Utility of PET/CT to Evaluate Retroperitoneal Lymph Node Metastasis in High-Risk Endometrial Cancer: Results of ACRIN 6671/GOG 0233 Trial.

Purpose To assess the diagnostic accuracy of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) combined with diagnostic contrast material-enhanced computed tomography (CT) in detecting lymph node (LN) metastasis in high-risk endometrial cancer. Materials and Methods This prospective multicenter HIPAA-compliant study had institutional review board approval, and all participants gave written informed consent. Data were accrued between January 2010 and June 2013. Patients underwent PET/CT and pelvic and abdominal lymphadenectomy. Two hundred seven of 215 enrolled patients had PET/CT and pathologic examination results for the abdomen and pelvis. Mean patient age was 62.7 years ± 9.6 (standard deviation). Data in all 23 patients with a positive abdominal examination and in 26 randomly selected patients with a negative abdominal examination were used for this central reader study. Seven independent blinded readers reviewed diagnostic CT and PET/CT results in different sessions 1 month apart. Accuracy was calculated at the participant level, correlating abdominal (right and left para-aortic and common iliac) and pelvic (right and left external iliac and obturator) LN regions with pathologic results, respecting laterality. Reader-average sensitivities, specificities, and areas under the receiver operating characteristic curve (AUCs) of PET/CT and diagnostic CT were compared. Power calculation was for sensitivity and specificity in the abdomen. Results Sensitivities of PET/CT versus diagnostic CT for the detection of LN metastasis were 0.65 (95% confidence interval [CI]: 0.57, 0.72) versus 0.50 (95% CI: 0.43, 0.58) (P = .01) in the abdomen and 0.65 (95% CI: 0.57, 0.72) versus 0.48 (95% CI: 0.41, 0.56) (P = .004) in the pelvis. Corresponding specificities were 0.88 (95% CI: 0.83, 0.92) versus 0.93 (95% CI: 0.89, 0.96) (P = .11) and 0.93 (95% CI: 0.86, 0.96) versus 0.89 (95% CI: 0.82, 0.94) (P = .27), and AUCs were 0.78 (95% CI: 0.66, 0.89) versus 0.74 (95% CI: 0.63, 0.86) (P = .39) and 0.82 (95% CI: 0.71, 0.92) versus 0.73 (95% CI: 0.63, 0.84) (P = .02). Conclusion FDG PET/CT has satisfactory diagnostic accuracy in the detection of abdominal LN metastasis in high-risk endometrial cancer. Compared with diagnostic CT alone, addition of PET to diagnostic CT significantly increased sensitivity in both the abdomen and pelvis while maintaining high specificity. © RSNA, 2017 Online supplemental material is available for this article.

Initial application of reduced port surgery using the single port access technique for laparoscopic canine ovariectomy.

OBJECTIVE: To describe the Single port access (SPA) laparoscopic entry technique for canine ovariectomy (OVE), report complications, and outcomes. STUDY DESIGN: Pilot study. ANIMALS: Intact female dogs (n = 6). METHODS: With owner consent, 6 intact female dogs had SPA laparoscopic OVE. Data, including signalment, surgical time (from incision to completion of closure), size and location of port placement, need for conversion (both to standard multiport laparoscopy and laparotomy), as well as any intraoperative complications including blood loss or tissue injury were recorded. RESULTS: Mean surgical time was 52.5 minutes (range, 45-60 minutes) and mean incision length, 1.8 cm (range, 1.5-2.0 cm). In an 18-kg mix breed dog (dog 3), a "single port rescue" was required and located on midline 2-cm caudal to the umbilicus. Close positioning of the trocars caused instrument interference, limited viewing, and prevented safe ligation of the ovarian vessels vein with a vessel-sealing device. OVE was successfully completed laparoscopically in all dogs. CONCLUSION: The SPA laparoscopic entry technique can be used in dogs, although instrument and camera interference can occur if trocar placement is too consolidated within the initial skin incision.

The road to reduced port surgery: from single big incisions to single small incisions, and beyond.

Single-port surgery has seen almost as rapid an application as multiport laparoscopy during the early 1990s. Hopefully, we will learn from our predecessors to apply the dictums of safety and science as we move forward with this new technique to ensure adequate adoption and successful outcomes with limited errors and concerns along the way.

Reduced port surgery: an economical, ecological, educational, and efficient approach to development of single port access surgery.

There has been an emergence of reduced port techniques for laparoscopic surgery over the past three years. Although growing in presentations and papers, few scientific studies have yet to be published demonstrating benefits and risks of these techniques. In particular, very little is mentioned regarding the increased costs. This brings to the forefront the concept that the development of new surgical techniques should adhere to safe standards of surgery and undergo continued evaluation during development to ensure they maintain safety, and are able to be reproduced by our colleagues. Evaluation also needs to focus on costs, both economical and ecological. A review of our first three years experience of single port access surgery has been done. Costs in terms of both the potential economic and environmental impact have also been evaluated as compared with multiport procedures. In the first 36 months of this evolving technique, we were able to mimic multiport procedures with similar results. The costs of single port access are less than comparable multiport procedures, both in terms of dollars as well as medical waste. We are able to now offer "proof of concept" of a novel reduced port procedure from four important aspects in the development of new surgical techniques. We demonstrate comparable results in terms of outcomes and safety, improvement in financial and environmental costs, as well as showing initial success with training and application of the procedure by our colleagues.

Single port access (SPA) cholecystectomy: a completely transumbilical approach.

