Carol L. Brown

Total laparoscopic radical hysterectomy with pelvic lymphadenectomy using the argon-beam coagulator: pilot data and comparison to laparotomy

OBJECTIVES The aim of this study was to describe the feasibility and outcome of total laparoscopic radical hysterectomy with pelvic lymphadenectomy for stage I cervical cancer using the argon-beam coagulator. METHODS A retrospective review was performed of patients with FIGO stage IA1-IB1 cervical cancer who underwent a total laparoscopic approach for definitive surgical treatment. Comparison was made to a cohort of 195 patients who were treated with laparotomy. RESULTS Between 12/2000 and 12/2002, 19 patients were offered the laparoscopic approach. The procedure was completed laparoscopically in 17 patients (89.5%). Two patients, in the beginning of the study, underwent conversion to laparotomy, 1 due to parametrial bleeding and 1 due to pelvic adhesions and cystotomy. Mean age was 42.6 years (range, 30-69 years); mean body mass index was 23.1 (range, 18-30); FIGO stage included IA1 with LVI (2), IA2 (6), IB1 (11). Mean pelvic lymph node count was 25.5 (range, 15-39), and 1 patient (5.3%) had positive nodes. Mean estimated blood loss was 301 cc (range, 75-1500 cc) compared to 693 cc in the laparotomy group (P < 0.01), mean operating time was 371 min (range, 230-600 min) compared to 295 min in the laparotomy group (P < 0.01), and mean hospital stay was 4.5 days (range, 3-11 days) compared to 9.7 days in the laparotomy group (P < 0.01). There were no ureteral injuries or fistula formation. All patients remain clinically disease free at the time of this report. CONCLUSIONS Total laparoscopic radical hysterectomy with pelvic lymphadenectomy for selected patients with stage I cervical cancer is feasible, safe, and associated with a low morbidity in the pilot phase. Estimated blood loss and postoperative hospitalization appear shorter than historical controls, at the cost of longer operating time. Oncologic outcome requires longer follow-up.

The incidence of pelvic lymph node metastasis by FIGO staging for patients with adequately surgically staged endometrial adenocarcinoma of endometrioid histology

The seminal Gynecologic Oncology Group study on surgical pathologic spread patterns of endometrial cancer demonstrated the risk of pelvic lymph node metastasis for clinical stage I endometrial cancer based on tumor grade and thirds of myometrial invasion. However, the FIGO staging system assigns surgical stage by categorizing depth of myometrial invasion in halves. The objective of this study was to determine the incidence of pelvic lymph node metastasis in endometrial cancer based on tumor grade and myometrial invasion as per the current FIGO staging system. We reviewed the records of all patients who underwent primary surgical staging for clinical stage I endometrial cancer at our institution between May 1993 and November 2005. To make the study cohort as homogeneous as possible, we included only cases of endometrioid histology. We also included only patients who had adequate staging, which was defined as a total hysterectomy with removal of at least eight pelvic lymph nodes. During the study period, 1036 patients underwent primary surgery for endometrial cancer. The study cohort was composed of the 349 patients who met study inclusion criteria. Distribution of tumor grade was as follows: grade 1, 80 (23%); grade 2, 182 (52%); and grade 3, 87 (25%). Overall, 30 patients (9%) had pelvic lymph node metastasis. The incidence of pelvic lymph node metastasis in relation to tumor grade and depth of myometrial invasion (none, inner half, and outer half) was as follows: grade 1–0%, 0%, and 0%, respectively; grade 2–4%, 10%, and 17%, respectively; and grade 3–0%, 7%, and 28%, respectively. We determined the incidence of pelvic nodal metastasis in a large cohort of endometrial cancer patients of uniform histologic subtype in relation to tumor grade and a one-half myometrial invasion cutoff. These data are more applicable to current surgical practice than the previously described one-third myometrial invasion cutoff results.

Sentinel lymph node mapping for grade 1 endometrial cancer: Is it the answer to the surgical staging dilemma?

