Hyperthermic intraperitoneal chemotherapy in ovarian cancer: an update.

In the treatment of advanced-stage epithelial ovarian cancer (EOC)-associated surgery and chemotherapy with intravenous platinum/taxane-based therapy most patients had early or late recurrence. Prevention of progression and recurrence is a major objective for the management of EOC. Recently, many clinical studies have evaluated the strategy with hyperthermic intraoperative intraperitoneal (IP) drug delivery. This is an update of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) in EOC and a view for future strategies. Until recently studies on HIPEC in patients with EOC were mostly retrospective and heterogeneous. Thanks to recent clinical trials, it is reasonable to conclude that surgical cytoreduction and HIPEC is an interesting approach in the management of EOC without increasing morbidity.

Early Second-Look Hysteroscopy: Prevention and Treatment of Intrauterine Post-surgical Adhesions.

Introduction: Intra-uterine adhesion (IUA) is one of the main causes of secondary infertility. The aim of this study was to evaluate the prevalence of IUA developing in women undergoing hysteroscopic resection for submucous myomas, polyps, and intrauterine synechiae and test the efficacy of second look hysteroscopy for diagnosing and treating post-surgical adhesions. Materials and Methods: We retrospectively collected data from reproductive age women who had a second look office hysteroscopy following hysteroscopic resection for myoma, polyp, or IUA at Foch hospital (Suresnes, France) between 2009 and 2017. Results: Six hundred and twenty two reproductive-age women underwent hysteroscopic resection for myoma, polyp, and/or IUA. Among them, 155 women had a second look hysteroscopy. In this group, 29/155 (18.7%) had IUA formation: 17/83 (20.5%) women who underwent hysteroscopic myomectomy, 5/46 (10.9%) women who underwent hysteroscopic polypectomy, and 7/26 (26.9%) women who underwent hysteroscopic lysis of adhesions. These IUA have been lysed by the office hysteroscopy procedure in 16/29 (55.2%) patients: 11/17 (64.7%), 2/5 (40%), and 3/7 (42.9%) in women who underwent hysteroscopic myomectomy, polypectomy and lysis of adhesion, respectively. Conclusion: IUA is a common complication of hysteroscopic surgery. Second look office hysteroscopy is an easy and effective procedure for diagnosing and removing newly formed IUA. It should be recommended for all women undergoing hysteroscopic resection for myomas, polyps, or IUA.

An update on preoperative assessment of the resectability of advanced ovarian cancer.

The best prognosis for advanced ovarian cancer is provided by no residual disease after primary cytoreductive surgery. It is thus important to be able to predict resectability that will result in complete cytoreduction, while avoiding unnecessary surgery that may leave residual disease. No single procedure appears to be sufficiently accurate and reliable to predict resectability. The process should include a preoperative workup based on clinical examination, biomarkers, especially tumor markers, and imaging, for which computed tomography, as well as sonography, magnetic resonance imaging and positron-emission tomography, can be used. This workup should provide sufficient information to determine whether complete cytoreduction is possible or if not, to propose neoadjuvant chemotherapy which is preferable in this case. For the remaining patients, laparoscopy is broadly recommended as an ultimate triage step. However, its modalities are still debated, and several scores have been proposed for standardization and improving accuracy. The risk of false negatives requires a final assessment of resectability as the first stage of cytoreductive surgery by laparotomy. Composite models, consisting of several criteria of workup and, sometimes, laparoscopy have been proposed to improve the accuracy of the predictive process. Regardless of the modality, the process appears to be accurate and reliable for predicting residual disease but less so for predicting complete cytoreduction and thus avoiding unnecessary surgery and an inappropriate treatment strategy. Overall, the proposed procedures are heterogeneous, sometimes unvalidated, or do not consider advances in surgery. Future techniques and/or models are still needed to improve the prediction of complete resectability.

Propensity score to evaluate prognosis in pregnancy-associated breast cancer: Analysis from a French cancer network.

