Outcomes of pre-operative brachytherapy followed by hysterectomy for early cervical cancer.

OBJECTIVE: The standard of care for early cervical cancer is radical hysterectomy; however, consideration of pre-operative brachytherapy has been explored. We report our experience using pre-operative brachytherapy plus Wertheim-type hysterectomy to treat early stage cervical cancer. METHODS: This single-center study evaluated consecutive patients with histologically proven node-negative early stage cervical cancer (International Federation of Gynecology and Obstetrics 2009 stage IB1-IIB) that was treated using pre-operative brachytherapy and hysterectomy. Pre-brachytherapy staging was performed using magnetic resonance imaging (MRI) and pelvic lymph node assessment was performed using lymphadenectomy. The tumor and cervical tissues were treated using brachytherapy (total dose 60 Gy) followed by Wertheim-type hysterectomy. The study included patients from January 2000 to December 2013. RESULTS: A total of 80 patients completed a median follow-up of 6.7 years (range 5.4-8.5). The surgical specimens revealed a pathological complete response for 61 patients (76%). Patients with incomplete responses generally had less than 1 cm residual tumor at the cervix, and only one patient had lymphovascular space involvement. The estimated 5-year rates were 88% for overall survival (95% CI 78% to 94%) and 82% for disease-free survival (95% CI 71% to 89%). Toxicities were generally mild-to-moderate, including 26 cases (33%) of grade 2 late toxicity and 10 cases (13%) of grade 3 late toxicity. Univariate analyses revealed that poor disease-free survival was associated with overweight status (≥25 kg/m2, HR 3.05, 95% CI 1.20 to 7.76, p=0.019) and MRI tumor size >3 cm (HR 3.05, 95% CI 1.23 to 7.51, p=0.016). CONCLUSIONS: Pre-operative brachytherapy followed by Wertheim-type hysterectomy may be safe and effective for early stage cervical cancer, although poorer outcomes were associated with overweight status and MRI tumor size >3 cm.

Extraperitoneal Para-Aortic Lymphadenectomy by Robot-Assisted Laparoscopy.

STUDY OBJECTIVE: To evaluate the outcomes of extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy. DESIGN: A retrospective study (Canadian Task Force classification III). SETTING: An academic institution. PATIENTS: Twenty-three consecutive patients with gynecologic cancer who presented for para-aortic lymphadenectomy between March 2016 and May 2017 were reviewed retrospectively. INTERVENTIONS: Extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was performed. MEASUREMENTS AND MAIN RESULTS: Of the 23 patients reviewed retrospectively, 10 had cervical cancer, 7 had endometrial cancer, 5 had adnexal cancer, and 1 had vaginal cancer. Data regarding patient characteristics, indication for para-aortic lymphadenectomy, type of surgery (infrarenal or inframesenteric), operative time, surgical complications, number of nodes retrieved, and postoperative hospital length of stay were collected. Two patients were excluded because of early perforation of the peritoneum. In total, 21 para-aortic lymphadenectomies were performed (16 infrarenal and 5 inframesenteric). The median skin-to-skin operating time of infrarenal extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was 170 minutes (range, 90-225 minutes), the median lymph node count was 18 (range, 11-38), and the median estimated blood loss was 50 mL (range, 10-600 mL). The median skin-to-skin operating time of inframesenteric extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was 120 minutes (range, 90-220 minutes), the median lymph node count was 10 (range, 7-19), and the median estimated blood loss was 30 mL (range, 10-100). Intraoperative complications included 1 thermal lesion of the left genitofemoral nerve, 1 thermal lesion of the left mesoureter (a ureteral stent was placed to avoid ureteric necrosis and fistula without after effect), and 1 lesion of the inferior vena cava that was sutured by robot-assisted laparoscopy. There were 2 additional cases of perforation of the peritoneum that occurred in the infrarenal group. The median hospital length of stay was 1 day (range, 0-7 days). Three patients were readmitted for symptomatic lymphocysts. CONCLUSION: Extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy provides good visualization of the operative field without arm conflict. Still, perforation of the peritoneum and symptomatic lymphocysts are a postoperative concern.

