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European Journal of Surgical Oncology :... Jun 2024Cervical cancer is a global public health concern. Despite ESGO recommendations and FIGO classification changes, management of locally advanced cervical cancer (LACC)...
INTRODUCTION
Cervical cancer is a global public health concern. Despite ESGO recommendations and FIGO classification changes, management of locally advanced cervical cancer (LACC) remains debated in France. Our study aimed to review LACC treatment practices and assess adherence to ESGO recommendations among different practitioners.
METHODS
From February 2021 to August 2022, we conducted a survey among gynecologic oncology surgeons, radiation oncologists, and medical oncologists practicing in France and managing LACC (FIGO stages IB3-IVA) according to the 2018 FIGO classification. We analyzed responses against the 2018 ESGO recommendations as a "gold standard."
RESULTS
Among 115 respondents (56% radiation oncologists, 30% surgeons, 13% medical oncologists), 48.6% of gynecologic surgeons didn't perform para-aortic lymphadenectomy (PAL) with significant radiologic pelvic involvement. PAL, when indicated by PET-CT, was more common in university hospitals (66.7% of surgeons). Surgeons in university hospitals also followed ESGO recommendations more closely. Overall, compliance with all ESGO recommendations was low: 5.7% of surgeons, 21.5% of radiation oncologists, and 60% of medical oncologists. Prophylactic para-aortic irradiation, per ESGO, was more frequent in comprehensive cancer centers (52% of radiation oncologists).
CONCLUSION
Adherence to ESGO recommendations for LACC treatment appears low in France, particularly in surgery, with limited PAL in cases of lymph node negativity on PET-CT. However, these recommendations are more often followed by surgeons in university hospitals and radiation oncologists in cancer centers. Adherence to these recommendations may impact patient survival and warrants evaluation of care quality, justifying the organization of LACC management in expert centers.
Topics: Humans; Female; Uterine Cervical Neoplasms; Lymph Node Excision; France; Guideline Adherence; Practice Patterns, Physicians'; Neoplasm Staging; Practice Guidelines as Topic; Positron Emission Tomography Computed Tomography; Oncologists; Radiation Oncologists; Patient Care Team; Surgeons; Surveys and Questionnaires
PubMed: 38642512
DOI: 10.1016/j.ejso.2024.108281 -
Gynecologic Oncology Reports Jun 2024Cervical stump malignancies are an uncommon finding post subtotal hysterectomy. Tumors arise from a primary cervical origin with an incidence of 1-5%. Other described...
BACKGROUND
Cervical stump malignancies are an uncommon finding post subtotal hysterectomy. Tumors arise from a primary cervical origin with an incidence of 1-5%. Other described malignancies can include uterine origin, ovarian origin or as metastases from another primary site. A uterine primary is an extremely rare entity and can result from remnant endometrial tissue at the stump apex.
CASE
70yo female with a history of remote supracervical hysterectomy for benign indication who presented with postmenopausal spotting. Endocervical curettage of the endocervical stump revealed a grade 2 endometrioid endometrial adenocarcinoma. She was taken to the operating for a robotic radical stump trachelectomy and sentinel lymph node dissection.
CONCLUSIONS
The surgical video delineates key surgical steps of robotic radical stump trachelectomy including robotic port placement and injection of ICG dye, adhesiolysis and restoration of normal anatomy, opening of the pelvic spaces and exposure of the retroperitoneum, identification and excision of pelvic sentinel lymph nodes, bladder dissection, ureterolysis and ligation of uterine remnant, ureteric tunnel dissection and mobilization of parametrial wing, delineation of a vaginal margin, colpotomy and specimen removal, and vaginal cuff closure.
PubMed: 38633672
DOI: 10.1016/j.gore.2024.101384 -
Journal of Robotic Surgery Apr 2024Lymphocele is one of the most common complications after radical prostatectomy. Multiple authors have proposed the use of vessel sealants or peritoneal interposition... (Meta-Analysis)
Meta-Analysis
Comparison of peritoneal interposition flaps and sealants for prevention of lymphocele after robotic radical prostatectomy and pelvic lymph node dissection: a systematic review, meta-analysis, Bayesian network meta-analysis, and meta-regression.
