To the Editor: Pediatric and adolescent gynecology (PAG) is a specialized branch of gynecology that focuses on reproductive health issues of women from infancy to adolescence.[1] In 1939, the Hungarian Dobszay first established the new branch. Since then, the PAG subject has begun to develop and gradually matured in the past 80 years. While PAG has witnessed significant development in western countries, a substantial unmet need persists in addressing specific health concerns among children and adolescents with gynecological disorders. In China, where the PAG discipline is still in its infancy, this situation becomes even more critical. The diseases young females experience in the gynecological field have own particularities.[1] Also, PAG shares connections with various medical disciplines, notably surgery. Investigating the inpatient disease spectrum, prevalence rates, and clinical characteristics of PAG surgical disorders is of significant clinical importance, yet no previous research has addressed this in China or other countries. Therefore, the study retrospectively analyzed the clinical data of 512 PAG inpatients aged 0–18 years who received surgical treatment at Peking University First Hospital (PKUFH) from January 2010 to May 2022, so as to comprehensively outline the inpatient disease spectrum and clinical characteristics of surgical disorders in PAG, with the aim of offering management recommendations and evidential support for future clinical work. The study was approved by the Institutional Review Board of PKUFH (No. 2022[593]) and informed consent was waived due to the retrospective nature of the study. Non-normally distributed quantitative variables are shown as median (Q1, Q3), and categorical variables as count and percentage. Comparison tests were performed using chi-square test and Fisher's exact test. The median (Q1, Q3) age of PAG surgical inpatients in the study was 16 (14, 18) years old. The youngest patient identified was a newborn diagnosed prenatally with an abdominal cyst measuring an average diameter of 72.5 mm. Merely 19 hours after birth, she underwent a laparotomy to remove a left ovarian cyst, which was later pathologically identified as a simple ovarian cyst. Within the study population, there were 32 patients (32/512, 6.25%) aged between 0 and 8 years, 133 patients (133/512, 25.97%) aged between 9 and 14 years, and 347 patients (347/512, 67.78%) aged between 15 and 18 years. Notably, adolescents who had entered puberty comprised the primary population affected by PAG diseases. The spectrum of surgical diseases among PAG inpatients encompasses various conditions, including adnexal masses (299/512, 58.39%), unwanted pregnancy (188/512, 36.72%), genital tract trauma (4/512, 0.78%), inguinal (4/512, 0.78%), retroperitoneal masses (4/512, 0.78%), abnormal uterine bleeding (AUB) (3/512, 0.59%), congenital uterine anomalies (3/512, 0.59%), uterine tumors (3/512, 0.59%), vaginal foreign bodies (3/512, 0.59%), and cervical tumors (1/512, 0.19%). Surgical interventions were performed for all patients included in the study. Adnexal masses emerged as the most prevalent cause necessitating hospitalized surgical treatment among PAG patients. The median age of patients diagnosed with adnexal masses was 15 (13, 17) years old. The age distribution shown in Table 1 underscores the higher prevalence of PAG adnexal masses in adolescents. The common types of adnexal masses included ovarian germ cell tumors (114/299, 38.13%), ovarian epithelial tumors (78/299, 26.09%), and paratubal cysts (75/299, 25.08%). These findings align with data from other PAG populations.[2] However, occurrences of ovarian sex cord stromal tumors, endometriotic cysts, and corpus luteum cysts were relatively rare. Previous research indicated that among masses requiring surgery, approximately 4–20% were malignant, constituting 1% of all pediatric malignancies.[3] In this study, the malignancy rate stood at 4.68% (14/299), with ovarian germ cell tumors exhibiting the highest malignancy rate (12/114, 10.53%) [Table 1]. Table 1 - Characteristics of adnexal masses in PAG. Type of adnexal masses Cases (N = 299) Age (years) Age distribution Overweight and obesity Menarche Elevated tumor markers† Tumor size >10 cm Malignancy 0–8 years 9–14 years 15–18 years Ovarian germ cell tumor 114 (38.1) 15 (12.0, 17.0) 12 (10.53) 39 (34.21) 63 (55.26) 40 (35.09) 91 (79.82) 40 (35.09) 18 (15.79) 12 (10.53) Ovarian epithelial tumor 78 (26.09) 15 (13.0, 17.0) 3 (3.85) 30 (38.46) 45 (57.69) 31 (39.74) 71 (91.03) 13 (16.67) 19 (24.36) 0 Ovarian sex cord stromal tumor 8 (2.7) 14.5(12.5, 16.0) 0 4 (50.00) 4 (50.00) 4 (50.00) 7 (87.50) 3 (37.50) 2 (25.00) 2 (25.00) Paratubal cyst 75 (25.08) 14 (13.0, 17.0) 0 38 (50.67) 37 (49.33) 