Can we use robotic surgery for the treatment of pelvic recurrence and locally advanced tumors in gynecological surgery?

Over the past 20 years, feasibility of laparoscopic approaches has been validated in gynecologic surgery. This procedure has specific challenges due its longer learning curve and the limits imposed by the technique. For the surgical treatment of recurrent pelvic cancers or locally advanced tumors, open surgery remains the gold standard for most surgical teams. Robotic assistance could be an interesting alternative. The aim of this study is to present our department's robotic surgical procedures in this specific field and show its feasibility and reproducibility on several patients.

White matter predicts functional connectivity in premanifest Huntington's disease.

OBJECTIVES: The distribution of pathology in neurodegenerative disease can be predicted by the organizational characteristics of white matter in healthy brains. However, we have very little evidence for the impact these pathological changes have on brain function. Understanding any such link between structure and function is critical for understanding how underlying brain pathology influences the progressive behavioral changes associated with neurodegeneration. Here, we demonstrate such a link between structure and function in individuals with premanifest Huntington's. METHODS: Using diffusion tractography and resting state functional magnetic resonance imaging to characterize white matter organization and functional connectivity, we investigate whether characteristic patterns of white matter organization in the healthy human brain shape the changes in functional coupling between brain regions in premanifest Huntington's disease. RESULTS: We find changes in functional connectivity in premanifest Huntington's disease that link directly to underlying patterns of white matter organization in healthy brains. Specifically, brain areas with strong structural connectivity show decreases in functional connectivity in premanifest Huntington's disease relative to controls, while regions with weak structural connectivity show increases in functional connectivity. Furthermore, we identify a pattern of dissociation in the strongest functional connections between anterior and posterior brain regions such that anterior functional connectivity increases in strength in premanifest Huntington's disease, while posterior functional connectivity decreases. INTERPRETATION: Our findings demonstrate that organizational principles of white matter underlie changes in functional connectivity in premanifest Huntington's disease. Furthermore, we demonstrate functional antero-posterior dissociation that is in keeping with the caudo-rostral gradient of striatal pathology in HD.

[Single-port versus mini-laparoscopy in benign adnexal surgery: Results of a not randomized pilot study]. / Cœlioscopie monotrocart versus micro-cœlioscopie dans la chirurgie annexielle bénigne : résultats d'une étude pilote non randomisée.

OBJECTIVE: Carry out a preliminary study comparing postoperative pain and intraoperative and postoperative complications between micro-laparoscopy and laparoscopic monotrocart non-oncological adnexal surgery. METHODS: All patients should benefit from a benign adnexal surgery were included prospectively from February to May 2014. The insufflation pressure, infiltration of trocar holes with a local anesthetic, postoperative analgesics were prescribed standardized. Operative and postoperative complications, type and length of hospital stay as well as EVA and analgesic consumption were recorded. RESULTS: Nine patients were included in monotrocart group versus 7 in the micro-laparoscopy group. There were no differences in operative and postoperative complications, the type and length of hospital stay, as well as cosmetics satisfaction. However, there was a significant difference in the VAS to D2 (2.15 vs. 4.08, P=0.04) and analgesic consumption at D0 (P=0.04), D1 (P=0.04), D2 (P=0.02) and D3 (P=0.01), for the benefit of micro-laparoscopy. DISCUSSION AND CONCLUSION: Despite an enrollment of patients low, micro-laparoscopy appears to have a significant advantage over the monotrocart laparoscopy for postoperative pain in benign adnexal surgery.

[Lobular invasive breast cancer prognostic factors: About 940 patients]. / Facteurs pronostiques des carcinomes lobulaires infiltrants du sein : à propos de 940 cas.

