Application of three-dimensional imaging software to map carcinomatosis in recurrent ovarian cancer.

The treatment of recurrent ovarian cancer has been based on systemic therapy. The role of secondary cytoreductive surgery has been addressed recently in several trials. Imaging plays a key role in helping the surgical team to decide which patients will have resectable disease and benefit from surgery. The role of staging laparoscopy and several imaging and clinical scores has been extensively debated in the field. In other surgical fields there have been reports of using 3D imaging software and 3D printed models to help surgeons better plan the surgical approach. To the best of our knowledge, we report the first case of a patient with recurrent ovarian cancer undergoing 3D modeling before secondary cytoreductive surgery. The 3D modeling was of most value to evaluate the extension of the disease in our patient who underwent a successful secondary cytoreductive surgery and is currently free of the disease.

Prognosis of polymerase epsilon (POLE) mutation in high-grade endometrioid endometrial cancer: Systematic review and meta-analysis.

BACKGROUND: POLE mutated endometrial carcinomas may represent a subspecific type of tumors harboring a more favorable prognosis. Grade 3 (G3 or high-grade) endometrioid endometrial carcinomas remain a clinical dilemma, with some tumors behaving as the low-grade counterparts and others presenting a more aggressive behavior. OBJECTIVES: To determine the association between POLE mutational status and the overall-survival (OS) and progression-free-survival (PFS) of patients with G3 endometrioid endometrial cancer (EC). We also aimed to determine the prevalence of POLE mutations in G3 endometrioid EC. METHODS: We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO No: CRD4202340008). We searched the following electronic databases: PubMed/Medline, EMBASE, Cochrane Library, Scopus, and Web of Science. For time-to-event data, the effect of POLE mutation in G3 EC was described using hazard ratios (HRs) and corresponding 95% confidence intervals (CIs). Individual patient data for each study was investigated if available from the study authors. If individual patient data were not available, information regarding time-to-event outcomes was extracted using an appropriate methodology. OS and PFS were analyzed using both one-stage and two-stage approaches, the Kaplan-Meier method, and Cox-proportional hazards models. RESULTS: This systematic review and meta-analysis included 19 studies with 3092 patients who had high-grade endometrioid EC. Patients with POLE mutations had lower risks of death (HR = 0.36, 95% CI 0.26 to 0.50, I2 = 0%, 10 trials) and disease progression (HR = 0.31, 95% CI 0.17 to 0.57, I2 = 33%, 10 trials). The pooled prevalence of POLE mutation was 11% (95% CI 9 to 13, I2 = 68%, 18 studies). CONCLUSION: POLE mutations in high-grade endometrioid EC are associated with a more favorable prognosis with increased OS and PFS.

"Mesenteric stripping using a Veress needle: A creative approach to resect small bowel disease in advanced ovarian cancer".

Small bowel involvement in patients with advanced ovarian cancer has been associated with a worse prognosis and recent data suggests it can be an independent factor associated with shorter disease-free interval (Casales Campos et al., 2022). In the upfront cytoreductive setting, small bowel residual disease (serosa and mesentery) has been identified as the most common site of residual disease (Heitz et al., 2016). The morbidity associated with multiple small bowel resections and the length of the remaining small bowel constitute major limiting factors. As the surgical armamentarium of the gynecologic oncologist has considerably broaden to include more radical procedures, addressing miliary small bowel disease remains extremely important in the quest to achieve complete gross resection (CGR) and thus improving the overall prognosis (Jurado and Chiva, 2021). We present a case of a patient with stage IIIC high grade serous ovarian carcinoma that already had started neoadjuvant chemotherapy before presenting for surgical options. After 4 cycles of carboplatin and paclitaxel, the patient was offered interval cytoreductive surgery plus HIPEC with cisplatin. During surgical exploration, miliary small bowel mesenteric disease was noted but with a grossly intact jejunoileal serosa. The patient underwent bilateral diaphragmatic stripping, cholecystectomy, extraperitoneal hysterectomy and multiple parietal peritonectomies. A decision was made to perform a mesenterectomy using a Veress needle. A standard insuflator was utilized to a maximum pressure of 4 mmHg. CGR was achieved and the patient underwent HIPEC as per institution protocol. The post operative course was uneventful and the patient was discharged five days after surgery. She is currently free of disease (20 months after surgery).

