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"Fanfani, F"
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Frozen section accurately allows pathological characterization of endometrial cancer in patients with a preoperative ambiguous or inconclusive diagnoses: our experience
Background
The aim of this study was to assess the agreement rate between intraoperative evaluation (IOE) and final diagnosis (FD) in a series of surgically resected endometrial carcinoma (EC), with a preoperative ambiguous or inconclusive diagnosis by endometrial biopsies and imaging.
Methods
A retrospective study was performed selecting patients who underwent surgery with IOE for suspected EC at our institution from 2012 to 2018. A K coefficient was determined with respect to the histotype, tumor grade, myometrial infiltration and cervical involvement.
Results
Data analysis has been performed on 202 women. The IOE evaluation was distributed as Endometrioid (
n
= 180) and Non-Endometrioid (
n
= 22). The comparison between the frozen section (FS) and the definitive histological subtype showed an overall agreement rate of 93,07% (k = 0.612) and an agreement of 97.2% for Endometrioid vs 59% for Non-Endometrioid tumors. The FIGO system grading was the same in 91,1% of patients, none was upgraded and in 8,9% downgraded. Observed agreements were 89,11% and 95,54% for myometrial and cervical involvement, respectively.
Conclusions
The good agreement between intraoperative grading, myometrial invasion and their histological definition on permanent sections highlights that FS is a good predictor for surgical outcome, in particular in presence of a preoperative ambiguous or inconclusive diagnostic evaluation.
Journal Article
Robotic Single-Port Platform in General, Urologic, and Gynecologic Surgeries: A Systematic Review of the Literature and Meta-analysis
Background
Robotic platforms have recently acquired progressive importance in different surgical fields, such as urology, gynecology, and general surgery. Through the years, new surgical robots have become available as single-port robotic platform. The study is aimed to value the single-port robotic platform characteristics in different surgical specialties.
Methods
The terms “LESS” OR “single port” OR “single site” AND “robot” OR “robotic” were systematically used to search the PubMed and Scopus databases. A total of 57 studies were considered eligible for the present review. The articles included were divided according to the surgical field in which the study was conducted: General surgery (29 articles), Gynecology (18 articles), Urology (10 articles).
Results
Most part of the articles showed the feasibility of robotic single-port surgical procedures and described advantages in terms of cosmetic, hospital stay, and in some series even cost reduction. A meta-analysis was conducted, showing a significant increment of complications using RSP if compared with SLPS and a trend (
P
= 0.008) when RSP was compared with LESS. The comparison of different techniques in terms of conversion to laparotomy did not show any significant difference.
Conclusion
Robotic single port potentially furnishes an important surgical and post-operatory improvement; however, some limits still prolong the surgical time and complication rate.
Journal Article
Minimally Invasive Approaches in Locally Advanced Cervical Cancer Patients Undergoing Radical Surgery After Chemoradiotherapy: A Propensity Score Analysis
PurposeChemoradiation (CT/RT) followed by radical surgery (RS) may play a role in locally advanced cervical cancer (LACC) patients with suboptimal response to CT/RT or in low-income countries with limited access to radiotherapy. Our aim is to evaluate oncological and surgical outcomes of minimally invasive radical surgery (MI-RS) compared with open radical surgery (O-RS).Patients and MethodsData for stage IB2–IVA cervical cancer patients managed by CT/RT and RS were retrospectively analyzed.ResultsBeginning with 686 patients, propensity score matching resulted in 462 cases (231 per group), balanced for FIGO stage, lymph node status, histotype, tumor grade, and clinical response to CT/RT. The 5-year disease-free survival (DFS) was 73.7% in the O-RS patients and 73.0% in the MI-RS patients (HR 1.034, 95% CI 0.708–1.512, p = 0.861). The 5-year locoregional recurrence rate was 12.5% (O-RS) versus 15.2% (MI-RS) (HR 1.174, 95% CI 0.656–2.104, p = 0.588). The 5-year disease-specific survival (DSS) was 80.4% in O-RS patients and 85.3% in the MI-RS group (HR 0.731, 95% CI 0.438–1.220, p = 0.228). Estimated blood loss was lower in the MI-RS group (p < 0.001), as was length of hospital stay (p < 0.001). Early postoperative complications occurred in 77 patients (33.3%) in the O-RS group versus 88 patients (38.1%) in the MI-RS group (p = 0.331). Fifty-six (24.2%) patients experienced late postoperative complications in the O-RS group, versus 61 patients (26.4%) in the MI-RS group (p = 0.668).ConclusionMI-RS and O-RS are associated with similar rates of recurrence and death in LACC patients managed by surgery after CT/RT. No difference in early or late complications was reported.
