Omental Biopsy Research Articles

6688 Clinical Presentation and Management of Highly Differentiated Follicular Carcinoma Arising from Struma Ovarii with DICER1 Mutation: A Case Report

Abstract Disclosure: S.M. Seav: None. J. Shah: None. C. Dosiou: None. Background: Struma ovarii (SO) is a rare type of ovarian teratoma comprised of > 50% thyroid tissue. Extra-ovarian spread of SO, called peritoneal strumosis, was previously considered benign given the lack of histological malignant features. The 2020 WHO Classification of Female Genital Tumors has reclassified this as highly differentiated follicular carcinoma arising from struma ovarii (HDFCO), highlighting its low-grade malignant potential.[1] We report a case of HDFCO with extensive peritoneal disease and discuss its management. Clinical Case: A 38-year-old female presented to her OBGYN for irregular menses. Pelvic MRI showed an 8 cm right ovarian mass. Right salpingo-oopherectomy and pelvic peritoneal biopsies revealed well-differentiated thyroid tissue. Thyroid ultrasound demonstrated a multinodular goiter with ATA high risk nodules; 4 of 5 biopsied with benign results. Her thyroglobulin (Tg) was 170 ng/mL (normal 2 – 35 ng/ml). No further intervention was recommended. Two years later she was referred to our clinic. CT of abdomen/pelvis showed multifocal residual disease. We recommended more aggressive management, given the diagnosis of HDFCO. All visible disease was resected in a diagnostic laparoscopy with pelvic and omental biopsies. Pathology showed well-differentiated thyroid tissue. Molecular testing for the FGFR4 mutation associated with HDFCO was negative, but there was a DICER1 mutation c.5428 G>T of undetermined significance. DICER1 mutations are associated with thyroid cancers2. A total thyroidectomy and radioactive iodine ablation (RAI) were recommended. Thyroid pathology was benign. Tg was 9 ng/mL one month post-op. MRI six months post-laparoscopy revealed only one 6 mm omental lesion. Withdrawal I-123 whole body scan (WBS) showed multiple peritoneal implants. Tg was 214 ng/mL and TSH was 72 ulU/mL. The patient was treated with 157 mCi of oral I-131. Given the extensive peritoneal disease, she received prophylactic oral dexamethasone for 2 weeks after RAI to decrease the risk of peritoneal inflammation and bowel obstruction potentially mediated by local inflammation from radiation-related tissue injury. Her Tg three months post-RAI was 4 ng/mL. The surveillance plan is to alternate between RAI WBS and MRI abdomen/pelvis every 6 months. Conclusions: Peritoneal strumosis, previously considered benign, has recently been reclassified as HFDCO, an extremely rare low-grade malignancy with no standardized treatment. We report the first case of extensive HFDCO with a DICER1 mutation. Given the significant peritoneal involvement, our case was treated with total thyroidectomy, surgical excision of all implants, RAI, and prophylactic steroids post-RAI. Further research into the prognostic factors and optimal treatment of HFDCO is needed. Reference: [1]Giovanopoulou et al. Curr Oncol. 2022; 29(12): 9105-9116. 2Sauer et al. Head Neck Pathol. 2022; 16(1): 190–199. Presentation: 6/1/2024

Abstract C069: Unraveling the complexity of malignant peritoneal mesothelioma: A comprehensive case study of diagnosis, clinical features, and therapeutic challenges in a 75-year-old male

