New surgery technique combining robotics and laparoscopy using the Hugo™ RAS system.

INTRODUCTION: Hybrid total laparoscopic hysterectomy combines conventional laparoscopic surgery and robot-assisted devices: the camera and assistant forceps are operated by a robotic device, whereas the surgeon performs laparoscopic procedures, enabling surgery with a completely fixed field of view and significantly reducing errors in forceps grasping and needle misalignment. Here, we examined whether using two arms of the Hugo™ robot-assisted surgery system, one for the camera and one for the assistant, would improve surgical accuracy compared with conventional total laparoscopic hysterectomy. MATERIALS AND SURGICAL TECHNIQUE: The surgical system reduced surgeon errors in grasping the forceps during training and stabilized forceps operation. Compared with conventional laparoscopic surgery, the use of the surgical system did not result in different operative durations. The stable surgical procedure was considered a major advantage. DISCUSSION: This new technique involving new equipment can improve surgeon training and performance. In the future, we will develop new techniques to improve surgical performance.

Outcome of robot-assisted surgery for stage IA endometrial cancer compared to open and laparoscopic surgeries: a retrospective study at a single institution.

Few studies have compared the efficacy of robot-assisted, laparoscopic, and open surgeries for endometrial cancer. When considering the position of robotic surgery in Japan, it was necessary to determine whether it was effective or not. We aimed to compare the efficacy and safety of these three types of surgeries for early-stage endometrial cancer. In total, 175 patients with endometrial cancer of preoperative stage IA, who had undergone laparotomic (n = 80), laparoscopic (n = 40), or robot-assisted (n = 55) modified radical hysterectomy at our hospital from 2010 to 2022, were included; surgical outcomes, perioperative complications, and prognoses were compared. Total operative and console times for robot-assisted surgery between patients who did or did not undergo pelvic lymphadenectomy were assessed. The robot-assisted group had the shortest total operative time. The estimated blood loss was lower in the laparoscopic and robot-assisted groups than in the laparotomy group. In advanced postoperative stage IA cases, there were no differences in progression-free and overall survival among the three groups. In the robot-assisted group, the operative time decreased as the number of operations increased; the learning curve was reached after 10 cases each of patients with and without pelvic lymphadenectomy. The frequency of perioperative complications of Clavien-Dindo classification Grade 1 or higher was the lowest in the robot-assisted group (p = 0.02). There were no complications of Clavien-Dindo classification Grade 2 or higher in the robot-assisted group. Robot-assisted surgery for stage IA endometrial cancer, a minimally invasive procedure, has fewer operative times and complications than those of laparoscopic and open surgeries in a single institution in Japan.

Malignant Pericardial Tamponade Secondary to Ovarian Clear Cell Carcinoma.

Malignant pericardial effusion is an uncommon metastatic manifestation of ovarian carcinoma. Few cases of ovarian serous carcinoma have been previously reported. Ovarian clear cell carcinoma is the second most common histologic subtype in East Asian countries and is a relatively rare in Western countries. Here, we report the case of cardiac tamponade secondary to Ovarian clear cell carcinoma. A 46-year-old woman with recurrent Ovarian clear cell carcinoma presented with worsening cough, palpitations, and shortness of breath during chemotherapy. Chest radiography and computed tomography confirmed a pleural effusion with cardiac tamponade. The patient underwent pericardial fenestration and drainage for cardiac tamponade. Pericardial fluid cytology showed malignant cells forming papillary and ball-like clusters with irregular stacking. The cells had a mirror ball-like appearance and collagenous stroma, in which a homogenous hyaline core was observed in the center of most tumor cell clusters. Based on these findings, a diagnosis of Ovarian clear cell carcinoma metastasis was made. She received palliative care and died 5 months after the operation without recurrent cardiac tamponade. This case suggests that cytological findings from pericardial effusion are useful in diagnosing Ovarian clear cell carcinoma metastasis.

Endometrial Cancer Arising in Adenomyosis That Could Not Be Diagnosed by Endometrial Biopsy: A Case Report.

