Dual docking robotic surgical staging for high risk endometrial cancer.

OBJECTIVE: The standard of care for patients with high intermediate and high risk endometrial cancer is surgical staging including total hysterectomy with bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy. Over the past decade, laparoscopic or robot-assisted minimally invasive surgery has showed many benefits in the management of endometrial cancer. Few studies have specifically assessed the use of minimally invasive surgery for staging of high risk endometrial cancer. The objective of this study was to evaluate the feasibility, the morbidity and oncologic outcomes of dual docking robot-assisted surgical staging of high risk endometrial cancer. METHODS: We conducted a retrospective observational study from January 2014 to March 2016 in patients with high risk endometrial cancer who underwent dual docking robotic hysterectomy with pelvic and paraaortic lymphadenectomy (± omentectomy). Patients' demographics, operative time, conversion rate, intra and postoperative complications, pathologic results, length of stay and survival were analyzed. RESULTS: Twenty patients met the inclusion criteria. Staging surgical procedure was performed robotically with a dual docking in 18 patients. Two patients were converted to laparotomy (1 for bladder extension, 1 for exposure reasons) and no patient had a laparoconversion for complication (conversion rate 10%). One patient was post operatively re-operated within 30 days because of port hernia. In one case, paraaortic lymphadenectomy was not performed because of hemorrhage risk. When the procedure was performed with robot-assisted surgery, the median number of paraaortic nodes was 19.5 (3-45). The median operative time was 240 min (180-300). Eighty-five percent (17/20) of patients were discharged at day 4 or before. The median time to start adjuvant treatments, when indicated, was 5.5 weeks. With a median follow up of 8 months (1-18 months), no tumor recurrence was reported. CONCLUSION: Robotic surgical staging with dual docking in women with high risk endometrial cancer seems to be feasible with few complications. More studies are required to assess the safety of robotic surgery and its impact on survival.

Is complete cytoreductive surgery feasible in this patient with ovarian cancer?

BACKGROUND: Post-operative residual tumor size is the main prognostic factor in advanced epithelial ovarian cancer. Our objective was to develop a score for predicting the feasibility of complete cytoreductive surgery in patients with advanced epithelial ovarian cancer. MATERIAL AND METHODS: Using data from a retrospective cohort of 123 patients with advanced ovarian cancer, we developed a score for predicting complete cytoreductive surgery, by performing multiple logistic regression after a jackknife procedure. RESULTS: Three criteria were independently associated with incomplete cytoreductive surgery confirmed by surgery: age >60 years (adjusted odds ratio [aOR], 6.37; 95% confidence interval [95%CI], 1.9-21.3), diaphragmatic carcinomatosis by computed tomography (aOR, 3.34; 95%CI, 1.1-9.9), and a Peritoneal Cancer Index >10 by diagnostic laparoscopy (aOR, 3.8; 95%CI, 1.4-10.2). A 10-point score was developed based on these three criteria. The area-under-the-curve of the score was 0.76 (95%CI, 0.67-0.86). The score discriminated between groups with low and high risks of incomplete cytoreductive surgery (4.4% [95% CI, 0-10.5] and 42.9% [95% CI, 26.3-59.4], respectively). Using a cutoff of 4, sensitivity of the score was 92.8% (95%CI, 83.2-100) and specificity was 77% (95%CI, 67.1-84.9) for predicting incomplete cytoreductive surgery. CONCLUSION: This easy-to-calculate score may prove useful to identify patients with ovarian peritoneal carcinomatosis in whom complete cytoreductive surgery is feasible.

Evidence for the use of robotically assisted surgery in gynecologic cancers.