Abstract Introduction: Malignant Peritoneal Mesothelioma (MPM) is a rare and aggressive intra-abdominal neoplasm originating from mesothelial cells. Although asbestos exposure is a known risk factor, MPM's molecular pathogenesis differs from its pleural counterpart. Case Presentation: A 75-year-old male, with a past medical history of recently diagnosed mesothelioma, presented to the emergency department for a two-week progression of abdominal distension, early satiety, and dyspnea aggravated by activity. One year prior, he initiated medical evaluation for fluid retention and abdominal distension. A recent omental biopsy confirmed the diagnosis of mesothelioma, prompting the initiation of chemotherapy every three weeks. Despite paracentesis performed monthly, the patient experienced worsening shortness of breath and early satiety post-chemotherapy. Discussion: Malignant Peritoneal Mesothelioma poses a diagnostic challenge due to the absence of specific signs or symptoms. Common manifestations include abdominal distension, pain, early satiety, weight loss, dyspnea, chest pain, and fatigue. Rare symptoms encompass new-onset hernia, fever of unknown origin, night sweats, or incidental findings during physical examinations or laparoscopy. Delays in presentation and diagnosis contribute to the advanced stage at diagnosis, with most cases having already spread throughout the abdominal cavity. Three distinct presentations of MPM include the Dry Painful Type, characterized by abdominal pain with minimal ascites; the Wet Type, presenting with abdominal distension and ascites; and the Mixed Type, combining abdominal pain and distension. Paraneoplastic phenomena, such as fever, thrombocytosis, malignancy-related thrombosis, hypoglycemia, hypoalbuminemia, paraneoplastic hepatopathy, and rarely, Coombs-positive Hemolytic anemia, further complicate the clinical picture. Surgical gross and microscopic descriptions of liver biopsies indicated chronic hepatitis with mild portal inflammation, grade 1, and no fibrosis, stage 0. Notably, the omental biopsy confirmed Malignant Mesothelioma of the epithelioid type. Immunohistochemical stains supported the diagnosis, revealing positivity for CK AE1/AE3, calretinin, WT1, CK7 (focally), and GATA3 (focally), while testing negative for BAP1, CDX2, chromogranin, CK20, hepatocyte antigen, PAX8, PSA, synaptophysin, and TTF1. Due to the rarity of MPM, no standardized treatment protocols exist. Cytoreductive surgery (CRS) and hyperthermic intraoperative peritoneal perfusion with chemotherapy (HIPEC) are recommended for selected patients without extraperitoneal disease spread, possessing a good performance status and potential for complete surgical cytoreduction. Systemic chemotherapy, particularly pemetrexed-based regimens, is advocated for patients ineligible for CRS/HIPEC. Conclusion: MPM's aggressive nature poses diagnostic and therapeutic challenges. The scarcity of standardized guidelines emphasizes the importance of ongoing research to enhance understanding, improve diagnostics, and develop targeted therapies Citation Format: Aliya M Khan, Mehmet Hepgur, Aryama Sharma. Unraveling the complexity of malignant peritoneal mesothelioma: A comprehensive case study of diagnosis, clinical features, and therapeutic challenges in a 75-year-old male [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C069.

Determination of the diagnostic accuracy of peritoneal biopsy with an 18G cutting needle under ultrasonography guidance and the contribution of CT findings to diagnosis before biopsy (our 8-year clinical experience)

Ultrasound-guided percutaneous core needle biopsy is an important technique in diagnosing mesenteric involvement. Diagnostic results were compared with pre-biopsy CT findings. The purpose of this study was to determine the diagnostic efficiency of omental lesion biopsies performed under ultrasound guidance and to investigate the relationship between pre-biopsy diagnostic CT findings. Demographic data of 70 patients who underwent omental biopsy under ultrasound guidance in our clinic between August 2015 and July 2023, the presence of a primary malignancy focus during the investigations conducted during the research, biopsy histopathology results, and pre-biopsy CT findings were retrospectively reviewed. This retrospective study included who underwent omental biopsy under ultrasound guidance, 48 (69%) were female, and 22 (31%) were male, with an average age of 61 (age range 15-95), and an average body mass index [BMI] of 27.7±6.9. Five (7%) of the 70 biopsy procedures were not pathologically diagnostic. Diagnostic results were compared with pre-biopsy CT findings. In all omental lesions, the percentage of omental infiltrative involvement in diagnostic CT was subjectively evaluated by two radiologists. 65 patients diagnosed pathologically, 47 (67%) were malignant, and 18 (26%) were benign. No complications occurred. Peritoneal biopsies under ultrasound guidance for mesenteric diseases detected on CT are a reliable procedure that can be easily applied. Ultrasonography imaging helps identify appropriate locations for targeted biopsies before deep percutaneous biopsy, increasing diagnostic accuracy, especially when omental lesions appear as infiltrative thickenings.

Carcinoma esophagus with small bowel metastasis: a case report with review of literature.

Small intestinal metastasis is extremely rare and only 13 cases have been reported till date and almost all such patients have presented with intestinal obstruction. The 5-year overall survival for metastatic esophageal cancer is as low as 5% while the patients with small intestinal metastasis have a median survival of only 3months (range 1-12months) despite undergoing radical resection of the small bowel. We present a case of a male in his 50's who presented with difficulty in swallowing for 4months. On evaluation, he was found to have squamous cell carcinoma in the mid thoracic esophagus. He underwent radical chemo-radiation up to 60Gy in 25 fractions over 5weeks. One week after completion of treatment he presented with ileal obstruction and omental nodules and surgical resection and evaluation of the respective ileal segment and omental biopsy revealed a metastatic squamous cell carcinoma. The patient expired 3months post-surgery. Carcinoma esophagus with small bowel metastasis has a very grave prognosis that patients rarely survive beyond 1year despite undergoing resection. Hence it is imperative to consider a small bowel metastasis when such patients present with clinical features of intestinal obstruction for early diagnosis and aggressive management.

