Solid Ovarian Mass Research Articles

Diffusion-weighted imaging of solid ovarian masses: Is it useful to differentiate benign from malignant?

Diffusion-weighted imaging of solid ovarian masses: Is it useful to differentiate benign from malignant?

IgG4 Related Disease Presenting As a Solid Ovarian Mass with Ureteric and Bladder Involvement: A Case Report

Study Objective IgG4-related disease (IgG4-RD), a systemic immune-mediated condition, presenting as a solid ovarian mass concerning for malignancy resected using a minimally invasive approach. Design A case report of a 43-year-old G3P3 with a history of total abdominal hysterectomy for fibroids presenting with pelvic pain and a newly diagnosed pelvic mass on imaging. Medical history was significant for diabetes. Setting N/A Patients or Participants N/A Interventions The procedure performed included laparoscopic resection of the right ovarian mass, enbloc resection of the lower right ureteral, partial radical cystectomy, uretoneocystotomy and bladder reconstruction. Measurements and Main Results CT abdomen and pelvis demonstrated prominent retroperitoneal lymph nodes and moderate right-sided hydronephroureterosis secondary to compression by the pelvic mass. Pelvic MRI demonstrated heterogeneous enhancement of the mass with possible bladder invasion. Tumor markers, CA -125 and CEA, were within normal limits. Intraoperative findings included a solid, complex right adnexal mass adherent to the right pelvic side wall incasing the right ureter with no clear ability to delineate tissue planes. In addition, the mass was found to be infiltrating the bladder around the ureteral orifice mimicking tumor invasion. Pathology report demonstrated extensive sclerosing fibrosis with ureteral obliteration, lymphocytic infiltrates and obliterative phlebitis highly suggestive of IgG4-RD. The pelvic washings were negative for malignant cells. On follow up, patient with resolved pelvic pain and no evidence of recurrence on imaging. Adjuvant corticosteroid treatment was initiated by Rheumatology to reduce recurrence risk. Conclusion IgG4-RD is a rare diagnosis that has yet to be described as an adnexal mass. Due to the close resemblance to malignancy, recognizing this disease clinically becomes very important. Given the evidence that there is response to early glucocorticoid therapy, it is important for gynecologists to be aware of this disease to facilitate an expedited diagnosis to prevent potential unnecessary invasive procedures.

A Case Report of Ovarian Fibrothecoma in a Premenopausal Women with Recurrent Menorrhagia

BACKGROUND: Ovarian fibrothecoma is a rare, benign, sex cord-stromal neoplasm, with a typically unilateral location in the ovary, characterized by mixed features of both fibroma and thecoma. Ovarian fibrothecoma is uncommon tumor of gonadal stromal cell origin accounting for 3-4% of all ovarian tumours.
 CASE PRESENTATION: We presented a rare case of a 46-year-old patient with recurrent menorrhagia in the past two years with no previous medical, surgical or gynecological history. She underwent two times curettage procedures. At the admission to hospital ultrasonography showed a homogenous solid right ovarian mass of size 2.5 cm x 3.5 cm. Endometrial curettage revealed simple hyperplasia of the endometrium. Diagnostic evaluation and surgical management are discussed along with a brief review of the literature. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was carried out. Histopathology confirmed fibrothecoma of the ovary, proliferative endometrium with hyperplasia without atypia and multiple uterine fibroids.
 CONCLUSION: In all patients presenting with recurrent menorrhagia and adnexal tumor the possibility of a granulosa cell tumor must be kept in mind during evaluation.

Metastatic carcinoid tumor of the ovary-A rare entity and role of CDX2 to distinguish pure primary carcinoid from metastatic carcinoid to the ovary

Metastatic ovarian carcinoid is a very rare entity which is usually of primary gastrointestinal origin. Distinction is difficult between pure primary ovarian carcinoid from metastatic carcinoid tumor of ovary, but distinction is very much crucial because it has clinical and prognostic implications.We are reporting a case of a 55yr old female presented with abdominal pain. Ultrasonography revealed bilateral solid ovarian mass. Macroscopically both the ovaries were enlarged, solid with surface nodularity. Morphology showed tumor cells mostly in insular and acinar configuration, round to oval nucleus, stippled chromatin and granular eosinophilic cytoplasm. IHC for synaptophysin and chromograin were strong positive. CDX2 was done which showed strong nuclear positive in 80% of tumor cells. The tumor was diagnosed as a metastatic carcinoid tumor to the ovary and primary tumor in the small intestine. This case was reported because of its rarity and usefulness of CDX2 to distinguish pure primary carcinoid from metastatic carcinoid to ovary.

