[Surgery for advanced stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Debulking surgery is the key step of advanced stage ovarian cancer treatment with chemotherapy. The quality of surgical resection is the main prognosis factor, thus a complete resection must be achieved (grade A) in an expert center (grade B). Surgery for stage IV is possible and has a benefit in case of complete peritoneal resection (LoE3). Pelvic and aortic lymphadenectomies are recommended in case of clinical or radiological suspicious lymph nodes (grade B). In absence of clinical or radiological suspicious lymph nodes and in case of complete peritoneal resection during initial debulking surgery, lymphadenectomy can be omitted because it won't change nor medical treatment nor overall survival (grade B). Neoadjuvant chemotherapy can be proposed in case of: impossibility to perform initial complete surgical resection (grade B) ; alteration of general state or co-morbidities or elderly patient (in order to decrease morbidity and increase quality of life) (grade B); stage IV with multiple intra-hepatic or pulmonary metastasis or important ascites with miliary (grade B). In case of stage III or IV ovarian cancer diagnosed on a biopsy during prior laparotomy, a neoadjuvant chemotherapy and interval debulking surgery should be preferred (gradeC). In case of palliative surgery or peroperative impossibility to perform a complete resection, no data regarding the type of surgery to perform influencing survival or quality of life is available. Peritoneal carcinosis description before resection and residual disease at the end of the surgery should be reported (size, location and reason of non-extirpability) (grade B). A score of peritoneal carcinosis such as Peritoneal Carcinosis Index (PCI) should be used in order to objectively evaluate the tumoral burden (gradeC). A standardized operative report is recommended (gradeC).

[Part II drafted from the short text of the French guidelines entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY and endorsed by INCa. (Systemic and intraperitoneal treatment, elderly, fertility preservation, follow-up)]

Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for all high-grade ovarian or Fallopian tube cancers, stage FIGO I-IIA (grade A). After a complete first surgery, it is recommended to deliver 6 cycles of intravenous (grade A) or to propose intraperitoneal (grade B) chemotherapy, to be discussed with patient, according to the benefit/risk ratio. After a complete interval surgery for a FIGO III stage, the hyperthermic intra peritoneal chemotherapy (HIPEC) can be proposed in the same conditions of the OV-HIPEC trial (grade B). In case of tumor residue after surgery or FIGO stage IV, chemotherapy associated with bevacizumab is recommended (grade A). For BRCA mutated patient, Olaparib is recommended (grade B).

[Part I drafted from the short text of the French Guidelines entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY and endorsed by INCa. (Diagnosis management, surgery, perioperative care, and pathological analysis)]

Faced to an undetermined ovarian mass on ultrasound, an MRI is recommended and the ROMA score (combining CA125 and HE4) can be proposed (grade A). In case of suspected early stage ovarian or fallopian tube cancer, omentectomy (at least infracolonic), appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C) and pelvic and para-aortic lymphadenectomy are recommended (grade B) for all histological types, except for the expansive mucinous subtype where lymphadenectomy may be omitted (grade C). Minimally invasive surgery is recommended for early stage ovarian cancer, if there is no risk of tumor rupture (grade B). Laparoscopic exploration for multiple biopsies (grade A) and to evaluate carcinomatosis score (at least using the Fagotti score) (grade C) are recommended to estimate the possibility of a complete surgery (i.e. no macroscopic residue). Complete medial laparotomy surgery is recommended for advanced cancers (grade B). It is recommended in advanced cancers to perform para-aortic and pelvic lymphadenectomy in case of clinical or radiological suspicion of metastatic lymph node (grade B). In the absence of clinical or radiological lymphadenopathy and in case of complete peritoneal surgery during an initial surgery for advanced cancer, it is possible not to perform a lymphadenectomy because it does not modify the medical treatment and the overall survival (grade B). Primary surgery is recommended when no tumor residue is possible (grade B).

Extraperitoneal Para-Aortic Lymphadenectomy by Robot-Assisted Laparoscopy

STUDY OBJECTIVE

To evaluate the outcomes of extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy.

DESIGN

A retrospective study (Canadian Task Force classification III).

SETTING

An academic institution.

PATIENTS

Twenty-three consecutive patients with gynecologic cancer who presented for para-aortic lymphadenectomy between March 2016 and May 2017 were reviewed retrospectively.

INTERVENTIONS

Extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was performed.

