Utility of indocyanine green injection in patients with cervical cancer besides the identification of sentinel lymph node (Review).

Due to the wide introduction of screening tests, patients with neoplastic diseases of the uterine cervix trend to be diagnosed in early stages of the disease, and less invasive surgical procedures are needed in certain cases. In this respect, the technique of sentinel lymph node dissection has been widely implemented as part of the therapeutic strategy, indocyanine green (ICG) being one of the most reliable markers for sentinel lymph node detection. However, it seems that this agent is extremely useful in order to achieve better short-term and long-term results after cervical cancer surgery, due to its capacity to determine the uterine vascular perfusion in cases in which conservative treatment, such as trachelectomy, is performed, as well as to prevent and treat lower limb lymphedema. A literature review was conducted of the studies which focused on the role of ICG utility in cervical cancer patients besides sentinel lymph node detection, special focus was given to vascularization preservation and lower limb lymphedema prevention and treatment.

Cytoreductive surgery for advanced stage ovarian cancer in the second trimester of pregnancy-a case report and literature review.

RATIONALE: Advanced stage ovarian cancer is rarely encountered in pregnant women, due to the high number of ultrasound imagistic studies performed during this period. The clinical course of patients diagnosed with advanced stage ovarian cancer is similar in pregnant and nonpregnant women. PATIENT CONCERNS: We present the case of a 27-year-old woman initially submitted to emergency surgery for ovarian cyst torsion in the ninth week of gestation, at that moment ovarian cystectomy being performed. DIAGNOSES: The histopathological studies demonstrated the presence of a moderately differentiated epithelial ovarian cancer. INTERVENTIONS: Although the interdisciplinary team decided for staging surgery followed by platinum-based chemotherapy beginning from the second trimester of pregnancy, both the patient and her family refused this strategy and opined for total hysterectomy en bloc with bilateral adnexectomy. Surprisingly, intraoperatively both ovaries had a tumoral aspect, whereas peritoneal carcinomatosis nodules were found in the Douglas pouch. Therefore, the neoplastic process was staged as a IIIC epithelial ovarian cancer, a total hysterectomy with bilateral adnexectomy, Douglas pouch peritonectomy, omentectomy, pelvic and para-aortic lymph node dissection being performed. OUTCOMES: The patient was discharged in the sixth postoperative day and was confined to the oncology service in order to be submitted to the standard taxanes and platinum based chemotherapy. LESSONS: Although ovarian cancer has been rarely reported during pregnancy, this diagnostic should be taken in consideration whenever persistent adnexal masses are encountered.

Right Upper Abdominal Resections in Advanced Stage Ovarian Cancer.

BACKGROUND/AIM: The right upper abdominal involvement is frequently encountered in patients with advanced stage ovarian cancer. The aim of this paper is to study the safety and efficacy of extended resections at this level as well as to determine the sites of residual disease. PATIENTS AND METHODS: Between January 2016 and December 2019, 26 patients submitted to right upper abdominal resections were identified. RESULTS: Peritoneal stripping and full thickness resections were the most commonly performed resections (in 57% and 19% of cases, respectively), followed by capsular liver resection and atypical liver resection (in 30% and 23% of cases, respectively) while the most common sites where resection was incomplete were the liver pedicle and porta hepatis. Exceptionally, one case necessitated performing a pancreatoduodenectomy as part of debulking surgery. Postoperatively, two cases developed serious complications and required reintervention; however, the overall mortality was null. CONCLUSION: Right upper abdominal resections seem to be feasible and effective in order to maximize the debulking effort with acceptable risks arising from perioperative complications.

Synchronous Cervical Adenocarcinoma and Ovarian Serous Adenocarcinoma-A Case Report and Literature Review.

Background/Aim: Synchronous gynecological malignancies are rarely encountered, and most often these cases are represented by synchronous ovarian and endometrial cancer. The aim of this paper is to present the case of a 53-year-old patient who was diagnosed with synchronous cervical and ovarian cancer. Case presentation: The patient had been initially investigated for vaginal bleeding and was submitted to a biopsy confirming the presence of a cervical adenocarcinoma. Once the diagnostic of malignancy was confirmed, the patient was submitted to a computed tomography which revealed the presence of large abdominal tumoral nodules of peritoneal carcinomatosis and was submitted to palliative chemotherapy with poor response. Eighteen months later she developed intestinal obstruction and was submitted to surgery. At that moment, synchronous ovarian and cervical tumors were diagnosed. Total radical hysterectomy with bilateral adnexectomy, pelvic and para-aortic lymph node dissection, omentectomy, and pelvic peritonectomy was performed; in the meantime, the histopathological studies confirmed the presence of two synchronous malignancies. Conclusion: Although synchronous lesions are rarely encountered, this eventuality should not be omitted. In such cases, surgery should be taken in consideration and the intent of radicality should regard both lesions.

