Maria Lucia Gagliardi

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.

Laparoscopic management of ureteral endometriosis in case of moderate-severe hydroureteronephrosis

OBJECTIVE To evaluate prospectively the efficacy of laparoscopic ureterolysis versus ureteroureterostomy in women with ureteral endometriosis. DESIGN Prospective study. SETTING Department of Obstetrics and Gynecology, Ospedale Sacro Cuore of Negrar, Verona, Italy, a tertiary care endometriosis referral center. PATIENT(S) Endometriotic patients with moderate-severe ureter dilatation. INTERVENTION(S) All women underwent laparoscopic endometriosis excision and concomitant laparoscopic ureterolysis, ureteroureterostomy, nephrectomy, or laparotomic ureterocystoneostomy. MAIN OUTCOME MEASURE(S) Clinical outcomes were evaluated. RESULT(S) Fifty-six patients with preoperative or intraoperative evidence of moderate-severe ureter dilatation were enrolled. Dysmenorrhea (91%) and dyspareunia (68%) were the symptoms more frequently reported; only two patients had typical obstructive uropathy pain. In 35 cases, laparoscopic ureterolysis, in 17 laparoscopic ureteroureterostomy, in 2 laparotomic ureterocystoneostomy, and in 2 laparoscopic nephrectomy was performed. 11 out of 35 (31.4%) major complications occurred in the ureterolysis group, and 2 out of 17 (11.7%) in the ureteroureterostomy group. Median follow-up time was 21 months. Ureteral endometriosis recurrence was surgically detected in three patients who underwent conservative ureteral surgery. CONCLUSION(S) Preoperative planning should be rigorous, and complete surgical excision of ureteral endometriosis should be ensured by a team of experts familiar with endometriosis, its multiple manifestations, and its management.

Excisional cone as fertility-sparing treatment in early-stage cervical cancer.

OBJECTIVE To describe a case series of early-stage cervical cancer patients treated with excisional cone instead of radical trachelectomy as fertility-sparing surgery. DESIGN Prospective study. SETTING University hospital. PATIENT(S) Early-stage cervical cancer (International Federation of Gynecology and Obstetrics stage IA2-IB1), age ≤ 45 years, tumor ≤ 20 mm. INTERVENTION(S) Cold-knife conization and laparoscopic pelvic lymphadenectomy. MAIN OUTCOME MEASURE(S) Recurrence and pregnancy rate. RESULT(S) There were 17 patients: 4 (23.5%) IA2, 13 (76.5%) IB1; 12 (70.5%) squamous cell carcinoma, 4 (23.5%) adenocarcinoma, and 1 (6%) glassy cell tumor. Four cases (23.5%) involved lymphovascular space invasion. The median number of lymph nodes removed was 18 (range 13-51). None of the patients received neoadjuvant chemotherapy, and two patients (12%) received three courses of adjuvant chemotherapy. No recurrences were observed after a median follow-up of 16 months (range 8-101 months). Two of five patients (40%) attempting to conceive had a spontaneous pregnancy and delivery. CONCLUSION(S) In selected and informed patients, conization and laparoscopic pelvic lymphadenectomy seems to be feasible as a fertility-sparing surgical approach.

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.

Total Laparoscopic Hysterectomy in Early-Stage Endometrial Cancer Using an Intrauterine Manipulator: Is It a Bias for Frozen Section Analysis? Case-Control Study

STUDY OBJECTIVE To evaluate whether the systematic use of an intrauterine manipulator influences the accuracy of frozen section analysis in early-stage endometrial cancer. DESIGN Case-control study (Canadian Task Force classification II-1). PATIENTS Three hundred fourteen consecutive women with early-stage endometrial cancer. INTERVENTIONS Between January 2004 and December 2009, 314 women with early-stage endometrial cancer underwent staging at laparoscopy (case group) or laparotomy (control group). All women in the case group underwent total laparoscopic hysterectomy using an intrauterine manipulator. MEASUREMENTS AND MAIN RESULTS The positive predictive value of frozen section analysis for myometrial infiltration, histotype, and grade of differentiation was 97.2%, 100%, and 97.2%, respectively. The correct diagnosis rate was of 85.7%. The accuracy of frozen section analysis, rate of correct diagnosis, and rate of tumor vascular invasion did not seem to be significantly modified by systematic use of an intrauterine manipulator for total laparoscopic hysterectomy compared with total abdominal hysterectomy in early-stage endometrial cancer staging. CONCLUSIONS Frozen section analysis of early-stage endometrial cancer is highly accurate, and systematic use of an intrauterine manipulator does not represent a bias for correct evaluation of the specimen.

Learning curve and pitfalls of a laparoscopic score to describe peritoneal carcinosis in advanced ovarian cancer

