Damienne Castaigne

Lymphatic spread in stage Ib and II cervical carcinoma: Anatomy and surgical implications

Objective To determine the frequency and topography of pelvic and para-aortic node involvement in cervical carcinoma and to identify the appropriate level for resection of the lymphatic chains. Methods Between 1985 and 1994, 421 women with stage Ib or II cervical carcinoma were treated by surgery in combination with irradiation. Each underwent a radical hysterectomy with systematic pelvic and para-aortic lymphadenectomy. Results A median of 34 lymph nodes were removed per patient. The overall frequency of lymph node involvement was 26%, and the frequency of para-aortic metastases was 8%. The frequency of lymph node metastasis was associated significantly with stage (x2 = 7.8; P < .02), tumor size (x2 = 14.8; P < .001), and patient age (x2 = 5.9; P < .05). The frequency of para-aortic involvement was below 3% in patients with small tumors (under 2 cm). When pelvic nodes were involved, the obturator group was concerned in 76 cases (18%) and the external iliac group in 48 patients (11%). When para-aortic nodes were involved, the left para-aortic chain was the most frequently concerned (23 patients [5%]). In eight of these patients, nodal involvement was found only above the level of the inferior mesenteric artery. Among 106 patients with pelvic positive nodes, 28 (26%) also had para-aortic metastatic nodes. Conclusion Para-aortic lymphadenectomy should remove all of the left para-aortic chain (inframesenteric and supramesenteric) and so should be performed up to the level of the left renal vein. According to the low frequency of para-aortic involvement when tumor size is below 2 cm, such a procedure could be avoided in patients with small tumors.

Clinical outcomes and fertility after conservative treatment of ovarian borderline tumors

OBJECTIVE To assess clinical outcome and fertility in patients treated conservatively for a low malignant potential (LMP) ovarian tumor. DESIGN Retrospective study. SETTING Gynecologic oncology department of a cancer care center in France. PATIENT(S) Forty-four patients treated with conservative management for a stage I (n = 32) or stage II or III (n = 12) LMP tumor. INTERVENTION(S) Thirty-three patients had unilateral adnexectomy and 11 had cystectomy. Cystectomy was bilateral in 1 patient and was done in conjunction with contralateral adnexectomy in 5 patients. MAIN OUTCOME MEASURE(S) Tumor recurrence and pregnancy rates. RESULT(S) Tumor recurrence rates after radical surgery (hysterectomy with bilateral salpingo-oophorectomy), adnexectomy, and cystectomy were 5.7%, 15.1%, and 36.3%, respectively (P<.01). Among patients who initially received conservative treatment, tumors did not recur in the form of invasive carcinoma. Five patients who had recurrence underwent repeated conservative management; these patients are alive and free of disease. Seventeen pregnancies (of which 15 were spontaneous) occurred in 14 patients; 13 pregnancies occurred in patients with stage I disease and 4 occurred in patients with stage III disease. CONCLUSION(S) Conservative management of LMP tumor significantly increases the risk of recurrence but does not affect overall survival. Such management offers even patients with advanced disease the chance to have spontaneous pregnancy. Conservative management might be proposed in young patients who wish to preserve their fertility, but careful follow-up will be required to detect tumor recurrence.

Ovarian transposition for patients with cervical carcinoma treated by radiosurgical combination

OBJECTIVE To assess the indications, effectiveness, and complications of ovarian transposition before pelvic irradiation for cervical cancer. DESIGN Prospective study. SETTING Gynecologic oncology department at a French cancer center. PATIENT(S) One hundred seven patients treated for cervical cancer. INTERVENTION(S) Ovarian transposition to the paracolic gutters with radical hysterectomy and lymphadenectomy. MAIN OUTCOME MEASURE(S) Clinical and laboratory follow-up tests for ovarian function. RESULT(S) Bilateral ovarian transposition was achieved in 104 patients (98%). Twelve patients were lost to follow-up or excluded because of evolution of the disease. Preservation of ovarian function was achieved in 83% of the patients having follow-up. The rates of ovarian preservation were 100% for patients treated exclusively by surgery, 90% for patients treated by postoperative vaginal brachytherapy, and 60% for patients treated by postoperative external radiation therapy and vaginal brachytherapy. The main risk for ovarian failure was found in patients treated by external radiation therapy. CONCLUSION(S) Ovarian transposition is a safe and effective procedure for preserving ovarian function in patients treated by a radiosurgical combination. This procedure should be performed in patients <40 years of age with a small invasive cervical carcinoma (<3 cm) treated by initial surgery. In such selected cases, the risk of ovarian metastasis is low.