Superior Mesenteric and Portal Vein Reconstruction With Cadaveric Allograft During Pancreatoduodenectomy - A Case Report and Literature Review.

BACKGROUND/AIM: During the last decade it has been widely demonstrated that venous involvement in pancreatic head cancer is not a sign of poor prognostic, while surgery with curative intent is feasible and with encouraging results. However, the location and extent of venous invasion can occasionally pose serious problems in terms of reconstruction. The aim of the paper is to describe a case in which total superior mesenteric and portal vein resection followed by reconstruction were successfully performed. CASE REPORT: We present the case of a 74-year-old patient submitted to surgery for locally advanced pancreatic cancer invading the portal and superior mesenteric veins. Surgery consisting of pancreatoduodenectomy en bloc with portal vein and superior mesenteric vein resection was performed. The venous axis was reconstructed by using a venous cadaveric allograft originating from the external iliac vein. The postoperative outcome was favorable and the histopathological studies confirmed the local invasion of the resected venous structures. CONCLUSION: The cadaveric venous allograft can be safely used in order to reconstruct the venous axis following extended vascular resections for pancreatic cancer.

Urinary Tract Resections as Part of Debulking Surgery for Locally Advanced Endometrial Stromal Sarcomas.

BACKGROUND/AIM: Although very rare tumors, uterine sarcomas are extremely aggressive gynecologic malignancies being responsible for a significant number of gynecological cancer-related deaths. However, in such cases, it seems that cytoreductive surgery might increase the lifespan if debulking to no residual disease is achieved. PATIENTS AND METHODS: We present a case series of three patients diagnosed with endometrial stromal sarcomas in which urinary tract resections were needed in order to maximize the debulking effort. RESULTS: In all cases total hysterectomy with bilateral adnexectomy was performed; in the meantime, urinary tract resection was needed due to the local extension of the neoplastic disease and consisted of unilateral ureteral resection followed by reimplantation through ureteroneocystostomy in one case, bilateral ureteral resection en bloc with partial cystectomy and ureteral reimplantation in one case and total cystectomy with bilateral ureterectomy followed by cutaneous ostomy in the third case. Moreover, one case also necessitated rectosigmoidian resection followed by colorectal anastomosis. In all cases no residual disease was encountered at the end of the debulking surgery. CONCLUSION: Urinary tract resections might be needed in order to maximize the debulking effort in patients presenting endometrial stromal sarcomas.

The Influence of the Preoperative Status on the Risk of Postoperative Complications After Cytoreductive Surgery for Advanced-stage Ovarian Cancer.

BACKGROUND/AIM: The aim of this study was to analyze the influence of preoperative status on the risk of developing further postoperative complications after debulking surgery for advanced-stage ovarian cancer. PATIENTS AND METHODS: A total of 80 consecutive patients submitted to surgery between 2014 and 2019 for advanced-stage ovarian cancer were retrospectively reviewed. RESULTS: Among the 80 cases there were seven patients who developed serious postoperative complications requiring reintervention. Among these cases it seems that association of obesity, poor nutritional status (defined as a lower than 3.5 g/dl serum albumin level) and elderly age were significantly associated with the risk of developing further complications. CONCLUSION: When selecting the candidates for debulking surgery for advanced-stage ovarian cancer attention should be focused on excluding cases presenting such preoperative risk factors in order to decrease the postoperative morbidity.

The Risk of Para-Aortic Lymph Node Metastases in Apparent Early Stage Ovarian Cancer.

