Francesco Fanfani

A Laparoscopy-Based Score To Predict Surgical Outcome in Patients With Advanced Ovarian Carcinoma: A Pilot Study

BackgroundOur objective was to set up a more objective quantitative laparoscopy-based model in predicting the chances of optimal cytoreductive surgery in advanced ovarian cancer patients.MethodsSixty-four advanced ovarian cancer patients were submitted to both laparoscopy and standard longitudinal laparotomy sequentially, to define the chances of optimal debulking surgery (residual disease ≤1 cm). Three patients could not be evaluated by laparoscopy because of the presence of multiple and tenacious adherences. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated for each laparoscopic parameter. On the basis of the statistical probability of each factor to predict surgical outcome, seven laparoscopic features were selected for inclusion in the final model. Each parameter was assigned a numerical score based on the strength of statistical association, and a total predictive index value was tabulated for each patient. Receiver operating characteristic curve analysis was used to assess the ability of the model to predict surgical outcome.ResultsAfter debulking surgery, 41 (67.2%) of 61 patients were left with optimal residual disease. The presence of omental cake, peritoneal carcinosis, diaphragmatic carcinosis, mesenteric retraction, bowel and/or stomach infiltration, and liver metastases satisfied the basic inclusion criteria and were assigned a final predictive index value of 2. In the final model, a predictive index score ≥8 identified patients undergoing suboptimal surgery with a specificity of 100%. The positive predictive value was 100%, and the negative predictive value was 70%.ConclusionsThe reliability of laparoscopy in assessing the chance of optimal cytoreduction can be improved by using a simple scoring system.

Postoperative pain after conventional laparoscopy and laparoendoscopic single site surgery (LESS) for benign adnexal disease: a randomized trial

OBJECTIVE To compare postoperative pain after laparoendoscopic single-site surgery (LESS) approach with conventional multiaccess laparoscopy (LPS). STUDY DESIGN Prospective randomized trial. SETTING University hospital. PATIENT(S) Benign adnexal disease. INTERVENTION(S) Postoperative pain was measured by using the visual analog scale (VAS) at 20 minutes, 2 hours, 4 hours, and 8 hours after surgery. The need for postoperative rescue doses of analgesia was also recorded. MAIN OUTCOME MEASURE(S) Pain after surgery. RESULT(S) A total of 60 patients were enrolled. Within 8 hours, patients who underwent conventional LPS complained of statistically significant greater postoperative pain at VAS evaluation than those undergoing LESS, both at rest and after Valsalva maneuver, with a higher need for rescue analgesia. CONCLUSION(S) LESS provides an advantage over conventional multiaccess LPS in terms of postoperative pain and need for rescue analgesia, with similar perioperative outcomes.

Prospective validation of a laparoscopic predictive model for optimal cytoreduction in advanced ovarian carcinoma

OBJECTIVE The purpose of this study was to validate the performance of a laparoscopy-based model to predict optimal cytoreduction in advanced ovarian cancer patients. STUDY DESIGN In a consecutive prospective series of 113 advanced ovarian cancer patients, the presence of omental cake, peritoneal and diaphragmatic extensive carcinosis, mesenteric retraction, bowel and stomach infiltration, spleen and/or liver superficial metastasis were investigated by laparoscopy. By summing the scores relative to all parameters, a laparoscopic assessment for each patient (total predictive index value = PIV) has been calculated. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy have been calculated for each PIV. RESULTS The overall accuracy rate of the laparoscopic procedure ranged between 77.3 and 100%. At a PIV >/= 8 the probability of optimally resecting the disease at laparotomy is equal to 0, and the rate of unnecessary exploratory laparotomy is 40.5%. CONCLUSION The proposed laparoscopic model appears a reliable and flexible tool to predict optimal cytoreduction in advanced ovarian cancer.

Laparoscopic Colorectal Resection for Bowel Endometriosis: Feasibility, Complications, and Clinical Outcome

OBJECTIVE To evaluate the short- and long-term outcomes of laparoscopic colorectal resection for endometriosis. DESIGN AND PATIENTS This study included 357 consecutive patients who underwent colorectal resection. We evaluated intraoperative and postoperative complications, symptom outcomes, and long-term follow-up. MAIN OUTCOME MEASURE Three hundred forty-three patients (96.1%) underwent laparoscopic colorectal resection, and radical endometriosis ablation was in 334 patients (93.6%). RESULTS Fourteen (3.9%) required laparoconversion. Median operating time was 300 (range, 85-720) minutes, with a median estimated blood loss of 250 (range, 50-550) mL. Radical endometriosis ablation was achieved in 334 patients (93.6%). Median ileus was 4 (range, 1-8) days, with a median postoperative hospitalization of 8 (range, 3-36) days. Early and late complications were observed in 44 patients (12.3%) and, in 35 of these (79.5%), surgical management was necessary. Median follow-up after colorectal resection was 19.6 (range, 6-48) months. The median preoperative and postoperative dyspareunia scores were 8 (range, 4-10) and 3 (range, 0-10), respectively (P < .04), and the median preoperative and postoperative gastrointestinal tract symptom scores were 7 (range, 2-10) and 2 (range, 0-10), respectively (P < .05). During follow-up, 24 of 286 recurrences (8.4%) were registered. Patients who previously underwent surgery for endometriosis showed a higher risk of recurrence compared with patients undergoing primary surgery (13.2% vs 3.4%; P < .048). CONCLUSIONS Laparoscopic colorectal resection for severe endometriosis is feasible and markedly improved endometriosis-related symptoms. Despite the risk of major postoperative complications, the procedure shows good results in terms of recurrence rate and could be adopted as the primary approach for patients with symptomatic colorectal infiltrating endometriosis.

Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study

OBJECTIVE To evaluate the efficacy of discoid resection for the treatment of deep infiltrating endometriosis and whether it could be considered to be a valid alternative to the rectosigmoid segmental resection. DESIGN Case-control study. SETTING Departments of Obstetrics and Gynecology, Ospedale Sacro Cuore of Negrar, Verona, and Catholic University of the Sacred Heart, Rome, Italy. PATIENT(S) Women with deep infiltrating and intestinal endometriosis divided into study group (48 patients) and control group (88 patients). INTERVENTION(S) All patients underwent laparoscopic endometriosis excision plus discoid rectosigmoid resection (study group) or segmental resection (control group). MAIN OUTCOME MEASURE(S) Short- and long-term outcomes. RESULT(S) In the study group, median operating time was 200 minutes, with a median estimated blood loss of 203 mL. Median ileus was 3 days with a median postoperative hospitalization of 7 days. Early complications were observed in six patients (12.5%), and in two of them (4.16%) a surgical management was necessary. Median follow-up period was 33 months, and five recurrences (10.4%) were registered. In the control group, no significant differences were noticed except for longer operative time, more temporary ileostomy, postoperative fever, and long-term bladder dysfunctions. CONCLUSION(S) Laparoscopic mechanical discoid resection is feasible, markedly improved endometriosis related symptoms, and could be considered as a worthy alternative to classic segmental resection in selected patients.

Laparoendoscopic single-site surgery (LESS) for ovarian cyst enucleation: report of first 3 cases

OBJECTIVE To report the feasibility of ovarian cyst enucleation by using a laparoendoscopic single-site trocar through a transumbilical access. DESIGN Case reports. SETTING Teaching and research hospital. PATIENT(S) Three patients affected by large ovarian cysts. INTERVENTION(S) Enucleation of three large ovarian cysts by using a laparoendoscopic single-site approach with a new multiport trocar and standard laparoscopic instruments. MAIN OUTCOME MEASURE(S) Conversion to a multiaccess standard laparoscopic technique. RESULT(S) No conversion to multiaccess standard laparoscopic technique and no intraoperative or postoperative complications were observed. Mean operative time was 79.6 minutes. All patients were discharged home on day 1. CONCLUSION(S) Laparoendoscopic single-site enucleation of large ovarian cysts with ovary sparing is feasible with standard laparoscopic instruments, safe and effective, with good results in terms of cosmesis and postoperative pain. More clinical data are needed to confirm these advantages compared with standard laparoscopic technique.

Simple conization and lymphadenectomy for the conservative treatment of stage IB1 cervical cancer. An Italian experience.

OBJECTIVES Simple conization represents a plausible treatment scheme for managing stage IA1-2 tumors conservatively. However its curative potential has not been widely exploited as regards stage IB1 lesions. Recent studies suggest that, in selected circumstances, patients with stage IB1 disease undergoing radical hysterectomy could have been safely cured by simple hysterectomy and even by cervical conization. METHODS Patients with stage IB1 cervical cancer desiring conservative management underwent simple conization and pelvic lymphadenectomy in three Italian institutes. RESULTS Thirty-six women received the conservative treatment since 1995 to 2010. Median age was 31 (range 24-40) years and median tumor size was 11.7 mm (range 8-25 mm). Adenocarcinoma was present in 12 cases (33%) and grade 3 neoplasia in 5 (14%). Lymph-vascular space involvement was detected in five patients (14%). Eleven had already a child while two had experienced an early abortion and a fetal loss at second trimester. After a median follow-up of 66 months (range 6-168) only one pelvic lymphnodal relapse was observed. Twenty-one pregnancies occurred in 17 patients and 14 live babies have been born (two preterm at 27 and 32 weeks) while one is ongoing. Three first-trimester miscarriages, one second-trimester fetal loss, an ectopic pregnancy and a termination of pregnancy have been recorded. Five patients decided to undergo hysterectomy after 3-12 years after conservative therapy: in one residual microinvasive adenocarcinoma was found. CONCLUSIONS Cervical conization represents a feasible conservative management of stage IB1 cervical cancer and shows a low risk of relapse, provided that patients are selected carefully. Conization would be suitable to treat stage IB lesions smaller than 15-20mm. with pathologic negative lymphnodes.

