Rapid recurrence of stage IIB non-gestational ovarian choriocarcinoma with minor yolk sac tumor: A rare case report and literature review.

Non-gestational ovarian choriocarcinoma (NGOC) is a rare phenomenon seldom reported in the literature. Patients often present with abdominopelvic pain, and sometimes a palpable adnexal mass. Surgical excision is paramount in treating this malignancy; however, fertility-preserving care is a debated topic among gynecologic oncologists. Most patients reported in the literature are nulliparous women of child-bearing age. It is important to consider fertility preservation whilst balancing oncologic outcomes. We present a case of an 18-year-old nulliparous female with stage IIB NGOC that had disease progression in the lungs and pelvis shortly after undergoing fertility-preserving surgery. She required emergent completion surgery and received etoposide (E), methotrexate (M), actinomycin-D (A), cyclophosphamide (C) and vincristine (O) (EMA-CO) with complete response. She remains disease-free after 21-months.

Malignant peritoneal cytologic contamination with robotic hysterectomy for endometrial cancer.

BACKGROUND: Malignant peritoneal cytology in endometrial cancer (EC) is not considered an independent adverse prognostic factor for uterine-confined disease and is not a determinant factor in the International Federation of Gynecology and Obstetrics (FIGO) staging system. NCCN Guidelines still recommend obtaining cytologies. The aim of this study was to determine the prevalence of peritoneal cytologic contamination following robotic hysterectomy for EC. METHODS: Peritoneal cytology from the pelvis and diaphragm were obtained at the initiation of surgery, and from the pelvis only at the completion of robotic hysterectomy with sentinel lymph node mapping (SLNM). Cytology specimens were evaluated for the presence of malignant cells. Pre- and post-hysterectomy cytology results were compared, and pelvic contamination was defined as conversion from negative to positive cytology following surgery. RESULTS: 244 patients underwent robotic hysterectomy with SLNM for EC. Pelvic contamination was identified in 32 (13.1%) cases. In multivariate analysis, pelvic contamination was associated with >50% myometrial invasion, tumor size >2 cm, lymphovascular space invasion (LVSI), and lymph node metastasis. There was no association with FIGO stage or histology subtypes. CONCLUSIONS: Malignant peritoneal contamination occurred during robotic surgery for EC. Large lesions (>2 cm), deep invasion (>50%), LVSI, and lymph node metastasis were each independently associated with peritoneal contamination. Whether or not peritoneal contamination increases risk for disease recurrence should be studied in larger series, including an evaluation of patterns of recurrence and the potential impact of adjuvant therapies. Until the clinical impact of peritoneal contamination during hysterectomy for EC is better understood, methods to reduce peritoneal contamination are warranted.

Multidisciplinary approach to pelvic leiomyomatosis with intracaval and intracardiac extension: A case report and review of the literature.

Intravenous leiomyomatosis (IVL) is an uncommon variant of leiomyoma characterized by intravascular proliferation of a histologically benign smooth muscle tumor extending beyond the uterus into the distant great vessels. Leiomyomatosis may reach the inferior vena cava, right atrium, and pulmonary arteries. Owing to its rare occurrence, intracardiac leiomyomatosis has been reported as isolated case reports and small case series. Early diagnosis and prompt surgical intervention are vital to prevent cardiac symptoms, pulmonary embolism, and sudden death. Complete tumor resection is essential for a favorable outcome, usually assisted with multimodal surgical imaging and multidisciplinary surgical planning. Herein, we report the case of a 50-year-old female that presented with a three-month history of abdominal pain and lower extremity edema with evidence of IVL extending to the inferior vena cava and right atrium. The patient was managed with a single-stage surgery involving cardiopulmonary bypass and excision of the right atrial and inferior vena cava tumors, as well as modified radical total abdominal hysterectomy and bilateral salpingo-oophorectomy.

Neoadjuvant chemotherapy followed by fertility sparing surgery in cervical cancers size 2-4 cm; emerging data and future perspectives.

BACKGROUND: Approach to the management of early stage cervical cancers with tumor size >2 cm in women who desire fertility preservation has been fraught with controversy. Fertility sparing surgery for FIGO 2018 stage IB cancers has been validated most for tumors ≤2 cm. In this review, our objective was to evaluate the oncologic and obstetric outcomes for women that underwent neoadjuvant chemotherapy (NACT) before fertility sparing surgery for tumors 2-4 cm. METHODS: We performed a systematic literature review and searched PubMed, Google Scholar, Cochrane Reviews and UpToDate (from January 2000 to February 2021) using the terms: cervical cancer, fertility preservation, trachelectomy, radical trachelectomy, neoadjuvant chemotherapy, cervical cancer treatment, stage IB1 or IB2 cervical cancer, and cervical cancer size 2-4 cm. We included manuscripts with information on patients with tumor sizes 2-4 cm, lymph node status, follow-up, obstetric and oncologic outcome. We excluded review articles or articles without all pertinent patient information. RESULTS: Eighteen articles were identified including 249 patients. For final analysis, 114 met inclusion criteria. All included patients had FIGO 2018 stage IB2 cervical cancer, underwent neoadjuvant chemotherapy and subsequent fertility sparing surgery. Vaginal radical trachelectomy, cold knife conization, abdominal radical trachelectomy, laparoscopic radical trachelectomy, simple vaginal trachelectomy, and cone laser were performed in 46 (40.4%), 26 (22.8%), 14 (12.3%), 13 (11.4%), 8 (7%), and 7 (6.1%) women, respectively. The most common regimen of chemotherapy was platinum-based therapy with cisplatin. The follow-up time reported in all studies ranged from 1 to 225 months. Of 64 attempted pregnancies, there were 49 (76.6%) viable deliveries which included 6 preterm births (9.4%). The recurrence rate was 6.1% and two patients (1.8%) died of disease. CONCLUSION: Fertility sparing surgery following NACT is an option for women with cervical cancers that are 2-4 cm that wish to preserve fertility without sacrificing oncologic or obstetric outcomes. Confirmation of these findings are anticipated from an ongoing international phase II clinical trial [1].

