Omental Cake Research Articles

Comparison of Ultrasound and CT Findings of Pelvic Masses with Histopathology: A Cross-sectional Study

Introduction: Benign and malignant pelvic masses can occur in different age groups, primary diagnosis and choosing the appropriate surgical procedure is very important. Ultrasound (USG) is the diagnostic test of choice in evaluating pelvic masses, while Computed Tomography (CT) scan is most helpful as a second-line study, for in-depth evaluation of the abdomen and pelvis. Aim: To compare the findings of ultrasound and CT scans of pelvic masses with definitive histopathological or laboratory findings. Materials and Methods: A cross-sectional study was conducted at Government Medical College and Rajindra Hospital, Patiala, Punjab, India, from December 2014 to September 2015. Sixty patients from Outpatient and Inpatient Department, with clinical suspicion of pelvic pathology, were evaluated sonographically and then by CT scan. Ultrasound characterisation of mass as high or low risk was done based on septae and solid part echogenicity. CT findings used to diagnose malignancy were cystic solid mass, necrosis in a solid lesion, cystic lesion with thick, irregular walls or septa, and/or papillary projections. The presence of ascites, lymphadenopathy, omental cake, peritoneal deposits, mesenteric deposits was noted to diagnose metastasis. Data was analysed using Statistical Package for Social Sciences (SPSS) version 16.0. A p-value was calculated using Chi-square test. For finding, the level of agreement between USG/CT scan and histopathology, Kappa statistic was applied. Results: Ultrasound had sensitivity of 73.7%, specificity of 80.3%, Positive Predictive Value (PPV) of 53.8% and Negative Predictive Value (NPV) of 90.7%. Computed tomography scan had a sensitivity of 78%, specificity of 95.08%, PPV of 83.3%, and NPV of 93.5%. Kappa statistics showed moderate level of agreement between USG and histopathological findings (k=0.47, p-value=0.017) and good level of agreement between CT scan and histopathological findings (k=0.68, p-value=0.001). Conclusion: Ultrasound with its good sensitivity can be used as an effective screening modality for pelvic masses. Computed tomography scan has better specificity than USG and should be used as a confirmatory investigation.

A case of primary adenocarcinoma of Meckel’s diverticulum presenting as ovarian mass and literature review

Meckel’s diverticulum (MD) is the most common congenital anomaly affecting the gastrointestinal tract. It is located on the anti-mesenteric border of the small intestine and occurs due to incomplete obliteration of the omphalomesenteric duct during embryogenesis. Tumors, particularly cancers, are rare complications of MD. Carcinoids are the most common malignancies in this site. Adenocarcinomas are extremely rare and carry a poor prognosis. Here, we present the case of adenocarcinoma of MD presenting as Krukenberg tumor in a 42-year-old lady and causing a diagnostic dilemma. Pelviabdominal examination revealed large bilateral adnexal masses along with ascites and computed tomography-guided fine-needle aspiration cytology from the right adnexal mass was suggestive of adenocarcinoma. At exploratory laparotomy, a MD was found with hard intramural growth palpable at the tip of MD adnexal deposits and omental caking. Immunohistochemistry revealed CK 7- and CK 20+ve and also CDX2 positive. The rarity of presentation of bilateral adnexal mass due to primary adenocarcinoma of MD urges us to report this case.

Multiquadrant Robotic Assisted Primary Cytoreduction for Stage III C Ovarian Cancer Part II Modified Posterior Exenteration

