Resection of presacral ganglioneurofibroma by laparoscopy

BACKGROUND

Tumors of the retrorectal space are rare. They comprise a heterogeneous group of benign or malignant tumors that cause similar symptoms due to their location in presacral space. If possible, complete surgery excision is the therapy of choice mainly through a sacral, abdominal-sacral, or a pure abdominal or perineal axis.

CASE REPORT

A 15-year-old asymptomatic patient was diagnosed with a retrouterine tumor during her first gynecological examination. Magnetic resonance imaging of the pelvis showed a 10 x 8.5 x 7-cm encapsulated presacral tumor. Retrorectal ganglioneurofibroma was removed by laparoscopy with preservation of the sympathetic and parasympathetic nerves and the sacral roots of the ischiadic nerves. No sensory or motoric dysfunction of the legs, bladder, or rectum was observed postoperatively.

CONCLUSION

This is the first case report of a complete endoscopic removal of large presacral ganglioneurofibroma in an asymptomatic woman.

Histopathological extent of rectal invasion by rectovaginal endometriosis

BACKGROUND

We aimed to evaluate the microscopic extent of endometriosis in surgical en-bloc specimens of vaginal skin, rectovaginal septum, cul-de-sac, and part of the rectosigmoid bowel.

METHODS

From December, 1997 to October, 2001, 50 patients with the trias of intestinal pain, palpable disease in the rectovaginal septum, and laparoscopic diagnosis of endometriosis of the cul-de-sac and/or rectosigmoid colon underwent combined laparoscopic-vaginal en-bloc resection of the cul-de-sac with partial resection of the posterior vaginal wall and rectum with reanastomosis by minilaparotomy. All surgical specimens were histopathologically evaluated in a standardized fashion.

RESULTS

The mean length of the bowel specimen was 7.48 cm. Endometriosis involved the serosa and muscularis propria in all patients, the submucosa in 17 patients (34%), and the mucosa in five patients (10%). After a mean follow-up of 32 months, 90% of patients reported a considerable improvement or were completely free of symptoms and the rate of recurrence was 4% (two patients).

CONCLUSIONS

Partial bowel resection indicates the depth and multifocality of endometriosis affecting the recto-sigmoid colon. Such extensive surgery appears justified by the extent of the lesions and the long-term relief of symptoms achieved.

Is the decision for colorectal resection justified by histopathologic findings: a prospective study of 100 patients with advanced ovarian cancer

OBJECTIVE

We compare the indication for colorectal resection in patients with advanced ovarian cancer with histopathologic findings. We describe the effect on pelvic control and morbidity associated with surgery.

METHODS

Between February 1995 and March 2001, 100 patients with FIGO stage IIIc ovarian cancer underwent pelvic en bloc resection with excision of the rectosigmoid colon as part of primary or secondary cytoreductive surgery. Decision for resection was made by the surgeon when tumor involvement of the cul-de-sac was suspected. Rectosigmoid infiltration was histopathologically defined as infiltration of the serosa or deeper.

RESULTS

In 73 of 100 patients (73%) tumor involvement of the rectum was confirmed histopathologically: infiltration of the serosa in 28 (28%) patients, infiltration of the muscularis in 31 (31%) patients, and infiltration of the mucosa in 14 (14%) patients; in 27 (27%) patients no infiltration was found. Histopathologically confirmed pelvic R0 resection was achieved in 85 (85%) patients. In 11 (11%) patients the pelvic resection margins were tumor-involved and in four (4%) patients visible parametric tumor remained in situ. Pelvic recurrence occurred in 4 (4.7%) of 85 optimally debulked patients compared with 9 (60%) of 15 patients with suboptimal pelvic resection status (P < 0.05). End colostomy could be prevented in 94 (94%) of 100 patients.

CONCLUSION

Pelvic en bloc surgery with rectosigmoid resection was justified by histopathologic outcome since deperitonealization with preservation of the rectosigmoid would have left tumor in situ in 73% of patients with suspected cul-de-sac involvement.