We have seen substantial changes in minimally invasive surgery since its development in the early 1900s. Over the past 10 years, the addition of natural orifice transluminal endoscopic surgery and robotics has turned our attention to improved cosmesis and advancements in instrumentation. We have developed a new technique-single port access (SPA) surgery-and have applied it to the cholecystectomy. In this paper, we present and review the application of this access technique to the first 5 consecutive patients that underwent an SPA cholecystectomy. All 5 patients were female, with an average age of 45 years and an average weight of 172 pounds. Indications included biliary dyskinesia and symptomatic cholelithiasis. Average operative time was 121 minutes in these initial 5 cases. All but 1 patient was discharged in 24 hours. At 6 months, no umbilical hernias were observed. This new technique allows for a complete cholecystectomy to be performed entirely through the umbilicus without the need for additional retraction sites or transabdominal sutures. This procedure utilizes the same basic technique of the laparoscopic cholecystectomy already employed by general surgeons. Therefore, the SPA cholecystectomy can be readily learned and performed by many surgeons without the need for expensive or experimental equipment. Using a single portal of entry to the abdominal cavity, the umbilicus, cosmesis, and scar reduction is achieved.

Single Port Access (SPA™) Minimal Access Surgery Through a Single Incision.

The practice of surgical techniques is constantly improving and evolving. In the last two decades, minimally invasive surgery has gained widespread acceptance. Virtually all procedures can now be performed laparoscopically. This trend not only provides better cosmesis, but offers decreased recovery times as well. The initial trend from open to laparoscopic surgery was to use smaller incisions. The natural continuation of this is to now decrease the number of incisions necessary to perform minimal access surgery. To this end, the authors have seen a constantly evolving stream of technology and instrumentation in laparoscopy. New venues, such as robotics and Natural Orifice. Transluminal Endoscopic Surgery (NOTES), have developed as well. As part of this evolution, the authors developed Single Port Access (SPA™) surgery in April 2007 as a novel and innovative platform of minimal access surgery. Its acceptance through our training programs, as well as the subsequent development of modified Single Port techniques, demonstrates the potential to develop a new platform of minimal access surgery. The SPA™ technique is a method of abdominal entry for a wide spectrum of laparoscopic procedures performed by multiple surgical specialties. Using the access techniques we developed, the authors have performed nearly 200 general surgical and gynecologic procedures through a single incision, often <2 cm in length and hidden within the umbilicus. In addition, the development of SPA™ surgery has been focused on using current and standard instrumentation, as well as currently practiced surgical techniques already familiar to surgeons in standard multiport laparoscopy. The "Independence of Motion" attained in this access technique, without the need for any new access or operative devices, allows up to four instruments to be place through a single incision<2 cm in length. We have striven to maintain safety principles of multiport laparoscopy, as well, and have continued to improve the technique to increase the availability and broad application of SPA™ surgery. Out technique and its application, across a broad range of surgical procedures and surgical specialties, are presented herein.

Computerized dynamic posturography for postural control assessment in patients with intermittent claudication.

Computerized dynamic posturography with the EquiTest is an objective technique for measuring postural strategies under challenging static and dynamic conditions. As part of a diagnostic assessment, the early detection of postural deficits is important so that appropriate and targeted interventions can be prescribed. The Sensory Organization Test (SOT) on the EquiTest determines an individual's use of the sensory systems (somatosensory, visual, and vestibular) that are responsible for postural control. Somatosensory and visual input are altered by the calibrated sway-referenced support surface and visual surround, which move in the anterior-posterior direction in response to the individual's postural sway. This creates a conflicting sensory experience. The Motor Control Test (MCT) challenges postural control by creating unexpected postural disturbances in the form of backwards and forwards translations. The translations are graded in magnitude and the time to recover from the perturbation is computed. Intermittent claudication, the most common symptom of peripheral arterial disease, is characterized by a cramping pain in the lower limbs and caused by muscle ischemia secondary to reduced blood flow to working muscles during physical exertion. Claudicants often display poor balance, making them susceptible to falls and activity avoidance. The Ankle Brachial Pressure Index (ABPI) is a noninvasive method for indicating the presence of peripheral arterial disease and intermittent claudication, a common symptom in the lower extremities. ABPI is measured as the highest systolic pressure from either the dorsalis pedis or posterior tibial artery divided by the highest brachial artery systolic pressure from either arm. This paper will focus on the use of computerized dynamic posturography in the assessment of balance in claudicants.

Phase I study of topotecan and radiation therapy in advanced cervical cancer.

OBJECTIVE: The goal of this study was to determine the maximal tolerated dose (MTD) of topotecan given with external-beam radiotherapy in advanced cervical cancer. METHODS: A prospective Phase I trial of topotecan given with standard external-beam radiotherapy was performed in patients with advanced squamous cell carcinoma of the cervix. Patients were treated with a starting dose of 0.5 mg/m(2) and escalated by 0.25 mg/m(2). Nine patients were treated. Hematologic and nonhematologic toxicity were measured. RESULTS: Patients were treated with 1.0 mg/m(2) daily for 5 days on Days 1-5 and 22-26 concomitantly with radiotherapy without significant toxicity. Grade III anemia in one case and Grade II leukopenia in two cases were seen in the three patients at this dose level. Dose-limiting toxicity was not reached. CONCLUSION: Topotecan can be safely administered at a dose of 1.0 mg/m(2) during external-beam radiotherapy for advanced cervical cancer.