Stefano Basile

Secondary Cytoreductive Surgery in Patients with Platinum-Sensitive Recurrent Ovarian Cancer

ABSTRACTBackgroundSecondary surgical cytoreduction (SCR) represents a promising therapeutic strategy for patients affected by ovarian cancer disease recurrence. The aim of this prospective observational trial was to analyze the role of SCR in patients with platinum-sensitive ovarian cancer.MethodsPatients with platinum-sensitive ovarian cancer underwent SCR by a single surgical team. Clinical and oncologic data were prospectively recorded. A total of 47 patients underwent SCR from 1999 to 2003.ResultsThe mean operating time was 210 minutes, and mean blood loss was 500 mL. The most frequent surgical procedures carried out were splenectomy, lymphadenectomy, bowel resection, and extensive peritonectomy. Optimal cytoreduction was achieved in 41 patients. Thirty-seven patients had no visible tumor at the end of SCR. Overall median survival was 49 months. Patients who achieved optimal residual disease had a median survival of 61 months, whereas patients who had residual disease >1 cm had a median survival of 19 months.ConclusionsPositive CA-125 (cancer antigen 125) was identified as a negative prognostic factor at multivariate analysis. After careful selection, optimal cytoreduction can be achieved in most patients who are subjected to SCR with acceptable morbidity. Residual tumor and CA-125 represent the most important prognostic factors.

Continent urinary diversion and low colorectal anastomosis after pelvic exenteration. Quality of life and complication risk

INTRODUCTION Pelvic exenteration is one of the most destructive gynecologic operations performed on an elective basis, with consequent detrimental effects on the quality of life. The use of reconstructive surgery has significantly improved the quality of life of women undergoing this type of procedure. In this paper we review our experience with continent urinary diversion (Miami Pouch) and low colorectal anastomosis at the Division of Gynecologic Oncology of the University of Miami. METHODS Patients who underwent creation of the continent urinary diversion Miami Pouch from 1988 to 1997 and supralevator pelvic exenteration with low colorectal resection and primary anastomosis from 1990 to 1997 have been included in this study. Management of complications, with particular emphasis on the conservative treatment, has been reviewed in detail for each patient. Open surgery and conservative treatment have been compared. Analysis of complications in irradiated and nonirradiated patients was performed. RESULTS 77 patients who underwent creation of the Miami Pouch entered this study. Forty patients underwent total pelvic exenteration, and 37 patients underwent posterior exenteration. The most common urinary complications were ureteral stricture/obstruction (22.1%), difficult catheterisation (19.5%) and pyelonephritis (16.9%). Conservative management strategies were successfully used in 80% of the complications. Analysis of breakdown and fistula formation after low colorectal anastomosis was performed on 77 patients. Thirty-five percent of the irradiated patients developed anastomotic breakdown or fistulas, while the occurrence of this type of complications was only 7.5% in the nonirradiated group. CONCLUSIONS Reconstructive procedures after pelvic exenteration present a significant risk of complications, especially in irradiated patients. Most of the complications related to the creation of continent urinary diversion can safely be treated conservatively. Low colorectal anastomosis carries an acceptable risk of complications in nonirradiated patients, but the risk in irradiated patients is very high, therefore, detailed patient selection and extensive counselling in these groups of patients is mandatory.

Secondary analyses from a randomized clinical trial: age as the key prognostic factor in endometrial carcinoma

OBJECTIVE The purpose of this study was to explore in greater depth the outcomes of the Italian randomized trial investigating the role of pelvic lymphadenectomy in clinical early stage endometrial cancer. In the attempt to identify the patients with poorer prognosis, the impact of age and body mass index were also thoroughly investigated by cancer-specific survival (CSS) analyses. STUDY DESIGN Survival outcomes of trial patients were analyzed in relation to age (≤65 years and >65 years) in the 2 arms (lymphadenectomy and no lymphadenectomy) and in the whole population of the trial. RESULTS Univariate and multivariable analyses of CSS and overall survival (OS) of patients showed that age >65 years is a strong independent poor prognostic factor (5-y OS 92.1% and 78.4% in ≤65 years and >65 years patients, respectively, P < .0001; 5-y CSS 93.8% and 83.5% in ≤65 years and >65 years patients, respectively, P = .003). Among women ≤65 years, node negative patients had 94.4% 5-y OS and 96.3% 5-y CSS vs 74.3% 5-y OS and 74.3% 5-y CSS for node positive patients (P = .009 and P = .002, respectively), while among women >65 y, node negative patients had 75.7% 5-y OS and 83.6% 5-y CSS vs 74.1% 5-y OS and 83.3% 5-y CSS for node positive patients (P = .55 and P = .58, respectively). Univariate and multivariable survival analyses in the whole trial population showed that older age, and higher tumor grade and stage were significantly associated to a worse prognosis. CONCLUSION Older women faced an intrinsic poorer survival whether or not they underwent lymphadenectomy, and, unexpectedly, irrespective of the presence of nodal metastasis. Only in older patients was obesity (body mass index >30) significantly associated with scarce prognosis.

