PET-MRI for evaluation of response to radiochemotherapy in patients with locally advanced cervical cancer.

OBJECTIVE: We aimed to analyze the diagnostic test accuracy of positron emission tomography and a magnetic resonance imaging scan (PET-MRI) fusion in evaluating tumor response after radiochemotherapy in patients with locally advanced cervical cancer. METHODS: Patients treated at two institutes between January 2008 and December 2016 were studied retrospectively. Re-evaluation by positron emission tomography (PET) and magnetic resonance imaging (MRI) was performed in a non-concurrent way 4-8 weeks after treatment. A nuclear medicine doctor and a radiologist (subsequently referred as "radiologists"), both experts in gynecological oncology, re-examined the post-treatment MRI and positron emission tomography-computed tomography (PET-CT) separately, and then performed a fusion of these examinations. In this study we describe this "a posteriori fusion methodology", with two levels, enabling limitation of anatomical shifts. The gold standard was anatomical pathology analysis of the surgical specimen, since all patients underwent surgery following this radiological re-evaluation. The radiologists' degree of certainty in their diagnoses, and the impact of fusion on their diagnostic confidence were assessed by the radiologists, using two Likert judgment scales. They also adjudicated on possible changes of interpretation after the fusion. RESULTS: Thirty-one patients were included. The PET-MRI fusion has a sensitivity of 79% and a specificity of 90%. The positive predictive value (PPV) was 94%, and the negative predictive value (NPV) was 69%. In 45% of cases (n=13), radiologists reported an improvement in their degree of certainty in their diagnosis using a Likert judgment scale, due to inspecting the PET and MRI fused. A change in interpretation of tumor response was observed using a Likert judgment scale in 31% of cases. CONCLUSION: PET-MRI fusion improves the radiologist's own diagnostic confidence in assessing response to concurrent radiochemotherapy in locally advanced cervical cancer. More studies using a latest generation hybrid system will be necessary to further compare to MRI and PET-CT.

Study of postoperative complications after the implementation of a multidisciplinary care pathway for patients with digestive endometriosis.

PURPOSE: To assess the quality of care following the establishment of a multidisciplinary care pathway for patient operated on for deep pelvic endometriosis with digestive impairment. METHODS: We conducted a retrospective monocentric study of patients suffering from deep infiltrating endometriosis, treated in Gynaecological Department at Toulouse University Hospital from January 2018 to December 2020. We compared our results to those of our previous study, Gornes et al. which showed a postoperative complication occurred in 37.8% of the cases and a postoperative severe complication according to the Clavien-Dindo classification (grades 3b) rate of 18.3%. RESULTS: 98 patients were included. Our study shows a clear decrease in postoperative complications with an overall complication rate of 19.4% and severe complications (grades 3b) of 4.1%. The rate of complication appeared to be significantly less frequent in the case of shaving in relation to other digestive procedures (p = 0.008) and in the case of a lesion of < 20 mm by MRI (p = 0.01). The use of multidisciplinary surgical care was more frequent in the case of multiple locations (66.7% vs. 41.8%, p = 0.07) and was more frequent in the case of transmural damage with echo endoscopy (and to a lesser degree in the case of damage of the muscularis or mucous membrane) (p = 0.05). CONCLUSIONS: Multidisciplinary care of endometriosis with digestive damage appears to be indispensable. The intraoperative intervention of a skilled digestive surgeon of bowel endometriosis helps create the best balance between effectiveness-complications-functional prognosis, with a reduction of severe postoperative complications.

Impact of hospital and surgeon case volume on morbidity in colorectal endometriosis management: a plea to define criteria for expert centers.

