Impact of initial surgical access on staging and survival of patients with stage I ovarian cancer.

The aim of this study was to compare staging by laparoscopy and laparotomy, and to compare survival in patients with laparoscopy versus laparotomy as the first surgical access. We conducted a retrospective analysis of patients with stage I ovarian cancer treated surgically between 1985 and 2001, and we included those patients with stage I epithelial cancer for whom follow-up data were available. For each patient, we recorded whether initial surgical staging was by laparoscopy or by laparotomy, the procedures done at initial staging surgery, and the outcomes. The data were evaluated by analysis of variance, Chi-square test or Fisher's exact test, logistic regression, Cox model, and log-rank test, using SPSS 7.5 and STATA. Initial staging was by laparoscopy in 34 patients, laparotomy in 114 patients, and laparoscopy converted to laparotomy in 30 patients. In the laparotomy group, patient age was significantly greater and tumor size significantly larger, as compared to the laparoscopy group. Staging after first surgery was often inadequate; most notably para-aortic lymph node dissection was done in 0% of laparoscopy patients, 18% of laparotomy patients, and 33% of conversion patients. Restaging surgery has been indicated in 88% of laparoscopy patients, 48% of laparotomy patients, and 46% of conversion ones. After a mean follow-up of 40 months, survival rates were not significantly different among the three patient groups. No deleterious influence of laparoscopy as first surgical access was detected by univariate or multivariate analysis. Despite of inaccurate radicality and staging during initial laparoscopy, this study found no harmful influence of laparoscopy as first initial access on outcomes of patients with stage I ovarian cancer.

[Laparoscopic treatment of borderline ovarian tumor: analysis of 54 patients and clinical outcomes]. / Traitement coelioscopique des tumeurs frontières (borderline) de l'ovaire: analyse d'une série de 54 patientes et implications thérapeutiques.

OBJECTIVE: The aim of this study is to assess the clinical outcomes of laparoscopic treatment of borderline ovarian tumor (BOT). PATIENTS AND METHODS: Retrospective analysis of 54 patients treated using a laparoscopic approach for a BOT between January 1984 and January 2002. RESULTS: A conservative management was initially performed in 45 patients (83%). Twenty-six patients underwent a reassessment surgery and 7 (27%) of them were upstaged following this procedure. Seven (13%) patients recurred in a remaining ovary following conservative surgery (5 patients) or on the peritoneum (2 patients). Three port-site localizations were observed. None of the patients treated with conservative management had recurrent disease under the form of ovarian carcinoma. Nine spontaneous pregnancies were observed in 6 patients from a group of 19 patients desiring pregnancy. All patients are today alive and disease-free. DISCUSSION AND CONCLUSION: Our study suggests that laparoscopic treatment could be safely performed in young patients with early stage BOT. Such procedure should be further evaluated in patients with BOT and peritoneal implants.

[Pelvic and para-aortic lymphatic involvement in tubal carcinoma: topography and surgical implications]. / Extension lymphatique pelvienne et lombo-aortique dans le cancer de la trompe: topographie et implications chirurgicales.

OBJECTIVE: The purpose of this study is to determine the topography of pelvic and para-aortic node involvement in Fallopian tube carcinoma (PFTC). This will help us to recommend appropriate surgical treatment options to the related patients. PATIENTS AND METHOD: A retrospective study was performed on 19 women with PFTC who underwent a systematic bilateral pelvic and para-aortic lymphadenectomy. RESULTS: The overall frequency of lymph node involvement was 47% (9/19). The frequency of pelvic and para-aortic metastases was 21% (4/19) and 42% (8/19) respectively. The frequency of lymph node metastases according to the stage of the disease (stage I, II and III) was : 29% (2/7), 50% (1/2) and 60% (6/10) respectively. The left para-aortic chain above the level of the inferior mesenteric artery was the site most frequently involved (75%) when para-aortic nodes were involved. DISCUSSION AND CONCLUSIONS: In patients with primary tubal carcinoma, the left para-aortic chain above the level of the inferior mesenteric artery is the most frequently involved. A complete lymphadenectomy (including all pelvic and para-aortic chains up to the level of the left renal vein) should be performed in patients with primary tubal carcinoma, even in patients with stage I disease.

Prognosis of stage III or IV primary peritoneal serous papillary carcinoma.

