Invasive Surgical Staging Research Articles

Use of indocyanine green dye for sentinel lymph node mapping in patients with endometrial cancer and a history of iodinated contrast allergy

ObjectivesSentinel lymph node (SLN) mapping is a surgical technique with high accuracy in detecting metastases while limiting morbidity associated with full lymphadenectomy in endometrial cancer. Cervical injection of indocyanine green (ICG) dye is associated with very high SLN detection rates; however, iodinated contrast allergy has traditionally been viewed as a contraindication to ICG use. The objective of this study was to describe the use of ICG in a population of patients with iodinated contrast allergies undergoing surgical staging for endometrial cancer. MethodsIRB approval was obtained. All patients with clinically early-stage endometrial cancer who underwent minimally invasive surgical staging with SLN mapping with ICG at a single academic institution from 1/1/2017 to 12/31/2020 were identified retrospectively. Patients with reported iodinated contrast allergies prior to surgery were identified. Data were collected through electronic medical record review and compared using descriptive statistics. Results820 patients who underwent minimally invasive surgical staging with SLN mapping with ICG were identified, and 25 had documented iodinated contrast allergies. Documented reactions included rash/hives (n = 10, 40 %), anaphylaxis (n = 6, 24 %), shortness of breath (n = 5, 20 %), diarrhea (n = 1, 4 %), and not specified (n = 3, 12 %). A majority (24/25, 96 %) received 4 mg intravenous dexamethasone during induction of general anesthesia as per the institutional enhanced recovery after surgery (ERAS) protocol. No patients experienced allergic reactions or other adverse events after ICG injection. ConclusionsNo patients in this cohort demonstrated an adverse reaction after ICG injection for SLN mapping. This study supports the reasonable safety of ICG in patients with contrast allergies, particularly when routine ERAS protocols containing dexamethasone are utilized.

Comparison of oncological outcomes between sentinel lymph node biopsy and complete lymphadenectomy for endometrial cancer.

Sentinel lymph node (SLN) mapping allows node-negative patients to be spared from the surgical comorbidities associated with total lymphadenectomy. This study aimed to evaluate the oncological outcomes of SLN biopsy versus complete lymph node dissection in patients with early-stage endometrial carcinoma. Retrospective analyses were performed in patients with pathologically confirmed endometrioid endometrial carcinoma, who underwent minimally invasive surgical staging with SLN biopsy or complete lymph node dissection at Yonsei Cancer Center between 2015 and 2019. A total of 301 patients were included in this study. Eighty-two patients underwent SLN biopsy, while 219 underwent complete lymph node dissection. There were no significant differences in patient characteristics between the two groups. In terms of operative characteristics, the SLN biopsy-only group had a significantly shorter surgical duration (p < 0.001) than the lymphadenectomy group. The mean follow-up period was 41.4 months. There were no differences in progression-free survival (PFS) and overall survival (OS) between the two groups (SLN biopsy vs. complete lymph node dissection; p = 0.798 and 0.301, respectively). Multivariate analysis revealed that SLN biopsy was not an independent prognostic factor for PFS or OS. Our results showed that SLN biopsy provided oncological outcomes similar to those of lymphadenectomy.

Clinical factors associated with failed sentinel lymph node mapping in endometrial cancer (527)

Clinical factors associated with failed sentinel lymph node mapping in endometrial cancer (527)

Interventional Pulmonology and Esophagus: Combined Endobronchial Ultrasound and Endoscopic Ultrasound for Mediastinal Staging.

Endoscopic ultrasound (EUS) techniques in addition to endobronchial ultrasound (EBUS) can lead to diagnosis and complete accurate staging of the mediastinum in a single session. This allows for decreased health care costs, less delay in diagnosis and treatment, reduced patient discomfort, and decreased morbidity compared with invasive surgical staging techniques. In comparison to conventional mediastinoscopy, the cost-effectiveness and reduced complication profile of the endoscopic approach has made this a superior initial step in the staging and diagnosis of lung cancer. Moreover, compared with EBUS alone, combined EUS and EBUS has significantly increased yield, as well as diagnostic sensitivity making a combined approach preferable as the emerging gold-standard technique for initial minimally invasive mediastinal staging. We discuss the advantage of using EUS in combination with EBUS and highlight techniques, lymph node landmarks, utility in staging and restaging of the mediastinum, roles in diagnosing mediastinal infections and granulomatous lesions, and future directions in endosonography.

