Robotic Compartment-Based Radical Surgery in Early-Stage Cervical Cancer

A radical hysterectomy with pelvic lymphadenectomy is the recommended treatment option in patients with early-stage cervical cancer. Although various classifications were developed in order to define the resection margins of this operation, no clear standardization could be achieved both in the nomenclature and in the extent of the surgery. Total mesometrial resection (TMMR) is a novel procedure which aims to remove all components of the compartment formed by Müllerian duct in which female reproductive organs develop. TMMR differs from the conventional radical hysterectomy techniques in that its surgical philosophy, terminology, and partly resection borders are different. In this paper, a TMMR with therapeutic pelvic lymphadenectomy operation that we performed for the first time with robot-assisted laparoscopic (robotic) approach in an early-stage cervical cancer patient was presented. This procedure has already been described in open surgery by Michael Höckel and translated to the robotic surgery by Rainer Kimmig. Our report is the second paper, to our knowledge, to present the initial experience regarding robotic TMMR in the English literature

Pulmonary recurrence in patients with endometrial cancer

Background: In this article, we aimed to define the clinical, pathological, and surgical factors predicting pulmonary recurrence (PR) and determining survival after PR in patients with endometrial cancer. Methods: Thirty-six (2.7%) patients were analyzed who suffered pulmonary failure in the first recurrence out of 1345 patients who had at least extrafascial hysterectomy plus bilateral salpingo-oophorectomy for endometrial cancer between January 1993 and May 2013. The recurrence was designated as an isolated PR in cases of the presence of recurrence only in the lung, while it was called a synchronized PR if the patient had extrapulmonary recurrence in addition to PR. Results: In the multivariate analysis in the entire cohort, only International Federation of Gynecology and Obstetrics stage was an independent prognostic factor for PR. Two-year overall survival (OS) was 52% in patients with PR. In the univariate analysis, early International Federation of Gynecology and Obstetrics stage, absence of lymphatic metastasis, negative lymphovascular space invasion, absence of cervical invasion, negative adnexal spread, negative peritoneal cytology, negative omental metastasis, adjuvant radiotherapy after initial surgery, isolated PR, and chemotherapy upon recurrence were associated with improved OS after PR. The OS was 54 months for patients with isolated PR, while it was 10 months for patients who had synchronized PR. Furthermore, OS was 43 months and 13 months for the patients who took chemotherapy and radiotherapy, respectively. Conclusion: Advanced stage is associated with PR. If recurrence is only in the lung, survival is better. Systemic treatment after PR is associated with improved survival. However, multi-center studies are required to standardize the treatment for PR

Stage IB Endometrioid Type Endometrial Cancer: The Role of Lymphadenectomy and Adjuvant Radiation Therapy

Objective: Both performances of lymphadenectomy and benefit of adding adjuvant radiotherapy are controversial for patients with International Federation of Gynecology and Obstetrics stage IB endometrioid type endometrial cancer. We aimed to identify the role of lymphadenectomy and adjuvant radiation therapy as well as clinicopathological prognostic factors for this group of patients. Study Design: Records of all patients (n=132) with stage IB endometrioid endometrial cancer who were referred to or treated in our institution between Jan 1992 and Dec 2013 were retrospectively reviewed. Cox Proportional Hazard Regression Analysis was used to determine the effects of lymphadenectomy and adjuvant radiation as well as other clinicopathological factors on disease free survival and overall survival. Results: Mean age was 59.9 years (range, 45-82). Lymphadenectomy didn't perform in 36 (27.3%) patients and 23 (17.4%) patients did not have any kind of adjuvant treatment. Mean lymph node count was 18.8 (range, 3-67). Federation of Gynecology and Obstetrics grade, lymphovascular space invasion, lymphadenectomy, receiving adjuvant treatment and type of received adjuvant therapy were not associated with disease free survival and overall survival for the entire cohort. In a subgroup of patients with grade1&2 tumor, 5-year disease free survival rates were 80% and 50% (p=0.4), respectively and overall survival rates were 94.8% and 93.8% (p=0.2), respectively for patients who had or didn't have adjuvant radiotherapy. While performance of lymphadenectomy was not significantly associated with disease free survival in this subgroup (p=0.56), this association was statistically significant for overall survival (97.9% vs. 86.4%, p=0.04) Conclusion: Benefit of adjuvant radiotherapy in regard to prevention of recurrence needs to be confirmed by further studies. Lymphadenectomy had a survival benefit for patients with myometrial invasion greater than a half of myometrial thickness

