Low incidence of port-site metastases after laparoscopic staging of uterine cancer

OBJECTIVE

To estimate the incidence of clinically detected port-site metastases (PSM) in patients with endometrial and cervical cancer treated at two gynecologic oncology services with extensive experience.

METHODS

All eligible uterine cancer patients laparoscopically staged at Centre Oscar Lambret in Lille and Institut Claudius Regaud in Toulouse, France, were reviewed. MEDLINE database was searched to identify articles on PSM after laparoscopic procedures for cervical and endometrial cancer.

RESULTS

During the study period, 1216 laparoscopic procedures for uterine cancer were performed. 921 patients underwent laparoscopic staging for cervical cancer and 295 for endometrial cancer. The overall incidence of PSM in our institutions was 0.4% per procedure (5 patients), and the incidence of PSM after laparoscopy for cervical and endometrial cancer was 0.43% and 0.33%, respectively. Excluding patients with peritoneal carcinomatosis, the rate of port-site recurrence in our series lowered to 0.16%, and the rate of isolated PSM to 0%. The median time to the development of PSM was 8 months (range 6-48), the median overall survival from diagnosis for all patients was 26 months (range 7-30), and median survival from recurrence was 5 months (range 1-20).

CONCLUSION

Although PSM is recognized as a complication of laparoscopy for ovarian cancer. PSM is a rare complication of laparoscopic staging for endometrial and cervical cancer. The majority of patients with PSM presented with associated synchronous disease. The incidence of isolated PSM can be maintained virtually to 0% by an adequate operative technique. We believe that PSM in patients with uterine cancer cannot be used as an argument against laparoscopic staging in uterine cancer.

[Are there still contra-indications to laparoscopic treatment of endometrial carcinoma?]

Laparoscopic treatment is becoming a standard of care for early endometrial carcinoma. However, not all patients are suitable for this approach. A review of the current literature provides some arguments to differentiate absolute contra-indications from relative ones, for which, whenever possible, some options are suggested.

Modified posterior pelvic exenteration for ovarian cancer

INTRODUCTION

A modified posterior pelvic exenteration (MPE) might be needed to reach an optimal tumoral reduction. The issue of this study is to relate a multicentric experience of this kind of resection.

MATERIALS

Three hundred five patients who needed an MPE were analyzed from 9 French cancer centers. One hundred sixty-eight MPEs were performed during initial surgery (55.1%), 69 during interval surgery (22.6%), 36 after chemotherapy (11.8%), and 32 for recurrences (10.5%).

RESULTS

Three hundred two colorectal anastomoses were realized with a protective stoma in 59 (19.5%) of cases and a stoma closure in 76.5% (51). The rate of functional anastomosis was 96% (290/302). Complications occurred in 26.9% (82/305) of the patients, with a fistula in 25 (8.2%). The reintervention rate was 8.8% (27/305). The median length of hospitalization was 15 days. The absence of a macroscopic residual disease was obtained in 58% (173/303) of cases. A residual disease that was 1 cm or smaller was observed in 73 cases (24%) and 2 cm or smaller observed in 36 (11.9%). Postoperative chemotherapy was started with a median time of 32 days.Postoperative death occurred in 1 patient (0.33%). The survival rates were 62.7% and 27.6% at 2 and 5 years, respectively. With a multivariate analysis, the 2 significant prognostic factors were residual disease and time of surgery (P < 0.0001).

CONCLUSIONS

A rectal invasion should not be an obstacle to reach the aim to obtain a macroscopic minimal residual disease or, if possible, the absence of one. An MPE is useful in those cases to reach optimal cytoreduction, with comparable results whatever the patient's age is. A temporary protective stoma should be considered only exceptionally.

Evaluation of the Edmonton Symptoms Assesment Scale (ESAS) symptoms improvement (SI) assessment as a prognostic factor for survival in advanced cancer patients (pts) undergoing palliative care (PC): An observational prospective study

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Background: ESAS is a validated tool for physical symptoms assessment in PC practice which evaluates symptoms through a numeric scale ( 0–10). The use of SI as a prognostic factor is controversial. To this purpose, an observational prospective study in advanced cancer pts previously treated with anti-cancer treatments and now undergoing only PC was conducted. Methods: Pts were considered eligible if no longer able to receive any anticancer treatment; they were scheduled to undergo ESAS assessment: 1) at the hospitalization time-point (TH); 2) at the hospital discharge time-point (TD). Symptoms’ scores were divided into 3 severity-classes (SC): mild (0–3, MI), moderate (4–6, MO) and severe (≥7, S). Differences across symptoms’ classes between TH and TD was analyzed with the paired-data McNemar-test, according to tumor types. KM method was used for survival calculation, according to ESAS score classes, and logrank test for curves comparison. Uni/multi-variate survival analysis including age, sex, tumour, symptoms number and score class, PaP (Palliative Prognostic)-score, KPS, were carried out using the Cox regression model. Results: ESAS was administered to 68 pts, gastrointesinal (GI)/lung (NSCLC): 39/29, median age: 69-yrs, KPS ≤50/>50: 27 (39.7 %)/ 41 (60.3%), PaP-score A/B/C: 26 (38.2%)/37 (54.4%)/C (7.4%). A statistically significant reduction of S-SC rates was observed, as shown in the Table . SI correlates with survival improvement: PaP score (HR 2.95, 95% CI 1.35–6.41, p=0.006) and anorexia (HR 3.21, 95% CI 1.33–7.72, p=0.009) appear to be prognostic factors for survival at the multivariate analaysis for GI pts; asthenia is the only significant variable (HR 5.11 CI 95% 1.86–14.03, p=.0.002) for NSCLC pts. Conclusions: SI according to ESAS after PC treatment represents an important prognostic factor for survival in pts no longer suitable to receive any anticancer active therapies. [Table: see text]

No significant financial relationships to disclose.

