Robot-assisted laparoscopic transperitoneal infrarenal lymphadenectomy in patients with locally advanced cervical cancer by single docking: Do we need a backup procedure?

To present our initial experience on the feasibility of robotic transperitoneal para-aortic lymphadenectomy up to left renal vein via single docking approach by high port insertion technique followed by left shoulder docking as a rescue backup procedure in surgically obstructed patients undergoing surgical staging because of locally advanced cervical cancer (LACC). Prospective observational preliminary study. Canadian Task Force classification II-3. Tertiary-care academic affiliated private hospital. Ten patients with LACC who underwent robotic transperitoneal infrarenal para-aortic lymphadenectomy between January 2012 and December 2014. All patients with pathologically proven cervical cancer underwent a PET/CT scanning in a similar fashion at the department of nuclear medicine. PET/CT scans were evaluated by the nuclear medicine specialist. Following pre-operative work-up, robot-assisted transperitoneal infrarenal para-aortic lymphadenectomy was performed up to left renal vein by the same experienced surgeon. Sections of 5 mm were performed and stained with routine hematoxylin and eosin (H&E), and node count was done separately by experienced gynecopathologist. During the study period, 12 consecutive patients with LACC were counseled for pre-therapeutic robot-assisted transperitoneal para-aortic lymphadenectomy. Two patients declined the procedure and underwent standardized chemo-radiation therapy whereas remaining ten patients constituted the study group. In the study group, the median age was 46 years (range 33-59 years), and the median body mass index 28.5 kg/m2 (range 18.5-35.1 kg/m2). Clinical staging was stage IIB in four patients, IIIB in four, and IVA in one. Histopathological diagnosis was squamous cell carcinoma in nine patients, and adenocarcinoma in one. On PET/CT scans, seven out of ten patients were positive for pelvic lymph node metastasis. With respect to para-aortic area, only one of the ten patients had suspected metastasis in PET/CT. For nine patients with LACC, the median docking time was 6.5 min (range 4-15 min), and the median operating time for para-aortic lymphadenectomy was 120 min (range 60-165 min). The median trocar time was 14.5 min (range 5-45 min). In two out of ten patients, the surgical removal of whole lymphatic tissue between inferior mesenteric artery and left renal vein was not completely possible by a single docking of robotic column. Therefore, a new optic trocar was placed in the umbilicus and the robotic column was relocated over the left shoulder of the patient and residual lymphatic tissue measuring approximately 2 cm in the long axis immediately below the left renal vein was removed and the surgery was completed up to the left renal vein. All para-aortic lymphadenectomies have been completed by robotic route. There were no intra-operative complications. No patient received a blood transfusion. Early post-operative grade 2 and 3a complications according to Dindo classification occurred in two patients: one symptomatic lymphocyst and one local infection on assistant port site in one patient. The patient with suspected para-aortic lymph node metastasis in PET/CT showed no metastatic disease on histopathologic exam of para-aortic lymph nodes. The patient with recurrent disease and negative para-aortic lymph nodes on frozen section examination underwent robot-assisted total pelvic exenteration. Five of the residual eight patients had histologically proven metastasis in the para-aortic lymph node(s). Treatment modification occurred in six patients related to pre-treatment staging surgery. According to pathological results, extended field radiation therapy has been added in five patients and it was omitted in one patient. The median time interval between surgery and initiation of radiotherapy was 12 days (range 6-23 days). Robotic transperitoneal infrarenal para-aortic lymphadenectomy up to left renal vein by high port insertion technique is a safe and feasible option for staging and treatment planning. However, technically, it is obstructed in a small group of patients and nodal staging surgery up to left renal vein can be completed by consecutive left shoulder docking approach as a backup rescue plan.

Do routine preoperative imaging techniques facilitate the operation in endometrial cancer?

