1
|
Falconer H, Norberg-Hardie A, Salehi S, Alfonzo E, Weydandt L, Dornhöfer N, Wolf B, Höckel M, Aktas B. Oncologic outcomes after Total Mesometrial Resection (TMMR) or treatment according to current international guidelines in FIGO (2009) stages IB1-IIB cervical cancer: an observational cohort study. EClinicalMedicine 2024; 73:102696. [PMID: 39007068 PMCID: PMC11245980 DOI: 10.1016/j.eclinm.2024.102696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 05/27/2024] [Accepted: 05/31/2024] [Indexed: 07/16/2024] Open
Abstract
Background According to international guidelines, standard treatment (ST) with curative intent in cervical cancer (CC) comprises radical hysterectomy and pelvic lymphadenectomy in early stages (International Federation of Gynecology and Obstetrics (FIGO) 2009 IB1, IIA1), adjuvant chemoradiation is recommended based on risk factors upon final pathology. Definitive chemoradiation is recommended in locally advanced stages (FIGO 2009 IB2, IIA2, IIB). Total mesometrial resection (TMMR) with therapeutic lymph node dissection (tLND) without adjuvant radiation has emerged as a promising treatment. Here we compare oncologic outcome by TMMR + tLND or ST. Methods In this observational cohort study, women treated according to international guidelines were identified in the population-based registries from Sweden and women treated with TMMR were identified in the Leipzig Mesometrial Resection (MMR) Study Database (DRKS 0001517) 2011-2020. Relevant clinical and tumour related variables were extracted. Recurrence-free survival (RFS) and overall survival (OS) by ST or TMMR was analysed with log-rank test, cumulative incidence function and proportional hazard regression yielding hazard ratios (HR) with 95% confidence intervals (CI), adjusted for relevant confounders. Findings Between 2011 and 2020, 1007 women were included in the final analysis. 733 women were treated according to ST and 274 with TMMR. RFS at five years was 77.9% (95% CI 74.3-81.1) and 82.6% (95% CI 77.2-86.9) for the ST and TMMR cohorts respectively (p = 0.053). In early-stage CC, RFS was higher after TMMR as compared to ST, 91.2% vs 81.8% (p = 0.002). In the adjusted analysis, TMMR was associated with a lower hazard of recurrence (HR 0.39; 95% CI 0.22-0.69) and death (HR 0.42; 95% CI 0.21-0.86) compared to ST. The absolute difference in risk of recurrence at 5 years was 9.4% (95% CI 3.2-15.7) in favor of TMMR. In locally advanced CC, no significant differences in RFS or OS was observed. Interpretation Compared to ST, TMMR without radiation therapy was associated with superior oncologic outcomes in women with early-stage cervical cancer whereas no difference was observed in locally advanced disease. Our findings together with previous evidence suggest that TMMR may be considered the primary option for both early-stage and locally advanced cervical cancer confined to the Müllerian compartment. Funding This study was supported by grants from Centre for Clinical Research Sörmland (Sweden) and Region Stockholm (Sweden).
Collapse
Affiliation(s)
- Henrik Falconer
- Department of Pelvic Cancer, Karolinska University Hospital and the Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Anna Norberg-Hardie
- Department of Pelvic Cancer, Karolinska University Hospital and the Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
| | - Sahar Salehi
- Department of Pelvic Cancer, Karolinska University Hospital and the Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Emilia Alfonzo
- Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital and Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Laura Weydandt
- Department of Gynecology, University Hospital Leipzig and Leipzig School of Radical Pelvic Surgery, University of Leipzig, Leipzig, Germany
| | - Nadja Dornhöfer
- Department of Gynecology, University Hospital Leipzig and Leipzig School of Radical Pelvic Surgery, University of Leipzig, Leipzig, Germany
| | - Benjamin Wolf
- Department of Gynecology, University Hospital Leipzig and Leipzig School of Radical Pelvic Surgery, University of Leipzig, Leipzig, Germany
| | - Michael Höckel
- Department of Gynecology, University Hospital Leipzig and Leipzig School of Radical Pelvic Surgery, University of Leipzig, Leipzig, Germany
| | - Bahriye Aktas
- Department of Gynecology, University Hospital Leipzig and Leipzig School of Radical Pelvic Surgery, University of Leipzig, Leipzig, Germany
| |
Collapse
|
2
|
Buderath P, Dang TM, Kimmig R. Cancer-field surgery for endometrial cancer by robotic peritoneal mesometrial resection and targeted compartmental lymphadenectomy (PMMR+TCL). J Gynecol Oncol 2024; 36:36.e13. [PMID: 38945527 DOI: 10.3802/jgo.2025.36.e13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 01/18/2024] [Accepted: 05/21/2024] [Indexed: 07/02/2024] Open
Abstract
OBJECTIVE Cancer-field surgery by peritoneal mesometrial resection and targeted compartmental lymphadenectomy (PMMR+TCL) for the treatment of endometrial cancer (EC) aims at optimal locoregional tumor control without the need for adjuvant radiotherapy. In a previous publication we could demonstrate the feasibility of the method and presented encouraging first oncologic data. METHODS Following up our 2021 publication, we present data on the treatment of EC by PMMR+TCL in much larger cohort and with longer follow-up. RESULTS One hundred and thirty-five patients with EC International Federation of Gynecology and Obstetrics (FIGO) I-IV (75.6% FIGO I) underwent cancer field surgery via PMMR+TCL for EC in the years 2016-2023. Mean follow-up in our cohort was 27.5 months (0, 83; 19.7). The procedure was feasible and safe with favorable intra-and postoperative complication rates. Even though 50.4% of patients had an indication for postoperative radiotherapy following national and international guidelines, the rate of postoperative irradiation administered was 10.4%. The overall recurrence rate was 8.1% and we observed 2 (1.5%) isolated locoregional recurrences. CONCLUSION Our results confirm the feasibility and safety of PMMR+TCL in EC patients. Oncologic data are very encouraging and hint at a superior locoregional control without adjuvant irradiation. Larger studies with longer follow-up will be needed to confirm these results.
Collapse
Affiliation(s)
- Paul Buderath
- Department for Gynecology and Obstetrics, University Hospital Essen, Essen, Germany.
| | - Tra My Dang
- Department for Gynecology and Obstetrics, University Hospital Essen, Essen, Germany
| | - Rainer Kimmig
- Department for Gynecology and Obstetrics, University Hospital Essen, Essen, Germany
| |
Collapse
|
3
|
Loverro M, Bizzarri N, Capomacchia FM, Watrowski R, Querleu D, Gioè A, Naldini A, Santullo F, Foschi N, Fagotti A, Scambia G, Fanfani F. Indocyanine green fluorescence applied to gynecologic oncology: beyond sentinel lymph node. Int J Surg 2024; 110:3641-3653. [PMID: 38489558 PMCID: PMC11175818 DOI: 10.1097/js9.0000000000001318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 02/26/2024] [Indexed: 03/17/2024]
Abstract
Indocyanine green (ICG), a well-known molecule employed in medicine for over five decades, has emerged as a versatile dye widely embraced across various surgical disciplines. In gynecologic oncology, its prevalent use revolves around the detection of sentinel lymph nodes. However, the true potential of ICG extends beyond this singular application, owing to its pragmatic utility, cost-effectiveness, and safety profile. Furthermore, ICG has been introduced in the theranostic landscape, marking a significant juncture in the evolution of its clinical utility. This narrative review aims to describe the expanding horizons of ICG fluorescence in gynecologic oncology, beyond the sentinel lymph node biopsy. The manifold applications reported within this manuscript include: 1) lymphography; 2) angiography; 3) nerve visualization; 4) ICG-driven resections; and 5) theranostic. The extensive exploration across these numerous applications, some of which are still in the preclinical phase, serves as a hypothesis generator, aiming to stimulate the development of clinical studies capable of expanding the use of this drug in our field, enhancing the care of gynecological cancer patients.