Early experience of robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein

OBJECTIVE

To describe our early experience with robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein, including Da Vinci robot positioning.

METHODS

Six patients underwent robotic-assisted laparoscopy using the Da Vinci apparatus. The patients included a man with a pT2 non-seminomatous germ cell tumour of the left testicle treated by chemotherapy with an incomplete response (mature teratoma), four women with locally advanced cervical cancer, and one case of bulky cancer of the vaginal cuff. The procedure was carried out using four port sites: one for the camera, one each for the no. 1 and no. 3 arms of the Da Vinci robot system, and one for the assistant.

RESULTS AND CONCLUSION

Robotic-assisted lymphadenectomy carried out using the Da Vinci system was safe and effective with a short learning period for an experienced oncological team. A larger prospective study is now required to evaluate this procedure further.

[Robotic assistance in gynaecological surgery: State-of-the-art]

From the Automated Endoscopic System for Optimal Positioning (AESOP), a robotic arm which operates the laparoscope, to the robots Zeus and da Vinci, robotic assistance in gynaecological endoscopic surgery has continuously evolved for the last fifteen years or so. It has brought about new technical advancements: the last generation robots offer a steady three-dimensional image, improved instrument dexterity and precision, higher ergonomics and comfort for the surgeon. The da Vinci robotic system has been used without evincing any specific morbidity in various cases, notably for tubal reanastomosis, myomectomy, hysterectomy, pelvic and para-aortic lymphadenectomy or sacrocolpopexy amongst others. Robotic assistance in gynaecology is thus feasible. Like conventional laparoscopic surgery, it allows decreased blood loss and morbidity as well as shorter hospital stay, as compared to laparotomy. It might indeed allow many surgical teams to perform minimally invasive surgical procedures which they were not used to performing by laparoscopy. Randomized prospective studies are needed to define its indications more precisely. Besides, its medico-financial impact should be evaluated too.

Therapeutic value of pretherapeutic extraperitoneal laparoscopic staging of locally advanced cervical carcinoma

BACKGROUND

Although cervical cancer is clinically staged, surgery has long been considered the best means to assess extrapelvic disease and remains the gold standard for the detection of both intraperitoneal spread and small volume nodal metastases. The objective of this study was to determine short- and long-term outcomes for patients with locally advanced cervical cancer who underwent pretherapeutic laparoscopic staging.

METHODS

From 1997 to 2004, 184 patients with stages IB2-IVA cervical cancer underwent pretherapeutic laparoscopic staging procedure including transperitoneal abdomino-pelvic exploration and extraperitoneal bilateral infrarenal paraaortic lymph node dissection. Patients were then treated with definitive radiotherapy tailored according to the staging results.

RESULTS

The median age and BMI were respectively 45.8 years old and 27.1 kg/m2. Most lesions were squamous (n=172) and clinical stage was evenly distributed. Median operative time was 155 min with an average of 20.8 lymph nodes removed. Postoperative hospital stay averaged 1.4 days. Major complications included 1 intraoperative ureteral injury and 1 postoperative bowel obstruction from an umbilical trocar site hernia. The final pathology revealed that 44 patients (24.3%) had metastatic disease within paraaortic lymph nodes. With a median follow-up of 26.8 months (average 32.9), 67 patients (36.4%) had recurrent disease. Overall 5-year survival rate was 58.3%. Successful resection of positive lymph node correlated with a survival advantage.

CONCLUSIONS

Pretherapeutic laparoscopic assessment of patients with locally advanced cervical cancer offers valuable information for individualized treatment planning with minimal morbidity. This appears to be a therapeutic effect with resection of positive nodes followed by a tailored chemoradiation therapy.

[Malignant ovarian germ cell tumours: a trial of 36 cases]

OBJECTIVE

With personal results and a review of the literature, we report the eventual interest of surgical staging in malignant ovarian germ cell tumours.

PATIENTS AND METHODS

This was a retrospective study of 36 patients (21.5-[8-61]) with malignant ovarian germ cell tumours between January 1984 and December 2004. There were 4 groups: no 1--dysgerminoma only, no 2--immature teratoma, no 3--malignant ovarian germ cell tumours with secretion. All the patients had a minimal follow up of 18 months after treatment. We reported conservative or non-conservative surgery, if surgical staging was made and description of eventual neoadjuvant or adjuvant chemotherapies and finally the recurrences and deaths.

