Primary myoepithelial carcinoma of the Vulva: Case of a rare tumor with malignant potential and review of literature.

•Primary myoepithelial carcinoma is rare with a handful of cases reported from the vulva.•There is no standard of treatment for primary myoepithelial carcinoma.•Current recommendations suggest excision with wide margins to be the best therapy.•Chemotherapy and immunotherapy should be considered in combination with excision.

Paracervical Block as a Strategy to Reduce Postoperative Pain after Laparoscopic Hysterectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To determine if performing a paracervical block with .5% bupivacaine before laparoscopic hysterectomy reduces postoperative pain. DESIGN: Double-blind randomized controlled trial (Canadian Task Force classification I). SETTING: University-affiliated hospital. PATIENTS: Women aged between 18 and 65 years scheduled to undergo total laparoscopic hysterectomy for benign indications. INTERVENTIONS: Eligible patients were allocated to control or treatment groups using block randomization. Surgeon administered injection of either .9% NaCl or .5% bupivacaine into the cervical stroma at the 3 and 9 o'clock positions after general anesthesia was established. Pain was assessed using a visual analog scale with a range from 0 to 10 at 30 and 60 minutes after extubation. MEASUREMENTS AND MAIN RESULTS: Forty-one patients met criteria for analysis. Based on randomization, 20 were allocated to the control arm and 21 to the treatment arm. We used Student t and Pearson χ2 tests to ensure both groups were homogenous to age (46.5 vs 46, p = .87), body mass index (35 vs 32.7 kg/m2, p = .45), minutes of operating time (132.5 vs 119.7, p = .11), specimen weight (138.8 vs 160.6 g, p = .44), and history of cesarean section (p = .58). Pain scores at 30 minutes (5.7 vs 3.2, p = .01) and 60 minutes (5.9 vs 2.3, p <.001) were significantly lower in the treatment arm. We dichotomized results depending on whether patients had successful postoperative pain control, defined as an average pain score of 4 or less. The χ2 test was used for comparison. Using this definition 25% of patients had successful pain control in the placebo group versus 71.4% in the treatment group. This was statistically significant (p = .003). Mean length of hospital stay (.65 vs .86 days, p = .44) was not statistically different. CONCLUSION: Performing a paracervical block with .5% bupivacaine before laparoscopic hysterectomy significantly reduces immediate postoperative pain. (ClinicalTrials.gov no.: NCT03027661.).

Perioperative outcomes of robotic hysterectomy with mini-laparotomy versus open hysterectomy for uterus weighing more than 250 g.

To compare perioperative outcomes in patients undergoing robotic hysterectomy and extraction of specimen via mini-laparotomy (RHML) versus open hysterectomy (OH) when uterus weighs more than 250 g. To study the factors determining the length of hospital stay in 2 groups. A retrospective analysis of all hysterectomies performed for uterus weighing more than 250 g from the year 2012 to 2015 was conducted. A total of 140 patients were divided into 2 groups based on the type of surgery; RHML (n = 82) and OH (n = 58). Mini-laparotomy consisted of a customised incision connecting 2 left lateral port sites for specimen extraction after completing the hysterectomy robotically. Patient factors and perioperative outcomes were compared using Student's t tests and Chi-square analysis. Mean length of stay (RHML = 1.4 days; OH = 3.4 days), estimated blood loss (EBL) (RHML = 119.9 ml; OH = 547.5 ml) and operative time (RHML = 191.5 min; OH = 162.8 min) were significantly different. No significant differences were noted for patient BMI, age, comorbidities, intraoperative complications, pathology of uterus and uterus weight. Postoperative complications were significantly different between two groups (RHML = 6.0%; OH = 15.5%; p = .021). None of the patients stayed less than 24 h in OH group compared to 59.8% patients in RHML group. Type of procedure (p = .004) and EBL (p = .002) significantly predicted the length of stay. Patients undergoing RHML have significantly shorter length of stay, EBL and postoperative complications than OH. The operative time for RHML was longer than OH, but the overall decreased length of stay overcomes this disadvantage. RHML approach retains the benefits of da Vinci, while simultaneously preserving the specimen.

Transfusion practice patterns in patients with anemia receiving myelosuppressive chemotherapy for nonmyeloid cancer: results from a prospective observational study.