Collapse
Affiliation(s)
- Matteo Loverro
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
| | - Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
| | | | - Rafał Watrowski
- Department of Gynecology and Obsterics, Helios Hospital Müllheim, Teaching Hospital of the University of Freiburg, 79379 Müllheim
- Faculty of Medicine, Medical Center - University of Freiburg, 79106 Freiburg, Germany
| | - Denis Querleu
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
| | - Alessandro Gioè
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
| | - Angelica Naldini
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
| | - Francesco Santullo
- Operational Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli
| | - Nazario Foschi
- Urology Division, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Anna Fagotti
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
- Università Cattolica del Sacro Cuore
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
- Università Cattolica del Sacro Cuore
| | - Francesco Fanfani
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
- Università Cattolica del Sacro Cuore
| |
Collapse
|
4
|
Chikazawa K, Imai K, Kuwata T, Konno R. Improved bladder function in radical hysterectomy without worsening oncologic outcome: resection of the posterior layer of the vesicouterine ligament with the procedure limited to the vesical veins. J Gynecol Oncol 2024; 35:e28. [PMID: 38156721 PMCID: PMC11107269 DOI: 10.3802/jgo.2024.35.e28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 10/02/2023] [Accepted: 11/26/2023] [Indexed: 01/03/2024] Open
Abstract
OBJECTIVE The classic Okabayashi nerve-sparing radical hysterectomy involves complete resection of the posterior leaf of the vesicouterine ligament, whereas in the simplified nerve-sparing radical hysterectomy, only the vesical veins and some connective tissue of the posterior layer of the vesicouterine ligament are resected. This study aimed to compare bladder function and cervical carcinoma relapse-free survival between these two techniques. METHODS We conducted a retrospective, historical control study. All female patients aged >20 years who were diagnosed with cervical cancer stage IB1-IIB and underwent radical hysterectomy with pelvic lymphadenectomy between 2009 and 2022 were enrolled. Patients who had a history of other cancers and those who were treated with non-surgical approaches or non-radical hysterectomy were excluded. The primary outcome was relapse-free survival during the follow-up period. RESULTS A total of 114 patients who underwent curative-intent radical hysterectomy were included in this study. The median follow-up duration was 60 months. No significant difference was observed in relapse-free survival between the two surgical procedures. The simplified nerve-sparing radical hysterectomy was superior in terms of both motor and sensory bladder function outcomes. CONCLUSION Resection of the posterior layer of the vesicouterine ligament, with the procedure limited to the vesical veins, is an effective and safe method for radical hysterectomy. It may be more useful for preserving the bladder function, without leading to unfavorable oncologic outcomes.
Collapse
Affiliation(s)
- Kenro Chikazawa
- Department of Obstetrics and Gynecology, Jichi Medical University, Saitama Medical Center, Saitama, Japan.
| | - Ken Imai
- Department of Obstetrics and Gynecology, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Tomoyuki Kuwata
- Department of Obstetrics and Gynecology, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Ryo Konno
- Department of Obstetrics and Gynecology, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| |
Collapse
|
5
|
Buderath P, Elgharib M, Kimmig R. Peritoneal mesometrial resection with lymphadenectomy following prior hysterectomy in intermediate/high-risk endometrial cancer: feasibility and safety. Arch Gynecol Obstet 2024; 309:1569-1574. [PMID: 38217762 PMCID: PMC10894095 DOI: 10.1007/s00404-023-07275-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/18/2023] [Indexed: 01/15/2024]
Abstract
OBJECTIVE Peritoneal mesometrial resection (PMMR) plus targeted compartmental lymphadenectomy (TCL) aims at removal of the locoregional cancer field in endometrial cancer (EC). Optimal locoregional control without adjuvant radiotherapy should be achieved concomitantly sparing systematic lymphadenectomy (LNE) for most of the patients. However, intermediate/high-risk EC is often definitely diagnosed postoperatively in simple hysterectomy specimen. Our aim was to evaluate feasibility and safety of a completing PMMR + TCL in patients following prior hysterectomy. METHODS We evaluated data from 32 patients with intermediate/high-risk EC treated with PMMR + TCL or systematic pelvic and periaortic LNE following prior hysterectomy. Perioperative data on disease characteristics and morbidity were collected and patients were contacted for follow-up to determine the recurrence and survival status. RESULTS We report data from 32 patients with a mean follow-up of 31.7 months. The recurrence rate was 12.5% (4/32) without any isolated locoregional recurrences. Only 21.9% of patients received adjuvant radiotherapy. Rates of intra- and postoperative complications were 6.3% and 18.8%, respectively. CONCLUSION Our data suggest that robotic PMMR can be performed following prior hysterectomy when previously unknown risk factors arise, albeit with a moderate increase in morbidity. Moreover, despite a relevant reduction of adjuvant radiotherapy, follow-up data suggest an excellent locoregional control even without adjuvant radiotherapy.
Collapse
Affiliation(s)
- Paul Buderath
- West German Cancer Center, Department for Gynaecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Mohamed Elgharib
- West German Cancer Center, Department for Gynaecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Rainer Kimmig
- West German Cancer Center, Department for Gynaecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| |
Collapse
|
6
|
Luo A, Lan X, Qiu Q, Zhou Q, Li J, Wu M, Liu P, Zhang H, Lu B, Lu Y, Lu W. LncRNA SFTA1P promotes cervical cancer progression by interaction with PTBP1 to facilitate TPM4 mRNA degradation. Cell Death Dis 2022; 13:936. [PMID: 36344495 PMCID: PMC9640654 DOI: 10.1038/s41419-022-05359-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/09/2022]
Abstract
Long non-coding RNAs (lncRNAs) play key roles in cancer development and progression. However, the biological function and clinical significance of most lncRNAs in cervical cancer remain elusive. In this study, we explore the function and mechanism of lncRNA surfactant associated 1 (SFTA1P) in cervical cancer. We firstly identified SFTA1P by analyzing the RNA sequencing data of cervical cancer from our previous study and from The Cancer Genome Atlas (TCGA). We then verified SFTA1P expression by qRT-PCR. The cell proliferation and migration capacity of SFTA1P was assessed by using CCK-8, colony formation, transwell and wound healing assays. RNA pull-down, RNA immunoprecipitation (RIP), RNA stability and western blot assays were used to reveal potential mechanisms. Athymic nude mice were used to evaluate tumorigenicity and metastasis in vivo. SFTA1P is upregulated in cervical tumor tissues and its high expression is associated with poor prognosis. Biologically, knockdown of SFTA1P inhibited the proliferation, migration, and invasion of cervical cancer cells in vitro, as well as tumorigenesis and metastasis in vivo. Mechanistically, SFTA1P was shown to interact with polypyrimidine tract binding protein 1 (PTBP1) to regulate the stability of tropomyosin 4 (TPM4) mRNA, thereby resulting in malignant cell phenotypes. TPM4 knockdown could attenuate the suppression of cell progression induced by either SFTA1P or PTBP1 knockdown. Our findings demonstrate that SFTA1P can promote tumor progression by mediating the degradation of TPM4 mRNA through its interaction with PTBP1 protein. This provides a potential therapeutic strategy to target the SFTA1P-PTBP1-TPM4 axis in cervical cancer.
Collapse
Affiliation(s)
- Aoran Luo
- grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital and Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, 310006 Zhejiang China
| | - Xiaoxiao Lan
- grid.13402.340000 0004 1759 700XWomen’s Reproductive Health Key Laboratory of Zhejiang Province and Department of Gynecologic Oncology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 Zhejiang China
| | - Qiongzi Qiu
- grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital and Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, 310006 Zhejiang China
| | - Qing Zhou
- grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital and Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, 310006 Zhejiang China
| | - Jia Li
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Medicine, Sir Run Run Shaw Hospital and Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, 310016 Zhejiang China
| | - Mengting Wu
- grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital and Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, 310006 Zhejiang China
| | - Pengyuan Liu
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Medicine, Sir Run Run Shaw Hospital and Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, 310016 Zhejiang China ,grid.13402.340000 0004 1759 700XCancer Center, Zhejiang University, Hangzhou, 310013 Zhejiang China
| | - Honghe Zhang
- grid.13402.340000 0004 1759 700XCancer Center, Zhejiang University, Hangzhou, 310013 Zhejiang China ,grid.13402.340000 0004 1759 700XDepartment of Pathology, Research Unit of Intelligence Classification of Tumor Pathology and Precision Therapy, Chinese Academy of Medical Sciences, Zhejiang University School of Medicine, Hangzhou, 310058 Zhejiang China
| | - Bingjian Lu
- grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital and Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, 310006 Zhejiang China
| | - Yan Lu
- grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital and Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, 310006 Zhejiang China ,grid.13402.340000 0004 1759 700XCancer Center, Zhejiang University, Hangzhou, 310013 Zhejiang China
| | - Weiguo Lu
- grid.13402.340000 0004 1759 700XWomen’s Reproductive Health Key Laboratory of Zhejiang Province and Department of Gynecologic Oncology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 Zhejiang China ,grid.13402.340000 0004 1759 700XCancer Center, Zhejiang University, Hangzhou, 310013 Zhejiang China
| |
Collapse
|
7
|
Lia M, Horn LC, Sodeikat P, Höckel M, Aktas B, Wolf B. The diagnostic value of core needle biopsy in cervical cancer: A retrospective analysis. PLoS One 2022; 17:e0262257. [PMID: 34986187 PMCID: PMC8730459 DOI: 10.1371/journal.pone.0262257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 12/21/2021] [Indexed: 12/24/2022] Open
Abstract
Cervical carcinoma is a major cause of morbidity and mortality among women worldwide. Histological subtype, lymphovascular space invasion and tumor grade could have a prognostic and predictive value for patients’ outcome and the knowledge of these histologic characteristics may influence clinical decision making. However, studies evaluating the diagnostic value of various biopsy techniques regarding these parameters of cervical cancer are scarce. We reviewed 318 cases of cervical carcinoma with available pathology reports from preoperative core needle biopsy (CNB) assessment and from final postoperative evaluation of the hysterectomy specimen. Setting the postoperative comprehensive pathological evaluation as reference, we analysed CNB assessment of histological tumor characteristics. In addition, we performed multivariable logistic regression to identify factors influencing the accuracy in identifying LVSI and tumor grade. CNB was highly accurate in discriminating histological subtype. Sensitivity and specificity were 98.8% and 89% for squamous cell carcinoma, 92.9% and 96.6% for adenocarcinoma, 33.3% and 100% in adenosquamous carcinoma respectively. Neuroendocrine carcinoma was always recognized correctly. The accuracy of the prediction of LVSI was 61.9% and was positively influenced by tumor size in preoperative magnetic resonance imaging and negatively influenced by strong peritumoral inflammation. High tumor grade (G3) was diagnosed accurately in 73.9% of cases and was influenced by histological tumor type. In conclusion, CNB is an accurate sampling technique for histological classification of cervical cancer and represents a reasonable alternative to other biopsy techniques.
