D. Querleu

Hybrid imaging by SPECT/CT for sentinel lymph node detection in patients with cancer of the uterine cervix

INTRODUCTIONnConventional lymphoscintigraphy provides planar images with little spatial information on location of pelvic sentinel lymph nodes (SLN). SPECT has better spatial resolution and, in combination with anatomic accuracy provided by CT improves SLN preoperative localization. The aim of the study was to report on the results of hybrid imaging of SLN in early cervical cancer patients treated at Claudius Regaud Cancer Center.nnnMETHODSnStages IA-IB1 cervical cancer patients undergoing preoperative SPECT/CT for SLN detection were analysed.nnnRESULTSnForty-one patients were included. A 100% SLN detection rate was achieved when a combined technique (radiotracer and blue dye) was used. At least one SLN was clearly visualized by SPECT/CT in 39 of 41 patients (95%) and full anatomic concordance with intraoperative anatomical location of SLN was found in 37 of the 39 patients with at least one SLN identified by SPECT/CT (95%). Location of removed SLN included the external and internal iliac area in 88% patients, the common iliac area in 10.5%, and the inframesenteric para-aortic area in 1.5%. No SLN was found in the infrarenal para-aortic region. Lymph node involvement was identified in 5 patients (12.1%). SLN correctly predicted lymph node involvement in all node-positive patients. However, SPECT/CT failed to identify 1 of the 5 metastatic SLN.nnnDISCUSSIONnSPECT/CT accurately detected preoperative SLN topography and enhanced diagnostic sensitivity of SLN imaging, improving surgical approach to patients with cervical cancer staging. Diagnostic quality of anatomic landmarks of CT images of SPECT/CT could be further improved by the use of contrast injected CT.

Low incidence of port-site metastases after laparoscopic staging of uterine cancer.

OBJECTIVEnTo estimate the incidence of clinically detected port-site metastases (PSM) in patients with endometrial and cervical cancer treated at two gynecologic oncology services with extensive experience.nnnMETHODSnAll eligible uterine cancer patients laparoscopically staged at Centre Oscar Lambret in Lille and Institut Claudius Regaud in Toulouse, France, were reviewed. MEDLINE database was searched to identify articles on PSM after laparoscopic procedures for cervical and endometrial cancer.nnnRESULTSnDuring the study period, 1216 laparoscopic procedures for uterine cancer were performed. 921 patients underwent laparoscopic staging for cervical cancer and 295 for endometrial cancer. The overall incidence of PSM in our institutions was 0.4% per procedure (5 patients), and the incidence of PSM after laparoscopy for cervical and endometrial cancer was 0.43% and 0.33%, respectively. Excluding patients with peritoneal carcinomatosis, the rate of port-site recurrence in our series lowered to 0.16%, and the rate of isolated PSM to 0%. The median time to the development of PSM was 8 months (range 6-48), the median overall survival from diagnosis for all patients was 26 months (range 7-30), and median survival from recurrence was 5 months (range 1-20).nnnCONCLUSIONnAlthough PSM is recognized as a complication of laparoscopy for ovarian cancer. PSM is a rare complication of laparoscopic staging for endometrial and cervical cancer. The majority of patients with PSM presented with associated synchronous disease. The incidence of isolated PSM can be maintained virtually to 0% by an adequate operative technique. We believe that PSM in patients with uterine cancer cannot be used as an argument against laparoscopic staging in uterine cancer.

Laparoscopic pelvic exenteration for gynaecological malignancy: Is there any advantage?

INTRODUCTIONnPelvic exenteration (PE) remains one of the most mutilating surgical procedures with important postoperative morbidity. Laparoscopic approach has emerged in an attempt to reduce postoperative complications. The aim of the present study was to compare outcomes between laparoscopic pelvic exenteration combined with a vaginal or perineal approach, versus classical approach.nnnMETHODSnA cohort study was performed by identifying patients who underwent laparoscopic pelvic exenteration, and retrospectively comparing data with open cases from the same period of time, from 2000 to 2008.nnnRESULTSnFourteen patients underwent laparoscopic PE and 29 patients underwent an open exenterative procedure. All patients except one (97.6%) had received prior radiotherapy. Eighteen patients (41.9%) underwent total PE, 17 anterior PE (39.5%), and 8 posterior PE (18.6%). Urinary diversion (UD) technique consisted of 24 Miami pouch (68.6%), 9 Bricker diversion (25.7%), 1 Kock pouch (2.9%), and 1 ureterostomy (2.9%). Most frequent postoperative complications were related to the urinary diversion (45%) and bowel reconstruction (27.9%). Median estimated blood loss for the laparoscopy and laparotomy group was 400 ml (range 200-700 ml) and 875 ml (range 200-1600 ml), respectively. Transfusion rate was also significantly higher in the laparotomy group. Operative time, margin status, length of hospital stay, operative and postoperative morbidity, and disease and overall survival were not significantly different between both groups.nnnCONCLUSIONSnLaparoscopic PE is feasible with curative intent to selected patients. Potential postoperative advantages of laparoscopic approach when compared to classical approach, oncological safety of the procedure, and QOL considerations need to be further investigated.

