E. Lambaudie

Laparoscopic identification of sentinel lymph nodes in early stage cervical cancer: Prospective study using a combination of patent blue dye injection and technetium radiocolloid injection

OBJECTIVEnTo determine the feasibility of intraoperative radioisotopic mapping using an endoscopic gamma probe associated with patent blue dye injection in patients with early stage cervical cancer.nnnMETHODSnBetween April 2001 and March 2002 a total of 12 patients underwent laparoscopic bilateral pelvic lymphadenectomy (squamous carcinoma in 10 cases, all stage FIGO IB1, and adenocarcinoma in 2 cases, stages IA2 and IB1). Lymphoscintigraphies were performed on the day before surgery to visualize sentinel lymph nodes, 31 +/- 22.5 and 174 +/- 34 min after injection of 200 microCi of technetium 99m rhenium sulfur colloid. The marker was injected at the 3, 6, 9, and 12 oclock positions. The day of surgery 2 ml of patent blue dye plus 2 ml of physiological serum was injected in the cervix, at the same locations as the radioactive isotope injection.nnnRESULTSnA total of 35 sentinel lymph nodes were detected. Eight sentinel lymph nodes were only detected by color, 8 sentinel lymph nodes were only detected by the endoscopic gamma probe, and 19 sentinel lymph nodes were hot and dyed. We found 3 metastatic lymph nodes. In one case, bilateral positive sentinel nodes were only detected by the endoscopic gamma probe. Permanent section identified one inframillimetric micrometastasis in a lymph node that was neither blue nor hot intraoperatively (sensitivity = 66%, specificity = 100%, positive predictive value = 100%, negative predictive value = 90%).nnnCONCLUSIONnThe identification of the sentinel lymph node with blue dye and radioisotope using an endoscopic gamma probe is feasible and improves detection rate. False negatives still occur, but the proportion is low even at the beginning of the learning curve. Isotopic imaging identifies nodes in areas outside the pelvis not routinely sampled in early cervical cancer patients.

Laparoscopic restaging of borderline ovarian tumours: results of 30 cases initially presumed as stage IA borderline ovarian tumours

Objectives To review our experience with the laparoscopic restaging procedure of presumed early stage borderline ovarian tumours.

A biomechanical study of the strength of vaginal tissues. Results on 16 post-menopausal patients presenting with genital prolapse.

AIMSnMeasurements of the tensile and bending strength of samples of vaginal tissue collected during corrective surgery of prolapse.nnnMATERIALS AND METHODSnOur measurements were conducted on two samples of vaginal tissue 2 cm x 2 cm collected during surgical correction of prolapse by vaginal route in 16 post-menopausal patients. The samples were collected from posterior vaginal fundus, were orientated, and then fixed on a plate holding the edges and allowing the tissue to be stretched over an orifice of 1 cm. The tensile measurements were made using a suture passed over this distance of 1 cm in one of the two samples by recording the strength curve in order to evaluate the force at rupture of the collagen fibres. The second sample was prepared in the same way and a piston of 1 cm diameter was made to penetrate to determine the strength of breakage of the fibres. The pressure and tensile strength curves were recorded up to rupture of the sample, as was the value of the tissue elongation.nnnRESULTSnThere was a great variability in the measurements of maximum strength at rupture of the vaginal samples and in the elongation before rupture of the samples. The mean rupture values in tensile tests were 44 and 59 N in bending with extremes of 12 and 130 N. The values of elongation before rupture of a 10 mm sample were 23 mm in tensile tests and 11 mm in bending tests. There was a great variability of results from one patient to another. There was no relation between the values observed and the patient age. There was a statistical relation between the elongation values of the samples and the maximum force before rupture in both the tensile and bending tests. There was also a relation between the measurement of the maximum force at rupture in bending and in tensile tests although there was no such relation in terms of the values of elongation before rupture.nnnDISCUSSIONnThere is no published reference concerning the strength at rupture or the tensile strength curves for human vaginal tissues. Vaginal tissues are however commonly used as a suspension component in the vast majority of operations for correcting prolapse or urinary incontinence. These suspensions are made by passing a suture through the thickness of the vaginal tissue. The results that we report do however show that these vaginal tissues are very variable in strength from one patient to another. The same finding was made in terms of the elongation values for the vaginal tissue before rupture. The values in bending tests showed that the highest rupture force values and the greatest mean elongation before rupture were lower than in tensile tests.nnnCONCLUSIONSnThese findings could explain some failures of these surgical procedures, which are all based on the tensile strength properties. Finally these results could be included in modelling of the reaction of vaginal tissues to the pressure experienced within the vagina.