Retroileal colorectal anastomosis after left-sided or transverse colectomy for advanced serous carcinoma of the ovary or uterus.

The ability to achieve complete or optimal cytoreduction in advanced or recurrent ovarian and uterine cancer is a well-established prognostic factor. Colonic resections are commonly required to achieve minimal or no residual disease. When multiple colonic resections are required there is a corresponding difficulty in obtaining sufficient colonic mobility to create tension-free anastomoses for restoration of gastrointestinal continuity; specifically, when a left hemicolectomy or a transverse colectomy is required in addition to a rectosigmoid resection, it may be difficult to achieve a tension-free colorectal anastomosis. We describe the use of retroileal routing of the colon to address this scenario in the context of gynecologic cancer debulking surgery. We report four cases in which the surgeon encountered limited colonic mobility after performing either a left hemicolectomy or a transverse colonic resection in addition to a rectosigmoid resection. In using a retroileal path to perform the colorectal anastomosis, we were able to achieve well-perfused and tension-free anastomoses. Complete gross resection was achieved in all four cases, with acceptable rates of perioperative complications.

Peritoneal deciduosis mimicking peritoneal Carcinomatosis: A case report.

Ectopic decidual reaction (or deciduosis) can be rarely seen in the peritoneum and most of the cases in the literature are associated with pregnancy. It is more commonly found in the ovaries, uterus and cervix. Although its pathophysiology is not totally understood, it is accepted that peritoneal deciduosis develops as a result of the progesterone induced metaplasia of subserosal stromal cells during pregnancy. It is important to distinguish this entity from oncologic conditions, namely metastatic carcinoma and mesothelioma. We report an unusual case of a 40 year-old non pregnant patient that presented with imaging findings suggestive of peritoneal carcinomatosis.

Right upper quadrant cytoreductive procedures and cardiophrenic lymph node resection in primary debulkig surgery for ovarian cancer.

Upfront debulking surgery followed by adjuvant chemotherapy still remains as the mainstay approach to patients with advanced ovarian cancer (Eisenhauer et al., 2006). Upper abdominal surgery is often required to achieve complete gross resection and there are several studies in the literature reporting increased survival, as well as a minimal but acceptable increase in morbidity, as a result of this shift in the surgical paradigm (Chi et al., 2009). Cardiophrenic lymph nodes (CPLNs), also referred to as paracardiac and supradiaphragmatic lymph nodes, are located just above the diaphragm. In diseases such as advanced ovarian cancer, where there is often considerable abdominal and peritoneal tumor burden, these lymph nodes can harbor metastases. These nodes are usually larger than 5 mm in diameter and are easily identified on computed tomography. Evidence suggests that this finding should not preclude primary debulking surgery (if resectable disease in the abdomen) as it is associated with an increased median overall survival even in stage IV disease (Cowan et al., 2017, Prader et al., 2016). We present a video highlighting one of the most commonly performed debulking procedures in the upper abdomen - right diaphragmatic peritoneal stripping (the patient had multiple small implants in both the diaphragmatic peritoneum and Morisons Pouch peritoneum, so en bloc resection was performed) - followed by a transabdominal excision of an enlarged right cardiophrenic lymph node. The defect was closed with a 2-0 polypropylene running suture.

Patterns of FIRST recurrence of stage IIIC1 endometrial cancer with no PARAAORTIC nodal assessment.

