C. Huchon

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.

Postoperative lymphocysts after lymphadenectomy for gynaecological malignancies: preventive techniques and prospects

Postoperative lymphocyst formation is an insufficiently recognised complication of lymphadenectomy for gynaecological malignancies. Lymphocysts are collections of lymph organised into cysts that develop in contact with lymphadenectomy compartments. There has been considerable debate about the relevance of lymphocyst prevention using surgical or pharmacotherapeutic methods. Here, we review the available studies about the impact of these methods on the incidence of lymphocysts. This review suggests that several techniques may decrease the incidence of lymphocysts when used in combination. On a literature basis, the peritoneum should be left open over the lymphadenectomy sites at the end of the procedure and drains should not be placed at the end of the procedure. Omentoplasty should be encouraged and further studies are needed to assess the potential benefits of new energies. Postoperative octreotide therapy seems beneficial but the role of this drug in pelvic oncological surgery remains to be determined.

Prise en charge des masses annexielles organiques : résultats d'une enquête de pratique

OBJECTIVES The aim of this study was first to describe the adnexal masses diagnoses and their management and secondly to assess the oncological relevance of these strategies. PATIENTS AND METHODS A prospective multicentric observational study of organic adnexal masses was conducted between June and November 2005. All patients presenting an organic adnexal tumor and for which a definitive histological diagnosis was subsequently available were eligible. Baseline characteristics, mode of discovery, preoperative assessment, peroperative findings, surgical treatment and pathological findings were collected. RESULTS Among the 278 patients treated for an adnexal mass during the study-period, 166 were included. Mean age was 42.8 years with a 25.3% menopause rate. The radiological assessment comprised an ultrasound examination in 98.8% of cases and an MRI in about one-fourth. The CA 125 marker was measured in half the patients and the carcinoembryonic antigen (CEA) marker in 19.9%. In all, 83.1% of tumors were found benign, 12.7% were malignant and 4.2% were borderlines on definitive histological examination. The surgical procedure comprised a cystectomy in 88 cases and an adnexectomy in 64 cases. Among those treated by cystectomy, one borderline tumor was found, whereas in those treated by adnexectomy, five borderline and 12 malignant masses were discovered. Peroperative conversion rates were 16% and 50% in borderline and malignant tumors. Accidental rupture of the cyst occurred in 29% of cases. A minimal preoperative assessment was defined, based upon the dimensions of the tumor and the dosage of at least one marker. These minimal criteria were met in only 28% of initial assessments. DISCUSSION AND CONCLUSION Ovarian borderline tumors and carcinomas are an important contingent of this study (16.9%). Twenty percent of them are diagnosed in an emergency situation. The management observed in this study is adapted to benign lesions. On the other hand, the rate of inappropriate procedures as well as incomplete staging in case of borderline or carcinomas is quite high.

Laparoscopy vs robotics in surgical management of endometrial cancer: comparison of intraoperative and postoperative complications.

STUDY OBJECTIVE To compare the rates of intraoperative and postoperative complications of robotic surgery and laparoscopy in the surgical treatment of endometrial cancer. DESIGN Unicentric retrospective study (Canadian Task Force classification II-2). SETTING Tertiary teaching hospital. PATIENTS The study was performed from January 2002 to December 2011 and included patients with endometrial cancer who underwent laparoscopic or robotically assisted laparoscopic surgical treatment. Data collected included preoperative data, tumor characteristics, intraoperative data (route of surgery, surgical procedures, and complications), and postoperative data (early and late complications according to the Clavien-Dindo classification, and length of hospital stay). Morbidity was compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS The study included 146 patients, of whom 106 underwent laparoscopy and 40 underwent robotically assisted surgery. The 2 groups were comparable in terms of demographic and preoperative data. Intraoperative complications occurred in 9.4% of patients who underwent laparoscopy and in none who underwent robotically assisted surgery (p = .06). There was no difference between the 2 groups in terms of postoperative events. CONCLUSION Robotically assisted surgery is not associated with a significant difference in intraoperative and postoperative complications, even when there were no intraoperative complications of robotically assisted surgery.

Diagnostic accuracy of hand-assisted laparoscopy in predicting resectability of peritoneal carcinomatosis from gynecological malignancies

OBJECTIVES Residual disease after excision surgery is the main prognostic factor in advanced ovarian cancer. Open surgery can delay neoadjuvant chemotherapy initiation. Therefore, a minimally invasive method for evaluating resectability would be of great interest. Aim of our study is to evaluate a new technique for assessing the extent of peritoneal carcinomatosis, combining manual palpation and standard laparoscopy. METHODS Prospective single-center study from October 2008 to January 2010. Patients with peritoneal carcinomatosis from gynecological malignancies were investigated by standard laparoscopy followed by laparoscopy plus manual palpation using Lapdisc(®) (Ethicon Inc.), at 43 abdominopelvic sites. When both techniques indicated resectability, standard cytoreduction surgery was performed via a midline laparotomy. The Fagotti, modified Fagotti, and Sugarbaker scores were computed. The diagnostic performance of each evaluation criterion was assessed by computing sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver-operating characteristic curves (ROC-AUCs). RESULTS Of the 29 included patients, 18 (62.1%) were considered to have resectable disease. Fourteen (14/18, 77.8%) had macroscopically complete cytoreduction. With Lapdisc(®), sensitivity was 100%, specificity 73.3%, PPV 77.8%, NPV 100%, and ROC-AUC 0.87. Corresponding values were as follows: laparoscopy, 100%, 40%, 60.9%, 100%, and 0.70; Fagotti and modified Fagotti scores, 100%, 46.7%, 63.6%, 100%, and 0.73; Sugarbaker score, 64.3%, 93.3%, 90%, 73.7%, and 0.79. The ROC-AUCs showed significantly better performance of Lapdisc(®) than of standard laparoscopy (P = 0.008). CONCLUSION Hand-assisted laparoscopy may perform better than laparoscopy alone for predicting the resectability of peritoneal carcinomatosis by increasing the number of sites evaluated.

