Prognostic Role of Neutrophil, Monocyte and Platelet to Lymphocyte Ratios in Advanced Ovarian Cancer According to the Time of Debulking Surgery.

Despite a multimodal radical treatment, mortality of advanced epithelial ovarian cancer (AEOC) remains high. Host-related factors, such as systemic inflammatory response and its interplay with the immune system, remain underexplored. We hypothesized that the prognostic impact of this response could vary between patients undergoing primary debulking surgery (PDS) and those undergoing interval debulking surgery (IDS). Therefore, we evaluated the outcomes of two surgical groups of newly diagnosed AEOC patients according to the neutrophil, monocyte and platelet to lymphocyte ratios (NLR, MLR, PLR), taking median ratio values as cutoffs. In the PDS group (n = 61), low NLR and PLR subgroups showed significantly better overall survival (not reached (NR) vs. 72.7 months, 95% confidence interval [CI]: 40.9-95.2, p = 0.019; and NR vs. 56.1 months, 95% CI: 40.9-95.2, p = 0.004, respectively) than those with high values. Similar results were observed in progression free survival. NLR and PLR-high values resulted in negative prognostic factors, adjusting for residual disease, BRCA1/2 status and stage (HR 2.48, 95% CI: 1.03-5.99, p = 0.043, and HR 2.91, 95% CI: 1.11-7.64, p = 0.03, respectively). In the IDS group (n = 85), ratios were not significant prognostic factors. We conclude that NLR and PLR may have prognostic value in the PDS setting, but none in IDS, suggesting that time of surgery can modulate the prognostic impact of baseline complete blood count (CBC).

Small Cell Carcinoma of the Vagina: First Systematic Review of Case Reports and Proposal of a Management Algorithm.

OBJECTIVES: Small cell carcinoma of the vagina (SmCCV) is an extremely rare disease. Evidence-based data and specific guidelines are lacking. We conducted the first systematic review of case reports to provide the most overall picture of SmCCV. MATERIALS AND METHODS: Literature search in PubMed and Scopus was performed using the terms "small cell carcinoma" and "vagina." English-language case reports of primary SmCCV up to January 2022 were included. RESULTS: Twenty-nine articles describing 44 cases met our inclusion criteria. We report a new case of our hospital. The global median overall survival (mOS) was 12.00 months (95% CI = 9.31-14.69). The mOS was not reached for stage I, and it was 12.00, 12.00, 9.00, and 8.00 months for stages II, III, IVA, and IVB, respectively (statistically significant differences between stage I and stages II, III, or IVA [log rank p = .003-.017]). Thirty-five cases received local treatments (77.8%). The mOS of patients treated with surgery ± complementary chemotherapy, radiotherapy ± complementary chemotherapy, chemoradiation ± complementary chemotherapy, and surgery + radiotherapy ± complementary chemotherapy were 11.00, 12.00, 17.00, and 29.00 months, respectively. The use of adjuvant or neoadjuvant chemotherapy (64.5%, mostly platinum + etoposide) showed longer mOS (77.00 vs 15.00 months). Four of 5 tested cases presented human papillomavirus infection, 3 of them presenting type 18. CONCLUSIONS: Small cell carcinoma of the vagina shows dismal prognosis. Multimodal local management plus complementary chemotherapy seems to achieve better outcomes. Human papillomavirus could be related to the development of SmCCV. A diagnostic-therapeutic algorithm is proposed.

Advantages of preoperative localization and surgical resection of metastatic axillary lymph nodes using magnetic seeds after neoadjuvant chemotherapy in breast cancer.

