Surgical Anatomical Structure of Uterine Artery Caudal Space for Robot-Assisted Extrafascial Hysterectomy With Ureterohypogastric Nerve Fascia Preservation: A Case Description.

A surgical technique has been developed using a robot-assisted system to create the surgical anatomical structure of the uterine artery caudal space (UACS), a landmark for performing extrafascial hysterectomy, enabling a safe and easy parametrial resection to prevent ureteral injury and cervical sidewall bleeding at hysterectomy. UACS is created to preserve the ureterohypogastric nerve fascia (UHNF), which envelopes the ureter and the hypogastric nerve, and the vesicohypogastric fascia (VF), which wraps the uterine artery and veins. The boundaries of UACS are UHNF laterally, the uterine cervix medially, and VF cranially. VF is penetrated between UACS and the medial pararectal space under the uterine vessels and transected. We present a case of early-stage uterine cancer and describe the new surgical technique in detail, using UACS as a surgical landmark. This surgical technique could be applied not only to early-stage uterine cancer but also to benign uterine tumors using a robot-assisted surgical system.

Ovarian torsion due to ovarian hyperstimulation syndrome diagnosed by sonographic whirlpool sign in the first trimester of pregnancy: A case report.

Ovarian torsion during pregnancy is a rare condition that needs prompt diagnosis and detorsion in order to preserve ovarian function. Diagnosing ovarian torsion is a difficult procedure especially in pregnant cases since radiation exposure should be avoided. Detecting the whirlpool sign by ultrasonography is a highly useful technique as it is noninvasive, less time-consuming, and radiation-free. Here is a case of ovarian torsion due to ovarian hyperstimulation syndrome diagnosed solely by sonographic features and in which laparoscopic detorsion was promptly performed. A 26-year-old woman in her sixth week of pregnancy visited a tertiary hospital with sudden onset lower abdomen pain. Transvaginal ultrasound detected an 8 cm left ovary and a whirlpool sign between the uterus and left ovary. Ovarian torsion was suspected and laparoscopic surgery was performed. Intraoperatively, an enlarged left ovary was twisted at 540° involving the left fallopian tube. After detorsion, bilateral ovaries were preserved and the postoperative course was uneventful. Ovarian torsion was suspected solely by ultrasonographic features which led to surgical detorsion quickly, resulting in the preservation of bilateral ovaries. Detecting the whirlpool sign when ovarian torsion is suspected is useful, especially in pregnant women.

Diagnostic Discordance in Intraoperative Frozen Section Diagnosis of Ovarian Tumors: A Literature Review and Analysis of 871 Cases Treated at a Japanese Cancer Center.

BACKGROUND: This study examined the accuracy and pitfalls associated with frozen section diagnosis of primary ovarian tumors and ovarian metastases based on the 2014 World Health Organization classification (WHO) criteria and proposed improvements from a pathologist's perspective. METHODS: We microscopically reviewed 871 cases of primary ovarian tumor (N = 802) and ovarian metastasis (N = 69) and compared the results of frozen sections with the final diagnosis. Malignant potential concordance (benign, borderline, or malignant) and specific discordant diagnosis rates were analyzed. Finally, we conducted a unique literature review of specific diagnostic errors in the frozen section diagnosis of primary ovarian tumors. RESULTS: Of 802 primary ovarian tumors, 50 (6.2%) cases showed discordant diagnoses in which mucinous carcinoma (40.5%), low-grade serous carcinoma (LGSC; 31.3%), and mucinous borderline tumor (18.4%) were frequently misinterpreted. Of 69 ovarian metastases, all 4 cases of low-grade appendiceal mucinous neoplasm (LAMN) were misdiagnosed as primary ovarian mucinous tumor. A literature review revealed that mucinous/serous borderline tumor or carcinoma accounted for approximately 70% of 217 reported discordant diagnoses. CONCLUSION: In the present study, the concordance rate of malignant potential of the tumor was comparable to that previously reported. Even in the 2014 WHO classification, primary ovarian mucinous borderline tumor/carcinoma and LGSC still comprised the majority of discordant cases. Grossing methods that reduce sampling error are required. LAMN was frequently misinterpreted as a benign or borderline ovarian mucinous tumor. To prevent this error, a differential algorithm integrating clinical information and gross findings should be developed.

Gross mucinous multinodular appearance aids in the identification of ovarian metastases in low-grade appendiceal mucinous neoplasms during intraoperative consultation.

