Neoadjuvant Chemotherapy plus Interval Cytoreductive Surgery with or without Hyperthermic Intraperitoneal Chemotherapy (NIHIPEC) in the Treatment of Advanced Ovarian Cancer: A Multicentric Propensity Score Study

INTRODUCTION

Epithelial ovarian cancer (EOC) is primarily confined to the peritoneal cavity. When primary complete surgery is not possible, neoadjuvant chemotherapy (NACT) is provided; however, the peritoneum-plasma barrier hinders the drug effect. The intraperitoneal administration of chemotherapy could eliminate residual microscopic peritoneal tumor cells and increase this effect by hyperthermia. Intraperitoneal hyperthermic chemotherapy (HIPEC) after interval cytoreductive surgery could improve outcomes in terms of disease-free survival (DFS) and overall survival (OS).

MATERIALS AND METHODS

A multicenter, retrospective observational study of advanced EOC patients who underwent interval cytoreductive surgery alone (CRSnoH) or interval cytoreductive surgery plus HIPEC (CRSH) was carried out in Spain between 07/2012 and 12/2021. A total of 515 patients were selected. Progression-free survival (PFS) and OS analyses were performed. The series of patients who underwent CRSH or CRSnoH was balanced regarding the risk factors using a statistical analysis technique called propensity score matching.

RESULTS

A total of 170 patients were included in each subgroup. The complete surgery rate was similar in both groups (79.4% vs. 84.7%). The median PFS times were 16 and 13 months in the CRSH and CRSnoH groups, respectively (Hazard ratio (HR) 0.74; 95% CI, 0.58-0.94; p = 0.031). The median OS times were 56 and 50 months in the CRSH and CRSnoH groups, respectively (HR, 0.88; 95% CI, 0.64-1.20; p = 0.44). There was no increase in complications in the CRSH group.

CONCLUSION

The addition of HIPEC after interval cytoreductive surgery is safe and increases DFS in advanced EOC patients.

Lymphovascular Space Invasion in Early-Stage Endometrial Cancer (LySEC): Patterns of Recurrence and Predictors. A Multicentre Retrospective Cohort Study of the Spain Gynecologic Oncology Group

The main aim is to compare oncological outcomes and patterns of recurrence of patients with early-stage endometrioid endometrial cancer according to lymphovascular space invasion (LVSI) status. The secondary objective is to determine preoperative predictors of LVSI. We performed a multicenter retrospective cohort study. A total of 3546 women diagnosed with postoperative early-stage (FIGO I-II, 2009) endometrioid endometrial cancer were included. Co-primary endpoints were disease-free survival (DFS), overall survival (OS), and pattern of recurrence. Cox proportional hazard models were used for time-to-event analysis. Univariate and multivariate logistical regression models were employed. Positive LVSI was identified in 528 patients (14.6%) and was an independent prognostic factor for DFS (HR 1.8), OS (HR 2.1) and distant recurrences (HR 2.37). Distant recurrences were more frequent in patients with positive LVSI (78.2% vs. 61.3%, p < 0.01). Deep myometrial invasion (OR 3.04), high-grade tumors (OR 2.54), cervical stroma invasion (OR 2.01), and tumor diameter ≥ 2 cm (OR 2.03) were independent predictors of LVSI. In conclusion, in these patients, LVSI is an independent risk factor for shorter DFS and OS, and distant recurrence, but not for local recurrence. Deep myometrial invasion, cervical stroma invasion, high-grade tumors, and a tumor diameter ≥ 2 cm are independent predictors of LVSI.

Postoperative Intestinal Fistula in Primary Advanced Ovarian Cancer Surgery

Background

Advanced ovarian cancer (AOC) requires an aggressive surgery with large visceral resections in order to achieve an optimal or complete cytoreduction and increase the patient’s survival. However, the surgical aggressiveness in the treatment of AOC is not exempt from major complications, such as the gastrointestinal fistula (GIF), which stands out among others due to its high morbidity and mortality.

Methods

We evaluated the clinicopathological features in patients with AOC and their association with GI. Data for 107 patients with AOC who underwent primary debulking surgery were analyzed retrospectively. Clinicopathological features, including demographic, surgical procedures and follow-up data, were analyzed in relation to GIF.

Results

GIF was present in 11% of patients in the study, 5 (4.5%) and 7 (6.4%) of colorectal and small bowel origin, respectively. GIF was significantly associated with peritoneal cancer index (PCI) >20, more than 2 visceral resections, and multiple digestive resections. Overall and disease-free survival were also associated with GIF. Multivariate analysis identified partial bowel obstruction and operative bleeding as independent prognostic factors for survival. The presence of GIF is positively associated with poor prognosis in patients with AOC.

