Ninad M Patil

Cesarean scar pregnancy and early placenta accreta share common histology

To determine, by evaluation of histological slides, images and descriptions of early (second‐trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

Differentiating Lymphovascular Invasion from Retraction Artifact on Histological Specimen of Breast Carcinoma and Their Implications on Prognosis

On a pathological specimen of breast cancer cells, retraction artifact during histological processing mimics true lymphovascular invasion (LVI). The accurate determination of the presence or absence of LVI is a factor in determining risk of having a positive sentinel node, or having additional positive axillary nodes after a positive sentinel node biopsy in women with early-stage breast cancer. The determination of nodal risk influences the decision of the treating physicians as to whether a sentinel node biopsy or completion axillary dissection is necessary. On slide preparation, ideal factors favoring true LVI include: a definite endothelial lining, with endothelial nuclei that seem to protrude into the lymphatic space; invasion in one lymphatic vessel (LV) lumen with nearby cancer glands that have minimal or no retraction; a tumor embolus in a LV clear lumen with outside nearby tumor bulk; a tumor embolus that is different in shape than its surrounding clear LV space; and a positive stain for fibrin, CD31, or CD34 on tumor embolus periphery.

Adrenocortical Carcinoma Masquerading as a Benign Adenoma on Computed Tomography Washout Study

An incidental adrenal mass is a common finding on cross-sectional imaging, with most of these lesions being benign adenomas. Indications for adrenalectomy turn on the likelihood that a mass is malignant or whether it exhibits metabolic activity. Modern imaging is considered highly accurate in differentiating adrenal adenomas from other adrenal pathology. We present a case of a 5-cm adrenal lesion with computed tomography washout characteristics consistent with a benign adenoma, which proved upon resection to be an adrenocortical carcinoma.

The use of pharmacogenomics for selection of therapy in non-small-cell lung cancer.

Introduction Performance status (PS) is the only known clinical predictor of outcome in patients with advanced non-small-cell lung cancer (NSCLC), although pharmacogenomic markers may also correlate with outcome. The aim of our study was to correlate clinical and pharmacogenomic measures with overall survival. Methods This was an IRB approved, retrospective study in which the medical records of 50 patients with advanced NSCLC from 1998–2008 were reviewed, and gender, race, PS, and chemotherapy regimens were documented. Stromal expression of pharmacogenomic markers (VEGFR, ERCC1, 14-3-3σ, pAKT, and PTEN) was measured. Clinical factors and pharmacogenomics markers were compared to overall survival using a Cox proportional hazards model. Results Forty patients received platinum-based therapy. Median age was 65 years. Improved PS, female gender, and gemcitabine therapy were significantly associated with longer overall survival (P = 0.004, P = 0.04, and P = 0.003, respectively). Age was not associated with survival. Caucasians had better overall survival in comparison to African Americans with median survival of 14.8 months versus 10.4 months (P = 0.1). Patients treated with platinum-based therapy had better survival of 15 months versus 8 months for non-platinum based therapy (P = 0.01). There was no significant association between any of the pharmacogenomics markers and overall survival other than in patients treated with platinum, in whom ERCC1 negativity was strongly associated with longer survival (P = 0.007). Conclusion ERCC1 negativity with platinum therapy, gemcitabine therapy, good PS, and female gender all correlated with improved overall survival in patients with advanced NSCLC.

Hysteroscopic assisted single-site robotic resection of cesarean scar defect (CSD): dual case reports and review of literature

The number of deliveries via cesarean section has increased in the United States, to a rate of 32.3%, which is almost double the global rate of 18.6%.1 With a greater rate of deliveries via cesarean section comes increased rate of associated complications in subsequent pregnancies and longer hospital stays.2 One complication of cesarean section is the formation of a cesarean scar defect (CSD), niche or isthmocele, which has no standard definition but can be grossly described as a disruption or defect in the myometrium associated with uterine scar.3–6 Approximately 1.9% of women are diagnosed with CSD, however the prevalence of CSD is difficult to quantify, given that smaller CSDs may be asymptomatic.4 As more women are encouraged towards a trial of labor after cesarean (TOLAC) the performance of the uterus during labor is of growing concern due to the risk of uterine rupture.2,7

Single-incision laparoscopic surgery of cesarean scar ectopic pregnancy: a case report and review of literature

