An Unusual Presentation: High-Grade Serous Carcinoma of the Fallopian Tube Manifesting With Altered Mental Status Secondary to a Single Brain Metastasis-A Case Report and Review of the Literature.

Epithelial ovarian and fallopian cancers are aggressive lesions that rarely metastasize to the central nervous system. Brain metastases usually occur in the setting of known primary disease or widespread metastatic disease. However, in extremely rare cases, an isolated intracranial neoplasm may be the first presentation of fallopian cancer. To the best of our knowledge, only one such case has been reported previously. We present an illustrative case with multimodality imaging and histopathologic correlation of a fallopian tube carcinoma first presenting with altered mental status secondary to an isolated brain metastasis. A 64-year-old female with no pertinent medical history presented with altered mentation. Initial workup identified a 1.6 cm avidly enhancing, solitary brain lesion at the gray-white junction with associated vasogenic edema concerning for either central nervous system lymphoma or metastatic disease. Additional imaging identified a 7.5 × 3 cm left adnexal lesion, initially thought to be a hydrosalpinx with hemorrhage, but magnetic resonance imaging suggested gynecologic malignancy. No lesions elsewhere in the body were identified. Given the lack of locoregional or systemic disease, the intracranial and pelvic lesions were assumed to represent synchronous but distinct processes. The intracranial lesion was biopsied. Preliminary results were suggestive of lymphoma, but further analysis was consistent with high-grade serous carcinoma of müllerian origin. Positron emission tomography/computed tomography was performed to evaluate for other neoplastic lesions, only highlighting the intracranial and pelvic lesions. At this point, a diagnosis of metastatic fallopian cancer was made. The patient was taken for robot-assisted laparoscopy with surgical debulking of the pelvic neoplasm, pathology demonstrating high-grade serous carcinoma of the fallopian tube, matching that of the intracranial lesion. Even though rare, metastatic fallopian cancer should be considered in patients with isolated brain lesions and adnexal lesions, even in the absence of locoregional or systemic disease.

Robotic LESS and Reduced-Port Hysterectomy Using the da Vinci SP Surgical System: A Single-Institution Case Series.

STUDY OBJECTIVE: To present a series of robotic laparoendoscopic single-site surgery (LESS) and reduced-port hysterectomy cases and discuss the surgical technique required for successful use on this new platform. DESIGN: Retrospective case series. SETTING: Academic medical center. PATIENTS: All patients undergoing robotic LESS or reduced-port hysterectomy with the SP1098 da Vinci SP Surgical System (Intuitive Surgical, Sunnyvale, CA) from December 2019 to March 2020. INTERVENTIONS: Robotic LESS or reduced-port hysterectomy. MEASUREMENTS AND MAIN RESULTS: A total of 8 cases of hysterectomy were performed successfully. Four cases included concomitant resection of endometriosis. Five cases required placement of an additional port. The average uterine weight was 136.1 g ± 61.5 g (range 87-246). The average estimated blood loss was 37.5 mL ± 27 mL (range 20-100). The average operative time was 86.5 minutes ± 27.1 minutes (range 60-132). The time required for vaginal cuff closure was available for patients 5 to 8, and ranged from 10 minutes to 13 minutes. All patients had same-day discharge. There were no conversions to alternative surgical modality, complications, or readmissions. CONCLUSION: Our preliminary experience with the SP1098 da Vinci SP Surgical System demonstrated the technical feasibility and safety of this surgical modality for gynecologic surgery. Additional studies examining postoperative outcomes and prospective studies comparing this modality with traditional robotic surgery are indicated.

Robotic Resection of Diaphragm Metastases in Ovarian Cancer: Technical Aspects.