A study of pelvic ligament strength

OBJECTIVESnTo measure the strength at tearing of pelvic ligaments used in the cure of prolapse and urinary incontinence.nnnMATERIAL AND METHODSnWe performed our measurements on pelvis ligaments from cadaveric specimens. We dissected 29 human female pelvis cadavers of which storage conditions differed. Ten were frozen, 10 fresh and 9 were stored in formalin. In each cadaver we dissected pre-vertebral ligaments at promontory and right and left symmetrical ligaments. These were the iliopectineal, sacrospinous and arcus tendineus of pelvic fascia. A subjective clinical evaluation of the ligament properties was performed by visual observation as well as finger palpation. Ligaments were classified into three groups. Group A contained high quality ligaments, in terms of thickness and apparent strength following finger palpation. Ligaments of doubtful quality were classified in group B and low apparent quality ligaments in group C. Then the ligaments were stitched by a suture taking the entire ligament and a force was applied on the vagina axis until tearing. The device used for strength measurement during traction was a SAMSON type force gauge, model EASY, serial number SMS-R-ES 300N manufactured by Andilog that was developed for the purpose of our study. Measurements were given in Newton (N).nnnRESULTSnThere was a great variability in the values obtained at tearing with minimal values at around 20N and maximal values at 200N. Individually measured, ligament strength varied between individuals, and for the same patient between the type of ligaments and the side. The pre-vertebral ligament was on average the strongest. There was no significant difference according to the storage condition except for the pre-vertebral ligament in formalin cadavers. For bilateral ligaments, there was no difference between the left and right side. The iliopectineal ligament was statistically significantly stronger than the sacrospinous and arcus tendineus of pelvic fascia. There was a correlation between subjective evaluation and objective strength measurements.nnnDISCUSSIONnNo papers have been published on the strength of pelvic ligaments at tearing. These are however routinely used in the cure of prolapse and urinary incontinence. Our results show that there is a great variability in strength between individuals, and for a same patient between the types of ligaments and side. These observations could explain some of the surgical intervention failures and demonstrate the importance of per-operative strength evaluation. Per-operative subjective evaluation of strength is related to objective measurements and could be used to determine the type of ligaments to be used for surgical suspension. Freezing does not damage pre-vertebral ligament strength and further studies are required to evaluate elasticity of pelvic ligaments.

Early experience of robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein

OBJECTIVEnTo describe our early experience with robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein, including Da Vinci robot positioning.nnnMETHODSnSix patients underwent robotic-assisted laparoscopy using the Da Vinci apparatus. The patients included a man with a pT2 non-seminomatous germ cell tumour of the left testicle treated by chemotherapy with an incomplete response (mature teratoma), four women with locally advanced cervical cancer, and one case of bulky cancer of the vaginal cuff. The procedure was carried out using four port sites: one for the camera, one each for the no. 1 and no. 3 arms of the Da Vinci robot system, and one for the assistant.nnnRESULTS AND CONCLUSIONnRobotic-assisted lymphadenectomy carried out using the Da Vinci system was safe and effective with a short learning period for an experienced oncological team. A larger prospective study is now required to evaluate this procedure further.

A history of cesareans is a risk factor in vaginal hysterectomies

Aims.u2002 This study describes the characteristics and per‐ and postoperative frequencies of complications in vaginal hysterectomies for benign lesions in patients with a history of cesareans. We compare these figures with the frequency of complications in vaginal hysterectomies without a history of such operations.

