Introduction of gasless laparoscopic surgery as a minimally invasive procedure for endometrial cancer and its usefulness from the viewpoint of the learning curve.

BACKGROUND: We investigated the usefulness of gasless laparoscopic surgery (GLS) using a subcutaneous abdominal wall lifting method for endometrial cancer. METHODS: We studied 105 patients with early endometrial cancer who underwent GLS (55) or open surgery (50). A uterine manipulator was used in all GLS cases. We compared operative time, blood loss, number of lymph nodes removed, hospital stay, perioperative complications, cases converted to laparotomy, and recurrence and survival rates. We also studied the learning curve and proficiency of GLS. RESULTS: The GLS group had significantly longer operative time (265 vs. 191 min), reduced blood loss (184 vs. 425 mL), shorter hospital stay (9.9 vs. 17.6 days), and fewer postoperative complications (1.8 vs. 12.0%) than the open group. No case was converted to laparotomy. Disease-free and overall survival rates at 4 years postoperatively (GLS vs. open groups) were 98.0 versus 97.8 and 100 versus 95.7%, respectively, and there was no significant difference between the groups. Regarding the learning curve for GLS, two different phases were observed in approximately 10 cases. Operator 2, who was not accustomed to laparoscopic surgery, showed a significant reduction in operative time in the later phase 2. CONCLUSIONS: GLS for endometrial cancer results in less bleeding, shorter hospital stay, and fewer complications than open surgery. Recurrence and survival rates were not significantly different from those of open surgery. This technique may be introduced in a short time for operators who are skilled at open surgery but not used to laparoscopic surgery.

Does the use of a uterine manipulator in robotic surgery for early-stage endometrial cancer affect oncological outcomes?

BACKGROUND: To investigate the impact of the use of a uterine manipulator in robot-assisted surgery for early-stage endometrial cancer on oncological outcome. METHODS: Eighty six robotic surgeries and sixty seven open surgeries were performed for early-stage endometrial cancer. Disease-free survival and overall survival at 5 years, and surgical results and postoperative complications were compared between surgeries. In robotic surgery, a uterine manipulator was used in all cases. RESULTS: There was no significant difference in oncological outcome between surgeries. Robotic surgery showed significantly longer operative time, less blood loss, and shorter hospital stay compared to open surgery. In robotic surgery, complications occurred significantly less frequently, and no patients required conversion to laparotomy. There were no clear correlations of positive lavage cytology with The International Federation of Gynecology nd Obstetrics stage, recurrence, and site of recurrence in either surgery. CONCLUSIONS: The use of a uterine manipulator during robotic surgery for early-stage endometrial cancer did not influence recurrence or survival.

Krüppel-like factor 5 is upregulated and induces cell proliferation in endometrial cancer.

Krüppel-like factor 5 (KLF5) is involved in various cellular processes, such as cell proliferation and survival. KLF5 has been implicated in cancer pathology. The aim of the present study was to investigate the expression levels and function of KLF5 in endometrial cancer. A total of 30 patients, including 12 patients with endometrial cancer and 18 with benign gynecological diseases (controls), were enrolled at Tokyo Medical University (Tokyo, Japan) between March 2017 and May 2018. Endometrial cancer and control endometrium tissues were collected, and the expression levels of KLF5 were determined using reverse transcription-quantitative PCR, western blotting and immunohistochemistry. For the functional analyses of KLF5 in endometrial cancer, the present study employed a loss-of-function strategy in the human endometrial cancer cell lines in vitro. Ishikawa and HEC1 cells were transduced with lentiviral constructs expressing shRNAs targeting KLF5. MTT and TUNEL assays were performed in cells after knockdown to analyze the role of KLF5 in cell proliferation and survival. The results revealed that the mRNA and protein expression levels of KLF5 were increased in endometrial cancer tissues. In vitro analyses demonstrated that depletion of KLF5 inhibited cell proliferation and decreased the expression levels of cyclin E1. However, silencing KLF5 did not induce cell death. Overall, these results indicated that KLF5 may be crucial in the tumorigenesis of endometrial cancer and has potential as a therapeutic target.

Pilot study on transdiaphragmatic thoracoscopic-assisted pleural biopsy and intrathoracic washing cytology for Stage IIIc ovarian cancer with diaphragmatic metastases.

