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Endometriosis is a chronic, estrogen-dependent, inflammatory disease that mainly affects women of reproductive age and is defined by the presence of endometrial glands and stroma at ectopic sites. Spontaneous hemoperitoneum due to bleeding of pelvic endometriotic foci represents a very rare and severe complication of endometriosis, although most cases described in literature regard pregnant women. We hereby present a case of a severe hemoperitoneum in a non-pregnant, 42 years old woman, under dienogest therapy for deep endometriosis. This life-threatening condition was promptly managed by performing an exploratory laparoscopy where the source of bleeding was found and hemostasis successfully achieved.Bleeding from pelvic endometriotic foci ought to be considered in the differential diagnosis of gynecological causes of acute abdomen and hemoperitoneum, even under medical therapy.

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BACKGROUND: Ovarian tumours are usually surgically removed because of the presumed risk of complications. Few large prospective studies on long-term follow-up of adnexal masses exist. We aimed to estimate the cumulative incidence of cyst complications and malignancy during the first 2 years of follow-up after adnexal masses have been classified as benign by use of ultrasonography. METHODS: In the international, prospective, cohort International Ovarian Tumor Analysis Phase 5 (IOTA5) study, patients aged 18 years or older with at least one adnexal mass who had been selected for surgery or conservative management after ultrasound assessment were recruited consecutively from 36 cancer and non-cancer centres in 14 countries. Follow-up of patients managed conservatively is ongoing at present. In this 2-year interim analysis, we analysed patients who were selected for conservative management of an adnexal mass judged to be benign on ultrasound on the basis of subjective assessment of ultrasound images. Conservative management included ultrasound and clinical follow-up at intervals of 3 months and 6 months, and then every 12 months thereafter. The main outcomes of this 2-year interim analysis were cumulative incidence of spontaneous resolution of the mass, torsion or cyst rupture, or borderline or invasive malignancy confirmed surgically in patients with a newly diagnosed adnexal mass. IOTA5 is registered with ClinicalTrials.gov, number NCT01698632, and the central Ethics Committee and the Belgian Federal Agency for Medicines and Health Products, number S51375/B32220095331, and is ongoing. FINDINGS: Between Jan 1, 2012, and March 1, 2015, 8519 patients were recruited to IOTA5. 3144 (37%) patients selected for conservative management were eligible for inclusion in our analysis, of whom 221 (7%) had no follow-up data and 336 (11%) were operated on before a planned follow-up scan was done. Of 2587 (82%) patients with follow-up data, 668 (26%) had a mass that was already in follow-up at recruitment, and 1919 (74%) presented with a new mass at recruitment (ie, not already in follow-up in the centre before recruitment). Median follow-up of patients with new masses was 27 months (IQR 14-38). The cumulative incidence of spontaneous resolution within 2 years of follow-up among those with a new mass at recruitment (n=1919) was 20·2% (95% CI 18·4-22·1), and of finding invasive malignancy at surgery was 0·4% (95% CI 0·1-0·6), 0·3% (<0·1-0·5) for a borderline tumour, 0·4% (0·1-0·7) for torsion, and 0·2% (<0·1-0·4) for cyst rupture. INTERPRETATION: Our results suggest that the risk of malignancy and acute complications is low if adnexal masses with benign ultrasound morphology are managed conservatively, which could be of value when counselling patients, and supports conservative management of adnexal masses classified as benign by use of ultrasound. FUNDING: Research Foundation Flanders, KU Leuven, Swedish Research Council.

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Ascites, adnexal mass and elevated CA125 levels almost always suggest advanced ovarian carcinoma. We present a case of a 37 years old multiparous lady who presented with such a classical picture. Radiological picture was suggestive of ovarian carcinoma with peritoneal metastasis. However, ascitic fluid cytology was negative for malignant cells. A differential diagnosis of tubercular mass was made. Ascitic fluid was sent for adenosine deaminase test that was negative. Fine needle aspiration cytology failed to reveal any sufficient sample for evaluation. Open laparotomy and biopsy was done that showed granulomas suggestive of tuberculosis. Category one anti tubercular treatment was started and symptoms resolved within one month.

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BACKGROUND: Malignant mixed Mullerian tumours (MMMTs) of the uterus and adnexa represent aggressive gynaecologic malignancies with a high rate of loco-regional and distant failure. For that reason, we evaluated the paclitaxel-ifosfamide-carboplatin (TICb) combination in patients with advanced MMMTs. METHODS: Female patients with advanced MMMTs, WHO-PS 0-2, no prior chemotherapy for systemic disease, unimpaired haemopoietic and organ function were eligible. Chemotherapy was administered at the following doses; paclitaxel: 175 mg m(-2) on day 1, ifosfamide: 2.0 g m(-2) day(-1)--days 1 and 2, and carboplatin at a target area under the curve 5 on day 2, with prophylactic G-CSF from day 3. RESULTS: Forty patients of a median age 61 (45-72) years, performance status 0-2 with advanced MMMTs of the uterus (n=34), tubes (n=2) or ovary (n=4) have entered and all were evaluable for response and toxicity. Responses were as follows: 27 out of 40 (67.5%) evaluable patients responded, with 11 complete responses and 16 partial responses, while 10 had stable disease, and 3 developed progressive disease. The median response duration was 9 months (range, 4-40 months), median progression-free survival 13 months (range, 3-42 months), while median overall survival 18 months (range, 4-48 months). Grade 3/4 neutropenia was recorded in 22 out of 40 (55%)--with 13 developing grade 4 (≤7 days) and 7 out of 40 (17.5%) of patients at least one episode of febrile neutropenia. CONCLUSION: In this study, it appears that the TICb combination, yielded important activity with manageable toxicity in females with advanced MMMTs warranting further randomised comparison with current standard regimens.

