Is clear cell carcinoma of abdominal wall surgery scar associated with endometriosis a poor prognosis? A case report and literature review

Is clear cell carcinoma of abdominal wall surgery scar associated with endometriosis a poor prognosis? 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A case report and literature review Xuzhi Liang, Hao Zeng, Zhe Tang, Jiejie Liao, Jiangtao Fan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-146993/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Clear cell carcinoma of abdominal wall surgery scar is a rare condition that can have many potential causes, and its early diagnosis is difficult after undergoing obstetrical and gynecological surgery unless performing tumor biopsy. So far, about 45 cases have been reported in the literature. This paper provides a case report and literature review of clear cell carcinoma on abdominal wall surgical scar. Case presentation We described the case of a 47-year-old woman reporting two lumps in the scar of abdomen. Her medical history was marked by a previous Caesarean section and two excisions of benign endometriosis nodules at the scar. Physical examination found a mass of about 6×5×5 cm on the left side of the scar with mucoid on the surface and a fixed abdominal wall mass of about 10×10×8 cm in the 2 transverse fingers under the umbilicus. Histological examination proved a clear cell carcinoma result. The patient received tumor excision and first-line chemotherapy with complete remission. A review of the literature showed that 91.3% of the cases had had a Caesarean section. Besides, approximately 34.2% of women died 5–48 months after diagnosis. The average age of women was 46.5 years and the average tumor size was 10 cm. Conclusion The abdominal wall mass of middle-aged women is closely related to the scar left by the previous Cesarean section and must be investigated in time and properly. Preoperative diagnosis is difficult and often incorrect, and there is no specific marker for malignant transformation. Treatment usually includes surgery, chemotherapy, and radiotherapy, but the prognosis is poor. Oncology Surgery clear cell carcinoma abdominal wall surgery scar chemotherapy prognosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Background The incidence of scar endometriosis in abdominal surgery is between 0.03% and 1.08% in women undergoing pelvic surgery [ 1 , 2 ]. Abdominal wall endometriosis caused by incisions is an often neglected disease [ 3 ]. Scar endometriosis is usually caused by the implantation of endometrial tissue into the soft tissue of the abdominal wall during surgery. Symptoms of endometriosis in abdominal surgical scars in obstetrics and gynecology include slowly developing lumps in or near the scar, as well as pain and abdominal swelling during menstruation. However, malignant transformation of abdominal wall endometriosis is very rare, including sarcomatoid degeneration [ 4 ], serous papillary carcinoma [ 5 , 6 ], rhabdomyosarcoma [ 7 ] as well as clear cell carcinoma (CCC). The most common histological type is CCC [ 8 ]. CCC caused by endometriosis is an invasive disease with a poor prognosis, with a 5-year survival rate of about 40% [ 8 ]. Diagnosis is challenging because the disease develops slowly and has no specific markers of malignant transformation. Here we report a patient with CCC of the abdominal wall at the scar site of a previous Cesarean section (CS). Besides, we reviewed the existing English literature on transparent clear cell carcinoma caused by endometriosis in the abdominal wall and compared the clinical features of abdominal wall masses of different sizes. Case Presentation A 47-year-old woman, grava 4, para 3, abortion 1, presented with two big abdominal masses, which were gradually enlarging after 2 previous excisions of an endometriotic nodule in a CS scar. This patient underwent a CS in 2001 due to fetal distress and transverse position. The CS procedure was successful, with no postoperative discomfort such as abdominal pain, abdominal distension, and the menstruation is regular. Early in 2017, she noticed a small mass of about 1 cm in right lower abdominal scar without menstrual period pain and itching. She underwent abdominal endometriosis mass resection in May 2017. During the operation, the boundary between the mass and abdominal wall tissue was not clear, and a mesh was placed to repair the abdominal wall. The mass containing chocolate-like fluid with a hard texture. The pathology of the nodule was reported as endometriosis with decidual degeneration. The mass in the abdominal wall is consistent with the adenomatoid tumor. Microscopically, a large amount of dilated cystic cavity was seen in the fibrous tissue, which was lined with a single layer of epithelium, which was flat or cuboidal cells, and interstitial mucus degeneration. Immunohistochemical stains included CKp (+), CK7 (+), ER (+), PR (-), CK (5/6), CR (+/-), D2-40 (+/-), CD34 (-), Ki-67-LI (10%). At the beginning of 2018, the patient again realized that she could touch the mass in the right lower abdominal scar, which was about 3 cm in size. During exercise, the lower abdomen occasionally felt slight pain, relieved with rest, and had nothing to do with the menstrual cycle. The abdominal mass gradually increased. In November 2019, she underwent excision of abdominal wall endometriosis and mesh repair because of abdominal wall mass. Postoperative pathology showed that endometriosis with deciduous degeneration. She was then given a subcutaneous injection of Leuprorelin for the purpose of preventing recurrence. However, the size of the right lower abdominal mass remained enlarged, and a similar painless mass, about 2×1×1 cm, was also found in the scar of the left lower abdominal CS in April 2020. She didn’t experience any pain at the scar during menstruation. She did not visit a doctor until the mass gradually enlarged and protruded the abdominal epidermis with broken ulcer and mucous bloody secretions in September 2020. She was then referred to our hospital for further management. At this time, physical examination revealed a 12 cm transverse shape of the CS scar of the lower abdomen. A purplish-black mass of about 6×5×5 cm can be seen on the left side of the scar with mucoid on the surface. A hard mass of about 10×10×8 cm can be palpated in the 2 transverse fingers under the umbilicus. Pelvic examination showed a normal-sized uterus and lateral adnexa. A biopsy from the mass in combination of immunohistochemical examination confirmed a pathology of endometriosis-associated CCC. The preoperative pelvic magnetic resonance imaging (MRI) showed that the parenchyma of the tumor showed equal T1 and long T2 signal intensity, with a clear boundary, and the larger one was 6.2x3.6x4.2 cm ( Fig. 1 A-C ) . No obvious enhancement was found on contrast-enhanced scan after injection of contrast agent. There was no abnormality in the uterus, bilateral adnexa, and no enlarged lymph nodes in the pelvis. Ultrasound scan showed normal liver, spleen, pancreas, kidneys, and no mass in the abdominal cavity. Hence, a multidisciplinary team including dermatology, gynecologic oncology, gastrointestinal glandular surgery, and plastic surgery department made a treatment plan for the patient preoperatively. During operation, gross complete excision with a surgical margin of 1 cm beyond the lesion of the abdominal wall including the rectus abdominis muscle, together with an abdominal wall reconstruction was performed ( Fig. 2 A-C, Fig. 3 A, Fig. 4 A and B) . It can be seen that the tumor infiltrated part of the fascia and rectus abdominal tissue, the bottom of the tumor reached the peritoneum and protruded to the abdominal cavity, and part of the omentum majus, intestine adhered to the peritoneum. No abnormality was found in the uterus and bilateral adnex, omentum and intestine. The pelvic lymph nodes were not enlarged. After separating the abdominal wall mass, the defect of fascia, rectus abdominis, and peritoneum on the right side of the wound could be seen, with an area of 15X13cm. Considering the large defect of rectus abdominis and peritoneum, mesh repair was performed ( Fig. 3 B. C) . Hysterectomy and bilateral salpingo-oophorectomy