SUN-920 Familial Paraganglioma Syndrome: A Rare Case of Secondary Hypertension in Young People

Paragangliomas are rare tumors originating in the autonomic nervous system, whose clinical manifestations are the result of excessive production of catecholamines.We present a case of a 26-year-old female with 5 years of disease characterized by episodic profuse sweating, headaches and high blood pressure refractory to antihypertensive treatment. She also had intermittent palpitations which intensified 1 month before admission. Patient was cataloged with diagnosis of endocrine hypertension. She had elevated urinary fractionated metanephrines, elevated plasma normethanephrin and plasma chromogranin A (CgA). Subsequently, an abdominal CT study was performed, finding a solid ovarian mass of defined edges located in retroperitoneal space, an intercave region immediately preceding the L2-L3 intervertebral disc that measured 26.2 x 23.9 x 28.8 mm. It was also found bilateral tumours at cervical level of 14 mm in right side and 10 mm in left side, suggestive of paranganglioma by magnetic resonance imaging (MRI).With a suspected diagnosis of paraganglioma of Zuckerkandl’s organ, beta and alpha-adrenergic blockage were carried out and surgical intervention was done by a block resection of the tumour. Anatomopathological diagnosis confirmed the suspicion of well-delimited capsulated paraganglioma of 2.0 X 1.0 X 0.3 cm, with low mitotic index (<2) and a result of positive sinaptophisin by immunohistochemistry. She reached complete remission and normal determinations in urine of catecholamines and methanephrines. Currently the patient is in follow-up with favorable evolution and succinate dehydrogenase type B (SDHB) gene test is pending.Despite infrequency of paragangliomas, it is important to take them into account in the differential diagnosis of hypertension, especially in young patients, due to their malignant potential and the effects of catecholamine secretion on the cardiovascular system.

Ультразвуковые аспекты и скрининг опухолей и опухолевидных образований яичников у пациенток репродуктивного возраста

Ovarian neoplasms can develop at any age, carry a high risk for malignant transformation, reduce the reproductive potential of a woman and are an indication for surgery. The search for optimal screening algorithms for ovarian tumors is still ongoing. The aim of this study was to evaluate the prognostic efficacy of ultrasonography (US) features in differentiating between benign, malignant and borderline tumors in reproductive-age women. We examined 168 reproductive-age women with ovarian masses who underwent surgery in 2012–2015 and compared the results of histopathological examinations with pulsed-Doppler US findings. We did not establish a correlation between the size/volume of the tumor and their morphological structure. We identified the echotexture characteristics associated with malignancy, including the presence of a solid component (р &lt; 0.001); septations (р = 0.029) and projections on the internal surface of the tumor capsule (р &lt; 0.001); moderate or significant buildup of free fluid in the small pelvis (р = 0.007), and the nodular surface of the tumor capsule (р = 0.008). Solid ovarian masses were at increased (31.69-fold) risk of transformation into malignant or borderline tumors, whereas for a mixed (cystic and solid) type the risk of such transformation increased 3.46-fold. We also identified Doppler parameters that can clearly discriminate between benign and malignant growths, including the blood flow rate in the tumor over 1.85 cm/s (р = 0.007) and RMI over 0.16 (р = 0.013). The sensitivity and specificity of our diagnostic model are 87% and 68%, respectively, with a probability threshold of 0.3.

The Usefulness of Diffusion Weighted and Contrast Enhanced Magnetic Resonance Imaging in Characterization of Inconclusive Ovarian Mass

Introduction: Ovarian cancer is the commonest reason for death in females due to gynecologic malignancy around the world. In contrast to other gynecologic tumours, the definitive diagnosis is accomplished days after of the index surgery by the histopathology. Preoperative assessment based on conventional MRI is not accurate. Information is expanding increasing about the ability of new MRI modalities to assess ovarian mass. Aim of the study: To assess the ability of dynamic contrast-enhanced MRI (DCE–MRI), and Diffusion-weighted image (DWI) to describe uncertain ovarian masses. Patients and Methods: This is a retrospective study. Patients were referred from radio-diagnosis department and gynecology department of Qena faculty of medicine hospitals, South Valley University. Patients had uncertain adnexal masses at ultrasound. Magnetic resonance examination was doneutilizing 1.5 Tesla machine. The protocol included T1WI, T2WI, T1WI following contrast, and DWI. Results: We included 44 patients with different forms of complex cystic and solid ovarian masses. The final pathology of the ovarian masses was 18 benign, 4 borderline, and 22 malignant. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for DWI were 100%, 94.4%, 96.3%, 100%, and 97.7% respectively. The performance of DWI was higher than the conventional MRI and DCE-MRI. Conclusion: DCE-MRI and DWI have accepted ability to recognize malignant ovarian mass.

