Giorgia Monterossi

The expression ratios of estrogen receptor α (ERα) to estrogen receptor β1 (ERβ1) and ERα to ERβ2 identify poor clinical outcome in endometrioid endometrial cancer

The prognostic relevance of estrogen (ER) and progesterone receptor (PR) expression in endometrioid endometrial cancer is still controversially discussed. The present study has focused on the evaluation of the prognostic value of ERα, ERβ1, ERβ2, and PR in this histotype. Specifically, we were interested in evaluating whether the relative level of ER subtype-specific expression (in terms of a ratio ERα/ERβ1 and ERα/ERβ2) would predict clinical outcome better than their absolute levels in patients with endometrioid endometrial cancer. To this end, protein content was assessed by immunohistochemistry in a group of 121 cases and staining was analyzed in relation to clinicopathologic variables, disease-free survival and overall survival. Results obtained have demonstrated that none of the biological markers analyzed possess an independent prognostic role with regard to disease-free survival. Multivariate analysis of overall survival has shown that ERα alone is not an independent prognostic indicator in patients with endometrioid endometrial cancer (hazard ratio [HR]; 0.5; 95% confidence interval [CI], 0.09-3.0; P = .5). On the other hand, an ERα/ERβ1 ratio of 1 or less or an ERα/ERβ2 ratio of 1 or less has proved to be independently associated with a higher risk of death (HR, 6.4 [95% CI, 1.0-40.6; P = .04] and 9.7 [95% CI, 1.1-85.3; P = .04], respectively) along with age, tumor stage, and Ki-67. In conclusion, we report here that the ERα/ERβ1 and ERα/ERβ2 expression ratios are independent prognostic markers of survival in endometrioid endometrial cancer; these findings suggest that phenotyping these interacting markers conjointly may better predict patient survival than each individual marker alone.

Laparoendoscopic Single-Site Surgery (LESS) for Treatment of Benign Adnexal Disease: Single-Center Experience Over 3-Years

STUDY OBJECTIVE To describe the effects of laparoendoscopic single-site (LESS) surgery performed over 3 consecutive years to treat adnexal disease and to report patient perioperative outcomes. DESIGN Retrospective clinical study (Canadian Task Force classification III). SETTING Tertiary care academic medical center. PATIENTS Women undergoing LESS because of a benign gynecologic indication, from January 2009 through December 2011. INTERVENTIONS Women with benign adnexal disease ≤10 cm underwent LESS surgery through a single 1.5- to 2.0-cm umbilical incision. Intraoperative and postoperative outcomes were carefully recorded, including the need for postoperative rescue analgesia. MEASUREMENTS AND MAIN RESULTS One hundred twenty-five patients were enrolled. Median patient age was 49 years, and median body mass index was 23. Surgical procedures included unilateral or bilateral salpingo-oophorectomy and unilateral or bilateral cyst enucleation. Median operative time was 48 minutes. Pain control was optimal, with an average visual analog score of 4/10. Both patients and surgeons were highly satisfied with the cosmetic result, and the cosmetic visual analog score was 9/10 at discharge and at 30 days after surgery. The number of women who underwent unilateral or bilateral salpingo-oophorectomy increased progressively and significantly yearly over the study period (16 vs 23 vs 40; p = .001). Median operative time for unilateral or bilateral salpingo-oophorectomy increased significantly from 2009 to 2010 and 2011 (34 vs 45 and 44 minutes; p = .001), together with median BMI (23 vs 23 vs 25; p = .04). CONCLUSION LESS is a desirable surgical approach in patients with simple adnexal disease.