National and international guidelines recommend referring patients with severe forms of endometriosis to expert centers. However, there is a lack of clear criteria to define an expert center. We examined the roles of surgeon and hospital procedure volumes as determinants of morbidity in deep infiltrating endometriosis of the rectum and sigmoid colon (DIERS). METHODS: We conducted a French retrospective multicenter study of hospital facilities performing colorectal surgery for DIERS in 2015. The primary end point was to analyze the relation between case volume and the incidence of complications. We estimated the optimal cut-off (OCO) determined by a minimal p-value approach. RESULTS: The study included 56 hospital facilities and collected data of 1135 cases of surgical management of colorectal endometriosis. The mean and median number of procedures per year and per surgeon were 9.17 and 5.58, respectively. The overall rate of grade III-V complication was 7.6% (82/1135). One grade V complication occurred. The rates of rectovaginal fistula, anastomotic leakage, pelvic abscess, and ureteral fistula were: 2.7% (31/1135), 0.79% (9/1135), 3.4% (39/1135), and 0.70% (8/1135), respectively. An OCO of 20 procedures per center and per year (p < 0.001) was defined. The OCO per surgeon and per year varied between seven (p = 0.007) and 13 procedures (p = 0.03). In a multivariate analysis, we found that only the volume of activity was independently correlated to complication outcomes (p = 0.0013). CONCLUSION: Our results contribute to providing objective morbidity data to determine criteria for defining expert centers for colorectal surgery for endometriosis.

Para-aortic workup in locally advanced cervical cancer: heterogeneity is still the rule. Results from a retrospective multicenter study.

PURPOSE: We retrospectively studied the different strategies of para-aortic (PA) staging of patients with PA involvement in locally advanced cervical cancer as conducted in eight centers in France and their impact upon survival and management. METHODS: All patients enrolled in this multicenter study presented with cervical cancer with PA involvement. The diagnosis of PA spread was based on imaging assessment of the PA area and/or pathological examination of harvested PA lymph nodes when staging lymphadenectomy was performed. Imaging modalities comprised positron emission tomography (PET), magnetic resonance imaging and/or computed tomography. Survival outcomes were evaluated retrospectively. RESULTS: One hundred and fifteen women were retrospectively studied. Radiological staging was conducted in 101 (87.8 %) patients. PET was performed in 66 patients (57.4 %). Its FN rate was 22.7 % (15/66) and its sensitivity 77.3 %. Para-aortic lymphadenectomy was conducted in a large proportion of patients (67.8 %). Its indications were not restricted to negative radiological workup. The lymphadenectomy rate was significantly higher in patients with earlier stages (p = 0.02) and lower tumor volume (p = 0.01). Treatment consisted of chemoradiation therapy with extended-field radiotherapy in all patients, followed by intracavitary brachytherapy in 94 cases (81.7 %) and completion surgery in 69 cases (60 %). Patients without para-aortic metastasis on radiological examination were more likely to receive all treatment modalities (p = 0.04). CONCLUSION: Despite established recommendations, our results point out the tremendous heterogeneity regarding para-aortic assessment. These differences in management are perhaps related to a recommended therapeutic strategy that does not appear to improve the poor prognosis associated with PA involvement.

Cervical cancer with paraaortic involvement: do patients truly benefit from tailored chemoradiation therapy? A retrospective study on 8 French centers.

We retrospectively studied the therapeutic significance of extended-field radiotherapy combined with concurrent platinum-based chemotherapy for the management of cervical carcinoma with paraaortic spread. Treatment response and survival outcomes were evaluated. One hundred and fifteen women were retrospectively studied. Radiological staging was conducted in 101 (87.8%) patients and paraaortic lymphadenectomy in 78 (67.8%). Patterns of treatment comprised chemoradiation therapy (100%), intracavitary brachytherapy (81.7%), completion surgery (60%) and neoadjuvant chemotherapy (4.3%). Four-year overall and disease-free survivals were 32.7% and 28.8%, respectively. Progression and relapse mostly involved the locoregional area and distant organs, rather than the paraaortic area. Advanced FIGO stage at baseline was the most significant prognostic factor (HR=3.02, p=0.01). Despite systematic extended-field chemoradiation therapy, paraaortic involvement in cervical cancer is associated with poor survival outcomes. The patterns of progression and recurrence suggest the existence of occult metastatic disease at presentation. Additional systemic treatment might thus be beneficial.

Bilateral femur metastases in low-grade endometrial carcinoma.

Lower-limb bone metastases are uncommon in low-grade endometrial carcinoma, and are mostly located on the axial skeleton. Here, we present a rare case of bilateral femur metastases in low-grade endometrial carcinoma and performed a review of the current literature.