OBJECTIVES: To assess the prognostic factors of T1 and T2 infiltrating lobular breast cancers, and to investigate predictive factors of axillary lymph node involvement. METHODS: This is a retrospective multicentric study, conducted from 1999 to 2008, among 13 french centers. All data concerning patients with breast cancer who underwent a primary surgical treatment including a sentinel lymph node procedure have been collected (tumors was stage T1 or T2). Patients underwent partial or radical mastectomy. Axillary lymph node dissection was done systematically (at the time of sentinel procedure evaluation), or in case of sentinel lymph node involvement. Among all the 8100 patients, 940 cases of lobular infiltrating tumors were extracted. Univariate analysis was done to identify significant prognosis factors, and then a Cox regression was applied. Analysis interested factors that improved disease free survival, overall survival and factors that influenced the chemotherapy indication. Different factors that may be related with lymph node involvement have been tested with univariate than multivariate analysis, to highlight predictive factors of axillary involvement. RESULTS: Median age was 60 years (27-89). Most of patients had tumours with a size superior to 10mm (n=676, 72%), with a minority of high SBR grade (n=38, 4%), and a majority of positive hormonal status (n = 880, 93, 6%). The median duration of follow-up was 59 months (1-131). Factors significantly associated with decreased disease free survival was histological grade 3 (hazard ratio [HR]: 3,85, IC 1,21-12,21), tumour size superior to 2cm (HR: 2,85, IC: 1,43-5,68) and macrometastatic lymph node status (HR: 3,11, IC: 1,47-6,58). Concerning overall survival, multivariate analysis demonstrated a significant impact of age less than 50 years (HR: 5,2, IC: 1,39-19,49), histological grade 3 (HR: 5,03, IC: 1,19-21,25), tumour size superior to 2cm (HR: 2,53, IC: 1,13-5,69). Analysis concerning macrometastatic lymph node status nearly reached significance (HR: 2,43, IC: 0,99-5,93). There was no detectable effect of chemotherapy regarding disease free survival (odds ratio [OR] 0,8, IC: 0,35-1,80) and overall survival (OR: 0,72, IC: 0,28-1,82). Disease free survival was similar between no axillary invasion (pN0) and isolated tumor cells (pNi+), or micrometastatic lymph nodes (pNmic). There were no difference neither between one or more than one macromatastatic lymph node. But disease free survival was statistically worse for pN1 compared to other lymph node status (pN0, pNi+ or pNmic). Factors associated with lymph node involvement after logistic regression was: age from 51 to 65 years (OR: 2,1, IC 1,45-3,04), age inferior to 50 years (OR 3,2, IC: 2,05-5,03), Tumour size superior to 2cm (OR 4,4, IC: 3,2-6,14), SBR grading 2 (OR 1,9, IC: 1,30-2,90) and SBR grade 3 (OR 3,5, IC: 1,61-7,75). CONCLUSION: The analysis of this series of 940 T1 and T2 lobular invasive breast carcinomas offers several information: factors associated with axillary lymph node involvement are age under 65 years, tumor size greater than 20mm, and a SBR grade 2 or 3. The same factors were significantly associated with the OS and DFS. The macrometastatic lymph node involvement has a significant impact on DFS and OS, which is not true for isolated cells and micrometastases, which seem to have the same prognosis as pN0.

[Conservation of the nipple-areola complex in case of mastectomy]. / Conservation de la plaque aréolo-mamelonnaire en cas de mastectomie.

Nipple-Sparing Mastectomy (NSM) is a procedure with skin-sparing mastectomy and nipple-areolar complex preservation in association with immediate reconstruction. The aim of this publication is to perform a review of oncological results, technical procedure, complications and indications of NSM with discussion of post-mastectomy radiotherapy indication. Local areolar recurrence is rare and treatment is performed by resection of the nipple-areolar complex. The nipple-areolar complex necrosis rate is a specific complication, observed between 1 to 30% in literature studies. Incisions and surgical procedure of dissection are discussed.

[Single-port surgery and adnexal procedures: which indications in oncological surgery?]. / Cœlioscopie par mono-trocart et chirurgie annexielle : quelles applications en chirurgie oncologique ?

OBJECTIVE: To show the interest of single trocar in order to perform uni- or bilateral salpingo-oophorectomies. PATIENTS AND METHODS: A descriptive study monocentric. RESULTS: A total of 79 unilateral or bilateral salpingo-oophorectomies were performed by single-port laparoscopy between January 2010 and September 2012 at the Institut Paoli-Calmettes (Marseille). There are three surgical indications: diagnostic, therapeutic and prophylactic. The median age was 50 years (22-78 years). The median BMI was 22.4 kg/m(2) (17.5 to 37.7 kg/m(2)). The median blood loss was 0cc (0cc-50cc). The median hospital stay of patient was one day (0-6 days). The conversion rate in this study was 8.8%. DISCUSSION AND CONCLUSION: The single-port laparoscopic approach to perform uni- or bilateral salpingo-oophorectomies is a natural evolution of the conventional laparoscopy. If the cosmetic role seems obvious, its therapeutic value compared to traditional technique must be demonstrated by prospective studies with larger numbers.

[Robot-assisted laparoscopy in the management of recurrent pelvic cancer]. / Place de la cœlioscopie robot-assistée dans la prise en charge des récidives de cancers pelviens.