RESULTS

Stages of FIGO were: group 1--IA n=2, IC n=2, IIB n=1, IIIA n=2, IIIC n=3; group 2--IA n=3 (G1, G2, G2), IC n=1 (G3); group 3--IA n=8, IC n=4, IIA n=1, IIIA n=1, IIIB n=3, IIIC n=5. Three patients had neoadjuvant chemotherapy. All the patients had cytoreductive surgery (conservative surgery n=31) with staging in 15 cases. Twenty-six patients had adjuvant chemotherapy. Five years global survival was 92%.

DISCUSSION AND CONCLUSION

Surgery in a young patient with malignant ovarian germ cells tumours must be conservative (adnexectomy) (preserving fertility and because of good prognostic). In case of stage IA with part of dysgerminoma and/or immature teratoma and/or embryonal carcinoma certified by surgical staging, strict follow up could be organized (clinic, radiology, AFP, HCG). In case of more than stage IA, chemotherapy is indicated after conservative surgery and surgical staging.

[Laparoscopic management of occult cervical cancer discovered after simple hysterectomy]

OBJECTIVES

To assess the feasibility and morbidity of surgical management by combined laparoscopic and vaginal approach after cervical cancer diagnosed at the time of simple hysterectomy.

PATIENTS AND METHODS

From 2000 to 2005, 10 patients were referred with occult cervical cancer discovered after simple hysterectomy. All these patients had laparoscopy for surgical staging.

RESULTS

Eight on ten patients had complete laparoscopic staging: pelvic lymphadenectomy (N=8), radical colpectomy (N=5). Operative time, pelvic lymph nodes resected, postoperative stay were respectively 261.3 minutes (200-400), 27 (23-38), 4.4 days. There were 2 symptomatic lymphocysts. Pelvic lymph nodes were positive for 1 patient with negative paraaortic nodes. Residual disease was present in 2 cases: 1 parametrial and vaginal involvement, 1 ovarian metastasis. 5 patients had adjuvant treatment: 2 combined pelvic external radiotherapy and brachytherapy, 1 pelvic external radiotherapy, 1 pelvic concurrent chemoradiation and 1 brachytherapy only. Two on ten patients needed a laparoconversion, one for ovarian involvement and one for technical failure. With a median follow-up of 29.7 months (4-63), 3 patients recurred. 3 patients recurred above 5 patients with pelvic lymphadenectomy but without parametrectomy versus no recurrence above 5 patients with pelvic lymphadenectomy and parametrectomy.

DISCUSSION AND CONCLUSION

Surgical staging of occult cervical cancer discovered after simple hysterectomy is necessary for indication of adjuvant treatment. Laparoscopy combined with vaginal surgery is feasible and safe, inducing fewer adhesions which is important for adjuvant radiotherapy. The realization of a radical parametrectomy seems to offer a local control of the disease and a decrease in the risk of recurrence, which need to be confirmed by conducting a study with more patients. This emphasize the necessity of creating a national record to register all women managed for occult cervical cancer.

Is systematic scalene node biopsy in pretreatment evaluation of locally advanced cervical carcinoma necessary?

OBJECTIVE

Cervical carcinomas mainly spread via lymphatics, stepwise from pelvic to aortic and scalenic lymph nodes. Metastatic nodes are the major prognostic factor in this disease. When scalenic nodes are involved, cervical cancer is considered to be disseminated. Since there is a major discrepancy in reported percentages of metastatic scalene nodes in the literature (0 to 50%), we proceeded to systematic pretreatment scalene node biopsy and then evaluated the validity of this procedure.

METHODS

From January 1998 to May 2003, 72 patients with locally advanced cervical carcinoma and no suspicious paraaortic or scalenic nodes (respectively on magnetic resonance imaging and clinically) had a systematic surgical pretreatment lymph node evaluation (retroperitoneal laparoscopic infrarenal paraaortic lymph node dissection and left scalenic lymph node biopsy). Scalene biopsy was examined using hematoxylin/eosin stain and immunohistochemistry (KL1 antibodies).

RESULTS

Among the 72 patients, 20 were stage IB2, 4 were IIA, 14 were IIB, 4 were IIIA, 27 were IIIB, 1 was IVA and 2 had a recurrent cervical carcinoma. Fourteen women had histologically confirmed paraaortic metastases (11 macroscopic, 3 microscopic). No metastatic involvement of the scalene nodes was detected. Fifteen patients developed a recurrence within 12 months (3 to 19 months). None of the patients developed scalenic recurrence.

CONCLUSION

Left scalene node biopsy does not appear to be mandatory in routine pretherapeutic lymph node evaluation of patients with advanced cervical carcinoma and no clinical suspicious nodes. It may be useful to prove disseminated disease in patients with suspicious clinical nodes or hot spots on PET-scan, if fine needle biopsy is unconclusive.

Audit of preoperative and early complications of laparoscopic lymph node dissection in 1000 gynecologic cancer patients

OBJECTIVE

Establish the reliability and safety of minimal invasive surgery in gynecologic oncology in a large-scale study. Estimate the complication rate on a large sample size.