PURPOSE: To assess the safety and effectiveness of magnetic seeds in preoperative localization and surgical dissection of metastatic axillary lymph nodes (LN+) in breast cancer patients with axillary involvement, after neoadjuvant chemotherapy (NAC). In addition, to assess the impact of targeted axillary dissection (TAD) in reducing the rate of false negatives (FN) in sentinel lymph node biopsy (SLNB). MATERIALS AND METHODS: A cross-sectional prospective cohort study was conducted from April 2017 to September 2019, including breast cancer patients with axillary lymph node involvement treated with NAC. Prior to NAC, the LN+ were marked by ultrasound-guided clip insertion. After NAC, a magnetic seed (Magseed®) was inserted in the clip-marked lymph node (MLN). During surgery, the MLN was located and removed with the aid of a magnetic detection probe (Sentimag®) and the sentinel lymph node was removed. Axillary lymph node dissection (ALND) was used to determine the rate of FN for SLNB alone and the combination of SLNB and MLN dissection, called TAD. RESULTS: The study included 29 patients (mean age, 55; range, 30-78 years). Selective preoperative localization and surgical dissection were successful for all 30 MLNs (100%). The MLN corresponded to the SLN in 50% of cases. After ALND, there were 21.4% (3/14) FN with SLNB alone and 5.9% (1/17) with TAD. CONCLUSIONS: Following NAC, selective surgical removal of MLN by preoperative localization using magnetic seeds is a safe and effective procedure with a success rate of 100%. Adding TAD reduces the rate of FN associated with SLNB alone.

Risk Factors for Recurrence after Robot-Assisted Radical Hysterectomy for Early-Stage Cervical Cancer: A Multicenter Retrospective Study.

This retrospective analysis aimed to assess the risk factors for recurrence in patients diagnosed with early-stage cervical cancer (≤IB1 or IIA1, FIGO 2009) undergoing robot-assisted radical hysterectomy in Spain and Portugal between 2009 and 2018. A second primary objective was to audit the oncological outcomes according to quality indicators (QI) proposed by the European Society of Gynecology Oncology (ESGO). The study population included 239 women. After a median follow-up of 51 months, recurrence occurred in 26 patients (10.9%). Independent factors for recurrence were clinical tumor size > 20 mm (hazard ratio (HR) 2.37), adenocarcinoma as histological type (HR 2.51), positive pelvic lymph nodes (HR 4.83), tumor grade 2 (HR 4.99), tumor grade 3 (HR 8.06), and having not performed sentinel lymph node biopsy (SLNB) (HR 4.08). All 5 QI selected were surpassed by our results. In patients with early-stage cervical cancer undergoing robotic radical hysterectomy, clinicians should be aware that tumor grade 2 and 3, tumor size > 20 mm, adenocarcinoma, positive pelvic nodes, and lack of performance of SLNB are risk factors for recurrence. Fulfillment of QI targets of the ESGO might be considered as an objective oncological outcome indicator supporting the minimally invasive approach for early-stage cervical cancer treatment.

Translational Research Opportunities Regarding Homologous Recombination in Ovarian Cancer.

Homologous recombination (HR) is a DNA repair pathway that is deficient in 50% of high-grade serous ovarian carcinomas (HGSOC). Deficient HR (DHR) constitutes a therapeutic opportunity for these patients, thanks to poly (ADP-ribose) polymerases (PARP) inhibitors (PARPi; olaparib, niraparib, and rucaparib are already commercialized). Although initially, PARPi were developed for patients with BRCA1/2 mutations, robust clinical data have shown their benefit in a broader population without DHR. This breakthrough in daily practice has raised several questions that necessitate further research: How can populations that will most benefit from PARPi be selected? At which stage of ovarian cancer should PARPi be used? Which strategies are reasonable to overcome PARPi resistance? In this paper, we present a summary of the literature and discuss the present clinical research involving PARPi (after reviewing ClinicalTrials.gov) from a translational perspective. Research into the functional biomarkers of DHR and clinical trials testing PARPi benefits as first-line setting or rechallenge are currently ongoing. Additionally, in the clinical setting, only secondary restoring mutations of BRCA1/2 have been identified as events inducing resistance to PARPi. The clinical frequency of this and other mechanisms that have been described in preclinics is unknown. It is of great importance to study mechanisms of resistance to PARPi to guide the clinical development of drug combinations.

Ultrasound-guided transvaginal thrombin injection of uterine arteries pseudoaneurysms.

