C. Nos

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.

Diagnostic performance of one-step nucleic acid amplification for intraoperative sentinel node metastasis detection in breast cancer patients.

The purpose of this prospective multicenter study was to assess one‐step nucleic acid amplification (OSNA) for intraoperative sentinel lymph node (SLN) metastasis detection in breast cancer patients, using final histology as the reference standard. OSNA results were also compared to intraoperative histology SLN evaluation and to standard clinicopathological risk markers. For this study, fresh SLNs were cut in four blocks, and alternate blocks were used for OSNA and histology. CK19 mRNA copy number was categorized as strongly positive, positive or negative. Positive histology was defined as presence of macrometastasis or micrometastasis. When discrepancies occurred, the entire SLNs were subjected to histological studies and the node lysates to additional molecular studies. Five hundred three SLN samples from 233 patients were studied. Mean time to evaluate two SLNs was 40 min. Sensitivity per patient was 91.4% (95% CI, 76.9–98.2%), specificity 93.3% (95% CI, 88.6–96.6%), positive likelihood ratio 13.7 and negative likelihood ratio 0.1. Sensitivity was 63.6% for frozen sections and 47.1% for touch imprint cytology. Both methods were 100% specific. Positive histology and positive OSNA were significantly associated with highest clinical stage, N1 status and vascular invasion; and OSNA results correlated with HER2/neu status and benefited patients with negative histology. These findings show that OSNA assay can allow detection of SLN metastasis in breast cancer patients intraoperatively with a good sensitivity, thus minimizing the need for second surgeries for axillary lymph node detection.

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.

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.

Ganglion sentinelle dans les cancers du col de faible stade. Données actuelles. Assurance qualité. Perspectives

Sentinel node biopsy appears as a promising technique for the assessment of nodal disease in early cervical cancers. Selection of a population with a low risk of nodal metastasis, a minimal training, and simple rules allow a low false negative rate. Sentinel node biopsy provides supplementary information, such as anatomical information (nodes outside of routine lymphadenectomy areas) and histological information (isolated tumors cells and micrometastases).

Chirurgia locoregionale dei tumori al seno

Il tumore al seno e il primo tumore nelle donne in Francia e in tutto il mondo. La chirurgia e una parte essenziale del trattamento. Attraverso lo screening, circa il 60% dei tumori al seno e ora diagnosticato in una fase iniziale (T1-T2N0). Lo sviluppo di trattamenti diversificati del tumore al seno ha permesso un’evoluzione chirurgica. Pertanto, il 70% dei tumori al seno invasivi e trattato con una chirurgia conservativa del seno, la tumorectomia (o mastectomia parziale), e con un trattamento “conservativo” dell’ascella: la tecnica del linfonodo sentinella, che e divenuta, nell’ultimo decennio, lo standard nella valutazione dello stato linfonodale in queste fasi. Inoltre, la chemioterapia neoadiuvante e le tecniche di oncoplastica hanno permesso di aumentare il tasso di conservazione del seno, tanto che la mastectomia radicale modificata, descritta da Madden nel 1972, che comprende una mastectomia totale e una dissecazione ascellare infra- e retropettorale, e ormai poco indicata. Anche la dissecazione ascellare e controversa e, se persiste ancora qualche indicazione ben nota, il prossimo decennio vedra probabilmente la sua fine. Sono di seguito descritte le tecniche di tumorectomia, mastectomia totale, tecnica del linfonodo sentinella e dissecazione ascellare.

Aportación del robot en cirugía endoscópica

El desarrollo de la cirugia minimamente invasiva, y mas particularmente de la laparoscopia desde la decada de 1980, ha permitido realizar un avance significativo en la cirugia ginecologica, tanto para enfermedades benignas como malignas. Las ventajas de la cirugia laparoscopica estan reconocidas desde hace muchos anos: disminucion de la hemorragia postoperatoria, reduccion del dolor postoperatorio, disminucion de la hospitalizacion, convalecencia mas rapida con reanudacion mas precoz de la actividad y ventajas esteticas. Sin embargo, el desarrollo de la laparoscopia no ha sido uniforme y esta tecnica se emplea demasiado poco en la actualidad en comparacion con la laparotomia, debido a su dificultad y a su curva de aprendizaje demasiado larga, quedando limitada a los centros y cirujanos con gran experiencia. La cirugia asistida por robot, que esta actualmente en pleno auge, esta en vias de convertirse en la alternativa a la laparoscopia y la laparotomia en el ambito de la cirugia ginecologica. Sus ventajas principales son la vision tridimensional, una exposicion controlada por el cirujano, una mayor ergonomia que permite disminuir la fatiga y aumentar la precision del cirujano, asi como una curva de aprendizaje mas corta que para la laparoscopia simple. Debido a que esta es una tecnica reciente, los datos de la literatura son numerosos, pero de calidad discutible por el momento, dada la falta de ensayos prospectivos y aleatorizados. Sin embargo, esta cirugia presenta varios inconvenientes: tamano y aparatosidad del robot, tiempo de instalacion, coste. Por tanto, esto implica la necesidad de sopesar bien las indicaciones de la laparoscopia asistida por robot, para equilibrar el balance beneficios/coste/organizacion. En este articulo, se analiza la aportacion de la cirugia asistida por robot en ginecologia, tanto en patologias benignas como malignas.

