Howard D. Epstein

Contemporary diagnosis and management of a uterine arteriovenous malformation.

BACKGROUND: Uterine arteriovenous malformations (AVMs) are extremely rare and can result in severe complications. Experience with diagnosis and management of these vascular malformations is very limited. CASE: We report on a patient with a history of nonmetastatic gestational trophoblastic disease. The patient developed a concomitant 4.4-cm intrauterine mass, suggestive of a molar pregnancy, during her second pregnancy. Despite suction and sharp curettage, the mass and menorrhagia persisted. After complex diagnostic imaging, the diagnosis of a uterine AVM was made. Subsequently, the patient underwent uterine arterial embolization and laparoscopic surgery to resect the mass. CONCLUSION: Because uterine AVMs are infrequently encountered, they initially may not be included in the differential diagnosis. The use of contemporary imaging, interventional radiology, and surgery can optimize patient outcome.

Sarcoidosis Presenting as an Intraperitoneal Mass.

Background: Sarcoidosis is an idiopathic, inflammatory condition primarily encountered within the lungs but very rarely identified in the peritoneum. Case Study: A 34-year-old woman presented with pleural effusion, ascites and an adnexal mass, indicative of ovarian cancer. Results: A biopsy revealed granulomas and lymphocytic infiltrate, consistent with sarcoidosis. The patient’s symptoms were resolved with corticosteroids. However, 2 years later, she developed another pelvic mass and underwent a diagnostic laparoscopy. Final pathology revealed granulomas and endometriosis, consistent with sarcoidosis. Conclusion: Since intraperitoneal sarcoidosis is extremely rare, the differential diagnosis is unlikely to include this condition in the context of presumptive ovarian cancer. However, in patients with a history of sarcoidosis, physicians should maintain a high index of suspicion to effectuate early detection and provide appropriate treatment.

Rapid manifestation of CNS metastatic disease in a cervical carcinoma patient: a case report.

Objectives: Brain metastases originating from primary cervical carcinoma are very rare. Despite surgery and adjuvant therapy, patient prognosis is extremely unfavorable. Prior studies have reported that the median time from the primary disease’s diagnosis to development of CNS metastases is approximately 18 months. Case Report: A 60-year-old woman was initially diagnosed and treated for FIGO clinical stage IB2 cervical carcinoma in March 2007. She underwent a radical hysterectomy, bilateral salpingo-oophorectomy and peri-aortic lymphadenectomy. Two weeks later, the patient presented with dysmetria and homonymous hemianopsia, which was related to a large right occipital CNS metastasis. The patient had surgery to resect the brain tumor and then received Gamma Knife stereotactic radiosurgery and chemotherapy. The neurological deficits were resolved and the patient’s disease status has since remained stable, with five months of follow-up. Conclusion: The incidence of brain metastases originating from primary cervical carcinoma is very rare. Furthermore, the occurrence of CNS metastatic disease manifesting itself within a couple weeks following diagnosis of the primary disease is even more unusual. Since the presenting symptoms of CNS metastatic disease are not well characterized and patient prognosis is very poor, oncology physicians should anticipate the presence of this condition in order to provide prompt and comprehensive treatment.

Gestational choriocarcinoma in the fallopian tube.

to be obscured by a lymphocyst, which was aspirated and excised. A Foley catheter was inserted for 24 h, which drained clear urine. Th e patient was discharged uneventfully 4 days aft er the operation. On day 7, she presented with off ensive blood-stained watery vaginal discharge and examination showed a possible vesicovaginal fi stula. Her white blood cell count was 11.6 cells/mm 3 and her CRP was 127 mg/l. She was started on co-amoxiclav and metronidazole and a 12F Foley indwelling catheter was inserted. Cultures from the high vaginal swab and urine sample were negative. A pelvic ultrasound showed vault collection (7 4 6 cm) and also a cystic area 4 2 3.5 cm in the left adnexum. A methylene blue test confi rmed the presence of the vesicovaginal fi stula and a larger bore 18F catheter was inserted. Upper urinary tracts were normal and the fi stula was identifi ed above the trigone on cystoscopy. A repair of the fi stula was performed, as the tissues appeared healthy. However, the patient experienced leakage within the fi rst 24 h. She was discharged with a size 18F catheter, for review in 12 weeks. Th e histology results available on day 16 showed an unusual area in the paracervix, which contained numerous small interlacing lymphovascular channels with bundles of smooth muscle cells in between the vascular spaces (Figure 1). Th e histology of the excised lymphocyst was similar to the paracervical lesion. Immunohistochemistry from both lesions showed strong positive staining of the smooth muscle cells, with actin and desmin. HMB45 testing also showed patchy and focal positivity in the smooth muscle cells. Th ese cells also had oestrogen and progesterone receptors. Th ese appearances indicated a poorly-defi ned lymphangioleiomyomatous process at these two diff erent anatomical sites. Extensive pulmonary cystic changes were noted on CT scan. Th e patient was a non-smoker and had no history of tuberous sclerosis complex. Extensive para-aortic and left common iliac lymphadenopathy, along with cystic areas in the pelvis was noted on the CT scan of abdomen and pelvis. Th e vesicovaginal fi stula persisted at 3 months and was successfully repaired vaginally. Histology of the fi stula tract was normal. At the 6-month review, the patient continues to have no leakage and remains under the care of physicians for long-term follow-up.