Trocar-site metastasis is not always due to laparoscopy

The use of laparoscopic surgical techniques for the management of gynecologic malignancies has increased over the last years. Metastasis developing at the trocar insertion site is an emerging problem. We present the case of a 66-year-old woman with endometrial cancer who was diagnosed with an umbilical tumor after laparoscopically assisted vaginal hysterectomy (LAVH) and bilateral salpingoophorectomy. The interval between LAVH and diagnosis of the umbilical tumor was 13 months. The tumor was excised, and metastasis of endometrial cancer was histologically confirmed. Review of computer tomograms taken before LAVH showed a tumor in the umbilical area that had not been recognized before therapy. Therefore, tumor manifestation at the abdominal wall after laparoscopic surgery should not automatically be considered the result of iatrogenic spreading.

Laparoscopic lymph node staging of cervical cancer in the 19th week of pregnancy. A case report

We present the case of a 39-year-old gravida I para 0 woman who underwent laparoscopic staging of lymph node involvement in cervical cancer in the 19th week of pregnancy. She had been diagnosed with adenosquamous carcinoma of the cervix, stage 1B1, grade 2, with tumor involvement of the lymphovascular space and tumor involved resection margins via a cone biopsy in the 16th week of pregnancy. In order to decide whether it would be safe to proceed with the pregnancy, she was submitted to the laparoscopic exposure and removal of 18 parametric and pelvic lymph nodes. One positive lymph node was detected at the right internal iliac artery; therefore, an open radical hysterectomy with paraaortic lymphadenectomy was performed. This case shows that lymph node staging for cervical cancer can be done laparoscopically in the 2nd trimester. Information yielded during the course of this procedure can be crucial in deciding whether it is possible to preserve the pregnancy.

Screening for high-grade cervical intra-epithelial neoplasia and cancer by testing for high-risk HPV, routine cytology or colposcopy

The validity of testing for high-risk types of human papillomavirus (HPV) in cervical cancer prevention programs is undetermined. We compared the performance on primary screening of HPV DNA testing, cytology and colposcopy in detecting cervical intra-epithelial neoplasia (CIN) grade 2 or 3 or cancer. A cohort of 4,761 women, median age 35 years, was screened by routine cytology, routine colposcopy and testing for high-risk HPV by a PCR-based method. Within an 8-month period, women with abnormal findings on cytology or screening colposcopy or in whom high-risk HPV types were detected were referred for colposcopy and biopsy. Women negative on all initial screening tests were followed by a second screening examination. To correct for work-up bias, the true prevalence of CIN 2 or 3 or cancer was estimated by projection from histologically verified subgroups. Cervical biopsies were taken in 364 women (7.6%), of whom 114 (2.4%) showed CIN 2 (n = 34) or CIN 3 (n = 71) or cancer (n = 9). High-risk HPV testing achieved bias-corrected performance measures of 89.4% sensitivity, 93.9% specificity, 35.8% positive predictive value and 99.6% negative predictive value. Bias-corrected rates of true- and false-positives by high-risk HPV testing compared to cytology (colposcopy) were about 4.5 (6.7) and 19.1 (7.4) times higher, respectively. The quality of routine cytology was controlled by computer-assisted review, and the observed number of true-positives more than doubled after adding automated review results. In middle-aged women, testing for high-risk HPV types, particularly when negative, may be used to increase the screening interval in programs for secondary prevention of cervical cancer.

Endoscopic axillary lymphadenectomy without prior liposuction. Development of a technique and initial experience

BACKGROUND

A new technique of endoscopic axillary lymphadenectomy without prior liposuction was developed by our group.

METHOD

A total of 33 patients with early stage breast cancer were treated by breast-conserving therapy and endoscopic axillary lymphadenectomy.

RESULTS

The median duration of the operation was 74.9 min (range, 30-130). Operation time was significantly shorter for the last 17 patients (p < 0.05) than for the first 16 patients. There were no intraoperative complications. The median number of removed lymph nodes was 14.5 (range, 2-28). Postoperatively three patients developed a seroma, one of which required evacuation. At postoperative day 5, arm mobility was unrestricted in 26 patients (78.7%); nine patients (27.2%) reported a loss of sensation in the outer side of the upper arm related to dermatome C5. One patient developed a temporary alar scapula, and one patient developed an axillary abscess 9 weeks after axillary lymphadenectomy during radiation therapy. After a median follow-up of 4.6 months seven patients reported persistent impairment of sensation, but all patients had regained full shoulder mobility.

CONCLUSION

Endoscopic axillary lymphadenectomy can be done safely without prior liposuction.