MEASUREMENTS AND MAIN RESULTS

Of the 23 patients reviewed retrospectively, 10 had cervical cancer, 7 had endometrial cancer, 5 had adnexal cancer, and 1 had vaginal cancer. Data regarding patient characteristics, indication for para-aortic lymphadenectomy, type of surgery (infrarenal or inframesenteric), operative time, surgical complications, number of nodes retrieved, and postoperative hospital length of stay were collected. Two patients were excluded because of early perforation of the peritoneum. In total, 21 para-aortic lymphadenectomies were performed (16 infrarenal and 5 inframesenteric). The median skin-to-skin operating time of infrarenal extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was 170 minutes (range, 90-225 minutes), the median lymph node count was 18 (range, 11-38), and the median estimated blood loss was 50 mL (range, 10-600 mL). The median skin-to-skin operating time of inframesenteric extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was 120 minutes (range, 90-220 minutes), the median lymph node count was 10 (range, 7-19), and the median estimated blood loss was 30 mL (range, 10-100). Intraoperative complications included 1 thermal lesion of the left genitofemoral nerve, 1 thermal lesion of the left mesoureter (a ureteral stent was placed to avoid ureteric necrosis and fistula without after effect), and 1 lesion of the inferior vena cava that was sutured by robot-assisted laparoscopy. There were 2 additional cases of perforation of the peritoneum that occurred in the infrarenal group. The median hospital length of stay was 1 day (range, 0-7 days). Three patients were readmitted for symptomatic lymphocysts.

CONCLUSION

Extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy provides good visualization of the operative field without arm conflict. Still, perforation of the peritoneum and symptomatic lymphocysts are a postoperative concern.

Prospective Assessment of First-Year Quality of Life After Pelvic Exenteration for Gynecologic Malignancy: A French Multicentric Study

BACKGROUND

Pelvic exenteration remains one of the most mutilating procedures, with important postoperative morbidity, an altered body image, and long-term physical and psychosocial concerns. This study aimed to assess quality of life (QOL) during the first year after pelvic exenteration for gynecologic malignancy performed with curative intent.

METHODS

A French multicentric prospective study was performed by including patients who underwent pelvic exenteration. Quality of life by measurement of functional and symptom scales was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 (version 3.0) and the EORTC QLQ-OV28 questionnaires before surgery, at baseline, and 1, 3, 6, and 12 months after the procedure.

RESULTS

The study enrolled 97 patients. Quality of life including physical, personal, fatigue, and anorexia reported in the QLQ-C30 was significantly reduced 1 month postoperatively and improved at least to baseline level 1 year after the procedure. Body image also was significantly reduced 1 month postoperatively. Global health, emotional, dyspnea, and anorexia items were significantly improved 1 year after surgery compared with baseline values. Unlike younger patients, elderly patients did not regain physical and social activities after pelvic exenteration.

CONCLUSIONS

Therapeutic decision on performing a pelvic exenteration can have a severe and permanent impact on all aspects of patients' QOL. Deterioration of QOL was most significant during the first 3 months after surgery. Elderly patients were the only group of patients with permanent decreased physical and social function. Preoperative evaluation and postoperative follow-up evaluation should include health-related QOL instruments, counseling by a multidisciplinary team to cover all aspects concerning stoma care, sexual function, and long-term concerns after surgery.

Combined Mass Spectrometry Imaging and Top-down Microproteomics Reveals Evidence of a Hidden Proteome in Ovarian Cancer

BACKGROUND

Recently, it was demonstrated that proteins can be translated from alternative open reading frames (altORFs), increasing the size of the actual proteome. Top-down mass spectrometry-based proteomics allows the identification of intact proteins containing post-translational modifications (PTMs) as well as truncated forms translated from reference ORFs or altORFs.

METHODS

Top-down tissue microproteomics was applied on benign, tumor and necrotic-fibrotic regions of serous ovarian cancer biopsies, identifying proteins exhibiting region-specific cellular localization and PTMs. The regions of interest (ROIs) were determined by MALDI mass spectrometry imaging and spatial segmentation.

FINDINGS

Analysis with a customized protein sequence database containing reference and alternative proteins (altprots) identified 15 altprots, including alternative G protein nucleolar 1 (AltGNL1) found in the tumor, and translated from an altORF nested within the GNL1 canonical coding sequence. Co-expression of GNL1 and altGNL1 was validated by transfection in HEK293 and HeLa cells with an expression plasmid containing a GNL1-FLAG^(V5) construct. Western blot and immunofluorescence experiments confirmed constitutive co-expression of altGNL1-V5 with GNL1-FLAG.

CONCLUSIONS

Taken together, our approach provides means to evaluate protein changes in the case of serous ovarian cancer, allowing the detection of potential markers that have never been considered.

Complication-related removal of totally implantable venous access port systems: Does the interval between placement and first use and the neutropenia-inducing potential of chemotherapy regimens influence their incidence? A four-year prospective study of 4045 patients

BACKGROUND

Totally implantable venous access port systems are widely used in oncology, with frequent complications that sometimes necessitate device removal. The aim of this study is to investigate the impact of the time interval between port placement and initiation of chemotherapy and the neutropenia-inducing potential of the chemotherapy administered upon complication-related port removal.

