F. Lecuru

Complications of lymphadenectomy for gynecologic cancer

INTRODUCTION Symptomatic postoperative lymphocysts (SPOLs) and lower-limb lymphedema (LLL) are probably underestimated complications of lymphadenectomy for gynecologic malignancies. Here, our objective was to evaluate the incidence and risk factors of SPOLs and LLL after pelvic and/or aortocaval lymphadenectomy for gynecologic malignancies. METHODS Single-center retrospective study of consecutive patients who underwent pelvic and/or aortocaval lymphadenectomy for ovarian cancer, endometrial cancer, or cervical cancer between January 2007 and November 2008. The incidences of SPOL and LLL were computed with their 95% confidence intervals (95%CIs). Multivariate logistic regression was performed to identify independent risk factors for SPOL and LLL. RESULTS We identified 88 patients including 36 with ovarian cancer, 35 with endometrial cancer, and 17 with cervical cancer. The overall incidence of SPOL was 34.5% (95%CI, 25-45) and that of LLL was 11.4% (95% confidence interval [95%CI], 5-18). Endometrial cancer was independently associated with a lower risk of SPOL (adjusted odds ratio [aOR], 0.09; 95%CI, 0.02-0.44) and one or more positive pelvic nodes with a higher risk of SPOL (aOR, 4.4; 95%CI, 1.2-16.3). Multivariate logistic regression failed to identify factors significantly associated with LLL. CONCLUSION Complications of lymphadenectomy for gynecologic malignancies are common. This finding supports a more restrictive use of lymphadenectomy or the use of less invasive techniques such as sentinel node biopsy.

Diagnostic performance of one-step nucleic acid amplification for intraoperative sentinel node metastasis detection in breast cancer patients.

The purpose of this prospective multicenter study was to assess one‐step nucleic acid amplification (OSNA) for intraoperative sentinel lymph node (SLN) metastasis detection in breast cancer patients, using final histology as the reference standard. OSNA results were also compared to intraoperative histology SLN evaluation and to standard clinicopathological risk markers. For this study, fresh SLNs were cut in four blocks, and alternate blocks were used for OSNA and histology. CK19 mRNA copy number was categorized as strongly positive, positive or negative. Positive histology was defined as presence of macrometastasis or micrometastasis. When discrepancies occurred, the entire SLNs were subjected to histological studies and the node lysates to additional molecular studies. Five hundred three SLN samples from 233 patients were studied. Mean time to evaluate two SLNs was 40 min. Sensitivity per patient was 91.4% (95% CI, 76.9–98.2%), specificity 93.3% (95% CI, 88.6–96.6%), positive likelihood ratio 13.7 and negative likelihood ratio 0.1. Sensitivity was 63.6% for frozen sections and 47.1% for touch imprint cytology. Both methods were 100% specific. Positive histology and positive OSNA were significantly associated with highest clinical stage, N1 status and vascular invasion; and OSNA results correlated with HER2/neu status and benefited patients with negative histology. These findings show that OSNA assay can allow detection of SLN metastasis in breast cancer patients intraoperatively with a good sensitivity, thus minimizing the need for second surgeries for axillary lymph node detection.

Diagnostic value of intraoperative examination of sentinel lymph node in early cervical cancer: a prospective, multicenter study.

