Cases reported "Uterine Neoplasms"

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1/10. Major hemorrhage in a patient with multiple submucous leiomyomata during the treatment of long-acting gonadotropin-releasing hormone agonist.

    Gonadotropin releasing hormone agonist (GnRH-agonist) therapy has been useful as an adjunct before myomectomy or hysterectomy for uterine myoma but the concealed risk is often overlooked. We report an extremely rare clinical presentation of a patient with multiple submucosal myomata during the treatment of long-acting gonadotropin-releasing hormone agonist (GnRH-agonist) in a 23-year-old, virgin woman. This patient exhibited heavy menstruation and severe anemia for half of a year. Ultrasound demonstrated multiple submucous myomata and intramural myomata. She received a conservative medical treatment by GnRH-agonist. The patient showed marked suppression of serum estradiol concentrations throughout treatment (< 20 pg/ml since first dose injection). The volume of the uterus decreased 21% and the total volume of the uterine myomata decreased 27% at the end of the second dose injection. However, a sudden onset of major hemorrhage occurred at the 65th day without "add-back" hormonal replacement therapy after initial therapy of GnRH-agonist. Hypovolemic shock followed soon and immediately resuscitation was performed. After resuscitation, the patient was treated with hysteroscopic myomectomy, followed by 30 ml balloon Foley catheter placement for compressing the intrauterine rough surface and hormonal replacement therapy. When uterus returned to the normal size at the end of the first week, intrauterine device was positioned and maintained for three months. The patient married four months later and got pregnant soon. Now she has a pregnancy of 22 gestational weeks. The phenomenon suggests presence of concealed and potential risk of GnRH-agonist for managing a patient with multiple submucous myomata, even though GnRH-agonist is a well-documented transient treatment for uterine myomata not only by its effect on tumor shrinkage and decreasing blood loss during the myomectomy but also by providing a time for hematological recovery. This unexpected and unwanted clinical presentation should be alerted.
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2/10. Uterine restoration after repeated expulsion of myomas after uterine artery embolization.

    A patient passed infarcted myomas 21, 27, and 35 days after uterine artery embolization. Transvaginal ultrasound examination did not reveal a myoma and her menstruation became normal with minimal bleeding. uterine artery embolization and expulsion of myomas vaginally can eliminate intramural and submucous myomas.
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3/10. Early pregnancy uninterrupted by laparoscopic bipolar coagulation of uterine vessels.

    Laparoscopic bipolar coagulation of uterine vessels (LBCUV) is reported to treat clinically symptomatic myomas that caused severe menorrhagia, but the viability of pregnancy after operation is unknown. A woman with clinically diagnosed uterine myomas, possibly with adenomyosis, had unexpected early pregnancy diagnosed at the time of LBCUV. The procedure resulted in improvement of menorrhagia to normal menstruation and reductions in the volume of both uterus and myomas. The intrauterine pregnancy was terminated at the woman's request. pregnancy may be possible after LBCUV, although none has been reported.
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4/10. Case of PSTT treated with chemotherapy followed by open uterine tumor resection to preserve fertility.

    BACKGROUND: Placental site trophoblastic tumor (PSTT) is a rare variant of gestational trophoblastic malignancy, usually seen in young women with a 20% fatality rate. The hysterectomy is general for PSTT, but hysterectomy is undesirable for patients who wish to remain fertile. Recent advancement of chemotherapy and tumor detection and assessment technologies should allow removal of tumor from the uterus by conservative surgery, without losing fertility, although very few cases have been reported to date. This report describes a young PSTT patient treated by combination chemotherapy and open uterine surgery, which resulted in an early restoration of the menstrual cycle and apparent preservation of fertility. CASE: A 26-year-old secundigravida primipara woman presented with a case of PSTT which was diagnosed 4 months after a spontaneous abortion. The tumor was confined to the uterus. Two courses of EMA/CO chemotherapy resulted in a remarkable reduction of the tumor mass, but low levels of serum beta-hCG persisted. After precise evaluation of the residual tumor by MRI and hysteroscopy, the anterior wall of the uterus was opened to resect the tumor in the posterior myometrium. An argon beam coagulator was used to evaporate the myometrium tissue surrounding the lesion. One week later, the patient had normal menstruation. MRI taken 2 weeks after the operation detected no tumor in the uterus nor uterine deformation. serum beta-hCG was reduced below the level of detection. CONCLUSIONS: Open uterine resection of PSTT tumor following appropriate chemotherapy could achieve long-term remission and save fertility of young patients who wish to avoid hysterectomy for future pregnancy.
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5/10. Cyclical haematuria sequel to uterine myomectomy: a case report.

    A thirty-year old married nulliparous lady had a difficult myomectomy done by a general practitioner one year prior to presentation. Two months after the operation, she had her menstruation, but with a concurrent total, painless haematuria. This combination continued for nine months before her family physician referred her to the urological clinic. Full urological work-up revealed an iatrogenic vesico-uterine fistula, but the features were not consistent with those of the classical vesico-uterine fistula syndrome. Transabdominal fistulectomy not only controlled the haematuria but also helped the patient to achieve a viable pregnancy.
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6/10. Vaginal expulsion of a submucosal myoma during treatment with long-acting gonadotropin-releasing hormone agonist.

