Minimally invasive versus open surgery for women with stage 1A1 and stage 1A2 cervical cancer: A retrospective database cohort study.

Background: Recent studies comparing minimally invasive versus open radical hysterectomy in patients with early-stage cervical cancer have reported a worse overall survival with minimally invasive surgery (MIS). However, in the patients with microscopic disease, there was no survival difference and the optimal surgical approach for microscopic cervical cancer remains unclear. Methods: Using the National Cancer Database, we identified a cohort of women who underwent hysterectomy as the primary treatment for stage IA1/IA2 cervical cancer between January 2010 and December 2016. Using multivariable logistic regression, our primary outcome was to compare overall survival between the open and MIS groups. The data was stratified for simple and radical hysterectomies. Secondary endpoint was comparison of readmission rates and length of stay (LOS). Results: We identified 6230 patients with stage IA1 and IA2 cervical cancer that underwent hysterectomy as primary treatment. 4054 of these women (65%) underwent MIS. There was no difference in age, lympho-vascular invasion, number of lymph nodes retrieved and histology between the two groups. In the overall cohort, there was no difference in survival between the open and the MIS group (Hazard ratio for the open group 1.23; CI 0.92-1.63). Post-operative radiation therapy was more common in the open group (5.24% vs 4.09%, p value < 0.02). The mean LOS (1.35 days vs 3.08 days) was shorter in MIS group (p value < 0.0001). No difference was found in the readmission rates (60% for the MIS group vs 55% for the open group; p value 0.14). Conclusions: Our data suggest that MIS is associated with similar overall survival and shorter length of hospital stay compared to the open hysterectomy in women with stage IA cervical cancer. Based on this large data set, MIS appears to be a safe and effective surgical approach for women with stage IA1/IA2 cervical cancer.

The care of pregnant women during the COVID-19 pandemic - response of a large health system in metropolitan New York.

The rapid progression of the coronavirus disease 2019 (COVID-19) outbreak presented extraordinary challenges to the US health care system, particularly straining resources in hard hit areas such as the New York metropolitan region. As a result, major changes in the delivery of obstetrical care were urgently needed, while maintaining patient safety on our maternity units. As the largest health system in the region, with 10 hospitals providing obstetrical services, and delivering over 30,000 babies annually, we needed to respond to this crisis in an organized, deliberate fashion. Our hospital footprint for Obstetrics was dramatically reduced to make room for the rapidly increasing numbers of COVID-19 patients, and established guidelines were quickly modified to reduce potential staff and patient exposures. New communication strategies were developed to facilitate maternity care across our hospitals, with significantly limited resources in personnel, equipment, and space. The lessons learned from these unexpected challenges offered an opportunity to reassess the delivery of obstetrical care without compromising quality and safety. These lessons may well prove valuable after the peak of the crisis has passed.

Primary gynecological non-Hodgkin's lymphoma: A differential diagnosis of a pelvic mass.

Primary Non-Hodgkin's lymphoma (NHL) can mimic gynecological malignancy, presenting as a pelvic mass in any organ of the female genital tract. Patients can present with elevated CA-125 and may lack the classical symptoms associated with lymphoma, such as fatigue, fever, night sweats and weight loss. We describe five patients that presented with primary NHL of the genital tract. Patients 1, 2, and 3 were not diagnosed pre-operatively, and underwent unnecessary cytoreductive surgery, while patients 4 and 5 were diagnosed by pre-operative biopsy. The diagnosis of primary pelvic lymphoma should be in the differential diagnosis of gynecological malignancies. Awareness of the disease and pre-operative diagnosis can be beneficial, as the patient may be able to avoid unnecessary staging operations and disease cytoreduction.

Extracorporeal Manual Morcellation of Very Large Uteri Within an Enclosed Endoscopic Bag: Our 5-Year Experience.

