Shintaro Yanazume

Severe leg compartment syndrome associated with dorsal lithotomy position during radical hysterectomy

We encountered a female patient with left‐leg compartment syndrome; a devastating complication, probably associated with prolonged dorsal lithotomy position during radical hysterectomy using intermittent pneumatic compression. This patient was intensively treated and fortunately recovered. However, leg compartment syndrome is poorly understood by gynecologists. We must always consider the potential risk of this life‐threatening complication when patients are placed in the dorsal lithotomy position for a prolonged period during extended surgery using intermittent external compression.

Large parasitic myomas in abdominal subcutaneous adipose tissue along a previous myomectomy scar

The incidence of iatrogenic parasitic uterine myomas associated with the use of a laparoscopic morcellator has been increasing over the past decade. Recently, we encountered a very rare case with a large parasitic myoma measuring 12 cm in diameter in the abdominal subcutaneous adipose tissue along an abdominal longitudinal surgical scar. The patient had twice undergone abdominal myomectomy for multiple fundal myomas. This is the first report describing a case with as large a parasitic myoma presenting in the suprafascial adipose tissue under the surgical scar after laparotomy. In such a case demonstrating a solid tumor of unknown cause after a gynecologic surgical procedure, a parasitic myoma must be included in the differential diagnosis.

Reassessment of the utility of frozen sections in endometrial cancer surgery using tumor diameter as an additional factor.

OBJECTIVE The purpose of this study was to improve the reliability of frozen section with the use of tumor diameter (TD) as an additional factor and intraoperatively to identify a subgroup of early endometrial cancers that would not require lymphadenectomy. STUDY DESIGN Data for 228 patients who underwent surgery with frozen section were analyzed retrospectively. Lymphadenectomy was performed in 86% of patients; the nodes were positive in 8%. RESULTS The accuracy of frozen section for myometrial invasion, grade, and low-risk prediction significantly increased with decreasing TD (P = .036) and was 98%, 95%, and 95%, respectively, when the TD was ≤3 cm. Patients with a TD of ≤2 cm and patients with a TD of 2-3 cm who had low-risk predictors had no nodal metastasis; patients with a TD of 2-3 cm who had intermediate-high risk predictors and a TD of >3 cm with any level of risk predictors were at risk of nodal metastases. CONCLUSION When the TD was ≤3 cm, the low-risk group that is defined by frozen section can be predicted accurately and safely to remain lymph-node metastasis free.

Can pelvic lymphadenectomy be omitted in stage IA2 to IIB uterine cervical cancer

Objectives The aims of this study were to predict pelvic lymph node metastasis in uterine cervical cancer before surgery and to evaluate the potential efficacy of omitting pelvic lymphadenectomy. Materials and Methods A total of 163 patients with invasive uterine cervical cancer in FIGO stage IA2 to IIB, all of whom underwent primary radical hysterectomy with pelvic lymphadenectomy, participated in this study. Results The incidences of pelvic lymph node metastasis in stage IA2, stage IB1, stage IB2, stage IIA, and stage IIB cervical cancer were 0% (0/12), 17% (13/76), 22% (6/27), 33% (8/24), and 63% (15/24), respectively. A significant difference was observed in overall survival with nodal metastasis status (P < 0.0001). Univariate analysis revealed that parametrial invasion (P < 0.0001), tumor markers (P = 0.0006), tumor size greater than 2 cm (P < 0.0001), tumor size less than 3 cm (P = 0.0009), and tumor size greater than 4 cm (P = 0.0024) were correlated with pelvic lymph node metastasis. However, multivariate analysis revealed that parametrial invasion (P = 0.01; odds ratio, 3.37; 95% confidence interval, 1.31–9.0) and tumor size greater than 2 cm (P = 0.005; odds ratio, 4.93; 95% confidence interval, 1.54–22.01) were independently associated with nodal metastasis. Conclusions Pelvic lymphadenectomy may be avoided in patients with negative parametrial invasion and a tumor size less than 2 cm, thereby minimizing postoperative complications.

Major causes of impractical brachytherapy in elderly patients with uterine cervical cancer

Incomplete brachytherapy is a major risk factor for recurrence. However, high‐dose‐rate intracavitary brachytherapy has not been assessed adequately in elderly patients with invasive cervical cancer. The present study investigated the clinical importance of intracavitary brachytherapy and risk factors of incomplete intracavitary brachytherapy in elderly patients with cervical cancer.

Potential proton beam therapy for recurrent endometrial cancer in the vagina

Proton beam radiotherapy mainly has been used in the gynecological field in patients with cervical cancer. The efficacy of proton beam therapy in patients with recurrent endometrial cancer has not yet been determined. A 77‐year‐old endometrial cancer patient presented with recurrence in the vagina without distant metastasis following hysterectomy. A hard mass measuring 6 cm originated from the apex of the vagina, surrounded the vaginal cavity, and infiltrated the proximal and distal vagina. The patient received proton beam radiotherapy using a less invasive particle treatment system while minimizing the dose to the surrounding normal tissues. The dose to the planning target volume was 74 Gy (relative biological effectiveness) with 37 fractions. The patient was treated with 150–210‐MeV proton beams for 53 days. Proton beam therapy led to the disappearance of tumors without any complications except for grade 1 cystitis although evidence of further complications is not available past our 6‐month follow‐up period. Proton beam therapy may become a useful treatment modality for recurrent endometrial cancer as well as cervical uterine cancer.

