Successful laparoscopic resection of retroperitoneal ectopic pregnancy between the abdominal aorta and inferior vena cava: A case report.

Retroperitoneal ectopic pregnancies are extremely rare; only a few cases having been reported. Here, we report laparoscopic removal of an asymptomatic retroperitoneal ectopic pregnancy from a 29-year-old woman who was referred to our hospital for a suspected ectopic pregnancy. Transvaginal ultrasound did not reveal a gestational sac in the uterus or pelvic cavity. However, abdominal contrast-enhanced computer tomography showed a gestational sac between the abdominal aorta and inferior vena cava. On laparoscopy, the gestational sac was confirmed to be in this retroperitoneal location and successfully removed with minimal bleeding. Histopathologic examination revealed chorionic villi surrounded by lymphatic tissue, suggesting lymphatic spread of the retroperitoneal ectopic pregnancy. In summary, contrast-enhanced computer tomography is very useful for locating the site of pregnancy in women suspected of having a retroperitoneal ectopic pregnancy. Timely diagnosis of a retroperitoneal ectopic pregnancy before bleeding occurs can enable their safe laparoscopic removal.

Risk-reducing salpingo-oophorectomy for Japanese women with hereditary breast and ovarian cancer: a single-institution 10-year experience.

BACKGROUND: For women diagnosed with hereditary breast and ovarian cancer, the clinical guidelines recommend risk-reducing salpingo-oophorectomy at age 35-40 years or after completion of childbearing. However, there is limited information regarding the current status of risk-reducing salpingo-oophorectomy in Japan. METHODS: To clarify factors influencing decision-making for risk-reducing salpingo-oophorectomy among Japanese women diagnosed with hereditary breast and ovarian cancer and their clinical outcomes, we analyzed the medical records of 157 Japanese women with germline BRCA pathogenic variants (BRCA1 n = 85, BRCA2 n = 71 and both n = 1) at our institution during 2011-21. Specimens obtained from risk-reducing salpingo-oophorectomy were histologically examined according to the sectioning and extensively examining the fimbriated end protocol. RESULTS: The risk-reducing salpingo-oophorectomy uptake rate was 42.7% (67/157). The median age at risk-reducing salpingo-oophorectomy was 47 years. Older age, married state and parity were significantly associated with risk-reducing salpingo-oophorectomy (P < 0.001, P = 0.002 and P = 0.04, respectively). History of breast cancer or family history of ovarian cancer did not reach statistical significance (P = 0.18 and P = 0.14, respectively). Multivariate analyses revealed that older age (≥45 years) and married state may be independent factors associated with risk-reducing salpingo-oophorectomy. Interestingly, the annual number of risk-reducing salpingo-oophorectomy peaked in 2016-17 and has increased again since 2020. The rate of occult cancers at risk-reducing salpingo-oophorectomy was 4.5% (3/67): ovarian cancer (n = 2) and serous tubal intraepithelial carcinoma (n = 1). CONCLUSION: Age and marital status significantly affected decision-making for risk-reducing salpingo-oophorectomy. This is the first study to suggest possible effects of Angelina Jolie's risk-reducing salpingo-oophorectomy in 2015 and the National Health Insurance introduced for risk-reducing salpingo-oophorectomy in 2020. The presence of occult cancers at risk-reducing salpingo-oophorectomy supports clinical guidelines recommending risk-reducing salpingo-oophorectomy at younger ages.

Utility of molecular subtypes and genetic alterations for evaluating clinical outcomes in 1029 patients with endometrial cancer.

BACKGROUND: We investigated the utility of a molecular classifier tool and genetic alterations for predicting prognosis in Japanese patients with endometrial cancer. METHODS: A total of 1029 patients with endometrial cancer from two independent cohorts were classified into four molecular subtype groups. The primary and secondary endpoints were relapse-free survival (RFS) and overall survival (OS), respectively. RESULTS: Among the 265 patients who underwent initial surgery, classified according to immunohistochemistry, patients with DNA polymerase epsilon exonuclease domain mutation had an excellent prognosis (RFS and OS), patients with no specific molecular profile (NSMP) and mismatch repair protein deficiency had an intermediate prognosis, and those with protein 53 abnormal expression (p53abn) had the worst prognosis (P < 0.001). In the NSMP group, mutant KRAS and wild-type ARID1A were associated with significantly poorer 5-year RFS (41.2%) than other genomic characteristics (P < 0.001). The distribution of the subtypes differed significantly between patients with recurrence/progression and classified by sequencing (n = 764) and patients who underwent initial surgery (P < 0.001). Among patients with recurrence/progression, 51.4% had the opportunity to receive molecular targeted therapy. CONCLUSIONS: A molecular classifier is a useful tool for determining prognosis and eligibility for molecularly targeted therapy in patients with endometrial cancer.

Preoperative Magnetic Resonance Imaging versus Intraoperative Frozen Section Diagnosis for Predicting the Deep Myometrial Invasion in Endometrial Cancer: Our Experience and Literature Review.