were not performed. The operation time was 300 minutes, of which 160 minutes were resected and 140 min was reconstructed. There were no intraoperative complications. The blood loss was estimated to be 200 mL. Pathologic examination of resected abdominal wall lesion showed CCC under the background of endometriosis with clear resection margins ( Fig. 5 ) . The patient was referred to plastic surgery for further care due to the huge surgical wound for 18 days. Chemotherapy with paclitaxel liposome and carboplatin regimen was conducted on day 19 and she was discharged on postoperative day 20. A month later, she returned to the hospital on time for chemotherapy, with no signs of recurrence. She is still closely followed up during the preparation of the manuscript. Discussion The diagnosis of malignant transformation of abdominal endometriosis is still a challenge for gynecologists. There are no characteristic symptoms and markers in the process of carcinogenesis. The best treatment for malignant transformation of abdominal endometriosis is not clear. We searched the articles published from September 1986 to December 2020 by Medline and EMBASE, and the search words were combined into medical subject entries. The keywords used for the search are as follows: "abdominal wall endometriosis" and "clear cell carcinoma". All relevant articles were retrieved and the list of relevant references was systematically reviewed to determine further reports that could be included in this analysis. Besides, reviews of cancer and endometriosis published over the same period were reviewed and their reference lists were searched for potential additional studies. We used SPSS 23.0 statistical software for statistical analysis. The unpaired t-test of continuous variables and the chi-square test of classified variables were used in the comparison between groups. GraphPad's Kaplan-Meier estimation was used for survival analysis. Finally, we included 45 patients in our systematic retrospective analysis, including 44 from the literature review and 1 from our organization. All of them reported that endometriosis was associated with malignant transformation of the surgical scar. The characteristics of the patients are shown in Table 1 . As shown in Fig. 6 , it is more common than previously reported, especially if we consider the increasing rate of CS in western countries [ 9 ]. The average age of the patients at the time of diagnosis was 46.5 years (range from 37 to 60), which was consistent with the retrospective analysis of Endometriosis-associated malignant transformation in an abdominal surgical scar by Mihailovici et al. [ 8 ]. Fifteen cases (33.3%) had a history of endometriosis and 28 cases (62.2%) had never been diagnosed with endometriosis before admission (2 cases were not clear). The average delay from the first operation to diagnosis was 17.9 years (standard deviation 6.6). CCC is related to uterine surgery, mainly the CS. Forty-two cases (91.1%) had at least one CS, of which 15 cases had 2 CS s, 6 cases had 3 CSs, and 4 cases (8.9%) had undergone other gynecological operations, usually CS ( Table 2 ). At least one excision of scar endometriosis was performed in 9 cases, including our case. Table 1 Summary of studies included in the review. Author Year Age Delay from first gynecological surgery(yr) Onset of symptoms(m) Lump size(cm) Surgery Pathology Patient outcome Follow-up time (m) Relapse Follow-up time (m) Death Giannella [ 15 ] 2020 45 15 3 20 no CCC NA yes 7 yes Behbehani[ 20 ] 2019 48 NA 5 7 yes CCC NA NA NA NA Tsuruga [ 12 ] 2019 49 15 3 5 yes CCC + EC 4.5 no NA NA Rivera [ 19 ] 2019 48 NA NA 7 yes CCC 2 no NA NA Lopes [ 10 ] 2019 48 12 84 12 yes CCC 3 no NA NA Lai [ 23 ] 2019 56 NA 396 6.5 yes CCC 3 yes, Inguinal LN 11 yes Lai [ 23 ] 2019 56 NA 252 12 yes CCC NA NA 5 yes Lai [ 23 ] 2019 45 NA 240 4.8 no CCC 7 yes, Abd. wall, inguinal LN 7 yes Gentile[ 26 ] 2018 42 7 8 10.6 yes CCC 2 no NA NA Mihailovici [ 8 ] 2017 47 22 264 11 yes CCC NA NA NA NA Wei [ 24 ] 2017 46 18 2 9.5 yes CCC 3 no NA NA Marques [ 27 ] 2017 47 24 3 8 yes CCC 45 no NA NA Kostrzeba [ 28 ] 2017 58 38 NA 25 yes CCC 3 no NA NA Graur[ 29 ] 2017 43 22 7 8.5 yes CCC 11 no NA NA Ferrandina [ 16 ] 2016 44 9 8 22 yes CCC 5 yes, liver 6 yes Sosa-Durán [ 30 ] 2015 45 NA 8 9 yes CCC 16 no NA NA Ruiz [ 11 ] 2015 41 20 NA 14.8 yes CCC 6 yes, local NA NA Ruiz [ 11 ] 2015 57 30 9 19.4 yes CCC NA no NA NA Aust [ 31 ] 2015 47 16 6 10 yes CCC 10 no NA NA Liu[ 32 ] 2014 39 10 60 6 yes CCC 10 yes, local 12 yes Heller [ 33 ] 2014 37 8 96 18 yes CCC 5 yes, NA NA Dobrosz [ 34 ] 2014 42 NA 16 NA yes CCC NA NA NA NA Ijichi [ 35 ] 2014 60 37 48 4 yes CCC 8 yes, local 23 no Shalin [ 36 ] 2012 47 NA 10 3 yes CCC 7 no NA NA Sawazaki [ 17 ] 2012 41 18 NA 4.8 yes CCC 4 no NA NA Mert [ 37 ] 2012 42 NA NA 17.8 yes CCC 26 no NA NA Mert [ 37 ] 2012 51 8 12 7 yes CCC 49 no NA NA Li [ 38 ] 2012 49 26 25 9 yes CCC 8 no NA NA Yan [ 21 ] 2011 41 5 4 6.3 yes CCC 24 no NA NA Bourdel [ 39 ] 2010 43 20 60 9 yes CCC 6 yes 22 yes Williams [ 40 ] 2009 53 24 4 4.7 yes CCC 3 yes, local, InguinalLN, lung 11 yes Matsuo [ 41 ] 2009 37 10 5 14 yes CCC 24 yes, local NA NA Rust [ 42 ] 2008 42 NA 24 4.9 yes CCC NA NA NA NA Barts [ 18 ] 2008 38 13 151 11 yes CCC 8 yes NA NA Achach [ 43 ] 2008 49 20 NA 8.5 yes CCC 6 yes, bladder and pelvic bone NA NA Razzouk [ 22 ] 2007 46 26 NA 17 yes CCC + EC 3 yes, liver 6 yes Harry [ 44 ] 2007 55 NA 15 4 yes CCC 18 no NA NA Sergent [ 45 ] 2006 45 25 17 20 yes CCC NA yes 6 yes Alberto [ 46 ] 2006 38 11 6 6 yes CCC NA NA NA NA Ishida [ 47 ] 2003 56 24 7 10 yes CCC NA yes, lung, bone and brain 48 yes Park [ 48 ] 1999 56 24 NA 5 yes CCC NA NA NA NA Miller [ 49 ] 1998 38 9 8 4 yes CCC 60 no NA NA Hitti [ 50 ] 1990 46 14 NA 6 yes CCC 30 no NA NA Schnieber Agner-Kolb [ 51 ] 1986 40 15 18 NA yes CCC NA yes 18 yes our case 2020 49 19 204 6.3 yes CCC 1 no NA NA Table 2 Characteristics of patients. n Percentage Age(yr) 46.5 ± 4.9 31–40 7 15.22% 41–50 28 60.87% 51–60 10 21.74% Previous gynecological surgery 1C 20 44.44% 2C 15 33.33% 3C 6 13.33% other surgeries 4 8.89% Delay from fist gynecological surgery (yr) 17.9 ± 6.6 0–10 7 20.59% 11–20 15 44.12% 21–30 10 29.41% 31–40 2 5.88% Onset of symptoms(yr) 4.4 ± 5.2 0–1 19 52.78% 1–2 6 16.67% 2–10 6 16.67% 10–33 5 13.89% Follow-up time (m) 15.0 ± 11.5(1–60) Because some literature did not specify the time of the events, the results of the delay from fist gynecological surgery,onset of symptoms, and follow-up time only counted the cases with specific years. As for tumor markers, CA 125 was detected in 24 cases before the operation. 14 cases were in the normal range (0-35U/mL), 10 cases were higher than the normal range, and the highest was 3157.9U/mL [ 10 ]. The preoperative detection of CEA,7 was in the normal range in 9 cases, above the normal range in 2 cases, up to 96.5 µg/L [ 11 ]. CA 199 was detected in 12 cases before treatment, and above the normal range in 4 cases, up to 222 µg/L [ 12 ]. ( Table S1 ). Previously, only 15 patients had a history of endometriosis (44 patients had available information) and 12 patients had no abdominal masses before diagnosis without any intermittent, periodic, or persistent pain. But all patients had palpable abdominal surgical scar masses with an average diameter of 10.0 cm (standard deviation 4.4 cm), up to 25 cm. The pathological results of the mass are shown in Table 3 . The most common histological type is CCC, in 43 cases (95.6%), followed by CCC with endometrioid carcinoma in 2 cases (4.4%). Of these, only 22 cases (51.2%) found coexisting endometriosis implants (Table 3 ). In these cases, additional samples for a thorough search for residual lesions of endometrial glands were not all successful. In 1925, Sampson [ 13 ] put forward the criteria for the diagnosis of malignant transformation of endometriosis: (a) benign and neoplastic endometrial tissue were shown in the tumor at the same time; (b) histology was compatible with the origin of the endometrium; (c) no other primary tumor sites were found. Besides, Scott proposed the fourth criterion in 1953 [ 14 ], that was, (d) the morphological manifestation of benign endometriosis adjacent to malignant tissue is a prerequisite for judging malignant