Impact of preoperative brachytherapy followed by radical hysterectomy in stage IB2 (FIGO 2018) cervical cancer: An analysis of SENTICOL I-II trials

INTRODUCTION

The goal of this study was to compare the outcomes of preoperative brachytherapy followed by radical surgery versus radical surgery alone in cervical cancer with tumor between 2 and 4 cm (FIGO 2018 IB2).

MATERIAL AND METHODS

SENTICOL I and SENTICOL II were two French prospective multicentric trials evaluating sentinel node biopsy in early-stage cervical cancer between 2005 and 2012. Preoperative brachytherapy (low-dose rate or pulse-dose rate at the dose of 60Gy) could be performed 6 to 8 weeks prior to the radical hysterectomy, at the discretion of each center. SENTICOL I and SENTICOL II cohorts were retrospectively analysed to compare the outcomes of preoperative brachytherapy or upfront surgery in patients with IB2 cervical tumor.

RESULTS

A total of 104 patients were included: 55 underwent upfront radical hysterectomy and 49 underwent preoperative brachytherapy followed by radical hysterectomy. Patients with preoperative brachytherapy were more likely to have no residual disease (71.4% vs. 25.5%, p < 0.0001) and to be defined as low risk according to Sedlis criteria (83.3% vs. 51.2%, p < 0.0001). Adjuvant treatments were required less frequently in case of preoperative brachytherapy (14.3% vs. 54.5%, p < 0.0001). Patients with preoperative brachytherapy experienced more postoperative complications grade ≥ 3 (24.5% vs. 9.1%, p = 0.03). Patients with preoperative brachytherapy had better 5-year disease-free survival compared to patients who underwent surgery alone, 93.6% and 74.4% respectively (p = 0.04).

CONCLUSION

Although preoperative brachytherapy was significantly associated with more severe postoperative complications, better pathologic features were obtained on surgical specimens and led to a better 5-year disease-free survival in IB2 cervical cancer.

Risk factors for failure of bilateral sentinel lymph node mapping in early-stage cervical cancer

BACKGROUND

The objective of this study was to determine clinical, tumoral and surgical factors associated with successful bilateral sentinel lymph node mapping (SBM) in early-stage cervical cancer.

METHODS

We performed an ancillary work on the data of two prospective trials on SLN biopsy for FIGO IA-IIA cervical cancer (SENTICOL I & II). Patients having Sentinel lymph node (SLN) mapping for early-stage cervical cancer were included between 2005 and 2012 from 28 French oncologic centers. SLN was detected by a combined labeling technique (blue and isotopic).

RESULTS

405 patients were included for analysis: SLNs were identified on at least one side of the pelvis in 381 patients (94.1%) and bilaterally in 326 patients (80.5%). The mean age was 45.4 years [22-85 years]. Most patients had IB1 pathologic FIGO 2018 stage (81.3%) and squamous cell carcinoma (71%). Surgeries were mainly performed by minimally invasive approach (368 patients - 90.9%). By multivariate analysis, lower SBM rate was significantly associated with Age ≥70 years (ORa = 0.02, 95%CI = [0.001-0.28], p = 0.004), tumor size larger than 20 mm (ORa = 0.46,95%CI = [0.21-0.99], p = 0.048) and Body-mass index higher than 30 kg/m² (ORa = 0.28, 95%CI = [0.12-0.65], p = 0.003). SBM rate was significantly higher in high skills centers (>5patients/year) (ORa = 8.05, 95%CI = [2.06-31.50], p = 0.003) and in SENTICOL II (2009-2012) compared to SENTICOL I (2005-2007) (ORa = 2.6, 95%CI = [1.23-5.51], p = 0.01).

CONCLUSIONS

In early-stage cervical cancer, bilateral SLN detection rates is lower in patients aged more than 70years, patients with BMI≥30 kg/m² and larger tumor ≥20 mm whereas stronger experience of SLN biopsy technique improves bilateral SLN detection.

A GCIG international survey: clinical practice patterns of sentinel lymph node biopsies in cervical cancer

PURPOSE

To evaluate the practice patterns among centers and physicians worldwide regarding sentinel lymph node biopsies (SLNB) in cervical cancer (CC) patients.

METHOD

A validated 35-item questionnaire regarding SLNB in CC supported by the Gynecologic Cancer Intergroup (GCIG), and sponsored by the North-Eastern German Society of Gynaecologic-Oncology (NOGGO) was sent to all major gynecological cancer societies across the globe for further distribution from October 2015 and continued for a period of 7 months.

RESULTS

One hundred and sixty-one institutions from around the world participated. One hundred and six (66%) of the participants were from university centers and 111 (69%) were gynecologic oncologists. One hundred and fifty-two (97%) performed lymphadenectomy (LNE) and 147 (94%) did so systematically; 97 (60%) used SLNB, due to lower morbidity (73%), reliability (55%) and time-saving (27%). In cases of positive SLNB (pN+), 39% of respondents stopped the operation and sent the patient for chemoradiation (CRT), 45% completed pelvic and paraaortic LNE, whereas 26% went on to perform a radical hysterectomy (RH) and systematic pelvic and paraaortic LNE. In case of negative SLNB (pN0), 39% of institutions still performed a systematic pelvic and paraaortic LNE.