PATIENTS AND METHODS

Between January 2010 and December 2013, 4045 consecutive patients were included in this observational, single-center prospective study. The chemotherapy regimens were classified as having a low (<10%), intermediate (10-20%), or high (>20%) risk for inducing neutropenia.

RESULTS

The overall removal rate due to complications was 7.2%. Among them, port-related infection (2.5%) and port expulsion (1%) were the most frequent. The interval between port insertion and its first use was shown to be a predictive factor for complication-related removal rates. A cut-off of 6 days was statistically significant (p = 0.008), as the removal rate for complications was 9.4% when this interval was 0-5 days and 5.7% when it was ≥6 days. Another factor associated with port complication rate was the neutropenia-inducing potential of the chemotherapy regimens used, with removal for complications involved in 5.5% of low-risk regimens versus 9.4% for the intermediate- and high-risk regimens (p = 0.003).

CONCLUSION

An interval of 6 days between placement and first use of the port reduces the removal rate from complications. The intermediate- and high-risk for neutropenia chemotherapy regimens are related to higher port removal rates from complications than low-risk regimens.

Surgery for early stage endometrial carcinoma in the obese patient

Obese patients have increased risk of developing endometrial cancer proportional to the excess in body mass index. In this review, we explored the latest information on surgical management and its adaptation to the obese condition. Mini-invasive treatments (laparoscopic, robotic, vaginal, or combinations) should be systematically considered. Prevention and active treatment of obesity seem an interesting approach to reduce incidence and severity of the disease.

Single-port or Classic Laparoscopy Compared With Laparotomy to Assess the Peritoneal Cancer Index in Primary Advanced Epithelial Ovarian Cancer

A thorough laparoscopic assessment of the abdominopelvic cavity is a crucial step in the workup of primary advanced epithelial ovarian cancer to decide whether up-front cytoreductive surgery or neoadjuvant chemotherapy is the best option for adequate management. The purpose of our study was to compare single-port laparoscopy (SPL), classic laparoscopy (CL), and laparotomy using the peritoneal cancer index (PCI). Patients treated for Fédération Internationale de Gynécologie et d'Obstétrique stage 3 or 4 epithelial ovarian cancer were included in our study when they underwent a PCI evaluation by laparoscopy followed by laparotomy for cytoreduction. According to the technique used for the "noninvasive" procedure (SPL vs CL), 2 groups were compared retrospectively. The individual records of all patients were reviewed and analyzed. From 2011 to 2014, 21 patients were assessed for PCI by SPL plus laparotomy versus 21 by CL plus laparotomy. The clinicopathological features were similar in both groups (not significant [NS]), except for performance status >0, which was more frequent in the SPL group (39% vs 6%, p = .04). Quotation of PCI was possible for all patients. Nonbrowsing areas marked 3 procedures in the SPL group and 2 procedures in the CL group (NS). The mean PCI score and the score of each region assessed by SPL and CL were comparable with the evaluation by laparotomy (NS). Completeness of cytoreduction was achieved in 78% of cases in both groups (NS). SPL and widely mini-invasive procedures seem to be effective tools compared with laparotomy to adequately assess the resectability of a peritoneal carcinomatosis using the PCI.

Robotically assisted para-aortic lymphadenectomy: surgical results: a cohort study of 487 patients

OBJECTIVES

The aim of this study was to evaluate perioperative outcomes of robotic-assisted laparoscopic para-aortic lymphadenectomy (PAL) in patients with gynecologic cancers during the learning phases of robotic surgery programs and to compare results of extraperitoneal versus transperitoneal approaches of PAL.

MATERIALS AND METHODS

This study is a retrospective multicentric study of patients who underwent robotically assisted laparoscopic PAL (N = 487). Eleven European centers and 1 US center participated in the study. Abstracted data included age, body mass index, indication, type of surgical approach (transperitoneal or extraperitoneal), associated surgical procedures, operative time, estimated blood loss, lymph node count, hospital length of stay (LOS), and complications. Para-aortic lymphadenectomy was performed by an extraperitoneal approach in 58 cases (12%) and transperitoneal in 429 cases (88%).

RESULTS

The mean (SD) para-aortic lymph node count was 12.6 (8.1), operative time was 217 (85) minutes, estimated blood loss was 105 (110) mL, and LOS was 2.8 (3.2) days. Four (0.8%) conversions to open and 2 (0.4%) conversions to laparoscopy were described. There were 32 lymphocysts (6.6%), 3 deep venous thromboses (0.6%), and 10 transfusions (2.1%). For transperitoneal approach, the average number of lymph nodes removed was higher in isolated PAL group than the hysterectomy combined group (report node counts 95% confidence interval, -7.29 to -3.52, P = 1.5 × 10⁻⁶). For isolated PAL, the LOS was shorter in the extraperitoneal group than in the transperitoneal group (report data 95% CI, -1.35 to -0.35, P = 0.001).

