Procalcitonin and C-reactive protein as early markers of anastomotic leakage in intestinal resections for advanced ovarian cancer (EDMOCS).

INTRODUCTION: Serum levels of procalcitonin and C-reactive protein (CRP) have been used to predict anastomotic leakage after colorectal surgery, but information is scarce in advanced ovarian cancer (AOC) surgery with bowel resection. This study aimed to assess the predictive value of procalcitonin and CRP in detecting anastomotic leakage after AOC surgery with bowel resection. The study also aimed to determine the optimal postoperative reference values and the best day for evaluating these markers. MATERIAL AND METHODS: This prospective, observational and multicentric trial included 92 patients with AOC undergoing debulking surgery with bowel resection between 2017 and 2020 in 10 reference hospitals in Spain. Procalcitonin and CRP levels were measured at baseline and on postoperative days 1-6. Receiver operating characteristic analysis was performed to evaluate the predictive value of procalcitonin and CRP at each postoperative day. Sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: Anastomotic leakage was detected in six patients (6.5%). Procalcitonin and CRP values were consistently higher in patients with anastomotic leakage at all postoperative days. The maximum area under the curve (AUC) for procalcitonin was observed at postoperative day 1 (AUC = 0.823) with a cutoff value of 3.8 ng/mL (83.3% sensitivity, 81.3% specificity). For CRP, the maximum AUC was found at postoperative day 3 (AUC = 0.833) with a cutoff level of 30.5 mg/dL (100% sensitivity, 80.4% specificity). CONCLUSIONS: Procalcitonin and C-reactive protein are potential biomarkers for early detection of anastomotic leakage after ovarian cancer surgery with bowel resection. Further prospective studies with a larger sample size are needed to confirm these findings.

An Easy Learning Approach to a Complex Surgical Technique: A Step-by-Step Site-Relapse Lateral Extended Endopelvic Resection (LEER).

Lateral pelvic sidewall involvement by gynecological tumors has been considered traditionally an absolute contraindication to curative resection.1 Moreover, the involvement of the pelvic sidewall at the time of relapse in cervical cancer after primary or adjuvant pelvic radiation occurs in 8.3% of patients.2,3 Laterally extended endopelvic resection (LEER), based on the ontogenetic compartment theory, provides a potential surgical option for patients for whom palliative therapy is the only alternative.4 This complex and ultraradical, surgical technique allows a high rate of complete resection in more than 70% of patients with gynecological cancers and lateral pelvic sidewall involvement. An adequate selection of patients and a deep knowledge of pelvic anatomy are crucial to obtain acceptable morbimortality rates and improved overall survival in this population.5 To deconstruct this complex procedure, we show a detailed step-by-step technique to facilitate the easy learning curve of this surgical technique. We review the Höckel original technique with different site-relapse adapted steps. We provide a pedagogical high-quality video (Video 1) and anatomical outline drawings (Fig. 1) to understand lateral pelvic wall anatomy and standardize this surgical technique. Our purpose is to bring this knowledge to gynecologists and pelvic surgeons in which pelvic lateral approach may be useful beyond gynecological oncologic surgery (Table 1).

OVA-LEAK: Prognostic score for colo-rectal anastomotic leakage in patients undergoing ovarian cancer surgery.

