Unusual trocar site metastasis in a uterine leiomyosarcoma after laparoscopic hysterectomy.

With widespread use of laparoscopy in patients with gynecologic malignancy, occasionally port-site metastasis is an item of concern. Herein we report a case of leiomyosarcoma of the uterus that metastasized to an accessory port after laparoscopic-assisted vaginal hysterectomy. A 46-year-old woman with a preoperative diagnosis of leiomyoma underwent laparoscopic-assisted vaginal hysterectomy. Final histopathologic findings revealed leiomyosarcoma. A postoperative abdominopelvic computed tomography scan demonstrated no evidence of metastatic tumor. The patient received 6 courses of combined chemotherapy consisting of cisplatin and ifosfamide. Follow-up computed tomography was performed because of pelvic pain at 4 months after treatment and revealed a recurrent pelvic tumor and a metastatic mass at previous right trocar site. At debulking surgery, a pelvic mass measuring 10 cm was observed, and a subcutaneous nodule measuring 4 cm was noted at the site of the right accessory port, with intact underlying peritoneum. After complete removal of both tumors, concurrent chemoradiation consisting of external radiotherapy and cisplatin was administered. Six months after the second surgery, a pelvic mass measuring 15 cm was observed. A second debulking surgical procedure was performed. However, the patient died of the disease 6 months after the second recurrence.

Treatment of fallopian tube metastasis in cervical cancer after laparoscopic ovarian transposition.

A 40-year-old woman, gravida 2, para 2, with squamous cell carcinoma of the cervix, stage IIB, underwent ovarian transposition. Bilateral salpingectomy was performed as part of the operative technique. Histopathologic analysis revealed mucosal spread of the tumor to one of the fallopian tubes. The patient underwent radiation of the ovaries in their new location in addition to standard chemoradiotherapy to the pelvis. There has been no evidence of disease for more than 5 years. Inasmuch as performance of bilateral salpingectomy in ovarian transposition is not standard practice, the finding of fallopian tube metastasis presented a dilemma to the clinician. It remains to be proved whether the finding of metastasis to the fallopian tubes can be evidence for ovarian metastasis in grossly normal-appearing ovaries to validate this practice. Literature review demonstrates that fallopian tube metastasis is usually associated with endometrial involvement.

Diagnostic Performances of Ultrasound-Based Models for Predicting Malignancy in Patients with Adnexal Masses.

This study compared the diagnostic performance of different ultrasound-based models in discriminating between benign and malignant ovarian masses in a Filipino population. This was a prospective cohort study in women with findings of an ovarian mass on ultrasound. All included patients underwent a physical examination before level III specialist ultrasonographic and Doppler evaluation using the different International Ovarian Tumor Analysis (IOTA) Group's risk models. Serum CA-125 and a second-generation multivariate index assay (MIA2G) were also determined for all patients. The ovarian imaging and biomarker results were correlated with the histological findings. A total of 260 patients with completed ultrasound, CA-125, MIA2G, and histopathologic results was included in the study. The presence of papillae with blood flow and irregular cyst walls during the ultrasound were significantly associated with a 20-fold (OR: 20.13, CI: 8.69−46.67, p < 0.01) and 10-fold (OR: 10.11, CI: 5.30−19.28, p < 0.01) increase in the likelihood of a malignant lesion, respectively. All individual sonologic procedures performed well in discerning malignant and benign ovarian lesions. IOTA-LR1 showed the highest accuracy (82.6%, 95% CI: 77.5−87%) for identifying ovarian cancer. IOTA-ADNEX showed the highest sensitivity (93.3%, 95% CI: 87.2−97.1%) while IOTA-LR2 exhibited the highest specificity (84.4%, 95% CI: 77.3−90%). Among the different serial test combinations, IOTA-LR1 with MIA2G and IOTA-LR2 with MIA2G showed the highest diagnostic accuracy (AUROC = 0.82). This study showed that all individual ultrasound-based models performed well in discerning malignant and benign ovarian lesions, with IOTA-LR1 exhibiting the highest accuracy.

Clinical Performance of a Multivariate Index Assay in Detecting Early-Stage Ovarian Cancer in Filipino Women.