CONCLUSIONS

Robotic-assisted PAL seems safe and feasible. More lymph nodes were removed during an isolated transperitoneal PAL dissection compared with a combined procedure with hysterectomy. Extraperitoneal approach seems attractive relative to transperitoneal dissection, but the superiority of one or the other way is not demonstrated by our study.

Safety of adjuvant intensity-modulated postoperative radiation therapy in endometrial cancer: Clinical data and dosimetric parameters according to the International Commission on Radiation Units (ICRU) 83 report

AIM

To report a single-institution experience using postoperative pelvic Intensity Modulation Radiation Therapy (IMRT) using tomotherapy accelerators (TA) in postoperative endometrial cancer (EC) regarding ICRU 83 recommendations.

BACKGROUND

IMRT in gynecological malignancies provides excellent dosimetric data, lower rates of adverse events and clinical data similar to historical series.

MATERIAL AND METHODS

Seventy-six patients with EC were postoperatively treated with adjuvant IMRT using TA. The IMRT dose was 45 Gy for patients without positive lymph nodes and Type I histology and 50.4 Gy for patients with positive lymph nodes and/or type II histology.

RESULTS

With a median follow-up of 29 months, the 12- and 24-month Overall Survival (OS) and Disease-Free Survival (DFS) were 96%, 93%, 87%, and 74%, respectively. Age of less than 60 years was associated with better OS (HR: 8.9; CI: 1.1-68) and DFS (HR: 3.5; CI: 1.2-10.2). Patients with Type II and Type I Grade III histology had a worse OS (HR: 3.3; CI: 1.1-11). Five women (6.6%) presented in-field local vaginal recurrence, 2 (2.6%) presented non-in-field vaginal recurrence, 4 (5.2%) presented pelvic node and distant recurrence and 11 (14.4%) presented only distant metastases. One patient stopped radiation treatment due to Grade III acute diarrhea. No Grade III late toxicity was observed. Planning Target Volume (PTV) coverage showed mean D2, D50, D95, and D98 of 51.64-46.23 Gy, 49.49-44.97 Gy, 48.62-43.96 Gy, and 48.47-43.58 Gy for patients who received 45 and 50.4 Gy, respectively.

CONCLUSIONS

IMRT with TA in postoperative EC shows excellent conformity and homogeneity of PTV dose. Without Grade III late toxicity, data from this cohort demonstrated the utility of IMRT.

F14512, a polyamine-vectorized inhibitor of topoisomerase II, exhibits a marked anti-tumor activity in ovarian cancer

Epithelial ovarian cancer is the fourth cause of death among cancer-bearing women and frequently associated with carboplatin resistance, underlining the need for more efficient and targeted therapies. F14512 is an epipodophylotoxin-core linked to a spermine chain which enters cells via the polyamine transport system (PTS). Here, we investigate this novel concept of vectorization in ovarian cancer. We compared the effects of etoposide and F14512 on a panel of five carboplatin-sensitive or resistant ovarian cancer models. We assessed the incorporation of F17073, a spermine-linked fluorescent probe, in these cells and in 18 clinical samples. We then showed that F14512 exhibits a high anti-proliferative and pro-apoptotic activity, particularly in cells with high levels of F17073 incorporation. Consistently, F14512 significantly inhibited tumor growth compared to etoposide, in a cisplatin-resistant A2780R subcutaneous model, at a dose of 1.25 mg/kg. In addition, ex vivo analysis indicated that 15 out of 18 patients presented a higher F17073 incorporation into tumor cells compared to normal cells. Overall, our data suggest that F14512, a targeted drug with a potent anti-tumor efficacy, constitutes a potential new therapy for highly PTS-positive and platinum-resistant ovarian cancer-bearing patients.

A Simple Laparoscopic Procedure to Restore a Normal Vaginal Length After Colpohysterectomy With Large Upper Colpectomy for Cervical and/or Vaginal Neoplasia

Colpohysterectomy is sometimes associated with a large upper colpectomy resulting in a shortened vagina, potentially impacting sexual function. We report on a preliminary experience of a laparoscopic colpoplasty to restore a normal vaginal length. Patients with shortened vaginas after a laparoscopic colpohysterectomy were considered for a laparoscopic modified Davydov's procedure to create a new vaginal vault using the peritoneum of the rectum and bladder. From 2010 to 2014, 8 patients were offered this procedure, after informed preoperative consent. Indications were 2 extensive recurrent vaginal intraepithelial neoplasias grade 3 and 6 radical hysterectomies for cervical cancer. Mean vaginal length before surgery was 3.8 cm (standard deviation, 1.6). Median operative time was 50 minutes (range, 45-90). Blood loss was minimal (50-100 mL). No perioperative complications occurred. Median vaginal length at discharge was 11.3 cm (range, 9-13). Sexual intercourse could be resumed around 10 weeks after surgery. At a median follow-up of 33.8 months (range, 2.4-51.3), 6 patients remained sexually active but 2 had stopped. Although this experience is small, this laparoscopic modified Davydov's procedure seems to be an effective procedure, adaptable to each patient's anatomy. If the initial postoperative regular self-dilatation is carefully observed, vaginal patency is durably restored and enables normal sexual function.

