Extended pelvic resection for gynecological malignancies: A review of out-of-the-box surgery.

The term 'out-of-the-box surgery' in gynecologic oncology was recently coined to describe the resection of tumor growing out of the endopelvic cavity. In the specific case of pelvic sidewall involvement, a laterally extended pelvic resection may be required. As previously defined by Höckel, this resection requires the en bloc removal of structures including the pelvic sidewall muscles, bones, nerves, and/or major vessels. This complex radical procedure leads to tumor-free margins in more than 75% of the patients, with reliable functional results. The rate of recurrence and overall survival are directly correlated with clear resection margins. Progress in imaging, surgical techniques, and perioperative care currently offer the opportunity to attempt surgical curative resection in selected patients for whom palliative therapy was the only alternative. However, the procedure is associated with a high rate of major postoperative complications affecting up to 60% of patients. Multidisciplinary expert centers are the most likely to achieve this complex surgery with favorable oncological outcomes. The aim of this review is to summarize the key issues of out-of-the-box surgery in gynecologic cancer.

Concordance between preoperative ESMO-ESGO-ESTRO risk classification and final histology in early-stage endometrial cancer.

OBJECTIVE: To evaluate the concordance between preoperative European Society for Medical Oncology (ESMO)-European Society of Gynaecological Oncology (ESGO)-European SocieTy for Radiotherapy and Oncology (ESTRO) risk classification in early-stage endometrial cancer (EC) assessed by biopsy and magnetic resonance imaging (MRI) with this classification based on histology of surgical specimen. METHODS: This bicentric retrospective study included women diagnosed with early-stage EC (≤stage II) who had a complete preoperative assessment and underwent a surgical management from January 2011 to December 2018. Patients were preoperatively classified into 3 degrees of risk of lymph node (LN) involvement based on biopsy and MRI. Based on final histological report, patients were re-classified using the preoperative classification. Concordance between the preoperative assessment and definitive histology was calculated with weighted Cohen's kappa coefficient. RESULTS: A total of 333 women were included and kappa coefficient of preoperative risk classification was 0.49. The risk was underestimated and overestimated in 37% and 10% of cases, respectively. Twenty-nine percent of patients had an incomplete LN staging according to the degree of risk of re-classification. The observed discordance in the risk classification was attributed to MRI in 75% of cases, to biopsy in 18% and in 7% to both (p<0.001). Kappa coefficient for concordance was 0.25 for MRI and 0.73 for biopsy. CONCLUSION: Concordance between preoperative ESMO-ESGO-ESTRO risk classification and final histology is weak. Given that the risk was underestimated in the majority of patients wrongly classified, sentinel LN procedure instead of no LN dissection could be an option offered to preoperative low-risk patients to decrease the indication of second surgery for re-staging and/or to avoid toxicity of adjuvant radiotherapy.

Outcomes of the use of different vulvar flaps for reconstruction during surgery for vulvar cancer.

BACKGROUND: Vulvar carcinoma is a rare cancer, accounting for 3-5% of all gynecological cancers. Surgery is the standard treatment for patients with early stage vulvar cancer and vulvar reconstruction can be performed for these patients. The present study aimed to compare three different flap and to analyze the outcomes of vulvar surgery. METHODS: We performed a single-center retrospective study between October 2001 and December 2015. We compare patients who underwent radical surgery for vulvar cancer combined with three different vulvar flap reconstructions (GTF, gluteal thigh flap; RF, rhomboid flap; VYF, V-Y flap). We collected data on the operating time, length of hospital stay, reoperation rate, and postoperative complications. RESULTS: We reviewed 179 patients who underwent radical vulvar surgery and 61 (34%) of these underwent additional reconstruction. There were no significant differences in clinical characteristics between the three groups. The median hospital stay was significantly longer for the GTF group (24 days) than RF (17 days) and than VYF (14 days) (p = 0.002). No significant differences were found concerning the operating time. Regarding postoperative complications, reoperation rates of 69%, 41%, and 25% were noted in the GTF, RF, and VYF group, respectively (p = 0.04); partial necrosis was the most common postoperative complication. The overall and recurrence-free survivals were comparable between the three groups. CONCLUSION: When the defect is too large, VYF seems to be the procedure of choice for ensuring healing without a prolonged hospital stay compared to RF and GTF. Moreover, VYF was associated with a lower reoperation rate within 60 days compared to RF and GTF.

Fertility Sparing Treatment in Patients With Early Stage Endometrial Cancer, Using a Combination of Surgery and GnRH Agonist: A Monocentric Retrospective Study and Review of the Literature.

Objectives: To evaluate the efficacy and safety of gonadotropin-releasing hormone (GnRH) agonist after endometrial resection in women suffering early stage endometrial carcinoma (EC) and/or endometrial intra-epithelial neoplasia (EIN). Design: A retrospective review of clinical files between January 1999 and December 2016. Setting: University hospital. Patients: Eighteen women younger than 41 years with grade 1 endometrial carcinoma (G1EC) and/or Endometrial intra-epithelial neoplasia (EIN). INTERVENTIONS: All patients received GnRH agonist for 3 months after an endometrial resection combined with a laparoscopy to exclude concomitant ovarian tumor and/or other extra-uterine disease. The patient underwent a follow-up of 3 months interval with endometrial sampling by hysteroscopy. Main Outcome Measure(s): The recurrence rate and the pregnancy rate after fertility sparing treatment. Results: We identified 9 patients with EIN (50%), 7 patients with G1EC (38.9%), 1 with combined histology (5.5%), and 1 with G2EC (5.5%). After a median follow-up of 40.7 months, 12 patients conserved their uterus (66.7%), and 8 (53.3%) patients were pregnant with a total of 14 pregnancies among those who tried to become pregnant. We observed a complete response rate in 12 patients (66.7%) but 3 of these patients relapsed (25%). We also found a stable disease in 6 patients (33.3%). Conclusions: Compared with other fertility sparing treatments, GnRH agonist after surgery is an effective fertility-sparing strategy for women with EIN and/or G1EC. We recommend hysterectomy once a family has been completed even if the literature does not clearly lead to radical surgery.