Alessandro Tropea

The role of cytoreductive surgery in advanced-stage ovarian cancer: a systematic review

It has already been proven that ovarian cancer is the sixth most common cancer among women, and it is considered the leading cause of death by gynecologic cancer in developed countries. This article is a literature review based on the use of cytoreductive surgery matched with adjuvant chemotherapy in advanced-stage ovarian cancer. According to the statistics, the difficulty of obtaining an early diagnosis results in a delay in the disease treatment and as a consequence, in many cases, ovarian cancer is still diagnosed in the advanced stage of the disease. Primary surgery is performed, in addition to diagnosis and staging, to achieve optimal cytoreduction. The purpose of this article is to review the different surgical approaches in the management of epithelial ovarian cancer, specifically the high-stage disease, with a special concentration on the most recent therapeutic additions to our current knowledge, such as hyperthermic intraperitoneal chemotherapy and new therapeutic drugs. Surgical treatment still plays a pivotal role in the management of advanced-stage ovarian cancer. Complete cytoreduction continues to be, when feasible, the objective to be attempted in the surgical treatment of advanced ovarian cancer. Obviously, the success of the operation depends on numerous factors, including patient selection, the locations of tumors, and surgeon expertise. To offer patients the best possible outcome with the least accompanying morbidity, strong consideration should be given to the referral of such patients to expert care centers for primary surgery, because it may be the best means currently available for improving overall survival.

Predictors of conversion in laparoscopic-assisted colectomy for colorectal cancer and clinical outcomes.

This study investigated risk factors and impact of open conversion on outcomes of 207 consecutive patients who had laparoscopic resection of colorectal cancer at our institution. Conversion occurred in 15.9% of patients, mostly because of invasion to adjacent structures (30.3%), bulky tumor (21.2%), and adhesions (18.2%). Converted patients had significant larger tumor size, advanced stage, increased operative blood loss, time to walk independently, prolonged hospital stay, number of massive hemorrhage, ileus, anastomotic hemorrhage, abdominal hemorrhage, peritonitis/septic shock, and wound infection than completed laparoscopy patients. Factors associated with conversion were obesity [relative risk (RR)=6.92; 95% confidence interval (CI), 1.7-28.09], date of operation (RR=0.37; 95% CI, 0.15-0.95), advanced tumor stage (RR=7.67; 95% CI; 1.19-49.2), size (RR=1.97; 95% CI, 1.42-2.72), and rectum location (RR=2.73; 95% CI, 1.09-6.84). Converted patients had worse cumulative disease-free (P<0.001) and overall survival (P<0.001) than laparoscopic completed patients.

Fertility sparing surgery for stage IA type I and G2 endometrial cancer in reproductive-aged patients: evidence-based approach and future perspectives

Fertility-sparing surgery (FSS) in reproductive-age patients affected by endometrial cancer (EC) gained growing attention in the last decade, although the first reports were already published in 1990–2000s. Nevertheless, only few patients undergoing FSS for stage I, type I EC had been reported in each case series, without a robust multicenter study. In the available literature there are even fewer reported cases of conservative treatment of Stage IA and G2 EC. Considering these important gaps in our current knowledge, the purpose of this review was to summarize the available evidence about conservative treatments for stage IA type I and G2 EC, to improve the pretreatment counseling for reproductive-age patients. According to our overview, women who have low-risk disease (G1 or G2, endometrioid histotype confined to the endometrium) are candidates for progestin therapy. In addition, FSS could be considered a valid option for reproductive-aged patients with stage IA type I and G2 EC. Nevertheless, we solicit new trials to clarify the medium- and long-term outcomes in this kind of patients.

