Chiaki Ban

Mechanism and clinical significance of elevated CA 125 levels in the sera of pregnant women

To clarify the mechanism of CA 125 elevation in maternal sera, serum levels of CA 125 and CA 19-9 were measured in 122 apparently healthy pregnant women (fifth to fortieth week of gestation) and 50 postpartum women (26 term deliveries and 24 second-trimester induced abortions). Serum levels of CA 125 showed an initial increase by the tenth week and then decreased to less than 35 U/ml, remaining below this level until delivery. However, within 1 hour after term delivery or second-trimester induced abortion, the CA 125 levels showed a second increase and decreased rapidly thereafter. In contrast, serum levels of CA 19-9 did not change significantly during these periods. Combined with our previous finding that the decidua contains abundant CA 125 but little CA 19-9, these results indicate that the elevated CA 125 levels in maternal sera originate from the decidual cells affected by chorionic invasion or the placental separation.

Adenocarcinomas arising from uterine adenomyosis: a report of four cases.

Adenocarcinomas arising from adenomyosis uteri are rare. This study reports four such cases and characterizes them clinically and microscopically. In all four patients, the endometrial cytology was negative, and MR imaging and ultrasound sonography did not detect the tumors preoperatively. The histological subtypes of the four tumors were endometrioid (one grade 1, one grade 3), serous, and clear cell. In three cases, the adenocarcinomas were present exclusively in the myometrium, and a transition between the carcinomas and the adenomyotic glands was observed in all cases. The eutopic endometrium was normal except in one case in which there was a small focus of invasive carcinoma. In two of four cases, pelvic or paraaortic lymph node metastases were present. In the carcinomas, ER immunoreactivity was not found in any tumor and PR positivity was found in only one tumor. In contrast, p53 immunopositivity was found in three of four carcinomas. Adenocarcinomas arising from adenomyosis are difficult to diagnose preoperatively, and their aggressive behavior in some cases seems to be related to the histological subtype.

Antibody Removal Therapy Used Successfully at Delivery of a Pregnant Patient with Glanzmann's Thrombasthenia and Multiple Anti‐Platelet Antibodies

Abstract. A 31‐year‐old Japanese woman with Glanzmanns thrombasthenia became pregnant voluntarily. She had had transfusions with more than 60 units for severe bleeding. She had multiple antibodies against HLA antigens and platelet glycoprotein Ilb/IIIa. No compatible platelets were available. To prevent serious hemorrhage during her delivery, antibody removal therapy was carried out three times. Large molecules including immunoglobulins were removed from more than 3 liters of plasma each time. After the titer of antiplatelet antibodies had decreased in the patients blood, antihuman globulin‐lymphocyte cytotoxicity test compatible platelets were transfused. Her bleeding time improved and delivery was induced successfully despite atonic hemorrhage of about 2,000 g of blood. Her infant had no bleeding problems. This patient is the first with Glanzmanns thrombasthenia to receive antibody removal therapy at delivery.

Immunohistochemical localization and tissue levels of tumor-associated glycoproteins CA 125 and CA 19-9 in the decidua and fetal membranes at various gestational ages.

To investigate the sources and biologic significance of CA 125 and CA 19-9 in amniotic fluid, immunohistochemical and biochemical localization of these tumor-associated glycoproteins in the decidua and fetal membranes was studied. Immunohistochemically, CA 125 and CA 19-9 were localized in the cytoplasm of decidua cells and amnion epithelial cells but not in the chorion and placental tissue. Biochemically, the 12,000 X g supernatant fractions of decidua and amnion tissues contained relatively large amounts of CA 125 and CA 19-9, 73% to 96% of which was present in the cytosolic fractions of these tissues. The CA 125 levels in the amniotic fluid decreased, whereas those of CA 19-9 increased with gestation, which correlated well with the respective levels in amnion tissues. These findings suggest that amnion cells produce and secrete these glycoproteins into the amniotic cavity. However, it is possible that the decidua also secretes CA 125 into the amniotic cavity through the chorion and amnion such as in the case of prolactin.

Ultrastructural study of minute uterine leiomyomas.

Summary:Minute uterine leiomyomas, less than 3 mm in diameter, were studied by electron microscopy. In five of 15 cases, morphologically different types of smooth muscle cell were identified. In the central region of leiomyomas, most myoma cells were characterized by filaments sporadically located in the cytoplasm and well-developed organelles. These cells were interpreted as immature smooth muscle cells. In the outer layer of nodules, the cells were a more mature form of smooth muscle cell and resembled normal myometrial cells. The differences suggest that differentiation of the smooth muscle cells occurs early in the growth of uterine leiomyoma.

Incidence of postoperative ileus after paraaortic lymph node dissection in patients with malignant gynecologic tumors.

