Lucia Tortorella

Cytoplasmic expression of estrogen receptor beta (ERβ) predicts poor clinical outcome in advanced serous ovarian cancer.

OBJECTIVE In this study we investigated the prognostic value of estrogen receptor α (ERα), ERβ and progesterone receptor (PR) expression in 58 untreated advanced serous ovarian cancer patients. The study also included 12 macroscopically and histopathologically normal ovaries. MATERIALS AND METHODS Protein expression was evaluated by immunohistochemistry, and antibody staining detected in both the nuclear and cytoplasmic compartments was taken into account. Immunopositivity was analyzed in relation to tumor clinicopathological variables, disease-free survival (DFS), and overall survival (OS). RESULTS Epithelial cells in ovarian cancer tissue showed significantly lower levels of nuclear ERβ and PR, but not ERα, than in normal ovarian tissue. In the case of ERβ, however, while normal ovarian epithelium exhibited almost exclusively strong nuclear staining, ovarian cancer tissue mostly showed cytoplasmic immunopositivity. Nuclear ERα and ERβ expression were not associated with clinical outcome. Conversely, any cytoplasmic ERβ expression was an independent unfavorable prognostic factor for DFS, a finding approaching statistical significance also for OS. These data suggest that, in advanced serous ovarian cancer, cytoplasmic ERβ signaling may be more important for patient survival than its nuclear signaling. In the case of PR, positivity was an independent favorable prognostic factor for DFS. CONCLUSIONS These novel findings, that need to be confirmed in a large prospective trial, suggest that additional prognostic, and possibly therapeutic opportunities may be available in advanced serous ovarian cancer.

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.

Perioperative outcomes of total laparoendoscopic single-site hysterectomy versus total robotic hysterectomy in endometrial cancer patients: A multicentre study

OBJECTIVE To compare the peri-operative outcomes between total laparo-endoscopic single-site (LESS) and robotic approaches for the staging and treatment of early stage endometrial cancer patients. METHODS A multicentre retrospective study involving three Italian gynaecological groups and one American centre. The peri-operative outcomes of LESS and robotic approach were compared in similar groups of patients, with regard to surgical outcomes and intra- and post-operative parameters and complications. RESULTS During the study period, 75 patients submitted to a total LESS hysterectomy and 75 patients received a total robotic hysterectomy. The median operative time - 122 versus 175 min (p=0.0001) - and the estimated blood loss - 50 versus 80 mL (p=0.03) - were slightly more favourable in the LESS group. The intra-operative complications were equally distributed (p=0.99); in the robotic group there were 4 (5.3%) post-operative grade IIIb complications versus 1 (1.3%) in the LESS group (p=0.172). CONCLUSIONS The LESS and robotic approaches both appear reasonable and each may have benefits and limitations depending upon the patient population. Further studies are needed to validate these preliminary conclusions.

Secondary cytoreductive surgery in patients with isolated platinum-resistant recurrent ovarian cancer: A retrospective analysis

OBJECTIVE To analyze the impact of secondary cytoreductive surgery (SCS) on survival outcome in a retrospective series of isolated platinum-resistant recurrent ovarian cancer. METHODS We evaluate a consecutive series of 268 ovarian cancer patients with platinum-resistant relapse. Isolated recurrence was defined as the presence of a single nodule, in a single anatomic site, and was observed in 27 cases (10.1%). In all women the presence of isolated relapse was assessed at radiological evaluation, and surgically confirmed in the SCS group. RESULTS Among the 27 patients with isolated recurrence, 16 (59.3%) received chemotherapy alone, and 11 (40.7%) complete SCS followed by non-platinum based chemotherapy. No significant differences were observed in the distribution of baseline clinico-pathological characteristics, pattern of recurrent disease, duration of PFI, and type of salvage chemotherapy between the two groups. In the SCS group, 6 patients (54.5%) showed isolated peritoneal relapse and 5 women (45.4%) showed isolated lymph nodal recurrence, and were treated with peritonectomy and lymphadenectomy, according with site of relapse. Two post-operative complications (18.2%) occurred: asymptomatic lymphocele and groin wound dehiscence. SCS significantly prolonged median time to first progression (12 months vs 3 months; p-value=0.016), median time to second progression (8 months vs 3 months; p-value=0.037), and post-relapse survival (PRS) (32 months vs 8 months; p-value=0.002). Residual tumor at 1st surgery (X(2)=5.690; p-value=0.017), duration of PFI (X(2)=5.401; p-value=0.020), and complete SCS (X(2)=4.250; p-value=0.039) retains independent prognostic role for PRS in multivariate analysis. CONCLUSIONS SCS prolongs PRS compared to chemotherapy alone in isolated platinum-resistant recurrent ovarian cancer.