PURPOSE OF REVIEW: Robotically assisted laparoscopy has been introduced in the armamentarium of gynaecologic oncology surgeons. A lot of studies compared robotic surgery and laparotomy when the real issue is to demonstrate the interest and added value of robotically assisted laparoscopy versus standard laparoscopy. In this review, we will describe the most meaningful indications and advantages of robotically assisted laparoscopy in gynaecologic oncology. RECENT FINDINGS: The learning curve for advanced procedures in robot-assisted laparoscopy is shorter and easier than with the standard laparoscopy, especially for beginners. In most of the series, operating time is longer with robot, but complication rates are often decreased, especially in obese patients with a conversion rate to laparotomy that is decreased compared with standard laparoscopy. Robot-assisted laparoscopy can be used for surgery of high-risk endometrial cancer, staging of early-ovarian cancer, and pelvic exenteration in case of recurrent malignancies. Furthermore, more recent robots allow performing sentinel node biopsy in endometrial or cervical cancer using fluorescence detection with indocyanine green. SUMMARY: The spreading of robotic surgery led to an enhancement of minimal invasive surgical approach in general, and to the development of new indications in gynaecologic oncology. The superiority of robot-assisted laparoscopy still has to be demonstrated with properly designed trials.

Robot-Assisted Laparoscopic Partial Colpectomy and Intracorporeal Ileal Conduit Urinary Diversion (Bricker) for Cervical Adenocarcinoma Recurrence.

Ileal conduit urinary diversion (Bricker) is a standard surgical open procedure. The Da Vinci robot allowed precision for this surgical procedure, especially for intracorporeal suturing. Meanwhile, few reports of robot-assisted laparoscopic ileal conduit diversion (Bricker) are described in the literature. We report the case of a 69-year-old patient with a vaginal recurrence of cervical adenocarcinoma associated with vesicovaginal fistula treated by robot-assisted laparoscopic partial colpectomy and ileal conduit urinary diversion (Bricker). The robot-assisted laparoscopic procedure followed all surgical steps of the open procedure. Postoperative period was free of complications.

Robotic extraperitoneal paraaortic lymphadenectomy in gynecological cancers: feasibility, safety, and short-term outcomes of isolated and combined procedures.

OBJECTIVE: The aim of our study was to report the technique, the feasibility, and perioperative results of robotic extraperitoneal paraaortic lymphadenectomy in gynecological cancers performed for isolated or combined procedures. METHODS: This is a retrospective study of 24 consecutive patients undergoing robotic extraperitoneal paraaortic lymphadenectomy using the Da Vinci Surgical system (Intuitive Inc, Sunnyvale, CA) (cervical cancer, n = 15; high-risk endometrial cancer, n = 8; and ovarian cancer, n = 2, including 1 synchronous tumor). Extraperitoneal paraaortic lymphadenectomy was performed using the surgical technique previously described by laparoscopy. RESULTS: Of the 24 included patients, 12 patients had isolated robotic extraperitoneal paraaortic lymphadenectomy, whereas the others underwent the following associated procedures: total hysterectomy with bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and omentectomy (n = 7); pelvic transperitoneal lymphadenectomy (n = 3), laparotomic Bricker procedure (n = 1), and colpectomy (n = 1). The median age of patients was 55 (42-64) years, and body mass index was 24.1 kg/m (20.9-26.1). The operation was completed in all patients except three with associated procedures. Perioperative difficulties were encountered in 9 patients (gas leakage, n = 7; adhesions, n = 2; and dissection difficulties, n = 1). The number of removed paraaortic lymph nodes was 18 (14-25). The operating times were 180 (150-210) minutes for isolated extraperitoneal paraaortic lymphadenectomy and 240 (180-300) minutes in case of associated procedures. There were 2 intraoperative (pneumothorax and renal artery injury) and 5 postoperative (3 grades 1-2 and 2 grade 3) complications. CONCLUSIONS: If robotic-assisted extraperitoneal paraaortic lymphadenectomy seems feasible in case of isolated procedure, further studies are required to prove its benefit compared with conventional laparoscopy.

[Sentinel lymph node in low stage cervical cancers. Current data. Quality assurance. Prospects]. / Ganglion sentinelle dans les cancers du col de faible stade. Données actuelles. Assurance qualité. Perspectives.