<h3>Study Objective</h3> To demonstrate Part II of multi-quadrant robotic assisted pelvic primary cytoreductive surgery for Stage IIIC epithelial ovarian cancer. <h3>Design</h3> A prospective single patient underwent robotic assisted cytoreductive surgery. Docking time for pelvic and abdominal dissection was recorded. The multiple procedures that patient underwent was recorded for operative time along with intraoperative complications and postoperative complication, estimated blood loss, and length of hospitalization. <h3>Setting</h3> Tertiary hospital. <h3>Patients or Participants</h3> Patient is a 56-year-old female presents with abdominal pain. CT scan showed no ascites soft tissue mass in the right hepatic gutter omental mass with minimal pelvic fluid and pelvic mass. CA 125 was 533. <h3>Interventions</h3> Robotic Xi. <h3>Measurements and Main Results</h3> The abdominal docking time was 2 minutes and 30 seconds. The pelvic docking time which was the time from de-docking after completion of abdominal dissection to rotating the boom to re-docking for pelvic dissection was 5 minutes and 30 seconds. Total operative time for both pelvic and abdominal dissection was 246 minutes. The operative time for right diaphragm peritonectomy 30 minutes and resection of omental caking with complete omentectomy was 68 minutes. The pelvic dissection which consisted of en bloc modified posterior exenteration procedure with total intracorporal sigmoid rectal anastomosis was 126 minutes. A complete cytoreductive surgery with no gross residual was achieved. EBL 200 cc and length of hospitalization was 4 days. There was no intraoperative or postoperative complication. <h3>Conclusion</h3> Robotic assisted multi-quadrant surgery is feasible to achieve upper abdominal, abdominal and pelvic procedures to achieve an optimal cytoreductive surgery for stage IIIc ovarian cancer.

Multiquadrant Robotic Assisted Primary Cytoreduction for Stage III C Ovarian Cancer Part I Complete Omentectomy Right Diaphragm Stripping

<h3>Study Objective</h3> To demonstrate Part I of multi-quadrant robotic assisted abdominal primary cytoreductive surgery for Stage IIIC epithelial ovarian cancer. <h3>Design</h3> A prospective single patient underwent robotic assisted cytoreductive surgery. Docking time for pelvic and abdominal dissection was recorded. The multiple procedures that patient underwent was recorded for operative time along with intraoperative complications and postoperative complication, estimated blood loss, and length of hospitalization. <h3>Setting</h3> Tertiary hospital. <h3>Patients or Participants</h3> Patient is a 56-year-old female presents with abdominal pain. CT scan showed no ascites soft tissue mass in the right hepatic gutter omental mass with minimal pelvic fluid and pelvic mass. CA 125 was 533. <h3>Interventions</h3> Robotic Xi. <h3>Measurements and Main Results</h3> The abdominal docking time was 2 minutes and 30 seconds. The pelvic docking time which was the time from de-docking after completion of abdominal dissection to rotating the boom to re-docking for pelvic dissection was 5 minutes and 30 seconds. Total operative time for both pelvic and abdominal dissection was 246 minutes. The operative time for right diaphragm peritonectomy 30 minutes and resection of omental caking with complete omentectomy was 68 minutes. The pelvic dissection which consisted of en bloc modified posterior exenteration procedure with total intracorporal sigmoid rectal anastomosis was 126 minutes. A complete cytoreductive surgery with no gross residual was achieved. EBL 200 cc and length of hospitalization was 4 days. There was no intraoperative or postoperative complication. <h3>Conclusion</h3> Robotic assisted multi-quadrant surgery is feasible to achieve upper abdominal, abdominal and pelvic procedures to achieve an optimal cytoreductive surgery for stage IIIc ovarian cancer.

Peritoneal tuberculosis mimicking advanced ovarian cancer case report: Laparoscopy as diagnostic modality.

