Laparoscopic Division of Median Sacral Artery and Dissection of Types III and IV Sacrococcygeal Teratomas to Decrease Intraoperative Hemorrhagic Complications: Case Series and Review of the Literature.

INTRODUCTION: Sacrococcygeal teratoma (SCT) is the most common teratoma presenting at birth. Life-threatening bleeding is a major complication during tumor excision in children. In this study we demonstrate our technique for laparoscopic division of median sacral artery (MSA) during dissection of SCT in 2 pediatric patients as a safe technique to minimize risk of hemorrhage. METHODS: Two female infants diagnosed with types III and IV SCTs underwent preoperative evaluation in the postnatal period. The first patient was an 18-month-old girl who presented with metastatic type IV teratoma, resected after neoadjuvant therapy, and the second patient was a 6-day-old girl with prenatal diagnosis of cystic type III teratoma. Using laparoscopy in both patients, the presacral space was reached by opening the peritoneal reflection with blunt dissection and the MSA was identified. Then it was carefully isolated and divided with 3 or 5 mm sealing device. The pelvic components of the tumors were partially dissected using laparoscopy. The first patient's tumor resection was completed using a posterior sagittal approach and the second patient required a standard Chevron incision. Along with the description of our technique, a review of the current literature for the management of SCT and MSA was performed. RESULTS: Both patients underwent successful laparoscopic division of the MSA and resection of the SCTs without complications. CONCLUSION: Laparoscopic MSA division before SCT excision offers a safe approach that can reduce the risk of hemorrhage during surgery.

[A Case of Aggressive Angiomyxoma in a 75-Year-Old Man].

Aggressive angiomyxoma is an uncommon mesenchymal tumor that mostly involves the pelvic and perineal regions in young women.We herein report an extremely rare case of aggressive angiomyxoma in a 75-year-old man. The patient had undergone follow-up for an intraductal papillary mucinous neoplasm.In September 2015, CT detected a tumor measuring 33 mm in diameter around the pelvis, and the tumor showed gradual increase in size.MRI revealed a relatively sharply marginated tumor with low signal intensity on T1-weighted images and high signal intensity on T2-weighted images.For treatment and diagnosis, we laparoscopically resected the tumor. Histopathologically, the specimen showed spindle tumor cells within a myxoid background and vascular structures.The tumor was diagnosed as aggressive angiomyxoma, and surgical margins were negative for tumor cells. The patient is currently doing well without any signs of recurrence as of 18 months postoperatively.

Surgical versus percutaneous isolated pelvic perfusion (IPP) for advanced melanoma: comparison in terms of melphalan pharmacokinetic pelvic bio-availability.

BACKGROUND: Isolated pelvic perfusion (IPP) can be used to treat unresectable melanoma metastases of the pelvis. IPP can be performed either by surgical or percutaneous approaches, using different balloon catheters. The aim of this study was to examine whether the surgical and percutaneous approaches were comparable with respect to tumor drug exposure in the pelvis. METHODS: A pharmacokinetic study was performed in 5 melanoma patients treated with surgical IPP and five with percutaneous IPP. Both groups received melphalan at the dose of 30 mg/m2. Melphalan pharmacokinetic analyses were performed and the main parameter used to evaluate pelvic tumor drug-exposure was the ratio of areas under the melphalan plasma concentration curves in the pelvis and the systemic compartment, during the perfusion time (AUC0 to 20). Non-parametric Mann-Whitney tests were employed for statistical comparisons. RESULTS: The median and interquartile range (IQR) values of the ratios between melphalan AUC0 to 20 in pelvic and systemic compartments were 7.9 (IQR 7.2 to 9.9) and 5 (IQR 4 to 7.9) for surgical and percutaneous IPPs, respectively (p = 0.209). CONCLUSIONS: Tumor exposure to drug using these two methods did not statistically differ and both methods, therefore, can be adopted interchangeably, utilizing a perfusion blood flow rate of approximately 120 ml/min. The small sample size is a limitation of this study but our preliminary results can be used to calculate the effect size of a larger trial. Trial Registration Clinical Trials.gov Identifier NCT01920516; date of trial registration: August 6, 2013.

