Robot-assisted versus open radical hysterectomy: A multi-institutional experience for early-stage cervical cancer

OBJECTIVE

To compare perioperative and clinico-pathological outcomes of patients with early-stage cervical cancer who underwent robot-assisted radical hysterectomy (RRH) and open radical hysterectomy (ORH).

METHODS

This retrospective multi-center study abstracted demographic, clinico-pathological and perioperative outcomes data from medical records of 491 cervical cancer patients treated with RRH (n = 259) ORH (n = 232) between 2005 and 2011 at two American and one Norwegian University Cancer Centres.

RESULTS

Mean estimated blood loss (EBL) and transfusion rates were less for RRH than for ORH (97 vs. 49 mL, p < 0.001, and 3% vs. 7%, p = 0.018, respectively). Mean length of hospital stay (LOS) was significantly shorter in RRH versus ORH (1.8 vs. 5.1 days, p < 0.001). Mean operative time was longer for RRH than ORH (220 vs. 156 min, p < 0.001). Although overall complications were similar (p = 0.49), intra-operative complications were less common in the RRH group than ORH (4% vs. 10%, p = 0.004). In multivariate regression analyses longer operative time, less EBL and intra-operative complications, shorter LOS, and more pre-operative cone were significantly associated with RRH versus ORH. Recurrence and death rates were not statistically different for the two groups at a mean follow-up time of 39 months (p = 1.00 and p = 0.48, respectively).

CONCLUSIONS

RRH had improved clinical outcomes compared to ORH in the treatment of early-stage cervical cancer in terms of EBL, intra-operative complications, transfusion rates, LOS, and pre-operative cone. Disease recurrence and survival were comparable for the two procedures.

Primary peritoneal low-grade serous carcinoma forming a mass in the colon mimicking a colonic primary carcinoma: a case report

Primary carcinomas of Müllerian origin involving the colon is not an uncommon phenomenon, with most cases reportedly associated with endometriosis. On the other hand, a primary peritoneal low-grade serous carcinoma presenting as a dominant mass in the colon and causing clinical symptoms mimicking a primary colonic carcinoma has not been reported in the literature to the best of the authors' knowledge. A case of a 66-year-old female patient who presented clinically with rectal bleeding and a rectosigmoid mass is described. The final histologic examination revealed a peritoneal low-grade serous carcinoma forming a dominant mass in the rectosigmoid colon. Of particular interest was a microscopic spectrum of serous epithelial proliferation in the peritoneal cavity and lymph nodes with morphologic features reminiscent of non-invasive and invasive implants in ovarian borderline serous tumors, which most likely denoted the precursors of the tumor in the colon.

Correlation of extreme drug resistant assay results and progression-free survival following intraperitoneal chemotherapy for advanced ovarian cancer

The aim of this study was to determine if in vitro extreme drug resistance (EDR) to platinum and/or taxane chemotherapy was predictive of patient response to intraperitoneal (I.P.) chemotherapy in patients with stage III or recurrent epithelial ovarian cancer (EOC). Fifty-six patients were retrospectively identified who underwent optimal cytoreductive surgery for primary or recurrent eOC and then received at least three cycles of either intravenous (I.V.) or I.P. chemotherapy with platinum and paclitaxel-based chemotherapy. EDR to platinum and/or paclitaxel was determined using a commercially available assay (Oncotech, Inc., Tustin, CA). The primary outcome measure was progression-free survival (PFS). Twenty-nine (52%) patients received I.P. chemotherapy and 27 (48%) received I.V. chemotherapy. The patients were well matched in terms of age, stage, grade and histology. Ten (35%) patients in the I.OP. arm and ten (37%) patients in the I.V. arm showed EDR to either platinum and/or paclitaxel. Median PFS for all I.P. chemotherapy patients was 23 months, compared with 13 months for those receiving I.V. chemotherapy (p = 0.04). Patients with EDR to platinum and/or taxane who underwent I.V. chemotherapy had a median PFS of 13.5 months, whereas those who underwent I.P. treatment had a median PFS of 15 months (p = 0.69). Median overall survival had not been reached at the time of analysis.No significant difference in PFS was noted between patients who underwent I.P. and those who underwent I.V. chemotherapy when EDR was predicted to either platinum or paclitaxel or both. These data suggest that the decision to offer I.P. chemotherapy, with the attendant increase in morbidity, in the setting of EDR to platinum and/or taxane chemotherapy, may not be beneficial. Prospective studies, preferably analyzing platinum or taxane EDR individually, are required to validate these observations.