OBJECTIVES: The aim of this study is to establish the feasibility of the management of recurrent pelvic cancers by robot-assisted laparoscopy, and particularly the feasibility of robot-assisted laparoscopy anterior pelvic exenteration, from a single center series of seven patients. PATIENTS AND METHODS: From February 2007 to April 2010, all patients cared for recurrent pelvic cancer have been included (n=7). Five patients have been cared for a cervical cancer recurrence, one patient for recurrent VAIN 3, and one patient for squamous cell carcinoma of the vaginal vault after hysterectomy for cervical carcinoma in situ. All patients were benefited from robot-assisted laparoscopy: two had surgery such as anterior pelvic exenteration with Miami Pouch urinary reconstruction, and five had colpectomy with or without lymph node removal, including one with vaginal preparation first before vaginal cuff resection. Data were collected prospectively identifying treatment history, intraoperative data, immediate outcomes, pathological findings, and long-term outcomes. RESULTS: From February 2007 to April 2010, 195 patients underwent robot-assisted laparoscopy at the Institut Paoli-Calmettes. Among them, seven patients had pelvic cancer recurrence. The median age was 53 years (44 to 67). The median BMI was 25 (19.7 to 35.3). The median Karnofsky index was 100 (80-100). The median operative time was 210 min (90 to 300) for colpectomy, 480 min for pelvectomy, 240 min (90-480) for the serie. The mean duration of the installation of the robot, all procedures combined, is estimated at 22.5 min (±4.8 min). There was no conversion to laparotomy, the median blood loss was 340 ml (100 to 800). One patient was transfused with two red blood cells. There was a surgical complication (wound of the inferior mesenteric artery). There were no early postoperative complications and the median hospital stay was 6 days (3-24). There was a late postoperative complication: a patient who underwent anterior pelvic exenteration had impaired wound healing, with scarring requiring led by the VAC system. On pathological findings, the average number of nodes removed in the pelvic was 8.5 (±2) on the left, and 4 (±1.4) on the right. Three patients had involved margins; it was an anterior pelvic exenteration and two colpectomy. There was no hospital mortality, neither post-operative mortality at D30 and D90. After a median follow up of 22 months (9-34), the recurrence rate was 71% (5 patients out of 7), and one patient died 10 months after the intervention of a pulmonary embolism. DISCUSSION AND CONCLUSION: The surgical management of recurrent cervical cancer by laparoscopy-assisted robot is feasible for selected indications, and could be proposed as an alternative to laparotomy. Monitoring data in this series raise the question of the validity of conservative treatment in cases of recurrent pelvic cancer. The possibilities in terms of urinary and vaginal reconstruction remain to be defined. The impact of this surgical approach on oncological data must be confirmed.

Role of robot-assisted laparoscopy in adjuvant surgery for locally advanced cervical cancer.

OBJECTIVE: The aim of this study was to compare the feasibility and efficacy of robot-assisted laparoscopy with traditional laparotomy and conventional laparoscopy in a series of patients with locally advanced cervical cancer managed in our two institutions. METHODS: Twenty-two patients who underwent robot-assisted laparoscopy were compared with 20 patients who underwent adjuvant surgery by laparotomy and 16 who underwent conventional laparoscopy, before the arrival of the Da Vinci surgical system. RESULTS: There was no significant difference between the three groups in terms of body mass index, FIGO stage, or tumor histology. The complication rate was similar in the three groups of patients, although there was a trend towards more lymphatic complications in the robot-assisted subgroup managed medically. There was no significant difference in the recurrence rate between the robot-assisted laparoscopy, conventional laparoscopy and laparotomy groups (27.3%, 29.4% and 30%, respectively). CONCLUSION: Robot-assisted laparoscopy is feasible after concurrent chemoradiation and brachytherapy in cases of locally advanced cervical cancer. This new surgical approach reduces hospital stay, and seems to result in less severe complications than conventional laparotomy without modifying the oncological outcome.

Tapping linked to function and structure in premanifest and symptomatic Huntington disease.

OBJECTIVE: Motor signs are functionally disabling features of Huntington disease. Characteristic motor signs define disease manifestation. Their severity and onset are assessed by the Total Motor Score of the Unified Huntington's Disease Rating Scale, a categorical scale limited by interrater variability and insensitivity in premanifest subjects. More objective, reliable, and precise measures are needed which permit clinical trials in premanifest populations. We hypothesized that motor deficits can be objectively quantified by force-transducer-based tapping and correlate with disease burden and brain atrophy. METHODS: A total of 123 controls, 120 premanifest, and 123 early symptomatic gene carriers performed a speeded and a metronome tapping task in the multicenter study TRACK-HD. Total Motor Score, CAG repeat length, and MRIs were obtained. The premanifest group was subdivided into A and B, based on the proximity to estimated disease onset, the manifest group into stages 1 and 2, according to their Total Functional Capacity scores. Analyses were performed centrally and blinded. RESULTS: Tapping variability distinguished between all groups and subgroups in both tasks and correlated with 1) disease burden, 2) clinical motor phenotype, 3) gray and white matter atrophy, and 4) cortical thinning. Speeded tapping was more sensitive to the detection of early changes. CONCLUSION: Tapping deficits are evident throughout manifest and premanifest stages. Deficits are more pronounced in later stages and correlate with clinical scores as well as regional brain atrophy, which implies a link between structure and function. The ability to track motor phenotype progression with force-transducer-based tapping measures will be tested prospectively in the TRACK-HD study.