OBJECTIVES Sentinel lymph node (SLN) biopsy is a surgical procedure proposed in early cervical cancer. This technique yields the potential interest to reduce the morbidity of complete lymphadenectomy, which could then be performed only in case of positive SLN. Intraoperative examination has a major per-operative role in predicting nodal involvement and preventing a second step procedure. The aim of this study was to assess the diagnostic value of intraoperative examination with frozen section (FS) or imprint cytology (IC) of SLNs in early cervical cancer. METHODS Prospective study in 7 centers (01/2005-06/2007) including patients with stage IA1 and lymphovascular space involvement to IB1 cervical cancer (squamous cell carcinoma, adenocarcinoma or adenosquamous carcinoma). SLNs were detected with a combined method (Tc99m+blue dye) and then removed laparoscopically. Intraoperative examination (FS or IC) was not systematically performed but recommended in case of macroscopical nodal enlargement in 5 centers. Results of intraoperative examination were compared with final histology performed by Hematoxylin-Eosin-Safran staining and immunohistochemistry. The diagnostic value of intraoperative examination was calculated. RESULTS One hundred and thirty-nine patients were analyzed in the study. The combined detection rate was 97.8% per patient, with 454 detected SLNs. One hundred and two patients (73.4%) had an intraoperative examination (97 patients with FS and 5 with IC). Among patients with intraoperative examination, 5 SLNs were positive (all with macrometastasis at final histology), as compared with 22 metastatic nodes at final result. The 17 false negative SLNs were: 4 macrometastasis, 4 micrometastasis and 9 isolated tumor cells. Sensitivity of the intraoperative examination per node was 20.7% [95%CI: 7.8%-45.4%] and the negative predictive value 93.0% [95%CI: 89.0%-95.9%]. CONCLUSIONS Intraoperative examination of SLNs by FS and IC has a poor diagnostic value. This is mainly related to micrometastasis and isolated tumor cells, which are not detected by intraoperative techniques. Other techniques, like new molecular assays, should be investigated to improve intraoperative assessment of SLNs.

Performance of office hysteroscopy and endometrial biopsy for detecting endometrial disease in women at risk of human non-polyposis colon cancer: a prospective study.

The objective of this study was to report the value of diagnostic hysteroscopy and endometrial biopsy for the detection of complex atypical hyperplasia or cancer in asymptomatic human non-polyposis colon cancer (HNPCC) patients. The secondary objective was to evaluate the accuracy of hysteroscopy, using endometrial biopsy as a gold standard. Consecutive patients at risk of HNPCC evaluated between January 1, 1999, and June 30, 2006 were included if they underwent diagnostic hysteroscopy at least once. Patients with a history of hysterectomy and those unwilling to undergo diagnostic hysteroscopy were not included. Yearly follow-up evaluations included diagnostic hysteroscopy, with endometrial biopsy. Hysteroscopic and histologic findings were recorded and compared. We included 62 patients, of whom 13 had mismatch repair gene mutations and 49 met Amsterdam II criteria. Of 125 attempted hysteroscopies, 11 (8%) failed. Hysteroscopy showed normally appearing mucosa in 46 cases, nonmalignant lesions in 65 cases, and possibly malignant lesions in 3 cases with abnormal uterine bleeding. Endometrial biopsy was attempted in 116 cases and failed in 12 (10%). Three cases each of simple hyperplasia and of cancer were diagnosed. No preinvasive or invasive lesions were found in asymptomatic women. When compared to endometrial biopsy, sensitivity of hysteroscopy was 100% for the detection of hyperplasia or cancer. No cases of cancer were diagnosed in asymptomatic patients in our study. However, diagnostic hysteroscopy ensured the diagnosis of endometrial adenocarcinoma in HNPCC women with bleeding. Nevertheless, usefulness and optimal modalities of screening remain to be determined.

Morbidity of diaphragmatic surgery for advanced ovarian cancer: Retrospective study of 148 cases

BACKGROUND Treatment of Advanced Ovarian Cancer (AOC) includes surgery with complete cytoreduction, one of the strongest prognostic factors. To achieve complete cytoreduction, diaphragmatic surgery is often required. There is currently a lack of information in the literature regarding the morbidity and impact of this type of surgery. The aim of this study is to report specific pulmonary morbidity and overall morbidity associated with diaphragmatic surgery in patients with AOC. MATERIALS AND METHODS We conducted a multicentric (6 centres), retrospective study that included 148 patients operated on between 2004 and 2008. Patient characteristics, surgical course and postoperative complications were collected. RESULTS The complete cytoreduction rate was 84%. The surgery was categorised by timing as initial, interval or recurrence surgery in 38%, 51% and 11% of patients, respectively. In 69% of patients, one or more postoperative complications occurred: pulmonary complication (42%), digestive fistula (7%) or lymphocyst (18%). The pulmonary complications were pleural effusion (37%), pulmonary embolism (5%), pneumothorax (4%) and pulmonary infection (2%). These complications required revision surgery, pleural evacuation, or lymphocyst evacuation in 13%, 14%, and 11% of the cases, respectively. Postoperative mortality was 3%. Risk factors for pulmonary complications were the addition of extensive upper surgery to the diaphragmatic surgery (p = 0.014) and the size of the diaphragmatic resection (p = 0.012). CONCLUSIONS Diaphragmatic surgery achieved complete removal of the tumour but resulted in pulmonary complications in addition to complications of radical surgery.