Robotic Surgery in Gynecology

Advanced laparoscopic procedures for gynecologic surgery have not been widely adopted in clinical practice despite nearly 20 years of improvements in laparoscopic technology. The da Vinci® robotic surgical system was cleared for use in gynecologic surgery in the U.S in 2005. Many surgeons have embraced da Vinci® technology over conventional laparoscopy because of its technologic advantages of wristed instrumentation, high definition 3-D optics, ergonomics, and autonomy of camera control. Furthermore, many surgeons with limited advanced laparoscopic skills have successfully converted their practice from primarily laparotomy to minimally invasive surgery using the da Vinci® System. The purpose of this article is to review the development of robotic procedures in gynecology through the current literature. This article reviews recent peer-reviewed literature concerning robotic-assisted laparoscopic procedures including hysterectomy, myomectomy, radical hysterectomy, pelvic and aortic lymphadenectomy, trachelectomy, parametrectomy, tubal anastamosis, sacrocolpopexy, and others. The majority of this literature consists of descriptive retrospective case series from the investigator's early experience; in fact these early reports represent innovation of a new operative technique. Some reports compare outcomes to open and standard laparoscopic procedures. Future prospective studies comparing complications, pain, return to routine activity, and long-term clinical outcomes with open and laparoscopic procedures will be necessary to completely appreciate the impact of robotic technology.

Molecular characterization of highly tumorigenic cell lines used in a xenograph model to investigate cellular therapy for the treatment of refractory ovarian cancer

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Background: Because current therapies for ovarian cancer (OC) have little impact on the long-term survival, there is a compelling need to develop innovative strategies. Our aim was to characterize OC cell lines which can be utilized to test cellular therapy in combination with cytokines or chemotherapies to elicit a graph versus tumor response to treat refractory OC patients. Methods: SKOV-3-RFP, a red fluorescent protein (RFP) expressing line, was passaged through nude mice to create more tumorigenic lines compared to parental SKOV-3 cells. Three SKOV-3-derived lines were established and characterized for IFNα-2b sensitivity, E-cadherinand CCN1gene expression, and STAT3 activation. The cells were grown in the presence of IFNα-2b to determine proliferative effects. Tumors were harvested when mice became moribund; ascitic fluid (AF) and solid tumor (ST) tissue were snap-frozen. Expression of E-cadherinand CCN1, which have been implicated to play role(s) in OC pathobiology, were analyzed in ST harvested from the mice and from SKOV3-derived lines (SKOV3-RFP, AF1, AF2, and AF3). We investigated the activation status in the SKOV3-derived cells of STAT3, which has been associated with malignant transformation and tumor progression. Results: Parental SKOV3-RFP cells when injected at a dose of 5x106 gave a tumor incidence of 4/6 in 14 weeks. AF1 and AF2, when injected at a dose of 1x106 resulted in 100% tumor incidence in 5-weeks (n = 5). These two lines were also more resistant to IFNα-2b compared to RFP. All SKOV3-derived lines and ST expressed E-cadherin by RT-PCR. None of the SKOV3-derived lines expressed CCN1; however, one of the two AF1 ST tested expressed CCN1. Both AF2 ST evaluated showed weak expression of CCN1. In vitro DNA-binding with electrophoretic mobility shift assay (EMSA), showed AF1 and AF3 cells harbor constitutively-active STAT3, whereas the RFP line does not. Conclusions: The SKOV3-derived lines that we developed will be a better model to test novel OC treatment regiments because these lines exhibit increased resistance to IFNα-2b, are more tumorigenic in a xenograph model, show aberrant STAT3 activation, and tumors harvested from these lines express genes that make these lines more aggressive.