OBJECTIVE: To evaluate the utility of transvaginal ultrasound-guided thrombin injection (UGTI) to treat uterine artery pseudoaneurysms (UAPs) as an alternative to emergency arterial embolization. METHODS: Two females presenting with heavy vaginal bleeding were diagnosed with UAPs by pelvic CT scan. After UAP identification by transvaginal ultrasound, 2 cm3 of thrombin (Tissucol®; Baxter Healthcare Corporation, Munich, Germany) was slowly injected into the UAPs using a 30-cm long 22-gauge needle through a needle guide attached to the vaginal probe. The same procedure was performed in both cases, and the Doppler sign disappeared immediately and the bleeding stopped. RESULTS: We describe two cases of UAPs treated with transvaginal UGTI: one after intrauterine tandem and vaginal colpostat insertion for brachytherapy after diagnosis of cervical cancer (Case 1) and the other after the insertion of a levonorgestrel-releasing intrauterine device (Case 2). CONCLUSION: Transvaginal UGTI could be a minimally invasive tool to treat selected cases of UAPs with severe vaginal bleeding. Advances in knowledge: Transvaginal UGTI could avoid the need for uterine embolization and emergency hysterectomy in selected cases of UAPs diagnosed by CT scan.

Preoperative Assessment of Myometrial Invasion in Endometrial Cancer by 3D Ultrasound and Diffusion-Weighted Magnetic Resonance Imaging: A Comparative Study.

OBJECTIVE: The prognosis of endometrial cancer depends on the correct surgical staging. In early stages, 18% to 30% rate of positive lymph nodes is reported with a myometrial invasion of 50% or more. According to this, patients with International Federation of Gynecology and Obstetrics stage Ib would benefit from staging lymphadenectomy. Therefore, it is important to classify these patients preoperatively to plan the surgery. In the recent years, 3-dimensional (3D) ultrasound and diffusion-weighted magnetic resonance imaging (DW-MRI) have been incorporated in the preoperative management of these patients. The aim of this study was to assess the usefulness of 3D ultrasound and DW-MRI as predictor of myometrial invasion in endometrial cancer. MATERIAL AND METHODS: We retrospectively compared the assessment of myometrial invasion by 3D ultrasound and DW-MRI with final pathologic evaluation on hysterectomy specimens, in 98 patients diagnosed of early-stage endometrial cancer, who underwent surgery at the Hospital Clinic of Barcelona between 2012 and 2015. RESULTS: Evaluation of the depth of myometrial invasion with 3D ultrasound had a sensitivity, specificity, and accuracy of 77%, 83% and 81%, respectively. Evaluation of the depth of myometrial invasion with DW-MRI had a sensitivity, specificity, and accuracy of 69%, 86%, and 81%, respectively. Association of both techniques improved all the values, showing a sensitivity, specificity, and accuracy of 87%, 93%, and 91%, respectively. In both 3D ultrasound and DW-MRI, the presence of leiomyomas was the first detectable cause of false negative (3% and 4%, respectively) and false-positive (3% and 1%, respectively). CONCLUSIONS: We conclude that the implementation of the 2 studies in early-stage endometrial cancer provides low false-negatives and false-positives rates. In cases of patients with leiomyomas, adenomiosis, or intrauterine fluid collection, definitive evaluation of myometrial invasion could be better deferred to intraoperative biopsy in an attempt to reduce false-negatives and false-positives rates.

Intestinal surgery performed by gynecologists.

INTRODUCTION: Our objective was to compare the feasibility and safety of surgical procedures to treat gynecological pathologies with intestinal involvement performed by skilled gynecological surgeons and by a multidisciplinary team of gynecologists plus colorectal surgeons. MATERIAL AND METHODS: We performed a comparative, observational, prospective study at a tertiary referral center. The population included all women undergoing bowel surgery for gynecological pathologies over a 3-year period. Cases were analyzed by the specialty of the main surgeon performing the intestinal procedure. The main outcome measures were surgical procedure characteristics and postoperative outcomes and complications. RESULTS: A total of 65 women were included. Surgery was exclusively performed by a subspecialized gynecologist in 30.8% of the women, and undertaken by a multidisciplinary team (colorectal surgeons and gynecologists) in 69.2%. The main demographic and clinical characteristics were comparable in both groups. Main indications for bowel resection in gynecological surgery were advanced ovarian cancer and deep infiltrating endometriosis. In addition to the standard gynecological surgical procedures, a total of 135 intestinal segments were resected, with sigmoid colon the most frequent intestinal segment resected in both groups (53% in the gynecologist group and in 60% in the multidisciplinary group). No significant differences were observed between the two groups in the distribution and frequency of surgical techniques used, rate of complications, mean hospitalization time or frequency of re-intervention. CONCLUSION: Skilled gynecological surgeons appear to be equally good at handling common intestinal problems as a team of gynecologist and colorectal surgeons.