La biopsie du ganglion sentinelle dans les cancers de l’endomètre est-elle faisable ?: Résultats sur 26 cas

OBJECTIVES: To evaluate detection rate, topography and false negatives of sentinel lymph node in endometrial cancer. MATERIAL AND METHODS: Twenty-six patients were included. Lymphoscintigraphy was performed the day before surgery. Preoperative detection of the sentinel lymph node was performed with cervical blue dye injection and a gamma probe. Separate pathology examinations were performed for sentinel and non-sentinel lymph nodes. Sentinel lymph nodes were examined with hematoxylin-eosin-safran stain, and immunohistochemistry if negative. RESULTS: Twenty-six patients had a positive lymphoscintigraphy. Preoperative detection was successful in 21 patients (80.8%): the detection rate with isotopic method, 19 cases (73.1%), was superior to the dye detection, 15 cases (57.7%). No isolated lombo-aortic sentinel lymph nodes were observed, and all sentinel lymph nodes were in the ilio-obturator region. Seven patients presented lymphatic spread, and 4 of them had at least one sentinel node. There was one micrometastasis in sentinel node, associated with isolated tumoral cells in pelvic lymphadenectomy. There was no false negative of sentinel node. CONCLUSION: The biopsy of sentinel lymph node is a feasible procedure in endometrial cancer. There was one micrometastatic sentinel node. However there was no isolated lomboaortic sentinel lymph node in this study.

Postoperative lymphocysts after lymphadenectomy for gynaecological malignancies: preventive techniques and prospects

Postoperative lymphocyst formation is an insufficiently recognised complication of lymphadenectomy for gynaecological malignancies. Lymphocysts are collections of lymph organised into cysts that develop in contact with lymphadenectomy compartments. There has been considerable debate about the relevance of lymphocyst prevention using surgical or pharmacotherapeutic methods. Here, we review the available studies about the impact of these methods on the incidence of lymphocysts. This review suggests that several techniques may decrease the incidence of lymphocysts when used in combination. On a literature basis, the peritoneum should be left open over the lymphadenectomy sites at the end of the procedure and drains should not be placed at the end of the procedure. Omentoplasty should be encouraged and further studies are needed to assess the potential benefits of new energies. Postoperative octreotide therapy seems beneficial but the role of this drug in pelvic oncological surgery remains to be determined.

Prise en charge des masses annexielles organiques : résultats d'une enquête de pratique

OBJECTIVES The aim of this study was first to describe the adnexal masses diagnoses and their management and secondly to assess the oncological relevance of these strategies. PATIENTS AND METHODS A prospective multicentric observational study of organic adnexal masses was conducted between June and November 2005. All patients presenting an organic adnexal tumor and for which a definitive histological diagnosis was subsequently available were eligible. Baseline characteristics, mode of discovery, preoperative assessment, peroperative findings, surgical treatment and pathological findings were collected. RESULTS Among the 278 patients treated for an adnexal mass during the study-period, 166 were included. Mean age was 42.8 years with a 25.3% menopause rate. The radiological assessment comprised an ultrasound examination in 98.8% of cases and an MRI in about one-fourth. The CA 125 marker was measured in half the patients and the carcinoembryonic antigen (CEA) marker in 19.9%. In all, 83.1% of tumors were found benign, 12.7% were malignant and 4.2% were borderlines on definitive histological examination. The surgical procedure comprised a cystectomy in 88 cases and an adnexectomy in 64 cases. Among those treated by cystectomy, one borderline tumor was found, whereas in those treated by adnexectomy, five borderline and 12 malignant masses were discovered. Peroperative conversion rates were 16% and 50% in borderline and malignant tumors. Accidental rupture of the cyst occurred in 29% of cases. A minimal preoperative assessment was defined, based upon the dimensions of the tumor and the dosage of at least one marker. These minimal criteria were met in only 28% of initial assessments. DISCUSSION AND CONCLUSION Ovarian borderline tumors and carcinomas are an important contingent of this study (16.9%). Twenty percent of them are diagnosed in an emergency situation. The management observed in this study is adapted to benign lesions. On the other hand, the rate of inappropriate procedures as well as incomplete staging in case of borderline or carcinomas is quite high.