Celiac lymph node resection and porta hepatis disease resection in advanced or recurrent epithelial ovarian, fallopian tube, and primary peritoneal cancer

INTRODUCTIONnPrognostic value of complete macroscopic resection of primary disease has been reported and confirmed in several publications. Published data indicate that extensive upper abdominal disease involving the hepatic pedicle and celiac trunk is associated with an abortion of the surgical procedure or with suboptimal residual disease.nnnMETHODSnAll patients who had disease at the porta hepatis or celiac lymph node resection as part of cytoreductive surgery were included. Medical and operative records with particular emphasis on extent and distribution of disease spread, number of peritonectomy procedures, visceral resections, and lymphadenectomy procedures were examined.nnnRESULTSnA total of 28 patients who underwent some kind of celiac lymph node resection or resection of metastatic involvement of the porta hepatis were included. Median preoperative serum Ca-125 level was 78U/ml (range, 30-2950U/ml), and median ascites volume was 1900ml (range, 0-10,000ml). Of the 28 patients, 23 underwent supra-radical surgery for diffuse peritoneal carcinomatosis. Median operative time was 252minutes (range, 100-540minutes). Complete cytoreduction to CCO was achieved in all except one case, who was cytoreduced to millimetric residue. Fifteen patients had positive celiac nodes and nineteen patients had peritoneal disease in the porta hepatis region.nnnDISCUSSIONnResection of enlarged nodes and metastatic disease to the porta hepatis is feasible with an acceptable morbidity. The decision to undergo an aggressive cytoreductive surgery is based on appropriate patient selection depending on the extension of surgical procedure, on medical comorbidities, and on the potential to tolerate an extensive procedure, rather than on specific anatomic locations.

Incidence of micrometastases in histologically negative para-aortic lymph nodes in advanced cervical cancer patients

OBJECTIVEnAims of the study were to identify the incidence of micrometastases in negative para-aortic lymph nodes, and to assess the utility of ultrastaging in histologic evaluation of para-aortic lymph nodes.nnnMATERIAL AND METHODSnPatients with advanced cervical cancer and negative para-aortic lymph nodes after routine histology examination were included. Paraffin-embedded tissue blocks were cut into 5-μm-thick slides at step serial sections at 200-μm intervals until there was no lymph node tissue left. 7 to 14 slides were obtained per lymph node and an immunohistochemistry staining with anti-cytokeratin antibody (EA1/EA3) was performed.nnnRESULTSn581 histologically negative aortic nodes of 24 patients with advanced cervical cancer were assessed for para-aortic micrometastases (PAM). The incidence of micrometastases by the total number of studied lymph nodes was 0.003%. PAM were identified in 2 patients (8.3%), and additional submicrometastases were also found in one of them (4.1%). A single metastatic cluster of less than 0.2 mm was found in an afferent lymphatic vessel of another patient, not considered as a submicrometastases. PAM incidence was too low to allow for evaluation of associated risk factors, and for analysis of prognostic significance.nnnCONCLUSIONnAlthough examination of PAM with ultrastaging and IHC is expensive and time-consuming, and difficult to be routinely applied to all negative lymph nodes retrieved in a para-aortic lymphadenectomy, this study adds to current evidence that removal of aortic nodes may benefit a subgroup of advanced cervical cancer patients with PAM and negative aortic lymph node at imaging techniques including PET-scan.

Indications and teaching of fertility preservation in the surgical management of gynecologic malignancies: European perspective

Young women affected by a malignant tumor have to cope, after the announcement of diagnosis, with the treatment and its secondary effects. Indeed, some of them may definitively impact on their fertility potential. Especially in pelvic tumors, treatments are more or less mutilating, either by a direct surgical resection of pelvic organs or by destruction of their functioning after chemotherapy or radiation therapy. Surgeons are often at the front line in the management of gynecologic tumors. It is important for them to be aware not only of the surgical techniques currently available to preserve fertility, but as well of their indications and limits, according to the tumor type or its treatment. This knowledge will enable them to deliver fair information to the patient or couple, keeping in mind that, multidisciplinarity is of a paramount importance and referring a patient to a more experienced team, is sometimes the best solution. Through a literature review, we report on the most recent results of the different options available today according to cancer localization as well as some opinions concerning indications, management, organization of care, and teaching of these techniques.