PURPOSE: To compare the prognosis of pregnancy associated breast cancer occurring during pregnancy (BCP) to non-pregnancy associated breast cancers (non-BCP) in young women managed at a national expert center. METHODS: Retrospective cohort study of a prospective database using propensity score matching (PSM) analysis with known prognostic factors. RESULTS: We analyzed data of 49 patients with BCP and 104 with non-BCP diagnosed between 2002 and 2017 at Tenon University Hospital (Paris, France). The BCP tumors were often locally advanced (lymph node metastases in 59%), of high grade (55%) and highly proliferative (67% with Ki67 ≥ 20%). After PSM, breast cancer-free survival (p = 0.45) and breast cancer specific survival (p = 0.81) were similar in the two groups. The recurrence rate was 12% vs 18% (p = 0.45) and the death rate was 6% vs 8% (p = 0.74) for the BCP and non-BCP groups, respectively. No difference in recurrence type was observed between the groups (p = 0.60). CONCLUSIONS: After PSM for known prognostic factors, the prognosis of BCP patients did not differ from that of young patients with non-BCP.

[Clues to differentiate pregnancy-associated breast cancer from those diagnosed in postpartum period: A monocentric experience of pregnancy-associated cancer network (CALG)]. / Arguments pour différencier les cancers du sein associés à la grossesse de ceux diagnostiqués dans le post-partum : expérience monocentrique du réseau cancer associé à la grossesse (CALG).

PURPOSE: To compare epidemiological, histological, therapeutic characteristics and prognosis of patients with breast cancer diagnosed during pregnancy with those diagnosed in postpartum period at a national expert center, « Cancer Associé à La Grossesse ¼ network. METHODS: Retrospective study of 108 patients with a pregnancy-associated breast cancer (PABC) between 2002 and 2016 comparing 51 patients with PABC during pregnancy and 57 patients with PABC of postpartum. RESULTS: Median gestational age at diagnosis was 16 weeks of gestation (WG). Median size (P=0.92), initial axillary pathology (P=0.29), histological type (P=0.33) and hormone receptor positive (P=0.93), were similar between groups. PABC during pregnancy overexpressed less frequently HER2 (12 % vs 36 %, P=0.003) and were less proliferant (Ki67≥15 %; 64 % vs 75 %, P=0.018) with less radical surgery (45 % vs 70 %, P=0.008). Sentinel lymph node biopsy was performed in 8 patients during pregnancy. Less patients of PABC during pregnancy received trastuzumab 12 % vs 37 %, P=0.003. Median delivery term was 37 WG. Median follow-up 3.2 vs 5.6 years (P=0.002) and recurrence rate for PABC during pregnancy and of postpartum were 3.2 vs 5.6 years (P=0.002) and 12 % vs 32 % (P=0.01), respectively. Our results emphasize histological, surgical and adjuvant treatment differences imposing differentiating PABC during pregnancy from those diagnosed in the postpartum period.

Preoperative diagnosis of tumor grade and type in endometrial cancer by pipelle sampling and hysteroscopy: Results of a French study.

BACKGROUND: No data are available to establish whether operative hysteroscopy is superior to standard pipelle sampling to determine histological and grade status in endometrial cancer (EC). The aim of this study was to evaluate whether pipelle device sampling or operative hysteroscopy had an impact on preoperative determination of histological and grade status in EC and consequently on surgical management. METHODS: Data of 224 women with EC receiving primary surgical treatment between 2002 and 2014 were abstracted from a single institution with maintained database. Women were staged on the basis of preoperative and final pathological findings according to the 2009 International FIGO classification. Discrepancies in pathological analysis were assessed between pipelle sampling or operative hysteroscopy and final histology. Values of p < 0.05 were considered to denote significant differences. RESULTS: 149 women underwent preoperative pipelle sampling and 75 operative hysteroscopy. Global discrepancies between pre-operative and post-operative analysis was 20.8% versus 20.0% in the pipelle device and operative hysteroscopy group, respectively, with no significant difference considering type 1 grade 1 or 2 versus type 1 grade 3 versus type 2 EC. Discrepancies in histological type between preoperative and final histology were found in 25 (16.8%) and 11 (14.7%) women in the pipelle device and operative hysteroscopy groups, respectively (p = 0.85). Discrepancies in histological grade between preoperative and final histology were found in 6 (5.8%) vs. 4 (7.0%) of the women in the pipelle device and operative hysteroscopy groups, respectively (p = 1). CONCLUSION: This study suggests that both pipelle sampling and operative hysteroscopy are of limited value in determining definitive histological type and grade. Additional investigations should be evaluated to better characterize the risk groups.

[A propensity score evaluation of single-port or multiport extraperitoneal para-aortic lymphadenectomy and the transperitoneal approach for gynecological cancers]. / Contribution du score de propension pour comparer la lymphadénectomie lombo-aortique par voies transpéritonéale et rétropéritonéale mono- ou multitrocarts.