This study evaluated the clinical performance and overall utility of a multivariate index assay in detecting early-stage ovarian cancer in a Filipino population. This is a prospective cohort study among Filipino women undergoing assessment for an ovarian mass in a tertiary center. Patients diagnosed with early-stage ovarian cancer and who underwent a physical examination before level III specialist ultrasonographic and Doppler evaluation, multivariate index assay (MIA2G), and surgery for an adnexal mass were included in this study. Ovarian tumors were classified as high-risk for malignancy based on the IOTA-LR2 score. The ovarian imaging and biomarker results were correlated with the reference standard: surgico-pathologic findings. The MIA2G exhibited the best overall performance among individual classifiers with a sensitivity of 91.7% and NPV of 84.7%, with a concomitant higher sensitivity in early-stage disease, whether as an individual classifier (93.5%) or in serial combination with ultrasound (85.5%). The performance of biomarkers (specificity, positive predictive values, and AUROC) such as MIA2G and CA-125 significantly improved when combined with an ultrasound risk scoring approach (p < 0.01). MIA2G showed a higher sensitivity for detecting lesions among EOC and late-stage ovarian cancers than otherwise. The application of biomarkers for evaluating ovarian masses in our local setting is secondary to ultrasound but adopting multivariate index assays rather than CA-125 would increase the detection of early-stage ovarian cancers regardless of menopausal status. This is most relevant in areas where level III sonographers or gynecologic oncologists are limited and preoperative referrals to these specialists can improve the survival of our patients.

Improving diagnostic strategies for ovarian cancer in Filipino women using ultrasound imaging and a multivariate index assay.

OBJECTIVE: To evaluate the clinical performance and overall utility of imaging and biomarker assays in discriminating between benign and malignant ovarian masses in a Filipino population. METHODS: This is a prospective cohort study among Filipino women undergoing assessment for an ovarian mass in a tertiary center. All included patients underwent a physical examination before level III specialist ultrasonographic and Doppler evaluation, multivariate index assay (MIA2G), and surgery for an adnexal mass. Ovarian tumors were classified as high-risk for malignancy based on the International Ovarian Tumour Analysis (IOTA) - Logistic Regression 2 (LR2) score. The ovarian imaging and biomarker results were correlated with the reference standard: histological findings. RESULTS: Among the 379 women with adnexal masses enrolled in this study, 291 were evaluable with ultrasound imaging, biomarker assays, and histopathological results. The risk of malignancy was higher for women classified as high-risk based on IOTA-LR2 (≥10%). The sensitivity, specificity, and diagnostic accuracy for the prediction of malignancy were 81.2%, 81%, and 0.81 (95% CI: 0.77-0.86) for IOTA-LR2; 77.5%, 66.7%, and 0.72 (95% CI: 0.67-0.77) for CA-125; and 91.3%, 41.2%, and 0.66 (95% CI: 0.62-0.71) for MIA2G. A combination of IOTA-LR2 and MIA2G significantly influenced the diagnostic performance and the result. When MIA2G was combined with IOTA-LR2 in parallel, the sensitivity (94.2%) and NPV (87.7%) increased, but the specificity (37.3%) decreased. When combined with IOTA-LR2 in series, there were fewer false positives, which resulted in improved specificity (85%). CONCLUSION: This study determined the utility of ovarian imaging and a second-generation multivariate index assay in predicting the risk of ovarian malignancy. IOTA-LR2 and MIA2G were useful in classifying patients with a high risk for ovarian malignancy.

Late Retroperitoneal Hematoma with Abscess Formation Following Laparoscopic Staging of Endometrial Cancer.

Herein, we report a case of a 63-year-old, nonobese, woman who underwent laparoscopic surgical staging for endometrial cancer with pelvic and para-aortic lymph node dissection. After being discharged, the patient presented to the emergency department with fever and abdominal pain, 1 week after the procedure. Abdominal tenderness, fever, and anemia were the key clinical and laboratory findings. A computed tomography (CT) scan revealed a cystic mass with air bubbles, located in the right iliopsoas region. The features were consistent with an infected hematoma at the right iliopsoas region, which was managed with antibiotics and CT-guided pigtail drainage. Laparoscopic surgical staging for endometrial cancer has been shown to have fewer early complications than open surgery. However, complications can still occur in the most experienced hands. Abscess arising from hematomas after laparoscopic surgical staging can be managed adequately with noninvasive CT-guided drainage.

Maintenance of ovarian function in end-of-life cervical cancer patient following primary surgico-radiotherapy and ovarian transposition.

A 35-year-old woman underwent laparoscopic radical hysterectomy, pelvic lymphadenectomy and ovarian transposition for stage IB2 cervical adenocarcinoma. She received adjuvant concurrent chemoradiation for poor pathologic risk factors but had tumor recurrence 20 months after the surgery. Transposed ovaries were uninvolved in the recurrence and progression. Salvage chemotherapy and radiotherapy were given. Despite systemic chemotherapy and repeat pelvic radiotherapy, the patient was able to maintain ovarian function. Ovarian transposition in cervical cancer is an easily performed procedure that does not alter the prognosis of the disease in some cases. Present recommendations for its use should be reevaluated so that more premenopausal cancer patients may benefit from this underutilized procedure.