[Management of epithelial ovarian cancer. Short text drafted from the French joint recommendations of FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY and endorsed by INCa]. / Texte court rédigé à partir de la recommandation nationale de bonnes pratiques cliniques « Conduites à tenir initiales devant des patientes atteintes d'un cancer épithélial de l'ovaire ¼ élaborée par FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY et labélisée par l'INCa ¼.

Faced to an undetermined ovarian mass on ultrasound, an MRI is recommended and the ROMA score (combining CA125 and HE4) can be proposed (grade A). In case of suspected early stage ovarian or fallopian tube cancer, omentectomy (at least infracolonic), appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C) and pelvic and para-aortic lymphadenectomy are recommended (grade B) for all histological types, except for the expansive mucinous subtype where lymphadenectomy may be omitted (grade C). Minimally invasive surgery is recommended for early stage ovarian cancer, if there is no risk of tumor rupture (grade B). Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for all high-grade ovarian or Fallopian tube cancers, stage FIGO I-IIA (grade A). In case of ovarian, Fallopian tube or primitive peritoneal cancer of FIGO III-IV stages, thoraco-abdomino-pelvic CT scan with injection (grade B) is recommended. Laparoscopic exploration for multiple biopsies (grade A) and to evaluate carcinomatosis score (at least using the Fagotti score) (grade C) are recommended to estimate the possibility of a complete surgery (i.e. no macroscopic residue). Complete medial laparotomy surgery is recommended for advanced cancers (grade B). It is recommended in advanced cancers to perform para-aortic and pelvic lymphadenectomy in case of clinical or radiological suspicion of metastatic lymph node (grade B). In the absence of clinical or radiological lymphadenopathy and in case of complete peritoneal surgery during an initial surgery for advanced cancer, it is possible not to perform a lymphadenectomy because it does not modify the medical treatment and the overall survival (grade B). Primary surgery is recommended when no tumor residue is possible (grade B). After a complete first surgery, it is recommended to deliver 6 cycles of intravenous (grade A) or to propose intraperitoneal (grade B) chemotherapy, to be discussed with patient, according to the benefit/risk ratio. After a complete interval surgery for a FIGO III stage, the hyperthermic intra peritoneal chemotherapy (HIPEC) can be proposed in the same conditions of the OV-HIPEC trial (grade B). In case of tumor residue after surgery or FIGO stage IV, chemotherapy associated with bevacizumab is recommended (grade A).

Prospective multicenter study evaluating the survival of patients with locally advanced cervical cancer undergoing laparoscopic para-aortic lymphadenectomy before chemoradiotherapy in the era of positron emission tomography imaging.

PURPOSE: The aim of this prospective study conducted in three French comprehensive cancer centers was to evaluate the therapeutic impact on survival of laparoscopic para-aortic (PA) staging surgery in locally advanced cervical cancer (LACC) before chemoradiotherapy. PATIENTS AND METHODS: We conducted a prospective multicenter study of 237 patients treated from 2004 to 2011 for LACC with negative positron emission tomography (PET) imaging of the PA area and undergoing laparoscopic PA lymphadenectomy. Radiation fields were extended to the PA area when PA nodes were involved. Chemoradiotherapy modalities were homogeneous across institutions. Patients with a poor prognosis histologic subtype or peritoneal carcinosis were excluded. RESULTS: Patients had clinical International Federation of Gynecology and Obstetrics stages IB2 (n = 79), IIA (n = 10), IIB (n = 121), III (n = 22), or IVA (n = 5). One hundred ninety-nine patients had squamous carcinoma, and 38 had adenocarcinoma/adenosquamous lesions. Twenty-nine patients (12%) had nodal involvement (false-negative PET-computed tomography [CT] results)-16 with a PA nodal metastasis measuring more than 5 mm and 13 with a nodal metastasis measuring ≤ 5 mm. Event-free survival rates at 3 years in patients without PA involvement or with PA metastasis measuring ≤ or more than 5 mm were 74% (SE, 4%), 69% (SE, 21%), and 17% (SE, 14%; P < .001). CONCLUSION: To our knowledge, this is the largest series of patients reported undergoing such a strategy. We obtained the same survival rate for patients with PA nodal metastasis ≤ 5 mm and patients without PA lymph node involvement, suggesting that this strategy is highly efficient in such patients. Conversely, the survival of patients with PA nodal involvement greater than 5 mm remained poor, despite the absence of extrapelvic disease on PET-CT imaging in this subgroup.

