Chiara Cassani

Robotic single-site hysterectomy: two institutions' preliminary experience.

To evaluate the feasibility, safety and peri‐ and postoperative outcomes of robotic single‐site hysterectomy for gynaecological diseases.

Vaginal cuff closure during robotic single-port hysterectomy: is the vaginal route always the best one?

The recent development of single-port robotic surgery in gynecologic surgery has added the benefits of minimally invasive surgery and greater aesthetic patient satisfaction to the other benefits that robotic surgery offers. However, single-port robotic hysterectomy has raised the question about a better approach to closure of the vaginal cuff. This report describes the technical feasibility of using robotic intracorporeal needles and extracorporeal knots to perform the vaginal cuff closure for selected patients.

Effectiveness of aromatase inhibitors in the treatment of advanced endometrial adenocarcinoma

PurposeType I endometrial cancer is a common tumor of the female genital tract. Since in post-menopausal women aromatase enzyme can stimulate the endometrial tissue neoplastic growth, the use of aromatase inhibitors may have a therapeutic effect, especially in patients not eligible for surgery.MethodsA systematic review has been performed, with a very specific scope, i.e., the use of aromatase inhibitors in the treatment of advanced or recurrent endometrial cancer, as a single agent or in combination with others drugs.ResultsOn the basis of the 117 records retrieved from the bibliographic search, the rationale for the use of aromatase inhibitors in endometrial cancer therapy is discussed. Six papers fall within the scope of our systematic review and their results are thoroughly analyzed. Moreover, we report our experience on the clinical effectiveness of anastrozole in the post-chemotherapy treatment of a patient affected by advanced-stage endometrial cancer.ConclusionIn general, aromatase inhibitors seem to have limited clinical benefit in the treatment of advanced and recurrent endometrial cancer, although further clinical trials are necessary to investigate more in depth their role. In our case, we experienced a positive feedback in terms of control of an advanced-stage disease.

Oxaliplatin for the treatment of ovarian cancer

Introduction: Oxaliplatin is an important drug in treatment of several solid tumors. Ovarian cancer (OC) is sensitive to chemotherapy and the overall response rate with primary therapy is about 75%. Unfortunately, 60 – 70% of patients experience recurrence requiring additional treatments and finally die of progressive disease within 5 years of the initial diagnosis. Currently, a platinum-based combination therapy is recommended in platinum-sensitive disease while a non-platinum single-agent therapy is preferred in platinum-resistant disease that is characterized by a low response rate. Areas covered: In this article, the authors review the Phase II and Phase III studies of oxaliplatin as an OC therapy. Furthermore, the authors discuss the pharmacokinetic and pharmacodynamic features of oxaliplatin. Expert opinion: Platinum emerged as the mainstay of OC treatment in frontline therapy, and platinum compounds remain a critical component of chemotherapy also in relapsed disease. Unfortunately, increasing exposure to carboplatin/cisplatin raises the risk of resistance or hypersensitivity to platinum. Several studies have demonstrated the safety and effectiveness of oxaliplatin, both alone and in combination regimens, in relapsed OC, demonstrating a good tolerability profile. Moreover, the therapeutic spectrum of oxaliplatin might be extended to OC patients who experienced hypersensitivity to carboplatin because of its favorable toxicity profile and at least equal efficacy.

Robotic Single-Site Surgery for Female-to-Male Transsexuals: Preliminary Experience

Hysterectomy with bilateral salpingo-oophorectomy is a part of gender reassignment surgery for the treatment of female-to-male transsexualism. Over the last years many efforts were made in order to reduce invasiveness of laparoscopic and robotic surgery such as the introduction of single-site approach. We report our preliminary experience on single-site robotic hysterectomy for cross-sex reassignment surgery. Our data suggest that single-site robotic hysterectomy is feasible and safe in female-to-male transsexualism with some benefits in terms of postoperative pain and aesthetic results.

Robotic Single Site Hysterectomy with Bilateral Salpingo-Oophorectomy in Female to Male Transsexualism

We read with interest the recent letter by Lazard et al. on laparoscopic single port access total hysterectomy and salpingooophorectomy (THSO) for female to male transsexualism [1]. The minimal invasive approach is certainly the best option for such individuals because it reduces the aesthetic damage. However, the standard laparoscopic hysterectomy still requires three pelvic accesses in abdominal wall, a sign indicating gynecological surgery with potential psychological consequences in vulnerable patients. The recent introduction of laparoendoscopic single-site surgery (LESS) in several surgical procedures, as hysterectomy and or adnexal surgery, permits to overcome standard laparoscopic aesthetic limitations, further reducing postoperative pain and offering a more rapid return to normal activity [2,3]. The introduction of robotic surgery by using the da Vinci Surgical System (Intuitive Surgical System, Sunnyvale, CA, USA), approved by the U.S. Food and Drugs Administration in 2005, seems to represent a step further in advancing the efficiency and the performance of complex laparoscopic maneuvers and permits a minimally invasive approach in many more patients [4]. LESS surgery still presents some obstacles, in particular, the “sword fighting” among instruments, and the recent development of single-site port robotic devices represents a substantial evolution. Indeed, the insertion of surgical instruments into the abdominal cavity through the umbilical access can cause a crossing of them with a reversion of the hands and a consequent major difficulty for the surgeon. The robot plays an important role by decreasing the impact of these technical limitations and still has the advantages of LESS in term of aesthetic outcome and pain reduction. Recently, we started a pilot study with the aim to investigate the effectiveness of robotic single port hysterectomy in sex reassignment surgery. Through a 2 cm trans-umbilical incision, we introduced in abdomen cavity the single-site port, grasped just above the lower rim using an atraumatic clamp, with a descending movement within the incision. The technique used for THSO was similar to that used in standard robotic surgery. Vaginal cuff was closed both with transvaginal and laparoscopic approach. Table 1 reports the perioperative data of the first five successful cases at our Institution. To the best of our knowledge, this is the first case series of THSO described in literature by using robotic single site device in the treatment of female to male transsexualism. Stefano Bogliolo, MD, Chiara Cassani, MD, Luciana Babilonti, MD, Valentina Musacchi, MD, Rossella Elena Nappi, PhD, and Arsenio Spinillo, PhD Department of Obstetrics and Gynaecology, IRCCS-Fondazione Policlinico San Matteo and University of Pavia, Pavia, Italy