Journal Article
A Treatment Selection Protocol for Recurrent Ovarian Cancer Patients: The Role of FDG-PET/CT and Staging Laparoscopy
Objective: To investigate the best diagnostic and staging strategy for recurrent ovarian cancer. Methods: The negative predictive value, specificity, positive predictive value, sensitivity, and accuracy rates of the fluorine-18-fluorodeoxyglucose positive emission tomography computed tomography (FDG-PET/CT) and staging laparoscopy in identifying surgically treatable/untreatable patients are assessed in a consecutive series of 70 recurrent ovarian cancer cases. Moreover, the diagnostic performance of each staging procedure in the evaluation of the number of nodules is analyzed. Results: The negative predictive value of the FDG-PET/CT was 83.3%, whereas the positive predictive value was 76.9%. Specificity was 55.6%, whereas sensitivity was 93.0%. Accuracy rate was 78.6%. Negative predictive value, specificity, positive predictive value, sensitivity, and accuracy rate of staging laparoscopy were 88.9, 64.0, 80.8, 95.0 and 83.1%, respectively. Combined radiological and laparoscopic evaluation showed a negative predictive value of 88.9%, a specificity of 59.3%, a positive predictive value of 78.8%, a sensitivity of 95.3%, and an accuracy rate of 81.4%. The number of nodules identified by FDG-PET/CT corresponded in only 23 patients (40.3%) at laparotomy, whereas 15 of 30 patients were correctly diagnosed (50.0%) by staging laparoscopy. Conclusions: The combination of FDG-PET/CT and staging laparoscopy has a significant effect on the multimodal approach to the population of patients with recurrent ovarian cancer. Such techniques should be considered complementary, because of the potential of each one to identify a different setting of the disease.
Journal Article
Is the sarcomatous component (homologous vs heterologous) the prognostic “driving force” in early-stage uterine carcinosarcomas? A retrospective multicenter study
Purpose
Uterine carcinosarcomas (UCSs) are aggressive biphasic malignancies, with a carcinomatous/epithelial component and a sarcomatous/mesenchymal counterpart. The aim of this study was to evaluate the impact of the sarcomatous component (homologous vs heterologous) on the overall survival (OS) and progression-free survival (PFS).
Methods
This is a multicenter observational retrospective study conducted in patients with stage I and II UCSs.
Results
Ninety-five women with histological diagnosis of early-stage UCSs were retrieved: 60 (63.2%) had tumors with homologous sarcomatous components, and 35 (36.8%) with heterologous. At univariate analysis, a stromal invasion ≥ 50%, the presence of clear cell, serous or undifferentiated carcinomatous component, the heterologous sarcomatous component and FIGO stage IB and II were shown to be variables with a statistically significant negative impact on PFS. Similarly, a depth of invasion ≥ 50%, the heterologous sarcomatous component and FIGO stage IB and II were statistically negative prognostic factors also concerning OS. At multivariate analysis, only the heterologous sarcomatous component was confirmed to be a statistically significant negative prognostic factor both on PFS (HR 2.362, 95% CI 1.207–4.623,
p
value = 0.012) and on OS (HR 1.950, 95% CI 1.032–3.684,
p
= 0.040).