PURPOSE: The significance of investigations of thoracic cavities as well as pleural biopsy and intrathoracic washing cytology through transdiaphragmatic thoracoscopy for stage IIIc ovarian cancer with diaphragmatic metastases was assessed as a prospective pilot study. SUBJECTS AND METHODS: Eligibility criteria were established to include patients with stage IIIc ovarian cancer in whom pleural effusions were not detected preoperationally, but prominent diaphragmatic metastases were observed when the abdomen was opened and those who submitted consent. Transdiaphragmatic thoracoscopy was performed after diaphragm stripping. Then, biopsy of the lesion suspected to be disseminated or the plural membrane of the thoracic opening was performed followed by washing cytology using physiological saline. RESULTS: Ten subjects were enrolled. Disseminated lesions were observed on plural membranes, and positive results were obtained in biopsy and washing cytology in 3 subjects. In addition, positive results were seen with biopsy alone in 2 subjects and with washing cytology alone in 2 subjects. Hence, a total of 7 subjects (70.0%) were up-staged to the level of stage IV. Postoperational complications were not observed in any of these cases. CONCLUSIONS: It was suggested that stage IIIc ovarian cancer with prominent diaphragmatic metastasis may advance to the level of stage IV from a clinical point of view even if carcinomatous pleural effusions are not detected pre-operationally. Therefore, it is thought that this operational method is useful in the management of progressive ovarian cancer.

Clinical significance of p21(WAF1/CIP1) and p53 expression in serous cystadenocarcinoma of the ovary.

There have been many reports indicating that the down-regulation of p21(WAF1/CIP1) is related to carcinogenesis and the development of various tumors; nevertheless, its association with epithelial ovarian cancer (EOC) remains controversial. In this study, we focused on serous ovarian cancer, which is the most prevalent histological type, and performed immunohistochemical analysis to examine the expression of p21(WAF1/CIP1) and p53 in 43 cases of serous-type EOC sourced from a single University Hospital: 14 stage I, 4 stage II, 21 stage III, and 4 stage IV. Positive p21(WAF1/CIP1) was found in 24 of 43 cases (56%), and positive p53 was detected in 21 of 43 cases (49%). Among stage III/IV cases, positive p21(WAF1/CIP1) staining was found in 11 of 25 cases (44%), and positive p53 staining was detected in 13 of 25 cases (52%). Univariate survival analysis for the entire cohort revealed that positive p21(WAF1/CIP1) was associated with a survival benefit. The 10-year survival rates of p21(WAF1/CIP1)-positive staining and p21(WAF1/CIP1)-negative staining were 82.4 and 39.5%, respectively, and there was a significant difference between the two groups (p<0.01). Overall survival for p21(WAF1/CIP1)-positive with p53-negative staining [p21(+)/p53(-)] was significantly different from p21(WAF1/CIP1)-positive with p53-positive [p21(+)/p53(+)], p21(WAF1/CIP1)-negative with p53-positive staining [p21(-)/p53(+)], and p21(WAF1/CIP1)-negative with p53-negative staining [p21(-)/p53(-)] (p<0.05). When only III/IV cases were evaluated, overall survival for [p21(+)/p53(-)] was significantly different from [p21(+)/p53(+)], [p21(-)/p53(+)], and [p21(-)/p53(-)] (p<0.05). These results suggested that the overexpression of p21(WAF1/CIP1) in conjunction with the loss of p53 expression was a stronger predictor of survival benefit than either molecule alone in Japanese serous-type advanced ovarian cancers with more than 10-year follow-up.

A pilot study of weekly paclitaxel administration for patients with relapsed cervical cancer after heavy medication.

No standard therapy has been established for patients with relapsed cervical cancer after applying radical hysterectomies including lymphadenectomies, radiotherapy, and platinum-based chemotherapy. This study was designed to evaluate the effectiveness and safety of weekly paclitaxel (TXL) therapy in patients who suffered a cervical cancer relapse after heavy treatment. The candidates for the study included patients with cervical cancer that recurred after radical therapy (including lymphadenectomies), postoperative radiotherapy, and platinum-based chemotherapy, the lesions of which could be evaluated by imaging diagnosis. Patients received 80 mg/m2 of TXL by intravenous drip in one hour. Premedications included 10 mg of dexamethasone (iv), 50 mg of cimetidine (iv), and 50 mg of diphenhydramine (po) administered 30 minutes before the TXL treatment. This procedure was repeated weekly on an ongoing basis. The median progression-free survival was 14 months (range: 0 to 24 months), and the median overall survival 19 months (range: 6 to 24 months). Grade-3 or higer hematologic toxicity was observed for leukocyte (total WBC) and neutrophil/granulocyte in one patient (12.5%), but was controllable with GCSF. The weekly TXL therapy was effective against cervical cancer relapse after heavy treatment and its toxicity was tolerable.