Techniques chirurgicales : médiastinoscopie vidéo-assistée, thoracotomie, VATS, RATS: Surgical techniques: video-assisted mediastinoscopy, thoracotomy, VATS, RATS

Oncologically complete resection is the mainstay of curative treatment for non-small cell lung cancer. The purpose of this manuscript is to provide an overview of surgical techniques and more specifically, the different approaches that are used for staging and radical treatment of lung cancer.Although the role of invasive surgical staging remains controversial, videomediastinoscopy remains a useful tool in staging of lung cancer. Its main indications are staging after a negative endosonographic examination and restaging after induction therapy. The different approaches that are available in thoracic surgery all have their advantages and disadvantages. Classical thoracotomies have evolved to minimally invasive surgery, mainly represented by video-assisted thoracic surgery (VATS) and robotically assisted thoracic surgery (RATS). Complete resection still remains the final aim, as this is one of the most important prognostic factors for lung cancer.© 2021 SPLF. Published by Elsevier Masson SAS. All rights reserved.

ASO Author Reflections: Minimally Invasive Surgical Staging in Endometrial Cancer Diagnosed After Supracervical Hysterectomy- The Role of Cervical Injection to Detect Sentinel Lymph Node with Indocyanine Green.

ASO Author Reflections: Minimally Invasive Surgical Staging in Endometrial Cancer Diagnosed After Supracervical Hysterectomy- The Role of Cervical Injection to Detect Sentinel Lymph Node with Indocyanine Green.

Survival after minimally invasive hysterectomy for type 2 uterine cancer

Objectives: Minimally invasive surgical (MIS) staging has become the standard of care for low-grade clinical stage I endometrioid uterine cancer based on randomized studies demonstrating survival outcomes comparable to laparotomy. However, there is limited data on the use of MIS for high-grade uterine cancers at much higher risk for local disease extension and metastasis. The LACC trial showed inferior survival among early-stage cervical cancer patients undergoing MIS compared to laparotomy. The aim of this study was to test the hypothesis that MIS staging of type 2 uterine cancers would be associated with inferior survival. Methods: The National Cancer Database was used to identify women with type 2 uterine cancer (serous, carcinosarcoma, high-grade endometrioid, clear cell) diagnosed from 2010-2015 who underwent primary surgical management. Patients with low grade endometrioid uterine cancer were excluded. MIS included both laparoscopic and robotic approaches. Inverse probability of treatment weighting (IPTW) was used to balance confounders between the MIS and laparotomy groups. Variables in the propensity score model included age, race, median neighborhood education and income, insurance status, year of diagnosis, tumor stage, size, and grade, medical co-morbidities, facility type, and location. Kaplan-Meier curves and Cox regression were used to compare survival. Results: A total of 54,027 women (mean age 65.0±10.1 years) were included in the analysis. 33,763 (62.5%) underwent MIS approach. Compared to those in the laparotomy group, patients treated with MIS were noted to have tumors that were smaller, had earlier stage disease, and were less likely to be graded as poorly differentiated. Following weighting, the 5 year survival rates were 63.4% for laparotomy and 66.5% for MIS. (Figure 1). Patients treated with an MIS approach demonstrated significantly improved survival compared to an open approach (HR=0.87; 95% CI [0.84, 0.91], p Download : Download high-res image (103KB) Download : Download full-size image Conclusions: MIS staging was performed in two-thirds of patients with type 2 uterine cancer yet with significant baseline differences compared to the laparotomy group. Propensity score weighted matching was used in an attempt to create equivalent cohorts from this large retrospective sample. Our findings support the null hypothesis that MIS staging is not inferior to laparotomy, which are consistent with prior literature on type 1 uterine cancer and reinforce that MIS is the preferred approach for surgical staging of all types of uterine cancer.

Contemporary Incidence of Medical Inoperability in Clinical Stage I Endometrial Cancer.