Mucinous Carcinoma of Ovary in a 15-Year-Old Girl, A Rare Case Report and Literature Review.

Ovarian epithelial tumors are common in adults, and the median patient age at presentation is 55 years. In children, epithelial tumors are rare and mostly benign. Mucinous cystadenocarcinoma is reported in only 11 cases less than 15 years old. This report describes the case of a 15-year-old postmenarchal Omani girl with ovarian mucinous carcinoma. She was admitted with severe epigastric pain and abdomen distension. CT scan showed a huge cystic lesion arising from the left adnexa filling the entire abdominal and pelvic cavity. The patient underwent laparotomy with left ovarian cystectomy and omental biopsy which revealed a 35 x 30 cm left ovarian cyst filled with turbid straw color fluid. Histopathology was reported as mucinous carcinoma. The patient later underwent cytoreductive surgery with left salpingo-oophorectomy, omentectomy, appendicectomy, and lymph node dissection that were negative for malignancy or metastatic disease. During follow-up, she developed a lymphocele in the pelvic cavity that was drained. There were no other significant issues during follow-up, as well as no evidence of recurrence or metastasis. Epithelial tumors of the ovary are rare in young girls, with malignant tumors being exceedingly rare. Fertility-sparing surgery is adopted over radical surgery in these patients, even though the recurrence rates with this treatment protocol are high. All cases should be under follow-up to look for recurrence and timely management.

Non-Metastatic Uterine Carcinosarcoma: A Tailored Approach or One Size Fits All?

Purpose: Uterine carcinosarcomas are highly aggressive tumors of the endometrium and are associated with a poor prognosis. The optimal adjuvant treatment for both early and advanced-stage patients remains unclear. Methods: Cases of uterine carcinosarcoma were identified in our institution’s pathology database between 2000 and 2022. Kaplan–Meier estimates were calculated for the local and distant recurrence-free, disease-free and overall survival; hazard ratios were calculated using Cox proportional hazards modelling for independent prognostic factors including the stage and treatment. Results: A total of 48 patients were identified as having uterine carcinosarcoma, of whom 70.8% were surgically staged. In total, 43 patients had pelvic-confined disease, while five had positive omental or peritoneal biopsies at surgery. There were 10 pelvic (20.8%) and 19 (39.6%) distant recurrences. None of the patients with stage IA disease who received chemotherapy and brachytherapy experienced disease recurrence. The local recurrence-free survival was 54.95%, the distant recurrence-free survival was 44.7%, and the overall survival was 59.6% at 5 years. Local recurrence-free survival and overall survival were inversely associated with advanced-stage OR 1.23 (p = 0.005) and OR 1.28 (p = 0.017), respectively, and no chemotherapy was associated with OR 1.96 (p = 0.06) and OR 2.08 (p = 0.056), respectively. Conclusion: The local and distant recurrence rates were high for advanced=stage patients even when treated with aggressive adjuvant therapy regimens. Chemotherapy may improve recurrence and survival. Early-stage patients may perform well with vaginal vault brachytherapy and chemotherapy. Further prospective comparisons are required between sequential, sandwich, and concurrent approaches to chemotherapy and radiotherapy, to optimize outcomes in this high-risk population.

Serous surface papillary borderline tumor of ovary – An underdiagnosed entity

A young female presented with complaints of dysmenorrhea for 8 months. Ultrasound of the pelvis showed an echogenic mass in the left adnexa with papillary projections and internal vascularity and encasing the left ovary. Subsequent magnetic resonance imaging (MRI) showed an intensely enhancing, lobulated solid mass with a frond-like appearance, and papillary projections surrounding the left ovary reminiscent of a “sea-anemone.” The right ovary showed a cystic lesion without enhancing papillary projections or mural nodules. There was mild pelvic ascites and few peritoneal nodules in the pelvis. The presumptive radiologic diagnosis was serous surface papillary borderline tumor (SSPBT) of the left ovary and a benign cyst in the right ovary. The patient was treated with the left salpingo-oophorectomy, right ovarian cystectomy, peritoneal, and omental biopsies. Histopathology confirmed the diagnosis of SSPBT of the left ovary with microinvasion (<5 mm) of the ovarian surface. The right ovarian cyst was a follicular cyst. The peritoneal biopsies were positive for implants from SSPBT. This report highlights the diagnostic utility of “sea-anemone” sign and reviews the clinical and radiopathologic features of SSPBT.