tumors originating from endometriosis. In the current situation, the first three criteria of the reported cases have been met, but the fourth criteria may not be met, which may be the result of the complete replacement of normal tissue due to the proliferation of a large number of tumors. Table 3 Pathological characteristics of lumps. Tumor size(cm) Histology Coexisting endometriosis Average Range CCC CCC + EC yes no Case(n) Percentage Case(n) Percentage Case(n) Percentage Case(n) Percentage 10.0 ± 4.4 (3,25) 43 95.60% 2 4.40% 22 51% 23 49% CCC: clear cell carcinoma, EC: endometrial cancer. Because some literature did not specify the pathological characteristics of lumps, the results of Pathological characteristics of lumps only counted the cases with specific results. Also, we classified the tumor into large masses and small masses by 10 cm in diameter. The correlation between mass size and clinical features was shown in Table 4 . The results suggested that patients with abdominal masses larger than 10 cm had more symptoms of abdominal pain before admission than those with small masses, and complained more about the pain caused by palpable masses (P = 0.015). There was no significant difference in other characteristics (P > 0.05). Table 4 The correlation between mass size and clinical features. Clinical data L-SE (8 cases) S-SE (16 cases) P Mean age (yr) (range) 47.8 (38–57) 46.8(38–60) NS No. of gynecological sugeries (range) 1.3 (1–3) 1.5(1–3) NS Delay from first surgery(y) 14.8 ± 7.7 18.0 ± 8.3 NS Onset of symptoms (m) 66.5 ± 74.9 34.6 ± 39.9 NS pain 7 8 0.015 no pain 1 8 L-SE: Large scar endometrioma(༞10cm); S-SE: Small scar endometrioma; NS: Not significant. NS: not significant. In terms of treatment, four patients received preoperative neoadjuvant chemotherapy (mainly platinum-based) [ 15 – 18 ], and one of them did not consider radical surgery because of the rapid progression of multiple metastases throughout the body [ 15 ]. Six patients were trying to treat vaginal estradiol medroxyprogesterone injection, leuprolide acetate, gestrinone, riptorelin, leiprim [ 10 , 19 – 22 ], including our case, but the effect was not satisfactory. Surgery is the main treatment for the most of patients. The first-stage operation was performed based on extensive resection of the tumor and extensive abdominal tissue. Two cases were not treated surgically because of multiple metastases throughout the body and the rapid progression of the disease [ 15 , 23 ]. Due to the extent of the fascia defect, 22 patients (47.8%) used mesh to reconstruct the abdominal wall (including our case]. Other regular operations include hysterectomy (27 cases, 60.0%) and/or salpingectomy (29 cases, 64.4%), and / or lymph node dissection (14 cases, 30.4%) and/or omental resection (15 cases, 33.3%). Although radical surgery is a major part of the treatment of all patients, our case did not performe hysterectomy and bilateral salpingo-oophorectomy plus pelvic lymphadenectomy, because no signs of the above organs were involved. Another reason is that we plan to perform postoperative radiotherapy for the patient after chemiotherapy. The follow-up adjuvant therapy is mainly chemotherapy, usually platinum and paclitaxel drugs. Twenty-nine cases (64.4%) received 1–9 cycles of adjuvant chemotherapy. However, due to the poor individual characteristics and compliance, adverse reactions, or partial reactions to the treatment, the treatment is interrupted and the efficacy of chemotherapy is difficult to evaluate. Only 16 patients (34.8%) received radiotherapy after surgery and chemotherapy ( Table S1 ). The above patients obtained the latest clinical follow-up information currently available, and eventually, 38 patients were able to know the outcome ( Table S1 ). The follow-up time of the above patients ranged from 1 to 60 months, with an average of 15.0 months. 34.2% of women (13/38) died between 5 and 48 months after diagnosis. As shown in the Kaplan-Meier survival curve ( Fig. 7 ), the median survival time is 48 months and the five-year survival rate is 35%. Seventeen patients were reported to relapse. The sites of recurrence were local (5 cases), lymphatic metastasis (3 cases, all inguinal lymph nodes) [ 15 , 20 , 24 ], distant metastasis (4 cases of liver, 2 cases of lung, 2 cases of brain, and 2 cases of bone). Univariate Cox regression model showed that the prognosis of patients with metastasis (17 cases, 17/37, Of the 38 cases with a specific follow-up period, one death was excluded because it was not known whether there was metastasis.) was worse than that without metastasis (20 cases, 20/37), as shown by Kaplan-Meier curve (Fig. 8 ) , suggesting that metastasis invasion is a poor prognostic factor affecting patient survival. This is consistent with Taburiaux's study [ 25 ]. At present, there is no multicenter RCT in the study of abdominal CCC. However, we can put forward some general directions for future treatment and research, and emphasize several findings that seem to appear from our data: (a) abdominal wall scar CCC appears in relatively young women and is an invasive disease with a poor prognosis, with a 5-year survival rate of about 35%. (b) it is an iatrogenic disease of abdominal wall scar formation after gynecological surgery, and CS is the most common. (c) the progression of the disease was slow, and the average time of diagnosis was 17.9 years after the first gynecology and obstetrics operation. In this case, it often relapses to benign nodules of endometriosis, and sometimes patients undergo repeated surgery. (d) the size of the tumor was large at the time of diagnosis, and most of them needed extensive surgical repair of abdominal wall defects. (e) the use of progesterone or gonadotropin-releasing hormone analogs (GnRH-a) before surgical treatment is limited to the number of cases, and the effects are not clear. The limitation of the review lies in the rarity of the disease, resulting in data collection based only on case reports, with heterologous information from different specialties. This leads to a lack of useful data, which limits statistical analysis. Although we have carried out a lot of statistical analysis, no clear results have been obtained. However, the results of this analysis can guide us to better understand the CCC risk factors and optimal treatment of abdominal wall endometriosis. Conclusion The transformation of abdominal endometriosis to CCC is a rare and little-known complication, but invasive surgical resection with a safe margin in combination with lymph node dissection is still the most effective and survival treatment. The role of adjuvant therapy is still unclear, so further research is needed to assess the long-term benefits. Our case did not undergo radical hysterectomy and lymphadenectomy because there was no local, lymph node and distant metastasis, and planned follow-up radiotherapy and chemotherapy. Of course we need to long term and closely follow up to investigate if lymphatic metastasis and distant metastasis occurred, including liver, lung, brain and bone metastasis. Abbreviations CS: cesarean section; CCC: clear cell carcinoma; MRI: magnetic resonance imaging. Declarations Acknowledgments Not applicable. Author Contributions Liang XZ and Zeng H wrote the first draft of the manuscript, Tang Z and Liao JJ participated in the patient’s management; Liang XZ and Fan JT performed the literature review; Fan JT performed radiological diagnosis and supervised the patient’s management, critically revised the paper and gave a scientific contribution. Funding Not applicable. Ethics approval and consent to participate Approval of the Ethics Committee of the First Affiliated Hospital of Guangxi Medical University was obtained for this study, and the patient signed informed consent form. Consent for publication The patient signed consent for publication. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated. 