C. Alboni

Laparoscopic nerve-sparing transperitoneal approach for endometriosis infiltrating the pelvic wall and somatic nerves: anatomical considerations and surgical technique

PurposeEndometriotic or fibrotic involvement of sacral plexus and pudendal and sciatic nerves may be quite frequently the endopelvic cause of ano-genital and pelvic pain. Feasibility of a laparoscopic transperitoneal approach to the somatic nerves of the pelvis was determined and showed by Possover et al. for diagnosis and treatment of ano-genital pain caused by pudendal and/or sacral nerve roots lesions and adopted at our institution. In this paper we report our experience and anatomo-surgical consideration regarding this technique.MethodsConfidence with this technique was obtained after several laparoscopic and laparotomic dissections on fresh, embalmed and formalin-fixed female cadavers and is now routinely performed at our institution in all cases of extensive endometriosis of the pelvic wall, involving the somatic nerves.ResultsWe describe two different laparoscopic transperitoneal approaches to the lateral pelvic wall in case of: (A) deep pelvic endometriosis with rectal and/or parametrial involvement extending to pelvic wall and somatic nerves; (B) isolated endometriosis of pelvic wall and somatic nerves.ConclusionsLaparoscopic transperitoneal retroperitoneal nerve-sparing approach to the pelvic wall proved to be a feasible and useful procedure even if limited to referred laparoscopic centers and anatomically experienced and skilled surgeons.

Oestrogen receptor 1 mRNA is a prognostic factor in ovarian cancer patients treated with neo-adjuvant chemotherapy: Determination by array and kinetic PCR in fresh tissue biopsies

Oestrogen receptors (ESRs) regulate the growth and differentiation of normal ovarian epithelia. However, to date their role as biomarkers in the clinical setting of ovarian cancer remains unclear. In view of potential endocrine treatment options, we tested the role of ESR1 mRNA expression in ovarian cancer in the context of a neo-adjuvant chemotherapy trial. Study participants had epithelial ovarian or peritoneal carcinoma unsuitable for optimal upfront surgery and were treated with neo-adjuvant platinum-based chemotherapy before surgery. RNA was isolated from frozen tumour biopsies before treatment. RNA expression of ESR1 was determined by microarray and reverse transcriptase kinetic PCR technologies. The prognostic value of ESR1 was tested using univariate and multivariate Cox proportional hazards models, Kaplan-Meier survival statistics and the log-rank test. ESR1 positively correlates with proliferation markers and histopathological grading. ESR1 was a significant predictor of survival as a continuous variable in the univariate Cox regression analysis. In multivariate analysis, elevated baseline ESR1 mRNA levels predicted prolonged progression-free survival (P=0.041) and overall survival (P=0.01) after neo-adjuvant chemotherapy, independently of pathological grade and age. We conclude that pretreatment ESR1 mRNA is associated with tumour growth and is a strong prognostic factor in ovarian cancer, independent of the strongest clinical parameters used in clinical routine. We suggest that ESR1 mRNA status should be considered in order to minimize possible confounding effects in ovarian cancer clinical trials, and that early treatment with anti-hormonal agents based on reliable hormone receptor status determination is worth investigating.

p53 expression, DNA ploidy and mitotic index as prognostic factors in patients with epithelial ovarian carcinoma.

Aims and Background Biological variables linked to genomic instability were examined and related to survival in 52 patients affected by ovarian carcinoma and nine patients with low malignant potential tumors (LMP). Methods DNA ploidy was measured by image cytometry in isolated neoplastic cells; the mitotic index was measured in Feulgen-toluidine blue-stained sections and p53 was investigated by immunohistochemistry. Results Twenty-five tumors (4 LMP) were peridiploid (ploidy <2.25c), 22 tumors (4 LMP) were hyperdiploid (2.25c>ploidy<2.9c) and 14 (1 LMP) had high ploidy (≥2.9c). Ml ranged from 0.3 to 24.2 with a mean of 1.8 for LMP and 6.8 for carcinomas (P <0.001). Widespread p53 overexpression was detected in 49% of carcinomas and in none of the LMP tumors. Conclusions Survival analysis performed in patients with carcinomas indicated that, of the examined biological variables, only Ml was moderately associated with survival in a subgroup of early-stage patients.

Three‐dimensional power Doppler imaging of uterine artery pseudoaneurysm treated unsuccessfully with selective embolization

A 24-year-old primigravida underwent a scheduled Cesarean delivery at 39 weeks’ gestation for breech presentation. Five weeks after the Cesarean section she presented to our emergency department with sudden onset of heavy vaginal bleeding and abdominal pain. Transvaginal ultrasound examination (Accuvix XQ, Medison Corp, Seoul, Korea) showed a hypoechoic area, measuring 14.4 × 8.8 mm, located at the level of the lower uterine segment, adjacent to the Cesarean suture, which involved the majority of the myometrial wall on the right side of the uterus (Figure 1a). Color Doppler sonography confirmed bidirectional systolic and diastolic flow (peak systolic velocity, 0.70 m/s; resistance index, 0.53) within the area, which appeared to be connected to the right uterine artery, findings consistent with a pseudoaneurysm of this vessel (Figure 1b). The patient underwent pelvic angiography and embolization of the pseudoaneurysm. Selective hypogastric arteriography using a 5-F cobra shaped catheter was performed and multiple metallic coils of 3 mm in diameter were deployed across the origin of the pseudoaneurysm from the uterine artery, followed by pledgets of gelatine sponge. Repeat ultrasound