CONCLUSION

In this survey worldwide, SLNB adoption is an encouraging 60%, yet ample differences exist regarding strategy, and to a lower extent the techniques used. Lack of experience is the most common reason SLNB is not performed. Efforts to increase surgical education on SLNB technique and multicenter prospective trials providing evidence-based guidelines are warranted.

[Prophylactic hysterectomy in Lynch syndrome: Feasibility and outcomes]

OBJECTIVES

Lynch syndrome (LS) is a hereditary predisposition to cancers, first of all, colo-rectal and endometrial cancers in women. Although recommended, gynecologic screening has never proven its benefit. Prophylactic surgery can be considered once the parental project is completed. There are few data regarding the assessment of prophylactic surgery. The objectives of our study were to evaluate the feasibility and morbidity of prophylactic hysterectomy in patients with Lynch syndrome.

METHODS

This is a descriptive retrospective study of consecutive patients with LS undergoing prophylactic hysterectomy at the Georges-Pompidou European Hospital from 2002 to 2016. We collected demographic characteristics, results of preoperative assessment, intra- and postoperative data, final pathologic result as well as postoperative follow-up data.

RESULTS

Forty patients were included in the study, and seventeen women had a history of colon cancer surgery. All hysterectomies were performed by laparoscopy, with two cases of laparoconversion. Two intraoperative complications occurred: serosal small bowel injuries and superficial bladder injury. Two early postoperative complications occurred (a peritonitis on small bowel perforation and a peritonitis on left ureteral injury) and two late complications (vesico-vaginal fistula and adhesive small bowel obstruction). All operative specimens were benign. With a median follow-up of 28 months [5-52], no patient had peritoneal cancer.

CONCLUSIONS

Our study shows that prophylactic hysterectomy in Lynch syndrome should be done with caution. Per and postoperative complication rates appear to be higher than in general population, probably related to a more frequent history of colorectal cancer. However, total hysterectomy with bilateral salpingo-oophorectomy appears to be an effective strategy for preventing gynecological cancers in women with the Lynch syndrome.

[Part II drafted from the short text of the French guidelines entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY and endorsed by INCa. (Systemic and intraperitoneal treatment, elderly, fertility preservation, follow-up)]

Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for all high-grade ovarian or Fallopian tube cancers, stage FIGO I-IIA (grade A). After a complete first surgery, it is recommended to deliver 6 cycles of intravenous (grade A) or to propose intraperitoneal (grade B) chemotherapy, to be discussed with patient, according to the benefit/risk ratio. After a complete interval surgery for a FIGO III stage, the hyperthermic intra peritoneal chemotherapy (HIPEC) can be proposed in the same conditions of the OV-HIPEC trial (grade B). In case of tumor residue after surgery or FIGO stage IV, chemotherapy associated with bevacizumab is recommended (grade A). For BRCA mutated patient, Olaparib is recommended (grade B).

[French joint recommendations Management for Epithelial Ovarian Cancer of FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY endorsed by INCa. Strengths and weaknesses]

A task force was organized to write French national recommendations for management of ovarian cancer. We proposed to present strengths and weaknesses of this work.

[Diagnostic value of imaging (ultrasonography, doppler, CT, MR, PET-CT) for the diagnosis of a suspicious ovarian mass and staging of ovarian, tubal or primary peritoneal cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Transvaginal ultrasound is the first-line examination allowing characterizing 80 to 90% of adnexal masses (LP1). If performed by an expert, a subjective analysis is optimal. If performed by a non-expert, combining the use of Simple Rules with subjective analysis can achieve the diagnostic performance of an expert (LP1). Whichever the chosen model (subjective analysis by an expert or combination of the Simple Rules with a subjective analysis by a non-expert), a second-line examination will have to be proposed in the complex or indeterminate cases (about 20% of the masses) (grade A). The best-performing second-line test for characterization is pelvic MRI (LP1). If read by an expert, a pathological hypothesis can or should be suggested (grade D). In case of non-expert reading, the use of the ADNEXMR score allows a reliable assessment of the positive predictive value of malignancy to guide the patient towards the best management (gradeC). For preoperative assessment and evaluation of resectability of ovarian, fallopian tube or primary peritoneal cancer, it is recommended to perform a chest abdomen and pelvis CT with contrast agent injection (LP2, grade B). In the event of a contraindication to the injection of iodinated contrast agent (severe renal insufficiency, GFR <30mL/min), an abdomen and pelvis MRI completed with a non-injected chest CT may be proposed (LP3, grade C). By analogy, the same examinations are recommended to evaluate the disease after neo-adjuvant chemotherapy (LP3, Recommendation grade C). Further studies will be required to determine whether PET-CT provides better lymph node assessment before retroperitoneal and pelvic lymphadenectomy. PET-CT may be used to eliminate lymph node involvement in the absence of suspicious lymph nodes on morphological examination (LP3, grade C). The report should specify the localizations leading to a risk of incomplete cytoreductive surgery and lesions outside the field explored during surgery.