Pretherapeutic staging of locally advanced cervical cancer: Inframesenteric paraaortic lymphadenectomy accuracy to detect paraaortic metastases in comparison with infrarenal paraaortic lymphadenectomy.

BACKGROUND: Extended-field chemoradiation therapy is usually performed in patients with locally advanced cervical cancer (LACC) and paraaortic (PA) node metastases. Considering the very low rate of skip metastases above inferior mesenteric artery, ilio-inframesenteric paraaortic lymph node dissection (IM-PALND) seems to be an adequate pattern of PALND. Our objective was to assess the accuracy of this management to determine PA nodal status in comparison with infrarenal paraaortic lymphadenectomy (IR-PALND) in case of squamous or glandular cervical cancer. METHODS: All patients with LACC and negative MRI and PET/CT imaging at paraaortic level had laparoscopic staging (followed, if negative, by extraperitoneal paraaortic lymphadenectomy). From January 2011 to September 2015, patients who had IM-PALND were included and were compared to a previous historical series of IR-PALND patients. The two groups differed only at the upper level of dissection. Characteristics of nodal involvement at paraaortic level depending on level of dissection, PET/CT imaging and histology were studied. RESULTS: 119 women were included in our study, with 56 patients in the IM-PALND group and 63 in the IR-PALND group. In the IM-PALND group, fewer nodes were resected (p<0.001). There was no difference between the two groups regarding nodal status at paraaortic level (p=0.77). Patterns of nodal involvement were similar whichever the histological subtype of cervical cancer (squamous or glandular). CONCLUSION: IM-PALND appears to be equally effective to assess paraaortic nodal involvement in LACC for both histological subtypes - glandular and squamous carcinomas - and to select patients for extended-field chemoradiation therapy.

Morbidity of Staging Inframesenteric Paraaortic Lymphadenectomy in Locally Advanced Cervical Cancer Compared With Infrarenal Lymphadenectomy.

OBJECTIVE: Extended-field chemoradiation is typically used for the management of patients with locally advanced cervical cancer. Given the low rate of skipped metastases above the inferior mesenteric artery, ilioinframesenteric dissection seems to be an acceptable pattern of paraaortic lymph node dissection (LND). Our objective is to compare the surgical morbidity of inframesenteric LND (IM-LND) with infrarenal LND (IR-LND). METHODS: In our center, all of the patients with locally advanced cervical cancer and negative magnetic resonance imaging and positron emission tomography-computed tomography imaging at the paraaortic level were offered laparoscopic staging including a diagnostic laparoscopy followed, if negative, by an extraperitoneal paraaortic lymphadenectomy. From January 2011 to September 2015, we included patients who had paraaortic LND from both common iliac bifurcations and divided them into 2 groups according to dissection pattern: to the inferior mesenteric artery (IM-LND) level or to the left renal vein (IR-LND) level. The perioperative and postoperative data were retrospectively recorded. RESULTS: A total of 119 women were included in our study: 56 in the IM-LND group and 63 in the IR-LND group. There was no difference in the patients' characteristics between groups. Regarding the surgical procedure, the operating time was shorter in the IM-LND group than the IR-LND group, 174 ± 50 minutes versus 209 ± 61 minutes (P = 0.001), respectively. There was no significant difference in intra- and postoperative complications, overall survival, or progression-free survival. CONCLUSIONS: In our series, exclusive IM-LND surgery is faster than IR-LND and results in similar morbidity and survival rates. These results confirm the feasibility and the applicability of IM-LND to simplify the surgical procedure without impacting survival. More patients should be included in the study to demonstrate the lower rate of morbidity.

Fluorescence-assisted sentinel (SND) and pelvic node dissections by single-port transvaginal laparoscopic surgery, for the management of an endometrial carcinoma (EC) in an elderly obese patient.