Conclusion

Given the importance of successful cytoreductive surgery in AOC, the assessment of the amount of tumor and the aggressiveness of the surgery to avoid the occurrence of GIF become a priority in patients with AOC.

Prognostic Value and Therapeutic Implication of Laparoscopic Extraperitoneal Paraaortic Staging in Locally Advanced Cervical Cancer: A Spanish Multicenter Study

PURPOSE

To assess the impact of laparoscopic extraperitoneal paraaortic staging in therapeutic planning and prognosis of patients with locally advanced cervical cancer (LACC) as compared with imaging staging.

METHODS

Retrospective multicenter study of stage IB2 and IIA2 to IVA (FIGO 2009) LACC patients who were candidates for primary chemoradiotherapy. The study (surgical) group included 634 patients undergoing laparoscopic/robotic extraperitoneal paraaortic staging treated with extended-field radiotherapy (EFRT) if lymph node involvement was confirmed. The control (imaging) group included 288 patients treated with EFRT when lymph node involvement was suspected on positron emission tomography-computed tomography scans and/or magnetic resonance imaging.

RESULTS

In the study group, a median of 13 (range 9-17) lymph nodes were removed, with a rate of positive paraaortic nodes of 18%, with metastatic size ≤ 5 mm in 20.4% of cases. Paraaortic EFRT was administered to 18% of patients in the study group and in 58% of controls. In 34% of patients from the surgical group, EFRT was modified according to surgical findings with respect to imaging staging. The median follow-up in the study and control groups was 3.7 and 4.8 years, respectively. In both groups, the overall survival and cancer-specific disease-free survival were similar. The time interval between diagnosis and starting EFRT was 18 days longer in the study group, without differences in overall survival as compared with controls (hazard ratio 1.00, 95% confidence interval 0.998-1.005; p = 0.307).

CONCLUSIONS

Laparoscopic extraperitoneal paraaortic staging in LACC patients is safe and modified therapeutic planning, allowing better selection of candidates for EFRT.

Peritoneal carcinomatosis index as a predictor of diaphragmatic involvement in stage III and IV ovarian cancer

Objective

To analyze the surgical outcomes and diaphragmatic involvement in stage III and IV ovarian cancer.

Patients and methods

All patients with stage III–IV ovarian cancer between January 2013 and January 2016 were included. The outcomes of interest reviewed were as follows: surgical (complications, mortality), peritoneal carcinomatosis index (PCI), rate of complete resection, and disease-free interval and survival.

Results

Fifty-seven patients were included, 38 (67%) with diaphragmatic involvement; in 10 cases (18%), diaphragmatic resection was required. Optimal cytoreduction (OCR) was obtained in 49 cases (86%). The PCI was >10 in 31 cases (54%). Respiratory complications occurred in 10 cases (18%) and mortality in 3 (5%). Disease-free survival rate in 3 years was 53%, being 87% in cases without diaphragmatic involvement. The overall survival rate in 3 years is 46%, 83% in the cases without diaphragmatic involvement and 27% in cases with affectation (p<0.05). In cases of OCR, 3 year survival rate was 65%. In the multivariate analysis for the overall survival of cases with OCR, the only independent prognostic factor found was the operative PCI. A strong correlation was found between the total PCI and the diaphragmatic PCI (p<0.001). With a PCI >10, virtually all cases will present diaphragmatic involvement (p<0.05).

Conclusion

The tumor burden is different in stages III and IV of advanced ovarian cancer and the PCI is an effective method to quantify it. The PCI constitutes an independent prognostic factor for the advanced stages of ovarian cancer. A PCI >10 constitutes a useful prognostic factor of the affectation and forces the surgeon to thoroughly review both diaphragms.

Endopelvic free anchor minisling technique for stress urinary incontinence treatment: 10 years of experience

INTRODUCTION AND HYPOTHESIS

We present our 10-year experience in treating stress urinary incontinence (SUI) using a new minisling technique based on a tension-free vaginal tape band designed by our group. The major advantage of this tape is the use of minibelt polypropylene inserted through a single retropubic incision without the use of needles-the Endopelvic Free Anchor (EFA)-based on its location at the midurethra with a U shape. For insertion, each branch is placed using a simple Pean clamp from the vagina with perforation of the endopelvic fascia to achieve a retropubic insertion.