No significant financial relationships to disclose.

Phase II trial of single-agent cetuximab in patients with persistent or recurrent epithelial ovarian or primary peritoneal carcinoma with the potential for dose escalation to rash

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Background: Data in other tumor types showed a correlation between severity of acneiform rash and cetuximab (Cet) response. This study evaluated if Cet dose escalation to cause Grade 2 rash correlated with anti-tumor activity and if sera-based markers could predict likelihood of response. Methods: A 2-stage design was used with 50 patients (pts) planned. Eligibility: persistent/recurrent ovarian or primary peritoneal carcinoma; up to 2 prior regimens, including 1 platinum/taxane-based regimen; ECOG PS = 2; measurable EGFR-positive tumors. Pts received an initial dose of Cet 400 mg/m2, then 250 mg/m2 weekly for two 3-week cycles. Pts who had SD and < Grade 2 rash were dose escalated in 75 mg/m2 increments every 3 weeks until Grade 2 rash or maximum 400 mg/m2. Blood, pre- and/or post-treatment, was obtained from 13 of 25 pts with measurable response and the sera evaluated for potential predictive markers of response. Results: The study was stopped due to inadequate number of responders among the first 25 pts. Median age: 58 years (range: 31–79); median number of cycles: 2 (range: 1–11). At first assessment, 4 pts remained at 250 mg/m2; 8 pts were dose-escalated to 325 mg/m2; of these, 4 were increased to 400 mg/m2. One pt achieved PR; 9 pts had best response of SD. Median PFS: 2.1 months; 4-month PFS rate: 25%; 1-year survival rate: 54.8%. Rash (96%) was the most common drug-related adverse event (2 pts with Grade 3); 1 pt had Cet-induced Grade 4 hypersensitivity. Serologic markers including cytokines, chemokines, and growth and angiogenic factors were analyzed in sera from 9 pts exhibiting PD and 4 pts with SD. In pre-treatment samples, the average values of 9 of these markers were significantly reduced in pts exhibiting SD vs PD (P=0.052 to 0.00018, t-test). Changes in marker levels after Cet treatment were not significant indicators of SD. Conclusions: Single-agent Cet showed minimal activity in these previously treated pts. However, the low number of dose-escalated pts limits complete evaluation of the hypothesis regarding response and dose escalation to rash. We did identify that pts with reduced levels of 9 serologic markers at baseline were more likely to have disease control on Cet treatment.

No significant financial relationships to disclose.

An evaluation of Groshong central venous catheters on a gynecologic oncology service

One hundred ten women with gynecologic malignancies underwent 116 subclavian vein Groshong catheter insertions at the bedside under local anesthesia and intravenous sedation. Three (2.6%) additional patients had unsuccessful insertions because of an inability to access the subclavian vein or thread the guidewire. Fluoroscopy was not used. There was one delayed pneumothorax and no insertion-related infections. The 111 single-lumen catheters used primarily for the administration of chemotherapy are the subject of this report. The mean age of patients was 60 (range 13 to 89) years and their average Gynecologic Oncology Group performance score was 1.1 (range, 0 to 3). Diagnoses include 74 ovarian, 19 cervical, 13 uterine, and 5 other gynecologic malignancies. Hyperalimentation was administered in 16 (14%) patients. Grade IV neutropenia occurred in 57 (51%) patients and 44 (40%) received granulocyte colony-stimulating factor during therapy. The average lifespan of catheters was 247 (range, 37 to 703) days, and 39 (35%) women died from disease with their catheter in situ at a mean time of 288 days. Thirty-seven (33%) catheters were removed after completion of chemotherapy at an average time of 239 (range, 78 to 448) days. As of 1/1/94, 22 patients continued to use their catheters at a mean of 313 (range, 182 to 509) days. The remaining 13 (11.7%) catheters were removed due to complications (7 episodes of bacteremia, 3 tunnel infections, 2 catheter migration/thromboses, and 1 catheter laceration). Twenty episodes of fever in 17 (15.3%) patients were evaluated with blood cultures in the absence of a tunnel infection. None of the 10 culture negative cases resulted in catheter removal, whereas 7 of 10 patients with bacteremia had catheters removed. Exit site infections occurred in 23 (21%) patients and were resolved with local measures and oral antibiotics. The risk of exit site cellulitis was 3.3% per month. When compared to placement of permanent central venous access devices at our institution in the operating room or radiology suite, bedside placement of Groshong catheters resulted in a savings of $1448 and $231 per case, respectively.