Sentinel node biopsy appears as a promising technique for the assessment of nodal disease in early cervical cancers. Selection of a population with a low risk of nodal metastasis, a minimal training, and simple rules allow a low false negative rate. Sentinel node biopsy provides supplementary information, such as anatomical information (nodes outside of routine lymphadenectomy areas) and histological information (isolated tumors cells and micrometastases).

Laparoscopy vs robotics in surgical management of endometrial cancer: comparison of intraoperative and postoperative complications.

STUDY OBJECTIVE: To compare the rates of intraoperative and postoperative complications of robotic surgery and laparoscopy in the surgical treatment of endometrial cancer. DESIGN: Unicentric retrospective study (Canadian Task Force classification II-2). SETTING: Tertiary teaching hospital. PATIENTS: The study was performed from January 2002 to December 2011 and included patients with endometrial cancer who underwent laparoscopic or robotically assisted laparoscopic surgical treatment. Data collected included preoperative data, tumor characteristics, intraoperative data (route of surgery, surgical procedures, and complications), and postoperative data (early and late complications according to the Clavien-Dindo classification, and length of hospital stay). Morbidity was compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS: The study included 146 patients, of whom 106 underwent laparoscopy and 40 underwent robotically assisted surgery. The 2 groups were comparable in terms of demographic and preoperative data. Intraoperative complications occurred in 9.4% of patients who underwent laparoscopy and in none who underwent robotically assisted surgery (p = .06). There was no difference between the 2 groups in terms of postoperative events. CONCLUSION: Robotically assisted surgery is not associated with a significant difference in intraoperative and postoperative complications, even when there were no intraoperative complications of robotically assisted surgery.

Ovarian cancer: sites of recurrence.

INTRODUCTION: Improved knowledge of recurrence sites after contemporary surgical management of ovarian cancer is needed. MATERIAL AND METHODS: We retrospectively reviewed consecutive patients managed for epithelial ovarian or tubal cancer with surgery and platinum-based chemotherapy between January 1, 2005, and December 31, 2009, in a tertiary teaching hospital. The site of first recurrence was recorded. Univariate analysis was performed to identify factors associated with site-specific recurrence. Overall survival and progression-free survival were computed using the Kaplan-Meier method, and log-rank tests were performed to assess the impact on survival of the variables of interest. RESULTS: Recurrences were noted in 3 (20%) of 15 International Federation of Gynecologists and Obstetricians stage I to IIa patients and 36 (62.1%) of 58 International Federation of Gynecologists and Obstetricians IIb to IV patients, and the median progression-free survival was 21.6 (2.5-71) and 19.3 (1.8-67.6) months, respectively. In the advanced-disease group, 75% of recurrences involved the peritoneum and 40% were confined to the peritoneum; peritoneal recurrences developed at both treated and untreated sites. Peritoneal recurrence was associated with greater initial peritoneal involvement (Sugarbaker score, 12.1 ± 8.2 vs 7.1 ± 7.4; P = 0.01) and residual postoperative tumor. Nodal recurrences were noted in 38% of all recurrences, usually in combination with peritoneal recurrence and in the abdominal territories. Isolated distant metastasis was a rare mode of recurrence (8%). CONCLUSIONS: The peritoneum is the main recurrence site in both early and advanced ovarian cancer. Initial disease spread and extent of surgery are associated with the recurrence risk. This article supports the view that more attention should be directed toward extensive treatment of the peritoneum.

Lower-limb drainage mapping for lymphedema risk reduction after pelvic lymphadenectomy for endometrial cancer.