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Case Rep Obstet Gynecol 2014, 2014: 642483. Shalin SC, Haws AL, Carter DG, Zarrin-Khameh N: Clear cell adenocarcinoma arising from endometriosis in abdominal wall cesarean section scar: a case report and review of the literature. J Cutan Pathol 2012, 39: 1035-1041. Mert I, Semaan A, Kim S, Ali-Fehmi R, Morris RT: Clear cell carcinoma arising in the abdominal wall: two case reports and literature review. Am J Obstet Gynecol 2012, 207: e7-9. Li X, Yang J, Cao D, Lang J, Chen J, Shen K: Clear-cell carcinoma of the abdominal wall after cesarean delivery. Obstet Gynecol 2012, 120: 445-448. Bourdel N, Durand M, Gimbergues P, Dauplat J, Canis M: Exclusive nodal recurrence after treatment of degenerated parietal endometriosis. Fertil Steril 2010, 93: 2074 e2071-2076. Williams C, Petignat P, Belisle A, Drouin P: Primary abdominal wall clear cell carcinoma: case report and review of literature. Anticancer Res 2009, 29: 1591-1593. Matsuo K, Alonsozana EL, Eno ML, Rosenshein NB, Im DD: Primary peritoneal clear cell adenocarcinoma arising in previous abdominal scar for endometriosis surgery. Arch Gynecol Obstet 2009, 280: 637-641. Rust MM, Susa J, Naylor R, Cavuoti D: Clear cell carcinoma in a background of endometriosis. Case report of a finding in a midline abdominal scar 5 years after a total abdominal hysterectomy. Acta Cytol 2008, 52: 475-480. Achach T, Rammeh S, Trabelsi A, Ltaief R, Ben Abdelkrim S, Mokni M, Korbi S: Clear cell adenocarcinoma arising from abdominal wall endometriosis. J Oncol 2008, 2008: 478325. Harry VN, Shanbhag S, Lyall M, Narayansingh GV, Parkin DE: Isolated clear cell adenocarcinoma in scar endometriosis mimicking an incisional hernia. Obstet Gynecol 2007, 110: 469-471. Sergent F, Baron M, Le Cornec JB, Scotte M, Mace P, Marpeau L: [Malignant transformation of abdominal wall endometriosis: a new case report]. J Gynecol Obstet Biol Reprod (Paris) 2006, 35: 186-190. Alberto VO, Lynch M, Labbei FN, Jeffers M: Primary abdominal wall clear cell carcinoma arising in a Caesarean section scar endometriosis. Ir J Med Sci 2006, 175: 69-71. Ishida GM, Motoyama T, Watanabe T, Emura I: Clear cell carcinoma arising in a cesarean section scar. Report of a case with fine needle aspiration cytology. Acta Cytol 2003, 47: 1095-1098. Park SW, Hong SM, Wu HG, Ha SW: Clear cell carcinoma arising in a Cesarean section scar endometriosis: a case report. J Korean Med Sci 1999, 14: 217-219. Miller DM, Schouls JJ, Ehlen TG: Clear cell carcinoma arising in extragonadal endometriosis in a caesarean section scar during pregnancy. Gynecol Oncol 1998, 70: 127-130. Hitti IF, Glasberg SS, Lubicz S: Clear cell carcinoma arising in extraovarian endometriosis: report of three cases and review of the literature. Gynecol Oncol 1990, 39: 314-320. Schnieber D, Wagner-Kolb D: [Malignant transformation of extragenital endometriosis]. Geburtshilfe Frauenheilkd 1986, 46: 658-659. Supplementary Files TableS1.xlsx Clinical parameters of studies included in the review. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-146993","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case report","associatedPublications":[],"authors":[{"id":8162680,"identity":"bb9f246d-4cf5-4969-a3a9-e3964179f24c","order_by":0,"name":"Xuzhi Liang","email":"","orcid":"","institution":"Guangxi Medical University First Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xuzhi","middleName":"","lastName":"Liang","suffix":""},{"id":8162681,"identity":"2e0e4b18-d210-4b5f-bc27-5085e527d859","order_by":1,"name":"Hao Zeng","email":"","orcid":"","institution":"Guangxi Medical University First Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Zeng","suffix":""},{"id":8162682,"identity":"0c303d1d-b1a8-49bc-a952-5a131a9a309e","order_by":2,"name":"Zhe Tang","email":"","orcid":"","institution":"Guangxi Medical University First Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhe","middleName":"","lastName":"Tang","suffix":""},{"id":8162683,"identity":"786df4ad-8a62-42b6-b945-74bc33679e8c","order_by":3,"name":"Jiejie Liao","email":"","orcid":"","institution":"Guangxi Medical University First Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiejie","middleName":"","lastName":"Liao","suffix":""},{"id":8162684,"identity":"bf46d52a-54eb-42f4-80c6-1d044b8e84f4","order_by":4,"name":"Jiangtao Fan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIie3QMQuCQBTA8SfB2fBUWuJA0q9guDT4YXRpcugjJMK15K409BUcG40DJ/sELUJzcKMNUTe23Y0N998e3I/HOwCT6Q+zzyMIgASJXXadmDSIVYJVA2wDF/vs2hz1CY8Dmsd8TjTJ/nWZZQwHwQEh9JadmhTVQDJmVy3fbWDdnFIlsUeHodxya3mNkEZ3NbGKN6MZo/nIkWiQhSSlw6KY0Bz0iD+TZMXSgGAfyU+m6ltcSYon+2B4KB9CTEno+QoC4Infiaqem0wmk0mnL1WwQyLltPBhAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-1308-4533","institution":"Guangxi Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jiangtao","middleName":"","lastName":"Fan","suffix":""}],"badges":[],"createdAt":"2021-01-13 19:34:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-146993/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-146993/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":5099694,"identity":"d7a7522e-5dc5-478a-912c-b0144410806c","added_by":"auto","created_at":"2021-01-19 20:17:57","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":183139,"visible":true,"origin":"","legend":"CT image of the abdominal mass shows two lower rectus muscle heterogeneous lumps: (A) Sagittal view. (B) Coronal view. (C) Transverse view.","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-146993/v1/532e1cfc6142a95b15511208.jpg"},{"id":5099695,"identity":"42379d60-8199-4fa9-ab0c-0ac317578f05","added_by":"auto","created_at":"2021-01-19 20:17:57","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":522858,"visible":true,"origin":"","legend":"Photograph showing an ulcerated abdominal nodule associated with a cesarean section scar.","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-146993/v1/a420c7477f942739d56df22f.jpg"},{"id":5099361,"identity":"d93a1061-8185-45b0-8382-e3eb9035ccc2","added_by":"auto","created_at":"2021-01-19 20:14:57","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":910440,"visible":true,"origin":"","legend":"Photograph showing intraoperative tumor resection process.\n(A).Large defect of the abdominal wall after removal of the mass. (B).Placement of patch. (C).Surgical suture.\n","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-146993/v1/d0f85463b2aad8a25d385f24.jpg"},{"id":5099696,"identity":"a8cfc9e3-0e09-448c-9bdb-1dad243e6616","added_by":"auto","created_at":"2021-01-19 20:17:57","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":841952,"visible":true,"origin":"","legend":"Macroscopic appearance demonstrating areas of cystic and solid components with brittle texture. (A).Gross appearance. (B). Internal components were shown after dissection.","description":"","filename":"figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-146993/v1/5be948456b2db01f4a5493aa.jpg"},{"id":5099701,"identity":"67815574-40ab-4831-8eb2-4920d0a8d337","added_by":"auto","created_at":"2021-01-19 20:17:58","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":149459,"visible":true,"origin":"","legend":"Histologic images of the tumor. (A). Higher magnification of cystic spaces lined by bland-appearing, flattened cells (H\u0026E stain, X200). (B). In other areas, the tumor shows irregular infiltrating glands with fibrous stroma. ","description":"","filename":"figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-146993/v1/c61c928ce2f94c00992168a0.jpg"},{"id":5099855,"identity":"9f7a46f3-0a1e-466e-99dc-16c194d60f51","added_by":"auto","created_at":"2021-01-19 20:20:58","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":64310,"visible":true,"origin":"","legend":"The year distribution of clear cell carcinoma caused by endometriosis in abdominal wall surgical wound has been reported.","description":"","filename":"figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-146993/v1/26e409a23c3f3bd70c0ab833.jpg"},{"id":5099363,"identity":"722dac7e-e58a-468f-ab4e-24a2802ea578","added_by":"auto","created_at":"2021-01-19 20:14:58","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":62952,"visible":true,"origin":"","legend":"Kaplan–Meier curve for survival in patients with endometriosis-associated malignant transformation in abdominal surgical-scar showing high mortality up to 60 months following diagnosis. The median survival time is 48 months and the five-year survival rate is 