Laparoscopic approach for peripartum hysterectomy.

Abnormal placentation is the most common indication for peripartum hysterectomy. To date, the approach described in the literature is laparotomy, which is associated with high morbidity and mortality. A 30-year-old gravida 4 para 3 had a postpartum diagnosis of placenta percreta. She was first treated conservatively. On day 3 after delivery, because of persistent vaginal bleeding, she underwent a laparoscopic hysterectomy. No postoperative complications occurred, and the patient was discharged on postoperative day 3. Laparoscopic peripartum hysterectomy could become the approach of choice in selected patients with abnormal placentation to avoid complications associated with laparotomy.

Robotic management of major vessel injury during pelvic lymphadenectomy.

Laparoscopic management of major vessel lesion is a challenging task during pelvic lymphadenectomy, and conversion is frequently necessary. Robotic surgery overcomes the limits of laparoscopy in vascular suturing. We describe a case of a 79-year-old woman with stage IB G3 endometrial adenocarcinoma, where an external iliac vein injury occurred during pelvic lymphadenectomy. This is the first case report that describes robotic management of a major vascular injury during pelvic lymphadenectomy by use of endoscopic bulldog clamps and robotic intracorporeal vascular sutures.

Laparoscopic adnexectomy of suspect ovarian masses: surgical technique used to avert spillage.

Herein is described and evaluated a safe laparoscopic adnexectomy technique for retroperitoneal dissection of suspect ovarian masses including the underlying peritoneum fixed to the ovary. Adopting this technique in cases of suspect adnexal masses enables the reduction of spilling and ensures an intact specimen. Twenty-two consecutive patients with suspect adnexal masses 10 cm or smaller underwent laparoscopic adnexectomy. Patients with bilateral suspect ovarian masses that required bilateral adnexectomy were enrolled only if they were no longer of childbearing age. Laparoscopy was feasible in all patients. No tumor spillage occurred. In 5 patients (23.6%), minilaparotomy was required to extract the specimen. Mean (SD) operating time was 80 (35-160) minutes, and estimated blood loss was 50 (10-100) mL. No major intraoperative complications occurred. Median (range) postoperative stay was 1 (1-3) day. Definitive pathologic analysis revealed benign pathologic conditions in 18 patients (81.8%), an ovarian tumor with low malignant potential in 3 patients (13.7%), and ovarian cancer in 1 patient (4.5%) in whom findings at frozen-section analysis were inconclusive. Median (range) follow-up of malignant ovarian tumors and of tumors with low malignant potential was 27 (21-29) months. No recurrence or port-site metastasis developed during follow-up. The data are encouraging for adoption of this technique to avert spillage during laparoscopic management of suspect adnexal masses, especially those firmly adherent to the peritoneum. However, the procedure must be validated in a larger series of patients to standardize the technique.

Neutropenic enterocolitis in an advanced epithelial ovarian cancer patient treated with paclitaxel/platinum-based chemotherapy: a case report and review of the literature.

BACKGROUND: Literature data show that neutropenic enterocolitis is a rare but severe complication that can occur in cancer patients treated with chemotherapy and especially with taxanes. CASE REPORT: A 60-year-old woman with stage Illc epithelial ovarian cancer developed neutropenic fever, abdominal pain, severe diarrhoea, nausea, vomiting and oral mucositis one week after the first postoperative cycle of paclitaxel (175 mg/m2 3-hour infusion) plus carboplatin-based chemotherapy. Abdominal X-ray showed diffuse dilatation of the ileal and colonic loops with air/fluid. The patient soon recovered after intensive supportive care. For the second cycle the dose of paclitaxel was reduced by 20%, but nine days later the patient again developed severe neutropenia with fever, abdominal colicky pain, diarrhoea and vomiting. The culture of blood samples collected on admission was found to be positive for Escherichia coli, whereas stools resulted negative for both enteric rods and Clostridium difficile toxin. The patient recovered with intensive supportive care, and chemotherapy was continued with single-agent carboplatin. DISCUSSION: The increasing use of paclitaxel in first-line as well as in the salvage treatment of epithelial ovarian cancer could increase the occurrence of neutropenic enterocolitis in patients with this malignancy. The importance of symptoms such as neutropenic fever, abdominal pain and tenderness and severe diarrhoea should be stressed in patients who receive taxane-based chemotherapy, and intensive supportive care management should be started immediately.

The expression ratios of estrogen receptor α (ERα) to estrogen receptor ß1 (ERß1) and ERα to ERß2 identify poor clinical outcome in endometrioid endometrial cancer.

The prognostic relevance of estrogen (ER) and progesterone receptor (PR) expression in endometrioid endometrial cancer is still controversially discussed. The present study has focused on the evaluation of the prognostic value of ERα, ERß1, ERß2, and PR in this histotype. Specifically, we were interested in evaluating whether the relative level of ER subtype-specific expression (in terms of a ratio ERα/ERß1 and ERα/ERß2) would predict clinical outcome better than their absolute levels in patients with endometrioid endometrial cancer. To this end, protein content was assessed by immunohistochemistry in a group of 121 cases and staining was analyzed in relation to clinicopathologic variables, disease-free survival and overall survival. Results obtained have demonstrated that none of the biological markers analyzed possess an independent prognostic role with regard to disease-free survival. Multivariate analysis of overall survival has shown that ERα alone is not an independent prognostic indicator in patients with endometrioid endometrial cancer (hazard ratio [HR]; 0.5; 95% confidence interval [CI], 0.09-3.0; P = .5). On the other hand, an ERα/ERß1 ratio of 1 or less or an ERα/ERß2 ratio of 1 or less has proved to be independently associated with a higher risk of death (HR, 6.4 [95% CI, 1.0-40.6; P = .04] and 9.7 [95% CI, 1.1-85.3; P = .04], respectively) along with age, tumor stage, and Ki-67. In conclusion, we report here that the ERα/ERß1 and ERα/ERß2 expression ratios are independent prognostic markers of survival in endometrioid endometrial cancer; these findings suggest that phenotyping these interacting markers conjointly may better predict patient survival than each individual marker alone.

Polycystic ovary syndrome and gynecological cancers: is there a link?

Polycystic ovary syndrome [PCOS] is the most common endocrinopathy of women in reproductive age. An association between PCOS and type-1 endometrial cancer has often been reported in the literature. The prolonged anovulation with consequent continued secretion of estrogen unopposed by progesterone may enhance the development and growth of this malignancy, particularly in young women. Hypersecretion of luteinizing hormone [LH], chronic hyperinsulinemia and increased serum insulin-like growth factor [IGF]-I levels may represent risk factors for endometrial cancer. However, data available in the literature do not allow a meta-analysis to be carried out to calculate an estimate of the relative risk of endometrial cancer in women with PCOS. Anecdotal cases of low-grade endometrial stromal sarcoma and carcinosarcoma have been reported in association with prolonged unopposed estrogen stimulation, and in particular with PCOS. A few studies have addressed the possibility of an association between PCOS and epithelial ovarian cancer risk, and the results are conflicting but generally reassuring, and similarly the few available data appear to exclude a strong association between PCOS and breast cancer.