Lymphocele is one of the most common complications after radical prostatectomy. Multiple authors have proposed the use of vessel sealants or peritoneal interposition techniques as preventive interventions. This study aimed to aggregate and analyze the available literature on different interventions which seek to prevent lymphocele through a Bayesian Network. A systematic review was performed to identify prospective studies evaluating strategies for lymphocele prevention after robot assisted laparoscopic prostatectomy + pelvic lymph node dissection. Data was inputted into Review Manager 5.4 for pairwise meta-analysis. Data was then used to build a network in R Studio. These networks were used to model 200,000 Markov Chains via MonteCarlo sampling. The results are expressed as odds ratios (OR) with 95% credible intervals (CrI). Meta-regression was used to determine coefficient of change and adjust for pelvic lymph node dissection extent. Ten studies providing data from 2211 patients were included. 1097 patients received an intervention and 1114 patients served as controls. Interposition with fenestration had the lowest risk of developing a lymphocele (OR 0.14 [0.04, 0.50], p = 0.003). All interventions, except sealants or patches, had significant decreased odds of lymphocele rates. Meta-analysis of all the included studies showed a decreased risk of developing a lymphocele (OR 0.42 [0.33, 0.53], p < 0.00001) for the intervention group. Perivesical fixation and interposition with fenestration appear to be effective interventions for reducing the overall incidence of lymphocele.
Topics: Humans; Male; Bayes Theorem; Lymph Node Excision; Lymphocele; Network Meta-Analysis; Prospective Studies; Prostatectomy; Robotic Surgical Procedures
PubMed: 38630430
DOI: 10.1007/s11701-024-01918-6 -
Minerva Obstetrics and Gynecology Apr 2024Uterine leiomyosarcoma is a rare malignant gynecologic tumor that arises from the myometrial or endometrial stromal precursor cells. This tumor has the highest...
Uterine leiomyosarcoma is a rare malignant gynecologic tumor that arises from the myometrial or endometrial stromal precursor cells. This tumor has the highest prevalence in the pre- and post-is more frequent between 40 and 60 years old. It has a very unfavorable prognosis: only early-stage tumors have an acceptable prognosis; unfortunately, it is often diagnosed accidentally, typically on an advanced stage, when hematological metastases have already spread. Surgery is the main treatment strategy, while systemic treatment and radiotherapy are not recommended due to the lack of results. Since metastatization is mainly hematological, lymphadenectomy is not recommended. Recent progresses have been achieved in advanced and recurrent disease, often inoperable, thanks to new chemotherapies, target therapies and immunotherapies. We reported the case of a 51-year-old woman evaluated for lumbar pain in the right region compatible with renal colic. The ultrasound evaluation revealed right hydronephrosis and the presence of a paraovarian or intraligamentary mass compatible with fibroma. The abdominal CT confirmed the presence of a mass with heterogeneous vascularization. Therefore, the patient underwent laparoscopic surgery to remove the lesion which resulted to be a leiomyosarcoma G2. During the following week the patient underwent a laparoscopic hysterectomy. The first step for differential diagnosis consists in the evaluation of clinicopathological features, followed by the analysis of preoperative imaging. Pelvic MRI represents the gold standard, while CT is used to detect metastases. The main issue is that imaging shows limited ability in differential diagnosis between benign and malign smooth muscle tumor. The definitive diagnosis is confirmed by histological analysis; this implies the necessity of improved attentions on the surgical procedure, which is often performed by steps with prolongation of the treatment pathway. To distinguish which fibroids presents a major risk to be misdiagnosed, some risk scores were developed (rPRESS in 2014 and pLMS in 2019), though actually they are not applied in clinical practice. Uterine leiomyosarcoma (uLMS) is rare but causes several deaths in perimenopausal women due to lack of effective treatments, although target therapies represent a future hope. Furthermore, clinical practice needs support through the development and improvement of diagnostic risk scores and their integration into guidelines.