Vaginal evisceration after hysterectomy: the repair by a laparoscopic and vaginal approach with a omental flap

BACKGROUNDnVaginal evisceration is generally repaired by vaginal or abdominal route. We describe two cases of vaginal evisceration using a combined laparoscopic and vaginal approach employing an omental flap.nnnCASESnCase 1: A radical abdominal hysterectomy was performed in a premenopausal patient for a FIGO IB1 cervical cancer. Four months later, she was found to have a vaginal cuff dehiscence which was repaired by a vaginal approach. Two months later, she had a vaginal cuff evisceration which was repaired using a combined laparoscopic and vaginal approach employing an omental flap with good success. Case 2: A postmenopausal woman who underwent an abdominal hysterectomy and pelvic lymphadenectomy for a FIGO IB endometrial cancer was noted to have a vaginal evisceration two months after primary surgery. This was also successfully repaired using a combined laparoscopic and vaginal approach employing an omental flap.nnnCONCLUSIONnThe combined laparoscopic and vaginal approach with omental flap is effective for repair of a vaginal cuff dehiscence with bowel evisceration. The addition of laparoscopy provides an opportunity for inspection of the small bowel, the peritoneal toilet, and mobilization of an omental flap.

Controverses et nouveautés dans l'adénocarcinome de l'endomètre

Resume Objectifs. – Donnees recentes et controverses concernant l’adenocarcinome endometrial uterinxa0: evaluation pre-operatoire de l’extension intra- et extra-uterine, staging chirurgical et ses indications et traitement adjuvant. Patientes et methodes. – Medline de 1998 a 2002 pour endometrial carcinoma. Resultats. – La cytologie cervicale est interessante lorsqu’une imagerie de qualite (IRM, echographie) n’est pas realisable et elle peut etre realisee en meme temps que la biopsie de l’endometre. L’existence de cellules suspectes ou adenocarcinomateuses ou l’elevation pre-operatoire du CA 125xa0serait en faveur d’une lesion evoluee ou agressive. Une evaluation abdominale et ganglionnaire precise est donc necessaire en plus du geste d’exerese local. L’IRM est le meilleur examen pre-operatoire car il donne des informations sur une atteinte abdominale, annexielle, ganglionnaire pelvienne ou lombo-aortique et evalue la penetration myometriale afin de guider le chirurgien pour le choix de la voie d’abord et pour l’interet d’une lymphadenectomie. La stadification chirurgicale doit faire partie du traitement sous la forme d’une evaluation peritoneale assortie d’une lymphadenectomie pelvienne completee par une dissection para-aortique en cas de ganglions pelviens positifs, de groupe a risquexa0: IC profond, grade 3, histologie non endometrioide (papillaire sereuse en particulier), atteinte annexielle ou intra-abdominale, surtout lorsque les conditions techniques sont favorables c’est-a-dire sans risque operatoire ajoute. La radiotherapie adjuvante pourrait etre evitee dans beaucoup de stades I pN0 documentes (donc avec stadification chirurgicale complete et curage ganglionnaire pelvien) mais la curietherapie postoperatoire idealement en haut debit de dose resterait indiquee dans les stades I a risque eleve de rechute locale soit dans les stades IC quel que soit le grade, ou I grade 3xa0ou I grade 2xa0a partir du stade Ib. Conclusion. – L’IRM pre-operatoire permet de choisir la voie d’abord de la chirurgie et de connaitre l’invasion myometriale pour poser ou non l’indication d’une lymphadenectomie pelvienne. La stadification chirurgicale doit faire partie du traitement du cancer de l’endometre. Ainsi la radiotherapie adjuvante pourrait etre evitee chez les patientes au stade I pN0.

