Should We Abandon Systematic Pelvic and Paraaortic Lymphadenectomy in Low-Grade Serous Ovarian Cancer?

BACKGROUND: Low-grade serous ovarian carcinoma (LGSOC) is a rare disease that accounts for 5% of all ovarian cancers and requires surgical complete debulking. To date, the prognostic value of pelvic and paraaortic lymphadenectomy remains unclear in this population. PATIENTS AND METHODS: This retrospective cohort of patients with a diagnosis of LGSOC was registered in the Tumeurs Malignes Rares Gynécologiques national network, between January 2000 and July 2017, at 25 centers. All LGSOC were confirmed after pathological review and operated by primary debulking surgery (PDS) or interval debulking surgery after neoadjuvant chemotherapy (NACT-IDS). Primary endpoints were overall survival (OS) and progression-free survival (PFS). RESULTS: A total of 126 patients were included, 86.1% were stage III/IV, and 74.6% underwent lymph node dissection (LND). According to the Completeness of Cancer Resection (CCR) score, 83.7% had complete resection. Median OS was 130 months, and median PFS was 41 months. Pelvic and paraaortic LND had no significant impact on OS (p = 0.78) or DFS (p = 0.93), and this was confirmed in subgroups (advanced stages FIGO III/IV, CCR score 0/1 or 2/3, and timing of surgery PDS or NACT-IDS). Histological positive paraaortic lymph nodes had a significant negative impact on PFS in the whole population (HR 2.21, 1.18-4.39, p = 0.02) and in the CC0/CC1 population (HR, 2.28, 1.13-4.59, p = 0.02). CONCLUSIONS: Systematic pelvic and paraaortic LND in patients with LGSOC improved neither overall nor PFS. A prospective trial would be necessary to validate these results but would be difficult to conduct due to the rarity of this disease.

Need for risk-adapted therapy for malignant ovarian germ cell tumors: A large multicenter analysis of germ cell tumors' patients from French TMRG network.

BACKGROUND: Malignant ovarian germ cell tumors are rare tumors, affecting young women with a generally favorable prognosis. The French reference network for Rare Malignant Gynecological Tumors (TMRG) aims to improve their management. The purpose of this study is to report clinicopathological features and long-term outcomes, to explore prognostic parameters and to help in considering adjuvant strategy for stage I patients. PATIENTS AND METHODS: Data from patients with MOGCT registered among 13 of the largest centers of the TMRG network were analyzed. We report clinicopathological features, estimated 5-year event-free survival (5y-EFS) and 5-year overall survival (5y-OS) of MOGCT patients. RESULTS: We collected data from 147 patients including 101 (68.7%) FIGO stage I patients. Histology identifies 40 dysgerminomas, 52 immature teratomas, 32 yolk sac tumors, 2 choriocarcinomas and 21 mixed tumors. Surgery was performed in 140 (95.2%) patients and 106 (72.1%) received first line chemotherapy. Twenty-two stage I patients did not receive chemotherapy. Relapse occurred in 24 patients: 13 were exclusively treated with upfront surgery and 11 received surgery and chemotherapy. 5y-EFS was 82% and 5y-OS was 92.4%. Stage I patients who underwent surgery alone had an estimated 5y-EFS of 54.6% and patients receiving adjuvant chemotherapy 94.4% (P < .001). However, no impact on estimated 5y-OS was observed: 96.3% versus 97.8% respectively (P = .62). FIGO stage, complete primary surgery and post-operative alpha fetoprotein level significantly correlated with survival. CONCLUSION: Adjuvant chemotherapy does not seem to improve survival in stage I patients. Active surveillance can be proposed for selected patients with a complete surgical staging.

The French national network dedicated to rare gynecological cancers diagnosis and management could improve the quality of surgery in daily practice of granulosa cell tumors. A TMRG and GINECO group Study.

