Maria Pastore

Complete remission of ovarian cancer induced intractable malignant ascites with intraperitoneal bevacizumab. Immunological observations and a literature review

SummaryMalignant ascites resistant to conventional drugs frequently affects ovarian cancer patients at the end of life. Here we report the case of a patient who benefited from complete resolution of ascites after low dose intraperitoneal administration of bevacizumab. Immunological analyses showed an initial increase in proportion and function of CD8+ effector T cells and a reduction of circulating Treg cells. A review of the current literature regarding bevacizumab in ovarian cancer is reported. Bevacizumab has shown a high efficacy in the treatment of ovarian cancer. Intraperitoneal administration induces an immune activation and appears promising in the treatment of malignant ascites.

Early prolapse of a neovagina created with self-dilatation and treated with sacrospinous ligament suspension in a patient with Mayer-Rokitansky-Küster-Hauser syndrome: a case report

OBJECTIVE To report a case of a patient who had an early prolapse of the neovagina, while using Franks dilators method, that was successfully treated with sacrospinous ligament suspension. DESIGN Case report. SETTING Tertiary-care university hospital. PATIENT(S) A 22-year-old woman with Mayer-Rokitansky-Küster-Hauser syndrome. INTERVENTION(S) Franks vaginal dilators method. MAIN OUTCOME MEASURE(S) Vaginal elongation by self-dilatation. Early prolapse of the neovagina. Surgical repair with vaginal sacrospinous ligament suspension. RESULT(S) A few months after the beginning of the treatment the patient had a prolapse of the neovagina. On pelvic examination, the total vaginal length was 5 cm with eversion of the vaginal apex 3 cm beyond the hymen with strain. Vaginal length was not satisfactory for the patient yet; therefore, the vaginal dilation program was continued to reach the prefixed vaginal length. Two months later the total vaginal length was 8 cm with eversion of the vaginal apex 6 cm beyond the hymen with strain. The patient underwent a sacrospinous ligament suspension. Twenty months after surgery, the patient had no symptoms and was highly satisfied with the result. CONCLUSION(S) Prolapse of a neovagina may occur early after conservative treatment. If the initial prefixed goal of vaginal length has not been reached when prolapse develops, the vaginal dilatation program may be continued. In our case vaginal sacrospinous ligament fixation was successful, with good anatomic and functional results.

Late aortic lymphocele and residual ovary syndrome after gynecological surgery

BackgroundGynecological surgery, as radical hysterectomy or pelvic and aortic lymphadenectomy, accounts for more than 50% of iatrogenic injuries. In premenopausal women, an hysterectomy with ovarian sparing and concomitant lateral ovarian transposition is frequently performed. However, the fate of the retained ovary is complicated by the residual ovarian syndrome (ROS) and one of the most common postoperative complications of the lymphadenectomy procedure is the lymphocele, with an average incidence of 22–48.5%. The differential diagnosis of a postoperative fluid collection includes, in addition to a lymphocele, urinoma, hematoma, seroma or abscess and the computed tomography (CT) findings alone is not enough.Case presentationWe describe a patient, affected by ROS concomitant with a asymptomatic lymphocele, initially confused with an aortic lymph nodes relapse, after abdominal radical hysterectomy. The patient was subjected to a surgical approach, included a diagnostic open laparoscopy and laparotomy with sovraombelico-pubic incision, wide opening of the pelvic peritoneum and retroperitoneum. Examination of the mass revealed, macroscopically, a ovary with multiloculated cystic masses filled with clear or yellow serous fluid and the layers were composed by flat or cuboidal mesothelial cells.ConclusionThe tribute of this case illustrates the atypical appearance with uncertain aetiology after complex imaging. Gynecologist and radiologist should acquaint with the appearance of fluid collection (urinoma, lymphocele, seroma, hematoma, abscess) in gynecologic oncology follow-up to properly differentiated from tumor recurrence.

Laparoendoscopic single‐site salpingectomy for treatment of ectopic pregnancy

⁎ Corresponding author at: Department of Obstetrics and Gynecology, Santo Spirito Hospital, University-affiliated Hospital, Lungotevere in Sassia, 1–00193 Rome, Italy. Tel./fax: +39 06683552339. E-mail address: marco.calcagno@uniroma1.it (M. Calcagno). Laparoendoscopic single-site surgery (LESS) has emerged as a method for increasing the cosmetic benefits of minimally invasive surgery and reducing the risks and morbidity associated with multiple working ports. Consecutive patients presenting with tubal pregnancy and hemodynamically stable conditions at the Santo Spirito Hospital, Rome, Italy, between March 1, 2010, and May 31, 2011, underwent laparoscopic salpingectomy with the LESS technique. Ruptured tubal pregnancies, previous pelvic surgery, and size of ectopic pregnancy were not considered to be exclusion criteria. All patients provided written consent after being informed about the possible risks and benefits of this experimental technique. A single flexible multichannel access port (SILS; Covidien, Mansfield, MA, USA) was inserted in the peritoneal cavity through a 2.0cm umbilical incision via open technique. Pneumoperitoneum was set at 13 mm Hg. A 10-mm 30° laparoscope was introduced and a uterine manipulator inserted. A 5-mm articulating grasper (Roticulator; Covidien, Mansfield, MA, USA) with the distal end moved downward 80° was used to help provide efficient upward retraction of the distal tube in order to optimize surgical exposure. A 5mm bipolar electrosurgical instrument with integrated cutting device (LigaSure; Valleylab, Boulder, CO, USA) was used to seal and cut the mesosalpinx beneath the tubal pregnancy and the proximal tubal stump. After the surgical specimen was removed, abdominal access was closed layer by layer. Patient and surgical data are listed in Table 1. Twelve women successfully underwent complete salpingectomy via LESS. The ectopic pregnancy was easily excised and the surgical specimen removed successfully in all cases. No perioperative complications occurred. All patients were discharged home on the first postoperative day and declared that they were highly satisfied with the procedure. One of the major concerns regarding LESS is that it is associated with a difficult and long learning curve because of several technical challenges such as crowding of the instruments and loss of triangulation. Few reports have described its use in themanagement of adnexal Table 1 Patient characteristics and surgical outcomes (n=12).

