Para-aortic Node Biopsy Research Articles

Female Patient With Massive Refractory Chylous Ascites Following Paraaortic Lymph Node Biopsy.

Female Patient With Massive Refractory Chylous Ascites Following Paraaortic Lymph Node Biopsy.

Serendipity and the Second Malignancy: Clear Cell Renal Carcinoma Workup Revealing a Paraaortic Paraganglioma With Post-Operative Vasoplegia

Pheochromocytoma and paraganglioma (PPGL) are neuroendocrine tumors requiring careful pre- and post-operative management to dampen fluctuations in catecholamines. These lesions are not typically biopsied due to risk of catecholamine-induced hemodynamic instability. This case illustrates the importance of considering PPGL in patients without typical symptoms, and highlights challenges with post-operative blood pressure management following use of phenoxybenzamine.A 52 year old man presented with a 40 lb weight loss. PET/CT revealed a right renal mass, enlarged retroperitoneal lymph nodes, and increased uptake in retroperitoneal and paraaortic lesions. Paraaortic lymph node biopsy was consistent with paraganglioma.This finding was unexpected as the patient did not report palpitations, paroxysmal hypertension, or diaphoresis. He had no family history of neuroendocrine tumors. Fortunately, he had no adverse effects during biopsy despite subsequent testing showing elevated plasma metanephrines (271 pg/mL, normal ≤ 57 pg/mL) and normetanephrines (770 pg/mL, normal ≤ 148 pg/mL). I-123 MIBG scan revealed an enlarged left paraaortic mass with increased activity consistent with paraganglioma. He started preoperative alpha blockade with phenoxybenzamine 14 days prior to surgery. Propranolol was added 10 days later to provide combined sympathetic blockade.The patient underwent partial right nephrectomy and resection of the paraaortic mass. Pathology showed renal cell carcinoma (RCC) and paraganglioma, respectively. On post-operative day 1, maintenance fluids were discontinued and he developed palpitations and tachycardia to 140 beats per minute, with blood pressure in the 130s/80s. RCC associated pulmonary embolism, beta-blocker withdrawal, and vasoplegia due to phenoxybenzamine use and paraganglioma resection were considered. The patient was treated with 4 additional liters of normal saline over the next two days to address post-operative vasoplegia, and his tachycardia resolved. Genetic testing for neuroendocrine tumor syndromes including Von Hippel-Lindau (VHL) is ongoing.Clinical Lessons: 1. PPGL should be considered in patients with newly identified intraabdominal masses, even in patients without typical symptoms of catecholamine excess to avoid high risk biopsy. 2. Paraganglioma resection is associated with vasoplegia due to post-operative reduction in circulating catecholamines. 3. The covalent, irreversible alpha antagonist phenoxybenzamine accumulates in adipose tissue, and clinical effects can last up to 7 days after discontinuation. Hypotension can be avoided with aggressive fluid resuscitation. Beta antagonists should be used with caution as they may precipitate hypotension. 4. For patients presenting with paraganglioma and renal cell cancer, genetic syndromes including VHL or RAPTAS etiologies should be considered.