Ovarian Endometrioid Borderline Tumor With Massive Squamous Differentiation: A Case Report

Abstract Introduction Ovarian endometrioid borderline tumor is uncommon and constitutes only 0.2% of all epithelial ovarian tumors. Many patients have associated endometriosis, and coexisting endometrial hyperplasia and/or carcinoma is commonly present. Methods Here we report an ovarian endometrioid borderline tumor with massive squamous differentiation. The peculiar histologic features made the diagnosis of this uncommon entity even more challenging. The patient was a 43-year-old female with a history of chronic pelvic pain. A pelvic ultrasound showed a 7.9-cm complex solid and cystic right ovarian mass and a hypoechoic left ovarian mass. Patient underwent a hysterectomy with bilateral salpingo-oophorectomy. Grossly, the right ovary showed a 2.5-cm solid and cystic lesion with focal papillary inner surface. Microscopic examination showed uterine adenomyosis with serosal endometriosis. The left ovary showed endometriosis with atypical hyperplasia. Initial representative sections from the right ovary demonstrated extensive squamous cell proliferation with papillary architecture. The squamous cells had pink or clear cytoplasm, intracellular bridging, irregular nuclei, and prominent nucleoli. Immunostains confirmed the squamous differentiation. Based on the histologic features and immunophenotype, a well-differentiated squamous cell carcinoma was considered one of the differential diagnoses. However, further examination of additional sections from entirely submitted lesion showed some areas with classic morphologic features of endometriosis with atypical hyperplasia. With the consideration of clinical-pathological correlations, a diagnosis of endometrioid papillary cystic borderline tumor with massive squamous differentiation was rendered and close follow-up was recommended. The patient was doing well at 4-month postoperative follow-up. Conclusion We present this case to emphasize (1) extensive squamous metaplasia arising in endometriosis can make the rendering of a definitive diagnosis challenging. (2) Primary squamous cell carcinoma of ovary is very rare. (3) Careful sampling is very important for achieving a precise pathologic diagnosis.

Ovarian Fibrothecoma

A postmenopausal woman presented with abdominal pain and increased urinary frequency. A unilateral solid ovarian mass was identified and excised. What is the best diagnosis for the lesion?a.Adult granulosa cell tumorb.Leiomyomac.Fibrothecomad.Clear cell carcinoma Answer: c. Fibrothecoma Fibroma/thecoma/fibrothecoma is a spectrum of benign sex cord–stromal tumors composed of fibroblastic stromal cells and/or luteinized theca-like cells. When both cell types are present in a tumor, it is typically classified as fibrothecoma. These tumors can occur at any age, but most commonly arise in middle-aged to postmenopausal women.1Young R.H. Ovarian sex cord-stromal tumours and their mimics.Pathology. 2018; 50: 5-15Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar

Solid ovarian masses: Lessons and pitfalls

Solid ovarian masses have a higher risk of malignancy compared to other tumour types. In this lecture, we will discuss the ultrasound features of the most common benign solid ovarian tumour, i.e. the fibroma of the ovary, and more rare solid ovarian tumours, including metastases, Brenner tumours and non-epithelial ovarian tumours.