Mutilación genital por mordedura en violencia de género / Genital mutilation bite in gender-based violence

La violencia de género es un importante problema de salud pública que requiere la adecuada colaboración interdisciplinar de distintas especialidades médicas. La mutilación genital femenina en este contexto es muy infrecuente. Se presenta el caso de una mujer de 30 años que, en el contexto de una supuesta relación sexual consentida con su pareja habitual, fue agredida mediante una mordedura, con arrancamiento parcial de los genitales externos. Se hace hincapié en el tratamiento quirúrgico llevado a cabo así como en la evaluación médico-forense posterior, con especial atención a la valoración del perjuicio estético resultante. El caso descrito se adecua a las características generales de la violencia de género en nuestro entorno en cuanto a mecanismos de producción (contusión compleja), mientras que diverge en su localización. La valoración del perjuicio estético tiene un gran componente subjetivo y es de difícil cuantificación. Se recomienda estimular la colaboración interdisciplinar, el cumplimiento del protocolo médico-forense de valoración urgente del riesgo de violencia de género, y el fomento de la investigación sobre la violencia de género (AU)

Gender-based violence is a major public health problem that requires interdisciplinary collaboration between several medical specialties. Female genital mutilation rarely affects victims of domestic violence. We report the case of a 30-year-old woman who presented with a female genital mutilation after being bitten by her regular partner after an 11-year-old relationship in the context of a supposed consented sexual intercourse, which resulted in partial avulsion of the external genitalia. We describe the reparative surgical procedure performed and the subsequent medico-legal evaluation, and the assessment of the resulting disfigurement. The case report described has the general characteristics of gender violence in our environment regarding the production mechanisms (complex contusion), although it diverges in the location. The assessment of the aesthetic damage has a large subjective component and is difficult to quantify. It is recommended to stimulate the interdisciplinary collaboration, the fulfillment of the medico-legal protocol that urgently stratifies the risk of gender violence patients, and the stimulation of research in this area (AU)

Is sphere assay useful for the identification of cancer initiating cells of the ovary?

OBJECTIVE: Current evidence suggests that the presence of tumor-initiating cells (TICs) in epithelial ovarian cancer (EOC) has a role in chemoresistance and relapse. Surface markers such as CD44(+)/CD24(-), CD117(+), and CD133(+) expression have been reported as potential markers for TICs related to ovarian cancer and tumorigenic cell lines. In this study, we have investigated if spheroid forms are TIC specific or whether they can also be produced by somatic stem cells from healthy tissue in vitro. In addition, we also investigated the specificity of surface markers to identify TICs from papillary serous EOC patients. METHODS: Cells were obtained from fresh tumors from 10 chemotherapy-naive patients with EOC, and cells from ovarian and tubal epithelium were obtained from 5 healthy menopausal women undergoing surgery for benign pathology and cultured in standard and in selective medium. Cells forming nonadherent spheroids were considered TICs, and the adherent cells were considered as non-TIC-like. Percentages of CD24(+), CD44(+), CD117(+), CD133(+), and vascular endothelial growth factor receptor (VEGF-R)(+) cell surface markers were analyzed by flow cytometry. RESULTS: Four of 10 EOC cell tissues were excluded from the study. Tumor cells cultured in selective medium developed spheroid forms after 1 to 7 weeks in 5 of 6 EOC patients. No spheroid forms were observed in cultures of cells from healthy women. Unlike previously published data, low levels of CD24(+), CD44(+), CD117(+), and VEGF-R(+) expression were observed in spheroid cells, whereas expression of CD133(+) was moderate but higher in adherent cells from papillary serous EOC cells in comparison with adherent cells from controls. CONCLUSIONS: Papillary serous EOC contains TICs that form spheroids with low expression of CD44(+), CD24(+), CD117(+) and VEGF-R(+). Further research is required to find specific surface markers to identify papillary serous TICs.

