Ester Valentina Cafà

Can the preoperative HE4 level predict optimal cytoreduction in patients with advanced ovarian carcinoma

OBJECTIVE Optimal surgical outcome has been proved to be one of the most powerful survival determinants in the management of ovarian cancer patients. Actually, for ovarian cancer patients there is no general consensus on the preoperatively establishment of cytoreducibility. METHODS Between January 2011 and June 2012 patients affected by suspicious advanced ovarian cancer, referred to the Department of Gynecology of Campus Biomedico of Rome were enrolled in the study. All patients had serum CA125 and HE4 measured preoperatively. After a complete laparoscopy to assess the possibility of optimal debulking surgery defined as no visible residual tumor after cytoreduction (RT=0), patients were submitted to primary cytoreductive surgery (Group A) or addressed to neoadjuvant chemotherapy (Group B). RESULTS After diagnostic open laparoscopy, 36 patients underwent optimal primary cytoreductive surgery (Group A) and 21 patients were addressed to neoadjuvant chemotherapy (Group B). In our population, based on ROC curve, the HE4 value of 262pmol/L is the best cut-off to identify patients candidates to optimal cytoreduction with a sensitivity of 86.1% and a specificity of 89.5% (PPV=93.9% and NPV=77%). In addition, CA125 has a sensitivity of 58.3% and a specificity of 84% at cut-off of 414 UI/mL (AUC is 0.68, 95% C.I.=0.620 to 0.861). CONCLUSION Our data indicate that preoperative HE4 is a better predictor for optimal cytoreduction compared to CA125. The best combination in predicting cytoreduction is HE4≤262 pmol/L and ascites <500mL with a sensitivity of 100% and a specificity of 89.5% (PPV=94% and NPV=100%).

Update on lymphadenectomy in early and advanced ovarian cancer

Purpose of review Pelvic and para-aortic lymphnode sampling is an integral part of the staging system of ovarian cancer. The issue concerning lymphadenectomy in the management of the disease is still debated, however. The purpose of this paper is to review the role of systematic lymphadenectomy in patients affected by early and advanced-stage ovarian cancer. Recent findings Some retrospective studies have revealed an increased survival rate in early-stage ovarian cancer patients after lymphadenectomy. Recently, the first randomized prospective trial, on lymphadenectomy in advanced-stage disease, was published. It evidenced an improvement in progression-free survival in patients who had undergone lymphadenectomy. Summary Systematic lymphadenectomy has a diagnostic value in early-stage ovarian cancer, thanks to the possibility of accurate clinical staging. As up to 22% of women, who were presumed to have early-stage ovarian cancers, are upstaged during the lymphadenectomy procedure, accurate staging can help to avoid unnecessary postoperative chemotherapy. In patients affected by advanced ovarian cancer, systematic lymphadenectomy statistically significantly improves progression-free survival and reduces recurrence rates despite a higher incidence of postoperative complications. As improvement of overall survival is not statistically significant, further studies are needed to balance risks and benefits of systematic lymphadenectomy in advanced-stage disease.

A comparison of three different entry techniques in gynecological laparoscopic surgery: a randomized prospective trial

OBJECTIVE Laparoscopic entry techniques vary and still remain debated. We conducted a randomized control trial to compare three entry techniques. STUDY DESIGN Women aged 18-70 years, nominated for laparoscopic surgery at University of Rome Campus Bio-Medico, were randomized into three different groups: Veress needle (VER), Direct trocar insertion (DIR) and Open technique (OP). For each group, minor complications (extra-peritoneal insufflation, trocar site bleeding, omental injury and surgical site infection), failed entry and time of entry of the main trocar were evaluated. Major complications were also considered. Between-group comparisons were performed using chi-square test. Significance P value was <0.05. RESULTS A series of 595 consecutive procedures were included: 193 in the VER group, 187 in the DIR group and 215 in the OP group. Minor complications occurred in 36 cases: extraperitoneal insufflation (n=6) in the VER group only, site bleeding (n=2 in the VER group, n=2 in the DIR group and n=1 in the OP group), site infection (n=5 in the VER and n=6 in OP group), and omental injury (n=6 in the VER group and n=3 in the DIR group). Failed entry occurred in 4 cases of the VER group and 1 case of the DIR group. Mean time of entry was 212.4, 71.4 and 161.7s for the VER, DIR and OP groups respectively. Among major complications, one bowel injury resulted following the Veress technique. CONCLUSIONS In our series, DIR and OP entry presented a lower risk of minor complications compared with VER. In addition, time of entry was shorter in DIR than with OP entry.

