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.