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Uterine sarcoma is a very aggressive and highly lethal disease. Even after a comprehensive staging surgery or en block cytoreduction surgery followed by multimodality therapy (often chemotherapy and/or radiation therapy), many patients relapse or present with distant metastases, and finally die of diseases. The worst outcome of uterine sarcomas is partly because of their rarity, unknown etiology, and highly divergent genetic aberration. Uterine sarcomas are often classified into four distinct subtypes, including uterine leiomyosarcoma, low-grade uterine endometrial stromal sarcoma, high-grade uterine endometrial stromal sarcoma, and undifferentiated uterine sarcoma. Currently, evidence from tumor biology found that these tumors showed alternation and/or mutation of genomes and the intracellular signal pathway. In addition, some preclinical studies showed promising results for targeting receptor tyrosine kinase signaling, phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin pathway, various kinds of growth factor pathways, Wnt/beta-catenin signaling pathway, transforming growth factor β/bone morphogenetic protein signal pathway, aurora kinase A, MDM2 proto-oncogene, histone deacetylases, sex hormone receptors, certain types of oncoproteins, and/or loss of tumor suppressor genes. The current review is attempted to summarize the recurrent advance of targeted therapy for uterine sarcomas.

Uterine sarcomas account for 3–7% of all uterine cancers. Because of their rarity, unknown etiology, and highly divergent genetic aberration, there is a lack of consensus on risk factors for occurrence and predictive poor outcomes as well as optimal therapeutic choices. Tumor types according to the World Health Organization classification include leiomyosarcoma, endometrial stroma sarcoma, and undifferentiated sarcoma. Staging is done using the 2014 Federation International Gynecology and Obstetrics and 2010 American Joint Committee on Cancer tumor, lymph node, and metastases systems. Tumor grade can be classified based on the French Federation of Cancer Centers Sarcoma Group system or the Broder’s system that incorporates tumor differentiation, mitotic count, and tumor necrosis. This review is a series of articles discussing uterine sarcoma, and this is Part I, which focuses on one of the subtypes of uterine sarcomas—uterine leiomyosarcoma. The clinical characteristics, diagnosis, outcome, and recent advances are summarized in this article.

Endometrial stromal tumors are rare uterine tumors (

Heavy menstrual bleeding, or menorrhagia, is subjectively defined as a “complaint of a large amount of bleeding during menstrual cycles that occurs over several consecutive cycles” and is objectively defined as menstrual blood loss of more than 80 mL per cycle that is associated with an anemia status (defined as a hemoglobin level of

Objective: Respect for patients' autonomy is a principle issue in medical ethics. Patients' understanding of antenatal serum screening for Down syndrome upon informed consent has barely been assessed. Our objective was to evaluate pregnant women's perceived level of understanding of this serum screening. Materials and Methods: Pregnant women between the 15th and 21st gestational week were randomized into control and experimental groups, and were asked to complete a questionnaire before and after genetic counselling provided by researchers. The primary endpoints were the perceived level of understanding of serum screening for Down syndrome and the autonomy of the decision making for this serum screening. The secondary endpoints were the anxiety and depression levels of these women. Results: Participants in the experimental group (n = 96) had a significantly higher perceived level of understanding of antenatal serum screening for Down syndrome than participants in the control group (n = 97). There were significantly more respondents in the experimental group making the decision themselves to undergo serum screening than women in the control group. Anxiety and depression levels were not significantly different between the women in the two groups. Conclusion: Pregnant women should be offered more information to allow them to make an informed decision before they undergo antenatal serum screening for Down syndrome. Comprehensive genetic counseling improved pregnant women's autonomy in deciding whether to participate in serum screening. Health service providers should make effort to fulfill the ethical requirements of informed consent.

Objective: Uterine leiomyomas rarely cause pseudo-Meigs' syndrome. We describe a case of pseudo-Meigs' syndrome during pregnancy. Case Report: A 35-year-old woman (gravida 0, para 0) experienced rapid abdominal distension over a period of 1 week in the first trimester. She had had an adnexal mass of 7 × 6 cm for 5 years but continued to have regular menstrual cycles. Serial imaging showed slow progressive enlargement of the adnexal mass but serum CA-125 levels remained normal. Ultrasonography showed a large solid mass that was 25 × 20 × 20 cm in size, with a uterine gestational sac and massive ascites. Both ovaries appeared normal and a small amount of pleural effusion was detected. CA-125 levels increased to 558.11 kU/L and exploratory laparotomy was performed. During surgery, the solid mass was found to be a pedunculated leiomyoma originating from the uterine fundus, with 3,200 mL of clear yellowish ascites. Myomectomy was performed and microscopic examination showed a leiomyoma with degenerative changes. The patient received regular prenatal examinations in outpatient clinics after discharge; a healthy female baby was delivered at term. Conclusion: Pseudo-Meigs' syndrome was diagnosed when hydrothorax and ascites occurred with a pelvic mass other than ovarian fibroma. Pregnancy may aggravate the syndrome.