Diaphragm metastases in ovarian cancer can be safely resected robotically in selected patients. The technique is similar to laparotomy, whether it is a peritoneal or full-thickness excision. Trocar placement is very important for successful resection and is dependent on the location of the disease. Metastases involving the left diaphragm and the ventral aspect of the right diaphragm are accessed with trocars placed slightly cranial to the umbilicus. Metastases in the dorsal aspect of the right diaphragm are removed with trocars in the upper quadrants. Metastases located in the lateral portion of the right diaphragm are excised using an infrahepatic approach, and those in the medial aspect are removed using a suprahepatic approach. In peritoneal resection, monopolar instruments must be kept at 10 W to 15 W to prevent contraction of the diaphragm and pleural perforation. Intraoperative pleural decompression is performed via an aspirating catheter. A video of the technique described in this report is available online (Supplementary Video 1).

Minimally Invasive Surgery for Resection of Diaphragm Metastases in Ovarian Cancer.

STUDY OBJECTIVE: To estimate pulmonary complications and diaphragm recurrence after resection of diaphragm metastases by minimally invasive surgery (MIS) for epithelial ovarian cancer (EOC). DESIGN: Retrospective analysis (Canadian Task Force classification III). SETTING: Mayo Clinic in Scottsdale, Arizona, from January 1, 2004, through January 31, 2014. PATIENTS: Selected cohort of 29 patients. INTERVENTIONS: Diaphragm resection by MIS (robotics, 21; laparoscopy, 8) for EOC. MEASUREMENTS AND MAIN RESULTS: To assess for pulmonary complications most likely due to diaphragm resection, patients were excluded if they had preoperative pleural effusions or pulmonary disease or had undergone additional upper abdominal procedures. Mean patient age was 58.7 years (standard deviation, 14.9) and mean BMI was 24.2 kg/m2 (standard deviation, 3.4). The mean size of diaphragm metastases was 56.7 mm (range, 2-145). Full-thickness resection was performed in 6 patients; 23 had peritoneal resection. Complete resection was achieved in all patients with no conversions to laparotomy. Two patients (6.9%) had pulmonary complications (pleural effusion). Six patients (20.7%) had diaphragm recurrence; 10 patients (34.5%) had recurrence at other abdominal sites. CONCLUSION: Resection of diaphragm metastases by MIS appears to be feasible and safe for selected patients, with similar recurrence as other abdominal sites.

Outcomes of Concurrent Breast and Gynecologic Risk Reduction Surgery.

BACKGROUND: Women considering risk reduction surgery after a diagnosis of breast/ovarian cancer and/or inherited cancer gene mutation face difficult decisions. The safety of combined breast and gynecologic surgery has not been well studied; therefore, we evaluated the outcomes for patients who have undergone coordinated multispecialty surgery. METHODS: We conducted a retrospective review of patients undergoing simultaneous breast and gynecologic surgery for newly or previously diagnosed breast cancer and/or an inherited cancer gene mutation during the same anesthetic at a single institution from 1999 to 2013. RESULTS: Seventy-three patients with a mean age of 50 years (range 27-88) were identified. Most patients had newly diagnosed breast cancer or ductal carcinoma in situ (62 %) and 28 patients (38 %) had an identified BRCA mutation. Almost all gynecologic procedures were for risk reduction or benign gynecologic conditions (97 %). Mastectomy was performed in 39 patients (53 %), the majority of whom (79 %) underwent immediate reconstruction. The most common gynecologic procedure involved bilateral salpingo-oophorectomy, which was performed alone in 18 patients (25 %) and combined with hysterectomy in 40 patients (55 %). A total of 32 patients (44 %) developed postoperative complications, most of which were minor and did not require surgical intervention or hospitalization. Two of the 19 patients who underwent implant reconstruction (11 %; 3 % of the entire cohort) had major infectious complications requiring explantation. CONCLUSION: Combined breast and gynecologic procedures for a breast cancer diagnosis and/or risk reduction in patients can be accomplished with acceptable morbidity. Concurrent operations, including reconstruction, can be offered to patients without negatively impacting their outcome.