Topics: Female; Humans; Middle Aged; Adult; Leiomyosarcoma; Uterine Neoplasms; Leiomyoma; Hysterectomy; Pelvic Neoplasms
PubMed: 38624194
DOI: 10.23736/S2724-606X.22.05131-4 -
Surgical Case Reports Apr 2024The majority of small bowel obstructions (SBO) are caused by adhesion due to abdominal surgery. Internal hernias, a very rare cause of SBO, can arise from exposed blood...
BACKGROUND
The majority of small bowel obstructions (SBO) are caused by adhesion due to abdominal surgery. Internal hernias, a very rare cause of SBO, can arise from exposed blood vessels and nerves during pelvic lymphadenectomy (PL). In this report, we present two cases of SBO following laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer, one case each, of which obstructions were attributed to the exposure of blood vessels and nerves during the procedures.
CASE PRESENTATION
Case 1: A 68-year-old man underwent laparoscopic perineal rectal amputation and LLND for rectal cancer. Four years and three months after surgery, he visited to the emergency room with a chief complaint of left groin pain. Computed tomography (CT) revealed a closed-loop in the left pelvic cavity. We performed an open surgery to find that the small intestine was fitted into the gap between the left obturator nerve and the left pelvic wall, which was exposed by LLND. The intestine was not resected because coloration and peristalsis of the intestine improved after the hernia was released. The obturator nerve was preserved. Case 2: A 57-year-old man underwent a robot-assisted rectal amputation with LLND for rectal cancer. Eight months after surgery, he presented to the emergency room with a complaint of abdominal pain. CT revealed a closed-loop in the right pelvic cavity, and he underwent a laparoscopic surgery with a diagnosis of strangulated SBO. The small intestine was strangulated by an internal hernia caused by the right umbilical arterial cord, which was exposed by LLND. The incarcerated small intestine was released from the gap between the umbilical arterial cord and the pelvic wall. No bowel resection was performed. The umbilical arterial cord causing the internal hernia was resected.
CONCLUSION
Although strangulated SBO due to an exposed intestinal cord after PL has been a rare condition to date, it is crucial for surgeons to keep this condition in mind.
PubMed: 38619675
DOI: 10.1186/s40792-024-01889-8 -
Zhonghua Nan Ke Xue = National Journal... Jul 2023To investigate the safety and efficacy of the two-channel dilatation procedure for subcutaneous tunneling in the lower abdomen during pelvic lymph node dissection for...
OBJECTIVE
To investigate the safety and efficacy of the two-channel dilatation procedure for subcutaneous tunneling in the lower abdomen during pelvic lymph node dissection for penile cancer.
METHODS
A retrospective analysis was conducted on the clinical data of 6 patients treated from January 2020 to December 2022 using the dual-channel expansion technique for penile cancer lymph node dissection.
RESULTS
All 6 cases ( 12 sides) successfully underwent prophylactic inguinal lymph node dissection. The average laparoscopic dissection time was ( 82.50 ± 12.08) minutes per side, with an average blood loss of (28.33 ± 10.95) ml. The number of lymph nodes dissected was (11.16 ± 1.02) for the superficial group and ( 0.67 ± 0.74 ) for the deep group. Postoperative pathology was negative in all cases. The average postoperative hospital stay was (7.33 ± 1.60 ) days, with a catheter removal time of (12.00 ± 2.06)days. Postoperative complications included abnormal skin sensations in 5 sides, lower limb edema in 3 sides, lymphedema in 3 sides, and cellulitis in 1 side. During a follow-up period of (20.60 ± 12.51)months, there were no instances of tumor recurrence or metastasis in the inguinal region among the patients.
CONCLUSION
The dual-channel expansion technique for inguinal lymph node dissection via a subcutaneous tunnel is a safe and feasible treatment for penile cancer. It has a low complication rate, allows for thorough dissection of inguinal lymph nodes, and offers advantages in terms of surgical time.
