Spotlight On: Oncology

This month we cast a spotlight on articles, SurgeryU videos, and Journal of Minimally Invasive Gynecology (JMIG) article recommendations from the AAGL Oncology Special Interest Group (SIG) led by Chair, Fernando Heredia, MD. 

Access to SurgeryU and JMIG are two of the many benefits included in AAGL membership. The SurgeryU library features high-definition surgical videos by experts from around the world. JMIG presents cutting-edge, peer-reviewed research, clinical opinions, and case report articles by the brightest minds in gynecologic surgery.

SurgeryU video recommendations by our SIGs are available for public access for a limited time. The links to JMIG article recommendations are accessible by AAGL members only. For full access to SurgeryU, JMIG, CME programming, and member-only discounts on meetings, join AAGL today! 

SurgeryU Video Recommendation #1:

Laparoscopic Transperitoneal Para-aortic Lymphadenectomy
by Drs. Audrey Tieko Tsunoda, Bruno Azevedo, Carlos EMC Andrade, Jose Clemente Linhares, and Reitan Ribeiro

This Video Highlights a Systematic Laparoscopic Transperitoneal approach to Para-Aortic Lymphadenectomy. It displays some tricks to expose appropriately critical retroperitoneal anatomy and the use of advanced energy devices.

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SurgeryU Video Recommendation #2:

Laparoscopic Technique for Extraction of Large Abdominopelvic Masses
by Drs. Kristin Ambacher, Meghan Moulton O’Leary, and Liane M. Belland

This video covers preoperative workup of large adnexal tumors and recommendations for MIS management, showing tricks for a safe extraction.

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SurgeryU Video Recommendation #3: 

Sentinel Lymph Node Mapping in Endometrial Cancer with Indocyanine Green and Overlay Mode
by Drs. Fernando Heredia, Gaston Donetch, Edison Krause, and Armando Menocal

This video shows the state-of-the-art standardized endoscopic management of a presumed early stage (FIGO I-II) Endometrial Cancer. Sentinel node mapping with ICG provides nodal status while sparing full systematic pelvic lymphadenectomy which translates in less morbidity for patients without compromising oncological outcomes. It is of paramount importance to understand this is a procedure that has to follow some rules and also the pathological processing has to be quite special (ultrastaging) to ensure a low false negative rate.

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JMIG Article Recommendation #1:

Success Rates of Sentinel Lymph Node Mapping for Endometrial Cancer in Patients with Body Mass Index < 45 Compared with Body Mass Index ≥ 45
by Drs. Nicole J. Fennimore, Katherine Fitch, Jaime Kiff, Bharti Garg, Elizabeth G. Munro, and Amanda S. Bruegl

This article studies a very important issue regarding sentinel Lymph node mapping in Obese patients. The rate of successful bilateral mapping decreases specially over BMI >45.

Journal of Minimally Invasive Gynecology, Volume 30, Issue 9, p735-741, September 2023, DOI: https://doi.org/10.1016/j.jmig.2023.03.005.

JMIG Article Recommendation #2:

An Extraordinary Location of Sentinel Lymph Nodes in a Patient with Endometrial Cancer
by Drs. Cihan Comba, Erkan Aslan, Betul Vatankulu, Zeynep Tatar, Ali Aslan Demir, and Omer Demir

This video article clearly depicts how important is to develop anatomical spaces and follow the lymphatic channels to identify Sentinel lymph nodes, even in unusual locations. It also shows beautiful second generation Nearly Infrared NIR/IGC platform overlay mode images. This is a major input for sentinel Lymph node mapping.

Journal of Minimally Invasive Gynecology, Volume 30, Issue 8, p613-614, August 2023, DOI: https://doi.org/10.1016/j.jmig.2023.04.012.

TAKING THE UTERUS “OUTSIDE THE BOX” IN GYNECOLOGIC ONCOLOGY

Earlier this year, Dr. Reitan Ribeiro from Brazil communicated the first live birth after laparoscopic Uterine Transposition (UT) (1).