International Federation of gynecology and obstetrics staging classification for cancer of the ovary, fallopian tube, and peritoneum: estimation of survival in patients with node-positive epithelial ovarian cancer.

OBJECTIVE: The objective of this study was to determine the survival of patients with node-positive epithelial ovarian cancer according to the 2014 International Federation of Gynecology and Obstetrics (FIGO) staging system. MATERIALS AND METHODS: We performed a retrospective chart review. Data from all consecutive patients with node-positive epithelial ovarian cancer (stages IIIC and IV) who underwent cytoreductive surgery at the Mayo Clinic from 1996 to 2000 were reassessed to evaluate the prognostic significance of the new FIGO stages. Multivariate Cox regression was performed, and Kaplan-Meier survival curves constructed. RESULTS: The distribution of the restaged patients was as follows: IIIA1, 23 patients (IIIA1i, 9 patients; and IIIA1ii, 14 patients); IIIA2, 3 patients; IIIB, 4; IIIC, 67 patients; IVA, 4 patients; and IVB, 15 patients. In the univariate analysis, the relative risk for positive nodes greater than 10 mm on the longer axis was 2.57 and 3.00 for patients with microscopic peritoneal disease, compared with patients with microscopic positive nodes. However, the difference was not statistically significant. Moreover, the univariate analyses revealed statistically significant differences for 2014 FIGO stages (IIIA, IIIB, IIIC, and IVA-B), anatomical sites of peritoneal metastases, and disease staged at IIIC because of the presence of omental metastases. Multivariate analysis showed that survival was higher in patients restaged to IIIA-B than in those restaged to IIIC and IV (hazard ratios, 2.75 and 3.16, respectively; P = 0.002). The hazard ratio for patients with abdominal peritoneal metastases was 2.76 compared with patients with pelvic peritoneal metastases (P = 0.001). CONCLUSIONS: The current 2014 FIGO staging system for ovarian cancer successfully correlates survival, anatomical location of peritoneal metastases, and extra-abdominal lymph node metastases.

Surgical Excision of Advanced Endometriosis: Perioperative Outcomes and Impacting Factors.

OBJECTIVE: To determine perioperative outcomes and factors impacting operating time, length of hospital stay, and complications of patients undergoing surgery for stage 3 or 4 endometriosis. DESIGN: Retrospective review of medical records (Canadian Task Force classification II-2). SETTING: Mayo Clinic Hospital, Phoenix, Arizona. PATIENTS: Women (n = 493) with endometriosis stage 3 and 4 undergoing surgical excision between March 15, 2005, and December 31, 2011. INTERVENTIONS: Robotic-assisted (n = 331) or laparoscopic (n = 162) excision. MEASUREMENTS: Age, body mass index, comorbidities, number and type of procedures per patient, type of surgical approach, operating time, blood loss, intraoperative and postoperative complications (within 42 days), and length of hospital stay. MAIN RESULTS: The mean patient age was 39.5 years; body mass index, 25.9; number of procedures, 3.3; operating time, 130.4 minutes; blood loss, 88.5 mL; and hospital stay, 1.0 days. Major complications occurred in 5 patients (1.5%). Fifty-nine patients (12.0%) underwent modified radical hysterectomy, 90 (18.3%) underwent ureteral and/or intestinal resection, and 3 (0.6%) underwent diaphragm resection. Factors significantly associated with operating time included age (p = .008) and blood loss, number of procedures per patient, and robotics (all p < .001). Length of stay was affected by age, operating time, and blood loss (all p < .001). Operating time was the only significant factor associated with postoperative complications (p < .001). CONCLUSION: Operating time is an independent and significant factor for postoperative complications and hospital stay.

Complications in robotic-assisted gynecologic surgery according to case type: a 6-year retrospective cohort study using Clavien-Dindo classification.