Topics: Humans; Male; Penile Neoplasms; Retrospective Studies; Neoplasm Recurrence, Local; Abdomen; Lymph Node Excision
PubMed: 38619414
DOI: No ID Found -
Annals of Surgical Oncology Jul 2024We demonstrate the surgical technique of removing the sentinel lymph nodes with its afferent lymphatic vessels attached to the hysterectomy specimen.
OBJECTIVE
We demonstrate the surgical technique of removing the sentinel lymph nodes with its afferent lymphatic vessels attached to the hysterectomy specimen.
DESIGN
Stepwise demonstration of the technique with narrated video footage.
SETTING
Sentinel lymph node sampling has been established as an acceptable staging method in endometrial cancer cases. Lymphatic anatomy has been described according to three consistent channels for endometrial cancer dissemination: (1) an upper paracervical pathway draining external or obturator lymph nodes; (2) a lower pathway draining internal iliac lymph nodes; and (3) the infundibulo-pelvic pathway with a course along the broad ligament. A study in patients with cervical cancer identified tumor cells in the afferent lymphatic vessels of the upper pathway, even when the corresponding sentinel node was negative (3/20 patients). This could be an important prognostic factor in patients with cervical cancer. Since the typical position of sentinel nodes is the same in both endometrial and cervical cancers, we aimed to assess the feasibility of removing 'en bloc' the sentinel node with its afferent lymphatic vessels, and the uterus. INTERVENTIONS: The Da Vinci Xi surgical system was used. Indocyanine green was injected cervically, the pelvic surgical spaces were developed, and the sentinel lymph nodes, along with the afferent lymphatic vessels, were identified using the Firefly infrared camera. The lymphovascular tissue was mobilized and separated from the uterine artery, which was skeletonized and ligated. Colpotomy was performed and the specimen was retrieved vaginally.
DISCUSSION
Emerging evidence regarding diagnosis, characterization, and treatment of endometrial cancer has introduced a new era, based on minimally invasive techniques for staging through sentinel lymph node biopsy, molecular classification, and personalized treatment algorithms that include immune checkpoint inhibitors and targeted therapies. Lymph node staging is one of the most significant prognostic factors in endometrial cancer patients and is a guide for adjuvant treatment. Sentinel lymph node biopsy is not inferior to conventional lymphadenectomy and is in fact a better way of identifying low-volume cancer through the use of ultrastaging, as part of the sentinel node algorithm. The dissection technique described in this video could offer an improvement in the staging of endometrial cancer, ensuring that the true sentinel lymph node is identified and that potential cancer cells inside the afferent lymphatic vessels are also excised. Therefore, it could be utilized as a more accurate way of planning adjuvant treatment and consequently improving recurrence and survival; however more studies are needed to further evaluate the feasibility and sensitivity of identifying disease in the afferent lymphatic vessels.
CONCLUSION
This novel surgical technique emphasizes the importance of anatomical knowledge and offers inspiration for studies with potential clinical benefit that should follow.
Topics: Humans; Female; Endometrial Neoplasms; Hysterectomy; Sentinel Lymph Node Biopsy; Sentinel Lymph Node; Prognosis; Lymph Node Excision; Indocyanine Green; Robotic Surgical Procedures; Lymphatic Vessels
PubMed: 38615152
DOI: 10.1245/s10434-024-15234-8 -
Cancers Apr 2024We aimed to determine whether surgical aortic staging by minimally invasive paraaortic lymphadenectomy (PALND) affects the pattern of first recurrence and survival in...
BACKGROUND
We aimed to determine whether surgical aortic staging by minimally invasive paraaortic lymphadenectomy (PALND) affects the pattern of first recurrence and survival in treated locally advanced cervical cancer (LACC) patients when compared to patients staged by imaging (noPALND).
METHODS
This study was a multicenter observational retrospective cohort study of patients with LACC treated at tertiary care hospitals throughout Spain. The inclusion criteria were histological diagnosis of squamous carcinoma, adenosquamous carcinoma, and/or adenocarcinoma; FIGO stages IB2, IIA2-IVA (FIGO 2009); and planned treatment with primary chemoradiotherapy between 2000 and 2016. Propensity score matching (PSM) was performed before the analysis.
