Impact of sentinel lymph node mapping on survival in patients with high-risk endometrial cancer in the early stage: A matched cohort study.

OBJECTIVE: The aim of this study was to compare patient survival using sentinel lymph node (SLN) procedure and pelvic lymphadenectomy for stating early-stage high risk endometrial cancer. METHODS: Patients who underwent surgery for early-stage high risk endometrial cancer between 2010 and 2017 were extracted from the incidence registry of the SEER program. We identified patients who underwent SLN mapping. Patients who initially underwent pelvic lymphadenectomy were selected as the comparison group. One-to-one matching was performed according to age, ethnicity, histology, extension and grade. The primary outcome was disease-specific survival. The secondary outcome was overall survival. RESULTS: A total of 326 patients who underwent SLN mapping and 326 who underwent pelvic lymphadenectomy initially were included in the study. The three-year analysis did not find a significant difference between the SLN and lymphadenectomy groups on disease-specific survival probability (88.2% vs 82.7, P = 0.07) and on overall survival probability (82.7% vs 78.2%, P = 0.57). Patients who underwent SLN mapping had a lower mean number of lymph nodes removed (mean 3 vs 16, P < 0.001) and there was a higher rate of patients with positive pelvic lymph nodes (18% vs 14%, P = 0.04). Following adjustment for confounding factors, disease-specific survival did not vary according to the lymph node intervention performed (P = 0.056), but the SLN group had better overall survival than those in the lymphadenectomy group (P = 0.047). CONCLUSION: The SLN technique was not associated with poorer disease-specific survival than pelvic lymphadenectomy even after adjustment. These results suggest that SLN is an acceptable and safe procedure in surgical staging for early-stage high-risk endometrial cancer.

Impact of vulvar reconstruction on the accuracy of a nomogram for predicting local recurrence after surgery for vulvar cancer.

BACKGROUND DATA: Vulvar carcinoma is a rare disease accounting for 3%-5% of all gynaecological cancers. Although surgery is the standard treatment at an early stage, the outcomes are highly correlated with clear resection margins. Therefore, surgical defects can be important and require reconstruction. The aim of this study was to evaluate vulvar reconstructions using a previously validated nomogram predicting the risk of local recurrence at 2 years. METHODS: Patients who underwent surgery for vulvar cancer between 1998 and 2017 were extracted from eight FRANCOGYN centres. We estimated the probability of local recurrence at 2 years using a previously validated nomogram and compared it with actual relapse in patients with or without vulvar reconstruction. Patients were clustered into tiertiles according to their nomogram score: low-, intermediate-, and high-risk for local relapse probability. RESULTS: We reviewed 254 patients, of whom 49 underwent immediate vulvar reconstruction. The predicted and actual probability of two-year local relapse were 20.1% and 15.7%, respectively, with a concordance index of 0.75. In the low- and intermediate-risk groups, the difference between predicted and observed recurrence was less than 10% in patients with or without vulvar reconstruction. For the high-risk group, the difference reached 25% and observed recurrence probability was lower in patients who underwent vulvar plasty compared with those who did not (20.0% vs. 36.2%, respectively). Local recurrence-free survival rates following vulvar reconstruction were comparable at two years (82.1% vs. 84.8%, respectively, p = 0.26). CONCLUSION: Vulvar reconstruction after surgical resection for vulvar cancer is safe. Vulvar reconstruction should be considered in aggressive cases to decrease local recurrence.

Does lymphadenectomy improve survival in patients with intermediate risk endometrial cancer? A multicentric study from the FRANCOGYN Research Group.

OBJECTIVE: The role of lymphadenectomy in intermediate risk endometrial cancer remains uncertain. We evaluated the impact of lymphadenectomy on overall survival and relapse-free survival for patients with intermediate risk endometrial cancer. METHODS: We retrospectively reviewed patients from the FRANCOGYN database with intermediate risk endometrial cancer, based on pre-operative and post-operative criteria (type 1, grade 1-2 tumors with deep (> 50%) myometrial invasion and no lymphovascular space invasion), who received primary surgical treatment between November 2002 and August 2013. We compared overall survival and relapse-free survival between staged and unstaged patients. RESULTS: From 1235 screened patients, we selected 108 patients with intermediate risk endometrial cancer. Eighty-two (75.9%) patients underwent nodal staging (consisting of pelvic +/- para-aortic lymphadenectomy). Among them, 35 (32.4%) had lymph node disease. The median follow-up was 25 months (range 0.4 to 155.0). The overall survival rates were 82.5% for patients staged (CI 64.2 to 91.9) vs 77.9 % for unstaged patients (CI 35.4 to 94.2) (P = 0.73). The relapse-free survival rates were 68.9% for staged patients (CI 51.2 to 81.3) vs 68.8% for unstaged patients (CI 29.1 to 89.3) (P=0.67). CONCLUSION: Systematic nodal staging does not appear to improve overall survival and relapse-free survival for patients with IR EC but could provide information to tailor adjuvant therapy. Sentinel lymph node dissection may be an effective and less invasive alternative staging technique and should provide a future alternative for this population.