[Part I drafted from the short text of the French Guidelines entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY and endorsed by INCa. (Diagnosis management, surgery, perioperative care, and pathological analysis)]

Faced to an undetermined ovarian mass on ultrasound, an MRI is recommended and the ROMA score (combining CA125 and HE4) can be proposed (grade A). In case of suspected early stage ovarian or fallopian tube cancer, omentectomy (at least infracolonic), appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C) and pelvic and para-aortic lymphadenectomy are recommended (grade B) for all histological types, except for the expansive mucinous subtype where lymphadenectomy may be omitted (grade C). Minimally invasive surgery is recommended for early stage ovarian cancer, if there is no risk of tumor rupture (grade B). Laparoscopic exploration for multiple biopsies (grade A) and to evaluate carcinomatosis score (at least using the Fagotti score) (grade C) are recommended to estimate the possibility of a complete surgery (i.e. no macroscopic residue). Complete medial laparotomy surgery is recommended for advanced cancers (grade B). It is recommended in advanced cancers to perform para-aortic and pelvic lymphadenectomy in case of clinical or radiological suspicion of metastatic lymph node (grade B). In the absence of clinical or radiological lymphadenopathy and in case of complete peritoneal surgery during an initial surgery for advanced cancer, it is possible not to perform a lymphadenectomy because it does not modify the medical treatment and the overall survival (grade B). Primary surgery is recommended when no tumor residue is possible (grade B).

ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: diagnosis, treatment and follow-up

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11-13 December 2014 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of endometrial cancer. Before the conference, the expert panel prepared three clinically relevant questions about endometrial cancer relating to the following four areas: prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. Results of this consensus conference, together with a summary of evidence supporting each recommendation, are detailed in this article. All participants have approved this final article.

Quality indicators in ovarian cancer surgery: report from the French Society of Gynecologic Oncology (Societe Francaise d'Oncologie Gynecologique, SFOG)

BACKGROUND

Based on registries, the European experience has been that <50% of patients are treated according to protocols and/or benefit from the minimum required surgery for ovarian cancer. The French Cancer Plan 2009-2013 considers the definition of qualitative indicators in ovarian cancer surgery in France. This endeavour was undertaken by the French Society of Gynaecologic Oncology (SFOG) in partnership with the French National College of Obstetricians and Gynecologists and all concerned learned societies in a multidisciplinary mindset.

METHODS

The quality indicators for the initial management of patients with ovarian cancer were based on the standards of practice determined from scientific evidence or expert consensus.

RESULTS

The indicators were divided into structural indicators, including material (equipment), human (number and qualification of staff), and organizational resources, process indicators, and outcome indicators.

CONCLUSIONS

The enforcement of a quality assurance programme in any country would undoubtedly promote improvement in the quality of care for ovarian cancer patients and would result in a dramatic positive impact on their survival. Such a policy is not only beneficial to the patient, but is also profitable for the healthcare system.

Accuracy of a nomogram for prediction of lymph-node metastasis detected with conventional histopathology and ultrastaging in endometrial cancer

BACKGROUND

We developed a nomogram based on five clinical and pathological characteristics to predict lymph-node (LN) metastasis with a high concordance probability in endometrial cancer. Sentinel LN (SLN) biopsy has been suggested as a compromise between systematic lymphadenectomy and no dissection in patients with low-risk endometrial cancer.

METHODS

Patients with stage I-II endometrial cancer had pelvic SLN and systematic pelvic-node dissection. All LNs were histopathologically examined, and the SLNs were examined by immunohistochemistry. We compared the accuracy of the nomogram at predicting LN detected with conventional histopathology (macrometastasis) and ultrastaging procedure using SLN (micrometastasis).

RESULTS

Thirty-eight of the 187 patients (20%) had pelvic LN metastases, 20 had macrometastases and 18 had micrometastases. For the prediction of macrometastases, the nomogram showed good discrimination, with an area under the receiver operating characteristic curve (AUC) of 0.76, and was well calibrated (average error =2.1%). For the prediction of micro- and macrometastases, the nomogram showed poorer discrimination, with an AUC of 0.67, and was less well calibrated (average error =10.9%).

CONCLUSION

Our nomogram is accurate at predicting LN macrometastases but less accurate at predicting micrometastases. Our results suggest that micrometastases are an 'intermediate state' between disease-free LN and macrometastasis.

Complications of lymphadenectomy for gynecologic cancer

INTRODUCTION

Symptomatic postoperative lymphocysts (SPOLs) and lower-limb lymphedema (LLL) are probably underestimated complications of lymphadenectomy for gynecologic malignancies. Here, our objective was to evaluate the incidence and risk factors of SPOLs and LLL after pelvic and/or aortocaval lymphadenectomy for gynecologic malignancies.

