Bilateral Pelvic Lymphadenectomy Research Articles

Surgical-pathological findings in type 1 and 2 endometrial cancer: An NRG Oncology/Gynecologic Oncology Group study on GOG-210 protocol

ObjectiveTo report clinical and pathologic relationships with disease spread in endometrial cancer patients. MethodsSurgical candidates with uterine cancer (adenocarcinoma or carcinosarcoma) who were eligible to participate in a surgical pathological study to create a clinically annotated tissue biorepository to support translational and clinical research studies. All patients were to undergo a hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic and para-aortic lymphadenectomy. From 2003–2007, open eligibility enrollment was conducted, and from 2007–2011, eligibility was restricted to enrich underrepresented patients or those at high risk. ResultsThis report details clinical pathological relationships associated with extra uterine disease spread of 5866 evaluable patients including those with endometrioid histology as well as papillary serous, clear cell and carcinosarcoma histologies. Review of unrestricted enrollment was constructed in an effort to capture a cross-section population representative of endometrial cancers seen by the GOG participating members. Evaluation of this group of patients suggested the more natural incidence of different surgical pathological findings as well as demographic information. The addition of 2151 patients enrolled during the restricted time interval allowed a total of 1630 poor histotype patients available for further analysis. As expected, endometrioid (E) cancers represented the largest enrollment and particularly E grade 1 and 2 (G1 and 2) were more frequently confined to the uterus. Grade 3 (G3) endometrioid cancers as well as the poor histotype (papillary serous, clear cell and carcinosarcoma) had a much greater propensity for extant disease. ConclusionsThis study confirms the previously reported surgical pathological findings for endometrioid cancers but in addition, using a large database of papillary serous, clear cell and carcinosarcoma, surgical pathological findings substantiate the categorization of poor histotypes for these cancers.

Bilateral Pelvic Lymphadenectomy in Robot-Assisted Laparoscopic Prostatectomy of Renal Transplant Recipients

Background: With a rise in age and number of renal transplant recipients, prostate cancer (PC) prevalence in this population is increasing. Surgical management of PC traditionally includes radical prostatectomy with pelvic lymph node dissection (PLND). However, patients with indwelling renal transplants are often managed nonoperatively or spared of a lymph node dissection ipsilateral to the transplanted kidney out of concern for transplant vascular or ureter injury. Case Presentation and Methods: We report two cases of robot-assisted laparoscopic radical prostatectomy (RALP) with bilateral PLND in a 69-year-old (Patient A) and 73-year-old (Patient B) African American renal transplant recipient. Both patients had extraperitoneal placement of their renal transplants adjacent to the right iliac vessels. Patient A had Gleason 4 + 4 cT1c disease in 12/12 cores with prostate-specific antigen (PSA) of 22.8. Patient B had left-sided Gleason 3 + 3 with 50% involvement of 3/6 cores as well as 50% involvement in 6/6 right-sided cores and PSA of 8.0. In both patients, bone scan was completed and did not show metastases. Ports on the patients' right sides were adjusted in a cephalad direction so as to avoid the transplanted kidney. The remaining ports were otherwise placed in the standard manner. Transplanted ureters were identified and dissected as a first step before proceeding with the prostatectomy. Bilateral PLND was possible in both cases without any vascular or ureteral injury. Notwithstanding PLND, prostatectomy, reconstruction technique, and postoperative care were otherwise unchanged. Immunosuppressant regimens continued throughout hospitalization. Results: Robotic console operative time and estimated blood loss was 3 hours 49 minutes and 200 mL for Patient A and 2 hours 48 minutes and 300 mL for Patient B. Patient A had bilateral obturator and internal iliac lymphadenectomy with eight negative lymph nodes harvested on the right side. Patient B received a bilateral obturator lymphadenectomy with two negative lymph nodes dissected on the right side. No intraoperative complications occurred for either patient. Patient A required fluid resuscitation for a creatinine bump that resolved and was safely discharged on POD 2. Patient B was discharged on POD 1. Both patients were prescribed a 60- to 90-day course of penile rehab with a PDE-5 inhibitor (tadalafil 5 mg). At 8 weeks follow-up, Patient A had a PSA of <0.1, was nonadherent on tadalafil, lacked erectile function, and continued having urinary incontinence, saturating two pads per day with nocturia. At 10- and 24-week follow-ups, Patient B maintained continence with partial return of erectile function on tadalafil, although not sufficient for penetration. His PSAs at 8- and 20-week follow-up were 0.036 and 0.102, respectively. At follow-up, neither patient had symptoms (abdominal pain and unilateral edema), suggestive of lymphocele formation. Conclusion: In our limited experience with two patients, RALP and bilateral PLND can be safely achieved in renal transplant recipients. D.D.E. is a proctor/lecturer for Intuitive Surgical and consultant for Medtronic. J.K., J.G.R., and B.W. declare that no competing financial interests exist. Runtime of video: 5 mins 2 secs

