[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).

How to perform a laparoscopic pelvic sentinel lymph node dissection using near-infrared fluorescence with indocyanine green in gynecological cancers

The role of pelvic sentinel lymph node dissection (SLND) is increasing in oncological pelvic surgery, especially in the management of cervical and endometrial cancer.SLND using indocyanine green (ICG) is safe and effective, and its sensitivity is higher than with other detection methods. The advantages of ICG are its low toxicity, its confinement within the vascular compartment, its rapid excretion, and the rarity of allergic reaction. These advantages confer to this fluorescent dye a superiority over blue, which can cause anaphylactic reactions. Using ICG does not require advance planning involving nuclear protection and delayed surgery, as are mandatory when using ⁹⁹Tc detection. ICG allows the surgeon to visualize the lymph nodes through the peritoneum and thus avoid wide dissection.According to European guidelines,1 the indications for SLND in cervical cancer are for patients with FIGO (International Federation of Gynecology and Obstetrics) IA1-IA2 disease, lymphovascular space involvement - positive status, without systematic pelvic lymphadenectomy - and patients with FIGO IB1-IIA1 disease, prior to systematic pelvic lymphadenectomy. Guidelines1 2 for endometrial cancer management state that SLND is indicated in cases of low-risk endometrial cancer (FIGO IA, grade 1-2), without systematic lymphadenectomy in cases of non-detection, with the technique being preferable to systematic lymphadenectomy in cases of intermediate-risk endometrial cancer (FIGO IB, grade 1-2, or FIGO IA, grade 3).2 Our objective is to review the technique of ICG injection and the real-time detection of pelvic SLNs using near-infrared imaging by means of a step-by-step explanation of the procedure using an instructional Video 1.

Advanced microRNA-based cancer diagnostics using amplified time-gated FRET

MicroRNAs (miRNAs) play an important role in cellular functions and in the development and progression of cancer. Precise quantification of endogenous miRNAs from different clinical patient and control samples combined with a one-to-one comparison to standard technologies is a challenging but necessary endeavor that is largely neglected by many emerging fluorescence technologies. Here, we present a simple, precise, sensitive, and specific ratiometric assay for absolute quantification of miRNAs. Isothermally amplified time-gated Förster resonance energy transfer (TG-FRET) between Tb donors and dye acceptors resulted in miRNA assays with single-nucleotide variant specificity and detection limits down to 4.2 ± 0.5 attomoles. Quantification of miR-21 from human tissues and plasma samples revealed the relevance for breast and ovarian cancer diagnostics. Analysis of miR-132 and miR-146a from acute monocytic leukemia cells (THP-1) demonstrated the broad applicability to different miRNAs and other types of clinical samples. Direct comparison to the gold standard RT-qPCR showed advantages of amplified TG-FRET concerning precision and specificity when quantifying low concentrations of miRNAs as required for diagnostic applications. Our results demonstrate that a careful implementation of rolling circle amplification and TG-FRET into one straightforward nucleic acid detection method can significantly advance the possibilities of miRNA-based cancer diagnostics and research.

[Microscopic peritoneal metastases of epithelial ovarian cancers. Clinical relevance, diagnostic and therapeutic tools]

Understanding the biology and progression mechanisms of peritoneal metastases in ovarian epithelial cancers (EOC) is important because peritoneal carcinomatosis is present or will occur during surveillance of a majority of patients. Despite the clinical remission achieved after complete macroscopic cytoreductive surgery and platinum-based chemotherapy, 60% of patients will develop peritoneal recurrence. This suggests that microscopic lesions, which are not eradicated by surgery may be present and may participate in the mechanisms leading to peritoneal recurrence. This paper discusses current available data on microscopic peritoneal metastases, their diagnosis and their treatment. We reviewed all publications dealing with microscopic peritoneal metastases of EOC between 1980 and 2017. The most recent and most relevant publications dealing with the treatment modalities of these metastases were selected. Peritoneal and epiploic microscopic localizations would occur in 1.2 to 15.1% of cases at early-stage and are not treated during conventional surgery. They could represent a potential therapeutic target. Local treatments (intraperitoneal chemotherapy, photodynamic therapy, fluorescence-guided surgery) seem to be necessary in addition to surgery and chemotherapy and may help reduce the risk of peritoneal recurrence. The place of these treatments in the management of EOC remains to be defined by subsequent researches.