METHODS

Single-center retrospective study of consecutive patients who underwent pelvic and/or aortocaval lymphadenectomy for ovarian cancer, endometrial cancer, or cervical cancer between January 2007 and November 2008. The incidences of SPOL and LLL were computed with their 95% confidence intervals (95%CIs). Multivariate logistic regression was performed to identify independent risk factors for SPOL and LLL.

RESULTS

We identified 88 patients including 36 with ovarian cancer, 35 with endometrial cancer, and 17 with cervical cancer. The overall incidence of SPOL was 34.5% (95%CI, 25-45) and that of LLL was 11.4% (95% confidence interval [95%CI], 5-18). Endometrial cancer was independently associated with a lower risk of SPOL (adjusted odds ratio [aOR], 0.09; 95%CI, 0.02-0.44) and one or more positive pelvic nodes with a higher risk of SPOL (aOR, 4.4; 95%CI, 1.2-16.3). Multivariate logistic regression failed to identify factors significantly associated with LLL.

CONCLUSION

Complications of lymphadenectomy for gynecologic malignancies are common. This finding supports a more restrictive use of lymphadenectomy or the use of less invasive techniques such as sentinel node biopsy.

[Robotic surgery in endometrial cancer: a review]

Robotic surgery has spread for a few years. This access is now important in urologic surgery, especially for prostatic procedures. Development of robotic surgery in gynecology is more recent. Gynecologic oncology is probably one of the most interesting fields of development of this access. Robotic surgery is frequently used in endometrial cancer. As no randomized study is available, it seems to be interesting to make a review of retrospective studies. Feasibility seems to be high and the learning curve is short (around 20 cases). Operative lengths are longer when compared to laparotomy, but are similar or shorter than laparoscopy. Robot setting increases the global length of the procedure, but decreases with experience. Operative blood loss, as well as transfusion rate are decreased when compared to laparotomy, but are similar to those of laparoscopy. The overall morbidity rate seems lower than with other approaches. Postoperative pain, hospital stay and time to recovery are decreased when compared to laparotomy as well as to laparoscopy for some authors. The main limit to the diffusion of robotic surgery is accessibility because of its important cost. Other limits are pointed out by the most trained teams.

[Sentinel lymph node procedure and uterine cancers]

Lymph node metastases in cervical and endometrial cancer are major prognostic factors. Lymph-nodal involvement determines adjuvant therapy. As imagery is not reliable to diagnose lymph node status, pelvic +/- para-aortic lymphadenectomy remains the gold standard. These surgical procedures are, however, responsible for specific morbidity: lymphocele and lymphedema. Sentinel lymph node procedure could avoid lymphadenectomy and their complications in cervical and endometrial cancer with good negative predictive values. We present actual indications, procedure and results of sentinel lymph node procedures in cervical and endometrial cancer.

[Retroperitoneal lymphadenectomy and survival of patients treated for an advanced ovarian cancer: the CARACO trial]

The standard management for advanced-stage epithelial ovarian cancer is optimum cytoreductive surgery followed by platinum based chemotherapy. However, retroperitoneal lymph node resection remains controversial. The multiple directions of the lymph drainage pathway in ovarian cancer have been recognized. The incidence and pattern of lymph node involvement depends on the extent of the disease and the histological type. Several published cohorts suggest the survival benefit of pelvic and para-aortic lymphadenectomy. A recent large randomized trial have demonstrated the potential benefit for surgical removal of bulky lymph nodes in term of progression-free survival but failed to show any overall survival benefit because of a critical methodology. Further randomised trials are needed to balance risks and benefits of systematic lymphadenectomy in advanced-stage disease. CARACO is a French ongoing trial, built to bring a reply to this important question. A huge effort for inclusion of the patients, and involving new teams, are mandatory.

[Current indications of lymphadenectomy in endometrial cancer]

Endometrial cancer is a tumor associated with a good prognosis as it is often diagnosed at an early stage. Up to 20 % of patients with stage I disease have a nodal involvement. Knowledge of nodal status provides important prognostic information. As preoperative assessment yields a poor value, prognostic lymphadenectomy appears to be indicated. However, therapeutic benefit of pelvic and para-aortic lymphadenectomy remains controversial. Recent randomized trials did not find any impact on survival for patients with low risk of nodal involvement. Thus, lymphadenectomy should no more be systematically performed in this low risk group. Nevertheless, pelvic and para-aortic lymphadenectomy seems to have a benefit in the high risk group, as isolated involved para-aortic nodes have been described.