OBJECTIVE To describe the accuracy of SLN mapping in patients with a preoperative diagnosis of grade 1 endometrial cancer. METHODS A prospective, non-randomized study of women with a preoperative diagnosis of endometrial cancer and clinical stage I disease was conducted. A subset analysis of patients with a preoperative diagnosis of grade 1 endometrial endometrioid cancer was performed. All patients had preoperative lymphoscintigraphy with Tc99m on the day of or day before surgery followed by an intraoperative injection of 2 cm(3) of isosulfan or methylene blue dye deep into the cervix or both cervix and fundus. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and regional nodal dissection. Hot and/or blue nodes were labeled as SLNs and sent for histopathological analysis. RESULTS Forty-two patients with a preoperative diagnosis of grade 1 endometrial carcinoma treated from 3/06 to 8/08 were identified. Twenty-five (60%) had laparoscopic surgery; 17 (40%) were treated by laparotomy. Preoperative lymphoscintigraphy visualized SLNs in 30 patients (71%); intraoperative localization of the SLN was possible in 36 patients (86%). A median of 3 SLNs (range, 1-14) and 14.5 non-SLNs (range, 4-55) were examined. In all, 4/36 (11%) had positive SLNs-3 seen on H&E and 1 as cytokeratin-positive cells on IHC. All node-positive cases were picked up by the SLN; there were no false-negative cases. The sensitivity of the SLN procedure in the 36 patients who had an SLN identified was 100%. CONCLUSION Sentinel lymph node mapping using a cervical injection with combined Tc and blue dye is feasible and accurate in patients with grade 1 endometrial cancer and may be a reasonable option for this select group of patients. Regional lymphadenectomy remains the gold standard in many practices, particularly for the approximately 15% of cases with failed SLN mapping.

Oncologic outcome of fertility-sparing radical trachelectomy versus radical hysterectomy for stage IB1 cervical carcinoma.

OBJECTIVE To compare the oncologic outcomes of women who underwent a fertility-sparing radical trachelectomy (RT) to those who underwent a radical hysterectomy (RH) for stage IB1 cervical carcinoma. METHODS We performed a case-control study of all patients with stage IB1 cervical carcinoma who underwent a vaginal or abdominal RT between 11/01 and 6/07. The control group consisted of patients with stage IB1 disease who underwent an RH between 11/91 and 6/07 and who would be considered candidates for fertility-sparing surgery. Information was extracted from a prospectively acquired database. Recurrence-free and disease-specific survival (RFS and DSS) were estimated using Kaplan-Meier estimates and compared with the log-rank test where indicated. Multivariate analysis was performed using the Cox regression method. RESULTS Forty stage IB1 patients underwent an RT and 110 patients underwent an RH. There were no statistical differences between the two groups for the following prognostic variables: histology, median number of lymph nodes removed, node positive rate, lymph-vascular space involvement (LVSI), or deep stromal invasion (DSI). The median follow-up for the entire group was 44 months. The 5-year RFS rate was 96% (for the RT group compared to 86% for the RH group (P=NS). On multivariate analysis in this group of stage IB1 lesions, tumor size <2 cm was not an independent predictor of outcome, but both LVSI and DSI retained independent predictive value (P=0.033 and 0.005, respectively). CONCLUSION For selected patients with stage IB1 cervical cancer, fertility-sparing radical trachelectomy appears to have a similar oncologic outcome to radical hysterectomy. LVSI and DSI appear to be more valuable predictors of outcome than tumor diameter in this subgroup of patients.

Intraperitoneal Chemotherapy for Ovarian Carcinoma: Results of Long-Term Follow-Up