An atypical presentation of an ovarian lymphoma: a case report

BackgroundOvarian lymphoma has a varied clinical presentation and rarely presents with heavy menstrual bleeding. It may occur de novo or secondary to systemic disease and macroscopically appear as solid ovarian tumors.Case presentationA 32-year-old Tamil woman presented with heavy menstrual bleeding of 4 months’ duration. On examination she was anemic with no lymphadenopathy. A large immobile pelvic mass and three firm nodules were found involving her vaginal walls. Ultrasonography suggested a fibroid uterus with two large pedunculated fibroids. Following preoperative optimization an endometrial sampling and biopsy of the nodules were done. Subsequently, histology revealed proliferative phase endometrium. The vaginal nodules showed lymphoid tissue.She presented a week later with an undulating fever and features of acute abdomen with clinical evidence of ascites. During an emergency laparotomy two large solid ovarian masses, gross ascites, pelvic lymph nodes, para-aortic lymph nodes, mesenteric lymph nodes, omental deposits, and a 24-week-size uterus were found. Bilateral oophorectomy was done. Laboratory investigations revealed raised lactate dehydrogenase with normal serum β-human chorionic gonadotropin, alpha-fetoprotein, and cancer antigen-125 levels. Histology of ovarian specimens revealed a diffuse large B cell lymphoma.A bone marrow biopsy revealed more than 80% infiltration with lymphoid cells. Two weeks after the laparotomy a computed tomography of her chest, abdomen, and pelvis revealed a pelvic mass, gross ascites, omental deposits, hepatosplenomegaly, and enlarged lymph nodes above and below her diaphragm. Immunohistochemistry confirmed the diagnosis of B cell lymphoblastic lymphoma. She was classified as stage IV E non-Hodgkin’s lymphoma on the Ann Arbor staging system.ConclusionThis is an atypical presentation of an ovarian lymphoma. The atypical presentations of ovarian lymphomas can lead to diagnostic dilemmas.

Iliopsoas Muscle Metastasis from Cervical Carcinoma

Introduction: Isolated metastasis of cervical carcinoma to iliopsoas region might be infrequent and its occurrence is a diagnostic challenge. The aim of this study was to report a case of iliopsoas muscle metastasis from cervical carcinoma. Case Presentation: A 52-year-old multiparous females complaining about post menopause bleeding was referred to the researcher’s oncology department. Gynecological examination revealed cervical mass with involved parameters and biopsy confirming squamous cell carcinoma. In addition, the patient had a large cystic mass on the lateral side of pelvic area and abdomen. Investigations detected solid ovarian mass associated with a rise of tumor marker CA-125 and CEA levels. Magnetic resonance imaging (MRI) and CT scan reports suggested possible hematoma in iliopsoas muscle. Imaging-guided biopsy detected metastatic squamous cell carcinoma in iliopsoas muscle mass. Based on diagnosis of advance stage cervical cancer, the patient received chemotherapy following adjuvant radiation therapy. Conclusions: Metastasis of squamous cell carcinoma of the cervix to iliopsoas muscle is considered as a rare event. It is recommended to keep this unusual manifestation in mind.

Laparoscopic Management of Primary Ovarian Leimyoma in a Patient with Pelvic Kidney : A Case Report

Leiomyoma is one of the rarest solid tumours of the ovary. We report a case of a 35 years old woman suffering from irregular menstruel periods and solid unilateral ovarian mass managed by laparoscopic removal. Medical history of the patient is remarkable because of coexisting pelvic kidney and a history of infertility necessiating IVF treatment including gonadotropin stimulation

Adenocarcinoma of the Lung Metastatic to the Ovary With a Signet Ring Cell Component

A nonsmoker 45-year-old woman, presented with a solid right ovarian mass. Microscopic examination revealed heterogeneous histology with tubular formations and extensive signet ring cell component that resembled the usual appearance of metastatic gastric carcinoma to the ovary. Moreover, the histology also showed solid nests of cells with a microvacuolated basophilic cytoplasm similar to those found in adenosquamous cervical carcinoma of glassy cell type. However, analysis of the patient's past history revealed a lung adenocarcinoma, diagnosed 4 years before, which prompted an immunohistochemical differential diagnosis, showing a strong expression for TTF-1 and Napsin A. A cervical primary was excluded taking into account both macroscopic findings and the negative expression of PAX8 and absence of human papillomavirus-related marker p16. This confirmed the pulmonary origin of ovarian tumor despite its heterogeneous morphology. This is the first reported case of ovarian metastatic lung adenocarcinoma, with a signet ring cell component and solid nests, mimicking both metastatic gastric carcinoma and adenosquamous carcinoma of glassy cell type.