Collapse
Affiliation(s)
- Massimiliano Lia
- Department of Gynecology and Obstetrics, University Hospital Leipzig, Leipzig, Germany
- * E-mail:
| | - Lars-Christian Horn
- Division of Gynecologic, Breast and Perinatal Pathology, University Hospital Leipzig, Leipzig, Germany
| | - Paulina Sodeikat
- Department of Gynecology and Obstetrics, University Hospital Leipzig, Leipzig, Germany
| | - Michael Höckel
- Department of Gynecology and Obstetrics, University Hospital Leipzig, Leipzig, Germany
| | - Bahriye Aktas
- Department of Gynecology and Obstetrics, University Hospital Leipzig, Leipzig, Germany
| | - Benjamin Wolf
- Department of Gynecology and Obstetrics, University Hospital Leipzig, Leipzig, Germany
| |
Collapse
|
8
|
Buderath P, Stukan M, Ruhwedel W, Strutas D, Feisel-Schwickardi G, Wimberger P, Kimmig R. Total mesometrial resection (TMMR) for cervical cancer FIGO IB-IIA: first results from the multicentric TMMR register study. J Gynecol Oncol 2021; 33:e9. [PMID: 34910390 PMCID: PMC8728671 DOI: 10.3802/jgo.2022.33.e9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 09/21/2021] [Accepted: 10/28/2021] [Indexed: 11/30/2022] Open
Abstract
Available data on total mesometrial resection and therapeutic lymphadenectomy (TMMR+tLNE) for the treatment of cervical cancer show excellent locoregional control rates without adjuvant chemoradiation. In 116 patients with cervical cancer stages IB–IIA the overall recurrence rate was 7.8% in a median follow-up time of 24 months. Locoregional recurrences occurred in 6.0% of patients. Objective The surgical concept of total mesometrial resection (TMMR) and therapeutic lymphadenectomy (tLNE) for the treatment of early cervical cancer is based on the ontogenetic cancer field model. Unicentric data show excellent locoregional control rates without adjuvant chemoradiation. However, there are so far no prospective, multicentric data supporting the method. Methods The multicentric TMMR register study was designed to answer the question whether the concept of TMMR+tLNE could be transferred to different centers and surgeons without compromising the outstanding oncologic results described in a unicentric setting. Results In 116 patients with cervical cancer stages IB–IIA, (International Federation of Gynecology and Obstetrics [FIGO] 2018), who underwent TMMR/tLNE, 25.0% were lymph node-positive. pT stages were pT1a in 3 patients (2.6%), pT1b1 in 82 (70.7%), pT1b2 in 18 (15.5%), pT2a in 4 (3.5%) and pT2b in 9 (7.8%). The overall recurrence rate was 7.8% in a median follow-up time of 24 months (6–80). Locoregional recurrences occurred in 6.0% of patients. One patient (0.9%) died from the disease during the observation period. Conclusion These are the first multicentric data on the surgical concept of TMMR and tLNE for the treatment of cervical cancer FIGO IB–IIA. We were able to reproduce the excellent oncologic data described for the method albeit with a relatively short median observation time. A randomized controlled trial seems warranted to definitely establish TMMR+tLNE as the method of choice for the treatment of early cervical cancer. Trial Registration ClinicalTrials.gov Identifier: NCT01819077
Collapse
Affiliation(s)
- Paul Buderath
- Department of Gynecology and Obstetrics, University Hospital Essen, Essen, Germany.
| | - Maciej Stukan
- Department of Gynecologic Oncology, Gdynia Oncology Center, Pomeranian Hospitals, Gdynia, Poland
| | - Wencke Ruhwedel
- Department of Gynecology and Obstetrics, Klinikum Gütersloh, Gütersloh, Germany
| | - Deivis Strutas
- Department of Gynecology, University Hospital Zürich, Zürich, Switzerland
| | | | - Pauline Wimberger
- Department of Gynecology and Obstetrics, University Hospital of Dresden, Technische Universität Dresden, Dresden, Germany
| | - Rainer Kimmig
- Department of Gynecology and Obstetrics, University Hospital Essen, Essen, Germany
| |
Collapse
|
9
|
Comprehensive Review of Fluorescence Applications in Gynecology. J Clin Med 2021; 10:jcm10194387. [PMID: 34640405 PMCID: PMC8509149 DOI: 10.3390/jcm10194387] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 12/11/2022] Open
Abstract
Since the introduction of indocyanine green (ICG) as a fluorophore in near-infrared imaging, fluorescence visualization has become an essential tool in many fields of surgery. In the field of gynecology, recent new applications have been proposed and found their place in clinical practice. Different applications in gynecology were investigated, subcategorized, and overviewed concerning surgical applications and available dyes. Specific applications in which fluorescence-guided surgery was implemented in gynecology are described in this manuscript—namely, sentinel node biopsy, mesometrium visualization, angiography of different organs, safety issues in pregnant women, ureters visualization, detection of peritoneal metastases, targeted fluorophores for cancer detection, fluorescent contamination hysterectomy, lymphography for lower limb lymphedema prevention, tumor margin detection, endometriosis, and metastases mapping. With evolving technology, further innovative research on the new applications of fluorescence visualization in cancer surgery may help to establish these techniques as standards of high-quality surgery in gynecology. However, more investigations are necessary in order to assess if these innovative tools can also be effective to improve patient outcomes and quality of life in different gynecologic malignancies.
Collapse
|
10
|
Stukan M, Buderath P, Szulczyński B, Gębicki J, Kimmig R. Accuracy of Ultrasonography and Magnetic Resonance Imaging for Preoperative Staging of Cervical Cancer-Analysis of Patients from the Prospective Study on Total Mesometrial Resection. Diagnostics (Basel) 2021; 11:diagnostics11101749. [PMID: 34679447 PMCID: PMC8534714 DOI: 10.3390/diagnostics11101749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/12/2021] [Accepted: 09/19/2021] [Indexed: 11/18/2022] Open
Abstract
We aimed to evaluate the accuracy of ultrasonography with gynecologic examination performed by a gynecological oncologist and magnetic resonance imaging (MRI) interpreted by a radiologist for the local and regional staging of patients with early-stage cervical cancer. The study was a single-site sub-analysis of the multi-institutional prospective, observational Total Mesometrial Resection (TMMR) Register Study, which included all consecutive study patients from Gdynia Oncology Center. Imaging results were compared with pathology findings. A total of 58 consecutive patients were enrolled, and 50 underwent both ultrasonography and MRI. The accuracy of tumor detection and measurement errors was comparable across ultrasonography and MRI. There were no significant differences between ultrasonography and MRI in the accuracy of detecting parametrial involvement (92%, confidence interval (CI) 84–100% vs. 76%, CI 64–88%, p = 0.3), uterine corpus infiltration (94%, CI 87–100% vs. 86%, CI 76–96%, p = 0.3), and vaginal fornix involvement (96%, CI 91–100% vs. 76%, CI 64–88%, p = 0.3). The importance of uterine corpus involvement for the first-line lymph node metastases was presented in few cases. The accuracy of ultrasonography was higher than MRI for correctly predicting tumor stage: International Federation of Gynecology and Obstetrics (FIGO)–2018: 69%, CI 57–81% vs. 42%, CI 28–56%, p = 0.002, T (from TNM system): 79%, CI 69–90% vs. 52%, CI 38–66%, p = 0.0005, and ontogenetic tumor staging: 88%, CI 80–96% vs. 70%, CI 57–83%, p = 0.005. For patients with cervical cancer who are eligible for TMMR and therapeutic lymphadenectomy, the accuracy of ultrasonography performed by gynecological oncologists is not inferior to that of MRI interpreted by a radiologist for assessing specific local parameters, and is more accurate for local staging of the disease and is thus more clinically useful for planning adequate surgical treatment.
