Minimally invasive management for multifocal pelvic retroperitoneal malignant paraganglioma: a neuropelveological approach.

BACKGROUND: Pheochromocytoma and Paraganglioma (PGL) are rare neuroendocrine tumors, with an estimated incidence of about 0.6 cases per 100.000 person/year. Overall, 3-8% of them are malignant. These tumors are characterized by a classic triad of symptoms (headaches, palpitations, profuse sweating) due to hypersecretion of catecholamines. Despite several advantages of minimally invasive surgery (MIS) for PGL debulking, the surgical approach is not standardized yet. In this scenario, we aimed to report a case of a multiple recurrent PGL with metastatic retroperitoneal localization involving the pelvic sidewall, excised with MIS. CASE PRESENTATION: We performed complete laparoscopic-assisted neuronavigation (LANN technique) with isolation of the sacral routes and the sciatic nerve to obtain complete exposure of the main anatomic landmarks. Robotic surgery was used to perform neurolysis of sacral plexus, and partial resection of left splanchnic nerves was needed. After the resection of the first mass, extensive neurolysis of all sacral routes, obturator nerve, pudendal nerve till the entrance of the pudendal (Alcock) canal, and sciatic nerve was performed. Finally, the mass was identified after trans gluteal incision and dissection of the maximum gluteal muscle, and a partial resection of the superior gluteal nerve and slicing of the sciatic nerve were needed to obtain a radical excision of the mass. Then neurorrhaphy of the sectioned nerve fibers of the superior gluteal nerve was performed, and nerve protection was obtained using a collagen nerve wrap. After 18 months of follow-up, the patient is free of disease at the MRI imaging and 123I-metaiodobenzylguanidine scintigraphy. CONCLUSIONS: Minimally invasive gynecological surgery with neuropelveological approach could be considered as a feasible option in case of multifocal pelvic retroperitoneal malignant paraganglioma of the pelvic side wall.

The burden of chronic disease, multimorbidity, and polypharmacy in adults with Down syndrome.

Data on clinical characteristics of adults with Down syndrome (DS) are limited and the clinical phenotype of these persons is poorly described. This study aimed to describe the occurrence of chronic diseases and pattern of medication use in a population of adults with DS. Participants were 421 community dwelling adults with DS, aged 18 years or older. Individuals were assessed through a standardized clinical protocol. Multimorbidity was defined as the occurrence of two or more chronic conditions and polypharmacy as the concomitant use of five or more medications. The mean age of study participants was 38.3 ± 12.8 years and 214 (51%) were women. Three hundred and seventy-four participants (88.8%) presented with multimorbidity. The most prevalent condition was visual impairment (72.9%), followed by thyroid disease (50.1%) and hearing impairment (26.8%). Chronic diseases were more prevalent among participants aged >40 years. The mean number of medications used was 2.09 and polypharmacy was observed in 10.5% of the study sample. Psychotropic medications were used by a mean of 0.7 individuals of the total sample. The high prevalence of multimorbidity and the common use of multiple medications contributes to a high level of clinical complexity, which appears to be similar to the degree of complexity of the older non-trisomic population. A comprehensive and holistic approach, commonly adopted in geriatric medicine, may provide the most appropriate care to persons with DS as they grow into adulthood.

Lower limb lymphedema after surgical staging for endometrial cancer: Current insights and future directions.

Lower extremity lymphedema (LEL) is a common complication following surgical staging of endometrial cancer. LEL is a chronic condition associated with significant impact on patient morbidity and quality of life (QoL). This review aimed to report the current evidence in the literature on secondary LEL after surgical staging for endometrial cancer, focusing on the incidence based on different approaches to lymph node staging, diagnosis, risk factors, and the impact on QoL. Due to the absence of a standardized agreement regarding the methodology for evaluating LEL, the documented frequency of occurrence fluctuates across different studies, ranging from 0% to 50%. Systematic pelvic lymphadenectomy appears to be the primary determinant associated with the emergence of LEL, whereas the implementation of sentinel lymph node biopsy has notably diminished the occurrence of this lymphatic complication after endometrial cancer staging. LEL is strongly associated with decreased QoL, lower limb function, and negative body image, and has a detrimental impact on cancer-related distress reported by survivors. Standardization of lymphedema assessment is needed, along with cross-cultural adaptation of subjective outcome measures for self-reported LEL. The advent of sentinel lymph node mapping represents the ideal approach for accurate nodal assessment with less short- and long-term morbidity. Further research is needed to definitively assess the prevalence and risk factors of LEL and to identify strategies to improve limb function and QoL in cancer survivors with this chronic condition.

Role of MRI in the Assessment of Cervical Cancer.

Cervical cancer is the fourth most common cancer in women, and it is divided into 2 main histological types: squamous cell carcinoma and adenocarcinoma. Extension of disease as well as the presence of metastases define the prognosis of patients. Accurate tumor staging at diagnosis is essential for adequate planning for treatment. There are several classifications of cervical cancer, and the most used are FIGO and TNM, which help classify the patient and guide the treatment. Imaging has a pivotal role in classifying patients, and MRI plays a decision-maker role both for diagnosis and for treatment planning. In this paper we highlight the role of MRI, alongside guidelines classification, in patients with different stages of cervical tumors.

Concordance of Radiological, Laparoscopic and Laparotomic Scoring to Predict Complete Cytoreduction in Women with Advanced Ovarian Cancer.

OBJECTIVE: To identify the best method among the radiologic, laparoscopic and laparotomic scoring assessment to predict the outcomes of cytoreductive surgery in patients with advanced ovarian cancer (AOC). METHODS: Patients with AOC who underwent pre-operative computed tomography (CT) scan, laparoscopic evaluation, and cytoreductive surgery between August 2016 and February 2021 were retrospectively reviewed. Predictive Index (PI) score and Peritoneal Cancer Index (PCI) scores were used to estimate the tumor load and predict the residual disease in the primary debulking surgery (PDS) and interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT) groups. Concordance percentages were calculated between the two scores. RESULTS: Among 100 eligible patients, 69 underwent PDS, and 31 underwent NACT and IDS. Complete cytoreduction was achieved in 72.5% of patients in the PDS group and 77.4% in the IDS. In patients undergoing PDS, the laparoscopic PI and the laparotomic PCI had the best accuracies for complete cytoreduction (R0) [area under the curve (AUC) = 0.78 and AUC = 0.83, respectively]. In the IDS group, the laparotomic PI (AUC = 0.75) and the laparoscopic PCI (AUC= 0.87) were associated with the best accuracy in R0 prediction. Furthermore, radiological assessment, through PI and PCI, was associated with the worst accuracy in either PDS or IDS group (PI in PDS: AUC = 0.64; PCI in PDS: AUC = 0.64; PI in IDS: AUC = 0.46; PCI in IDS: AUC = 0.47). CONCLUSION: The laparoscopic score assessment had high accuracy for optimal cytoreduction in AOC patients undergoing PDS or IDS. Integrating diagnostic laparoscopy in the decision-making algorithm to accurately triage AOC patients to different treatment strategies seems necessary.