PURPOSE: The decision to prescribe packed red blood cell (PRBC) transfusions in patients with chemotherapy-induced anemia (CIA) includes assessment of clinical features such as the patient's cancer type and treatment regimen, severity of anemia symptoms, and presence of comorbidities. We examined contemporary transfusion practices in patients with nonmyeloid cancer and CIA. METHODS: Key inclusion criteria were age ≥ 18 years with nonmyeloid cancer, receiving first/second-line myelosuppressive chemotherapy, baseline hemoglobin (Hb) ≤ 10.0 g/dL, and planned to receive ≥ 1 PRBC transfusions. Exclusion criteria were receipt of erythropoiesis-stimulating agents within 8 weeks of screening and/or chronic renal insufficiency. Data were collected from patients' medical records, laboratory values, and physician/provider questionnaires. Proportion of patients for each clinical consideration leading to a decision to prescribe a PRBC transfusion and 95% exact binomial confidence intervals were determined. RESULTS: The study enrolled 154 patients at 18 sites in USA; 147 (95.5%) received a PRBC transfusion. Fatigue was the most common symptom affecting the decision to prescribe a PRBC transfusion (101 [69.2%] patients). Of the three reasons selected as primary considerations for prescribing a PRBC transfusion, anemia symptoms (106 [72.1%] patients) was the most frequently reported, followed by Hb value (37 [25.2%] patients) and medical history (4 [2.7%] patients). CONCLUSIONS: In this study, the primary consideration for prescribing a PRBC transfusion was anemia symptoms in 72.1% of patients, with only 25.2% of patients prescribed a transfusion based exclusively on Hb value. Results indicate that clinical judgment and patient symptoms, not just Hb value, were used in decisions to prescribe PRBC transfusions.

Robotic-Assisted Laparoscopic Abdominal Cerclage Placement During Pregnancy.

STUDY OBJECTIVE: The objective of this study is to report our center's series of robotic-assisted laparoscopic abdominal cerclage (RALAC) placement during pregnancy. DESIGN: Descriptive study (Canadian Task Force classification III). SETTING: Single academic institution. PATIENTS: Patients undergoing RALAC placement during pregnancy. INTERVENTIONS: Eleven patients underwent RALAC. MEASUREMENTS AND MAIN RESULTS: Nine out of 11 (81.8%) primary RALAC procedures resulted in a viable live-born neonate; 8 (72.7%) were born at >34 weeks of gestation. Three patients (27.3%) had preterm premature rupture of membranes on postoperative day one, 2 of whom subsequently underwent a dilation and curettage, and 1 patient carried the pregnancy to 29 weeks and delivered a live-born neonate. Four patients had subsequent pregnancies after placement of a RALAC in the antepartum period, all of whom carried successfully beyond 36 weeks, for a total of 16 pregnancies. Fourteen pregnancies (87.5%) resulted in a live birth, and 13 pregnancies (81.3%) were delivered beyond 34 weeks. CONCLUSION: RALAC is a minimally invasive procedure with an acceptable risk profile and comparable efficacy to traditional open abdominal cerclage. RALAC may be considered an acceptable alternative to open abdominal cerclage in pregnancy, and may be a particularly favorable option in certain settings.

Nonobstructive Acute Renal Failure with a Large Solitary Fibroid.

A 38-year-old African American woman presenting with acute abdominal pain and nonobstructive renal failure was found to have an enlarged fibroid uterus. A differential for sepsis was considered. Lab evaluation revealed an elevated creatinine and myoglobin level at 3.9 mg/dL and 2140 ng/mL, respectively. Ongoing hemodynamic instability mandated surgery for acute abdomen. A 25 cm fibroid uterus was extirpated through a total abdominal hysterectomy. Immediate improvement of acute nephropathy mirrored the postoperative decline in serum myoglobin levels. Myoglobinemia from a massive degenerating fibroid is associated with nonobstructive acute renal failure.

Additional uses of a vaginal fornices delineator.

