Satoyo Otsuka

Intra- and postoperative complications associated with diaphragmatic surgery for advanced ovarian cancer

Diaphragmatic resection is frequently required to achieve optimal cytoreduction with no residual disease in patients with advanced ovarian cancer. Pleural effusion and pneumothorax are known short-term postoperative complications of diaphragmatic resection; however, few studies have reported intraoperative and long-term postoperative complications of this procedure. We investigated the intraoperative, as well as short- and long-term postoperative complications of diaphragmatic resection. Of the patients with stage III/IV ovarian cancer, who were initially treated at our hospital between 2008 and 2020, 267 patients who underwent diaphragmatic resection were included in this study. We recorded details regarding the type of diaphragmatic resection, type of closure, and intraoperative, as well as short- and long-term postoperative complications. Of the 264 patients who underwent right-sided diaphragmatic resection, 235 underwent full-thickness resection and 29 underwent peritoneal stripping. Of the 118 patients who underwent left-sided diaphragmatic resection, 23 underwent full-thickness resection and 95 underwent peritoneal stripping. Intraoperative complications occurred in 5 patients (massive bleeding from the right hepatic vein [n=1], massive bleeding during excision of the liver adherent to the diaphragm [n=1], and lung injury [n=3]). Short-term complications included pleural effusion that necessitated drainage in 2 and pneumothorax after drain removal in 1 patient. Long-term complications included right diaphragmatic hernia in 1, left diaphragmatic hernia in 2, and pancreaticopleural fistula in 1 patient. Diaphragmatic resection was associated with a low incidence of intra- and postoperative complications, which highlights the safety of this approach for management of advanced ovarian cancer.

Evaluation of the usefulness of sentinel lymph node mapping using indocyanine green in patients with cervical and endometrial cancers: A single‐center prospective exploratory study

AbstractAimSentinel lymph node (SLN) mapping using indocyanine green (ICG) is an alternative for reducing comprehensive lymph node dissection and its associated morbidity. This trial aimed to assess the efficacy and safety of ICG for SLN detection in patients with cervical and endometrial cancers at a single academic teaching hospital.MethodsThis single‐arm, open‐label trial conducted at Chiba University Hospital included patients with endometrial or cervical cancer, aged 20–70 years, with an Eastern Cooperative Oncology Group performance status of 0 or 1. ICG was injected into the uterine cervix after anesthesia induction. For patients with endometrial cancer, ICG was additionally injected into the uterine myometrium after laparotomy. Imaging‐assisted surgery was then performed to locate and remove the SLNs. Systematic pelvic lymph node dissection was performed as the standard procedure, with additional para‐aortic lymph node dissection in selected cases.ResultsThe overall and bilateral SLN detection rates were 80.4% (37/46) and 50.0% (23/46), respectively. SLN identification was successful in 37 patients. Of these, 34 had pathologically negative SLNs, and all of them showed no lymph node metastasis in the backup dissection (negative predictive value: 100%). The remaining three cases had pathologically positive SLNs. No adverse events were observed in a total of 49 enrolled patients.ConclusionsICG injection was found to be safe. SLN mapping using ICG has demonstrated significant potential in reducing surgical interventions and associated complications in the treatment of early‐stage gynecological cancers.

Macroscopic Monozygotic Androgenetic/Biparental Mosaicism: Molecular Characterization and Clinical Implications