Management of the axilla in conservatively treated breast cancer: 592 Patients treated at institut Gustave-Roussy

Between June 1970 and April 1982, 592 patients with unilateral T1 and small T2 breast cancers were managed conservatively at the Institut Gustave-Roussy. The treatment policy for the axilla was to perform a lower axillary dissection and to proceed to axillary clearance ( +/- radiotherapy) in patients with axillary invasion by tumor (N+). Some N+ patients had only lower axillary dissection and radiotherapy. Five hundred fifty-eight patients underwent axillary surgery which was a lower axillary dissection in 374 patients (67%) and axillary clearance in 184 patients (33%). There was axillary invasion in 198 cases (36%). Only five patients relapsed in the axilla and the probability of axillary relapse at 5 years was 1.2%. There were no axillary relapses in N+ patients who had had an axillary clearance whether irradiated or not. The incidence of upper limb complications was significantly greater in patients undergoing axillary surgery and radiotherapy compared with axillary surgery alone (p less than 0.0001). It is concluded that a lower axillary dissection accurately identifies N-patients and an axillary clearance in N+ patients ensures good local control and avoids the morbidity associated with axillary irradiation.

Fertility results after conservative treatment of advanced stage serous borderline tumour of the ovary

Objective To assess the fertility of patients treated conservatively for a Stage II or III borderline ovarian tumour.

Laparoscopic ovarian transposition for pelvic malignancies: indications and functional outcomes

OBJECTIVE To assess the indications and effectiveness of laparoscopic ovarian transposition before pelvic irradiation for a gynecologic cancer. DESIGN Prospective study. SETTING A gynecologic oncology department in a French anti-cancer center. PATIENT(S) Twenty-four patients treated for pelvic cancer. INTERVENTION(S) Laparoscopic ovarian transposition to paracolic gutters. Uterine conservation in 18 patients. MAIN OUTCOME MEASURE(S) Clinical and laboratory follow-up tests of ovarian function. RESULT(S) Bilateral laparoscopic ovarian transposition was achieved in 22 patients (94%). Twelve patients were treated for clear cell adenocarcinoma of the cervix and/or upper vagina, 6 patients for invasive squamous cervical carcinoma, 3 patients for pelvic sarcoma, 1 patient for recurrent cervical cancer to the upper vagina, 1 patient for ependymoma of the cauda equina, and 1 patient for ovarian dysgerminoma. Ovarian preservation was achieved in 79%. Three pregnancies were obtained. CONCLUSION(S) Laparoscopic ovarian transposition is a safe and effective procedure for preserving ovarian function. Bilateral ovarian transposition should be performed. The main indications for laparoscopic ovarian transposition are a patient with a small invasive cervical carcinoma (<2 cm) in a patient <40 years of age who is treated by initial laparoscopically assisted vaginal radical hysterectomy and a patient with a clear cell adenocarcinoma of the cervix and upper vagina.

Value and cost evaluation of routine follow-up for patients with clinical stage I/II endometrial cancer

The aim of the study was to determine the value and the costs of routine follow-up for the detection of recurrences in patients treated for endometrial cancer. Between 1986 and 1995, 390 women with clinical stage I/II endometrial carcinoma were treated with combined surgery-radiation therapy. After treatment, follow-up was based on the clinical examination, a systematic Papanicolaou (Pap) smear and radiography (chest X-ray and abdomino-pelvic ultrasonography). 27 patients relapsed: 22 patients had symptoms and 5 were asymptomatic. None of the patients had recurrence detected on the routine Pap smear nor on the systematic chest X-ray. In conclusion, the follow-up of patients treated for endometrial cancer based on routine Pap smears and systematic radiography does not permit earlier detection of recurrences. Follow-up should simply include a clinical examination whose frequency should be based on prognostic factors. Approximately two-thirds of this cost was due to systematic examinations (Pap smears and radiography). Our results indicate that such expenditure could be avoided.