OBJECTIVE: To explore the feasibility of an oncologically acceptable management for an intermediate-risk endometrial cancer (EC) in an elderly, using the combination of transvaginal single-port laparoscopy and sentinel node policy. METHODS: For this 85-years old patient, BMI 32kg/m2, with IB grade 2 endometrioid EC, a single vaginal approach was attempted [1] to perform a total hysterectomy, bilateral salpinago-oophorectomy and pelvic node assessment guided by SND [2]. Injections of indocyanine green (ICG) were performed at 3 and 9 o'clock and 2 depths [3] into the uterine cervix A simple vaginal hysterectomy was first performed using a 5mm vessel sealer (LigaSure®-Medtronics) to limit ICG leakage. As poorly accessible, adnexas were divided close to cornuas; uterine corpus was delivered vaginally. Then, a single port device (Gelpoint®-Applied), equipped with 3 trocars for optique and instruments, was installed through vagina. After transvaginal pneumoperitoneum insufflation, bowel loops were cleared from the pelvis. Latero-pelvic peritoneum was incised between external iliac pedicles and ureters. Following the algorithm, node dissection was limited to sentinel node clearly identified on the right side under color-segmented fluorescence (Pinpoint®-Novadaq), but a full pelvic dissection completed an unsatisfactory SND on the left side. Procedure was terminated with salpingo-oophorectomies. After protected vaginal specimen delivery, the single-port device was removed and vagina was closed as usual. RESULTS: Patient was discharged on the 1st post-operative day. Final pathology confirmed the FIGO stageIB grade2 EC. CONCLUSIONS: A transvaginal laparoscopic pelvic SND after vaginal hysterectomy is feasible. This single-port "NOTES" strategy bridges the previous gaps of a pure vaginal approach and seems interesting in fragile EC patients.

Boari flap ureteroneocystostomy in an oncological patient.

OBJECTIVE: Demonstration of surgical steps of a Boari Flap ureteroneocystostomy in an oncological context. METHODS: Clinical case of a 66-year-old woman diagnosed with a left-pelvic recurrence of a high-grade serous ovarian carcinoma, involving the left ureter. After transection of 5cm of ureteral length, up to the level of the bifurcation of common iliac vessels, it was decided to perform a Boari Flap for ureteral reimplantation. RESULTS: Through the tubularization of a bladder flap, the extension of the ureter to the bladder is possible. After mobilization and psoas fixation, the bladder is opened on its anterior surface, in a rhomboid incision, and a full thickness bladder flap is extended cranially and tubularized for anastomosis of the proximal ureteral segment. The ureter is reimplanted after creation of an anti-reflux system with a submucosal tunnel between the mucosa and the detrusor. To finish the procedure, the bladder is closed in two layers with a running monofilament absorbable suture. CONCLUSIONS: Boari Flap ureteroneocystostomy is an uncommon urinary reconstruction, useful to correct distal ureteric defects caused by traumatic, oncological or iatrogenic injuries [1]. The success rate of ureteral reimplantation can be higher than 85% [2]. This technique is suitable for anastomosis of lumbar ureteral segments, allowing the better correction of higher and more extensive defects than the Psoas-Hitch technique. The flap length should compensate the ureteric defect and enable a tension free anastomosis.

Should Systematic Infrarenal Para-aortic Dissection Be the Rule in the Pretherapeutic Staging of Primary or Recurrent Locally Advanced Cervix Cancer Patients With a Negative Preoperative Para-aortic PET Imaging?

BACKGROUND: Extended-field chemoradiation is the usual management of patients with locally advanced cervical cancer (LACC) and para-aortic node metastases (PA pN1). It is efficient but not without morbidity. Assessment of PA lymph node positivity by PA lymphadenectomy is the most accurate method to select the candidates for this treatment. Hence, to clarify the dissection pattern, we wanted to test the true incidence of isolated/skip node metastasis, above the level of the inferior mesenteric artery (IMA). MATERIALS AND METHODS: All patients with LACC and negative magnetic resonance imaging and positron emission tomography-computed tomography imaging at the PA level were offered a laparoscopic staging encompassing a diagnostic laparoscopy followed, if negative, by an extraperitoneal PA lymphadenectomy. All nodes were removed from both common iliac bifurcations up to the left renal vein. Node groups, below and above the IMA, were separately sent to the pathologist for definitive examination. RESULTS: From January 2010 to December 2013, 196 stage IB1 with pelvic pN1, IB2, to IVA LACC patients from 2 cancer centers who fulfilled the criteria were included in this institutional review board-approved study after informed consent. Thirty patients (15%) had PA pN1. Only 1 patient had positive nodes exclusively located above the IMA (3.3% of the pN1 group; 95% confidence interval, 0%-9.7%). Complications were observed in 15 (7.6%) of 196 patients. CONCLUSIONS: Given the very low rate of skip metastases above the IMA and the potential additional morbidity of a systematic extended dissection, a bilateral ilioinframesenteric dissection seems to be an acceptable pattern of PA lymphadenectomy in LACC patients.