Laparoscopy vs robotics in surgical management of endometrial cancer: comparison of intraoperative and postoperative complications.

STUDY OBJECTIVE To compare the rates of intraoperative and postoperative complications of robotic surgery and laparoscopy in the surgical treatment of endometrial cancer. DESIGN Unicentric retrospective study (Canadian Task Force classification II-2). SETTING Tertiary teaching hospital. PATIENTS The study was performed from January 2002 to December 2011 and included patients with endometrial cancer who underwent laparoscopic or robotically assisted laparoscopic surgical treatment. Data collected included preoperative data, tumor characteristics, intraoperative data (route of surgery, surgical procedures, and complications), and postoperative data (early and late complications according to the Clavien-Dindo classification, and length of hospital stay). Morbidity was compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS The study included 146 patients, of whom 106 underwent laparoscopy and 40 underwent robotically assisted surgery. The 2 groups were comparable in terms of demographic and preoperative data. Intraoperative complications occurred in 9.4% of patients who underwent laparoscopy and in none who underwent robotically assisted surgery (p = .06). There was no difference between the 2 groups in terms of postoperative events. CONCLUSION Robotically assisted surgery is not associated with a significant difference in intraoperative and postoperative complications, even when there were no intraoperative complications of robotically assisted surgery.

Contribution of lymphoscintigraphy to intraoperative sentinel lymph node detection in early cervical cancer: Analysis of the prospective multicenter SENTICOL cohort

PURPOSE To evaluate the contribution of preoperative lymphoscintigraphy to intraoperative lymphatic mapping (ILM) in early cervical cancer METHODS We conducted an ancillary analysis of the multicenter prospective SENTICOL study in early cervical cancer. Radiocolloid was injected intracervically on the day before (long protocol) or morning of (short protocol) surgery, lymphoscintigraphy was performed, and the results of a centralized image review were communicated to the surgeons. ILM was performed on combined radioactivity/patent blue detection. Sentinel lymph nodes (SLNs) were electively sampled before routine bilateral pelvic lymphadenectomy by laparoscopy. RESULTS Of 139 patients in the modified intention-to-diagnose analysis, 114 had centrally reviewed lymphoscintigrams, which showed 352 SLNs in 100 patients. Lymphoscintigraphy and ILM detection rates were 87.8% and 97.8%, respectively. Agreement between lymphoscintigraphy and ILM was low for the number of SLNs (κ=0.23; -0.04; 0.49) and bilateral SLNs (κ=0.36; 0.2; 0.52). No patient without SLNs by ILM had SLNs by lymphoscintigraphy. Lymphoscintigraphy identified substantial proportions of unusual drainage pathways. No patients with metastatic nodes had SLNs by lymphoscintigraphy but not by ILM in the relevant territory. In 1 of the 2 patients with false-negative SLN results, SLNs were bilateral by lymphoscintigraphy and unilateral by ILM. CONCLUSION Although the detection rate was lower by lymphoscintigraphy than by ILM, the substantial proportions of SLNs in unusual territories provided valuable guidance for the surgical exploration. Awareness of the limited agreement between lymphoscintigraphic and surgical detection might help surgeons decrease the false-negative rate.