Outcome quality standards in advanced ovarian cancer surgery

INTRODUCTION

Advanced ovarian cancer surgery (AOCS) frequently results in serious postoperative complications. Because managing AOCS is difficult, some standards need to be established that allow surgeons to assess the quality of treatment provided and consider what aspects should improve. This study aimed to identify quality indicators (QIs) of clinical relevance and to establish their acceptable quality limits (i.e., standard) in AOCS.

MATERIALS AND METHODS

We performed a systematic search on clinical practice guidelines, consensus conferences, and reviews on the outcome and quality of AOCS to identify which QIs have clinical relevance in AOCS. We then searched the literature (from January 2006 to December 2018) for each QI in combination with the keywords of advanced ovarian cancer, surgery, outcome, and oncology. Standards for each QI were determined by statistical process control techniques. The acceptable quality limits for each QI were defined as being within the limits of the 99.8% interval, which indicated a favorable outcome.

RESULTS

A total of 38 studies were included. The QIs selected for AOCS were complete removal of the tumor upon visual inspection (complete cytoreductive surgery), a residual tumor of < 1 cm (optimal cytoreductive surgery), a residual tumor of > 1 cm (suboptimal cytoreductive surgery), major morbidity, and 5-year survival. The rates of complete cytoreductive surgery, optimal cytoreductive surgery, suboptimal cytoreductive surgery, morbidity, and 5-year survival had quality limits of < 27%, < 23%, > 39%, > 33%, and < 27%, respectively.

CONCLUSION

Our results provide a general view of clinical indicators for AOCS. Acceptable quality limits that can be considered as standards were established.

Step by step Indiana pouch construction in a previously irradiated patient with a cervical cancer relapse

INTRODUCTION

Radiation therapy and radical pelvic surgery, either radical cystectomy or pelvic exenteration, is the golden standard treatment for infiltrating bladder carcinoma, as well as advanced or recurrent cervical, vulvar, vaginal and endometrial cancer. However, due to the poor radiation sensitivity of the cervix and vagina, a high-radiation dose is required, leading to early and/or late onset urogenital complications in approximately 50% of the patients.

CASE PRESENTATION

The following case report describes a 64-year-old native Russian woman presenting a relapse of a vaginal cuff squamous cell carcinoma, who underwent a laterally extended endopelvic resection (LEER) followed by a neobladder reconstruction based on the Indiana pouch (IP) technique. The process is described here step by step.

DISCUSSION

Indiana pouch urinary diversion was based on thorough research, the reproducibility of the technique, our urologist's experience with the Indiana Pouch, as well the lower rate of complications published in various separate series.

CONCLUSION

Indiana pouch is a successful continence urinary reservoir with a reproductible technique, however long-term observation is needed.

Hepatic epithelioid hemangioendothelioma: A great mimicker

INTRODUCTION

Epithelioid hemangioendothelioma is a malignant mesenchymal tumor of unknown etiology. They tend to be asymptomatic or with non-specific symptoms. The lesion is usually multiple and variable size.

PRESENTATION OF CASE

We describe a clinical case of a 23-years-old patient diagnosed with a pelvic mass, a possible uterine fibroid or adnexal mass, and multiple liver lesions that seemed an advanced ovarian cancer presentation and after liver biopsy turned out to be a hepatic epithelioid hemangioendothelioma.

DISCUSSION

It may be confused with a metastatic process in diagnostic imaging. There have been described some possible risk factors but the etiology remains unknown. The prognosis is usually lethal in 50% of cases. The surgical removal of the lesion and liver transplant appear to be the only hope for these patients.

CONCLUSION

Epithelioid hemangioendothelioma must be part of our differential diagnosis when we find a liver tumour, especially in young women. Treatment is excision of the tumour in limited disease. In the case of unresectable disease are candidates for liver transplantation.

Use of negative pressure wound therapy after infection and flap dehiscence in radical vulvectomy: A case report

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Radical vulvectomy is a very agressive surgery.

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Deshiscence of vulvar wound is one of the most feared complications.

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Negative wound pressure therapy could be incorporate in the management of this complications.

Introduction

Vulvar cancer has a lower incidence in high income countries, but is rising, in part, due to the high life expectancy in these societies. Radical vulvectomy is still the standard treatment in initial stages. Wound dehiscence contitututes one of the most common postoperative complications.

Presentation of case

A 76 year old patient with a squamous cell carcinoma of the vulva, FIGO staged, IIIb is presented. Radical vulvectomy and bilateral inguinal lymph node dissection with lotus petal flaps reconstruction are performed as the first treatment. Wound infection and dehiscence of lotus petal flaps was seen postoperatively. Initial management consisted in antibiotics administration and removing necrotic tissue from surgical wound. After this initial treatment, negative wound pressure therapy was applied for 37 days with good results.

Discussion

Wound dehiscence in radical vulvectomy remains the most frequent complication in the treatment of vulvar cancer. The treatment of this complications is still challenging for most gynecologic oncologist surgeons.

Conclusion

The utilization of the negative wound pressure therapy could contribute to reduce hospitalization and the direct and indirect costs of these complications.

Treatment and follow-up in an asymptomatic malignant struma ovarii: A case report

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Struma ovarii is a rare and asymptomatic ovarian tumor and is usually diagnosed by the pathologist.

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Struma ovarii malignancy is from thyroid origin and usually associated with thyroid tumors.

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Management and follow up is not well established.

Introduction

Struma ovarii is a rare ovarian tumor, representing 0.5-1% of all ovarian tumors and 2–5% of ovarian teratomas. It is defined as an ovarian teratoma composed mostly of thyroid tissue. The symptoms are nonspecific, and the imaging studies can help in characterize the mass; however, the definitive diagnosis is usually given by the Pathologist. Classically, the treatment is the surgical resection of the ovarian mass, however there is no consensus regarding the follow-up.

Presentation of case

An asymptomatic malignant struma ovarii in a 43 year-old patient is presented. The diagnosis was postoperatively following a laparoscopic adnexectomy due to an apparently benign ovarian teratoma. The histopathology results revealed a mature ovarian cystic teratoma with papillary carcinoma with immunohistochemical characteristics suggesting a thyroid origin. Seeing that there was no thyroid affectation or metastatic disease, we decided a conservative management. A yearly follow-up with CT scan and tumor markers was performed. The endocrinologist also performed annual controls with thyroid ultrasound and serum tests. The patient has remained asymptomatic during these last four years.

Discussion

There is little evidence in literature on the conservative management in cases with evidence of malignancy. If fertility preservation is desired, an unilateral oophorectomy could be performed, along with levels of serum thyroglobulin as a marker of relapse. Other authors claim for aggressive ovarian cancer surgery followed by a total thyroidectomy. There is still no established management for struma ovarii patients and the choice for a conservative or radical approach depends only on the professional decision.