OBJECTIVE: The French national rare gynecological tumor network has been established to improve the quality of care through offering expertise in double reading histological diagnosis, reviewing cases and guiding management of these tumors through specialized multidisciplinary tumor boards and online clinical guidelines (www.ovaire-rare.com). The aim of this study is to evaluate the impact of the development and implementation of this network by assessing the conformity of medical practice with the guidelines concerning the granulosa cell tumors (GCTs). METHODS: This is a French nationwide study, including 463 patients (out of the 639 identified patients) with a definitive diagnosis of GCT between 2011 and 2016. Surgical practices were analyzed for conformity with the current guidelines (www.ovaire-rare.org). Medical records, surgical and pathological reports were systematically analyzed. Total conformity was defined by a conservative (unilateral salpingo-oophorectomy) or radical surgery (hysterectomy and bilateral salpingo-oophorectomy) including surgical staging (omentectomy, peritoneal biopsies and peritoneal cytology) according to the FIGO stage. Partial conformity referred to a conservative or radical surgery without surgical staging and non-conformity was defined as a non-optimal surgery as recommended by the guidelines. RESULTS: Median age at diagnosis was 49 years old (range 10-89). The median size of tumor was 94 mm (range 5-400). Radical surgery was performed in 240 patients (52%); while a fertility-sparing surgery was performed in 98 cases (21%). A surgical staging was performed in 76 cases (16%) and an evaluation of the endometrium in 289 cases (62%). Surgery was fully compliant with the guidelines in 65 patients (14%), partially compliant in 213 patients (46%), non-compliant in 137 patients (30%) and not assessable in 48 cases (10%). A statistically significant difference for compliance was observed in restaging surgery (p < 0,001), radical surgery (p = 0,017) and the period (before or after) of the implementation of the network (p < 0,001). Survival analyses did not allow us to demonstrate a significant difference in overall survival nor in PFS although there was a trend in favor of optimal surgery compared to incomplete/non optimal surgery. CONCLUSION: Surgical management's conformity to the guidelines increases over time from 2011 to 2016. According to this study, the implementation of a national network dedicated to rare gynecologic tumors seems to significantly improve the surgical management of the patients with ovarian granulosa cell tumors.

Networking for ovarian rare tumors: a significant breakthrough improving disease management.

BACKGROUND: Rare ovarian tumors represent >20% of all ovarian cancers. Given the rarity of these tumors, natural history, prognostic factors are not clearly identified. The extreme variability of patients (age, histological subtypes, stage) induces multiple and complex therapeutic strategies. METHODS: Since 2011, a national network with a dedicated system for referral, up to 22 regional and three national reference centers (RC) has been supported by the French National Cancer Institute (INCa). The network aims to prospectively monitor the management of rare ovarian tumors and provide an equal access to medical expertise and innovative treatments to all French patients through a dedicated website, www.ovaire-rare.org. RESULTS: Over a 5-year activity, 4612 patients have been included. Patients' inclusions increased from 553 in 2011 to 1202 in 2015. Expert pathology review and patients' files discussion in dedicated multidisciplinary tumor boards increased from 166 cases in 2011 (25%) to 538 (45%) in 2015. Pathology review consistently modified the medical strategy in 5-9% every year. The rate of patients' files discussed in RC similarly increased from 294 (53%) to 789 (66%). An increasing number (357 in 5 years) of gynecologic (non-ovarian) rare tumors were also registered by physicians seeking for pathological or medical advice from expert tumor boards. CONCLUSION: Such a nation-wide organization for rare gynecological tumors has invaluable benefits, not only for patients, but also for epidemiological, clinical and biological research.

Quality of life after mastectomy with or without immediate breast reconstruction.