STUDY DESIGN

From December 1998 to November 2004, 1000 gynecologic cancer patients underwent pelvic and/or aortic lymphadenectomies by laparoscopy. A total of 1192 pelvic and aortic lymphadenectomies have been performed: 777 pelvic (757 transperitoneal, 20 extraperitoneal) and 415 aortic lymphadenectomies (155 transperitoneal, 260 extraperitoneal). Main indications for laparoscopic lymph node dissection were: early cervical carcinoma (n = 456), advanced cervical carcinoma (n = 219), vaginal carcinoma (n = 4), endometrial carcinoma (n = 182), and ovarian carcinoma (n = 139). Surgical laparoscopic management via laparoscopy was achieved during the same operative session in 372 patients.

RESULTS

No lethality occurred. Thirteen open surgeries (1.3%) were required as a result of failure to complete a satisfactory laparoscopic procedure. Intraoperative, early postoperative complication rate, and lymphocyst formation rate were 2.0%, 2.9%, and 7.1%, respectively. A laparotomy was required for complication in seven patients (7 per 1000), including five returns to operating room. Eleven significant intraoperative vascular injuries occurred, but none required a laparotomy. The most frequently encountered visceral complications were bowel complications (n = 7), urinary tract complications (n = 5), and nerve injuries (n = 5).

CONCLUSION

Evidence is given on a large series that laparoscopic lymph node dissection is safe. Laparoscopic surgery may be considered as the gold standard of assessment of the status of regional lymph nodes in gynecologic malignancies.

Laparoscopic staging of early ovarian carcinoma

PURPOSE OF REVIEW

A European randomized trial on early stage ovarian cancer confirmed the importance of accurate staging to select candidates for adjuvant chemotherapy. Since early-stage disease is often discovered incidentally, staging is not always carried out or inadequately performed at the time of primary surgery. Laparoscopy was reported more than 10 years ago as a method of performing the staging procedure while avoiding the morbidity from a classical midline incision.

RECENT FINDINGS

Several teams have recently published their results on laparoscopic staging. Updated results of an earlier series in addition to other recent studies are discussed. All highlight the advantages and limits of the method.

SUMMARY

Complete laparoscopic management seems feasible in selected cases of apparently early stage ovarian cancer. Re-staging procedures remain an ideal indication for laparoscopy in early adnexal carcinomas. Due to the critical nature of the information obtained, this approach should only be reserved for teams trained in advanced laparoscopy.

[Laparoscopic surgery in gynaecological tumors]

The use of laparoscopic staging and/or surgery in the field of gynaecological oncology was pioneered in the late 80's and the first reports were published in the early 90's. The issue has been initially most controversial, and is still debated, with some justification considering the possible adverse consequences of surgical mismanagement of gynaecologic malignancy. Since then, a number of papers have confirmed the absence of significant adverse effects on survival after laparoscopic diagnosis or surgery in gynaecological cancers. New developments cover virtually all the basic techniques in cancer surgery, including major exenterative surgery. The use of extraperitoneal technique for aortic dissections is emerging as a new tool. New indications, such as radical vaginal trachelectomy (Dargent operation), radical parametrectomy, pelvic sentinel node identification, decisional laparoscopy in adnexal malignancies, or the use of pretherapeutic surgical staging of uterine cancers, have been developed in direct relation with the use of laparoscopic techniques. Worldwide interest clearly demonstrates that laparoscopic techniques must now be part of the armamentarium of the gynaecologic oncologist. Postoperative morbidity and recurrence risk do not seem to be affected. Cost-efficiency of laparoscopic procedures is based on the reduction of hospital stay and recovery time, particularly in obese patients. Combined training in gynaecologic oncology and in laparoscopic and/or vaginal surgery is more than ever mandatory to reduce the operating time, which is becoming similar to laparotomy in experiences hands, and avoid the risk of inadequate staging or management of pelvic malignancies.

Advanced ovarian carcinoma: Which place for neoadjuvant chemotherapy?

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Background: Most patients with ovarian carcinoma are diagnosed at an advanced stage. The ability to surgically resect tumor to microscopic residual disease remains a major prognostic factor. The use of a preoperative chemotherapy for patients with bulky disease is still debated. The objective of this study was to evaluate this therapeutic sequence. Methods: We retrospectively collected data from 207 stage III ovarian cancer patients between January 1998 and August 2004. 127 patients were considered as poor surgical candidates and received neoadjuvant chemotherapy. After 3 courses of a platinum-based chemotherapy, 51 patients who showed a good response by CA125 and CT scan underwent an interval debulking surgery (Group A). For the 43 patients with a partial response or stable disease, 3 other cycles of the same protocol were administered, followed by a secondary surgery (Group B). The remaining 33 patients progressed and had no surgery (GroupC). Results: Optimal tumor debulking (residuum <1 mm) was achieved in 90% and 81% of group A and B patients respectively. Node involvement was not different between the two groups (62%). After a median follow-up of 20.8 months, 98 patients had relapsed and 54 had died. Median OS was 42 months, 37.2 months and 14.4 months for group A, B and C respectively. Three-year OS was 76.7% for group A vs. 50.9% for group B (p = 0.11). Two-year disease free survival was not statistically different for groups A and B (17.3% and 18.5%). In the combined A and B sub-group, univariate analysis for OS showed non-optimal staging according to EORTC criteria (p = 0.005), post-surgical residuum (p = 0.02) and lack of lymphadenectomy (p = 0.01) as adverse prognostic factors. On multivariate analysis, only non-optimal staging remained significant. Conclusions: Neoadjuvant chemotherapy is feasible. We believe the difference in overall survival between groups A and B was likely due to a higher chemosensitivity for group A. Our results support the importance of an optimal surgical staging and the possible therapeutic role of routine lymphadenectomy.

