Cytokine release syndrome induced by immune checkpoint inhibitor treatment for uterine cervical cancer recurrence: A case report.

Cytokine release syndrome (CRS) is a systemic inflammatory condition caused by an excessive immune response and cytokine overproduction. CRS is a life-threatening condition that is often associated with chimeric antigen receptor T-cell therapy. Despite the increased use of immune checkpoint inhibitors (ICIs), ICI-induced CRS remains rare. The present study describes a case of CRS that occurred after the administration of ICIs for recurrent adenocarcinoma of the uterine cervix. A 49-year-old woman received paclitaxel, carboplatin and pembrolizumab for recurrent cervical adenocarcinoma. On day 27 of the third cycle, the patient was admitted with a fever and suspected pyelonephritis. The following day, hypotension, upper respiratory symptoms and myalgia of the extremities were noted, and the left ventricular ejection fraction (LVEF) was decreased to 20%. Multiorgan failure (MOF) occurred, and the patient received ventilator support and continuous hemodiafiltration. Rhabdomyolysis, pancreatitis, erythema multiforme and enteritis were observed. CRS was diagnosed based on elevated ferritin and IL-6 levels. Steroid pulse therapy was administered; however, the MOF did not improve and the anti-IL-6-receptor monoclonal antibody tocilizumab (TOC) was administered. Subsequently, the LVEF improved to 50%, and the patient was removed from the ventilator on day 4 and from the continuous hemodiafiltration unit on day 6 after TOC administration. The patient was discharged on day 21. In conclusion, considering that ICI-induced CRS is a rare but severe complication, fever and other systemic conditions following ICI administration should be monitored.

Intranodal lymphangiography under microsurgery for refractory lymphatic ascites after pelvic lymphadenectomy.

Lymphatic ascites is a postoperative complication of lymph node dissection. Most symptomatic cases improve with conservative treatments. However, optimal management strategies for intractable lymphatic ascites remain controversial, and clinicians sometimes encounter intractable lymphatic ascites that does not respond to conservative management. We herein report a case of postoperative intractable lymphatic ascites that was successfully treated with intranodal lymphangiography (LG) from inguinal lymph nodes under microsurgery. A 56-year-old woman was diagnosed with stage II endometrial cancer and underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomies. On postoperative day (POD) 13, the patient presented with abdominal distention, and lymphatic ascites was diagnosed. Although the patient was treated with conservative management and lymphaticovenular anastomosis, her lymphatic ascites did not resolve. Finally, intranodal LG from the inguinal region was performed under microsurgery. A 2-cm incision was made on each side of the inguinal region. Once the lymph nodes were identified, a 23-gauge needle was inserted into the lymph node and lipiodol was injected. Extravasation of lipiodol into the abdomen from the left side of the lower pelvic region was confirmed. The postoperative course was uneventful. The ascites gradually decreased and disappeared within two weeks after LG.

Total laparoscopic hysterectomy when there is posterior cul-de-sac obliteration: a step-by-step nerve-sparing technique.

Dense adhesions because of severe endometriosis between the posterior cervical peritoneum and the anterior sigmoid or rectum obliterate the cul-de-sac and distort normal anatomic landmarks. Surgery for endometriosis is associated with severe complications, including ureteral and rectal injuries and voiding dysfunction. Surgeons should recognize the importance of not only avoiding ureteral and rectal injuries but also focusing on the preservation of the hypogastric nerves. Herein, we reported the anatomic highlights and surgical steps of laparoscopic hysterectomy for posterior cul-de-sac obliteration with the nerve-sparing technique.

Relationship between placental hemodynamics and placental histological analysis in third trimester.

AIM: To investigate whether vascularization index (VI), flow index (FI), and vascularization flow index (VFI) correlate with the pathological structure of the placenta and whether there were any differences in VI, FI, VFI, and placental pathological structure between the normal and preeclampsia (PE) groups. METHODS: Fifty-five pregnant women (normal group, n = 27; PE group, n = 28) underwent VI, FI, and VFI at four locations in the placenta during the second and third trimesters. Two hematoxylin and eosin (HE)-stained specimens of the postpartum placenta were prepared. We randomly selected two of these locations and used ImageJ, an open-source image package, to quantify intervillous blood vessels (IBV), intervillous spaces (IS), and intervillous blood vessels + intervillous spaces (IBV + IS) per unit placenta and analyzed their correlation with VI, FI, and VFI. RESULTS: There was no positive correlation between VI, FI, VFI, IBV, IS, and IBV + IS. There were no significant differences in VI, FI, and VFI between the normal and PE groups; however, there were significant differences in IBV, IS, and IBV + IS in the PE group compared to those in the normal group. CONCLUSIONS: Placental hemodynamics measured by VI, FI, and VFI were not positively correlated with placental morphology in the third trimester. There were no differences in the VI, FI, and VFI in the third trimester between the normal and PE groups, suggesting that these may reflect placental circulatory insufficiency.

Acute ST-segment elevations following paclitaxel administration for uterine cervical cancer: a case report and literature review.