AIMS: To study the prognosis of patients with stage IIIC/IV primary peritoneal serous papillary carcinoma (PSPC) (study group) compared with that of patients with epithelial ovarian carcinoma (EOC) (control group). METHODS: A retrospective case-control study including a study group of 37 patients who were matched with a control group of 37 patients. Patients were matched for the histologic subtype (serous tumor), tumor stage, tumor grade, residual disease at the end of debulking surgery (initial or interval) and age (+/-5 years). RESULTS: Debulking surgery was performed initially or at interval surgery in respectively, 10 and 27 patients in the study group and 17 and 20 in the control group. All patients were treated with platinum-based chemotherapy (combined with paclitaxel in 33) in both groups. The overall survival rate at 3 years in the study and control groups was, respectively, 60% versus 55% (NS). However, event-free survival rates at 3 years (CI 95%) were statistically different (respectively, 29% in the study group versus 16% in the control group: p=0.008). CONCLUSIONS: Peritoneal disease is more bulky in patients with PSPC. Neoadjuvant chemotherapy is more often required to achieve optimal debulking surgery in PSPC. Overall survival of patients with PSPC is similar to that of their EOC counterparts. Thus, the management of PSPC should not be different from that of advanced stage EOC.

Stage I ovarian cancer: comparison of laparoscopy and laparotomy on staging and survival.

OBJECTIVE: The aim of this study was to compare staging accurateness as well as survival when managing early ovarian cancers by laparoscopy or laparotomy. MATERIAL AND METHODS: We have conducted a retrospective and multicentric study in France. Only Stage I ovarian epithelial cancers operated on from January 1, 1985 to December 31, 1999 were taken into account. Respondents had to fill in a form detailing in each case the surgical access; the surgical acts performed during the initial intervention as well as data on the patient's follow-up. Lack of follow-up or final Stage > I were considered as exclusion criteria. Data were recorded and analysed with SPSS 7.5 and STATA (Stata statistical sofware 7.0). (ANOVA, chi-square test or Fisher's exact test and log-rank test). RESULTS: 105 cases were included: 14 patients were exclusively operated on by laparoscopy (group 1), 13 other patients were subjected to a conversion from laparoscopy to laparotomy (group 2) and 78 patients exclusively underwent laparotomy (group 3). Patients in group 3 were significantly more frequently postmenopausal and had larger lesions. Cyst rupture was rare during laparoscopy (21%) and the use of an endobag was achieved in only 21% of the patients in group 1. Radical treatment was significantly more frequent in group 3 when compared to group 1 (67% vs 23%, p < 0.05). Laparoscopy was not adequate for staging since no lymphadenectomy was carried out by this approach. However, only 27% of patients subjected to an open approach underwent lymphadenectomy and omentectomy. The outcome in terms of survival was similar in the three groups with a mean follow-up period of 1,221 days (+/- 832) (p = 0.1). CONCLUSION: Laparoscopic management of early ovarian cancer is poorly efficient in staging although disease-free survival does not seem to be affected. Further evaluation of laparoscopy in this indication is needed.

[Place and results of frozen section analysis in the management of malignant and borderline ovarian tumors]. / Place et résultats de l'examen extemporané dans la stratégie chirurgicale des tumeurs épithéliales malignes et à la limite de la malignité de l'ovaire.

The management of ovarian tumors discovered during laparoscopy depends equally on the surgeon and the pathologist. Thus, the surgeon will undergo a more or less radical surgery depending on frozen section analysis (FSA),which depends mainly on the pathologist's skills, the histopathologic type and the volume and the localization of the tumor. The accuracy of FSA is higher in ovarian cancer than in borderline tumor. In patients treated initially with a laparoscopic approach, if the FSA demonstrates the presence of an invasive carcinoma, a conversion to laparotomy should be performed in order to complete the surgical staging. If the FSA demonstrates the presence of a borderline tumor, an exclusive laparoscopic approach could be discussed.

[Are nodal metastases in ovarian cancer chemoresistant lesions? Comparative study of initial lymphadenectomy or after chemotherapy]. / Les métastases ganglionnaires du cancer épithélial de l'ovaire sont-elles chimio-sensibles?