MP64-15 ROBOTIC ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY IN ISUP GRADE 5 PROSTATE CANCER: ONCOLOGICAL OUTCOMES

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy V1 Apr 2017MP64-15 ROBOTIC ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY IN ISUP GRADE 5 PROSTATE CANCER: ONCOLOGICAL OUTCOMES Itay Sagy, Charles Nottingham, Shay Golan, Matt Galocy, and Arieh Shalhav Itay SagyItay Sagy More articles by this author , Charles NottinghamCharles Nottingham More articles by this author , Shay GolanShay Golan More articles by this author , Matt GalocyMatt Galocy More articles by this author , and Arieh ShalhavArieh Shalhav More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1988AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We present here oncological outcome for patients with International Society of Urological Pathology (ISUP) Grade 5 prostate cancer (PC) who underwent primary treatment with robotic assisted laparoscopic radical prostatectomy (RALP). METHODS Using a prospectively collected institutional registry, we identified patients with clinically organ confined and locally advanced (cT1-T3N0M0) ISUP Grade 5 PC who underwent RALP with bilateral pelvic lymphadenectomy as primary treatment between 2005 and 2013. RESULTS We included 106 patients with median age of 65 years (IQR 58.5-68). The majority of patients had clinically organ-confined disease (90%). Following surgery, 71 patients (67%) were upstaged to pT3 and 40 patients (38%) were downgraded to Gleason score 8 or 7. With median follow-up of 63.5 months (IQR 34-85), 50 patients (48%) had biochemical failure: 24 patients (23%) had PSA persistence and 26 patients (24%) had biochemical recurrence (BCR). Adjuvant and salvage RT were administered to 12 (11%) and 34 (32%) patients, respectively; adjuvant and salvage ADT were given to two (2%) and 31 (29%) patients, respectively; 9 patients (8%) received subsequent therapies. Eleven patients (10%) had systemic failure and 10 patients (9.5%) died: 3 (3%) from prostate cancer and 7 (7%) from other causes. Using Kaplan-Meier estimate, the 5-year overall, disease specific, metastasis-free and disease-free survivals are 91%, 96%, 88%, and 59% respectively. Using univariate analysis, pre-operative PSA, number of cores involved with ISUP grade 5 PC on biopsy, percentage of positive cores on biopsy, and pathological T stage were all correlated with both biochemical and systemic failure. CONCLUSIONS The disease volume on pre-operative biopsy and specifically the amount of Gleason 5 pattern predicted both biochemical and systemic failure. RALP in ISUP grade 5 PC is a viable treatment option in the multimodality management of PC, it affords local control and might improve long-term oncologic outcomes. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e850 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Itay Sagy More articles by this author Charles Nottingham More articles by this author Shay Golan More articles by this author Matt Galocy More articles by this author Arieh Shalhav More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

LYMPHOCYSTS AFTER LAPAROSCOPIC AND OPEN HYSTERECTOMY WITH PELVIC LYMPHADENECTOMY FOR ENDOMETRIAL CANCER

Total number of 648 endometrial cancer patients who had undergone hysterectomy, bilateral salpingo-ophorectomy and bilateral pelvic lymphadenectomy with laparoscopic and open access constituted the study group. Ultrasound examination of the pelvis was carried out for all patients after surgery to identify lymphocysts. The overall incidence of lymphocysts was 320/648 (49.4%): 179/320 (55.9%) after open surgery and 141/320 (44.06%) after laparoscopy (р=0,01). The majority of lymphocysts were asymptomatic. Symptomatic lymphocysts occurred in 5.6% of patients. Several risk factors for the development of symptomatic lymphocysts were determined.