Collapse
Affiliation(s)
- Maciej Stukan
- Department of Gynecologic Oncology, Gdynia Oncology Center, Pomeranian Hospitals, ul. Powstania Styczniowego 1, 81519 Gdynia, Poland
- Division of Propedeutics of Oncology, Medical University of Gdańsk, ul. Powstania Styczniowego 9B, 81519 Gdynia, Poland
- Correspondence: or ; Tel.: +48-58-7260508
| | - Paul Buderath
- West German Cancer Center, Department for Gynecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (P.B.); (R.K.)
| | - Bartosz Szulczyński
- Department of Process Engineering and Chemical Technology, Faculty of Chemistry, Gdańsk University of Technology, ul. Narutowicza 11/12, 80233 Gdańsk, Poland; (B.S.); (J.G.)
| | - Jacek Gębicki
- Department of Process Engineering and Chemical Technology, Faculty of Chemistry, Gdańsk University of Technology, ul. Narutowicza 11/12, 80233 Gdańsk, Poland; (B.S.); (J.G.)
| | - Rainer Kimmig
- West German Cancer Center, Department for Gynecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (P.B.); (R.K.)
| |
Collapse
|
11
|
Bayer A, Heinze T, Alkatout I, Osmonov D, Stelzner S, Wedel T. Embryological Development and Topographic Anatomy of Pelvic Compartments-Surgical Relevance for Pelvic Lymphonodectomy. J Clin Med 2021; 10:jcm10040708. [PMID: 33670197 PMCID: PMC7916954 DOI: 10.3390/jcm10040708] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 01/03/2023] Open
Abstract
Background: The oncological outcome of surgery for the treatment of pelvic malignancies can be improved by performing pelvic lymphonodectomy. However, the extent and regions of lymph node harvest are debated and require profound knowledge of anatomy in order to avoid collateral damage. Methods: The embryological development and topographic anatomy of pelvic compartments in relation to pelvic lymphonodectomy for rectal, uterine, and prostate cancer are reviewed. Based on pre-dissected anatomical specimens, lymph node regions and drainage routes of the posterior and urogenital pelvic compartments are described in both genders. Anatomical landmarks are highlighted to identify structures at risk of injury during pelvic lymphonodectomy. Results: The ontogenesis of urogenital and anorectal compartments and their lymphatic supply are key factors for adequate lymphonodectomy, and have led to compartment-based surgical resection strategies. However, pelvic lymphonodectomy bears the risk of injury to somatic and autonomic nerves, vessels, and organs, depending on the regions and extent of surgery. Conclusion: Embryologically defined, compartment-based resection of pelvic malignancies and their lymphatic drainage routes are based on clearly delineated anatomical landmarks, which permit template-oriented pelvic lymphonodectomy. Comprehensive knowledge of pelvic anatomy, the exchange of surgical concepts between specialties, and minimally invasive techniques will optimize pelvic lymphonodectomy and reduce complications.
Collapse
Affiliation(s)
- Andreas Bayer
- Kurt Semm Center for Minimally Invasive and Robotic Surgery, Center of Clinical Anatomy, Institute of Anatomy, Kiel University, 24098 Kiel, Germany; (A.B.); (T.H.)
| | - Tillmann Heinze
- Kurt Semm Center for Minimally Invasive and Robotic Surgery, Center of Clinical Anatomy, Institute of Anatomy, Kiel University, 24098 Kiel, Germany; (A.B.); (T.H.)
| | - Ibrahim Alkatout
- Kurt Semm Center for Minimally Invasive and Robotic Surgery, Department of Obstetrics and Gynecology, Campus Kiel, University Hospital Schleswig Holstein, 24105 Kiel, Germany
- Correspondence: (I.A.); (T.W.); Tel.: +49-431-500-21450 (I.A.); +49-431-880-2489 (T.W.)
| | - Daniar Osmonov
- Kurt Semm Center for Minimally Invasive and Robotic Surgery, Department of Urology, Campus Kiel, University Hospital Schleswig Holstein, 24105 Kiel, Germany;
| | - Sigmar Stelzner
- Department of General Surgery, Hospital Dresden-Friedrichstadt, 01067 Dresden, Germany;
| | - Thilo Wedel
- Kurt Semm Center for Minimally Invasive and Robotic Surgery, Center of Clinical Anatomy, Institute of Anatomy, Kiel University, 24098 Kiel, Germany; (A.B.); (T.H.)
- Correspondence: (I.A.); (T.W.); Tel.: +49-431-500-21450 (I.A.); +49-431-880-2489 (T.W.)
| |
Collapse
|
12
|
Buderath P, Rusch P, Mach P, Kimmig R. Cancer field surgery in endometrial cancer: peritoneal mesometrial resection and targeted compartmental lymphadenectomy for locoregional control. J Gynecol Oncol 2020; 32:e7. [PMID: 33185048 PMCID: PMC7767647 DOI: 10.3802/jgo.2021.32.e7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/01/2020] [Indexed: 02/08/2023] Open
Abstract
Objective Peritoneal mesometrial resection (PMMR) plus targeted compartmental lymphadenectomy (TCL) aims at removal of the locoregional cancer field in endometrial cancer (EC). Optimal locoregional control without adjuvant radiotherapy and acceptable surgical morbidity should be achieved concomitantly sparing systematic lymphadenectomy (LNE) for most of the patients. Methods We evaluated data from 132 patients treated for EC. Out of these, between January 2017 and June 2020 we performed robotic PMMR and TCL on 51 women. We present the first data of feasibility and safety of the procedure as well as preliminary oncological results. Results The 51 patients treated with robotic PMMR and TCL showed comparable morbidity to classic laparoscopic hysterectomy or PMMR without LNE. One intraoperative complication occurred. Postoperative complications grade 3 and higher occurred in 2 cases (3.9%). One of these (85 years old) experienced grade 5 following pulmonary embolism with lysis therapy. Fifteen patients (29.4%) could be spared complete LNE. The rate of adjuvant radiotherapy was 3.9% in our collective (n=2), compared to 39.2% of patients (n=20) eligible for irradiation according to international guidelines. In a mean follow-up time of 15 months (0–41), no locoregional recurrences were observed, although three patients showed distant relapse. Conclusions Our data suggest that robotic PMMR and pelvic TCL can be performed regardless of BMI and comorbidities without a relevant increase in surgical morbidity. Moreover, despite a relevant reduction of adjuvant radiotherapy, first follow-up data hint at a favorable locoregional recurrence rate in the reported cohort.
Collapse
Affiliation(s)
- Paul Buderath
- West German Cancer Center, Department for Gynaecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
| | - Peter Rusch
- West German Cancer Center, Department for Gynaecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Pawel Mach
- West German Cancer Center, Department for Gynaecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Rainer Kimmig
- West German Cancer Center, Department for Gynaecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
13
|
Wolf B, Espig O, Stolzenburg JU, Horn LC, Aktas B, Höckel M. Preservation of the mesureter to reduce urinary complications: analysis of data from the observational Leipzig School MMR study. BJOG 2020; 127:859-865. [PMID: 32037645 DOI: 10.1111/1471-0528.16167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the feasibility and effect of mesureteral preservation on urinary complications in the context of total mesometrial resection (TMMR), a surgical treatment for cervical cancer. DESIGN Retrospective cohort study with historic control. SETTING Single tertiary academic centre. POPULATION Women older than 18 with primary cervical cancer staged FIGO IB1-IIB enrolled in the prospective Leipzig School MMR study and underwent total mesometrial resection (TMMR) without adjuvant radiation. METHOD We retrospectively analysed 100 consecutive TMMR procedures which were performed for cancer of the uterine cervix and in which the mesureter was preserved (intervention group, 01/2014-06/2017). We compared this group with the previous 100 consecutive TMMRs, which were performed before the introduction of mesureteral preservation (control group, 09/2010-01/2014). MAIN OUTCOME MEASURES The occurrence of urological and specifically ureteral complications. RESULTS Mesureteral preservation was feasible and was associated with a significant decrease in ureteral complications (11% without mesureteral preservation versus 3% with mesureteral preservation, P = 0.049). Furthermore, we found a significant decrease in the number of postoperative percutaneous nephrostomies and re-operations (7% versus none, P = 0.014). There was also a trend towards a decrease in other urinary complications such as postoperative bladder atony and uretero-vaginal fistulas. CONCLUSION The mesureter constitutes a convenient dissection plane enabling the preservation of lateral ureteral blood supply during TMMR. In our study, maintenance of mesureteral integrity was associated with a significant reduction in ureteral complications. Mesureteral preservation might also be useful in other types of pelvic surgeries that carry a high risk of ureteral damage. TWEETABLE ABSTRACT Surgical preservation of the mesureter in cervical cancer patients was associated with a reduction in urinary complications.