BACKGROUND: Mastectomy with immediate breast reconstruction (IBR) is a surgical strategy in breast cancer when breast-conserving surgery is not an option. There is a lack of evidence showing an advantage of mastectomy plus IBR over mastectomy alone on health-related quality of life (QoL). METHODS: A large prospective multicentre survey, STIC-RMI (support of innovative and expensive techniques - immediate breast reconstruction), was undertaken to study the changes in QoL in patients treated by mastectomy with or without IBR. Patients were recruited between 2007 and 2009. European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23 instruments were used to assess QoL before operation, and at 6 and 12 months after surgery. A propensity score was used to compare QoL between mastectomy alone and mastectomy plus IBR, with limited bias. RESULTS: A total of 595 patients were included from 22 French academic hospitals, of whom 407 (68·4 per cent) underwent IBR. One-year data were available for 71·1 per cent of patients. Factors associated with IBR were age, histological tumour type, palpable nodes and an attempt at breast-conserving surgery. At inclusion, QoL was significantly better in the IBR group (P < 0·001) and there was no significant change in either group during 1 year compared with baseline. Results for the QLQ-BR23 functional dimension varied according to propensity score quartiles; IBR had no influence in the lowest quartile. In the upper quartiles, QoL increased slightly over the year among patients who had IBR, whereas it decreased among those who had mastectomy alone (P = 0·037). Satisfaction with the cosmetic outcome strongly influenced QoL, especially in upper quartiles (P < 0·001). However, an unsatisfactory outcome after IBR was still considered a better condition than simple mastectomy. CONCLUSION: The QoL benefit provided by IBR depends on patients' life status at inclusion; young active women with an in situ tumour are more likely to preserve their QoL after IBR.

Survival effect of laparoscopic para-aortic staging in locally advanced cervical cancer: a retrospective cohort analysis.

OBJECTIVE: This study compares two methods of evaluating para-aortic node involvement in locally advanced cervical cancer (LACC) in order to define external radiotherapy treatment fields: laparoscopic surgical para-aortic lymphadenectomy or PET-CT imaging. POPULATION: We selected 187 patients with LACC who had been treated by chemoradiation therapy in two comprehensive cancer centres from January 2001 to December 2013. A total of 98 underwent para-aortic evaluation by PET-CT (Centre 1) and 89 received surgical laparoscopic excision (Centre 2). METHODS: All patients with LACC were retrospectively collected in each centre. OS and DFS were calculated using the Kaplan-Meier's method and survival curves were compared using log-rank test. MAIN OUTCOME MEASURES: Outcomes were the comparison of patients' disease-free (DFS) and overall survival (OS) between the two centres. RESULTS: Patients had a significantly better disease-free survival in cohort 1 than in cohort 2, at 2 years [80.9% (71.7-87.5) versus 57.1% (46.1-67.3)] and at 5 years [70.5% (58.8-79.9) versus 49.2% (38.2-60.4)] (P = 0.009). These results are confirmed by multivariate analysis model [hazard ratio (HR) 1.93; 95% CI 1.03-3.61; P = 0.04]. The overall survival was also better in cohort 1, both at 2 and 5 years [93.5% (86.5-97.0) versus 78.5% (68.5-86.0) and 85.1% (73.2-92.2) versus 63.8% (51.9-74.2), respectively; P = 0.006]. The multivariate analysis model found concordant results with an increased relative risk of death for patients treated in cohort 2 (HR 2.55; 95% CI 1.09-5.99; P = 0.01). CONCLUSION: In this retrospective cohort analysis, para-aortic surgical staging in LACC is more deleterious for patients than is radiological staging in terms of OS and DFS. TWEETABLE ABSTRACT: Para-aortic surgical staging in LACC is more deleterious for patients than clinical staging.

Surgical Complexity Impact on Survival After Complete Cytoreductive Surgery for Advanced Ovarian Cancer.