Single-port or Classic Laparoscopy Compared With Laparotomy to Assess the Peritoneal Cancer Index in Primary Advanced Epithelial Ovarian Cancer.

A thorough laparoscopic assessment of the abdominopelvic cavity is a crucial step in the workup of primary advanced epithelial ovarian cancer to decide whether up-front cytoreductive surgery or neoadjuvant chemotherapy is the best option for adequate management. The purpose of our study was to compare single-port laparoscopy (SPL), classic laparoscopy (CL), and laparotomy using the peritoneal cancer index (PCI). Patients treated for Fédération Internationale de Gynécologie et d'Obstétrique stage 3 or 4 epithelial ovarian cancer were included in our study when they underwent a PCI evaluation by laparoscopy followed by laparotomy for cytoreduction. According to the technique used for the "noninvasive" procedure (SPL vs CL), 2 groups were compared retrospectively. The individual records of all patients were reviewed and analyzed. From 2011 to 2014, 21 patients were assessed for PCI by SPL plus laparotomy versus 21 by CL plus laparotomy. The clinicopathological features were similar in both groups (not significant [NS]), except for performance status >0, which was more frequent in the SPL group (39% vs 6%, p = .04). Quotation of PCI was possible for all patients. Nonbrowsing areas marked 3 procedures in the SPL group and 2 procedures in the CL group (NS). The mean PCI score and the score of each region assessed by SPL and CL were comparable with the evaluation by laparotomy (NS). Completeness of cytoreduction was achieved in 78% of cases in both groups (NS). SPL and widely mini-invasive procedures seem to be effective tools compared with laparotomy to adequately assess the resectability of a peritoneal carcinomatosis using the PCI.

A Simple Laparoscopic Procedure to Restore a Normal Vaginal Length After Colpohysterectomy With Large Upper Colpectomy for Cervical and/or Vaginal Neoplasia.

Colpohysterectomy is sometimes associated with a large upper colpectomy resulting in a shortened vagina, potentially impacting sexual function. We report on a preliminary experience of a laparoscopic colpoplasty to restore a normal vaginal length. Patients with shortened vaginas after a laparoscopic colpohysterectomy were considered for a laparoscopic modified Davydov's procedure to create a new vaginal vault using the peritoneum of the rectum and bladder. From 2010 to 2014, 8 patients were offered this procedure, after informed preoperative consent. Indications were 2 extensive recurrent vaginal intraepithelial neoplasias grade 3 and 6 radical hysterectomies for cervical cancer. Mean vaginal length before surgery was 3.8 cm (standard deviation, 1.6). Median operative time was 50 minutes (range, 45-90). Blood loss was minimal (50-100 mL). No perioperative complications occurred. Median vaginal length at discharge was 11.3 cm (range, 9-13). Sexual intercourse could be resumed around 10 weeks after surgery. At a median follow-up of 33.8 months (range, 2.4-51.3), 6 patients remained sexually active but 2 had stopped. Although this experience is small, this laparoscopic modified Davydov's procedure seems to be an effective procedure, adaptable to each patient's anatomy. If the initial postoperative regular self-dilatation is carefully observed, vaginal patency is durably restored and enables normal sexual function.

Occult invasive cervical cancer found after inadvertent simple hysterectomy: is the ideal management: systematic parametrectomy with or without radiotherapy or radiotherapy only?

