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VNOTES is a novel technique that allows access to the pelvic-abdominal cavity through the vagina. Myomectomy can be performed by vNOTES even through anterior cul-de-sac incision and for selected cases of uterine malformation. Here we present a 29-years-old patient with a complaint about pelvic discomfort. Pelvic examination revealed an 8 cm palpable mass in the right iliac region. The magnetic resonance exam revealed a bicornuate uterus attached to a subserosal fibroid that was 7.7 × 6.6 × 6.0 cm in size. The fibroid was positioned anteriorly to the uterus so the vNOTES approach was indicated through the anterior cul-de-sac. The surgery was performed without any complication and the patient was discharged the next day. The final pathological analysis confirmed uterine leiomyoma and the patient had a good postoperative evaluation. In Conclusion, vNOTES myomectomy may be feasible for selected patients even with uterine malformation., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Competing Interests: Competing interests: None declared.

Objective:  To evaluate whether the use of intraoperative ultrasound leads to more conservative surgeries for benign ovarian tumors., Methods:  Women who underwent surgery between 2007 and 2017 for benign ovarian tumors were retrospectively analyzed. The women were classified into two groups: those who underwent intraoperative ultrasound (group A) and those who did not (group B). In group A, minimally-invasive surgery was performed for most patients (a specific laparoscopic ultrasound probe was used), and four patients were submitted to laparotomy (a linear ultrasound probe was used). The primary endpoint was ovarian sparing surgery (oophoroplasty)., Results:  Among the 82 cases identified, only 36 met the inclusion criteria for the present study. Out of these cases, 25 underwent intraoperative ultrasound, and 11 did not. There were no significant differences in arterial hypertension, diabetes, smoking history, and body mass index for the two groups ( p  = 0.450). Tumor diameter was also similar for both groups, ranging from 1 cm to 11 cm in group A and from 1.3 cm to 10 cm in group B ( p  = 0.594). Tumor histology confirmed mature teratomas for all of the cases in group B and for 68.0% of the cases in group A. When the intraoperative ultrasound was performed, a more conservative surgery was performed ( p  < 0.001)., Conclusion:  The use of intraoperative ultrasound resulted in more conservative surgeries for the resection of benign ovarian tumors at our center., Competing Interests: The authors have none to declare., (Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil.)

Glauco Baiocchi, M.D., Ph.D., Maria Dirlei Begnami, M.D., Ph.D., Michael Jenwei Chen, M.D., Elza Mieko Fukazawa, M.D., Ph.D., Levon Badiglian-Filho, M.D., Ph.D., Antonio Cassio Assis Pellizzon, M.D., Ph.D., Fernando Augusto Soares, M.D., Ph.D., and Ademar Lopes, M.D., Ph.D. OBJECTIVE: To evaluate HER-2 expression as a predictor of the response to radiotherapy and its value as a prognostic marker. STUDY DESIGN: A retrospective analysis was performed in a series of 34 individuals with advanced stage cervical cancer who underwent radiotherapy followed by radical hysterectomy. HER-2 expression was measured by immunohistochemistry in biopsies from all patients prior to radiotherapy and in 14 patients with residual tumors after radiotherapy. The presence of gene amplification was also examined. RESULTS: Eighteen (53%) patients had residual disease after radical hysterectomy. HER-2 was expressed in 26.5% of cases. Gene amplification by FISH was detected in 2.9% of cases. HER-2 expression was associated with a higher risk of residual disease after radiotherapy (p= 0.019). HER-2 expression did not correlate with the risk of recurrence or death. CONCLUSION: The prevalence of HER-2 expression is low in cervical cancer, and although HER-2 can predict the response to radiotherapy, it does not correlate with poor outcomes.