Collapse
Affiliation(s)
- B Wolf
- Department of Gynaecology, University Hospital Leipzig, Leipzig, Germany
| | - O Espig
- Department of Urology, University Hospital Leipzig, Leipzig, Germany
| | - J-U Stolzenburg
- Department of Urology, University Hospital Leipzig, Leipzig, Germany
| | - L-C Horn
- Division of Gynaecologic, Breast, and Perinatal Pathology, University Hospital Leipzig, Leipzig, Germany
| | - B Aktas
- Department of Gynaecology, University Hospital Leipzig, Leipzig, Germany
| | - M Höckel
- Department of Gynaecology, University Hospital Leipzig, Leipzig, Germany
| |
Collapse
|
14
|
Horn LC, Brambs CE, Opitz S, Ulrich UA, Höhn AK. [The 2019 FIGO classification for cervical carcinoma-what's new?]. DER PATHOLOGE 2019; 40:629-635. [PMID: 31612260 DOI: 10.1007/s00292-019-00675-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Numerous therapeutic and prognostic studies of cervical carcinoma have necessitated a revision of the FIGO classification.For microinvasive carcinomas, the horizontal dimension is no longer considered and diagnosis and staging will solely be made by the depth of cervical stromal invasion. Lymphovascular invasion beyond the deepest point of stromal infiltration by tumor cells does not alter the stage.There will be a new subclassification of macroinvasive carcinoma confined to the uterine cervix, which will be made by largest tumor extension as follows: FIGO IB1/T1b1 - invasive carcinoma >0.5 cm depth of stromal invasion and ≤2 cm in largest dimension, FIGO IBII/T1b2: - invasive carcinoma >2 cm and ≤4 cm, FIGO IBII/T1b3 - invasive carcinoma >4 cm. Pelvic as well as para-aortic lymph nodes will be defined as regional nodes. Pelvic lymph node metastases only will be categorised as FIGO IIIC1/pN1a and para-aortic lymph node involvement with or without concomitant pelvic involvement will be FIGO IIIC2/pN1b. Uterine corpus as well as adnexal involvement are not relevant for staging purpose.
Collapse
Affiliation(s)
- L-C Horn
- Arbeitsgruppe Mamma‑, Gynäko- & Perinatalpathologie, Institut für Pathologie, Universitätsklinikum Leipzig AöR, Liebigstraße 26, 04103, Leipzig, Deutschland.
| | - C E Brambs
- Frauenklinik des Klinikums rechts der Isar, Technische Universität München, München, Deutschland
| | - S Opitz
- Arbeitsgruppe Mamma‑, Gynäko- & Perinatalpathologie, Institut für Pathologie, Universitätsklinikum Leipzig AöR, Liebigstraße 26, 04103, Leipzig, Deutschland
| | - U A Ulrich
- Klinik für Gynäkologie und Geburtshilfe, Martin-Luther-Krankenhaus, Berlin, Deutschland
| | - A K Höhn
- Arbeitsgruppe Mamma‑, Gynäko- & Perinatalpathologie, Institut für Pathologie, Universitätsklinikum Leipzig AöR, Liebigstraße 26, 04103, Leipzig, Deutschland
| |
Collapse
|
15
|
Kanno K, Andou M, Yanai S, Toeda M, Nimura R, Ichikawa F, Teishikata Y, Shirane T, Sakate S, Kihira T, Hamasaki Y, Sawada M, Shirane A, Ota Y. Long-term oncological outcomes of minimally invasive radical hysterectomy for early-stage cervical cancer: A retrospective, single-institutional study in the wake of the LACC trial. J Obstet Gynaecol Res 2019; 45:2425-2434. [PMID: 31502349 DOI: 10.1111/jog.14116] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/25/2019] [Indexed: 12/11/2022]
Abstract
AIM The objective of this study was to investigate the long-term oncological outcomes of minimally invasive radical hysterectomy (MIRH) for the treatment of early-stage cervical cancer retrospectively in the wake of the laparoscopic approach to cervical cancer (LACC) trial. METHODS A total of 109 patients with stage IA1 with lymphovascular space involvement, IA2, and IB1 cervical cancers were included in this study. The surgical and oncological outcomes were retrospectively evaluated. All patients underwent type C MIRH with a no-touch isolation technique for cervical tumor. RESULTS The median number of resected pelvic lymph nodes was 36 (range, 14-94), and 10 patients (9.2%) had positive nodes. One patient (0.9%) had positive surgical margins. Forty-six patients (42%) underwent adjuvant therapy. The median follow-up time was 73 months (range, 30-146 months). Five patients (4.6%) developed recurrent disease, and 3 patients (2.8%) died of cervical cancer. The 5-year disease-free survival and overall survival rates were 96.3% and 97.2%, respectively. A comparison between patients with tumor diameter ≤ 2 cm (n = 59) and those with tumor diameter > 2 cm (n = 50) did not identify any significant differences, with 5-year disease-free survival 96.6% versus 94.0% and 5-year overall survival 98.3% versus 96.0%, respectively. CONCLUSION In this retrospective study, MIRH with a no-touch isolation technique for stage IA to IB1 cervical cancer was a safe approach in terms of oncological outcomes. However, every surgeon who treats early-stage cervical cancer should inform each patient of the results of the LACC trial because it has an exceedingly high impact.
Collapse
Affiliation(s)
- Kiyoshi Kanno
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Masaaki Andou
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Shiori Yanai
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Mitsuru Toeda
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Ryo Nimura
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Fuyuki Ichikawa
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Yasuhiro Teishikata
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Terumi Shirane
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Shintaro Sakate
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Tomohisa Kihira
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Yoichiro Hamasaki
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Mari Sawada
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Akira Shirane
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Yoshiaki Ota
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| |
Collapse
|
16
|
Kubitschke H, Wolf B, Morawetz E, Horn LC, Aktas B, Behn U, Höckel M, Käs J. Roadmap to Local Tumour Growth: Insights from Cervical Cancer. Sci Rep 2019; 9:12768. [PMID: 31484955 PMCID: PMC6726627 DOI: 10.1038/s41598-019-49182-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 08/21/2019] [Indexed: 12/25/2022] Open
Abstract
Wide tumour excision is currently the standard approach to surgical treatment of solid cancers including carcinomas of the lower genital tract. This strategy is based on the premise that tumours exhibit isotropic growth potential. We reviewed and analysed local tumour spreading patterns in 518 patients with cancer of the uterine cervix who underwent surgical tumour resection. Based on data obtained from pathological examination of the surgical specimen, we applied computational modelling techniques to simulate local tumour spread in order to identify parameters influencing preferred infiltration patterns and used area-proportional Euler diagrams to detect and confirm ordered patterns of tumour spread. Some anatomical structures, e.g. tissues of the urinary bladder, were significantly more likely to be infiltrated than other structures, e.g. the ureter and the rectum. Computational models assuming isotropic growth could not explain these infiltration patterns. Introducing ontogenetic distance of a tissue relative to the uterine cervix as a parameter led to accurate predictions of the clinically observed infiltration likelihoods. The clinical data indicates that successive infiltration likelihoods of ontogenetically distant tissues are nearly perfect subsets of ontogenetically closer tissues. The prevailing assumption of isotropic tumour extension has significant shortcomings in the case of cervical cancer. Rather, cervical cancer spread seems to follow ontogenetically defined trajectories.
Collapse
Affiliation(s)
- Hans Kubitschke
- Peter Debye Institute for Soft Matter Physics, Leipzig University, Leipzig, Germany
| | - Benjamin Wolf
- Department of Gynecology, Women's and Children's Centre, University Hospital Leipzig, Leipzig, Germany.,Leipzig School of Radical Pelvic Surgery, Leipzig University, Leipzig, Germany
| | - Erik Morawetz
- Peter Debye Institute for Soft Matter Physics, Leipzig University, Leipzig, Germany
| | - Lars-Christian Horn
- Division of Gynecologic, Breast and Perinatal Pathology, University Hospital Leipzig, Leipzig, Germany
| | - Bahriye Aktas
- Department of Gynecology, Women's and Children's Centre, University Hospital Leipzig, Leipzig, Germany.,Leipzig School of Radical Pelvic Surgery, Leipzig University, Leipzig, Germany
| | - Ulrich Behn
- Institute of Theoretical Physics, Leipzig University, Leipzig, Germany
| | - Michael Höckel
- Department of Gynecology, Women's and Children's Centre, University Hospital Leipzig, Leipzig, Germany.,Leipzig School of Radical Pelvic Surgery, Leipzig University, Leipzig, Germany
| | - Josef Käs
- Peter Debye Institute for Soft Matter Physics, Leipzig University, Leipzig, Germany.
| |
Collapse
|
17
|
Raspagliesi F, Bogani G. Radical surgery for cervical cancer. Lancet Oncol 2019; 20:1198-1199. [PMID: 31383546 DOI: 10.1016/s1470-2045(19)30409-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 06/06/2019] [Accepted: 06/07/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Francesco Raspagliesi
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan 20133, Italy.