Dealing with microscopic peritoneal metastases of epithelial ovarian cancer. A surgical challenge.

Understanding biology and progression mechanisms of peritoneal metastases of epithelial ovarian cancer (EOC) is a cornerstone in the knowledge and the comprehensive management of the disease. Despite clinical remission after the association of complete cytoreductive surgery and platinum-based chemotherapy, peritoneal recurrence still occurs in 60% of patients. Eligible studies, published from 1980 to June 2016, were retrieved through ClinicalTrials.gov, MEDLINE, Cochrane databases and bibliography searches. We reviewed all publications that deals with microscopic peritoneal metastases of EOC in French and English. To discuss expected benefits of intraperitoneal (IP) chemotherapy, fluorescence-guided surgery or IP photodynamic therapy, we reviewed most recent and relevant studies. The final reference list was generated on the basis of originality and relevance to the broad scope of this review. Published data concerning early-stage ovarian cancer suggest that occult peritoneal or epiploic metastases are present in 1.2%-15.1% of cases. In the frequent case of advanced-stage disease, residual microscopic lesions are ignored by conventional surgery. We are convinced that microscopic peritoneal metastases are a relevant surgical therapeutic target. This article discusses existing data on microscopic peritoneal metastases, the treatment indications, the diagnostic and therapeutic surgical approaches to be developed and their expected benefits. A local therapeutic strategy to target microscopic lesions is needed in addition to complete macroscopic cytoreductive surgery to decrease the rate of peritoneal recurrence. Intraperitoneal chemotherapy, and targeted photodynamic therapy could play a role in this new paradigm. The roles of these different options must be defined by future researches.

[Fertility sparing treatment in women affected by cervical cancer larger than 2cm]. / Préservation de la fertilité chez les patientes atteintes d'un cancer du col de plus de 2cm.

OBJECTIVE: We report our experience on fertility sparing treatment in young women affected by cervical cancer of more than 2cm. METHODS: Between July 2012 and February 2014, five patients presenting cervical tumors larger than 2cm (IB1>2cm) (23-35) and wishing to preserve fertility have been treated at our institution. Laparoscopic pelvic and para-aortic lymphadenectomy was performed for all patients. When lymph nodes were free of disease, patients had neoadjuvant chemotherapy followed by surgical conservative treatment. RESULTS: Four patients underwent a cisplatin based neoadjuvant chemotherapy before conservative surgery: radical trachelectomy or simple trachelectomy. One patient with nodal involvement underwent a 3cycle chemotherapy followed by concurrent radiochemotherapy. Hematologic toxicity grade 3 was observed in one patient leading to a change of chemotherapy. Two patients showed complete disappearance of tumor and two a partial response to neoadjuvant treatment. After a mean follow up of 20.5months (14-33), no relapse was observed. To date, no pregnancy was obtained. CONCLUSION: Lymph node staging followed by neoadjuvant chemotherapy and radical trachelectomy seems to be a promising treatment scheme for patients with cervical tumors IB1>2cm pN0 seeking parenthood.

Age impact on human papillomavirus vaccination in France in 2014: A study from the National Health Insurance Database.

INTRODUCTION: Human papillomavirus (HPV) is the main cause of cervical cancer. In France, since March 2007, HPV vaccination has been recommended for girls aged 14, in addition to a catch-up program for girls aged 15 to 23. In October 2012, the target population was changed to 11- to 14-year-old girls. The main objective of the present study was to evaluate the impact of the recommendation change on HPV vaccination coverage and compliance. METHODS: We conducted a descriptive study of the Échantillon Généraliste des Bénéficiaires (EGB), which is a random 1/97 permanent sample from the French National Health Insurance Database. We focused our analyses on girls aged 11 to 17 years who were covered by the main insurance scheme (which covers 77% of the French population). RESULTS: We included 16,195 girls in this analysis. At the last update of the database (06/15/2014), 42% of 17-year-old girls had been vaccinated, with more than 50% of them having been vaccinated at age 14. Between January 2012 and June 2014, patients were reimbursed for a total of 7698 doses of the HPV vaccine. During the first trimester of 2013, the number of vaccinated 11- to 13-year-old girls increased, growing by more than 20-fold between the last trimester of 2012 (n=8) and the last trimester of 2013 (n=178). Less than 60% of the vaccinated patients received 3 injections. DISCUSSION: Implementation of the new recommendations was rapid but had only a slight impact on vaccination coverage.

[Photodynamic therapy and urothelial carcinoma]. / Thérapie photodynamique et carcinomes urothéliaux.