STUDY OBJECTIVES: To describe a technique to manually morcellate large uteri within a polyurethane endoscopic bag at the time of laparoscopic hysterectomy, and report perioperative outcomes from our 5 years of experience. STUDY DESIGN: Retrospective review of all consecutive hysterectomies with uterine weight >500 g performed between January 2010 and December 2014 in which the uterus was manually morcellated within an endoscopic bag by either an abdominal or vaginal approach (Canadian Task Force Classification Level III). SETTING: Tertiary care academic medical center. PATIENTS: A total of 104 women with a uterine weight >500 g who underwent laparoscopic hysterectomy using a manual morcellation technique. INTERVENTION: Manual morcellation was done extracorporeally, within a partially exteriorized specimen bag, using a scalpel under direct visualization by the operating surgeon. MEASUREMENTS AND MAIN RESULTS: A total of 104 laparoscopic hysterectomies were performed in women with a uterus weighing >500 g using a manual morcellation technique for specimen extraction. The median patient age was 48.1 years (range, 34-69 years), and the median body mass index was 31.0 kg/m(2) (range, 19.1-56.7 kg/m(2)). The median blood loss and specimen weight were 200 mL (range, 20-1200 mL) and 741.5 g (range, 500-1930 g), respectively. Morcellation was performed through an abdominal approach in 58.7% of the patients and through a vaginal approach in 41.3%. The median duration of morcellation was 14.8 minutes (range, 4.5-21.6 minutes) for the abdominal route and 11.7 minutes (range, 5.2-16.8 minutes) for the vaginal route. Occult malignancy was identified in 2 patients. There were no complications related to the morcellation technique or gross bag rupture. CONCLUSION: Manual morcellation within an endoscopic bag allows for the extraction of large uteri without the use of a power morcellator. In our 5 years of experience, we have not experienced any incidence of gross spillage, visually noted bag rupture, or complications associated with our morcellation technique.

Robotic surgery for staging of serous papillary and clear cell carcinoma of the endometrium.

BACKGROUND: The feasibility of robotic staging for high-risk endometrial cancer is unclear. METHODS: Retrospective review of papillary serous and clear cell endometrial cancer open staging (OS) and robotic staging (RS) cases (2009-2011) by two gynaecological oncologists. RESULTS: There were 15 OS and 17 RS cases (no conversions). Age, uterine weight and body mass index were comparable, with more stage I RS cases. Operative time (172.5 vs 124.2 min, p = 0.0005), blood loss (71.9 vs 310.0 ml, p = 0.0002), hospital stay (5.4 vs 1.2 days, p = 0.0016) and lymphadenectomy yield (16.8 vs 10.2 nodes, p = 0.0041) were decreased for RS. Optimal cytoreduction rates (100% vs 93%, p = 0.2794), follow-up (19.9 vs 27.1 months, p = 0.2283) and recurrences (three vs five, p = 0.5395) were equivalent. Disease-free survival (54.5% vs 66.7%, p = 0.5302) and overall survival rates (81.8% vs 80.0%, p = 0.9075) were equivalent. CONCLUSIONS: Robotic staging is feasible with minimal blood loss, a short operative time and recovery and good optimal cytoreduction rates.

External validation of a nomogram for predicting survival of women with uterine cancer in a cohort of African American patients.

OBJECTIVE: This study aimed to externally validate a nomogram for predicting overall survival of women with uterine cancer in an African American population. METHODS: After the institutional review board approval, data from the uterine cancer database from 2 major teaching hospitals in Brooklyn, NY, were analyzed. The predicted survival for each patient was calculated with the use of the nonogram; the data were clustered in deciles and compared with the observed survival data. RESULTS: High incidence of aggressive histologic types (22% carcinosarcoma, 16% serous/clear cell), poorly differentiated (53% grade 3), and advanced stage (38% stage III or IV) tumors was found in our study population. The median follow-up for survivors was 52 months (range, 1-274 months). The observed and predicted 3-year overall survival probabilities were significantly different (62.5% vs 72.6%, P < 0.001). Similarly, the observed 5-year overall survival probability was significantly lower than the predicted by the nomogram (55.5% vs 63.4%, P < 0.001). The discrepancy between predicted and observed survival was more pronounced in the midrisk groups. CONCLUSIONS: The nomogram is not an adequate tool to predict survival in the African American population with cancer of the uterine corpus. Race seems to be a significant, independent factor that affects survival and should be included in predictive models.

Management of intravascular leiomyomatosis: laparoscopic surgery for ordinary uterine fibroids led to an extraordinary finding.