Robotic Radical Parametrectomy With Upper Vaginectomy and Pelvic Lymphadenectomy in Patients With Occult Cervical Carcinoma After Extrafascial Hysterectomy

Study ObjectiveTo confirm the safety and feasibility outcomes of robotic radical parametrectomy and pelvic lymphadenectomy and compare the clinicopathological features of women requiring adjuvant treatment with the historical literature. DesignRetrospective cohort study and review of literature (Canadian Task Force classification II-2). SettingDepartment of Obstetrics and Gynecology, University of North Carolina at Chapel Hill. PatientsAll patients who underwent robotic radical parametrectomy with upper vaginectomy (RRPV), and pelvic lymphadenectomy for occult cervical cancer discovered after an extrafascial hysterectomy at our institution between January 2007 and December 2015. InterventionsRRPV and pelvic lymphadenectomy for occult cervical cancer discovered after an extrafascial hysterectomy. We also performed a literature review of the literature on radical parametrectomy after occult cervical carcinoma. Measurements and Main ResultsSeventeen patients with invasive carcinoma of the cervix discovered after extrafascial hysterectomy underwent RRPV with bilateral pelvic lymphadenectomy. There were 2 intraoperative complications, including 1 bowel injury and 1 bladder injury. One patient required a blood transfusion of 2 units. Three patients underwent adjuvant treatment with chemoradiation with radiation-sensitizing cisplatin. One of these patients had residual carcinoma on the upper vagina, 1 patient had positive parametria and pelvic nodes, and 1 patient had positive pelvic lymph nodes. No patients experienced recurrence, and 1 patient died from unknown causes at 59.4 months after surgery. We analyzed 15 studies reported in the literature and found 238 women who underwent radical parametrectomy; however, no specific preoperative pathological features predicted outcomes, the need for adjuvant treatment, or parametrial involvement. ConclusionRRPV is a feasible and safe treatment option. As reflected in the literature, RRPV can help avoid empiric adjuvant chemoradiation; however, no pathological features predict the need for adjuvant treatment after surgery.

Impact of castration resistant status on overall survival for prostate cancer patients treated with radical prostatectomy.

e562 Background: We estimated the natural history and predictive factors of oncological outcomes in patients with prostate cancer (PCa) after radical prostatectomy (RP). Methods: In this retrospective study, we reviewed the clinical and pathological records of 1083 PCa patients who underwent RP and bilateral pelvic lymphadenectomy with or without neoadjuvant therapy between July 1996 and December 2014 at Hirosaki University. All patients were followed-up by assessing serum prostate-specific antigen (PSA) and testosterone levels every 3 months for 5 years and every 6 months thereafter. The endpoint was the oncological outcomes after surgery. Univariate analyses were performed using the Kaplan-Meier and log-rank methods, and the multivariate analysis was performed using a Cox proportional hazard model. Results: The 5-year and 10-year overall survival rates were 98.5 % and 92.0 %, respectively. At the end of the study, 226 patients (20.8%) showed biochemical recurrence and 28 patients (2.6%) had developed castration-resistant Pca (CRPC). The patients with CRPC were significantly poor prognosis compared with those without CRPC (P &lt; 0.01). On multivariate analysis, although preoperative variables were no significant differences, only CRPC was significantly associated with OS. Conclusions: RP was shown to provide excellent long-term survival with OS at 10 years. In addition, a small proportion of the patients treated with RP had CRPC and died of Pca within 10 years. Development to castration resistant status may have critical impact on OS.

Encountering “Dropped” Gallstones During Robotic-assisted Laparoscopic Radical Prostatectomy

We describe a case of an unusual finding during robotic-assisted laparoscopic radical prostatectomy and bilateral pelvic lymphadenectomy in a 66-year-old man with stage IIb (T2c, N0, M0) prostate adenocarcinoma. During the operation, intraperitoneal examination of the rectovesical pouch revealed calcifications and stones, which were subsequently identified as gallstones. Although these stones were not noted initially on this patient's preoperative multiparametric magnetic resonance imaging, a retrospective review demonstrated hypointense foci in the rectovesical pouch. Here, we describe the first reported case of visualization of dropped gallstones on a prostate multiparametric magnetic resonance imaging and retrieval during robotic prostatectomy.