Bevacizumab Does Not Reduce the Lymphocele Rate in Advanced Ovarian Cancer After Complete Cytoreductive Surgery

BACKGROUND/AIM

We aimed to evaluate the impact of bevacizumab on the lymphocele rate in patients after complete cytoreductive surgery for advanced ovarian cancer.

PATIENTS AND METHODS

This retrospective study included patients with advanced ovarian cancer who had undergone complete cytoreductive surgery with pelvic and para-aortic lymphadenectomy at the Gustave Roussy Institute from 2005 to 2014. The introduction of bevacizumab was discussed in a multidisciplinary meeting.

RESULTS

During the study period, 247 patients were included; 24.6% of patients (61 patients) received adjuvant bevacizumab. The rate of symptomatic lymphocele was 34% (84 patients). In the lymphocele group, patients tended to receive adjuvant bevacizumab more often than did the control group (32% and 21%, respectively, p=0.05). In multivariate analysis, bevacizumab was not significantly associated with the risk of symptomatic lymphocele (hazard ratio(HR)=1.62, 95% confidence interval(CI)=0.87-3.01, p=0.12).

CONCLUSION

Adjuvant bevacizumab has no impact on the formation or duration of symptomatic lymphocele in patients after complete cytoreductive surgery for advanced ovarian cancer.

Multicenter prospective evaluation of the reliability of the combined use of two models to predict non-sentinel lymph node status in breast cancer patients with metastatic sentinel lymph nodes: the MSKCC nomogram and the Tenon score. Results of the NOTEGS study

Background:

The purpose of this study was to prospectively evaluate the combined use of The Memorial Sloan Kettering Cancer Center nomogram and Tenon score to select, in patients with metastatic sentinel lymph node (SN), those at low risk of metastatic non-SN for whom additional axillary lymph node dissection (ALND) could be avoided.

Methods:

From January 2011 to July 2012, a prospective non-interventional nationwide study was conducted (NCT01509963). We sought to identify the false reassurance rate (FRR, a negative test result is false) in patients with both a ⩽10% probability of metastatic non-SN with the MSKCC nomogram and a Tenon score ⩽3.5 (low risk): the proportion of patients with metastatic non-SN at additional ALND. Our hypothesis was that these patients would have a FRR⩽5%.

Results:

Data on 2822 patients with breast cancer from 53 institutions were prospectively recorded. At least one SN was metastatic (isolated tumour cells, micro- or macrometastases) in 696 patients (24.7%). Among patients with ALND and complete data to calculate combined risk (n=504), 67 and 437 patients had low and high combined risk, respectively. Patients at low risk had less ALND (47%) compared to patients at high risk (P<0.001). This study did not meet its primary objective because the FRR in patients with low risk was 16.4% (11 out of 67) (95% confidence interval (CI): 9.7–23.1%). In the high-risk group, 33.9% (148 out of 437) (95% CI: 29.6–38.4%) had non-SN metastases (P=0.004).

Conclusions:

In this controlled prospective study, metastatic SN patients with both a ⩽10% probability of metastatic non-SN with the MSKCC nomogram and a Tenon score ⩽3.5 failed to identify patients at low risk of metastatic non-SN when completion ALND was not systematic.

Plasma miR-200b in ovarian carcinoma patients: distinct pattern of pre/post-treatment variation compared to CA-125 and potential for prediction of progression-free survival

Ovarian carcinomas (OvCa) are highly heterogeneous malignancies. We investigated four circulating plasma microRNAs (miR-21, miR-34a, miR-200b and miR-205) as candidate biomarkers. Using qPCR, we assessed the plasma concentration of these markers in 101 women, including 51 previously untreated OvCa patients, 25 healthy women and 25 patients bearing benign pelvic lesions. For a subset of 33 OvCa patients, the assay was repeated at the end of the primary treatment. The pattern of variations (post- minus pre-treatment) of concentration was compared to that of CA-125. A Cox regression model was used to study the association between variations and the progression-free survival (PFS). Plasma miR-200b proved to have a greater average concentration in OvCa samples (median 2^−ΔΔCt = 15.18) than in samples linked to non-malignant lesions (median 2^−ΔΔCt = 1.26, p-value = 0.0004). Its concentration was highly heterogeneous among OvCa patients, without any correlations with the FIGO stage and the pre-treatment CA-125 level. The decrease in CA-125 concentration was constant and often dramatic, while the variations of miR-200b concentration were much more diverse. The variation of miR-200b was marginally associated with the PFS (hazard ratio=2.95 95%CI=[0.94; 9.28], p=0.06) while miR-200b as a continuous time-dependent variable was significantly associated (HR=1.06 [1.02; 1.10], p=0.003). This study is the first direct empirical evidence that miR-200b can provide additional information, independent of CA-125 in OvCa patients.