We hypothesized that the activation of cyclooxygenase (COX)-2, epidermal growth factor receptor (EGFR), and ErbB-2 signaling is required for cervical intraepithelial neoplasia (CIN) lesions to progress to cervical cancer. A retrospective analysis was performed in 179 patients with Stage I squamous cell carcinoma (SCC) and 233 patients with CIN (112 CIN I, 47 CIN II, and 74 CIN III). COX-2, EGFR, and ErbB-2 expression was analyzed by immunohistochemistry using the ACIS III automated imaging system. The mean expression of COX-2, EGFR, and ErbB-2 was compared between the various stages of CIN and SCC. COX-2 mean expression was predominantly cytoplasmic, increasing significantly from CIN I to CIN II, CIN III, and SCC (P<0.001). EGFR mean expression also rose significantly during tumor progression from CIN I to SCC (P=0.001). CIN I samples were negative for ErbB-2 expression. CIN II, CIN III, and SCC were considered positive for ErbB-2 expression in 2.2%, 14%, and 16.2% of cases, respectively. There was also a statistically significant correlation between increase of ErbB-2 positivity from CIN to SCC. We conclude that COX-2, EGFR, and ErbB-2 expression increase significantly during the progression of CIN to cancer.

Objectives: To examine the immunohistochemical expression of cyclooxygenase-2 (COX-2) and nuclear factor-κB (NF-κB) in benign endometrial polyps (EPs), endometrial hyperplasia (EH), endometrial intraepithelial neoplasia (EIN), and endometrioid endometrial cancer (EC)., Methods: The immunohistochemical expression of COX-2 and NF-κB was performed using an Aperio Scanscope XT automated system in 218 patients with endometrioid EC and 107 patients with nonmalignant endometrial lesions: 53 with benign EPs, 37 with EH, and 17 with EIN., Results: COX-2 and NF-κB p50 expression were significantly lower in EC compared with nonmalignant lesions. We observed significant decreased NF-κB p65 expression in EC vs EPs (P < .001) and EH (P = .014) as well as in EIN vs. EPs (P = .01). For patients with EC, COX-2 correlated positively with NF-κB p65 and NF-κB p50 (P < .001). Grade 3 tumors had a higher mean expression of NF-κB p65 (P = .03). NF-κB p50, NF-κB p65, and COX-2 expression had no impact on survival., Conclusions: We conclude that COX-2 and NF-κB expression are lower in EC compared with nonmalignant endometrial lesions. COX-2 and NF-κB expression have no prognostic value in EC.