OBJECTIVE: The aim of this study is to compare the rates of nodal involvement in epithelial ovarian cancer (EOC) in patients who underwent initial lymphadenectomy (before chemotherapy/group 1) and patients who underwent lymphadenectomy after chemotherapy (during interval debulking surgery/group 2 or second-look surgery/group 3). PATIENTS AND METHODS: The rates of nodal involvement in 205 patients with EOC who underwent complete pelvic and paraaortic lympadenectomy were compared. One hundred and five patients underwent this surgical procedure at the end of chemotherapy (group 3) or during chemotherapy (group 2) for 28 patients (with three courses of a platinum-based regimen containing paclitaxel) and were compared to 100 patients who underwent initial lymphadenectomy (group 1). RESULTS: In patients with stage I and II disease the rate of nodal involvement in group 1 and 3 were similar (respectively 19% vs. 21% and 50% vs. 33% in stage I or II disease-NS). In patients with stage III disease, the rates of nodal involvement in patients treated with initial surgery, interval debulking surgery (with paclitaxel-based regimen) and second-look surgery were respectively: 53%, 58% and 48% (NS). Adding to the platinum-based regimen does not seem to improve node sterilization rates. DISCUSSION AND CONCLUSIONS: The rates of nodal involvement seem to be similar in patients treated before or after chemotherapy but the comparison of groups is difficult because the presence of several bias (particularly in early stage disease). Such results suggest that nodal metastases are not totally sterilized by chemotherapy. However, further studies are needed to evaluate the therapeutic value of lymphadenectomy in patients with nodal involvement.

Effect of laparoscopy versus laparotomy on circulating tumor cells using isolation by size of epithelial tumor cells.

AIM: To assess the effect of laparoscopy on circulating tumor cell (CTC) detection in case of carcinosis. MATERIAL AND METHODS: We compared laparoscopy versus laparotomy on tumor cell blood release in an animal model of ovarian carcinosis obtained by intraperitoneal inoculation of IGR-OV1 cells in nude rats. Animals were randomly assigned to one of the following groups: CO(2) laparoscopy (L), gasless laparoscopy (GL), midline laparotomy (ML), or general anesthesia as control (C). A 0.5 ml blood sample was taken in each case before and after experiment and tested with a novel assay, ISET (isolation by size of epithelial tumor cells), which isolates CTC by filtration on account of their size. Statistics were performed with the Fisher's and the Chi-square tests. RESULTS: Ten rats were included in each group. We did not find any significant difference in CTC prevalence before and after surgery (2/14 versus 3/19, respectively, P = 1). Similarly, the three surgical accesses were equivalent with one post-experiment detection per group: 1/5 for L, 1/7 for ML, 1/7 for GL, and 1/6 for C (P = 0.9). CONCLUSION: This trial did not show any deleterious effect of laparoscopy on CTC when compared to laparotomy.

Are nodal metastases in ovarian cancer chemoresistant lesions? Analysis of nodal involvement in 105 patients treated with preoperative chemotherapy.

BACKGROUND: To report the rates of nodal involvement in epithelial ovarian cancer (EOC) in patients who underwent initial lymphadenectomy (before chemotherapy) and patients who underwent lymphadenectomy after chemotherapy. STUDY DESIGN: The rates of nodal involvement in 205 patients with EOC who underwent complete bilateral pelvic and para-aortic lympadenectomy between 1985 and 2001 were analyzed: 100 women underwent this surgical procedure before chemotherapy (initial surgery) and 105 at the end of chemotherapy (second-look surgery for 77 patients with 6 courses of a platinum-based regimen) or during chemotherapy (interval debulking surgery for 28 patients with 3 courses of a platinum-based regimen containing paclitaxel). RESULTS: The overall frequency of lymph-node involvement was 35% (35/100) in patients treated with initial surgery, 54% (15/28) in the interval debulking surgery group and 36% (28/77) in the second-look surgery group. In patients with Stage III disease, the rates of nodal involvement in patients treated with initial surgery, interval debulking surgery (with paclitaxel-based regimen) and second-look surgery were respectively: 53% (15/28), 58% (15/26) and 48% (20/42). The rates of nodal involvement in patients who underwent lymphadenectomy prior to or after chemotherapy were not statistically different whatever the stage of the disease. Adding paclitaxel to the platinum-based regimen does not seem to improve node sterilization rates. CONCLUSIONS: The rates of nodal involvement seem to be similar in patients treated before or after chemotherapy. Such results suggest that nodal metastases are not as chemosensitive as peritoneal lesions. However, further studies are needed to evaluate the therapeutic value of lymphadenectomy in patients with nodal involvement.

Clinical outcome after laparoscopic pure management of borderline ovarian tumors: results of a series of 34 patients.