OBJECTIVE: The objective of the present study was to define and validate an anastomotic leak prognostic score based on previously described and reported anastomotic leak risk factors (OVA-LEAK: https://n9.cl/ova-leakscore) and to establish if the use of OVA-LEAK score is better than clinical criteria (surgeon's choice) selecting anastomosis to be protected with a diverting ileostomy. MATERIAL & METHODS: This is a retrospective, multicentre cohort study that included patients who underwent cytoreductive surgery for primary advanced or relapsed ovarian cancer with colorectal resection and anastomosis between January 2011 and June 2021. Data from patients already included in the previous predictive model were not considered in the present analysis. To validate the performance of our logistic regression model, we used the OVA-LEAK formula (Annex I: https://n9.cl/ova-leakscore) for estimating leakage probabilities in a new independent cohort. Then, receiver operating characteristic (ROC) analysis was performed and area under the curve (AUC) was used to measure the performance of the model. Additionally, the Brier score was also estimated. 95% confidence intervals (CI) for each of the estimated performance measures were also calculated. RESULTS: 848 out of 1159 recruited patients were finally included in the multivariable logistic regression model validation. The AUC of the new cohort was 0.63 for predicting anastomotic leak. Considering a cut-off point of 22.1% to be 'positive' (to get a leak) this would provide a sensitivity of 0.45, specificity of 0.80, positive predictive value of 0.09 and negative predictive value of 0.97 for anastomotic leak. If we consider this cut-off point to select patients at risk of leak for bowel diversion, up to 22.5% of the sampled patients would undergo a diverting ileostomy and 47% (18/40) of the anastomotic leaks would be 'protected' with the stoma. Nevertheless, if we consider only the 'clinical criteria' for performing or not a diverting ileostomy, only 12.5% (5/40) of the leaks would be 'protected' with a stoma, with a rate of diverting ileostomy of up to 24.3%. CONCLUSIONS: Compared with subjective clinical criteria, the use of a predictive model for anastomotic leak improves the selection of patients who would benefit from a diverting ileostomy without increasing the rate of stoma use.

Fertility sparing treatment in patients with endometrial cancer (FERT-ENC): a multicentric retrospective study from the Spanish Investigational Network Gynecologic Oncology Group (SPAIN-GOG).

OBJECTIVE: The primary objective was to evaluate the response rate of conservative treatment for endometrial cancer, and the secondary objective was to assess oncological, fertility and obstetric outcomes in patients who underwent fertility preservation treatment. MATERIAL AND METHODS: This multicentre, observational, retrospective study evaluated endometrial cancer patients who underwent fertility-sparing treatment in Spanish centres between January 2010 and January 2020. Seventy-three patients with stage IA endometrioid adenocarcinoma of the uterus were included in the study. RESULTS: The levonorgestrel intrauterine device (LNG-IUD) was the most common fertility-sparing treatment (53.4%), followed by megestrol acetate (20.5%) and medroxyprogesterone acetate (16.4%). During the 24-month follow-up period, the rate of complete response to fertility-sparing management was 74% (n = 54), and 8.2% (n = 6) of patients presented a partial response. Additionally, 13 (17.8%) patients presented with persistent disease and six (8.2%) relapsed after response. The LNG-IUD was associated with a higher complete response rate than the other methods (87.2 vs. 58.8%; p = 0.01). Surgical treatment (at least hysterectomy) was performed in 44 (60.3%) patients as the end of fertility-sparing treatment. Four (5.5%) patients presented relapse after surgery, associated with final FIGO stage III (p = 0.036), myometrial invasion > 50% (p = 0.018) and final tumour grade 2-3 (p = 0.018). The mean follow-up period was 57.8 (range 6-159) months. The 5-year relapse-free survival and overall survival rates were 92.6% [95% CI (81.3, 97.2)] and 93.5% [95% CI (80.7, 97.9)], respectively. During follow-up, three patients (4.1%) died of the disease after completion of surgical treatment. Up to 50.7% of patients included in the study attempted to get pregnant. Of these, the rate of pregnancy was 81.1% (n = 30/37), and reproductive techniques were used for this purpose in 78.4% of cases. CONCLUSIONS: Fertility-sparing management presented a high response rate in patients with endometrial cancer. LNG-IUD was associated with a better response rate compared to the other treatment options. Moreover, in patients using this management method, pregnancy could be achieved using reproductive techniques.

Molecular Management of High-Grade Serous Ovarian Carcinoma.

High-grade serous ovarian carcinoma (HGSOC) represents the most common form of epithelial ovarian carcinoma. The absence of specific symptoms leads to late-stage diagnosis, making HGSOC one of the gynecological cancers with the worst prognosis. The cellular origin of HGSOC and the role of reproductive hormones, genetic traits (such as alterations in P53 and DNA-repair mechanisms), chromosomal instability, or dysregulation of crucial signaling pathways have been considered when evaluating prognosis and response to therapy in HGSOC patients. However, the detection of HGSOC is still based on traditional methods such as carbohydrate antigen 125 (CA125) detection and ultrasound, and the combined use of these methods has yet to support significant reductions in overall mortality rates. The current paradigm for HGSOC management has moved towards early diagnosis via the non-invasive detection of molecular markers through liquid biopsies. This review presents an integrated view of the relevant cellular and molecular aspects involved in the etiopathogenesis of HGSOC and brings together studies that consider new horizons for the possible early detection of this gynecological cancer.