Vers une évolution du dogme de la chirurgie « optimale » dans les cancers de l’ovaire

The dismal outcome of ovarian, fallopian tube, and primary peritoneal carcinomas calls for an increase in surgical aggressiveness. After a long era during which incomplete cytoreduction was considered acceptable, it has been established that the outcome is directly related to the amount of diseased tissue left in place. Probably as a result of technical imitations of surgeons and anesthesiologists, the majority of teams have fixed a cut-off value of 2 cm to define what was called optimal cytoreduction. Although it is now established that reaching the 2 cm cut-off value is the minimal required target, the target has moved towards complete removal of visible implants. However, the methods of assessment of residual disease and the very concept of complete cytoreduction suffer from limitations.

Impact pronostique de la morcellation chirurgicale en cas de cancers utérins : du « principe de précaution » au « réalisme »

Minimally invasive surgery has demonstrated benefits that include improved pain control, decreased infection risk, and faster surgical recovery and return to work. Morcellation is an integral part of making laparoscopic surgery possible for the removal of large uterine leiomyomata, and the development of power morcellation has increased efficiency during these procedures. Morcellation may expose patients to increased morbidity in certain circumstances. This is particularly true in cases of unrecognized malignancy, where intra-abdominal dissemination of cancer may worsen the prognosis (overall survival and disease free survival). A critical review of published data supports that tissue morcellation can be performed safely in screened and selected patients.

Vaginal reconstruction with pedicled vertical deep inferior epigastric perforator flap (diep) after pelvic exenteration. A consecutive case series

Vaginal reconstruction after pelvic exenteration (PE) represents a challenge for the oncologic surgeon. Since the introduction of perforator flaps, using pedicled vertical DIEP (deep inferior epigastric perforator) flap allows to reduce the donor site complication rate. From November 2012 to December 2014, 27 PEs were performed in our institution. 13 patients who underwent PE with vaginal reconstruction and programmed DIEP procedure for gynecologic malignancies were registered. Nine patients underwent PE for recurrent disease and four for primary treatment. Six of the 13 patients have a preoperative fistula. Anterior PE was performed in 10 patients, and total PE in 3 patients. A vertical DIEP flap was performed in 10 patients using one or two medial perforators. The reasons for abortion of vertical DIEP flap procedure were: failure to localizing perforator vessels in two cases, and unavailability of plastic surgeon in one case. A vertical fascia-sparring rectus abdominis myocutaneous flap was then harvested. Median length of surgery was 335min, and 60min for DIEP harvesting and vaginal reconstruction. No flap necrosis occurred. One patient in the VRAM (vertical rectus abdominis myocutaneous) group experienced a late incisional hernia and one patient in the DIEP flap group required revision for vaginal stenosis. In our experience, DIEP flap represents our preferred choice of flap for circumferential vaginal reconstruction after PE. To achieve a high reproducibility, the technically demanding pedicled vertical DIEP flap has to be harvested by a trained surgeon, after strict evaluation of the preoperative imaging with identification and localization of perforator vessels.

Préservation de la fertilité, contraception et traitement hormonal de la ménopause chez les femmes traitées pour tumeurs malignes rares de l’ovaire : recommandations du réseau national dédié aux cancers gynécologiques rares (TMRG/GINECO)

INTRODUCTIONnRare ovarian tumors include complex borderline ovarian tumors, sex-cord tumors, germ cell tumors, and rare epithelial tumors. Indications and modalities of fertility preservation, infertility management and contraindications for hormonal contraception or menopause hormone therapy are frequent issues in clinical practice. A panel of experts from the French national network dedicated to rare gynaecological cancers, and of experts in reproductive medicine and gynaecology have worked on guidelines about fertility preservation, contraception and menopause hormone therapy in women treated for ovarian rare tumors.nnnMETHODSnA panel of 39 experts from different specialties contributed to the preparation of the guidelines, following the DELPHI method (formal consensus method). Statements were drafted after a systematic literature review, and then rated through two successive rounds.nnnRESULTSnThirty-five recommendations were selected, and concerned indications for fertility preservation, contraindications for ovarian stimulation (in the context of fertility preservation or for infertility management), contraceptive options (especially hormonal ones), and menopause hormone therapy for each tumor type. Overall, prudence has been recommended in the case of potentially hormone-sensitive tumors such as sex cord tumors, serous and endometrioid low-grade adenocarcinomas, as well as for high-risk serous borderline ovarian tumors.nnnDISCUSSIONnIn the context of a scarce literature, a formal consensus method allowed the elaboration of guidelines, which will help clinicians in the management of these patients.