P031 Whipple's disease: a multidisciplinary conundrum

Abstract Background/Aims A 45-year-old male patient presented in 2015 with a six-month history of relapsing and remitting polyarthralgia. Hand X-rays appeared normal. Serology showed mildly elevated inflammatory markers. Autoimmune profile including anti-CCP antibody, rheumatoid factor and ANA was negative. His initial diagnosis was palindromic rheumatism. He was under watchful waiting in rheumatology clinic having declined a trial of hydroxychloroquine, when in 2018 he developed severe epigastric pain. Over the subsequent 18 months he was noted to have dramatic weight loss, fatigue and drenching night sweats. Methods Investigations showed microcytic anaemia with elevated inflammatory markers (Hb 98 g/L, CRP 161 mg/L, ESR 68 mm/hr). Serum ACE, bone profile, thyroid function and urate levels were normal. Chest X-ray was unremarkable. HIV and hepatitis screening was negative. Endoscopy with jejunal biopsy was performed, with mild gastritis only on histopathology and normal D2 biopsies. He was found to be H pylori positive, and notably felt his B-symptoms much improved with triple antibiotic and PPI eradication therapy. CT abdomen demonstrated widespread mesenteric lymphadenopathy. Para-aortic lymph node biopsy showed non-necrotising granulomata suggestive of either sarcoidosis or an infective etiology such as tuberculosis (TB). Given the clinical picture, the patient was commenced on high dose oral prednisolone and methotrexate for suspected sarcoidosis. Results The patient made some clinical improvement, particularly with regards to arthralgia, however his B-symptoms returned with any reduction in steroid dose. Serology showed worsening anaemia with iron and folate deficiency, and increasing inflammatory markers. We therefore decided to perform a PET CT and refer to Haematology for consideration of a lymphoproliferative disease. PET CT demonstrated lymphadenopathy without avid uptake. A second lymph node biopsy was performed which showed florid histiocytic infiltration within which there were numerous PAS positive particles consistent with Whipple's disease. This was confirmed as tropheryma whipplei on PCR. Whipple's disease is a rare systemic infectious disease causing arthralgia, diarrhoea, abdominal pain and weight loss. Treatment consists of antibiotic therapy. On further questioning, the patient had grown up on a farm. There is a known association with Whipple's disease in the agricultural community as it is a soil-borne organism. Conclusion Our patient has made an excellent recovery. He remains under the care of our rheumatology team and the London School of Tropical Medicine and Hygiene. Treatment plan is 12 months of combined therapy with doxycycline and hydroxychloroquine. He underwent a lumbar puncture to rule out meningeal Whipple disease. We have also commenced sulfasalazine for persistent arthritis, which we feel could be a reactive phenomenon. Our key learning points from this case were to use a stepwise approach to diagnosis, involve relevant specialty teams and that it in complex cases it is useful to go back to the history. Disclosure F. Baldeweg: None. A. Nuttall: None. D. Arul: None. A. Childerhouse: None.

EP04 Hypercalcaemia of sarcoidosis in a patient with severe renal impairment successfully treated with denosumab

Abstract Background Denosumab has been used for the management of hypercalcaemia of malignancy where bisphosphonates are contraindicated (e.g. due to severe renal impairment). Unlike bisphosphonates, denosumab is not cleared by the kidneys. In one case report of a patient with multiple myeloma and severe renal impairment, denosumab therapy was associated with improvement in renal function. There are limited data for its use in the management of resorption related hypercalcaemia due to other causes including sarcoidosis. Methods We present the case of a 60 year old female with background chronic kidney disease (CKD), diabetes mellitus with severe retinopathy, non-alcoholic fatty liver disease, hypertension, and previous stroke. She was diagnosed with biopsy-proven sarcoidosis after she was admitted with hypercalcaemia of 3.7mmol/L. Her parathyroid hormone (PTH) was suppressed and total 25 vitamin D was low at 35 nmol/L. CT scan showed splenomegaly and multiple enlarged lymph nodes in the chest and abdomen. Lungs were clear. A CT guided para-aortic lymph node biopsy revealed non-caseating epithelioid granulomas with multinucleated giant cells. Her hypercalcaemia initially responded to intravenous hydration, high doses of oral and intravenous glucocorticoids, and pamidronate. Azathioprine was later started and the dose gradually titrated. However on reducing the dose of oral prednisolone, serum calcium started to rise reaching 2.9mmol/L in February 2019. Her eGFR was 22mL/min. Using FRAX, her 10 year probability of major osteoporotic and hip fracture was 13% and 1.1% respectively. Results The patient was given denosumab 60mg via subcutaneous route in March 2019 and her calcium has been normal since (see table). This is associated with improvement in renal function. Her PTH which was suppressed at presentation (0.7) was raised at 21.3 (normal range 1.3 - 9.3) pmol/L when last checked in September 2019, as would be expected in CKD. She is currently on 7mg of prednisolone and gradually weaning off. She remains on azathioprine 100mg BD. Conclusion We conclude that denosumab could be an option for the management of hypercalcaemia of sarcoidosis if bisphosphonates are contraindicated. More data are required to establish safety at variable degrees of renal impairment and to identify an optimal dose for this indication. Disclosures R. Alshakh None. N. Gendi None.