Introduction and importancePeritoneal Tuberculosis is one of extrapulmonary tuberculosis that occurs in 1-2% of patients, its incidence is higher in developing countries. It is very difficult to diagnosed and can mimic advanced ovarian cases. Making an accurate diagnosis is vital, laparoscopy is a great modality for this purpose.Case presentationA 36 years-old woman got referred with abdominal distention and weight loss from an internist and digestive surgeon. The abdominal computed tomography said thickening of the stomach wall with ascites. Ultrasound concluded the uterus, ovary, and endometrium within normal. The CA 125 levels elevated to 1200 U/mL and the complete blood count was normal. We were making diagnosis of peritoneal tuberculosis, peritoneal carcinomatosis, and advanced ovarian cancer. We did the diagnostic laparoscopic and taking a biopsy sample, ascites with peritoneal carcinomatosis and omental cake were found, the peritoneal cavity was covered by miliary nodules. Histopathology results concluded peritoneal tuberculosis without malignancy signs. The patient was treated with tuberculosis drugs. The follow-up evaluations show significant clinical improvement.Clinical discussionWhen facing patients with massive ascites and elevated CA 125 without any ovary enlargement, a gynecologist should think that it may be a peritoneal TB case with peritoneal carcinomatosis and advance ovarian cancer possibility as differential diagnosis especially in developing countries. An exact diagnosis can be made using laparoscopy and histopathology examination.ConclusionLaparoscopy is the best modality to differentiate between peritoneal tuberculosis, peritoneal carcinomatosis, and advance ovarian cancer. The benefits are direct visualization and could take a biopsy for histology examination.

S3173 Gastric Masson’s Hemangioma: A Rare Cause of Hematemesis

Introduction: Intravascular papillary endothelial hyperplasia (IPEH) or Masson’s Hemangioma (MH) is a rare, benign vascular tumor. It is most commonly reported to occur in the head, neck and hands. MH in the gastrointestinal (GI) tract is exceedingly uncommon, with no reported cases of gastric MH till date. We report a unique patient with gastric MH who presented with massive hematemesis. Case Description/Methods: A 41-year-old male presented to the hospital with several episodes of hematemesis with clots. His medical history was significant for pulmonary embolism status post IVC filter and hepatic arteriovenous malformation status post coil embolization. He denied alcohol abuse, retching or prior episodes of hematemesis. Patient was on aspirin 81 mg/day, but was not taking non steroidal anti inflammatory drugs or anti-coagulants. Vital signs were normal and physical assessment was unremarkable except for melena on the rectal exam. Subsequent esophagogastroduodenoscopy showed a 4x4 cm protuberant, ulcerated gastric submucosal mass on lesser curvature of distal body with overlying clot but no active bleeding (Fig. 1a). A follow up CT scan of the abdomen and pelvis showed a 4.0 x 3.3 x 3.6 cm mass in the lesser curvature of the gastric body which extended into the gastro-hepatic space (Fig. 1b). Patient developed recurrent hematemesis and was immediately taken for surgical resection. Exploratory laparotomy and wedge resection of actively bleeding 5 cm ulcerated gastric mass was performed (Fig. 1c). Histologically, the lesion showed a central area consisting of thrombotic material surrounded by a proliferation of papillary structures and hyperplastic endothelial cells. CD34 and Factor VIII stains were positive for endothelial cells and Elastic Van Gieson stain confirmed the lesion was within a large vessel. These findings were consistent with a diagnosis of Masson’s Hemangioma (Fig. 1d). Patient had an uneventful post-surgical course and was discharged with follow up in the surgery clinic. Discussion: Masson’s Hemangioma in the GI tract is an extremely rare entity which may lead to life threatening GI bleed. Lesions are reactive endothelial hyperplasia around a pre-existing thrombus, mostly associated with underlying prothrombotic states. It is important to rule out aggressive vascular lesions such as angiosarcoma, when considering the histologic diagnoses of MH. Surgical resection represents a definitive cure and is associated with an excellent prognosis.Figure 1.: A: Axial contrast-enhanced CT: Enlarged, heterogeneously-enhancing bilateral ovaries (arrows), representing infiltrating Krukenberg tumors. U, Uterus. A, Ascites. B: Axial contrast-enhanced CT: Enlarged periaortic and pericaval lymph nodes (arrows), suspicious for metastatic disease. A, Ascites. C:Sagittal contrast-enhanced CT: Irregular thickening with nodular enhancement of the gastric body (white arrows), as is seen with infiltrating malignancy. Reticulation and soft-tissue density of the omental fat (red arrows), representing omental caking.