Neoadjuvant Dose-Dense Gemcitabine plus Docetaxel and Vinorelbine plus Epirubicin for Operable Breast Cancer: Improved Prognosis in Triple-Negative Tumors

AbstractBackground: Neoadjuvant anti-tumor activity of an alternating taxane- and anthracycline-based dose-dense regimen in patients with operable, noninflammatory large breast cancer was investigated. Objective: The objective is to study the rate of pathological complete response in patients with breast cancer receiving dose-dense chemotherapy sequentially with gemcitabine plus docetaxel and vinorelbine plus epirubicin. Methods: Women (n = 74) with clinical stage II or III breast cancer were enrolled in this open-label, multicenter study to receive six 2-weekly courses of gemcitabine 1000 mg/m2 plus docetaxel 75 mg/m2 on days 1 and 15, and vinorelbine 25 mg/m2 plus epirubicin 100mg/m2 on days 29 and 43. Patients with an objective response on day 56 then received another cycle of gemcitabine/ docetaxel on day 57 and of vinorelbine/epirubicin on day 71. Conservative surgery was scheduled for all patients. Results: Of the patients enrolled, 30% had triple-negative breast cancer (TNBC). The pathologic complete response (pCR) rate was 22% overall, but was higher in TNBC than patients without TNBC (40.9% vs 14.0%; p=0.028). Among patients with a pCR, patients with TNBC had similar recurrence-free survival (RFS) and overall survival (OS) to patients without TNBC. Among those without a pCR, RFS rates for patients with TNBC were significantly lower than for patients without TNBC (p=0.04). The most common severe hematologic toxicity was neutropenia. Conclusions: Administering four drugs in a dose-dense alternating sequence gave a high pCR in patients with operable, invasive breast cancer. Patients with TNBC with a pCR had similar OS to patients without TNBC, whereas patients with TNBC without a pCR had poorer survival rate than their non- TNBC counterparts.

A life-threatening ectopic pregnancy with etonogestrel implant.

BACKGROUND Etonogestrel contraceptive implant is a highly effective subdermal method of long-acting hormonal contraception for women. CASE We describe a case of ruptured ectopic pregnancy occurring in a patient with an etonogestrel contraceptive implant (Implanon®). The only factor predisposing to a failure in this case is a moderately elevated body mass index of 29. However, the implant was in place for less than 2 years, and the plasma levels of etonogestrel were within the expected range. CONCLUSION This case report emphasizes the fact that ectopic pregnancy should not be formally ruled out in women using this contraceptive, and it highlights the need for further study of the effect of body weight on this contraceptive method.

Procédure du ganglion sentinelle et cancers utérins

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.

Cáncer de endometrio en el síndrome de Lynch

El sindrome de Lynch se caracteriza por una predisposicion genetica a sufrir cancer colorrectal, relacionada con la mutacion de un gen de reparacion del acido desoxirribonucleico (ADN). Los pacientes afectados estan expuestos al riesgo de desarrollar cancer colorrectal, pero tambien muchos otros tumores que pertenecen al espectro del cancer colorrectal no poliposico hereditario (HNPCC, por sus siglas en ingles), y, entre estos, en primer lugar, el cancer de endometrio: el riesgo acumulado de desarrollar la enfermedad a la edad de 80 anos llega al 40%. Estos canceres de endometrio tienen la particularidad de presentarse a una edad temprana y, desde un buen comienzo, en un estadio avanzado. Aunque no esta validada, debe recomendarse la deteccion precoz de los tumores ginecologicos. Se basa en la exploracion fisica, la ecografia pelvica y la extraccion de una muestra de endometrio. Toda hemorragia anormal debe motivar una consulta urgente. Una vez satisfechos los proyectos de maternidad, debe proponerse la cirugia profilactica (histerectomia total no conservadora).

Effect of neoadjuvant alternating taxane- and anthracycline-based dose-dense regimen for operable breast cancer on prognosis in triple-negative tumors with a complete histological response.

610 Background: Neoadjuvant antitumour activity of an alternating taxane- and anthracycline-based dose-dense regimen in patients with operable, noninflammatory large breast cancer was investigated. Methods: Women (n = 74) with clinical stage II or III breast cancer were enrolled in this open-label, multicentre study to receive six twice-weekly courses of: gemcitabine 1,000 mg/m2 plus docetaxel 75 mg/m2 on days 1 and 15 and vinorelbine 25 mg/m2 plus epirubicin 100 mg/m2 on days 29 and 43. Patients with an objective response on day 56 then received another cycle of gemcitabine/docetaxel on day 57 and of vinorelbine/epirubicin on day 71. Conservative surgery was scheduled for all patients. Results: Of the patients enrolled, 30% had triple-negative breast cancer (TNBC). Thepathological complete response (pCR) rate was 22% overall, but was higher in TNBC than non-TNBC patients (40.9% versus 14.0%; p = 0.028). Among patients with a pCR, TNBC patients had similar recurrence-free survival (RFS) and overall surviv...