Cesarean scar ectopic pregnancy (CSEP) is the rarest location for ectopic pregnancy (incidence of 1:1,800 to 1:1,216);1,2 with implantation in the cesarean scar defect (CSD) of the uterus,3,4 There are two types of CSEP; Type 1 has progression toward the uterine cavity; Type 2 is deep within the Myometrium.5 The primary pathology stems from poor wound healing, resulting in focal thinning of the uterine scar or migration of the embryo through a microscopic fistula wedge defect exposing the site for implantation.6,7 Additional complications include rupture, hemorrhage, and uterine rupture due to weakness of the cesarean scar.8−10

Single site robotic-assisted laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic congestion syndrome; a case report and review of literature

Abbreviations: LESS, laparoendoscopic single-site surgery; MRA, magnetic resonance angiography; SILS, single-incision laparoscopic surgery; CPP, chronic pelvic pain; PCS, pelvic congestion syndrome; RASI, robotic assisted single incision laparoscopic; AUB, abnormal uterine bleeding; IP, infundibulopelvic; ICG, indocyanine green; NSAIDs, non-steroidal anti-inflammatory drugs; GnRH, gonadotropin releasing hormone; CBT, cognitive behavioral therapy; MIGS, minimally invasive gynecological surgery

Multimodal molecular analysis of an atypical small cell carcinoma of the ovary, hypercalcemic type

A 12-yr-old normocalcemic female treated for a ruptured ovarian juvenile granulosa cell tumor at an outside hospital presented for exploratory laparotomy and gross surgical debulking of pelvic recurrence. Morphologically, the tumor was composed of sheets and nests of small blue cells forming cysts of various sizes and focal mucinous differentiation. Epithelial membrane antigen (EMA), patchy inhibin, and strong and diffuse p53 immunoreactivity were also observed. A revised diagnosis of mixed sex cord stromal tumor with heterologous elements was favored because of the inhibin immunoreactivity. Targeted next-generation sequencing of the tumor revealed a SMARCA4 c.1141C>T, p.Arg381Ter (NM_001128849.1) nonsense mutation and an in-frame 18-bp TP53 deletion (c.594_611del18, p.Gly199_Glu204del, NM_001126112.2). Cytogenetic analysis revealed a normal 46,XX karyotype, and OncoScan single-nucleotide polymorphism array analysis demonstrated copy-neutral loss of heterozygosity (CN-LOH) of 19p13.3-19p13.2 and mosaic CN-LOH of 17p13.3-p11.2 encompassing the SMARCA4 and TP53 loci, respectively. Subsequent germline SMARCA4 sequencing confirmed a heterozygous SMARCA4 p.Arg381Ter mutation. In lieu of the molecular findings, the diagnosis was amended to small cell carcinoma of the ovary, hypercalcemic type (SCCOHT). The patient was treated aggressively with paclitaxel, carboplatin, and bevacizumab. She received an autologous stem cell transplant but died 5 mo after SCCOHT diagnosis secondary to complications of the transplant. This case expands the morphologic, immunophenotypic, and genomic spectrum of SCCOHT and highlights how multimodal molecular analysis can assist with the diagnosis and clinical management of SCCOHT patients.

Laparoendoscopic Single-Site Surgery for Management of Heterotopic Pregnancy: A Case Report and Review of Literature

Background Heterotopic pregnancy occurs when two pregnancies occur simultaneously in the uterus and an ectopic location. Treatment includes removal of the ectopic pregnancy with preservation of the intrauterine pregnancy. Treatment is done laparoscopically with either a Laparoendoscopic Single-Site Surgery (LESS) or a multiport laparoscopic surgery. Case We present a case of a first trimester heterotopic pregnancy in a 42-year-old gravida 5, para 0-1-3-1 female with previous history of left salpingectomy, who underwent laparoscopic right salpingectomy and lysis of adhesions (LOA) via Single-Incision Laparoscopic Surgery (SILS). Conclusion Although LESS for benign OB/GYN cases is feasible, safe, and equally effective compared to the conventional laparoscopic techniques, studies have suggested no clinically relevant advantages in the frequency of perioperative complications between LESS and conventional methods. No data on the cost effectiveness of LESS versus conventional methods are available. LESS utilizes only one surgical incision which may lead to decreased pain and better cosmetic outcome when compared to multiport procedure. One significant undesirable aspect of LESS is the crowding of the surgical area as only one incision is made. Therefore, all instruments go through one port, which can lead to obstruction of the surgeons vision and in some cases higher rate of procedure failure resulting in conversion to multiport procedure.