The sarcopenia index measured using the lumbar paraspinal muscle is associated with prognosis in endometrial cancer.

OBJECTIVE: The number of type-II endometrial cancer patients has been increasing and the prognosis is not favorable. We aim to investigate whether sarcopenia index in any of several different muscles could serve as a novel biomarker of prognosis in patients with type-II endometrial cancer. METHODS: We retrospectively investigated a total of 194 patients at four hospitals. Ninety patients were treated as derivation set and the other 104 patients as validation set. Using preoperative computed tomography images, we measured the horizontal cross-sectional area at the third lumbar spine level: the (i) psoas major, (ii) iliac and (iii) paraspinal muscle. The clinical information including recurrence-free survival and overall survival were retrospectively collected. These results were validated with external data sets of three hospitals. RESULTS: The median values of the sarcopenia index (cm2/m2) ± standard deviation with the first data of 90 patients using the psoas, iliac and paraspinal muscle were 3.4 ± 1.0, 1.7 ± 0.6 and 12.6 ± 3.2, respectively. In univariate analyses, the sarcopenia indexes measured using the psoas or paraspinal muscle were associated with recurrence-free survival and overall survival. On the other hand, in multivariate analyses, only the sarcopenia index using paraspinal muscle was significantly related to recurrence-free survival (hazard ratio = 3.78, 95% confidence intervals = 1.29-5.97, P = 0.009) and overall survival (hazard ratio = 3.13, 95% confidence interval = 1.18-8.26, P = 0.022). Paraspinal sarcopenia index was also related to overall survival (hazard ratio = 3.74, 95% confidence interval = 1.31-10.72, P = 0.014) even in patients with advanced stage. Serum albumin was significantly correlated with the sarcopenia index (P = 0.012). Within the analysis of the validation set, sarcopenia index using paraspinal muscle was related to recurrence-free survival (hazard ratio = 2.06, P = 0.045) in multivariate analysis and recurrence-free survival (P = 0.009) in patients with advanced stage. CONCLUSIONS: The sarcopenia index using the paraspinal muscle, not psoas, could be a suitable index to predict recurrence-free survival and overall survival in patients with type-II endometrial cancer even in advanced stage.

Questionnaire survey regarding current status of minimally invasive surgery for endometrial cancer in Japan: A cross-sectional survey for JSGOE members.

AIM: Minimally invasive surgery (MIS) has been introduced as an alternative to more radical surgical procedures. The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy conducted a cross-sectional questionnaire survey to ascertain the status of MIS for endometrial cancer. METHODS: The survey was conducted between May 10 and June 30, 2022. The questionnaire included information on personal attributes, academic affiliations, qualifications, hysterectomies, and intraoperative procedures performed. RESULTS: The total number of questionnaire respondents was 436 (9.2% of the membership). The hysterectomy methods and percentage performed were as follows: simple total hysterectomy (equivalent to benign surgery), 3%; simple total hysterectomy with care to avoid shaving the cervix, 31%; extended total hysterectomy, 48%; and modified radical hysterectomy, 15%. An analysis of hysterectomies performed using MIS for endometrial cancer by qualified gynecologists of endoscopy or board-certified gynecologic oncologists showed a tendency not to choose simple total hysterectomy compared to the gynecologists who did not hold certification (p = 0.019, p = 0.045, and p = 0.010, respectively). Additionally, 67% of respondents did not use uterine manipulators, and 59% of the respondents did not perform lymph node dissection following the guidelines for treating endometrial cancer in Japan. CONCLUSION: This study provided the current status of MIS for endometrial cancer in Japan. The hysterectomy method, use of uterine manipulators, and criteria for omitting lymph node dissection were generally in agreement with the guidelines. Currently, an extra-fascial simple hysterectomy, including at least not shaving the cervix, was a major method for early invasive endometrial cancer using MIS.

Surgical skill and oncological outcome of laparoscopic radical hysterectomy: JGOG1081s-A1, an ancillary analysis of the Japanese Gynecologic Oncology Group Study JGOG1081.

OBJECTIVES: We investigated whether surgical skill and procedure were related to oncological outcomes in cervical cancer patients who underwent Laparoscopic Radical Hysterectomy (LRH). METHODS: We previously assessed data of LRH from 251 patients with FIGO stage (2009) IA2, IB1and IIA1 cervical cancer collected for JGOG 1081s study. 1) The JGOG 1081s cohort study was re-examined to refine the surgical details and extend the follow-up period as chart review. 2) Unedited videos for recurrent cases and matched non-recurrent control cases were newly compared by experts for various surgical skills and surgical procedures using the modified Objective Structured Assessment of Technical Skills (OSATS) tool, without awareness of the recurrence status as video review. RESULTS: After a median follow-up of 46 months, tumors had recurred in 31 of the 251 patients. The five-year Recurrence-Free Survival rate was 86.9% (81.8-90.6) and five-year Overall Survival rate was 93.7% (87.5-96.8). Multivariate analysis from chart reviews found that an experience with LRH of less than 20 cases per institution was an independent prognostic factor for recurrence (Hazard Ratio (HR) 2.49, 95%CI 1.12-5.53, p = 0.025). For the surgical video review, we compared 23 videos of recurrent cases with 23 background-matched non-recurrent controls. Lower modified OSATS scores from the video review were consistently trended to have a higher risk of recurrence. CONCLUSIONS: Our new study has found that LRH surgical experience and skill trended to have better oncological outcomes.