Laparoscopic lymphadenectomy in advanced cervical cancer: prognostic and therapeutic value.

OBJECTIVE: Clinical benefit of surgical staging in locally advanced cervical cancer has not yet been proved. The goal of this study was to analyze the prognostic and therapeutic value of laparoscopic para-aortic lymphadenectomy with selective excision of suspicious pelvic nodes in patients with locally advanced cervical cancer. METHODS: This is a retrospective study including 109 women treated in a single institution from 2000 to 2009. The International Federation of Gynecology and Obstetrics stage was IB2 in 12 women, IIB in 58 women, and IIIB in 39 women. None had suspicious para-aortic nodes by presurgical imaging evaluation. All patients underwent extraperitoneal para-aortic laparoscopic lymphadenectomy with selective excision of enlarged pelvic nodes and received pelvic radiotherapy with concomitant chemotherapy. Extended lumboaortic radiation therapy was added to patients with metastatic para-aortic nodes. The mean ± SD follow-up time was 43.1 ± 33.7 months. RESULTS: Metastatic lymph nodes were identified in 23 (21.1%) of 109 patients in the para-aortic area and in 24 (53.3%) of 45 patients who underwent selective excision of pelvic nodes. Patients with nodal metastases had increased risk of mortality than those with negative nodes independently of the location (pelvic and/or para-aortic) of the metastases (hazard ratio, 4.07; 95% confidence interval, 1.36-12.16 for patients with pelvic metastases [P = 0.012]; and 3.73; 95% confidence interval, 1.38-10.09 for patients with para-aortic metastases [P = 0.010]). In the subset of women with para-aortic metastases treated by extended lumboaortic radiation therapy, neither the number of lymph nodes removed nor the number of positive nodes were associated with survival (P = 0.556 and P = 0.195, respectively). CONCLUSION: Para-aortic and pelvic lymphadenectomy provides valuable information about mortality risk in patients with locally advanced cervical cancer.

Transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR): a new method for sentinel lymph node detection in endometrial cancer.

OBJECTIVE: The objective of this prospective study was to determine the feasibility, safety and performance of a new method for sentinel lymph node (SLN) detection in endometrial cancer (EC) using transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR). METHODS: From 2006 to 2011, 74 patients with high-risk EC were included in the study. Twenty-four hours before surgery 148MBq of (99m)Tc-nanocolloid (8mL) was injected into two spots in the anterior and posterior myometrium using an ultrasound-guided transvaginal puncture. SLN was localized preoperatively by lymphoscintigraphy and intraoperatively with gamma probe. After SLN biopsy the patients underwent a complete laparoscopic pelvic and paraaortic lymphadenectomy. RESULTS: The TUMIR method was successfully achieved in 67/74 patients (90.5%). SLN was identified in 55 women (74.3%). No adverse effects were observed. Pelvic drainage was observed in 87.2% of women and paraaortic SLN was identified in 45.4%, with 12.8% of the patients draining only in this area. The mean number of SLN retrieved was 2.8 per patient (range 1 to 9). Metastatic disease was found in 13 (23.6%) patients. Metastatic involvement of the paraaortic lymph nodes was observed in 4 (30.7%) cases. All were identified by TUMIR. The sensitivity and negative predictive value of SLN detected by TUMIR to detect metastasis were 92.3% (95% CI 22.9-100) and 97.7% (95% CI 82.0-100), respectively. CONCLUSIONS: TUMIR is a safe, feasible method to detect SLN in patients with EC, has a good detection rate and provides representative information of the lymphatic drainage of EC.

Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: a randomized clinical trial with a five-year follow-up.