Monocyte-chemo-attractant-protein-1 (MCP-1)-gene expression in cervical intra-epithelial neoplasias and cervical carcinomas

Chemokines play a central role in the chemotactic activation of immunological effector cells. One of the currently best characterized chemokines is the monocyte-chemo-attractant protein-1 (MCP-1), which is involved in the cross-talk with cells of the monocyte-macrophage lineage. Since macrophages and macrophage-derived cytokines appear to be important in the transcriptional regulation of "high-risk" types of human papillomaviruses (HPV), we monitored MCP-1 expression by in situ hybridization (ISH) in histologically distinct stages of cervical intra-epithelial neoplasms (CIN), cervical cancer and non-HPV-associated cases of erosive endocervicitis. Here, we demonstrate that high-grade dysplasia (CIN III, n = 9) completely lacks both MCP-1 expression and CD68+-macrophage infiltration, while MCP-1-specific signals were occasionally detectable in one out of 5 CIN-II and in one out of 3 CIN-I lesions. Inspection of hyperplastic squamous epithelium adjacent to cervical carcinomas reveals high MCP-1 expression and accumulation of infiltrating macrophages. In contrast, no macrophages could be detected in corresponding hyperplastic tissue areas surrounding CIN-II and CIN-III lesions, although MCP-1 was found to be highly expressed. Finally, in agreement with our earlier in vitro data, invasive carcinomas of the cervix uteri showed MCP-1-specific hybridization signals and macrophage infiltration only in the stroma surrounding the carcinoma cells and in endothelial cells of capillaries, especially at the invasion front of the tumor, while the inner mass of the carcinomas was completely negative. On the other hand, ISH and histochemical evaluation of inflammatory, non-HPV-associated cases of erosive endocervicitis indicate strong MCP-1 expression, which is regularly accompanied by chemotactic appearance of macrophages. These observations indicate that dysregulation of MCP-1-gene expression may represent an important step during HPV-linked carcinogenesis, allowing the escape of virus-positive cells from local immune response.

Distribution of 14 high risk HPV types in cervical intraepithelial neoplasia detected by a non-radioactive general primer PCR mediated enzyme immunoassay

AIM

To evaluate the presence of high risk human papillomaviruses (HPV) in cervical smears showing intraepithelial neoplasia (CIN).

METHODS

The presence of 14 high risk HPV was evaluated in 114 cervical smears with CIN of different degrees, by comparing a non-radioactive polymerase chain reaction (PCR) enzyme immunoassay (EIA) with conventional PCR followed by radioactive Southern blot hybridisation. General primer PCR amplicons detecting low risk and high risk HPV were typed for 14 different high risk HPV types (HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68) by a non-radioactive PCR-EIA. Virus load of HPV 16 positive CIN was assessed using the semiquantitative PCR-EIA.

RESULTS

Histological evaluation confirmed CIN I in 49 cases (mean age 29.0 years, range 17 to 52), CIN II in 31 cases (mean age 30.8 years, 18 to 54), and CIN III in 34 cases (mean age 31.1 years, 16 to 57). The non-radioactive PCR-EIA showed an overall agreement rate of 90% (kappa value 0.75) when compared with conventional general primer PCR followed by radioactive Southern blot hybridisation. High risk HPVs were detected in 47% of CIN I, 77% of CIN II, and 97% of CIN III (p < or = 0.02). HPV types 39, 51, 56, and 58 were found in CIN I exclusively (between 2% and 8%). HPV 16 and HPV 31 were detected in 12% and 2% of CIN I, 35% and 21% of CIN II, and 74% and 13% of CIN III, respectively (p < or = 0.03 and p < or = 0.04). The virus load estimated by the semiquantitative PCR-EIA of HPV 16 was similar in CIN I, CIN II, and CIN III.

CONCLUSIONS

The PCR-EIA has high clinical sensitivity for detecting CIN II/III (90%). There was a significantly higher prevalence rate of HPV 16 and 31 in CIN III than in CIN I and II.

Laparoscopic para-aortic and pelvic lymphadenectomy: experience with 150 patients and review of the literature

OBJECTIVE

The clinical usefulness of laparoscopic pelvic and para-aortic lymphadenectomy for staging and therapy of gynecological cancer was analyzed prospectively.