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CONTEXT: There are few reports on the management of extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type (MALT), which are based on the experience of a single institution, as opposed to large multicenter randomized trials. AIM: The aim of this study was to report on the clinical experience of a single institution. MATERIALS AND METHODS: A retrospective review was undertaken of records of 95 patients with MALT lymphoma of the ocular adnexa. Histologic diagnosis of MALT lymphoma was made according to established criteria, and clinical staging was carried out to determine treatment modalities. All patients were treated by external beam irradiation (30.6-45.0 Gy) after biopsy. Additional chemotherapy was performed in accordance with the clinical stage of the disease. All the patients were treated by the same hemato-oncologist and radio-oncologist. RESULTS: Almost all patients showed complete response, except for four patients who showed partial response. In two of 95 patients, contralateral eye showed recurrence, and they were salvaged by additional radiotherapy. The 3-year overall survival and event-free survival rates were 100 and 97%, respectively, by Kaplan-Meier survival analysis. Moreover, there were no serious radiation-associated complications. CONCLUSIONS: Radiotherapy alone can be an important treatment modality for the local control and survival in patients with localized MALT lymphoma of ocular adnexa. Systemic chemotherapy should be considered in patients with advanced stage disease.

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Image-guided core biopsy of the omentum and peritoneum was described a decade ago and has since been validated in a number of large studies as a safe and effective means of providing a tissue diagnosis in patients with undiagnosed peritoneal disease. Some studies have addressed its ability for determining whether peritoneal infiltration and/or omental masses in patients with prior malignancy represent recurrent disease or a new disease process. Others have focused on the specific issue of women suspected to have advanced peritoneal carcinomatosis from ovarian or primary peritoneal cancer where the primary management of the patient is directed by the tissue diagnosis. The initial management of many of these women, especially those with advanced disease or substantial comorbidity, is with primary chemotherapy. With current clinical trials for ovarian cancer directed to specific morphological subtypes of the disease, image-guided core biopsy offers a rapid and well tolerated nonsurgical means of providing this information. In this Review, we discuss the technique and its clinical applications, and critically examine the currently available alternative options.

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Salmonella sp is a significant cause of morbidity and mortality. Although commonly infecting the gastrointestinal system, other presentations are not unheard of. Salmonella is an unlikely and an unusual cause of genital tract infection. We describe a woman with suspected pelvic inflammatory disease eventually confirmed as Salmonella O C2 infection.

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OBJECTIVE: To investigate the effects of genistein on reperfusion injury in a rat ovarian torsion-detorsion model. DESIGN: Controlled experimental study. SETTING: University animal research laboratory. SUBJECT(S): Thirty-two Wistar-Albino rats. INTERVENTION(S): The rats were divided into four groups. Sham operation was performed in group I. In group II, 5 mg/kg genistein was given intraperitoneally (IP) during laparotomy, and right ovaries were removed 4 hours later. In group III, right ovaries were subjected to 4 hours of adnexal ischemia by use of vascular clips, and after ischemic insult, 4 hours of reperfusion was maintained by removing the clips. In group IV, after the ischemic period, 5 mg/kg genistein was given IP, and 4 hours of reperfusion was maintained. Right ovaries were surgically removed at the end of the procedure in each group. MAIN OUTCOME MEASURE(S): Ovarian histopathologic findings were scored and compared among study groups. Serum and ovarian tissue malondialdehyde (MDA), glutathione peroxidase, and superoxide dismutase, levels were measured. RESULT(S): Ovarian tissue damage scores were significantly different among groups and were seen to correlate with ovarian tissue MDA levels. Genistein significantly decreased the tissue damage scores, ovarian tissue MDA levels, and serum MDA levels. CONCLUSION(S): Genistein attenuates ischemia-reperfusion injury in rat adnexal torsion-detorsion model.

