Randomized trial of surgical staging (extraperitoneal or laparoscopic) versus clinical staging in locally advanced cervical cancer

OBJECTIVE: To define the role of pretreatment surgical staging for locally advanced cervical carcinoma. METHODS: A two-step randomized trial was conducted to compare clinical staging (arm A) versus surgical staging (arm B) and to compare the laparoscopic (LAP) with the extraperitoneal (EXP) approach in previously untreated locally advanced cervical carcinoma. After the first randomization, those in arm B were randomly allocated to either LAP or EXP. An interim analysis was planned to evaluate the feasibility of LAP versus EXP, which led to the current report. RESULTS: A total of 61 patients were eligible (arm A, 29; arm B, 32). The operation time, blood loss, and lymph node yield of LAP and EXP were not significantly different. Serious acute and late toxicity was not different between arm A and arm B, or LAP versus EXP. Para-aortic node metastasis was documented in 25% (95% confidence interval, 10% to 40%) of patients on arm B. An interim analysis was performed in January 2000. Patients on arm B had significantly worse progression-free survival than those on arm A. Hazard ratios of relapse/persistent or death were 3.13 (P = 0.005) and 1.76 (P = 0.150), respectively. Patient accrual was terminated according to the early stopping rules. With further follow-up till December 2001, the difference in progression-free survival remained significant (P = 0.003), and the difference in overall survival became significant (P = 0.024) as the data matured. CONCLUSION: The benefit of pretreatment surgical staging for cervical carcinoma remained unproven. The detrimental effects of surgical staging observed in this study must be considered in the design of clinical guidelines or future trials.     

Changing surgical approaches to vulvar cancer.

Interest in reducing surgical morbidity and maintaining sexual function continues to stimulate the development of tissue-conserving vulvar operations for patients with resectable vulvar cancers. A growing body of clinical experience has demonstrated the safety of this approach, but further refinements of technique and patient eligibility criteria are likely. Tissue-flap reconstruction of the vulva has expanded the surgeon's ability to radically resect large cancers with less morbidity and functional impairment. The range of available techniques allows a more versatile surgical approach that can be individualized to lesion size and location. The risk of local recurrence is strongly related to the adequacy of resection margins. Radical resection of recurrent vulvar disease can salvage significant numbers of node-negative patients.     

Comprehensive surgical staging for endometrial cancer

Despite a shift from clinical to surgical staging of endometrial cancer in 1988, performance of comprehensive surgical staging for clinically early-stage endometrial cancer remains controversial. Low-, intermediate-, and high-risk groups have been defined pathologically. Herein, we describe the risks and benefits of comprehensive surgical staging. Comprehensive surgical staging is encouraged in high-risk histologies, whereas a method of triage should be used to determine who among the low-grade endometrioid histology may benefit from comprehensive staging.     

腹腔镜在卵巢癌手术分期与治疗中的应用

腹腔镜在卵巢癌诊治中的应用目前争议较多。文章重点就腹腔镜用于卵巢癌诊断、评估、分期与补充分期手术、监测与随访等方面的现状与共识,以及腹腔镜下卵巢癌肿瘤细胞减灭术的进展和争议等问题做一阐述,希望能为临床应用与研究提供参考。     

Comparison between 155 cases of robotic vs. 150 cases of open surgical staging for endometrial cancer

Objective

To compare the outcomes of 155 cases of endometrial cancer who had robot-assisted surgical staging to 150 open cases.

Methods

Retrospective chart review of cases of endometrial cancer that underwent staging two different ways by two surgeons at an academic institution.

Results

Mean age was 62.4 years in the robotic arm and 65 (P = 0.04) in the open arm. Mean body mass index was 34.5 Kg/m² in the robotic arm and 33 Kg/m² in the open arm (P = 0.2). Pelvic and para-aortic lymph node dissection were performed in 94.8% and 67.7% of the robotic cases versus 95.3% and 74% of the open cases, respectively. Mean operative time was 127 min in the robotic arm, and 141 min in the open arm (P = 0.0001). Mean lymph node count was 20.3 in the robotic arm, and 20 in the open arm (P = 0.567). Mean estimated blood loss was 119 ml in the robotic arm and 185 in the open arm (P = 0.015). Mean hospital stay was 1.5 days in the robotic arm, and 4 days in the open arm (P = 0.0001). The incidence of postoperative ileus (0.6% vs. 10.7%, P = 0.0001), infections (5.2% vs. 24%, P = 0.0001), anemia/transfusion (1.3% vs. 7.7%, P = 0.005), and cardiopulmonary complications (3.2% vs.14.7%, P = 0.003) was significantly lower in the robotic arm vs. the open arm. There was one death in the robotic arm attributed to pre-existing cardiac condition.