No significant financial relationships to disclose.

[Endometrial cancer by laparoscopy and vaginal approach in the obese patient]

To prove feasibility of laparoscopic and vaginal surgical approach in obese patients with endometrial cancer, 81 patients were included retrospectively in 2 Cancer Centres : 41 obese and 40 non obese. We performed hysterectomy with oophorectomy and pelvic lymphadenectomy by laparoscopic and vaginal approach. Operative time was higher for obese patients vs non obese (150 vs 121 minutes, p = 0.01) but pelvic nodes (16.3 vs 16.2), postoperative stay (3.8 [2-8] vs 3.6 days [2-7]), complications and disease-free survival (93 % vs 83 %) were similar. Matching 41 obese patients treated by laparoscopy with 29 obese patients with endometrial cancer treated by laparotomy, hospital stay was shorter in the laparoscopic group (3.8 [2-8] vs 7.4 days [5-10] p < 0.001) and pelvic nodes (16.3 [3-50] vs 11.5 [2-34]), operative time (149.9 [80-300] vs 167.9 minutes [60-390]) and disease-free survival (93 vs 80 %) were similar. One patient treated by laparotomy never received intended radiotherapy because of a delay greater than 3 months caused by cutaneous necrosis. For obese patients with stage I endometrial adenocarcinoma, laparoscopic approach should be first choice because of similar operative complications and pelvic nodes, shorter hospital stay and less abdominal wall morbidity associated with lower risk to delay adjuvant radiotherapy.

[What is new in the surgical treatment of pelvic gynecologic cancers?]

General tendency of modern cancerology is the research of adequacy between extent of disease and treatments. This concept is of course valid for gynaecology and we saw these last months the promising results of fertility-sparing surgery: in initial cervical cancers and in ovarian cancer with good prognosis. Actual Studies should define a clear attitude in patient less than 40 with initial endometrial cancer. At the same time, the development of laparoscopic surgery has continued in cervical cancer staging. If use of sentinel node in endometrial or vulvar cancers remains discussed as for its reliability, importance of staging was stressed for cervical cancer and initial ovarian cancer. Laparoscopic surgery is confirmed in patient at risk with endometrial cancer but it is necessary to stress efforts of French teams which still push back the technical limits of laparoscopic approach like pelvic exenteration or intra-peritoneal chemohyperthermia in advanced ovarian cancer. The adventure continues....

Complications des lymphadénectomies cœlioscopiques en oncologie gynécologique : 1102 interventions chez 915 patientes

OBJECTIVE

Evaluate complications of pelvic and para aortic laparoscopic lymphadenectomies in oncologic gynaecology to confirm the surgical approach and include it in current therapy.

PATIENTS AND METHODS

From December 1998 to March 2004, 915 patients underwent pelvic and/or aortic lymphadenectomies by laparoscopy. Among them, 771 were operated on at the centre Oscar-Lambret (Lille, France), whereas 144 underwent surgery at the institut Claudius-Regaud (Toulouse, France). Laparoscopic lymphadenectomies could be indicated along with other procedures in 98 early adnexal carcinomas, in 237 cervical carcinomas and 216 locally advanced cervical carcinomas. It may also be included as part of cancer therapy with (radical) hysterectomy/trachelectomy in 161 endometrial and 203 up front surgical cervical carcinomas.

RESULTS

A total of 1102 pelvic and aortic lymphadenectomies have been performed: 714 pelvic (694 trans peritoneal, 20 extra peritoneal) and 388 aortic lymphadenectomies (154 transperitoneal, 234 extraperitoneal). Seventeen open surgeries (1.85%) were necessary for technical reasons or complications.

DISCUSSION AND CONCLUSIONS

Laparoscopic lymphadenectomies are safe and accurate with no more complications than by laparotomy and no death up to now.

Chirurgie initiale ou d'intervalle dans les cancers de l'ovaire de stade avancé ? État de la question en 2004 et critères de sélection des patientes

The management of advanced stage ovarian cancer has been deeply modified over the last few years. In patients with massive peritoneal spread, the use of neoadjuvant chemotherapy, followed by interval surgery, reduces the morbidity of radical surgery with an improvement of the quality of life. Nevertheless, results of ongoing randomized studies should be waited before stating about the results on survival of such management compared to initial debulking surgery. Waiting such results, the standard treatment of advanced stage ovarian cancer in 2005 remains initial surgery, performed in order to obtain ideally a total resection of all macroscopic diseases, and followed by adjuvant chemotherapy. However, in patients with massive spread, interval debulking surgery is becoming an interesting option, and will perhaps become a standard management. But criteria to select patients between initial and interval debulking surgery should be clearly defined. Those different points will be studied in this paper.