Conclusion
Carcinomatous and sarcomatous components both played a role in tumor progression and patients’ survival. However, only the sarcomatous component retained a statistical significance at the multivariable model suggesting its preeminent prognostic role in early-stage UCSs.
Journal Article
827 How to do retroperitoneal en bloc posterior pelvic exenteration in advanced ovarian cancer: Hudson-Dellepiane procedure in 10 steps
Introduction/Background*The aim of cytoreduction in advanced ovarian cancer is complete removal of gross disease. Retroperitoneal approach is crucial in radical surgery for advanced ovarian cancer. Hudson-Delle Piane is a radical procedure which allows en-bloc removal of uterus, ovaries, pouch of Douglas peritoneum, recto-sigmoid with a retrograde approach in cases where recto-simoid sparing is not an option.MethodologyWe present an educational video on how to perform retroperitoneal en bloc posterior pelvic exenteration in advanced ovarian cancer with a step-by-step procedure. The patient was a 52-year-old woman, with body mass index of 21.1 who presented with abdominal pain and distension; the CT-scan showed peritoneal carcinomatosis. The different phases of the Fagotti’s score performed at diagnostic laparoscopy to triage for the operability, are demonstrated. The Vizzielli’s score was used to determine the risk of post-operative complications in case of primary debulking surgery is also presented.Result(s)*Immediately after the diagnostic laparoscopy a conversion to laparotomy with a cytoreductive surgery was performed. The Hudson-Delle Piane technique is demonstrated in 10 steps. The surgery lasted 360 minutes and the estimated blood loss was 400 ml. No peri-operative complication was recorded. The histology revealed a FIGO stage IIIC high-grade serous ovarian cancer.Conclusion*The present video demonstrates that retroperitoneal approach to advanced ovarian cancer with high volume pelvic disease, allows en bloc tumor debulking with safe handling of important structures.
Journal Article
SF021/#830 Minimally invasive secondary cytoreductive surgery for hepato-renal recess isolated recurrence of serous endometrial cancer in brca1 mutated patient
IntroductionThis film shows the surgical management of a young BRCA1 mutated women affected by a recurrence of serous endometrial carcinoma (SEC). This aggressive subtype of endometrial cancer recurs in 30–80% of cases and shares most of its molecular features with serous ovarian cancer. The role of BRCA mutations in this setting is still not completely understood. The aim of this film was to show how a minimal invasive surgical approach is safe and feasible in selected patients.DescriptionIn the video we present the case of a hepato-renal recess isolated recurrence of serous endometrial carcinoma. Patient positioning and port placement were critical to achieve an optimal exposure of the liver 6th segment and the Morison’s pouch. An extensive removal of visceral adhesions was performed and the metastasis was then exposed. The tumor infiltrated the liver parenchyma for less than 2 cm. A superficial wedge resection was executed until complete removal of the lesion. The procedure has been performed in 90 minutes. Post-operative course was unremarkable and the patient was discharged on post-operative day 3. The patient was able to resume her oral PARP inhibitor after 10 days. Histopathology report confirmed the metastatic localization of a high-grade serous cancer.ConclusionsPotential benefits of minimally invasive approach include reduced blood loss, less pain, faster recovery and a short interval to chemotherapy. The personalised treatment of recurrent endometrial serous cancer should be guided by the molecular pattern of the disease and by the surgical skills with a multidisciplinary approach. video: https://www.dropbox.com/s/glhyzjy7na5l0ls/MINIMALLY%20INVASIVE%20SECONDARY%20CYTOREDUCTIVE%20SURGERY%20FOR%20HEPATORENAL%20RECESS%20ISOLATED%20RECURRENCE%20OF%20SEROUS%20ENDOMETRIAL%20CANCER%20IN%20BRCA1%20MUTATED%20PATIENT.mp4?dl=0
Journal Article
Timing and Pattern of Recurrence in Ovarian Cancer Patients with High Tumor Dissemination Treated with Primary Debulking Surgery Versus Neoadjuvant Chemotherapy
Purpose
To compare the timing and pattern of recurrence in patients with advanced ovarian cancer (AOC) receiving primary debulking surgery (PDS) versus neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS).