Objective: Inguinal lymph node (LN) metastasis is an important prognostic factor in vulvar cancer. Our aims were to analyze the prognostic value of LN metastasis with regard to the number of LNs that were involved and their laterality and compare these results with the current FIGO staging system., Methods: A retrospective analysis was performed in a series of 234 individuals who underwent inguinal lymphadenectomy for vulvar squamous cell carcinoma from January 1980 to February 2010., Results: The mean age was 68 years. One hundred seven (45.7%) patients had LN metastasis. Despite the FIGO staging, we did not observe any significant difference in the risk of recurrence or death between patients with 1 positive LN and ≥ 2 positive LNs. Moreover, there was no difference in outcome between the presence of 1 and 2 positive LNs. On categorizing patients into 3 groups-absence of LN involvement, 1-2 positive LNs, and ≥ 3 positive LNs-we achieved a significantly better prognostic correlation for progression-free survival, disease-specific survival, and overall survival. Extracapsular spread retained a prognostic role for the risk of recurrence in multivariate analysis. Further, for patients with ≥ 2 positive LNs, the presence of bilateral positive LNs did not negatively impact the risk of recurrence or death compared with those with unilateral positive LNs., Conclusions: Our data suggest that the prognostic effect of bilateral LNs reflects the worse prognosis of multiple positive LNs. Regarding prognosis, LN involvement should be categorized into 2 groups-1-2 positive LNs and ≥ 3 positive LNs., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Inguinal lymph node (LN) metastasis is an important prognostic factor in vulvar cancer. Our aim was to determine the prognostic value of the number of resected LNs in inguinofemoral lymphadenectomy., Methods: A retrospective analysis was performed in a series of 158 individuals who underwent bilateral inguinofemoral lymphadenectomy for vulvar squamous cell carcinoma from January 1980 to February 2010., Results: The mean age was 67 years (range: 15-90). Median tumor size was 5 cm (range: 1-18). A median of 22.5 inguinal LNs (range: 2-57) was resected. Thirteen (8.2%) patients had <12 LNs resected, and 145 (91.8%) had ≥ 12 LNs resected. Eighty (50.6%) patients had LN metastasis, with a median of 2 positive LNs (range: 1-16). Of those with positive LNs, 19 (23.8%), 23 (28.8%), and 38 (47.5%) patients had 1, 2, and 3 or more positive LNs, respectively. Thirty-three (41.2%) patients had bilateral LN metastasis. For patients without LN involvement, we failed to observe any significant difference between patients with <12 LNs and ≥ 12 LNs that were resected with regard to risk of recurrence (p=0.97) and death from cancer (p=0.43) in 5 years. However, resection of <12 LNs in patients with positive LNs negatively impacted the risk of recurrence (p=0.003) and death from cancer (p=0.043)., Conclusions: Resection of fewer than 12 LNs in vulvar cancer has a negative impact on outcome for patients with positive inguinal LNs., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Aims: The nuclear factor κ B (NF-κB) family comprises transcription factors that promote the development and progression of cancer. The NF-κB pathway is induced by radiation therapy and may be related to tumour radioresistance. The aim of this study was to evaluate the expression of NF-κB as a predictor of the response to radiotherapy and its value as a prognostic marker., Methods: A retrospective analysis was performed in a series of 32 individuals with stage IB2 and IIB cervical cancer who underwent radiotherapy, followed by radical hysterectomy, from January 1992 to June 2001. NF-κB-p65 and NF-κB-p50 expression was examined by immunohistochemistry in biopsies from all patients before radiotherapy and in 12 patients with residual tumours after radiotherapy., Results: 16 (50%) patients had residual disease after radical hysterectomy. The median follow-up time was 73.5 months, and the 5-year overall survival was 66.5%. Before radiotherapy, cytoplasmic expression of NF-κB-p65 and NF-κB-p50 was noted in 91% and 97% of cases, respectively, versus 59% of cases with nuclear expression of these subunits. Cytoplasmic expression of NF-κB-p65 and NF-κB-p50 in the residual tumours after radiotherapy was observed in 50% of cases; 75% of cases with residual tumours had nuclear expression of NF-κB-p50 versus none with NF-κB-p65. NF-κB-p65 and NF-κB-p50 did not correlate with the risk of residual tumours after radiotherapy or recurrence or death., Conclusions: These data suggest that NF-κB does not predict the response to radiotherapy and does not correlate with poor outcomes in advanced cervical cancer.

Purpose: Teratoma is one of the most common ovarian neoplasms and frequently leads to laparoscopic surgical procedure. When this tumor is small and the ovarian surface seems regular during the surgery, it is difficult to localize the tumor., Methods: We used a standard transvaginal ultrasound probe during the procedure and filled the pelvic cavity with saline solution of 0.9% in order to create an interface between the saline solution and the surgical instruments., Results: We could localize the teratoma with confidence and precision, allowing to perform a sparing surgery., Conclusion: This is a simple, secure and efficient technique that can be performed in most of the institutions.

Background: Studies addressing mesenteric and mesocolic lymph node metastasis in patients with advanced ovarian cancer that have undergone bowel resection are lacking., Methods: A retrospective analysis was performed in a series of 50 individuals who underwent surgical cytoreduction for epithelial ovarian cancer that included bowel resection from April 2004 to September 2010., Results: Forty-one patients had bowel resection with mesenteric lymph nodes that were suitable for analysis. Twenty-four (58.5%) patients underwent retosigmoidectomies, 14 (34.1%) received other types of colectomies, and three (7.3%) underwent small bowel resection. There was serosal involvement in 14 cases (34.1%), muscularis propria invasion in 13 cases (31.7%), submucosa invasion in six cases (14.6%), and mucosa in eight cases (19.5%). Lymphatic invasion was observed in 24 patients (58.5%). A median of 14 mesenteric lymph nodes were analyzed. Metastatic lymph nodes were observed in 29 (70.7%) cases. Invasion into the muscularis propria (P = 0.036), lymphatic invasion (P = 0.045), and retroperitoneal lymph node metastasis (P = 0.002) correlated significantly with mesenteric lymph node involvement., Conclusions: Resection of regional lymph nodes of affected organs that is similar to surgical procedures that are performed for colorectal carcinoma is an appropriate, optimal debulking surgery for patients with ovarian carcinoma., (Copyright © 2011 Wiley-Liss, Inc.)