35%","description":"","filename":"figure7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-146993/v1/b354f449c0468e1298343e2d.jpg"},{"id":5099698,"identity":"5dbc8b73-4367-46cd-b163-f6c3b86755f9","added_by":"auto","created_at":"2021-01-19 20:17:57","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":101718,"visible":true,"origin":"","legend":"Kaplan–Meier curve for survival between patients with metastasis and without metastasis during the follow-up treatment.","description":"","filename":"figure8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-146993/v1/6ec47da60d12b3acb4c6af7b.jpg"},{"id":13650085,"identity":"208e5ff0-c052-43ac-8539-2af35e13ba39","added_by":"auto","created_at":"2021-09-17 09:39:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1941392,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-146993/v1/2ade992f-11c3-4ce1-ad6a-58ba62cb6c7a.pdf"},{"id":5099854,"identity":"a6e76a77-bc78-419e-aa0b-0b1573d5b3ab","added_by":"auto","created_at":"2021-01-19 20:20:57","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22765,"visible":true,"origin":"","legend":"Clinical parameters of studies included in the review.","description":"","filename":"TableS1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-146993/v1/7f575d0c6b7d04926e4acc4d.xlsx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eIs clear cell carcinoma of abdominal wall surgery scar associated with endometriosis a poor prognosis? A case report and literature review\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eThe incidence of scar endometriosis in abdominal surgery is between 0.03% and 1.08% in women undergoing pelvic surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Abdominal wall endometriosis caused by incisions is an often neglected disease [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Scar endometriosis is usually caused by the implantation of endometrial tissue into the soft tissue of the abdominal wall during surgery. Symptoms of endometriosis in abdominal surgical scars in obstetrics and gynecology include slowly developing lumps in or near the scar, as well as pain and abdominal swelling during menstruation. However, malignant transformation of abdominal wall endometriosis is very rare, including sarcomatoid degeneration [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], serous papillary carcinoma [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], rhabdomyosarcoma [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] as well as clear cell carcinoma (CCC). The most common histological type is CCC [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. CCC caused by endometriosis is an invasive disease with a poor prognosis, with a 5-year survival rate of about 40% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Diagnosis is challenging because the disease develops slowly and has no specific markers of malignant transformation.\u003c/p\u003e \u003cp\u003eHere we report a patient with CCC of the abdominal wall at the scar site of a previous Cesarean section (CS). Besides, we reviewed the existing English literature on transparent clear cell carcinoma caused by endometriosis in the abdominal wall and compared the clinical features of abdominal wall masses of different sizes.\u003c/p\u003e "},{"header":"Case Presentation","content":" \u003cp\u003eA 47-year-old woman, grava 4, para 3, abortion 1, presented with two big abdominal masses, which were gradually enlarging after 2 previous excisions of an endometriotic nodule in a CS scar. This patient underwent a CS in 2001 due to fetal distress and transverse position. The CS procedure was successful, with no postoperative discomfort such as abdominal pain, abdominal distension, and the menstruation is regular. Early in 2017, she noticed a small mass of about 1\u0026nbsp;cm in right lower abdominal scar without menstrual period pain and itching. She underwent abdominal endometriosis mass resection in May 2017. During the operation, the boundary between the mass and abdominal wall tissue was not clear, and a mesh was placed to repair the abdominal wall. The mass containing chocolate-like fluid with a hard texture. The pathology of the nodule was reported as endometriosis with decidual degeneration. The mass in the abdominal wall is consistent with the adenomatoid tumor. Microscopically, a large amount of dilated cystic cavity was seen in the fibrous tissue, which was lined with a single layer of epithelium, which was flat or cuboidal cells, and interstitial mucus degeneration. Immunohistochemical stains included CKp (+), CK7 (+), ER (+), PR (-), CK (5/6), CR (+/-), D2-40 (+/-), CD34 (-), Ki-67-LI (10%).\u003c/p\u003e \u003cp\u003eAt the beginning of 2018, the patient again realized that she could touch the mass in the right lower abdominal scar, which was about 3\u0026nbsp;cm in size. During exercise, the lower abdomen occasionally felt slight pain, relieved with rest, and had nothing to do with the menstrual cycle. The abdominal mass gradually increased. In November 2019, she underwent excision of abdominal wall endometriosis and mesh repair because of abdominal wall mass. Postoperative pathology showed that endometriosis with deciduous degeneration. She was then given a subcutaneous injection of Leuprorelin for the purpose of preventing recurrence. However, the size of the right lower abdominal mass remained enlarged, and a similar painless mass, about 2\u0026times;1\u0026times;1\u0026nbsp;cm, was also found in the scar of the left lower abdominal CS in April 2020. She didn\u0026rsquo;t experience any pain at the scar during menstruation. She did not visit a doctor until the mass gradually enlarged and protruded the abdominal epidermis with broken ulcer and mucous bloody secretions in September 2020. She was then referred to our hospital for further management. At this time, physical examination revealed a 12\u0026nbsp;cm transverse shape of the CS scar of the lower abdomen. A purplish-black mass of about 6\u0026times;5\u0026times;5\u0026nbsp;cm can be seen on the left side of the scar with mucoid on the surface. A hard mass of about 10\u0026times;10\u0026times;8\u0026nbsp;cm can be palpated in the 2 transverse fingers under the umbilicus. Pelvic examination showed a normal-sized uterus and lateral adnexa. A biopsy from the mass in combination of immunohistochemical examination confirmed a pathology of endometriosis-associated CCC.\u003c/p\u003e \u003cp\u003eThe preoperative pelvic magnetic resonance imaging (MRI) showed that the parenchyma of the tumor showed equal T1 and long T2 signal intensity, with a clear boundary, and the larger one was 6.2x3.6x4.2\u0026nbsp;cm \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-C\u003cb\u003e)\u003c/b\u003e. No obvious enhancement was found on contrast-enhanced scan after injection of contrast agent. There was no abnormality in the uterus, bilateral adnexa, and no enlarged lymph nodes in the pelvis. Ultrasound scan showed normal liver, spleen, pancreas, kidneys, and no mass in the abdominal cavity. Hence, a multidisciplinary team including dermatology, gynecologic oncology, gastrointestinal glandular surgery, and plastic surgery department made a treatment plan for the patient preoperatively. During operation, gross complete excision with a surgical margin of 1\u0026nbsp;cm beyond the lesion of the abdominal wall including the rectus abdominis muscle, together with an abdominal wall reconstruction was performed \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA-C, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA \u003cb\u003eand B)\u003c/b\u003e. It can be seen that the tumor infiltrated part of the fascia and rectus abdominal tissue, the bottom of the tumor reached the peritoneum and protruded to the abdominal cavity, and part of the omentum majus, intestine adhered to the peritoneum. No abnormality was found in the uterus and bilateral adnex, omentum and intestine. The pelvic lymph nodes were not enlarged. After separating the abdominal wall mass, the defect of fascia, rectus abdominis, and peritoneum on the right side of the wound could be seen, with an area of 15X13cm. Considering the large defect of rectus abdominis and peritoneum, mesh repair was performed \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB.\u003cb\u003eC)\u003c/b\u003e. Hysterectomy and bilateral salpingo-oophorectomy were not performed. The operation time was 300 minutes, of which 160 minutes were resected and 140\u0026nbsp;min was reconstructed. There were no intraoperative complications. The blood loss was estimated to be 200\u0026nbsp;mL. Pathologic examination of resected abdominal wall lesion showed CCC under the background of endometriosis with clear resection margins \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The patient was referred to plastic surgery for further care due to the huge surgical wound for 18 days. Chemotherapy with paclitaxel liposome and carboplatin regimen was conducted on day 19 and she was discharged on postoperative day 20. A month later, she returned to the hospital on time for chemotherapy, with no signs of recurrence. She is still closely followed up during the preparation of the manuscript.\u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eThe diagnosis of malignant transformation of abdominal endometriosis is still a challenge for gynecologists. There are no characteristic symptoms and markers in the process of carcinogenesis. The best treatment for malignant transformation of abdominal endometriosis is not clear. We searched the articles published from September 1986 to December 2020 by Medline and EMBASE, and the search words were combined into medical subject entries. The keywords used for the search are as follows: \"abdominal wall endometriosis\" and \"clear cell carcinoma\". All relevant articles were retrieved and the list of relevant references was systematically reviewed to determine further reports that could be included in this analysis. Besides, reviews of cancer and endometriosis published over the same period were reviewed and their reference lists were searched for potential additional studies. We used SPSS 23.0 statistical software for statistical analysis. The unpaired t-test of continuous variables and the chi-square test of classified variables were used in the comparison between groups. GraphPad's Kaplan-Meier estimation was used for survival analysis.\u003c/p\u003e \u003cp\u003eFinally, we included 45 patients in our systematic retrospective analysis, including 44 from the literature review and 1 from our organization. All of them reported that endometriosis was associated with malignant transformation of the surgical scar. The characteristics of the patients are shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e, it is more common than previously reported, especially if we consider the increasing rate of CS in western countries [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The average age of the patients at the time of diagnosis was 46.5\u0026nbsp;years (range from 37 to 60), which was consistent with the retrospective analysis of Endometriosis-associated malignant transformation in an abdominal surgical scar by Mihailovici et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Fifteen cases (33.3%) had a history of endometriosis and 28 cases (62.2%) had never been diagnosed with endometriosis before admission (2 cases were not clear). The average delay from the first operation to diagnosis was 17.9\u0026nbsp;years (standard deviation 6.6). CCC is related to uterine surgery, mainly the CS. Forty-two cases (91.1%) had at least one CS, of which 15 cases had 2 CS s, 6 cases had 3 CSs, and 4 cases (8.9%) had undergone other gynecological operations, usually CS \u003cb\u003e(\u003c/b\u003eTable \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e At least one excision of scar endometriosis was performed in 9 cases, including our case.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of studies included in the review.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDelay from first gynecological surgery(yr)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOnset of symptoms(m)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLump size(cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePathology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c12\" namest=\"c9\"\u003e \u003cp\u003ePatient outcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFollow-up time (m)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRelapse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eFollow-up time (m)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGiannella [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehbehani[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTsuruga [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u0026thinsp;+\u0026thinsp;EC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRivera [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLopes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLai [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes, Inguinal LN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLai [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLai [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes, Abd. wall,\u003c/p\u003e \u003cp\u003einguinal LN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGentile[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMihailovici [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWei [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarques [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKostrzeba [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraur[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFerrandina [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes, liver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSosa-Dur\u0026aacute;n [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRuiz [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes, local\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRuiz [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAust [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiu[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes, local\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeller [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDobrosz [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIjichi [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes, local\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShalin [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSawazaki [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMert [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMert [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLi [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYan [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBourdel [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilliams [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes, local, InguinalLN, lung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMatsuo [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes, local\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRust [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarts [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAchach [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes, bladder and pelvic bone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRazzouk [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u0026thinsp;+\u0026thinsp;EC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes, liver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarry [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSergent [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlberto [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIshida [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes, lung, bone and\u003c/p\u003e \u003cp\u003ebrain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePark [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiller [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHitti [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchnieber Agner-Kolb [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eour case\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAge(yr)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e46.