[Sentinel node detection applied to breast cancer: 2007 update]

The technique of detection and resection of the sentinel lymph node applied to early breast cancer management aims to spare the patient with a low risk of lymph node involvement an unnecessary axillary lymphadenectomy. This innovating technique lies on the double hypothesis of an accuracy to predict non sentinel lymph node status and to induce a lower morbidity when compared with axillary lymphadenectomy. This multidisciplinary technique depends on surgeons, nuclear physicians and pathologists. In practice sentinel lymph nodes are detected thanks to two types of tracers, the Blue and the colloids marked with technetium, harvested by the surgeon guided by the blue lymphatic channel and the use of a gamma probe detection, analyzed by the pathologist according to a particular procedure with the concept of serial slices, and possibly immuno histo chemistry. The objectives of this review are to specify the state of knowledge concerning the different steps: detection, surgical resection and the pathological analysis of the sentinels lymph nodes and to focus on validated and controversial indications, and on the main ongoing trials.

Combined Laparoscopically Harvested Omental Flap With Meshed Skin Grafts and Vacuum-Assisted Closure for Reconstruction of Complex Chest Wall Defects

BACKGROUND

Chest wall reconstruction after radiation damage is a challenge in oncologic and plastic surgery. The defect can be reconstructed with laparoscopically harvested omental flap and meshed skin grafts. Our aim was to evaluate the use of vacuum-assisted closure (V.A.C.) in combination with laparoscopically harvested omental flap and meshed skin graft for treating these complex wounds.

METHODS

Between October 2003 and December 2004, 11 patients underwent a chest wall reconstruction with laparoscopic omentoplasty and V.A.C. treatment of severe chest wall radionecrosis after breast cancer treatment (n = 10) or for locally advanced breast cancer treated first by irradiation (n = 1).

RESULTS

Laparoscopic harvesting was uneventful in 10 cases. One patient had a laparoscopic transverse colic resection because of a middle colic artery injury. Mean time of the laparoscopic procedure was 53 minutes (range: 35-120). Wound surface area averaged 360 cm (range: 80-750). The mean duration of V.A.C. treatment was 9.3 days (range: 6-16). Nine patients showed primary wound healing without adverse events. Complications occurred in 3 patients. One developed a pulmonary infection and died after healing during the postoperative course. One presented a partial flap loss, leading to delayed healing after 45 days. One patient with severe radiation damage and a complete brachial plexus paralysis required a shoulder amputation after an extensive necrosis. All but 1 patient are alive and resumed their normal daily activities.

CONCLUSIONS

Combination of laparoscopic omentoplasty and V.A.C. can successfully be used for reconstruction of complex chest wall radiation damage.

[Laparoscopy-assisted vaginal pelvic exenteration]

OBJECTIVE

The aim of the study was to evaluate the feasibility, morbidity and survival outcome of laparoscopy-assisted vaginal pelvic exenteration.

PATIENTS AND METHODS

Since 2000, 7 en-bloc pelvic exenteration combining a vaginal or perineal approach and laparoscopic approach have been performed in our cancer center associated with complex laparoscopic reconstruction. All patients but one received previous irradiation. Two patients underwent a total pelvic exenteration; three patients an anterior and middle exenteration; two patients a middle and posterior exenteration. Urinary system was reconstructed with an ileal loop in one case, with a hand-assisted laparoscopic Miami pouch in four cases. Reconstruction of the vagina was performed with an omental cylinder in three cases, with a gluteal thigh flap in one case. A colorectal anastomosis was performed in three patients, one patient had an end colostomy. A mini-laparotomy conversion was necessary in one case because of a pelvic side involvement to perform an intraoperative irradiation.

RESULTS

Mean time of the procedure was 6.5 hours with peroperative bleeding less than 500 cm3. Four patients presented minor complications. No revision of the Miami pouch was necessary. Mean length of hospital stay was 27 days. The four patients with a Miami pouch were able to self catheterize at the time of discharge. Mean follow-up was 14 months. Four patients died of the disease (three were metastatic). One patient presented a local recurrence. Two patients are free of disease.

DISCUSSION AND CONCLUSION

Laparoscopic or laparoscopy-assisted vaginal pelvic exenteration followed by reconstruction is feasible with curative intent in selected patients.

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.

Abdominal wall metastasis of ovarian carcinoma after low transverse abdominal incision: report of two cases and review of literature

Occurrence of parietal metastases after surgery for a suspect adnexal mass may worsen the prognosis of the disease. However, it is not clear whether abdominal wall metastases is related to specific biologic features or simply to surgical mismanagement involving small incisions and traumatic extraction of the specimen, resulting in direct seeding of cancer cells. We report two cases with development of parietal dissemination of ovarian carcinomas after Pfannenstiel incision. The two patients needed parietal resection to obtain optimal surgical cytoreduction. Pfannenstiel incisions for exploration of suspicious adnexal masses increase the risk of extensive parietal metastasis in case of malignancy because they require reflection of several sheaths of tissue. The parietal extension of the disease may need major parietal resection that can worsen the functional and general outcome of the patients.