OBJECTIVES: Pelvic lymphadenectomy is associated with a significant risk of lower-limb lymphedema. In this proof-of-concept study, we evaluated the feasibility of identifying the lower-limb drainage nodes (LLDNs) during pelvic lymphadenectomy for endometrial cancer. Secondary objectives were to map lower-limb drainage and to assess the diagnostic value of our mapping technique. METHODS: This prospective study included patients with endometrial cancer requiring pelvic lymphadenectomy, without neoadjuvant radiotherapy or chemotherapy and without history of lower-limb surgery. A radiopharmaceutical was injected into both feet on the day before surgery. LLDNs were identified using preoperative lymphoscintigraphy and intraoperative isotopic probe detection, then removed before complete pelvic lymphadenectomy. LLDNs and pelvic lymphadenectomy specimens underwent separate histological analysis. RESULTS: Of the 12 patients with early-stage endometrial cancer, 10 underwent preoperative lymphoscintigraphy, which consistently identified inguinal, femoral, and pelvic LLDNs (detection rate: 100%). The intraoperative detection rate was 83% (10/12). Median number of hot nodes per patient was 5 nodes (range: 3-7) on the right and 3 nodes (range: 2-6) on the left. Of 107 LLDNs, 106 were in the external iliac area, including 38 in the lateral group and 45 in the intermediate and medial groups. None of the patients had node metastases at any site. No early complications related to the technique occurred. CONCLUSION: Our mapping technique appears feasible, safe, and associated with a high LLDN identification rate. LLDN mapping may allow the preservation of LLDNs, thereby decreasing the risk of lower-limb lymphedema and improving quality of life.

Value of three-dimensional contrast-enhanced power Doppler ultrasound for characterizing adnexal masses.

AIMS: The aim of this study was to assess the diagnostic performance of 3-D contrast-enhanced power Doppler ultrasonography (3-D CEPDUS) for differentiating benign and malignant adnexal masses. MATERIAL AND METHODS: Consecutive patients with adnexal masses were included prospectively and underwent 2-D ultrasonography and 3-D CEPDUS in a tertiary centre in Paris, France. The main outcome measure was the diagnostic accuracy of 3-D CEPDUS to diagnose malignant and borderline adnexal masses. The reference standard was the final histological examination. Two-dimensional ultrasonography and 3-D CEPDUS were compared using semiquantitative scores. Three-dimensional CEPDUS assessed vessel density, vessel pattern, and three vascular indexes in a 5-mL region of interest (vascularization index [VI], flow index [FI], and vascularization flow index [VFI]). The 2-D and 3-D examinations were done by different sonographers who were blinded to the other test. The pathologist was blinded to ultrasonography findings. RESULTS: Of 99 patients, 88 had benign tumors and were compared to the 11 patients with borderline (n = 5) or malignant (n = 6) tumors. The sensitivity of the subjective 2-D score was 55% (95% confidence interval [CI], 25-84) and specificity 94% (95%CI, 89-99). The sensitivity of the subjective 3-D score was 82% (95%CI, 58-100) and specificity 90% (95%CI, 83-96). Improvement of detection of malignant or borderline tumors by subjective 3-D score was 150%. Vessel density and patterns were not more efficient than the subjective 3-D score. The mean vascular index values were significantly different between benign and borderline/malignant groups: VI, 7.2 versus 35.5 (P < 0.0001); FI, 37.0 versus 48.2 (P = 0.003); and VFI, 2.9 versus 17.6 (P < 0.0001), respectively. CONCLUSIONS: 3-D CEPDUS improves detection of malignant and borderline adnexal masses.

Postoperative lymphocysts after lymphadenectomy for gynaecological malignancies: preventive techniques and prospects.

Postoperative lymphocyst formation is an insufficiently recognised complication of lymphadenectomy for gynaecological malignancies. Lymphocysts are collections of lymph organised into cysts that develop in contact with lymphadenectomy compartments. There has been considerable debate about the relevance of lymphocyst prevention using surgical or pharmacotherapeutic methods. Here, we review the available studies about the impact of these methods on the incidence of lymphocysts. This review suggests that several techniques may decrease the incidence of lymphocysts when used in combination. On a literature basis, the peritoneum should be left open over the lymphadenectomy sites at the end of the procedure and drains should not be placed at the end of the procedure. Omentoplasty should be encouraged and further studies are needed to assess the potential benefits of new energies. Postoperative octreotide therapy seems beneficial but the role of this drug in pelvic oncological surgery remains to be determined.