Lymph node disorders and prognostic value of nodal involvement in patients treated for a borderline ovarian tumor: an analysis of a series of 42 lymphadenectomies.

BACKGROUND The aim of this study is to evaluate the rate and the clinical outcomes of lymph node involvement in patients treated for borderline ovarian tumor (BOT). STUDY DESIGN Forty-two patients were treated for BOT with a procedure that included lymphadenectomy. Twenty-four patients underwent a pelvic lymphadenectomy, 6 a paraaortic lymphadenectomy, and 12 both procedures. Thirty-two patients underwent systematic lymphadenectomy, five because of associated cancer (uterine cervix or corpus) and five because of bulky nodes discovered during the surgical procedure. RESULTS An endosalpingiosis was present in 11 (26%) patients who underwent lymphadenectomy. Eight patients had nodal involvement related to the BOT. All patients with nodal involvement had serous BOT with peritoneal implants. None of the patients with a mucinous tumor had nodal involvement. None of the patients with early-stage disease (without peritoneal disease) had nodal involvement discovered after routine lymphadenectomy. None of the patients with nodal involvement died of borderline tumor. One patient died of a complication of adjuvant therapy (leukemia after chemotherapy). CONCLUSIONS The prognosis of patients with borderline tumors of the ovary and nodal involvement is excellent. Routine lymphadenectomy should not be performed in patients with early-stage disease. This procedure should be carried out in patients with serous tumor and enlarged lymph nodes.

Results of Hysterectomy in Patients With Bulky Residual Disease at the End of Chemoradiotherapy for Stage IB2/II Cervical Carcinoma

BackgroundWe assessed the clinical outcome after hysterectomy in patients with bulky residual disease after chemoradiotherapy for stage IB2/II cervical carcinoma.MethodsSubjects were 10 patients who had bulky (>2 cm) residual disease in the cervix after external radiotherapy (45 Gy) combined with concomitant chemotherapy (cisplatin 40 mg/m2/week) and uterovaginal brachytherapy (15 Gy).ResultsExtrafascial hysterectomy was performed in three patients, type II radical hysterectomy was performed in six patients, and pelvic exenteration was performed in one patient. Pelvic lymphadenectomy was performed in eight patients, and para-aortic lymphadenectomy was performed in eight. Five patients had nodal involvement (pelvic nodes in four and para-aortic nodes in four), and six had lymphovascular space involvement. Surgical margins were free in nine patients. Seven patients developed grade 2 (n = 3) and/or grade 3 (n = 4) complications. The median duration of follow-up after surgery was 22 months (range, 1–37 months). With follow-up available in nine patients, seven relapsed, and only two remained disease free.ConclusionsThis series confirms the high rate of nodal spread in patients with bulky residual cervical disease after chemoradiotherapy. Furthermore, patients who underwent hysterectomy had a high complication rate. Only two patients are alive and disease free. The results of surgery are disappointing; surgery does not seem to improve the survival of these patients.

Arterioureteral Fistula After Extended Resection of Pelvic Tumors: Report of Three Cases and Review of the Literature

Arterioureteral fistulas are rare. Three patients with arterioureteral fistulas complicating extended resection of pelvic tumors associated with bilateral cutaneous ureterostomy in the right lower quadrant are reported. In one case, the fistula involved the left ureter, the right common iliac artery, and the inferior mesenteric artery. Pathological iliac artery, pelvic cancer, or operated ureteral stones are often incriminated in the genesis of ureteroarterial fistulas. Insertion of a ureteral catheter has been found to be the main promoting factor. The common iliac artery is involved frequently. Clinical presentation is often limited to gross hematuria, whereas complementary investigations have not proved to be sensitive. Surgical treatment is often complex, but must be undertaken early, even in the absence of absolute proof of diagnosis, in order to preclude uncontrollable massive hemorrhage.