Robot-assisted laparoscopic resection of a huge pelvic tumor: A case report.

The traditional open surgery, for the treatment of huge tumor in the narrow space of pelvic cavity and in close proximity to pelvic organs and neurovascular structures, is very difficult and challenging. We report a case of huge neurilemmoma operated using the robot-assisted laparoscopy. We used interventional pre-operation embolization to control blood supply of tumor because MRI showed the tumor had a sufficient blood supply.

[Complex pelvic and sarcoma surgery with vascular replacement]. / Komplexe Becken- und Sarkomchirurgie mit Gefäßersatz.

Due to optimization of surgical techniques in surgical oncology and vascular surgery, the most modern approaches of anesthesia and intensive care medicine and effective multimodal therapeutic strategies, locally advanced malignant tumors are resected more frequently with a potentially curative intent. In the case of extensive tumors with infiltration of vital vascular structures or of structures which are crucial for extremity preservation, the necessary surgical procedure for complete tumor removal poses a major challenge for the surgeon and incorporates a high risk of perioperative morbidity for the patient. The decision to attempt tumor resection should therefore always be based on a concept considering all aspects of the malignant disease. The treating team should be highly experienced in this complex field of surgery, not only with respect to the surgical approach but also regarding the management of postoperative complications. In this article relevant aspects of decision making, surgical technique and postoperative outcome for malignant tumors involving vascular structures of the retroperitoneum and pelvis are presented.

Effect of parallel radiofrequency transmission on arterial input function selection in dynamic contrast-enhanced 3 Tesla pelvic MRI.

BACKGROUND: To evaluate whether parallel radiofrequency transmission (mTX) can improve the symmetry of the left and right femoral arteries in dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) of prostate and bladder cancer. METHODS: Eighteen prostate and 24 bladder cancer patients underwent 3.0 Tesla DCE-MRI scan with a single transmission channel coil. Subsequently, 21 prostate and 21 bladder cancer patients were scanned using the dual channel mTX upgrade. The precontrast signal ( S0) and the maximum enhancement ratio (MER) were measured in both the left and the right femoral arteries. Within the patient cohort, the ratio of S0 and MER in the left artery to that in the right artery ( S0_LR, MER_LR) was calculated with and without the use of mTX. Left to right asymmetry indices for S0 ( S0_LRasym) and MER ( MER_LRasym) were defined as the absolute values of the difference between S0_LR and 1, and the difference between MER_LR and 1, respectively. RESULTS: S0_LRasym, and MER_LRasym were 0.21 and 0.19 for prostate cancer patients with mTX, and 0.43 and 0.45 for the ones imaged without it (P < 0.001). Also, for the bladder cancer patients, S0_LRasym, and MER_LRasym were 0.11 and 0.9 with mTX, while imaging without it yielded 0.52 and 0.39 (P < 0.001). CONCLUSION: mTX can significantly improve left-to-right symmetry of femoral artery precontrast signal and contrast enhancement.

Three-dimensional computed tomography of pelvic masses in Mayer-Rokitansky-Küster-Hauser syndrome.

BACKGROUND: Mayer-Rokitansky-Küster-Hauser syndrome is a rare congenital anomaly characterized by congenital aplasia or hypoplasia of the uterus and vagina. We report a case of Mayer-Rokitansky-Küster-Hauser syndrome with multiple large pelvic masses diagnosed by three-dimensional computed tomography (CT) angiography. CASE: A 40-year-old woman with Mayer-Rokitansky-Küster-Hauser syndrome presented with an abdominal mass that had grown for 3 months. Magnetic resonance imaging (MRI) confirmed several solid masses, and normal bilateral ovaries were detected; three-dimensional CT revealed that these tumors were supplied from the right ovarian and uterine arteries, suggesting that they arose from the uterus. Accordingly, leiomyoma was suspected. Laparoscopic surgery was contraindicated, and the patient therefore underwent laparotomy. The masses were resected with the bilateral rudimentary uteri and fallopian tubes, and pathologic evaluation confirmed leiomyoma. CONCLUSIONS: Combined MRI and three-dimensional CT angiography can accurately evaluate the origin and anatomic properties of leiomyomas in patients with Mayer-Rokitansky-Küster-Hauser syndrome.

