Camille Jauffret

Role of robot-assisted laparoscopy in adjuvant surgery for locally advanced cervical cancer.

OBJECTIVE The aim of this study was to compare the feasibility and efficacy of robot-assisted laparoscopy with traditional laparotomy and conventional laparoscopy in a series of patients with locally advanced cervical cancer managed in our two institutions. METHODS Twenty-two patients who underwent robot-assisted laparoscopy were compared with 20 patients who underwent adjuvant surgery by laparotomy and 16 who underwent conventional laparoscopy, before the arrival of the Da Vinci surgical system. RESULTS There was no significant difference between the three groups in terms of body mass index, FIGO stage, or tumor histology. The complication rate was similar in the three groups of patients, although there was a trend towards more lymphatic complications in the robot-assisted subgroup managed medically. There was no significant difference in the recurrence rate between the robot-assisted laparoscopy, conventional laparoscopy and laparotomy groups (27.3%, 29.4% and 30%, respectively). CONCLUSION Robot-assisted laparoscopy is feasible after concurrent chemoradiation and brachytherapy in cases of locally advanced cervical cancer. This new surgical approach reduces hospital stay, and seems to result in less severe complications than conventional laparotomy without modifying the oncological outcome.

Role of a double docking to improve lymph node dissection: when robotically assisted laparoscopy for para-aortic lymphadenectomy is associated to a pelvic procedure.

Objective The objective of this study was to demonstrate that robotically assisted laparoscopy for aortic lymph node dissection was improved when double docking (DD) of the Da Vinci system is used for combined surgical procedures [defined by the combination of a pelvic procedure and a para-aortic lymphadenectomy (PAL)]. Methods From February 2007 to February 2013, 41 patients underwent combined procedures including PAL up to the left renal vein in 2 cancer centers. We used 2 different approaches as follows: a single docking (SD) of the Da Vinci system (transperitoneal PAL and pelvic surgery) during the first period (22 patients) and a DD during the second period (19 patients). We recorded retrospectively the lymph node count (main criteria), operative time, estimated blood loss, hospital stay, and postoperative complications. Results We observed a statistical difference between SD and DD concerning aortic lymph node count (5.86 vs 10.89, P < 0.005). Operative time is longer in the DD group (326.1 vs 239.4 minutes, P < 0.05). No difference was observed concerning estimated blood loss. Hospital stay was longer in the DD group (4.9 vs 3.2 days, P < 0.05). Only 1 conversion to open was described in the SD group. Conclusions In our experience of robotically assisted laparoscopy, when PAL is combined to a pelvic procedure, the use of a DD seems to improve aortic lymph node count. Despite a longer operative time compared to SD, DD seems to be a good solution to combine the advantages of robotic assistance to our quality criteria of aortic dissection. Synopsis We compare 2 techniques to realize robotic assisted para-aortic lymphadenectomy combined with pelvic procedure. Double docking seems to improve histological results compared to single docking.

Impact of preoperative magnetic resonance imaging in breast cancer patients candidates for an intraoperative partial breast irradiation

Objective: Partial breast irradiation (PBI) could be a reasonable option in patients with early breast cancer (BC) provided that an adequate patient selection, based on robustly established criteria is performed. A preoperative magnetic resonance imaging (MRI) in patient selection for PBI is not consensual. The aim of this retrospective study was to assess the impact of preoperative MRI on patient eligibility for PBI. Methods: Since March 2012, patients with early BC, meeting the Inca’s criteria for PBI were offered the possibility of shortened treatment through intra-operative radiation therapy, either in a prospective trial or off protocol. Eligibility criteria based on physical examination, mammography and ultrasound, and a pathological exam of biopsy, were as follows: menopaused woman 55 years or older with a T1, N0, hormonal-receptor-positive and HER2-negative, invasive, non-lobular epithelioma, without extensive intraductal component (defined as more than 25% of ductal component on biopsy), non-fast-growing tumor, without lymphovascular invasion (LVI), without criteria for adjuvant chemotherapy. A contrast-enhanced MRI was not routinely performed, but at the discretion of the physician as was the rule in TARGIT-A trial. We assessed the rate of additional cancer revealed by the preoperative MRI, remote in the same breast not detected by mammography and/or ultrasound. Results: Between March 2012 and February 2014, 179 early BC patients meeting the required criteria were planned for an intraoperative radiotherapy (IORT)-PBI. Seventy nine percent of them (141/179) underwent a breast MRI as part of preoperative assessment. ACR3-ACR4 abnormalities not detected by mammograms or ultrasound were found in 44 patients (31%), which prompted a focused mammary ultra-sound, and a biopsy was realized in 29/141 patients (21%). A second breast carcinoma was found in 10 patients (7% of patients with a preoperative MRI, 4 ipsilateral lesions, 5 contralateral lesions, and one both ipsi- and contralateral lesion, precluding IORT-PBI in 5/141 patients (4%). Conclusions: The use of preoperative MRI in patient staging leads to diagnosis of an ipsilateral second BC in 4% of cases, which appears substantial in a highly selected population. We therefore support the routine use of this exam for the staging of patient candidate for a PBI.