STUDY OBJECTIVE: To estimate the risk of postoperative complications in robotic-assisted gynecologic surgery according to case type. STUDY DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Mayo Clinic Arizona. PATIENTS: All 1155 patients who underwent robotic-assisted gynecologic surgery between March 2004 and December 2009 were included. Patients were primarily white (94.3%), with a mean (SD) age of 51.5 (15.4) years, and were overweight, with body mass index (BMI) of 27.2 (6.8). INTERVENTIONS: Risk of complications, overall and according to Clavien-Dindo grade, and incidence of specific complications were analyzed. Robotic-assisted gynecologic surgical procedures were categorized postoperatively according to case type as benign simple (e.g., oophorectomy, simple hysterectomy) in 552 (47.8%) patients, benign complex (e.g., excision of invasive endometriosis) in 262 (22.7%), urogynecologic in 121 (10.5%), and oncologic in 220 (19.1%). MEASUREMENTS AND MAIN RESULTS: Intraoperative complications occurred in 3.2% of patients. Postoperative complications of any type occurred in 18.4% of patients. Conversion to laparotomy was necessary in 2.7%. Urologic complications were more common in urogynecologic cases (5.8%) as compared with benign simple (0.5%), benign complex (2.7%), and oncologic (3.2%). Bleeding complications were most common in oncologic cases (5%). Clavien-Dindo grade ≥ 3 complications occurred in 5.2% of patients overall, and were >3-fold likely to occur in benign complex, urogynecologic, and oncologic cases than in benign simple cases. When adjusted for age, BMI, estimated blood loss, operative time, length of stay, and previous pelvic surgery, complications were nearly twice as common for benign complex (odds ratio [OR] 1.7; 95% confidence interval [CI], 1.1-2.7), urogynecologic (OR 1.9; 95% CI, 1.0-3.4), and oncologic (OR 1.9; 95% CI, 1.1-3.1) cases as for benign simple cases, although weakly significant. Case type, BMI, estimated blood loss, and length of stay remained important factors in predicting postoperative complications. CONCLUSION: The incidence of complications in robotic-assisted gynecologic surgery varies according to case type. Defining the role of patient and surgical variables such as case type in the occurrence of complications may help in identification of cases with increased risk, to improve patient counseling and surgical outcome.

Analysis of secondary cytoreduction for recurrent ovarian cancer by robotics, laparoscopy and laparotomy.

OBJECTIVE: Analysis of perioperative outcomes and survival of patients with recurrent ovarian cancer undergoing secondary cytoreduction by robotics, laparoscopy, or laparotomy. METHODS: Retrospective analysis of 52 selected patients with recurrent ovarian cancer undergoing secondary cytoreduction by laparoscopy (9), laparotomy (33) or robotics (10) between January 2006 and December 2010. Comparison was made by a total of 21 factors including age, BMI, number of previous surgeries, tumor type and grade, number of procedures, and 15 types of procedures performed at secondary cytoreduction. RESULTS: For all patients, the mean operating time was 213.8 min, mean blood loss 657.4 ml; and mean hospital stay 7.5 days. Complete debulking was achieved in 75% of patients. Postoperative complications were noted in 36.5% of patients. Overall and progression-free survival at 3-years were 58.8% and 34.1%, respectively. Laparoscopy and robotics had reduced blood loss and hospital stay, while no differences were observed among the three groups for operating time, complications, complete debulking, and survival. CONCLUSION: Selected patients with recurrent ovarian cancer benefit from a laparoscopic or robotic secondary cytoreduction without compromising survival. Robotics and laparoscopy provide similar perioperative outcomes, and reduced blood loss and shorter hospital stay as compared to laparotomy. Laparotomy seems preferable for patients with widespread peritoneal implants, multiple sites of recurrence, and/or extensive adhesions.

Same-day dismissal for endometrial cancer robotic surgery: feasibility factors.