[FIRST EXPERIENCE OF APPLICATION OF TECHNOLOGY OF A TWO-STREAM LOW-FREQUENCY ULTRASOUND TECHNOLOGY IN ABDOMINAL SURGERY].

Biophysical peculiarities of action on tissues of a two-strem low-frequency ultrasound (TSLFU) technology, elaborated by "Arobella Medical LLC" (USA) firm, were studied. Capacity of ultrasound to separate a pathologically-changed and healthy tissues, to divide the structures in accordance to their bioacoustical parameters constitutes the technology peculiarities. The presence of such a biophysical effect permits to achieve high resectability (R0) in patients with oncological diseases. Antibacterial effect and stimulation of intraorgan microcirculation with ultrasound irradiation were noted. Biophysical peculiarities of TSLFU were successfully applied in surgical treatment of 48 patients, suffering inflammatory and oncological diseases of the abdominal cavity organs.

Value of tumor vessel sign in isolated circumscribed hypervascular abdominopelvic mesenchymal tumors on multidetector computed tomography.

OBJECTIVE: The objective was to determine the usefulness of the tumor vessel sign for differentiating the groups of circumscribed hypervascular abdominopelvic mesenchymal tumors. METHODS: We enrolled a total of 4 groups such as patients with gastrointestinal stromal tumor (GIST) (26 patients), those with paraganglioma (9 patients), those with primary sarcomas (13 patients, excluding those with liposarcoma), and those with desmoid tumor (6 patients). The reviewers evaluated the presence of tumor vessels capable of directly tracing from the tumor margin to the named vessels. RESULTS: Twenty-five of 26 GIST cases, all of the paragangliomas, all of the primary sarcomas, and all of the desmoid tumors showed a positive sign. For the sign confirming GIST, the sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were 96.2%, 100%, 100%, 96.6%, and 98.1%, respectively. The values of the area under the receiver operating characteristic curve have good or excellent diagnostic accuracies. CONCLUSIONS: The presence of the sign is considered to be helpful for differentiating the 4 groups of tumors.

Tumor feeding artery reconstruction with multislice spiral CT in the diagnosis of pelvic tumors of unknown origin.

PURPOSE: We aimed to compare multislice spiral computed tomography (MSCT) angiography diagnosis with both surgical findings and postoperative pathological results in patients with pelvic tumors of unknown origin. In addition, the diagnostic accuracy of MSCT angiography was compared with that of routine computed tomography for tumor feeding artery volume reconstruction to determine the origin and nature of pelvic tumors. MATERIALS AND METHODS: The records of 43 patients with pelvic tumors of unknown origin who underwent MSCT angiography were retrospectively reviewed. Volume reconstructions using add vessel and merge views methods were performed for abdominal and pelvic blood vessels. The tumor origin was identified based on observations of the origin, number, morphology, starting/ending locations, route, and distribution of the tumor feeding arteries. RESULTS: Overall, the mean tumor diameter was 9.8±3.5 cm (range, 4.2-23.5 cm); 11 tumors (25.6%) were cystic in nature; and 32 tumors (74.4%) were either solid/cystic or solid in nature. When considering all MSCT angiography examinations used to predict the nature of the tumor (e.g., malignant or benign), the sensitivity and specificity were 77.3% and 95.2%, respectively. The positive and negative predictive values were 94.4% and 80%, respectively. The overall diagnostic accuracy was 86.05% with an area under the curve of 0.961 (95% confidence interval, 0.913-1.000). CONCLUSIONS: MSCT angiography volume reconstruction for pelvic tumor feeding arteries of unknown origin is highly valuable for localization, qualitative diagnosis, and quantitative diagnosis of pelvic tumors.

Extragonadal sclerosing stromal tumor: a rare case report.

Sclerosing stromal tumor is a rare, benign, sex cord stromal tumor of the ovary. We report a case of extragonadal sclerosing stromal tumor in a 45-year-old woman who presented with menstrual irregularity and vague pelvic pain. Imaging studies showed a well-defined mass between the posterior wall of the bladder and uterus, suspected of being a pedunculated leiomyoma. The histopathological and immunohistochemical study was consistent with sclerosing stromal tumor. No ovarian tissue was found on representative sectioning. This is the first case of sclerosing stromal tumor in an extragonadal location.