Laparoscopic vs. open treatment of endometrial cancer in the elderly and very elderly: An age-stratified multicenter study on 1606 women

UNLABELLED Objective To investigate in depth the effect of increasing age on the peri-operative outcomes of laparoscopic treatment for endometrial cancer, compared to open surgery, with stratification of patients according to the different definitions of elderly age used in the literature. METHODS Data of consecutive patients who underwent surgery for endometrial cancer staging at six centers were reviewed and analyzed according to surgical approach (laparoscopic or open), different definitions of elderly and very elderly age (≥65years, ≥75years, ≥80years), and class of age (<65; ≥65-<75; ≥75-80; ≥80years). Multivariable analysis to correct for possible confounders and propensity-score matching to minimize selection bias were used. RESULTS A total of 1606 patients were included: 938 and 668 patients received laparoscopic and open surgery, respectively. With increasing age, fewer patients received laparoscopy (P<0.001 with ANOVA). The percentage of patients who received lymphadenectomy declined significantly in both groups for age ≥80years. Blood transfusions, incidence and severity of post-operative complications, and hospital stay were significantly lower among patients who had laparoscopy both in younger (<65years) and elderly (whether defined as ≥65 or ≥75years) patients, with no effect of age on any of the characteristics analyzed ( ANOVA P>0.05). The same tendency was observed among very-elderly patients (≥80years). Multivariable and propensity score-matched analysis confirmed these findings. CONCLUSIONS Laparoscopy for staging endometrial cancer retains its advantages over open surgery even in elderly and very-elderly patients. Our data strongly suggest that minimally-invasive surgery is advantageous even among subjects ≥80years.

Telelap Alf-X–Assisted Laparoscopy for Ovarian Cyst Enucleation: Report of the First 10 Cases

This prospective single-institutional clinical trial sought to assess the safety and feasibility of laparoscopic benign ovarian cyst enucleation with a novel robotic-assisted laparoscopic system. Here we report a series of 10 patients treated using the Telelap ALF-X system in the first clinical application on patients at the Division of Gynecologic Oncology, Catholic University of the Sacred Heart of Rome. The primary inclusion criterion was the presence of monolateral ovarian cyst without a preoperative assessment suspicious for malignancy. Intraoperative data, including docking time, operative time, estimated blood loss, intraoperative and perioperative complications, and conversion to either standard laparoscopy or laparotomy, were collected. The cysts were removed with an ovary-sparing technique with respect to conservative surgical principles. The median operative time was 46.3 minutes, and patients without postoperative complications were discharged at 1 or 2 days after the procedure. Telelap ALF-X laparoscopic enucleation of benign ovarian cysts with an ovary-sparing technique is feasible, safe, and effective; however, more clinical data are needed to determine whether this approach can offer any other benefits over other minimally invasive surgical techniques.

Laparoendoscopic single-site hysterectomy: Is it safe and feasible?

Purpose of review The goal was to evaluate the safety, feasibility, and reproducibility of total and radical single-site hysterectomy. Recent findings Minimally invasive surgery represents the gold standard for benign and malignant gynecological disease. Laparoendoscopic single-site surgery has emerged as a new technical concept to decrease parietal trauma and improve body image. Laparoendoscopic single-site surgery is not a new essay, but recent developments in surgical technology have resulted in an exponential enlargement of indications. Recently published data showed feasibility, safety, and reproducibility of single-port hysterectomy for benign and malignant gynecological diseases. Summary Laparoendoscopic single-site surgery represents a new challenge in minimally invasive surgery and appears to be feasible and safe to perform in a variety of gynecologic diseases. The aim of this review is to critically analyze the recent literature about single-site hysterectomy.

Elderly and very elderly advanced ovarian cancer patients: Does the age influence the surgical management?

BACKGROUND To examine the surgical treatment and clinical outcome of elderly and very elderly advanced epithelial ovarian cancer patients. METHODS We retrospectively analyzed FIGO stage IIIC-IV ovarian cancer patients, divided in elderly (Group A, >65 and <75 years) and very elderly patients (Group B, ≥ 75 years) treated by primary debulking surgery (PDS) or by interval debulking surgery (IDS) at the Catholic University at Rome and Campobasso, Italy. RESULTS 164 patients were included: 123 (Group A) and 41 (Group B). Complete cytoreduction was achieved in 60 patients (60.6%) in Group A and in 20 patients (62.5%) in Group B (p = 0.75). In the remaining cases, optimal cytoreduction was performed (39 cases (39.4%) in Group A and 12 (37.5%) in Group B; p = 0.75). In Group A complete/optimal debulking was achieved in 53 patients (53.5%) at PDS and in 46 patients (46.5%) at IDS (p = 0.55). In the Group B a higher rate of patients was debulked at IDS with respect to PDS (10 (31.3%) vs. 22 patients (68.7%); p = 0.02). In Group A patients debulked at PDS showed better DFS (p = 0.007) and OS (p = 0.003) with respect to patients submitted to successful IDS, whereas in group B we did not observed any survival difference according to time of cytoreduction. CONCLUSIONS Our data suggest that elderly and very elderly patients may tolerate radical and ultra-radical surgery. These patients should be managed in a gynecologic oncology unit, with prudent but complete approach.