This technique was invented and first reported by Dr. Ribeiro in 2017(2). As a concept, UT is a new surgical option to preserve fertility in patients that need pelvic radiation. Laparoscopic transposition of the uterus to the upper abdomen, outside the planned radiation field, is done by preserving its blood supply through both infundibulopelvic ligaments. After radiation therapy is given, a second endoscopic procedure repositions the uterus in the pelvis. The original case reported by Ribeiro was a 26-year-old nulligravid woman with a 5 cm T3N1M0 rectal adenocarcinoma, who underwent a rectosigmoidectomy during the uterine repositioning surgery. Since then, at least 15 patients with other malignancies have undergone this procedure for other malignancies, including pediatric patients (3) and gynecological cancers (4).

The first report was received with astonishment and awe by the Gynecologic Oncology community. Besides the logical oncologic outcome concerns, there were reasonable doubts whether perfusion exclusively through the ovarian arteries could maintain an advanced pregnancy. As information from radical trachelectomy without uterine artery preservation was quite encouraging, it seemed possible that ovarian arteries could bear the burden. Even if Dr. Christhardt Köhler from Germany showed an excellent uterine perfusion with ICG during both the first (uterine displacement) and second (uterine replacement) procedures of UT (5) there was uncertainty about pregnancy viability.

The birth of a healthy male infant at 36 weeks, after natural conception, validated the feasibility of uterine transposition. The mother was a 28-year-old woman with a left iliac and thoracic synchronous myxoid low-grade liposarcoma resected with close margins at the time of UT. She conceived spontaneously 32 months later. A 1-year follow-up of mother and child has been unremarkable. One month after this report Dr. Aldo López from Perú reported a second live birth after UT (6).

We see in Dr Ribeiro´s innovative surgical endoscopic technique a bright light of hope in the possibility of uterine, and potentially fertility preservation for patients with pelvic malignancies that need radiation as part of the standard oncological treatment.

References:

1. Ribeiro R, Anselmi MC, Schneider GA, Rodrigues Furtado JP, Mohamed Abau Shwareb MG, Linhares JC. First live birth after uterine transposition. Fertil Steril. 2023 Jul;120(1):188-193. doi: 10.1016/j.fertnstert.2023.02.033. Epub 2023 Mar 1. PMID: 36863432.
2. Ribeiro R, Rebolho JC, Tsumanuma FK, Brandalize GG, Trippia CH, Saab KA. Uterine transposition: technique and a case report. Fertil Steril. 2017 Aug;108(2):320-324.e1. doi: 10.1016/j.fertnstert.2017.06.016. Epub 2017 Jul 8. PMID: 28697913.
3. Baiocchi G, Vieira M, Moretti-Marques R, Mantoan H, Faloppa C, Damasceno RCF, Paula SOC, Tsunoda AT, Ribeiro R. Uterine transposition for gynecological cancers. Int J Gynecol Cancer. 2021 Mar;31(3):442-446. doi: 10.1136/ijgc-2020-001780. Erratum in: Int J Gynecol Cancer. 2021 Dec;31(12):1623. PMID: 33649011.
4. Vieira MA, Vieira AGS, Fonseca DSL, Jorge GE, Lopes LF, Ribeiro RC. Uterine transposition in a pre-pubertal patient. Int J Gynecol Cancer. 2021 Mar;31(3):492-493. doi: 10.1136/ijgc-2020-002074. PMID: 33649020.
5. Kohler C, Kettner P, Arnold D, Puhl G, Marnitz S, Plaikner A. Repeated intravenous indocyanine green application to prove uterine perfusion during uterus transposition. Int J Gynecol Cancer. 2022 Nov 7;32(11):1479-1480. doi: 10.1136/ijgc-2022-003647. PMID: 35764348.
6. Lopez A, Perez Villena JF, Guevara Jabiles A, Davila K, Sernaque Quintana R, Ribeiro R. Uterine transposition and successful pregnancy in a patient with rectal cancer. Int J Gynecol Cancer. 2023 Aug 7;33(8):1310-1315. doi: 10.1136/ijgc-2023-004661. PMID: 37549972.

About the Authors:
     

Fernando Heredia, MD
Darío Roque, MD

Dr. Heredia is Chair of the AAGL Oncology SIG and a Gynecologic Oncologist and Associate Professor at Universidad de Concepción in Concepcion Biobio Region, Chile.

Dr. Roque is a Board Member of the AAGL Oncology SIG and a Gynecologic Oncologist and Associate Professor at Northwestern University, Feinberg School of Medicine in Chicago, Illinois.  