The aim of this study was to investigate the factors in feasibility and safety of same-day dismissal (SDD) of endometrial cancer patients undergoing robotic hysterectomy and staging. A single-institution retrospective chart review of endometrial cancer patients who underwent robotic hysterectomy and staging between 2012 and 2021 was performed. Patient demographics, medical and surgical history, intra- and postoperative events were examined as possible factors related to non-SDD. These factors were analyzed using univariate (chi-square test) and multivariate logistic regression analysis. Of the 292 patients, 117 (40%) had SDD, and 175 (60%) had non-SDD. The SDD rate increased from 13.8% to 88% over the 10-year study period. The factors significantly associated with non-SDD (p < 0.05) were surgery in the first 5 years after the introduction of the SDD and ERAS protocols (2012-2016), age > 75 years, and comorbidities such as cardiovascular diseases, anemia (Hb < 11 g/dl), and anticoagulant therapy. Extensive adhesiolysis, the performance of complete pelvic and/or aortic lymphadenectomy, operating time > 180 min, and PACU discharge after 2:00 p.m. were significant factors for non-SDD. Sentinel lymph node sampling was significantly associated with SDD (OR 0.050; CI 0.273-0.934, p = 0.029). We reported no significant difference in the number, setting and timing of any unscheduled postoperative contacts, complications, and readmissions between SDD and non-SDD groups. SDD after robotic hysterectomy and staging for endometrial cancer is feasible and safe. There are patient and surgery factors for the failure of SDD. The sentinel lymph node sampling was significantly associated with achieving SDD. Trial registration: Institutional Review Board approved the study protocol (#: 1764-05).

The role of lymphadenectomy in node-positive epithelial ovarian cancer.

OBJECTIVE: To evaluate the therapeutic role of pelvic and aortic lymphadenectomy in patients with epithelial ovarian cancer (EOC) and positive nodes (stages IIIC and IV). METHODS: Retrospective chart review. Data from all consecutive patients with EOC and positive retroperitoneal lymph nodes (stage IIIC and IV) in Mayo Clinic from 1996 to 2000 were included. To evaluate the impact of nodal metastases, the extent of lymphadenectomy was compared according to the number of nodes removed and positive nodes resected. Multivariable Cox regression and Kaplan-Meier survival curves were used for analysis. RESULTS: The median number of nodes removed was 31 (pelvic, 21.5, and aortic, 10), and the median number of positive nodes was 5. The 5-year overall survival was 44.8%. On multivariate analysis, only the extent of peritoneal metastases before surgery was a significant factor for survival (P = 0.001 for stage IIIC and P = 0.004 for stage IV). Analysis of 83 patients with advanced peritoneal disease more than 2 cm demonstrated before debulking, removal of more than 40 lymph nodes was a significant prognostic factor for overall survival (hazard ratio, 0.52; P = 0.032; 95% confidence interval, 0.29-0.35). In 29 patients with advanced peritoneal disease and no residual disease after debulking, removal of more than 10 positive was a factor for survival. CONCLUSIONS: There was a survival benefit in patients with EOC with advanced peritoneal disease more than 2 cm before debulking when more than 40 lymph nodes were removed. There was an additional survival benefit in those patients with no residual disease after debulking when more than 10 positive nodes were removed.

Ovarian remnant syndrome: comparison of laparotomy, laparoscopy and robotic surgery.