| | - Giorgio Bogani
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan 20133, Italy
| |
Collapse
|
18
|
Höckel M, Wolf B, Schmidt K, Mende M, Aktas B, Kimmig R, Dornhöfer N, Horn LC. Surgical resection based on ontogenetic cancer field theory for cervical cancer: mature results from a single-centre, prospective, observational, cohort study. Lancet Oncol 2019; 20:1316-1326. [PMID: 31383547 DOI: 10.1016/s1470-2045(19)30389-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/14/2019] [Accepted: 05/21/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous findings from our centre suggest that carcinoma of the cervix propagates within ontogenetic cancer fields, tissue compartments defined by staged morphogenesis. We aimed to determine whether surgical treatment that accounts for stage-associated, ontogenetic cancer fields and their associated lymphoid tissues results in locoregional tumour control without the need for adjuvant radiotherapy. METHODS We did the final clinical and histopathological evaluation of data from, the single-centre, observational, cohort study, the Leipzig School Mesometrial Resection Study. Patients of any age with stage IB1, IB2, IIA1, IIA2, or IIB cervical cancer (according to 2009 International Federation of Gynecology and Obstetrics [FIGO]) had total mesometrial resection or extended mesometrial resection and therapeutic lymph node dissection, done on the basis of ontogenetic cancer fields. We defined sentinel node, first-line, second-line, and third-line lymph node regions as progressive regional cancer fields. Primary outcomes were disease-specific survival and recurrence-free survival, and treatment-related morbidity (assessed with the Franco-Italian glossary). Applying Cox proportional hazard models, ontogenetic local (T) and regional (N) tumour staging was compared with pathological T and N staging. This trial is registered with the German Clinical Trials Register, number DRKS00015171. FINDINGS Between Oct 16, 1999, and June 27, 2017, 523 patients were treated per protocol and followed up for a median of 61·8 months (IQR 49·3-94·8). In 495 patients with cervical cancer treated with cancer field surgery, 5-year disease-specific survival was 89·4% (95% CI 86·5-92·4) and recurrence-free survival was 83·1% (79·7-86·6). In the per-protocol population of 523 patients, treatment-related morbidity comprised 112 (21%) grade 2 and 15 (3%) grade 3 complications. The most common moderate and severe treatment-related complications and sequelae were wound dehiscence (17 [3%]), hydronephrosis (17 [3%]), bowel obstruction (26 [5%]), and lymph oedema (33 [6%]). One patient (<1%), who received total mesometrial resection, died from postoperative brain infarction. INTERPRETATION Total or extended mesometrial resection with therapeutic lymph node dissection based on ontogenetic cancer fields results in good survival outcomes of patients with cervical cancer in our institution, but needs to be investigated further in multicentre trials. FUNDING Leipzig School of Radical Pelvic Surgery, University of Leipzig Medical School, and the Gynecologic Oncology Research Foundation.
Collapse
Affiliation(s)
- Michael Höckel
- Leipzig School of Radical Pelvic Surgery, University of Leipzig, Leipzig, Germany; Department of Gynecology and Obstetrics, University of Essen, Essen, Germany; Department of Gynecology and Obstetrics, Technical University of Munich, Munich, Germany.
| | - Benjamin Wolf
- Department of Gynecology and Obstetrics, University of Leipzig, Leipzig, Germany
| | - Katja Schmidt
- Institute of Anatomy, University of Leipzig, Leipzig, Germany
| | - Meinhard Mende
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Bahriye Aktas
- Department of Gynecology and Obstetrics, University of Leipzig, Leipzig, Germany
| | - Rainer Kimmig
- Department of Gynecology and Obstetrics, University of Essen, Essen, Germany
| | - Nadja Dornhöfer
- Department of Gynecology and Obstetrics, University of Leipzig, Leipzig, Germany
| | - Lars-Christian Horn
- Division of Breast, Gynecological and Perinatal Pathology, University of Leipzig, Leipzig, Germany
| |
Collapse
|
19
|
Höckel M, Behn U. The Order of Cancer: A Theory of Malignant Progression by Inverse Morphogenesis. Front Oncol 2019; 9:416. [PMID: 31192124 PMCID: PMC6548852 DOI: 10.3389/fonc.2019.00416] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 05/02/2019] [Indexed: 01/15/2023] Open
Abstract
Local spread patterns of malignant tumors follow permissive tissue territories, i.e., cancer fields, as shown for cervical and vulvar carcinoma. The cancer fields are associated in reverse order to the mature derivatives of the morphogenetic fields instrumental in the stepwise development of the tissue from which the tumor arose. This suggests that cancer progression may be linked to morphogenesis by inversion of the cellular bauplan sequence. Successive attractor transitions caused by proliferation-associated constraints of topobiological information processing are proposed for both morphogenesis and cancer. In morphogenesis these transitions sequentially activate bauplans with increasing complexity at decreasing plasticity restricting the permissive territories of the progenitor cell populations. Somatic mutations leading to cell proliferation in domains normally reserved for differentiation trigger the inverse cascade of bauplan changes that increase topobiological plasticity at decreased complexity and stepwise enlarge the permissive territory of neoplastic cells consistent with the clinical manifestations of cancer. The order provided by the sequence of attractor transitions and the defined topography of the permissive territories can be exploited for more accurate tumor staging and for locoregional tumor treatment either by surgery or radiotherapy with higher curative potential.
Collapse
Affiliation(s)
- Michael Höckel
- Department of Gynecology, Women's and Children's Center, University of Leipzig, Leipzig, Germany.,Leipzig School of Radical Pelvic Surgery, University of Leipzig, Leipzig, Germany.,Department of Gynecology and Obstetrics, University of Essen, Essen, Germany
| | - Ulrich Behn
- Faculty of Physics and Earth Sciences, Institute of Theoretical Physics, University of Leipzig, Leipzig, Germany
| |
Collapse
|
20
|
Höckel M, Trott S, Dornhöfer N, Horn LC, Hentschel B, Wolf B. Vulvar field resection based on ontogenetic cancer field theory for surgical treatment of vulvar carcinoma: a single-centre, single-group, prospective trial. Lancet Oncol 2018. [PMID: 29530664 DOI: 10.1016/s1470-2045(18)30109-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The incidence of vulvar cancer is increasing, but surgical treatment-the current standard of care-often leads to unsatisfactory outcomes, especially in patients with node-positive disease. Preliminary results at our centre showed that locoregional spread of vulvar carcinoma occurs within tissue domains defined by stepwise embryonic and fetal development (ontogenetic cancer fields and associated lymph node regions). We propose that clinical translation of these insights into practice could improve outcomes of surgical treatment of vulvar cancer. METHODS We did a single-centre prospective trial at the University of Leipzig's Cancer Center. Eligible patients were aged 18 years or older, had ontogenetic stage 1-3b histologically proven primary carcinoma of the vulva, and had not undergone previous surgical or radiotherapy treatment for vulvar cancer or any other major perineal or pelvic disease. In view of staged morphogenesis of the vulva from the cloacal membrane endoderm at Carnegie stage 11 to adulthood, we defined the tissue domains of tumour spread according to the theory of ontogenetic cancer fields. On the basis of ontogenetic staging, patients were treated locally with partial, total, or extended vulvar field resection; regionally with therapeutic inguinopelvic lymph node dissection; and anatomical reconstruction without adjuvant radiotherapy. The primary endpoints were recurrence-free survival, disease-specific survival, and early postoperative complications. Analysis of tumour spread and early postoperative surgical complications was done by intention to treat (ie, all patients were included), whereas outcome analyses were done per protocol. This ongoing trial is registered with the German Clinical Trials Register, number DRKS00013358. FINDINGS Between March 1, 2009, and June 8, 2017, 97 consecutive patients were included in the study, of whom 94 were treated per protocol with vulvar field resection, therapeutic inguinopelvic lymph node dissection, and anatomical reconstruction without adjuvant radiotherapy. 46 patients had moderate or severe postoperative complications, especially infectious perineal and inguinal wound dehiscence. 3-year recurrence-free survival in all patients was 85·1% (95% CI 76·9-93·3), and 3-year disease-specific survival was 86·0% (78·2-93·8). INTERPRETATION Our results support the theory of ontogenetic cancer fields for vulvar carcinoma, accord with our previous findings in cervical cancer, and suggest the general applicability of the theory. Application of the concept of cancer field resection could improve outcomes in patients with vulvar carcinoma, but needs to be investigated further in multicentre randomised controlled trials. FUNDING Leipzig School of Radical Pelvic Surgery and Gynecologic Oncology Research Foundation.