44 (58.67) 74 (98.67) 3 (4.00) 7 (9.33) 0 Endometriotic cyst 10 (3.34) 18 (17.0, 18.0) 0 1 (10.00) 9 (90.00) 0 10 (100.00) 5 (50.00) 1 (10.00) 0 Corpus luteum cyst 6 (2.01) 15 (12.0, 15.0) 0 2 (33.33) 4 (66.67) 1 (16.67) 6 (100.00) 0 0 0 Others* 8 (2.68) 12 (4.5, 14.5) 3 (37.50) 3 (37.50) 2 (25.00) 1 (12.50) 3 (37.50) 1 (12.50) 0 0 Total 299 15 (13.0, 17.0) 18 (6.02) 117 (39.13) 164 (54.85) 121 (40.47) 262 (87.63) 65 (21.74) 47 (15.72) 14 (4.68) Data were presented as n (%) and median (Q1, Q3). *Others include ovarian follicular cyst, mesothelial cyst, simple cyst, and ovarian edema. †Tumor markers included CA125, CA199, CA153, AFP, SCC, HE4, hCG, and NSE. One or more elevated tumor markers detected was defined as "elevated." AFP: Alpha-fetoprotein; HE4: Human epididymis protein 4; hCG: Human chorionic gonadotropin; NSE: Neuron-specific enolase; PAG: Pediatric and adolescent gynecology; SCC: Squamous cell carcinoma antigen. Among PAG patients diagnosed with adnexal masses, 40.47% (121/299) were classified as overweight or obese. The prevalence of overweight and obesity among paratubal cysts was the highest, reaching 58.67% (44/75), followed by sex cord stromal tumors, epithelial tumors, and ovarian germ cell tumors. Conversely, endometriotic cysts and corpus luteal cysts were more commonly observed in adolescents with normal body weight. Compared to the 2020 report on Chinese residents, showing 11.1% overweight and 7.9% obesity rates among 6–17-year-olds, overweight and obesity are significantly higher in PAG patients with adnexal masses in the study than in the general population. Recent epidemiological studies have presented the correlation between obesity and ovarian cancer, which may be related to the increase of estrogen, insulin, and insulin-like growth factor levels caused by body fat accumulation.[4] Previous investigations have also observed the correlation between paratubal cysts and obesity. The mechanism could be the activation of WNT/CTNNB1 (wingless-related mouse mammary tumor virus (MMTV) integration site gene family/beta-catenin 1) signal pathway, which awaits further studies. The results highlight the significance of weight management during the initial stages of the female life cycle. The most prevalent initial symptom observed in PAG patients with adnexal masses was abdominal pain, encompassing both chronic and acute abdominal discomfort. Immediate assessment of children and adolescents with adnexal masses and abdominal pain is essential to identify serious complications like adnexal torsion or tumor rupture, which could result in ovarian necrosis or intraperitoneal hemorrhage. In our study, surgical confirmation revealed that 17.73% of the adnexal masses experienced torsion, with 13 cases (24.53%) necessitating adnexectomy due to ovarian ischemic necrosis. Earlier research has indicated a higher likelihood of torsion occurrence when the tumor diameter exceeds 5 cm.[2] Notably, our study established a statistical correlation between the risk of tumor torsion and tumor size (χ2 = 6.20, P = 0.045). Specifically, tumors ranging from 5 to 10 cm bore the highest torsion risk at 21.82% (36/165). However, no statistically significant correlation was found between tumor size and malignancy risk (χ2 = 1.99, P = 0.37). Preserving fertility and ovarian function should remain the primary objective for this demographic. Hence, early diagnosis is imperative to mitigate the risk of ovarian torsion and to enhance prognosis. Second to adnexal mass, the proportion of unwanted pregnancy was 36.72% (188/512). The rate of adolescent pregnancy has been steadily declining over the last 10 years.[5] In the US, the 2020 birth rates for teenagers aged 15–17 years and 18–19 years were respectively down 6% and 7% from 2019. Nevertheless, the number is still terrifying and remains a significant public health concern. Adolescent pregnancy increases the risk of complications like preeclampsia, preterm birth, and infant mortality. It can negatively affect the health development of young mothers, including potential infertility from induced abortions and higher sexual transmitted infection exposure from unprotected sex.[5] In Beijing's well-educated region, Unwanted pregnancies still lead to significant adolescent gynecologic surgeries, underscoring the urgent need for effective prevention. This includes delaying sexual activity, and promoting reliable contraceptive use. AUB is a common menstrual symptom among female adolescents. The average menarche age in well-nourished populations is around 12–13 years, with irregular cycles common in the initial 2–3 years.