Effects of unilateral ovariectomy on female fertility outcome.

PURPOSE: To compare the fertility outcome among women subjected to unilateral ovariectomy and other abdominal or non-gynaecologic pelvic surgery. METHODS: In this retrospective cohort study, 113 fertile women, surgically treated between 1990 and 2001 at Sapienza University of Rome with unilateral ovariectomy (UO), appendectomy (AP) or cholecystectomy (CO) for benign disease, were analysed for fertility outcome. Patients with assessed pre-surgical fertility defects, previous abdominal or pelvic surgeries and post-surgical contraception were not included. RESULTS: Thirty-five women underwent UO, 39 were subjected to AP and 39 were treated with CO. After a minimum 10-year post-surgical interval, the overall number of successful pregnancies was 75. The rate of women who experienced at least one post-operative successful pregnancy was: 48.5 % in UO, 41 % in AP and 53.8 % in CO (UO vs. AP, P = 0.55; UO vs. CO, P = 0.99; AP vs. CO, P = 0.53). One patient (2.8 %) in UO, one patient (2.6 %) in AP and two patients (5.1 %) in CO underwent Assisted Reproductive Technology to become pregnant. The rate of women who reported at least one miscarriage was: 10/35 (28.5 %) in UO, 11/39 (28.2 %) in AP, 12/39 (30.8 %) in CO (UO vs. AP, P = 0.93; UO vs. CO, P = 0.89; AP vs. CO, P = 0.81). One ectopic pregnancy was reported in CO group and one stillbirth occurred in one AP patient. CONCLUSIONS: No statistical difference in terms of post-operative fertility outcome between patients subjected to UO, AP or CO was found, thus allowing to suppose that the removal of one ovary does not significantly worsen the female fertility outcome respect to other abdominal or pelvic procedures.

Intraperitoneal chemotherapy by ultrasound-guided direct puncture in recurrent ovarian cancer: feasibility, compliance, and complications.

OBJECTIVE: This prospective pilot study investigated the feasibility, complications, and compliance of the administration of intraperitoneal (IP) chemotherapy by direct puncture under ultrasonographic guidance performed on consecutive patients with recurrent ovarian cancer (ROC). METHODS: Patients were evaluated to undergo secondary cytoreduction and/or to receive IP chemotherapy. Patients received standard intravenous therapy for ROC plus IP administration by direct puncture needle, under ultrasonographic guidance. RESULTS: From January 2008 to January 2011, 38 patients were enrolled. A total of 402 IP procedures were performed, with a mean of 10.5 procedures per patient. The feasibility rate was 97.4%. In 237 cases (98.8%) of subgroup 1 (abdominal wall thickness ≤6 cm), the procedure was performed after 1 attempt, meanwhile in 6% of cases of subgroup 2 (abdominal wall thickness >6 cm), more than 1 attempt was necessary (P < 0.01). The mean procedure time was 10 minutes (range, 5-30 minutes). We recorded a total of 2.25% mild intraprocedure complications. No significant difference was identified for the complication rate according to the abdominal wall thickness or according to the number of previous laparotomies. A total of 5 procedures (1.2%) were not performed as a result of patients' noncompliance. The mean pain score according to the visual analog pain scale was moderate at the first evaluation (after 3 minutes) and mild at the final evaluation (after 10 minutes). CONCLUSIONS: The administration of IP chemotherapy with a direct puncture, under ultrasound guidance, for patients with ROC, is a safe and feasible method, with a high acceptance from patients.

Complete remission of ovarian cancer induced intractable malignant ascites with intraperitoneal bevacizumab. Immunological observations and a literature review.

Malignant ascites resistant to conventional drugs frequently affects ovarian cancer patients at the end of life. Here we report the case of a patient who benefited from complete resolution of ascites after low dose intraperitoneal administration of bevacizumab. Immunological analyses showed an initial increase in proportion and function of CD8(+) effector T cells and a reduction of circulating T(reg) cells. A review of the current literature regarding bevacizumab in ovarian cancer is reported. Bevacizumab has shown a high efficacy in the treatment of ovarian cancer. Intraperitoneal administration induces an immune activation and appears promising in the treatment of malignant ascites.

Laparoscopy compared with laparoscopically guided minilaparotomy for large adnexal masses: a randomized controlled trial.