Characteristics and clinical outcome of T1 breast cancer: a multicenter retrospective cohort study

BACKGROUNDnA subgroup of T1N0M0 breast cancer (BC) carries a high potential of relapse, and thus may require adjuvant systemic therapy (AST).nnnPATIENTS AND METHODSnRetrospective analysis of all patients with T1 BC, who underwent surgery from January 1999 to December 2009 at 13 French sites. AST was not standardized.nnnRESULTSnAmong 8100 women operated, 5423 had T1 tumors (708 T1a, 2208 T1b and 2508 T1c 11-15 mm). T1a differed significantly from T1b tumors with respect to several parameters (lower age, more frequent negative hormonal status and positive HER2 status, less frequent lymphovascular invasion), exhibiting a mix of favorable and poor prognosis factors. Overall survival was not different between T1a, b or c tumors but recurrence-free survival was significantly higher in T1b than in T1a tumors (P = 0.001). In multivariate analysis, tumor grade, hormone therapy and lymphovascular invasion were independent prognostic factors.nnnCONCLUSIONnRelatively poor outcome of patients with T1a tumors might be explained by a high frequency of risk factors in this subgroup (frequent negative hormone receptors and HER2 overexpression) and by a less frequent administration of AST (endocrine treatment and chemotherapy). Tumor size might not be the main determinant of prognosis in T1 BC.BACKGROUNDnA subgroup of T1N0M0 breast cancer (BC) carries a high potential of relapse, and thus may require adjuvant systemic therapy (AST).nnnPATIENTS AND METHODSnRetrospective analysis of all patients with T1 BC, who underwent surgery from January 1999 to December 2009 at 13 French sites. AST was not standardized.nnnRESULTSnAmong 8100 women operated, 5423 had T1 tumors (708 T1a, 2208 T1b and 2508 T1c 11-15 mm). T1a differed significantly from T1b tumors with respect to several parameters (lower age, more frequent negative hormonal status and positive HER2 status, less frequent lymphovascular invasion), exhibiting a mix of favorable and poor prognosis factors. Overall survival was not different between T1a, b or c tumors but recurrence-free survival was significantly higher in T1b than in T1a tumors (P = 0.001). In multivariate analysis, tumor grade, hormone therapy and lymphovascular invasion were independent prognostic factors.nnnCONCLUSIONnRelatively poor outcome of patients with T1a tumors might be explained by a high frequency of risk factors in this subgroup (frequent negative hormone receptors and HER2 overexpression) and by a less frequent administration of AST (endocrine treatment and chemotherapy). Tumor size might not be the main determinant of prognosis in T1 BC.

Survival impact and predictive factors of axillary recurrence after sentinel biopsy.

BACKGROUNDnThe rate of axillary recurrence (AR) after sentinel lymph node biopsy is usually low but few studies investigated its impact on survival. Our aim was to determine the rate and predictive factors of AR in a large cohort of breast cancer patients and its impact on survival.nnnPATIENTS AND METHODSnFrom 1999 to 2013, 14,095 patients who underwent surgery for clinically N0 previously untreated breast cancer and had sentinel lymph node biopsy were analysed. A simplified score predictive of AR was established.nnnRESULTSnMedian follow-up was 55.2 months. AR was observed in 0.51% of cases, with a median time to onset of 43.4 months. In multivariate analysis, the occurrence of AR was significantly correlated with grade 2 or 3 disease, absence of radiotherapy and tumour subtype (hormonal receptor [HR]- / human estrogen receptor [HER]+). AR rates were 1% for triple-negative tumours, 2.8% for HER2-positive tumours, 0.4% for luminal A tumours, 0.9% for HER2-negative luminal B tumours, and 0.5% for HER2-positive luminal B tumours. A simplified score predictive of the occurrence of AR was established. Patients could be divided into three different score groups (p < 0.0001). In multivariate analysis, overall survival was significantly lower in cases of AR (p < 0.0001), age >50, lymphovascular invasion, grade 3 disease, sentinel node (SN) macrometastases, tumour size >20 mm, absence of chemotherapy and triple-negative phenotype. Survival in patients with AR was significantly lower in case of early-onset (2 years) AR (p = 0.017).nnnCONCLUSIONSnIsolated AR is more common in Her2-positive/HR-negative triple-negative tumours with a more severe prognosis in triple-negative and Her2-positive/HR-negative tumours, and represents an independent adverse factor justifying an indication for systemic treatment for AR treatment. However, the benefit of any systemic treatment remains to be proven.