BACKGROUND: The aim of this study was to assess clinical outcome after laparoscopic treatment of borderline ovarian tumor (BOT). PATIENTS AND METHODS: Thirty-four patients treated initially and/or for recurrent disease using a laparoscopic approach for BOT from 1984 to January 2002. RESULTS: Thirty-four patients underwent laparoscopic pure treatment (without conversion by laparotomy and/or reassessment surgery by laparotomy) for BOT. Conservative treatment was performed in 31 (91%) patients. Median follow-up time was 45 months (range 6-228). Six (17%) patients recurred (in the remaining ovary following conservative surgery in five patients and in the peritoneum in one patient). Two port-site metastases were observed. None of the patients had recurrent disease in the form of ovarian carcinoma. Nine spontaneous pregnancies were observed in six patients from a group of 15 patients desiring pregnancy. All patients are alive today and disease-free. CONCLUSION: These results seem to demonstrate that laparoscopic treatment can be safely performed in young patients with early stage BOT. Such a procedure is then feasible, but should be evaluated in patients with BOT and peritoneal implants.

Value of routine follow-up procedures for patients with stage I/II cervical cancer treated with combined surgery-radiation therapy.

BACKGROUND: The aim of this study was to determine the value of routine follow-up for the detection of recurrence in patients treated for cervical cancer. PATIENTS AND METHODS: From 1986 to 1998, 583 women with stage I and II cervical carcinoma were treated with combined surgery-radiation therapy. After treatment, follow-up was based on clinical examination, a systematic Pap smear and radiography (chest X-ray and abdomino-pelvic ultrasonography). RESULTS: Forty-five patients had recurrence observed with a delay > or = 6 months following the end of treatment. Thirty-eight patients had symptoms and seven were asymptomatic at the time of their recurrence. Among asymptomatic patients only two recurrences were diagnosed following routine examinations. Survival is similar in asymptomatic and symptomatic recurrent patients. CONCLUSIONS: In conclusion, follow-up of patients treated for cervical cancer based on routine Pap smears and systematic radiography does not permit earlier detection of recurrence and does not increase survival.

[Modalities and limits of conservative treatment of adenocarcinoma in situ of the uterine cervix: analysis of nine cases and review of the literature]. / Modalités et limites du traitement conservateur des adénocarcinomes in situ du col utérin : analyse de neuf cas et revue de la littérature.

OBJECTIVE: The aim of this study is to assess the results of conservative management of adenocarcinoma in situ (AIS) of the uterine cervix in young patients. PATIENTS AND METHODS: Data of 16 patients treated for AIS were reviewed: 10 were treated initially conservatively (cold knife conization in five patients, loop excision in three patients and cervical amputation in two patients) and six radically. One patient treated initially conservatively with loop excision and positive margins underwent a completion surgery (hysterectomy). RESULTS: None patient had recurrence whatever the type of surgery (radical or conservative) with a mean follow-up of 74 months. Two pregnancies were observed. DISCUSSION AND CONCLUSIONS: Conservative surgery for patients with AIS could be considered in young patients. But [for] reviewing literature several conditions should be respected: careful follow-up after conservative treatment; cold knife conization; length of cone specimen >25 mm and free margins. If those criteria are respected the risk of recurrent disease under the form of invasive carcinoma is low.

[Surgery for uterine sarcoma: review of the literature and recommendations for the standard surgical procedure]. / Chirurgie des sarcomes utérins: revue de la littérature et recommandations sur la prise en charge chirurgicale.

Hysterectomy and bilateral salpingo-oophorectomy is the gold standard for the surgical procedure of uterine sarcoma in case of tumor limited to the uterine corpus. Omentectomy and lymphadenectomy should be performed in carcinosarcoma. In others histologic subtypes, lymphadenectomy should be performed only in patients with enlarged nodes discovered at the time of the surgical procedure. Surgical resection should be ideally performed without uterine parcelling out and so using a laparotomy in order to avoid this risk.

Sentinel lymphadenectomy without systematic axillary dissection in breast cancer patients: predictors of non-sentinel lymph node metastasis.

AIMS: To identify factors predicting metastatic involvement of non sentinel axillary lymph nodes in breast cancer patients who underwent sentinel lymph node (SLN) biopsy followed by complete axillary dissection only in case of metastatic sentinel lymph node. METHODS: A prospective database including 165 breast cancer patients who underwent SLN biopsy without further complete axillary dissection in case of non-metastatic SLN was reviewed. Primary tumor size, pathologic grade, lymphatic invasion in the primary tumor, estrogen receptor status, tumor size in the SLN and number of metastatic SLNs were tested as possible predictors of metastatic involvement of non-SLN. RESULTS: The sentinel lymph node detection rate was 97% (160/165 patients). The mean number of SLNs per patient was 1.8 (range: 1-5). Fifty patients (31.3%) had a metastatic axillary SLN: 10 of the 42 patients with T1a or T1b breast tumors and 40 of the 118 patients with T1c< or = 15mm tumors. Fifteen of the 50 patients with metastatic SLN had metastatic non-SLN. Primary tumor size, tumor size in the SLN, pathologic grade, estrogen receptor status and age were not significantly associated with metastatic involvement of non-SLN. Number of metastatic SLNs fell short of reaching statistical significance (P: NS). Lymphatic invasion in the primary tumor was the only factor significantly associated with the presence of tumor in the non SLN (P<0.01). CONCLUSION: In our series, only lymphatic invasion in the primary tumor was correlated with metastases detection in the non-SLN. We could not identify a subset of patients without metastatic non-SLN in patients with metastatic SLN.