Prospective validation of an intraoperative algorithm to guide surgical staging in early endometrial cancer

ObjectivesProspectively validate an intraoperative surgical staging algorithm to stratify patients with early endometrial cancer by risk of lymph node metastasis. MethodsSubjects with endometrial cancer clinically confined to the uterus were prospectively enrolled at an academic cancer center between Jan 2012 and Jun 2015. Study participants were stratified intraoperatively into two groups based on risk of nodal involvement using cell type, tumor grade, myometrial invasion, and tumor size in accordance with an established protocol from the Mayo Clinic. Low risk (LR) subjects received extrafascial hysterectomy with bilateral salpingo-oophorectomy; high risk (HR) patients received complete surgical staging including bilateral pelvic and para-aortic lymphadenectomy. ResultsOf the 200 subjects enrolled, 194 were eligible for analysis. The algorithm identified 132 (68%) HR and 62 (32%) LR cancers. Of the HR subjects, 126 had lymphadenectomy performed with 14 (11%) positive for nodal metastases. Five HR subjects experienced disease recurrence. Of the 62 LR cancers, two patients developed disease recurrence. Ten LR cancers were upgraded to HR on final pathology due to lesion size (6) and grade (4). None of these patients experienced disease recurrence. The algorithm demonstrated 90% sensitivity (18/20) and 36% specificity (62/174) as determined by positive lymph nodes and/or disease recurrence. ConclusionsIntraoperative assessment of early endometrial cancer can be used to determine the extent of surgical staging. The studied algorithm has low specificity and modifications are necessary to better match the surgical procedure to the risk of metastatic cancer.

Role of pelvic and para-aortic lymphadenectomy in abandoned radical hysterectomy in cervical cancer

BackgroundCervical cancer (CC) occupies fourth place in cancer incidence and mortality worldwide in women, with 560,505 new cases and 284,923 deaths per year. Approximately, nine of every ten (87%) take place in developing countries. When a macroscopic nodal involvement is discovered during a radical hysterectomy (RH), there is controversy in the literature between resect macroscopic lymph node compromise or abandonment of the surgery and sending the patient for standard chemo-radiotherapy treatment. The objective of this study is to compare the prognosis of patients with CC whom RH was abandoned and bilateral pelvic lymphadenectomy and para-aortic lymphadenectomy was performed with that of patients who were only biopsied or with removal of a suspicious lymph node, treated with concomitant radiotherapy/chemotherapy in the standard manner.MethodsA descriptive and retrospective study was conducted in two institutions from Mexico and Colombia. Clinical records of patients with early-stage CC programmed for RH with an intraoperative finding of pelvic lymph, para-aortic nodes, or any extracervical involvement that contraindicates the continuation of surgery were obtained. Between January 2007 and December 2012, 42 clinical patients complied with study inclusion criteria and were selected for analysis.ResultsIn patients with CC whom RH was abandoned due to lymph node affectation, there is no difference in overall survival or in disease-free period between systematic lymphadenectomy and tumor removal or lymph node biopsy, in pelvic lymph nodes as well as in para-aortic lymph nodes, when these patients receive adjuvant treatment with concomitant radiotherapy/chemotherapy.ConclusionsThis is a hypothesis-generator study; thus, the recommendation is made to conduct randomized prospective studies to procure better knowledge on the impact of bilateral pelvic and para-aortic lymphadenectomy on this group of patients.

Since surgery isn't getting any easier, why is reimbursement going down? An update from the SGO taskforce on coding and reimbursement

In 2015, there was an 18% reduction in the Relative Value Units (RVUs) that the Center for Medicare and Medicaid Services (CMS) assigned to the Current Procedural Terminology (CPT) code 58571 (Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less; with removal of tube(s) and/or ovary(s)→TLH+BSO). The other CPT codes for laparoscopic hysterectomy and laparoscopic supracervical hysterectomy (58541–58544 and 58570–58573) lost between 12 and 23% of their assigned RVUs. In 2016, the laparoscopic lymph node dissection codes 38570 (Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple), 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy), and 38572 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), single or multiple) lost between 5.5 and 16.3% of their RVU's.The goals of this article from the Society of Gynecologic Oncology (SGO) Task force on Coding and Reimbursement are 1) to inform the SGO members on why CMS identified these codes as a part of their misvalued services screening program and then finalized a reduction in their payment levels; and 2) outline the role individual providers have in CMS' methodology used to determine the reimbursement of a surgical procedure.

Abdominal radical trachelectomy guided by sentinel lymph node biopsy for stage IB1 cervical cancer with tumors >2 cm.