The efficacy and safety of the cytobrush during pregnancy

The safety and efficacy of abrasive cytology, using the cytobrush, were evaluated in 300 pregnant patients. When compared to conventional cytology obtained with a cotton-tipped applicator there was no difference in adverse pregnancy events. Smear adequacy (containing endocervical cells) was statistically (P less than 0.01) and clinically increased from 21 to 86%. The use of abrasive cervical cytology was associated with a twofold increase in the incidence of abnormal smears.

Surgical aspects of cervical cancer

Surgery maintains an important role in the diagnosis and treatment of premalignant as well as early invasive and recurrent cervical cancer. Although the indications for and benefits of surgical staging remain to be determined, specific procedures frequently are necessary to manage treatment-related complications. The authors review the indications, morbidity, and outcome of these procedures.

Surgical staging of uterine cancer: an analysis of perioperative morbidity

Surgical staging documented extrauterine disease in 27.9% of 168 patients with apparent early-clinical-stage uterine cancer. An analysis of operative time (78 +/- 21 min), blood loss (332 +/- 160 cc), and surgical site infection risks (4.7%) indicated little additional risk of lymphadenectomy. The long-term risk of lymphocyst (1.3%) or lymphedema (0.7%) was small. The histologic information obtained from staging was utilized to rationally guide the need for adjunctive teletherapy. The overall risk of recurrence (median follow-up, 26 months) with surgical Stage I disease was 2.6%.

Identification of human papillomavirus type 16 in primary and recurrent cervical cancer following radiation therapy

Formalin-fixed, paraffin-embedded tissue blocks from 13 women with cervical carcinoma that recurred following radiation therapy were evaluated for the presence of human papillomavirus (HPV) by in situ hybridization using ribonucleic acid 35S-labeled probes for HPV types 6, 11, 16, and 18. Ten of thirteen patients also had pretreatment biopsies from their primary tumors available for analysis. HPV 16 was detected in both primary and recurrent lesions in 4 women. In 1 case, HPV was detected in the primary tumor and not in the recurrence. HPV 16 was also present in three recurrent cancers from which primary lesions were not available for probing. Radiation therapy did not alter the hybridization signal strength or pattern, suggesting that the HPV genome copy number was not significantly affected. The persistence of HPV 16 in recurrent cervical carcinoma is consistent with the theory that HPV plays a role in maintaining the malignant state.

The use of in situ hybridization to show human papillomavirus deoxyribonucleic acid in metastatic cancer cells within lymph nodes

Southern blot hybridization has been used to identify human papillomavirus types in both primary tumors and lymph node metastases. However, this technique requires fresh-frozen tissue and is incapable of localizing deoxyribonucleic acid sequences to specific cell types in the tumor sample. In contrast, in situ hybridization precisely locates viral sequences within tumor cells while preserving cellular architecture. Further, in situ hybridization requires only small samples of formalin-fixed, paraffin-embedded tissues. Five lymph nodes (from four patients) containing metastatic cervical squamous tumor cells (identified with hematoxylin and eosinophil staining) were analyzed with in situ hybridization techniques with human papillomavirus type 16 deoxyribonucleic acid probes labeled with sulfur 35. The primary cervical cancer from all four patients had been shown to contain human papillomavirus type 16 sequences by Southern blot. Three specimens from two patients clearly showed the presence of human papillomavirus type 16 sequences within the nuclei of metastatic tumor cells, whereas two specimens were nondiagnostic most likely as a result of the small volume of cancer relative to the size of the lymph node. This information indicates that it is the tumor cells themselves that contain viral deoxyribonucleic acid and provides additional evidence linking human papillomavirus with cervical carcinogenesis.