Usefulness of routine intraoperative staging of suspicious adnexal tumours: illustration by two cases of adult granulosa cell tumour

Granulosa cell tumours (GCTs) account for less than 3% of all ovarian malignancies but are among the most common sex cord-stromal tumours. They may develop at any age. Symptoms related to oestrogen production by the tumour may occur. Because GCTs are uncommon and cannot be diagnosed preoperatively, their management is challenging. Surgery with salpingo-oophorectomy and painstaking staging is mandatory. Adjuvant chemotherapy is required in some patients. We report two cases of adult GCTs that illustrate the usefulness of extensive abdominal exploration in every patient with a suspicious ovarian mass, to obviate the need for a second staging procedure. With this strategy, the prognosis is excellent, although the possibility of late recurrences requires prolonged follow-up.

[French recommendations for ovarian cancer management during pregnancy]

Evaluation of the fetus using prenatal ultrasound has resulted in increased detection of asymptomatic adnexal masses during pregnancy. Such masses are rarely malignant (1/10 000 to 1/50 000 pregnancies), but the possibility of borderline or cancer must be considered. It is a common assumption by both patients and physicians that if an ovarian cancer is diagnosed during pregnancy, treatment necessitates sacrificing the well-being of the fetus. However, in most cases, it is possible to offer appropriate treatment to the mother without placing the fetus at serious risk. The care of a pregnant woman with cancer involves evaluation of sometimes competing maternal and fetal risks and benefits. These recommendation approaches attempt to balance these risks and benefits; however, they should be considered advisory and should not replace specific interdisciplinary consultation with specialists in maternal-fetal medicine, gynecologic oncology, and pediatrics, as well as imaging and pathology, as needed. Second level ultrasound including Doppler is needed. MRI is not often necessary, and CA 125 is of low contribution. We suggest surgery be performed after 15 SA for ovarian masses which (1) persist into the second trimester, (2) are greater than 5 to 10 cm in diameter, or (3) have solid or mixed solid and cystic ultrasound characteristics. During antepartum surgical staging and debulking, homolateral salpingo-oophorectomy and peritoneal cytology and exploration are necessary. Women found to have advanced stage epithelial ovarian cancer should consider having completion of the debulking of the reproductive organs at the conclusion of the pregnancy. If chemotherapy is indicated, we recommend delaying administration, if possible, after the delivery or at least after 20 SA in order to minimize the potential fetal toxicity.

[Endometrial cancer in HNPCC syndrome]

The Hereditary Non-Polyposis Colorectal Cancer syndrome (HNPCC) has initially been described as a predisposition to colorectal cancers (CRC). Subsequently, other cancers, such as endometrial cancers (EC), have been added. The objective of this review was to update data on endometrial cancers of HNPCC syndrome. Endometrial cancers of the HNPCC syndrome are characterized by a younger age at diagnosis (46-48 year old), and a higher cumulative risk along life (30% at 70 years). Complex atypical hyperplasia seems to occur before the cancer, but the transition between precursors and cancer seems to be short. Histology of endometrial cancers of the HNPCC syndrome appears quite similar to that of sporadic cases, except for non-endometrioid lesions which seem more frequent and could occur in younger women. Screening of endometrial cancer in predisposed women should associate annual clinical examination, transvaginal sonography and endometrial sampling. Unfortunately, available data on screening by sonography show that this test seems poorly accurate, with no asymptomatic cancer or hyperplasia recognized and interval cancers between screenings. Endometrial biopsy appears as the most interesting method, since 11 asymptomatic cancers and 14 hyperplasia have been diagnosed in 175 mutation carriers. Diagnostic hysteroscopy seems also interesting, but requires further evaluation. Prophylactic hysterectomy confers a complete protection against endometrial cancer. However, perioperative morbidity (especially in women with history of colorectal surgery) and long-term effects of ovarian suppression should also be considered. Screening of endometrial cancer remains the main objective of the management of those patients. Endometrial biopsy should have a larger place.

Performance of office hysteroscopy and endometrial biopsy for detecting endometrial disease in women at risk of human non-polyposis colon cancer: a prospective study

The objective of this study was to report the value of diagnostic hysteroscopy and endometrial biopsy for the detection of complex atypical hyperplasia or cancer in asymptomatic human non-polyposis colon cancer (HNPCC) patients. The secondary objective was to evaluate the accuracy of hysteroscopy, using endometrial biopsy as a gold standard. Consecutive patients at risk of HNPCC evaluated between January 1, 1999, and June 30, 2006 were included if they underwent diagnostic hysteroscopy at least once. Patients with a history of hysterectomy and those unwilling to undergo diagnostic hysteroscopy were not included. Yearly follow-up evaluations included diagnostic hysteroscopy, with endometrial biopsy. Hysteroscopic and histologic findings were recorded and compared. We included 62 patients, of whom 13 had mismatch repair gene mutations and 49 met Amsterdam II criteria. Of 125 attempted hysteroscopies, 11 (8%) failed. Hysteroscopy showed normally appearing mucosa in 46 cases, nonmalignant lesions in 65 cases, and possibly malignant lesions in 3 cases with abnormal uterine bleeding. Endometrial biopsy was attempted in 116 cases and failed in 12 (10%). Three cases each of simple hyperplasia and of cancer were diagnosed. No preinvasive or invasive lesions were found in asymptomatic women. When compared to endometrial biopsy, sensitivity of hysteroscopy was 100% for the detection of hyperplasia or cancer. No cases of cancer were diagnosed in asymptomatic patients in our study. However, diagnostic hysteroscopy ensured the diagnosis of endometrial adenocarcinoma in HNPCC women with bleeding. Nevertheless, usefulness and optimal modalities of screening remain to be determined.