BackgroundParaaortic lymph node metastasis is an important prognostic factor in gynecologic malignancy. However, paraaortic lymph node dissection (PAND) is not done routinely in Japan because of the difficulty of the procedure and the high incidence of complications. We performed PAND in 217 patients in a 7-year period. In the present study, we focused on the occurrence of postoperative ileus in patients who underwent PAND.MethodsTwo hundred and seventeen patients with malignant gynecologic tumors were operated on at our hospital between January 1995 and August 2001. All patients underwent PAND and pelvic lymph node dissection (114 patients had a radical hysterectomy; 103 patients had a simple hysterectomy). We evaluated postoperative ileus in three categories of severity.ResultsThe average operation time and blood loss in the patients with radical and simple hysterectomies with PAND were 317 min and 1158 g, and 246 min and 820 g, respectively. The incidence of postoperative ileus was 12.9% (28/217). Although there were no significant differences in the occurrence of ileus between patients with the radical and simple hysterectomies (10.5% vs 15.5%), the incidence of ileus in patients with radical hysterectomy with PAND was significantly higher than that in a control group of patients with radical hysterectomy without PAND (10.5% vs 3.4%). However, in the PAND patients the postoperative ileus was mostly mild or moderate (10 mild cases, 15 moderate cases, and 3 severe cases). Severe ileus occurred in three patients with radical hysterectomy with PAND. Although a repeat operation was necessary for two of these three patients with severe ileus, they recovered uneventfully.ConclusionPAND for malignant gynecologic tumors is a feasible and safe operative procedure, with a low incidence of postoperative ileus.

Extrapulmonary lymphangioleiomyomatosis in pelvic and paraaortic lymph nodes associated with uterine cancer: a report of 3 cases.

We report 3 cases of extrapulmonary lymphangioleiomyomatosis incidentally found in pelvic and paraaortic lymph nodes in association with uterine cancers. Three women, 47-year-old, 59-year-old, and 71-year-old, respectively, had uterine cancers and underwent hysterectomy, bilateral salpingo-oophorectomy, and pelvic and paraaortic lymph node excision. None of the 3 patients had tuberous sclerosis complex or lymphangioleiomyomatosis in other organs. None had any history of extrinsic hormonal administration. The postoperative pathologic diagnoses were uterine cervical squamous cell carcinoma for the first patient and endometrioid adenocarcinomas for the second and the third patients. Besides these malignant lesions, all 3 patients showed spindle cell proliferation, 2 to 5 mm in size, in 1 to 8 foci of the pelvic and paraaortic lymph nodes. The spindle cells having small polygonal nuclei and inconspicuous nucleoli with palely eosinophilic cytoplasm, reminiscent of immature smooth muscle cells, proliferated in nested and whorling patterns. Neither cellular atypia nor mitotic figures were observed. Immunohistochemically, these spindle cells were positive for α-Smooth Muscle Actin, Desmin, HMB45, Microphthalmia Transcription Factor, Estrogen receptor, and Progesterone receptor. And the network of the vascular-like channels surrounded by these spindle cells was positive for D2-40. From the pathologic and immunohistochemical findings, the spindle cell proliferation in the lymph nodes is best interpreted as lymphangioleiomyomatosis.

Adenomatoid tumor—like structures in the subperitoneal nodules produced by sex steroids

Multiple subperitoneal nodules were produced in the abdominal cavities of guinea pigs treated with various doses of estradiol benzoate for 3 months. Gland-like structures with intervening fibrous stroma were observed in 20% of these nodules. These gland-like structures resembled adenomatoid tumors, but were composed of cells that resembled mesothelium, ciliated cells, and cells with mucin in the cytoplasm. Some parts were composed of cells that had a squamous appearance. In guinea pigs, pretreatment with estradiol benzoate followed by treatment with a combination of estradiol benzoate and progesterone for 1 to 3 months produced nodules with gland-like structures similar to those produced by estrogen treatment alone. However, the gland-like structures were composed only of cells that resembled mesothelium and cells with cilia. Therefore, we conjecture that the formation of gland-like structures in the subperitoneal nodules is the result of mesothelial inclusions and their proliferation and that some of these mesothelial cells were differentiated into ciliated, mucinous, and squamous cells by estrogen.

Case of Budd–Chiari syndrome 3 months after vaginal delivery

Budd–Chiari syndrome is a rather unusual clinical situation caused by occlusion of the hepatic vein of inferior vena cava, the classical triad of which are abdominal pain, ascites and hepatomegaly. A 29‐year‐old gravida 3 para 1 woman delivered an immature male baby weighing 2172 g with an Apgar score of 9 points at 35 weeks and 3 days of gestation. She was transferred to the National Hospital Organization Osaka National Hospital 112 days after delivery due to the sudden development of massive ascites. Magnetic resonance angiography and enhanced computed tomography detected the occlusion by thrombosis of both the middle and left hepatic veins, so she was diagnosed with Budd–Chiari syndrome. Her protein C antigen and activity were 37% and 50%, respectively, corresponding to type 1 protein C deficiency. Conservative treatment by continuous oral treatment of spironolactone (25 mg/day), furosemide (20 mg/day) and prophylactic warfarin (2 mg/day) much improved the ascites.

A case of uterine cervical adenocarcinoma associated with small cell carcinoma

Extrapulmonary small cell carcinomas are often associated with carcinomas of other cell types. Although a hypothesis that extrapulmonary small cell carcinomas arise from a multipotential stem cell could explain this mixed feature, recent molecular evidence supports another possibility that the small cell component may arise as a late‐stage phenomenon in the progression of more organ‐typical carcinomas. Here, we report a case of uterine cervical adenocarcinoma containing 30% of small cell carcinoma. Adenocarcinoma was located in the endometrial side of the tumor that was adjacent to the normal cervical region, while small cell carcinoma was located in the periphery of the tumor. The transition from adenocarcinoma to small cell carcinoma was observed in the boundary area. These findings suggest that cervical small cell carcinoma can be differentiated from pre‐existing adenocarcinoma and offer further support to the hypothesis that the small cell component arises as a late‐stage phenomenon in the progression of more organ‐typical carcinomas.