Prognostic significance of mediastinal 18F-FDG uptake in PET/CT in advanced ovarian cancer.

PURPOSE: To evaluate the prognostic significance of increased mediastinal (18)F-FDG uptake in PET/CT for the staging of advanced ovarian cancer. METHODS: We retrospectively evaluated patients managed for FIGO stage III/IV ovarian cancer between 1 January 2006 and 1 June 2009. Patients were included if they had undergone (18)F-FDG PET/CT and surgery for initial staging. Exclusion criteria were age younger than 18 years, inability to undergo general anaesthesia, recurrent ovarian cancer, and borderline or nonepithelial malignancy. Whole-body PET/CT was performed after intravenous (18)F-FDG injection. The location of abnormal hot spots and (18)F-FDG maximal standard uptake values (SUV(max)) were recorded. We compared the complete cytoreduction and survival rates in groups defined based on mediastinal (18)F-FDG uptake and SUV(max) values. Kaplan-Meier curves of overall survival and disease-free survival were compared using the log-rank test. Hazard ratios with their 95% confidence intervals were computed. Adjusted hazard ratios were obtained using a multivariate Cox model. RESULTS: We included 53 patients, of whom 17 (32%) had increased mediastinal (18)F-FDG uptake. Complete cytoreduction was achieved in 14 (87.5%) of the 16 patients managed with primary surgery and in 21 (75%) of the 28 patients managed with interval surgery. Complete cytoreduction was achieved significantly more often among patients without increased mediastinal (18)F-FDG uptake (80.6% vs. 35.3%; p = 0.001). Disease-free survival was comparable between the two groups. By univariate analysis, overall mortality was significantly higher among patients with increased mediastinal (18)F-FDG uptake (hazard ratio 5.70, 95% confidence interval 1.74-18.6). The only factor significantly associated with overall survival by multivariate analysis was complete cytoreduction (adjusted hazard ratio 0.24, 95% confidence interval 0.07-0.89). CONCLUSION: Increased mediastinal (18)F-FDG uptake was common in patients with advanced ovarian cancer. However, complete cytoreduction, which was significantly more frequent among patients without mediastinal (18)F-FDG uptake, was the only factor independently associated with survival.

Role of video-assisted thoracoscopy in patients with ovarian cancer and pleural effusion.

OBJECTIVES: To evaluate the feasibility of video-assisted thoracoscopy (VAT) for staging advanced ovarian cancer, to measure the performance of preoperative computed tomography (CT) for diagnosing pleural metastases, to assess the correlation between pleural and abdominal involvement, and to measure the impact of VAT on patient management. METHODS: We retrospectively evaluated 16 VAT procedures in 15 patients with advanced ovarian malignancies and pleural effusions. The reason for VAT was either to evaluate unilateral or bilateral pleural effusions (n = 15) or to evaluate pleural metastases after neoadjuvant chemotherapy (n = 1). Preoperative CT was performed routinely, and findings were compared with those of VAT. The rates of involvement of the hepatic pedicle, mesentery, and right side of the diaphragm were compared with the rate of pleural involvement. RESULTS: The right side of the chest was examined 12 times; and the left side, 4 times. There were no complications; 1 procedure was stopped because of ventilatory intolerance. Video-assisted thoracoscopy identified metastases smaller than 1 cm in 5 patients and larger than 1 cm in 2 additional patients; there was no evidence of pleural involvement in 6 patients. Computed tomography had 14% sensitivity and 25% specificity for pleural status determination, using VAT biopsy as the reference standard. Pleural involvement did not correlate with involvement of the hepatic pedicle, mesentery, or right side of the diaphragm. CONCLUSIONS: Video-assisted thoracoscopy performs better than CT for evaluating pleural involvement in ovarian cancer. Video-assisted thoracoscopy supplies accurate data on thoracic involvement, which does not seem predictable from the peritoneal involvement. Video-assisted thoracoscopy may impact patient management.