SAT369 Rare Cause of Hyperandrogenism and Elevated 17 OH Progesterone Levels - Ovarian Steroid Cell Tumor (NOS)

Abstract Disclosure: A. Shafi: None. G. Meier Surrey: None. Background:There are several causes of hyperandrogenism. We report a rare cause of hyperandrogenism and elevated 17 OH progesterone levels due to ovarian steroid cell tumor Clinical Case: A 21 yr old female presented to our clinic for evaluation of secondary amenorrhea and hirsutism for 2 years. She also endorsed deepening of voice and possible clitoromegaly. On physical exam she had hirsutism, acne with mild clitoromegaly. Labs were pertinent for normal TSH, Ft4, prolactin, DHEAS, am cortisol 14.85 ug/dl, ACTH 16 pg/ml (6-50), IGF-1 303 ng/ml (830-456), but elevated total and free testosterone 394.5 ng/dl (10-75), 70.5 pg/ml (0.2-5) respectively, elevated 17 OH progesterone 842 ng/dl (23-431 ng/dl depending on the menstrual phase). Due to testosterone >3x ULN, and significant symptoms of hirsutism/hyperandrogenism there was a concern for androgen producing tumor and therefore CT abdomen and Pelvis was obtained which showed “heterogeneously enhancing right adnexal mass measuring 6 x 5.1 x 5.4 cm causing leftward displacement of the uterus and left ovary. Right ovary was not identified and is likely inseparable from the right adnexal mass”. She underwent a laparoscopic Right salpingo oophorectomy with pelvic washings, peritoneal biopsies and omental biopsy. Pathology of ovary showed a steroid cell tumor, NOS. Pt seen 2 months post surgery pt reported that her menstrual cycles had become regular, however she continued to have acne and hirsutism for which she was referred to Dermatology. Post surgery 17 OH progesterone levels had normalized. Conclusion:Steroid cell tumors of the ovary are extremely rare, accounting for only 0.1% of all ovarian tumors. The clinical presentation may take many forms, including abdominal pain, distention, irregular menstrual cycles, and hirsutism. Labs can show elevated 17 OH progesterone levels. Therefore among other etiologies clinicians should also consider Ovarian Steroid cell tumor (NOS) as a possible cause for hypernadorgenism and elevated 17 OH progesterone levels Presentation Date: Saturday, June 17, 2023

The Regulation of Endothelin-1 in Pregnancies Complicated by Gestational Diabetes: Uncovering the Vascular Effects of Insulin.

Gestational diabetes mellitus (GDM) is a condition of pregnancy defined by new-onset hyperglycemia. GDM is associated with impaired maternal endothelial and vascular reactivity. Endothelin-1 (ET-1) is a potent vasoconstrictor that contributes to endothelial dysfunction, however, its abundance and actions in GDM are unclear. Maternal plasma was obtained from pregnancies complicated by GDM (n = 24) and gestation-matched controls (n = 42); circulating ET-1 levels were assessed by ELISA. Human omental arteries from healthy pregnancies and those complicated by GDM were dissected from omental fat biopsies and collected at cesarean section. mRNA expression of ET-1 and its receptors, ETA and ETB, in addition to vascular cell adhesion molecule-1 (VCAM1) and intercellular adhesion molecule-1 (ICAM1) were assessed by qPCR (n = 28). Using wire myography, we investigated vascular constriction to ET-1 (10-11-10-4 M) in omental arteries from pregnancies complicated by GDM, compared to gestation-matched controls (n = 7). GDM cases were stratified by clinical management, diet intervention (n = 5), or insulin treatment (n = 6). Additionally, arteries from healthy pregnancies were treated with insulin (1 mU/mL (n = 7) and 10 mU/mL (n = 5)) or vehicle control. Vasoactive response to ET-1 was measured via wire myography. Circulating ET-1 levels and mRNA expression of the ET-1 system in omental arteries were not found to be significantly different between pregnancies complicated by GDM compared to healthy controls. However, we found insulin treatment during pregnancy and in ex vivo models reduced ET-1 vasoconstriction of maternal vasculature in GDM. These data suggest insulin may improve vascular function in GDM, however, further investigation is needed to define the role of ET-1 in pregnancy.

Increased stiffness of omental arteries from late pregnant women at advanced maternal age.