Conclusion

Robotic-assisted staging reaps the benefits of minimally invasive surgery without compromising the adequacy of the procedure. Dedication to the technique shortens the operative time.     

Prognostic factors and a value of 2009 FIGO staging system in vulvar cancer

Objective

In 2009, International Federation of Gynecology and Obstetrics (FIGO) modified staging of vulvar cancer—the prognostic significance of the new classification relative to the prior system as well as to the commonly recognized prognostic factors has not been assessed. The aim of this study was to test prognostic ability of 2009 staging in a cohort of uniformly treated and staged cases with long-term follow-up.

Methods

Pathologic characteristics were obtained by blind review of the original tissue samples. 76 patients who qualified for surgery on the basis of the same criteria, with full clinical history, were included in the study. The histological analyses were performed on 76 and 35 paraffin-embedded tissue samples from primary tumors and lymph nodes, respectively. Survival analyses included the Kaplan–Meier method, log-rank test and Cox proportional hazards model.

Results

Univariate analysis has demonstrated that age (p = 0.0170), lymph node metastasis (p = 0.0393), tumor grade (p = 0.0086) and FIGO1994 stage (p = 0.001) were the significant prognostic factors for overall survival. Multivariate analysis has demonstrated that growing age (HR 2.25, 95 % CI 0.79–3.71, p = 0.0321), tumor grade (G1 vs. G2 and G3) (HR 1–3.11, 95 % CI 1.6–4.62, p = 0.0057) and FIGO1994 stage (HR 1.78, 95 % CI 0.55–3.01, p = 0.0061) are independent prognostic factors with respect to overall survival.

Conclusions

The results indicate the prognostic advantage of the 1994 FIGO staging as it has become an independent prognostic factor in contrast to the new FIGO system. This should be tested in future larger cohort studies. Differentiation grade turned out to be a very valuable independent prognostic factor and should be incorporated as a routine component of the histopathologic reports in vulvar cancer.     

The assessment and surgical management of early-stage vulvar cancer

The treatment of early vulvar cancer has undergone a major paradigm shift from a radical surgical approach to tissue-sparing surgery and preservation of sexual function. Stage I and II tumours represent two-thirds of the cases, and 5-year survival rates reach 80-90%. These tumours, with clinically negative nodes, do not require metastatic work-up, and the patients are submitted to surgery. Stage IA tumours, with a depth of stromal invasion of less than 1 mm, have a very low risk of lymph node (LN) involvement (<1%) and are treated by radical (wide) local excision without the need for lymphadenectomy. The remaining patients with stage I or II disease undergo radical (wide) local excision of the vulvar lesion, accompanied by some sort of inguinal lymphadenectomy. Evaluation of the lymph nodes using sentinel node mapping appears promising and is extensively reviewed. It should probably include serial sectioning and immunohistochemistry to detect micrometastases, although their true clinical importance remains to be determined. Molecular detection methods that reveal cancer cells in sites not detectable by routine histology have been introduced to evaluate sentinel lymph nodes and may eventually become part of the routine metastatic work-up.     

Laparoscopic surgical staging of early ovarian cancer

Since its advent in the early 1990s, laparoscopic surgical staging for early ovarian cancer has been explored as an option with the potential to offer women equivalent cancer control and survival as provided by laparotomy but with the clear benefits of minimally invasive surgery. A limited but expanding body of literature suggests aggressive surgical staging can be performed with equivalent tissue assessment compared with laparotomy. Given the lack of randomized, controlled trials, the risks and benefits of such a procedure remain ambiguous. This review summarizes the current body of literature regarding the role of laparoscopy in upfront surgical staging of ovarian cancer. This review presents the history, rationale, and established benefits and risks of utilizing this approach in women who present with malignancy that appears confined to the ovary. Although retrospective data confirm the feasibility, safety, and efficacy of laparoscopic staging of early ovarian cancer, more prospective data will be required to confirm equivalent survival in a patient population that has the potential to be cured.     