INTRODUCTION: Endoscopic para-aortic lymphadenectomy (PALN) is a crucial step in the management of gynecological cancers. However, some concerns exist on the completeness of PALN according to the route (transperitoneal vs. extraperitoneal single-port or multiport). We compared these three surgical techniques using a propensity score. METHODS: We retrospectively reviewed all patients undergoing an endoscopic PALN for a gynecological cancer from May 2010 to Mars 2015. Fifty-one patients had a single-port extraperitoneal PALN, 16 a multiport extraperitoneal PALN and 62 a transperitoneal PALN. Factors independently related to technique performances were tested on a multivariate model adjusted for a propensity score. RESULTS: The number of lymph nodes removed by transperitoneal route was 15 and extraperitoneal route single and multiport was 12. After adjustment for the propensity score of undergoing the extraperitoneal approach, no difference in the number of lymph node removed was noted (P=0.17). There was more lymphocyst after transperitoneal (17%) and multiport extraperitoneal PALN (19%) than after extraperitoneal PALN (2%) (P=0.04). Success rate of single-port extraperitoneal PALN was 94% (n=48). Four patients required a conversion to an open route due to vascular injury. DISCUSSION: Using a propensity score, single-port extraperitoneal route offers similar efficacy to perform PALN than transperitoneal or multiport extraperitoneal route but with less lymphocysts.

Single-Port Extra- and Transperitoneal Approach for Paraaortic Lymphadenectomy in Gynecologic Cancers: A Propensity-Adjusted Analysis.

BACKGROUND: Endoscopic paraaortic lymphadenectomy (PALN), an important step in the management of gynecologic cancers, is associated with low morbidity. However, some concerns exist about the completeness of PALN according to the route (transperitoneal vs. single-port extraperitoneal). METHODS: This study retrospectively reviewed the records of patients who had undergone an endoscopic PALN for a gynecologic cancer from May 2010 to August 2014 at the authors' center. The findings showed that 44 patients had a single-port extraperitoneal PALN and 56 had a transperitoneal PALN. The factors independently related to technical performances were tested with a multivariate model adjusted for a propensity score. RESULTS: A median of 16 lymph nodes were removed by the transperitoneal route and 12 by the extraperitoneal route (p = 0.04). No difference in the number of lymph nodes removed was observed after adjustment for the propensity score of patients who underwent the extraperitoneal approach (p = 0.9). The transperitoneal route was associated with more lymphocysts (20 vs. 2% for the extraperitoneal approach) (p = 0.008). The success rate for the extraperitoneal PALN was 91% (n = 40), with the three remaining patients requiring conversion to the transperitoneal route due to a peritoneal breach. CONCLUSION: This propensity-score-adjusted study supports the conclusion that the efficacy of the single-port extraperitoneal route is similar to that of the transperitoneal route for PALN.

Relevance of sentinel lymph node procedure for patients with high-risk endometrial cancer.

OBJECTIVE: While the accuracy of the Sentinel Lymph Node (SLN) procedure has been validated in patients with early-stage endometrial cancer (EC) at low and intermediate risk of recurrence, its relevance for high-risk EC remains unknown. The aim of this study was to evaluate the contribution of SLN biopsy in staging patients with presumed high-risk EC. METHODS: This retrospective multicenter study, conducted from January 2001 to December 2012, included 180 patients with early-stage EC undergoing SLN biopsy. Detection rate and false negative rate were assessed according to risk groups of recurrence. RESULTS: SLNs were detected in 159/180 patients (88%) and were bilateral in 63% of cases. Of the 180 patients, 41 (22%) had a positive lymph node. Ultrastaging detected metastases undiagnosed by conventional histology in 17/41 patients (41%). The false negative rate was 6% (9/159); 2.3% in the low/intermediate risk group and 20% in the high-risk group (p = 0.0008). Lymphovascular space invasion (LVSI) was present in 48 patients (27%). Preoperative findings classified 146 patients as ESMO low/intermediate risk (81%) and 34 as high risk (19%). Ten of the 34 patients (29%) in the presumed high-risk group were downstaged on final histology and 5/18 patients (28%) initially diagnosed with type 2 were finally classified as having type 1 EC. Classification was more likely discordant for patients with preoperative type 2 EC (p = 0.03) and in the initial high-risk group (p = 0.02). CONCLUSIONS: SLN biopsy associated with LVSI status can select which high-risk patients with EC would benefit from comprehensive staging.