[Advanced ovarian cancer: upfront or interval debulcking surgery?]. / Cancer de l'ovaire de stade avancé : chirurgie initiale ou intervallaire ?

In the French standard treatment of ovarian cancer in 2007, interval debulcking surgery is an option. The standard treatment is always upfront debulcking surgery when no macroscopic residu is possible. In the recent EORTC randomized study, there was no significative difference between upfront debulcking surgery and interval debulcking surgery after neo-adjuvant chemotherapy. In this paper, we have discussed about the first treatment of ovarian cancer.

[Impact of surgical access on staging of early borderline and invasive tumors of the ovary]. / Effet de la voie d'abord sur la stadification chirurgicale des lésions ovariennes frontières et des cancers à un stade précoce.

The objectives were to evaluate the impact of the surgical approach on the staging of borderline tumors and early-stage malignancies of the ovary. We retrospectively reviewed cases of borderline and invasive ovarian tumors stages Ia through Ic treated surgically between January 1, 1985 and December 31, 2001. We compared the rates of potentially harmful procedures according to the surgical approach. The quality of surgical staging was assessed by examining each required procedure and by determining a score. The influence of variables related to patient characteristics, preoperative workup, and initial surgery on staging quality was tested by univariate analysis. Variables independently associated with staging quality were entered in a logistic regression model. SPPS 7.5 and STATA 8 software was used for statistical tests. Of 118 patients with borderline tumors, 48 (41 %) underwent laparoscopic surgery, 54 (45 %) laparotomy, and 16 (14 %) laparoscopy converted to laparotomy. Surgery was conservative in 57 % of cases overall ; this proportion was significantly greater with laparoscopy than with laparotomy (p < 0.05) and in younger women (p < 0.001). Intraoperative tumor rupture occurred in 9 % of patients, with no significant difference across surgical approaches (p = 0.1). Bag extraction was used in 19 (40 %) of 48 laparoscopically treated patients. Staging was incomplete in 73 % of patients. By univariate analysis, bilateral adnexectomy and, to a lesser extent, age > 44 years, laparotomy, hysterectomy, and treatment after 1995 predicted at least partial staging. Factors independently associated with at least partial staging in the multivariate model were treatment after 1995, bilateral adnexectomy, and hysterectomy. Of 178 patients with invasive tumors, 34 underwent laparoscopic surgery, 114 laparotomy, and 30 conversion from laparoscopy to laparotomy. The laparotomy group was characterized by significantly older patient age and larger tumors, compared to the laparoscopy group. Staging was often inadequate after initial surgery, most notably with low rates of paraaortic lymphadenectomy (0 % in the laparoscopy group, 18 % in the laparotomy group, and 33 % in the conversion group). Staging is often less complete with laparoscopy than with laparotomy. In patients with invasive cancer, inadequate initial staging is common, most notably when laparoscopy is used. The surgeons training seems of major importance.

[Ovarian cancer: diagnosis of early stages, referral of patients and management]. / Cancer de l'ovaire: diagnostic des formes précoces, orientation des malades et prise en charge.

Early ovarian cancers account for 25 to 30% of cases. They constitute the only curable cases. There is no specific clinical symptom of early ovarian cancer. Paraneoplasic syndroms, especially phlebitis, are of major importance when they occur in young women. In most of cases, the diagnosis is performed during the management of a complex ovarian cysts. Quality of the preoperative work-up, especially sonography, and management by a specialised team are the best factors to provide an early diagnosis and a comprehensive staging. These two factors are known as predictive of good prognosis. Chemotherapy is frequently indicated post-operatively. In young women, a conservative management can be proposed to preserve their fertility.