[6] Up to 95% of adolescents with AUB experience ovulatory dysfunction due to an immature hypothalamic-pituitary-ovarian axis. Treatment focuses on preserving fertility, with medical therapy as the primary approach. Despite menstrual disorders being common in adolescents, most are managed with medical treatment and outpatient follow-up. Only a few, with severe symptoms like heavy bleeding and anemia, require hospitalization for surgical intervention. The study's three AUB cases, treated with either hysteroscopy, curettage, or a levonorgestrel intrauterine device, highlight that adolescent AUB seldom necessitates surgery. Thus, medical treatment is preferred for adolescent AUB, reserving surgery for critical situations.[6] The study included three PAG cases with uterine anomalies requiring surgery, even though uterine anomalies are relatively common in the general population, with a prevalence of 3.2–5.5%. Most cases do not need surgical intervention in youth. Surgery in adolescence, such as for a hemi-uterus with a non-communicating functional rudimentary cavity, is very rare. Surgical treatment for uterine anomalies is typically reserved for childbearing years due to infertility, menorrhagia, or pelvic masses, highlighting the difference in gynecological disease management between children/adolescents and adults. The PAG surgical spectrum also covered rare cases like genital tract trauma, inguinal and retroperitoneal masses, vaginal foreign bodies, and uterine and cervical tumors. Such conditions are infrequent and sporadic, with surgery being the recommended treatment. In conclusion, PAG is an essential aspect of women's health throughout their life cycles. The most prevalent surgical disease is adnexal mass and its symptoms are mainly acute or chronic abdominal pain. It is imperative for medical professionals and society at large to prioritize health education for underage women, facilitate physical examinations, and promote healthy lifestyles and weight management. These efforts are essential for enhancing reproductive health and overall quality of life as these individuals transition into adulthood. Conflicts of interest None.

To editor: Uterine myomas are the most common benign tumors of the female reproductive system, with a reported prevalence of 0.1% to 3.9% during pregnancy.1 Among these, 10% to 30% cause severe pregnancy complications including miscarriage, placenta previa, fetal growth restriction, preterm labor, fetal malpresentations, and postpartum hemorrhage related to the number, volume, and location of myomas.2,3 Uterine myomas are usually asymptomatic but occasionally may cause acute abdominal pain secondary to pedunculated myoma torsion or compression of urinary and gastrointestinal organs. Although conservative treatment is considered as golden standard, surgery is not routinely recommended because of the risks of severe hemorrhage, pregnancy loss, preterm labor, and uterine rupture. However, in cases with torsion of pedunculated myoma or persistent symptoms not responding to conservative treatment, myomectomy should be considered.4,5 Since Lucas et al.6 first reported laparoscopic myomectomy during pregnancy in 1994, the major advantages of this minimally invasive approach, including minor postoperative pain and quick recovery, have been widely accepted. We present two cases of successful laparoscopic myomectomy during pregnancy and literature reviews to investigate the application of laparoscopy in the diagnosis and treatment of pregnancy complicated with uterine myomas. The patients' informed consents were obtained. Case 1 A 34-year-old woman at 15 weeks of gestation presented to the emergency room with progressive abdominal pain localized to the right lower quadrant. Upon examination, a hard and tender mass was palpable on the right lower quadrant. The ultrasound confirmed multiple uterine myomas, and the largest one was pedunculated on the right anterior wall measuring 83 mm × 71 mm × 56 mm. The patient's condition did not resolve after 24 hours of conservative treatment, consisting of bed rest (the rest cure) and antibiotic therapy (cefuroxime). Because of the persistent symptoms, the decision was made to perform a laparoscopic myomectomy. The first trocar was placed 10 cm above the fundus of the uterus with the open Hasson technique, and the intra-abdominal pressure was achieved at 12 mm Hg. Two ancillary trocars were placed under laparoscopic vision on the right and left sides of the umbilicus. An 8-cm pedunculated myoma was detected on the right anterior wall of the uterus with a pedicle of 3 cm twisted for 180 degrees. The pedicle was ligated with double Roeder knots and resected by the ultrasonic scalpel. Following coagulation with bipolar forceps, reconstruction of the uterine wall was carried out using a double-layered Vicryl suture. The operating time was 78 minutes, of which 30 minutes was