Integrative Genomic and Transcriptomic Profiling Reveals a Differential Molecular Signature in Uterine Leiomyoma versus Leiomyosarcoma.

The absence of standardized molecular profiling to differentiate uterine leiomyosarcomas versus leiomyomas represents a current diagnostic challenge. In this study, we aimed to search for a differential molecular signature for these myometrial tumors based on artificial intelligence. For this purpose, differential exome and transcriptome-wide research was performed on histologically confirmed leiomyomas (n = 52) and leiomyosarcomas (n = 44) to elucidate differences between and within these two entities. We identified a significantly higher tumor mutation burden in leiomyosarcomas vs. leiomyomas in terms of somatic single-nucleotide variants (171,863 vs. 81,152), indels (9491 vs. 4098), and copy number variants (8390 vs. 5376). Further, we discovered alterations in specific copy number variant regions that affect the expression of some tumor suppressor genes. A transcriptomic analysis revealed 489 differentially expressed genes between these two conditions, as well as structural rearrangements targeting ATRX and RAD51B. These results allowed us to develop a machine learning approach based on 19 differentially expressed genes that differentiate both tumor types with high sensitivity and specificity. Our findings provide a novel molecular signature for the diagnosis of leiomyoma and leiomyosarcoma, which could be helpful to complement the current morphological and immunohistochemical diagnosis and may lay the foundation for the future evaluation of malignancy risk.

Vesicovaginal Fistula Repair by Modified Martius Flap: A Step-by-Step Surgical Technique Video.

BACKGROUND: Fistula repair in the perineal region represents a major challenge for surgeons. It is important for the medical community to facilitate and disclose these techniques. OBJECTIVE: The aim of this article was to show a stepwise approach for a direct repair and use of a Martius flap for a vesicovaginal fistula. METHODS: We show a single case performed in a patient who presented with a vesicovaginal fistula diagnosed after surgery, which did not respond to conservative management. The procedure consists of the following steps: intraoperative cystoscopy, anatomical direct repair of the fistulous tract between the bladder and vagina, and modified Martius flap. CONCLUSIONS: Martius flap is a repair technique used for complex fistula in the perineal region. It is a simple, safe, and reproducible procedure with good long-term functional and esthetic results.

Machine Learning-Based Integration of Prognostic Magnetic Resonance Imaging Biomarkers for Myometrial Invasion Stratification in Endometrial Cancer.

BACKGROUND: Estimation of the depth of myometrial invasion (MI) in endometrial cancer is pivotal in the preoperatively staging. Magnetic resonance (MR) reports suffer from human subjectivity. Multiparametric MR imaging radiomics and parameters may improve the diagnostic accuracy. PURPOSE: To discriminate between patients with MI ≥ 50% using a machine learning-based model combining texture features and descriptors from preoperatively MR images. STUDY TYPE: Retrospective. POPULATION: One hundred forty-three women with endometrial cancer were included. The series was split into training (n = 107, 46 with MI ≥ 50%) and test (n = 36, 16 with MI ≥ 50%) cohorts. FIELD STRENGTH/SEQUENCES: Fast spin echo T2-weighted (T2W), diffusion-weighted (DW), and T1-weighted gradient echo dynamic contrast-enhanced (DCE) sequences were obtained at 1.5 or 3 T magnets. ASSESSMENT: Tumors were manually segmented slice-by-slice. Texture metrics were calculated from T2W and ADC map images. Also, the apparent diffusion coefficient (ADC), wash-in slope, wash-out slope, initial area under the curve at 60 sec and at 90 sec, initial slope, time to peak and peak amplitude maps from DCE sequences were obtained as parameters. MR diagnostic models using single-sequence features and a combination of features and parameters from the three sequences were built to estimate MI using Adaboost methods. The pathological depth of MI was used as gold standard. STATISTICAL TEST: Area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, accuracy, positive predictive value, negative predictive value, precision and recall were computed to assess the Adaboost models performance. RESULTS: The diagnostic model based on the features and parameters combination showed the best performance to depict patient with MI ≥ 50% in the test cohort (accuracy = 86.1% and AUROC = 87.1%). The rest of diagnostic models showed a worse accuracy (accuracy = 41.67%-63.89% and AUROC = 41.43%-63.13%). DATA CONCLUSION: The model combining the texture features from T2W and ADC map images with the semi-quantitative parameters from DW and DCE series allow the preoperative estimation of myometrial invasion. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 3.