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.22%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.87%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.74%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePrevious gynecological surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.44%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.33%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.33%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eother surgeries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.89%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eDelay from fist gynecological surgery (yr)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.59%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.12%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.41%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.88%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eOnset of symptoms(yr)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.78%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.67%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.67%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.89%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up time (m)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e15.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5(1\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eBecause some literature did not specify the time of the events, the results of the delay from fist gynecological surgery,onset of symptoms, and follow-up time only counted the cases with specific years.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs for tumor markers, CA 125 was detected in 24 cases before the operation. 14 cases were in the normal range (0-35U/mL), 10 cases were higher than the normal range, and the highest was 3157.9U/mL [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The preoperative detection of CEA,7 was in the normal range in 9 cases, above the normal range in 2 cases, up to 96.5\u0026nbsp;\u0026micro;g/L [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. CA 199 was detected in 12 cases before treatment, and above the normal range in 4 cases, up to 222\u0026nbsp;\u0026micro;g/L [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. (\u003cb\u003eTable S1\u003c/b\u003e).\u003c/p\u003e \u003cp\u003ePreviously, only 15 patients had a history of endometriosis (44 patients had available information) and 12 patients had no abdominal masses before diagnosis without any intermittent, periodic, or persistent pain. But all patients had palpable abdominal surgical scar masses with an average diameter of 10.0\u0026nbsp;cm (standard deviation 4.4\u0026nbsp;cm), up to 25\u0026nbsp;cm. The pathological results of the mass are shown in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The most common histological type is CCC, in 43 cases (95.6%), followed by CCC with endometrioid carcinoma in 2 cases (4.4%). Of these, only 22 cases (51.2%) found coexisting endometriosis implants (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In these cases, additional samples for a thorough search for residual lesions of endometrial glands were not all successful. In 1925, Sampson [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] put forward the criteria for the diagnosis of malignant transformation of endometriosis: (a) benign and neoplastic endometrial tissue were shown in the tumor at the same time; (b) histology was compatible with the origin of the endometrium; (c) no other primary tumor sites were found. Besides, Scott proposed the fourth criterion in 1953 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], that was, (d) the morphological manifestation of benign endometriosis adjacent to malignant tissue is a prerequisite for judging malignant tumors originating from endometriosis. In the current situation, the first three criteria of the reported cases have been met, but the fourth criteria may not be met, which may be the result of the complete replacement of normal tissue due to the proliferation of a large number of tumors.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePathological characteristics of lumps.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size(cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eHistology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eCoexisting endometriosis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eCCC\u0026thinsp;+\u0026thinsp;EC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase(n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCase(n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCase(n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCase(n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(3,25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e51%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e49%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eCCC: clear cell carcinoma, EC: endometrial cancer.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eBecause some literature did not specify the pathological characteristics of lumps, the results of Pathological characteristics of lumps only counted the cases with specific results.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAlso, we classified the tumor into large masses and small masses by 10\u0026nbsp;cm in diameter. The correlation between mass size and clinical features was shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The results suggested that patients with abdominal masses larger than 10\u0026nbsp;cm had more symptoms of abdominal pain before admission than those with small masses, and complained more about the pain caused by palpable masses (P\u0026thinsp;=\u0026thinsp;0.015). There was no significant difference in other characteristics (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe correlation between mass size and clinical features.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL-SE (8 cases)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS-SE (16 cases)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age (yr) (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.8 (38\u0026ndash;57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.8(38\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of gynecological sugeries (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5(1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelay from first surgery(y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnset of symptoms (m)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.5\u0026thinsp;\u0026plusmn;\u0026thinsp;74.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.6\u0026thinsp;\u0026plusmn;\u0026thinsp;39.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eL-SE: Large scar endometrioma(༞10cm); S-SE: Small scar endometrioma; NS: Not significant.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNS: not significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn terms of treatment, four patients received preoperative neoadjuvant chemotherapy (mainly platinum-based) [\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and one of them did not consider radical surgery because of the rapid progression of multiple metastases throughout the body [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Six patients were trying to treat vaginal estradiol medroxyprogesterone injection, leuprolide acetate, gestrinone, riptorelin, leiprim [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], including our case, but the effect was not satisfactory. Surgery is the main treatment for the most of patients. The first-stage operation was performed based on extensive resection of the tumor and extensive abdominal tissue. Two cases were not treated surgically because of multiple metastases throughout the body and the rapid progression of the disease [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Due to the extent of the fascia defect, 22 patients (47.8%) used mesh to reconstruct the abdominal wall (including our case]. Other regular operations include hysterectomy (27 cases, 60.0%) and/or salpingectomy (29 cases, 64.4%), and / or lymph node dissection (14 cases, 30.4%) and/or omental resection (15 cases, 33.3%). Although radical surgery is a major part of the treatment of all patients, our case did not performe hysterectomy and bilateral salpingo-oophorectomy plus pelvic lymphadenectomy, because no signs of the above organs were involved. Another reason is that we plan to perform postoperative radiotherapy for the patient after chemiotherapy. The follow-up adjuvant therapy is mainly chemotherapy, usually platinum and paclitaxel drugs. Twenty-nine cases (64.4%) received 1\u0026ndash;9 cycles of adjuvant chemotherapy. However, due to the poor individual characteristics and compliance, adverse reactions, or partial reactions to the treatment, the treatment is interrupted and the efficacy of chemotherapy is difficult to evaluate. Only 16 patients (34.8%) received radiotherapy after surgery and chemotherapy (\u003cb\u003eTable S1\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eThe above patients obtained the latest clinical follow-up information currently available, and eventually, 38 patients were able to know the outcome (\u003cb\u003eTable S1\u003c/b\u003e). The follow-up time of the above patients ranged from 1 to 60 months, with an average of 15.0\u0026nbsp;months. 