VAGINAL MELANOMA

Introduction

Vaginal melanoma is a rare vaginal neoplasm with an aggressive course. This rare disease case report presents the vaginal melanoma case of a postmenopausal woman.

Case

An 82-year-old G14P10 presented with postmenopausal bleeding that began two months prior. She also noted a mass near her vagina on self-examination. She was seen by a benign gynecologist and referred to gynecologic oncology for further evaluation. On pelvic examination under anesthesia, her cervix was grossly normal and flush with the vaginal walls, consistent with menopause. Two polypoid, friable, hyperpigmented lesions were noted at the distal vagina bilaterally near the introitus. Smaller, polypoid, hyperpigmented lesions were also noted surrounding the distal urethra. Several flat, hyperpigmented lesions were noted throughout the anterior and posterior vagina.

The most prominent lesions were surgically excised; however, the entirety of the lesions could not be removed due to the extent of the disease. Pathology of the larger lesions returned as malignant melanoma, and the smaller periurethral lesions were melanoma in situ. Histologic examination of the malignant melanoma was confirmed by epithelioid spindle cells in solid sheets within the subepithelial stroma. A PET CT demonstrated increased metabolic activity in the lower vagina consistent with the patient’s known malignancy. No evidence of metastatic disease was noted on brain MRI. As of this report, the patient was referred for systemic therapy for unresectable disease.

Discussion

Vaginal melanoma impacts 0.026/100,000 women (1), was first reported in 1887 (2), and currently comprises 0.3%-0.8% (3) of all melanomas in females.

Symptoms that frequently occur in vaginal melanomas are the presence of a vaginal mass – as in our case – pain, discharge, and abnormal vaginal bleeding (2,4).

Treatment options for patients with vaginal melanoma are limited. Treatment modalities consist of resection, radiotherapy, and adjuvant systemic therapy. (2,5). Physicians should also use a multidisciplinary care team (gynecologic oncology, medical oncology, and dermatology) when treating patients with vaginal melanoma (6).

References

1. Kühn, F et al. “Primary Malignant Vaginal Melanoma – Case Report and Review of the Literature.” Geburtshilfe und Frauenheilkundevol. 72,8 (2012): 740-743. doi:10.1055/s-0032-1315006
2. Kalampokas E, Kalampokas T, Damaskos C. Primary Vaginal Melanoma, A Rare and Aggressive Entity. A Case Report and Review of the Literature. In Vivo. 2017 Jan 2;31(1):133-139. doi: 10.21873/invivo.11036. PMID: 28064232; PMCID: PMC5354139.
3. Puri S, Asotra S. Primary vaginal malignant melanoma: A rare entity with review of literature. J Cancer Res Ther. 2019 Oct-Dec;15(6):1392-1394. doi: 10.4103/jcrt.JCRT_893_15. PMID: 31898678.
4. Borazjani, G et al. “Primary malignant melanoma of the vagina: a clinicopathological analysis of 10 cases.” Gynecologic oncology, vol. 37,2 (1990): 264-7. doi:10.1016/0090-8258(90)90345-l
5. Kirschner, Austin N et al. “Treatment approach and outcomes of vaginal melanoma.” International journal of gynecological cancer: official journal of the International Gynecological Cancer Society, vol. 23,8 (2013): 1484-9. doi:10.1097/IGC.0b013e3182a1ced8
6. Matsuo, Koji et al. “Treatment specialty-specific characteristics and outcomes in women with vulvo-vaginal melanoma: A JGOG-JSCS joint study.” Journal of surgical oncology, vol. 125,8 (2022): 1333-1337. doi:10.1002/jso.26835

About the Authors: 
    

Marian Yvette Williams-Brown, MD, MMS, FACOG
Justin Jensen, MD

Dr. Williams-Brown is a Board Member of the AAGL Oncology SIG, Director of the Division of Gynecologic Oncology, Associate Professor, and Director of the Fellowship in Minimally Invasive Gynecologic Surgery at Dell Medical School, The University of Texas in Austin, Texas.

Dr. Jensen is a fellow in the Fellowship in Minimally Invasive Gynecologic Surgery at Dell Medical School, The University of Texas in Austin, Texas.