Tristan Gauthier

Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy: about fourteen consecutive cases.

OBJECTIVEnTo report the feasibility and reproducibility of single port extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer.nnnMETHODSnThe same single port was used for the transperitoneal step and the extraperitoneal approach used thereafter (in the absence of peritoneal disease) for the lymphadenectomy. Para-aortic lymphadenectomy was performed via a left-sided extraperitoneal approach.nnnRESULTSnFourteen consecutive patients with cervical cancer underwent a laparoscopic staging procedure (3 stage IB2, 10 IIB and 1 stage IVA). No patient had para-aortic FDG uptake on PET/CT. In one case lymphadenectomy was unfeasible because of vascular anomalies of the renal vessels (low insertion of 2 left renal arteries). The median operative time was 190 min (range, 135-250). The median number of lymph nodes removed was 14 [range, 2-23]. The definitive pathological analysis revealed that three patients had metastatic disease. No conversion to conventional multiport laparoscopy was necessary.nnnCONCLUSIONSnThis series reports that para-aortic lymphadenectomy technique via the extraperitoneal approach with a multichannel single port is feasible and reproducible.

Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy for locally advanced cervical cancer: assessment after 52 consecutive patients

BackgroundTo report the feasibility and reproducibility of single-port extraperitoneal para-aortic (PA) lymphadenectomy exclusively using conventional instruments in locally advanced cervical cancer (LACC) and to evaluate the learning curve.MethodsFrom January 2011 to January 2013, 52 a total of consecutive patients with LACC were candidates for extraperitoneal PA lymphadenectomy via an original single-port approach that we developed. All patients underwent positron emission tomography–computed tomography that indicated no PA uptake.ResultsFifty consecutive patients underwent single-port staging surgery. Two patients had peritoneal carcinomatosis and were not submitted to PA lymphadenectomy. Median age and body mass index were, respectively 47 (range 27–68) years and 23 (range 16–37)xa0kg/m2. In one case, lymphadenectomy was unfeasible because of renal vessel anomalies (a bifurcated left renal vein crossed the aorta at the level of the inferior mesenteric artery), and two nodes were removed. Conventional instruments were used in all cases. The median operative time was 180 (range 110–270)xa0min. The median and mean number of nodes removed were, respectively, 18 (range 2–47) and 19.4. Six (12xa0%) patients had metastatic PA disease. No conversion to laparotomy or conventional multiport laparoscopy was required. The median postoperative hospital stay and the interval between staging surgery and the beginning of chemoradiation were, respectively, 2 (range 1–26) days and 16.5 (range 1–60) days. The learning curve was evaluated at seven procedures with a decreased median operative time at 160 (range 110–240)xa0min.ConclusionsExtraperitoneal staging via a single-port left iliac approach is feasible with conventional tools, is reproducible and safe, and offers a high degree of cosmetic satisfaction.

A New Single-Port Approach to Perform a Transperitoneal Step and an Extraperitoneal Para-Aortic Lymphadenectomy with a Single Incision

Chemoradiation therapy (CRT), a combination of external beam irradiation and brachytherapy with concurrent chemotherapy, is considered the standard treatment for bulky cervical cancer ( stage IB2 according to the International Federation of Gynecology and Obstetrics [FIGO] classification) by many North American and Western European teams. The incidence of para-aortic (PA) nodal metastasis n these tumors ranges from 10% to 25%. Positron emission tomography (PET) with or without CT imaging is the most accurate imaging modality for evaluating extrapelvic disease in locally advanced cervical cancer (LACC), When PA nodes are known to be metastatic, the radiation field is extended from the pelvis to include the PA area. However, the rate of false negatives at PET-CT assessment of PA metastasis in LACC is 12%, increasing to 22% if PET-CT reveals pelvic lymph nodes with suspicious metastases. The concept of surgical staging has gained momenum with the development of laparoscopy, which reduces urgical complications. Since January 2011, this surgical taging procedure has been performed more often in our nstitution using a single-port extraperitoneal approach, hich was previously described by our team. We have efined this procedure and developed a “real” single-port pproach avoiding a second transumbilical port (to explore he peritoneum), which was used in the first procedure. We eport in this series a new procedure for performing these wo steps via a single access with only one incision.

Mélanome vaginal : une localisation particulièrement défavorable

OBJECTIVEnThe aim of this study was to describe the clinical features of vaginal melanoma and treatments available.nnnPATIENTS AND METHODSnThis is a retrospective review of patients with primary vaginal melanoma operated from 2000 to 2010 at Gustave-Roussy Institute.nnnRESULTSnSix patients had surgery for a vaginal melanoma out of 37 patients operated for vaginal cancer in our institute in the same period (13.6%). Median age was 53.5 years [48-66]. The melanoma presented as a macroscopically visible nodular tumor in all case. Median tumour size was 5.4cm [1.5-15]. Five of the six patients had a [18F] fluoro-deoxy-glucose positron-emission tomography combined with integrated computed tomography (FDG-PET/CT) before surgery. Initial management included two conservative treatments and four colpectomy with one anterior exenteration. Two sigmoidcolpoplasties were performed. Lymph node metastases were found in only one patient. Median progression free survival was 10.5 months [4-51]. All patients have relapsed, three of them in the 6 months following surgery. Recurrences were local in three patients and distant in three patients. Local recurrences were surgically treated. In one case, electrochemotherapy was performed. One patient with locoregional disease underwent a pelvic isolated perfusion. One patient had a KIT mutation. Two patients died at 12 and 83 months.nnnDISCUSSION AND CONCLUSIONnVaginal melanoma had a poor prognosis. The 5-year overall survival is under 20% from literature data. Local and/or distant recurrences are frequent and new local and adjuvant treatments are currently evaluated.