BACKGROUND: After the diagnosis of occult cervical cancer during simple hysterectomy, is the best treatment option for the patient surgery with or without radiotherapy or radiation therapy only? Our study aims to answer this question. MATERIALS AND METHODS: We retrospectively analyzed 29 patients with occult cervical cancer found after inadvertent simple hysterectomy and who were referred to our cancer center between 2000 and 2010. All of the patients were discussed by the tumor board. Thirteen patients underwent surgery (radical parametrectomy and pelvic lymphadenectomy) using the minimally invasive approach (surgical group), and 16 patients underwent pelvic lymphadenectomy and radiation therapy or concurrent chemoradiation (radiation group). RESULTS: Age, BMI, and the tumor diameter were not statistically different between the surgical and radiation group: 44 and 49 (± 11) years (p = .23), 24.6 (± 6.2) and 26.7 (± 5) (p = 0.33), and 22 (± 13) and 31 (± 11) mm (p = .09), respectively. The 5-year overall and disease-free survivals for the surgical and radiation groups were: 100 and 77 % (p = .04), and 86 and 37 % (p = .02), respectively. These results were statistically significant. CONCLUSIONS: In the case of occult cervical cancer found after simple hysterectomy, radical parametrectomy with pelvic lymphadenectomy using minimally invasive surgery seems to be more efficient than radiation therapy or concurrent chemoradiation, with acceptable minimal morbidity being observed.

Managing Endometrial Cancer: The Role of Pelvic Lymphadenectomy and Secondary Surgery.

PURPOSE: In November 2010, the French National Cancer Institute published new guidelines for managing endometrial cancer. Pelvic lymphadenectomy is not indicated for preoperative low-intermediate risk type 1 endometrial cancer, and high-risk patients should undergo secondary surgery with para-aortic lymphadenectomy. This study evaluated these new guidelines with regard to overall survival (OS), relapse-free survival (RFS), and morbidity for patients with low-intermediate risk disease. METHODS: We evaluated all type 1 endometrial cancer patients with low-intermediate risk of recurrence who were treated from 1 January 1997 through 31 December 2012. All patients were classified according to the 2009 International Federation of Gynecology and Obstetrics staging criteria and the European Society for Medical Oncology. RESULTS: Overall, 230 patients were included (159 before and 71 after the new guidelines were issued). Pelvic lymphadenectomies were performed before and after the new guidelines in 77.4 and 28.6 % of patients, respectively (p < 0.001). After 2010, eight patients also underwent secondary surgery, which consisted of a para-aortic lymphadenectomy for lymphovascular space invasion (LVSI). This second surgery changed the adjuvant treatment for one patient. OS and RFS were similar between both groups, and no difference in morbidity was observed between the groups. LVSI was an independent factor for OS [hazard ratio (HR) 7.2, 95 % CI 3.1-17; p < 0.001] and RFS (HR 3.7, 95 % CI 1.6-8.5; p < 0.003). CONCLUSIONS: Fewer pelvic lymphadenectomies in low-intermediate risk patients did not affect OS, RFS, or morbidity, including patients with secondary surgery. We must gather additional data with a longer follow-up period to not only confirm our results but to also fully investigate the paradoxical absence of decreased morbidity that our study has shown.

Extraperitoneal Para-aortic Lymphadenectomy by Robot-Assisted Laparoscopy in Gynecologic Oncology: Preliminary Experience and Advantages and Limitations.

BACKGROUND: We are reporting the preliminary multicentric experience in extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy (EPLRL) in gynecologic oncology. MATERIALS AND METHODS: Two teams from the cancer centers performed EPLRL in 37 patients with gynecologic cancer. RESULTS: There were 30 patients with cervical cancer, 6 with endometrial cancer, and 1 with adnexal cancer. The skin-to-skin operative time, mean lymph node count, and estimated blood loss were 221 (±61) minutes, 18.7 (±11), and 105 (±134) mL.There was no conversion to laparotomy, one laparoscopic conversion for hemorrhage lateral to the inferior mesenteric artery, and one use of hemostatic matrix for an injury to the left gonadal artery (2 nontransfused patients). The proportion of patients who reported postoperative complications was 32.5% (12/37): 7 with lymphocysts with computed tomographic scan drainage (19%), 3 with leg dysesthesia (left genitofemoral nerve), 1 with leg lymphedema, and 1 with lateral aortic hematoma not requiring a transfusion or return to the operating room. CONCLUSION: The EPLRL technique is feasible and efficient but with a high rate of symptomatic lymphocyst. A marsupialization could be useful to decrease the risk of lymphocyst.