Isolated vulvar Langerhans cell histiocytosis.

•Primary vulvar Langerhans cell histiocytosis is rare with less than 40 reported cases.•Diagnosis of vulvar LCH requires prompt metastatic workup to rule out multisystem involvement.•Treatment protocols for isolated vulvar LCH vary widely and there is not an established standard of care.•Continue surveillance is warranted even after prolonged periods of remission.

Plexiform Neurofibroma of the Uterus: A Case Report.

The female genital tract system is rarely affected by neurofibromatosis type 1 (NF1). Plexiform neurofibromas are congenital lesions that occur in patients with NF1. The vulva is the most frequent genital location but vaginal, cervical, uterine, and ovarian neurofibromas have rarely been reported. We describe a case of plexiform neurofibromas involving the uterine cervix in a patient with known NF1 that presented with chronic pelvic pain and heavy menstrual bleeding.

Improved Outcomes With an Enhanced Recovery Approach to Cesarean Delivery.

OBJECTIVE: To examine the results of a quality-improvement study that implemented an enhanced recovery after surgery (ERAS) program for cesarean delivery. METHODS: A pre-post design was used to assess changes in opioid use, length of stay, and costs among all patients undergoing cesarean delivery before and after implementation of an evidence-based ERAS pathway for the preoperative, intraoperative, and postoperative management of patients beginning December 2018. RESULTS: A total of 3,679 cesarean deliveries (scheduled and emergent) were included from January 1, 2018, through August 31, 2019, of which 2,171 occurred before implementation on December 17, 2018, and 1,508 occurred postimplementation. Eighty-four percent of patients received opioids as inpatients after cesarean delivery during the preimplementation period, as compared with 24% in the postimplementation period (odds ratio [OR] 16.8, 95% CI 14.3-19.9). Among patients who required any opioids, the total morphine milligram equivalents also significantly decreased (median 56.5 vs 15.0, mean relative change 0.32, 95% CI 0.28-0.35). Compared with the preimplementation period, those in the postimplementation period had a shorter postcesarean length of stay (3.2 vs 2.7 days, mean relative change 0.82, 95% CI 0.80-0.83, median 3 days in both periods), lower median direct costs by $349 (mean relative change 0.93, 95% CI 0.91-0.95), and no change in the 30-day readmission rate (1.4% vs 1.7%, OR 0.83, 95% CI 0.49-1.41). CONCLUSION: An ERAS approach for the cesarean delivery population is associated with improved outcomes including decreases in opioid use, length of stay, and costs.

Leptomeningeal spread of gestational trophoblastic neoplasia in a 19-year old woman.

Gestational trophoblastic neoplasia (GTN) with brain metastasis is usually seen in patients with advanced disease. Ten percent of metastatic gestational trophoblastic disease involves the brain and spinal cord, most often manifesting as an intracerebral mass or subdural hematoma, and are generally known to be a poor prognostic factor (Dadlani et al., 2010). Leptomeningeal metastases are tremendously rare and not well documented in the literature. A standardized treatment regimen for patients with brain metastases has not been established and is controversial due to a number of multimodal treatments that have been published in the literature without a prospective trial having been completed. We report a case of a patient with gestational trophoblastic disease that metastasized to the lung and leptomeninges, who after treatment with induction chemotherapy using etoposide (E) and cisplatin (P) followed by etoposide, methotrexate and dactinomycin (EMA) chemotherapy achieved a complete response without brain radiation (Han et al., 2012).

Acute effects of a caffeine-taurine energy drink on repeated sprint performance of American college football players.

Consumption of energy drinks is common among athletes; however, there is a lack of research on the efficacy of these beverages for short-duration, intense exercise. The purpose of this research was to investigate the acute effects of a low-calorie caffeine-taurine energy drink (AdvoCare Spark) on repeated sprint performance and anaerobic power in National Collegiate Athletic Association Division I football players. Twenty football players (age 19.7 ± 1.8 yr, height 184.9 ± 5.3 cm, weight 100.3 ± 21.7 kg) participated in a double-blind, randomized crossover study in which they received the energy drink or an isoenergetic, isovolumetric, non-caffeinated placebo in 2 trials separated by 7 days. The Running Based Anaerobic Sprint Test, consisting of six 35-m sprints with 10 s of rest between sprints, was used to assess anaerobic power. Sprint times were recorded with an automatic electronic timer. The beverage treatment did not significantly affect power (F = 3.84, p = .066) or sprint time (F = 3.06, p = .097). However, there was a significant interaction effect between caffeine use and the beverage for sprint times (F = 4.62, p = .045), as well as for anaerobic power (F = 5.40, p = .032), indicating a confounding effect. In conclusion, a caffeine-taurine energy drink did not improve the sprint performance or anaerobic power of college football players, but the level of caffeine use by the athletes likely influenced the effect of the drink.