Managing Endometrial Cancer: The Role of Pelvic Lymphadenectomy and Secondary Surgery

PURPOSE

In November 2010, the French National Cancer Institute published new guidelines for managing endometrial cancer. Pelvic lymphadenectomy is not indicated for preoperative low-intermediate risk type 1 endometrial cancer, and high-risk patients should undergo secondary surgery with para-aortic lymphadenectomy. This study evaluated these new guidelines with regard to overall survival (OS), relapse-free survival (RFS), and morbidity for patients with low-intermediate risk disease.

METHODS

We evaluated all type 1 endometrial cancer patients with low-intermediate risk of recurrence who were treated from 1 January 1997 through 31 December 2012. All patients were classified according to the 2009 International Federation of Gynecology and Obstetrics staging criteria and the European Society for Medical Oncology.

RESULTS

Overall, 230 patients were included (159 before and 71 after the new guidelines were issued). Pelvic lymphadenectomies were performed before and after the new guidelines in 77.4 and 28.6 % of patients, respectively (p < 0.001). After 2010, eight patients also underwent secondary surgery, which consisted of a para-aortic lymphadenectomy for lymphovascular space invasion (LVSI). This second surgery changed the adjuvant treatment for one patient. OS and RFS were similar between both groups, and no difference in morbidity was observed between the groups. LVSI was an independent factor for OS [hazard ratio (HR) 7.2, 95 % CI 3.1-17; p < 0.001] and RFS (HR 3.7, 95 % CI 1.6-8.5; p < 0.003).

CONCLUSIONS

Fewer pelvic lymphadenectomies in low-intermediate risk patients did not affect OS, RFS, or morbidity, including patients with secondary surgery. We must gather additional data with a longer follow-up period to not only confirm our results but to also fully investigate the paradoxical absence of decreased morbidity that our study has shown.

Asymptomatic pelvic metastasis from thymic carcinoma: a case report

Thymic epithelial tumors are rare and often occur somewhere local. Metastatic sites of thymic carcinomas (Masaoka-Koga stage IVb) are mostly seen in the lung, liver and brain. We report a 64-year-old female with an initial diagnosis of thymoma B3 who first showed thoracic recurrences and then an asymptomatic isolated pelvic metastasis from her thymic carcinoma.

A new laparoscopic method of bowel radio-protection before pelvic chemoradiation of locally advanced cervix cancers

BACKGROUND

Chemoradiation therapy (CRT) has become the mainstay of locally advanced cervical carcinomas (LACC). However, the price to pay is a significant rate of both early and late colo-rectal toxicities, which may impact on survivors' quality of life. To reduce the incidence of such complications, we suggest a simple technique of pelvic radioprotection.

MATERIALS AND METHODS

An omental flap is created which is placed to fill the Douglas pouch to both increase the space between rectum and uterine cervix and prevent small bowel to fall in and to be exposed to radiation. In addition, a long sigmoid loop is retracted and fixed in the left paracolic gutter to prevent its irradiation as well.

RESULTS

From May 2011 to May 2012, 51 successive LACC patients were offered this procedure in addition of a laparoscopic staging. All but 2 with too small an omentum benefitted from omentoplasty, while sigmoidopexy was performed in all but one patient with a long and free sigmoid loop. No immediate adverse effect was observed. The volume of retro-uterine omental flap averaged 7.17 ± 3.79 cm(3). Sequential measurements of the utero-rectal space throughout CRT duration showed a real and durable increase in the distance between these organs, resulting in a drop in the dose of irradiation to recto-sigmoid. With 10 ± 4.5-month median follow-up, we did not observe any rectal or small bowel early or late adverse effects of CRT.

CONCLUSIONS

Although this series is preliminary, this simple procedure, feasible by laparoscopy (or laparotomy), seems effective to prevent recto-sigmoid as well as small bowel from radio-induced complications due to pelvic CRT.

Prospective Multicenter Study Evaluating the Survival of Patients With Locally Advanced Cervical Cancer Undergoing Laparoscopic Para-Aortic Lymphadenectomy Before Chemoradiotherapy in the Era of Positron Emission Tomography Imaging

Purpose

The aim of this prospective study conducted in three French comprehensive cancer centers was to evaluate the therapeutic impact on survival of laparoscopic para-aortic (PA) staging surgery in locally advanced cervical cancer (LACC) before chemoradiotherapy.