Concordance of gross surgical and final fixed margins in vulvar intraepithelial neoplasia 3 and vulvar cancer

OBJECTIVE: To prospectively evaluate the concordance of initial surgical vulvar margins and final fixed margins and to determine the amount of microscopic pathology of grossly negative margins in women with vulvar intraepithelial neoplasia (VIN) 3 or vulvar carcinoma. STUDY DESIGN: Women with VIN 3 or vulvar carcinoma undergoing surgical excision were identified. Prior to excision, acetic acid was used to highlight the lesions, and 2 sutures were placed, 1 at the edge of gross disease and another 1 cm distal from the first. After specimen removal and fixation, the distance between sutures and microscopic involvement of VIN was determined. RESULTS: Twenty-seven women were enrolled; however, only 19 had final fixed specimens that could be accurately measured. The median fixed distance of the vulvar margin was 0.85 cm (mean, 0.83; SD, 0.19) as compared to the gross, 1-cm margin (p = 0.001). Three subjects (16%) had microscopic involvement by VIN 3 in the grossly negative epithelium between the 2 sutures, but none had a positive peripheral margin. CONCLUSION: The gross surgical margin after vulvar resection is reduced by 15% when measured in its final fixed state, and a grossly negative 1-cm margin will seldom harbor significant disease.     

Multimodal surgical guidance towards the sentinel node in vulvar cancer

Introduction

Conventional sentinel node (SN) mapping is performed by injecting a radiocolloid followed by lymphoscintigraphy (and SPECT/CT imaging). An extra intraoperative injection with blue dye can then allow for optical identification of the SN. In order to improve the current clinical standard, the hybrid tracer indocyanine green (ICG)-^99mTc-nanocolloid was introduced, a tracer that is both radioactive and fluorescent. This feasibility study aimed to evaluate the value of a multimodal-based SN biopsy in vulvar cancer.

Materials and methods

Fifteen patients with vulvar cancer (29 groins) scheduled for SN biopsy were peritumorally injected with ICG-^99mTc-nanocolloid followed by lymphoscintigraphy and SPECT/CT imaging to identify the SNs. In thirteen patients, shortly before the start of the operation, blue dye was intradermally injected around the lesion. SNs were harvested using a combination of radiotracing, fluorescence imaging, and optical blue dye detection. A portable gamma camera was used before and after SN excision to confirm excision of the preoperatively defined SNs.

Results

Preoperative lymphoscintigraphy and SPECT/CT imaging visualized drainage to 39 SNs in 28 groins. During the operation, 98% (ex vivo 100%) of the SNs were radioactive. With fluorescence imaging 96% of the SNs (ex vivo 100%) could be visualized. Only 65% of the SNs had stained blue at the time of excision.

Conclusion

ICG-^99mTc-nanocolloid can be used for preoperative SN identification and enables multimodal (radioactive and fluorescent) surgical guidance in patients with vulvar cancer. The addition of fluorescence-based optical guidance offers more effective SN visualization compared to blue dye.     

The significance of surgical staging in intermediate-risk endometrial cancer

Objective

The objective was to evaluate rates of nodal disease in endometrial cancer within risk groups based on uterine factors, and to estimate the rate of potential undertreatment and impact on survival if nodal status was unknown.

Methods

This was a population-based retrospective cohort study of endometrioid-type endometrial cancer in British Columbia from 2005 to 2009. All women with a preoperative grade 2/3 cancer underwent hysterectomy, bilateral salpingo-oophorectomy (HBSO) and lymphadenectomy, and those with intermediate- or high-risk disease based on uterine factors after HBSO alone underwent secondary lymphadenectomy. We compared rates of node-positivity and potential undertreatment in each group if nodal status had been unknown (chi-square test), and estimated the survival benefit from lymphadenectomy.

Results

There were 222 women who underwent primary or secondary lymphadenectomy. Median age was 65 (range 38-86) and median number of lymph nodes was 10 (range 2-39). Of the 66 women with intermediate-risk disease (grade 1 or 2 tumor, deep myometrial invasion), 6 had nodal disease (9.1%) and received adjuvant chemotherapy. They remain disease-free after 24 months (range 8-55). They would not have qualified for chemotherapy based on uterine factors alone, and would have been undertreated compared to other risk groups (chi-square p = 0.071). A 1% survival benefit was estimated from lymphadenectomy.

Conclusion

Women with a grade 1 or 2 tumor and deep myometrial invasion have a 9% risk of nodal disease. Lymphadenectomy is significant for this subgroup as they would have been undertreated based on uterine risk factors alone, although the survival benefit is limited.     