Accuracy of prediction of pelvic lymph node status using sentinel lymph node biopsy (SLNB), and outcomes of SLNB-guided abdominal radical trachelectomy (ART) were assessed. Patients with stage IB1 (Figure 2009) cervical cancer and with tumors >2 cm were enrolled. Prior to fertility-sparing surgery 99mTc-labeled phytate was administered. SLNs were intraoperatively identified, excised, and assessed using fast-frozen sections. Systematic bilateral pelvic lymphadenectomy with or without para-aortic lymphadenectomy was subsequently undertaken. The SLN detection rate was 91.8% (45/49 patients); 8.2% (4/49) had radical hysterectomies because of metastatic primary SLNs. All SLNs received routine immunopathological examination to detect micrometastasis. Sensitivity, accuracy, and false negative rates were 100%, 100%, and 0%, respectively. ART was successfully completed in 45 patients (median follow-up, 61 [range, 4–149] months). Three of the 45 (6.7%) were lost to follow-up; two relapsed and one died of tumor progression. Overall 3-year survival and progression-free survival rates were 97.6% and 95.2%, respectively. Of the 19 patients who attempted to conceive after surgery, five achieved pregnancy, and one had a live birth in the third trimester. We concluded that SLNB using 99mTc-labeled phytate can accurately assess pelvic node status. SLNB-guided ART is safe and feasible in patients selected for fertility-sparing procedures.

Predicting Model of Lymph Node Metastasis Using Preoperative Tumor Grade, Transvaginal Ultrasound, and Serum CA-125 Level in Patients With Endometrial Cancer.

The purpose of this study was to evaluate the predicting model for lymph node metastasis using preoperative tumor grade, transvaginal sonography (TVS), and serum cancer antigen 125 (CA-125) level in patients with endometrial cancer. Between January 2000 and February 2013, we identified 172 consecutive patients with surgically staged endometrial cancer. Transvaginal sonography was performed by an expert gynecologic radiologist in all patients. All patients had complete staging surgery including total hysterectomy with bilateral pelvic and para-aortic lymphadenectomy and were staged according to the 2009 International Federation of Gynecology and Obstetrics classification. Various clinicopathologic data were obtained from medical records and were retrospectively analyzed. Of 172 patients, 138 patients presented with stage I (118 IA and 20 IB), 12 had stage II, 18 had stage III (2 IIIA, 1 IIIB, 8 IIIC1, and 7 IIIC2), and 2 had stage IV diseases. Most patients had endometrioid adenocarcinoma (88.4%), and others (12.6%) had nonendometrioid histology. Eighteen patients (10.5%) were found to have lymph node metastasis. Deep myometrial invasion on preoperative TVS (≥50%), high serum CA-125 level (≥ 35 IU/mL), preoperative grade 2 or 3 tumors were significant preoperative factors predicting lymph node metastasis. There was no significant association between preoperative histology and lymph node metastasis. We calculated the simple model predicting lymph node metastasis based on preoperative tumor grade, TVS findings, and CA-125 level using logistic regression analysis. The sensitivity and specificity of this model were 94% and 57%, respectively (area under the curve, 0.84; 95% confidence interval [CI], 0.74-0.93; P < 0.01). Preoperative tumor grade, myometrial invasion on preoperative TVS, and CA-125 can accurately predict lymph node metastasis in patients with endometrial cancer. The current study suggests the possibility that TVS could be positively used for preoperative evaluation strategy in the low-resource countries instead of expensive imaging modalities such as magnetic resonance imaging or positron emission tomography-computed tomography.

Comprehensive Staging of Uterine Carcinosarcoma Using a Multiquadrant Robotic Platform

Study ObjectiveTo demonstrate the feasibility of multiquadrant staging of a uterine carcinosarcoma using the latest-generation robotic platform. DesignStep-by-step explanation of the technique using videos and pictures (educative video). SettingAlthough laparoscopic and robotic-assisted laparoscopic staging of high-risk uterine cancer is well incorporated into many gynecologic oncology practices, extensive para-aortic lymphadenectomies above the inferior mesenteric artery are less commonly performed. Additionally, infracolic omentectomies are frequently performed in lieu of infragastric omentectomies. PatientA 67-year-old woman with a newly diagnosed uterine carcinosarcoma. InterventionMultiquadrant comprehensive staging of uterine carcinosarcoma using the latest-generation robotic platform. Measurements and Main ResultsWe demonstrate in this video a facile approach for robotic surgeons to perform an extensive para-aortic lymphadenectomy up to the renal vessels, as well an infragastric omentectomy, using the latest-generation multiquadrant robotic platform. This platform allows for facile rotation from an upper abdominal view to perform the para-aortic lymphadenectomy and omentectomy, to a pelvic view to complete the pelvic lymphadenectomies, hysterectomy and bilateral salpingo-oophorectomy. We demonstrate this technique in a 67-year-old woman with a newly diagnosed uterine carcinosarcoma who underwent a robotic-assisted laparoscopic total hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy, and infragastric omentectomy via the Xi Da Vinci Robot (Intuitive Surgical, Sunnyvale, CA). Total operative time was 280 minutes (50 minutes for the omentectomy, 86 minutes for the para-aortic lymphadenectomy). Estimated blood loss was 50 mL. Final pathology revealed a stage IA uterine carcinosarcoma; a total of 27 para-aortic lymph nodes and 20 pelvic lymph nodes were removed, and the size of the excised omentum was 68 × 10 × 1.2 cm. ConclusionThe technique of using alternating dual perspectives (upper abdominal or pelvic views) through a multiquadrant robotic platform enables the robotic surgeon to perform extensive para-aortic lymphadenectomies and omentectomies without resorting to laparoscopic surgery to complete these procedures.