[The role of laparoscopy in ovarian carcinoma]

Diagnostic laparoscopy is a standard in the surgical management of adnexal masses, and is a tool in the diagnosis of early ovarian cancers. On the other hand, there are a lot of limitations to the use of laparoscopic surgery in the management of early ovarian cancer, and open surgery remains a standard. Laparoscopic surgery is used in there assessment of inadequately staged apparently early ovarian cancers. In the case of obviously advanced ovarian cancer, laparoscopic examination may help to decide whether to propose upfront surgery or neoadjuvant chemotherapy. Laparoscopy may also be used in the follow up of previously treated patients. Prophylactic oophorectomy is routinely performed using laparoscopic surgery.

Laparoscopic restaging of early stage invasive adnexal tumors: a 10-year experience

Surgical staging of apparent early stage adnexal carcinoma provides indispensable information. A significant number of patients are referred to tertiary centers with inadequate staging information. We report on our experience with late results of laparoscopic restaging procedure in uncompletely managed early adnexal carcinomas.

MATERIALS AND METHODS

From 1991 to 2001, 53 laparoscopic restaging operations were performed: 42 patients were restaged early after initial surgery for an ovarian carcinoma (OC) in 35 of them, and for fallopian tube carcinomas (FTCs) in 7 others. Eleven patients were assessed as a second-look procedure, after six courses of platinum-based chemotherapy indicated for a high-risk tumor. The procedure systematically followed the guidelines of laparotomy.

RESULTS

All except one (adhesions) procedures were successfully completed. Operative room time averaged 238 min and hospital stay 3.1 days. Only one major complication required laparotomy (1.8%). In the primary restaging group, eight patients were upstaged (19%) and were given chemotherapy. After a 54-month median follow-up, 3 out of the 34 remaining patients diagnosed as stage IA grades 1-2 (6.4%) recurred and died. In the group of 11 second-look operations, 4 were found positive after chemotherapy. One of the positive patient recurred and died.

CONCLUSIONS

Laparoscopy seems to be an acceptable technical option to perform restaging of apparently early adnexal carcinomas. It spares the patients the discomfort of repeat laparotomy. Long-term outcome results suggest that laparoscopic staging, provided it meets the standards, accurately detects the patients who need chemotherapy and safely select the patients who can be proposed surgery only.

[Endometrioid adenocarcinoma arising from adenomyosis. A case report and literature review]

In spite of many references to carcinoma arising from endometriosis, there are few documented cases in the literature of endometrioid adenocarcinoma developed in association with adenomyosis. We report a case of endometrioid adenocarcinoma arising from adenomyosis. Carcinogenic and prognostic factors as well as the therapeutic consequences of this unusual situation are discussed. The use of hormonal replacement therapy by patients with a prior history of adenomyosis is also examined.

Comparaison des adhérences postopératoires après lymphadénectomies para-aortiques par laparotomie avec versus sans Intergel

INTRODUCTION

Advanced cancers of the cervix are treated by external radiotherapy within range limits which depend on the para-aortic ganglion metastases found during surgical staging. The presence of postoperative intraperitoneal adhesions increases the risk of postradical enteritis. The aim of this study is to investigate the efficacy of an anti-adhesive substance (Intergel) undergoing para-aortic lymphadenectomy by laparotomy.

MATERIALS AND METHODS

We conduced a prospective, randomized study on 60 pigs divided into 2 groups (with and without Intergel) undergoing para-aortic lymphadenectomy by laparotomy to compare the efficacy of an anti-adhesive substance using an adhesion scoring system based on density and surface area in question.

RESULTS

There was no difference between the 2 groups in terms of duration of surgery, number of ganglia removed, postoperative mortality and per and postoperative morbidity, especially the adhesion process.

CONCLUSION

Administration of an anti-adhesive substance such as Intergel does not reduce the adhesion process after para-aortic lymphadenectomy in animals. However, perhaps we can not interpret these results because of the too much quantity of anti-adhesive substance for the animal weight, and because of the too precocious control.

[Lymph node dissection in the surgical management of stage I endometrial carcinomas]

The indication and extent of lymph node dissection in the surgical management of endometrial cancers remain highly controversial. Randomized studies are badly needed but will probably lack for the next years, considering the large sample size required to show a small difference in survival. The trend towards a reduction in the routine use of external radiation therapy weakens the argument that radiation therapy makes adequate lymph node dissection useless. The balance stays between the risk for node involvement and the expected complications rate of the procedure. Lymph node dissection is advised whenever there is a non-negligible risk of node metastasis in a patient at low surgical risk.

[Dynamic MRI in the assessment of surgical results in genital prolapse: report of a case]

We wish to discuss the importance of MRI in association with the clinical pelvic examination for the study of vaginal prolapse, especially for the posterior compartment (rectocele, elytrocele). The increased sensitivity of static and dynamic MRI allowed a clinico-radiology relation more exactly for the study of prolapse. We describe a clinical observation where the RMI used before and after surgery is more reliable than the only clinic examination.

Prospective evaluation of surgical staging of advanced cervical cancer via a laparoscopic extraperitoneal approach

OBJECTIVES

To report on a large series of cervical cancer patients at risk for lymph node metastasis who underwent surgical staging by a novel technique.

METHODS

Between 1/97 and 3/02, we identified 111 patients who underwent an infrarenal aortic and common iliac lymph node dissection via a laparoscopic extraperitoneal approach for either bulky or locally advanced cervical cancer. We reviewed the medical records and extracted pertinent information.