Periaortic Abdominal Fat Area as a Predictor of Surgical Difficulties during Extraperitoneal Laparoscopic Para-aortic Lymphadenectomy.

STUDY OBJECTIVE: To evaluate whether obesity is a marker of surgical difficulty during extraperitoneal para-aortic lymphadenectomy. DESIGN: Retrospective observational cohort study. SETTING: Tertiary medical center in the Kanazawa area of Japan. PATIENTS: Eighty-four patients with primary endometrial cancer who underwent extraperitoneal laparoscopic para-aortic lymphadenectomy (LPAND) between January 2005 and December 2017 were included. INTERVENTIONS: We investigated the correlation between operative times and body mass indexes, visceral fat areas, and periabdominal artery fat areas (PAFAs). The number of lymph nodes harvested was used as an indicator of the degree of surgical completion. MEASUREMENTS AND MAIN RESULTS: There was no correlation between the operative time and body mass index. Significant correlations were observed between operative time and visceral fat area (p = .026; r = 0.243) and between operative time and PAFA (p = .007; r = 0.293). A multivariate analysis showed that PAFA was a significant independent marker that could be used to predict prolonged operative times for extraperitoneal LPAND (p = .045; odds ratio, 3.05). The number of para-aortic lymph nodes harvested was not significant in the high- and low-PAFA groups (22 and 25, respectively; p = .525). CONCLUSION: PAFA is an adequate marker of prolonged operative time for extraperitoneal LPAND among patients with endometrial cancer.

Simultaneous resection of endometrial cancer and high-level paraaortic paraganglioma using retroperitoneoscopic surgery.

•Paraganglioma is sometimes suspected as lymph node metastasis or lymph node recurrence of various malignant tumors.•Retroperitoneoscopic surgery is a valid approach to treat the tumor, located above the renal vein.•Resection using retroperitoneoscopic surgery without catecholamine-related complications is possible.

Acquired hemophilia A manifesting as plasma transfusion-uncontrolled severe bleeding 2 weeks after chorioamnionitis-induced abortion.

Acquired hemophilia A (AHA) is a serious and rare complication of pregnancy, caused by autoantibodies to coagulation factor VIII after delivery. We here report the case of a 36-year-old primigravida woman who developed AHA following chorioamnionitis-caused miscarriage in the second trimester. Thirteen days after abortion, sudden, massive vaginal bleeding occurred with marked prolongation of activated partial thromboplastin time (APTT) in the absence of other abnormal coagulation data. Sequential transfusion of fresh frozen plasma did not achieve normalization of APTT. Further examination confirmed reduction of coagulation factor VIII and the presence of its inhibitor, leading to the final diagnosis of AHA. The patient was effectively treated with bypassing agents (activated prothrombin complex concentrate and recombinant activated factor VII) and immunosuppressive therapy. Fifteen months after remission, the patient became pregnant and successfully achieved term delivery with no signs of recurrence. This case illustrates that AHA should be considered in the occurrence of plasma transfusion-uncontrolled severe bleeding after delivery.

Amylase-producing ovarian carcinoma: A case report and a retrospective study.

► Amylase-producing ovarian carcinoma may mimic pancreatitis. ► Hyperamylasemia is common in ovarian carcinoma. ► Serum amylase may be a promising tumor marker.

Redefinition of the pelvic connective tissue: in situ histologic examination.

OBJECTIVES: : The objectives of this study were to find a common perspective in clinical and gross/systemic anatomy for the pelvic connective tissue (subperitoneal fascia) and to establish a new pelvic anatomy. METHODS: : The histologic sections from 5 fixed cadavers were obtained from a total of 17 fixed and 11 fresh cadavers. On the basis of our past surgical and research findings, the relationship between the pelvic organs and the pelvic connective tissue was observed from in situ histologic sections of the whole pelvis. RESULTS: : Subperitoneal fasciae, a term that is expressed in gross/systemic anatomy, were manifested as a 3-dimensional structure by a complex of "ligaments," as defined in clinical terminology. In the supine position, this structure consisted of the sagittal plane formed by the rectouterine ligament and vesicouterine ligament; the perpendicular plane by the vesicohypogastric fascia, transverse cervical ligament, and lateral rectal ligament; and the horizontal plane by the superior fascia of the levator ani muscle. CONCLUSIONS: : The ligaments were regarded as a compatible component of the subperitoneal fascia. Our anatomical concept of the pelvic connective tissue differed from that for classic clinical anatomy.