OBJECTIVE: To assess the rates and distribution of first recurrence in patients with FIGO stage IIIC1 endometrial cancer (EC) who did not undergo paraaortic dissection at surgical staging. METHODS: We retrospectively selected all (n = 207) stage IIIC1 patients treated at a single institution from 5/1993-1/2017. Sites of first recurrence were identified, disease-free (DFS) and overall survival (OS) calculated, multivariate logistic regression performed to identify factors associated with recurrence. RESULTS: Three-year DFS and OS were 66.5% and 85.7%, respectively. The most common histology was endometroid (64.2%). Three-year DFS was 81% (SE±3.8%) endometrioid vs. 39.5% (SE±6.6%) non-endometrioid (P < 0.001). Three-year OS was 96.9% (SE±1.8%) endometrioid vs. 65.6% (SE±6.7%) non-endometrioid (P < 0.001). Sixty-two (30.1%) patients recurred. Patterns of recurrence were: 14 (8.3%) multiple sites, 17 (8.2%) abdominal, 14 (6.8%) extra-abdominal, 17 (8.3%) isolated nodal (8 of these (3.9%) paraaortic). Patients with isolated tumor cells (ITCs) in lymph nodes only had 12/71 (17%) recurrence rate vs. 50/135 (37%) for patients with micro-/macrometastasis. On univariate analysis, grade (HR 4.67 95%CI 1.5-14.5, P = 0.008), histology (HR 4.9 95%CI 2.6-9.3, P < 0.001), myometrial invasion (HR 1.9 95%CI 1.04-3.5, P = 0.04), pelvic washing (HR 2.2 95%CI 1.1-4.5, P = 0.03), tumor volume in pelvic LNs (ITC vs. micro-/macrometastasis; HR 0.3 95%CI 0.2-0.7, P = 0.003) were associated with recurrence. On multivariate analysis, only histology was associated with recurrence (HR 7.88 95%CI 3.43-18.13, P < 0.001). CONCLUSIONS: Isolated paraaortic recurrence in stage IIIC1 EC is uncommon. Micro-/macrometastasis were associated with twice the recurrence rate compared to ITC. These data will help clinicians counsel patients with stage IIIC1 EC regarding paraaortic assessment.

Late Retroperitoneal Hematoma with Abscess Formation Following Laparoscopic Staging of Endometrial Cancer.

Herein, we report a case of a 63-year-old, nonobese, woman who underwent laparoscopic surgical staging for endometrial cancer with pelvic and para-aortic lymph node dissection. After being discharged, the patient presented to the emergency department with fever and abdominal pain, 1 week after the procedure. Abdominal tenderness, fever, and anemia were the key clinical and laboratory findings. A computed tomography (CT) scan revealed a cystic mass with air bubbles, located in the right iliopsoas region. The features were consistent with an infected hematoma at the right iliopsoas region, which was managed with antibiotics and CT-guided pigtail drainage. Laparoscopic surgical staging for endometrial cancer has been shown to have fewer early complications than open surgery. However, complications can still occur in the most experienced hands. Abscess arising from hematomas after laparoscopic surgical staging can be managed adequately with noninvasive CT-guided drainage.

Twin anemia polycythemia sequence: a report of three cases.

BACKGROUND: Vascular anastomoses in monochorionic placentas are the key factor in the develop- ment of several complications, including twin anemiapolycythemia sequence (TAPS). TAPS is an uncommon form of chronic fetofetal transfusion, characterized by large intertwin hemoglobin (Hb) differences in the absence of amniotic fluid discordances. CASE: We report 3 unusual cases of spontaneous TAPS. Looking to the intertwin Hb differences, each case fits in a different stage of postnatal twin anemia-polycythemia classification. Five of the 6 twins had a good outcome despite major hemodynamic changes. CONCLUSION: Spontaneous TAPS is by far more infrequent than its postlaser counterpart. Our report is somewhat uncommon due to the fact that the 3 cases were spontaneous, consecutive, and each one fit as an example of the various degrees of severity according to the described classifications of this condition.

Borderline Ovarian Tumor during Pregnancy: A Case Report.

We report a case of a 33 year-old pregnant woman who was diagnosed at the time of the first trimester ultrasound with a multilocular solid arising form the right ovary. An abdominal MRI was performed afterwards and it revealed a pelvic mass, developing from the right ovary, with a liquid component but with a major solid area. CA 125 was within the normal range values. A laparotomy followed by right salpingo-oophorectomy was performed at 14 weeks of gestation and both the frozen section and the definitive histology revealed a borderline mucinous ovarian tumor. Ovarian tumors of low malignant potential comprise 10%-20% of all ovarian malignancies. They carry an excellent prognosis with 95%-99% long-term survival. Whereas in the past, radical surgery (hysterectomy and bilateral salpingo-oophorectomy with peritoneal staging) was standard regardless of the age of the patient, unilateral salpingo-oophorectomy with or without staging has become the recommended management for women who desire childbearing. In the absence of large prospective randomized trials it is difficult to know which are the best management practices and especially to determine the right moment during pregnancy to perform surgery in these patients.

Abdominal mass mimicking a leiomyoma: Malignant uterine solitary fibrous tumor.

► Apparent symptomatic leiomyoma in a young woman. ► Leiomyoma with a gross appearance somewhat different than usual. ► Malignant solitary fibrous tumor of the uterus.