Uterine adenomyosis is an estrogen-dependent tumor and one of the most common benign diseases in sexually mature women. The frequency of endometrial cancer associated with adenomyosis has been reported to be 18%-66%. On the other hand, endometrial cancer arising in adenomyosis (EC-AIA) is extremely rare. EC-AIA is now considered a different entity from and has a worse prognosis than endometrial cancer with adenomyosis (EC-A). In the present study, we report a case of endometrial cancer with adenomyosis in which endometrial biopsy failed to provide a definitive diagnosis. A 63-year-old female patient presented with endometrial thickening. Endometrial cytology was positive, and magnetic resonance imaging (MRI) showed small lesions suggestive of endometrial cancer with shallow invasion and adenomyosis. However, an endometrial biopsy showed only metaplasia, and careful follow-up was initiated. Subsequent endometrial cytology showed enlarged and round nuclei, uniform chromatin distribution, no thickening of nuclear margins, and abundant cytoplasm appearing in a sheet-like arrangement, suggesting atypical cells of endometrial glands with metaplasia. Three suspicious positive results and one positive result were observed, but repeated biopsies did not lead to the diagnosis of malignancy. The patient underwent diagnostic hysterectomy 19 months after the initial visit. The postoperative histopathological diagnosis was stage IA endometrial cancer (endometrioid carcinoma G1). This case of endometrial cancer associated with adenomyosis was difficult to diagnose. Our findings demonstrate that EC-AIA should be considered even if no lesions were detected by endometrial biopsy.

Efficacy of panniculectomy-combined surgery in superobese patients with endometrial cancer: A case report and literature review.

INTRODUCTION: Panniculectomy is regarded as an effective approach in highly obese patients with endometrial cancer to improve surgical access or space of the surgical field. PRESENTATION OF CASE: A 66-year-old nulliparous woman was brought in from another hospital to our institute for newly diagnosed endometrial carcinoma. The patient was 158 cm in height and weighed 135.8 kg during the first visit to our hospital. Her body mass Index (BMI) was 54.4 kg/m2. Unfortunately, the patient developed an umbilical hernia and strangulation before the surgery. Emergency partial ileal resection and simple closure of the umbilical hernia were performed. We were finally able to perform simple hysterectomy, and bilateral salpingo-oophorectomy with panniculectomy. Her weight at the time of surgery was 115.5 kg which had been reduced by 20 kg from the time she was first brought in, and the BMI decreased from 54.4 to 45.3 kg/m2. The patient underwent follow-up without adjuvant therapy since she was in the low-risk group, and showed no signs of recurrence 12 months after surgery. DISCUSSION: There are various risks associated with surgery in highly obese patients. Diabetes mellitus, hypertension and smoking are reported to be risk factors of wound complication in panniculectomy, and it was reported that diabetes mellitus was an independent risk factor. CONCLUSION: The combination of panniculectomy was considered as an effective approach to perform safe surgery for obese patients.

Evaluating Chemotherapy-induced Nausea and Vomiting and Food Intake in Patients With Gynecologic Cancer.

BACKGROUND/AIM: Treatments for controlling delayed nausea after chemotherapy are inadequate, potentially inciting malnutrition. We sought to determine the incidence of nausea, anorexia, and food intake after chemotherapy. PATIENTS AND METHODS: Subjects were females with gynecological cancers who underwent chemotherapy between 2008 and 2013. Nausea, anorexia, and food intake in the acute (day 1) and delayed phases (days 2 and 3) were retrospectively evaluated. RESULTS: Subjects included 156 females. Chemotherapies were highly (HEC; n=24) and moderately emetogenic (MEC; n=132). There were no significant between-group differences for anorexia control during either the acute or the delayed phase and both groups demonstrated significantly worse control of nausea during the delayed phase. In the HEC group, food intake was significantly reduced on days 2 and 3 compared with day 1. CONCLUSION: Rates of nausea, anorexia, and food intake significantly worsened over time, particularly in the MEC group. Current supportive therapies appear inadequate and should be improved.