Robotically assisted para-aortic lymphadenectomy: surgical results: a cohort study of 487 patients.

OBJECTIVES: The aim of this study was to evaluate perioperative outcomes of robotic-assisted laparoscopic para-aortic lymphadenectomy (PAL) in patients with gynecologic cancers during the learning phases of robotic surgery programs and to compare results of extraperitoneal versus transperitoneal approaches of PAL. MATERIALS AND METHODS: This study is a retrospective multicentric study of patients who underwent robotically assisted laparoscopic PAL (N = 487). Eleven European centers and 1 US center participated in the study. Abstracted data included age, body mass index, indication, type of surgical approach (transperitoneal or extraperitoneal), associated surgical procedures, operative time, estimated blood loss, lymph node count, hospital length of stay (LOS), and complications. Para-aortic lymphadenectomy was performed by an extraperitoneal approach in 58 cases (12%) and transperitoneal in 429 cases (88%). RESULTS: The mean (SD) para-aortic lymph node count was 12.6 (8.1), operative time was 217 (85) minutes, estimated blood loss was 105 (110) mL, and LOS was 2.8 (3.2) days. Four (0.8%) conversions to open and 2 (0.4%) conversions to laparoscopy were described. There were 32 lymphocysts (6.6%), 3 deep venous thromboses (0.6%), and 10 transfusions (2.1%). For transperitoneal approach, the average number of lymph nodes removed was higher in isolated PAL group than the hysterectomy combined group (report node counts 95% confidence interval, -7.29 to -3.52, P = 1.5 × 10⁻6). For isolated PAL, the LOS was shorter in the extraperitoneal group than in the transperitoneal group (report data 95% CI, -1.35 to -0.35, P = 0.001). CONCLUSIONS: Robotic-assisted PAL seems safe and feasible. More lymph nodes were removed during an isolated transperitoneal PAL dissection compared with a combined procedure with hysterectomy. Extraperitoneal approach seems attractive relative to transperitoneal dissection, but the superiority of one or the other way is not demonstrated by our study.

Robot-assisted laparoscopy for deep infiltrating endometriosis: international multicentric retrospective study.

BACKGROUND: This study aimed to assess the interest in robot-assisted laparoscopy for deep infiltrating endometriosis and to investigate the perioperative results. METHODS: From November 2008 to April 2012, 164 women with stage 4 endometriosis who underwent robot-assisted laparoscopy (da Vinci Intuitive Surgical System) were included by to eight international participating clinical centers. This study evaluated the procedures performed, the duration of the intervention, the complications, the recurrence, and the impact on fertility. RESULTS: The average operative time was 180 min. The main complications were laparotomy (n = 1, 0.6%), sutured bowel injury (n = 2, 1.2%), transfusion for a 2,300-ml bleed (n = 1), prolonged urinary catheterization (n = 1, 0.6%), ureter-bladder anastomotic leak (n = 1, 0.6%), and ureteral fistula after ureterolysis (n = 2, 1.2%). The reoperation rate was 1.8% (n = 3). The mean follow-up period was 10.2 months. A full recovery was experienced by 86.7% (98/113) of the patients. After surgery, 41.2% (42/102) of the patients had a desire for pregnancy, and 28.2% (11/39) of them became pregnant. CONCLUSION: This study analyzed the largest series of robot-assisted laparoscopies for deep infiltrating endometriosis published in the literature. No increase in surgical time, blood loss, or intra- or postoperative complications was observed. The interest in robot-assisted laparoscopy for deep infiltrating endometriosis seems to be promising.

Evaluation of the sentinel lymph node algorithm with blue dye labeling for early-stage endometrial cancer in a multicentric setting.