OBJECTIVE: To address the efficacy in terms of intraperitoneal spillage of laparoscopically guided minilaparotomy compared with operative laparoscopy for large adnexal cysts. METHODS: A randomized controlled trial was carried out at a tertiary referral center from January 2005 to September 2006. Sixty eligible patients affected by nonendometriotic adnexal cysts with diameter between 7 and 18 cm were randomly assigned to either operative laparoscopy or laparoscopically guided minilaparotomy. RESULTS: The relative risk for intraperitoneal spillage among women treated with laparoscopy was 5.55 (95% confidence interval 1.88-16.33). Operative times were significantly shorter in patients who underwent laparoscopically guided minilaparotomy. Surgical difficulty was significantly higher in patients treated with laparoscopy. However, postoperative stay was shorter. CONCLUSION: Laparoscopically guided minilaparotomy, when compared with laparoscopy, is able to reduce intraperitoneal spillage in patients with presumably benign large adnexal masses, with minimal increase in patient short- and long-term discomfort. Because data regarding the importance of intraperitoneal spillage during surgery for benign and malignant pathologies, as well as rupture rates during traditional laparotomy, are scarce, traditional laparotomy still represents the standard treatment. In women desiring a minimally invasive strategy for large cysts, laparoscopically guided minilaparotomy should be considered. CLINICAL TRIAL REGISTRATION: Australian Clinical Trials Registry, www.actr.org.au, ACTR N012607000241437, LEVEL OF EVIDENCE: I.

Neoadjuvant chemotherapy plus radical surgery in locally advanced cervical cancer during pregnancy: a case report.

Management of cervicocarcinoma during pregnancy is influenced by gestational age, stage of disease, and patient's desire to maintain her pregnancy. We report a case of a pregnant patient with locally advanced cervicocarcinoma successfully treated by neoadjuvant chemotherapy, followed by caesarean section and radical surgery.

Solitary gastric recurrence from ovarian carcinoma: a case report and literature review.

BACKGROUND: Isolated gastric recurrence due to ovarian cancer is a rare event and is usually associated with gastrointestinal symptoms. CASE REPORT: We report a case of an isolated gastric recurrence of ovarian carcinoma in an otherwise asymptomatic 42-year-old woman in whom diagnosis was made using the FDG-PET/CT scan followed by laparoscopy. CONCLUSIONS: In rare cases, ovarian cancer can directly recur on the stomach without any symptoms. FDG-PET/CT scan and diagnostic laparoscopy are effective in leading to an early diagnosis of disease recurrence.

Immunological and Clinical Impact of Cancer Stem Cells in Vulvar Cancer: Role of CD133/CD24/ABCG2-Expressing Cells.

BACKGROUND: Cancer stem cells (CSCs) are tumour-initiating cells with self-renewal properties and chemo/radio-resistance. Regulatory T-cells (Tregs) influence CSCs through several mechanisms. In different solid tumours, the presence of both cell populations correlated with poor survival. In vulvar cancer, little is known regarding biological markers able to predict patient prognosis. We investigated the presence and clinical impact of CSCs and infiltrating Treg in primary vulvar cancer. MATERIALS AND METHODS: Paraffin-embedded tissue specimens derived from 43 patients with vulvar cancer were analyzed by immunohistochemistry for the expression of prominin-1 (CD133), CD24, ATP-binding cassette sub-family G member 2 (ABCG2) (CSC markers) and forkhead box protein P3 (FOXP3) (Treg marker). RESULTS: CD133 expression correlated with younger age at diagnosis (p<0.01), lymph-node metastasis (p<0.05) and larger tumour diameter (p<0.05). CD133+ tumours showed a high FOXP3+ T-cell infiltration. Overall survival and progression-free survival were not influenced by the expression of the analyzed biomarkers. CONCLUSION: In vulvar cancer, CSCs were more frequently expressed in younger aged patients and those with aggressive disease. Their presence was also associated with high Treg infiltration, which contributes to the generation of an immunosuppressive milieu.

Surgical treatment of an isolated omental cervical cancer recurrence: report of a case and review of the literature.

AIMS AND BACKGROUND: Recurrent cervical cancer has traditionally been associated with a dismal prognosis. Historically, patients who developed distant metastases from cervical cancer were not considered eligible for surgical resection; only palliative treatment options are available, generally consisting of chemo- and/or radiotherapy. Metastases usually appear in the liver, lung or lymph nodes. The abdominal cavity is a quite unusual site of recurrence and the disease usually has multiple foci. For this reason, peritoneal involvement by cervical cancer is considered a contraindication to local treatment. METHODS AND STUDY DESIGN: We report the first case of a 30-year-old woman with isolated intra-abdominal cervical cancer recurrence diagnosed with 18F-FDG PET/CT, successfully surgically treated. RESULTS: Histopathological analysis confirmed the tumor to be an omental relapse of squamous cervical cancer previously treated with anterior pelvic exenteration and platinum based chemotherapy. The patient underwent adjuvant treatment with 3 cycles of topotecan and has remained free of disease during the 4 years of follow-up. CONCLUSIONS: In selected cases with isolated recurrences, a surgical resection may provide a long term complete remission in recurrent cervical cancer patients.