Collapse
Affiliation(s)
- Michael Höckel
- Department of Gynecology, Women's and Children's Center, University of Leipzig, Leipzig, Germany; Leipzig School of Radical Pelvic Surgery, University of Leipzig, Leipzig, Germany.
| | - Sophia Trott
- Department of Gynecology, Women's and Children's Center, University of Leipzig, Leipzig, Germany
| | - Nadja Dornhöfer
- Department of Gynecology, Women's and Children's Center, University of Leipzig, Leipzig, Germany
| | - Lars-Christian Horn
- Division of Breast, Gynecological and Perinatal Pathology, Institute of Pathology, University of Leipzig, Leipzig, Germany
| | - Bettina Hentschel
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Benjamin Wolf
- Department of Gynecology, Women's and Children's Center, University of Leipzig, Leipzig, Germany
| |
Collapse
|
21
|
Steinke H, Wiersbicki D, Speckert ML, Merkwitz C, Wolfskämpf T, Wolf B. Periodic acid-Schiff (PAS) reaction and plastination in whole body slices. A novel technique to identify fascial tissue structures. Ann Anat 2017; 216:29-35. [PMID: 29146471 DOI: 10.1016/j.aanat.2017.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 09/21/2017] [Accepted: 10/23/2017] [Indexed: 01/25/2023]
Abstract
Since collagen rich fascial tissue is often very delicate and difficult to discern on native tissue slices, we have developed a method for staining full-body slices using the periodic acid-Schiff (PAS) reaction with subsequent plastination. Since the PAS reaction primarily stains carbohydrates, we could exploit the circumstance that different collagen types vary in carbohydrate content. Contrary to fasciae, tissues such as muscle, bone, nerves and blood vessels exhibit significantly less staining or remain unstained. We have validated the whole-body slice staining results in microscopic tissue slides which were stained with standard extracellular matrix stains such as Masson-Goldner trichrome stain and van-Gieson stain. Furthermore, we have performed immunofluorescence imaging to confirm the presence of collagen in the stained tissue. We achieved very good staining and plastination results and were able to clearly identify even very thin fascia in transversal body slices. This technique may prove useful in advancing our knowledge on the complex topography of fascial structures.
Collapse
Affiliation(s)
- Hanno Steinke
- Institute for Anatomy, Leipzig University, Liebigstr. 13, D-04103 Leipzig, Germany.
| | - Dina Wiersbicki
- Institute for Anatomy, Leipzig University, Liebigstr. 13, D-04103 Leipzig, Germany
| | - Marie-Lynn Speckert
- Institute for Anatomy, Leipzig University, Liebigstr. 13, D-04103 Leipzig, Germany
| | - Claudia Merkwitz
- Institute for Anatomy, Leipzig University, Liebigstr. 13, D-04103 Leipzig, Germany
| | - Thomas Wolfskämpf
- Institute for Anatomy, Leipzig University, Liebigstr. 13, D-04103 Leipzig, Germany
| | - Benjamin Wolf
- Department of Obstetrics and Gynecology, Women and Children Center, University Hospital Leipzig, Liebigstr. 20a, D-04103 Leipzig, Germany
| |
Collapse
|
22
|
Valentini AL, Gui B, Miccò M, Giuliani M, Rodolfino E, Ninivaggi V, Iacobucci M, Marino M, Gambacorta MA, Testa AC, Zannoni GF, Bonomo L. MRI anatomy of parametrial extension to better identify local pathways of disease spread in cervical cancer. Diagn Interv Radiol 2017; 22:319-25. [PMID: 27165471 DOI: 10.5152/dir.2015.15282] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This paper highlights an updated anatomy of parametrial extension with emphasis on magnetic resonance imaging (MRI) assessment of disease spread in the parametrium in patients with locally advanced cervical cancer. Pelvic landmarks were identified to assess the anterior and posterior extensions of the parametria, besides the lateral extension, as defined in a previous anatomical study. A series of schematic drawings and MRI images are shown to document the anatomical delineation of disease on MRI, which is crucial not only for correct image-based three-dimensional radiotherapy but also for the surgical oncologist, since neoadjuvant chemoradiotherapy followed by radical surgery is emerging in Europe as a valid alternative to standard chemoradiation.
Collapse
Affiliation(s)
- Anna Lia Valentini
- Department of Radiological Sciences, Institute of Radiology, Catholic University of Sacred Heart, Rome, Italy.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Wolf B, Ganzer R, Stolzenburg JU, Hentschel B, Horn LC, Höckel M. Extended mesometrial resection (EMMR): Surgical approach to the treatment of locally advanced cervical cancer based on the theory of ontogenetic cancer fields. Gynecol Oncol 2017; 146:292-298. [PMID: 28526168 DOI: 10.1016/j.ygyno.2017.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/05/2017] [Accepted: 05/07/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Based on ontogenetic-anatomic considerations, we have introduced total mesometrial resection (TMMR) and laterally extended endopelvic resection (LEER) as surgical treatments for patients with cancer of the uterine cervix FIGO stages I B1 - IV A. For a subset of patients with locally advanced disease we have sought to develop an operative strategy characterized by the resection of additional tissue at risk for tumor infiltration as compared to TMMR, but less than in LEER, preserving the urinary bladder function. METHODS We conducted a prospective single center study to evaluate the feasibility of extended mesometrial resection (EMMR) and therapeutic lymph node dissection as a surgical treatment approach for patients with cervical cancer fixed to the urinary bladder and/or its mesenteries as determined by intraoperative evaluation. None of the patients received postoperative adjuvant radiotherapy. RESULTS 48 consecutive patients were accrued into the trial. Median tumor size was 5cm, and 85% of all patients were found to have lymph node metastases. Complete tumor resection (R0) was achieved in all cases. Recurrence free survival at 5years was 54.1% (95% CI 38.3-69.9). The overall survival rate was 62.6% (95% CI 45.6-79.6) at 5years. Perioperative morbidity represented by grade II and III complications (determined by the Franco-Italian glossary) occurred in 25% and 15% of patients, respectively. CONCLUSION We demonstrate in this study the feasibility of EMMR as a surgical treatment approach for patients with locally advanced cervical cancer and regional lymph node invasion without the necessity for postoperative adjuvant radiation.
Collapse
Affiliation(s)
- Benjamin Wolf
- Department of Gynecology, Leipzig University Hospital, Leipzig, Germany
| | - Roman Ganzer
- Department of Urology, Leipzig University Hospital, Leipzig, Germany
| | | | - Bettina Hentschel
- Institute for Medical Statistics and Epidemiology, Leipzig University, Leipzig, Germany
| | | | - Michael Höckel
- Department of Gynecology, Leipzig University Hospital, Leipzig, Germany.
| |
Collapse
|
24
|
Höckel M, Wolf B, Hentschel B, Horn LC. Surgical treatment and histopathological assessment of advanced cervicovaginal carcinoma: A prospective study and retrospective analysis. Eur J Cancer 2017; 70:99-110. [DOI: 10.1016/j.ejca.2016.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 10/07/2016] [Accepted: 10/10/2016] [Indexed: 11/25/2022]
|
25
|
Kyo S, Kato T, Nakayama K. Current concepts and practical techniques of nerve-sparing laparoscopic radical hysterectomy. Eur J Obstet Gynecol Reprod Biol 2016; 207:80-88. [PMID: 27825032 DOI: 10.1016/j.ejogrb.2016.10.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/29/2016] [Accepted: 10/21/2016] [Indexed: 12/26/2022]
Abstract
Laparoscopic radical hysterectomy has been widely performed for patients with early-stage cervical cancer. The operative techniques for nerve-sparing to avoid bladder dysfunction have been established during the past three decades in abdominal radical hysterectomy, but how these techniques can be applied to laparoscopic surgery has not been fully discussed. Prolonged operation time or decreased radicality due to less accessibility via a limited number of trocars may be a disadvantage of the laparoscopic approach, but the magnified visual field in laparoscopy may enable fine manipulation, especially for preserving autonomic nerve tracts. The present review article introduces the practical techniques for sparing bladder branches of pelvic nerves in laparoscopic radical hysterectomy based on understanding of the pelvic anatomy, clearly focusing on the differences from the techniques in abdominal hysterectomy.