Can sentinel lymph node biopsy replace pelvic lymphadenectomy for early cervical cancer?

ObjectiveEvaluate recurrence-free survival (RFS) and short-term morbidity in patients with early cervical cancer who undergo bilateral pelvic lymphadenectomy (BPLND) versus bilateral sentinel lymph node biopsy only (BSLNB) at primary surgery. MethodsAll patients with pathologically confirmed node negative stage IA/IB cervical cancer managed with BPLND or BSLNB were identified in the University of Toronto's prospective cervical cancer database from May 1984–June 2015. Groups were compared with Wilcoxon rank-sum, Chi-square, and Fisher's exact tests. Predictors of RFS were identified with Cox proportional hazard models. Kaplan-Meier survival curves were compared. Statistical significance was p<0.05. Results1188 node negative patients were identified, BPLND-1078; BSLNB-110. There was no difference between BPLND and BSLNB in 2 and 5year RFS (95% vs 97% and 92% vs 93% respectively), tumor size, histology, invasion depth, intra-operative complications or short-term morbidity. BPLND was associated with increased surgical time (2.8 vs 2.0h, p<0.001), blood loss (500mL vs 100mL, p<0.001), transfusion (23% vs 0%, p<0.001) and post-operative infection (11% vs 0%, p=0.001). Age, surgery date, stage, LVSI, and radicality of surgery differed between groups. Controlling for age, stage, LVSI, invasion depth and histology, there was no significant difference in RFS between groups. Only invasion depth, LVSI and histology were predictors of RFS. ConclusionA negative BSLNB is not associated with a difference in RFS compared to a negative BPLND. Short-term morbidity may be reduced, however due to the long study period, changes in demographics and surgery may contribute to differences noted.

Clinical efficacy analysis of preoperative neoadjuvant chemotherapy with high-dose dense paclitaxel plus cisplatin in Stages IB2, IIA2, IIB cervical cancer in Iran.

In Iran, the authors use neoadjuvant chemotherapy (NACT) prior to surgery in cervical cancer due to limited access to the radiotherapy and very prolonged waiting time in accession to radiotherapy. The study was done to analyze the efficacy of the NACT with high dose-dense paclitaxel and cisplatin before radical surgery on cure rate, survival rate, and the progression of free survival rate of bulky tumor of cervical cancer in Stages 1B2, IId A2, and IIB. Fifty-two patients with cervical cancer in Stages Ib2, IIA2, and IIB were selected, and responding patients to chemotherapy were scheduled to undergo radical hysterectomy and bilateral pelvic lymphadenectomy with or without para-aortic lymphadenectomy. Fifty out of 52 patients with a median age of 50 years were evaluable for clinical response. Thirty-two patients (64%) responded to the NACT including six (12%) with a complete clinical response. There was no statistical relationship between clinical response, tumor stage and size, and parametrical involvement, however, patients with higher grade of tumor, adenocarcinoma or tumor in upper 2/3 of vagina showed a higher probability of no response to chemotherapy. Downstaging after NACT in all stages was statistically significant regarding pathologic findings and clinical response (p = 0.002). Five-year survival was 88% and factors affecting survival and disease-free survival were pathological response and tumor site based on cox-regression analysis. Overall recurrence rate was 20% and tumor size was the only significant relevant factor for recurrence (p = 0.017). Combined regimen of chemotherapy in locally advanced cervical cancer proved to be valuable and efficacious without any late complications.

Effects of Neoadjuvant Chemotherapy Plus Radical Surgery as Front Line Treatment Strategy in Patients Affected by FIGO Stage III Cervical Cancer.