required for morcellation. The specimen was placed in a self-made bag, and a morcellator was used inside the bag to minimize spillage. No intraoperative complications occurred. Perioperative fetal examination turned out normal. No urinary catheter was indwelled, and the patient urinated well 2 hours after surgery. The patient went back to a semiliquid diet 6 hours after surgery and transited to a full diet the next day. The patient was discharged 72 hours after surgery with a complete resolution of the symptoms. A pathological examination confirmed the diagnosis of a 165-g myoma with red degeneration. At the 40th gestational week, the patient delivered a healthy female infant weighing 3470 g via cesarean section because of fetal distress during the first stage of labor. Apgar score was all 10 at 1 and 5 minutes. During the cesarean section, a 4-cm subserous myoma was resected on the anterior wall. We found evidence of the previous myomectomy, but no structural defect was observed. The postoperative course was uneventful. Case 2 A 31-year-old woman presented to the emergency room at 20 weeks of gestation complaining of abdominal heaviness and frequent urination. The ultrasound showed uterine myoma with a diameter of 4 cm in her first trimester. Upon examination, a hard mass was palpable in the right lower quadrant. The ultrasound revealed a pedunculated myoma measuring 68 mm × 49 mm × 39 mm in the right anterior wall. The initial treatment was conservative including bed rest, antibiotics (cefotiam), and tocolytic therapy (indomethacin). Because of the worsening of these symptoms after 72 hours of medical treatment, likely related to a significant increase in the size of the myoma and possible degeneration, the decision was made to perform a laparoscopic myomectomy with the patient's consent. We observed a 7-cm pedunculated myoma protruding from the right anterior wall on a 4-cm stalk (Fig. 1). The myoma was removed using the same procedures described in case 1 (Fig. 2). The operating time was 83 minutes, of which 25 minutes was required for enclosed morcellation. No surgical complications occurred. The perioperative fetal examination turned out normal. Hospitalization lasted for 7 days including antibiotic and tocolytic therapy. The pathological examination confirmed the diagnosis of a 70-g myoma with hyaline degeneration and necrosis in many areas (Fig. 3). At the 38th gestational week, the patient spontaneously delivered a male infant weighing 3195 g. Apgar score was all 10 at 1 and 5 minutes. The postpartum recovery went well.Figure 1: Laparoscopic feature of the pedunculated myoma protruding from the right anterior wall.Figure 2: Uterine wall was reconstructed by Vicryl suture.Figure 3: Pathology picture of the degeneration area of the myoma section (hematoxylin-eosin stain, original magnification ×100).Discussion Although the treatment of uterine myomas during pregnancy tends to be conservative, in some cases, surgery cannot be postponed. The main indications are rapid growth of myomas suspected for malignancy or resulting in compression of other pelvic organs, acute abdominal pain caused by red infarction or torsion of pedunculated myomas not responsive to conservative therapy.7–11 Laparotomy or laparoscopic surgery can be determined by the volume and location of the myomas, the patient's physical condition, and the surgeon's experience.9 The two cases reported in this article were in the second trimester of pregnancy, the abdominal cavity was relatively sufficient, and the myomas were both single and pedunculated; surgeries performed by experienced surgeons could not only reduce intraoperative blood loss and postoperative pain but also promote earlier mobilization to avoid thromboembolism and achieve quick recovery. To date, we found 14 cases of laparoscopic myomectomy during pregnancy reported from 1994 to 2015.6–8,10,12–19 All cases reported acute abdominal pain as the main surgical indication. The gestational age at diagnosis ranged from 10 to 25 weeks. The largest diameter of the myomas measured from 5 to 24 cm with a weight of up to 1500 g. The operation time ranged from 39 to 150 minutes, and the carbon dioxide pressure was maintained at less than 10 to 14 mm Hg. No cases of intraoperative complications were reported. In 10 cases, the delivery modes were mentioned, and in 5 cases, vaginal delivery was reported. We concluded that the basic principles required for laparoscopic myomectomy during pregnancy were as follows12,20: (1) The operation should be performed by experienced surgeons. (2) The open Hasson technique is preferred for entrance to the peritoneal cavity. The insertion site should be adjusted according to the fundal height and location of myomas, and the accessory