Patients and Methods

We conducted a prospective multicenter study of 237 patients treated from 2004 to 2011 for LACC with negative positron emission tomography (PET) imaging of the PA area and undergoing laparoscopic PA lymphadenectomy. Radiation fields were extended to the PA area when PA nodes were involved. Chemoradiotherapy modalities were homogeneous across institutions. Patients with a poor prognosis histologic subtype or peritoneal carcinosis were excluded.

Results

Patients had clinical International Federation of Gynecology and Obstetrics stages IB2 (n = 79), IIA (n = 10), IIB (n = 121), III (n = 22), or IVA (n = 5). One hundred ninety-nine patients had squamous carcinoma, and 38 had adenocarcinoma/adenosquamous lesions. Twenty-nine patients (12%) had nodal involvement (false-negative PET–computed tomography [CT] results)—16 with a PA nodal metastasis measuring more than 5 mm and 13 with a nodal metastasis measuring ≤ 5 mm. Event-free survival rates at 3 years in patients without PA involvement or with PA metastasis measuring ≤ or more than 5 mm were 74% (SE, 4%), 69% (SE, 21%), and 17% (SE, 14%; P < .001).

Conclusion

To our knowledge, this is the largest series of patients reported undergoing such a strategy. We obtained the same survival rate for patients with PA nodal metastasis ≤ 5 mm and patients without PA lymph node involvement, suggesting that this strategy is highly efficient in such patients. Conversely, the survival of patients with PA nodal involvement greater than 5 mm remained poor, despite the absence of extrapelvic disease on PET-CT imaging in this subgroup.

Nodal-staging surgery for locally advanced cervical cancer in the era of PET

Chemoradiation therapy is deemed the standard treatment by many North American and European teams for treatment of locally advanced cervical cancer. The prevalence of para-aortic nodal metastasis in these tumours is 10-25%. PET (with or without CT) is the most accurate imaging modality to assess extrapelvic disease in such tumours. The true-positive rate of PET is high, suggesting that surgical staging is not necessary if uptake takes place in the para-aortic region. Nevertheless, false-negative results (in the para-aortic region) have been recorded in 12% of patients, rising to 22% in those with uptake during PET of the pelvic nodes. In such situations, laparoscopic surgical para-aortic staging still has an important role for detection of patients with occult para-aortic spread misdiagnosed on PET or PET-CT, allowing optimisation of treatment (extension of radiation therapy fields to include the para-aortic area). Complications of the laparoscopic procedure were noted in 0-7% of patients. Survival of individuals (missed by PET) with para-aortic nodal metastasis of 5 mm or less (and managed by extended field chemoradiation therapy) seems to be similar to survival of those without para-aortic spread, suggesting a positive therapeutic effect of the addition of staging surgery. Nevertheless, the effect on survival of potential delay of chemoradiation owing to use of PET and staging surgery, and acute and late complications of surgery followed by chemoradiation therapy (particularly in case of extended field chemoradiation to para-aortic area), need to be studied.

Prospective multicenter study evaluating the survival of patients with locally advanced cervical cancer (LACC) and negative positron emission tomography with computerized tomography (PET-CT) in the para-aortic area undergoing laparoscopic para-aortic (PA) lymphadenectomy before chemoradiation therapy

5083

Background: In three comprehensive cancer centers, patients with LACC were systematically staged using conventional and PET-CT imaging before chemoradiotherapy. If patients had no uptake in the PA area, laparoscopic extraperitoneal PA surgery was then performed to define radiation field limits more accurately. The aim of this study was to evaluate the therapeutic impact of this management. Methods: A prospective multicenter series of 237 patients treated from 2004 to 2011 for LACC with a negative PET-CT of the PA area and undergoing laparoscopic PA lymphadenectomy. Radiation fields were extended to PA area when PA nodes were involved. Chemoradiotherapy modalities were homogeneous between Institutions. Patients with a poor prognosis histologic subtype, peritoneal carcinomatosis or ovarian metastasis were excluded. Results: Clinical stages were IB2 (n=79), IIA (n=10), IIB (n=120), III (n=23), IVA (n=5). The histologic types were squamous carcinoma (n=197), adenocarcinoma (n=34) and others (n=6). Twenty-nine (11%) patients had nodal involvement (false negative PET-CT results): 16 with PA nodal metastasis measuring > 5 mm and 13 < 5 mm. With a median follow-up of 18 (range, 0-67) months, disease-free survival (DFS) at 2 years in patients without and with PA involvement was respectively 76% (68%-83%) and 61% (37%-80%)(p=.007). DFS at 2 years in patients without PA involvement or with PA metastasis measuring < or > 5 mm was respectively 76% (68%-83%), 89% (57%-98%) and 38% (14%-68%)(p=.0006). Conclusions: This is the largest series of patients reported undergoing such strategy. We obtained a similar survival rate for patients with PA nodal metastasis < 5 mm and patients without PA lymph node involvement suggesting that this strategy is highly efficient in such patients. Conversely, the survival of patients with PA nodal involvement > 5 mm remained poor, despite no extrapelvic disease at PET-CT imaging in this subgroup. Other treatment modalities should be evaluated for these patients.