A vaginal fornices delineator was introduced in the mid-90s by a gynecologic surgeon named Charles Koh as a device that would facilitate total laparoscopic hysterectomy. It is also used in robot-assisted and traditional laparoscopic hysterectomies. The delineator delineates the vaginal fornices and provides improved visualization of vital structures during a hysterectomy. The determination of the anatomic level of the cervix is vital in the identification of the inferior borders of a total hysterectomy and to avoid injury to the ureters and uterine vessels. As such, we describe 3 gynecologic surgeries in which the identification of this level was suboptimal. Our solution was to utilize a vaginal fornices delineator as the cervical "guide" to enhance this visualization and to allow for a complete and safe surgical outcome. The following surgical scenarios and the surgical facilitation provided by the vaginal fornices delineator will be presented: (1) a postpartum cesarean hysterectomy complicated by a large lower uterine fibroid tumor that distorts the cervix, (2) a robotic-assisted placement of an abdominal cerclage in a first-trimester pregnancy, (3) abdominal hysterectomy complicated by a necrotizing uterine infection and the associated difficulty in the identification of the cervicouterine junction.

PRECEDENT: a randomized phase II trial comparing vintafolide (EC145) and pegylated liposomal doxorubicin (PLD) in combination versus PLD alone in patients with platinum-resistant ovarian cancer.

PURPOSE: Vintafolide (EC145) is a folic acid-desacetylvinblastine conjugate that binds to the folate receptor (FR), which is expressed on the majority of epithelial ovarian cancers. This randomized phase II trial evaluated vintafolide combined with pegylated liposomal doxorubicin (PLD) compared with PLD alone. The utility of an FR-targeted imaging agent, (99m)Tc-etarfolatide (EC20), in selecting patients likely to benefit from vintafolide was also examined. PATIENTS AND METHODS: Women with recurrent platinum-resistant ovarian cancer who had undergone ≤ two prior cytotoxic regimens were randomly assigned at a 2:1 ratio to PLD (50 mg/m(2) intravenously [IV] once every 28 days) with or without vintafolide (2.5 mg IV three times per week during weeks 1 and 3). Etarfolatide scanning was optional. The primary objective was to compare progression-free survival (PFS) between the groups. RESULTS: The intent-to-treat population comprised 149 patients. Median PFS was 5.0 and 2.7 months for the vintafolide plus PLD and PLD-alone arms, respectively (hazard ratio [HR], 0.63; 95% CI, 0.41 to 0.96; P = .031). The greatest benefit was observed in patients with 100% of lesions positive for FR, with median PFS of 5.5 compared with 1.5 months for PLD alone (HR, 0.38; 95% CI, 0.17 to 0.85; P = .013). The group of patients with FR-positive disease (10% to 90%) experienced some PFS improvement (HR, 0.873), whereas patients with disease that did not express FR experienced no PFS benefit (HR, 1.806). CONCLUSION: Vintafolide plus PLD is the first combination to demonstrate an improvement over standard therapy in a randomized trial of patients with platinum-resistant ovarian cancer. Etarfolatide can identify patients likely to benefit from vintafolide.

Physician knowledge and opinions about sexually transmitted infections and the human papillomavirus vaccine: a community based survey.

BACKGROUND: The new Human Papillomavirus (HPV) vaccine is targeted to pre-adolescents; therefore pediatric providers will be its most frequent supplier. METHODS: A survey focusing on physician knowledge and opinions about sexually transmitted infections (STIs) and the HPV vaccine was distributed to pediatric providers in Chattanooga, TN. RESULTS: Response rate of 171 distributed surveys was 59 percent. Most doctors rated their STI knowledge base as adequate (93 percent), felt comfortable counseling on STIs (80 percent), and felt comfortable counseling about the vaccine and administering it (78 percent). Most also felt the vaccine should be incorporated into the current pediatric vaccination schedule (63 percent) eventually for males and (females (63 percent), aged 10-14 years (54 percent). While four percent of respondents felt this vaccine might promote a false sense of security against STIs, none felt it would promote promiscuity. CONCLUSION: Most surveyed providers feel comfortable counseling their patients about STIs and support the current recommendations for the HPV vaccine.

Incidental finding of pseudomyxoma peritonei at primary cesarean section.