Vaginal apex necrosis following use of the Frank method of dilation for vaginal agenesis due to Mayer-Rokitansky-Kuster-Hauser syndrome.

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Re: Tomasz Rechberger, Konrad Futyma, Katarzyna Jankiewicz, et al. The Clinical Effectiveness of Retropubic (IVS-02) and Transobturator (IVS-04) Midurethral Slings: Randomized Trial. Eur Urol 2009;56:24–30

We read with interest the paper by Rechberger et al [1] on a randomised trial evaluating the clinical effectiveness of retropubic (IVS-02) and transobturator (IVS-04) midurethral slings for the treatment of female stress urinary incontinence (SUI). Overall, there was no statistically significant difference in clinical efficacy between these two procedures after 18 mo of follow-up, with 92% and 88.3% of cured or improved patients in the IVS-02 and IVS04 groups, respectively ( p = 0.39). When patients were stratified on severity of SUI and Valsalva leak point pressure (VLPP) (>60 cm H2O and <60 cm H2O), statistically significant differences in cure rate between subgroups were found only for the IVS-04 procedure. The authors concluded that both procedures are equally efficacious and that the retropubic route appears to be more efficient in the intrinsic sphincter deficiency (ISD) group [1]. We would like to offer our contribution to the argument: It is well known that the most important prognostic factor for the success of the midurethral sling procedure is urethral mobility. Supporting evidence was reported in a meta-analysis by Muller et al, demonstrating that in patients undergoing a midurethral sling, urethral hypermobility is associated with increased efficacy in contrast to women with a fixed urethra, who are at significant risk for procedure failure [2]. Several studies specifically addressing the effectiveness of tension-free vaginal tape (TVT) in women with SUI and ISD reported that women with a fixed urethra are at significantly increased risk of failure of the procedure, with a failure rate as high as 57–66% [2]. Limited clinical investigation has focused specifically on comparison of success rates in retropubic versus transobturator cohorts with documented ISD. Recently, Costantini et al investigated the prognostic value of VLPP for midurethral sling outcomes using data from a randomised controlled study of 145 women with SUI or mixed urinary incontinence and urethral hypermobility

Laparoendoscopic single‐site assisted vaginal hysterectomy

[1] Mulayim B, Celik NY, Onalan G, Bagis T, Zeyneloglu HB. Sublingual misoprostol for cervical ripening before diagnostic hysteroscopy in premenopausal women: a randomized, double blind, placebo-controlled trial. Fertil Steril 2010;93(7):2400–4. [2] Lee YY, Kim TJ, Kang H, Choi CH, Lee JW, Kim BG, et al. The use of misoprostol before hysteroscopic surgery in non-pregnant premenopausal women: a randomized comparison of sublingual, oral and vaginal administrations. Hum Reprod 2010;25(8): 1942–8. [3] Singh N, Ghosh B, Naha M, Mittal S. Vaginal misoprostol for cervical priming prior to diagnostic hysteroscopy–efficacy, safety and patient satisfaction: a randomized controlled trial. Arch Gynecol Obstet 2009;279(1):37–40. [4] Waddell G, Desindes S, Takser L, Beauchemin MC, Bessette P. Cervical ripening using vaginal misoprostol before hysteroscopy: a double-blind randomized trial. J Minim Invasive Gynecol 2008;15(6):739–44.

Umbilical port site enterocutaneous fistula after laparoscopy for endometrial malignancy.

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Three-day topotecan schedule in heavily pretreated recurrent ovarian cancer patients

Objective: To evaluate the clinical benefit of a 3-day topotecan schedule in heavily pretreated recurrent ovarian cancer patients scheduled for palliative treatment. Methods: Eligibility criteria were 2 or more prior chemotherapy regimens, Eastern Cooperative Oncology Group performance status of 2 or less; adequate organ function, assessable disease by serum CA-125 measurement before each cycle; and 1 or more cycle of topotecan (1.5 mg/m2 per day) on 3 consecutive days of a 28-day treatment cycle. Toxicity was graded according to the National Cancer Institute Common Toxicity Criteria version 3. Tumor response, stable disease, and progression were evaluated on the basis of CA-125 levels. Results: A total of 68 patients were considered eligible for the study. Median age was 58 years (range, 40-77 years), and the median number of prior chemotherapy regimens was 2 (range, 2-6). A total of 272 cycles of topotecan were administered, with a median of 4 cycles per patient (range, 1-8). No treatment delays or dose reduction was recorded. Major toxicities were grade 3/4 (18%) neutropenia, neutropenic fever (6%), grade 4 thrombocytopenia (3%), requirements for blood (5%), and platelet transfusions (3%). Thirty-five (54%) of the 64 evaluable patients showed a clinical benefit. Of these, 11 patients (17%) had a partial response, and 24 (37%) had stable disease with a median time to progression of 7.5 months (range, 6-10 months) and 4 months (range, 2-6 months), respectively. Conclusion: More than half of heavily pretreated ovarian cancer patients may benefit from 3-day topotecan.