trocars should be placed under visualization. (3) CO2 insufflation of 10 to 15 mm Hg can be safely used. However, try to keep the CO2 pressure at less than 12 mm Hg if adequate visualization is maintained. (4) Patients should be placed in the left lateral recumbent position and minimize the degree of inclination to avoid maternal hypotension and improve placental perfusion. (5) Minimize manipulation of the uterus to avoid severe hemorrhage. (6) Endoloop and bipolar electricity are recommended to use in the basement of myomas to ensure hemostasis and preserve the myometrium. (7) Fetal heart rate should be monitored preoperatively and postoperatively. The two cases reported in this article chose the access sites according to the gestational age and established pneumoperitoneum with an open technique. The CO2 pressure was maintained at 12 mm Hg, while the patients' degree of inclination was minimized to reduce the risks of CO2 absorption and maternal hypotension. Roeder knots and bipolar coagulation were applied to the pedicles to ensure hemostasis and preserve the myometrium. We performed enclosed morcellation through the lateral ancillary trocar without damage to the uterus. In our opinion, whether the morcellation was performed through the umbilicus or the enlarged accessory trocar, or a small suprapubic incision, should be based on gestational week, the volume and location of the myoma, and the surgeon's experience. The most important thing is to be very careful to avoid damage to the uterus and surrounding tissues and shorten the operation time as far as possible. Based on the limited studies reporting sufficient surgical details of laparotomy, the median duration of surgery was 53 minutes (range, 20–150 minutes) for both approaches analyzed together.11 In the case of pedunculated myomas with medium volume, the time required for morcellation would not be significantly prolonged, making laparoscopic surgery preferable to laparotomy. It is worth noting that enclosed morcellation should be applied to minimize spillage of myoma chips leading to leiomyomatosis of dissemination of incidental leiomyosarcoma.21 However, surgery may not always be performed by laparoscopy. Among the reported myomectomies, most of the removed myomas were subserous pedunculated, intramural myomas, which are relatively rare. At present, the surgical records of intramural myomectomy are all laparotomies.22 Therefore, in the case of numerous, large, intramural myomas, laparotomy is necessary. Shigemi et al.23 conducted a nationwide retrospective cohort study containing 6018 patients who undertook laparotomy or laparoscopic surgery because of appendicitis, cholecystitis, benign adnexal lesions, and uterine myomas. The results confirmed that the great advantages of laparoscopic surgery over laparotomy are to reduce postoperative pain and shorten intake time, thus promoting the early recovery of patients' activities and gastrointestinal function and reducing the risk of abdominal adhesion and deep venous thrombosis without increasing the incidence of adverse outcomes such as preterm labor, fetal intrauterine growth restriction, and stillbirth and neonatal death. Tocolytics are no longer recommended to be used prophylactically but should be considered when signs of preterm labor are present.20 If there is no indication of a cesarean section, vaginal delivery can be carried out under close supervision. This study has certain strengths and limitations. The strengths are that we have comprehensively summarized and analyzed the literature on myomectomy during pregnancy reported in recent years and highlighted the key points of performing laparoscopic myomectomy during pregnancy. A significant limitation is an inability to perform a meta-analysis of the different surgical approaches. In addition, most studies are case reports of limited evidence power, and there is a great amount of unreported data and missing information that may bias the overall outcomes. In agreement with the outcomes of our cases and the available literature, surgical treatment should be considered when symptomatic subserous myoma was suspected and did not respond to conservative treatment during pregnancy. Especially for medium-volume, pedunculated myomas, laparoscopic myomectomy performed by experienced surgeons could be considered the best choice.

一、病例摘要 患者26岁,因"孕17+6周,间断下腹痛12 d,加重1d"于2016年2月24日急诊入北京大学第一医院.平素月经规律,否认盆腔炎病史,既往体检无异常.末次月经:2015年10月22日,早孕期曾间断少量阴道出血,超声示宫内孕活胎,双附件区未见异常.停经16+2周无诱因出现间断下腹痛,不重,无阴道出血、恶心、呕吐及发热,未就诊.1d前腹痛加重,外院予静脉抗生素治疗效果不佳,遂转诊北京大学第一医院.患者自发病以来饮食如常,二便可,无里急后重.查体:一般情况好,心肺无异常,腹软,肝脾肋下未及,子宫如孕18周,无宫缩,胎心148次/min,左附件区增厚,压痛明显,未触及具体包块,右附件区无异常.B超示宫内孕活胎,左侧宫底上方可探及不均质回声团3.2 cm×2.9 cm×1.6 cm,与子宫间可见一低回声团,直径1.1 cm,内可探及血流信号,提示左卵巢扭转待除外.遂以"腹痛待查,左附件扭转?"急诊入院.