The challenge of rapid diagnosis in oncology: Diagnostic accuracy and cost analysis of a large-scale one-stop breast clinic

PURPOSE

Rapid diagnosis is a key issue in modern oncology, for which one-stop breast clinics are a model. We aimed to assess the diagnosis accuracy and procedure costs of a large-scale one-stop breast clinic.

PATIENTS AND METHODS

A total of 10,602 individuals with suspect breast lesions attended the Gustave Roussy's regional one-stop breast clinic between 2004 and 2012. The multidisciplinary clinic uses multimodal imaging together with ultrasonography-guided fine needle aspiration for masses and ultrasonography-guided and stereotactic biopsies as needed. Diagnostic accuracy was assessed by comparing one-stop diagnosis to the consolidated diagnosis obtained after surgery or biopsy or long-term monitoring. The medical cost per patient of the care pathway was assessed from patient-level data collected prospectively.

RESULTS

Sixty-nine percent of the patients had masses, while 31% had micro-calcifications or other non-mass lesions. In 75% of the cases (87% of masses), an exact diagnosis could be given on the same day. In the base-case analysis (i.e. considering only benign and malignant lesions at one-stop and at consolidated diagnoses), the sensitivity of the one-stop clinic was 98.4%, specificity 99.8%, positive and negative predictive values 99.7% and 99.0%. In the sensitivity analysis (reclassification of suspect, atypical and undetermined lesions), diagnostic sensitivity varied from 90.3% to 98.5% and specificity varied from 94.3% to 99.8%. The mean medical cost per patient of one-stop diagnostic procedure was €420.

CONCLUSIONS

One-stop breast clinic can provide timely and cost-efficient delivery of highly accurate diagnoses and serve as models of care for multiple settings, including rapid screening-linked diagnosis.

Fertility-sparing surgery in epithelial ovarian cancer

Since the last two decades, the feasibility of fertility-sparing surgery in early-stage epithelial ovarian cancer has been explored by several teams. Despite the impossibility of conducting a randomized trial to validate this management, evidence-based data suggest that in selected cases, the preservation of the uterus and at least one part of the ovary does not lead to a high risk of relapse. Conservative surgery maintains organ function, enables patients of childbearing age to preserve their fertility and improves their quality of life. In this review, we analyze the main series in the literature on this topic in order to highlight the selected criteria for conservative management and to summarize oncological and fertility outcomes.

Plasma miR-200b in ovarian carcinoma patients: distinct pattern of pre/post-treatment variation compared to CA-125 and potential for prediction of progression-free survival

Ovarian carcinomas (OvCa) are highly heterogeneous malignancies. We investigated four circulating plasma microRNAs (miR-21, miR-34a, miR-200b and miR-205) as candidate biomarkers. Using qPCR, we assessed the plasma concentration of these markers in 101 women, including 51 previously untreated OvCa patients, 25 healthy women and 25 patients bearing benign pelvic lesions. For a subset of 33 OvCa patients, the assay was repeated at the end of the primary treatment. The pattern of variations (post- minus pre-treatment) of concentration was compared to that of CA-125. A Cox regression model was used to study the association between variations and the progression-free survival (PFS). Plasma miR-200b proved to have a greater average concentration in OvCa samples (median 2-ΔΔCt = 15.18) than in samples linked to non-malignant lesions (median 2-ΔΔCt = 1.26, p-value = 0.0004). Its concentration was highly heterogeneous among OvCa patients, without any correlations with the FIGO stage and the pre-treatment CA-125 level. The decrease in CA-125 concentration was constant and often dramatic, while the variations of miR-200b concentration were much more diverse. The variation of miR-200b was marginally associated with the PFS (hazard ratio=2.95 95%CI=[0.94; 9.28], p=0.06) while miR-200b as a continuous time-dependent variable was significantly associated (HR=1.06 [1.02; 1.10], p=0.003). This study is the first direct empirical evidence that miR-200b can provide additional information, independent of CA-125 in OvCa patients.