Background and objectives: To identify the risk factors for para-aortic lymph node metastases in cases with presumed early stage ovarian cancer. Materials and methods: Between 2014 and 2019, 48 patients with apparent early stage ovarian cancer were submitted to surgery. In all cases, pelvic and para-aortic lymph node dissection was performed for staging purposes. Results: Among the 48 cases we identified nine cases with positive pelvic lymph nodes and 11 cases with positive para-aortic lymph nodes. The positivity of the retrieved lymph nodes was significantly correlated with the histopathological subtype represented by serous histology (p = 0.02), as well as with the degree of differentiation (p = 0.004). Conclusion: Patients with serous ovarian carcinomas in association with a poorer degree of differentiation are at risk of associated lymph node metastases even in presumed early stages of the disease. Therefore, lymph node dissection should be performed in such cases in order to provide adequate staging and tailoring of further treatment.

Aortic Reconstruction by Cadaveric Graft After Radical Resection of Recurrent Retroperitoneal Leyomiosarcoma - A Case Report and Literature Review.

BACKGROUND/AIM: Retroperitoneal sarcomas represent very aggressive malignancies with high capacity of invading the surrounding vital structures. CASE REPORT: We present the case of a 46-year-old patient who had been initially diagnosed with a large retroperitoneal mass 18 months ago. At that moment the mass was resected en bloc with the inferior cava vein, which was reconstructed using a cadaveric graft, the histopathological studies demonstrating the presence of a leiomyosarcoma. One year later she was diagnosed with recurrent disease invading the abdominal aorta and a liver metastasis. This time the recurrence was resected en bloc with the abdominal aorta, which was reconstructed by placing a cadaveric graft; atypical liver resection was also performed. The postoperative course was uneventful. CONCLUSION: Extended vascular resections and cadaveric graft reconstructions might be needed in order to achieve a good local control of the disease in patients with retroperitoneal sarcomas.

Total Exenteration En Bloc with a Nephrectomy for Locally Advanced Cervical Cancer Invading a Pelvic Kidney-a Case Report and Literature Review.

Introduction: Extended pelvic resection might be the option of choice in patients presenting locally advanced cervical cancer. However, the possibility of a co-existence of an ectopic, pelvic kidney that is invaded by such a tumor is extremely rare. Case Presentation: A 54-year-old female patient, diagnosed with locally advanced cervical cancer in the presence of a pelvic kidney, was submitted to surgery with curative intent. A large, abscessed cervical tumor invading the urinary bladder and the rectum was found, so a total exenteration was planned. Intraoperatively, tumor invasion of the left kidney, which was found in an ectopic, pelvic position was also encountered; therefore, total pelvic exenteration in association with a left nephrectomy was successfully performed. Conclusions: The presence of an ectopic, pelvic disposition of the kidney makes it susceptible to be invaded by locally advanced pelvic tumors; in such cases, a nephrectomy might also be needed.

Extended Pelvic Resections as Part of Secondary Cytoreduction for Relapsed Ovarian Adenocarcinoma.

BACKGROUND/AIM: Ovarian cancer presents an aggressive tumor biology, a significant number of patients experiencing recurrent disease. The aim of this study was to examine the feasibility and effectiveness of secondary debulking surgery for relapsed ovarian cancer. PATIENTS AND METHODS: Between 2014 and 2018, debulking surgery for relapsed ovarian cancer was performed in 40 cases. RESULTS: Debulking surgery to no residual disease was achieved in 31 cases; among the remaining cases, an R1 resection was feasible in six cases, while in the remaining three cases an R2 resection was performed. The most commonly performed visceral resections were represented by rectosigmoidian resection, right colon resection, total or partial cystectomy and unilateral or bilateral ureteral resection. The early postoperative morbidity rate was 32.5% while the postoperative mortality rate was 2.5%. CONCLUSION: Extended pelvic resections are feasible in patients with relapsed ovarian cancer and might be performed with acceptable rates of postoperative complications.

Pancreatoduodenectomy After Neoadjuvant Chemotherapy for Locally Advanced Pancreatic Cancer in the Presence of an Aberrant Right Hepatic Artery.

BACKGROUND/AIM: Locally advanced pancreatic head cancer remains an aggressive malignancy with a low likelihood of achieving resectability after neoadjuvant chemotherapy. Resection is even more difficult if anatomical variations of the blood supply are present. CASE REPORT: We present the case of a 62-year-old male diagnosed with locally advanced pancreatic cancer in the presence of an aberrant right hepatic artery originating from the superior mesenteric artery. After completing six cycles of neoadjuvant chemotherapy consisting of irinotecan and oxaliplatin, resectability was achieved, the patient being submitted to pancreatoduodenectomy. Intraoperatively, the presence of an aberrant right hepatic artery originating from the superior mesenteric artery was confirmed. The postoperative course was uneventful, the patient being discharged on the eight postoperative day, while the histopathological studies confirmed the negativity of the resection margins. CONCLUSION: Resectability can be achieved after neoadjuvant chemotherapy for locally advanced pancreatic cancer. However, attention should be focused on the possibility of the presence of anatomical variations of the pancreatic and liver blood supply.