PURPOSE: Photodynamic therapy (PDT) is an innovative therapeutic modality in urologic oncology. MATERIAL AND METHODS: We reviewed the current literature on principles and modalities of PDT in urothelial and penile oncology. RESULTS: PDT has been tested for the treatment recurrent superficial bladder tumors and in situ carcinoma. Carcinologic efficacy has been observed with first generation photosensitizer. The lack of selectivity for tumoral cells was responsible of serious adverse events. Development of selective photosensitizers has reduced the importance of side effects. Data concerning PDT for upper urinary tract and urethra carcinoma are still limited. CONCLUSION: First PDT clinical applications in urothelial oncology have shown some effectiveness at the cost of significant morbidity. The development of selective photosensitizers should help to reduce side effects.

Continuous or fractionated photodynamic therapy? Comparison of three PDT schemes for ovarian peritoneal micrometastasis treatment in a rat model.

OBJECTIVE: This experimental study aimed to compare three illumination schemes to optimize hexaminolaevulinate (HAL)-PDT in a rat tumor model with advanced ovarian cancer. MATERIALS AND METHODS: Peritoneal carcinomatosis was induced by intraperitoneal 5×10(6)NuTu-19 cells injection in 60 female rats Fisher 344. Carcinomatosis was obtained 50 days post-tumor induction. Four hours post-intraperitoneal HAL (Photocure ASA, Oslo, Norway) injection, three different schemes of PDT were performed during 25 min on a 1cm(2) area. (A) Fractionated illumination (n=20) with an on-off cycle ("on": 2 min and "off": 1 min) at 30mW cm(-2) until a fluence of 30J cm(-2), (B) continuous illumination (n=20) at 30mW cm(-2) with a fluence of (45J cm(-2)C) continuous illumination (n=20) at 20mW cm(-2) with a fluence of 30J cm(-2). Laser light was generated using a 532nm KTP laser (Laser Quantum, Stockport, UK). Biopsies were taken 24h after treatment. Quantitative histology was performed. Necrosis value was determined: 0-no necrosis to 4-full necrosis. Depth of necrosis was then measured for each sample and correlated to Necrosis value. RESULTS: HAL-PDT was efficient in producing necrosis irrespective of the scheme. Tumor destruction was superior with fractionated illumination compared to both continuous illumination schemes regarding to the depth of necrosis (213±113µm vs 154±133µm vs 171±155µm) (p<0.05) or to the full necrosis rate (50% vs 30% vs 10%) (p<0.0001). CONCLUSION: Fractionated illumination during photodynamic therapy (PDT) was shown to improve tumor response. Fractionated illumination with short intervals should be considered for an effective PDT of advanced ovarian cancer.

An uncommon case of urethrovaginal fistula resulting from tension-free vaginal tape.

Urethrovaginal fistula (UVF) is an uncommon complication after sub-urethral sling placement. This is a report of a 51-year-old woman with stress urinary incontinence who underwent a tension-free vaginal tape (TVT(R)) in July 2001. Thirty-nine months after the procedure, she complained about pelvic and vaginal pain, bleeding from the vagina and stress urinary incontinence. The gynecological examination revealed a large mid UVF hidden by a 1 cm granuloma. The UVF was closed using simple sutures after removal of the sling. No subsequent treatment was performed.

Comparison of continuous and fractionated illumination during hexaminolaevulinate-photodynamic therapy.

OBJECTIVE: This experimental study aimed to compare continuous and fractionated illumination to optimize hexaminolaevulinate (HAL)-photodynamic therapy (PDT) in a rat tumour model with advanced ovarian cancer. MATERIALS AND METHODS: Intraperitoneal 10(6) Nu Tu-19 cells were injected in 36 female rats Fisher 344. Peritoneal carcinomatosis was obtained 26 days post-tumour induction. Four hours post-intraperitoneal HAL (Photocure ASA, Oslo, Norway) injection, two schemes of PDT were performed at 30 mW cm(-2) on a 1cm(2) area: fractionated illumination (n=16) with a on-off cycle ("on": 2 min and "off": 1 min) until a fluence of 30 J cm(-2) was delivered, and continuous illumination (n=20) with a fluence of 45 J cm(-2). Laser light was generated using a 532 nm KTP laser (Laser Quantum, Stockport, UK). Biopsies were taken 24h after treatment. Semi-quantitative histology was performed. Necrosis value was determined-0: no necrosis to 4: full necrosis. RESULTS: HAL-PDT was efficient in producing necrosis irrespective of the scheme (NV=3.34+/-0.91). Tumour destruction was superior with fractionated illumination compared to continuous illumination (3.67+/-0.70 vs. 3.10+/-0.94) (p<0.05). CONCLUSION: Fractionated illumination during photodynamic therapy was shown to improve tumour response. Fractionated illumination with short intervals should be considered for an effective PDT of advanced ovarian cancer.