METHODS

From May 2001 to May 2011, we surgically treated 166 women with primary first- or second-degree SUI due to urethral hypermobility without genital prolapse. All were evaluated according to our study protocol, which included clinical and urodynamic evaluation before and 12 months after surgery.

RESULTS

With a median follow-up of 5 (1-11) years, 152 patients (91.6 %) were fully cured both from urodynamic and subjective points of view. Six patients (3.6 %) had significant improvement, and eight (4.8 %) were identified as technique failure. Complications included one bladder perforation (0.6 %), two cases of postoperative urinary retention (1.24 %), two of retropubic hematoma (1.24 %), and one of de novo urgency (0.6 %). No reinterventions were necessary, and there were no major bleeding complications, no chronic pain or de novo dyspareunia, and no voiding difficulty.

CONCLUSIONS

EFA is a viable, safe, and effective technique for treating UI due to urethral hypermobility.

Role of minimally invasive surgery in complex adnexal tumours and ovarian cancer

Ovarian cancer is one of the most common causes of cancer-related death in women. Adnexal masses are frequently diagnosed during reproductive age and often require surgical removal. The risk of malignancy when dealing with a complex adnexal mass should be defined prior to surgery and several scoring systems may be useful for this purpose. Laparoscopic management of ovarian tumours allows a minimally invasive approach with respect to several oncological assumptions. In the last decade concerns have been raised regarding the risk of cyst rupture and tumour spillage as a consequence of the laparoscopic technique itself both in early and advanced stages of ovarian cancer. Although limited data have been reported in the literature on the use of minimally invasive techniques in ovarian cancer, the clear benefits of this approach must be balanced with the potential hazards in different clinical situations. Laparoscopic staging in borderline tumours and presumed early-stage ovarian cancer performed by a laparoscopic oncologist seems to be safe and effective when compared to laparotomy. The precise role of laparoscopy in patients with more advanced cancer is still to be defined, and the risk of suboptimal surgery should never outweigh the potential benefits of minimally invasive surgery. Thus, a tailored prediction of optimal laparoscopic debulking is mandatory in these patients.

Expression of the Fibrinolytic Components in Endometriosis

Endometriosis is a benign gynaecologic disease defined as the presence of endometrial tissue outside the uterus. This tissue has the ability to implant at ectopic sites, such as ovary and peritoneum, where a local extracellular proteolysis might take place. An altered expression of several components of the fibrinolytic system in the endometrium and peritoneal fluid of women with the disease has been suggested as a key factor in the establishment of the endometriotic lesions. There is evidence of increased fibrinolytic activity in the eutopic endometrium of these women, resulting in endometrial fragments with a high potential to degrade the extracellular matrix and facilitate implantation. Proteolytic status is determined by the imbalance between plasminogen activators and plasminogen activator inhibitors, which are expressed differently depending on the type of lesion considered and the stage of the disease. The aim of the present study is to review the expression of the plasminogen activator system in endometriosis, and to consider the clinical implications and the possible further research efforts in this disease.

Plasminogen activators and plasminogen activator inhibitors in endometriosis

Endometriosis is one of the most frequent benign gynecological diseases that affect women. Little is known about the pathogenesis and etiology of endometriosis, despite the numerous studies performed in this field. Although endometriosis is a benign disease, the endometrial tissue, after attachment to the peritoneum, has the ability to grow and invade the surrounding tissues. Similar to neoplastic growth, local extracellular proteolysis might take place, and therefore, the fibrinolytic system may be involved. An altered expression of several components of the fibrinolytic system in the endometrium and peritoneal fluid of women with the disease has been suggested as a key factor in the establishment of the endometriotic lesions. There is evidence of increased fibrinolytic activity in the eutopic endometrium of these women, resulting in endometrial fragments with a high potential to degrade the extracellular matrix and facilitate implantation. The peritoneum possesses an inherent fibrinolytic activity that is responsible for the degradation of the fibrin deposits originated after an injury. This physiological function allows a correct repair of the mesothelium, and therefore, prevents the formation of adhesions. Peritoneal fluid of women with endometriosis and pelvic adhesions has shown to have an increased fibrinolytic activity that may be implicated in reducing the formation of new adhesions. Endometriotic tissue has abnormal proteolytic capacity, which is determined by modifications of the fibrinolytic parameters in this tissue. Proteolytic status is determined by the imbalance between plasminogen activators and plasminogen activator inhibitors, which are expressed differently depending on the type of lesion considered and the stage of the disease. The aim of the present study is to review the role of the plasminogen activator system in endometriosis, consider the clinical implications and focus on possible further research efforts and therapeutic applications in this disease.