Power Morcellation in the Bag: Surgical Technique and Clinical Applications

Introduction: Morcellation refers to the division of specimens into smaller pieces or fragments to facilitate the removal of tissue through small incisions during minimally invasive procedures. Most commonly it may be performed after laparoscopic hysterectomy (for enlarged uteri) or myomectomy. Recently, the use of power morcellation has been discouraged because of the risk of spreading an unsuspected uterine malignancy. In this video (run time 9:51), the authors demonstrate the surgical technique for laparoscopic power morcellation in the bag and some clinical applications of it. Patients and Methods: In our department, laparoscopic gynecologic procedures are performed using four trocars: one 10-mm umbilical trocar for the zero degree laparoscope and three 5-mm trocars for the instruments, one at the right iliac fossa, 2 cm medial to the right anterior superior iliac spine, another one at the left iliac fossa, 2 cm medial to the left anterior superior iliac spine, and the third one in the midline, 8 to 10 cm below the umbilical trocar. Whenever power morcellation is needed, the 5-mm trocar at the left iliac fossa is replaced by a 15-mm trocar for the morcellator at the end of the procedure, specifically for the step of morcellation. To perform the power morcellation within a bag, the authors use a large tissue retrieval bag (3100 mL). The bag is placed inside the abdominal cavity through the 15-mm trocar. The mouth of the bag is opened and the specimen to be morcellated is put inside the bag. The bag is closed pulling the draw string and it is retrieved from the abdominal cavity through the 15-mm trocar. This allowed for the externalization of the mouth of the bag through the skin incision. Then, the 15-mm trocar is replaced through the mouth of the bag. Pneumoperitoneum is insufflated through the 10-mm umbilical trocar. The assistant grabs the deeper part of the bag and pulls it out through the skin at the right iliac fossa. Finally, the surgeon grabs the closest portion of the bag to the umbilicus and externalizes it through the umbilical trocar. In this way, we have three different sites of the bag outside the abdominal cavity. The trocars are reinserted inside the bag. The insufflation pressure is increased from 12 mm Hg to 15 mm Hg and the insufflation is performed within the specimen bag. In this way, the specimen can be enclosed morcellated under direct visualization. Results: The procedure was effectively performed in four patients with different pathologies: (1) a 40-year-old woman with a 400 g uterus requiring total laparoscopic hysterectomy due to leiomyomas and abnormal uterine bleeding, (2) a 35-year-old woman undergoing laparoscopic myomectomy, (3) a 45-year-old woman undergoing subtotal laparoscopic hysterectomy for a 900 g uterus, and (4) a 49-year-old woman with a 65 mm solid ovarian mass (serous cystadenofibroma). In all patients, power morcellation could be performed safely within the bag. Conclusions: Power morcellation within a bag is a feasible technique. It may be an alternative way to preserve the benefits of minimally invasive surgery while mitigating the risks whenever specimen morcellation is necessary. No competing financial interests exist. Runtime of video: 9 mins 51 secs

Immature teratoma with microscopic yolk sac tumor: A case of diagnostic challenge on histology

An adolescent girl with raised alpha-fetoprotein (AFP) levels presented with a left-sided large solid ovarian mass. Microscopically, the tumor was composed of a variety of immature and mature tissues derived from the three germ layers having very sparse (single focus of) immature neuroepithelium. Few areas also showed the presence of a reticular pattern of yolk sac tumor (YST). Hence, the tumor was diagnosed as immature teratoma with microscopic foci of yolk sac elements. After 6 months of cisplatin-based chemotherapy, she developed a recurrence which was composed of mature teratoma on histology. In this case, the single focus of immature neuroepithelium caused a difficulty in labeling this tumor as an immature teratoma which otherwise resembled a mature teratoma. The raised AFP levels suggested the presence of yolk sac element, the classical form of which was seen at microscopy in only a few areas. As compared to the markedly elevated serum AFP levels, the classical yolk sac tumorous area was very limited thus advocating the view that differentiated glands with subnuclear vacuoles similar to immature endoderm represent well-differentiated forms of YST. [1]

Benign lesions that mimic cancer: Ovarian

As ovarian masses are common in both pre- and in postmenopausal age, a life time risk of up to 5-10% to undergo pelvic surgery has been reported [1]. However, the likelihood of malignancy in these lesions is extremely low. Imaging, particularly, US and MRI, have been integrated as diagnostic tools to better define indications for adequate surgery and to guide referral to specialized centers. Imaging findings are assessed in the context with clinical data, patient history, age, and tumor markers. Furthermore, various risk assessment indices to predict malignancy have been established using clinical and/or imaging parameters. Advances in imaging including the combination of morphologic and functional parameters have further improved the diagnostic performance of MRI. Thus the majority of indeterminate masses on US and CT can be correctly diagnosed with MRI [2,3]. MRI is most beneficial in women with a low likelihood of cancer. Endometriomas, common mimicks of ovarian cancer in CT and US, display specific imaging findings in MRI. This is also true for subserous leiomyomas, which are often difficult to differentiate from solid ovarian masses in US. Meticulous analysis of anatomical landmarks and displacement patterns aid in differentiation of benign extraovarian tumors, particulary of extraperitoneal origin, e.g of neurinomas, from ovarian cancer. Some complex cystic and solid adnexal masses may be challenging to differentiate from ovarian cancer. In these lesions integration of clinical findings will allow in most cases differentiation of benign lesions from cancer. Ovarian torsion, pelvic hematoma, and extrauterine pregnancy are typically associated with pelvic pain. Pain and inflammatory laboratory findings suggest tubo ovarian abscess (TOA). TOA may mimick ovarian cancer even in advanced imaging, including MRI and PET/CT. Aspergillosis, a subtype of TOA mimicks ovarian cancer due to its complex morphology and invasive growth pattern. Differentiation of peritoneal tuberculosis from advanced ovarian cancer is difficult and requires biopsy [4]. Ovarian pseudocysts and cystadenofibroma display typical findings in most cases. However, some of the benign pelvic lesions still present a diagnostic dilemma [5]. These include rare entities, e.g. atypical dermoids, monodermal dermoids, collision tumors, and sometimes also hemorrhage of functional cysts.