OBJECTIVE: To compare laparotomy, laparoscopy and robotic surgery in the management of ovarian remnant syndrome. DESIGN: Retrospective comparative study. SETTING: Mayo Clinic Arizona and Mayo Clinic Rochester, USA. POPULATION: Women who underwent surgical treatment for ovarian remnant syndrome. METHODS: The clinical records of 223 patients with histologically documented residual cortical ovarian tissue excised at Mayo Clinic by laparotomy, laparoscopy or a robotic approach, from January 1985 through February 2009, were reviewed. Data collected included the patient's age, body mass index, previous medical and surgical history, symptoms, prior management of ovarian remnant syndrome, preoperative imaging study, intraoperative details, postoperative course, complications and follow-up data. MAIN OUTCOME MEASURES: Intraoperative and postoperative outcomes. RESULTS: One hundred and eighty-seven patients (83.9%) were operated by laparotomy, 19 (8.5%) by laparoscopy and 17 (7.6%) by a robotic approach. Estimated blood loss and length of stay were significantly lower in the robotic and laparoscopic groups compared with laparotomy (p < 0.01). After a mean follow-up of 21.1 ± 32.4 months, the rate of pain improvement was 93.1, 94.4 and 71.4% for the laparotomy, laparoscopy and robotic surgery group, respectively. CONCLUSIONS: Robotic and laparoscopic surgery for the treatment of ovarian remnant syndrome offer advantages over laparotomy in terms of reduced blood loss, lower postoperative complications and shorter length of stay.

Does MIS Play a Role in the Treatment of Advanced Ovarian Cancer?

Neoadjuvant chemotherapy allows a minimally invasive approach for interval debulking in patients with ovarian cancer considered unresectable to no residual disease by laparotomy at diagnosis. The aim of the study was to evaluate the type of surgical approach at interval debulking (ID) after three courses of carboplatin and taxol in patients with unresectable ovarian cancer at diagnosis compared with the type of surgical approach at primary debulking (PD). A secondary objective was to compare the perioperative outcomes of MIS vs. laparotomy at ID. A retrospective review of the type of surgical approach at ID following three courses of carboplatin and taxol was compared with the surgical approach at PD, and a review of the perioperative outcomes of MIS vs. open at ID was performed during the period from 21 January 2012, through 21 February 2013, for stage IIIC > 2 cm or IV epithelial ovarian cancer (EOC) unresectable at diagnosis and the surgical approach at PD. During the study period, 127 patients with stage IIIC or IV EOC met the inclusion criteria. Minimally invasive surgery (MIS), laparoscopic or robotic, was used in 21.6% of patients at ID and in 23.3% of patients at PD. At ID, MIS patients had a shorter hospital stay as compared to laparotomy (2 vs. 8 days; p < 0.001). At 5 year follow-up, 31.5% of EOC patients were alive (ID MIS: 47.5% vs. ID open: 30%; PD MIS: 41% vs. PD open: 28%), while 24.4% had no evidence of disease (ID MIS: 39% vs. ID open: 19.5%; PD MIS: 32% vs. PD open: 22%). Among living patients, 22% had evidence of disease. Neoadjuvant chemotherapy is a form of chemo-debulking and allows a minimally invasive approach at interval debulking in about one-fifth of the patients, with initial disease deemed unresectable to no residual tumor at initial diagnosis.

Granulomatosis with Polyangiitis-Mimicking Advanced Gynecological Cancer: A Case Report and Systematic Review of the Literature.

(1) Background: Granulomatosis with polyangiitis (GPA) is a necrotizing vasculitis that mimics gynecologic cancer. In GPA patients, the genitourinary system is affected in <1%. The objective of the study was to provide a systematic review of the literature of GPA patients with gynecological involvement. (2) Methods: PubMed and Embase were searched from inception to July 2021 for GPA patients with gynecological involvement Medical Subject Headings (MeSH) and free-text terms. Exclusion criteria were other language, review articles, pregnancy, fertility, or male patients. Data were extracted on clinical evolution, symptoms, examinations findings, diagnosis delay, treatment, outcome, patient status, and follow-up. (3) Results: Seventeen studies included data from patients with GPA and primary or relapsed gynecological involvement. 68% of the authors of this review thought the patient had cancer. The main gynecological symptom is bleeding, but exclusive gynecologic symptomatology is rare (ENT: 63%, lungs: 44%, kidneys-urinary tract: 53%). GPA could affect all areas of the genital tract, but the most frequent location is the uterine cervix. Medical treatment for GPA is effective. (4) Conclusions: GPA of the female genital tract must be considered when biopsies of an ulcerated malignant-appearing cervical or vaginal mass are negative for malignancy even when they are unspecific. Rheumatology consultation is indicated.