[What is new in the surgical treatment of pelvic gynecologic cancers?]. / Actualités chirurgicales dans les cancers gynécologiques pelviens.

General tendency of modern cancerology is the research of adequacy between extent of disease and treatments. This concept is of course valid for gynaecology and we saw these last months the promising results of fertility-sparing surgery: in initial cervical cancers and in ovarian cancer with good prognosis. Actual Studies should define a clear attitude in patient less than 40 with initial endometrial cancer. At the same time, the development of laparoscopic surgery has continued in cervical cancer staging. If use of sentinel node in endometrial or vulvar cancers remains discussed as for its reliability, importance of staging was stressed for cervical cancer and initial ovarian cancer. Laparoscopic surgery is confirmed in patient at risk with endometrial cancer but it is necessary to stress efforts of French teams which still push back the technical limits of laparoscopic approach like pelvic exenteration or intra-peritoneal chemohyperthermia in advanced ovarian cancer. The adventure continues....

[The choice of approach in the surgical management of endometrial carcinoma: a retrospective serie of 155 cases]. / Places respectives des différentes voies d'abord chirurgicales dans le traitement du cancer de l'endomètre au stade I clinique: étude de 155 cas.

SETTING: Retrospective study of patients consecutively managed surgically for apparent stage I endometrial carcinoma in a comprehensive cancer center, using a standardized protocol for the choice of surgical approach: laparoscopically assisted vaginal hysterectomy (LAVH) as standard procedure, vaginal surgery in apparent stage IA grade 1 or in patients in poor medical condition, laparotomy in the case of subserous myometrial involvement at imaging or in patients with enlarged uteri or in the presence of a contra-indication to laparoscopy. MATERIALS AND METHODS: Excluding 2 patients in whom laparoscopy was converted in laparotomy, and 1 patient who had a full laparoscopic hysterectomy, the records of 155 patients were reviewed. All patients had a preoperative sonogram, and 74% had a preoperative MRI. Preoperative data, preoperative staging, operative data, pathological staging, postoperative complications, recurrence and survival were recorded. RESULTS: 69 patients (43.6%) had a LAVH procedure (group LAVH), 58 patients (36.7%) were treated by laparotomy (group TAH), and 28 patients (18%) were treated by simple vaginal hysterectomy (group VH). Patients in the vaginal group were significantly heavier (VH 91.3 kg 33, range 53-175) than those of the other two groups (TAH 76.5 12.7, range 48-142; LAVH 71.1 18.5, range 47-102). The number of large (> 10 cm) uteri was significantly greater in the TAH group (46.5%) than the LAVH group (26.1%, p = 0.02) or the VH group (14.3%, p = 0.007). Myometrial invasion was suspected in 53.6% of the VH group, 72.6% of the LAVH group, and 71.4% of the TAH group. Deep myometrial invasion was suspected in no patient of the VH group, 14.5% of the LAVH group and 70.7% of the TAH group. The LAVH group had a significantly longer mean operative time than the TAH group or the VH group. The number of perioperative complications was significantly higher in the TAH group (22.4%) compared to the LAVH group (5.6%) and the VH group (0%). Blood loss was significantly elevated in the laparotomy group compared to the other two groups. The mean number of nodes removed was significantly higher in the LAVH group (15.8 7.8, range 4-37) compared to the TAH group (11 5.3, range 2-25, p = 0.002). Of 155 patients, 100 (64.5%) had correct preoperative staging. In 19 (12.3%), FIGO stage was overestimated preoperatively, and in 36 (23.2%) the FIGO stage was underestimated preoperatively. Survival curves were not found significantly different between groups.