Objective: Ectopic pregnancy embedded in a previous cesarean section scar is rare. We report two cases of cesarean section scar pregnancy managed with conservative treatment. Case Reports: The first patient was a 39-year-old woman who presented with vaginal spotting and delayed menstruation. She had undergone two previous cesarean sections and was found to be at 5 weeks' gestation. The second patient was a 38-year-old woman with one previous cesarean section. She presented with vaginal bleeding and abdominal fullness and was found to be at 7 weeks' gestation. In both cases, cesarean section scar pregnancies were diagnosed by transvaginal sonography. Intragestational sac injection of methotrexate (MTX) 50 mg was administered under transabdominal sonographic guidance, followed by multiple doses of intramuscular MTX. Serum β-human chorionic gonadotropin levels declined gradually and reabsorption of the gestational sacs was confirmed by sonography. Conclusion: Early detection of cesarean section scar pregnancy allowed the choice of several conservative treatment options. Intragestational sac injection of MTX followed by systemic MTX was effective in terminating the ectopic pregnancy, even after a fetal heartbeat was detected.

Objective: Pure primary ovarian choriocarcinomas are very rare, and the nongestational type is even more uncommon. No definitive treatment protocol for this disease has been established due to its rarity. We report the case of a 21-year-old female with a pure primary nongestational choriocarcinoma of the ovary and her response to multidrug chemotherapy after surgery. Case Report: The patient received seven courses of postoperative chemotherapy with etoposide, methotrexate, actinomycin-D, cyclophosphamide and vincristine (EMA/CO) after suboptimal cytoreductive surgery. Serum levels of the tumor marker !-human chorionic gonadotropin (!-HCG) dramatically decreased, and no evidence of recurrence was detected. Unfortunately, the patient died of sepsis 7 months after diagnosis. Conclusion: Pure primary nongestational choriocarcinoma is believed to have a poor prognosis. EMA/CO proved to be useful in decreasing serum !-HCG levels in our patient, but more clinical experience is required in the management of this aggressive malignancy. In addition, it is necessary to closely monitor the side effects of the chemotherapy.

Objective: Laparoscopic gynecologic surgery has gained worldwide popularity in the past few years, but complications of this technique do occur. Bowel injuries, which may occur as a result of the insertion of an insufflation needle or trocar, are a rare complication of laparoscopy. They are generally recognized either immediately or within a few days postoperatively. Case Report: We present a case of laparoscopic perforation of the small bowel in a patient who had previously undergone surgery for an ectopic pregnancy and an adhesive ileus. After converting to a laparotomy, a jejunal loop adhesive to the anterior abdominal wall was discovered at the site of the trocar puncture. One puncture hiatus was observed and sutured. The follow-up was uneventful. Conclusion: The incidence of bowel injuries occurring during access and surgical procedures significantly decreases with experience. Most importantly, if trocar injury does accidentally occur, laparoscopists must be alert to the possibility, detect it early, take proper action and manage the complications to reduce morbidity and mortality.

Objective: We report two cases of lower abdominal tumor with acute bowel obstruction. Preoperatively, gynecologic tumors were considered to be the cause. However, colorectal cancer was discovered during exploratory laparotomy. Case Reports: An 81-year-old obese woman suffered from lower abdominal pain for some days, and there had been no stool passage for 2 weeks. Plain abdominal film revealed a dilated bowel lumen. A right ovarian cystic tumor was noted from pelvic sonography. The bowel obstruction was considered to be a result of external compression of the ovarian tumor. However, adenocarcinoma of the colon with lymph nodes and right ovary metastasis was confirmed by exploratory laparotomy. In the second case, a 45-year-old obese woman had problems with changed bowel habit (diarrhea and frequency) in the last 6 months. A huge uterus above the umbilicus with multiple myomas were revealed by pelvic sonography. Plain abdominal film showed a distended bowel lumen. Multiple huge exophytic myomatous masses in the uterus and metastatic adenocarcinoma to the left ovary were confirmed at laparotomy. Conclusion: Although a lower abdominal tumor with bowel obstruction can be considered to be a result of a gynecologic tumor by physical examination and sonography, colorectal cancer should be included in the differential diagnosis.

Objective: The major treatment options for immune thrombocytopenic purpura (ITP) are corticosteroids or intravenous immunoglobulin. If the patient fails to respond to medical treatment, splenectomy should be considered. Case Report: A 27-year-old pregnant woman, gravida 2, para 1, was referred to our hospital because of ITP at 35 weeks' gestation. Steroid therapy had been prescribed (75 mg/day prednisolone) since 31 weeks' gestation, but no response was observed. The patient was admitted to our ward due to premature rupture of membranes at 36 weeks' gestation, and cesarean section was performed as she had had a previous cesarean section. After delivery of the infant, splenectomy was performed as definitive therapy for her ITP. The patient's initial postoperative course was uneventful; the platelet count on the follow-up visit 6 weeks later was 109,000 cells/mL. Conclusion: ITP should be managed with steroid therapy or intravenous immunoglobulin. When these fail, splenectomy may be the only remaining option.