To assess the clinical efficacy and prognostic outcome of neoadjuvant chemotherapy (NACT) plus radical surgery (RS) as front line treatment in patients with FIGO stage III cervical cancer (CC). In this retrospective study, 52 FIGO stage III CC patients treated from 2005 to 2015 were included. All patients received platinum-based chemotherapy. Patients reporting clinical response or stable disease after NACT underwent to RS and bilateral systematic pelvic lymphadenectomy with or without aortic lymphadenectomy or anterior exenteration. Patients with progressive disease underwent palliative management. After NACT, clinical response was observed in 23 patients (44%): 4 (7.7%) complete and 19 (36.5%) partial responses, respectively. Also, 15 patients (28.8%) had stable disease and 14 (26.9%) showed disease progression. RS was performed in 40 cases (76.9%): respectively, 28 (70%) and 7 (17.5%) underwent type C2 and D radical hysterectomy, while 5 patients (12.5%) underwent anterior exenteration. At pathological evaluation, 23 patients (57.5%) had positive pelvic nodes and 4 (10%) also had positive aortic nodes. In 6 patients (15%), moderate-severe (G3-G5) complications occurred. A total of 27 patients (67.5%) received adjuvant therapy: 16 patients (40%) received chemotherapy, 10 (25%) received chemoradiation and 1 (2.5%) received radiotherapy. Disease relapse occurred in 24 cases (60%). After follow-up period of 60months, the median OS of the whole population included was 37months. Among the 40 surgically treated patients, median OS and DFS were 48 and 23months, respectively. NACT plus RS represent a valid alternative with acceptable morbidity for patients with stage III CC.

Preoperative local staging of endometrial cancer: the challenge of imaging techniques and serum biomarkers.

The aim of this study is to prospectively evaluate and compare the accuracy of high-frequency TVS and of two type of MRI (dynamic contrast-enhanced MRI or diffusion-weighted MRI), in association with HE4 in preoperative endometrial cancer (EC) staging. Starting from January 2012 to February 2015, all patients with EC at prior endometrial biopsy, referred to the Division of Gynaecologic Oncology of the University Campus Bio-Medico of Rome, were prospectively included in the study. All of them underwent complete surgical staging hysterectomy and bilateral oophorectomy, pelvic and lumboaortic lymphadenectomy, according to 2011 NCCN guidelines. The day before surgery, patients underwent to transvaginal ultrasonography (TVS), HE4 serum dosage, and using a computer-based random procedure, to dynamic contrast-enhanced MRI (Group A) or to diffusion-weighted MRI (Group B), to assess myometrial invasion and cervical involvement. Starting from January 2012 to February 2015, a total of 79 patients were considered for the analysis and randomly divided into Group A (n=38) and Group B (n=41). Regarding myometrial invasion, MRI and TVS resulted comparable in terms of preoperative detection. Concerning the cervical infiltration, the association between TVS and HE4 is characterized by a better preoperative diagnostic validity (TVS+HE4 96.3 vs. 91% for MRI and 85% for the TVS). Our results, even the low number of enrolled patients, are promising and may lead to a greater efficiency and lower health care costs in identifying those women who require radical surgery and pelvic lymphadenectomy and should be addressed, in specialized centers.

Laparoscopic radical trachelectomy for preservation of fertility in early cervical cancer. A case report

Abstract Background Radical hysterectomy is the standard treatment for patients with early-stage cervical cancer. However, for women who wish to preserve fertility, radical trachelectomy is a safe and viable option. Objective To present the first case of laparoscopic radical trachelectomy performed in the National Cancer Institute, and published in Mexico. Clinical case Patient, 34 years old, gravid 1, caesarean 1, stage IB1 cervical cancer, squamous, wishing to preserve fertility. She underwent a laparoscopic radical trachelectomy and bilateral dissection of the pelvic lymph nodes. Operation time was 330 min, and the estimated blood loss was 100 ml. There were no intraoperative or postoperative complications. The final pathology reported a tumour of 15 mm with infiltration of 7 mm, surgical margins without injury, and pelvic nodes without tumour. After a 12 month follow-up, the patient is having regular periods, but has not yet tried to get pregnant. No evidence of recurrence. Conclusions Laparoscopic radical trachelectomy and bilateral pelvic lymphadenectomy is a safe alternative in young patients who wish to preserve fertility with early stage cervical cancer.