INTRODUCTION: The direct relationship between surgical radicality to compensate biologic behavior and improvement of patient outcome at the time of primary or interval cytoreduction remains unclear. OBJECTIVE: The aim of this study was to evaluate the impact of disease extension and surgical complexity on survival after complete macroscopic resection for stage IIIC-IV ovarian cancer. MATERIALS AND METHODS: Medical records from seven referral centers in France were reviewed to identify all patients who had complete cytoreductive surgery for stage IIIC-IV epithelial ovarian, fallopian, or primary peritoneal cancer. All patients had at least six cycles of carboplatin and paclitaxel combination therapy. RESULTS: From the 374 consecutive patients with complete cytoreduction who were included in this study, stage, grade, upper abdominal disease, surgical complexity, and carcinomatosis extent were significantly associated with disease-free survival (DFS) at univariate analysis. Stage IV and the need for ultra-radical procedures were significantly associated with lower overall survival (OS). On multivariate analysis, radical surgery, including more than two visceral resections, was significantly associated with decreased DFS and OS. CONCLUSIONS: Patients who need complex surgical procedures involving two or more visceral resections in order to achieve successful complete cytoreduction have worse outcome than patients with less extensive procedures. The negative impact of surgical complexity was not significant in patients who underwent upfront procedures. Tumor volume and extension were associated with decreased DFS in patients undergoing a primary surgical approach. This adds to the evidence that, even though complete cytoreduction is currently the objective of surgery, tumor load remains an independent poor prognostic factor and probably reflects a more aggressive behavior.

Results of a multicenter phase I dose-finding trial of hyperthermic intraperitoneal cisplatin after neoadjuvant chemotherapy and complete cytoreductive surgery and followed by maintenance bevacizumab in initially unresectable ovarian cancer.

PURPOSE: Hyperthermic intraperitoneal chemotherapy (HIPEC) may improve the outcome of patients with initially unresectable ovarian cancer who are eligible for complete cytoreductive surgery (CCRS) after neoadjuvant chemotherapy. The main objective of this multicenter phase-I study was to identify the recommended dose of cisplatin for HIPEC at CCRS after neoadjuvant carboplatin and paclitaxel (CP). METHODS: Patients were treated with 6cycles of CP followed by CCRS and HIPEC using cisplatin heated for one hour at 42°C+/-1°C. Four cisplatin dose-levels were evaluated: 50, 60, 70, 80mg/m(2). Dose-limiting toxicities (DLTs) were defined as a grade≥IIIb adverse event (Dindo classification). The Continual Reassessment Method was used for this dose-finding study, with a target percentage of DLT set at 20%. Twenty-two cycles (15mg/kg/cycle) of maintenance bevacizumab therapy were planned after surgery. RESULTS: Between June-2011 and September-2012, 30 patients were recruited. No DLT occurred at the first three dose-levels (4, 4 and 5 patients at 50, 60 and 70mg/m(2) respectively). At dose-level 4 (80mg/m(2), 17 patients), four DLTs occurred: renal failure (n=2), peritonitis (n=1) and hemorrhage (n=1). Eight weeks after surgery, creatinine clearance was reduced to <30mL/min in 3 patients, all treated at 80mg/m(2), and between 30 and 60mL/min in 6 patients (2, 1, 1 and 2 at the four dose-levels respectively). Twenty patients started maintenance bevacizumab, and 7 received the 22 courses initially planned. CONCLUSIONS: Based on the observed DLTs and prolonged impairment of renal function, we recommend a dose of 70mg/m(2) of cisplatin for HIPEC.

Systematic (complete) para-aortic lymphadenectomy: description of a novel surgical classification with technical and anatomical considerations.

The clinical indications for a complete para-aortic lymphadenectomy in the surgical management of gynaecological malignancies remain controversial. The debate on complete para-aortic node dissection is hindered by the absence of an identifiable and accepted definition for the procedure of systematic (complete) para-aortic node dissection. In this paper we propose a classification of para-aortic lymphadenectomy. We have identified and imaged the most common and rare para-aortic vascular anomalies that we have encountered. An understanding of the anatomical anomalies in this area also provides a useful reference for the surgical technique that is adopted in order to ensure the completeness of excision.

Prognostic value of initial tumor parameters after metastatic relapse.

