Detection of Mesenteric Tumor Using Dynamic Contrast Enhanced MRI.

PURPOSE: This study was designed to evaluate the use of a novel imaging technique, dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI), for detecting mesenteric peritoneal metastases. METHODS: Thirty-four patients underwent preoperative conventional MRI, including T1, T2, diffusion-weighted (DWI), and delayed gadolinium MRI, as well as DCE MRI. DCE MRI involved imaging the peritoneal cavity every 9 s for 6 min. DCE images were processed to generate parametric maps of tumor vascularity. Two oncologic surgeons and a radiologist reviewed conventional MRI for all tumor and then later reviewed the conventional MRI plus the DCE parametric maps. Images were reviewed for tumor of the parietal peritoneum, porta hepatis, bowel serosa, upper small bowel mesentery, lower small bowel mesentery, and pelvis. Conventional MRI and DCE + MRI findings were compared to operative and histopathologic reports for tumor detection. PCI scores were calculated for surgery, MRI, and DCE. RESULTS: Upper mesenteric tumor was present in 21 patients. DCE images showed a sensitivity of 100%, specificity of 92%, and accuracy of 97% compared with conventional MRI sensitivity of 24%, specificity of 93%, and accuracy of 50% (p = 0.006). Lower mesenteric tumor was present in 22 patients. DCE images showed a sensitivity of 100%, specificity of 92%, and accuracy of 97% compared with conventional MRI sensitivity of 45%, specificity of 92%, and accuracy of 62% (p = 0.008). The mean surgical PCI for all 34 patients was 23.4 compared with MRI 20.0 (p = 0.003) and DCE MRI 24.1 (p = 0.26). The addition of the DCE images improved the accuracy of total PCI by > 10% in 16 (0.46) patients. For PCI regions 9-12, the mean surgical PCI was 6.0 compared with MRI 4.8 (p = 0.08) and DCE 6.6 (p = 0.02). The addition of DCE images improved the accuracy of the regional PCI > 10% in 15 (0.43) patients. CONCLUSIONS: DCE MRI provides a novel contrast tool that improves detection of mesenteric tumor. Depicting small-volume mesenteric tumor is better on DCE MRI compared with conventional MRI.

Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program.

STUDY OBJECTIVE: Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program. DESIGN: Retrospective analysis (II-2) of all patients who underwent laparoscopic extraperitoneal surgical staging at Women and Children's Hospital for locally advanced cervical cancer between June 2002 and June 2005. SETTING: Gynecologic oncology fellowship training program at a University-County Hospital PATIENTS: Thirty-two patients with clinical stage IIB-IVA cervical carcinoma were identified. INTERVENTIONS: Laparoscopic extraperitoneal surgical staging for clinical stage IIB-IVA cervical cancer. MEASUREMENTS AND MAIN RESULTS: A total of 32 cases of laparoscopic extraperitoneal surgical staging for locally advanced cervical cancer performed by fellows-in-training were identified. Fellows were first assistant surgeon in 10 cases, and operating surgeon in 22 cases. Each fellow was mentored an average of 5 cases as first assistant surgeon. As operating surgeon, all 22 fellow cases (100%) were successfully performed without conversion to laparotomy. Fellow mean operative time was 163 minutes. Fellow mean aortic nodal count was 14. Fellow mean blood loss was 42 mL. The mean hospital stay was 1.6 days. Overall, 2 patients (6.2%) experienced a complication from the procedure. Over one half (53%) of the patients reported a prior abdominal surgery. No lymphedema has been reported in patients who underwent laparoscopic extraperitoneal surgical staging with a median follow-up of 10 months. Surgical comorbidities such as hypertension, diabetes, and obesity were common in the study group. A steep surgical learning curve for the fellows was demonstrated by comparing mean operative times to academic year. Aortic nodal metastasis was detected in 25% of cases, and 14% were occult. CONCLUSIONS: It is feasible to teach laparoscopic extraperitoneal surgical staging to fellows-in-training. Our data suggest that by the end of training, fellows can become proficient with the procedure and are capable of surgical outcomes and complication rates comparable to reported literature.

Extraperitoneal laparoscopic lymph node staging: the University of Southern California experience.

OBJECTIVES: To describe our experience with extraperitoneal lymph node staging in gynecologic oncology. MATERIALS AND METHODS: The extraperitoneal approach was performed to assess the lymph node histology in patients with gynecologic malignancies. The nodes are approached from a lateral approach after dissecting open the extraperitoneal space bluntly and with insufflation. Bilateral aortic nodes are taken from a left-sided or right-sided approach depending on the patient's characteristics. RESULTS: Forty-six patients underwent this procedure over a 2.5-year period. Thirty-seven patients had cervical cancer. The median BMI was 27.1 (17.7-38.1). The median lymph node yield was 14 (0-60). Two patients had disruption of the peritoneum such that the aortic lymphadenectomy had to be completed transperitoneally. No patients required laparotomy. No patients required transfusion. DISCUSSION: This technique permits histologic evaluation of the retroperitoneal nodes with minimal risk of intraabdominal adhesions. Recovery is rapid and further therapy can be prescribed shortly. The data on the nodes can assist in treatment planning.

Anastrozole, an aromatase inhibitor, and medroxyprogesterone acetate therapy in premenopausal obese women with endometrial cancer: a report of two cases successfully treated without hysterectomy.

BACKGROUND: Hormonal therapy for endometrial cancer is occasionally warranted in the premenopausal woman who is interested in maintaining fertility. Combining progesterone with an agent that eliminates the adipose production of estrogen will theoretically be more effective than progesterone alone. CASES: Two cases of reproductive-aged women with grade 1 endometrial cancer who were treated with medroxyprogesterone acetate and anastrozole daily for 3 and 6 months subsequently reverted to normal endometrium. CONCLUSION: Progesterone combined with the elimination of adipose production of estrogen may be an effective therapy in well-differentiated endometrial cancer in the obese premenopausal woman.

Detection of residual subclinical ovarian carcinoma after completion of adjuvant chemotherapy.

PURPOSE: We sought to test the hypothesis that the presence of telomerase activity in peritoneal washings of patients treated for ovarian carcinoma is a sensitive and specific indicator of the presence of residual disease. We hypothesized that this test, if added to second-look procedure protocols, could help determine whether residual disease is present or not in patients who have completed their adjuvant chemotherapy for ovarian carcinoma. EXPERIMENTAL DESIGN: Peritoneal washings were obtained from 100 consecutive patients undergoing a second-look procedure after treatment for ovarian carcinoma (cases) and from 100 patients undergoing surgery for benign gynecological conditions (controls). The washings were assayed for telomerase activity using the telomerase repeat amplification protocol. The results were compared to the histological and cytological findings. RESULTS: Among our 100 cases, 82 (82%) had either positive second-look procedures or expressed telomerase in their peritoneal washings. Fifty-three (53%) had positive second-look procedures, whereas 66 (66%) tested positive for telomerase. Twenty-nine of the 47 patients (62%) with negative second-look procedures tested positive for telomerase. Of the 53 patients with positive second-look procedures, 37 (70%) tested positive for telomerase. None of the 100 controls (0%) expressed telomerase in their peritoneal washings. CONCLUSIONS: Telomerase activity in peritoneal washings of patients treated for ovarian carcinoma and undergoing a second-look procedure may provide a means of increasing the sensitivity of such procedures for the detection of residual disease while maintaining a high level of specificity.