FDG-PET/CT and Para-Aortic Staging in Endometrial Cancer. A French Multicentric Study.

BACKGROUND: FDG-PET/CT is a noninvasive examination that could be helpful for the management of endometrial cancer. The aim of this study was to evaluate the performance of FDG-PET/CT in assessing para-aortic lymph-node involvement in high-risk endometrial cancer. METHODS: We performed a retrospective multicenter study including all patients who had a high-risk endometrial cancer with a preoperative FDG-PET/CT and a para-aortic lymphadenectomy (PAL) between 2009 and 2019. The main objective was to evaluate the overall performance of FDG-PET/CT. The secondary objectives were to evaluate its performances according to the histological type and according to FDG-PET/CT date (before or after hysterectomy), and to compare its overall performance with that of the MRI scan. RESULTS: We included 200 patients from six different centers. After the false positive FDG-PET/CT was reread by nuclear physicians, FDG-PET/CT had a sensitivity of 61.8%, a specificity of 89.7%, a positive predictive value of 69.4%, a negative predictive value of 86.1%, and an AUC of 0.76. There were no statistically significant differences in the performances according to either histological type and or FDG-PET/CT date. The sensitivity of FDG-PET/CT was better than that of MRI (p < 0.01), but the specificity was not (p = 0.82). CONCLUSION: Currently, FDG-PET/CT alone cannot replace PAL for the lymph node evaluation of high-risk endometrial cancers. It seems essential to reread it in multidisciplinary meetings before validating the therapeutic management of patients, particularly in the case of isolated para-aortic involvement.

Assessment of Lymph Node Involvement with PET-CT in Advanced Epithelial Ovarian Cancer. A FRANCOGYN Group Study.

The objective of our study is to evaluate the diagnostic performance of positron emission tomography/computed tomography (PET-CT) for the assessment of lymph node involvement in advanced epithelial ovarian, fallopian tubal or peritoneal cancer (EOC). This was a retrospective, bicentric study. We included all patients over 18 years of age with a histological diagnosis of advanced EOC who had undergone PET-CT at the time of diagnosis or prior to cytoreduction surgery with pelvic or para-aortic lymphadenectomy. We included 145 patients with primary advanced EOC. The performance of PET-CT was calculated from the data of 63 patients. The sensitivity of PET-CT for preoperative lymph node evaluation was 26.7%, specificity was 90.9%, PPV was 72.7%, and NPV was 57.7%. The accuracy rate was 60.3%, and the false-negative rate was 34.9%. In the case of primary cytoreduction (n = 16), the sensitivity of PET-CT was 50%, specificity was 87.5%, PPV was 80%, and NPV was 63.6%. The accuracy rate was 68.8%, and the false negative rate was 25%. After neoadjuvant chemotherapy (n = 47), the sensitivity of PET-CT was 18.2%, specificity was 92%, PPV was 66.7%, and NPV was 56.1%. The accuracy rate was 57.5%, and the false negative rate was 38.3%. Due to its high specificity, the performance of a preoperative PET-CT scan could contribute to the de-escalation and reduction of lymphadenectomy in the surgical management of advanced EOC in a significant number of patients free of lymph node metastases.

Training for next generation surgeons: a pilot study of robot-assisted hysterectomy managed by resident using dual console.

PURPOSE: To assess feasibility of a standardized robot-assisted hysterectomy managed by resident and supervised by senior surgeon using dual-console on a 21-step grid (max score = 42) assessing resident autonomy. METHODS: A total of seven patients managed between September 2019 and March 2020 by six residents in gynecology and obstetrics were included. Standardized robot-assisted hysterectomy for endometrial cancer or adenomyosis was performed. RESULTS: No conversion to laparotomy, no intra- or post-operative incidents were reported. Mean score on the evaluation scale was 29.8 out of 42 (SD = 7.3). Mean operative time was 104 min (SD = 23). Mean average suturing time was, respectively, 335 s (SD = 57 s) and 270 s (SD = 53 s) for the first and the fourth knot. There was a 65 s improvement between the first and the fourth intracorporeal knot (p = 0.043). The perceived workload evaluated with the NASA TLX score showed a low level of stress (Temporal demand = 1.6 /10), and a low level of frustration (Frustration level = 3.6/10). Experience gained during the surgery was felt to be important (Commitment = 8.6/10). CONCLUSION: Standardized robot-assisted hysterectomy managed by a resident supervised by a senior surgeon using the dual-console seems feasible. This tool could be useful to assess residents' surgical skills.