PURPOSE To determine long-term survival and predictors of recurrence in a retrospective cohort of patients with epithelial ovarian cancer treated with intraperitoneal (IP) chemotherapy. PATIENTS AND METHODS Records were reviewed of 433 patients who received IP therapy for ovarian cancer between 1984 and 1998; follow-up data were available for 411 patients. IP therapy was provided as consolidation therapy (n = 89), or for treatment of persistent (n = 310) or recurrent (n = 12) disease after surgery and initial systemic therapy; therapy usually consisted of platinum-based combination therapy. Statistical analysis included tests for associations between potential prognostic factors, and between prognostic factors and survival. Survival probabilities were estimated by Kaplan-Meier methods, and prognostic factors for survival were evaluated by a Cox proportional hazard model. RESULTS The mean age of patients was 52 years (range, 25 to 76 years). Distribution by stage and grade was as follows: stage I, 7; II, 24; III, 342; IV, 52; not available (NA), 8; and grade 1, 30; 2, 99; and 3, 289; NA, 15. The median survival from initiation of IP therapy by residual disease was none, 8.7 years; microscopic, 4.8 years; less than 1 cm, 3.3 years; more than 1 cm, 1.2 years. In a multivariate analysis, the only significant predictors of long-term survival were grade and size of residual disease at initiation of IP therapy. CONCLUSION Prolonged survival was observed in selected patients receiving IP platinum-based therapy. It is not possible to determine the contribution of IP therapy to survival in this study. A relationship between size of disease at the initiation of IP therapy and long-term survival was demonstrated.

Quality of life in women at risk for ovarian cancer who have undergone risk-reducing oophorectomy

OBJECTIVES Women at risk for ovarian cancer may consider risk-reducing salpingo-oophorectomy (RRSO), and desire information regarding the health consequences of the procedure. We studied women who had undergone RRSO to assess quality of life after the procedure. METHODS Women (n = 59) undergoing RRSO between 1 January 1997 and 31 July 2000 completed a questionnaire composed of the Symptom Checklist (SCL), the Medical Outcomes Study SF-36 Health Survey, the Center for Epidemiological Studies Depression Scale, the Impact of Events Scale, and the Sexual Functioning Questionnaire-Female. RESULTS At a mean of 23.8 months after RRSO, overall quality of life was similar to that reported for the general population and for breast cancer survivors. Estrogen deprivation symptoms, particularly vaginal dryness (35.2%) and dyspareunia (27.7%), were commonly bothersome. Genital symptoms resulting in sexual dysfunction were the most significant predictors of satisfaction with surgery. The prevalence of depression (20.4%) was similar to that of the general population, but a significant proportion of the group (20.7%) continued to report significant ovarian cancer-specific worries despite surgery. CONCLUSION Vaginal symptoms are bothersome to women who have undergone RRSO, but overall health and psychological outcomes are not impaired. Although coital symptoms may not be a direct consequence of RRSO, they are the most important predictors of satisfaction. A proportion of women continue to report worries about ovarian cancer after surgery, and these women are at risk for psychological distress.

The rate of port-site metastases after 2251 laparoscopic procedures in women with underlying malignant disease.

BACKGROUND The aim was to describe the rate of laparoscopic trocar-related subcutaneous tumor implants in women with underlying malignant disease. METHODS An analysis of a prospective database of all patients undergoing transperitoneal laparoscopic procedures for malignant conditions performed by the gynecologic oncology service. RESULTS Between July 1991 and April 2007, laparoscopic procedures were performed in 1694 patients with a malignant intraabdominal condition and in 505 breast cancer patients undergoing risk-reducing, diagnostic or therapeutic laparoscopic procedures without intraabdominal disease. Port-site metastases were documented in 20 of 1694 patients (1.18%) who underwent laparoscopic procedures for a malignant intraabdominal condition. Of these, 15 patients had a diagnosis of epithelial ovarian or fallopian tube carcinoma, 2 had breast cancer, 2 had cervical cancer, and 1 had uterine cancer. Nineteen of 20 patients (95%) had simultaneous carcinomatosis or metastases to other sites at the time of port-site metastasis. Patients who developed port-site metastases within 7 months from the laparoscopic procedure had a median survival of 12 months whereas patients who developed port-site metastasis >7 months had a median survival of 37 months (P=0.004). No port-site recurrence was documented in patients undergoing risk-reducing, diagnostic or therapeutic laparoscopic procedures for breast cancer without intraabdominal disease. CONCLUSION The rate of port-site tumor implantation after laparoscopic procedures in women with malignant disease is low and almost always occurs in the setting of synchronous, advanced intraabdominal or distant metastatic disease. The presence of port-site implantation is a surrogate for advanced disease and should not be used as an argument against laparoscopic surgery in gynecologic malignancies.