Advanced maternal age (≥35 years) is a risk factor for poor pregnancy outcomes. Pregnancy requires extensive maternal vascular adaptations, and with age, our blood vessels become stiffer and change in structure (collagen and elastin). However, the effect of advanced maternal age on the structure of human resistance arteries during pregnancy is unknown. As omental resistance arteries contribute to blood pressure regulation, assessing their structure in pregnancy may inform on the causal mechanisms underlying pregnancy complications in women of advanced maternal age. Omental fat biopsies were obtained from younger (<35 years) or advanced maternal age (≥35 years) women during caesarean delivery (n = 7-9/group). Arteries (200-300 µm) were isolated and passive mechanical properties (circumferential stress and strain) assessed with pressure myography. Collagen (Masson's Trichrome) and elastin (Verhoff) were visualized histologically and % positively-stained area was assessed. Median maternal age was 32 years (range 25-34) for younger, and 38 years (range 35-42) for women of advanced maternal age. Circumferential strain was lower in arteries from advanced maternal age versus younger women but circumferential stress was not different. Omental artery collagen levels were similar, while elastin levels were lower with advanced maternal age versus younger pregnancies. The collagen:elastin ratio was greater in arteries from advanced maternal age versus younger women. In conclusion, omental arteries from women of advanced maternal age were less compliant with less elastin compared with arteries of younger controls, which may affect how vascular stressors are tolerated during pregnancy. Understanding how vascular aging affects pregnancy adaptations may contribute to better pregnancy outcomes.

Diagnostic Accuracy and Safety of Ultrasound Guided Omental Biopsy: Single Center Experience

Aim: Omental biopsy has conventionally been performed using a surgical approach. The thickened omentum can serve as a useful target for ultrasonography guided percutaneous biopsy, in clinical practice. The objective of our study was to determine the diagnostic value and safety of ultrasound guided percutaneous biopsy of omental thickening. Additionally, we aim to investigate the correlation of biopsy results with the paracentesis fluid cytology.&#x0D; Methods: This retrospective study included 49 patients (33 women and 16 men; mean age, 64 ± 13.9 [SD] years) who underwent ultrasound guided omental biopsy between 2014 and 2022 at a single institution at which US served as the first-line modality for omental biopsy guidance. Post-biopsy clinical follow-up were reviewed for each patient. We compare the outcomes of biopsy and paracentesis fluid cytology results. &#x0D; Results: Total 49 patients were included in our study. US-guided biopsy was diagnostic in 46/49 (93.8%) of patients. There were total 36 (73.4%) malignant cases, 5 (10.2%) chronic inflammation suggestive of tuberculosis, while 2 (4.1%) were chronic peritoneal infection. In 3 patients, the result of core biopsy was benign and reported as Ig4-related inflammatory pseudotumor, desmoid fibromatosis and fat necrosis-foreign body reaction. Out of 36 malignant cases, majority 17 (47.2%) had ovarian cancer. There were no major complications. In 21 of 25 patients (%84) who underwent paracentesis fluid sampling, cytology results (malign or bening cytology) were found to be consistent with omental biopsy results. The ascitic cytological evaluation was favourable for malignancy in 16/25 (64%) patients.&#x0D; &#x0D; Conclusions: Ultrasound-guided percutaneous biopsy of omentum is less expensive, safe and effective method with a high diagnostic accuracy. Paracentesis fluid cytology results are highly sensitive in patients with omental thickening.

A Curious Case of Omental Oxalate Crystals in a Patient With Struma Ovarii: Pointers to an Unusual Clinicopathological Scenario.

Percutaneous image-guided biopsies are becoming increasingly common in routine pathology practice, with the greater omentum emerging as a common target. We present herein an account of a middle-aged lady with a complex ovarian mass, omental thickening, and raised serum CA125; clinically suspected to have advanced ovarian malignancy. Fine needle aspiration cytology (FNAC) from the ovarian mass was inconclusive. Omental biopsy revealed only refractile, birefringent crystalline material with surrounding foreign body giant cell reaction; thus surprising the clinical team. Subsequent resection of the ovarian mass showed a teratoma composed exclusively of thyroid tissue, diagnosed as struma ovarii. The omental crystals, interpreted as calcium oxalate crystals, were possibly a consequence of colloid seeding during the ovarian mass FNAC.

