Faculty Bibliography

BACKGROUND/UNASSIGNED:Number of organ transplant recipients continues to rise worldwide with increasing accessibility and growing advancements in transplant medicine. Transplant patients have at least a two-to-four fold higher risk of developing cancer compared to the general population. As the prevalence of transplant patients increases, a growing number of these patients are expected to present with concurrent conditions such as cancer, requiring more complex and interdisciplinary care. CASE/UNASSIGNED:A 44-year-old patient with an intraperitoneal pelvic renal transplant, found to have high-grade ovarian adenocarcinoma most likely arising from endometriosis, successfully underwent surgical staging, adjuvant chemotherapy, and subsequent pelvic radiation for recurrence. Her kidney function and graft viability were preserved throughout her treatment with careful monitoring. CONCLUSION/UNASSIGNED:Management of reproductive tract cancers in kidney transplant recipients is complex. Current practices largely rely on evidence from observational studies and case reports for these cancers and more research is needed in this area.

OBJECTIVE/UNASSIGNED:The use of energy during minimally invasive surgery is associated with thermal damage that can affect the process of wound healing. METHODS/UNASSIGNED:This was a randomized clinical trial including 78 women who underwent total laparoscopic hysterectomy. Patients were randomized based on the device used for colpotomy, monopolar hook versus harmonic scalpel. The thickness of the cauterized margins in the cervicovaginal tissues of the hysterectomy specimens was measured by the pathologist. RESULTS/UNASSIGNED: = 0.001)). With regard to secondary outcome measures, there was no significant difference between the two groups. CONCLUSION/UNASSIGNED:https://en.irct.ir/trial/33902?revision=61236. IRCT20180130038567N2.

BACKGROUND/UNASSIGNED:Number of organ transplant recipients continues to rise worldwide with increasing accessibility and growing advancements in transplant medicine. Transplant patients have at least a two-to-four fold higher risk of developing cancer compared to the general population. As the prevalence of transplant patients increases, a growing number of these patients are expected to present with concurrent conditions such as cancer, requiring more complex and interdisciplinary care. CASE/UNASSIGNED:A 44-year-old patient with an intraperitoneal pelvic renal transplant, found to have high-grade ovarian adenocarcinoma most likely arising from endometriosis, successfully underwent surgical staging, adjuvant chemotherapy, and subsequent pelvic radiation for recurrence. Her kidney function and graft viability were preserved throughout her treatment with careful monitoring. CONCLUSION/UNASSIGNED:Management of reproductive tract cancers in kidney transplant recipients is complex. Current practices largely rely on evidence from observational studies and case reports for these cancers and more research is needed in this area.

Ovarian endometriomas affect many patients with endometriosis and have significant effects on quality of life, fertility, and risk of malignancy. Endometriomas range from small (1-3 cm), densely fibrotic cysts to large (20 cm or greater) cysts with varying degrees of fibrosis. Endometriomas are hypothesized to form from endometriotic invasion or metaplasia of functional cysts or alternatively from ovarian surface endometriosis that bleeds into the ovarian cortex. Different mechanisms of endometrioma formation may help explain the phenotypic variability observed among endometriomas. Laparoscopic surgery is the preferred first-line modality of diagnosis and treatment of endometriomas. Ovarian cystectomy is preferred over cyst ablation or sclerotherapy for enabling pathologic diagnosis, improving symptoms, preventing recurrence, and optimizing fertility outcomes. Cystectomy for small, densely adherent endometriomas is made challenging by dense fibrosis of the cyst capsule obliterating the plane with normal ovarian cortex, whereas cystectomy for large endometriomas can carry unique challenges as a result of adhesions between the cyst and pelvic structures. Preoperative and postoperative hormonal suppression can improve operative outcomes and decrease the risk of endometrioma recurrence. Whether the optimal management, fertility consequences, and malignant potential of endometriomas vary on the basis of size and phenotype remains to be fully explored.

Endometriosis is a frequent, estrogen-dependent, chronic disease, characterized by the presence of endometrial glands and stroma outside of the uterine cavity. Although it is not considered a precursor of cancer, endometriosis is associated with ovarian cancer. In this review, we summarized the evidence that clear-cell and endometrioid ovarian carcinomas (endometriosis-associated ovarian carcinoma-EAOC) may arise in endometriosis. The most frequent genomic alterations in these carcinomas are mutations in the AT-rich interaction domain containing protein 1A (ARID1A) gene, a subunit of the SWI/SNF chromatin remodeling complex, and alterations in phosphatidylinositol 3-kinase (PI3K) which frequently coexist. Recent studies have also suggested the simultaneous role of the PTEN tumor-suppressor gene in the early malignant transformation of endometriosis and the contribution of deficient MMR (mismatch repair) protein status in the pathogenesis of EAOC. In addition to activating and inactivating mutations in cancer driver genes, the complex pathogenesis of EAOC involves multiple other mechanisms such as the modulation of cancer driver genes via the transcriptional and post-translational (miRNA) modulation of cancer driver genes and the interplay with the inflammatory tissue microenvironment. This knowledge is being translated into the clinical management of endometriosis and EAOC. This includes the identification of the new biomarkers predictive of the risk of endometriosis and cancer, and it will shape the precision oncology treatment of EAOC.

