Giovanni Favero

Invasive cervical cancer during pregnancy: laparoscopic nodal evaluation before oncologic treatment delay.

INTRODUCTION Cervical cancer is the most frequently encountered malignancy during pregnancy. Presence of nodal metastasis is the most important negative prognostic factor and its assessment represents a crucial parameter to decide if pregnancy can safely continue. We describe the results of 18 pregnant patients with cervical cancer who had their nodal status proved by means of laparoscopy. MATERIAL AND METHODS Eighteen patients with cervical cancer who underwent laparoscopic pelvic lymphadenectomy during pregnancy at Charité-University Berlin and Friedrich-Schiller-University Jena between 1999 and 2010 were analyzed retrospectively. RESULTS The mean age at diagnosis was 32 years (26-40) and gestational age between 6 and 23 weeks of pregnancy. The following FIGO stages of cervical cancer were treated: 1a1 for two women, 1a2 for one woman, 1b1 for thirteen women, 1b2 for one woman and 2a for one woman. The histological type was squamous carcinoma in nine cases and adenocarcinoma also in nine cases. All laparoscopic procedures were successfully completed; there was no surgery-associated mortality, morbidity, or conversion to laparotomy. Additionally, there were no complications for either mother or child related to the general anesthesia. The mean number of lymph nodes removed was 17 (6-46). Definitive cancer treatment was delayed for fourteen out of eighteen patients until delivery with an average delay interval of 17 (9-28) weeks. Lymph nodes were positive in 16% of the cases (3/18) and these patients received immediate cancer treatment. One patient decided to interrupt the gestation before delivery despite negative lymph nodes. Fourteen patients reached fetal maturity and gave birth to healthy babies by caesarean section. All patients are alive without evidence of disease at a mean follow-up time of 38 (5-128) months. CONCLUSION Laparoscopic pelvic lymphadenectomy during pregnancy is feasible and safe. Results suggest that in patients with cervical cancer complicated by pregnancy a planned delay of oncologic treatment can be a safe option after tumor metastasis to lymph nodes has been histopathologically ruled out.

Laparoscopic approach for correction of chylous fistula after pelvic and paraaortic lymphadenectomy.

Chylous fistula is an uncommon but challenging complication after lymphadenectomy for treatment of gynecologic cancers. Its presence contributes substantially to increased morbidity and may retard the onset of adjuvant therapies. Treatment options include dietary modifications or surgical intervention. A 68-year-old woman with renal insufficiency developed chylous ascites after pelvic und para-aortic laparoscopic lymph node dissection followed by chemoradiation for treatment of class IIb cervical cancer. Conservative treatment failed, and the patient underwent laparoscopic exploration. The leakage was identified near the cisterna chyle, and was closed with sutures. There was no evidence of recurrence after 2-month follow-up. This case demonstrates successful laparoscopic management of chylous ascites after para-aortic lymphadenectomy and chemoradiation, using suturing.

Laparoscopic Pelvic Lymphadenectomy in a Patient with Cervical Cancer Stage Ib1 Complicated by a Twin Pregnancy

Cervical cancer is the most frequently observed malignancy during pregnancy. The presence of nodal metastasis is the most important negative predictor factor, and its assessment is crucial in deciding whether the pregnancy can safely continue. To our knowledge, this is the first report of a twin pregnancy complicated by cancer of the uterine cervix that was successfully treated with laparoscopic pelvic lymphadenectomy and subsequently with neoadjuvant chemotherapy. A 35-year-old woman, gravida 2, para 1, with a dichorionic-diamniotic twin pregnancy underwent laparoscopic staging of the pelvic lymph nodes at 17 weeks of gestation. Cervical adenocarcinoma, grade 2, stage 1b1 with lymphovascular space invasion was diagnosed. Nineteen negative nodes were removed, and the patient was counseled to continue the pregnancy. On the basis of tumor size and detection of lymphovascular space invasion, cisplatin as neoadjuvant chemotherapy was administered until week 32 of gestation, when a cesarean section delivery was performed, along with radical hysterectomy. No complications to the neonates or to the mother due to the therapy were observed. This case demonstrates the safety of operative nodal staging during gestation, even in a twin pregnancy. Exclusion of nodal metastasis may improve oncologic outcomes, and neoadjuvant chemotherapy should be administered when indicated.

Laparoscopy for differential diagnosis of a pelvic mass in a patient with Mayer-Rokitanski-Küster-Hauser (MRKH) syndrome.

OBJECTIVE To report a rare case of a myoma simulating a pelvic tumor in a patient with Mayer-Rokitanski-Küster-Hauser (MRKH) syndrome. The rudimentary uterus may develop fibroids, and this event can lead to problems in differential diagnosis, especially if no vaginal reconstruction has been carried out. DESIGN Case-report. SETTING University hospital. PATIENT(S) A 39-year-old patient with MRKH syndrome presented with a solid pelvic mass 9 cm in diameter on ultrasound and magnetic resonance imaging that could not be differentiated between fibroid and ovarian tumor. INTERVENTION(S) The patient was laparoscopically operated, and a fibroid of the right uterine residual was detected and removed. RESULT(S) Histology confirmed a benign leiomyoma. CONCLUSION(S) In patients with MRKH syndrome, laparoscopy allows analysis of the origin of a solid pelvic tumor and its removal. Especially in patients without vaginal reconstruction, laparoscopy may be superior to imaging techniques.

Uncommon synchronous association between ovarian carcinoma and gastrointestinal stromal tumor: a case study and literature review.

BACKGROUND The association of gastrointestinal stromal tumors (GIST) and other cancers is well known, but its synchronous occurrence with gynecological malignancies is very uncommon. Usually, the diagnosis is accidentally established. We describe a patient with GIST and concurrent ovarian cancer and discuss the clinical implications of this finding. CASE REPORT A 64-year-old woman with a prior diagnosis of ovarian cancer developed a second recurrence after having undergone two operations and adjuvant chemotherapy. While tumor debulking was performed, a small, nonsuspicious lesion was removed from the greater curvature of the stomach. Histology revealed a GIST. CONCLUSION The association of GIST and ovarian cancer is a rarity and its synchronicity may alter the oncological prognosis and therapy of the patient.

Correction of iatrogenic injury of the obturator nerve during pelvic laparoscopic lymphadenectomy by the use of sural nerve grafts

Highlights • Intraoperative injury of the obturator nerve is not an infrequent complication of gynecological surgeries.• This injury can occur in association with pelvic lymphadenectomy for uterine or cervical cancer.• This manuscript demonstrates an alternative technique for the obturator nerve repair, when primary end to end anastomosis is not possible.

Neoadjuvant chemotherapy in second trimester pregnant patients with cervical cancer: First study on in vivo concentrations of cisplatinum in fetal and maternal compartments.

5104 Background: Cervical cancer in the second trimester of pregnancy is rare but decision for termination or delay of pregnancy is always a challenge and multidisciplinary cooperation and consultation is mandatory. Platinum-based chemotherapy is recommended to prevent cancer progression during waiting time for fetal maturity but knowledge about passage of platinum through placenta is very limited. Methods: Between 5/2008 and 1/2010 six consecutive patients with cervical cancer diagnosed in second trimester underwent (re-)conisation and/or pelvic laparoscopic lymphadenectomy. In consent with the patients delay of pregnancy in combination with neoadjuvant chemotherapy was performed because of local residual tumor, high-risk situation or advanced disease. After 3 cycles (one patient 2) of cisplatin chemotherapy caesarean section together with radical (1× simple) hysterectomy was performed not less than 32 week of gestation. At the time of delivery synchronous samples from maternal blood, umbilical cord bloo...