Ultrastaging protocol in sentinel lymph node for apparent early stage ovarian cancer.

OBJECTIVE: The objective of the present study is to determine the role of sentinel lymph node (SLN) ultrastaging in apparent early-stage ovarian cancer. METHODS: We previously demonstrated the feasibility of SLN in early-stage ovarian cancer in a pilot study and in a clinical trial (NCT03452982). The SLN of the 30 patients involved in both were processed following an ultrastaging protocol. The cost of ultrastaging processing was also reported. RESULTS: A SLN was detected in up to 91.3% and 90% in the pelvic and para-aortic region, respectively. In all cases, a SLN was detected at least in one field, pelvic or para-aortic. The mean time from injection to SLN resection was 53.3 ± 20.3 min. Two of 30 (6.6%) patients had a contralateral SLN in the para-aortic field, but no patients had contralateral SLN within the pelvic field after injection. The mean number of harvested SLN was 2.1 ± 1.4 (range: 0-5) and 2.7 ± 1.5 (range: 0-7) in the pelvic and para-aortic region, respectively. Two patients were upgraded to stage IIIA1 because of lymph node metastasis. In the first case, based on single sections and haematoxylin and eosin (H&E) examination, a pelvic SLN micrometastasis (1 mm) was found on the first H&E section. By using the ultrastaging protocol, the size of the metastasis was increased to 2.1 mm (macrometastasis). In the same patient, the ultrastaging study of the inframesenteric para-cava SLNs found isolated tumour cells in the subcapsular and interfollicular lymph nodes sinus in one of the two SLN harvested (in one of the sections at the fourth and fifth ultrastage levels). The other upstaged case was a para-aortic macrometastasis in a patient in whom the SLN was not identified in the para-aortic field because of the absence of migration from the infundibulo-pelvic stump injection. The cost of ultrastaging in each patient depended on the total number of SLN retrieved, averaging 96.8 € (range: 0-230.5) and 124.5 € (range: 0-322.7€) for pelvic and para-aortic SLN, respectively. CONCLUSIONS: A uniform protocol for ultrastaging is essential for lower-volume metastasis detection and to provide reproducible information between upcoming studies, as evidence about SLN in ovarian cancer is growing.

M-TRAP: Safety and performance of metastatic tumor cell trap device in advanced ovarian cancer patients.

OBJECTIVE: Despite radical surgery and chemotherapy, most patients with ovarian cancer die due to disease progression. M-Trap is an implantable medical device designed to capture peritoneal disseminated tumor cells with the aim to focalize the disease. This trial analyzed the safety and performance of the device. METHODS: This first-in-human prospective, multi-center, non-blinded, single-arm study enrolled 23 women with high-grade serous advanced ovarian cancer. After primary or interval debulking surgery, 3 M-Trap devices were placed in the peritoneum of the abdominal cavity. 18-months post-implantation or at disease progression, devices were initially removed by laparoscopy. The primary safety endpoint was freedom from device and procedure-related major adverse events (MAEs) through 6-months post-implantation compared to an historical control. The primary performance endpoint was histopathologic evidence of tumor cells capture. RESULTS: Only one major adverse event was attributable to the device. 18 women were free of device and procedure related MAEs (78.3%). However, the primary safety endpoint was not achieved (p = 0.131), primarily attributable to the greater surgical complexity of the M-Trap patient population. 62% of recurrent patients demonstrated tumor cell capture in at least one device with a minimal tumor cell infiltration. No other long-term device-related adverse events were reported. The secondary performance endpoint demonstrated a lack of disease focalization. CONCLUSIONS: The M-Trap technology failed to meet its primary safety objective, although when adjusted for surgical complexity, the study approved it. Likewise, the devices did not demonstrate the anticipated benefits in terms of tumor cell capture and disease focalization in recurrent ovarian cancer.