Classical prognostic factors of breast cancer are correlated to disease-free survival and overall survival (OS); their precise role is less known on metastatic disease. A total of 511 breast cancer patients without initial metastasis were treated. OS was divided in time to distant recurrence and metastatic survival (MS). Age, Scarff-Bloom-Richardson (SBR) grade, hormone receptor, axillary node involvement, and Nottingham prognostic index predicted MS in univariate analysis. Multivariate analysis retained age, SBR grade, and axillary lymph node involvement as significant independent prognostic factors. Interactions are still present between initial parameters and MS. The clinician has to take into account for treatment choice.

Celiac lymph node resection and porta hepatis disease resection in advanced or recurrent epithelial ovarian, fallopian tube, and primary peritoneal cancer.

INTRODUCTION: Prognostic value of complete macroscopic resection of primary disease has been reported and confirmed in several publications. Published data indicate that extensive upper abdominal disease involving the hepatic pedicle and celiac trunk is associated with an abortion of the surgical procedure or with suboptimal residual disease. METHODS: All patients who had disease at the porta hepatis or celiac lymph node resection as part of cytoreductive surgery were included. Medical and operative records with particular emphasis on extent and distribution of disease spread, number of peritonectomy procedures, visceral resections, and lymphadenectomy procedures were examined. RESULTS: A total of 28 patients who underwent some kind of celiac lymph node resection or resection of metastatic involvement of the porta hepatis were included. Median preoperative serum Ca-125 level was 78U/ml (range, 30-2950U/ml), and median ascites volume was 1900ml (range, 0-10,000ml). Of the 28 patients, 23 underwent supra-radical surgery for diffuse peritoneal carcinomatosis. Median operative time was 252minutes (range, 100-540minutes). Complete cytoreduction to CCO was achieved in all except one case, who was cytoreduced to millimetric residue. Fifteen patients had positive celiac nodes and nineteen patients had peritoneal disease in the porta hepatis region. DISCUSSION: Resection of enlarged nodes and metastatic disease to the porta hepatis is feasible with an acceptable morbidity. The decision to undergo an aggressive cytoreductive surgery is based on appropriate patient selection depending on the extension of surgical procedure, on medical comorbidities, and on the potential to tolerate an extensive procedure, rather than on specific anatomic locations.

Laparoscopic pelvic exenteration for gynaecological malignancy: is there any advantage?

INTRODUCTION: Pelvic exenteration (PE) remains one of the most mutilating surgical procedures with important postoperative morbidity. Laparoscopic approach has emerged in an attempt to reduce postoperative complications. The aim of the present study was to compare outcomes between laparoscopic pelvic exenteration combined with a vaginal or perineal approach, versus classical approach. METHODS: A cohort study was performed by identifying patients who underwent laparoscopic pelvic exenteration, and retrospectively comparing data with open cases from the same period of time, from 2000 to 2008. RESULTS: Fourteen patients underwent laparoscopic PE and 29 patients underwent an open exenterative procedure. All patients except one (97.6%) had received prior radiotherapy. Eighteen patients (41.9%) underwent total PE, 17 anterior PE (39.5%), and 8 posterior PE (18.6%). Urinary diversion (UD) technique consisted of 24 Miami pouch (68.6%), 9 Bricker diversion (25.7%), 1 Kock pouch (2.9%), and 1 ureterostomy (2.9%). Most frequent postoperative complications were related to the urinary diversion (45%) and bowel reconstruction (27.9%). Median estimated blood loss for the laparoscopy and laparotomy group was 400 ml (range 200-700 ml) and 875 ml (range 200-1600 ml), respectively. Transfusion rate was also significantly higher in the laparotomy group. Operative time, margin status, length of hospital stay, operative and postoperative morbidity, and disease and overall survival were not significantly different between both groups. CONCLUSIONS: Laparoscopic PE is feasible with curative intent to selected patients. Potential postoperative advantages of laparoscopic approach when compared to classical approach, oncological safety of the procedure, and QOL considerations need to be further investigated.

