Abstract | Revitalizing Women's Healthcare Together

September 29-30, 2023 

Correspondence to: naomimwhittaker@gmail.com
Naomi Whittaker, MD1

1UPMC Divine Mercy, PA, USA.
Author Affiliations

Title: Case Series Demonstrating Diagnosis and Complete Curative Treatment of Four Rare Cancers by a Single Non-oncologic Gynecologic Surgeon due to use of Systematic Mapping of the Abdomen and Pelvis (S-MAP) and “Near-contact” Laparoscopy (NCL) Techniques

Introduction: To date, no standard criteria exist for how to perform a diagnostic laparoscopy.

Case Descriptions:

Case A:
In the NCL surgery using S-MAP, a 2 mm lesion of Well-differentiated papillary mesothelioma (WDPM) was found in the right pelvic sidewall. Further work up negative.

Case B:
27 yo G0 presented for a second opinion for dysmenorrhea after surgery for endometriosis by faculty at an academic center.
In the NCL/SPAM surgery, pathology came back positive for well-differentiated neuroendocrine tumor, 0.5 mm, free margins, negative lymph nodes.

Case C:
33 year old G3P2012 who presented with irregular cycles, dysmenorrhea, and infertility.
With NCL/S-MAP surgery, she underwent surgery which removed stage IV well differentiated Neuroendocrine tumor of appendix (mass 2.5 cm) plus 2 cancerous specimens from the pelvis (0.3 to 0.8 cm).
With oncology, she underwent hemicolectomy. Lymph nodes, margins, and pelvis were negative. No chemotherapy or radiation was indicated. After two years, she is in remission.

Case D:
27 yo G1P1 was recommended to undergo hysterectomy after laparoscopy when seeking fertility treatments, presented for a second opinion.
She underwent surgery with NCL/S-MAP with findings: appendiceal/cecal mass, mass on terminal ileum, bilateral endometriomas, frozen pelvis: rectum and bowel stuck to posterior uterus, and frozen pelvis. Appendectomy with partial cecectomy was performed and pathology resulted as grade 1 neuroendocrine tumor of appendix (1.5 cm).

Further work up and ileocecal valve resection were negative for malignancy. Of note, she was found to have an FSH of 34.6 and achieved spontaneous pregnancy after additional excision surgeries, adhesion prevention and DHEA supplementation.

Discussion:
The NCL technique was originally coined by Dr. Redwine (PMID: 3190209). The S-MAP method was described in the NaProTechnology textbook by Dr. Thomas Hilgers.

These cases were performed by a single surgeon over the course of three years using the techniques of NCL and S-MAP techniques. No other malignancies were encountered. All of them were cured by surgery after further work up (including additional imaging and surgeries).

Three out of four of these cancers were neuroendocrine tumors of the appendix which have an incidence of 0.95 in 100,000. That means that the likelihood of 3 cases found by a single surgeon are 0.0000000001. The second malignancy (WDPM) is limited to case reports in the literature.

This data suggests statistical impossibility, and therefore, it is not likely a random chance. It may suggest that surgical technique is important and that these cancers (both with relatively low mortality rates) are likely more common (and therefore also missed at time of laparoscopy). Or, perhaps, endometriosis, infertility, or common exposures of these patient populations could be a risk factor for these cancers. However, these risk factors are not reported in the literature (PMID: 36176500).

Conclusion:
This case series and statistics suggests that systematic, thorough laparoscopy can be highly effective when using a NCL/S-MAP approach.  Scientific methods and standardization should be incorporated into the gold standard of endometriosis treatment to allow reproducibility by other physicians. This would allow for advanced data collection, improving diagnosis, treatment and assessment of endometriosis. Otherwise, advancements for the treatment of endometriosis will be limited.

Keywords: endometriosis, laparoscopy, cancer