OBJECTIVE: To investigate the effect of two laparoscopic techniques for treatment of ovarian endometriomas on recurrence rate. DESIGN: Prospective randomized clinical trial. SETTING: University teaching hospital. PATIENT(S): Ninety women with ovarian endometriomas. INTERVENTION(S): Patients were randomly selected to undergo either laparoscopic cystectomy (group 1) or laser vaporization (group 2) of ovarian endometrioma. MAIN OUTCOME MEASURE(S): Recurrence, evaluated by ultrasound scan examination, was assessed at 12 and 60 months of follow-up. RESULT(S): Endometrioma recurrence rate was higher, though not significantly different, in group 2 at 60 months of follow-up. Nevertheless, at 12 months of follow-up recurrences were statistically higher in group 2. CONCLUSION(S): The comparison between laparoscopic laser ablation and laparoscopic cystectomy for ovarian endometriomas after long-term follow-up showed earlier recurrences and a higher recurrence rate in the laser group, although at 5 years of follow-up there were no statistically significant differences.

Added value of intraoperative real-time imaging in searches for difficult-to-locate sentinel nodes.

UNLABELLED: Localization of sentinel lymph nodes can be challenging if they are in difficult anatomic locations or near high radiotracer activity. The purpose of this study was to assess the value of intraoperative real-time imaging using a portable gamma-camera in conjunction with a conventional gamma-counting probe when it is difficult to localize the sentinel node. METHODS: After (99m)Tc-nanocolloid injection, patients with various malignancies underwent presurgical lymphoscintigraphy followed by surgery (usually the next day). We evaluated 20 patients who required sentinel lymph node biopsy and in whom the location or other characteristics of the sentinel node would make intraoperative retrieval difficult. During surgery, the sentinel node was localized using a portable gamma-camera together with a hand-held gamma-probe. A (153)Gd pointer or (125)I seed was used to better depict the sentinel node location in real time. RESULTS: Using only a conventional hand-held gamma-probe, surgeons were able to definitively localize the sentinel node in 15 of 20 patients. Intraoperatively, the portable gamma-camera showed uptake by the definite sentinel node in 19 of 20 patients and helped to precisely localize the node with the hand-held gamma-probe in 4 patients. In 1 of these patients, the sentinel node was metastatic. CONCLUSION: The combination of a standard hand-held gamma-probe and real-time imaging provided by a portable gamma-camera offers a high intraoperative detection rate in patients with difficult sentinel node localization as assessed by presurgical lymphoscintigraphy.

Comparative study of laparoscopically assisted radical vaginal hysterectomy and open Wertheim-Meigs in patients with early-stage cervical cancer: eleven years of experience.

INTRODUCTION: The aim of this study was to compare the feasibility, safety, and survival outcomes of Coelio-Schauta (CS) procedure versus open Wertheim-Meigs (WM) as primary surgical treatment of early-stage cervical cancer. METHODS: Observational study on the consecutive cases of cervical cancer undergoing CS during the last 11 years at our institution was performed. Data on clinical characteristics of patients, surgical performance, long-term morbidity, and survival were prospectively analyzed and compared with a historical series of 23 consecutive WM performed at the same hospital in the immediate previous period. RESULTS: Sixty-seven patients were included in the study group (CS). Cases and controls were comparable in age, body mass index, stage, tumor size, and histological diagnosis. The number of pelvic nodes, disease-free margin, and complications rate were similar in both groups, but blood loss and blood transfusion rate were marginally less in the CS group. Operating time was longer in the first 20 CS patients, but it became comparable to WM once the learning curve was overcome. Hospital stay was significantly shorter in the CS group as well as the bladder function recovery time. However, no differences were seen regarding long-term urinary and bowel function between groups. Four patients (5.9%) from the CS group and 3 (13%) in the WM group had recurrence. Mortality rates were 3% and 8.7%, respectively (P = not significant). CONCLUSIONS: The CS procedure is a suitable alternative to WM for small-volume, early-stage cervical cancer, showing a good safety profile, shorter postoperative recovery time, and similar survival outcomes.

Recurrence and survival in surgically treated endometrioid endometrial cancer.