S1681 Malignant Peritoneal Mesothelioma (PeM) With Rhabdoid Features Masquerading as Idiopathic Necrotizing Pancreatitis With Mucinous Ascites: A Case Report and Literature Review

Introduction: Malignant Mesothelioma (MM) is a great masquerader, presenting as infection, metastasis, other cancers or as a paraneoplastic syndrome. Malignant peritoneal mesothelioma (PeM) accounts for about 10-15% of all cases of mesothelioma. MM presenting with malignant gastrointestinal (GI) polyps is also rare, with only 16 reported cases of mesothelioma presenting as metastatic disease in the GI tract. Here, we present the clinicopathologic findings of a case of a malignant peritoneal rhabdoid mesothelioma presenting as a necrotizing pancreatic mass, recurrent deep vein thrombosis (DVT), chylous ascites, and late onset weight loss. Case Description/Methods: A 76-year-old female initially presenting with idiopathic necrotizing pancreatitis. She continued to report persistent vague lower and mid abdominal pain. Six months after her initial admission the patient developed a DVT and pulmonary embolism (PE) requiring thrombectomy and anticoagulation with a recurrent DVT requiring IVC filter placement. She continued to have recurrent ascites and an enlarging peripancreatic fluid collection. Multiple paracenteses were performed with studies negative for infection and cytology negative for malignancy; however, most samples could not be analyzed due to fluid viscosity. An endoscopic retrograde cholangiopancreatography was performed with pancreatic and biliary stents placed. Almost one year after the patient’s initial admission, cross-sectional abdominal imaging showed omental caking with enlargement of the proximal pancreas. An endoscopic ultrasound with fine needle aspiration was performed was non-diagnostic. Lymphangiogram performed chylous nature of ascites. MRI showed a large fluid volume surrounding the pancreas and extended into the pararenal spaces. There was a mass effect leading to displacement of the surrounding structures. Diagnostic laparoscopy showed abdominal wall and peritoneal implants in addition to a large, firm, and highly vascularized epigastric mass. Pathology showed peritoneal mesothelioma. Discussion: We have presented a case of PeM with rhabdoid features present in the peritoneum and in gastric polyps. PeMs are rare tumors with a non-specific clinical presentation. These lesions are also difficult to diagnose and definitive diagnosis of MPM requires surgically obtained tissue. To our knowledge, this is the first case with these features.

Ultrasound for Preoperatively Predicting Pathology Grade, Complete Cytoreduction Possibility, and Survival Outcomes of Pseudomyxoma Peritonei.

ObjectivesThis study aimed to investigate the value of using ultrasound (US) preoperatively for predicting pathological classification, complete cytoreduction possibility, and survival rate of patients with pseudomyxoma peritonei (PMP).MethodsWe retrospectively studied PMP patients who were scheduled for cytoreductive surgery between May 2009 and October 2019. US examination was performed before surgery. Factors related to high-grade pathology and poor completeness of cytoreduction (CC) score were identified. Associations between ultrasound characteristics and the survival status were also examined to identify independent predictive factors.ResultsPMP patients with clear ascites, abdominal lymph nodes, omental cake, abdominal mass, portal infiltration, and mesenteric involvement visible on US were considered to have high-grade pathology. Various US features were shown to be independent prognostic markers for inadequate cytoreduction in PMP patients. Portal infiltration and mesenteric involvement were significant prognostic factors for lower survival rates (hazard ratio = 3.092, 3.932, respectively). A visual nomogram including these factors was constructed to predict survival rates. The consistency index was 0.777, which reflected relatively high accuracy.ConclusionsPreoperative US has the potential to predict pathological grade and resectability of PMP. Portal infiltration and mesenteric involvement were independent predictors of poor clinical outcomes in PMP patients. Furthermore, a simple-to-use nomogram derived from our study data may be a helpful visual tool in clinical practice to predict 1-, 2-, and 3-year survival rates for PMP patients.

Splenectomy and Distal Pancreaticosplenectomy: Surgical Anatomy and Technique Specific to Advanced Ovarian Cancer.