Performance of laparoscopy in identifying malignant ovarian cysts

BACKGROUND

Peroperative identification of malignancy is crucial to management planning for ovarian cysts. The aim of this study was to evaluate the performance of laparoscopy in identifying malignant ovarian cysts.

METHODS

Patients undergoing laparoscopy for ovarian cysts from 1998 to 2001 were enrolled prospectively. Physical findings, Doppler ultrasonography, and serum CA 125 served to compute two risk-of-malignancy indexes (RMI-1 and RMI-2), and laparoscopy findings served to categorize lesions as benign, possibly malignant, or malignant. Frozen sections were examined as needed. Final histology was the reference.

RESULTS

Of 313 patients, 294 had benign cysts, six borderline lesions, and 13 malignancies. Sensitivity and specificity were respectively 84 and 93% for RMI-1, 92 and 80% for RMI-2, 100 and 99% for laparoscopy, 91 and 100% for frozen sections, and 100 and 100% for laparoscopy plus frozen sections, which had 100% negative predictive value. Six (1.8%) adverse events occurred.

CONCLUSIONS

Laparoscopy reliably identifies ovarian cancer and borderline disease. Morbidity is low compared to oncologic surgery.

Impact of initial surgical access on staging and survival of patients with stage I ovarian cancer

The aim of this study was to compare staging by laparoscopy and laparotomy, and to compare survival in patients with laparoscopy versus laparotomy as the first surgical access. We conducted a retrospective analysis of patients with stage I ovarian cancer treated surgically between 1985 and 2001, and we included those patients with stage I epithelial cancer for whom follow-up data were available. For each patient, we recorded whether initial surgical staging was by laparoscopy or by laparotomy, the procedures done at initial staging surgery, and the outcomes. The data were evaluated by analysis of variance, Chi-square test or Fisher's exact test, logistic regression, Cox model, and log-rank test, using SPSS 7.5 and STATA. Initial staging was by laparoscopy in 34 patients, laparotomy in 114 patients, and laparoscopy converted to laparotomy in 30 patients. In the laparotomy group, patient age was significantly greater and tumor size significantly larger, as compared to the laparoscopy group. Staging after first surgery was often inadequate; most notably para-aortic lymph node dissection was done in 0% of laparoscopy patients, 18% of laparotomy patients, and 33% of conversion patients. Restaging surgery has been indicated in 88% of laparoscopy patients, 48% of laparotomy patients, and 46% of conversion ones. After a mean follow-up of 40 months, survival rates were not significantly different among the three patient groups. No deleterious influence of laparoscopy as first surgical access was detected by univariate or multivariate analysis. Despite of inaccurate radicality and staging during initial laparoscopy, this study found no harmful influence of laparoscopy as first initial access on outcomes of patients with stage I ovarian cancer.

Which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings and is there a way of making a correct diagnosis?

OBJECTIVES

To determine which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings, and to determine if the use of logistic regression models for calculation of individual risk of malignancy would improve the diagnostic accuracy in difficult tumors.

METHODS

In a prospective, international, European multicenter study involving nine centers, 1066 women with a pelvic mass judged to be of extrauterine origin underwent transvaginal ultrasound examination by an experienced ultrasound examiner before surgery. A standardized examination technique and predefined definitions of ultrasound characteristics were used. On the basis of subjective evaluation of ultrasound findings, the examiner classified each mass as being certainly benign, probably benign, unclassifiable, probably malignant or certainly malignant. Even when the examiner found the mass unclassifiable (i.e. difficult mass) he or she was obliged to state whether the mass was more likely to be benign or malignant. Borderline tumors were classified as malignant.

RESULTS

There were 90 (8%) unclassifiable masses. Multiple logistic regression analysis showed papillary projections, >10 locules in a cyst without solid components, low-level echogenicity of cyst fluid, and moderate vascularization as assessed subjectively at color Doppler examination to be ultrasound variables independently associated with unclassifiable mass. Borderline malignant tumors (n = 55) proved to be most difficult to assess with only 47% being correctly classified (i.e. classified as malignant), 29% being incorrectly classified (i.e. classified as benign) and 24% being unclassifiable vs. 90% of non-borderline tumors being correctly classified, 3% being incorrectly classified and 8% being unclassifiable (P < 0.0001). Papillary cystadeno(fibro)mas, myomas and cases of struma ovarii were also more common among the unclassifiable masses than among the classifiable ones (5.6% vs. 1.1%, P = 0.008; 4.4% vs. 0.9%, P = 0.02; 4.4% vs. 0.2%, P = 0.0006). No ultrasound variable or clinical variable (including CA 125) entered a logistic regression model to predict malignancy in difficult masses. A model could be constructed for difficult masses containing papillary projections but this model performed no better than subjective evaluation of the ultrasound image. Sensitivity and specificity of subjective evaluation with regard to malignancy in the group of unclassifiable masses were 56% (14/25) and 77% (50/65) vs. 91% (220/241) and 97% (712/735) in the classifiable masses.