Minimally invasive surgical (MIS) staging is the standard treatment approach for clinical stage I endometrial cancer. Historical rates of inoperability in endometrial cancer are approximately 10%. Given surgical and medical advancements against increasing population obesity, we aimed to describe a contemporary incidence of medical inoperability in clinical stage I endometrial cancer. Patients diagnosed with clinical stage I endometrial cancer of any histology from April 2014 to December 2018 were included in this retrospective cohort study. The primary outcome, medical inoperability, was defined as (1) patients deemed inoperable by a gynecologic oncologist at initial consultation, (2) patients deemed inoperable during preoperative clearance, or (3) an aborted hysterectomy. Fisher's exact or χ2, and Student's t-test or Wilcoxon rank sum test were used, as appropriate, for data analysis. Multivariable logistic regression was also employed. Overall, 767 patients were included, of which 4.6% (35/767) were determined to be inoperable. The inoperable group had a higher body mass index (52.7 vs. 33.9, p < 0.001), and increased rates of diabetes (62.8%, 22/35 vs. 27.1%, 199/732, p < 0.001), coronary artery disease (31.4%, 11/35 vs. 7.1%, 52/732, p < 0.001), and hypertension (94.3%, 33/35 vs. 70.2%, 514/732, p < 0.001). Of those with attempted surgical staging, hysterectomy was aborted intraoperatively in 0.68% (5/737). The overall complication rate was 11.6% (86/737). With maximal surgical effort and MIS, hysterectomy is possible in > 95% of patients with newly diagnosed endometrial cancer treated at a high-volume center. Complication rates were comparable to other trials evaluating the safety of MIS staging for endometrial cancer.

Minimally invasive surgical staging for early stage ovarian cancer: A long-term follow up

IntroductionThe standard treatment for epithelial early stage ovarian cancer (eEOC) includes laparotomic surgical staging, according to ESGO-ESMO guidelines. In the last decade, many investigators have assessed the safety and feasibility of minimally invasive surgery (MIS) staging in properly selected patients. However, survival data related to different surgical approaches (open versus MIS) are extremely limited. The aim of this study is to analyze the long-term oncological outcomes in eEOC patients treated with MIS. Materials and methodsThis is a multicenter observational retrospective study conducted in two tertiary oncological centers. We selected all consecutive women who underwent a laparoscopic or robotic staging for eEOC. ResultsFrom January 2008 to December 2016, 254 eEOC patients underwent a MIS staging (188 laparoscopic staging and 66 robotic staging). Overall, 18.1% of patients were upstaged due to pathological findings. A total of 203 (79.9%) patients received platinum-based adjuvant chemotherapy.After a median follow-up of 61 months (range 13–118), 39 (15.3%) patients experienced recurrence. The 5-years progression free survival (PFS) and overall survival rates were 84.0% and 93.8%, respectively.In the univariate analysis, favorable variables influencing PFS were young age (≤45 years), non-serous histotype, tumor grade 1-2, and FIGO stage IA/IB. In the multivariate analysis, only grade 3 was shown to keep its negative independent prognostic value (HR = 3.47; p = 0.004), whereas FIGO stage ≥ IC showed a trend toward significance (HR = 1.75; p = 0.099). ConclusionThis retrospective study represents the longest follow-up of eEOC patients managed by MIS. The MIS is a valuable therapeutic option in appropriately selected patients, although a randomized controlled trial is needed.

Laparoscopic vs. robotic-assisted laparoscopy in endometrial cancer staging: large retrospective single-institution study

ObjectiveThe aim of this study is to analyze and draw the potential differences between the robotic-assisted surgery (RS) and the laparoscopy (LPS) in endometrial cancer staging.MethodsIn this single-institution retrospective study we enrolled 1,221 consecutive clinical stage I–III endometrial cancer patients undergone minimally invasive surgical staging. We compared patients treated by LPS and by RS, on the basis of perioperative and oncological outcomes (disease-free survival [DFS] and overall survival [OS]). A sub-analysis of the high-risk endometrial cancer population was performed in the 2 cohorts.ResultsThe 2 cohorts (766 treated by LPS and 455 by RS) were homogeneous in terms of perioperative and pathological data. We recorded differences in number of relapse/progression (11.7% in LPS vs. 7% in RS, p=0.008) and in number of deaths (9.8% in LPS vs. 4.8% in RS, p=0.002). Whereas, univariate and multivariate analyses according to DFS and OS confirmed that the surgical approach did not influence the DFS or the OS. In the multivariable analysis the association of the age and grading was significant for DFS and OS. In the sub-analysis of the 426 high risk EC patients (280 in LPS and 146 in RS) the univariate and the multivariate confirmed the influence of the age in DFS and OS, independently of the minimally invasive approach.ConclusionsIn our large retrospective analysis, we confirmed that the RS and LPS have similar efficacy and safety for endometrial cancer staging also for the high-risk endometrial cancer patients.

