Evaluation de modèles pour prédire l’envahissement de 4 ganglions métastatiques ou plus chez les patientes atteintes d’un cancer du sein T1-T2 avec 1 à 3 ganglions sentinelles positifs

Contexte : plusieurs modèles mathématiques existent pour prédire l’atteinte de 4 ganglions métastatiques ou plus dans les cancers du sein avec métastases du ganglion sentinelle (GS) : le score de Louisville, et les nomogrammes de Katz et de Helsinki. L’envahissement de plus de 3 ganglions est un élément important dans la décision de curage axillaire complémentaire et d’utilisation des tests génomiques. Objectif : évaluation des 3 scores et nomogrammes sur la population de l’étude NOTEGS afin de prédire les patientes ayant 4 ganglions métastatiques ou plus. Méthodes : cette étude prospective multicentrique incluait 3157 patientes atteintes d’un cancer du sein invasif T1-2 et ayant au moins un GS positif. La validation des 3 scores était évaluée par le calcul de la discrimination, de la calibration, du taux de faux positifs et négatifs, des sensibilités et spécificités. Résultats : parmi les 2936 patientes analysables, 502 avaient entre 1 et 3 GS positifs et ont eu un curage axillaire complémentaire. Parmi ces patientes, 75 (14,9%) avaient 4 ganglions métastatiques ou plus. Les index de concordances étaient de 0,69, 0,74 et 0,77 et les taux de faux négatifs étaient de 5,4%, 3,5% et de 4,8% pourle score de Louisville et les nomogrammes de Helsinki et de Katz respectivement. Les calibrations étaient insuffisantes pour les nomogrammes mais essentiellement aux dépens des patientes à haut risque. Le nomogramme de Katz plaçait plus de patientes dans le groupe à bas risque (46% vs 11% (Louisville) et 22% (Helsinki)). Conclusion : notre étude montre que le nomogramme de Katz est le plus adapté pour identifier les patientes à risque d'avoir plus de 3 ganglions axillaires métastatiques

Pelvic exenteration by robotically-assisted laparoscopy: A feasibility series of 6 cases

After concomitant chemo-radiation therapy, 20 to 30% of advanced cervical cancers recur in irradiated territory. Pelvic exenteration remains a therapeutic option for selected patients. However, this procedure remains complex because of tissue fragility after radiotherapy and their associated co-morbidities. Minimally invasive surgery such as robotically assisted laparoscopy may overcome these surgical challenges. The objective of this study was to evaluate the feasibility of pelvic exenteration with robotically assisted laparoscopy.Patients who underwent this procedure between 2015 and 2016 were included. Patients characteristics, treatment indication, intraoperative events, immediate and late complications, and histological outcomes were recorded.The data of 6 patients were analyzed. The primary cancer staging ranged from IB1 to IIB. All cases were loco-regional recurrence and 2 cases presented with with vesico-vaginal fistula. All patients had a history of pelvic irradiation. The mean operative time was 6.7 h. No complications occurred during surgery. The average hospital stay was 11.5 days. Immediate complications were mostly represented by urinary tract infections (4/5). Histological margins were clear in 67% (4/6), and a focal involvement was found in 33% (2/6) of cases. Late complications occurred within 82 days on average and included stenosis of ileal anastomosis, wound infection, acute renal failure, and pulmonary embolism. Revision surgery was necessary in 2 cases. There were 3 local recurrences occurring within an average of 215 days.In the light of these results, pelvic exenteration by robotically assisted laparoscopy may represent a valuable treatment modality of recurrent cervical cancer with low immediate postoperative morbidity

Clinical Impact of Lymphadenectomy after Neoadjuvant Chemotherapy in Advanced Epithelial Ovarian Cancer: A Review of Available Data

Recent robust data allow for omitting lymph node dissection for patients with advanced epithelial ovarian cancer (EOC) and without any suspicion of lymph node metastases, without compromising recurrence-free survival (RFS), nor overall survival (OS), in the setting of primary surgical treatment. Evidence supporting the same postulate for patients undergoing complete cytoreductive surgery after neoadjuvant chemotherapy (NACT) is lacking. Throughout a systematic literature review, the aim of our study was to evaluate the impact of lymph node dissection in patients undergoing surgery for advanced-stage EOC after NACT. A total of 1094 patients, included in six retrospective series, underwent either systematic, selective or no lymph node dissection. Only one study reveals a positive effect of lymphadenectomy on OS, and two on RFS. The four remaining series fail to demonstrate any beneficial effect on survival, neither for RFS nor OS. All of them highlight the higher peri- and post-operative complication rate associated with systematic lymph node dissection. Despite heterogeneity in the design of the studies included, there seems to be a trend showing no improvement on OS for systematic lymph node dissection in node negative patients. A well-conducted prospective trial is mandatory to evaluate this matter