Laparoscopically guided minilaparotomy: a minimally invasive approach for the treatment of gynaecologic diseases in morbidly obese patients.

OBJECTIVE: Obese patients are at greater risk of gynaecologic surgery. Laparotomy is generally performed, even though this approach is regarded as highly invasive, whereas laparoscopy, though minimally invasive, is relatively contraindicated because of the high conversion rates to laparotomy. In light of this, we propose laparoscopically guided transverse minilaparotomy (LGTM) as a minimally invasive alternative technique. The rationale of diagnostic laparoscopy is to evaluate the feasibility of a minimally invasive approach. We have evaluated the feasibility and compared the outcomes with a historical group treated with laparotomy (LPTM), in morbidly obese patients (MOP) subjected to gynaecologic surgery. STUDY DESIGN: From November 2004, MOPs with body mass index (BMI) ≥ 40 kg/m² and admitted for gynaecologic surgery (early stage endometrial cancer and benign disease) were enrolled in this observational study and submitted to LGTM. Patients with a uterine size greater than the umbilical transverse line and with indication for vaginal surgery were excluded operative data and outcome were prospectively recorded. RESULTS: LGTM was feasible in 34 cases (87%) out of 39. In two women, the procedure was aborted due to intraperitoneal and ovarian malignant disease spread diagnosed at laparoscopy. In three cases, conversion was necessary due to severe adhesions in one case; laparoscopically unrecognized disease spread in the parametria in the second, and in the remaining case a right common iliac vein injury during lymphadenectomy. When compared to LPTM, haemoglobin drop and postoperative stay were significantly reduced with LGTM. Complications were higher in the control group: due to a significantly higher incidence of wound dehiscence (OR 0.27, 95% CI 0.05-1.32, p<0.05). CONCLUSIONS: LGTM is feasible in the vast majority of MOPs and achieves significantly better results when compared to the standard approach.

Multiple Bulky Lymph Nodal Metastasis in Microinvasive Cervical Cancer: A Case Report and Literature Review.

Microinvasive squamous cell cervival carcinoma is characterized by an exceptional incidence of lymph nodal metastasis. We report the case of a 45-year-old woman affected by IA1 squamous cell carcinoma, found to have massive pelvic lymph nodal metastasis. After a systematic pelvic and aortic selective lymphadenectomy, at 16 months of follow-up, she is still disease-free. Patients suitable for conservative therapy should be carefully counselled about the established risks and benefits of nondestructive treatment options.

Resectoscopic versus bipolar electrode excision of endometrial polyps: a randomized study.

OBJECTIVE: To evaluate operative resectoscopy versus hysteroscopic bipolar electrode excision for the treatment of endometrial polyps. DESIGN: Prospective, randomized study. SETTING: Tertiary-care university hospital. PATIENT(S): One hundred consecutive patients with endometrial polyps. INTERVENTION(S): Patients underwent diagnostic hysteroscopy, and after assignment on a random basis, they underwent polyp excision either by operative resectoscopy or by a bipolar electrode passed through the operating sheath of a small-caliber hysteroscope. MAIN OUTCOME MEASURE(S) AND RESULT(S): Operating times, difficulty of the operation, surgeon satisfaction with the procedure, intra- and postoperative complications, postoperative pain, and patient satisfaction were recorded. The two procedures did not differ in total surgery times. In subgroup analysis, the resectoscope was faster for large polyps (>2 cm) and for polyps with a fundal implant. The bipolar electric probe was faster for small polyps (<2 cm) and for polyps with a nonfundal implant. CONCLUSION(S): Operative resectoscopy appears to be the technique of choice for endometrial polyps >2 cm or with a fundal implant. Bipolar electrode excision appears to be preferable for smaller, nonfundal polyps.

Histologic analysis of endometriomas: what the surgeon needs to know.