PP4 inhibition sensitizes ovarian cancer to NK cell-mediated cytotoxicity via STAT1 activation and inflammatory signaling.

BACKGROUND: Increased infiltration of T cells into ovarian tumors has been repeatedly shown to be predictive of enhanced patient survival. However, despite the evidence of an active immune response in ovarian cancer (OC), the frequency of responses to immune checkpoint blockade (ICB) therapy in OC is much lower than other cancer types. Recent studies have highlighted that deficiencies in the DNA damage response (DDR) can drive increased genomic instability and tumor immunogenicity, which leads to enhanced responses to ICB. Protein phosphatase 4 (PP4) is a critical regulator of the DDR; however, its potential role in antitumor immunity is currently unknown. RESULTS: Our results show that the PP4 inhibitor, fostriecin, combined with carboplatin leads to increased carboplatin sensitivity, DNA damage, and micronuclei formation. Using multiple OC cell lines, we show that PP4 inhibition or PPP4C knockdown combined with carboplatin triggers inflammatory signaling via Nuclear factor kappa B (NF-κB) and signal transducer and activator of transcription 1 (STAT1) activation. This resulted in increased expression of the pro-inflammatory cytokines and chemokines: CCL5, CXCL10, and IL-6. In addition, IFNB1 expression was increased suggesting activation of the type I interferon response. Conditioned media from OC cells treated with the combination of PP4 inhibitor and carboplatin significantly increased migration of both CD8 T cell and natural killer (NK) cells over carboplatin treatment alone. Knockdown of stimulator of interferon genes (STING) in OC cells significantly abrogated the increase in CD8 T-cell migration induced by PP4 inhibition. Co-culture of NK-92 cells and OC cells with PPP4C or PPP4R3B knockdown resulted in strong induction of NK cell interferon-γ, increased degranulation, and increased NK cell-mediated cytotoxicity against OC cells. Stable knockdown of PP4C in a syngeneic, immunocompetent mouse model of OC resulted in significantly reduced tumor growth in vivo. Tumors with PP4C knockdown had increased infiltration of NK cells, NK T cells, and CD4+ T cells. Addition of low dose carboplatin treatment led to increased CD8+ T-cell infiltration in PP4C knockdown tumors as compared with the untreated PP4C knockdown tumors. CONCLUSIONS: Our work has identified a role for PP4 inhibition in promoting inflammatory signaling and enhanced immune cell effector function. These findings support the further investigation of PP4 inhibitors to enhance chemo-immunotherapy for OC treatment.

Robotic nerve-sparing radical hysterectomy: feasibility and technique.

OBJECTIVE: To describe the anatomy of pelvic autonomic nerves as it applies to nerve-sparing radical hysterectomy, and the technique, feasibility, and results of robotic nerve-sparing radical hysterectomy. METHODS: Prospective evaluation of 6 patients undergoing robotic nerve-sparing radical hysterectomy (type C1) for cervical cancer Stage IB (1B1 in 3 and 1B2 in 3 patients). Pelvic lymphadenectomy was performed in 3 patients and pelvic and aortic in the remaining 3 patients. RESULTS: The operation was completed in all patients. The mean age of the patients was 51.0 (range 33-73) and mean BMI 27.8 (range 23.2-35.1). The mean operating time was 238.6 min (range 207-256), mean blood loss 135 ml (range 100-150), mean number of lymph nodes was 23.6 (range 19-29), mean hospital stay was 2 days (range 1-4). There were no intraoperative complications. Postoperative complications occurred in 1 patient with an ileus who required an extended hospital stay. One patient did not regain normal urinary voidings until the fourth week after surgery. All patients remain free of disease. CONCLUSION: Robotic nerve-sparing radical hysterectomy is safe and feasible. Urinary dysfunction may occur.