A successful intraoperative diagnosis of coexisting lymphoma and endometrial cancer

BackgroundThe coexistence of hematological malignancy with endometrial cancer is a rare phenomenon. We report a case of coexistence of endometrial cancer with follicular lymphoma which we suspected preoperatively and diagnosed during surgery by a multidisciplinary intraoperative assessment.Case presentationA 67-year-old woman was referred to our hospital due to a suspicion of an endometrial cancer. Endometrial biopsy revealed grade 1 endometrioid adenocarcinoma. MRI showed invasion of the tumor into the outer half of the myometrium, and abdominal CT showed para-aortic and atypical mesentery lymphadenopathy which was suspected to be metastasis of endometrial cancer or malignant lymphoma. Abdominal hysterectomy with bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, partial omentectomy, and mesentery lymph node biopsy for endometrial cancer were performed. The mesentery and para-aortic lymph nodes that were sent for frozen section analysis showed no metastasis of the endometrial cancer. We simultaneously conducted an unusual intraoperative emergent four-color flow cytometry and intraoperatively diagnosed a B cell lymphoma in the mesenteric lymph nodes. Because this multidisciplinary assessment, we were able to avoid an unnecessary intestinal resection. The final pathological diagnosis was an endometrioid carcinoma (G1, FIGO stage IA), with a synchronous follicular lymphoma.ConclusionAlthough a rare event in endometrial cancer surgery, it is necessary to be alert to the possibility of a synchronous lymphoma in cases of unusual site adenopathy.

2422 Post-Transplant Lymphoproliferative Disorder

INTRODUCTION: Post-transplant lymphoproliferative disorder (PTLD) is a rare but severe complication in both solid organ and hematopoietic stem cell transplantation. PTLD is caused by the dysfunction of T-cells as a result of the immunosuppressive therapy commonly used in transplant patients. This dysfunction then causes abnormal lymphoid proliferation leading to malignancy. We discuss a case of PTLD presenting in the form of a small bowel obstruction in a patient with dual liver, kidney transplantation. CASE DESCRIPTION/METHODS: A 68-year-old man with previous NASH cirrhosis status post a deceased donor liver and kidney transplant presented to the hospital with nausea, vomiting, and abdominal distension. Prior to presentation he had been maintained at home on Cellcept and Tacrolimus for many years. He was doing well until 3 months prior to presentation when he noted the onset of night sweats. He had no other symptoms until two days prior to presentation when he had the abrupt onset of abdominal pain, distention, nausea and vomiting causing his presentation to the ED. On arrival his initial work up was significant for a mild leukocytosis, anemia, and AKI. He had a CT abdomen and pelvis done which was significant for a small bowel obstruction secondary to a small bowel mass along with mesenteric and retroperitoneal lymphadenopathy, raising the concern of PTLD on initial presentation. Interventional radiology was then consulted and performed a para-aortic lymph node biopsy. EBV and CMV PCR returned negative but the surgical pathology returned as Diffuse Large B Cell Lymphoma with double expression, suggesting a diagnosis of Post Transplant Lymphoproliferative Disorder. He was started on the R-CHOP chemotherapy regimen inpatient and was discharged for further outpatient treatment. DISCUSSION: This case is a rather classic presentation of a rare complication of immunosuppressive therapy, demonstrating the possible lethal side effects of these often life saving drugs. Swift diagnosis was made possible due to early clinical suspicion and rapid involvement of a multitude of different medical specialties. This case demonstrated the need for multi-disciplinary team at all transplant centers and how close communication between consultants is key to these patients success.

Massive Reactionary Haemorrhage Due to Superior Mesenteric Artery Blowout Following Laparoscopic Biopsy of Retroperitoneal Mass - A Case Report

Thermal injury on vascular walls can result in delayed rupture of vessels. This can be a cause of life threatening reactionary haemorrhage. Increasing use of energy devices in laparoscopic surgeries can rarely result in such events which may have devastating consequences. Careful usage of these heat generating energy sources can prevent such incidences and prompt resuscitation and haemorrhage control are lifesaving. We present a case report of a severe haemorrhage from blow out of superior mesenteric artery following laparoscopic para-aortic lymph node biopsy.