[Impact of the LACC study. A SFOG survey]. / Impact de l'étude LACC. Une enquête de la SFOG.

INTRODUCTION: The LACC (Laparoscopic Approach to Cervical Cancer Trial) study, released in 2018, described oncological findings in favour of open surgery compared to the minimally invasive pathway in the management of early stage cervical cancers. Our aim was to assess the impact of this study on surgical practices in France. METHOD: Online questionnaire, consisting of 13 questions addressed to gynecology oncology french society (SFOG) surgeons. RESULTS: Forty questionnaires were collected. The median annual number of radical hysterectomy was 5 (0-20). Prior to the study, 92.5 % of cervical cancer patients had radical hysterectomy by minimally invasive surgery. In case of laparoscopy or robot, the uterine manipulator was used in 67.6 % and the colpotomy was performed intra-abdominally (78.4 %). After the LACC study, 60 % changed their practice. Open surgery was favored by 75 % of those who modified their practice. Among those continuing to perform minimally invasive surgeries, the manipulator and the intracorporeal colpotomy were discontinued. One-third of surgeons have changed their surgical practice for endometrial cancer in parallel. CONCLUSION: The results of the LACC study led to a change in surgical practices with an increase in open surgery and a stop in the use of the uterine manipulator and the laparoscopic/robotic intracorporeal colpotomy in the surgical management of early stage of cervical cancer.

Description of an initiation program to robotic in vivo gynecological surgery for junior surgeons.

INTRODUCTION: Most gynecological residents or junior surgeons do not practice nor experience robotic surgery due to lack of access during residency or poor knowledge about this growing surgical technology. This study evaluated the feasibility and safety of a 3-half-day experiencing and training session for robot-assisted gynecological surgery designed for residents and fellows. MATERIEL AND METHODS: This is a prospective, single-center observational study about a training course aimed at residents or fellows at the university teaching hospital of Limoges (France). It spreads over three consecutive half-days: one dedicated to simulation exercises involving the Da Vinci Skills Simulator© and the other two, to practice in two robot-assisted procedures with dual-console equipment supervised by a senior surgeon (as it is usually performed in a university teaching hospital). Complications during surgery, patient's medical records as well as the participants' performances during in vivo suturing acts were gathered. Feedback on the session was obtained with a questionnaire at the end of the course. RESULTS: Twelve sessions involving 24 patients operated on by 34 trainees from 16 different teaching university hospitals across the country took place. No conversion to laparotomy nor any major peri- or post-operative complication was reported. Time for stitching decreased significantly (p=.016) between the first and the second in vivo surgery. Use of the dual console was found helpful and most attendees (96.8%) would recommend this training session. CONCLUSION: We showed this training course with both simulation and in vivo surgery was feasible, safe and was a well-liked initiation program for robotic surgery.

The Key Role of Warm and Cold Ischemia in Uterus Transplantation: A Review.

Introduction: Uterus transplantation (UTx) is a promising treatment for uterine infertility that has resulted in several births since 2014. Ischemia is a key step in organ transplantation because it may lead to changes jeopardizing graft viability. Method: We performed a systematic review of animal and human studies relating to uterine ischemia. Results: We retained 64 studies published since 2000. There were 35 studies in animals, 24 in humans, and five literature reviews. Modest preliminary results in large animals and humans are limited but encouraging. In small animals, pregnancies have been reported to occur after 24 h of cold ischemia (CI). In ewes, uterine contractions have been detected after 24 h of CI. Furthermore, it has been shown in animals that uterine tolerance to CI and to warm ischemia (WI) can be increased by pharmacological products. In women, mean CI time in studies of births from uteri obtained from live donors was between 2 h 47 min and 6 h 20 min from a deceased donor; with only one birth in this case. Muscle contractions have also been demonstrated in myometrial samples from women, after six or more hours of CI. Conclusion: The uterus seems to be able to tolerate a prolonged period of CI, of at least six hours. Studies of the ischemia tolerance of the uterus and ways to improve it are essential for the development of UTx, particularly for procedures using grafts from deceased donors.