34.2% of women (13/38) died between 5 and 48\u0026nbsp;months after diagnosis. As shown in the Kaplan-Meier survival curve \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e), the median survival time is 48\u0026nbsp;months and the five-year survival rate is 35%. Seventeen patients were reported to relapse. The sites of recurrence were local (5 cases), lymphatic metastasis (3 cases, all inguinal lymph nodes) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], distant metastasis (4 cases of liver, 2 cases of lung, 2 cases of brain, and 2 cases of bone). Univariate Cox regression model showed that the prognosis of patients with metastasis (17 cases, 17/37, Of the 38 cases with a specific follow-up period, one death was excluded because it was not known whether there was metastasis.) was worse than that without metastasis (20 cases, 20/37), as shown by Kaplan-Meier curve (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e, suggesting that metastasis invasion is a poor prognostic factor affecting patient survival. This is consistent with Taburiaux's study [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt present, there is no multicenter RCT in the study of abdominal CCC. However, we can put forward some general directions for future treatment and research, and emphasize several findings that seem to appear from our data: (a) abdominal wall scar CCC appears in relatively young women and is an invasive disease with a poor prognosis, with a 5-year survival rate of about 35%. (b) it is an iatrogenic disease of abdominal wall scar formation after gynecological surgery, and CS is the most common. (c) the progression of the disease was slow, and the average time of diagnosis was 17.9\u0026nbsp;years after the first gynecology and obstetrics operation. In this case, it often relapses to benign nodules of endometriosis, and sometimes patients undergo repeated surgery. (d) the size of the tumor was large at the time of diagnosis, and most of them needed extensive surgical repair of abdominal wall defects. (e) the use of progesterone or gonadotropin-releasing hormone analogs (GnRH-a) before surgical treatment is limited to the number of cases, and the effects are not clear.\u003c/p\u003e \u003cp\u003eThe limitation of the review lies in the rarity of the disease, resulting in data collection based only on case reports, with heterologous information from different specialties. This leads to a lack of useful data, which limits statistical analysis. Although we have carried out a lot of statistical analysis, no clear results have been obtained. However, the results of this analysis can guide us to better understand the CCC risk factors and optimal treatment of abdominal wall endometriosis.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eThe transformation of abdominal endometriosis to CCC is a rare and little-known complication, but invasive surgical resection with a safe margin in combination with lymph node dissection is still the most effective and survival treatment. The role of adjuvant therapy is still unclear, so further research is needed to assess the long-term benefits. Our case did not undergo radical hysterectomy and lymphadenectomy because there was no local, lymph node and distant metastasis, and planned follow-up radiotherapy and chemotherapy. Of course we need to long term and closely follow up to investigate if lymphatic metastasis and distant metastasis occurred, including liver, lung, brain and bone metastasis.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eCS: cesarean section; CCC: clear cell carcinoma; MRI: magnetic resonance imaging.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLiang XZ and Zeng H wrote the first draft of the manuscript, Tang Z and Liao JJ participated in the patient\u0026rsquo;s management; Liang XZ and Fan JT performed the literature review; Fan JT performed radiological diagnosis and supervised the patient\u0026rsquo;s management, critically revised the paper and gave a scientific contribution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval of the Ethics Committee of the First Affiliated Hospital of Guangxi Medical University was obtained for this study, and the patient signed informed consent form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient signed consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKocakusak A, Arpinar E, Arikan S, Demirbag N, Tarlaci A, Kabaca C: \u003cstrong\u003eAbdominal wall endometriosis: a diagnostic dilemma for surgeons.\u003c/strong\u003e\u003cem\u003eMed Princ Pract \u003c/em\u003e2005, \u003cstrong\u003e14:\u003c/strong\u003e434-437.\u003c/li\u003e\n\u003cli\u003eVan Gorp T, Amant F, Neven P, Vergote I, Moerman P: \u003cstrong\u003eEndometriosis and the development of malignant tumours of the pelvis. 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So far, about 45 cases have been reported in the literature. This paper provides a case report and literature review of clear cell carcinoma on abdominal wall surgical scar.\u003c/p\u003e\u003cp\u003eCase presentation\u003c/p\u003e\u003cp\u003eWe described the case of a 47-year-old woman reporting two lumps in the scar of abdomen. Her medical history was marked by a previous Caesarean section and two excisions of benign endometriosis nodules at the scar. Physical examination found a mass of about 6×5×5\u0026nbsp;cm on the left side of the scar with mucoid on the surface and a fixed abdominal wall mass of about 10×10×8\u0026nbsp;cm in the 2 transverse fingers under the umbilicus. Histological examination proved a clear cell carcinoma result. The patient received tumor excision and first-line chemotherapy with complete remission. A review of the literature showed that 91.3% of the cases had had a Caesarean section. Besides, approximately 34.2% of women died 5–48\u0026nbsp;months after diagnosis. The average age of women was 46.5\u0026nbsp;years and the average tumor size was 10\u0026nbsp;cm.\u003c/p\u003e\u003cp\u003eConclusion\u003c/p\u003e\u003cp\u003eThe abdominal wall mass of middle-aged women is closely related to the scar left by the previous Cesarean section and must be investigated in time and properly. Preoperative diagnosis is difficult and often incorrect, and there is no specific marker for malignant transformation. Treatment usually includes surgery, chemotherapy, and radiotherapy, but the prognosis is poor.\u003c/p\u003e","manuscriptTitle":"Is clear cell carcinoma of abdominal wall surgery scar associated with endometriosis a poor prognosis? A case report and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-01-19 20:14:55","doi":"10.21203/rs.3.rs-146993/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4451e00e-1b2b-4e89-980d-0f755e01de49","owner":[],"postedDate":"January 19th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":1902780,"name":"Oncology"},{"id":1902781,"name":"Surgery"}],"tags":[],"updatedAt":"2021-01-19T20:14:57+00:00","versionOfRecord":[],"versionCreatedAt":"2021-01-19 20:14:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-146993","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-146993","identity":"rs-146993","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}