[Study of surplus cost of robotic assistance for radical hysterectomy, versus laparotomy and standard laparoscopy]

OBJECTIVES

The study purpose was to compare the costs among robotic, laparoscopic and open radical hysterectomy for cervical cancer.

PATIENTS AND METHODS

Thirty-seven patients underwent robotic radical hysterectomy for cervical cancer. Cases were performed by three surgeons, at two institutions, and were retrospectively reviewed to perform a cost comparison between all three modalities. We included costs for edible materials in anesthesia and surgery, but costs for staff and indirect financial expenses were excluded. Those data are compared to open and laparoscopic radical hysterectomy data.

RESULTS

The average cost for robotic assistance presented a surplus of 1796 euros compare to laparotomy and 1313 euros compare to standard laparoscopy in 2008, and 1320 and 837 euros respectively.

DISCUSSION AND CONCLUSION

The average cost for radical hysterectomy was highest for robotic, followed by standard laparoscopy, and least for laparotomy. However, over only 2 years of use, this difference tends to decrease. Medico-economic impact is the main restraint for robotic assistance development, and needs to be assessed permanently.

[Clinical approach in vulvar cancer surgery]

Vulva cancer is rare. It is mainly treated through surgery. Recurrent scarring complications can prolong the period of hospitalisation. To reduce scar dihiscence, the nursing team of the Oscar Lambret Centre in Lille treats scars by negative pressure as a preventative measure. It also integrates into its clinical approach the prevention of pain and malnutrition.

Totally implantable venous access port systems and risk factors for complications: a one-year prospective study in a cancer centre

BACKGROUND

Totally Implantable Venous Access Port Systems (TIVAPS) are widely used in oncology, but complications are frequent, sometimes necessitating device removal and consequently delays in chemotherapy. The aim of this study was to investigate possible risk factors for morbidity.

METHODS

A total of 815 consecutive cancer patients (median age: 56.2 years [0.8-85.2]; 522 female) were enrolled in this observational, single-centre study between May 2nd 2006 and April 30th 2007. TIVAPS implantation involved principally cephalic or external jugular vein access. Patients were followed up for one year unless the device was removed earlier.

RESULTS

The overall morbidity rate was 16.1% (131/815). Complications necessitated device removal in 55 patients a mean of 3.7 months [0.2-12.0] after implantation. These comprised TIVAPS-related infection (19), port expulsion (14), catheter migration (6), venous thrombosis (5), mechanical problems (3), skin disorders (2), pain (2), drug extravasation (2) infection unrelated to TIVAPS (1) and inflammation (1). No patient died during the study. The factor most strongly predictive of complications was the interval between insertion and first use of the TIVAPS, ranging from 0 to 135 days (median: 8.0 days). The morbidity rate was 24.4% when this interval was 0-3 days, 17.1% when it was 4-7 days and 12.1% when it exceeded 7 days (p < 0.01; Chi(2) test). The median interval was 6 days (0-53) and 8 days (0-135), respectively, in patients with and without complications (p < 0.001).

CONCLUSION

To reduce complications, an interval of at least 8 days between placement of the TIVAPS and its first use may be advisable.

[Management of pregnant women with advanced cervical cancer: About five cases observed in Lille from 2002 till 2009. Evaluation of practices referring to the new French recommendations of 2008]

PURPOSE

An update on the management of invasive cervical cancer (from stage IB) diagnosed during pregnancy with reference to the recent French guidelines.

PATIENTS AND METHODS

We retrospectively analyzed patients for whom invasive cervical cancer was diagnosed during pregnancy and managed jointly by Jeanne-de-Flandres and Roubaix maternity and by Oscar-Lambret cancer center between 2002 and 2009.

RESULTS

Five patients were included: four stage IB1, and one stage IB2. Five pregnancies resulted in the birth of six alive children. Three patients received neoadjuvant chemotherapy during pregnancy. One patient had a laparoscopic pelvic lymphadenectomy in first trimester. Two laparoscopic extraperitoneal paraortic lymphadenectomy have been made. The mean time of survey is 47.5 months (12-94 months). One patient died of her cancer.