Robotic Single-Site Surgery in Management of Obese Patients With Early-Stage Endometrial Cancer

Supracervical Hysterectomy and Laparoscopic Myomectomy, a Retrospective Trial Including 4791 Women’’ by Lieng et al [1]. The authors conclude that ‘‘the incidence of uterine LMS in the population of women referred for anticipated benign fibroids was 0.0054’’ (26 out of 4791 women). However, we are concerned that this sentence misstates the data presented in the paper. Of the 26 women with LMS, 6 were diagnosed by endometrial biopsy before the surgical treatment and 14 were treated by open hysterectomy and bilateral salpingooophorectomy owing to ‘‘clinical preoperative suspicion of a malignant condition.’’ And, as the authors state, only ‘‘6 women with uterine LMS were treated according to anticipated benign fibroids.’’ This is an important distinction; if 6 women with LMS were diagnosed before surgery and 14 other women had a clinical suspicion of a malignant condition, then these 20 women were not considered to have benign fibroids before surgery. Consequently, only the remaining 6 women with LMS were considered to have benign fibroids preoperatively. Thus, the incidence should be stated as 6 unsuspected LMS cases out of 4771 women thought to have benign fibroids preoperatively, equal to 1 of 795, or 0.001. Owing to the current important discussions about the riskof LMS, we feel that the authors’ conclusion should be clarified.

The role of fulvestrant in endometrial cancer

ABSTRACT Introduction: Endometrial cancer is the most common malignancy of the female genital tract in industrialized countries. The traditional treatment of endometrial cancer is based on a surgical approach. In recent years, systemic endocrine therapy has demonstrated good efficacy in recurrent or metastatic setting, delaying progression, ameliorating quality of life and palliating symptoms. Areas covered: Phase I and II studies on selective estrogen receptor down-regulators used for the treatment of endometrial cancer treatment have been reviewed. The pharmacokinetic and pharmacodynamic features of selective receptor down-regulators have been also investigated. Expert opinion: Selective estrogen receptor down-regulators may exhibit clinical efficacy in the treatment of gynecological malignancies due to their pure estrogen receptor antagonist properties. However, up to now data are still limited and some unsolved questions remain. Fulvestrant has poor oral bioavailability and low pharmacodynamic characteristics. Further trials are required to examine new selective estrogen receptor down-regulator agents with better pharmacodynamic and pharmacokinetic profiles.

Role of dacarbazine in the treatment of recurrent mullerian adenosarcoma with sarcomatous overgrowth: Our experience

The incidence of uterine sarcoma ranges 1–3% of the female genital tract cancer. Mullerian adenosarcoma (MA) represents the 8–10% of these tumours (Clement and Scully 1974). According to Clement and Scully’s classification, MA is a mixture of epithelial and stromal components (Clement and Scully, 1974). A particular variant of MA is mullerian adenosarcoma with sarcomatous overgrowth (MASO), which is characterised by the presence of high-grade sarcomatous component occupying the inferior quarter of the neoplastic mass (Clement 1989). The presence of heterologous elements, necrosis, vascular invasion, high mitotic index, deep myometrial invasion or extra-uterine localisations leads to a strongly unfavourable prognosis (Clement 1989; Duggal et al. 2010; Tanner et al. 2013). Recently, at our institution, we have started a protocol that includes the chemotherapy use of dacarbazine (DTIC) in MASO recurrence treatment. In this work, we report on the case of a 72-year-old woman treated in the third chemotherapy line who amply benefitted from the cure. To our knowledge, this represents the first report of such a practice.

Veliparib for the treatment of ovarian cancer

ABSTRACT Introduction: Ovarian cancer represents the sixth most commonly diagnosed cancer among women, with an incidence of 6.1 cases per 100.000 women and a cumulative lifetime risk of 0.5%. Treatment is based on debulking surgery and platinum-based chemotherapy, with the potential combination with taxane. However, the recently available data on the genetic basis and aetiology of ovarian cancer has led to the development of new anticancer drugs. Poly(ADP-ribose) polymerase (PARP) inhibitors are one of the most promising new classes of targeted agents currently under investigation for the treatment of ovarian cancer. Veliparib is a small molecule that inhibits both PARP-1 and PARP-2 and was originally shown to be efficacious in BRCA-associated tumors. Areas covered: This manuscript reviews the Phase I and II studies investigating the use of veliparib in ovarian cancer. This article also provides and discusses the pharmacokinetics and pharmacodynamics of veliparib. Expert opinion: It is still being discussed whether PARP inhibitors should be used in a front-line or relapsed setting, alone or in combination with cytotoxic chemotherapy or as maintenance treatment. In terms of veliparib, further investigations are needed to explore its full potential in ovarian cancer. It is hoped that the ongoing phase 3 trials will help to further elucidate it potential as a treatment option.