Impact of uterine manipulator on oncological outcome in endometrial cancer surgery.

BACKGROUND: There are limited data available to indicate whether oncological outcomes might be influenced by the uterine manipulator, which is used at the time of hysterectomy for minimally invasive surgery in patients with endometrial cancer. The current evidence derives from retrospective studies with limited sample sizes. Without substantial evidence to support its use, surgeons are required to make decisions about its use based only on their personal choice and surgical experience. OBJECTIVE: To evaluate the use of the uterine manipulator on oncological outcomes after minimally invasive surgery, for apparent early-stage endometrial cancer. STUDY DESIGN: We performed a retrospective multicentric study to assess the oncological safety of uterine manipulator use in patients with apparent early-stage endometrial cancer, treated with minimally invasive surgery. The type of manipulator, surgical staging, histology, lymphovascular space invasion, International Federation of Gynecology and Obstetrics stage, adjuvant treatment, recurrence, and pattern of recurrence were evaluated. The primary objective was to determine the relapse rate. The secondary objective was to determine recurrence-free survival, overall survival, and the pattern of recurrence. RESULTS: A total of 2661 women from 15 centers were included; 1756 patients underwent hysterectomy with a uterine manipulator and 905 without it. Both groups were balanced with respect to histology, tumor grade, myometrial invasion, International Federation of Gynecology and Obstetrics stage, and adjuvant therapy. The rate of recurrence was 11.69% in the uterine manipulator group and 7.4% in the no-manipulator group (P<.001). The use of the uterine manipulator was associated with a higher risk of recurrence (hazard ratio, 2.31; 95% confidence interval, 1.27-4.20; P=.006). The use of uterine manipulator in uterus-confined endometrial cancer (International Federation of Gynecology and Obstetrics [FIGO] I-II) was associated with lower disease-free survival (hazard ratio, 1.74; 95% confidence interval, 0.57-0.97; P=.027) and higher risk of death (hazard ratio, 1.74; 95% confidence interval, 1.07-2.83; P=.026). No differences were found regarding the pattern of recurrence between both groups (chi-square statistic, 1.74; P=.63). CONCLUSION: In this study, the use of a uterine manipulator was associated with a worse oncological outcome in patients with uterus-confined endometrial cancer (International Federation of Gynecology and Obstetrics I-II) who underwent minimally invasive surgery. Prospective trials are essential to confirm these results.

Protective Maneuver to Avoid Tumor Spillage during Laparoscopic Radical Hysterectomy: Vaginal Cuff Closure.

