Laparoscopic Resection of a High Grade Serous Ovarian Cancer that Recurred at the Vaginal Stump with Extensive Pelvic Adhesions after Complete Surgical Staging.

STUDY OBJECTIVE: To show laparoscopic resection of a high grade serous ovarian cancer that recurred at the vaginal stump with extensive pelvic adhesions after complete surgical staging. DESIGN: Stepwise demonstration of the procedure with narrated video footage. SETTING: University hospital. INTERVENTIONS: We reported a case of a 62-year-old woman with a history of complete surgical staging of high grade serous ovarian cancer staged IIB, which consisted of hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, and omentectomy, about 18 months before this admission. She received 6 courses of carboplatin/paclitaxel combination therapy after complete surgical staging and achieved complete remission. About 12 months after the last course of chemotherapy, she visited the local clinic because of irregular vaginal bleeding. Physical examination revealed a 3 × 3 × 2 cm3 mass at the vaginal vault. Biopsy of the mass was performed under colposcopy, and pathological reports showed recurrent high grade serous cancer. Her serum cancer antigen 125 level was in normal range. Positron emission tomographic/computed tomographic imaging (PET/CT) showed no evidence of disease dissemination. A diagnosis of recurrent high grade serous ovarian cancer was made. After the biopsy of the recurrent mass, there were no visible lesions, which made us believe that laparoscopy management would not contribute to intraperitoneal spread of the tumors. Therefore, laparoscopic resection of the vaginal stump was scheduled. The key steps of the procedure were summarized as follows. First, the bowels were released from the side abdominal wall to expose bilateral external iliac vessels. Second, bilateral ureters were identified and mobilized to avoid incidental ureter injuries. Third, we opened the rectovaginal space and detached the rectum from the posterior vaginal wall. Fourth, the posterior vesical wall was separated from the vaginal stump. After exposure of the key anatomic landmarks, laparoscopic resection of the vaginal stump was performed safely. Final pathologic report showed recurrent high grade serous ovarian cancer. The patient received 6 courses of carboplatin/paclitaxel combination therapy, and maintenance therapy with olaparib was suggested, but the patient refused to accept this suggestion. She is still in complete remission 8 months after surgery. CONCLUSION: Laparoscopic resection of a high grade serous ovarian cancer that recurred at the vaginal stump with extensive pelvic adhesions after complete surgical staging was achieved successfully in a logical way. The critical point of the procedure is to expose the key anatomic landmarks of the pelvis to avoid incidental injuries [1].

A Way to Reduce the Occurrence of Intraoperative Capsule Rupture in Presumed Clinically Early-stage Ovarian Cancer with Adhesions to the Abdominal Wall.

STUDY OBJECTIVE: To present a procedure to reduce the occurrence of intraoperative capsule rupture in presumed clinically early-stage ovarian cancer with adhesions to the abdominal wall. DESIGN: Stepwise presentation of the procedure with narrated video footage. SETTING: The occurrence of intraoperative capsule rupture exerts a negative effect on the prognosis of early-stage ovarian cancer [1,2]. Thus, it is important to reduce intraoperative capsule rupture to improve the oncologic outcome of such patients. In this video we describe a laparoscopic procedure to minimize the risk of intraoperative capsule rupture in presumed clinically early-stage ovarian cancer with adhesions to the abdominal wall. A 52-year-old woman was referred from a local clinic for a 6 × 6 × 4-cm left ovarian mass and a 7 × 6 × 6-cm right ovarian mass. Her serum cancer antigen 125 level was 214.4U/mL. Pelvic magnetic resonance imaging and positron emission tomographic/computed tomographic imaging showed no evidence of metastatic diseases or lymph node involvement. A diagnosis of ovarian malignancy was suspected. INTERVENTIONS: Laparoscopic evaluation suggested that the right adnexa was adhered to the right abdominal wall and there was no evidence of tumor seeding in the peritoneal cavity. We collected the peritoneal lavage fluid. Since pelvic adhesiolysis between the right adnexa and the abdominal wall may increase the occurrence of intraoperative capsule rupture of the ovarian tumor, leading to a worse clinical outcome, we decided to remove both the right adnexa as well as the adhered peritoneum. The key steps of the procedure are summarized as follows. First, the utero-ovarian ligament and tubal isthmus were coagulated and excised. Second, the pelvic peritoneum was excised, and the infundibulo-pelvic ligament and ureter were identified and mobilized. Third, the infundibulo-pelvic ligament was coagulated and excised. Fourth, the pelvic peritoneum which was adhered to the right adnexa was dissected off the ureter and excised. Then, the resected right adnexa as well as the adhered peritoneum were collected in a disposable pocket and removed to avoid further contamination. Adenocarcinoma was diagnosed by frozen section evaluation. So, surgical staging was performed laparoscopically, and consisted of hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, omentectomy, and random peritoneal biopsies from the pelvis, paracolic gutters, and undersurfaces of the diaphragm. Final pathologic reports showed ovarian clear cell carcinoma with involvement of both ovaries and the adhered peritoneum. CONCLUSION: Our method is effective for intact removal of the involved adnexa without rupture and the adhered pelvic peritoneum with potential for tumor seeding.

Targeted induction of bone marrow mesenchymal stem cells to have effectiveness on diabetic pancreatic restoration.

Although bone marrow-derived mesenchymal stem cells (BMSCs) have been reported to be effective for the attenuation of diabetes, they have limitations. Whether BMSCs can be target-induced by pancreatic stem cells (PSCs) to have effectiveness for the restoration of diabetic islet injury was unknown. In this study, based on their successful isolation and cultivation, BMSCs were co-cultured with PSCs. The pancreatic stem cells markers, Nestin and Neurogenin3 in co-cultured BMSCs were detected to evaluate the target-induction effects. After the diabetic rats were intravenously injected with the target-induced BMSCs, general indicators and islet morphology were detected. The islet insulin generation, and serum insulin and C-peptide contents were measured. It was found that after co-culture, the mRNA expressions, protein contents and distributions of Nestin and Neurogenin3, were dramatically high in BMSCs, indicating that they were successfully target-induced to pancreatic stem-like cells. Furthermore, the target-induced BMSCs had beneficial effects on serum glycated albumin levels and glycogen contents as well as islet morphology of the diabetic rats. Besides elevation of islet insulin generation, the target-induced BMSCs had significant effect on serum insulin and C-peptide contents. In conclusion, BMSCs could be target-induced by PSCs to have effectiveness on the pancreatic restoration of diabetic rats.