The American Surgeon™

Metastasectomy for Isolated Right-Sided Thoracic Lymph Node Metastasis From Tubal Carcinoma

Clinical Characteristics and Diagnostic-Therapeutic Analysis of Pulmonary Benign Metastasizing Leiomyoma: A 10-Case Retrospective Study and Systematic Review

Background Pulmonary benign metastasizing leiomyoma (PBML), characterized by histologically benign lung metastases from uterine leiomyomas, represents a rare hormone-dependent entity with enigmatic pathogenesis. The aim of the study was to define the clinical-radiological features and therapeutic management of pulmonary benign metastasizing leiomyoma. Methods A total of 115 cases of PBML in women were reviewed, including 105 cases selected from PubMed and 10 cases treated at our institution from 2014 to 2025. Data encompassed clinical history, imaging findings, pathological diagnosis, treatments, and follow-up outcomes. A comprehensive literature review was undertaken. No prospective interventions were performed. Results A systematic review identified 105 published PBML cases. Combined with our institutional cohort (n = 10), analysis of 115 patients revealed a median age of 46 years, with bilateral pulmonary nodules present in 68.7% of cases and a history of uterine surgery in 92.1%. Immunohistochemistry consistently showed positivity for smooth muscle markers (90%), estrogen receptor (86.3%), and progesterone receptor (88.2%). Surgical resection of pulmonary lesions was performed in 42.6% (49/115) of patients and was associated with a favorable prognosis, with 85.2% (41/48) of surgically managed patients achieving disease-free status during follow-up. Conclusion Pulmonary benign metastasizing leiomyoma is a rare hormone-dependent neoplasm linked to uterine leiomyoma. Pathological verification remains essential for diagnosis. Surgical resection may correlate with favorable outcomes, necessitating long-term recurrence surveillance.

Breast Cancer Surveillance Following Ovarian Cancer in BRCA Mutation Carriers

BRCA1 or 2 mutations result in higher cancer risk for breast cancer (BC) and epithelial ovarian cancer (EOC) for carriers than exists in the general population. Optimal breast imaging surveillance in these patients has not been well defined. An Institutional Review Board-approved, multi-institutional retrospective chart review was performed. Patients diagnosed with BRCA-associated EOC between 1990-2015 were identified; demographic and clinical data were collected and analyzed. 192 BRCA mutation–positive patients with EOC were identified. 16/192 (8.3%) women were diagnosed with BC following EOC, at a median of 50 (range 5-327) months following EOC diagnosis and median age 59.5 (45-84) years. Breast cancer was most commonly detected on mammogram 7/16 (44%) or clinical exam 7/16 (44%). 2/16 (12.5%) had occult BC found during risk-reducing mastectomy. 14 (88%) had early-stage (0-2) disease. At mean follow-up of 8.1 years, 6 (37.5%) patients with BC following EOC had died due to EOC. The risk of BC diagnosis following EOC in BRCA mutation carriers is low; most of these BCs are early stage and diagnosed with mammography or physical exam. Overall, survival in BRCA mutation carriers is dominated by EOC-related mortality. Breast cancer surveillance in BRCA mutation carriers following EOC should prioritize nonsurgical strategies.

Ovary-Sparing Surgery for Ovarian Teratoma in an Infant with Nonbilious Vomiting

Ovarian teratoma is the most common ovarian tumor in children with an overall incidence of 2.6 cases per 100,000 girls per year. Diagnosis and management are challenging due to its nonspecific presentation, malignancy determination, and need to conserve fertility. A previously healthy 5-month-old female infant presented with fever, abdominal distension, and nonbilious emesis, and an 8.2 × 6.8 × 6.1-centimeter pelvic mass originating from the left adnexa was found on imaging. Due to concern for malignancy and torsion, exploratory laparotomy and ovarian-sparing surgery (OSS) with resection of the mass were performed. Histology showed a grade 1 teratoma. This case illustrates a challenging diagnosis and its symptom overlap with other etiologies in infants. The keys to diagnosing and managing this entity are including ovarian pathology in the differential diagnosis and performing OSS whenever possible. Furthermore, ultrasound follow-up is needed to monitor for ipsilateral and contralateral ovarian tumors later in life.

Acute Large Ovarian Cyst After Surgical Resection of Juvenile Granulosa Cell Tumor Stage 1C

Juvenile granulosa cell tumors (JGCTs) are rare, though carry significant burden of morbidity and mortality. A 15-year-old menstruating female with abdominal pain was diagnosed with a large 22.3 cm pelvic mass. CA-125 and LDH were elevated. Exploratory laparotomy was undertaken due to lesion size, and left salpingo-oophorectomy with omentectomy was completed. Pathology confirmed JGCTs with focal disruption, consistent with Stage IC disease. Six weeks postoperatively, the patient experienced recurrent abdominal pain and ultrasound revealed a 7.9 cm right ovarian cystic structure. Given size and nodularity, management was discussed with a multidisciplinary team. Serial ultrasounds demonstrated resolution of the cyst. Workup for ovarian masses in pediatric patients has added complexity of fertility preservation. Once ovarian torsion is ruled out, imaging and laboratory studies are completed to characterize the mass. In pediatric patients with cancer of the Mullerian structures and risk of infertility, decision-making can be challenging and is best managed with a multidisciplinary approach.