Sentinel Node Mapping Vs. Sentinel Node Mapping Plus Backup Lymphadenectomy in Endometrial Cancer: 3-Year Outcome

Study Objective Sentinel node mapping (SLNM) has replaced lymphadenectomy for staging surgery in apparent early-stage endometrial cancer (EC). Here, we evaluate long-term survival of two different approaches of nodal assessment in EC. Design This is a multi-institutional retrospective study evaluating long-term outcomes (at least 3 years) of EC patients having SLNM alone and SLNM followed by lymphadenectomy. In order to reduce possible confounding factors we applied a propensity-matched algorithm. Survival outcomes were assessed using Kaplan-Meier and Cox proportional hazard models. Setting Three oncologic referral centers. Patients or Participants Consecutive EC patients having minimally invasive surgical staging. Interventions Laparoscopic hysterectomy plus SLNM with or without backup lymphadenectomy. Measurements and Main Results Applying a propensity score matching algorithm we selected 180 patients having SLNM (90 SLNM vs. 90 SLNM followed by lymphadenectomy). Median follow-up time was 69 months. Overall, 10% of patients were diagnosed with positive nodes. Low volume disease was observed in 16 cases (5 micrometastasis and 11 isolated tumor cells). Patients having SLNM followed by lymphadenectomy had not a higher possibility to be diagnosed with a stage IIIC disease in comparison to SLNM alone (p=0.389). The survival analysis comparing did not show statistical differences in terms of disease-free (p=0.570, log-rank test) and overall survival (p=0.911, log-rank test) were similar between groups. No survival differences were observed also after stratification in low, intermediate and high-risk patients (p>0.20). Conclusion Our study highlighted that laparoscopic staging is safe and effective in EC. SLNM provides similar long-term oncologic outcomes than lymphadenectomy. Further evidence is warranted to assess the prognostic value of low-volume disease detected by ultra staging in patients following SLNM.

Contemporary incidence of medical inoperability in clinical stage I endometrial cancer

Objective: Minimally invasive surgical (MIS) staging is standard-of-care treatment for women with clinical stage I endometrial cancer (EC). Historical rates of medical inoperability in EC do not account for advances in MIS treatment. We aimed to describe a contemporary incidence of medical inoperability in women with newly diagnosed clinical stage I EC at a single, high-volume center.

Perioperative outcomes and disparities in utilization of sentinel lymph node biopsy in minimally invasive staging of endometrial cancer

ObjectiveTo assess the emergence of sentinel lymph node biopsy (SLNB) for disparities in utilization, and impacts on perioperative outcomes. MethodsRetrospective cohort study of the National Cancer Database, selecting for patients with T1NxM0 endometrial cancer undergoing minimally invasive surgical staging from 2012 to 2016. Disparities in SLNB utilization were described. Propensity matching was performed. Association of SLNB with perioperative outcomes was assessed with logistic regression. ResultsAmong 67,365 patients, 6356 (9.4%) underwent SLNB, increasing from 2.8% to 16.3% from 2012 to 2016. Disparities were identified within race (7.0% Black, 9.4% non-Black), ethnicity (8.3% Hispanic, 9.5% non-Hispanic), insurance (6.0% uninsured, 9.5% insured), county density (3.7% rural, 9.8% metro), and income (7.0% bottom-quartile, 11.8% top-quartile). Risk of conversion to open surgery was lower with SLNB alone (1.03%) or SLNB followed by LND (1.40%), versus upfront LND (2.80%). SLNB was associated with reduced risk of conversion to open surgery in Intention-To-Treat (SLNB+/-LND vs. upfront LND; ORITT = 0.53; 95%CI 0.39–0.72) and Per-Protocol (PP; SLNB alone vs. upfront LND or SLNB+LND; ORPP = 0.49; 95%CI 0.32–0.75) comparisons. SLNB was also associated with lower risk of length of stay >1 day (overall rate 6.3%; ORITT = 0.51; 95%CI 0.40–0.64; ORPP = 0.39; 95%CI 0.28–0.55), and unplanned readmission (overall rate 2.3%; ORPP = 0.52; 95%CI 0.33–0.81). There were no deaths within 90 days among 1370 SLNB alone cases, versus 2/1294 (0.15%) for SLNB+LND, and 123/28,828 (0.41%) for upfront LND. ConclusionWe identified significant disparities in the utilization of SLNB, as well as evidence that this less-invasive technique is associated with lower rates of certain perioperative complications. Equitable access to this emerging technique could lessen disparate outcomes.