Plasma miR-200b in ovarian carcinoma patients: distinct pattern of pre/post-treatment variation compared to CA-125 and potential for prediction of progression-free survival

Ovarian carcinomas (OvCa) are highly heterogeneous malignancies. We investigated four circulating plasma microRNAs (miR-21, miR-34a, miR-200b and miR-205) as candidate biomarkers. Using qPCR, we assessed the plasma concentration of these markers in 101 women, including 51 previously untreated OvCa patients, 25 healthy women and 25 patients bearing benign pelvic lesions. For a subset of 33 OvCa patients, the assay was repeated at the end of the primary treatment. The pattern of variations (post- minus pre-treatment) of concentration was compared to that of CA-125. A Cox regression model was used to study the association between variations and the progression-free survival (PFS). Plasma miR-200b proved to have a greater average concentration in OvCa samples (median 2-ΔΔCt = 15.18) than in samples linked to non-malignant lesions (median 2-ΔΔCt = 1.26, p-value = 0.0004). Its concentration was highly heterogeneous among OvCa patients, without any correlations with the FIGO stage and the pre-treatment CA-125 level. The decrease in CA-125 concentration was constant and often dramatic, while the variations of miR-200b concentration were much more diverse. The variation of miR-200b was marginally associated with the PFS (hazard ratio=2.95 95%CI=[0.94; 9.28], p=0.06) while miR-200b as a continuous time-dependent variable was significantly associated (HR=1.06 [1.02; 1.10], p=0.003). This study is the first direct empirical evidence that miR-200b can provide additional information, independent of CA-125 in OvCa patients.

Laparoendoscopic Single-site Surgery (LESS) for Prophylactic Salpingo-oophorectomy Improves Cosmetic Satisfaction Compared to Standard Laparoscopy

AIM

Less invasive prophylactic bilateral salpingo-oophorectomy (PBSO) may diminish the general consequences of surgery for BRCA mutation carriers. The objective of the present study was to compare the psychological impact and satisfaction following minimal-invasive laparoendoscopic single-site surgery (LESS) versus that observed with the standard procedure.

PATIENTS AND METHODS

This prospective longitudinal study was proposed to all consecutive patients who underwent ambulatory PBSO between January 2012 and January 2014 at our Center. The psychological impact and esthetic satisfaction were prospectively studied. Patients rated their satisfaction using the 4-grade Likert scale. Their emotional state and postoperative pain were explored respectively with validated questionnaires (IES-R, PANAS) and the Verbal Numerical Rating Scale (VNRS). Operative outcomes were also analyzed.

RESULTS

Twenty patients underwent LESS PBSO and 10 patients had the standard laparoscopic (SL) PBSO. The mean satisfaction scores were significantly higher in the LESS group one month and six months after surgery. Both groups reported a reduction of intrusive thoughts and negative affects after surgery. Postoperative pain and operative outcomes were similar.

CONCLUSION

A significant improvement of cosmetic satisfaction after LESS compared to SL could help patients accept PBSO. The emotional impact of PBSO is not modified by ambulatory LESS.

New Pointers for Surgical Staging of Borderline Ovarian Tumors

BACKGROUND

Surgical management of borderline ovarian tumors (BOTs) is similar to that of ovarian cancer apart from lymphadenectomy. However, the complete procedure including peritoneal washing, infracolic omentectomy and random peritoneal biopsies remains a subject of controversy especially in presumed early stage BOTs. To evaluate the prognostic value of complete surgical staging on recurrence rates, recurrence free (RFS) and overall survival (OS) in a multicentre cohort of BOTs.

METHODS

This retrospective multicentre study included 428 patients with BOTs diagnosed from January 1980 to December 2008. Survival estimates were based on Kaplan-Meier calculations and RFS defined as the time from the date of surgery to the date of recurrence.

RESULTS

The median time of follow-up was 94.9 months (range: 60.00-207.3). The overall recurrence rate was 23.8 %. There was no difference in 5-year RFS between patients with and without complete surgical staging 78.1 % (95 % CI 68.9-88.6) and 70.9 % (95 % CI 64.6-77.8), (p = 0.0806). In the whole cohort, 5-year OS was higher for patients with complete surgical staging 98.4 % (95 % CI 96.8-1.0) and 93.8 % (95 % CI 88.1-1), (p = 0.0182) but this difference was not significant for patients with FIGO stage I 98.6 % (95 % CI 96.7-1) and 92.7 % (95 % CI 83.4-1.0), p = 0.1275, respectively.

CONCLUSIONS

Complete staging surgery should be considered as a cornerstone treatment for patients with advanced stage BOT but not for those with stage I disease.