Abstract #1397957: Papillary Thyroid Carcinoma Arising from Malignant Struma Ovarii

Struma ovarii is a rare ovarian teratoma characterized by the presence of thyroid tissue. It can be functional leading to hyperthyroidism or transform into malignant thyroid cancer. We present a case of a 46-year-old woman without risk factors for thyroid cancer, who was found to have a cystic ovarian lesion suspicious for malignancy. Surgery revealed struma ovarii with papillary thyroid cancer. A 46-year-old woman presented with right lower quadrant abdominal pain associated with urinary incontinence. She was found to have palpable mass in the lower abdomen on physical examination. Abdominal/pelvic computed tomography (CT) scan showed a 12.7 cm right ovarian complex cystic lesion and a 5.9 cm left ovarian complex cyst. She underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, radical pelvic dissection, and omental biopsy. Pathology revealed struma ovarii of the right adnexa, with a 1.8 cm papillary thyroid cancer noted to be well to moderately differentiated without ovarian surface or fallopian tube involvement. It was staged as pT1aNxMx. BRAF mutation was negative. The contralateral ovary, fallopian tubes, and uterus were negative for malignancy. Post-operative labs included thyroglobulin antigen of 20.1 ng/ml, thyroglobulin antibodies were undetectable, thyroid stimulating hormone (TSH) of 3.53 mIU/L (0.4-4.5 mIU/L) and Free T4 of 1.1 ng/dl (0.8-1.8 ng/dl). Thyroid ultrasound (US) showed a 6 mm hypoechoic nodular lesion in the right isthmus. She was started on levothyroxine to suppress her TSH to the low normal level and she is planned to follow up on the small thyroid nodule with US in 3-5 years. The vast majority of struma ovarii are benign in nature and less likely to transform into malignant tissue. Most of the tumor transformation occurs in the form of papillary thyroid carcinoma, and the risk tends to be higher with larger-size ovarian teratomas >5 cm. The presenting symptoms are indistinguishable between benign and malignant tumors, and usually present with lower abdominal pain. Diagnosing papillary thyroid cancer in struma ovarii tumors is often challenging given the lack of distinct imaging characteristics and specific tumor markers. Additionally, cancer antigen 125 (CA-125) has no value. The mainstay for management is surgical resection. Regardless of the surgical strategy used, patients with malignant struma ovarii have an excellent disease-specific survival rate overall. However, staging is key to assessing if thyroidectomy and radioactive iodine are needed. Surveillance with thyroid imaging and biochemical markers is recommended, however, the disease is curable in most cases.

Oral ω-3 PUFA supplementation modulates inflammation in adipose tissue depots in morbidly obese women: A randomized trial

ObjectivesObesity is characterized by local and systemic low-grade inflammatory responses. Adipose tissue macrophages (ATM) play decisive roles in inflammation, insulin signaling, and various metabolic dysfunctions. Diets enriched with ω-3 polyunsaturated fatty acids (PUFAs) have been shown to improve health and mitigate pathologic conditions. However, the effects of ω-3 PUFA on adipose tissue inflammation, ATM number, and phenotype are poorly defined in human obesity. The aim of this study was to examine differences in expression of metabolic-inflammatory markers in omental, mesenteric, and subcutaneous fat depots of obese women supplemented with ω-3 PUFAs for 4 wk compared with a low-calorie diet before bariatric surgery. MethodsIn a randomized controlled trial, inflammatory markers in the abdominal adipose tissue and the systemic response in obese women were studied. Patients were treated with a 2-wk low-calorie diet (LCD) or a 4-wk ω-3 PUFA-enriched diet (920 mg eicosapentaenoic acid, 760 mg docosahexaenoic acid daily) before laparoscopic bypass surgery. Omental, mesenteric, and subcutaneous adipose tissue biopsies were collected during surgery and analyzed for quantity and phenotype of ATMs, and profiled for adipokines, cytokines, and signal transduction molecules. ResultsThe chronic inflammatory state characterized by ATM markers was mostly improved by ω-3 PUFAs in visceral adipose tissue. We observed a decreased expression of CD45, CCL2, and CD68, indicating a lower inflammatory state. In patients with type 2 diabetes, ω-3 PUFAs lowered the expression of Netrin-1. ConclusionsCompared with an LCD, a diet enriched with ω-3 PUFAs influences the inflammatory state in different adipose tissue depots, by affecting markers of adipose tissue inflammation, macrophage phenotype, and retention. However, this was not reflected in clinical parameters such as insulin resistance and inflammatory cytokines. Subcutaneous adipose tissue and visceral adipose tissue have different responses to an LCD or a ω-3 PUFA-enriched diet. The presence of diabetes modifies the expression of inflammatory markers.