Pelvic and aortic lymphadenectomy in cervical cancer: The standardization of surgical procedure and its clinical impact

Cervical cancer ranks as the second most frequent cancer in women in the world, and nodal metastasis seems to be the first step of tumor spread in most cases. Since lymph node involvement is a major prognostic factor in cervical carcinoma, lymphatic spread of cervical cancer has been one of the most studied surgical topics in gynecologic oncology. Traditionally, lymph nodes stations have been accurately analyzed, improving surgical techniques of nodal dissection, which have been more and more intensive during years with the aim of improving survival. Oppositely, on the basis of recent acquisitions in cancer immunology and new anti-cancer immunotherapies and vaccines, the importance of lymph nodes has been recently reconsidered. Unfortunately, lymph node status is still difficult to be assessed pre-operatively with a high level of accuracy, and intra-operatively by sentinel node techniques, which remain inadequate for many aspects according to several gynecologic oncologists. The absence of definitive evidence of survival advantage given by extensive lymphadenectomy in all cervical cancer cases indicates that nodal dissection should be performed on the objective risk of node metastasis in each case. To date, the mainstay of detecting lymph node metastasis is still the histologic evaluation, therefore a proper resection of mostly involved lymph nodes remains a crucial surgical step when treating cervical cancer.

Anterior Colporrhaphy Plus Inside-out Tension-free Vaginal Tape for Associated Stress Urinary Incontinence and Cystocele

STUDY OBJECTIVE To reveal the efficacy and feasibility of concomitant anterior colporrhaphy and tension-free vaginal tape-obturator to treat stress urinary incontinence (SUI) and concomitant cystocele. DESIGN Controlled trial without randomization (Canadian Task Force classification II-1). SETTING University hospitals in Rome, Italy. PATIENTS Fifty consecutive patients with SUI associated with symptomatic cystocele were enrolled into the study. Exclusion criteria were: uterine prolapse greater than or equal to 1, rectocele greater than or equal to 1, overactive bladder, overactive bladder symptoms, intrinsic urethral sphincter deficiency, urinary retention, previous anti-incontinence and/or prolapse surgery, neurologic bladder, psychiatric disease, body mass index greater than 30, and elevated intraabdominal pressure. The preoperative evaluation consisted of: complete history, physical examination, 3-day voiding diary, and urodynamic testing. The International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) was used to subjectively quantify the patient perception of SUI symptom severity. INTERVENTIONS All patients underwent an ultralateral anterior colporrhaphy plus tension-free vaginal tape-obturator. MEASUREMENTS AND MAIN RESULTS In all, 43 (91%) and 46 (92%) patients were objectively cured for cystocele and SUI, respectively. The median operating time, blood loss, and hospitalization were 43 minutes (range 35-56), 64 mL (range 40-148), and 1 day (range 1-2), respectively. Overall early postoperative complication rate was 16%, although all were minor. Only 1 patient, at 12-month follow-up, developed tape erosion that required surgical removal. The ICIQ-UI SF questionnaire scores were 13.4 +/- 6.8 and 3.5 +/- 3.2 (p <.01) between preoperative and 12-month follow-up, respectively. CONCLUSION Concomitant tension-free vaginal tape-obturator plus ultralateral anterior colporrhaphy are feasible and safe procedures for the treatment of SUI and with associated cystocele with a high success rate and low intraoperative and postoperative complications rate.

Laparoscopic Adnexectomy of Suspect Ovarian Masses: Surgical Technique Used To Avert Spillage

Herein is described and evaluated a safe laparoscopic adnexectomy technique for retroperitoneal dissection of suspect ovarian masses including the underlying peritoneum fixed to the ovary. Adopting this technique in cases of suspect adnexal masses enables the reduction of spilling and ensures an intact specimen. Twenty-two consecutive patients with suspect adnexal masses 10 cm or smaller underwent laparoscopic adnexectomy. Patients with bilateral suspect ovarian masses that required bilateral adnexectomy were enrolled only if they were no longer of childbearing age. Laparoscopy was feasible in all patients. No tumor spillage occurred. In 5 patients (23.6%), minilaparotomy was required to extract the specimen. Mean (SD) operating time was 80 (35-160) minutes, and estimated blood loss was 50 (10-100) mL. No major intraoperative complications occurred. Median (range) postoperative stay was 1 (1-3) day. Definitive pathologic analysis revealed benign pathologic conditions in 18 patients (81.8%), an ovarian tumor with low malignant potential in 3 patients (13.7%), and ovarian cancer in 1 patient (4.5%) in whom findings at frozen-section analysis were inconclusive. Median (range) follow-up of malignant ovarian tumors and of tumors with low malignant potential was 27 (21-29) months. No recurrence or port-site metastasis developed during follow-up. The data are encouraging for adoption of this technique to avert spillage during laparoscopic management of suspect adnexal masses, especially those firmly adherent to the peritoneum. However, the procedure must be validated in a larger series of patients to standardize the technique.