Minimally invasive surgical management of early-stage cervical cancer: an analysis of the risk factors of surgical complications and of oncologic outcomes.

OBJECTIVES: The objective of this study was to evaluate the morbidity and the oncologic outcomes of laparoscopic radical hysterectomy in treating early-stage cervical cancer. METHODS: We included all patients with early-stage cervical cancer (IA, IB1, IIA1, and IIB), as assessed by the Federation International of Gynecology and Obstetrics staging criteria, undergoing laparoscopic radical hysterectomy from January 1999 to December 2013 in our center. Morbidity was classified according to the Clavien and Dindo classification. RESULTS: A total of 170 patients were included in which 7 patients were in stage IA2, 150 in IB1, 2 in IIA, and 7 in IIB. The mean operation time was 256 minutes (67-495 minutes). Fourteen severe perioperative complications (8.2%) occurred, in which 5 patients (2.9%) required conversion to an open procedure: 3 bowel injuries, 3 hemorrhages, 2 ureteral injuries, 3 bladder injuries, 2 severe adhesions, and 1 intolerance to the Trendelenburg position. Fourteen patients (8.2%) presented with 1 severe postoperative complication (grade III or more). Two factors appeared as independent risk factors for perioperative and/or postoperative complications: the tumor size (odds ratio, 1.128; 95% confidence interval, 1.054-1.207) and operative time (odds ratio, 1.0116; 95% confidence interval, 1.003-1.020). In a median follow-up of 47.7 months, the 5-year overall survival was 94.1% (range, 88.1%-97.3%), and the 5-year disease-free survival was 88.8% (range, 81.0%-92.6%). CONCLUSIONS: The laparoscopic approach was favorable for both perioperative and postoperative morbidity. With the advantage of minimal invasiveness, laparoscopic treatment by experienced surgeons is an alternative for early-stage cervical cancer with correct long-term survival outcomes. Mini-invasive surgery could be the standard in early-stage cervical cancer.

Single-port access laparoscopic surgery in gynecologic oncology: outcomes and feasibility.

OBJECTIVES: Single-port access laparoscopic surgery (SPALS) is supposed to simplify and improve the outcomes of current multiport laparoscopic procedures. This retrospective study was performed to assess the actual outcomes of SPALS in 2 simple gynecological oncology procedures, namely, diagnostic laparoscopy and bilateral adnexectomy. METHODS: We conducted a retrospective monocentric study. Case files of only those women who underwent bilateral adnexectomies and diagnostic and/or staging laparoscopy were studied with respect to the operative room time, intraoperative and postoperative complications, postoperative pain, and lengths of hospital stays. The main objective was to assess the feasibility and utility of SPALS surgery in gynecology. The secondary objective was to compare this group with a cohort of patients with multiport conventional laparoscopic surgery (MPCLS) performed during the same period. RESULTS: From December 2009 to March 2013, there were 134 patients who underwent these 2 procedures. Eighty adnexectomies were performed, 41 by SPALS and 39 by MPCLS. Fifty-four diagnostic laparoscopies were performed, with 27 patients in each group. In the group of adnexectomies, operative time was significantly lower in SPALS compared with MPCLS (36 vs 59 minutes, P < 10) and also compared with the postoperative stay (1 vs 2.2 nights, P < 10). By contrast, no significant difference was observed between the 2 methods of access in all the parameters studied in the group of diagnostic laparoscopies. CONCLUSIONS: Our experience demonstrates that SPALS is feasible and safe for simple gynecological procedures. This approach may result in a smooth postoperative course and shorter hospital stay and can thus be promoted to a day care procedure.

[Anterior dislocation of a Incarcerated Retroverted Uterus at 21 weeks of amenorrhea : Case Report. ]. / Luxation antérieure d'un utérus rétroversé incarcéré à 21 semaines d'aménorrhée : à propos d'un cas.