OBJECTIVE: To assess the role of routine intravenous pyelography (IVP), rectoscopy and additional imaging techniques like computed tomography (CT) and abdominal ultrasonography (USG) for the evaluation of patients with endometrial cancer. MATERIALS AND METHODS: A total of 97 women with endometrial cancer (82 endometrioid and 15 non-endometrioid type) of all stages (Stage I = 65, II = 14, III = 13, IV = 5) were included in the study. Of these, 50 women were admitted because of postmenopausal bleeding, 24 with irregular vaginal bleeding and 7 with pain and leucorrhea, whereas the others had no complaints. Only one patient had symptoms related to the gastrointestinal system, but none for the urinary system. Preoperative CT (n = 45), IVP (n = 78), rectoscopy (n = 46), and USG or colonoscopy (n = 37) were performed on our patients. All the women had total abdominal hysterectomy and bilateral salpingo-oophorectomy, with/without pelvic (n = 81) and paraaortic (n = 34) lymphonodectomy, and omentectomy (n = 35). RESULTS: In 39 of 45 women who had CT, it had no effect on the operation and did not facilitate the operation. In two women there were pathological findings on CT and some interventions (resection and anastomosis) were performed on the gastrointestinal tract in these patients. However, CT had overcome pathological findings related with the gastrointestinal or urinary systems in four women, who needed interventions to these systems during the operation. CT was not performed on six women who needed interventions to the gastrointestinal system during the operations. Three patients had pathological findings (fissure, external compression) in rectoscopy, but only one patient had ileo-transverstomy, in which rectoscopic finding had not predicted the necessity of that procedure. Out of 78 IVP, the only finding was external compression to the bladder in 38 patients, and this finding had no contribution to the operation. Among women who had USG or colonoscopy (n = 37) performed, five had pathological findings that contributed to the extensiveness or the mode of the operations (liver nodules, polyps in the colon). CONCLUSIONS: Routine preoperative computed tomography, intravenous pyelography, rectoscopy or abdominal USG and colonoscopy have little impact on the decision and the prediction of the extensiveness of the operation.

Breast cancer, ovarian gonadoblastoma and cervical cancer in a patient with Peutz-Jeghers Syndrome.

BACKGROUND: Peutz-Jeghers Syndrome (PJS) is a rare autosomal dominant disorder characterized by gastrointestinal hamartomatous polyps and mucocutaneous pigmentation. Patients with PJS have increased risk for gastrointestinal, breast, and female genital tract cancers. CASE: Multiple genital tract cancers in a 34-year-old woman with PJS are described. The patient, who was admitted to our department with severe vaginal bleeding, was performed right salpingo-oophorectomy because of pure gonadoblastoma in 1996. In 2003, concomitant to cervical carcinoma, breast cancer was diagnosed. Patient underwent left modified radical mastectomy due to the invasive papillary carcinoma. The patient received six cycles combination chemotherapy and radiation therapy because of stage IIIB cervical cancer. CONCLUSION(S): This is the first case report presenting PJS associated with multiple genital tract tumors including ovarian gonadoblastoma in literature. The clinical significance of these tumors in PJS patients has been reviewed.

Expression of Bcl-2 and Ki-67 in tamoxifen-associated endometrial polyps: comparison with postmenopausal polyps.

BACKGROUND: The aim of this study was to evaluate the expression of Bcl-2 and Ki-67 in tamoxifen (TAM)-associated endometrial polyps and postmenopausal polyps. MATERIAL AND METHODS: For this purpose, a retrospective analysis of paraffin-embedded specimens was carried out. Polyps of 20 postmenopausal and 14 TAM-treated patients, 11 simple endometrial hyperplasia, 10 atypical complex endometrial hyperplasia and 8 endometrial adenocarcinoma specimens were included in the study. Hematoxylin/eosin-stained sections were evaluated. Immunohistochemical staining was performed to investigate the expression of Bcl-2 protein and the Ki-67 proliferation index. RESULTS: There was no statistically significant difference between the 5 groups with regard to Bcl- 2 staining (p > 0.05). However, Bcl-2 expression in TAM-associated polyps was higher (86%) than in the postmenopausal control group (80%). Positive Ki-67 was highest in the endometrial adenocarcinoma specimens, followed by the atypical complex endometrial hyperplasia group (p < 0.0001). Compared to these 2 groups, Ki- 67 expression was lower in TAM-associated polyps, but Ki-67 indexes were significantly higher in the TAM-associated group than in the control group (p < 0.0001). CONCLUSION: Since TAM-associated polyps tend to have higher proliferation indexes and Ki-67 ratios than control groups, we suggest that they are likely to have a higher malignant potential.

Placenta percreta diagnosed after first-trimester pregnancy termination: a case report.

BACKGROUND: Placenta percreta in early pregnancy has been documented in only a few cases. This is the first report of placenta percreta diagnosed after an extended period from pregnancy termination. CASE: A woman with a history of a previous cesarean section presented with heavy and irregular vaginal bleeding beginning immediately after pregnancy termination at 7 weeks' gestation. Failed response to hormonal treatment and curettage necessitated hysterectomy. Histologic examination revealed a placenta percreta. CONCLUSION: Although placenta percreta is an uncommon occurrence, clinicians should consider it in patients who have a uterotomy scar and complain of long-term metrorrhagia following pregnancy termination.