Neuropilin-1 expression identifies a subset of regulatory T cells in human lymph nodes that is modulated by preoperative chemoradiation therapy in cervical cancer

We examined the phenotype and function of CD4+ T cells expressing the semaphorin III receptor neuropilin‐1 (Nrp1) in human lymph nodes and peripheral blood. In lymph nodes, Nrp1 identified a small regulatory CD4+ CD25high T‐cell subpopulation (Nrp1+ Treg) that expressed higher levels of Forkhead box P3 (Foxp3) message and protein than Nrp1− Treg, and various molecular markers of activated Treg, i.e. CD45RO, human leucocyte antigen (HLA)‐DR and glucocorticoid‐induced tumour necrosis factor receptor (GITR). Similarly to conventional Treg, Nrp1+ Treg proliferated poorly in vitro, and exerted contact‐dependent in vitro suppression of T‐cell proliferation and cytokine secretion. However, Nrp1+ Treg were more efficient than Nrp1− Treg at inducing suppression. Nrp1 was also expressed on a small subpopulation of CD25int and CD25− CD4+ T cells that expressed more Foxp3, CD45RO, HLA‐DR and GITR than their Nrp1− counterparts. In contrast, in peripheral blood Nrp1 identified a minor CD4+ T‐cell subset that did not display the phenotypic features of Treg lacking Foxp3 expression and marginally expressing CD25. Hence, the function of Nrp1+ CD4+ T cells seemingly depends on their anatomical location. In a previous report, we proposed that Treg may curb the anti‐tumour T‐cell response in cervical cancer. We show here that Treg and Nrp1+ Treg levels dropped in the tumour‐draining lymph nodes of patients with cervical cancer following preoperative chemoradiotherapy in a direct relationship with the reduction of tumour mass, suggesting that suppressor cell elimination facilitated the generation of T cells mediating the destruction of the neoplastic cells left behind after cytotoxic therapy.

A treatment selection protocol for recurrent ovarian cancer patients: the role of FDG-PET/CT and staging laparoscopy.

Objective: To investigate the best diagnostic and staging strategy for recurrent ovarian cancer. Methods: The negative predictive value, specificity, positive predictive value, sensitivity, and accuracy rates of the fluorine-18-fluorodeoxyglucose positive emission tomography computed tomography (FDG-PET/CT) and staging laparoscopy in identifying surgically treatable/untreatable patients are assessed in a consecutive series of 70 recurrent ovarian cancer cases. Moreover, the diagnostic performance of each staging procedure in the evaluation of the number of nodules is analyzed. Results: The negative predictive value of the FDG-PET/CT was 83.3%, whereas the positive predictive value was 76.9%. Specificity was 55.6%, whereas sensitivity was 93.0%. Accuracy rate was 78.6%. Negative predictive value, specificity, positive predictive value, sensitivity, and accuracy rate of staging laparoscopy were 88.9, 64.0, 80.8, 95.0 and 83.1%, respectively. Combined radiological and laparoscopic evaluation showed a negative predictive value of 88.9%, a specificity of 59.3%, a positive predictive value of 78.8%, a sensitivity of 95.3%, and an accuracy rate of 81.4%. The number of nodules identified by FDG-PET/CT corresponded in only 23 patients (40.3%) at laparotomy, whereas 15 of 30 patients were correctly diagnosed (50.0%) by staging laparoscopy. Conclusions: The combination of FDG-PET/CT and staging laparoscopy has a significant effect on the multimodal approach to the population of patients with recurrent ovarian cancer. Such techniques should be considered complementary, because of the potential of each one to identify a different setting of the disease.

Impact of Interval Debulking Surgery on Clinical Outcome in Primary Unresectable FIGO Stage IIIc Ovarian Cancer Patients

Objectives: To report the results of neoadjuvant chemotherapy (NACT) and the impact of interval debulking surgery (IDS) on clinical outcomes of patients considered unresectable at primary surgery. Methods: Retrospective analysis was carried out on 73 consecutive stage IIIc ovarian cancer patients treated with platinum-based NACT followed by IDS. Their clinical outcomes were compared with those of 111 consecutive stage IIIc ovarian cancer patients treated with primary cytoreduction followed by platinum-based adjuvant chemotherapy. Results: Patients who underwent successful IDS had a more favorable prognosis than those who did not in terms of time to progression (TTP) (p = 0.00001), and overall survival (OS) (p = 0.0001). On the other hand, in the group of patients that underwent successful IDS, no differences in survival outcomes were observed between patients with no residual disease and patients with macroscopic residual disease <2 cm after IDS (p = n.s.). Conclusions: NACT followed by successful IDS can achieve good results in terms of survival outcomes in a high percentage of chemoresponsive IIIc ovarian cancer patients classified as unresectable at primary surgery. These results are in fact inferior to those achievable with optimal primary cytoreduction; however, they were quite similar to those seen with suboptimal primary cytoreduction.