P1.18-24 Neoadjuvant Therapy versus Upfront Surgery for NSCLC Patients with Clinically Suspected Subaortic or Paraaortic Lymph Nodes

Subaortic lymph nodes (#LN5) and para-aortic lymph nodes (#LN6) cannot be accessed by routine mediastinoscopy and E(B)US-FNA but need additional invasive surgical staging methods such as VATS or anterior mediastinotomy. Therefore, a considerable number of patients with suspected #LN5 or #LN6 receive multimodal treatment or, upfront surgery based on imaging staging only. We investigated survival outcomes of each therapeutic strategy. An institutional lung cancer database of consecutive patients between 2007 and 2016 (N=134) was reviewed retrospectively. Eligible patients had pathologically confirmed non-small cell lung cancer with clinically suspected #LN5 or #LN6 involvement by CT or PET-CT without clinical or pathological evidence of other N2 station involvement. Excluded are those with involvement of other N2 stations, unexpected N2, low grade malignancy, and prior history of cancer. Patients in group 1 received neoadjuvant therapy followed by surgery (n=68) and those in group 2 underwent upfront surgery (n=66). Group 1 consisted of patients with clinically suspected (n=39, 57%), and biopsy-proven #LN5 or #LN6 (n=29, 43%) by VATS (n=19), anterior mediastinotomy (n=6), or EUS-FNA (n=4). They received preoperative chemoradiation (n=62, 91%) and the rest received chemotherapy (n=6, 9%). Nodal down-staging was occurred in 36 (53%) patients whereas persistent N2 in 32 (47%). On the contrary, group 2 consisted of patients with clinically suspected #LN5 or 6 (n=66). After surgery, 30 (45%) patients were confirmed to have pathologic N0 or N1. The rest 36 (55%) patients were confirmed pathologic N2, and 29 (81%) of them received adjuvant therapy: chemoradiation in 23, and chemotherapy in 6. Overall survival rate at 5-year (5YOS) were 50.5% in group 1 versus 58.9% in group 2 (p=0.55); recurrence-free survival at 5-year (5YRFS) was 42.2% versus 46.7% (p=0.98), respectively. In subgroup, the 5YOS were 44.6% in pathologic N2 in group 2, which were similar to persistent N2 (52.8%, p=0.6), down-staged (49.2%, p=0.89), or biopsy-proven N2 (57.8%, p=0.54) in group 1. The 5YRFS were 26.7% in pathologic N2 in group 2, which were similar to persistent N2 (30.3%, p=0.89) and biopsy-proven N2 (43.9%, p=0.15), but lower than down-staged (53%, p=0.03) in group 1. Upfront surgery or omission of invasive mediastinal staging for #LN5 or 6 may not compromise survival outcomes. Each therapeutic strategy is effective in terms of oncologic outcomes.

Pseudovascular Invasion: Minimally Invasive Surgery for Endometrial Cancer.