Upper Abdominal Resections as Part of Tertiary Cytoreduction for Relapsed Ovarian Cancer.

BACKGROUND/AIM: The role of upper abdominal resection as part of debulking surgery for advanced-stage or relapsed ovarian cancer has been widely debated. The aim of this study was to investigate the safety and efficacy of upper abdominal resection as part of tertiary cytoreduction. PATIENTS AND METHODS: Between 2005 and 2019, 11 cases presenting upper abdominal recurrences after surgically treated ovarian cancer were submitted to surgery with radical intent. RESULTS: Complete debulking surgery was feasible in eight cases, optimal debulking was performed in two cases, while in one case a suboptimal resection was performed. The most commonly performed upper abdominal resections consisted of liver resection in seven cases, splenectomy in four cases, diaphragmatic resection in three cases, pancreatic tail resection in two cases and partial gastrectomy in another two cases. Postoperative complications were encountered in two cases, while postoperative mortality was null. CONCLUSION: Extended upper abdominal resection can be safely performed in order to increase the chances of optimal debulking surgery at the time of tertiary cytoreduction.

Risk Factors for Postoperative Complications After Vulvar Surgery.

BACKGROUND/AIM: Although the trends of surgical treatment in vulvar cancer patients are towards less extended resections, a significant number of cases are still diagnosed with locally advanced diseases imposing performing extended resections. The aim of this paper is to identify the prognostic factors for the development of early postoperative complications following vulvar surgery. PATIENTS AND METHODS: Between 2017 and 2019, 145 patients with vulvar cancer were submitted to surgery with a curative intent. RESULTS: Among these cases there were 93 cases diagnosed with early stages of the disease and 52 cases diagnosed with advanced stages. The risk of postoperative complications was significantly influenced by: i) the stage of the disease, ii) the preoperative levels of serum albumin, iii) the status of the resection margins, iv) previous history of irradiation, v) length of hospital stay and vi) association of comorbidities. CONCLUSION: Vulvar cancer surgery for locally advanced disease is still associated with high rates of postoperative complications, and an attentive selection of cases submitted to surgery is mandatory.

The Impact of the Preoperative Status on the Short-term Outcomes After Exenteration and Pelvic Reconstruction.

BACKGROUND/AIM: The aim of this study was to analyse the influence of the preoperative status on the perioperative outcomes of patients submitted to pelvic reconstructions after exenteration. MATERIALS AND METHODS: Between January 2017 and December 2018, pelvic exenteration was performed in 86 cases; patients were classified according to their age, nutritional status and association of reconstructive surgery. RESULTS: The median age was 56 years, while the median level of serum albumin was 3.6 g/dl. Reconstructive surgery was more frequently performed in younger patients, while the rate of postoperative complications was similar between the two groups, while the rate of postoperative complications was significantly higher among cases with lower serum albumin levels. CONCLUSION: Reconstructive surgery should be performed in selected patients. Elderly cases as well as those presenting a poorer nutritional status are at higher risk of developing postoperative complications.

Pelvic Exenteration for Locally Advanced and Relapsed Pelvic Malignancies - An Analysis of 100 Cases.

BACKGROUND/AIM: Although pelvic exenteration is an aggressive surgical procedure, it remains almost the only curative solution for patients diagnosed with large pelvic malignancies. PATIENTS AND METHODS: We present a series of 100 patients submitted to pelvic exenteration with curative intent. RESULTS: The origin of the primary tumor was most commonly represented by cervical cancer, followed by, endometrial cancer, rectal cancer, ovarian cancer and vulvo-vaginal cancer. An R0 resection was confirmed in 68 cases, while the remaining 32 cases presented lateral positive resection margins or perineal positive margins. The postoperative morbidity rate was 37% while the mortality rate was 3%. As for the-long term outcomes, the median overall survival time was 38.7 months, being most significantly influenced by the origin of the primary tumor. CONCLUSION: Although pelvic exenteration is still associated with an increased morbidity, an important improvement in the long-term survival can be achieved, especially if radical resection is feasible.