Diffusion-weighted magnetic resonance imaging in the assessment of ovarian masses with suspicious features: Strengths and challenges

ObjectiveTo evaluate diagnostic performance of diffusion weighted imaging (DWI) in evaluating ovarian masses with suspicious features on magnetic resonance imaging (MRI). Patients and methodsPelvic MRI and DWI assessed 235 complex and solid ovarian masses of suspicious MRI features. On DWI, scanning acquired by b values: 0, 500, 1000 and 1500. Analysis considered signal intensity (SI) at b1000 and the mean ADC values for the solid components of the masses. ResultsIncluded masses proved benign in 75(32%), borderline (low potential malignancy) in 55(23.4%) and malignant in 105(44.6%). Restricted diffusion was observed in all of the invasive malignancy (57.1%, n=105/184). Benign and borderline tumors with high DWI SI presented 15.2% and 27.7% respectively (P<0.05). The mean ADC value was 1.2+0.34×10−3mm2/s, 1.1+0.06×10−3mm2/s, and 0.83+0.15×10−3mm2/s for benign, borderline and malignant masses respectively. The ADC values of malignant masses and benign masses with fibrous components showed no significant difference (P=0.333). Significant difference was detected in those with fatty tissue (P=0.002). ConclusionDWI supported by conventional MRI data can confirm or exclude malignancy in suspicious ovarian masses. The combined analysis of quantitative and qualitative criteria and knowledge of the sequence pitfalls are required.

A Rare Cause of Postoperative Hypotension

A 62-year-old woman presented with a 3-month history of abdominal distension and decreased exercise tolerance. A chest radiograph showed a probable left pleural effusion (Fig 1). A CT scan of the abdomen revealed a solid ovarian mass with omental caking and a large volume of ascites; there was also confirmation of a left pleural effusion. Three days before surgery a CT pulmonary angiogram (CTPA) showed no evidence of pulmonary thromboembolism (PTE). The patient had some improvement in her symptoms after paracentesis and thoracentesis with drainage of 2,000 mL and 250 mL of fluid, respectively. She underwent total abdominal hysterectomy, bilateral oophorectomy, and partial sigmoid resection with an estimated blood loss of 850 mL. During the operation, she received 5 L of crystalloid and required phenylephrine at 40 to 80 μg/min to maintain a mean arterial pressure &gt; 65 mm Hg. She was extubated after surgery, but immediately after extubation, she became markedly hypotensive and hypoxemic with a BP of 50/20 mm Hg and an oxygen saturation of 70%. An ECG showed T-wave inversions from V1 to V5 and an S1Q3T3 pattern (Fig 2). A bedside echocardiogram showed an enlarged right ventricle (RV), septal dyskinesia, and obliteration of the left ventricle, all consistent with systolic and diastolic RV overload (Fig 3).

Mechanical morcellation of a solid ovarian mass in a pneumo-bag

Objectives: We present a case of a 32-year-old patient who previously underwent simple hysterectomy and bilateral pelvic sentinel lymph node biopsy for epidermoid carcinoma of the cervix. Pathology showed a 5-mm residual tumor at the cervix and the patient was referred for laparoscopic radical nerve-sparing parametrectomy and bilateral pelvic lymphadenectomy. Methods: This video shows the complete technique of the surgery, including patient and team positioning, trocar placement, and step-bystep dissection of planes, vessels, nerves, and other pelvic structures. Snapshots of the surgery with all relevant anatomic structures identified are shown during the video. Conclusions: This didactic surgical film demonstrates that parametrectomy, when systematically performed, is a reliable procedure with minimal complications.