Borderline smooth muscle tumors of the uterus.

At present, decision regarding where to place a uterine smooth muscle tumor that deviates from the most obvious leiomyoma and leiomyosarcoma groups still depends on time-honored conventional criteria. The focus of categorization should be the clinical outcome and not nosology. To improve accuracy in predicting clinical behavior, a multivariate approach is needed. This involves combining background clinical information, intraoperative and gross findings,multiple relevant morphologic criteria, and immunohistochemical studies. The authors believe that in future, as the number of cases with intermediate clinical outcome and morphologic features increases, and as molecular markers of prognosis are studied, managing these tumors will become more objective.

Invasive inflammatory pseudotumor of uterine cervix: a case report.

BACKGROUND: Inflammatory pseudotumor (IPT) of the cervix uteri has been reported in only one patient. Here, we present a case of cervical IPT with bilateral parametrial involvement causing hydroureteronephrosis. CASE: A 48-year-old, gravida 2, para 1, woman was referred for evaluation of lower abdominal pain and right-sided hydroureteronephrosis. On speculum and colposcopic examinations, the cervix appeared normal. Computed tomography scan revealed a 5 cm x 4 cm mass in the cervix invading both parametria. At laparotomy, the cervix was globally enlarged and both parametria were infiltrated by a tumor of rubbery consistency. After freeing both ureters, the cervix was removed with bilateral parametria and 2-cm vaginal cuff. Histologically, the tumor was characterized by proliferation of fibroblast-like spindle cells and diffuse infiltration of plasma cells and lymphocytes. Immunohistochemical staining showed that the lymphocytes were polyclonal. Immunostaining for smooth muscle actin was negative. The tumor was thus identified as inflammatory pseudotumor. Cervical stroma, bilateral parametria, and subepithelial tissues of the vagina were involved with tumor. However, invasion was not identified in the epithelia of the cervix and vagina or surgical margins of the resected specimen. Postoperative course was uneventful. There is no evidence of recurrent disease 8 months following surgery. CONCLUSION: The case we present is the second reported case of cervical IPT. It is unique in showing locally aggressive behavior. Surgical resection appears to be the treatment of choice for IPT.

Ovarian dysgerminoma associated with Pseudo-Meigs' syndrome and functioning ovarian stroma: a case report.

BACKGROUND: We present the first case of an ovarian dysgerminoma complicated by pseudo-Meigs' syndrome. Furthermore, this is the fourth reported case of ovarian dysgerminoma with functioning ovarian stroma resulting elevated androgen levels preoperatively. CASE: A 25-year-old white female was referred to our department for abdominal swelling and a rapidly enlarging abdominal mass. Chest X-ray showed massive right pleural effusion. Abdominopelvic CT scan showed a left adnexal solid mass and ascites. Preoperative abnormally elevated hormone levels were as follows: free testosterone 7.7 pg/mL, androstenodione 13.6 ng/mL, and cortisol 29.4 microg/dL. Left salpingo-oophorectomy and wedge resection of the right ovary were performed. Final histopathological investigation of the left ovary was dysgerminoma associated with stromal luteinization. CONCLUSION: Dysgerminoma should be considered in the differential diagnosis in a young patient with a pelvic mass, ascites, and pleural effusion and preoperative counseling should be directed accordingly. In addition, dysgerminomas may be accompanied by ovarian stromal luteinization and steroid hormone production, which occasionally result in chemical or clinical hyperandrogenism.

Ovarian hemangioma presenting with hyperandrogenism and endometrial cancer: a case report.

BACKGROUND: Hemangiomas are very rare tumors of the ovary. Here, we report a case of a mixed capillary and cavernous ovarian hemangioma and endometrial carcinoma presenting with postmenopausal bleeding, male pattern receding frontal hairline, and high serum androgen and estradiol levels. CASE: A 70-year-old White female underwent laparotomy for endometrial carcinoma. Intraoperative frozen-section examination of the uterus revealed a 3.5 x 3 cm, grade 1 endometrioid adenocarcinoma of the endometrium with more than 50% myometrial invasion. The left ovary contained a 1.5 x 1 x 1 cm, well-circumscribed hemorrhagic nodule on the cut surface. Final histopathological examination of the small nodule demonstrated multiple, enlarged, blood-filled vascular channels lined by a single layer of flattened regular endothelial cells with no atypical features. Vascular spaces within the tumor were of different sizes, ranging from small to large, and were separated by connective tissue. The surrounding ovarian stroma was hyperplastic and contained clusters of luteinized stromal cells. Microscopy of the right ovary showed minimal stromal proliferation and no luteinization of the ovarian stroma. CONCLUSION: This is the first case of an ovarian hemangioma synchronous with a well-differentiated endometrial carcinoma. Absence of estrogen and progesterone receptors in the endothelial cells of the hemangioma suggests that ovarian hemangiomas may occur independent of stimulation by estrogen and progesterone.