First‐trimester placenta percreta with urinary bladder invasion

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Leiomyosarcoma with Synchronous Clear Cell Ovarian Carcinoma

Background: Uterine leiomyomas are typically considered benign lesions. Despite aggressive management, they can be unpredictable and eventually exhibit disease recurrence several years following initial treatment. Case Report: We report a case involving a 55-year-old woman who was treated for a uterine leiomyoma at an outside medical institution 20 years ago. In November 2009, she presented to our gynecologic oncology service with a complex mass. Following surgery, the patient was diagnosed with a 16 cm ovarian mass and a synchronous leiomyosarcoma; the latter neoplasm appeared to originate from a previously resected uterine leiomyoma. Conclusions: The coexistence of these two lesions is exceedingly rare. We suspect that the leiomyosarcoma developed from either the patient’s original uterine leiomyoma or leiomyomatosis peritonealis disseminata.

The safety and feasibility of minimally invasive sentinel lymph node staging using indocyanine green in the management of endometrial cancer

OBJECTIVES The purpose of this study was to report on the feasibility of laparoscopic sentinel lymph node (SLN) staging using indocyanine green (ICG) in the management of endometrial cancer. STUDY DESIGN We retrospectively evaluated the charts of presumed, clinical stage I endometrial cancer patients who underwent robotic-assisted surgery that incorporated mapping with ICG and SLN dissection from January 2016 until February 2017. Patient demographics, operative characteristics (e.g., complications, lymph node counts) and pathology data were evaluated. RESULTS There were 87 patients who were included in the study. A total of 370 lymph nodes were removed, of which 245 were SLNs; unilateral and bilateral mapping of the SLNs was achieved in 84 (96.5%) and 71 (81.6%) of subjects, respectively. There were 10 (11.5%) patients who had metastatic disease identified within 22 (5.9%) of the total (n = 370) lymph nodes extracted, 19 (7.7%) of which were sentinel lymph nodes. We did not observe any intraoperative complications. CONCLUSION The results from our study suggest that minimally invasive SLN staging using ICG is a feasible procedure that is potentially effective at detecting metastases, which may ultimately attenuate the incidence of surgical morbidity.

A smooth-muscle tumor of uncertain malignant potential harboring metastatic breast cancer.

ing results revealed that the tumor was estrogen/progesterone receptor positive but negative for Her-2/neu amplification. Medical treatment was strongly recommended but she declined this option and elected to undergo surveillance. The patient reported that she was unaware of her most recent mammogram and had a medical history significant for viral hepatitis in 1976. In December 2007, an abnormal positron emission tomography/conputed tomography (PET/CT) scan exhibited a large area of intense metabolic activity in the pelvis (fig. 1), which was suspicious for metastatic disease. A pelvic ultrasound exhibited a 12.7-cm uterus containing 3 fibroids. In an attempt to preclude a gynecologic malignancy, the patient was then referred for a gynecologic oncology consultation in January 2008. An endometrial biopsy and potential hysterectomy were subsequently recommended, but she declined. The patient was treated with neoadjuvant chemotherapy comprising 3 cycles of cyclophosphamide (600 mg/m), epirubicin (75 mg/m), and 5-fluorouracil (600 mg/m), followed by 3 cycles of docetaxel (80 mg/m) from January 2008 to April 2008. She then underwent a right-sided mastectomy, sentinel node biopsy, axillary node dissection, and radiotherapy (5040 cGy) in June 2008, followed by breast reconstruction surgery. The patient was slated to begin exemestane (25 mg) in August 2008, but elected to delay therapy until March 2009 because she was still recovering from the effects of chemotherapy and breast reconstruction surgery. In August 2009, she had a PET/CT scan that exhibited a metastasis on her right ischial tuberosity. Since it was unclear when the metastasis originally developed, the patient remained on exemestane. However, in December 2009, a PET/CT demonstrated progressive disease and, thus, the patient began fulvestrant (250 mg) therapy. In March 2010, the patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Final pathology revealed metastatic carcinoma consistent with breast primary. Moreover, there was a metastasis identified within a 5.2-cm STUMP. Cytokeratin 7 immunostaining (40 ×) revealed nests of rounded carcinoma cells which did not stain the mesenchymal STUMP (fig. 2). A hematoxylin and eosin (H & E) stain (40 ×) demonstrated closely situated, rounded nests of metastatic breast carcinoma and large, spindly cells of STUMP, predominantly on the right side with abundant mesenchymal stroma (smooth-muscle tissue) (fig. 3). Currently, the patient is being treated with multiple anti-estrogen agents but she continues to develop progressive disease. Additional chemotherapy regimens have been recommended, but the patient prefers to remain on anti-estrogen therapy. She receives routine follow-up from her medical oncologist and gynecologic oncologist.

Endometrial Adenocarcinoma with Concomitant Left Atrial Myxoma

Background: Atrial myxomas are the most common primary heart tumors and predominantly considered to be benign lesions. Case Study: We report a case involving a 77-year-old woman who presented with a pelvic mass. She was found to have a primary endometrial cancer and primary lung cancer with concomitant metastatic adrenal gland and mesenteric lesions. Her prior medical history also included an untreated 4.0 × 2.0-cm left atrial myxoma which was identified on CT scan during the workup of her pelvic mass. Results: A clinical decision was made to proceed with surgery for the pelvic mass with a subsequent recommendation for left atrial mass resection. Currently, the patient is scheduled to begin chemotherapy for primary lung cancer. Conclusion: The reported incidence of uterine cancer and a concurrent atrial myxoma is very rare. Consequently, the manner and timing in which treatment should be provided is imprecise. In the present case, the risk for cardiac complications was high, but given the presence of a partial bowel obstruction and the need to diagnose the primary site of her metastatic malignancy, the decision was made to proceed with exploratory abdominal surgery.