The role of lymph node resection in ovarian cancer: analysis of the Surveillance, Epidemiology, and End Results (SEER) database.

OBJECTIVE: The therapeutic role of lymphadenectomy on the survival in patients with ovarian cancer is controversial. The aim of this study was to evaluate the survival impact of lymphadenectomy, depending on the disease stage and extent of the surgery. DESIGN: The surveillance, epidemiology, and end results (SEER) registry provided ovarian cancer data from 17 registries. SETTING: Surveillance, Epidemiology, and End Results database. POPULATION: The study population comprised 49,783 patients. METHODS: Survival was studied according to the number of lymph nodes removed, with stratifications on disease stage and extent of surgery. MAIN OUTCOME MEASURE: The 5-year cause-specific survival rate. RESULTS: The median follow up for patients alive at the last follow-up visit was 39 months. The five-year cause-specific survival rates were 37, 62, and 71% for the groups in which no lymph nodes were examined, in which between one and nine nodes were examined, and in which ten or more nodes were examined, respectively (P< 0.001). Avoiding lymphadenectomy was deleterious in all stages of the disease. It was maximal for International Federation of Gynecology and Obstetrics (FIGO) stage-II patients, but there was no significant interaction between stage and extent of lymphadenectomy. The cause-specific survival was found to significantly increase when more nodes were resected, even if the surgical procedure consisted of debulking surgery or a pelvic exenteration. CONCLUSION: Our study suggests a beneficial effect of lymphadenectomy in epithelial ovarian tumours, regardless of the stage of disease and extent of surgery. However, potential biases inherent to this retrospective methodology, such as staging migration, defining the extent of residual disease, and the possibility that thorough lymphadenectomy may reflect the quality of cytoreductive surgery, preclude any formal conclusions on the therapeutic role of lymphadenectomy.

Pulmonary morbidity of diaphragmatic surgery for stage III/IV ovarian cancer.

OBJECTIVE: To determine the morbidity of diaphragmatic peritonectomy. DESIGN: Prospective cohort study. SETTING: A Gynecology Department of a University Hospital. POPULATION: From 2005 to 2007, thirty-seven consecutive patients underwent surgery for stage IIIC or IV ovarian cancer. METHODS: Patients were separated into a diaphragmatic surgery group (n = 18) and a control group (n = 19). Diaphragmatic surgery may consist of coagulation, stripping or muscle resection. MAIN OUTCOME MEASURES: Postoperative course and outcome were analysed. RESULTS: Patients in group 1 (diaphragmatic surgery) underwent more intestinal resection (89% versus 37%, P = 0.01) and pelvic (94% versus 63%, P = 0.02) or para-aortic lymphadenectomy (94% versus 53%, P = 0.04). Neither the mean estimated blood loss (960 ml versus 909 ml) nor the rates of intra-operative blood transfusion (11 versus 9) were significantly different between the two groups. The mean operative time was higher in group 1 (480 minutes versus 316 minutes, P < 0.05). There were thirteen postoperative complications in group 1 and eight in group 2 (P = 0.065). In group 1, the main complication was pleural effusion (seven cases): four patients required secondary pleural drainage, two required only pleural puncture and one had both procedures. There were more complete cytoreduction in group 1 than in group 2 (89% versus 63%, P = 0.068). CONCLUSIONS: Diaphragm peritonectomies and resections are an effective way to cytoreduce diaphragm carcinomatosis and increase the rate of optimal debulking surgery. Such procedures frequently result in pleural effusion, but with no long-term morbidity.

[Ovarian epithelial dysplasia: myth or reality? Review]. / Dysplasie épithéliale ovarienne: mythe ou réalité? Revue de la littérature.