Ovarian cancer is one of the most aggressive malignancies in women and usually presents at an advanced stage. Complete tumor debulking and platinum sensitivity are the two important determinants of survival in ovarian cancer. Upper abdominal surgery with bowel resections and peritonectomy are usually needed to achieve optimal cytoreduction. Splenic disease in the form of diaphragmatic peritoneal disease or omental caking at the splenic hilum is not infrequent. Around 1-2% of these require distal pancreaticosplenectomy (DPS) and the decision to perform DPS versus splenectomy should be made early in the intraoperative period to prevent unnecessary hilar dissection and bleeding. We hereby describe the surgical anatomy of the spleen and pancreas and point of technique of splenectomy and DPS specific to advanced ovarian cancers.

Middle-aged Lady With Extensive Omental Caking, Peritoneal Nodules, and Pelvic Masses.

Middle-aged Lady With Extensive Omental Caking, Peritoneal Nodules, and Pelvic Masses.

Diffuse peritoneal lymphomatosis or abdominal tuberculosis: a clinico-radiological conundrum

Primary extra nodal lymphoma occurs in approximately 25% to 40% of patients and is more common in patients with NHL. Diffuse large B-cell lymphoma (DLBCL) is the dominant histological subtype. A 60-year-old gentleman presented to our hospital with pain abdomen associated with abdominal distension since a month, few constitutional symptoms with bilateral axillary and inguinal lymphadenopathy. Blood investigations showed high total count with significantly high LDH levels. Provisional diagnosis of tubercular Abdomen/Malignant Ascites with Unknown primary was made. CT Abdomen showed large bowel wall thickening with parietal peritoneal lesions with omental cake. Excision biopsy of inguinal lymph node showed lymphoid follicles with poorly defined attenuated mantle zones having centrocytes and centroblasts. Immunohistochemistry was positive for markers, which confirmed the diagnosis of Stage 4B DLBCL, germinal center B-cell type. Sepsis and acute kidney injury occurred and the patient expired, 6 days after diagnosis. To conclude, Peritoneal lymphomatosis is an extremely rare condition. This case highlights the need to have a high index of suspicion for malignancy, when a given case is clinically diagnosed with tuberculosis as and when new findings appear during investigation.

ADDED VALUE OF POSITRON EMISSION TOMOGRAPHY/ COMPUTED TOMOGRAPHY IN DETECTION OF PERITONEAL CARCINOMATOSIS

The peritoneum consists of 2 layers the parietal layer covering the inner surface of abdomen and visceral layer which reflects over and surround the abdominal organs. Peritoneal carcinomatosis is one of the frequent sites of metastasis in many gastrointestinal and gynecological tumors mostly colorectal and ovarian cancer. Various forms of peritoneal carcinomatosis could be noted in the form of ascites, micronodular, nodular, plaque like, mass like, omental cake, teca aspect and ileal freezing.Positron emission tomography (PET) is being increasingly used for diagnosis, staging, and follow-up of various malignancies. In peritoneal carcinomatosis, FDG-PET/CT has been shown to have higher sensitivity and positive predictive value (up to 92%) compared to FDG-PET and CT alone. It also has higher specificity (up to 97%) compared to FDG-PET alone, with similar specificity compared to CT alone. It is more useful than just PET the addition of CT allows better anatomic visualization and can detect the presence of cancer lesions based on the glucose uptake of the cells. It identifies the exact localization and area of the peritoneal metastasis, PET-CT provides better accuracy. It adds good value to the conventional imaging mainly for monitoring response to the therapy, especially on long-term follow-up. PET/CT has multiple clinical applications in peritoneal oncology detecting the primary tumor in unknown primary, tumor staging and restaging; treatment planning, post therapy response, differentiating recurrence from post therapy changes; distinguishing malignant from benign peritoneal disease; can be used as a biomarker as well as alternative tracers for cancer evaluation.

A Prediction Model for Optimal Primary Debulking Surgery Based on Preoperative Computed Tomography Scans and Clinical Factors in Patients With Advanced Ovarian Cancer: A Multicenter Retrospective Cohort Study.