Ovarian metastases of low-grade appendiceal mucinous neoplasms (LAMNs) show grossly abundant nodular mucous cells, with a gross mucinous multinodular appearance and a histological resemblance to primary ovarian mucinous tumors (POMTs). This study aimed to elucidate the utility of gross features including the gross mucinous multinodular appearance and available clinical information at the time of intraoperative consultation, in distinguishing the ovarian metastases of LAMNs from POMTs or the ovarian metastases of colorectal cancer (CRC). In total, 776 patients with primary ovarian tumor and 68 patients with ovarian metastases underwent intraoperative consultation during 1998-2018. Of the total cases, 4 ovarian metastases of LAMNs, 19 ovarian metastases of CRC, and 50 POMTs (36 borderline tumors and 14 carcinomas) were identified. The gross features including the gross mucinous multinodular appearance were analyzed based on the gross photographs obtained before formalin fixation and the available clinical information collected during intraoperative consultation. The analysis indicated that the ovarian metastases of LAMNs significantly presented with gross mucinous multinodular appearance (4/4 vs. 0/50, P < 0.0001), extraovarian disease (4/4 vs. 2/50, P < 0.0001), ovarian surface involvement (3/4 vs. 2/50, P = 0.0016), and abnormal appendix (4/4 vs. 0/50, P < 0.0001) as compared to POMT. Moreover, the gross mucinous multinodular appearance was a distinguishable feature between the ovarian metastases of LAMNs and ovarian metastases of CRC (4/4 vs. 0/19, P = 0.0001). Based on these results, we proposed an algorithm to diagnose ovarian tumors using the gross mucinous multinodular appearance. Thus, recognizing unique gross features including the gross mucinous multinodular appearance would be useful for both pathologists and surgeons to accurately diagnose ovarian metastases of LAMNs during intraoperative consultation.

Malignant struma ovarii presenting with follicular carcinoma: A case report with molecular analysis.

Malignant struma ovarii presenting with follicular carcinoma is extremely rare, and its mechanism of tumorigenesis remains unknown. Here, we present a case of malignant struma ovarii with peritoneal dissemination of follicular carcinoma, for which a molecular analysis for major oncogenic gene alterations in follicular thyroid carcinoma was performed. A 39-year-old nulliparous woman was referred with a diagnosis of highly differentiated follicular carcinoma of ovarian origin. Primary thyroid cancer was not diagnosed, and she had a normal thyroid function. 123I scintigraphy revealed multiple peritoneal dissemination that was surgically resected. Histologically, the tumor consisted of numerous follicles without nuclear features of papillary thyroid carcinoma. Tumor samples were investigated for 50 cancer-related genes, including RAS, BRAF, and p53, and PPARg-PAX8 gene fusion by targeted DNA sequencing and fluorescence in situ hybridization, respectively. No major oncogenic gene alterations were detected. These negative findings suggest a different mechanism of tumorigenesis from that of adult-type follicular thyroid carcinoma.

Methods for Measuring and Staging a Uterine Cervical Adenocarcinoma Showing Intracystic Papillary Growth: A Case Report.

Endocervical adenocarcinomas usually demonstrate infiltrative and/or destructive invasion, and the depth and horizontal extent of the invasion are known to have prognostic utility. Here, we report the unusual case of a patient with endocervical adenocarcinoma showing intracystic papillary growth and discuss our methods for measuring and staging this lesion. A 45-yr-old Japanese woman (gravida, 0; para, 0) underwent a cone biopsy for squamous cell carcinoma in situ and atypical glandular cells. Macroscopically, an intracystic tumor (∼7.5 mm in diameter) was detected in the cervix. Microscopically, we observed both squamous cell carcinoma in situ and adenocarcinoma involving the squamo-columnar junction. Adenocarcinoma cells lining the nabothian cyst showed papillary proliferation and expansile stromal invasion without desmoplastic reaction. We evaluated this macroscopically and found that the visible papillary growth and expansile invasion deviated from the adenocarcinoma in situ; hence, we concluded that this lesion was an International Federation of Gynecology and Obstetrics stage IB1 adenocarcinoma. The patient underwent an abdominal radical hysterectomy, followed by bilateral salpingo-oophorectomy and pelvic lymph node dissection. No residual cervical cancer, other gynecologic malignancies, or lymph node metastases were observed. Further studies using cases with the same growth pattern are needed to determine whether our evaluation method is optimal for this type of lesion.