after model established and serum TNF-α at 4 weeks in estrogen-treated groups were significantly higher than those in control group (all P<0.05). The mean size of endometriotic lesions in the estrogen-treated groups was also significantly larger than that in the control group 2 weeks and 4 weeks after model established (all P<0.05). Meanwhile, both at week 2 and week 4, the mean ratio of degranulation/total number of mast cells by toluidine blue staining in low-dose estrogen group was significantly higher than that in the control group (P<0.05). The expression of NGF in high-dose estrogen group was significantly higher than that in the control group at week 4(P<0.05). CONCLUSION: Estrogen can promote the growth of endometriotic lesions and may mediate the pathogenesis of endometriosis by activating mast cells, which may be associated with increasing TNF-α and NGF levels.

[Sodium cromoglycate attenuates experimental endometriosis in rats by regulating mast cells].

OBJECTIVE: To investigate the effect of sodium cromoglycate on experimental endometriosis in rats. METHODS: Endometriosis model was established in 36 unpregnant female SD rats by transplanting autologous fragments of endometrium to the inner surface of the abdominal wall. The endometriotic lesions were measured by a second laparotomy 2 weeks after surgery. Then the rats were randomly divided into four groups (n=8 in each group) to receive intraperitoneal injection of different doses of sodium cromoglycate for 2 weeks: high-dose group (20 mg·kg⁻¹·d⁻¹); low-dose group (10 mg·kg⁻¹·d⁻¹); the negative control group and the blank control group. The animals were sacrificed and the size of the lesions were measured. The endometriosis model of SD rats was identified by HE staining and immunohistochemical staining of keratin and vimentin. The total number of mast cells and their degranulation were measured by Toluidine blue staining; the concentrations of TNF-α in serum were measured by enzyme linked immunosorbent assay; the concentrations of estradiol in serum were measured by enzyme immunoassay; the expression of tryptase and nerve growth factor (NGF) were measured by immunohistochemical staining. RESULTS: The number of activated mast cells (MC) by Toluidine blue staining in high-dose group was significantly lower than that in negative control group (P<0.05), and its ratio of degranulation/total number of MC was significantly lower than that in negative control group or blank control group (P<0.05). The serum TNF-α levels and tryptase expression in tissues in high-dose group were significantly lower than those in negative control group or blank control group (P<0.05). However, no significant difference in the size of endometriotic lesions and expression of NGF was found among groups (P>0.05). CONCLUSION: Sodium cromoglycate can stabilize mast cells from degranulation, which may relieve the clinical symptoms of endometriosis by reducing TNF-α and tryptase levels.

[Effects of simvastatin on expression of CTGF and α-SMA in renal tubulointerstitium of rats with diabetic nephropathy].

OBJECTIVE: To investigate the effects of low-dose simvastatin on the expression of connective tissue growth factor (CTGF) and α-smooth muscle actin (α-SMA) in the renal tubulointerstitium of rats with diabetic nephropathy. METHODS: Sixty male SD rats were randomly divided into three groups: Group C (control group), Group D, in which diabetes was induced by stroptozotocin (STZ) and Group DS, in which STZ-induced diabetic rats were treated with low-dose (no cholesterol-lowering effect) simvastatin. The following parameters were measured after 6 weeks and 12 weeks in each groups, respectively: body weight and kidney weight, 24-h urinary albumin excretion (UAE), biochemical indexes including blood glucose (GLU), low density lipoprotein (LDL), high density lipoprotein (HDL), triglycerides (TG) and serum creatinine (SCr). The expression of CTGF and α-SMA in renal tubulointerstitium was assessed by immunohistochemical method. RESULT: After 6 and 12 weeks, there were no significant differences in SCr, LDL, HDL and TG levels among all three groups. The expression levels of CTGF and α-SMA in the tubulointerstitium of Group DS were significantly decreased compared with those of Group D at week 6 (P<0.05); there were no significant differences compared with Group C (P>0.05). After 12 weeks, CTGF and α-SMA expressions in Group DS were also lower than those in Group D (P<0.05); while higher than those in Group C (P<0.05). CONCLUSION: Simvastatin with a under cholesterol-lowering dose, can decrease the expression levels of CTGF and α-SMA in renal tubulointerstitium of rats with diabetic nephropathy, by which the progression of the tubulointerstitial fibrosis would be delayed.

[Meta-analysis of ultrasonography in diagnosis of deeply infiltrating endometriosis].