CONCLUSION

The diagnosis of cervical cancer during pregnancy involves the same therapeutic guidelines in the absence of pregnancy. The laparoscopic pelvic lymphadenectomy (up to 20 to 24 weeks of gestation) is crucial in the therapeutic treatment for tumors less than 4cm. Neoadjuvant chemotherapy is used during pregnancy for patients refusing medical termination of pregnancy.

Accuracy of 18-fluoro-2-deoxy-D-glucose positron emission tomography in the pretherapeutic detection of occult para-aortic node involvement in patients with a locally advanced cervical carcinoma

PURPOSE

Patients with locally advanced cervical cancer (LACC) are usually treated with concurrent chemoradiotherapy. Extended-field chemoradiotherapy is indicated in case of para-aortic node involvement at initial assessment. 18-Fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18-FDG PET/CT) is currently considered to be the most accurate method of detection of node or distant metastases. The goal of this study was to evaluate the accuracy of PET at detecting para-aortic lymph node metastases in LACC patients with a negative morphological imaging.

METHODS

Patients from five French institutions with LACC and both negative morphologic (magnetic resonance imaging, CT scan) and functional (PET or PET/CT) findings at the para-aortic level and distantly were submitted to a systematic infrarenal para-aortic node dissection either by laparoscopy or laparotomy. On the basis of pathological results, sensitivity, specificity, and positive and negative predictive values of PET/CT were assessed for para-aortic lymph node involvement.

RESULTS

A total of 125 LACC patients (stage IB2-IVA disease with two local recurrences) fulfilled the inclusion criteria. All had an ilio-infrarenal para-aortic lymphadenectomy, either by laparoscopy (n = 117) or laparotomy (n = 8). Twenty-one patients (16.8%) had pathologically proven para-aortic metastases. Among them, 14 (66.7%) had negative PET/CT. Overall morbidity of surgery was 7.2%. All but one of the complications were mild and did not delay chemoradiotherapy. Sensitivity, specificity, and positive and negative predictive value of the PET/CT were 33.3, 94.2, 53.8, and 87.5%, respectively, for the detection of microscopic lymph node metastases.

CONCLUSIONS

Laparoscopic staging surgery seems warranted in LACC patients with negative PET scan who are candidates for definitive concurrent chemoradiotherapy or exenteration.

[Twenty-two cases of uterine carcinosarcomas]

OBJECTIVES

Twenty-two uterine carcinosarcomas were treated and followed in two centers over 10 years. We wanted to describe them and review the literature on the subject.

PATIENTS AND METHODS

We describe all uterine carcinosarcomas treated in Lille, over 10 years, both in department of gynecology, Hospital Jeanne-de-Flandre (11 patients), and in department of gynecologic oncology of Centre Oscar-Lambret (11 patients).

RESULTS

For the 22 patients included, we give age at time of diagnosis, body mass index, pre and post surgical histology, details of surgical treatment, adjuvant treatment and evolution of the pathology. Mean age at time of diagnosis was 69.6. Sixty-eight percent of patients had overweight or obesity. Revealing symptoms were in 91% of cases post-menopausal meno- or metrorrhagias. Preoperatively, histology had an important number of false negative and, 57% of diagnoses were ignored in our study. All patients had first intention surgery, only 54% were yet at an early stage. Sixteen had association radiotherapy, eight of chemotherapy, two declined any adjuvant treatment. Ten patients died with a mean survival of 12.9 months, eight had a good evolution still at 35 months, two had recent pelvic relapse, two were lost to follow-up.

CONCLUSION

Uterine carcinosarcomas are rare, aggressive, yet not very well known tumors. First line treatment will be surgery with peritoneal cytology, hysterectomy, bilateral adnexectomy, pelvic and sometimes lumbo-aortic lymphadenectomy, omentectomy, peritoneal biopsies. Adjuvant chemotherapy has shown its interest in this type of tumor. Radiotherapy is still debated.

[Para-aortic lymphadenectomy in advanced-stage cervical cancer: standard procedure in 2010?]

With tumour size, node involvement is the most important prognosis factor in advanced stage cervical cancer. Para-aortic (PA) disease is observed in 15 to 30% of these patients. CT scan and magnetic resonance imaging (MRI) are not efficient enough to detect these lesions and PET CT have false negatives. Surgical staging is useful to detect carcinosis associated and to adapt therapy (radiotherapy fields are extended if PA nodes are involved). Laparoscopy was crucial to develop this staging because its morbidity associated to chemoradiotherapy is limited. If prognosis impact of PA lymphadenectomy is well established, therapeutic impact is still discussed. The systematic extension of this staging to pelvic nodes that are included in the basic radiotherapy fields is debated because it does not modify therapeutic management and is morbid. Radiotherapy progress, especially with boost and combination to MRI (MRIT), will impact on future therapeutic management.