Harmonic scalpel versus conventional electrosurgery in the treatment of vulvar cancer

OBJECTIVE: To compare differences in blood loss, operative time, and intra- and postoperative complications with the harmonic scalpel or conventional electrosurgery in the treatment of vulvar cancer. METHODS: Consecutive patients who underwent radical vulvectomy with inguinal lymphadenectomy using the harmonic scalpel (HS) or conventional electrosurgery (CE) were compared. RESULTS: A total of 42 patients were included, 22 in the HS group and 20 in the CE group. Mean blood loss was significantly less in the HS group compared with the CE group (127 mL vs 210 mL; P<0.05) and mean operative time was significantly shorter with the HS compared with CE (117 minutes vs 142 minutes; P<0.05). There were no significant differences between the 2 groups in postoperative complications. CONCLUSION: Use of the harmonic scalpel for surgical treatment of vulvar cancer is safe and has several advantages, including decreased operative time and blood loss, improved visibility in the operative field, and good postoperative outcome.     

Exploratory celiotomy for surgical staging of cervical cancer

Exploratory celiotomy has been evaluated for surgical staging of cervical cancer prior to therapy. In an 18 month period, 70 of 82 patients with untreated cervical cancer were explored abdominally prior to definitive treatment. Exploration revealed that clinical staging was inaccurate in 38.6 per cent of patients studied. Fourteen and three tenths per cent of the patients had aortic lymph node metastasis. Surgical staging modified therapy considerably whether primary therapy was by radical operation or radiation. This approach to cervical cancer hopefully will improve the over-all 5 year survival rate.     

Surgical treatment of vulvar cancer.

59 (80%) of 74 patients with vulvar cancer treated at the University Department of Obstetrics and Gynecology in Ljubljana in the period 1973-85 underwent radical vulvectomy with bilateral inguinofemoral lymphadenectomy, and 15 (20%) patients single vulvectomy because of advanced age and poor general condition. Histologically there were 69 cases of squamous cell carcinoma, 1 adenocarcinoma, 3 malignant melanoma and 1 rhabdomyosarcoma. 52% of the patients were classified as Stage I, 41% Stage II and 7% Stage III. Positive inguinofemoral nodes were observed in 24% (6.5% in Stage I, 35% in Stage II and 80% in Stage III). The total 5 year survival rate was 70% (83% in Stage I, 61% in Stage II and 20% in Stage III). The 5 year survival rate in the patients with negative nodes was 80%, and in cases with positive nodes only 50% in spite of postoperative irradiation. None of the 3 patients with melanoma survived 2 years nor did the patient with rhabdomyosarcoma. There was no case of primary mortality. Nowadays the cure rate for vulvar cancer is higher especially owing to the improvement of operability. The problem of lymphatic and distant metastases still remains unresolved.     

外阴癌手术切口愈合不良的防治

外阴癌手术后切口愈合不良一直是妇科肿瘤医生所面临的挑战和难题。根据肿瘤特点和病情需要制定适宜的手术范围和手术方式,并在术前、术中及术后各个环节做好预防工作,是促进外阴癌手术切口愈合、减少切口相关并发症的根本措施。本文在分析切口愈合不良影响因素的基础上提出预防切口愈合不良的建议和措施,以供临床借鉴和参考。     

Radical versus conservative surgery for vulvar carcinoma.

OBJECTIVE: The comparison of the radical and conservative surgical approaches for vulvar carcinoma in relation to the rate of recurrence and complications. METHODS: The records of invasive vulvar carcinoma cases were retrospectively reviewed in Istanbul University, Cerrahpasa School of Medicine, Gynecologic Oncology Division and Social Insurance Institution, Ankara Maternity Hospital, Gynecologic Oncology Department. Surgically treated cases with squamous histology were divided into radical vulvectomy and conservative procedures groups and were compared with respect to recurrence, complications, and disease-free survival. RESULTS: One hundred thirteen cases of invasive vulvar carcinoma cases were of squamous histopathology and 92 of these were surgically treated. The rate of local recurrence was lower in the radical vulvectomy group (25%) compared to conservative procedures groups (42.5%; p>0.05). The complication rates were comparable between the radical vulvectomy and conservative procedures groups (32.7% versus 35%, respectively; p>0.05). At the end of five years of the follow-up, the disease-free survival rates were 51.5% in radical vulvectomy group versus 35.7% in conservative procedures group (p>0.05). CONCLUSION: The rate of recurrence, complication, and disease-free survival are similar for the radical vulvectomy and the conservative procedures. Deciding the surgical strategy for vulvar carcinoma should depend on the experience of the surgeon for the short-term adequate results.