Diffuse Large B-cell Lymphoma Presenting as Upper Gastrointestinal Bleeding

Gastric lymphoma is a rare cause of GI bleeding. We hereby report a case of diffuse large B-cell lymphoma that extensively invaded the stomach, spleen and pancreatic tail and demonstrates the aggressive nature of the disease and our diagnostic and therapeutic approach. A 74-year-old woman with a history of peptic ulcer disease presented with dark output from her nasogastric tube and melena. CT without contrast two months ago showed a large necrotic mass invading the spleen, for which she underwent a non-diagnostic CT-guided para-aortic lymph node biopsy as well as laparoscopic biopsy of greater curvature lymph node and retroperitoneal mass that was suspicious for lymphoma. On presentation, she was febrile, hypotensive and tachycardic. She was intubated and sedated. Labs revealed a Hgb of 7.9 g/dL, WBC 33.8 K/mm, AST 125 IU/L, ALP 186 U/L, alb 1.6 g/dL, T bili 2.4 mg/dL. CT scan on admission showed heterogeneous neoplasm involving the pancreatic tail, gastric body, spleen and metastatic upper abdominal lymphadenopathy (Figure 1). PET demonstrated an intensely FDG-avid confluent mass involving the pancreatic tail, spleen and greater curvature of the stomach with FDG-avid abdominal adenopathy (Figure 2). EGD showed a nonbleeding, large infiltrative non-circumferential mass on the lesser curvature of the stomach (Figure 3). A review of the prior laparoscopic biopsies showed large atypical cells of B-cell origin based on PAX5, CD19 and CD79a expression, diagnosis of a diffuse large B-cell lymphoma was made. Results of EGD with biopsy and laparoscopic biopsy were consistent. Given recurrent active bleeding requiring vasopressors and transfusions, IR was consulted and hemostasis achieved with embolization of left gastric and splenic artery. However, she died soon after discharge due to the diffuse nature of the disease. Diffuse large B-cell lymphoma is the most common type of non-Hodgkin lymphoma. Since DLBCL can advance quickly, it usually requires immediate chemotherapeutic treatment once the diagnosis is established. Surgery is considered as second-line treatment for severe perforation, bleeding, or a need for palliative treatment. An EGD can help confirm the diagnosis and rule out other sources of bleeding. In this setting, EGD biopsy could have obviated the need for a laparoscopic biopsy. Given the extent of tumor involvement in our case, endoscopic hemostasis is rarely successful and IR is necessary for hemostasis.Figure: A large mass inseparable from the pancreatic tail and gastric antrum inferiorly was seen on CT abdomen/pelvis. This appears to invade the spleen at the splenic hilum and the largest component of the mass measures up to 11 x 7.2 x 12 cm.Figure: Intensely FDG-avid confluent mass with central necrosis is noted involving the pancreatic tail, spleen and greater curvature of the stomach, correlating to hypoenhancing mass noted on CT measuring approximately 11.5 x 7.2 cm.Figure: EGD showed a large, infiltrative mass with oozing and stigmata of recent bleed.

Incidence of Histologically Proven Pelvic and Para-Aortic Lymph Node Metastases and Rate of Upstaging in Patients with Locally Advanced Cervical Cancer: Results of a Prospective Randomized Trial