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OBJECTIVES: Pulmonary edema has been shown to occur following ischemia-reperfusion injury in a variety of organs and effects of several pharmacological agents on ischemia-reperfusion-induced damage has been investigated previously. However, there are only a few studies in the literature about pulmonary injury following adnexial ischemia-reperfusion. In this study we aimed at investigating pulmonary changes following adnexial ischemia-reperfusion and the effects of melatonin on noncardiogenic pulmonary edema secondary to adnexial ischemia-reperfusion. METHODS: A total of 32 Dunkin-Harley guinea pigs were randomly divided into four groups. In group I, oopherectomy was performed following adnexial torsion of three hours (ischemia). Adnexial torsion of three hours followed by a 3 hours detorsion period (reperfusion) and then oopherectomy was performed in remaining three groups. No therapy was given in group one and two while isotonic saline and melatonin was applied intraperitoneally in groups three and four, respectively. Serum malondialdehyde (MDA) levels of operated ovaries and lungs and polimorphonuclear leucocyte infiltration of lungs were determined. RESULTS: MDA levels in serum, ovary and lungs were higher in detorsion groups (groups II, III) than torsion group (group I) (p<0.01). Melatonin administration significantly decreased the polimorphonuclear leukocytes infiltration of lung parenchime and MDA levels in serum, ovaries and lungs (groups II and IV; groups III and IV; p<0.01, p<0.01). MDA levels and lung tissue PNL infiltration levels of melatonin administered detorsioned group was similar to those levels of only salphingo-oopherectomy performed group (Group I and IV, p>0.05). CONCLUSION: Pathophysiology of ischemia-reperfusion must be considered in the cases of adnexial torsion where detorsion is thought. As an antioxidant, melatonin administration might be helpful in decreasing post-operative morbidity by decreasing reperfusion injury of lungs.

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Following identification of the proportion of pelvic congestion among symptomatic patients complaining of chronic pelvic pain, and in a totally asymptomatic group of patients requesting tubal ligation, the efficiency of goserelin acetate versus medroxyprogesterone acetate was compared objectively using pelvic venogram scores, and subjectively by symptom resolution, improvement of psychological status and sexual functioning in a prospective randomized trial in 47 patients with pure pelvic congestion syndrome. Patients received either goserelin acetate (3.6 mg/month for 6 months) or medroxyprogesterone acetate (MPA; 30 mg/day for 6 months). Among patients with chronic pelvic pain, those with pure pelvic congestion were mostly parous, had the most severe pelvic signs and symptom scores, lowest rates of sexual functioning, and higher states of anxiety and depression as compared with others. At 1 year after treatment, goserelin remained superior to MPA in terms of pelvic venographic improvement as an objective measure. In alleviation of signs and symptomatology, improvement of sexual functioning and reduction of anxiety and depressive states as subjective measures, goserelin acetate achieved a statistically significant advantage (P = 0.0001) compared with MPA.

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The occurrence of pelvic inflammatory disease and tubo-ovarian abscesses previously has been regarded as essentially nonexistent in the patient who has undergone tubal sterilization, although there have been isolated reports in the literature. This case describes a patient who underwent tubal ligation approximately 6 years prior to presenting with bilateral ruptured tubo-ovarian abscesses. The patient underwent emergency surgery and had an uneventful recovery. Theoretically, although bilateral tubal ligation should preclude the development of pelvic inflammatory disease, it is a diagnosis that should be considered in the patient presenting with lower pelvic and abdominal pain.

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We report 2 patients with pelvic-peritoneal tuberculosis and elevated serum and peritoneal fluid levels of Ca-125. The first was a young and infertile women who had cul-de-sac nodularity and dysmenorrhea. The other was postmenopausal and presented with weight loss and ascites. While a preoperative diagnosis of endometriosis was made in the former, intraperitoneal malignancy was considered in the latter. The diagnosis of pelvic-peritoneal tuberculosis was reached by laparoscopic-directed biopsy in both patients. Serum levels of Ca-125 returned to normal limits following antituberculous drug treatment.

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By means of the serum level of estradiol and the vaginal smear indexes the antigonadotropic activity of the preparation Danoval (2-3-isoxasol-17-ethinyltestosterone) is indirectly evaluated on 15 infertility patients with laparoscopic proved endometriosis. After 5 month's course of treatment with 400 mg daily the level of estradiol decreased from 1.54 to 0.31 nmol/l, IA from 20.8 to 10.4 and IP from 32 to 17.3. The side effects are slight and descend from the pharmacological properties of the preparation. Two patients became pregnant in three months after the treatment.

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A series of 201 cycles of ovarian hyperstimulation syndrome (OHSS) in 154 women were reviewed. Pregnancy occurred in 75 of 201 cycles. Twelve pregnant women (16%) presented with torsion of hyperstimulated ovary, but only 3 out of 126 patients (2.3%) who did not conceive had torsion. Because diagnosis of adnexal torsion is usually uncertain and surgical intervention is likely to be delayed, these infertile women risk losing their ovaries. The clinical picture of torsion of adnexa in patients with OHSS is presented here. The combination of ovarian enlargement, abdominal pain, nausea, progressive leukocytosis, and anemias might indicate torsion of adnexa. Although during operation the adnexa appears dark, hemorrhagic and ischemic, we suggest that it can be saved by simply unwinding it. In 11 such cases intraoperative unwinding of the adnexa was performed, and in 8 patients it was the only operative procedure. No postoperative complications were noted and in all the cases the ovaries were proven functional by ultrasonography. We concluded that torsion of hyperstimulated adnexa in patients who conceived after gonadotropin therapy, is a special entity that requires more attention to achieve early diagnosis. Nevertheless even with delayed diagnosis, the ovary can still be saved.

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