Embryonal rhabdomyosarcoma (RMS) of the female genital tract usually occurs in the vagina during childhood. The uterine cervix as a primary site is rare, but is more frequent until the second decade of life. It usually has a good prognosis and the treatment is based on multidrug chemotherapy, radiotherapy and surgery. RMS accounts for <5% of all adult soft tissue sarcomas. Previous reports that included all primary sites showed a poorer five-year disease specific survival for adults with RMS when compared to the pediatric population. This difference has been attributed to a higher proportion of adverse prognostic clinical and pathological factors, and to inadequate treatment given to adults with RMS. A total of 115 patients with cervical embryonal RMS have previously been described; however, only 10 cases were reported in women older than 40 years. We present a 47-year-old woman treated with radical hysterectomy followed by adjuvant chemotherapy and review the current literature., (© 2011 The Authors. Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology.)

Lymphangitic carcinomatosis of the lungs secondary to cervical cancer is a rare condition. It still has an unknown pathophysiology and is related to high mortality rates. Diagnosis is often delayed due to the common symptoms of nonproductive cough and dyspnea. There are only 10 cases described in the literature. Most of the reported cases received only supportive care due to low performance status. Only three reported patients received palliative chemotherapy. We describe a case that has successfully received platinum-based chemotherapy.

Purpose: Chylous ascites is an infrequent postoperative complication after retroperitoneal surgical procedure. Despite its infrequent occurrence, postoperative chylous ascites are associated with significant morbidity. Reports of chylous ascites or fistula after retroperitoneal lymph node dissection for gynecologic malignancies without radiation therapy are rare. A search in the English literature showed only 31 cases of chylous fistula for gynecologic malignancies. Treatment may be conservative with low-fat oral diet with medium-chain triglycerides associated or not to octreotide and total parenteral nutrition. In case of conservative measures failure, it can be managed by surgical intervention or peritoneo-venous shunt., Methods: We report two cases of chylous fistula following systematic pelvic and retroperitoneal lymph node dissection for gynecological cancer without radiotherapy and review the literature., Results: Both were successfully managed with the maintenance of the postoperative drain, total parenteral nutrition, octreotide and dietary intervention., Conclusions: Chylous ascites should be included in differential diagnosis of abdominal distention after surgical retroperitoneal approach or radiotherapy. Most of the patients may have their chylous ascites successfully treated with conservative management. However, the best policy is to prevent chylous complications by employing meticulous dissection techniques and careful control of the major lymphatics by suture ligation during the primary surgical intervention.

Context and Objective: Vulvar melanoma is a rare disease. We describe the experience of a single institution and review the literature., Design and Setting: Retrospective study at the Department of Gynecology, Hospital do Cancer A. C. Camargo., Methods: Eleven patients with vulvar melanoma attended between January 1987 and December 2006 were reviewed regarding clinicopathological characteristics, surgical therapy and follow-up., Results: The initial symptoms were vulvar lesions, pruritus, pain and bleeding. The median age was 64.8 years. The median depth of invasion was 3.08 mm. The staging ranged from IB to IIIC (American Joint Committee on Cancer, 2002). All the patients underwent vulvectomy. Two patients did not undergo primary elective lymphadenectomy. Bilateral inguinal lymphadenectomy was performed on five patients, and one had unilateral inguinal lymphadenectomy. Sentinel lymph node investigation was performed on three patients. Five patients had locoregional recurrence. Prolonged survival was only achieved in the absence of lymph node involvement. The median follow-up was 56 months. The median disease-free survival was 15 months and the median overall survival was 29 months., Conclusions: The prognosis for patients with vulvar melanoma is generally poor, with a high tendency towards regional and distant recurrence. Depth of invasion and lymph node involvement are the most important prognostic factors. In most cases, resection of the lesion with adequate margins may replace vulvectomy. Elective inguinal femoral lymphadenectomy remains the standard lymph node staging procedure. Sentinel lymph node investigation is feasible and should be performed by a multidisciplinary team with experience of this method.