AIM: The present study was designed to directly compare the diagnostic performance of preoperative magnetic resonance imaging (MRI) and intraoperative frozen section (FS) diagnoses in predicting deep myometrial invasion (MI) of endometrial cancer. METHODS: Using MRI findings and FS diagnoses, 194 patients with surgically staged endometrial cancer were evaluated for deep MI between 2006 and 2018. Definitive histological diagnosis of paraffin sections of excised tissues was used as the gold standard approach. RESULTS: Of 194 cases, 53 (27.3%) cases were finally diagnosed as having deep MI (≥50%). There was 82% total agreement between MRI and FS diagnoses in predicting deep MI, with a kappa value of 0.54 (95% confidence interval [CI] = 0.40-0.67, moderate agreement). The sensitivity of FS diagnosis (0.66, 95% CI = 0.52-0.78) for predicting deep MI was lower than that of MRI (0.77, 95% CI = 0.63-0.87; p = 0.21), while the specificity of FS (0.98, 95% CI = 0.93-0.99) was significantly higher than that of MRI (0.88, 95% CI = 0.81-0.93; p = 0.001). Overall, the accuracy of FS (0.89, 95% CI = 0.84-0.93) was higher than that of MRI (0.85, 95% CI = 0.79-0.90), although the difference did not reach statistical significance (p = 0.23). The accuracy (0.95, 95% CI = 0.90-0.97) was very high in cases with concordant MRI and FS results. CONCLUSIONS: MRI and FS showed different diagnostic characteristics for predicting deep MI, with a higher specificity observed for FS and the greatest accuracy obtained in concordant cases. Thus, our findings recommend the addition of FS diagnosis, either alone or in conjunction with MRI, to MI evaluation.

Laparoscopic Anterior Pelvic Exenteration with Super Radical Parametrectomy for a Recurrent Low-Grade Endometrial Sarcoma That is Resistant to Hormone Therapy and Chemotherapy.

STUDY OBJECTIVE: To show total laparoscopic complete resection of a recurrent low-grade endometrial sarcoma. DESIGN: Step-by-step demonstration of the technique of laparoscopic anterior pelvic exenteration with super radical parametrectomy, including the explanation of detailed pelvic anatomy (Canadian Task Force classification III). SETTING: Low-grade endometrial stromal sarcoma (LGESS) is a rare malignancy that makes up around 0.2% of all uterine malignancies [1]. Total abdominal hysterectomy and bilateral salpingo-oophorectomy is a standard treatment; however, the recurrence risk is quite high [2]. For a recurrent LGESS that is resistant to hormone therapy and chemotherapy, complete resection with negative surgical margins (R0 resection) can be the most promising method [3]. PATIENT: The patient had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy because of a LGESS. Almost 20 years later, a recurrent LGESS was detected at the vaginal stump, and the patient underwent several rounds of chemotherapy and hormonal therapy. These treatments were inefficacious, and the recurrent tumor progressed. An abdominal computed tomographic scan revealed that the recurrent tumor occupied the vaginal stump, involved the bladder and the left ureter, and extended to the left pelvic sidewall. INTERVENTIONS: Anterior pelvic exenteration with super radical parametrectomy was performed laparoscopically with no blood transfusion. R0 resection could be achieved without any intraoperative and postoperative complications. Without any adjuvant treatment, there has been no sign of recurrence during the 12 months that have passed since the surgery. This video obtained institutional review board approval through our local ethics committee in the Cancer Institutional Hospital (institutional review board number 2016-1007). CONCLUSION: The good visualization and meticulous dissection provided during laparoscopic surgery can make the approach advantageous and may contribute to R0 achievement.

Resection of the inferior pubic ramus to completely remove locally advance adenoid cystic carcinoma of Bartholin's gland.

OBJECTIVE: Some sections of the pelvic bone can be removed without severe loss of function, including the inferior pubic ramus. Here we report a technique for the complete resection of locally advanced adenoid cystic carcinoma (ACC) of the Bartholin's gland that had invaded the obturator muscle and inferior pubic ramus. METHODS: We chose to operate because there was little evidence of definitive radiotherapy for ACC of the vulva. As preoperative imaging did not suggest lymph node metastasis, we omitted lymphadenectomy. The perineal incision was made to obtain at least a 2-cm margin of the normal tissue around the tumor at the lateral side. The histologic margin was based on head and neck data as this disease presents more commonly in that part of the body. Pelvic reconstruction was performed using the gracilis myocutaneous flap, and the ileal conduit reservoir and sigmoid stoma was constructed. RESULTS: Total pelvic excenteration with resection of the inferior ramus was performed. As the actual margin distance was >2cm, postoperative radiotherapy was not needed. As a part of her surveillance regimen, MRI was performed every 6months and CT of the chest was performed annually. One year postoperatively, she is alive with no evidence of disease. During the last follow-up, she did not have any major complications in daily life. If anything, she cannot run. CONCLUSIONS: Understanding that the inferior pubic ramus can be resected without severe functional loss will increase treatment choice. We achieved complete resection of locally advanced ACC of the Bartholin's gland.

Secondary debulking surgery for isolated pelvic nodal recurrence requiring external iliac vein excision and reconstruction in a patient with ovarian cancer.

OBJECTIVE: We report the details of a cytoreduction technique for pelvic lymph node recurrence with involvement of the external iliac vein (EIV) requiring a partial resection and reconstruction of the EIV. METHODS: A 51-year-old woman presented with ovarian cancer and isolated nodal recurrence located on the right side of the pelvis. As the tumor had infiltrated the EIV wall, we performed the EIV excision and reconstruction using an autogenous graft. RESULTS: EIV reconstruction was achieved using a right ovarian vein patch. No intra- or early postoperative complications occurred. A postoperative enhanced magnetic resonance imaging examination confirmed the patency of the EIV. CONCLUSION: An en bloc EIV excision and reconstruction for contiguous tumor involvement seems to be a feasible and safe surgical option.