Prosthetic surgery versus native tissue repair of cystocele: literature review

Cystocele is the most common pelvic organ prolapse. It is defined as the descent of the bladder into the anterior vaginal wall. Aging is significantly associated with the prevalence and severity of pelvic organ prolapse. Treatment may be conservative or surgical according to symptoms, prolapse degree and not forgetting both patient and doctor preferences. Identify the most efficient surgical treatment to treat cystocele and its recurrences. Scientific literature was reviewed searching PubMed/MEDLINE database for articles published between 1996 and 2015 and using the terms pelvic organ prolapse, cystocele, mesh surgery, traditional repair, pelvic organ prolapse recurrence, complications, sexual function. There are two different surgical approaches for the treatment of cystocele: traditional repair and mesh repair. Prosthetic treatment gives higher anatomical success rate and fewer recurrence while traditional anterior repair has less complications. Surgical treatment in general improves both the anatomical success rate and the quality of life. The choice of surgery, between traditional and mesh repair, has to be personalized related to the prolapse grade and women tissues.

New procedures for the identification of sentinel lymph node: shaping the horizon of future management in early stage uterine cervical cancer

Lymph node metastasis is one of the most important prognostic factors for uterine cervical cancer, although lymph node status is not part of the International Federation of Gynaecology and Obstetrics (FIGO) staging. Considering the increasing attention about the topic, we performed a comprehensive review of the literature, to assess the accuracy of real-time fluorescence sentinel lymph node (SLN) for the detection of nodal metastases in patients with early stage cervical cancer (ESCC). In this work, we discuss the different techniques for SLN mapping and the accuracy of each one of them and, basing on these data, summarize the most important recommendations. In particular, we suggest to perform indocyanine green-SLN technique for ESCC, since it showed the highest accuracy for the detection of nodal metastases.

Mini-Invasive Approach Contributes to Expand the Indication for Liver Resection for Hepatocellular Carcinoma Without Increasing the Incidence of Posthepatectomy Liver Failure and Other Perioperative Complications: A Single-Center Analysis.

BACKGROUND Liver resection (LR) for hepatocellular carcinoma (HCC) is the best alternative option for increasing the survival of many patients with intermediate or advanced stages of the Barcelona Clinic Liver Cancer staging classification. Mini-invasive approach may play a positive role in treating a tumor rising almost exclusively in a diseased liver. METHODS A prospectively collected database was retrospectively reviewed for 167 consecutive patients who underwent LR between 1999 and 2015. RESULTS A total of 38 LRs were performed from 1999 to 2009 (Period I), and 129 between 2010 and 2015 (Period II). Laparoscopic procedures increased from 5.3% to 38.1%. Not undergoing laparoscopic LR increased length of stay, and Clavien Grade II or worse complications. Ninety-day mortality decreased from 5.2% to 0%, and morbidity did not differ significantly, despite the fact that the most complex patients were in Period II. CONCLUSIONS Mini-invasive approaches allow to safely expand limits of LR for HCC; in particular, laparoscopic approach favors surgical option even in more complex patients without increase the risk of posthepatic liver failure or other postsurgical complications.

A novel HIPEC technique using hybrid CO 2 recirculation system: intra-abdominal diffusion test in a porcine model

The role of loco-regional treatment of peritoneal carcinomatosis using intraperitoneal chemotherapy is still investigated. Actually, new technologies are suitable for these procedures, especially a new hybrid system using CO2 called Peritoneal Recirculation System (PRS-1.0 Combat). A HIPEC procedure in a porcine model using the PRS system was conducted. The objective of experimentation was to assess the distribution of liquid inside the abdomen, by using methylene blue instead of chemotherapy. Moreover, we positioned six different thermal probes in different abdominal regions inside the abdomen to measure the temperature during procedure. During the procedure, all thermal probes recorded an average temperature of 41.5°. At the end of infusion, the abdomen was emptied and then opened; the tracer distribution was recorded. No technical problems were recorded during the procedure. Good distribution of tracer was recorded. More studies are needed to investigate better this new technology.

Tumor markers of uterine cervical cancer: a new scenario to guide surgical practice?