Changes in the metabolic composition of storage solution with prolonged cold ischemia of the uterus.

INTRODUCTION: The development of uterine transplantation (UTx) from deceased donors requires knowledge of the tolerance of the uterus to prolonged cold ischemia (CI). This can be evaluated through the use of biological parameters to assess degradation of the organ between its procurement and transplantation. The objective of this study was to analyze changes in the metabolic composition of the storage solution in cases of prolonged CI in uteri from ewes. METHODS: Eighteen uterine auto-transplantations were performed in ewes. CI time was 1 h (T1) or 24 h (T24). Samples of Celsior® were taken when the explanted uterus was flushed (T0) and at the end of CI. A dual approach to metabolic analyses was followed: targeted biochemical analyses targeting several predefined metabolites and non-targeted metabolomics analyses based on nuclear magnetic resonance (NMR). RESULTS: Metabolic analyses were performed on 16 explanted uteri. Metabolomic profiles differed significantly between T1 and T24 (p = 0.003). Hypoxia-associated degradation of the organ was demonstrated by the significantly higher lactate levels at T24 than at T1 (p < 0.05), accompanied by cell lysis, and significantly higher levels of creatine kinase activity in T24 than in T1 uteri (p < 0.05). Oxidative stress increased over time, with a significantly higher oxidized glutathione/glutathione ratio for T24 than for T1 uteri (p < 0.05). CONCLUSION: The metabolic results indicate a significant degradation of the uterus during 24 h of CI. Metabolic analysis of the storage solution could be used as a non-invasive tool for evaluating uterine degradation during CI before transplantation.

Para-aortic Lymph Node Invasion in High-risk Endometrial Cancer: Performance of 18FDG PET-CT.

AIM: 18F-Fluorodeoxyglucose positron-emission tomography integrated with computed tomography (18FDG PET-CT) is a non-invasive examination that could be helpful for the management of endometrial cancer. This study investigated the performance of 18FDG PET-CT in assessing para-aortic (PA) lymph-node involvement in high-risk endometrial cancer. MATERIALS AND METHODS: This was a retrospective, single-center study carried out between 2009 and 2018. The inclusion criteria were high-risk and locally advanced type 1 or 2 endometrial cancer with 18FDG PET-CT before PA lymphadenectomy. RESULTS: During the study period, among 142 patients with high-risk endometrial cancer, 35 patients (24.6%) underwent 18FDG PET-CT followed by PA lymphadenectomy. In 25% of cases, PA lymphadenectomy was not performed due to the discovery of metastasis. 18FDG PET-CT had a sensitivity of 50%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 75%, accuracy of 80% and an area under the curve of 0.75 for the evaluation of PA involvement. CONCLUSION: According to its high specificity in PA lymph-node evaluation, a positive PET scan might allow PA lymphadenectomy to be avoided.

Organizing a uterus transplantation programme: The designation of Uterus Transplantation Centres in France.

Absolute uterine factor infertility affects several thousand young women in France. The first healthy child delivered to a uterus transplant recipient took place in 2014, and uterus transplantation is developing rapidly in many countries. The French College of Gynaecologists and Obstetricians (CNGOF) formed a uterus transplantation committee (CETUF) in 2015 to advance this technology in France. The CETUF sets out the criteria for the designation of Uterus Transplantation Centres. The objectives, requirements, operation and responsibilities of these centres have been described. Their responsibilities for organizing geographical coverage, continuity of care, communication, training, research and evaluation have been defined. This document will serve as a guide for the authorities concerned, to ensure that the means are provided to adequately manage patients with absolute uterine factor infertility who require uterus transplantation.