ObjectiveThis study assessed the predictive value of preoperative computed tomography (CT) scans and clinical factors for optimal debulking surgery (ODS) in patients with advanced ovarian cancer (AOC).MethodsPatients with AOC in International Federation of Gynecology and Obstetrics (FIGO) stage III-IV who underwent primary debulking surgery (PDS) between 2016 and 2019 from nine tertiary Chinese hospitals were included. Large-volume ascites, diffuse peritoneal thickening, omental cake, retroperitoneal lymph node enlargement (RLNE) below and above the inferior mesenteric artery (IMA), and suspected pelvic bowel, abdominal bowel, liver surface, liver parenchyma and portal, spleen, diaphragm and pleural lesions were evaluated on CT. Preoperative factors included age, platelet count, and albumin and CA125 levels.ResultsOverall, 296 patients were included, and 250 (84.5%) underwent ODS. The prediction model included age >60 years (P=0.016; prediction index value, PIV=1), a CA125 level >800 U/ml (P=0.033, PIV=1), abdominal bowel metastasis (P=0.034, PIV=1), spleen metastasis (P<0.001, PIV=2), diaphragmatic metastasis (P=0.014, PIV=2), and an RLNE above the IMA (P<0.001, PIV=2). This model had superior discrimination (AUC=0.788>0.750), and the Hosmer-Lemeshow test indicated its stable calibration (P=0.600>0.050). With the aim of maximizing the accuracy of prediction and minimizing the rate of inappropriate explorations, a total PIV ≥5 achieved the highest accuracy of 85.47% and identified patients who underwent suboptimal PDS with a specificity of 100%.ConclusionsWe developed a prediction model based on two preoperative clinical factors and four radiological criteria to predict unsatisfactory debulking surgery in patients with AOC. The accuracy of this prediction model needs to be validated and adjusted in further multicenter prospective studies.

An Atypical Case of Burkitt Lymphoma with Diffuse Peritoneal, Omental and Periportal Invasion

Diffuse peritoneal and especially periportal invasion of Burkitt lymphoma is very rarely seen. We present a case of a 16-year-old boy presenting with abdominal pain and constipation, without improvement after enemas. Abdominal ultrasound revealed a diffuse infiltrating peritoneal mass, omental caking, ascites, and a periportal mass, confirmed by computed tomography (CT). No lymphadenopathies were seen. Biopsy was performed and the diagnosis of Burkitt lymphoma was made. Although very rare, it is important to include lymphoma in the differential diagnosis of diffuse peritoneal and periportal invasion in children, as it can mimic peritoneal carcinomatosis.

Critical Analysis of Stage IV Epithelial Ovarian Cancer Patients after Treatment with Neoadjuvant Chemotherapy followed by Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC).

Background Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) after neoadjuvant chemotherapy (NACT) showed promise as initial treatment for stage IIIC (SIII) epithelial ovarian cancer (EOC); however, stage IV (SIV) outcomes are rarely reported. We assessed our experience and outcomes treating newly diagnosed SIV EOC with NACT plus CRS/HIPEC compared to SIII patients. Methods Advanced EOC from 2015–2018 managed with NACT (carboplatin/paclitaxel) due to unresectable disease or poor performance status followed by interval CRS/HIPEC were reviewed. Perioperative factors were assessed. Overall survival (OS) and progression-free survival (PFS) were analyzed by stage. Results Twenty-seven FIGO stage IIIC (n = 12) and IV (n = 15) patients were reviewed. Median NACT cycles were 3 and 4, respectively. Post-NACT omental caking, ascites, and pleural effusions decreased/resolved in 91%, 91%, and 100% of SIII and 85%, 92%, and 71% of SIV. SIII/SIV median PCI was 21 and 20 obtaining 92% and 100% complete cytoreduction (≤0.25 cm), respectively. Median organ resections were 6 and 7, respectively. Grade III/IV surgical complications were 0% SIII and 23% SIV, without hospital mortality. Median time to adjuvant chemotherapy was 53 and 74 days, respectively (p=0.007). SIII OS at 1 and 2 years was 100% and 83% and 87% and 76% in SIV (p=0.269). SIII 1-year PFS was 54%; median PFS: 12 months. SIV 1- and 2- year PFS was 47% and 23%; median PFS: 12 months (p=0.944). Conclusion Outcomes in select initially diagnosed and unresectable SIV EOC are similar to SIII after NACT plus CRS/HIPEC. SIV EOC may benefit from CRS/HIPEC, and further studies should explore this treatment approach.