Facteurs pronostiques des carcinomes lobulaires infiltrants du sein : à propos de 940 cas

OBJECTIVES To assess the prognostic factors of T1 and T2 infiltrating lobular breast cancers, and to investigate predictive factors of axillary lymph node involvement. METHODS This is a retrospective multicentric study, conducted from 1999 to 2008, among 13 french centers. All data concerning patients with breast cancer who underwent a primary surgical treatment including a sentinel lymph node procedure have been collected (tumors was stage T1 or T2). Patients underwent partial or radical mastectomy. Axillary lymph node dissection was done systematically (at the time of sentinel procedure evaluation), or in case of sentinel lymph node involvement. Among all the 8100 patients, 940 cases of lobular infiltrating tumors were extracted. Univariate analysis was done to identify significant prognosis factors, and then a Cox regression was applied. Analysis interested factors that improved disease free survival, overall survival and factors that influenced the chemotherapy indication. Different factors that may be related with lymph node involvement have been tested with univariate than multivariate analysis, to highlight predictive factors of axillary involvement. RESULTS Median age was 60 years (27-89). Most of patients had tumours with a size superior to 10mm (n=676, 72%), with a minority of high SBR grade (n=38, 4%), and a majority of positive hormonal status (n = 880, 93, 6%). The median duration of follow-up was 59 months (1-131). Factors significantly associated with decreased disease free survival was histological grade 3 (hazard ratio [HR]: 3,85, IC 1,21-12,21), tumour size superior to 2cm (HR: 2,85, IC: 1,43-5,68) and macrometastatic lymph node status (HR: 3,11, IC: 1,47-6,58). Concerning overall survival, multivariate analysis demonstrated a significant impact of age less than 50 years (HR: 5,2, IC: 1,39-19,49), histological grade 3 (HR: 5,03, IC: 1,19-21,25), tumour size superior to 2cm (HR: 2,53, IC: 1,13-5,69). Analysis concerning macrometastatic lymph node status nearly reached significance (HR: 2,43, IC: 0,99-5,93). There was no detectable effect of chemotherapy regarding disease free survival (odds ratio [OR] 0,8, IC: 0,35-1,80) and overall survival (OR: 0,72, IC: 0,28-1,82). Disease free survival was similar between no axillary invasion (pN0) and isolated tumor cells (pNi+), or micrometastatic lymph nodes (pNmic). There were no difference neither between one or more than one macromatastatic lymph node. But disease free survival was statistically worse for pN1 compared to other lymph node status (pN0, pNi+ or pNmic). Factors associated with lymph node involvement after logistic regression was: age from 51 to 65 years (OR: 2,1, IC 1,45-3,04), age inferior to 50 years (OR 3,2, IC: 2,05-5,03), Tumour size superior to 2cm (OR 4,4, IC: 3,2-6,14), SBR grading 2 (OR 1,9, IC: 1,30-2,90) and SBR grade 3 (OR 3,5, IC: 1,61-7,75). CONCLUSION The analysis of this series of 940 T1 and T2 lobular invasive breast carcinomas offers several information: factors associated with axillary lymph node involvement are age under 65 years, tumor size greater than 20mm, and a SBR grade 2 or 3. The same factors were significantly associated with the OS and DFS. The macrometastatic lymph node involvement has a significant impact on DFS and OS, which is not true for isolated cells and micrometastases, which seem to have the same prognosis as pN0.

Contribution of intraoperative radiotherapy (IORT) for therapeutic de-escalation in early breast cancer: Report of a single institution's experience

The spread of systematic screening and the emergence of oncoplastic techniques allow more breast conservative treatment associating lumpectomy and external beam radiation therapy. In order to furthermore facilitate the patients treatment, intraoperative radiation therapy (IORT) has been developed. The oncological safety of this technique has been studied, and is considered acceptable. Many questions remain unsolved in regard of the toxicity of this procedure as well as the patients selection criteria. In this study, we present the first results and complications rate of patients treated by IORT in a single French institution.

Cancer du sein et creux axillaire : état de l’art et perspectives

A therapeutic surgical de-escalation has been observed since many years with an actual prolongation for axillary lymph node area treatment. Axillary lymph node dissection (ALND) omission has been studied before and after validation of sentinel node (SN) biopsy procedure. A non-inferiority of ALND omission has been reported in case of non-involved SN. ALND omission has been studied in case of SN involvement without consensus in relation with scientific level of proof and with selective indications. The purpose of this work is to make a synthesis of the experiences on this subject then to envisage the current and future perspectives.