Ovarian epithelial dysplasia has been described in the ovarian surface epithelium by histologic, morphometric and nuclear profile studies. It could represent a potential precursor of ovarian malignancy in patients with genetic risk of ovarian cancer, although its natural history and progression to carcinoma are unpredictable. Diagnosis and identification of ovarian dysplasia would certainly be useful to understand the early steps of ovarian carcinogenesis. However, dysplasia in relation with ovulation induction seems to have a different pattern. We report dysplasia definitions and the current clinical management.

[Radical trachelectomy: From the laparoscopic approach to the vaginal route]. / Trachélectomie élargie: de la laparoscopie à la voie vaginale.

OBJECTIVE: To report our experience of laparoscopic and vaginal radical trachelectomies. MATERIAL AND METHODS: Between February 2001 and May 2005, 10 patients met the requirements for a trachelectomy: 6 for a laparoscopic procedure, 4 for a vaginal procedure. In the laparoscopic procedure, coagulation of the uterine artery had to be performed in 2 patients whereas in the vaginal approach, it was always possible to conserve it. RESULTS: Mean age was 30 years. Median follow-up time was 25 months. Five patients were grade Ia2 and five were grade Ib1. One patient presented numerous lymphatic emboli and underwent radiation and chemotherapy. She died of a peritoneal progression of the disease. One had her baby with a scheduled C-section. One had a spontaneous miscarriage at 7 weeks. CONCLUSION: The radical trachelectomy technique as described by Professor Dargent relies on the selective ligature of the cervico vaginal arteries and the necessity to preserve the uterine arteries. In our experience and that of others reported in the literature, the laparoscopic approach does not always permit to conserve them. In our opinion, the vaginal approach constitutes the best option.

[Laparoscopic pelvic exenteration for cervical cancer relapse: preliminary study]. / Exentérations pelviennes par laparoscopie.

OBJECTIVES: To determine the feasibility and short and midterm results of laparoscopic pelvic exenteration for cervical cancer relapse. Materials and methods. Five patients with centro-pelvic recurrence within 3 to 13 months after combined chemo-radiation therapy (associated to surgery for two cases) for cervical cancer tumors were included in a pilot study. RESULTS: The procedures consisted in a complete pelvic exenteration with colo-anal anastomosis and ileal-loop conduit for 2 patients, a posterior pelvic exenteration including uterus, vagina and rectum with colo-anal anastomosis for 1 patient, an anterior pelvic exenteration including bladder and vagina with an ileal-loop conduit for 1 patient and a anterior pelvic exenteration with a laparoscopic hand assisted Miami Pouch for 1 patient. The 5 procedures were successful with no conversion to laparotomy. Time of procedure ranged between 4 h 30 and 9 hours. Average blood loss was 370 cc. Three patients developed metastatic recurrences and died. The two patients with anterior exenteration are alive and free of disease 11 and 15 months after the procedure. CONCLUSION: Laparoscopic pelvic exenteration procedures are feasible. A larger series is necessary to determine the advantages of this technique compared to laparotomy.

[Anatomoclinical study of ovarian cancers in patients with history of hysterectomy for benign pathology]. / Étude anatomoclinique des cancers de l'ovaire chez les patientes aux antécédents d'hystérectomie pour pathologie bénigne.