OBJECTIVE: To demonstrate the feasibility of a protective maneuver to avoid tumor exposure during laparoscopic radical hysterectomy. DESIGN: This video illustrates the vaginal cuff closure technique in cervical cancer surgery. SETTING: The Oncologic Gynecology Department at the University Hospital La Fe. INTERVENTIONS: After the Laparoscopic Approach to Cervical Cancer trial [1], the laparoscopic approach to the surgical treatment of cervical cancer has been questioned: laparotomic surgery has been associated with a better cancer outcome. This publication has changed the current approach recommendation for performing radical hysterectomy from minimally invasive surgery to open surgery. There are some theories that might justify these findings. In minimally invasive surgery, the use of a uterine manipulator can condition the spread owing to erosion and friction caused on the tumor, even leading to the perforation of the tumor. In addition, intraperitoneal colpotomy can lead to pelvic peritoneum contamination by the tumor. To close the gap between laparoscopy and laparotomy, some protective maneuvers, such as vaginal cuff closure, have been proposed [2,3]. These strategies aim to reduce the possibility of manipulation or exposure of the tumor to the pelvis during colpotomy in laparoscopic radical hysterectomy. These protective maneuvers have been shown to decrease the relapse rate in retrospective studies [4]. However, prospective trials are needed to elucidate and confirm these findings. In this video, we explain step-by-step the technique of vaginal cuff closure before a radical hysterectomy performance for uterine cervical cancer. First, the nodal status is established by laparoscopic sentinel lymph node dissection and frozen section study. Bilateral pelvic lymphadenectomy is completed according to the size of the tumor. In the case of negative nodal status, the vaginal cuff is closed: Approximately 2 to 3 cm from the tumor (depending on its size), a circumferential incision of the vaginal mucosa is performed, followed by the dissection of the vaginal wall, which should be sufficient to allow a tension-free vaginal closure. The vaginal cuff is then closed with a running suture. A laparoscopic radical hysterectomy is then completed, and the surgical specimen is removed without any manipulation of the tumor. CONCLUSION: Avoiding manipulation of the tumor during cancer surgery is crucial. A vaginal cuff closure technique appears to be an easy protective maneuver that prevents tumor exposure and manipulation during laparoscopic radical hysterectomy.

Implications of extraperitoneal paraaortic lymphadenectomy to the left renal vein in locally advanced cervical cancer. A Spanish multicenter study.

OBJECTIVE: Paraaortic lymph node involvement is an important prognostic factor in locally advanced cervical cancer (LACC), but the anatomic limit of aortic lymphadenectomy is controversial. We assessed the impact of extraperitoneal paraaortic lymphadenectomy up to the left renal vein in patients with LACC undergoing pretherapeutic staging. METHODS: A retrospective, multicenter study of patients with LACC stages FIGO 2009 IB2 and IIA2-IVA treated in 10 Spanish reference hospitals in gynecological oncology between 2000 and 2016. Sites of metastatic paraaortic lymph nodes above or below the inferior mesenteric artery were evaluated. Procedural-related intraoperative and early and late complications were assessed. RESULTS: We included 634 patients undergoing paraaortic lymphadenectomy, in 616 (97.2%) of which the left renal vein was the upper limit of dissection (laparoscopy 592, robotic-assisted 24). The median surgical time was 150 min (interquartile range (IQR) 120-180), blood loss was 50 mL (range 20-80), and the length of stay was 2 days (range 2-3). Metastatic paraaortic involvement was found in 114 patients (18.5%), with infrarenal metastases in 73 (64%) of them. There were 11 patients (9.6%) with infrarenal metastases only, whereas in the remaining 62 (54.4%) patients concomitant infrarenal and inframesenteric metastases were observed. Intraoperative, early, and late postoperative complications occurred in 3.6%, 7.0%, and 4.5% of patients, respectively. CONCLUSIONS: In this study of patients with LACC undergoing surgical staging, paraaortic lymphadenectomy up to the left renal vein detected skip or isolated infrarenal metastasis in 9.6% of patients, with an acceptable surgical morbidity.

Sentinel lymph node technique in early-stage ovarian cancer (SENTOV): a phase II clinical trial.

OBJECTIVE: Early-stage ovarian cancer might represent an ideal disease scenario for sentinel lymph node application. Nevertheless, the published experience seems to be limited. Our objective was to assess the feasibility and safety concerns of sentinel lymph node biopsy in patients with clinical stage I-II ovarian cancer. METHODS: We conducted a prospective cohort study of 20 patients with histologically confirmed ovarian cancer. 99mTc and indocyanine green were injected into both the utero-ovarian and infundibulopelvic ligament stump, if they were present, during surgical staging. An intraoperative gamma probe and near-infrared fluorescence imaging were used to detect the sentinel lymph nodes. Inclusion criteria included: >18 years of age, suspicious adnexal mass (unilateral or bilateral) at ultrasound and CT imaging or confirmed ovarian tumor after previous surgery (unilateral or bilateral salpingo-oophorectomy with or without hysterectomy). Adverse events were recorded through postoperative day 30. The primary trial end point was to report adverse events related to the technique, including the use of 99mTc and ICG intraperitoneally, as well as the feasibility of the technique. RESULTS: A total of 20 patients were included in the analysis. Sentinel lymph nodes were detected in 14/15 (93%) pelvic and all 20 (100%) para-aortic regions. Five patients did not have utero-ovarian injection because of prior hysterectomy. The mean time from injection to sentinel lymph node resection was 53±15 min (range; 30-80). The mean number of harvested sentinel lymph nodes was 2.2±1.5 (range; 0-5) lymph nodes in the pelvis and 3.3±1.8 (range; 1-7) lymph nodes in the para-aortic region. There were no adverse intraoperative events, nor any within the 30 days of follow-up related with the technique. CONCLUSION: Sentinel lymph node mapping in early-stage ovarian cancer is feasible without major intraoperative or < 30 days safety concerns. (NCT03452982). TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT03452982.