Elevated serum TNF-alpha levels in normal-weight women with polycystic ovaries or the polycystic ovary syndrome.

OBJECTIVE: To compare the serum tumor necrosis factor-alpha (TNF-alpha) levels in nonobese women with those in women with polycystic ovaries (PCO) and polycystic ovary syndrome (PCOS) and healthy controls. STUDY DESIGN: Twenty-one sonographically and biochemically diagnosed women with PCOS, 19 with PCO and 14 healthy women were recruited for the study. Serum TNF-alpha levels were measured in all three groups. Insulin and glucose serum concentrations were analyzed before and after a 75-g oral glucose tolerance test in all samples. The serum TNF-alpha, glucose and insulin levels were compared in PCOS, PCO and controls. RESULTS: Serum TNF-alpha levels were similar in the PCOS and PCO groups (23.67 +/- 5.58 and 13.58 +/- 1.34 pg/mL, respectively) and significantly higher than in the control group. Serum TNF-alpha levels did not significantly correlated with body mass index, serum total testosterone, LH, DHEAS, fasting glucose and fasting insulin levels or glucose and insulin area under the curve values in the three groups. CONCLUSION: We found similar TNF-alpha levels in patients with PCOS and with PCO; however, there was no correlation between the TNF-alpha and insulin, glucose and androgen levels in the study.

Maternal serum cytokine levels in women with hyperemesis gravidarum in the first trimester of pregnancy.

OBJECTIVE: To compare serum cytokine levels in patients with hyperemesis gravidarum with levels in healthy pregnant and nonpregnant women. DESIGN: Case-control study. SETTING: Clinical and academic research center. PATIENT(S): Thirty women with hyperemesis gravidarum, 30 healthy women in the first trimester of pregnancy, and 30 healthy nonpregnant women. MAIN OUTCOME MEASURE(S): Serum levels of interleukin-1beta, interleukin-2 receptor, interleukin-6, interleukin-8, and tumor necrosis factor (TNF)-alpha. RESULT(S): Median serum levels of interleukin-2 receptor and interleukin-8 did not differ significantly among the three groups. Serum levels of interleukin-1beta and interleukin-6 were significantly higher in healthy pregnant women than in healthy nonpregnant women. Median TNF-alpha levels were significantly higher in women with hyperemesis (25.8 pg/mL [range, 4.9-140 pg/mL]) than in healthy pregnant and nonpregnant women (10.85 pg/mL [range, 4.1-35.8 pg/mL] and 12 pg/mL [4.3-68.2 pg/mL], respectively). CONCLUSION(S): Levels of TNF-alpha were significantly higher in patients with hyperemesis gravidarum than in healthy pregnant and nonpregnant women. Thus, TNF-alpha may be involved in the etiology of hyperemesis gravidarum.

Prenatally closed gastroschisis with midgut atresia.

Spontaneous prenatal closure of gastroschisis (GS) is rare and usually associated with atresia of the midgut. We describe a case of GS diagnosed at 20 weeks' gestation that resolved spontaneously in utero. At delivery the infant had an ileus. A laparotomy with a jejunocolostomy was performed, but she died at 2 months of age due to complications of total parenteral nutrition.

Effects of oral continuous and transdermal cyclic 17-beta estradiol and norethindrone acetate replacement therapy on platelet aggregation in postmenopausal women.

OBJECTIVE: To evaluate the effects of an oral continuous and transdermal cyclic 17-beta estradiol and norethindrone acetate combination on platelet aggregation in post-menopausal women. STUDY DESIGN: Fifty postmenopausal women were randomly assigned to receive 17-beta estradiol and norethindrone acetate either orally continuously or transdermally cyclically and sequentially. Platelet counts and maximum platelet aggregation rates were measured before and after three months treatment. RESULTS: At three months there were no significant changes in platelet counts or in adenosine diphosphate-induced or epinephrine-induced platelet aggregation rates in either treatment group. CONCLUSION: Hormone replacement treatment with a 17-beta estradiol and norethindrone acetate combination either orally continuously or transdermally cyclically and sequentially does not affect platelet aggregation in postmenopausal women.