case_images: PMC11695505_01
case_images: Magnetic resonance imaging (MRI), tumor markers, and histological findings during the clinical course of treatment. A. MRI during clinical course of treatment.a, b Images at diagnosis before paclitaxel and carboplatin (TC). Uterine tumor filled in uterine cavity (arrow), and peritoneal dissemination in Douglas pouch and left side of the pelvic floor (dotted line). c, d Images before lenvatinib and pembrolizumab (LP). Both uterine tumor (arrow) and the disseminated lesions (dotted line) were enlarged. e, f Images after LP. Both uterine tumor (arrow) and the disseminated lesions had shrunk, however the left ovarian tumor (dotted line) was enlarged. B. Time course of serum CA-125 during medication and surgery. After the initiation of the LP therapy tumor markers significantly decreased and later plateaued. C. Pathological images of primary uterine tumor and ovarian metastasis (hematoxylin-eosin staining). a Endometrial aspiration biopsy before TC. Well-differentiated endometrioid carcinoma with cribriform proliferation of the glands and scant solid areas was observed. b Uterine tumor tissue of conversion surgery. No significant change was observed compared to the aspiration biopsy specimen. c Left ovarian tumor tissue of conversion surgery. No significant difference between uterine tumor and aspiration biopsy specimen was observed. Original magnification of all pictures was high-power field (200x). Black bars mean 50 microm
case_images: 13691_2024_739_Fig1_HTML.jpg
case_images: PMC11695505_01_13691_2024_739_Fig1_HTML.jpg
case_images: Fig1
case_images: Magnetic resonance imaging (MRI) and contrast-enhanced computed tomography (CT) confirmed endometrial tumor with multiple dissemination in the Douglas pouch, right pleural effusion, and ascites (Fig. 1A). Serum cancer antigen (CA)125 and CA19-9 levels was 379 U/mL and 230 U/mL, respectively, before chemotherapy (Fig 1B). Further, the MRI showed that both the intrauterine lesion and peritoneal masses had enlarged and a new left ovarian tumor was observed (Fig 1A). LP therapy was selected as a second-line treatment, leading to tumor shrinkage and a significant decrease in tumor markers (Fig. 1B). By 6 months, peritoneal dissemination was not visible on MRI; however, the primary lesion remained and the left ovarian metastasis slightly increased (Fig. 1A).
case_images: Intraoperative, macroscopic, and pathological findings. A. Intraoperative finding and specimen images. a Intraoperative finding. Miliary dissemination in the Douglas pouch was found but no other macroscopic peritoneal tumor was detected. The left ovary was enlarged to 5 cm. b Specimens of uterus with pelvic peritoneum and rectum and right adnexa. Miliary dissemination in Douglas pouch was found. c Specimen of the incised uterus and rectum. The uterine cavity was filled with papillary tumor. d Specimen of the incised left adnexa. The left ovary was enlarged and was filled with papillary tumor. Black bars mean 2 cm. B. Representative immunohistochemical findings (IHC) for lymphocyte surface antigen in uterine tumor and left ovarian metastatic tumor. a CD4-positive cells in uterine tumor. White ring showed many positive cells. b CD8-positive cells in uterine tumor. White ring showed many positive cells. c CD20-positive cells in uterine tumor. Arrowheads showed positive cells. d CD4-positive cells in left ovary. Arrowheads showed positive cells. e CD8-positive cells in left ovary. White ring showed many positive cells. f CD20-positive cells in left ovary. No positive cell was found. Original magnification of all pictures was high-power field (200x). Black bars mean 50 microm
case_images: 13691_2024_739_Fig2_HTML.jpg
case_images: PMC11695505_01_13691_2024_739_Fig2_HTML.jpg
case_images: Fig2
case_images: Intraoperatively, the left ovary was enlarged; however, peritoneal dissemination in the Douglas pouch was reduced to miliary grain size, with no other peritoneal lesions (Fig 2A). No rectal infiltration was noted (Fig. 2A). Immunohistochemistry showed a locally higher infiltration of CD4-positive and CD8-positive cells in the uterine tumor compared to the ovarian tumor and scarce presence of CD20-positive cells in both tumors (Fig 2B).
case_images: Rectal anastomotic leakage and second operation. A. Computed tomography on postoperative day 11. Intraabdominal free air (arrowhead) and pelvic abscess around rectal anastomosis (arrow) were found. B. Intraperitoneal findings by exploratory laparoscopy. a Purulent ascites was observed around the anastomotic site. b Pelvic abscess was removed and a drain was inserted into the abscess cavity (dotted area). C. Postoperative contrast enema for detecting rectal anastomotic leakage on second-postoperative day 8. a CT scan following gastrografin contrast enema revealed the back side of leakage around rectal anastomosis (arrowhead). b Gastrografin contrast enema also indicated rectal anastomotic leakage (arrowhead)
case_images: 13691_2024_739_Fig3_HTML.jpg
case_images: PMC11695505_01_13691_2024_739_Fig3_HTML.jpg
case_images: Fig3
case_images: CRP level increased to 5 mg/dL on POD 11. CT scan revealed an unusually large amount of free air and a suspected abscess at the rectal anastomosis site (Fig. 3A). Emergent exploratory laparoscopy demonstrated a perforation of the peritoneal abscess around the rectal anastomosis (Fig. 3B). Contrast enema and plain pelvic CT scan following gastrografin contrast enema revealed posterior rectal anastomotic leakage on second-POD 8 (Fig. 3C).