Objective: The use of energy during minimally invasive surgery is associated with thermal damage that can affect the process of wound healing. Methods: This was a randomized clinical trial including 78 women who underwent total laparoscopic hysterectomy. Patients were randomized based on the device used for colpotomy, monopolar hook versus harmonic scalpel. The thickness of the cauterized margins in the cervicovaginal tissues of the hysterectomy specimens was measured by the pathologist. Results: The primary outcome was the amount of lateral thermal damage based on histologic assessment. Secondary endpoints included postoperative pain scores and postoperative complications. Baseline characteristics were comparable between the two groups. The amount of thermal injury in the monopolar group was significantly greater in only one region, the right lateral order of the cuff (3.85 ± 1.01 mm vs. 3.08 ± 0.95 mm (p = 0.001)). With regard to secondary outcome measures, there was no significant difference between the two groups. Conclusion: The use of the harmonic device was associated with significantly less tissue damage during colpotomy in the right lateral cuff region. This is especially important in overweight and obese women in whom the distance between the cervix and the ureter is shorter. Trial Registration https://en.irct.ir/trial/33902?revision=61236. IRCT20180130038567N2.

Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000, approximately 2 to 20 times more frequently than in the age-matched general population. The most common types of adnexal masses in pregnancy requiring surgical management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%), serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of adnexal masses in pregnancy are malignant. While most adnexal masses in pregnancy can be safely observed and around 70% spontaneously resolve, a minority warrant surgical intervention due to symptoms, risk of torsion, or suspicion for malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy due to accuracy, safety, and availability. Several ultrasound mass scoring systems, including the Sassone, Lerner, International Ovarian Tumor Analysis (IOTA) Simple Rules, and IOTA Assessment of Different NEoplasias in the adneXa (ADNEX) scoring systems have been validated specifically in pregnant populations. Decisions regarding expectant versus surgical management of adnexal masses in pregnancy must balance the risks of torsion or malignancy with the likelihood of spontaneous resolution and the risks of surgery. Laparoscopic surgery is preferred over open surgery when possible due to consistently demonstrated shorter hospital length of stay and less post-operative pain, as well as some data demonstrating shorter operative time, lower blood loss, and lower risks of fetal loss, pre-term birth, and low birth weight. Best practices for laparoscopic surgery during pregnancy include left lateral decubitus positioning after the first trimester, port placement with respect to uterine size and pathology location, insufflation pressure of less than 12-15 mm Hg, intraoperative maternal capnography, pre- and post-operative fetal heart rate and contraction monitoring, and appropriate mechanical and chemical thromboprophylaxis. While planning surgery for the second trimester generally affords time for mass resolution while optimizing visualization with regards to uterine size and pathology location, necessary surgery should not be delayed due to gestational age. When performed at a facility with appropriate obstetric, anesthetic, and neonatal support, adnexal surgery in pregnancy generally results in excellent outcomes for mother and fetus.

BACKGROUND:Congenital müllerian anomalies are found in 8.0% of women with infertility and up to 5.5% of women in a general population. Cervical diverticulum is a type of cervical malformation that can be congenital or acquired, with only select cases documented in the literature. Cervical diverticulum can be asymptomatic or present with abnormal uterine bleeding, pelvic pain, or infertility. Previously described management options are largely limited to observation or exploratory laparotomy. CASE:A 35-year-old woman, gravida 2 para 2, presented with persistent menorrhagia, pelvic pain, and abdominal bloating and was found to have an 8-cm right adnexal mass on pelvic ultrasonography. Magnetic resonance imaging showed a hemorrhagic cervical mass communicating with the uterine cavity. The mass was resected laparoscopically, and pathology revealed fibromuscular tissue with endocervical epithelium consistent with a cervical diverticulum. CONCLUSION:Isolated cervical diverticula are rare but should be considered in the differential diagnosis of adnexal masses. Laparoscopic surgery is a safe, minimally invasive approach for evaluation and repair of cervical diverticula.