ABSTRACTHydatidiform moles represent abnormal pregnancies characterized by trophoblastic hyperproliferation. However, accurate diagnosis of partial hydatidiform moles (PHM) remains challenging. We present a rare case of a monozygotic androgenetic/biparental mosaic in a 26‐year‐old primigravida. The patient was referred to our institution for a suspected PHM, and ultrasonography revealed a nonviable embryo‐like structure alongside villous formations with focal cystic changes. Pathological examination of the evacuated tissue revealed the coexistence of normal and hydropic villi. Histological assessment with p57KIP2 immunohistochemistry initially suggested PHM; however, some cytotrophoblasts and villous stromal cells were negative for p57KIP2 immunoreactivity. Therefore, we conducted short tandem repeat analysis separately for normal villous tissue and cystic villous lesions to elucidate the genetic origin of this unusual presentation. The normal villous portion exhibited biparental diploidy, whereas the cystic villous portion exhibited androgenetic monospermic patterns. Comparisons across all 16 loci revealed concordance between the paternal alleles of biparental diploid villi and the androgenic molar alleles, indicating a single sperm origin. SNP array analysis with B allele frequency plotting confirmed these findings at the whole‐genome level; normal villi showed biparental diploid patterns, whereas cystic villi displayed uniparental disomic patterns. These results demonstrate that both components originated from a monozygotic conception rather than from dizygotic twinning. Therefore, we propose a clinical category based on the sequelae of endoduplication and the formation of a tripolar spindle apparatus through the first meiotic division, encompassing macroscopic androgenetic/biparental mosaicism, twin pregnancy with a hydatidiform mole, microscopic androgenetic/biparental mosaicism, and confined placental mosaicism. Given the presence of androgenetic elements and our institutional experience with gestational trophoblastic neoplasia development in a similar case, we recommend that such cases be managed according to complete hydatidiform mole surveillance protocols. This case highlights the diagnostic challenges posed by monozygotic androgenetic/biparental mosaic mechanisms and emphasizes the importance of molecular genetic analysis for the accurate diagnosis and appropriate clinical management of atypical hydatidiform moles.

Resolution of pelvic postoperative spindle cell nodule with sarcomatous onset after 9 years of follow‐up

AbstractIntroductionPostoperative spindle cell nodules are benign and reactive lesions that occur at the previous surgical site. It often develops like a sarcoma and is resected via highly invasive procedures. To date, there have been no published reports on the natural progression of postoperative spindle cell nodules without surgical intervention.CaseA 45‐year‐old woman underwent a total abdominal hysterectomy for leiomyoma. A 5‐cm pelvic mass exposed in the vaginal stump developed 7 weeks later, causing genital bleeding. Positron emission tomography–computed tomography revealed a pelvic mass and an enlarged pelvic lymph node with high uptake. We suspected an invasive sarcoma in the pelvis. However, through a transvaginal needle biopsy, the mass was diagnosed as a postoperative spindle cell nodule posthysterectomy. The nodule slowly reduced in size and completely disappeared 9 years posthysterectomy.ConclusionsCorrect diagnosis of this nodule with sarcomatous onset based on biopsy was important to avoid unnecessary surgeries. The lesion completely disappeared spontaneously after long‐term follow‐up.

Predictors of postoperative pancreatic fistula after splenectomy with or without distal pancreatectomy performed as a component of cytoreductive surgery for advanced ovarian cancer

Splenectomy with or without distal pancreatectomy is occasionally performed during cytoreductive surgery for advanced ovarian cancer. We investigated pre-, intra-, postoperative risk factors and predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) in patients who underwent cytoreductive surgery for advanced ovarian cancer. We investigated 165 consecutive patients with ovarian, fallopian tube, and peritoneal carcinoma categorized as stage III/IV disease, who underwent splenectomy with or without distal pancreatectomy as a component of cytoreductive surgery performed as initial treatment at Chiba University Hospital. Patient characteristics, clinical factors, and surgical outcomes were compared between those with and without CR-POPF. CR-POPF occurred in 20 patients (12%). There were no significant intergroup differences in the characteristics between patients with CR-POPF and patients without CR-POPF except for operative time, intraoperative blood loss, amylase (AMY) levels in drain fluid on postoperative day (POD)1 and POD3, and pancreatic stump thickness. Multivariate analysis showed that the POD3 drain fluid AMY level was the only significant risk factor and predictor of CR-POPF in patients who underwent cytoreductive surgery for advanced ovarian cancer. The receiver operating characteristic curve of the POD3 drain fluid AMY level, which predicted development of CR-POPF showed an area under the curve of 0.77, and the optimal cut-off value of AMY was 808 U/L. A pancreatic fistula did not occur in patients with POD3 drain fluid AMY levels <130 U/L. The POD3 drain fluid AMY level can be early diagnostic predictor CR-POPF after splenectomy with or without distal pancreatectomy for advanced ovarian cancer.