Objective. To prospectively estimate the agreement between a fellow in training in gynecologic oncology and a senior surgeon performing a laparoscopic score to describe peritoneal carcinosis diffusion in patients with advanced ovarian cancer. Design: Single‐institutional non‐inferiority trial. Setting. University hospital tertiary care center. Population. Ninety consecutive patients with primary advanced ovarian cancer. Methods. The patients underwent staging‐laparoscopy by a fellow in gynecologic oncology and a senior surgeon, sequentially and blindly. Single laparoscopic parameters (omental cake, peritoneal and diaphragmatic carcinosis, mesenteric retraction, bowel stomach infiltration, superficial liver metastasis) and a comprehensive laparoscopic score (PIV) were assessed in each procedure and registered. Main outcome measures. No differences in the score discriminating performance for predicting optimal cytoreduction were observed between fellows’ and seniors’ evaluations. Results. The median number of staging laparoscopies performed by each fellow was 30 (range 28–32). The median score was 6 (0–10) for the fellows and 6 (0–14) for senior surgeons (p=ns). Results were superimposable in 57 of 90 patients (63.3%). Dividing the study period into two blocks, cases 1–45 and cases 46–90, differences were equally distributed over time (16.6 vs. 20%; p=0.9). The area under the curve of the receiver operating characteristic (ROC) curves for the score of fellows and seniors was 0.86 and 0.89, respectively (p=ns). Conclusions. The laparoscopic assessment of peritoneal cancer diffusion according to a laparoscopic score can reliably be carried out by a fellow in gynecologic oncology after 12 months’ experience without significant differences from a senior surgeons assessment.

Successful pregnancy in stage IE primary non-Hodgkin's lymphoma of uterine cervix treated with neoadjuvant chemotherapy and conservative surgery.

Background: Primary non-Hodgkin’s lymphoma involving the uterine cervix is extremely rare with a frequency of 0.008% of all cervical tumors. No standard treatment has been defined for this disease. Case: A 29-year-old Caucasian woman with primary non-Hodgkin stage IE lymphoma of the uterine cervix was treated with neoadjuvant chemotherapy and conservative surgery. Three years after completion of primary treatment, she became pregnant and successfully delivered a full-term healthy baby. Conclusion: This case report supports the data that a conservative strategy consisting of neoadjuvant chemotherapy followed by a uterine-preserving approach represents an adequate option for young highly motivated patients who desire to preserve the childbearing potential.

Narrow-Band Imaging in Laparoscopic Management of Cervical Carcinoma

Peritoneal metastasis detected at initial diagnosis of squamous cell carcinoma of the uterine cervix is extremely rare [1,2]. The presence of peritoneal implants is crucial in the clinical management of cervical carcinoma because it identifies patients suitable to receive systemic chemotherapy. Surgical identification of lesions suspicious for peritoneal implants and histologic confirmation depend on the surgeon’s level of skill and structural characteristics of the implants. Endoscopic biopsy is considered the criterion standard for diagnosis. One method of increasing the predictive value of identified lesions is to enhance the visual markers of neoplastic implants. The neovascularization that is inherent in the pathologic features of neoplastic lesions may be used to enable identification of implants not usually observed using narrow-band imaging (NBI). The NBI system (Olympus Winter & Ibe GmbH, Hamburg, Germany) uses optic image enhancement technology that emphasizes capillary blood vessels and microstructures containing hemoglobin on the mucosal surface. Compared with conventional light of 300 to 700 nm, narrow bands at 415 and 540 nm are strongly absorbed by hemoglobin, which increases the contrast of blood vessels. Thus, microscopic blood vessels not clearly seen under conventional light can be observed. In several studies of gastroscopy, colonoscopy, and bronchoscopy, NBI has been reported as a possible tool for detection of irregular vascular patterns indicative of malignant lesions in the early diagnosis of cancer [3,4]. A recent pilot study described a series of 20 consecutive

Narrow-band imaging in laparoscopic management of recurrent platinum sensitive ovarian cancer.

The recurrence risk for advanced ovarian cancer managed using surgical cytoreduction and adjuvant chemotherapy is 60% to 70% [1]. The standard treatment of recurrent disease is still under debate and depends on patient history and characteristics of the tumor [1,2]. Recently, the role of cytoreductive surgery for platinum-sensitive cancer has been reassessed, and findings indicate that residual tumor is the most valuable determining factor for survival, even in recurrent disease [3]. Preliminary data seem to demonstrate that the addition of hyperthermic intraperitoneal intraoperative chemotherapy (HIPEC) could improve overall survival in these patients [4,5]. Laparoscopic evaluation performed before cytoreductive surgery and HIPEC can be helpful both to obtain a pathologic diagnosis of recurrent disease and to examine the possibility of complete surgical debulking [6]. In particular, the use of narrowband imaging (NBI; Olympus Winter & Ibe GmbH, Hamburg, Germany) is proving to be a good adjunct for laparoscopic evaluation, enabling clarification of the structures observed and, thus, facilitating the diagnosis [7]. Herein we describe our experience with use of NBI during diagnostic laparoscopy in 2 platinum-sensitive patients with recurrent ovarian cancer. Case 1

Investigational agents against platinum-resistant ovarian cancer

Ovarian cancer is still the fourth cause of death by cancer among women and is the most fatal among gynaecological tumours. The goal of treatment for patients with recurrent, platinum-resistant (platinum-free interval < 6 months) ovarian cancer is the palliation of symptoms because no evidence indicates that present therapies may prolong survival in this setting of patients. Successful management of these patients depends on the identification of agents that are not cross-resistant with platinum compounds. The development of molecular biology is providing us with new information on the molecular basis of cancer, its mechanism of initiation and progression, and supply the need of a more patient-tailored therapy where specific tumours are treated with specific drugs. This paper reports and discusses new developments in the treatment of platinum-resistant ovarian cancer patients. The authors present proteomic advances, including the HER kinases, the 26S proteasome and the angiogenesis pathway. The opportunities to change the treatment of ovarian cancer will require creative clinical trial design but the next 10 years promise to be filled with therapeutic advances for patients with ovarian cancer.