Background: Surgical staging is associated with a significant rate of upstaging compared to clinical/radiological staging in patients with locally advanced cervical cancer. Objective: To analyze the stage-specific percentage of pelvic and para-aortic lymph node metastases and the upstaging ratio in a prospective randomized trial (Uterus-11). Methods: FIGO stage IIB-IVA cervical cancer patients were randomized to surgical staging (arm A) or to clinical staging and primary chemoradiation (arm B). Arm B patients underwent CT-guided biopsy of suspicious para-aortic lymph nodes. Confirmed para-aortic metastasis patients received extended-field radiation therapy. Results: A total of 234 patients were enrolled, including 120 (arm A) and 114 (arm B) treated per protocol. The groups were well balanced. Pelvic and para-aortic lymph node metastases were identified after surgical staging in 51 and 24% of patients, respectively (p < 0.001). Pelvic and para-aortic lymph node metastases were confirmed in 45 and 20% of IIB patients and in 71 and 37% of IIIB patients, respectively. Upstaging occurred in 39/120 (33%) in arm A and in 9/114 (8%) in arm B (p < 0.001). Conclusion: The histological results in both groups led to a considerable rate of upstaging. Oncological data from the Uterus-11 study may reveal whether modified therapy translates into a survival benefit.

Urothelial carcinoma of donor origin in a kidney transplant patient

BackgroundMalignancy after transplantation is an uncommon multifactorial occurrence. Immunosuppression to prevent graft rejection is described as a major risk factor in malignancy development in the post-transplant state. Donor-derived malignancy is...

Importance of Para-Aortic Lymph Node Biopsy in Type II Endometrial Carcinomas with Negative Sentinel Lymph Nodes

Importance of Para-Aortic Lymph Node Biopsy in Type II Endometrial Carcinomas with Negative Sentinel Lymph Nodes

Utility of ovarian biopsy in pancreatic metastasis of high-grade serous ovarian carcinoma: A case report.

It is very rare that ovarian carcinoma metastasizes to the pancreas, and pathological diagnosis is required to confirm the primary site. The present study reported a 73-year-old woman with serous carcinoma of the ovary that metastasized to the tail of the pancreas. Metastasis was confirmed by pathological and immunohistochemical examination of a biopsy of the ovarian tumor, an endoscopic ultrasound-guided fine-needle aspiration biopsy of the pancreatic tumor and computerized tomography-guided paraaortic lymph node biopsy. A biopsy of the ovarian tumor is useful to make a precise diagnosis and to determine proper treatment when ovarian and pancreatic tumors are identified at the same time and the primary neoplasm is uncertain.

A non-randomized confirmatory study regarding selection of fertility-sparing surgery for patients with epithelial ovarian cancer: Japan Clinical Oncology Group Study (JCOG1203).

Fertility-sparing treatment has been accepted as a standard treatment for epithelial ovarian cancer in stage IA non-clear cell histology grade 1/grade 2. In order to expand an indication of fertility-sparing treatment, we have started a non-randomized confirmatory trial for stage IA clear cell histology and stage IC unilateral non-clear cell histology grade 1/grade 2. The protocol-defined fertility-sparing surgery is optimal staging laparotomy including unilateral salpingo-oophorectomy, omentectomy, peritoneal cytology and pelvic and para-aortic lymph node dissection or biopsy. After fertility-sparing surgery, four to six cycles of adjuvant chemotherapy with paclitaxel and carboplatin are administered. We plan to enroll 250 patients with an indication of fertility-sparing surgery, and then the primary analysis is to be conducted for 63 operated patients with pathologically confirmed stage IA clear cell histology and stage IC unilateral non-clear cell histology grade 1/grade 2. The primary endpoint is 5-year overall survival. Secondary endpoints are other survival endpoints and factors related to reproduction. This trial has been registered at the UMIN Clinical Trials Registry as UMIN000013380.

腹腔鏡下子宮腟上部切断術・仙骨腟固定術後に子宮体癌が発覚した1例

Since the Food and Drug Administration warning in 2011 against transvaginal mesh operation for pelvic organ prolapse, this operation is avoided owing to its severe complications. Instead, laparoscopic sacrocolpopexy (LSC) is selected by many urogynecologists. For the strong attachment between the cervix and mesh, supracevical hysterectomy is usually performed before LSC. Uterine removal from the intra-abdominal space requires intraperitoneal shredding or morcellation of the specimen. In cases of unexpected uterine malignancy, shredding or morcellation of the uterine specimen may interfere with the appropriate staging and increase the risks of malignant cell dissemination. We here report a case of uterine endometrioid adenocarcinoma diagnosed after supracervical hysterectomy and sacrocolpopexy for pelvic organ prolapse. The patient was 49 years old (gravida 4, para 2). She underwent laparoscopic supracervical hysterectomy and LSC for pelvic organ prolapse. Preoperative transvaginal ultrasound did not show thickening of the endometrium, and the endometrial cytology was negative. However, the pathologic examination after the initial operation showed uterine endometrioid adenocarcinoma, stage I. Accordingly, she was referred to our hospital and underwent trachelectomy, pelvic lymph node dissection, and paraaortic lymph node biopsy. This case indicates that we need to be aware of the possibility of uterine malignancy in cases of laparoscopic supracervical hysterectomy and LSC.