OBJECTIVES: Sentinel lymph node (SLN) removal may be a midterm between no and full pelvic dissection in early endometrial cancer. Whereas the use of blue dye alone in SLN detection has a poor accuracy, its integration in an SLN algorithm may yield better results and overcome hurdles such as the requirement of nuclear medicine facility. METHODS: Sixty-six patients with clinical stage I endometrial cancer were prospectively enrolled in a multicentre study between May 2003 and June 2009. Patent blue was injected intraoperatively into the cervix. We retrospectively assessed the accuracy of a previously described SLN algorithm consisting of the following sequence: (1) pelvic node area is inspected for removal of all mapped SLN and (2) excision of every suspicious non-SLN, (3) in the absence of mapping in a hemipelvis, a standard ipsilateral lymphadenectomy is then performed. RESULTS: Sentinel nodes were identified in 41 patients (62.1%), mostly in interiliac and obturator areas. None was detected in the para-aortic area. Detection was bilateral in 23 cases (56.1%). Seven patients (10.6%) had positive nodes. The false-negative rate was 40% using SLN detection alone. When the algorithm was applied, the false-negative rate was 14.3%. The use of a SLN algorithm would have avoided 53% of lymphadenectomies CONCLUSION: Our multicentric evaluation validates the use of a SLN algorithm based on blue-only sentinel node mapping in early-stage endometrial cancer. The application of such SLN algorithm should be evaluated in a prospective context and might lead to decrease unnecessary lymphadenectomies.

Virilizing sclerosing-stromal tumor of the ovary in a young woman with McCune Albright syndrome: clinical, pathological, and immunohistochemical studies.

CONTEXT: McCune-Albright syndrome (MAS) is characterized by polyostotic fibrous dysplasia, café-au-lait skin pigmentations, and gonadotropin-independent sexual precocious puberty, resulting from a somatic postzygotic activating mutation of the GNAS1 gene. SETTING: We report a virilizing sclerosing-stromal tumor of the ovary in a young female with MAS. PATIENT: She presented polyostotic fibrous dysplasia of the left upper and lower limbs and a café-au-lait skin spot in the posterior area of the neck. She had a history of precocious puberty, diagnosed at the age of 6 years and treated with cyproterone acetate until the age of 10 years; then she developed central puberty with severe oligomenorrhea. At the age of 23 years, she was hospitalized for a virilization syndrome including hirsutism, acne, deepening of the voice, amenorrhea, and clitoromegaly. Serum levels of T were dramatically increased (1293 ng/dl; normal range, 10-80). The abdominal computed tomography scan revealed a solid mass located on the left ovary. INTERVENTION: An ovariectomy was performed, and histological examination revealed a sclerosing-stromal tumor with pseudolobular pattern. RESULTS: Immunohistochemical studies revealed that the tumor cells expressed all steroidogenic enzymes involved in androgen synthesis. Molecular analysis revealed that ovarian tumor cells harbored the Arg 201 activating mutation in the GNAS1 gene. After surgery, T levels returned to normal, the patient retrieved a normal gonadal function, and she was able to become pregnant. CONCLUSION: This observation extends the clinical spectrum of ovarian pathology of women with MAS. However, the mechanisms causing this ovarian tumor remain unclear, even if the gsp oncogene has been implicated in the pathogenesis of some gonadal tumors.

Laparoscopic observation of the diaphragm undersurface in the staging of peritoneal carcinomatosis: comparison of three optical systems.

OBJECTIVES: Endoscopy is a key tool in the diagnosis and management planning of peritoneal carcinomatosis. The aim of this study was to determine which type of endoscope is the most efficient for comprehensive staging of the upper abdomen peritoneal surface. METHODS: From April 2010 to February 2011, endoscopies were performed on five human female fresh-frozen cadavers. Three endoscopes (rigid 0°, 30° and flexible) were used consecutively and compared. RESULTS: The diaphragmatic areas explored with the flexible endoscope were significantly larger than those with the other two. On average, 135 (range 66-225), 168 (range 96-306), and 201 (range 128-399)cm(2) were observed using the 0°, 30°, and flexible laparoscopes, respectively. The p value obtained using the exact Wilcoxon test for paired data was 0.0019 between the 0° and 30° endoscopes and between the 30° and flexible endoscopes. The 30° endoscope was consistently better than the 0° endoscope for the observation of the diaphragm and spleen undersurface. CONCLUSION: Flexible endoscopy seemed to be the most efficient for the evaluation of peritoneal carcinomatosis. However, due to a poorer image, the need for considerable practice, and the high equipment and maintenance cost of the flexible endoscope, the rigid 30° endoscope seems to be the best compromise.