OC227: Early 3D aspects of recurrence of borderline ovarian tumors

important for fetal viability, supplying the fetal brain and heart with oxygen and glucose. The objective of the study was to investigate the glucose uptake in fetal organs using PET during acute and chronic hypoxia. Methods: In 12 fetal sheep PET imaging was performed on a highresolution PET scanner (Siemens ECAT/EXACT, Germany). Blood flow volume in the umbilical vein (UV) and ductus venosus (DV) was measured using color Doppler ultrasound systems and the umbilical supply to the liver was calculated. For acute hypoxia, oxygen was reduced in the ventilated gas mixture. Fetoscopic coagulation of major placental vessels was performed using a 30◦ endoscope and bipolar forceps (Karl Storz, Germany) in three pregnant ewes (GA 85 ± 8 days, mean ± SD) for chronic hypoxia. FDG uptake in fetal brain and liver was estimated using dynamic PET imaging over 60 min. Input functions were derived from arterial and venous blood samples of mother sheep scaled by fetal blood samples taken from the umbilical cord vein by cordocentesis under ultrasound guidance to determine gas values in the UV. Results: During hypoxia fetal pH, BE and umbilical liver blood supply were reduced significantly. FDG uptake of the heart increased during hypoxia, but was not changed significantly in the liver.

P41.11: Three‐dimensional power Doppler angiography in the diagnosis of pseudoaneurysm of the uterine artery

artery PI, had increased risk for Cesarean section and lower birth weight, lower gestational age at delivery, lower apgar scores and higher need for neonatal intensive care. Uterine Doppler test have a positive prediction value of 58% to predict adverse perinatal outcome and therefore it could be useful to assess SGA fetus with normal umbilical Doppler. CPR at diagnosis of SGA was not useful to assess the subsequent adverse outcome.

P29.07: Early diagnosis and conservative management of cervical ectopic pregnancy

Objectives: To evaluate the criteria of early diagnosis and the role of conservative management in the treatment of cervical pregnancies. Methods: We made a retrospective analysis of all cervical ectopic pregnancies diagnosed in our department from January 2001 to December 2005. The diagnosis of cervical pregnancy was made by transvaginal ultrasound (empty uterine cavity, distended/enlarged cervix, gestational sac below the level of internal os, negative ‘sliding sign’, peritrophoblastic blood flow on Doppler evaluation). Data about medical history were recorded in all cases. Serum human chorionic gonadotropin (hCG) levels were evaluated at time of diagnosis and during the follow-up until resolution. Conservative management was obtained with administration of systemic (50 mg/m2) and/or intra-amniotic (50 mg) methotraxate. After three months from the treatment all patients underwent an hysteroscopic evaluation of cervical canal and uterine cavity. Results: Five cases of ectopic pregnancy were diagnosed during the study period. No risk factors were found in patients medical history. Sonographic diagnosis was between 7 and 10 weeks of gestation. Serum hCG levels at diagnosis were between 4446 and 10 087 IU/L. Two cases were successfully treated with systemic and intraamniotic administration of methotrexate, three case were managed successfully with a single dose of intra-amniotic metothrexate. Serum hCG levels started to decrease from day 4 after the treatment. No early or late complications occurred. All patients were followed up until serum hCG levels were < 5 IU/L. Hysteroscopic evaluation confirmed absence of sinechiae/lesions at the level of cervical implant of ectopic pregnancy in all patients. Conclusion: Early diagnosis of cervical pregnancy allows a conservative fertility-sparing management that is effective and safe.

OP16.04: Evaluation of response to neoadjuvant chemotherapy in advanced ovarian cancer by transvaginal sonography

Objectives: Neoadiuvant chemotherapy (NAC) has been proposed as a possible alternative to up-front debulking surgery in advanced ovarian cancer. We evaluated the response to NAC by transvaginal sonography (TVS). Methods: Twenty-six patients with histologically confirmed diagnosis of ovarian cancer underwent TVS before and during NAC (first, third and sixth cycle). We evaluated the regression of tumor size according to RECIST criteria, the regression of ascites according to a quantitative score (0: absence, 1:< 2 cm, 2:> 2 cm, 3:> 5 cm), the regression of peritoneal implants and intratumoral blood flow. After six cycles of NAC, interval debulking surgery (IDS) was performed in responder patients; non-responders had a second line of chemotherapy. We compared sonographic evaluation of response to NAC to pathological response. Results: Among 26 patients prospectively enrolled in the study (mean age 60), 13 were stage IIIC and 13 were stage IV; 19 patients had NAC and IDS and seven had second-line chemotherapy. Measurement of tumor size showed a regression> 90% in 5/26 patients, > 50% and< 90% in 16/26 patients and persistent disease in five patients. Before NAC ascites was seen in 23/26 (88.5%) patients and after treatment it disappeared in 17 patients. In 6/7 (85%) patients with persistent or progressive disease, ascites was found until the sixth cycle. Peritoneal implants were seen in 18/26 patients (69%); after NAC peritoneal implants disappeared in 14/18 (78%) patients. Intratumoral blood flow was found in 22/26 (84%) patients; after NAC vascularization was not detectable in 13 patients, while a persistent small venous vessel was observed in nine. Conclusions: TVS seems to be feasible and accurate in the evaluation of response to NAC, showing ascites pattern of evolution as the more accurate feature: persistence of ascites can be considered a pattern of non-responder patients to NAC.