BACKGROUND: An incarcerated uterus refers to the retroversion of a pregnant uterus within the pelvis due to the absence of a forward tilt at the end of the first trimester. An incarcerated uterus that is overlooked or only discovered perpartum can cause severe obstetrical complications. Several authors have shared their experience with uterine incarceration management at 12, 14, and 16 weeks of amenorrhea. CASE: Our report concerns a case of uterine incarceration management at 21 weeks of amenorrhea, achieved by way of a specific anesthesia protocol and the positioning of the patient, which allowed the disimpaction of the uterus with the help of external maneuvers. No recurrence was observed. CONCLUSION: Uterine incarceration management is possible beyond 16 weeks of amenorrhea.

Background: An incarcerated uterus refers to the retroversion of a pregnant uterus within the pelvis due to the absence of a forward tilt at the end of the first trimester. An incarcerated uterus that is overlooked or only discovered perpartum can cause severe obstetrical complications. Several authors have shared their experience with uterine incarceration management at 12, 14, and 16 weeks of amenorrhea. Case: Our report concerns a case of uterine incarceration management at 21 weeks of amenorrhea, achieved by way of a specific anesthesia protocol and the positioning of the patient, which allowed the disimpaction of the uterus with the help of external maneuvers. No recurrence was observed. Conclusion: Uterine incarceration management is possible beyond 16 weeks of amenorrhea.

Is There a Place for Brachytherapy in Vulvar Cancer? A Narrative Review.

Vulvar cancer is a relatively rare neoplasm. The essential treatment is surgery for the primary tumour. However, postoperative recurrence rates are high, even in early-stage disease when tumour-free surgical margins are achieved or in the absence of associated risk factors (lymph node metastases, deep stromal invasion or invasion of the lymphatic vascular space). Radiotherapy plays an important role in the treatment of vulvar cancer. Adjuvant treatment after surgery as well as primary treatment of locally advanced vulvar cancer (LAVC) is composed of two key radiotherapy treatment scenarios, external beam radiation therapy (EBRT) either combined or not combined with brachytherapy (BT). In a recurrence setting, where surgery is not an option, BT alone or in combination with EBRT can be used. Compared to EBRT, BT has the radiobiological potential to improve dose to the target volume, minimise the dose to organs at risk, and facilitate hypofractionated-accelerated treatment. This narrative review presents recent data on the role of BT in the treatment of primary and/or recurrent vulvar cancer, including radiobiological, clinical, and therapeutic aspects.

Prognostic impact of tumor size reduction assessed by magnetic resonance imaging after radiochemotherapy in patients with locally advanced cervical cancer.

Objective: Pelvic magnetic resonance imaging (MRI) is a key exam used for the initial assessment of loco-regional involvement of cervical cancer. In patients with locally advanced cervical cancer, MRI is used to evaluate the early response to radiochemotherapy before image-guided brachytherapy, the prognostic impact of which we aimed to study. Methods: Patients with locally advanced cervical cancer treated using concomitant radiochemotherapy followed by closure treatment between January 2010 and December 2015 were included in this study. Clinical, anatomopathological, radiological, therapeutic, and follow-up data were evaluated. Results: After applying the inclusion and exclusion criteria to the initially chosen 310 patients, 232 were included for evaluation (median follow-up period, 5.3 years). The median age was 50 years (range, 25-83 years), and the median tumor size was 47.5 mm (range, 0-105 mm). Based on the International Federation of Gynaecology and Obstetrics classification system, 9 patients were in stage IB2; 20, IB3; 2, IIA; 63, IIB; 4, IIIA; 7, IIIB; and 127, IIIC1 or higher. The re-evaluation MRI was performed at the median dose of 55.5 Gy, and median reduction in tumor size was 55.2% (range, -20-100%). There was a difference between the disease-free and overall survival rates of the patients with a tumor response greater or lesser than 50%. The risk of recurrence or death reduced by 39% in patients with a tumor size reduction >50%. The overall 5-year survival rate of patients with a response greater and lesser than 50% were 77.7% and 61.5%, respectively. The 5-year disease-free survival rate for these two groups of patients were 68.8% and 51.5%, respectively. Conclusion: Our study confirms the prognostic impact of tumor size reduction using MRI data obtained after radiochemotherapy in patients with locally advanced cervical cancer.

Autologous peritoneal grafts permit rapid reperitonealization and prevent postoperative abdominal adhesions in an experimental rat study.