Early stage (IA-IB) primary carcinoma of the fallopian tube: case-control comparison to adenocarcinoma of the ovary.

OBJECTIVE: Early stage primary carcinoma of the fallopian tube (PCFT) is an uncommon condition when strict criteria are applied. The aim of this study was to compare the outcome stage IA-IB PCFT to a matched group of ovarian cancer (OC). METHODS: Between 1990 and 2008, 32 patients with stage IA-IB of PCFT were recorded in the database of three French Institutions. A control group of patients with OC was constituted. RESULTS: Eleven eligible PCFT cases and 29 OC controls fulfilled the stringent inclusion criteria. Median follow-up was 70.2 months. Five-year overall survival was 83.3% (95% confidence interval [CI], 27.3 to 97.5) for PCFT and 88.0% (95% CI, 66.9 to 96.0) for OC (p=0.93). In the subgroup of patients with grade 2-3, the outcome was similar in PCFT compared to OC patients (p=0.75). Five-year relapse-free survival was respectively 62.5% (95% CI, 22.9 to 86.1) and 85.0% (95% CI, 64.6 to 94.2) in the PCFT and OC groups (p=0.07). In the subgroup of patients (grade 2-3), there was no difference between PCFT and OC (p=0.65). CONCLUSION: The findings did not reveal any difference in prognosis between early stage of PCFT and OC when grade is taken into account. Management of PCFT should mirror that of ovarian carcinoma.

Evaluation of a trainer phantom in the learning phase of sentinel lymph node identification in breast cancer.

BACKGROUND: The concept of a learning phase is difficult to implement in a university setting, as it is unacceptable to subject a patient who requires only lymphadenectomy to axillary dissection for the purpose of training surgeons. We therefore sought to evaluate intraoperative sentinel node detection using a phantom, the Senti-Trainer. Learning phases on the Senti-Trainer and detection rate were assessed in order to determine whether the proficiency of surgeons in training improved with the number of procedures. METHODS: Twenty residents each performed 30 detection procedures of a sentinel node on the silicon phantom. Each resident was evaluated at each procedure, and an observation report was made every five procedures. Evaluation was single-blind as the surgeons did not know the result of the previous detection and were aware of the results only after the thirtieth procedure. RESULTS: The mean detection rate was 75% during the first procedure and reached 95% (or 5% detection errors) at the 30th procedure (p<0.0001; OR=6.33 with a 95% CI=[2.31; 17.33]). Proficiency in sentinel lymph node (SLN) identification also increased with the number of procedures performed. The ability to localize SLN improved during the learning phase with the increasing number of procedures performed. Mean detection time during the 30 procedures was 150 s (range: 115-210 s). CONCLUSIONS: Training on a phantom showed that this is a valuable teaching tool that enables surgeons to become familiar with gamma probes. It cannot replace the clinical training phase, but is an important aid to proficiency in intraoperative detection.

Completion surgery or not after concurrent chemoradiotherapy for locally advanced cervical cancer?

OBJECTIVES: The role of additional surgery in patients responding to radiation and chemotherapy for locally advanced cervical cancer is controversial. The goal of this study was to compare disease-free survival (DFS) and overall survival (OS) of two groups of patients, with or without additional surgery. STUDY DESIGN: One hundred and eleven patients with advanced cervical cancer who responded to chemoradiotherapy followed by brachytherapy were included in a retrospective, multicenter series. RESULTS: Of the patients who had completion surgery (Group 1), 22.4% (15/67) had recurrence compared with 36.4% (16/44) of those who did not have surgery (Group 2). The difference is statistically significant (p=0.01). The relative risk of disease progression or death was 0.41 (95% confidence interval 0.20-0.85) (p=0.01) in favor of completion surgery. After multivariate analysis, only age, pathology and initial tumor size remained significant (respectively p=0.003, p=0.001 and p=0.03). Among the locations of recurrence in Group 1, 46.7% were pelvic (7/15) compared with 56.2% in Group 2 (9/16). In Group 1, 16.4% (11/67) of the patients died of disease compared to 20.4% (9/44) in Group 2. Of these, 45.4% (5/11) in Group 1 died after pelvic recurrence as compared to 77.8% (7/9) in Group 2. CONCLUSION: Completion surgery does not improve OS but may improve DFS. There is no consensus regarding completion surgery in advanced cervical cancer with a good response to the standard treatment but we think it is safer to propose it.