子宫肌瘤是育龄女性最常见的生殖系统良性肿瘤.妊娠合并子宫肌瘤发生率为0.1％ ～3.9％,随着婚育年龄后延,其发病率有所上升[1] ,约10％ ～30％患者在妊娠期、分娩期及产褥期出现并发症[2].自1994年Lucas等[3]报道妊娠期腹腔镜子宫肌瘤剔除术( laparoscopic myomectomy during pregnancy,LMdP)以来,在条件具备的前提下,逐渐替代开腹手术成为孕期处理有症状子宫肌瘤的一种手段.本文对该术式的历史与现状、围术期问题等进展进行综述,以期对临床工作有所帮助.

Acute abdomen in pregnancy can be divided into pregnancy-related and non-pregnancy-related type.This article reviewed the different types of acute abdomen caused by gynecological problems during pregnancy.Also,the progress of laparoscopic surgical technique and the perioperative management and the influence of the operation on pregnancy outcomes in patients who developed acute abdomen and underwent laparoscopic surgery in pregnancy were also analyzed,to provide information for the application of emergency laparoscopic surgery in pregnancy.

To the Editor: With the advancement of laparoscopic techniques, minimally invasive surgery is more widely applied in various conditions. The guidelines, published by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) in 2017, considered that laparoscopic surgery could be safely performed at any stage of pregnancy, although best in mid-term. Since 2004, our team has carried out more than 150 laparoscopic procedures in pregnant patients who wanted to preserve their pregnancy. However, only six of these cases were in the late-term. Here we report a case of right ovarian cyst torsion successfully treated by laparoscopic oophorocystectomy in a patient at 35 weeks gestation. Following this operation, a healthy female of 3000 g was delivered at 40 weeks gestation.

子宫肌瘤合并妊娠临床常见。对有意愿继续妊娠的子宫肌瘤合并妊娠患者，发生因肌瘤所致急腹症或压迫症状明显时，可考虑行妊娠期子宫肌瘤切除术，但妊娠期手术有造成妊娠丢失或术中发生难以控制的大出血而不得以切除子宫的可能，因此，无论是开腹还是腹腔镜途径，目前还不作为妊娠合并子宫肌瘤的首选治疗方案。本文报告1例妊娠15周余成功实施腹腔镜手术切除带蒂浆膜下子宫肌瘤的患者，因急腹症、疑诊子宫浆膜下肌瘤蒂扭转入院，保守治疗无效而行腹腔镜手术治疗。术后继续妊娠至40周 +4自然临产，第一产程因胎儿窘迫行剖宫产术，术中再次剔除肌瘤并探查前次腹腔镜手术子宫瘢痕愈合良好，产后1年随诊，母儿健康。本文同时对妊娠期腹腔镜的文献进行复习，认为在妊娠中期因肌瘤扭转或红色变性出现疼痛或明显压迫症状，保守治疗无效时，可考虑腹腔镜探查，在保证妊娠安全的情况下，切除肌瘤、缓解症状，以获得良好的母儿预后。

We provide an overview of the detailed information on the application and fundings of the National Natural Science Foundation of China in reproductive system/perinatology/neonatology in 2018 to facilitate future applications for researchers and physicians in this area in 2019.In-depth analysis was performed from different aspects among all the applications;areas for improving in the format and compiling of the application form were pointed out together with practical suggestions;possible interesting topics in future application were also implicated.

Objective To analyze the values of several factors in differential diagnosis of ovarian tumors and to evaluate the diagnostic values of modified risk of malignancy index (mRMI) for ovarian tumors.Methods The data of 1792 women with ovarian tumors admitted to Peking University First Hospital for surgical exploration between January 2010 and January 2017 were retrospectively analyzed.The differences of several clinical indicators between benign and malignant ovarian tumors were calculated.The diagnostic values of the 4 RMIs and various modified methods were analyzed according to ROC curves (receiver operating characteristic curve).Results The sensitivities of 4 RMIs for diagnosing malignant tumors ranged from 57.2％ to 62.8％,specificities ranged from 89.0％ to 91.9％.RMI4 was significantly better than RMI1,2,3 in terms of diagnostic efficiency.The diagnostic efficiency of 4 RMIs could be improved when RI (resistance index) was added to the formulas,and modified RMI4 had the best diagnostic efficiency with a sensitivity of 77.0％ and a specificity of 79.0％.Conclusions RMIs are useful indexes for the differentiation between benign and malignant ovarian tumors.RI could significantly improve the diagnostic efficiency.The advised mRMI equals to (ultrasound score + RI score) × menopausal score × CA125 (carbohydrate antigen 125) × tumor size score [mRMI=(U+R) × M × CA125 × S],with a cutofflevel of 190.