Sentinel Lymph Node Technique in Apparent Early Ovarian Cancer: Laparoscopic Technique.

STUDY OBJECTIVE: To demonstrate the feasibility of laparoscopic sentinel lymph node technique in presumed early-stage ovarian cancer. DESIGN: Video illustrating the laparoscopic performance of the sentinel lymph node technique in ovarian cancer. SETTING: The Oncologic Gynecology Department at the University Hospital La Fe. PATIENTS: Candidates for the technique presented an apparent early stage ovarian cancer. The technique was performed in the context of a clinical trial called SENTOV (NCT03452982). INTERVENTIONS: To date, lymphadenectomy is recommended after the diagnosis of apparent early-stage ovarian cancer as part of the surgical staging. Minimally invasive surgery can be considered for the purpose of restaging [1]. Up to 14% of the patients are upstaged because of positive lymph nodes after pelvic and para-aortic lymphadenectomy [2]. Regarding low-grade tumors, a lower rate of lymph node involvement has been reported [3]. Sentinel lymph node technique has been reported to be feasible in a recent pilot study [4]. Two clinical trials (Sentinel Lymph Node in Early Ovarian Cancer and Sentine Lymph Node in Early Ovarian Cancer) are currently ongoing to clarify the use of sentinel lymph node technique in early ovarian cancer. The injection points were at the infundibulopelvic and ovarian ligament stumps. Two hundred microliters of saline solution containing 37 MBq of technetium-99m nanocolloid followed by 0.5 mL of indocyanine green (ICG) was injected subperitoneally. We used a 27 G needle at each injection point. Immediately after injection and also at 15 and 30 minutes after injection, the operative field was checked guided by the acoustic signal of the gamma probe and the near-infrared camera. We performed a minimum dissection looking for the sentinel lymph node or nodes in the pelvic and para-aortic region. Any lymph node with a remarkable radioactivity count as high as 10 times the background and/or dyed with ICG was considered a sentinel lymph node and was harvested separately. A systematic surgical staging was performed after the sentinel lymph node procedure was completed. Because of its small size, the ICG molecule is not caught in the lymph node valve system and keeps migrating when performing lymphography. An exhaustive direct view of the dye path is required to avoid misleading detection of the real sentinel lymph node. This theoretical problem is resolved by the use of the 99mTC-nanocolloid. This tracer gets trapped into the lymph node valve system because of its molecular size and does not keep migrating as does ICG. As such, a combination of both methods is proposed. CONCLUSION: Laparoscopic performance of sentinel lymph node technique in ovarian cancer seems to achievable. Between 2017 and 2019, this procedure was performed in 30 patients (13 laparoscopic), in the context of our pilot experience [4] and the Sentinel Lymph Node in Early Ovarian Cancer clinical trial (NCT03452982).

Incidence, predictors and clinical outcome of pancreatic fistula in patients receiving splenectomy for advanced or recurrent ovarian cancer: a large multicentric experience.