Factors influencing the decision to offer immediate breast reconstruction after mastectomy for ductal carcinoma in situ (DCIS): the Institut Gustave Roussy Breast Cancer Study Group experience.

BACKGROUND: The increased rate of ductal carcinoma in situ (DCIS) is associated with a rise in indications for mastectomy and immediate breast reconstruction (IBR). The purpose of our study was to evaluate the factors affecting the indications for IBR and its modalities. STUDY DESIGN: Data concerning two hundred and thirty-eight consecutive patients with DCIS who had undergone modified radical mastectomy and a sentinel lymph node biopsy (SLNB) between 2005 and 2011 were extracted from our database. We then conducted a comparative study between patients who had undergone IBR and those who had not, to determine which factors affected the decision to offer IBR (LOE II). RESULTS: About 57.1% had IBR and 42.9% had no reconstruction. The most common reason why IBR had not been performed was that it had not been proposed by the surgeon (33.4%). Of the 136 patients offered IBR, an implant had been proposed to the majority of them (81.6%). The IBR rate was highest among women under 50 years (52.2%), and was lower among women with diabetes (0.7%) or obesity (8.8%). The choice of reconstruction was not affected by tobacco use or positive SLNB results. CONCLUSION: Factors predictive of the IBR reflect the influence of surgeon counselling and, to a lesser extent, consideration of patient comorbidities. However, there is a need to improve patient information and physician referral.

Sentinel node biopsy upstages patients with presumed low- and intermediate-risk endometrial cancer: results of a multicenter study.

BACKGROUND: There is some controversy about the relevance of lymphadenectomy in patients with early stage endometrial cancer. The aim of this study was to evaluate the contribution of sentinel lymph node (SLN) biopsy in staging patients with presumed low- and intermediate-risk endometrial cancer. METHODS: This retrospective multicenter study was conducted from July 2007 to December 2011 including 103 patients with presumed low- or intermediate-risk endometrial cancer who had undergone SLN biopsy. Concordance between preoperative staging and definitive histology as well as contribution of SLN biopsy and ultrastaging to upstage patients were assessed. RESULTS: SLNs were detected in 89 patients (86.4 %), 56 (62.9 %) of whom had presumed low-risk and 33 (37.1 %) intermediate-risk endometrial cancer. Of the 89 patients, 14 (15.7 %) had positive SLNs. Twelve (21.4 %) of the 56 patients with presumed low-risk disease were upstaged by definitive histology, among whom 3 (25 %) had pelvic positive SLNs. Seven (21.2 %) of the 33 patients with intermediate-risk disease were upstaged by definitive histology, 1 (14.3 %) of whom had positive SLNs. Ultrastaging detected metastases undiagnosed by conventional histology in 6 (42.8 %) of 14 of patients with positive SLNs. CONCLUSIONS: SLN biopsy associated with ultrastaging is relevant to stage low- or intermediate-risk endometrial cancer and could help guide adjuvant therapies.

A nomogram for predicting lymph node metastasis of presumed stage I and II endometrial cancer.

OBJECTIVE: Our objective was to develop a nomogram based on pathological hysterectomy characteristics to provide a more individualized and accurate estimation of lymph node metastasis in endometrial cancer. STUDY DESIGN: Data from the Surveillance, Epidemiology, and End Results database for 18,294 patients who underwent hysterectomy and lymphadenectomy were analyzed. A multivariate logistic regression analysis of selected prognostic features was performed, and a nomogram to predict lymph node metastasis was constructed. A cohort of 434 patients was used for the external validation. RESULTS: The nomogram showed good discrimination with an area under the receiver operating characteristic curve of 0.80 (95% confidence interval, 0.79-0.81) in the training set and 0.79 (95% confidence interval, 0.78-0.80) in the validation set. The nomogram was well calibrated. CONCLUSION: We developed a nomogram based on 5 clinical and pathological characteristics to predict lymph node metastasis with a high concordance probability.

Anti-N-methyl-D-aspartate receptor encephalitis complicating ovarian teratomas: a case report.

Anti-N-methyl-D-aspartate receptor encephalitis is an emerging disease that affects young women. Its diagnosis can be delayed because of the neuropsychiatric symptoms in the foreground, but early removal of the associated teratoma improves the prognosis. We report the treatment of a patient with anti-N-methyl-D-aspartate receptor encephalitis that was related to an ovarian teratoma.