Methods
We retrospectively evaluated a consecutive series of 175 stage IIIC–IV epithelial ovarian cancer patients, with diffuse peritoneal carcinomatosis documented at initial surgical exploration. Forty patients received complete PDS, and the remaining 135 were treated with NACT followed by IDS with absent residual tumor after surgery.
Results
No differences were observed in the distribution of clinical pathological characteristics at the time of diagnosis between the two groups. The median follow-up was 31 months (range 9–150 months). We observed 20 (50.0 %) recurrences in the PDS group compared to 103 (76.3 %) in the IDS group (
p
= 0.001). Duration of primary platinum-free interval (PFI) was shorter in IDS compared to PDS group (13 vs. 21 months, respectively;
p
= 0.014). A significantly higher percentage of patients in the IDS group experienced platinum-resistant recurrences (35.9 vs. 5.0 %;
p
= 0.006) and carcinomatosis at the time of relapse (57.3 vs. 20.0 %;
p
= 0.0021). Finally, in women with platinum-sensitive recurrence, we observed a shorter secondary PFI in the IDS compared to PDS group (
p
= 0.006).
Conclusions
We documented a better behavior of recurrent disease in AOC patients with diffuse peritoneal carcinomatosis treated with complete PDS compared to women submitted to NACT followed by IDS with no residual tumor after surgery.
Journal Article
806 Impact of obesity on sentinel lymph-node mapping in patients with apparent early-stage endometrial cancer: a propensity-matched multicenter study
Introduction/Background*Obese patients pose both surgical and anesthetic challenges, as their comorbidities contribute to adverse outcomes.In this setting, minimally invasive approach and the introduction of the Sentinel Lymph-Node (SLN) algorithm in endometrial cancer (EC) treatment acquire a particular relevance, allowing to reduce both operative times and surgical difficulties.However, conflicting data exists on the impact of Body Mass Index (BMI) on SLN detection.The primary study endpoint was to investigate the impact of obesity on overall detection rate, bilateral mapping, and mapping failure rate. In addition, we evaluated possible differences in terms of surgical management and ‘empty packet dissection’ rate among the two study groups.MethodologyMulticenter, propensity-matched, retrospective study.Data of patients with apparently early-stage EC were retrospectively retrieved. Study population was divided into women with BMI
Journal Article
387 Developing and validating ultrasound-based radiomics models for predicting high-risk endometrial cancer
Introduction/Background*Transvaginal ultrasound examination is the first imaging investigation for endometrial cancer. Ultrasound-based models for predicting high risk endometrial cancer have recently been published. However, none of these models includes radiomics features. Radiomics is an innovative high throughput technique extracting and translating high numbers of features from medical images into mineable data.Aim of this study was to develop and validate ultrasound-based radiomics models, aiming to differentiating high risk category, as defined by ESMO-ESGO-ESTRO in 2016, versus the remaining categories of risk.MethodologyThis is a multicenter retrospective observational study. Patients with histologically confirmed diagnosis of endometrial cancer who had undergone preoperative ultrasound examination between 2016 and 2019 were identified from two centers. Patients recruited in Center 1 (Rome) were included as ‘training set’ (n=396), while patients enrolled in Center 2 (Milan), as ‘external validation set’ (n=102). Radiomics analysis was applied to the