RARE-56. PERITONEAL SEEDING OF A DIFFUSE LEPTOMENINGEAL GLIONEURONAL TUMOR IN A CHILD

Diffuse leptomeningeal glioneuronal tumors (DLGNT) are rare neoplasms of the central nervous system and have been included in the 2016 update of the WHO classification. This is the first description of a DLGNT disseminating to the peritoneal cavity via a ventriculoperitoneal shunt (VPS) in a child. We describe an 11-year old girl who received a VPS for a Dandy-Walker malformation at the age of seven, and was diagnosed with a spinal pilocytic astrocytoma with leptomeningeal metastases six months later. She received chemotherapy (SIOP-LGG protocol) with partial response, and had progressive disease eight months after therapy cessation. Following a novel biopsy, the diagnosis was revised to a DLGNT, with a KIAA1549-BRAF fusion and loss of 1p. She received vinblastine, but was clinically progressive and craniospinal radiotherapy was initiated. 13 months later, she suddenly presented with ascites. The inferior vena cava was compressed due to the ascites, and an abdominal drain was placed, with massive fluid release. Abdominal MRI indicated an omental cake and peritoneal contrast enhancement. Bone metastases were suspected in the iliac and femoral bones. Anatomopathological examination of the ascites showed an atypical cell population, with irregular, hyperchromatic and enlarged nuclei resembling the primary tumor. The cells were positive for synaptophysin, MAP2 and weakly positive for S100. Pan-NTRK staining was negative. The diagnosis of a metastatic localization of the DLGNT was made, due to seeding of tumoral cells via the VPS. Treatment with a MEK-inhibitor was initiated, but was stopped due to progressive disease and she died 3 weeks later.

Adnexal Mass with an Unknown Histology

Background: Ovarian malignancy is a common malignancy in women. Most malignancies are adenocarcinoma. However, adnexal metastases from squamous cell carcinoma (SCC) of the cervix are uncommon. Case: We present a 53-year-old nulliparous postmenopausal woman who presented with pain in abdomen, adnexal mass, and high CA125 levels. On local examination, vagina and cervix were apparently healthy with retroverted uterus of normal size, and bilateral (B/L) forniceal thickening was present. Pouch of Douglas and rectal mucosa were free. Clinicoradiologic diagnosis was an ovarian malignancy. Results: Intraoperatively, ∼150 mL mucinous ascites and omental caking with subcentimeter deposits on right subhepatic peritoneum were noted. Uterus was apparently normal and B/L adnexal masses with stretched and dilated B/L tubes were seen, ovaries could not be visualized separately (right = 6 × 5 cm, left = 7 × 4 cm). B/L pelvic lymph nodes were grossly enlarged with pelvic peritoneal deposits. A total abdominal hysterectomy with B/L pelvic lymph node dissection with total omentectomy with excision of pelvic and subhepatic peritoneal deposits with appendicectomy was done and a Sugarbaker's completeness cytoreduction score 0 (CC-0) was achieved. Final histopathologic examination postsurgery revealed disseminated SCC of the cervix. Conclusions: Before confirming a diagnosis of primary SCC of the ovary, a consideration of possible origin from a cervical tumor should be made, unless overt features of primary neoplasia are immediately obvious.

Guideline No. 403: Initial Investigation and Management of Adnexal Masses.