The impact on survival of two different staging strategies in apparent early stage endometrial cancer comparing sentinel lymph nodes mapping algorithm and selective lymphadenectomy: An Italian retrospective analysis of two reference centers

OBJECTIVE The role of lymphadenectomy in endometrial cancer is still uncertain. We aimed to evaluate the survival outcomes of two different strategies in apparent uterine confined disease by comparing sentinel lymph node (SLN) mapping and selective lymphadenectomy (LD). METHODS We retrospectively reviewed women with preoperative stage I endometrial cancer underwent surgical staging with either SLN mapping, or LD in two Italian centers. RESULTS Eight hundred and two women underwent surgical staging for preoperative stage I endometrial cancer were revised (145 Monza; 657 Rome). All patients underwent peritoneal washing, simple hysterectomy with bilateral salpingo-oophorectomy and nodal staging including SLN mapping, or LD. Overall 8229 lymph nodes were removed (1595 in Monza, 6634 in Rome). Pelvic lymphadenectomy was performed in 33.1% and 52.4% in Monza and Rome, respectively (p<0.001). Patients with positive pelvic LN were 16.7% and 7.3%, in SLN and LD groups, respectively (p=0.002). Disease-free survival (DFS) curves did not showed a statistically significant difference between centers and strategies adopted (SLN mapping, LD, SLN+LD) with a HR of 0.87 (95% CI 0.63-2.16; p=0.475). CONCLUSIONS Survival outcomes were similar for both strategies. The SLN strategy allowed to identify a higher rate of stage IIIC1 disease even with a lower median number of lymph node removed in SLN group. Applying a SLN algorithm does not impair the prognosis of endometrial cancer patients. The clinical impact and management of low volume metastasis in high-risk patients should be further clarify.

Learning a new robotic surgical device: Telelap Alf X in gynaecological surgery

To assess the learning curve associated with tele‐assisted surgery.

3 mm Senhance robotic hysterectomy: a step towards future perspectives

In the last two decades, surgical approach for hysterectomy has evolved significantly [1]. On the one hand single-site surgery, minilaparoscopy and the more recent percutaneous approach have led to an increasing search of minimal invasiveness [2]; on the other hand, technology reached the highest expression in robotics [3, 4]. Whereas minimizing laparoscopic access permitted to achieve a further and significant reduction of invasiveness while maintaining surgical adequacy, robotic technology allowed the possibility to overcome common limits of laparoscopic approach extending the advantages of endoscopic surgery to “difficult cases” for whom the only surgical way would have been an extensive laparotomy. Apparently, these two trends deeply diverge from each other. However, technological improvement is constantly redefining the concept of the “minimal” surgical approach. In 2013 the introduction of Telelap ALF-X robotic system (now called SenhanceTM—Transenterix USA) represented a unique innovation in this panorama: robotic technology applied to a pure laparoscopic setting with reusable instruments and 5 mm ancillary trocar [5]. System description Senhance surgical platform is based on three independent robotic arms that are remotely controlled by the Surgeon. From the control unit, named “cockpit”, the surgeon drives the robotic arms by utilizing robotic controls that replicate the laparoscopic manipulators. Immediately below the 3D-HD screen, an infrared sensor, the “eye tracking system”, constantly tracks the surgeon’s eye movement and drives the camera according to the specific point the surgeon is looking at. On each robotic arm, 5 or 3 mm strength and reusable instruments can be hooked and inserted in the peritoneal cavity through standard trocars. A 10-mm balloon trocar is inserted in the umbilicus for the 10-mm 3D-HD camera (Viking System). Once the operative procedure has started, each robotic arm detects the force applied on tissues: these data are processed by the system and translated in “haptic feedback” on the control manipulator. Main characteristics of this innovative technology have been widely investigated in terms of safety and efficacy in gynecological procedures in our Division of Gynecologic Oncology of the Policlinico Agostino Gemelli in Rome [6]. Basing on this premises, looking back to published data in terms of ultra-minimally invasive instrumentation and considering the high versatility of the system, Transenterix recently introduced a totally new CE-marked robotic instrumentation: driven by utilizing surgeons’ requests, a set of 3-mm monopolar reusable robotic instruments was developed to cross the line of both minimally invasive and robotic surgery. Representing an absolute innovation, for the first time in the robotic era, 3 mm instruments are hooked on a robotic platform. From July to September 2017, four patients with indication of hysterectomy with bilateral salpingo-oophorectomy for risk-reducing purpose or premalignant endometrial disease were considered eligible for 3 mm Senhance surgery. IRB approval was obtained and the patients were enrolled after the signing of informed consent. The same surgeon with an experience of more than 100 Senhance procedures performed all surgeries. A standard laparoscopic port placement was adopted for the surgical procedures. * Salvatore Gueli Alletti gueliallettis@gmail.com