ultrasound images. Clinical (including preoperative biopsy), ultrasound and radiomics features that proved to be different at the univariate analysis on the training set were considered for multivariate analysis and for developing ultrasound-based machine learning assessment models.Result(s)*For discriminating high risk category versus the other categories one random forest model from the radiomics features (radiomics model), one binary logistic regression model from clinical and ultrasound features (clinical-ultrasound model), and another binary logistic regression model from clinical, ultrasound and previously selected radiomics features (mixed model) were created.In the validation set, the radiomics model for predicting high risk showed AUC 0.80, sensitivity 58.7%, specificity 85.7%, positive likelihood ratio (LR+) 4.10 and negative likelihood ratio (LR-) 0.48; the clinical-ultrasound model showed AUC 0.87, sensitivity 67.3%, specificity 89.2%, LR+ 6.29 and LR- 0.37; and the mixed model showed AUC 0.88, sensitivity 67.3%, specificity 91.0%, LR+ 7.55 and LR- 0.36 (table 1).Abstract 387 Table 1Logistic regression models for discriminating high risk group versus other three groups, and low risk group versus the other risk groups for validation set. Predictive Models Optimal cut-off AUC estimate (95% CI ) Sensitivity (%) (95% CI ) Specificity (%) (95% CI ) Accuracy (%) (95% CI ) PPV (%) (95% CI ) NPV (%) (95% CI ) LR+ (95% CI ) LR- (95% CI ) TP (n) TN (n) FN (n) FP (n) Total (n) Radiomics model to predict low risk 0.38 0.71 (0.61 – 0.81) 65.0 (49.6 – 78.3) 64.5 (52.2 – 75.5) 64.7 (55.1 – 73.5) 54.2 (40.2 -67.7) 74.1 (61.3 – 84.3) 1.83 (1.22 – 2.75) 0.54 (0.34 – 0.86) 26 40 14 22 102 Clinical-ultrasound model to predict low risk 0.46 0.85 (0.78 – 0.92) 70.0 (54.7 – 82.4) 80.6 (69.5 – 88.9) 76.4 (67.0 – 84.3) 70.0 (54.7– 82.4) 80.6 (69.5 – 88.9) 3.62 (2.09 – 6.25) 0.37 (0.23 – 0.61) 28 50 12 12 102 Mixed model to predict low risk 0.36 0.85 (0.80 – 0.93) 87.5 (74.7 – 95.0) 72.5 (60.6 – 82.4) 78.4 (69.1 – 85.9) 67.3 (53.8 – 78.8) 90.0 (79.4 – 96.0) 3.19 (2.09 – 4.86) 0.17 (0.0 – 0.40) 35 45 5 17 102 Radiomics model to predict high risk 0.41 0.80 (0.70 – 0.88) 58.7 (44.3 – 72.0) 85.7 (74.8 – 93.0) 73.5 (64.4 – 81.3) 77.1 (61.5 – 88.6) 71.6 (60.1 -81.4) 4.10 (2.12 – 7.96) 0.48 (0.33 – 0.71) 27 48 19 8 102 Clinical-ultrasound model to predict high risk 0.40 0.87 (0.81 – 0.94) 67.3 (53.1 – 79.5) 89.2 (78.5 – 95.0) 79.4 (70.2 – 86.7) 83.7 (68.8 – 92.3) 76.9 (65.3 -85.4) 6.29 (2.88 – 14.0) 0.37 (0.24 – 0.56) 31 50 15 6 102 Mixed model to predict high risk 0.42 0.88 (0.81 – 0.93) 67.3 (52.9 – 79.1) 91.0 (80.7 – 96.1) 80.3 (71.3 – 87.5) 86.1 (71.3 – 93.9) 77.2 (65.8 – 85.7) 7.55 (3.19 – 18.0) 0.36 (0.23 – 0.55) 31 51 15 5 102 AUC, area under the receiver-operating characteristics curve; LR+, positive likelihood ratio; LR-, negative likelihood ratio; NPV, negative predictive value; PPV, positive predictive value; TN, true negatives; TP, true positives, FN, false negatives; FP, false positives. Radiomics model is a model generated from radiomics features. Clinical-ultrasound model is a model generated from clinical and ultrasound features. Mixed model is a model generated from clinical, ultrasound and radiomics features.Conclusion*The mixed model including radiomics, clinical (including preoperative biopsy) and ultrasound features provided the best performance, even if the accuracy was slightly higher in comparison with the model based only on clinical and ultrasound variables. Interestingly, the model based only on radiomics features was able to provide good accuracy to discriminate high risk group versus the others.
Journal Article