Background and Objectives:To determine if the use of an intrauterine manipulator is associated with an increased incidence of pseudovascular invasion on pathologic evaluation of hysterectomy specimens for endometrial cancer and to assess the possible implications of pseudovascular space invasion in the treatment of endometrial cancer.Methods:We performed a retrospective cohort study of patients with early stage (I/II) endometrial cancer who underwent minimally invasive surgical staging. The following data were abstracted: race, body mass index, grade, age, stage, histology, presence or absence of lymphovascular space invasion (LVSI), peritoneal cytology, and adjuvant treatment. Slides were blindly reviewed by a gynecologic pathologist.Results:Of the104 patients meeting eligibility criteria, 74 cases were reviewed in detail (the study was terminated early based on the results of an interim analysis). Patients in the no-manipulator group were older (P = .02) and had a higher stage 1B/II (P = .01) than patients in the manipulator group. No difference was found in the incidence of pseudovascular invasion between the manipulator and the no-manipulator groups (P = .86). Subgroup analysis showed no association of pseudovascular invasion with tumor grade (P = .79). Five patients were identified to have pseudovascular invasion misdiagnosed as true LVSI—4 had endometrioid and 1 had serous histology. Of these, 3 were in the manipulator group. Two received adjuvant radiotherapy which they not have gotten, absent reported lymphovascular invasion.Conclusion:The use of a uterine manipulator does not appear to increase the rate of pseudovascular invasion in our limited data set. Misdiagnosis of pseudovascular invasion as LVSI can result in risk migration of patients with potential for harm from unwarranted adjuvant therapy.

Diagnostic Accuracy of Different Surgical Procedures for Axillary Staging After Neoadjuvant Systemic Therapy in Node-positive Breast Cancer: A Systematic Review and Meta-analysis.

Objective:The aim of this study was to perform a systematic review and meta-analysis to assess the accuracy of different surgical axillary staging procedures compared with ALND.Summary of Background Data:Optimal axillary staging after neoadjuvant systemic therapy (NST) in node-positive breast cancer is an area of controversy. Several less invasive procedures, such as sentinel lymph node biopsy (SLNB), marking axillary lymph node with radioactive iodine seed (MARI), and targeted axillary dissection (a combination of SLNB and a MARI-like procedure), have been proposed to replace the conventional axillary lymph node dissection (ALND) with its concomitant morbidity.Methods:PubMed and Embase were searched for studies comparing less invasive surgical axillary staging procedures to ALND to identify axillary burden after NST in patients with pathologically confirmed node-positive breast cancer (cN+). A meta-analysis was performed to compare identification rate (IFR), false-negative rate (FNR), and negative predictive value (NPV).Results:Of 1132 records, 20 unique studies with 2217 patients were included in quantitative analysis: 17 studies on SLNB, 1 study on MARI, and 2 studies on a combination procedure. Overall axillary pathologic complete response rate was 37%. For SLNB, pooled rates of IFR and FNR were 89% and 17%. NPV ranged from 57% to 86%. For MARI, IFR was 97%, FNR 7%, and NPV 83%. For the combination procedure, IFR was 100%, FNR ranged from 2% to 4%, and NPV from 92% to 97%.Conclusion:Axillary staging by a combination procedure consisting of SLNB with excision of a pre-NST marked positive lymph node appears to be most accurate for axillary staging after NST. More evidence from prospective multicenter trials is needed to confirm this.

Surgical approaches in women with endometrial cancer with a body mass index greater than 35 kg/m2.

Endometrial cancer is often associated with obesity. We want to compare the outcomes of surgical staging according to the surgical approach in patients with a body mass index ≥35 kg/m2 . A retrospective cohort study with 138 patients with endometrial cancer and body mass index ≥35 kg/m2 with different surgical staging routes: laparotomy (LPT; n = 94) and minimally invasive surgery (MIS): laparoscopy (LPC; n = 18) + robotic assisted laparoscopy (n = 26). Lymphadenectomy rate was similar in the three groups; there were no differences in the number of nodes removed. Decreased bleeding (P = 0.002) and hospital admission length (P < 0.001) was observed in the endoscopic group. Less early-postoperative complications were observed in the robotic approach (P = 0.007). Significant differences were not observed in recurrence-free survival or in overall survival. Minimal invasive surgical staging in obese women with endometrial cancer could represent the surgical route of choice because it decreases operative bleeding, hospital admission length and the early postoperative complication rate without compromising recurrence-free survival or overall survival.