Abdominal wall metastasis of ovarian carcinoma after low transverse abdominal incision: report of two cases and review of literature

Occurrence of parietal metastases after surgery for a suspect adnexal mass may worsen the prognosis of the disease. However, it is not clear whether abdominal wall metastases is related to specific biologic features or simply to surgical mismanagement involving small incisions and traumatic extraction of the specimen, resulting in direct seeding of cancer cells. We report two cases with development of parietal dissemination of ovarian carcinomas after Pfannenstiel incision. The two patients needed parietal resection to obtain optimal surgical cytoreduction. Pfannenstiel incisions for exploration of suspicious adnexal masses increase the risk of extensive parietal metastasis in case of malignancy because they require reflection of several sheaths of tissue. The parietal extension of the disease may need major parietal resection that can worsen the functional and general outcome of the patients.

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.

[Locoregional recurrence of ovarian cancer: the place of surgery]

Standard therapy for advanced ovarian cancer includes cytoreductive surgery associated with platin based chemotherapy. Secondary surgery for recurrent ovarian cancer remains controversial. Actually there is not randomized trial based on this question. Furthermore literature shows that patients with recurrent disease may derive a significant survival benefit from optimal debulking. The datas availables indicate that prolonged disease free interval and feasibility of complete surgical resection are the main prognosis criteria. Proper selection of patients with recurrent ovarian cancer is essential to improve the therapeutic benefit of secondary surgery. There is a large place for trials and evaluation of innovatives techniques as hyperthermic intraperitoneal chemotherapy or intraperitoneal radio-immunotherapy.

[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.

[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.

[Reoperation for refractory postoperative chylous ascites: value of peritoneovenous shunt combined with closure of lympho-peritoneal fistula]

Postoperative chylous ascites is a rare but serious complication resulting in denutrition, lymphopenia and infection. The first-intent treatment is usually conservative. We report a case of chylous ascites after retroperitoneal lymphadenectomy for testicular cancer, persisting despite conservative treatment then successfully treated by lymphostasis combined with peritoneovenous shunt. In case of high-output postoperative chylous ascites in low-risk patients with presumed localization of fistula, reoperation is indicated for lymphostasis. We advise to associate a peritoneovenous shunt in case of incomplete closure of the lymphoperitoneal fistula to avoid the morbidity of prolonged ascites.

[Deimons-Meigs syndrome and elevated CA-125: diagnosis of ovarian cancer and therapeutic implications]

Regarding a original observation of the Deimons-Meigs syndrome, the authors have derived, from a review of the literature, the main clinicals and etiopathogenics characteristics, and tried to discuss the terms and conditions of a therapeutic treatment appropriate to such a situation.

[Obesity and assisted reproduction techniques]

Obesity was defined by a body mass index more than 30 kg/m2. Many risks were related to this pathology, and sometimes, menstrual disorders or infertility. In order to obtain an adequate response to ovarian stimulation during IVF cycles, higher doses of menotropins are necessary in the group of obese patients. The mechanism of this phenomenon is still unclear. Leptin is one of the main hypothesis, and could act on obesity and reproductive system simultaneously. The likelihood to have an ongoing pregnancy after IVF treatment is less in the group of obese patients because of the increased risk of miscarriage and obstetrical complications. Weight loss prior IVF remains the main advice in order to decrease the risks of the procedure and to treat successfully these patients.

Pharmacokinetics of lithium in plasma and red blood cells in acute and chronic intoxicated patients

Lithium disposition in plasma, red blood cells (RBC) and urine was studied in acute self-poisoned patients upon chronic lithium therapy (n = 4) and in chronic intoxicated patients receiving oral lithium (n = 10). Following acute intoxication upon chronic lithium therapy, lithium pharmacokinetics did not differ from previous reports. Terminal plasma half-life ranged from 19.0-29.0 h and RBC/plasma ratio was 0.32 +/- 0.11. The distribution volume of the terminal phase, Vz, was estimated at 0.84 +/- 0.32 l/kg and renal clearance was 0.38 +/- 0.11 ml/mn/kg. After chronic intoxication lithium pharmacokinetics differed from those of the acute patients. Terminal plasma half-life ranged from 36.5-79.4 h and zero-order decline appeared in 8 of the 10 patients. The RBC/plasma ratio was 0.87 +/- 0.22 on admission. Vz was estimated at 0.71 +/- 0.27 l/kg and renal clearance was 0.16 +/- 0.07 ml/mn/kg. These modifications in lithium elimination kinetics could be related to the decrease in the glomerular filtration rate with age or renal dysfunction in this group of patients.