The incidence of major complications after the performance of extensive upper abdominal surgical procedures during primary cytoreduction of advanced ovarian, tubal, and peritoneal carcinomas.

OBJECTIVE To assess the morbidity and mortality associated with extensive upper abdominal surgery (EUAS) performed during primary cytoreduction for advanced ovarian carcinoma. METHODS We identified all patients who underwent EUAS during primary cytoreduction for advanced ovarian, tubal, or peritoneal cancer at our institution from 1/01 to 12/06. Major grade 3-5 complications were those that led to invasive radiologic intervention, re-operation, unplanned ICU admission, chronic disability, or death within 30 days of surgery. RESULTS There were 141 eligible patients, with a median age of 60 years (range, 38-82). The majority of patients had stage IIIC disease, 103 (73%); serous histology, 131 (93%); and ascites, 118 (84%). There were 229 EUAS procedures performed-diaphragm peritonectomy, 101 (72%); splenectomy, 45 (32%); full-thickness diaphragm resection, 19 (14%); partial hepatectomy, 18 (13%); distal pancreatectomy, 17 (12%); cholecystectomy, 15 (11%); and resection of porta hepatis tumor, 14 (10%). Cytoreductive outcomes were: no gross residual, 42 (30%); residual ≤ 1cm, 85 (60%); and residual >1cm, 14 (10%). Grade 3-5 complications occurred in 31 (22%) patients, including 2 mortalities (1.4%). In 21/31 (68%), the complication was successfully managed with percutaneous drainage of infected or non-infected collections. Overall median survival for all patients was 57 months. CONCLUSIONS Rates of major morbidity and mortality following EUAS for primary cytoreduction were 22% and 1.4%, respectively. Approximately two-thirds of complications were readily managed by percutaneous drainage of collections. With an overall median survival of 57 months in a cohort of patients with a large tumor burden, this rate of morbidity and mortality appears acceptable.

Laparotomy to complete staging of presumed early ovarian cancer

Objective To assess the findings and complications laparotomies for completely staging presumed early-stage ovarian cancer in patients whose initial surgery was inadequate. Methods Records of 45 patients surgically restaged at our institution, after having been incompletely staged elsewhere, were reviewed for original operative, reports, pathologic diagnoses, restaging procedures, operative results, and perioperative complications. Results Initial clinical staging was IA, 28; IB, three; IC 12; II A, one; IIB, one. Histologic distribution was as follows: invasive epithelial, 19 (42%); borderline epithelial, 16(36%); germ cell tumor, seven (16%); and stromal tumor, three (6%). Seven of the 45 patients (16%) had their disease reclassified to a more advanced stage. Of patients with borderline ovarian tumors, two initially staged as IA, were restaged to IB and IC, and one was restaged from IIB to IIIA. Three patients with invasive epithelial adenocarcinoma were reclassified to a higher stage: one, with a presumed stage IC, poorly differentiated adenocarcinoma, to IIB; and a third, with a IIA, poorly differentiated adenocarcinoma, to IIIC. A patient with granulosa cell tumor, initially staged as IC, was restaged to IIB; Fifteen patients (33%) had complications after restaging laparotomy for presumed early ovarian cancer were reclassified to a higher stage, resulting in alteration of treatment for only one patient. In 18 patients with invasive cancer, the second operation confirmed the presence of low-risk stage IA/B disease, allowing adjuvant chemotherapy to be withheld. Conclusion Although restaging laparotomies provide important prognostic information with minimal morbidity, they provide little benefit to those patients already requiring chemotherapy based on the original operative findings.

Racial disparity in survival among patients with advanced/recurrent endometrial adenocarcinoma: a Gynecologic Oncology Group study.

Previous studies have reported shorter survival of black women compared with white women who had advanced/recurrent endometrial cancer. It has been suggested that this may reflect racially based differences in treatment.