Malignant peritoneal mesothelioma with unresolving haemorrhagic ascites- A case report

Peritoneal mesothelioma being a rare tumor is difficult to diagnose and start treatment. Pleura is the most common area being affected by mesothelioma, peritoneum being the second common site, and in some cases synchronous pleural and peritoneal mesotheliomas are observed (30–45% of the cases). The presentation of mesothelioma is not up to mark leading to difficulty in diagnosis due to lack of specific symptoms and clinical findings. In addition, in the absence of previous asbestos exposure a delay in the diagnosis is not rare. Here we report a case of malignant peritoneal mesotheliomas. The diagnostic and therapeutic approaches for these rare neoplasms are discussed. A 24 year old male patient was admitted with complaints of pain abdomen (on &amp; off) and abdominal distension since 15 days, with no inhalational exposure to asbestos, causing diagnostic confusion. He had history of unresolving haemorrhagic ascites. No drug allergy was noted. Diagnostic laproscopy was done, shows multiple omental nodules. Omental biopsy along with immunohistochemistry leads to diagnosis of malignant peritoneal mesothelioma. Peritoneal mesotheliomas are infrequent clinical entities. However, patients presenting with prolonged abdominal pain and ascitis should be considered to have atypical pathologies with peritoneal mesotheliomas being one of the differentials.

The impact of lymphovascular space invasion on survival in early stage low-grade endometrioid endometrial cancer

BackgroundThe lymphovascular space invasion (LVSI) is suggested as a prognostic factor for endometrial cancer in many studies, but it has not yet been employed in FIGO staging system. The present study was aimed to evaluate the impact of LVSI on survival in patients with early stage endometrioid endometrial cancer.MethodsThis retrospective cohort was conducted on early stage endometrial cancer patients who underwent surgical staging [total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO)] and omental biopsy at Referral Teaching Hospitals of Tehran from 2005 to 2021. Patient’s age, menopause status, tumor grade, tumor size, depth of myometrial invasion, LVSI and lower segment involvement were recorded. Data were analyzed with SPSS 22.Results415 patients with stage I and grade 1–2, endometrioid endometrial cancer were analyzed. 100 patients (24.1%) were LVSI-positive. 3-year and 5-year survival rates were 97.1% and 88.9%, respectively. Recurrence occurred in 53 patients (12.8%). 3-year overall survival rates in LVSI-negative and LVSI-positive were 98.7% and 92%. These rates for 5-year survival were 92.1% and 79%, respectively. Recurrence rates in LVSI-negative were 8.9% while it was 25% in LVSI-positive cases. Multivariate analysis showed that LVSI has significant correlation with 3-year and 5-year overall survival rates.ConclusionsLVSI in early stage endometrial cancer significantly and independently influences 3-year and 5-year survival rates and acts as a strong prognostic factor in these patients. LVSI should be implemented in endometrial cancer staging systems due to its significant correlation with cancer recurrence rates and 5-year survival rates.

Endometrial serous carcinoma with extensive squamous differentiation mimicking primary endometrial squamous cell carcinoma: Clinicopathological and molecular analysis of a case with literature review

In the histological assessment of endometrial carcinoma, the presence of squamous differentiation is generally considered inconsistent with a serous histotype. Herein, we report a case of endometrial serous carcinoma with extensive squamous differentiation mimicking squamous cell carcinoma, with literature review.A 67-years-old-woman underwent hysterectomy, bilateral salpingo-oophorectomy, sentinel lymph node resection, omental and peritoneal biopsies, due to a 8cm endometrial mass. Histologically, the tumor showed squamous carcinoma features with positivity for squamous cell markers (p40, p63, cytokeratin-5/6, cytokeratin-34βE12) and negativity for Müllerian markers (PAX8, estrogen receptor, progesterone receptor). No immunohistochemical/molecular alterations typical ofendometrioid carcinoma (i.e., PTEN loss, mismatch repair deficiency, nuclear β-catenin expression,POLEmutation) were observed. P53 showed aberrant pattern and p16 showed basal positivity. The tumor infiltrated the myometrium full-thickness with extensive lymphovascular space invasion. Surprisingly, the sentinel lymph node metastasis showed overt serous carcinoma features. Additional sampling of the endometrial mass revealed a minor. In conclusion, serous carcinoma may show diffuse squamous differentiation. In the case of suspected primary endometrial squamous cell carcinoma, an extensive sampling is warranted.

Suspicious Positive Peritoneal Cytology (Class III) in Endometrial Cancer Does Not Affect Prognosis.