Hysterectomy with extended surgical staging and radiotherapy versus hysterectomy alone and radiotherapy in stage I endometrial cancer: a comparison of complication rates

Extended surgical staging (ESS) has been added to total hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) in patients with clinical Stage I endometrial cancer in order to better define patterns of metastatic spread and the response to treatment. Adjuvant radiotherapy has a demonstrated efficacy in decreasing central recurrence in Stage I disease. The combined use of radical surgery and pelvic radiotherapy for cervical cancer patients results in an increased incidence of complications. This study compares major complication rates in Stage I endometrial cancer patients who underwent either TAHBSO with ESS or TAHBSO alone followed by adjuvant external beam radiotherapy (RT). Records of 52 patients with clinical stage I endometrial cancer were reviewed. Thirty-two patients underwent TAHBSO plus ESS and 20 patients had TAHBSO alone. All patients received postoperative, whole pelvis external radiotherapy. Four patients suffered complications potentially related to treatment which required rehospitalization, and all 4 were in the group which had undergone ESS. A comparison of complication rates between the ESS + RT group (4/37 or 10.8%) and TAHBSO + RT group (0/20) suggested a trend toward significance (P less than 0.10). Treatment protocols using extended surgical staging prior to adjuvant radiotherapy in Stage I endometrial cancer should examine complications potentially related to this combination, to further define treatment risks and benefits.

Monitoring the course of cervical carcinoma with the squamous cell carcinoma serum radioimmunoassay

Serum samples were collected from 611 gynecologic patients for measurement of squamous cell carcinoma antigen levels using the Abbott Laboratories squamous cell carcinoma antigen radioimmunoassay kit. Sixteen of 83 patients (19.3%) with cervical dysplasia and 72 of 135 (53.3%) with primary or recurrent cervical carcinoma had levels above 2.4 ng/mL. In contrast, only seven of 373 women (1.9%) without genital tract squamous cell intraepithelial neoplasia or carcinoma had squamous cell carcinoma antigen levels above 2.4 ng/mL. Fifty-six patients with cervical cancer were followed for correlation of squamous cell carcinoma antigen levels to disease course, and 20 had persistent or recurrent disease after therapy; rising squamous cell carcinoma antigen levels predicted disease in 15 of these 20 patients with recurrence (13 of 15 with elevated pre-treatment levels and two of five with normal pre-treatment levels). Rising squamous cell carcinoma antigen levels preceded the clinical detection of disease in ten patients by a mean of 4.6 months (range 2-7.5 months); in the remaining five, squamous cell carcinoma antigen levels were elevated only when disease recurrence was documented. Although measurement of squamous cell carcinoma antigen levels is not a sensitive screening method for cervical cancer (sensitivity 53.3%), the test has good specificity (94.3%); the majority of patients with false-positive elevations had other genital tract squamous cell neoplasias. The squamous cell carcinoma antigen assay may be a useful aid for monitoring the disease course of cervical carcinoma.

Melanosis of the cervix

Benign and malignant melanotic cervical lesions are rare and require biopsy to rule out melanoma. Reported is a case of cervical melanosis, defined as benign epithelial pigmentation.

Psammoma bodies in a cervicovaginal smear associated with an intrauterine device. A case report

Psammoma bodies were found in a cervicovaginal smear, presumably related to the patient's use of an intrauterine device. Colposcopy, endocervical and uterine curettage, and laparoscopy with pelvic washings ruled out other conditions that may be associated with psammoma bodies.