Case presentation: Nodular sclerosis classical Hodgkin lymphoma bearing Epstein-Barr virus that developed in an older man

A 63-year-old man was admitted to our institution due to loss of 6 kilograms in body weight during the past 2 months. There was no surface lymphadenopathy, and the spleen was palpated 3 finger-breadths below the left costal margin. The hemoglobin level was 11.1 g/dL, white blood cell count 7,100/µL, including 13.0% lymphocytes, and platelet count 121×103/µL. Serum albumin was 3.4 g/dL, C-reactive protein 18.0 mg/dL, erythrocyte sedimentation rate 78 mm/hr, and soluble interleukin-2 receptor 7,107 U/mL. Computed tomography of the body demonstrated an enlarged spleen containing multiple nodules and marked para-aortic lymphadenopathy, as well as supraclavicular lymph node swelling, and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) revealed strong uptake within the enlarged lymph nodes and spleen. A paraaortic lymph node biopsy showed the nodular sclerosis (NS) subtype of classical Hodgkin lymphoma (CHL), and infection with Epstein-Barr virus (EBV) was determined based on the positivity of EBV-encoded small RNAs and polymerase chain reaction amplification of the virus fragment. The patient was diagnosed with CSIII-2B disease of NSCHL and treated with ABVD combination chemotherapy. An 18F-FDG PET scan performed after 2 cycles of ABVD showed resolution of 18F-FDG-avid lymphadenopathy and splenomegaly. The patient finally achieved a complete response after the completion of 6 cycles of ABVD. The pathogenesis of the present case of EBV-positive NSCHL involving an older man may not be identical to that of EBV-negative NSCHL that predominantly develops in younger patients. Despite the presence of risk factors before treatment, an early complete metabolic response determined by 18F-FDG PET suggests long-term progression-free survival.

Initial experience with a new technique of endoscopic and ultrasonographic access for biopsy of para-aortic (station 6) mediastinal lymph nodes without traversing the aorta

All lymph node stations but the para-aortic are accessible by a combination of endoscopic ultrasound and endobronchial ultrasound. We recently described an echographic-endoscopic technique for the biopsy of para-aortic (station 6) lymph nodes without traversing the thoracic aorta. This study reviewed our initial experience with this new technique. This first-in-human evaluation of the biopsy of station 6 mediastinal lymph nodes with curvilinear endoscopic ultrasound without arterial puncture used a retrospective case series design to study 12 consecutive patients who underwent this new technique. Station 6 lymph nodes were approached with a long fine needle aspiration approach (6-8 cm) through the proximal esophagus. The needle was passed through the esophagus intothe mediastinum just medial to the left subclavian artery. It was then directed toward the para-aortic location(6-8cm trajectory) to reach and enter the para-aortic lymph nodes without piercing the aorta or great vessels. Successful cytologic diagnoses of station 6 lymph nodes were obtained in all cases (lymphocytes in all samples). No morbidity resulted from the procedure, nor was any observed at 30 days after the procedure. Patient anatomy may preclude safe access in certain situations. Endoscopic ultrasound access of para-aortic (station 6) lymph nodes allows complete, minimally invasive mediastinal lymph node staging and diagnosis without traversal of the aorta. This technique, the final piece of the puzzle required for complete staging of the mediastinum with nonsurgical endoscopic techniques, is reproducible and safe.