BACKGROUND: Reperitonealization has attracted increasing attention for its potential to prevent postoperative abdominal adhesions and subsequent related complications. We studied the effect of an autologous peritoneal graft on reperitonealization and prevention of adhesions in a rat model. METHODS: A standardized peritoneal lesion was induced on the parietal peritoneum by electrocoagulation and sutures. Twenty adult rats sustaining these lesions were randomized to 1 of 4 groups: (1) autologuous peritoneal graft with the side of mesothelial cells exposed to the abdominal cavity; (2) autologuous peritoneal graft with the side of subserosa containing fibroblasts exposed to the abdominal cavity; (3) cell sheet consisting of autologuous mesothelial cells and fibroblasts; or (4) nontreated group (Control). Fourteen days after the operation, abdominal adhesions were evaluated by macroscopic observation and histologic assessment. RESULTS: Macroscopic observation revealed that in mesothelial cells/fibroblasts grafts, there was no adhesion on the surface of the peritoneal graft covering the lesion. In contrast, in the other 3 groups, all rats obviously revealed extended and severe adhesions. Histology showed that mesothelial cells exist on the surface of the graft in mesothelial cells/fibroblasts graft, but no mesothelial cells were observed in the samples from the other groups. CONCLUSION: Autologous peritoneal grafts prevented postoperative abdominal adhesions in this rat model. As the mechanism of this prevention, the mesothelial cells survived and contributed to reperitonealization, only when they were transplanted as a part of the autologous peritoneal grafts and were located on the surface exposed to the abdomen.

Locally advanced adenocarcinoma of the cervix on uterus didelphys: a case report.

In November 2013, a woman with Herlyn-Werner-Wunderlich (HWW) syndrome was diagnosed with a locally advanced left cervical adenocarcinoma. The patient's malformation consisted of two uteri with two cervixes, a obstructed vagina, and a left renal agenesis. Classification FIGO: stage IIIa because of infiltration of the inferior third of the vagina wall. Locoregional management comprised an infrarenal lateral aortic lymphadenectomy followed by concomitant radio-chemotherapy to the pelvic (inguinal, pelvic, and infrarenal para aortic nodes) volumes. A total of 50.4 Gy were delivered (1.8 Gy/fraction/day) to the node (inguinal, pelvic, and aortic infrarenal) and pelvic volume; a concomitant boost to the primary cervical tumor and macroscopic nodes to 59.92 Gy (2.14 Gy/fraction/day) was performed. 20 Gy were delivered with intracavitary brachytherapy boost with mold technique and a pulsed-dose-rate technique due to the rarity of this uterine malformation. After 30 months of follow-up, there was no evidence of locoregional or distant recurrence.

Chemotherapy drug extravasation in totally implantable venous access port systems: how effective is early surgical lavage?

PURPOSE: Totally implantable venous access port systems (TIVAPS) are a widely used and an essential tool in the efficient delivery of chemotherapy. Chemotherapy drug extravasation (CDE) can have dire consequences and will delay treatment. The purpose of this study is to both clarify the management of CDE and show the effectiveness of early surgical lavage (ESL). METHODS: Patients who had presented to the Cancer Center of Lille (France) with TIVAPS inserted between January 2004 and April 2013 and CDE had their medical records reviewed retrospectively. RESULTS: Thirty patients and 33 events were analyzed. Implicated agents were vesicants (51.5%), irritants (45.5%) and non-vesicants (3%). Huber needle malpositionning was involved in 27 cases. Surgery was performed in 97% of cases, 87.5% of which were for ESL with 53.1% of the latter requiring TIVAPS extraction. Six patients required a second intervention due to adverse outcomes (severe cases). Vesicants were found to be implicated in four out of six severe cases and oxaliplatin in two others. Extravasated volume was above 50 ml in 80% of cases. Only one patient required a skin graft. CONCLUSIONS: CDEs should be managed in specialized centers. ESL allows for limited tissue contact of the chemotherapy drug whilst using a simple, widely accessible technique. The two main factors that correlate with adverse outcome seem to be the nature of the implicated agent (vesicants) and the extravasated volume (above 50 ml) leading to worse outcomes. Oxaliplatin should be considered as a vesicant.