CONCLUSIONS

Borderline tumors cause great diagnostic difficulties, but so do papillary cystadeno(fibro)mas, struma ovarii and some myomas. Logistic regression models do not solve the diagnostic problem in difficult pelvic masses.

[Is sentinel node biopsy feasible in endometrial cancer? Results in 26 patients]

OBJECTIVES

To evaluate detection rate, topography and false negatives of sentinel lymph node in endometrial cancer.

MATERIAL AND METHODS

Twenty-six patients were included. Lymphoscintigraphy was performed the day before surgery. Preoperative detection of the sentinel lymph node was performed with cervical blue dye injection and a gamma probe. Separate pathology examinations were performed for sentinel and non-sentinel lymph nodes. Sentinel lymph nodes were examined with hematoxylin-eosin-safran stain, and immunohistochemistry if negative.

RESULTS

Twenty-six patients had a positive lymphoscintigraphy. Preoperative detection was successful in 21 patients (80.8%): the detection rate with isotopic method, 19 cases (73.1%), was superior to the dye detection, 15 cases (57.7%). No isolated lombo-aortic sentinel lymph nodes were observed, and all sentinel lymph nodes were in the ilio-obturator region. Seven patients presented lymphatic spread, and 4 of them had at least one sentinel node. There was one micrometastasis in sentinel node, associated with isolated tumoral cells in pelvic lymphadenectomy. There was no false negative of sentinel node.

CONCLUSION

The biopsy of sentinel lymph node is a feasible procedure in endometrial cancer. There was one micrometastatic sentinel node. However there was no isolated lomboaortic sentinel lymph node in this study.

Sentinel node biopsy helps to diagnose spread of endometrial cancer. A case report

BACKGROUND

The sentinel lymph node (SLN) could improve the staging of endometrial cancer.

CASE

In a patient with endometrial cancer, preoperative lymphoscintigraphy showed a highly radioactive SLN in the left external iliac chain and a radioactive SLN in the right external iliac chain and at the promontory. Intraoperative lymphatic mapping using blue dye and a hand-held gamma probe showed the same nodes, as well as a blue node near the vena cava. Selective removal of these nodes allowed detection of a micrometastasis in the left external iliac node. Pelvic node dissection was performed, and a micrometastasis was found in a left non sentinel iliac node.

CONCLUSION

The presence in our patient of micrometastases in a SLN and in a non-SLN belonging to the same chain confirms the value of SLN detection for diagnosing tumor spread.

Stage I ovarian cancer: comparison of laparoscopy and laparotomy on staging and survival

OBJECTIVE

The aim of this study was to compare staging accurateness as well as survival when managing early ovarian cancers by laparoscopy or laparotomy.

MATERIAL AND METHODS

We have conducted a retrospective and multicentric study in France. Only Stage I ovarian epithelial cancers operated on from January 1, 1985 to December 31, 1999 were taken into account. Respondents had to fill in a form detailing in each case the surgical access; the surgical acts performed during the initial intervention as well as data on the patient's follow-up. Lack of follow-up or final Stage > I were considered as exclusion criteria. Data were recorded and analysed with SPSS 7.5 and STATA (Stata statistical sofware 7.0). (ANOVA, chi-square test or Fisher's exact test and log-rank test).

RESULTS

105 cases were included: 14 patients were exclusively operated on by laparoscopy (group 1), 13 other patients were subjected to a conversion from laparoscopy to laparotomy (group 2) and 78 patients exclusively underwent laparotomy (group 3). Patients in group 3 were significantly more frequently postmenopausal and had larger lesions. Cyst rupture was rare during laparoscopy (21%) and the use of an endobag was achieved in only 21% of the patients in group 1. Radical treatment was significantly more frequent in group 3 when compared to group 1 (67% vs 23%, p < 0.05). Laparoscopy was not adequate for staging since no lymphadenectomy was carried out by this approach. However, only 27% of patients subjected to an open approach underwent lymphadenectomy and omentectomy. The outcome in terms of survival was similar in the three groups with a mean follow-up period of 1,221 days (+/- 832) (p = 0.1).

CONCLUSION

Laparoscopic management of early ovarian cancer is poorly efficient in staging although disease-free survival does not seem to be affected. Further evaluation of laparoscopy in this indication is needed.

Port site metastasis after laparoscopy for uterine cervical carcinoma

BACKGROUND

Aim of this study was to review cases reported of port-site recurrence (PSR) after laparoscopy for uterine cervical carcinoma.

METHODS

A Medline computer database search from January 1980 to September 2002.