Paclitaxel-induced cardiac ischemia is a rare but life-threatening complication. Although it may be difficult to distinguish from hypersensitivity or infusion reactions, it should not be overlooked. We herein report a rare case of ST-segment elevation following the administration of paclitaxel for uterine cervical cancer and review the literature regarding paclitaxel-induced cardiac ischemia.A 48-year-old woman with uterine cervical cancer with no cardiovascular risk factors was admitted to our hospital for concurrent chemoradiotherapy (CCRT) and planned to receive weekly paclitaxel and carboplatin for a total of 5 weeks. Just after the completion of the first cycle of paclitaxel infusion, she presented with diaphoresis and her consciousness level decreased. Electrocardiography showed ST elevation, suggesting acute myocardial infarction. Laboratory testing revealed troponin I positivity. Emergency coronary angiography (CAG) revealed a normal coronary artery, suggesting paclitaxel-induced vasospasm. After CAG, the patient was hemodynamically stable and was returned to the gynecologic unit two days after CAG. CCRT without paclitaxel was continued and the patient was uneventfully discharged from hospital.

Perioperative Serum Creatinine Change and Delayed Urologic Complications Following Total Laparoscopic Hysterectomy for Benign Indications.

Objectives: The objective of the study was to investigate the association between perioperative serum creatinine change and delayed urologic complications following total laparoscopic hysterectomy (TLH) for benign indications. Materials and Methods: A total of 510 cases (503 cases without delayed urologic injuries and 7 cases with delayed urologic injuries) in which TLH was performed for benign indications were retrospectively reviewed. The patient characteristics and surgical outcomes were compared between patients with and without delayed urologic injuries. Laboratory markers (serum creatinine level at the preoperative and postoperative periods, white blood cell [WBC] ratio, and C-reactive protein [CRP] ratio) were analyzed to evaluate the diagnostic value of these laboratory markers. Results: There were no statistically significant differences in age, parity, body mass index, the presence of diabetes mellitus, preoperative GnRH agonist use, previous history of abdominal surgery or the performance of adnexal surgery, ASRM score, the presence of cul-de-sac obliteration, operative time, blood loss or weight of the resected specimens between the two groups. The proportions of patients who showed an elevated creatinine level on postoperative day 1 was significantly higher in the delayed urologic injury group (9.9% vs. 57%, P < 0.001). The combination of the three laboratory markers yielded an area under the ROC curve value of 0.75 (95% confidence interval, 0.491-1) in the detection of delayed urologic injuries. Conclusion: A change in the serum creatine level over baseline after surgery may indicate the possibility of urologic injuries. The combination of creatinine change and other factors, such as WBC or CRP would be helpful for detecting urologic complications after TLH.

A case of preeclampsia developing massive ascites after delivery.

We experienced a case of preeclampsia in which massive ascites became apparent in the postpartum period. The patient had isolated proteinuria without hypertension before delivery. The infant had fatal growth restriction and neonatal distress. Massive ascites and isolated proteinuria are important symptoms for predicting the aggravation of PE.

Laparoscopically Resected Venous Adventitial Cystic Disease that was Difficult to Distinguish from an Ovarian Tumor.

Adventitial cystic disease (ACD) is a rare condition in which a mucinous cyst forms within the adventitia, usually in arteries but rarely in veins. A 79-year-old patient presented with stomachache and nausea. Computerized tomography showed pelvic cysts on either side of the pelvis. The right tumor was 120×100 mm, and the left tumor was 45×35 mm. Our diagnosis was bilateral ovarian tumors and we performed laparoscopic tumor resection. In the abdominal cavity, we saw that the left ovary was swollen by about 3-4 cm and the right ovary was normal size. There was a mucous cyst located in the right retroperitoneal cavity that adhered around and bordered the right external iliac vein and the right obturator nerve. We peeled the adhesion away carefully and resected the tumor but the operation caused temporary obturator nerve paralysis. From pathological examination, we diagnosed the right retroperitoneal cyst to be venous ACD originating from the right external iliac vein. We found that venous ACD can grow as large as a pelvic tumor and is difficult to distinguish from an ovarian tumor, which is why we chose laparoscopic surgery. In this case, we performed the operation laparoscopically and no sequelae or recurrent tumor appeared during a 1-year follow-up. However, graft replacement is sometimes necessary for ACD, thus venous ACD should be considered a differential diagnosis and a surgical strategy should be developed when pelvic tumors are observed.

[A Case of Segmental Dysgenesis at the Terminal Portion(C1)of the Internal Carotid Artery with an Anomalous Collateral Vessel Containing Plexiform(Twig-like)Networks as a Possible Cause of Intracerebral Hemorrhage].

A 65-year-old woman was transferred to our hospital because of loss of consciousness along with a right hemiplegia due to an intracerebral hematoma(ICH)that extended from the left temporal lobe to the lateral part of the basal ganglia. CT angiograms(CTA)and 3D-rotational angiograms showed an absence of the distal C1 segment of the left internal carotid artery(ICA), and an anomalous collateral vessel arising from the proximal end of the left A2 with plexiform(twig-like)arterial networks, supplying antegrade blood flow to the left middle cerebral artery territory. The caliber of the left carotid arterial system decreased from the origin to the terminal end. The source images of CTA revealed that the plexiform arteries were very close to the ICH, suggesting that the vessels might have caused the bleeding. Because a hypoplastic left carotid canal was observed, the segmental dysgenesis of the C1 portion of the left ICA seemed to have occurred during the early embryonic period. T2-weighted DRIVE images of MRI demonstrated the presence of a cord-like rudimentary structure corresponding to the distal C1 and proximal M1 portions. The patient was managed conservatively and was transferred to another hospital for subsequent rehabilitation. Segmental dysgenesis of the C1 portion is extremely rare. To our knowledge, only a single report has been published. The present findings suggest that 1)an anomalous collateral vessel corresponding to Heubner's artery evolved with residual primitive plexiform(twig-like)arterial networks and 2)this anomalous structure has not been proposed as a type of collateral systems for ICA dysgenesis.