Primary appendiceal carcinoma is extremely rare and is found in approximately 1% of appendectomy specimens. When cancer is present, the most frequent histology is mucinous adenocarcinoma. Neoplasms of the appendix that secrete mucin such as adenocarcinoma may rupture, leading to intraperitoneal seeding of the peritoneum and producing the clinical picture of pseudomyxoma peritonei (PMP). PMP is characterized by mucin-producing neoplastic cells that have seeded the peritoneum from the ruptured viscous and continue to secrete copious amounts of gelatinous material that accumulates in the abdomen producing the characteristic "jelly belly." A review of the medical literature revealed no cases of PMP diagnosed at time of cesarean section. A previously healthy gravida 5, para 3 underwent cesarean section. Upon opening of the peritoneum, copious amounts of gelatinous, yellow-tinged mucoid material was noted. A general surgeon was consulted, and grossly necrotic-appearing appendix was noted. The patient underwent appendectomy with right hemicolectomy. Pathology showed well-differentiated mucinous adenocarcinoma of the appendix. PMP is associated with gastrointestinal and ovarian carcinomas. Although somewhat rare, these cancers may occur in pregnancy. Because nonspecific abdominal pain and increasing abdominal girth are common in pregnancy, patients' complaints may go ignored. Early diagnosis of a potentially life-threatening disease requires that clinicians expand the differential diagnosis and consider the possibility of a malignant neoplasm presenting in the pregnant female.

Robotic-assisted laparoscopic placement of transabdominal cerclage during pregnancy.

Cervical incompetence treated with transabdominal cerclage can carry significant morbidity with the need for sequential laparotomies and necessitating prolonged postoperative recovery. Laparoscopic transabdominal cerclage placement has been described but has significant limitations with only two-dimensional depth perception and limited dexterity. Robotic-assisted laparoscopic surgery (RALS) is rapidly gaining acceptance in gynecologic surgery. RALS has reportedly been used for placement of an interval transabdominal cerclage. We report the first two cases where the da Vinci robot was used during pregnancy for placement of abdominal cerclage. Two women were successfully treated with robotic-assisted laparoscopic placement of transabdominal cerclage in pregnancy. Robotic-assisted laparoscopic transabdominal cerclage placement is less invasive and is effective not only as an interval procedure but also during pregnancy, offering the patient an alternative to the traditional laparotomy with quicker recovery time.

Sentinel node identification and the ability to detect metastatic tumor to inguinal lymph nodes in squamous cell cancer of the vulva.

OBJECTIVES: The goal of this study was to identify one or more inguinal sentinel nodes in patients with primary squamous cell carcinoma of the vulva and to determine the ability of the sentinel node to predict metastasis to the inguinal lymphatic basin. METHODS: Techniques employing technetium-99m (Tc-99m) sulfur colloid and isosulfan blue dye were utilized to identify sentinel nodes in the inguinal lymphatic beds. Technetium-99m sulfur colloid was injected intradermally at the tumor margins 90-180 min preoperatively followed by a similar injection of isosulfan blue dye 5-10 min before the groin dissection. A handheld collimated gamma counter was employed to identify Tc-99m-labeled sentinel nodes. Lymphatic tracts that had taken up blue dye and their corresponding sentinel node were also identified and retrieved. A completion inguinal dissection was then performed. Each sentinel node was labeled as hot and blue, hot and nonblue, or cold and blue. The sentinel nodes were subjected to pathologic examination with step sections and nonsentinel nodes were evaluated in the standard fashion. RESULTS: Twenty-one patients with a median age of 79 were entered onto protocol and a total of 31 inguinal node dissections were performed. A sentinel node was identified in 31/31 (100%) groin dissections with the use of Tc-99m. Isosulfan blue dye identified a sentinel node in 19/31 (61%) groin dissections. Surgical staging revealed 7 patients with stage I disease, 5 with stage II disease, 5 with stage III disease, and 4 with stage IV disease. Lymph nodes in 9 groin dissections were found to have metastatic disease, and in 4 of these dissections, the sentinel node was the only positive node. Lymph nodes in 22 groin dissections had no evidence of metastasis. No false-negative sentinel lymph nodes were obtained (sentinel node negative and a nonsentinel node positive). CONCLUSION: Tc-99m sulfur colloid is superior to isosulfan blue dye in the detection of sentinel nodes in inguinal dissections of patients with vulvar cancer. A sentinel node dissection utilizing Tc-99m alone can identify a sentinel node in all inguinal dissections. Pathologic examination with step sections has shown the sentinel node to be an accurate predictor of metastatic disease to the inguinal nodal chain.