To aid primary care physicians, emergency medicine physicians, and gynaecologists in the initial investigation of adnexal masses, defined as lumps that appear near the uterus or in or around ovaries, fallopian tubes, or surrounding connective tissue, and to outline recommendations for identifying women who would benefit from a referral to a gynaecologic oncologist for further management. Gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists, radiologists, sonographers, nurses, medical learners, residents, and fellows. Adult women 18 years of age and older presenting for the evaluation of an adnexal mass. Women with adnexal masses should be assessed for personal risk factors, history, and physical findings. Initial evaluation should also include imaging and laboratory testing to triage women for management of their care either by a gynaecologic oncologist or as per SOGC guideline no. 404 on the initial investigation and management of benign ovarian masses. A search of PubMed, Cochrane Wiley, and the Cochrane systematic reviews was conducted in January 2018 for English-language materials involving human subjects published since 2000 using three sets of terms: (i) ovarian cancer, ovarian carcinoma, adnexal disease, ovarian neoplasm, adnexal mass, fallopian tube disease, fallopian tube neoplasm, ovarian cyst, and ovarian tumour; (ii) the above terms in combination with predict neoplasm staging, follow-up, and staging; and (iii) the above two sets of terms in combination with ultrasound, tumour marker, CA 125, CEA, CA19-9, HE4, multivariable-index-assay, risk-of-ovarian-malignancy-algorithm, risk-of-malignancy-index, diagnostic imaging, CT, MRI, and PET. Relevant evidence was selected for inclusion in descending order of quality of evidence as follows: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional articles were identified through cross-referencing the identified reviews. The total number of studies identified was 2350, with 59 being included in this review. The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework (Table A1 of Online Appendix A). See Table A2 of Online Appendix A for the interpretation of strong and weak recommendations. The summary of findings is available upon request. Adnexal masses are common, and guidelines on how to triage them and manage the care of patients presenting with adnexal masses will continue to guide the practice of primary care providers and gynaecologists. Ovarian cancer outcomes are improved when initial surgery is performed by a gynaecologic oncologist, likely as a result of complete surgical staging and optimal cytoreduction. Given these superior outcomes, guidelines to assist in the triage of adnexal masses and the referral and management of the care of patients with an adnexal mass are critical. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

The Influence of "Omental Cake" Presence on the Completeness of Cytoreduction in Advanced-stage Ovarian Cancer.

The presence of "omental cake" has been considered since long as a negative prognostic factor in patients diagnosed with advanced-stage ovarian cancer. The aim of this paper was to study the impact of "omental cake" presence on the perioperative outcomes in advanced-stage ovarian cancer. Between 2015 and 2020, 85 patients were submitted to surgery for advanced-stage ovarian cancer. Among cases diagnosed with "omental cake" the rate of complete cytoreduction was significantly diminished when compared to cases in which this entity was not revealed. In the meantime, the presence of omental cake among cases in which complete debulking was achievable was significantly associated with a higher number of digestive resections when compared to the other cases submitted to surgery and in which tumoral transformation of the omentum was encountered. The presence of "omental cake" is associated with a higher rate of incomplete resections. However, in cases in which complete debulking was achieved, the presence of omental cake was associated with a significantly higher number of digestive tract resections.

A Case of Peritoneal Sarcomatoid Mesothelioma with Absence of Occupationl Exposure to Asbestos

Sarcomatoid mesothelioma is not very common, mesothelioma is directly attributable to occupational asbestos exposure, with 90% of cases showing a history of exposure. A 66-year-old male was admitted with an abdominal pain that persisted for 3 weeks. He had no abdominal mass. Computed tomography showed soft tissue thickening in perihepatic space and nodularities in omentum and peritoneum with ascites. There was no absolute diagnosis evidence in ascites analysis. Although the pathology of ascites was free for malignancy, the patient underwent omentum biopsy for definitive diagnosis. In laproscopic exploration, there was omental cake, peritoneal nodular seeding. It was suspected cancer carcinomatosis. Immunohistochemical findings suggested that it was sarcomatoid masothelioma. This is the rare case of a peritoneal sarcomatoid mesothelioma, without any exposure to asbestos.