Prognostic factors for patients with advanced stage serous borderline tumours of the ovary.

BACKGROUND: The aim of this study was to determine the prognostic factors for patients with advanced stage, low malignant potential ovarian tumour (LMPOT). PATIENTS AND METHODS: A retrospective review of 80 patients with serous LMPOT and peritoneal implants treated at or referred to our institution was carried out. RESULTS: Sixty-five patients had non-invasive implants. Fifteen patients had invasive implants. Twenty-nine patients had stage II and 51 patients had stage III disease. Three patients died of evolutive invasive disease and four of complications of treatment. The only prognostic factor of progression to 'evolutive invasive disease' is the pathologic subtype of peritoneal implants. The 5-year rates of evolutive invasive disease in patients with non-invasive implants and invasive implants were 2% and 31%, respectively (P <0.002). CONCLUSIONS: In this series, the only prognostic factor for patients with advanced stage borderline tumour is the type of peritoneal implant. More patients died of the treatment's complications than of the disease itself. The patients' prognosis with non-invasive implants seems to be excellent, and conservative management could be discussed in younger patients.

Results of interval debulking surgery in advanced stage ovarian cancer: an exposed-non-exposed study.

BACKGROUND: To study the results of interval debulking surgery (IDS) in patients treated for 'unresectable' advanced stage ovarian cancer compared with primary debulking surgery (PDS) followed by chemotherapy. PATIENTS AND METHODS: An exposed-non-exposed study including a group of 34 patients who underwent an IDS and were matched to an historic control group of 34 patients treated with PDS. RESULTS: Optimal cytoreductive surgery was achieved in 94% (32 out of 34) of patients in both groups. The rates of post-operative morbidity, blood transfusion and median length of hospitalisation were significantly reduced in the study (IDS) group, but survival did not differ in both groups. CONCLUSIONS: IDS in patients with advanced stage ovarian cancer offers the same chance of survival as PDS, but it is better tolerated.

[Hysterosonography]. / Hystérosonographie.

Hysterosonography, which consists in the injection of some cc of saline in the uterine cavity during sonography, allows an exploration of the uterine cavity and of the endometrium. Accuracy of hysterosonography is similar to that of office hysteroscopy. Hysterosonography distinguishes normal cavities from pathologic ones, endometrial atrophy from mucosal anomalies, polyps from myomas. Conversely, endometrial biopsy is still necessary for diagnosis of hyperplasia or cancer. Hysterosonography can also be proposed for first trimester bleedings, trophoblast retention or ectopic pregnancy. In the near future it could be applied to therapeutic goals such as sonographic section of polyps.

[Results and fertility after conservative treatment of invasive epithelial ovarian cancer]. / Résultats carcinologiques et fertilité après traitement conservateur des cancers épithéliaux invasifs de l'ovaire.

OBJECTIVE: The aim of this study is to assess the clinical outcome and fertility in patients managed conservatively for epithelial ovarian cancer (EOC). PATIENTS: Datas of 42 patients treated conservatively for EOC were reviewed. Thirty-seven followed-up patients with complete data were analyzed. Optimal surgical staging was performed in two cases during the initial surgery and in 33 patients during a reassessment surgery. Six patients underwent a hysterectomy during this restaging surgery. RESULTS: Among 31 patients treated conservatively following the restaging surgery, the FIGO staging distribution was: 24 stage IA (grade 1 n = 10; grade 2 n = 12; grade 3 n = 2); two stages IC; two stage II and two patients with initial stage unknown. Ten patients recurred (eight on the remaining ovary). The disease free survival at five years for patients with stage IA grade 1 and two tumors were respectively 89 and 66%. All patients with stage > IA recurred. Only five pregnancies (four spontaneous and one following IVF procedure) were obtained. CONCLUSION: Conservative surgery for patients with EOC could be considered in young patient with stage IA grade 1 disease adequately staged and desiring to preserve fertility potential but should not performed in patients with FIGO stage > IA.