OBJECTIVE: To establish the various anatomoclinical characteristics of ovarian cancer in patients with a history of hysterectomy for benign disease. METHODS: This is a comparative, retrospective, monocentric and descriptive study, carried out at the Centre of Jean-Perrin in patients with ovarian cancer between 2005 and 2014 and with a history of hysterectomy for benign disease. Each patient was paired with a non-hysterectomy patient with ovarian cancer. The two populations were matched 1 to 5, based on their age at diagnosis and their FIGO stage. RESULTS: During the period of the study, 249 patients were operated for de novo ovarian neoplasia, 43 patients had a history of hysterectomy (group 1) and 206 remaining patients represented the control group (group 2). There was no difference in overall survival and disease-free survival between the two subpopulations of patients (P=0.59 and P=0.38). On CT-scan assessment, the lymph node involvement risk was greater than 2.6 in the group of patients with hysterectomy (P=0.00038). Peritoneal Cancer Index scores of the two subgroups of populations were comparable, there were an average of 13.65 for group 1 versus 12.31 for group 2 (P=0.28). The rate of rectosigmoid resection was higher in group 1: 48.6% versus 32.9% in group 2 without any significant difference (P=0.07). Hundred and thirty-three patients undergone lumbar aortic lymphadenectomy, with node involvement found in 83% of patients in the hysterectomy group and 51% of patients in the control group (P=0.0053). CONCLUSION: Indication of lumbar aortic lymphadenectomy should be taken in better consideration in patients with history of inter-adnexial hysterectomy. These data must be thoroughly assessed with a prospective multicenter comparative study.

The role of laparoscopy to evaluate candidates for complete cytoreduction of peritoneal carcinomatosis and hyperthermic intraperitoneal chemotherapy.

AIM: The aim of this study was to evaluate the role of explorative laparoscopy to evaluate candidates for complete resection of peritoneal carcinomatosis (PC) combined with hyperthermic intraperitoneal chemotherapy (HIPC). METHODS: The database of the surgical department of the Institut Gustave Roussy was used to select 113 patients planned to undergo a maximal cytoreductive surgery combined with HIPC for PC between April 2001 and July 2003. Among them, 11 underwent an explorative laparoscopy because extent of the PC was insufficiently documented to evaluate its resectability. Patient records were retrospectively reviewed. RESULTS: Laparoscopic evaluation was successful in all 11 patients. The median operating time was 38 min (range 23-75 min). The laparoscopic examinations were well tolerated in all cases. The median length of hospital stay was 1.7 days. For three patients, the PC was as judge as unresectable. A complete resection of the PC combined with HIPC was performed in seven out of the eight patients with PC considered resectable at laparoscopy. One patient was diagnosed with more extensive disease than that as assessed by the evaluative laparoscopy. Of note, for 20% of the patients with straight away laparotomy, the complete cytoreduction was not possible. CONCLUSION: Laparoscopic scoring of peritoneal carcinomatosis is accurate to assess the complete resectability of PC in patients for which there is inadequate or contradictory information concerning disease extent.

Survival in cervix cancer patients treated with radiotherapy followed by radical surgery.

AIM: To determine the incidence and predictive value of residual disease in the hysterectomy specimens of cervical cancer patients treated with primary radiotherapy, with or without chemotherapy, followed by surgery and to determine whether pathologically confirmed residual disease is a surrogate marker of outcome. METHODS: The medical records of patients treated for stage IB/II carcinoma of the cervix in a single institution between 1985 and 2000 were retrospectively analysed into two different groups, depending on whether they had received radiotherapy or concurrent chemo-radiotherapy. Six to 8 weeks after irradiation, all patients underwent radical or extrafascial hysterectomy and pelvic and para-aortic lymphadenectomy. RESULTS: A total of 403 patients were included in the study (360 in the radiotherapy only group and 43 in the chemo-radiotherapy group). One hundred and seventy-eight patients had residual disease on hysterectomy specimens in the radiotherapy group. Considering only the stages IB2 and II, 126 (52%) and 16 (37%) patients had residual disease on hysterectomy specimens in the radiotherapy group and in the chemo-radiotherapy group, respectively (P=0.08). Residual disease was associated with pelvic and para-aortic nodal metastases. The 5-year local control and overall survival rates were 88 and 86%, respectively, in the patients with complete pathologic response and 73 and 62%, respectively, in the patients with residual disease (P<0.001). In multivariate analysis, FIGO stage, residual disease, and pathologic nodal involvement were independent predictive factors of both local recurrence and overall survival. CONCLUSION: Pathologically confirmed residual disease on hysterectomy specimen is an independent and strong predictive factor of both local recurrence and overall survival.