PURPOSE: To evaluate the incidence, predictors and clinical outcome of pancreatic fistulas in patients receiving splenectomy during cytoreductive surgery for advanced or recurrent ovarian cancer. METHODS: Data of women who underwent splenectomy during cytoreduction for advanced or recurrent ovarian cancer from December 2012 to May 2018 were retrospectively retrieved from the oncological databases of five institutions. Surgical, post-operative and follow-up data were analysed. RESULTS: Overall, 260 patients were included in the study. Pancreatic resection was performed in 45 (17.6%) women, 23 of whom received capsule resection alone, while 22 required tail resection. Hyperthermic intraperitoneal chemotherapy (HIPEC) was administered in 28 (10.8%) patients. In the overall population, a pancreatic fistula was detected in 32 (12.3%) patients, and pancreatic resection (p-value = 0.033) and HIPEC administration (p-value = 0.039) were associated with fistula development. In multivariate analysis, HIPEC (OR = 2.573; p-value = 0.058) was confirmed as a risk factor for fistula development in women receiving splenectomy alone, while concomitant cholecystectomy (OR = 2.680; p-value = 0.012) was identified as the only independent predictor of the occurrence of pancreatic fistulas in those receiving additional distal pancreatectomy. Although the median length of hospital stay was higher in women with pancreatic leakage (p-value = 0.008), the median time from surgery to adjuvant treatment was not significantly increased. CONCLUSION: HIPEC was identified as a risk factor for pancreatic fistulas in patients who underwent splenectomy alone, while concomitant cholecystectomy was the only independent predictor of fistula in those receiving additional pancreatectomy. The development of pancreatic leakage was not associated with increased post-operative mortality or delay in the initiation of chemotherapy.

Comparative study of three different managements after colorectal anastomosis in ovarian cancer: conservative management, diverting ileostomy, and ghost ileostomy.

OBJECTIVE: Anastomotic leak remains the main concern after colorectal anastomosis in ovarian cancer. Our objective was to compare the use of three different management approaches after colorectal resection and anastomosis in patients with ovarian cancer. METHODS: Between January 2010 and June 2018, a total of 133 patients with International Federation of Gynecology and Obstetrics (FIGO) stage II-IV ovarian cancer who underwent colorectal resection and anastomosis were included. According to the approach followed after colorectal anastomosis and during the post-operative period, patients were stratified into three groups: conservative management and observation, diverting ileostomy, or ghost ileostomy technique. Univariate analyses were performed for quantitative variables by applying Student's t test or Mann-Whitney U test and for qualitative variables by using the χ2 test (or Fisher's test according to the sample size). RESULTS: A total of 145 patients underwent colorectal resection during cytoreduction for FIGO stage II-IV ovarian cancer. Twelve patients were excluded because a colostomy was required. Thus, 133 patients were included in the final analysis. Modified posterior pelvic exenteration was performed in 121 (91%) patients and recto-sigmoid resection in 12 (9%) patients with relapse. The approach after anastomosis was wait-and-see in 72 patients (54.1%), diverting ileostomy in 19 patients (14.4%), and ghost ileostomy in 42 patients (31.5%). There were no differences in diagnosis, age, body mass index, ECOG (Eastern Cooperative Oncology Group), histology, tumor grade, FIGO stage, or type of surgery between the groups. No differences were found regarding the anastomosis leak related factors or the rate of anastomotic leak between the three groups (5.6% vs 5.3% vs 4.8%; p=0.98). Two patients died because of the anastomotic leak in the wait-and-see group, and none died in the diverting ileostomy or ghost ileostomy group. In the diverting ileostomy group, a higher number of patients had complications compared with the ghost ileostomy group (78.9% vs 7.1%; p<0.01). Four patients (21.1%) developed dehydration due to high output stoma (>1500 mL) causing electrolyte imbalance in the diverting ileostomy group, and one patient (2.4%) in the ghost ileostomy group (p=0.03). The stoma reversal rate was 73.7% for the diverting ileostomy group and 100% for the ghost ileostomy group. CONCLUSIONS: There were no differences found in the rate of anastomotic leak among the three groups of patients. The use of ghost ileostomy avoids the drawbacks of diverting ileostomy and seems to have advantages over routine diverting ileostomy and wait-and-see approaches for ovarian cancer patients undergoing colorectal anastomosis. Rates of stoma reversal are lower after diverting ileostomy when compared with ghost ileostomy.