Comparison of Outcomes after Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Among Patients with Non-Mucinous vs Mucinous Tumors

Background Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is well established for mucinous cancers with peritoneal dissemination. Its role for non-mucinous tumors is less defined. This study compares outcomes between mucinous and non-mucinous cancer patients undergoing CRS-HIPEC to better understand therapeutic impact. Methods A prospectively maintained database of CRS-HIPEC patients at an academic tertiary referral center from 2011-2023 was analyzed, including patients with appendiceal, colorectal, gastric, ovarian tumors, and soft tissue sarcomas. Survival outcomes were assessed using Kaplan Meier curves and multivariate Cox-proportional hazards models. Results Among 195 patients, 55 (28%) had non-mucinous cancers and 140 (72%) mucinous tumors. The non-mucinous group had lower PCI (median 9 vs 14, P < 0.0001) was more frequently high grade (43.6% vs 22.9%, P = 0.004) with lymph node metastases (65.5% vs 17.1%, P < 0.0001). Length of stay, 30-day readmissions, and Clavien Dindo scores were similar between groups. There was no significant difference in overall (aHR 1.67, 95% CI 0.84-3.33) or cancer-specific survival (aHR 1.34, 95% CI 0.60-3.00) between groups. Non-mucinous patients did have a higher risk of cancer progression (aHR 2.50 95% CI 1.43-4.36), although this was primarily driven by differences in the appendiceal subgroup and was not seen in colorectal cancer patients. Discussion Despite differential loco-regional features, non-mucinous cancer patients had similar survival after CRS-HIPEC. Differences in progression were primarily seen in those with appendiceal cancers, not colorectal tumors. These findings support the use of CRS-HIPEC across histologic subtypes, contributing to prognostication and risk-stratification for patients with differing cancer histopathology.

Inequities in Surgical Access for Women With Endometrial Cancer in the United States: Opportunities for Surgical Justice

Significant disparities exist in women with endometrial cancer. Disparate incidence and mortality rates affect many populations including racial/ethnic minority women and women who live in rural communities. These populations are more likely to experience delays in care due to multi-dimensional factors ranging from lack of awareness between the women and their non-gynecologic providers to lack of access to health care and/or to gynecologic oncologists. Multiple layers of intervention will be needed to mitigate the inequities, including policy changes, advocacy to change insurance coverage, and network inclusion of gynecologic oncologists. There are opportunities for non-gynecological surgical specialists who take care of women at risk of endometrial cancer to facilitate multidisciplinary care and to refer as appropriately to gynecologic specialty care.

Multiple Intraabdominal and Pelvic Cystadenomas From Ovarian Remnant Syndrome

Serous cystadenomas are benign epithelial neoplasms of the ovary, and they typically have an average size of around 10 cm. Our patient is a 68-year-old female who originally presented with abdominal page. Our patient’s prior surgical history includes a bilateral salpingo-oophorectomy. Computed tomography scans showed five abdominal and pelvic masses of significant size. Our patient elected to undergo exploratory laparotomy and mass excision, and all five masses were able to be removed successfully. Final pathology confirmed the diagnosis of serous cystadenomas consistent with ovarian origin despite our patient undergoing a previous bilateral salpingo-oophorectomy. Our patient presented with a rare syndrome known as ovarian remnant syndrome that is thought to be caused by difficult hysterectomy procedures and prior abdominal surgeries that can unknowingly leave ovarian remnants. Second, the patient was found to have 5 abdominal and pelvic masses, and most of the masses were a very large size.

Delayed Hematogenous Metastasis Versus Second Primary Squamous Cell Carcinoma of the Neck in a Patient With Previous Cancer of the Cervix

Squamous cell carcinoma (SCC) of the uterine cervix commonly spreads through direct infiltration and disseminates by lymphatic or hematogenous pathways. The most frequent locations for metastasis are lungs, liver, and bone. Other distant metastatic sites are rare, with only 1 reported case of neck metastasis. We present here a 73-year-old female with a prior human papillomavirus (HPV) + SCC of the cervix that had metastasized to her peri-aortic lymph nodes. Eight years after diagnosis and treatment, she returned with a hypermetabolic supraclavicular lymph node and new left-sided neck mass. Biopsy of the neck mass revealed invasive SCC positive for high-risk HPV genotype. The presence of high-risk HPV genotypes in both the cervix and supraclavicular lymph node, without evidence of second primary tumor, implies that the neck mass is a delayed metastasis of the patient’s previous cervical cancer. This marks the second recorded case of neck metastasis from a SCC of the cervix.