Parasitic leiomyoma: a case report.

To report a case of parasitic myomas and examine associations and risk factors, a 35 years old lady presented with a lump in the lower abdomen in Bangladesh Medical College Hospital, Dhaka. Retrospective review was performed based on indications for surgery; types of prior surgeries; prior use of morcellation; and locations of parasitic myomas. Pathologic confirmation of specimen was obtained. Surgery performed by laparotomy. Myoma was found occupying the pelvis and upper abdomen. Parasitic myomas may occur spontaneously as pedunculated subserosal myomas lose their uterine blood supply and parasitize to other organs. More parasitic myomas may be iatrogenically created after surgery, particularly surgery using morcellation techniques. With increasing rates of laparoscopic procedures, surgeons should be aware of the potential for iatrogenic parasitic myoma formation, their likely increasing frequency, and intraoperative precautions should be taken to minimize occurrence of the type of myoma.

Pelvic angiomyolipoma.

Angiomyolipoma is a rare benign tumor most commonly found in the kidney and, infrequently, extrarenally. We report a case of pelvic angiomyolipoma in a male patient without stigmata of tuberous sclerosis. The patient presented with right retroperitoneal bleeding and was found to have bilateral renal angiomyolipomas as well as a pelvic mass with similar appearance as the other lesions. He underwent urgent embolization of the large right angiomyolipoma and subsequent robot-assisted left laparoscopic partial nephrectomy with simultaneous resection of the pelvic mass, which was well-tolerated. Pathology confirmed what is, to our knowledge, the only reported case of pelvic angiomyolipoma.

A proposal for a new scoring system to evaluate pelvic masses: Pelvic Masses Score (PMS).

OBJECTIVES: Ovarian cancer is the fourth leading cause of death among neoplastic diseases in women. In spite of constant improvement in surgical, chemotherapeutic and immunologic techniques, which can induce long remission periods, the five-year survival rate has not really changed over the past thirty years. We tried to create a sonographic scoring system, called PMS, that could be helpful in diagnosis of pelvic masses. STUDY DESIGN: The three most commonly used and validated indexes--Sassone score, Ovarian Tumor Index (OTI), and Risk of Malignancy Index 3 (RMI3)--were applied to a population of 102 women with adnexal masses. We developed a new scoring system, named Pelvic Masses Score (PMS), that takes into account the ultrasound morphological pattern, the Doppler flowmetry of the pelvic mass, the CA125 serum level and the menopausal status. We then applied this scoring system to a population of 160 women for validation of the score. RESULTS: Statistical analysis of the data obtained from the new scoring system reveals that sensitivity, specificity, positive and negative predictive values (PPV and NPV) are higher than in the case of data separately derived from the Sassone score, OTI index or RMI index. CONCLUSIONS: Our preliminary data showed good results in term of sensitivity, specify and predictive values compared to other old scoring systems. A larger prospective study is required to confirm these preliminary data. The number of cases will be expanded to permit a better evaluation of PMS.

Tumour perfusion assessment during regional hyperthermia treatment: comparison of temperature probe measurement with H(2)(15)O-PET perfusion.

PURPOSE: Hyperthermia treatment might increase tumour oxygenation and perfusion, as has been reported for experimental tumours. The present study was performed to investigate this hypothesis in patients undergoing regional hyperthermia treatment. METHODS: Thirteen patients with primary or recurrent pelvic tumours were included in this study. Prior to and up to one hour after regional hyperthermia, perfusion was quantitatively determined by H(2)(15)O-PET. The fused CT-PET images were used to extract tumour time-activity curves and to identify the catheter position. Perfusion was calculated from the total tumour time-activity curves and for the time-activity curves at the catheter site. Additionally, perfusion was calculated from the temperature-time curves measured using temperature probes. RESULTS: Perfusion values calculated using H(2)(15)O-PET and those deduced from temperature probe measurements are significantly correlated with a correlation coefficient, R = 0.21. The perfusion values deduced from the temperature measured in a body cavity do not provide information about average tumour perfusion. Perfusion values deduced from the temperature are overestimated for very poorly perfused tissues and underestimated for highly perfused tissues. CONCLUSIONS: Temperature measurement during hyperthermia may allow only determination of intermediate perfusion values.