RESULTS

We reported 13 cases published of PSR after laparoscopy for cervical carcinoma. The majority of them were squamous carcinoma (9/13 at least, 69%) and initial staging of disease was Ib (7/13 (54%)). Median of interval between laparoscopy and diagnostic of PSR was 7 months (min 1.5 month, max 48 months). Of 10 cases of laparoscopy with lymphadenectomy, in three cases (30%) nodes were not involved. PSR developed at the port through which tissues was extracted in four cases (30.1%) or another port in five cases (38.5%). At the time of PSR, five patients (38.5%) were free of disease.

CONCLUSIONS

PSR were reported after laparoscopy for lymphadenenectomy with or without hysterectomy and with or without node involvement. In some cases, umbilical metastases should not be systematically diagnosed as PSR and a diagnosis of Sister Mary Joseph's nodule may be discussed.

[Hysterosonography]

Hysterosonography, which consists in the injection of some cc of saline in the uterine cavity during sonography, allows an exploration of the uterine cavity and of the endometrium. Accuracy of hysterosonography is similar to that of office hysteroscopy. Hysterosonography distinguishes normal cavities from pathologic ones, endometrial atrophy from mucosal anomalies, polyps from myomas. Conversely, endometrial biopsy is still necessary for diagnosis of hyperplasia or cancer. Hysterosonography can also be proposed for first trimester bleedings, trophoblast retention or ectopic pregnancy. In the near future it could be applied to therapeutic goals such as sonographic section of polyps.

[Prevention of port-site metastasis after laparoscopy]

Port-site metastasis is a major complication of surgical laparoscopy for gynaecologic oncology. Aetiology of port-site metastases is multifactorial. Surgical conditions and laparoscopic environment were determinant. Several means of prevention were evaluated to prevent occurrence of port-site metastases. Aim of this review is to report optimal surgical conditions, laparoscopic environment and means of prevention to decrease risk of port-site metastases.

Impact of pneumoperitoneum on tumor growth

AIM OF THE STUDY

To compare intraperitoneal tumor growth after CO2 laparoscopy (L), gasless laparoscopy (GL), midline laparotomy (ML), and general anesthesia (GA) as a control.

MATERIALS AND METHODS

A prospective randomized trial was carried out in nude rats. A carcinomatosis was obtained by intraperitoneal injection of either one of the two human ovarian cancer cell lines IGR-OV1 or NIH:OVCAR-3. Rats secondly underwent randomly different kind of procedures: CO2 L (8 mmHg, 60 min), GL (traction by a balloon for 60 min), ML (bowel removed and let on a mesh for 60 min), or GA. The rats were finally killed 10 or 35 days after surgery (respectively in IGR-OV1, or NIH:OVCAR-3 models). Tumor growth was assessed by the weight of the omental metastasis and MIB1 immunostaining. Peritoneal dissemination as well as abdominal wall metastases were assessed by pathological examination. Statistical analysis used the chi-square test (or Fisher exact test) and Bonferroni method for multiple comparison between groups.

RESULTS

Fifteen rats were included in each group. Mean omental weight was significantly increased after surgery (3.1 to 5.6 g), when compared to control (2.4 g), but no significant difference was recorded between the three surgical accesses. MIB1 immunostaining was poor in the PNP group (37%), whereas it was higher after midline laparotomy (51%), but the difference was not significant (p = 0.07). Similarly, no significant variation was recorded in the NIH:OVCAR-3 model for omental weight or MIB1 staining. CO2 pneumoperitoneum significantly increased right diaphragmatic dome involvement in the NIH:OVCAR-3 model. Abdominal wall metastases were significantly more frequent after surgery when compared to the control group, but no significant difference could be demonstrated between surgical groups in each model.

CONCLUSION

In these solid tumor models, CO2 pneumoperitoneum had no deleterious effect on tumor growth when compared to gasless laparoscopy or midline laparotomy.

Impact of different gases and pneumoperitoneum pressures on tumor growth during laparoscopy in a rat model

BACKGROUND

The influence on intraperitoneal tumor growth of the choice of gas and pneumoperitoneum pressure during laparoscopy is still unknown. This study compared tumor growth after laparoscopy with different gases and pneumoperitoneum pressures in an immunodeficient model.

METHODS

In an initial experiment, 60 nude rats were randomly allocated to undergo laparoscopy at different pneumoperitoneum pressures (gasless, 4 mmHg, or 8 mm Hg.) In a second experiment, 23 nude rats were randomly allocated to undergo laparoscopy with different gases (carbon dioxide or helium). Surgery was carried out 7 days after intraperitoneal injection of IGR-OV1 cells. The rats were killed 7 days after surgery. Tumor growth was assessed by the weight of the omental metastasis. For statistical analysis, we used analysis of variance (ANOVA).

RESULTS

Mean omental weight was similar for all groups, regardless of the pneumoperitoneum pressure (p = 0.86) or the type of gas (p = 0.80).

CONCLUSION

Physical parameters of gas have a limited impact on tumor growth.