Treatment of gynecological disease in obese patient: which role for telelap ALF-X platform?

In the last years, spread of robotic technology allowed the possibility to overcome common limits of laparoscopic approach and determined to offer advantages of endoscopic surgery to ‘‘difficult cases’’ for whom the only surgical way would have been an extensive laparotomy. In gynecological field, robotics gave the possibility to reduce impact of surgery in obese patients. This specific subset of patients represents an increasing number in worldwide statistics [1]. The well-known advantages of endoscopic surgery in obese patients in terms of decreased morbidity and complications [2] together with a maintained surgical efficacy represent the strong points of this approach. With respect to robotics, the clinical benefits are counterbalanced by the elevated cost of acquisition as well as of planned preventative maintenance [3]. Recently introduced in this panorama, the new robotic platform Telelap ALF-X seems to provide feasibility and efficacy in gynecological surgical procedures [4] together with a more acceptable costs/operation due to reusable instruments and conventional 5 mm ports [5] (Figs. 1, 2). In its first clinical experience in the Division of Oncologic Gynecology of the Catholic University of the Sacred Heart of Rome, the system has been widely investigated, both in easier surgical procedures [6] and oncological aspects [7]. Based on these premises, looking back to collected data, we decided to investigate the perioperative outcomes in TELELAP ALF-X-assisted surgical procedures in an obese patient population. From September 2013 to May 2014, 13 obese patients with median BMI 30.48 (range 30.09–35.06) underwent TELELAP ALF-X-surgery for presumed benign or borderline adnexal disease and benign or early stage malignant uterine disease. All patients were enrolled in the context of previously IRB approved trial (A/1517/CE/2012). We divided patients into 2 groups in accordance with the surgical procedure: the Group 1 includes 3 patients submitted to bilateral salpingo-oophorectomy, instead 10 patients submitted to total hysterectomy are comprised in Group 2. For Group 1, the OT has a median value of 19 min (15–24), the EBL was 0 and patients were discharged in day 1. The median operative time for Group 2 was 177 min (69–235): in particular, this record was deeply influenced by pelvic lymphadenectomy performed in 2 cases (OT 215 and 175 min) and by diagnosis of bilateral ovarian masses suspected for borderline ovarian tumor that required salpingo-oophorectomy for frozen section before hysterectomy (OT 235 min). Median EBL of this group was 100 ml (0–100) and median time to discharge was 2 days (1–4). For both groups, no conversion and perioperative complications were registered. Based on these preliminary results, we believe that the role of Telelap Alf-X platform should be deeply investigated in the treatment of gynecological diseases even in a larger population obese patients to establish the real benefits in terms of feasibility safety and clinical outcomes. & C. Rossitto cristiano.rossitto@gmail.com