Linfadenectomías en el cáncer de endometrio

El cancer de endometrio es el cancer ginecologico mas frecuente. La indicacion de linfadenectomias se ha modificado en los ultimos anos. Sistematicos, pelvicos y en ocasiones extendidos a la region aorticocava, los vaciamientos ganglionares se deciden en funcion de parametros histologicos que definen grupos de riesgo (asi como la operabilidad de la paciente). Los vaciamientos ya no se recomiendan para las pacientes en las que el riesgo metastasico ganglionar se considera bajo o intermedio. En dos ensayos terapeuticos, en los que se incluyo en su mayoria a este tipo de pacientes, los vaciamientos pelvicos no demostraron ningun beneficio. La tecnica del ganglio centinela, que permite una extirpacion quirurgica ganglionar dirigida con muy buena sensibilidad, probablemente sea una alternativa interesante para estas pacientes. Por el contrario, para las pacientes de alto riesgo se propone un vaciamiento aorticocava y en ocasiones pelvico, con la condicion de que el estado general lo permita y que el resultado tenga una repercusion en los tratamientos adyuvantes. Esta desescalada terapeutica es paralela a la evolucion de las indicaciones de radioterapia postoperatoria.

Tecnica e risultati del prelievo del linfonodo sentinella nei cancri del collo e del corpo dell’utero

La biopsia del linfonodo sentinella e una metodica diagnostica che permette il prelievo linfonodale mirato delle prime stazioni linfonodali di un tumore, rappresentativo dei linfonodi a valle. Questa tecnica si sviluppa da una decina di anni nei cancri dell’utero, per i quali lo status linfonodale e un fattore prognostico principale. I suoi obiettivi principali sono di ridurre la morbilita degli svuotamenti completi, di individuare dei territori di drenaggio inattesi e, anche, di realizzare un’ultrastadiazione linfonodale. La tecnica di rilevamento combinata, con coloranti e isotopi, e quella che apporta i migliori risultati in termini di tasso di individuazione. I dati della letteratura sulla biopsia del linfonodo sentinella nei cancri del collo precoci hanno dimostrato ampiamente la sua fattibilita. I tassi di individuazione sono molto buoni, come anche il suo valore diagnostico. La tecnica permette di realizzare un’ultrastadiazione linfonodale evidenziando delle micrometastasi. Il prelievo del linfonodo sentinella e realizzabile anche nei cancri dell’endometrio, con, tuttavia, dei tassi di individuazione e di falsi negativi molto variabili secondo le casistiche, influenzati soprattutto dalla via di iniezione. Se l’iniezione intratumorale, realizzata soprattutto mediante isteroscopia, e quella che permette di evidenziare meglio il vero drenaggio linfatico del tumore, la sua attuazione e, tuttavia, assai poco riproducibile.

Técnica y resultados de la biopsia del ganglio centinela en los cánceres del cuello y del cuerpo uterinos

La biopsia del ganglio centinela es un metodo diagnostico que permite la extirpacion dirigida de las primeras invasiones ganglionares de un tumor, una muestra que es representativa de los ganglios subsiguientes. Esta tecnica se esta desarrollando desde hace unos 10 anos con relacion a los canceres del utero, en los cuales el estado ganglionar es un factor pronostico principal. Sus objetivos principales son limitar la morbilidad de los vaciamientos ganglionares completos, detectar territorios de drenaje inesperados y efectuar una ultraestadificacion ganglionar. La tecnica de deteccion combinada, por tincion e isotopica, produce los mejores resultados en cuanto a indices de deteccion. Los datos de las publicaciones sobre la biopsia precoz del ganglio centinela en los canceres del cuello uterino confirman ampliamente la utilidad de esta practica. Los indices de deteccion y el valor diagnostico son muy buenos. La tecnica hace posible una ultraestadificacion ganglionar para demostrar micrometastasis. La biopsia del ganglio centinela tambien es factible en los canceres de endometrio, pero los indices de deteccion y de falsos negativos varian mucho segun las series, principalmente en relacion con la via de inyeccion. Aunque la inyeccion intratumoral por histeroscopia es la que permite demostrar mejor el verdadero drenaje linfatico del tumor, su realizacion es bastante poco reproducible.