Use of H(2) (15)O-PET for investigating perfusion changes in pelvic tumors due to regional hyperthermia.

PURPOSE: An increase in tumor oxygenation and perfusion due to hyperthermia has been reported for experimental tumors. The present study was performed to investigate this hypothesis in patients who underwent regional hyperthermia. METHODS: Twenty-seven patients with primary or recurrent pelvic tumors were included in this study. Prior to and up to 1 h after regional hyperthermia, perfusion and partition coefficient were quantitatively determined by utilizing H(2) (15)O-PET. First pass PET images were fused with the segmented common iliac artery from separately acquired CT scan. The arterial input function was extracted from the common iliac arteries using the dynamic PET images and the fused CT. The fused images were also used to extract tumor activity-time curves. Perfusion was calculated from the total tumor curves with correction for arterial spill-over. Changes in perfusion and partition coefficient were analyzed and correlated with various treatment parameters. RESULTS: Heating under hyperthermia conditions significantly increased the partition coefficient for pelvic tumors (P = 0.005). The increase correlated with the duration of hyperthermia and was found in patients treated for more than 1 h and persisted for more than 1 h after the end. Significant changes in perfusion were not observed. Perfusion had recurred to initial values 20 min after heating. CONCLUSIONS: The increase in partition coefficient reflects an increased diffusion distance of radio-labeled water. Therefore water diffusion is increased due to hyperthermia. Analogous to water diffusion, the diffusion of inert gases is also facilitated, improving the oxygenation of hypoxic tumor cells. Our results suggest that tumor oxygenation can probably be enhanced by regional hyperthermia for a period of more than 1 h after heating, provided hyperthermia is applied for at least 60 min. The effect was observed to be reversible within one week.

The use of autologous femoral vein for the repair of the common iliac vein after resection of a pheochromocytoma.

AIM: To illustrate the use of autologous femoral vein for grafting ilio-caval vein defects following abdomino-pelvic tumour resections. METHODS: Case report and literature review. RESULTS: Durable restoration of ilio-caval patency was achieved, with minimal morbidity from graft harvesting. CONCLUSIONS: Autologous femoral vein presents a viable graft option for the immediate reconstruction of large intra-abdominal vein deficits.

Dynamic MRI for imaging tumor microvasculature: comparison of susceptibility and relaxivity techniques in pelvic tumors.

PURPOSE: To assess the reproducibility of intrinsic relaxivity and both relaxivity- and susceptibility-based dynamic contrast enhanced (DCE) MRI in pelvic tumors; to correlate kinetic parameters obtained and to assess whether acute antivascular effects are seen in response to cisplatin- or taxane-based chemotherapy. MATERIALS AND METHODS: T1-weighted and T2*-weighted DCE-MRI and basal R2* measurements were performed on three consecutive days in women with gynecological tumors. The third scan was 21.0 (range 17.3-23.5) hours after the first cycle of chemotherapy. Kinetic parameter estimates were obtained and correlated between techniques. Test-retest reproducibility and response to treatment were assessed. RESULTS: Relative blood volume (rBV) and relative blood flow (rBF) correlated strongly with transfer constant (Ktrans), kep, and the initial area under the gadopentetate dimeglumine (Gd-DTPA) concentration-time curve (IAUGC) (all P<0.01). The group 95% confidence interval (CI) for change was -10.8 to +12.1%; +/-5.1%; -9.5 to +10.5%; +/-7.5%; for Ktrans, ve, kep, and IAUGC, respectively, and +/-13.6%, +/-2.4%, +/-11.6%, and +/-11.0%, for rBV, mean transit time (MTT), rBF, and R2*, respectively. There were no significant acute changes in kinetic parameter estimates in response to treatment on group analysis, apart from a small decrease in ve. CONCLUSION: The results confirm the dominant influence of flow on Ktrans in untreated gynecological tumors. There is no evidence of an acute, large magnitude antivascular effect caused by cisplatin- or taxane-based chemotherapy.