Serum vascular endothelial growth factor A and vascular endothelial growth factor receptor 2 as prognostic biomarkers for uterine cervical cancer.

BACKGROUND: There are few studies on serum vascular endothelial growth factors and receptors (VEGF/VEGFRs) in patients with uterine cervical cancer (CC). The aim of this study was to determine whether VEGF/VEGFRs could be used as prognostic biomarkers in patients with CC. METHODS: A total of 107 patients with stage IB to IIB CC, who underwent radical hysterectomy at Tottori University Hospital between 2006 and 2015, were included in this study. Serum samples were collected prior to radical hysterectomy, and levels of VEGF-A, VEGF-C, VEGFR-1, and VEGFR-2 were analyzed by enzyme-linked immunosorbent assays. We evaluated the association between the levels of these angiogenic factors and clinicopathologic variables. Survival analysis of 93 patients treated between 2006 and 2013 was performed. RESULTS: The levels of VEGF-A in patients with bulky tumor, pelvic lymph-node involvement (PLNI), and parametrial infiltration (PI) were significantly higher than those in patients without these factors (P = 0.022, P = 0.020, and P = 0.0013, respectively). The overall survival (OS) of patients with high VEGF-A and VEGFR-2 defined by median levels was significantly lower than the OS of patients with low levels of VEGF-A and VEGFR-2 (P = 0.014, P = 0.012, respectively). Multivariate analysis revealed that PLNI, serum VEGF-A levels, and serum VEGFR-2 levels were independent prognostic factors for OS (hazard ratio for VEGF-A 3.42, 95% CI 1.07-13.2; hazard ratio for VEGFR-2 6.37, 95% CI 1.59-43.5). CONCLUSION: Our results suggest that serum VEGF-A and VEGFR-2 may be promising prognostic biomarkers for CC.

Comparison of laparoscopic surgery and conventional laparotomy for surgical staging of patients with presumed low-risk endometrial cancer: The current state of Japan.

OBJECTIVE: National health insurance coverage for the laparoscopic staging surgery for patients with stage IA endometrial cancer started from April 2014 in Japan. We conducted this retrospective study to evaluate the surgical outcomes of the laparoscopic surgery for patients with low-risk endometrial cancer compared with those of the laparotomy. MATERIALS AND METHODS: A total of 120 patients with presumed low-risk endometrial cancer, who were treated at Tottori University Hospital between 2005 and 2016, were eligible for this study. The laparoscopic staging surgery included only the pelvic lymphadenectomy and not the para-aortic lymphadenectomy. We evaluated the discrepancy between preoperative presumption and postoperative diagnosis of recurrent risk factors. RESULTS: Forty patients underwent the laparoscopic surgery and 80 patients received the laparotomy. The laparoscopic surgery resulted in less intraoperative blood loss and shorter hospital stay. The operative time was significantly longer for the laparoscopic surgery compared with the laparotomy, but this difference was not seen in obese patients with a body mass index ≥30 kg/m2. The type of the surgical procedure did not affect the incidence of perioperative complications. Among 120 patients, 104 (86.6%) were diagnosed as FIGO stage IA, 118 (98.3%) with endometrioid adenocarcinoma grade 1 or 2, and 107 (89.1%) with myometrial invasion depth <50%. CONCLUSION: The laparoscopic staging surgery is a feasible and safe alternative to the laparotomy for patients with presumed low-risk endometrial cancer, especially for obese patients. To perform the laparoscopic surgery for patients with stage IA endometrial cancer under the current national health insurance system, it is important to limit the candidates to low-risk disease based on a precise diagnosis before the surgery.

Recurrent colon perforation after discontinuation of bevacizumab for ovarian cancer.

Bevacizumab (Bev) is an antiangiogenic drug used to treat various malignances, including ovarian cancer (OC). Bev is generally well-tolerated; however, it has a characteristic toxicity profile. In particular, gastrointestinal perforation (GIP) is a rare but serious side effect that can be lethal. A 55-year-old woman with recurrent OC had an episode of GIP during third-line chemotherapy comprising Bev and topotecan (TPT). Bev was discontinued while TPT was continued as monotherapy. Three months after discontinuation of Bev, the patient presented with left lower abdominal pain and was diagnosed with a second GIP. She had emergent surgery. One year later, she is still alive and healthy, and is continuing TPT. This is the first report of recurrent GIP after discontinuation of Bev. Our case suggests that physicians should be aware of GIP even after the discontinuation of Bev.