Laparoscopic approach for peripartum hysterectomy.

Abnormal placentation is the most common indication for peripartum hysterectomy. To date, the approach described in the literature is laparotomy, which is associated with high morbidity and mortality. A 30-year-old gravida 4 para 3 had a postpartum diagnosis of placenta percreta. She was first treated conservatively. On day 3 after delivery, because of persistent vaginal bleeding, she underwent a laparoscopic hysterectomy. No postoperative complications occurred, and the patient was discharged on postoperative day 3. Laparoscopic peripartum hysterectomy could become the approach of choice in selected patients with abnormal placentation to avoid complications associated with laparotomy.

Robotic Management of Major Vessel Injury During Pelvic Lymphadenectomy

Laparoscopic management of major vessel lesion is a challenging task during pelvic lymphadenectomy, and conversion is frequently necessary. Robotic surgery overcomes the limits of laparoscopy in vascular suturing. We describe a case of a 79-year-old woman with stage IB G3 endometrial adenocarcinoma, where an external iliac vein injury occurred during pelvic lymphadenectomy. This is the first case report that describes robotic management of a major vascular injury during pelvic lymphadenectomy by use of endoscopic bulldog clamps and robotic intracorporeal vascular sutures.

Is pregnancy a predisposing factor for Dieulafoy's duodenal lesion or only a coincidence?

Dieulafoy’s lesion (DL) is a rare vascular abnormality of a submucosal artery, associated with a minute mucosal defect, that can be the cause of a massive, potentially lifethreatening, gastrointestinal (GI) hemorrhage [1]. Although such lesions may develop anywhere throughout the entire GI tract, they most often develop in the proximal stomach [1]. Safety and efficacy of endoscopic management for DLs have been widely recognized. Various endoscopic techniques, including injection therapy, thermal probes, laser therapy, endoscopic band ligation and hemoclipping have been used with high rates of successful hemostasis [2]. To date, no cases of bleeding DL in pregnant woman have been described in literature. We describe a case of a 35-years-old, ninth week pregnant woman referred to our Emergency Department because of melena in the previous 2 days, sickness and syncopal episode. Blood examination showed red blood cells 2.9 × 106/ L (normal range: 4.0—5.2); hemoglobin 7.1 g/dL (normal range: 12.0—16.0); mean cell volume 75.9 fL (normal range: 80.0—100.0). Heart rate was 130 bpm; blood pressure 100/70 mmHg; SatO2 100%. No blood was encountered after nose-gastric tube placement. We started red blood cells transfusion, while performed ultrasonography showed intra-uterine normal gestational sac, with a living fetus, crown rump length 24.8 mm, corresponding to predicted gestational age. The performed esophagogastroduodenoscopy under deep sedation showed blood in the second duodenal portion but no hemorrhagic lesion was observed. We decided to change the gastroscope with the colonoscope reaching the third duodenal portion where a Dieulafoy’s spurting lesion was observed (Fig. 1) and the bleeding was stopped with four metallic clips placement (Fig. 2). Patient was submitted to a second look upper GI endoscopy 2 days later showing the clips correctly placed and no evidence of rebleeding. At 1 month followup, patient still does not have any sign of GI bleeding, and pregnancy is physiologically going on. Figure 2 Placement of four metallic clips on the bleeding lesion.

Association between Helicobacter pylori infection and vulvar lichen sclerosus: a clinical comparative study

1. Llombart B, Serra-Guillén C, Monteagudo C, et al. Dermatofibrosarcoma protuberans: a comprehensive review and update on diagnosis and management. Semin Diagn Pathol 2013; 30: 13-28. 2. Zambo I, Vesely K. WHO classification of tumours of soft tissue and bone 2013: the main changes compared to the 3rd edition. Cesk Patol 2014; 50: 64-70. 3. Chuan MT, Tsai TF, Wu MC, et al. Atrophic pigmented dermatofibrosarcoma presenting as infraorbital hyperpigmentation. Dermatology 1997; 194: 65-7. 4. Taura M, Wada M, Kataoka Y, et al. Case of pigmented dermatofibrosarcoma protuberans with atrophic change. J Dermatol 2016; 43: 1231-2. 5. Llombart B, Serra-Guillén C, Monteagudo C, et al. Dermatofibrosarcoma protuberans: a comprehensive review and update on diagnosis and management. Semin Diagn Pathol 2013; 30: 13-28. 6. Rodriguez-Jurado R, Palacios C, Durán-McKinster C, et al. Medallion-like dermal dendrocyte hamartoma: a new clinical and histopathologically distinct lesion. J Am Acad Dermatol 2004; 51: 359-63. 7. Goncharuk V, Mulvaney M, Carlson JA. Bednár tumor associated with dermal melanocytosis: melanocytic colonization or neuroectodermal multidirectional differentiation? J Cutan Pathol 2003; 30: 147-51.