{"paper_id":"5f275cf6-b9f5-42bd-9c6c-9a32d77b8b02","body_text":"The utility of the 3D \nimaging software in the \nmacroscopic rendering \nof complex gynecologic \nspecimens\nTo the editor: The macroscopic rendering of a surgical \ngynecologic specimen can sometimes be difficult, particularly \nif the medical practitioner is faced with a rare and complex \ncondition. In the last years the radiological imaging has made \ngreat strides in this direction. However, these sophisticated \ntechniques are not without risks for the patients (e.g., ionizing \nradiation, contrast medium) and they cannot always be easily \naccessible. Under this perspective, a new generation of three-\ndimensional (3D) imaging softwares for the anatomical ren-\ndering of the human body, and related surgical pathologies, \nare in the development phase [1 ]. We have recently tested \none of these platforms with encouraging results in a 39-year-\nold female, affected by a high-grade endometrial stromal \nsarcoma, arisen in the context of an extrapelvic endometriotic \nfocus at the level of the right inguinal ligament. Inguinal \nendometriosis is a rare condition occurring in only 0.6% \nof women and it is usually associated with previous pelvic \nsurgery [2]. Our patient in fact was submitted to the surgical \nremoval of an endometriotic scar of the right parametrium 9 \nyears ago. The occurrence of an endometrial stromal sarcoma \nwithin an endometriotic nodule is a rare, but possible, event, \npreviously described at the level of vulva, vagina, ovary, round \nligament, rectosigmoid colon, terminal ileum, abdominal \nwall, and sciatic nerve [ 3-7]. In our case, the sarcoma had \ngrown from the right inguinal ligament until reaching 23.5 \ncm of maximal diameter. It was bordered by a discontinuous \npseudo-capsule and the presurgical computed tomography \n(CT)-scan showed a diffuse infiltrative front of growth in the \nsurrounding deep tissues. For this reason, the patient was \npromptly submitted to a software-assisted surgery with ab-\ndominal wall reconstruction. Starting from the CT images, the \nsoftware has been developed to upload them and to assign \na predefined color in relation to the signal intensity. Then, it \nhas worked using different subtraction filters and a 3D-space \nvision. More in detail, it has been possible to tip and rotate \nthe neoplasia through 360\no\n, removing anatomical layers, in \norder to view any pathological structure, and making easier to \nexplain complex surgical correlations. The subtraction filters \navailable were: dermal subtraction filter, superficial muscular \nCopyright © 2015. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology \nThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License \n(http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and \nreproduction in any medium, provided the original work is properly cited.\nwww.ejgo.org\nCorrespondence\nJ Gynecol Oncol Vol. 26, No. 2:168-169\nhttp://dx.doi.org/10.3802/jgo.2015.26.2.168\npISSN 2005-0380 · eISSN 2005-0399\nFig. 1. (A) A longitudinal digitalized image of the abdomen, centered on \nthe umbilicus, is seen without application of subtraction filters. (B) The \ndermal subtraction filter allows to remove the skin surface, which does \nnot show pathological alterations. (C) The superficial muscle subtraction \nfilter is able to subtract the superficial muscle layer and the sarcoma \nappears as a right-sided abdominal bulky mass (asterisk). The neoplasia \nshows a pseudo-capsule (yellow arrows), an area of colliquation (white \narrow) and take its origin from the right inguinal ligament (white circle). \nThe green pointer of spatial orientation is also reported. (D) The deep \nmuscle subtraction filter points out the infiltration of the surrounding \ndeep tissues, which appears as a color distortion (asterisk). (E) On a \ntransversal section, the visceral subtraction filter displays the presence \nof a massive front of neoplastic infiltration towards the intestine \n(asterisk). (F) The gross appearance confirms what has been previously \nobserved by the digitalized images.\nA B\nC D\nE F\n\n3D imaging software application in gynecologic oncology\nJ Gynecol Oncol Vol. 26, No. 2:168-169 www.ejgo.org 169\nsubtraction filter, deep muscular subtraction filter, and visceral \nsubtraction filter. The software has been able to detect the \nneoplasia origin from the right inguinal ligament and to better \ndefine the infiltration front, favoring a radical surgery (Fig. 1). \nIt has been proved a useful tool in the surgical and pathologi-\ncal approach to this unique case, never reported in literature. \nIts major advantages appear to be the running on portable \nelectronic devices, such as notebook or tablet, an easy-to-\nuse interface with intuitive functionality, and the opportunity \nto purchase for each unit. For the future, an implementation \nwith standardization of software-assisted procedures could \nbe useful in the gynecologic management of the patients \naffected by uncommon malignancies.\nCONFLICT OF INTEREST \nNo potential conflict of interest relevant to this article was \nreported.\nREFERENCES\n 1. Zeller JL. New 3D imaging software opens new vistas. JAMA 2006; \n296:2908-13.\n 2. Bergamini A, Almirante G, Taccagni G, Mangili G, Vigano P, Candiani \nM. Endometriosis-associated tumor at the inguinal site: report of a \ncase diagnosed during pregnancy and literature review. J Obstet \nGynaecol Res 2014;40:1132-6.\n 3. Kim JY, Hong SY, Sung HJ, Oh HK, Koh SB. A case of multiple meta-\nstatic low-grade endometrial stromal sarcoma arising from an ovarian \nendometriotic lesion. J Gynecol Oncol 2009;20:122-5.\n 4. Alcazar JL, Guerriero S, Ajossa S, Parodo G, Piras B, Peiretti M, et al. \nExtragenital endometrial stromal sarcoma arising in endometriosis. \nGynecol Obstet Invest 2012;73:265-71.\n 5. Sato K, Ueda Y, Sugaya J, Ozaki M, Hisaoka M, Katsuda S. Extra uterine \nendometrial stromal sarcoma with JAZF1/JJAZ1 fusion confirmed \nby RT-PCR and interphase FISH presenting as an inguinal tumor. \nVirchows Arch 2007;450:349-53.\n 6. Sinha R, Sundaram M. Endometrial stromal sarcoma from \nendometriosis. J Minim Invasive Gynecol 2010;17:541-2.\n 7. Usta TA, Sonmez SE, Oztarhan A, Karacan T. Endometrial stromal \nsarcoma in the abdominal wall arising from scar endometriosis. J \nObstet Gynaecol 2014;34:541-2.\nLuca Roncati\n1\n, Beniamino Palmieri\n2\n, Teresa Pusiol\n3\n, \nFrancesco Piscioli\n3\n, Michele Scialpi\n4\n, Giuseppe Barbolini\n1\n, \nAntonio Maiorana\n1\nDepartments of \n1\nDiagnostic and Clinical Medicine, \n2\nGeneral \nSurgery and Surgical Specialties, University of Modena and \nReggio Emilia, Modena; \n3\nProvincial Health Care Services, \nInstitute of Pathology, Santa Maria del Carmine Hospital, \nRovereto; \n4\nDepartment of Radiology, University of Perugia, \nPerugia, Italy\nCorrespondence to Luca Roncati\nDepartment of Diagnostic and Clinical Medicine, Policlinico Hospital, \nUniversity of Modena and Reggio Emilia, I-41124 Modena, Italy. E-mail: \nemailmedical@gmail.com\nhttp://dx.doi.org/10.3802/jgo.2015.26.2.168","source_license":"CC0","license_restricted":false}