An incidentally discovered asymptomatic para-aortic paraganglioma with Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited disorder characterized by mucocutaneous melanin pigmentation and gastrointestinal (GI) tract hamartomatous polyps and an increased risk of malignancy. In addition to polyposis, previous studies have reported increased risk of GI and extraGI malignancies in PJS patients, compared with that of the general population. The most common extraintestinal malignancies reported in previous studies are pancreatic, breast, ovarian and testicular cancers.We report the case of a 17-year-old boy who presented with generalized weakness, recurrent sharp abdominal pain and melena, had exploratory laparotomy and ileal resection for ileo-ileal intussusception. Pigmentation of the buccal mucosa was noted. An abdominal computed tomography scan (CT) revealed multiple polyps in small bowel loops. Gastroscopy revealed multiple dimunitive polyps in stomach and pedunculated polyp in duodenum. Colonoscopy revealed multiple colonic polyps. Pathological examination of the polyps confirmed hamartomas with smooth muscle arborization, compatible with Peutz-Jeghers polyps. CT scan guided left para-aortic lymph node biopsy revealed the characteristic features of extra-adrenal para-aortic paraganglioma. Although cases of various GI and extra GI malignancies in PJS patients has been reported, the present case appears to be the first in literature in which the PJS syndrome was associated with asymptomatic extraadrenal para-aortic paraganglioma. Patients with PJS should be treated by endoscopic or surgical resection and need whole-body screening.

Rapidly growing ovarian endometrioid adenocarcinoma involving the vagina: A case report

Objective We present a rare case of a very rapidly growing stage IV ovarian endometrioid adenocarcinoma involving the uterine cervix and vagina without lymph node involvement. Case Report A 43-year-old woman visited the hospital with complaints of lower abdominal discomfort and vaginal bleeding over the previous 3 months. Serum levels of tumor marker CA 125 and SCC antigen (TA-4) were normal. On magnetic resonance imaging, a 7.9 × 9.7 cm heterogeneous mass with intermediate signal intensity was observed in the posterior low body of the uterus. Two months ago, a computed tomography scan revealed an approximate 4.5 × 3.0 cm heterogeneously enhanced subserosal mass with internal ill-defined hypodensities. A laparotomy, including a total abdominal hysterectomy with resection of the upper vagina, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, appendectomy, total omentectomy, and biopsy of rectal serosa was performed. A histological examination revealed poorly differentiated endometrioid ovarian adenocarcinoma with vaginal involvement. The patient had an uncomplicated post-operative course. After discharge, she completed six cycles of adjuvant chemotherapy with paclitaxel (175 mg/m 2) and carboplatin (300 mg/m 2) and has remained clinically disease-free until June 2010. Conclusion Epithelial ovarian cancer may grow very rapidly. The frequent measurement of tumor size by ultrasonography may provide important information on detection in a subset of ovarian carcinomas that develop from preexisting, detectable lesions.

Evaluation of Procedure of Laparoscopic Para-Aortic Lymph Node Biopsy: Comparison between Transperitoneal Approach and Extraperitoneal Approach

In gastrointestinal laparoscopic surgery, paraaortic lymphadenectomy is usually performed using a transperitoneal approach (TP), and the use of an extraperitoneal approach (EP) has been scarcely reported. Biopsy of the para-aortic lymph nodes was performed using TP with 3 ports on the patient with esophageal cancer, and EP lymphnode biopsy was performed with 4 ports with malignant lymphoma. The effect of TP vs. EP was evaluated regarding the intraoperative and postoperative complications. TP was difficult for massive biopsy, 1.5cm sized several lymph nodes along the common hepatic artery were biopsied. On the other hand, using EP a 5cm sized paraaortic lymph node was successfully performed. There was no difference between TP and EP in intraoperative blood loss and operation time, respectively, but EP showed great advantage with respect to postoperative complications and length of administration in hospital. Laparoscopic biopsy of para-aortic lymph nodes using EP is a useful method compared with the TP.

New technique performed by using EUS access for biopsy of para-aortic (station 6) mediastinal lymph nodes without traversing the aorta (with )

New technique performed by using EUS access for biopsy of para-aortic (station 6) mediastinal lymph nodes without traversing the aorta (with )