[Evaluation of QOL with orally disintegrating antiemetic tablets in outpatient chemotherapy].

An investigation into the effect of orally disintegrating antiemetic tablets (ramosetron OD 0.1 mg) on 16 outpatients undergoing chemotherapy for recurrent gynecologic malignancies was carried out using a questionnaire to evaluate their quality of life (QOL). The patients were divided into 2 groups: a control group in which the patients received only an intravenous drip infusion of 0.3 mg of ramosetron on the day of their chemotherapy and a double antiemetic therapy group in which the patients were treated with orally disintegrating antiemetic tablets for 4 days in addition to the intravenous drip. When outpatient chemotherapy (paclitaxel 80 mg/m2/1 h div + CBDCA AUC 2/1 h div) was performed, a comparison was made between the 2 groups, based on the results of a QOL questionnaire for antiemetic therapy during cancer chemotherapy (Ishihara's QOL survey method). This study found a greater improvement in QOL in the double antiemetic therapy group on days 2 to 4, a period when deterioration in QOL is usually observed. These findings suggest that orally disintegrating antiemetic tablets as a measure to reduce delayed nausea and vomiting are useful for improving QOL.

Prognostic factor on optimal debulking surgery by maximum effort for stage IIIC epithelial ovarian cancer.

OBJECTIVES: The aim of this study was to assess the prognostic factor of radical surgery in patients with stage IIIc ovarian cancer. STUDY DESIGN: Fifty-two patients were subjected to the study. The complete resection or optimal primary cytoreductive surgery (OPCS) was set as the maximum effort, and the accomplishment rate and prognosis were assessed. In addition, the poor prognosis cases among the OPCS-accomplished were evaluated with several factors based on univariate and multivariate analyses. RESULTS: The OPCS accomplishment rate was 84.6%. A worse prognosis was obtained in the more-than-4-weeks-delayed postoperative chemotherapy group, assessing poor-outcome cases in the OPCS group. A case that required more than three colon resections was the significant factor for the delay of postoperative chemotherapy. CONCLUSIONS: OPCS should be performed with maximum effort to improve the prognosis of stage IIIc ovarian cancer. We should avoid any delay in starting postoperative chemotherapy. In cases that require more than three colon resections, it seems that 'perioperative management' should be reconsidered and that priority should be given to postoperative management so that chemotherapy can be started soon after the operation.

Sclerosing stromal tumor of the ovary with elevated CA125.

The case is reported herein of an 18-year-old woman who developed sclerosing stromal tumor of the ovary. Although she was suspected to have a malignant tumor due to magnetic resonance imaging findings and an abnormal blood CA125 value, the tumor was benign. The immunohistochemical staining by CA125 antibody was negative. She had an uneventful postoperative course, with no postoperative recurrence of the tumor.

Combination chemotherapy with paclitaxel and intraperitoneal cisplatin for ovarian cancer with disseminated lesions in the peritoneum and the diaphragm.

BACKGROUND: In ovarian cancer, the management of micrometastases disseminated in the peritoneal cavity is extremely important. We performed intravenous paclitaxel (PAC) infusion combined with cisplatin (CDDP) intraperitoneal infusion for progressive ovarian cancer. METHODS: Twelve patients with progressive epithelial ovarian cancer (FIGO IIIc), which was resected using an optimal method at primary surgery, except for disseminated lesions in the peritoneum and the diaphragm, were studied. At primary surgery, a reservoir was placed in the peritoneal cavity. If metastases were identified in the diaphragm, then another reservoir was also placed in the subdiaphragm (double reservoirs). The basic regimen was set at 175 mg/m(2) with divided doses of PAC and 75 mg/m(2) CDDP by intraperitoneal injection. When a double reservoir was used, 30 mg/m(2) of subdiaphragmatic CDDP and 45 mg/m(2) of intraperitoneal CDDP were administered. The patients received five courses of this regimen. The response to the therapy was evaluated with tumor markers, and by using cytodiagnoses on the peritoneal washing fluid collected from the reservoirs. RESULTS: After five courses of the chemotherapy, the tumor marker levels and cytodiagnoses of all patients became negative. With reference to adverse effects, grade 3-4 neutropenia was detected in 2 patients (16.6%), peripheral neuropathy was detected in 4 patients (33.3%), and alopecia was detected in 11 patients (91.6%). The median follow-up period was 29.2 months and median progression-free survival was 25.6 months. CONCLUSION: The combination chemotherapy with intravenous PAC and intraperitoneal CDDP was effective on ovarian cancer with disseminated lesions in the peritoneum and the diaphragm, having only mild adverse effects.