    OBJECTIVE: gonadotropin-releasing hormone agonist (GnRH agonist) therapy has been useful as an adjunct before myomectomy or hysterectomy for uterine myoma. CASE REPORT: A 26-year-old woman without sexual exposure was diagnosed with a submucosal myoma and treated with long-acting GnRH agonist. This patient exhibited heavy menstruation and severe anemia for 2 years and consulted our outpatient department. Transabdominal ultrasound demonstrated a 3.5-cm submucosal myoma within the endometrial cavity. The patient showed a marked suppression of serum estradiol concentrations throughout the treatment (< 20 pg/mL at the second dose injection). The volume of the uterus and uterine myoma decreased to two-thirds of the original size at the end of the second dose injection. However, a sudden onset of severe abdominal cramping pain occurred on the 76th day and a ping-pong sized mass was expelled from the vagina. She visited our outpatient department for evaluation, where ultrasound failed to detect the previous submucosal uterine myoma. A 3-year follow-up has been uneventful. CONCLUSION: Spontaneous expulsion of submucosal myomas might occur after the administration of GnRH agonist; hence, it may be an acceptable alternative for symptomatic females without sexual exposure.
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7/10. Management of submucous uterine fibroid with buserelin, gemeprost and hysteroscopic resection.

    A 19-year-old virgin presented with severe menorrhagia and a haemoglobin level of 76 g/L as a problem of management. A 5 cm diameter submucous fibroid was identified at hysteroscopy and biopsied but was unable to be removed. The luteinising hormone releasing hormone agonist, buserelin, was used in an attempt to produce symptomatic relief. One week after commencing buserelin therapy, severe menorrhagia occurred and the patient was admitted to hospital with a haemoglobin concentration of 24 g/L. buserelin treatment was continued and no further menstruation occurred over the following year. As the patient was now well, hysteroscopic submucous fibroid resection was contemplated. Due to cervical rigidity in this teenager, a 1 mg gemeprost pessary was inserted into the posterior vaginal fornix three hours before surgery. This allowed an operative hysteroscope to be inserted into the uterus and a fibroid resection to be performed. Menstrual blood loss has been normal for six months after hysteroscopy. A combined medical and surgical approach may avoid hysterectomy in such problem patients.
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8/10. endometriosis in association with uterine anomaly.

    endometriosis is frequently a chronic process, which may begin soon after menarche. The process may be enhanced by mechanical obstruction. Theories of retrograde menstruation and metaplasia still remain in vogue. endometriosis is a cause of both acute and chronic pelvic pain in the adolescent. We present case reports of mullerian lateral wall fusion defects with surgical correction and evidence for resorption of endometriosis. Clinicians must be aware that patients with uterine anomalies may develop extensive endometriosis, which upon creation of an unobstructed outflow tract results in complete resorption. Furthermore, the mechanism of formation of endometriosis in association with an outflow tract obstruction may be very different from that associated with infertility. We recommend consideration of endometriosis and/or a reproductive tract abnormality in the adolescent with persistent pelvic pain.
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9/10. Iatrogenic endometriosis: substantiation of the Sampson hypothesis.

    A 31-year-old woman developed unilateral endometriosis at the site of ovarian implantation to a uterine window. This complication of the Estes procedure resembles the experimental endometriosis induced in rhesus monkeys by causing intraabdominal menstruation. This adds support to the Sampson hypothesis of endometriosis development.
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10/10. Extensive iatrogenic adenomyosis after laparoscopic myomectomy.

    OBJECTIVE: To report a case of iatrogenic adenomyosis as a result of not reconstructing the uterine wall during a laparoscopic myomectomy. DESIGN: Retrospective case report. SETTING: University hospital. PATIENT(S): A 34-year-old woman, gravida O, had been referred to our institution for medical care. A laparoscopic penetrating leiomyomata uteri was removed 8 months before this hospital admission. Approximately 3 months after the initial laparoscopic myomectomy, she began experiencing pelvic pain in the middle low abdominal area, more accentuated in the second phase of the menstrual cycle, with peak pain during menstruation. The pain became progressively worse. Microcytic-hypochromic anemia secondary to menorrhagia was documented. Flexible office hysteroscopy, contrast ultrasonography, and magnetic resonance imaging (MRI) results suggested the presence of focal adenomyosis. INTERVENTION(S): Eight months after the initial laparoscopic myomectomy, the patient underwent a second-look laparoscopy to excise the visual uterine wall defect and reconstruct laparoscopically the layers of the uterine wall. MAIN OUTCOME MEASURE(S): Uterine wall histopathology and menstrual history. RESULT(S): Resolution of patient's pain, resumption of normal menses, and secondary anemia was ameliorated. CONCLUSION(S): Suturing the myometrium in layers during a laparoscopic myomectomy is necessary to prevent iatrogenic adenomyosis.
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