Significance of High-Risk Human Papillomavirus Testing for Atypical Glandular Cells on Cervical Cytology.

OBJECTIVES: The aim of this study was to evaluate the diagnostic significance of high-risk human papillomavirus (hrHPV) testing for managing women with atypical glandular cells (AGC) and to explore the distribution of hrHPV genotypes. METHODS: We analyzed cytologic and histopathologic diagnoses in patients referred to our institution due to AGC or atypical squamous cells of undetermined significance (ASC-US). All patients underwent hrHPV testing and genotyping, and positive (PPV) and negative predictive values (NPV) for cervical intraepithelial neoplasia (CIN) 2 or worse [CIN2+/adenocarcinoma in situ (AIS)+] were calculated. RESULTS: Among 41 cases previously diagnosed with AGC, 22 (53%) were classified as CIN2+ (2 squamous cell carcinomas), whereas only 2 were AIS or adenocarcinoma. Twenty-seven (65.8%) cases in the AGC group were hrHPV positive. The most frequent genotypes in both the ASC-US and AGC groups were HPV16 and HPV52. The PPV of hrHPV testing for CIN2+/AIS+ was significantly higher in the AGC than in the ASC-US group (74.1 vs. 35.0%; p = 0.0005). The NPV for CIN2+/AIS+ was significantly lower in the AGC than in the ASC-US group (74.4 vs. 100%; p = 0.0441). CONCLUSION: In patients with AGC, both glandular and squamous lesions must be monitored. hrHPV testing is useful for detecting CIN2+/AIS+ in AGC.

Serum Vascular Endothelial Growth Factor-A as a Prognostic Biomarker for Epithelial Ovarian Cancer.

BACKGROUND: Bevacizumab, which targets vascular endothelial growth factor (VEGF)-A, has recently been proven to be effective for the treatment of epithelial ovarian cancer (EOC). Thus, interest in VEGF-A has increased. There are few reports on concomitant detection of both ligands and its soluble receptors in serum samples, and the significance of serum VEGF-A in EOC is unclear, unlike the situation with tissue samples. We conducted the present study to explore the levels of serum VEGF family and its receptors and to evaluate their utility as prognostic biomarkers. METHODS: A total of 128 patients with EOC, who were consecutively treated at Tottori University Hospital between 2006 and 2012, were included. Blood samples were collected before initial surgery. Serum concentrations of VEGF-A, VEGF-C, VEGFR-1, and VEGFR-2 were analyzed by enzyme-linked immunosorbent assay. We also examined the mRNA and protein expression of VEGF-A in tumor tissue from 30 cases by real-time reverse transcription polymerase chain reaction and immunohistochemistry. RESULTS: The levels of VEGF-A in patients with stage III/IV disease were significantly higher than those with stage I/II disease (P = 0.0036). On the other hand, the level of VEGFR-2 in stage III/IV was significantly lower than that in stage I/II (P = 0.0026). With the cutoff value of VEGF/VEGFRs at the median level, the overall survival (OS) for patients with high VEGF-A levels was significantly lower than those with low levels (P = 0.015). Patients with high VEGFR-2 levels showed better prognosis than those with low VEGFR-2 levels (P = 0.023). Multivariate analysis revealed that International Federation of Gynecology and Obstetrics stage and serum VEGF-A were independent prognostic factors for OS [hazard ratio 2.01, 95% confidence interval (1.13-3.63), P = 0.017]. There was no significant correlation between mRNA or protein expression and serum levels of VEGF-A. CONCLUSIONS: Serum VEGF-A is an independent prognostic factor for OS in patients with EOC, implying that serum VEGF-A is a prognostic biomarker for EOC. Further study to validate the data is needed.