OBJECTIVE: To evaluate by thorough pathologic analysis the histologic features of the endometrioma wall excised at laparoscopy. DESIGN: Prospective series of consecutive patients. SETTING: Tertiary care, university hospital. PATIENT(S): Fifty-nine patients with ovarian endometriomas. A total of 70 cysts were examined. INTERVENTION(S): Patients underwent operative laparoscopy with the stripping technique for excision of the ovarian endometrioma. MAIN OUTCOME MEASURE(S): A thorough histologic examination was performed on the entire cyst wall specimen. RESULT(S): Histologic examination confirmed the endometriotic nature of the cyst in 100% of the cases. The inner wall of the endometrioma was covered by endometriotic tissue on 60% of the surface. The mean cyst wall thickness was 1.4 mm. The mean value of maximal depth of endometriosis penetration in the endometrioma wall was 0.6 mm. In 99% of the cases the maximal penetration of the endometriotic tissue was <1.5 mm. CONCLUSION(S): In the present study, we demonstrate that the endometrioma wall contains endometriotic tissue in 100% of the cases. However, the endometriotic tissue may cover the inner cyst wall for a surface that varies between 10% and 98% of the entire wall (median value 60%). This tissue may reach a depth of 2 mm, but for most of the surface it does not penetrate >1.5 mm. These histologic data may help the gynecologic laparoscopist select the surgical approach that maximally preserves healthy ovarian tissue.

Neoadjuvant chemotherapy followed by radical surgery in patients affected by FIGO stage IVA cervical cancer.

BACKGROUND: Concomitant chemoradiotherapy represents the standard treatment for patients affected by locally advanced cervical cancer. Survival rates in patients affected by FIGO stage IVA disease remain poor. Some authors have suggested that neoadjuvant chemotherapy followed by radical surgery might be a valid alternative to standard treatment. The objective of this study was to analyze the feasibility and results obtained by neoadjuvant chemotherapy in patients affected by stage IVA disease. METHODS: Eighteen patients affected by FIGO stage IVA cervical cancer were treated with 175 mg/m(2) paclitaxel and 75 mg/m(2) cisplatin every 21 days for three courses followed by radical surgery when feasible. RESULTS: All patients were subjected to the three planned chemotherapy courses. Two patients achieved a complete clinical response, and 10 patients achieved a partial clinical response. Ten patients were subjected to anterior pelvic exenteration, whereas the remaining eight patients were treated with chemotherapy, radiotherapy, and concomitant chemoradiotherapy. The estimated 3-year and 5-year overall survival rates were 47.4% and 31.6%, respectively. Patients eligible for surgery benefited from significantly longer survival rates. CONCLUSIONS: Neoadjuvant chemotherapy followed by radical surgery is feasible in approximately half of patients affected by FIGO stage IVA cervical cancer. Overall survival rates appear similar to those reported with concomitant chemoradiotherapy. Patients who are amenable to radical surgery after chemotherapy may benefit from long-term survival rates.

Ovarian cancer, diagnosed with PET, with bilateral inguinal lymphadenopathy as primary presenting sign.

BACKGROUND: Ovarian cancer groin lymph nodes metastases are rare. Only one case of disease spread isolated to the groins has been reported in the English literature. We report the case of a patient with bilateral inguinal lymphadenopathy due to tumor metastases and in which tumor origin was diagnosed using [(18)F]fluorodeoxyglucose positron emission tomography (PET). CASE REPORT: This is the first case of bilateral groin lymph nodes as sole site of metastases from ovarian cancer. Primary origin was identified using PET. CONCLUSIONS: In rare cases, the ovaries can directly metastasis to the groin even in a relatively initial tumor growth phase. PET may play a role in the diagnosis of occult ovarian tumors.

Splenectomy during secondary cytoreduction for ovarian cancer disease recurrence: surgical and survival data.

BACKGROUND: Ovarian cancer disease recurs predominantly in the abdomen, with the spleen usually involved as part of a vast spread of upper-abdominal disease or, less frequently, as an isolated site of disease recurrence. Very few reports are available in the literature on the outcome of patients subjected to splenectomy during secondary cytoreduction. The aim of this study was to identify prognostic factors and to review surgical and clinical data in order to identify those patients who would benefit the most from splenectomy during secondary cytoreduction. METHODS: This was a retrospective review of platinum-sensitive recurrent epithelial ovarian cancer patients who underwent splenectomy as part of secondary cytoreduction. Surgical and survival data were recorded. RESULTS: Twenty-four patients were identified. Multiple site disease recurrence was observed in 15 patients. The spleen was involved at the hilus in 12 patients; surface and intraparenchymal metastases were equally present. Optimal cytoreduction was achieved in all patients. At a median follow-up of 30 months, median progression-free and overall survival from the time of secondary surgery were 34 and 56 months, respectively. Overall survival was significantly correlated to residual disease at secondary surgery, disease-free survival, consolidation chemotherapy, and type of adjuvant therapy. CONCLUSIONS: Splenectomy as part of secondary cytoreduction is a feasible and safe procedure. Secondary cytoreduction in selected groups of patients is confirmed to be associated with high long-term survival rates even when aggressive surgery of the upper abdomen is required.