Accuracy and reproducibility of the peritoneal cancer index in advanced ovarian cancer during laparoscopy and laparotomy.

Background The aim of this prospective study was to evaluate the accuracy of the peritoneal cancer index (PCI) between laparoscopy and laparotomy and to evaluate the reproducibility of this index between 2 surgeons (junior vs senior) in advanced-stage ovarian cancer (ASOC). In ASOC, the quality of cytoreductive surgery, which is the main prognostic factor, is correlated with the extent of the disease and thus with the PCI. The reliability of this scoring index between different surgeons during laparoscopy and laparotomy has not been investigated in this disease. Methods Between April 2010 and October 2011, for each of the 29 patients undergoing complete cytoreductive surgery, 1 senior surgeon and 1 junior surgeon quantified the PCI score at 3 time points on the same day: during laparoscopy and during laparotomy, at the beginning and at the end. A concordance analysis was conducted with Bland and Altman’s method and estimated by intraclass correlation coefficients. Results There was high concordance of the PCI score between the junior and senior surgeons during the laparoscopic and laparotomic procedures: the mean differences were not significantly different from 0 (P < 0.05) and 95% limits of agreement were ±3.5 and ±3.0, respectively. Laparoscopy underestimated the PCI score by approximately 2 points compared to the beginning of the laparotomy: the mean biases were −2.0 (95% confidence interval, −2.8 to −1.2) for the senior surgeon and −2.2 (95% confidence interval, −3.1 to 1.3) for the junior surgeon. Conclusions The PCI is reproducible and reliable for evaluating peritoneal spread in ASOC.

Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy: 3 consecutive cases.

Objective We report the feasibility and the technique of single-port extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer. Methods The same single port was used for the transperitoneal step (to discriminate intraperitoneal disease) and the extraperitoneal approach used thereafter (in the absence of peritoneal or ovarian spread) for the lymphadenectomy. Para-aortic lymphadenectomy was performed via the left-sided extraperitoneal approach by a 2- to 3-cm incision, which was made 1 cm above the usual incision to the left of McBurney’s point. We used conventional instruments in all cases. Results Three consecutive patients with cervical cancer had undergone a pretherapeutic laparoscopic staging procedure (1 stage IB2 and 2 stage IIB). The histologic types were squamous carcinoma (n = 2) and adenocarcinoma (n = 1). No patients had pelvic or para-aortic uptakes on preoperative positron emission tomography computed tomography imaging. The mean operative time was 223 minutes (range, 210–250 minutes). The mean number of lymph nodes removed was 19 (range, 15–23). The definitive pathological analysis had revealed that one patient had metastatic disease. No failures occurred with the single-port procedure, and no conversion to conventional multiport laparoscopy was reported. Conclusions This preliminary series reports on the feasibility of the para-aortic lymphadenectomy technique via the extraperitoneal approach with a multichannel single port using conventional instruments. Nevertheless, the safety of this procedure (compared to conventional laparoscopic approach) needs to be explored in a further larger study.

Article originalMélanome vaginal : une localisation particulièrement défavorableMalignant melanoma of the vagina: Pejorative location

OBJECTIVEnThe aim of this study was to describe the clinical features of vaginal melanoma and treatments available.nnnPATIENTS AND METHODSnThis is a retrospective review of patients with primary vaginal melanoma operated from 2000 to 2010 at Gustave-Roussy Institute.nnnRESULTSnSix patients had surgery for a vaginal melanoma out of 37 patients operated for vaginal cancer in our institute in the same period (13.6%). Median age was 53.5 years [48-66]. The melanoma presented as a macroscopically visible nodular tumor in all case. Median tumour size was 5.4cm [1.5-15]. Five of the six patients had a [18F] fluoro-deoxy-glucose positron-emission tomography combined with integrated computed tomography (FDG-PET/CT) before surgery. Initial management included two conservative treatments and four colpectomy with one anterior exenteration. Two sigmoidcolpoplasties were performed. Lymph node metastases were found in only one patient. Median progression free survival was 10.5 months [4-51]. All patients have relapsed, three of them in the 6 months following surgery. Recurrences were local in three patients and distant in three patients. Local recurrences were surgically treated. In one case, electrochemotherapy was performed. One patient with locoregional disease underwent a pelvic isolated perfusion. One patient had a KIT mutation. Two patients died at 12 and 83 months.nnnDISCUSSION AND CONCLUSIONnVaginal melanoma had a poor prognosis. The 5-year overall survival is under 20% from literature data. Local and/or distant recurrences are frequent and new local and adjuvant treatments are currently evaluated.