METHOD

Laparoscopic para-aortic and pelvic lymphadenectomy was performed in 150 patients with cervical (n = 96), endometrial (n = 41), or ovarian cancer (n = 13). Lymphadenectomy was combined with laparoscopically assisted vaginal radical hysterectomy in 70 patients, with laparoscopically assisted vaginal hysterectomy and/or bilateral salpingo-oophorectomy and/or appendectomy and/or omentectomy in 24 patients, with trachelectomy in 2 patients, and with laparoscopic radical hysterectomy in 2 patients; lymphadenectomy alone was performed in 52 patients. Right-sided para-aortic lymphadenectomy extended to the level of the right ovarian vein; left-sided dissection reached the level of the inferior mesenteric artery. In ovarian tumors, dissection was extended to the level of the renal vessels; in addition, the ovarian vessels were removed with the surrounding tissue. Peri- and postoperative data were collected prospectively to monitor progress of surgical performance.

RESULTS

Mean operative time was 36 min (15-105 min) for right-sided para-aortic and 24 min (12-49 min) for left-sided para-aortic lymphadenectomy; bilateral pelvic lymphadenectomy took 64 min (44-110 min). On average 26.8 (10-56) pelvic lymph nodes and 7.3 (0-19) para-aortic lymph nodes were sampled. Major vessels were injured in 7 patients of which 4 patients required laparotomy. Patients undergoing lymphadenectomy alone were admitted for 3.2 days on average.

CONCLUSIONS

Laparoscopic para-aortic and pelvic lymphadenectomy is effective for staging and treatment of gynecologic cancers.

Laparoscopic assistance for extended radicality of radical vaginal hysterectomy: description of a technique

OBJECTIVE

We developed and standardized a surgical technique, which allows radical hysterectomy by a combined laparoscopic and vaginal approach with radicalness equivalent to a type III procedure according to Rutledge.

METHOD

Thirty-six consecutive patients with cervical cancer stage IB1-IIIA with high risk for parametrial involvement were treated between May 1996 and March 1998.

RESULTS

Bilateral para-aortic and pelvic lymphadenectomy and resection of the cardinal ligaments was performed laparoscopically using bipolar coagulation. Dissection of the ureters and resection of bladder pillars and uterosacral ligaments was performed transvaginally. On average 6.5 cm of cardinal ligament could be removed per side.

CONCLUSIONS

With the laparoscopic-vaginal technique described a radical hysterectomy type III can be performed.

Value of laparoscopic evaluation of paraaortic and pelvic lymph nodes for treatment of cervical cancer

OBJECTIVE

Laparoscopy was used to identify and localize suspicious lymph nodes in patients with cervical cancer.

STUDY DESIGN

Eighty-four patients with cervical cancer International Federation of Gynecology and Obstetrics stage IA2 to IV were staged by laparoscopic paraaortic and pelvic lymphadenectomy. The accuracy of laparoscopic assessment of lymph node status was compared with the histologic result. Positive lymph nodes were localized topographically by use of laparoscopy.

RESULTS

Sensitivity and specificity of laparoscopic evaluation for identifying positive paraaortic and pelvic lymph nodes was 92.3%. Combination of laparoscopic evaluation and frozen section helped to diagnose all patients with involved lymph nodes correctly. In 13 of 84 (15.4%) patients the result of lymph node assessment by laparoscopic evaluation and frozen section changed primary therapy. In two of these patients one positive lymph node was located in the lateral part of the cardinal ligament, and the hysterectomy was extended to be a more radical procedure.

CONCLUSIONS

Laparoscopic evaluation identified the lymph node status in patients with cervical cancer with high accuracy. Topographic localization showed that the lateral part of the cardinal ligament is involved early in lymph node spread.

[Value of laparoscopic pelvic lymph node excision in inguinal vulvar carcinoma metastasis]

We performed a laparoscopic pelvic lymphadenectomy in three patients with vulvar cancer FIGO stage II or III and positive inguinal lymph nodes. Computertomographical and lymphographical findings of pelvic lymph nodes did not correlate with the histological findings in two patients: Surgical staging up-graded the clinical stage in one patient. No intra- or postoperative complications were encountered. Laparoscopic pelvic lymphadenectomy in inguinal metastasizing vulvar cancer is a valuable method with low peri- and postoperative morbidity.

