Gloria Salvo

Sensitivity and negative predictive value for sentinel lymph node biopsy in women with early-stage cervical cancer

OBJECTIVE The role of sentinel lymph node (SLN) biopsy alone for staging of early-stage cervical cancer remains controversial. We aimed to determine the validity of this technique in women with early-stage cervical cancer. METHODS We retrospectively reviewed women with early-stage cervical cancer who underwent SLN mapping followed by complete pelvic lymphadenectomy as part of initial surgical management from August 1997 through October 2015. All modes of surgical approach were included. Lymphatic mapping was performed using blue dye, technetium-99m sulfur colloid (Tc-99), and/or indocyanine green (ICG). We determined SLN detection rates, sensitivity and negative predictive value. RESULTS One hundred eighty-eight patients were included, and 35 (19%) had lymph node metastases. At least one SLN was identified in 170 patients (90%), and bilateral SLNs were identified in 117 patients (62%). The majority of SLNs (83%) were found in the pelvis. There was no difference in detection rates between mapping agents, surgical approach, patients with and without prior conization or between patients with tumors <2cm and ≥2cm. The detection rate for bilateral SLNs was significantly lower in women with body mass index (BMI)>30kg/m2 than in women with lower BMI (p=0.03). Metastatic disease in sentinel nodes was detected by H&E staining in 78% of cases and required ultrastaging/immunohistochemistry in 22% of cases. Only one patient had a false-negative result, yielding a sensitivity of 96.4% (95% CI 79.8%-99.8%) and negative predictive value of 99.3% (95% CI 95.6%-100%). The false-negative rate was 3.6%. CONCLUSIONS In these women with early-stage cervical cancer, SLN biopsy had very high sensitivity and negative predictive value. We believe it is time to change the standard of care for women with early-stage cervical cancer to SLN biopsy only.

A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs

Enhanced recovery after surgery (ERAS) programs aim to hasten functional recovery and improve postoperative outcomes. However, there is a paucity of data on ERAS programs in gynecologic surgery. We reviewed the published literature on ERAS programs in colorectal surgery, general gynecologic surgery, and gynecologic oncology surgery to evaluate the impact of such programs on outcomes, and to identify key elements in establishing a successful ERAS program. ERAS programs are associated with shorter length of hospital stay, a reduction in overall health care costs, and improvements in patient satisfaction. We suggest an ERAS program for gynecologic oncology practice involving preoperative, intraoperative, and postoperative strategies including; preadmission counseling, avoidance of preoperative bowel preparation, use of opioid-sparing multimodal perioperative analgesia (including loco-regional analgesia), intraoperative goal-directed fluid therapy (GDT), and use of minimally invasive surgical techniques with avoidance of routine use of nasogastric tube, drains and/or catheters. Postoperatively, it is important to encourage early feeding, early mobilization, timely removal of tubes and drains, if present, and function oriented multimodal analgesia regimens. Successful implementation of an ERAS program requires a multidisciplinary team effort and active participation of the patient in their goal-oriented functional recovery program. However, future outcome studies should evaluate the efficacy of an intervention within the pathway, include objective measures of symptom burden and control, study measures of functional recovery, and quantify outcomes of the program in relation to the rates of adherence to the key elements of care in gynecologic oncology such as oncologic outcomes and return to intended oncologic therapy (RIOT).

Role of Video-Assisted Thoracoscopy in Advanced Ovarian Cancer: A Literature Review.

Abstract Tools that accurately predict the presence of metastatic ovarian cancer in the pleura are limited. Thus, we sought to summarize the current literature on video-assisted thoracoscopic surgery (VATS) and its applicability in patients with advanced ovarian cancer. A total of 187 patients with suspected ovarian cancer who underwent the VATS procedure were identified for this analysis. The median patient age was 59.4 years (range, 20.3–83 years). The median operative time for VATS was 32 minutes (range, 5–65 minutes). In 89 patients (48%), VATS revealed macroscopic disease in the pleural cavity. After VATS, 44 patients underwent neoadjuvant chemotherapy, and the remaining 143 patients underwent primary cytoreductive surgery. Video-assisted thoracoscopic surgery led to a change in disease stage or management in 76 patients (41%). Among patients with pleural effusions, VATS revealed pleural disease in 57% of patients, and 73% of patients with positive pleural cytology had evidence of pleural disease at the time of VATS. In addition, 23.5% of patients with negative pleural cytology had evidence of pleural disease at the time of VATS. Prospective trials are needed to accurately evaluate the impact of VATS on disease-free and overall survival in patients with advanced ovarian cancer. Video-assisted thoracoscopic surgery can help determine which patients are ideal candidates for surgical cytoreduction.