Type B Laparoscopic Radical Trachelectomy With Pelvic Lymphadenectomy for Early Cervical Cancer

Study ObjectiveTo demonstrate the technique of laparoscopic radical trachelectomy (LRT) and laparoscopic pelvic lymphadenectomy for early cervical cancer. DesignCase report (Canadian Task Force Classification Study design III). SettingTertiary referral centre in Strasbourg, France. BackgroundOver the past 15 years, gynecologic oncologists have sought ways to preserve female fertility when treating invasive cervical cancer. Many cases of cervical cancer have been diagnosed in young women with a desire to preserve their fertility. As more women are delaying childbearing, fertility preservation has become an important consideration. Radical hysterectomy and bilateral pelvic lymphadenectomy represent the standard surgical treatment for stage IA2-IB1 cervical cancer. In some women with small localized invasive cervical cancer, there is hope for a pregnancy after treatment. Vaginal radical trachelectomy (VRT) is a fertilitypreserving surgical procedure for early-stage cervical cancers. The National Comprehensive Cancer Network has published guidelines stating that radical trachelectomy is part of the standard of care for women desiring to preserve their future fertility. VRTwas introduced in 1987 with its first reported use in 1994, and since then more than 1000 cases of VRT have been reported involving more than 250 live births. The tumor recurrence rate is between 4.2% and 5.3%, and the mortality rate is between 2.5% and 3.2%. However, VRT has several limitations despite results demonstrating the safety of the procedure. One limitation is that it is an inadequate procedure for nulliparous patients and those with history of previous conization with adverse vaginal anatomy. In addition, it is difficult to learn the techniques involved in radical vaginal surgery. PatientsA 26 year-old nulliparous women with a FIGO Stage IB1 squamous cell tumor of the cervix. A first conisation was performed with no safe resection margins. InterventionIn this video we show a type B laparoscopic radical trachelectomy with round ligament and uterine artery preservation. A laparoscopic pelvic lymphadenectomy was also performed. Our institutional review board approved this study. Measurements and Main ResultsOperative time was 240 minutes. Intraoperative blood loss was less than 100 mL. The operation was performed successfully with no intraoperative complications. Pathological findings demonstrated the presence of a cervical intraepithelial neoplasia 2 on the anterior lips from an 11 o'clock to a 1 o'clock position. Resection margins were safe. The surgical specimen did not show any residual invasive carcinoma. Twenty one lymph nodes were removed, 7 on the right side, and 14 on the left side. No metastatic adenopathy was found. The patient was discharged on day 11. After 5 months, no late complications or recurrence was detected. ConclusionsLRT appears to be a safe option for women who intend to maintain their desire for a future pregnancy.

Five year survival surgical outcome for clinic stage I cervical cancer: Comparison of robotic vs. laparoscopic or laparotomy radical hysterectomy

Objectives: To determine if there is a difference in 5-year survival between robotic versus laparoscopic versus open radical hysterectomy in the treatment of clinical stage I cervical cancer. Methods: Retrospective case-matched cohort study was undertaken from 1999 to 2014. Age, subset of stage I, histology and tumor grade in the cohort, and robotic, laparoscopic, and open radical hysterectomy were analyzed. Overall survival for surgical treatment for stage I cervical cancer was analyzed. The 5-year survival for each respective surgical treatment was analyzed to determine if there was difference among robotic, laparoscopic and radical hysterectomy. Results: During the period 1999 to 2014, 110 patients underwent radical hysterectomy with bilateral pelvic lymphadenectomy (RHBPLND) for clinical stage I cervical cancer. From 1999 to 2008, 28 (25.5%) patients underwent open RHBPLND (ORHBPLND), and (30.9%) patients underwent laparoscopic radical hysterectomy with pelvic lymphadenectomy (LRHBPLND). From 2008 to 2015, 48 (43.6%) patients underwent robotic radical hysterectomy with bilateral pelvic lymphadenectomy (RoRHBPLND). Of those who underwent robotic surgery, 25% were stage 1a2, 47.9 % were stage 1B1, and 10.4% stage IB2. The overall 5-year survival was 87.5%. The 5-year survival for robotic, laparoscopic, and open surgical cohorts were 87.5%, 96.9%, and 82.1%, respectively. There was no difference in 5 -ear survival for stage IA2, IB1, and IB2 for all 3 surgical procedures. We also reviewed histology, grade, and parametrial as well as vaginal cuff measurements in all 3 groups. Conclusions: The overall 5-year survival for RoRHBPLND for treatment of clinical stage I cervical is 87.5%. There was no difference in 5-year survival among RoRHBPLND, LRHBPLND, and ORHBPLND.