Anterior Pelvic Exenteration for Chemo-irradiated Non-diethylstilbestrol Exposed Clear Cell Vaginal Cancer.

BACKGROUND/AIM: Clear cell vaginal adeno-carcinomas are rare tumors occurring in women which are usually treated by chemo radiotherapy with good outcomes. However, in certain cases, this treatment is not associated with complete response and a further surgery is needed. CASE REPORT: We present the case of a 38-year-old patient diagnosed with stage IVA clear cell vaginal cancer who had been previously submitted to radio chemotherapy and in whom the lesion persisted after the oncological treatment; therefore, the patient was proposed for surgery with curative intent. The tumor was resected by performing an anterior pelvic exenteration with good outcomes, the patient being discharged in the seventh postoperative day. At one-year follow-up the patient remains free of recurrent disease. CONCLUSION: Pelvic exenteration with curative intent might be the option of choice for persistent locally advanced clear cell vaginal cancer.

Pancreatoduodenectomy En Bloc With Vascular Resections in Borderline Resectable Pancreatic Cancer.

BACKGROUND/AIM: Pancreatic cancer remains asymptomatic for a long period of time, being frequently diagnosed when vascular invasion is already present. Such cases are widely known as borderline lesions. The aim of this study was to identify the effectiveness of vascular resection in this subgroup of patients. PATIENTS AND METHODS: Fifteen such cases were submitted to surgery with curative intent. RESULTS: Eight cases were diagnosed with borderline resectable lesions with portal vein invasion and were submitted to per primam resection and seven cases were initially diagnosed with arterial invasion and had been initially submitted to neoadjuvant chemotherapy followed by resection. In all cases portal vein resection was needed while in other four cases association of superior mesenteric artery resection was performed. Postoperatively, five patients developed complications requiring reoperation, three of whom died at the end of the first postoperative month. The histopathological studies confirmed the completeness of resection in all cases. CONCLUSION: Vascular resections in pancreatic cancer resections remain demanding procedures, and are reserved for cases in which a radical resection is feasible.

Reconstruction of Inferior Right Hepatic Veins in Living Donor Liver Transplantation.

BACKGROUND: A proper knowledge of the anatomy of the liver (including its vascular particularities) is mandatory in cases which are going to be submitted to major hepatic resection, including living donor liver transplantation. CASE REPORT: We present the case of a living donor liver transplantation in which a particularity of the anatomy of the hepatic veins was reported for the donor: two inferior hepatic veins for segments 5 and 6. This particularity imposed the need for creation of a supplemental anastomosis in the recipient: a phleboplasty of the two inferior veins followed by direct re-implantation into the inferior cava vein. However, the postoperative course was uneventful for both the donor and the recipient. CONCLUSION: In certain cases presenting vascular particularities such as two inferior hepatic veins, phleboplasty followed by reimplantation into the inferior cava vein might be needed in order to provide a good vascular outflow of the liver graft.

The Impact on the Long-term Outcomes of Hormonal Status After Hepatic Resection for Breast Cancer Liver Metastases.

BACKGROUND/AIM: Breast cancer remains one of the most frequently encountered malignancies worldwide, which is in most cases diagnosed in early stages of disease. However, although surgery and adjuvant oncological treatment are performed with curative intent, a certain number of cases will develop distant metastases. In cases presenting oligometastatic disease, surgery might be tempted in order to maximize the benefit in terms of survival. The aim of this paper was to identify which cases could benefit most after liver resection for breast cancer liver metastases. MATERIALS AND METHODS: The study included 67 patients submitted to surgery for breast cancer liver metastases between 2003 and 2017 in the "Dan Setlacec" Center of Gastrointestinal Diseases and Liver Transplantation, Fundeni Clinical Institute. RESULTS: Patients diagnosed with hormone-positive breast tumors reported a significantly higher disease-free and overall survival after resection of the primary tumor. After resection for breast cancer liver metastases, patients presenting hormone receptors at the level of the metastatic sites also experienced a better outcome when compared to those in which hormonal receptors were absent. However, the difference was not statistically significant. CONCLUSION: Liver resection for breast cancer liver metastases seems to be associated with the best outcomes in terms of survival in patients presenting positive hormonal receptors status.