Prognostic effect of isolated paraaortic nodal spread in endometrial cancer

Objective: To evaluate the prognostic effect of isolated paraaortic lymph node metastasis in endometrial cancer (EC). Material and Methods: This retrospective study included patients with FIGO 2009 stage IIIC2 disease due to isolated paraaortic lymph node metastasis (LNM). Patients with sarcomatous histology, synchronous gynecologic cancers and patients with concurrent pelvic lymph node metastases or patients that have intraabdominal tumor spread were excluded. Kaplan-Meier method was used for calculation of progression free survival (PFS) and overall survival. Results: One thousand six hundred and fourteen patients were operated for EC during study period. Nine hundred and sixty-one patients underwent lymph node dissection and 25 (2.6%) were found to have isolated LNM in paraaortic region and these constituted the study cohort. Twenty (80%) patients had endometrioid EC. Median number of retrieved lymph nodes from pelvic region and paraaortic region was 21.5 (range: 5-41) and 34.5 (range: 1-65), respectively. Median number of metastatic paraaortic nodes was 1 (range: 1-32). The median follow-up time was 15 months (range 5-94). Seven (28%) patients recurred after a median of 20 months (range, 3-99) from initial surgery. Three patients recurred only in pelvis, one patient had upper abdominal spread and 3 had isolated extraabdominal recurrence. Involvement of uterine serosa, positive peritoneal cytology and presence of adnexal metastasis were significantly associated with diminished PFS (p<0.05). Conclusion: The presence of serosal involvement or adnexal involvement is as important as gross peritoneal spread and is related with poor survival in patients with isolated paraaortic nodal spread in EC. Chemotherapy should be the mainstay of treatment in this patient cohort which may eradicate systemic tumor spread

Neoadjuvant chemotherapy in patients with stage IVB uterine serous carcinoma: a Turkish multicentric study

The aim of this study was to evaluate the prognostic factors for and determine the effect of neoadjuvant chemotherapy (NACT) on oncologic outcome in stage IVB pure serous endometrial carcinoma patients who received taxane and platinum. Forty-two patients with 2009 International Federation of Gynecology and Obstetrics (FIGO) stage IVB uterine serous carcinoma were enrolled from six gynecologic oncology centers and a study group was created. The study group had a 2-year disease-free survival (DFS) of 32% and 2-year disease-specific survival (DSS) of 73%. On univariate analysis; lymphadenectomy (not performed vs. performed), paraaortic lymph node metastasis (positive vs. negative) and number of metastatic lymph node count (≤5 vs. >5) were found to have statistical significance for DFS (p < 0.001, p = 0.026 and p = 0.044, respectively). Adnexal metastasis (positive vs. negative) and type of cytoreductive surgery (maximal vs. optimal and suboptimal) had statistical significance for DSS (p = 0.041 and p = 0.015, respectively). Receiving NACT did not affect DFS and DSS in stage IVB uterine serous carcinoma patients. As our sample size was small, precise conclusions could not be made for suggesting the use of NACT in advanced stage uterine serous carcinoma. For more accurate results, more randomized controlled studies are needed in this patient group.IMPACT STATEMENT What is already known on this subject? Endometrial carcinoma is the most common type of gynecologic tract malignancies and usually it is diagnosed at early stages. Although the favorable prognosis, uterine serous carcinoma (USC), one of the rarest subtypes, has a poorer prognosis when compared to other histological subtypes. USC has a propensity to spread beyond pelvis. Due to this aggressive behavior, surgical intervention could not be feasible in advanced stage disease. What do the results of this study add? Our study evaluated the prognostic factors that affect survival in advanced stage USC patients. Also we investigated that neoadjuvant chemotherapy (NACT) could improve oncologic outcomes. Performing lymphadenectomy, presence of paraaortic lymph node and adnexal metastasis, number of metastatic lymph nodes and type of cytoreductive surgery improved survival in advanced stage USC patients. However, NACT did not have a statistical significance as a predictor for disease-specific survival (DSS) and disease-free survival (DFS). What are the implications of these findings for clinical practice and/or further research? Maximal surgical effort should be performed in advanced stage USC according to our results. On the other hand, NACT had no impact on DSS and DFS rates. For this reason, we could not be able to suggest the routine use of NACT in advanced stage USC. But more randomized controlled trials are warranted for confirmation of our results