REM (RISK OF ENDOMETRIAL MALIGNANCY): A PROPOSAL FOR A NEW SCORING SYSTEM TO EVALUATE RISK OF ENDOMETRIAL MALIGNANCY .

Purpose: It is often difficult to distinguish a benign endometrial disease from a malignancy and tools to help the physician are needed to triage patients into high and low risk of endometrial cancer. The purpose of this study was to obtain a predictive model to assess the risk of endometrial malignancy (REM) in women with ultrasound endometrial abnormalities. Experimental Design: Women, between ages 45 to 80 years, diagnosed through ultrasound with endometrial abnormalities and scheduled to have surgery were enrolled on a prospective study at the Department of Gynaecologic Oncology of Campus Bio-Medico, University of Rome. Preoperative clinical, ultrasound and laboratory characteristics were taken into account. Logistic regression algorithm was used to categorize patients into low- and high-risk groups for endometrial cancer. Results: A total of 675 patients were considered for the analysis: 88 with endometrial cancer and 587 with benign endometrial disease. We divided the patients into two groups: training set (TS) and verification set (VS). Preoperative age, symptom, HE4 levels, and ultrasound endometrial thickness were found statistically significant, and were included into a multivariate logistic regression model to determine the probability to have endometrial cancer. In the TS, REM reported 93.3% sensitivity and 97.1% specificity [positive predictive value (PPV), 0.83; negative predictive value (NPV), 0.98; AUC, 0.957; 95% confidence interval (CI), 0.908–0.984]. In the VS, REM reported 89.3% sensitivity and 95.4% specificity (PPV, 0.73; NPV, 0.98; AUC, 0.919; 95% CI, 0.829–0.970). Conclusions: Our data support the use of REM to triage patients into low- and high-risk groups for endometrial cancer, even if an external validation of the model is needed. Clin Cancer Res; 19(20); 5733–9. ©2013 AACR.

Intraoperative contact ultrasonography during open myomectomy for uterine fibroids

OBJECTIVE To evaluate the benefit of intraoperative ultrasound applied directly to the uterine serosa during surgery for uterine fibroids. DESIGN Prospective study. SETTING University hospital, tertiary care. PATIENT(S) Women admitted for open myomectomy due to uterine fibroids. INTERVENTION(S) Intraoperative ultrasound (IUS) and intraoperative palpation were performed to detect the number of residual fibroids at the end of surgery, then the number of fibroids was recorded at anatomopathology examination. MAIN OUTCOME MEASURE(S) Residual fibroids detected at IUS and intraoperative palpation at the end of open myomectomy. RESULT(S) The comparison between the number of residual fibroids at IUS and at intraoperative palpation was statistically significant. CONCLUSION(S) Intraoperative ultrasound is more efficient than palpation in detecting residual leiomyomata at the end of open myomectomy.