Positive peritoneal cytology is a poor prognostic factor in patients with advanced endometrial cancer. Suspicious positive peritoneal cytology (class III) is commonly encountered in clinical practice. However, no standard treatment protocol exists for its management. Here, we investigated a possible relationship between suspicious positive peritoneal cytology, disease stage, risk factors, and endometrial cancer prognosis. We included patients diagnosed with endometrial cancer who underwent total hysterectomy and peritoneal cytology at the University of Tokyo Hospital between 2008 and 2022. Overall, 670 patients were included in the analyses; both demographic and clinical data of the patients were collected. The proportion of patients with lymph node metastasis was significantly different between peritoneal cytology groups, showing lymph node metastasis to be more extensive in patients with positive or suspicious positive peritoneal cytology than in patients with negative peritoneal cytology (p &lt; 0.05). Thirty-nine patients had suspicious positive peritoneal cytology. Omental resection and biopsy were performed in 16 cases. No case of omental metastasis was found. Among patients with suspected ascites cytology, no patient experienced symptom recurrence or death. Therefore, monitoring lymph node metastasis in suspicious positive cases is essential. Moreover, a change of treatment method based on the finding of suspected positive peritoneal cytology is not necessary.

Diagnostic Performance of Ultrasound in Predicting the Extension of Disease in Advanced Ovarian Cancer

Aim: To assess the diagnostic performance of ultrasound in predicting the extension of disease in advanced ovarian cancer. Study design: Prospective observational study. Place and duration of study: Department of Obstetrics &amp; Gynaecology, Islam Teaching Hospital, Sialkot from 1st July 2020 to 30th June 2021. Methodology: Fifty-nine patients were enrolled and each patient underwent ultrasonography preoperatively and was assigned a six Fagotti-score. Surgical removal of ovarian mass was done through laparotomy. Midline incision was given. Peritoneal washings were taken for cytology. Omental biopsies were taken from various sites. Total abdominal hysterectomy was performed with bilateral oophorectomy. The ultrasound results and intraoperative extent of the ovarian malignancy spread were compared. The Cohen’s Kappa results were interpreted. Results: The mean age was 51.5±5.2 years. The range of Cohens Kappa was 0.7 in cases of carcinomatosis presented on the smaller/larger bowel. The predictive agreement value between the ultrasound and surgical cases for Cohens Kappa was 0.75 and 0.73 with mean as 0.74. Conclusion: The ultrasonography can be used as an important tool in identifying the advancement extent of ovarian cancer. Keywords: Ovarian cancer, Ultrasound, Cohen’s Kappa

Is MDCT an accurate tool to differentiate between benign and malignant etiology in diffuse peritoneal disease?

There is often considerable overlap of imaging findings in benign and malignant peritoneal diseases. We evaluated patients with diffuse peritoneal disease, to assess the diagnostic value of MDCT in predicting benign or malignant etiology in patients with unknown etiology, by analyzing the various patterns of involvement, particularly tuberculosis (TB) vs malignancy. One hundred and thirty-six patients with diffuse peritoneal disease who had abdominal CT and subsequently underwent omental biopsies were included in the study. Peritoneal, mesenteric and omental involvement by disease was evaluated on CT using specific parameters. The presence of lymphadenopathy, ascites, scalloping of organs, involvement of liver and spleen, were also compared between benign and malignant conditions using histopathology as the gold standard. In 136 patients, 72 benign and 64 malignant pathologies were classified as per histopathology. Higher age (p < 0.001), increasing omental thickness (mean 25.2mm, p = 0.004), omental caking (p < 0.001), > 10mm mesenteric/peritoneal nodules (p < 0.03), visceral scalloping (p = 0.001), free ascites (p = 0.003), serosal involvement (p = 0.004) and bilateral pleural effusion (p = 0.02) were associated with malignant etiology. Mesenteric thickening/stranding (p = 0.02), mesenteric adenopathy (p < 0.001), necrotic nodes (p = 0.02), splenomegaly (p = < 0.001) and higher attenuation (> 20HU) of ascitic fluid (p < 0.001) were associated with benign etiology. The presence of mesenteric thickening or stranding (p = 0.01), splenomegaly (p = 0.02), higher ascitic fluid attenuation > 20HU (p = < 0.01), mesenteric adenopathy (p < 0.01), necrotic nodes (p = 0.03) favored tuberculosis. CT had diagnostic accuracy (79.3, 86.7%), sensitivity (79.2, 74.6%) and specificity (79.4, 97%) for observers 1 and 2, respectively (Kappa 0.713). Contrast-enhanced MDCT has good sensitivity, specificity and accuracy in differentiating benign and malignant etiologies of diffuse peritoneal disease. Multiple common parameters can be used to differentiate between tuberculous peritonitis and peritoneal carcinomatosis.