Collapse
Affiliation(s)
- Satoru Kyo
- Department of Obstetrics and Gynecology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane 693-8501, Japan.
| | - Tomoyasu Kato
- Department of Gynecologic, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Kentaro Nakayama
- Department of Obstetrics and Gynecology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane 693-8501, Japan
| |
Collapse
|
26
|
Vizzielli G, Lucidi A, Gallotta V, Petrillo M, Dessole M, Fagotti A, Costantini B, Scambia G, Chiantera V. Robotic Total Mesometrial Resection versus Laparoscopic Total Mesometrial Resection in Early Cervical Cancer: A Case-Control Study. J Minim Invasive Gynecol 2016; 23:804-9. [DOI: 10.1016/j.jmig.2016.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/08/2016] [Accepted: 04/08/2016] [Indexed: 10/21/2022]
|
27
|
Santiago IA, Gomes AP, Heald RJ. An ontogenetic approach to gynecologic malignancies. Insights Imaging 2016; 7:329-39. [PMID: 27084346 PMCID: PMC4877347 DOI: 10.1007/s13244-016-0480-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 01/31/2016] [Accepted: 02/04/2016] [Indexed: 12/17/2022] Open
Abstract
Abstract Ontogenetic anatomy is the mapping of body compartments established during early embryologic development, particularly well demarcated in the adult pelvis. Traditional cancer surgery is based on wide tumour excision with a safe margin, whereas the ontogenetic theory of local tumour spread claims that local dissemination is facilitated in the ontogenetic compartment of origin, but suppressed at its borders in the early stages of cancer development. Optimal local control of cancer is achieved by whole compartment resection with intact margins following ontogenetic “planes”. The principles embodied in this hypothesis are most convincingly supported by the results of the implementation of total mesorectal excision in rectal cancer, and more recently, by innovative surgical approaches to gynaecologic malignancies. The high resolution contrast of MR, accurately delineating pelvic fascial compartments, makes it the best imaging modality for gynaecologic cancer surgery planning following these principles, but requires interpretation of imaging anatomy from a different perspective. Teaching Points • Ontogenetic anatomy refers to mapping of embryologically determined body compartments. • Ontogenetic theory claims tumour growth is not isometrical, but rather compartment permissive. • Ontogenetic principles are highly supported by the outcome results of total mesorectal excision. • Innovative gynaecologic cancer surgery approaches based on ontogenetic theory show promising results.
Collapse
Affiliation(s)
- Inês A Santiago
- Radiology Department, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal.
| | - António P Gomes
- B Surgery Department, Hospital Fernando Fonseca, E.P.E., IC19, 2720-276, Amadora, Portugal
| | - Richard J Heald
- Colorectal Surgery Department, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| |
Collapse
|
28
|
Kimmig R, Aktas B, Buderath P, Rusch P, Heubner M. Intraoperative navigation in robotically assisted compartmental surgery of uterine cancer by visualisation of embryologically derived lymphatic networks with indocyanine-green (ICG). J Surg Oncol 2016; 113:554-9. [PMID: 26792025 PMCID: PMC6221053 DOI: 10.1002/jso.24174] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/06/2016] [Indexed: 01/27/2023]
Abstract
Background and Objectives To evaluate feasibility of intraoperative visualization of embryologically defined organ compartments and their drainage by ICG in uterine cancer. Methods Total of 2.5 mg of ICG have been injected into cervix or corpus in uterine cancer patients immediately prior to surgery. Green fluorescence was intermittently detected during robotically assisted laparoscopic surgery (Firefly System®, Intuitve Surgical Inc.). Total of 36 patients with uterine cancer without macroscopically suspicious nodes were evaluated with respect to their compartmental lymphatic network, collecting lymphatic vessels, and the connection to the postponed lymph basins. Results Müllerian (sub) compartment and transport of lymph fluid along the lymphatic collectors and connecting vessels to the postponed lymph basins could be visualized invariably in all patients. Cervix drained along the ligamentous and caudal part of vascular mesometria, whereas midcorporal and fundal drainage occurred along the upper part of vascular mesometria and along the mesonephric pathway along the ovarian vessels. Conclusions Visualization of lymphatic network and downstream flow of lymphatic fluid to the postponed lymph basins by ICG is feasible; it can be used to navigate along compartment boarders for education, intraoperative orientation, and quality control. It seems to confirm the compartmental order of pelvic organ systems and postponed lymph basins. J. Surg. Oncol. 2016;113:554–559. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Rainer Kimmig
- Department of Gynecology and Obstetrics, West-German Tumor Center, University of Duisburg-Essen, Essen, Germany
| | - Bahriye Aktas
- Department of Gynecology and Obstetrics, West-German Tumor Center, University of Duisburg-Essen, Essen, Germany
| | - Paul Buderath
- Department of Gynecology and Obstetrics, West-German Tumor Center, University of Duisburg-Essen, Essen, Germany
| | - Peter Rusch
- Department of Gynecology and Obstetrics, West-German Tumor Center, University of Duisburg-Essen, Essen, Germany
| | - Martin Heubner
- Department of Gynecology and Obstetrics, West-German Tumor Center, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
29
|
Embryologically based radical hysterectomy as peritoneal mesometrial resection (PMMR) with pelvic and para-aortic lymphadenectomy for loco-regional tumor control in endometrial cancer: first evidence for efficacy. Arch Gynecol Obstet 2015; 294:153-60. [PMID: 26596725 PMCID: PMC4908154 DOI: 10.1007/s00404-015-3956-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/02/2015] [Indexed: 01/06/2023]
Abstract
Objective To evaluate the feasibility and efficacy of embryologically based compartmental surgery for locoregional tumor control in intermediate and high risk endometrial cancer: peritoneal mesometrial resection with therapeutic pelvic and para-aortic lymphadenectomy by robotically assisted laparoscopy. Methods 75 consecutive surgically treated patients with uterine malignancies have been analyzed. 68 patients with histologically proven endometrial cancer and complete robotically assisted surgery have been included in this study on morbidity and oncological outcome. 56 % of the patients were at intermediate/high risk with either stage IAG3 or IB (n = 22) or stage II–IV (n = 16). Adjuvant EBRT was offered to three patients only (4 %), whereas five received isolated vaginal brachytherapy (7 %). Indocyanine-green (ICG) fluorescence lymphography is demonstrated being useful for additional intraoperative visualization of the compartment borders and lymphatic drainage to the postponed lymph compartments. Results After a mean follow-up of 32 months, there were only two loco-regional recurrences (2.9 %). Both recurrences were apparently cured by salvage therapy. 9 patients died; 6 (8.8 %) from metastatic disease (5) or unknown cause (1), 3 (4.4 %) from intercurrent disease without evidence of disease. One patient (1.4 %) experienced a peritoneal carcinosis and is alive. There were 8/68 perioperative complications (12 %). No perioperative mortality was observed. Conclusions Embryologically defined compartmental surgery by robotically assisted laparoscopy seems to be feasible and safe in endometrial cancer. The low loco-regional recurrence rate of 2.9 % in spite of a very low percentage of adjuvant radiotherapy and 56 % of intermediate/high risk tumors should stimulate to initiate a multicentre trial to evaluate the value of compartmental surgery for prevention of locoregional recurrence in endometrial cancer.
Collapse
|
30
|
Laparoscopic radical hysterectomy in cervical cancer as total mesometrial resection (L-TMMR): a multicentric experience. Gynecol Oncol 2015; 139:47-51. [PMID: 26166805 DOI: 10.1016/j.ygyno.2015.07.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To analyze the feasibility of total mesometrial resection by laparoscopy (L-TMMR) in a multicentric series of early stage cervical cancer. METHOD We prospectively evaluated a consecutive series of cervical cancer patients with pre-operative FIGO stages IA2-IB1 at the Catholic University in Rome and in Campobasso and the Charitè University in Berlin. All cases were assessed at pre-operative MRI scan and clinically confirmed by investigation under anesthesia, adhering strictly to the FIGO criteria. The surgical and post-surgical data were collected. RESULTS 104 women with cervical cancer were admitted between July 2013 and August 2014 and among them 71 patients with pre-operative FIGO stages IA2-IB1 were treated with L-TMMR. One laparotomic conversion was registered. The median operative time was 260min (120-670min), estimated blood loss was 100cm(3) (25-900cm(3)), and the median length of hospital stay was 6days (2-26days). We observed 8 intra-operative complications including a vascular injury of the left internal iliac vein that caused conversion, 6 vesical injuries and 1 ureteral injury managed laparoscopically. Two vescico-vaginal fistula and one hemoperitoneum were observed as major post-operative complications (4.2%). CONCLUSION L-TMMR can be safely performed in selected cervical cancer patients. Further larger prospective trials are needed to evaluate the oncological outcome of patients undergoing this surgical procedure.
Collapse
|
31
|
Kim HS, Kim TH, Suh DH, Kim SY, Kim MA, Jeong CW, Hong KS, Song YS. Success Factors of Laparoscopic Nerve-sparing Radical Hysterectomy for Preserving Bladder Function in Patients with Cervical Cancer: A Protocol-Based Prospective Cohort Study. Ann Surg Oncol 2015; 22:1987-1995. [DOI: 10.1245/s10434-014-4197-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
32
|
Krishnatreya M, Kataki AC, Sharma JD, Nandy P, Gogoi G. Association of Educational Levels with Survival in Indian Patients with Cancer of the Uterine Cervix. Asian Pac J Cancer Prev 2015; 16:3121-3. [DOI: 10.7314/apjcp.2015.16.8.3121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
33
|
|
34
|
Höckel M. Long-Term Experience with (Laterally) Extended Endopelvic Resection (LEER) in Relapsed Pelvic Malignancies. Curr Oncol Rep 2015; 17:435. [DOI: 10.1007/s11912-014-0435-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
35
|
Affiliation(s)
- Noriaki Sakuragi
- Department of Gynecology, Hokkaido University Graduate School of Medicine, North 15, West 7, Kita-ku, Sapporo, 060-8638, Japan.
| |
Collapse
|