OBJECTIVE: To evaluate the quality of literatures and the accuracy of ultrasonography in diagnosis of deeply infiltrating endometriosis (DIE). METHODS: The database of Medline (1966 to 2009), the excerpta medica database (EMBASE, 1980 to 2009), Chinese biological medicine on disc (CBMdisc, 1978 to 2009), China national knowledge infrastructure (CNKI, 1979 to 2009) and VIP for Chinese technology periodical database (VIP, 1989 to 2009) Cochrane library of studies about the diagnosis of ultrasound for DIE were searched and analyzed. Quality assessment of diagnostic accuracy studies (QUADAS) items were used to evaluate the quality of literatures. The sensitivity, specificity, positive likelihood ratio (+LR), negative likelihood ratio (-LR), diagnostic test odds ratio (DOR) for the pooled analysis and heterogeneity test were analyzed for transvaginal ultrasonography (TVUS), transrectal ultrasonography (TRUS) and rectal endoscopic sonography (EUS) by Meta-disc software, and drew the summary receiver operating characteristic (SROC) curves for those without heterogeneity. RESULTS: Totally 15 literatures in English were enrolled into this study. The positive rate of 10 items of QUADAS were above 60%, whereas that of the 11th item "Were the reference standard results interpreted without knowledge of the results of the index test" was 46.7%; none of studies had mentioned the 13th item "Were uninterpretable/intermediate test results reported". All researches had no heterogeneity by explored threshold effect. The results of pooled sensitivity, specificity, +LR, -LR, DOR were 0.925, 0.986, 30.036, 0.107, 299.25 for TRUS, 0.799, 0.944, 11.972, 0.187, 69.126 for transvaginal ultrasonography (TVUS), and 0.635, 0.928, 8.022, 0.320, 39.606 for EUS, respectively. Area under the curve of EUS was 0.9479, and that of TVUS was 0.9246. CONCLUSIONS: TRUS, TVUS and EUS all showed optimal value in diagnosis of DIE. The bias identified from the 15 studies might be mainly resulted from reference standard review bias.

[Diagnosis and treatment of complicated interstitial pregnancy].

OBJECTIVE: To review the diagnosis and treatment of interstitial pregnancy. METHODS: Four cases with complicated interstitial pregnancy were diagnosed and treated from January, 2004 to June, 2007 at the Affiliated Obstetrics and Gynecology Hospital, College of Medicine, Zhejiang University. The clinical data and follow-up records were analyzed retrospectively. RESULTS: All 4 nulliparous patients were misdiagnosed before operation. The median age was 30 years (25-34 years), and the median duration of amenorrhea was 48 days (37-58 days). The median concentrations of serum beta-hCG were 3245.5 IU/L (282-30729 IU/L). Two patients with interstitial pregnancy had high levels of beta-hCG, and were diagnosed and treated under laparoscopy. Among them one patient was underwent transcervical curettage under laparoscopic guidance,and another underwent laparoscopic salpingotomy. The remained two patients had low levels of beta-hCG, and were diagnosed and treated under hysteroscopy, 50 mg methorexate(MTX)was injected into the implanted sites under hysteroscopic guidance. The levels of serum beta-hCG in 4 patients dropped down quickly, reaching undetected levels at a mean duration of 13 days after operation. Three months postoperatively, ultrasonic examination revealed the normal contour of uterus. CONCLUSIONS: Endoscopic examination is helpful to make a correct diagnosis, and transcervical curettage (or transcatheter chemotherapy) under laparoscopic guidance (or under hysteroscopic guidance) may be a promising approach for young or nulliparous women with interstitial pregnancy who want to maintain future fertility.

[Possibility of PTEN expression on predicting pathologic risk factors of endometrioid adenocarcinoma before operation].

BACKGROUND & OBJECTIVE: Fully estimating pathologic risk factors is important for selecting operation and predicting prognosis for endometrioid adenocarcinoma. Phosphatase and tension homology deleted on chromosome ten (PTEN), taken as the housekeeping gene of endometrium, has the highest mutation rate in endometrioid adenocarcinoma. This study was to investigate the effect of PTEN on predicting pathologic risk factors of endometrioid adenocarcinoma before operation. METHODS: Clinicopathologic data of 107 patients with endometrioid adenocarcinoma were retrospectively analyzed. The expression of PTEN was detected by SP immunohistochemistry. Correlations of PTEN to high risk factors, such as differentiation, myometrium invasion, and lymphatic metastasis, were analyzed. RESULTS: Deletion rate of PTEN was 56.1% in the 107 endometrioid adenocarcinoma patients. PTEN expression had no correlations to histological differentiation (P=0.695), myometrium invasion (P=0.921), lymphatic metastasis (P=0.682), surgical stage (P=0.750), estrogen receptor (P=0.281), and progestin receptor (P=0.260). CONCLUSION: Detection of PTEN can't predict the high risk factors of endometrioid adenocarcinoma before operation.