RESULTS
After PSM and sample replacement, 1092 patients were included for analysis (noPALND n = 546, PALND n = 546). Twenty-one percent of patients recurred during follow-up, with the PALND group having almost double the recurrences of the noPALND group (noPALND: 15.0%, PALND: 28.0%, < 0.001). Nodal (regional) recurrences were more frequently observed in PALND patients (noPALND:2.4%, PALND: 11.2%, < 0.001). Among those who recurred regionally, 57.1% recurred at the pelvic nodes, 37.1% recurred at the aortic nodes, and 5.7% recurred simultaneously at both the pelvic and aortic nodes. Patients who underwent a staging PALND were more frequently diagnosed with a distant recurrence (noPALND: 7.0%, PALND: 15.6%, < 0.001). PALND patients presented poorer overall, cancer-specific, and disease-free survival when compared to patients in the noPALND group.
CONCLUSION
After treatment, surgically staged patients with LACC recurred more frequently and showed worse survival rates.
PubMed: 38611101
DOI: 10.3390/cancers16071423 -
Journal of Medical Case Reports Apr 2024Total pelvic exenteration is the ultimate solution for rectovesicovaginal fistula caused by radiation therapy, yet total pelvic exenteration frequently causes...
The effect of physical therapy and mechanical stimulation on dysfunction of lower extremities after total pelvic exenteration in cervical carcinoma patient with rectovesicovaginal fistula induced by radiotherapy: a case report.
BACKGROUND
Total pelvic exenteration is the ultimate solution for rectovesicovaginal fistula caused by radiation therapy, yet total pelvic exenteration frequently causes intraoperative complications and postoperative complications. These complications are responsible for the dysfunction of lower extremities, impaired quality of life, and even the high long-term morbidity rate, thus multidisciplinary cooperation and early intervention for prevention of complications are necessary. Physical therapy was found to reduce the postoperative complications and promote rehabilitation, yet the effect on how physiotherapy prevents and treats complications after total pelvic exenteration and pelvic lymphadenectomy remains unclear.
CASE PRESENTATION
A 50-year-old Chinese woman gradually developed perianal and pelvic floor pain and discomfort, right lower limb numbness, and involuntary vaginal discharge owing to recurrence and metastasis of cervical cancer more than half a year ago. Diagnosed as rectovesicovaginal fistula caused by radiation, she received total pelvic exenteration and subsequently developed severe lower limb edema, swelling pain, obturator nerve injury, and motor dysfunction. The patient was referred to a physiotherapist who performed rehabilitation evaluation and found edema in both lower extremities, right inguinal region pain (numeric pain rate scale 5/10), decreased temperature sensation and light touch in the medial thigh of the right lower limb, decreased right hip adductor muscle strength (manual muscle test 1/5) and right hip flexor muscle strength (manual muscle test 1/5), inability actively to adduct and flex the right hip with knee extension, low de Morton mobility Index score (0/100), and low Modified Barthel Index score (35/100). Routine physiotherapy was performed in 2 weeks, including therapeutic exercises, mechanical stimulation and electrical stimulation as well as manual therapy. The outcomes showed that physiotherapy significantly reduced lower limb pain and swelling, and improved hip range of motion, motor function, and activities of daily living, but still did not prevent thrombosis.
CONCLUSION
Standardized physical therapy demonstrates the effect on postoperative complications after total pelvic exenteration and pelvic lymphadenectomy. This supports the necessity of multidisciplinary cooperation and early physiotherapy intervention. Further research is needed to determine the causes of thrombosis after standardized intervention, and more randomized controlled trials are needed to investigate the efficacy of physical therapy after total pelvic exenteration.
Topics: Female; Humans; Middle Aged; Activities of Daily Living; Pelvic Exenteration; Quality of Life; Uterine Cervical Neoplasms; Lower Extremity; Physical Therapy Modalities; Pelvic Pain; Edema; Postoperative Complications; Thrombosis
PubMed: 38610054
DOI: 10.1186/s13256-024-04516-0