Enhanced recovery after surgery program in older patients undergoing gynaecologic oncological surgery is feasible and safe

BACKGROUND Enhanced Recovery After Surgery Programs (ERP) include multimodal approaches of perioperative patients clinical pathways designed to achieve early recovery after surgery and a decreased length of hospital stay (LOS). By allowing patients to return rapidly to their everyday surroundings, older patients are those who could take the greatest benefit from ERP. This is the first study to date to assess feasibility and safety of ERP on older patients undergoing gynaecologic oncological surgery. METHODS Data were prospectively collected between December 2015 and September 2017 at the Institut Paoli-Calmettes, a French comprehensive cancer centre. All the patients included in the study were referred for hysterectomy and/or pelvic or para-aortic lymphadenectomy for gynaecological cancer. The primary objective was to achieve similar LOS in patients ≥70 years old compared to younger patients without increasing the proportion of complications and readmission rates. A binary (LOS < or ≥ 2 days) logistic regression was built, including age, Charlson score, BMI, ASA score, oncological indication, surgical procedures and surgical approaches. G8 score was estimated for all the ≥70 years old patients. RESULTS Of a total of 329 patients, 75 were ≥70 years old and 254 were <70. Except a disparity in oncological indications with a higher proportion of endometrial cancer in the ≥70 years old group (56% vs. 27%; p < 0.01), there were no differences in patients characteristics and surgical procedures. Age ≥ 70 years was associated with a longer LOS (means, 3.88 vs. 3.11 days; p = 0.024) only in univariate analysis. Considering the logistic regression, age was no longer associated with LOS. Total hysterectomy with pelvic lymphadenectomy and ASA score ≥ 3 were independently associated with longer LOS while mini-invasive techniques were associated with a shorter LOS. Morbidities and readmissions occurred respectively in 23% and 8% of the total population without any difference between the two groups. In the ≥70 years old population, G8 score was not predictive of LOS, morbidities or readmissions. CONCLUSION Although it is already widely accepted that ERP improves early recovery, our study shows that ERP for patients over 70 years of age undergoing gynaecologic oncological surgery is as safe and feasible as on younger patients.

Chirurgie gynéco-oncologique et ambulatoire

RésuméDans le domaine de la chirurgie oncologique gynécologique et sénologique, l’hospitalisation ambulatoire s’est particulièrement développée. Pour la chirurgie mammaire, cette évolution a pu se faire grâce à une organisation adaptée qui tient compte de ces spécificités et des étapes pré- per- et postopératoires. Parallèlement, la chirurgie en hospitalisation ambulatoire pour la gynécologie pelvienne oncologique a commencé à se développer, mais de manière plus limitée. Nous allons envisager : 1) les définitions de l’ambulatoire ; 2) l’organisation spécifique ainsi que les mesures facilitatrices, y compris financières ; 3) l’apport des techniques miniinvasives ; 4) les indications actuelles et perspectives.AbstractIn the field of gynaecological and senological oncological surgery, admission to the outpatient department is particularly developed. For breast surgery, this development was made possible through an appropriate structure that takes into account the special requirements and the pre-, intra- and post-operative stages. At the same time, outpatient surgery for gynaecological oncological pelvic procedures is beginning to be developed, however it is more limited. We are proposing: 1) definitions of outpatient care; 2) the specific structure, as well as how this will be facilitated, including financial means; 3) the contribution of minimally invasive techniques; 4) current and future indications.

Cancer du sein et creux axillaire: état de l'art et perspectivesBreast cancer and axillary area: state of the art and perspectives

A therapeutic surgical de-escalation has been observed since many years with an actual prolongation for axillary lymph node area treatment. Axillary lymph node dissection (ALND) omission has been studied before and after validation of sentinel node (SN) biopsy procedure. A non-inferiority of ALND omission has been reported in case of non-involved SN. ALND omission has been studied in case of SN involvement without consensus in relation with scientific level of proof and with selective indications. The purpose of this work is to make a synthesis of the experiences on this subject then to envisage the current and future perspectives.

Actualités sur l’assistance robotisée en chirurgie oncogynécologique

Laparoscopic approach, over the past 20 years, has become, in gynoncologic surgery, a gold standard for several teams. Introduced 10 years ago, robotic-assisted laparoscopy is increasingly used in the gynecologic surgical field. For the surgeon, advantages of this intuitive robotic surgery are the three-dimensional approaches, the precision of the dissection with robotic instrument articulation, and a shorter learning curve compared with conventional laparoscopy. For the patients, a quicker postoperative recovery, less postoperative pain, and lower blood loss compared with laparoscopy seem to emerge. This review summarizes all the published results of robotic assistance used in cervical and endometrial cancer surgical management.RésuméDepuis 20 ans, la coelioscopie est devenue une voie d’abord chirurgicale incontournable, particulièrement en gynécologie. Introduite depuis une dizaine d’années, l’assistance robotisée est de plus en plus utilisée, la chirurgie gynécologique oncologique constituant un éventail d’indications privilégié. Pour le chirurgien, ses avantages sont la restitution d’une vision en trois dimensions, l’absence de tout tremblement et donc une précision du geste plus grande (les instruments sont voués de sept degrés de libertéet permettant des mouvements à 360°), et enfin un apprentissage plus rapide que la coelioscopie conventionnelle. Pour nos patientes, les publications actuelles semblent en faveur d’une diminution de la morbidité (réduction des hémorragies peropératoires, diminution des douleurs postopératoires, durée d’hospitalisation plus courte). Dans cette revue de la littérature, nous faisons un état des lieux des résultats de l’assistance robotisée appliquée à la prise en charge des cancers pelviens.