Alexithymia–A Disorder of the Regulatory Mechanism of the Emotion Elaboration–and Quality of Life in Gynecologic Surgery

STUDY OBJECTIVE Alexithymia is a disorder of the regulatory mechanism of the emotion elaboration. To verify the influence of the personality trait in the evaluation of quality of life (QoL), we analyzed the effect of alexithymia on the outcome of gynecologic surgery. The purpose of this study was to investigate the presence of alexithymia by using the Toronto Alexithymia Scale (TAS)-20, and to examine the relationship between alexithymia and self-reported descriptors of QoL in a gynecologic population. DESIGN All patients were evaluated in a semistructured interview in which personal, medical, and social data were collected. They were provided with a set of questionnaires that included both measure of alexithymia (TAS-20) and QoL perception (the Medical Outcomes Study short-form general health survey-36 [SF-36]). The patients were assessed before the surgical procedure and 1 month postoperatively. SETTING Campus BioMedico Hospital in Rome, Italy. PATIENTS In all, 40 consecutive patients with benign gynecologic pathology were enrolled in the study. INTERVENTIONS A total of 20 of the patients underwent laparoscopy (LPS) and 20 underwent laparotomy (LPT). MEASUREMENTS AND MAIN RESULTS Patients were separated into 2 groups, with respect to the TAS questionnaire score: the high-level alexithymia (HA) group, with scores above 59, and the low-level alexithymia group, with scores below 59. The HA group represented 61% in patients who underwent LPS and 50% in patients who were submitted to LPT. Patients who underwent LPS showed a slight decrease in the QoL score after the surgical procedure. Patients who underwent LPT showed different QoL scores depending on the high or low TAS level: high-level TAS group showed higher SF-36 domain scores compared with the presurgical scores, whereas low-level TAS group showed lower scores compared with the presurgical scores. CONCLUSION Our data show that the subjective QoL tested with SF-36 in patients with gynecologic conditions undergoing surgery is clearly influenced by the level of alexithymia. This influence is clearly detectable when a more invasive surgery is performed. In this case, patients with low-level alexithymia show a worsening of QoL. Contrarily, patients with HA have a better perception of QoL after more invasive surgery.

Liposome Encapsulated Doxorubicin Citrate (Ledc) as an AlternativeTherapeutic Option for Patients with Recurrent Ovarian Cancer Sufferingfrom Doxorubicin-Related Cutaneous Toxicity

Introduction: Pegylated liposomal doxorubicin (PLD) is considered to be the single-agent of first choice for patients with recurrent ovarian cancer following paclitaxel/carboplatin-based chemotherapy. However, this drug is associated with a local inflammatory tissue reaction, called palmoplantar erythrodysesthesia (PPE). A new liposomal formulation, known as Liposome Encapsulated Doxorubicin Citrate (LEDC), has been developed in the past decades to limit PPE. In this study we report our experience with LEDC in patients with recurrent ovarian cancer who discontinued doxil due to severe PPE. Methods: The present retrospective study included 43 patients with recurrent ovarian cancer who were treated with LEDC administered at the dose of 50 mg/mq every 3 weeks until disease progression or unacceptable toxicity. Toxicity was graded according to the National Cancer Institute Common Toxicity Criteria Version 3. Response was graded according to Response Evaluation Criteria in Solid Tumors (RECIST). Results: A total of 32 patients completed planned 6 cycles of chemotherapy. A complete response was achieved in 6%, partial response in 20%, stable disease in 37% and progression in 9% of patients. No cutaneous toxicity was reported. Conclusion: LEDC is a well tolerated drug and a valid therapeutic option for patients with ovarian cancer suffering from doxil-related cutaneous toxicity.

Ovarian Carcinoid Tumor with Nodal Metastases: Case Report

Primary ovarian carcinoid tumors are very rare, they represent less than 0.1% of all ovarian cancers. The insular type is the most common, followed by the stromal, trabecular and mucinous types. A woman of 47 years old presented with lower abdominal pain, ultrasound evaluation revealed a voluminous pelvic mass on the right side. The patient underwent debulking surgery, it was diagnosed a carcinoid of the left ovary with prevalent trabecular and partly cribriform and insular pattern. Our patient had periaortic lymph node metastases, in this respect there is no evidence of involvement of lymph nodes for primary ovary, especially in the trabecular form, except for intestinal and pulmonary carcinoids. Therefore, this is the fi rst case of mixed primary ovarian carcinoid, particularly in predominantly trabecular form, with lymph node metastases, as described in the literature.