Is It Possible to Prevent Nontherapeutic Laparotomies in Breast Cancer Patients With Isolated Adnexal Masses?

Introduction: The risk of ovarian malignancy is increasing in patients with a history of breast cancer. Thus, well-defined predictors of ovarian malignancy should be identified to determine surgical or conservative management of adnexal masses in women with breast cancer. This study aimed to clarify the predictors of malignant ovarian tumors in patients with breast cancer with an isolated adnexal mass. Methods: Breast cancer patients diagnosed with an adnexal mass who underwent surgery between 2010 and 2021 at a tertiary cancer center were included in the study. Patients with suspected extra ovarian metastases were excluded. Results: A total of 40 breast cancer patients who underwent surgery for ovarian masses were identified. 23 (57.5%) women had benign ovarian tumors and 17 (42.5%) had malignant ovarian tumors. Among the malignant ovarian tumors, there were three (17.6%) metastatic breast cancers in the ovary and 14 (82.4%) primary ovarian cancers. In univariate analyses, the risk of malignant ovarian tumors increased in women with age >52 years ( P = .012), postmenopausal status ( P = .023), CA 125 ≥ 35 IU/ml ( P = .001), CA 15-3 ≥ 32 IU/ml ( P = .002), and complex ovarian masses ( P < .001). Ovarian malignancies were observed in 82.4% of patients who had complex ovarian masses. Conclusion: Ovarian malignancies were diagnosed in 82.4% of the breast cancers who had complex ovarian mass on USG examination. Therefore, surgery is recommended in women with complex ovarian masses. Postmenopausal status, age >52 years, CA 125 ≥ 35 IU/ml, and CA 15-3 ≥ 32 were other risk factors for ovarian malignancy.

Palliative Intervention for Malignant Bowel Obstruction Comes at a Cost: A National Inpatient Study

Background: Malignant bowel obstruction (MBO) due to peritoneal carcinomatosis (PC) is associated with poor outcomes. Optimal management for palliation remains unclear. This study aims to characterize nonoperative, procedural, and operative management strategies for MBO and evaluate its association with mortality and cost. Materials and Methods: ICD-10 coding identified patient admissions from the 2018 to 2019 National Inpatient Sample (NIS) for MBO with PC from gastrointestinal or ovarian primary cancers. Management was categorized as nonoperative, procedural, or surgical. Multivariate analysis was used to associate treatment with mortality and cost. Results: 356,316 patient admissions were identified, with a mean age of 63 years. Gender, race, and insurance status were similar among groups. Length of stay (LOS) was longest in the surgical group (surgical: 17 days; procedural: 14 days; nonoperative: 7 days; P = .001). In comparison to nonoperative, procedural and surgical patients had statistically higher hospital charges, post-discharge medical needs, palliative care consults, and admission to rehab centers. Mortality was 7% in nonoperative, 9% in procedural, and 8% in surgical ( P = .007) groups. In adjusted analyses, older age, palliative care consult, and non-Medicare payer status were associated with higher mortality. Compared to nonoperative, procedural and surgical groups resulted in increased costs (procedural: $17K more; surgical: $30K more). Conclusions: Admissions for procedural and surgical treatment of MBO are associated with increased LOS, hospital costs, and discharge needs. Optimal management remains challenging. Clinicians must examine all options prior to recommending palliative interventions given a trend towards higher resource utilization and mortality.

When to Consider Lynch Syndrome in Non-Colon and Non-Endometrial Malignancies

Lynch syndrome (LS) is a common genetic syndrome characterized by pathogenic mutations of DNA mismatch repair genes resulting in a hereditary predisposition to cancer. While typically associated with colonic and endometrial cancer, LS additionally influences the development of many other malignancies. The Amsterdam II and Revised Bethesda Guidelines are the established clinical criteria for diagnosing LS. These guidelines are based on the most general characteristics of LS and do not address specific characteristics of the less commonly LS-associated malignancies. For individuals that present initially with a non-colon and non-endometrial malignancy, recommendations and guidelines on when to consider screening for LS are limited. Therefore, it is essential that clinicians are familiar with distinct LS-associated patient- and tumor-specific characteristics, especially of the less common LS-associated cancers, so that LS’s diagnosis is not missed. In this review article, we focus on extra-colonic and extra-endometrial LS-associated cancers, paying particular attention to any established or currently investigated cancer features that help raise suspicion for LS and potentially lead to its earlier diagnosis. This review will also discuss current guidelines specific to each LS-associated malignancy.