Low-grade endometrial stromal sarcoma with intravenous thrombus extension: a multidisciplinary surgical challenge.

Low-grade endometrial stromal sarcoma (LG-ESS) usually exhibits indolent behavior, often misdiagnosed and is associated with a favorable prognosis [1]. Despite the indolent nature of LG-ESS, recurrence is common, the risk is as high as 1 in 3 to 1 in 2 [2]. The behavior of such tumors can lead to invade blood vessels [3]. An intravascular tumor is associated with direct risk of sudden death from pulmonary embolism. There are very few reported cases with clinically obvious intravascular extension. Chemotherapy, radiotherapy and hormone therapy are adjuvant treatments that have not been able to demonstrate a definitive benefit in survival [4]. We want to take advantage of the opportunity, so far unpublished, to demonstrate with this case the surgical challenge described step by step, as well as to demonstrate the importance of surgery as the only curative treatment even in extended intravascular disease [5]. Here in, we present the surgical challenge of a LG-ESS in a 59-year old woman with iliac and cava vein tumoral thrombus extension. We performed a tumoral thrombectomy and vascular repair, with a pelvic exenteration and double barrel wet colostomy. After performing pelvic exenteration, the thrombus with intravascular involvement was addressed at 2 points: inferior cava vein and right common iliac vein with the extraction of the entire thrombus. These defects are corrected by angioplasty and venorrhaphy, respectively. The surgery got a complete cytoreduction. It lasted 290 minutes, with 430 mL blood loss. In patients with LG-ESS, cytoreduction is a reliable option even in extended metastatic disease.

Optimal cytoreduction: is a CT's picture worth a surgeon's word?

INTRODUCTION: The presence of residual disease after cytoreductive surgery is subjectively determined by the surgeon at the end of the operation. Nevertheless, in up to 21-49% of CT scans, residual disease can be found. The aim of this study was to establish the relationship between post-surgical CT findings after optimal cytoreduction in patients with advanced ovarian cancer and oncological outcome. MATERIAL AND METHODS: Patients with advanced ovarian cancer (FIGO II and IV), diagnosed between 2007 and 2019 in Hospital La Fe Valencia, in whom cytoreductive surgery was performed, achieving R0 or R1, were assessed for eligibility (n = 440). A total of 323 patients were excluded because a post-operative CT scan was not performed between the third and eighth post-surgery week and prior to the start of chemotherapy. RESULTS: 117 patients were finally included. The CT findings were classified into three categories: no evidence, suspicious or conclusive of residual tumour/progressive disease. 29.9% of CT scans were "conclusive of residual tumour/progressive disease". No differences were found when the DFS (p = 0.158) and OS (p = 0.215) of the three groups were compared (p = 0.158). CONCLUSION: After cytoreduction in ovarian cancer with no macroscopic disease or residual tumour < 1 cm result, up to 29.9% of post-operative CT scans before chemotherapy found measurable residual or progressive disease. Notwithstanding, a worse DFS or OS was not associated with this group of patients.