Since the introduction of Pap smear screening, the incidence and mortality of cervical cancer (CC) have been reduced drastically in USA and in other western states. Nevertheless, CC still remains the main cause of death from gynecological cancer in developing countries where screening programs are scant or inexistent. This evidence highlights the efficacy of screening, and the wide use of Human Papilloma Viruses (HPV) vaccines in developed countries. More and more people are, consequentially, undergoing a screening procedure, usually combined with HPV DNA test, increasing the early diagnosis of intraepithelial HPV-related lesions. The long transit time from early cervical lesion to invasive cancer provides an opportunity to identify pre-cancerous lesions where treatment result is maximum. In fact, when an invasive CC occurs, the overall survival rate strictly depends on stage of disease with an average survival of 70% at 5 years. Under the pressure of this reality, researches have made efforts to individuate cancer markers as indicator of specific cancer events. Some markers were showed to be able to detect those intraepithelial lesions have more chance to evolve to invasive forms (p16ink4a, p16, E-cadherin, Ki67, pRb, p53). Markers such as CEA, SCC-Ag, CD44, have been developed to detect invasive forms. Although cancer markers actually are not used only for early diagnosis, they may be useful in others fields of application such as evaluation and monitoring of treatments to improve diagnosis and treatment of CC.

Target Therapies for Uterine Carcinosarcomas: Current Evidence and Future Perspectives

Carcinosarcomas (CS) in gynecology are very infrequent and represent only 2–5% of uterine cancers. Despite surgical cytoreduction and subsequent chemotherapy being the primary treatment for uterine CS, the overall five-year survival rate is 30 ± 9% and recurrence is extremely common (50–80%). Due to the poor prognosis of CS, new strategies have been developed in the last few decades, targeting known dysfunctional molecular pathways for immunotherapy. In this paper, we aimed to gather the available evidence on the latest therapies for the treatment of CS. We performed a systematic review using the terms “uterine carcinosarcoma”, “uterine Malignant Mixed Müllerian Tumors”, “target therapies”, “angiogenesis therapy”, “cancer stem cell therapy”, “prognostic biomarker”, and “novel antibody-drug”. Based on our results, the differential expression and accessibility of epithelial cell adhesion molecule-1 on metastatic/chemotherapy-resistant CS cells in comparison to normal tissues and Human Epidermal Growth Factor Receptor 2 (HER2) open up new possibilities in the field of target therapy. Nevertheless, future investigations are needed to clarify the impact of these new therapies on survival rate and medium-/long-term outcomes.

Association between Liver Perfusate Natural Killer Cellular Subset from Deceased Brain Donors and Acute Cellular Rejection after Liver Transplantation Procedure: Single Center Analysis

Background Our study focuses on the cytofluorimetric examination of a monocentric series of consecutive liver perfusates (LPs) after whole graft washout in consecutive series of adult deceased brain donors (DBDs) and the predicting role of Natural Killer (NK) cell subset on the biopsy-proven acute cellular rejections (ACRs) after liver transplants (LTs). Methods NK, T cells and Mucosal-associated invariant T (MAIT) cells were purified by flow cytometry using CD3, CD4, CD8 and CD56 from LPs and concentrations and phenotypes were matched with DBD characteristics to determine the relative percentages of T and NK cells. The retrospective study was performed by analyzing indications, timing, surgical techniques and outcomes of consecutive patients underwent LT between 2010 and 2014 in our centre. Results LPs were collected during the back-table surgical time after the procurement procedures for 47 DBD for adult recipient. (Figure 1) NK cell subset was strictly related to younger donor age (p = 0.003) and higher body mass index (BMI) (p = 0.01). At multivariate analysis, donor BMI was associated with reduced percentage of NK obtained by LP of DBDs (OR, -0.3% CI, 0.58-0.95, p = 0.01). A picture of severe-moderate biopsy-proven ACR was detected in 7 recipients underwent LT using whole liver allografts procured by DBDs. A significative association was observed between the quote of NK cell under the median value of NK cell LP subset (33.4%) and the evidence of severe-moderate ACR (p = 0.04). Figure. No caption available. Conclusion Based on our experience a novel potential role of T and NK cells could be determined in ACR after LT from DBD, and this might be of high relevance for liver graft procurement and immunosuppression management.