RESULTS

There were no intraoperative complications. Mean patient age was 46 (+/- 9) years. Mean node count was 19 (+/- 12). Thirty (27%) patients had lymph node metastasis. The mean operative time was 157 (+/- 46) min, and mean postoperative stay was 2 days. The majority of complications in the early part of the series were symptomatic lymphoceles. Since 4/01, preventive peritoneal marsupialization has been performed without lymphocele occurrence (37 patients). Two patients (2%) required reoperation. In the node-positive group, extended-field radiation and chemotherapy were well tolerated, but prognosis was dismal (median survival, 27 months). In the node-negative group, the median survival after pelvic radiation limited to the lower level of the surgical dissection was not reached after an average follow-up of 16.6 months.

CONCLUSIONS

This novel technique is feasible and combines the benefits of laparoscopy with those of a retroperitoneal approach. It can be used to tailor external radiation therapy. The benefits of extended-field radiation therapy remain unclear; however, this approach does not preclude later use of radiation therapy, whereas possibly minimizing associated toxicities secondary to adhesions.

[Endometrial cancer: what's new?]

OBJECTIVES

New and much debated data of the endometrial cancer concerning the preoperative assessment of myometrial invasion, the surgical staging, and the adjuvant treatment.

PATIENTS AND METHODS

Medline (1998-2002): searching for "endometrial carcinoma".

RESULTS

The pap smears are useful when it is difficult to have a transvaginal ultrasonography or an MRI. We can perform the pap smears and the endometrial biopsy in the clinic. If a patient has pap smears with malignant cells or elevated preoperative CA 125, it probably is a cancer with poor prognostic factors. Surgical staging with abdominal and node evaluation is necessary. The MRI seems to be the best preoperative imaging because we have information about adnexal and abdominal metastases, pelvic or aortic nodes and the invasion of the myometrium. So it gives us information on the surgical route, and provides indication for a lymphadenectomy. The surgical staging is a part of the treatment of the endometrial cancer: an exploration of the peritoneal cavity, a pelvic lymphadenectomy, a para-aortic lymphadenectomy if the pelvic nodes are positive or if there are factors of bad prognosis (deep stage IC, grade 3, adnexal or abdominal involvement, serous carcinoma of the endometrium). It can be performed if technical conditions are correct. The adjuvant teletherapy in the documented stage IpN0 (surgical staging with pelvic lymphadenectomy) does not seem to be necessary. But we can perform an adjuvant brachytherapy (high-dose rate if it is possible) in patients with a high local recurrence (stage IC, stage I with grade 3, stage IB grade 2).

CONCLUSION

The preoperative MRI is useful choosing the surgical approach, and the depth of the myometrial invasion, which can be an indication for a pelvic lymphadenectomy. The surgical staging must be a part of the treatment of the endometrial cancer. So the adjuvant teletherapy in patients with stage IpN0 documented should not be used.

Long-term results of the Burch procedure combined with abdominal sacrocolpopexy for treatment of vault prolapse

The aim of the study was to determine the long-term results of Burch procedures combined with vault prolapse repair by abdominal sacrocolpopexy. Between 1986 and 1997 82 women (mean age 46.0 years, range 27-79) underwent sacrocolpopexy combined with a Burch procedure. All patients presented with urinary incontinence and vault prolapse. The surgery consisted of a Burch procedure using non-absorbable suture material, and abdominal sacrocolpopexy with a non-absorbable mesh. The mesh was placed anteriorly and posteriorly in 66 cases, posteriorly (rectovaginal) in 12, and anteriorly (vesicovaginal) in 4. Additional procedures included hysterectomy (34 cases), enterocele repair (79 cases), and posterior repair with perineorrhaphy (65 cases). Failure was defined as the presence of persistent or worsened postoperative stress urinary incontinence (SUI). At a mean follow-up of 86 months (range 24-133) 34% (28/82) of patients were dry, and another 46% (38/82) were improved compared to their preoperative status. The postoperative SUI rate (persistent, worsened) after the placement of a single anterior mesh (4 failures out of 4) was higher than the postoperative SUI rate after combined meshes (41 failures out of 66) (log rank P = 0.05). All the patients with a history of prior surgery had worsened or persistent stress urinary incontinence (7/7), but 63% (47/75) of those with no prior surgery for stress urinary incontinence had worsened or persistent stress urinary incontinence (log rank P = 0.01). One case of recurrent rectocele was observed (after 20 months) and treated by transvaginal Richter sacrospinous fixation. At a mean follow up of 7 years, the Burch procedure combined with abdominal sacrocolpopexy appears to be less effective than previously published long-term results for the Burch procedure alone.

Vaginal evisceration after hysterectomy: the repair by a laparoscopic and vaginal approach with a omental flap

BACKGROUND

Vaginal evisceration is generally repaired by vaginal or abdominal route. We describe two cases of vaginal evisceration using a combined laparoscopic and vaginal approach employing an omental flap.