Low grade endometrial stromal sarcoma (LGESS) is a very rare malignant tumor. The standard treatment of LGESS is total hysterectomy with bilateral adnexectomy. Fertility preserving treatment for LGESS is rarely reported and the prognosis needs to be studied. Here we report a case of term birth pregnancy after fertility preserving treatment for LGESS. A 26-year-old single woman who had studied overseas was hospitalized on 20th July 2009 for a myoma found by B-ultrasound and anemia that had persisted for nearly one week. She had had a regular period (7 d/37 d) with menorrhagia, but without dysmenorrhea. The last menstrual period was 26th June 2009. A pelvic mass was found by B-ultrasound a week previous in her physical examination, which was diagnosed as a 5-cm diameter myoma, and her HGB was 87 g/L. She immediately returned to our hospital and a repeated ultrasound showed a 5.0 cm× 4.0 cm × 3.9 cm mass with heterogeneous echogenicity in the fundus of the uterus that was diagnosed as an intramural myoma. Then she was admitted for laparoscopic myomectomy. She was in good health and had no history of pregnancy or family history of cancer. Physical examination: Temperature 36.4°C, pulse 82 times per minute, breath 18 times per minute, blood pressure 110/70 mmHg, and no abnormalities were found during the physical examination. Pelvic examination showed a normal vulva, vagina and smooth cervix. The uterus was in an anterior position and enlarged as at six gestational weeks. A 5-cm diameter palpable tumor was found in the fundus which was hard, and could be mobilized without tenderness. Both adnexal areas were normal. Laboratory examination: hemoglobin 84 g/L, white blood cells 3.28×109/L, and platelet 232×109/L. Blood biochemistry values, chest film, and ECG were normal. B-ultrasound showed a 5.0 cm × 4.0 cm × 3.9 cm mass with heterogeneous low level echogenicity which had a distinct margin in the fundus with rich blood flow, and RI 0.60. Diagnosis on admission: Uterine myoma with secondary anemia (mild). Laparoscopic myomectomy was performed on 22nd July. A mass of about 6 cm×5 cm was found in the anterior wall of the uterus near the fundus. The mass had a smooth surface and had no adhesions with adjacent tissues. Both adnexa appeared normal. The 12 U pituitrin was injected inside the pseudocapsule of the myoma. The pseudocapsule was then transected and the myoma was completely stripped. The myoma crossed the uterine wall to the cavity and was covered by about 3 cm × 3cm endometrium. The endometrium was closed by two interrupted figure-ofeight sutures using 1# Ethicon line. A continuous suture was then used to close the muscular layer. The specimen of the myoma weighed 50 g; it was pink and tough and was taken out after it shattered. The surgery took 1 hour and 15 minutes and there was minimal bleeding. The patient was discharged five days after the operation. One week after the operation pathology reported the tumor was a low grade endometrial stromal sarcoma (SMA+, CD10-). A PET-CT on 20 days after the operation showed FDG uptake increased on a 2.2 cm × 2.3 cm area of the anterior uterine wall. A B-ultrasound 26 days after the operation showed a 2.3 cm × 1.7 cm heterogeneous mass with low level echogenicity and an obscure margin in the fundus and the blood flow around the mass was rich. A 1.5 cm × 0.8 cm× 0.7 cm intrauterine occupied lesion was also found. She accepted a hysteroscopy and fractional D&C guided by B-ultrasound 27 days after the operation. The pathology report of the endometrium tissue showed a proliferated endometrium that contained foci of necrosis and fibroplastic proliferation, and acute and chronic inflammatory cell infiltration was also observed. Because the patient was a young, unmarried girl with no child and suffered from a low-grade malignancy, chemotherapy and progesterone therapy was provided on request from her parents and herself for preserving her fertility. She accepted four cycles of chemotherapy monthly after the operation, with ifosfamide 2.0 g for five days each cycle. During the chemotherapy routine blood, urine, hepato-renal function, chest films, and ECG were regularly reviewed. In addition, oral medroxyprogesterone, 250 mg q.d. per os, was started from the first day of chemotherapy and continued for seven months. Diagnosis on discharge was low-grade endometrial stromal sarcoma, stage I. She maintained her regular menstrual period with minimal bleeding after the operation. B-ultrasound and pelvic MRI conducted half-yearly after the operation showed no abnormity. She got married abroad one and a half years after the surgery and then conceived. She had an uneventful pregnancy and had a planned