Virilising ovarian tumour: a case associating a Sertoli-Leydig cell tumour and a Brenner tumour.

Ovarian Sertoli-Leydig cell tumours (SLCT), also termed arrhenoblastomas, are the most frequent virilising tumours in women of reproductive age. Very rare secretory Brenner tumours (BT) have been described, generally after the menopause. A 31-year-old woman sought medical advice for secondary amenorrhoea, progressive hirsutism and a 5-year history of virilisation syndrome with clitoromegaly. Testosterone was markedly high (285 ng/dl, N<85) with moderate elevation of delta 4-androstenedione (D4AD) (311 ng/dl, N <270), dehydroepiandrosterone sulfate (DHEAS) (366 µg/dl, N <340) and 17-hydroxyprogesterone (17OHP) (275 ng/dl). LH was 9 IU/l, FSH 4.3 IU/l, estradiol 60 pg/ml and progesterone 314 ng/100 ml. Cortisol was decreased (1.3 µg/dl) after the dexamethasone suppression test. Pelvic MRI showed a 5-cm right ovarian tumour with a 2.5 cm nodular component and cystic areas, and two nodules measuring 11 mm and 15 mm above the right and left ovaries. After right ovariectomy by laparoscopy, pathological examination concluded on a 3-cm SLCT and a 2-cm BT; the nodules above the ovaries were dysembryoplastic cysts. Postoperatively, testosterone level was normal after 24 h (26 ng/dl), estradiol and progesterone rapidly decreased, cyclic secretion then resumed and the patient menstruated at day 27. To our knowledge, this is the first report of an ovarian tumour associating a Sertoli-Leydig cell tumour and a Brenner tumour in a patient with virilisation syndrome which resolved after ovariectomy.

Motion estimation in ultrasound imaging applied to the diagnostic of pelvic floor disorders.

The main purpose of this paper is to show the potential of tissue motion estimation in ultrasound imaging for the diagnostic of pelvic floor disorders. We propose to evaluate the tissue motion using a method based on a local deformable model and on image features (local phase and orientation) extracted from the monogenic signal. The proposed method is well adapted to the pelvic organ deformations and estimates motion with subpixel precision without the need for interpolation. The estimated motion is used to visualize the bladder local deformation and to extract quantitative figures such as the deformation parameters and the bladder angle variation. These results could potentially be interesting to characterize the degree of the pelvic organ prolapse.

Results of surgery after concurrent chemoradiotherapy in advanced cervical cancer: comparison of extended hysterectomy and extrafascial hysterectomy.

OBJECTIVES: The primary objective of this study was to compare disease-free survival (DFS) and overall survival (OS) of patients with and without completion surgery. The secondary objective was to compare DFS and OS of patients who had had systematic simple extrafascial hysterectomy or extended hysterectomy. The other objectives were to compare early and late complications with and without completion surgery and between the various surgical techniques. METHODS: One hundred seventy-one patients with advanced cervical cancer were included in a retrospective, multicenter series. RESULTS: The rate of pelvic control was 81.29% in our study after chemoradiotherapy, but histological residual cervical tumor persisted in nearly half of cases (49.71%). After a mean follow-up of 33 months, OS and DFS were not significantly higher in surgically treated patients, nor was the complication rate higher. Overall survival and DFS were not better after radical hysterectomy than after extrafascial hysterectomy. Statistically significant predictors of survival were clinical stage, tumor size, node extension, and residual tumor after chemoradiotherapy. CONCLUSION: There is no consensus regarding the maximal residual tumor volume after chemoradiotherapy suitable for surgery as there is no reliable imaging yet. Therefore, extrafascial hysterectomy with bilateral pelvic lymphadenectomy seems as a reasonable option if there are histological factors suggesting poor prognosis.