CASES

Case 1: A radical abdominal hysterectomy was performed in a premenopausal patient for a FIGO IB1 cervical cancer. Four months later, she was found to have a vaginal cuff dehiscence which was repaired by a vaginal approach. Two months later, she had a vaginal cuff evisceration which was repaired using a combined laparoscopic and vaginal approach employing an omental flap with good success. Case 2: A postmenopausal woman who underwent an abdominal hysterectomy and pelvic lymphadenectomy for a FIGO IB endometrial cancer was noted to have a vaginal evisceration two months after primary surgery. This was also successfully repaired using a combined laparoscopic and vaginal approach employing an omental flap.

CONCLUSION

The combined laparoscopic and vaginal approach with omental flap is effective for repair of a vaginal cuff dehiscence with bowel evisceration. The addition of laparoscopy provides an opportunity for inspection of the small bowel, the peritoneal toilet, and mobilization of an omental flap.

[The choice of approach in the surgical management of endometrial carcinoma: a retrospective serie of 155 cases]

SETTING

Retrospective study of patients consecutively managed surgically for apparent stage I endometrial carcinoma in a comprehensive cancer center, using a standardized protocol for the choice of surgical approach: laparoscopically assisted vaginal hysterectomy (LAVH) as standard procedure, vaginal surgery in apparent stage IA grade 1 or in patients in poor medical condition, laparotomy in the case of subserous myometrial involvement at imaging or in patients with enlarged uteri or in the presence of a contra-indication to laparoscopy.

MATERIALS AND METHODS

Excluding 2 patients in whom laparoscopy was converted in laparotomy, and 1 patient who had a full laparoscopic hysterectomy, the records of 155 patients were reviewed. All patients had a preoperative sonogram, and 74% had a preoperative MRI. Preoperative data, preoperative staging, operative data, pathological staging, postoperative complications, recurrence and survival were recorded.

RESULTS

69 patients (43.6%) had a LAVH procedure (group LAVH), 58 patients (36.7%) were treated by laparotomy (group TAH), and 28 patients (18%) were treated by simple vaginal hysterectomy (group VH). Patients in the vaginal group were significantly heavier (VH 91.3 kg 33, range 53-175) than those of the other two groups (TAH 76.5 12.7, range 48-142; LAVH 71.1 18.5, range 47-102). The number of large (> 10 cm) uteri was significantly greater in the TAH group (46.5%) than the LAVH group (26.1%, p = 0.02) or the VH group (14.3%, p = 0.007). Myometrial invasion was suspected in 53.6% of the VH group, 72.6% of the LAVH group, and 71.4% of the TAH group. Deep myometrial invasion was suspected in no patient of the VH group, 14.5% of the LAVH group and 70.7% of the TAH group. The LAVH group had a significantly longer mean operative time than the TAH group or the VH group. The number of perioperative complications was significantly higher in the TAH group (22.4%) compared to the LAVH group (5.6%) and the VH group (0%). Blood loss was significantly elevated in the laparotomy group compared to the other two groups. The mean number of nodes removed was significantly higher in the LAVH group (15.8 7.8, range 4-37) compared to the TAH group (11 5.3, range 2-25, p = 0.002). Of 155 patients, 100 (64.5%) had correct preoperative staging. In 19 (12.3%), FIGO stage was overestimated preoperatively, and in 36 (23.2%) the FIGO stage was underestimated preoperatively. Survival curves were not found significantly different between groups.

Laparoscopic identification of sentinel lymph nodes in early stage cervical cancer: prospective study using a combination of patent blue dye injection and technetium radiocolloid injection

OBJECTIVE

To determine the feasibility of intraoperative radioisotopic mapping using an endoscopic gamma probe associated with patent blue dye injection in patients with early stage cervical cancer.

METHODS

Between April 2001 and March 2002 a total of 12 patients underwent laparoscopic bilateral pelvic lymphadenectomy (squamous carcinoma in 10 cases, all stage FIGO IB1, and adenocarcinoma in 2 cases, stages IA2 and IB1). Lymphoscintigraphies were performed on the day before surgery to visualize sentinel lymph nodes, 31 +/- 22.5 and 174 +/- 34 min after injection of 200 microCi of technetium 99m rhenium sulfur colloid. The marker was injected at the 3, 6, 9, and 12 o'clock positions. The day of surgery 2 ml of patent blue dye plus 2 ml of physiological serum was injected in the cervix, at the same locations as the radioactive isotope injection.

RESULTS

A total of 35 sentinel lymph nodes were detected. Eight sentinel lymph nodes were only detected by color, 8 sentinel lymph nodes were only detected by the endoscopic gamma probe, and 19 sentinel lymph nodes were "hot and dyed." We found 3 metastatic lymph nodes. In one case, bilateral positive sentinel nodes were only detected by the endoscopic gamma probe. Permanent section identified one inframillimetric micrometastasis in a lymph node that was neither blue nor hot intraoperatively (sensitivity = 66%, specificity = 100%, positive predictive value = 100%, negative predictive value = 90%).

CONCLUSION

The identification of the sentinel lymph node with blue dye and radioisotope using an endoscopic gamma probe is feasible and improves detection rate. False negatives still occur, but the proportion is low even at the beginning of the learning curve. Isotopic imaging identifies nodes in areas outside the pelvis not routinely sampled in early cervical cancer patients.