cesarean delivery of a baby girl which weighed 2837 g at 37 weeks. The uterus was explored in the c-section and no abnormity was found. There were no pelvic adhesions reported. She and her baby were both healthy at 3-month and 6-month follow up after delivery. At 47 months since her laparoscopic surgery, no signs of recurrence were identified. Endometrial stromal sarcoma (ESS) is a very rare malignant uterine tumor that accounts for 0.2% of all uterine malignancies and has an annual incidence of 1-2 per million women. The mean age of women affected by ESS is 42 to 58 years.1 According to the histopathology, ESS can be divided into two categories: LGESS (less than 10 mitotic figures per 10 high power field (HPF), no obvious cellular atypism) and high-grade endometrial stromal sarcoma (HGESS, more than 10 mitotic figures per 10 HPF, obvious cellular atypism); the former has a much better prognosis than the latter. The International Federation of Gynecology and Obstetrics (FIGO) staging for uterine sarcoma published in 2009 was used to stage ESS.1 Because of the lack of specificity of both symptoms and imaging findings, preoperative diagnosis is rarely achieved and the final diagnosis usually depends on pathology. In this case, the initial diagnosis was intramural myoma protruding to the mucosa that was based on her symptoms and operative findings. However, pathology confirmed it was ESS. LGESS has a better prognosis in all ESS cases. The standard treatment is total hysterectomy with bilateral adnexectomy, and postoperative chemo-radiotherapy to ensure a better prognosis. But there is no enough evidence about a definite schedule for the adjuvant therapy. Hormone therapy is another important therapy for ESS, but there is no clear evidence for the best dose and duration. A large dose of progesterone is commonly used. Estrogen and progesterone receptors are over expressed in ESS, so a high concentration of progesterone can combine with the receptors and binding proteins are produced that can act with inner cell growth factors and make it inactivation. As a result, the tumor growth is slowed or stopped. Late recurrence is a characteristic of ESS and the pelvic cavity is the most common recurrence site. The related factors of recurrence are pathological type, surgical pathological stage and the surgical method. A study2 showed there were significant differences in recurrence rates between patients with LGESS and HGESS (37% vs. 87%, P <0.001), early stage and late stage (19% vs. 43%, P<0.05), and those receiving total hysterectomy with bilateral adnexectomy and keeping one or two ovaries (7%, followed up to 57 months vs. 93%, followed up to 87 months, P <0.01). A higher recurrence rate in patients keeping ovaries may be associated with the continuous stimulation of residual tumor cells by estrogen. A report of 41 cases of LGESS3 showed the 5-year and 10-year survival rates after treatment were 87.5% and 77.8%, the recurrence rate was 43.9%, and the mean recurrence time was 31 months. According to overseas reports, the recurrence time ranged from three months to 23 years, and the mean recurrence time was about three years.4 After the operation, it is advised to follow up once every three months for the first year and once every half-year for the next four years and yearly afterwards.1 The LGESS patients are often very young, and some of them may expect to have fertility preserved. But such cases are rarely reported. All patients were alive after a median follow-up time of 51 months. Two patients had a full-term spontaneous delivery and one patient had a miscarriage at 8-weeks of pregnancy. In this case, the patient was young, unmarried and had no child; she and her family requested preserving fertility, so she received chemotherapy and progesterone therapy. The patient had a successful pregnancy and delivery after treatment, and no tumor recurrence was found 47 months after the operation. Because of the low incidence of ESS, reports of fertility preserving cases are rarely seen. There is no standard schedule of postoperative treatment. Clinically, the treatment for uterine leiomyosarcoma is often referred. There have been some experiences of recurrence after fertility preserving treatment. Koskas et al4 reported a 34-year-old LGESS patient who conceived and delivered after fertility preserving surgery and recurrence was identified in the pelvic cavity after delivery. Total hysterectomy with bilateral adnexectomy was advised as late recurrence is common for LGESS. In this case, the follow-up time was close to the mean recurrence time. Although no recurrence has been found, it is still necessary to follow up regularly for any signs of recurrence.