An unexpected diagnosis of intravascular leiomyomatosis was made during a laparoscopic procedure. As the extent of the disease was unknown, the initial procedure was limited to laparoscopic hysterectomy and salpingo-oophorectomy. Postoperative computed tomography imaging demonstrated intravascular leiomyomatosis extending into the suprarenal inferior vena cava. The patient underwent exploratory laparotomy to excise residual tumor.

Laparoscopic hysterectomy with manual morcellation of the uterus: an original technique that permits the safe and quick removal of a large uterus.

We present an original technique to rapidly extract a large uterus during laparoscopic hysterectomy. Manually morcellating the uterus is a safe and effective technique that overcomes the technical difficulties associated with traditional electrical morcellators.

Sonographic and magnetic resonance imaging findings of pelvic abscess following uterine perforation sustained during office endometrial sampling.

Pipelle endometrial sampling, an outpatient, office-based procedure, provides comparative successful endometrial sampling in comparison with other techniques including conventional dilatation and curettage. We present an unusual occurrence in which office Pipelle endometrial sampling in a perimenopausal patient was complicated 10 days later by lower abdominal pain and intermittent fever. Sonography depicted findings consistent with a large pelvic abscess overriding the uterine fundus. Sonography and magnetic resonance imaging confirmed the presence of the unusual pelvic abscess and, in addition, noted findings consistent with perforation of the uterus during endometrial sampling.

Transvaginal sonography of postabortal (Redo) syndrome.

Acute hematometra, also termed the postabortal syndrome or redo syndrome, is a rare immediate complication of suction curettage characterized by severe lower abdominal cramping in association with an enlarged and markedly tender uterus. We describe the transvaginal sonographic features of this syndrome.

Sonographic Findings of Medullary Thyroid Carcinoma Leading to Diagnosis of Multiple Endocrine Neoplasia Type 2a during Pregnancy.

Multiple endocrine neoplasia (MEN) type 2a (Sipple's syndrome) is characterized by medullary thyroid carcinoma and pheochromocytoma, and in a smaller percentage of cases, multiglandular parathyroid hyperplasia. This autosomal-dominant syndrome is due to a mutation in the rearranged during transfection (RET) proto-oncogene located on chromosome 10cen-10q11.2 and rarely complicates pregnancy. We present an unusual case in a patient with an enlarged thyroid with sonographic findings characteristic of thyroid cancer, which led to diagnosis and subsequent management of RET proto-oncogene-positive MEN type 2a complicating pregnancy.

Sulfatase activity in normal and neoplastic endometrium.

BACKGROUND: Dehydroepiandrosterone sulfate (DHEAS) is metabolized to active androgens and estrogens, which may have a role in the development of endometrial cancer. METHODS: We studied DHEAS conversion to dehydroepiandrosterone (DHEA) in normal and neoplastic endometrium utilizing gas chromatography-mass spectral (GC-MS) analysis. Endometrial homogenate was incubated with known amounts of DHEAS for 4 h at 37 degrees C. Methanol extract was separated from debris by centrifugation, concentrated to 200 microl and 1 microl injected into the GC-MS instrument, equipped with a CP-Sil 8 column. DHEAS and DHEA areas were calculated by autoquantization and DHEA/DHEAS ratio was used for comparing sulfatase activity among normal endometrium (n = 6), Stage I endometrioid carcinoma (EC) (n = 15), Stage I mixed mesodermal Mullerian tumor (MMMT) (n = 6) and Stage I uterine papillary serous carcinoma (UPSC) (n = 7). RESULTS: DHEA/DHEAS ratios in normal endometrium, EC, MMMT and UPSC were 1.45 +/- 1.10, 5.63 +/- 3.27, 2.88 +/- 0.99, and 3.04 +/- 1.76, respectively. Sulfatase activity was significantly higher in EC when compared with normal endometrium (p < 0.001), MMMT (p < 0.05), and UPSC (p < 0.05). The enzyme activity did not differ significantly between low-grade and high-grade EC tumors (5.8 +/- 2.77 and 5.49 +/- 3.84, respectively, p > 0.05). CONCLUSION: Stage I EC have higher sulfatase activity than normal endometrium, and Stage I MMMT and UPSC tumors.