INTRODUCTION: The objective of this study was to evaluate different surgical treatments and radiotherapy on patterns of recurrence and overall survival in patients with endometrioid-type endometrial cancer. MATERIALS AND METHODS: The retrospective records of 162 patients with endometrioid endometrial cancer were collected. Patients were surgically treated from 1997 to 2002. Recurrence and survival were analyzed according to patient age, surgical procedure, lymphadenectomy, externalbeam irradiation, brachytherapy, surgical stage, myometrial invasion, and tumor grade. Standard statistical calculations were used. RESULTS: Median age was 64 years. Median follow-up was 44 months. Overall, ten patients (5.6%) experienced recurrence and 14 (8.6%) died. With univariate analysis, statistical significance for survival was found for age older than 70 years, tumor grade, myometrial invasion, and stage. Multivariate analysis, however, found only age, stage, and grade to be significant. With univariate analysis, statistical significance for recurrence was found for tumor grade, stage, and external-beam radiotherapy as risk factors. Multivariate analysis found only radiotherapy and brachytherapy to be significant, but in an inverted sense, with brachytherapy having a protective effect. CONCLUSION: Our results suggest that brachytherapy protects against recurrence and that neither a surgical approach nor a lymphadenectomy appear to affect recurrence or survival in patients with surgically treated endometrioid endometrial cancer.

Metastatic carcinoma of the gallbladder mimicking an advanced cervical carcinoma.

BACKGROUND: Metastasis to the uterine cervix from a non-gynecologic neoplasm is extremely rare. To our knowledge, only three cases of primary carcinoma of the gallbladder with metastasis to the cervix have been previously reported. We report a case of metastatic gallbladder carcinoma mimicking a stage IIIB cervical carcinoma. CASE: A 74 year-old woman presented with pain in her left lumbar area radiating to her left flank. On physical examination, a 6 cm cervical tumor involving the left parametrium was noted. A computed tomography (CT) scan of the pelvis showed left-sided hydronephrosis and hydroureter with distal ureteral obstruction. A Pap smear revealed adenocarcinoma, and a biopsy of the endocervical canal was consistent with poorly differentiated adenocarcinoma. The patient was referred to a tertiary care center. On review of the biopsy after referral, the carcinoma was felt to be unusual for an endocervical primary and immunohistochemical stains were ordered. The carcinoma was positive for cytokeratin 7, had only focal cytoplasmic staining for p16, and was negative for carcinoembryonic antigen and cytokeratin 20. Upon presentation, the patient complained of new onset of shortness of breath and cough. A chest CT revealed multiple lesions in both lungs suggestive of metastatic disease, and an abdominal CT revealed a gallbladder tumor with extension into the liver. The patient underwent a CT-guided biopsy of one of the lung lesions and the pathologic findings were consistent with metastatic adenocarcinoma. The patient was diagnosed with stage IVB primary gallbladder adenocarcinoma and was treated with capecitabine, but her condition deteriorated rapidly and she died 5 months later. CONCLUSION: In patients with an atypical presentation for cervical adenocarcinoma, it is important to consider a metastatic tumor in the differential diagnosis and to perform a thorough work-up for metastatic disease before initiating therapy.

Combined positron emission tomography and computed tomography for the detection of recurrent ovarian mucinous adenocarcinoma.

BACKGROUND: The role of combined positron emission tomography and computed tomography (PET-CT) in the diagnosis of recurrent ovarian mucinous adenocarcinoma is uncertain because of previous reports that PET has limited sensitivity in the detection of mucinous neoplasms. CASE: A 71-year-old white woman presented with complaints of right lower quadrant pain and a palpable adnexal mass. Physical examination and transvaginal ultrasonography revealed a 12 x 13 cm cystic mass in the left side of the pelvis. Exploratory laparotomy, optimal tumor-reductive surgery, total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, and omentectomy were performed. The diagnosis was FIGO stage IIIC well-differentiated ovarian mucinous adenocarcinoma. The patient was treated with 6 cycles of carboplatin and paclitaxel. Four months after completing chemotherapy, the patient was noted to have an elevated serum CA125 level (72 U/mL), being otherwise asymptomatic. Findings on abdominal and pelvic CT were compatible with postsurgical changes. PET-CT was performed and revealed increased metabolism along the posterior aspect of the right rectus abdominis muscle and abutting the anterior wall of an adjacent loop of bowel. CONCLUSION: PET-CT may identify clinically occult recurrent ovarian mucinous adenocarcinoma.