Minimally Invasive Staging of Apparent Stage I Malignant Ovarian Germ Cell Tumors: Prevalence and Outcomes

Study ObjectiveEvaluate the prevalence, trends, and outcomes of minimally invasive surgical (MIS) staging of malignant ovarian germ cell tumors (MOGCTs) apparently confined to the ovary. DesignRetrospective cohort study (Canadian Task Force classification II-2). SettingParticipating hospitals in the National Cancer Data Base. PatientsWomen diagnosed between 2010 and 2014 with a MOGCT apparently confined to the ovary with information on the planned surgical approach. InterventionsStaging with MIS or laparotomy. Measurement and Main ResultsA total of 918 patients were identified. MIS was planned for 294 patients (32%): a laparoscopic approach for 237 patients and a robotic-assisted approach for 57 patients. Rate of conversion to laparotomy was 11% (46 cases), 1.7% and 15.6% in the robotic and laparoscopy groups, respectively (p = .003). No difference in the use of MIS was noted based on year of diagnosis (p = .38). By multivariate analysis white race, higher level of education, and smaller tumor size were associated with the receipt of MIS. Patients in the MIS group were less likely to undergo lymph node dissection (39.6% vs 51.3%, p = .001) and omentectomy (18.7% vs 28.5%, p = .002). Hospital stay after surgery was shorter for patients who had MIS (median, 2 vs 3 days; p <.001). Unplanned 30-day readmission rate was also lower in the MIS group (1.4% vs 3.9%, p = .043). No difference in overall survival was noted between the 2 groups (p = .81). ConclusionMIS for apparent early-stage MOGCTs was less comprehensive but associated with a decreased hospital stay and unplanned readmission rate.

Minimally invasive staging of esophageal cancer.

Esophageal cancer is one of the most common malignancies in the world today and the sixth-leading cause of cancer-related mortality. Accurate preoperative staging of esophageal cancer is imperative to the selection of appropriate treatments. Patients with esophageal carcinomas typically undergo a multimodality staging process including noninvasive imaging techniques, such as computed tomography (CT) and positron emission tomography (PET), as well as endoscopic ultrasound (EUS), which is slightly more invasive. Minimally invasive surgical staging, with laparoscopy, occasionally in combination with video-assisted thoracoscopy, is used in the staging process at select institutions and has been shown to be more accurate than noninvasive staging modalities. Two major advantages of minimally invasive surgical staging over conventional techniques are the improved assessment of locoregional disease and enhanced identification of distant metastases. These advantages decrease the likelihood that the patient will undergo a nontherapeutic laparotomy. Currently, no clear consensus exists regarding which patients with esophageal cancer would benefit most from the addition of minimally invasive surgical staging. We have, however, found that minimally invasive surgical staging with laparoscopy is particularly valuable in detection of occult distant metastases. In this article, we summarize the staging modalities for esophageal cancer including minimally invasive surgical staging.

Minimally Invasive Surgical Staging for Ovarian Carcinoma: A Propensity-Matched Comparison With Traditional Open Surgery

Study ObjectiveGrowing evidence supports the safety of a laparoscopic approach for patients affected by apparent early-stage ovarian cancer. However, no well-designed studies comparing laparoscopic and open surgical staging are available. In the present investigation we aimed to provide a balanced long-term comparison between these 2 approaches. DesignRetrospective study (Canadian Task Force classification II-2). SettingTertiary center. PatientsData of consecutive patients affected by early-stage ovarian cancer who had laparoscopic staging were matched 1:1 with a cohort of patients undergoing open surgical staging. The matching was conducted by a propensity-score comparison. InterventionLaparoscopic and open surgical staging. Measurements and Main ResultsFifty patient pairs (100 patients: 50 undergoing laparoscopic staging vs 50 undergoing open surgical staging) were included. Demographic and baseline oncologic characteristics were balanced between groups (p > .2). We observed that patients undergoing laparoscopic staging experienced longer operative time (207.2 [71.6] minutes vs 180.7 [47.0] minutes; p = .04), lower blood loss (150 [52.7] mL vs 339.8 [225.9] mL; p < .001), and shorter length of hospital stay (4.0 [2.6] days vs 6.1 [1.6] days; p < .001) compared with patients undergoing open surgical staging. No conversion to open surgery occurred. Complication rate was similar between groups. No difference in survival outcomes were observed, after a mean (SD) follow-up of 49.5 (64) and 52.6 (31.7) months after laparoscopic and open surgical staging, respectively. ConclusionsOur findings suggest that the implementation of minimally invasive staging does not influence survival outcomes of patients affected by early-stage ovarian cancer. Laparoscopic staging improved patient outcomes, reducing length of hospital stay. Further large prospective studies are warranted.