Simple trachelectomy with pelvic lymphadenectomy as a viable treatment option in pregnant patients with stage IB1 (≥2 cm) cervical cancer: Bridging the gap to fetal viability

OBJECTIVE Cervical cancer is the most common gynecologic cancer in pregnancy. This study aims to evaluate simple trachelectomy and pelvic lymphadenectomy in patients with stage IB1 (≥2 cm) cervical cancer wishing to maintain their pregnancy. METHODS We included patients with stage IB1 (≥2 cm) cervical cancer who underwent simple trachelectomy and minimally invasive pelvic lymphadenectomy during pregnancy from January 2004 to August 2016. Data analysis included demographics, perioperative, obstetrics, and oncologic outcomes. RESULTS A total of 5 patients were included. Median age was 30 years (range; 26-38). Median gestational age (GA) at diagnosis was 12 weeks (range; 7-18) and at treatment intervention 16.5 weeks (range; 12-19). Histologic subtypes included: adenocarcinoma (3 patients) and squamous cell carcinoma (2 patients). Median tumor size by clinical exam was 27 mm (range; 20-40), grade 2 (range; 2-3) and depth of invasion 10 mm (range; 1.5-12). All patients underwent laparoscopic (1) or robotic (4) pelvic lymphadenectomy followed by vaginal simple trachelectomy. Median operative time was 193 min (range; 155-259), estimated blood loss 100 ml (range; 50-550) and length of stay 2 days (range; 1-3). There were no intraoperative or postoperative complications (<30 days). Median number of lymph nodes removed was 14 (range; 5-15). One patient had bilateral microscopic positive nodes. The median gestational age at delivery was 39 weeks (range; 28-40.6). After median follow-up of 75 months (range; 18-168), all patients are alive without disease. CONCLUSION Simple trachelectomy with pelvic lymph node dissection may be a safe option in pregnant patients with stage IB1 (>2 cm) cervical cancer wishing to maintain their pregnancy.

Bowel surgery in an Enhanced Surgical Recovery Programme (ESRP) for gynaecologic surgery: Is recovery still enhanced or do we need to take a step back?

Objectives: The aim of this study was to assess the impact of ERAS approach (“fluid restrictive & drainless”) on open liver resections for HCC comparing their outcome with open resections in pre-ERAS period and with laparoscopic surgery. Methods: 207 patients undergoing minor liver resection for HCC were divided into three groups: Group A, open minor resections in pre-ERAS period (95 patients); Group B, laparoscopic ERAS resections (55 patients); Group C, open ERAS resections (57 patients). Results: Blood loss was lower in group C and B compared with group A. Postoperative morbidity was 26.5% in group A, 16.3% in group B and 12.1% in group C (p<0.05). Ascites was less frequent in group B (7.5%) and C (6.2%) compared with group A (12%). Median time for functional recovery in groups B (3 days) and C (3 days) was shorter compared with group A (5 days). Conclusion: The laparoscopic approach was associated with reduced blood loss and postoperativemorbidity. In patients who are not candidates to minimally-invasive approach, ERAS management seems to be associated with a reduction in blood loss and postoperative morbidity. Results achieved in this group of patients were more similar to those of laparoscopy than to pre-ERAS open surgery. Disclosure of interest: None declared.

Implementation of an Enhanced Surgical Recovery Programme (ESRP) in gynaecologic oncology: Has the development of a preoperative order set improved compliance for preventive analgesia and deep venous thromboembolic (DVT) prophylaxis?

Javier D. Lasala , Jagtar Singh Heir , Gabriel E. Mena , Alpa M. Nick , Larissa A. Meyer , Maria D. Iniesta , Mark F. Munsell , Gloria Salvo , Juan P. Cata , Ifeyinwa Ifeanyi , Vijaya Gottumukkala , Katherine E. Cain , Pedro T. Ramirez . Anaesthesiology, University of Texas MD Anderson Cancer Center, Houston, United States; Gyn Onc & Reproductive Med, University of Texas MD Anderson Cancer Center, Houston, United States; Biostatistics, University of Texas MD Anderson Cancer Center, Houston, United States; 4 Pharmacy Clinical Programs, University of Texas MD Anderson Cancer Center, Houston, United States