A laparoscopic risk-adjusted model to predict major complications after primary debulking surgery in ovarian cancer: A single-institution assessment

OBJECTIVE To develop and validate a simple adjusted laparoscopic score to predict major postoperative complications after primary debulking surgery (PDS) in advanced epithelial ovarian cancer (AEOC). METHODS From January 2006 to June 2015, preoperative, intraoperative, and post-operative outcome data from patients undergoing staging laparoscopy (S-LPS) before receiving PDS (n=555) were prospectively collected in an electronic database and retrospectively analyzed. Major complications were defined as levels 3 to 5 of MSKCC classification. On the basis of a multivariate regression model, the score was developed using a random two-thirds of the population (n=370) and was validated on the remaining one-third patients (n=185). RESULTS Major complication rate was 18.3% (102/555). Significant predictors included in the scoring system were: poor performance status, presence of ascites (>500cm(3)), CA125 serum level (>1000U/ml), and high laparoscopic tumor load (predictive index value, PIV ≥8). The mean risk of developing major postoperative complications was 3.7% in patients with score 0 to 2, 13.2% in patients with score 3 to 5, 37.1% in patients with score 6 to 8. In the validation population, the predicted risk of major complications was 17.8% (33/185) versus a 16.7% (31/185) observed risk (C-statistic index=0.790). CONCLUSION This new score may accurately predict a patients postoperative outcome. Early identification of high-risk patients could help the surgeon to adopt tailored strategies on individual basis.

Cytoplasmic expression of oestrogen receptor beta (ERβ) as a prognostic factor in vulvar squamous cell carcinoma in elderly women.

Zannoni G F, Prisco M G, Vellone V G, De Stefano I, Vizzielli G, Tortorella L, Fagotti A, Scambia G & Gallo D 
(2011) Histopathology 59, 909–917

Beyond sentinel node algorithm. Toward a more tailored surgery for cervical cancer patients

Nowadays cervical cancer is frequently diagnosed at early stage. For these patients lymph node metastasis (LNM) is considered the most important prognostic factor. During the last decade many efforts have been made to reduce rate of complications associated with lymphadenectomy (LND). A great interest has arisen in sentinel lymph node (SLN) biopsy as a technique able to decrease number of LND performed and, at the same time, to assess lymph nodal status. High diagnostic performances have been reached thanks to SLN surgical algorithm. However, despite the efforts, about 25% of these patients undergo at least unilateral LND to meet NCCN recommendations. Data of women with International Federation of Gynecology and Obstetrics stage IA1‐IB1/IIA1 cervical carcinoma were retrospectively collected by six Italian institutions. All patients underwent complete preoperative staging workup and were primarily treated by radical hysterectomy and pelvic bilateral LND. A total of 368 patients with early‐stage cervical cancer were identified. Among them 333 (90.5%) showed no suspicious enlarged nodes at the preoperative magnetic resonance imaging (MRI). In this subset, tumor diameter ≥20 mm was the only independent predictor of LN status (P = 0.003). None of the 106 patients with negative MRI nodal assessment, with squamous and adenosquamous histotype and a tumor diameter less than 2 cm had LNM. Based on these results we propose a new modified SLN surgical algorithm that could safely reduce LND performed in patients with very low‐risk early‐stage cervical cancer.

Locally advanced cervical cancer complicating pregnancy: A case of competing risks from the Catholic University of the Sacred Heart in Rome

A case of stage IB2 cervical cancer at 27 weeks of pregnancy, treated with neoadjuvant chemotherapy followed by radical Cesarean hysterectomy with full pelvic and infra-mesenteric lymphadenectomy, and adjuvant chemo-radiation is described. While she remains without disease, her baby was diagnosed with acute myelogenous leukemia. We highlight the pre-operative work-up, treatment options, safety, feasibility, and outcomes for the mother and her fetus.

Ovarian Cancer Management in the Oldest Old: Improving Outcomes and Tailoring Treatments

Ovarian cancer is the most common cause of death from gynecological cancers in developed countries. It is a common disease of older women at or above 63 years upon diagnosis. Thanks to advance in new treatments, mortality from ovarian cancer has declined in developed countries in the last decade. This decline in mortality rate is unevenly distributed across the age-spectrum. While mortality in younger women has decreased 21.7%, for elderly women it has declined only 2.2%. Even if ovarian cancer is clearly a disease of the elderly, older women are underrepresented in clinical trials, and scant evidence exists for the treatment of women older than 80 years. Moreover, older women are frequently undertreated, receive less chemotherapy and less combination of surgery and chemotherapy, despite the fact that this is considered the optimal treatment modality. This may be mainly due to the lack of evidence and physician’s confidence in the management of elderly women with ovarian cancer. In this review, we focus on the management of older women with ovarian cancer, considering geriatric features tied to this population.