[Abdominal actinomycosis with IUD]

We report a case of abdominal actinomycosis in a 54 year old woman using an intrauterine device for a period of 8 years. The most important finding was a tuboovarialabscess at the left pelvic side with involvement of the serosa of the jejunum, ileum, sigma, and omentum majus. Intraoperative exploration showed a solid retroperitoneal infiltration between the pelvic side wall and sigma. Another infiltration was found on the left side of the abdominal wall. The diagnosis was confirmed by histopathological examination and the patient was treated by a combination of Aminopenicillin and Metronidazol. After a period of three months we observed a complete regression of the clinical and the MRI findings.

[Preserving fertility in early cervix carcinoma: trachelectomy with laparoscopic lymphadenectomy]

We report two cases of trachelectomy with laparoscopic paraaortic and pelvic lymphadenectomy in young women with early cervical cancer. Surgery took 225 and 275 minutes, respectively. A total of 49 and 27 lymph nodes were resected. Both patients were discharged on postoperative day 5. Preservation of fertility in such young women with early disease seems feasible.

[Results of coloscopic polypectomy in respect of the dignity (author's transl)]

The commonest type of polyps in the large intestine in our series of 506 polypectomies in 262 patients were adenomas (64%) especially tubular adenomas. Severe epithelial atypia being present in 11% of all adenomas and it was three times more discovered in villous adenomas than in tubular forms and with increasing adenomas size. Because severe epithelial atypia could be observed in polyps with diameters less than 5 mm it should be demanded to remove each polyp for an exact histological examination independent of his size. Single forceps biopsies of polyps do not allow the estimation of their further development in view of malignancy.

[Gastritis and stomach ulcer]

Patients with ventricular ulcer (n = 109) were examined endoscopically and bioptically concerning the frequency of an at the same time existing gastritis. It was shown that stomachs with ulcer practically without any exception, i.e. in 96 per cent, had a pangastritis. In the endoscopic comparative group without focal lesions (n = 231) a gradually less pronouncedly expressed gastritis is present than in patients with ulcer. Patients with gastric ulcer and such persons with endoscopical negative dyspepsia (endoscopic comparative group) have common the more pronounced appearance of the gastritis in the antrum (antritis) than in the corpus. Gastric ulcers appeared in males at the age from 30 to 49 years twice as often as in females. The latter showed an approximately linear increase of the frequency of corpus ulcers between 20 and 69 years. In antrum ulcers like in duodenal ulcers the males dominate at the age from 20 to 59 years, whereas the females prevail in the 7th decennium.

[Duodenitis]

In 211 bulboscopies 108 normal findings, 29 duodenal ulcers, 44 cases of scar bulb, 4 times erosions of the bulb and 26 times a bulbitis alone (macroscopically) were found. The macroscopic findings duodenitis were confirmed histologically in 85%, the macroscopic findings normal bulbous mucous membrane only in 30% of the cases. In patients with the histological findings duodenitis the bulbous mucous membrane was endoscopically regarded as normal in 70% of the cases. Patients with duodenitis more frequently have an antrum gastritis and less frequently a corpus gastritis than a control group corresponding to age without any macroscopic changes at the stomach and duodenal bulb. On account of its clinico-therapeutic importance is referred to the fact to demarcate the peptic corrosive bulbitis (bulbitis with bulboscopically probable lesion) from the bulbitis without bulboscopic lesion.

[Chronic gastritis in stomach cancer]

In a random test of 128 patients with neoplasms of the stomach and in a control group of 170 persons corresponding to age without any focal lesion at the stomach the connection between carcinoma of the stomach and the chronic gastritis was tested. The carcinoma of the stomach is always accompanied by chronic gastritis. The chronic atrophic gastritis with intestinal metaplasia is significantly more frequent than in control persons. We found the chronic atrophic gastritis with intestinal metaplasia more frequently than in the adenocarcinoma (environmental carcinoma) than in the solid carcinoma. The clear dependence of age of the carcinoma of the stomach is confirmed; particularly great increase of the frequency of the carcinoma in the male in the fourth to the seventh decennium of life, in which case males more frequently have an adenocarcinoma, females, on the other hand, a solid carcinoma.

[The so called early stomach carcinoma and its histological definition]

The histological findings of twenty bioptically diagnosed early cancers of the stomach are described. In the delimitation of the so-called borderline-lesions the intestinal metaplasia in the mucous membrane of the stomach must particularly be taken into consideration. The differentiated ripe form of the intestinal metaplasia is no precancerosis. However, within the process of intestinalisation atypias may appear, which represent possible transitional forms to carcinoma.