Identification of new risk factors for wound separation in gynecologic malignancy surgery

The purpose of this study was to compare prophylactic subcutaneous drainage plus subcuticular sutures versus staples for the risk of wound separation after skin closure following gynecologic malignancy surgery, and to investigate the risk factors of this procedure.

Cryotherapy for Massive Vulvar Lymphatic Leakage Complicated with Lymphangiomas Following Gynecological Cancer Treatment

Vulvar lymphatic leakage is a severe complication associated with gynecological cancer treatments. However, standard treatment strategies have not yet been determined. We encountered a rare case of a 76-year-old multiparous woman suffering from massive lymphatic fluid leakage from the entire vulva, and papules developed and were identified as lymphangiomas. A large amount of straw-colored discharge continued from all vulvar papules, which extended over the mons pubis. Nine years ago, the patient had undergone a radical hysterectomy with concurrent chemoradiation for uterine cervical cancer treatment. Her serum albumin level was 1.9 mg/dl, which was attributed to the loss of a large amount of lymph fluid due to leakage from the vulva. Her quality of life gradually decreased because of general fatigue and the need for frequent diaper exchanges every 2 h. The patient received a less-invasive treatment with cryotherapy using liquid nitrogen. She also received a multimodality treatment consisting of the intravenous administration of albumin, massage of the lower limbs and intensive rehabilitation. Cryotherapy was administered once a week for 3 months. Her discharge almost stopped and vulvar lymphangiomas decreased without any major complications. To the best of our knowledge, this is the first case report of massive lymphatic leakage complicated with vulvar lymphangiomas. Additionally, this case may represent the first successful treatment of vulva lymph leakage by cryotherapy without recurrence. Cryotherapy may have the potential to improve the quality of life as a less-invasive treatment for gynecological cancer survivors without serious complications.

Clinical management of uterine cervical mullerian adenosarcoma: A clinicopathological study of six cases and review of the literature

OBJECTIVE To assess the clinicopathological characteristics and clinical management of patients diagnosed with mullerian adenosarcoma of the uterine cervix. MATERIALS AND METHODS Records of six patients surgically treated for cervical mullerian adenosarcoma were reviewed. RESULTS The median age of the patients was 50 years (range, 17-74). Four patients presented with vaginal bleeding and two of them had watery discharge as the primary symptoms. Three nulliparous patients who hoped to preserve their uterus were included in this study and only one of the three patients received fertility-preservation surgery. Five patients underwent hysterectomy (simple in 3, modified radical in 2) with bilateral salpingo-oophorectomy or bilateral salpingectomy. One patient underwent conization of the cervix to preserve her fertility as there was no sarcomatous overgrowth, heterologous elements, or deep cervical stromal invasion. A recurrence of cervical mullerian adenosarcoma with sarcomatous overgrowth was observed in one patient who underwent simple hysterectomy. CONCLUSION The presence of sarcomatous overgrowth and deep cervical stromal invasion are associated with poor prognosis. Along with adequate counseling, fertility-preservation surgery may be an acceptable option for exophytic cervical mullerian adenosarcoma in the cases that do not show sarcomatous overgrowth and deep cervical stromal invasion.

Efficacy of palonosetron plus dexamethasone in preventing chemotherapy-induced nausea and emesis in patients receiving carboplatin-based chemotherapy for gynecologic cancers: a phase II study by the West Japan Gynecologic Oncology Group (WJGOG 131)

Objective Palonosetron is effective for the management of acute and delayed chemotherapy-induced nausea and vomiting (CINV). While emetogenic carboplatin-based chemotherapy is widely used to treat gynecologic cancers, few studies have evaluated the antiemetic effectiveness of palonosetron in this setting. Methods A multicenter, single-arm, open-label phase II trial was conducted to evaluate the safety and effectiveness of palonosetron in controlling CINV in patients with gynecologic cancer. Chemotherapy-naïve patients received intravenous palonosetron (0.75 mg/body) and dexamethasone before the infusion of carboplatin-based chemotherapy on day 1. Dexamethasone was administered (orally or intravenously) on days 2–3. The incidence and severity of CINV were evaluated using the patient-completed Multinational Association of Supportive Care in Cancer Antiemesis Tool and treatment diaries. The primary endpoint was the proportion of patients experiencing complete control (CC) of vomiting, with “no rescue antiemetic medication” and “no clinically significant nausea” or “only mild nausea” in the delayed phase (24–120 hours post-chemotherapy). Secondary endpoints were the proportion of patients with a complete response (CR: “no vomiting” and “no rescue antiemetic medication”) in the acute (0–24 hours), delayed (24–120 hours), and overall (0–120 hours) phases, and CC in the acute and overall phases. Results Efficacy was assessable in 77 of 80 patients recruited. In the acute and delayed phases, the CR rates the primary endpoint, were 71.4% and 59.7% and the CC rates, the secondary endpoint, were 97.4% and 96.1%, respectively. Conclusion While palonosetron effectively controls acute CINV, additional antiemetic management is warranted in the delayed phase after carboplatin-based chemotherapy in gynecologic cancer patients (Trial registry at UMIN Clinical Trials Registry, UMIN000012806).