Use of a new energy-based vessel ligation device during laparoscopic gynecologic oncologic surgery.

BACKGROUND: Achieving hemostasis may sometimes be challenging, especially in minimal access surgery. The objective of this study was to evaluate the safety and effectiveness of a new ligation device. METHODS: The LigaSure vessel sealing system, consisting of a bipolar radio frequency generator and a 5-mm laparoscopic Maryland-style grasper-dissector (LigaSure Lap), was used in 15 patients undergoing advanced laparoscopic gynecologic procedures. RESULTS: Reliable vessel sealing was achieved in all the patients, with minimal sticking, charring, and lateral thermal spread. A decrease in blood loss and operating time was noted. CONCLUSIONS: This new energy-based vessel ligation device appears to be effective in advanced laparoscopic gynecologic procedures. Larger studies are needed to evaluate the complication rate and the cost effectiveness of this new technology.

Bone metastasis from a granulosa cell tumor of the ovary.

BACKGROUND: Granulosa cell tumors (GCT) of the ovary generally have a good prognosis. Recurrences tend to be late and are usually abdominopelvic. Bone metastases are extremely rare. CASE: A case of recurrent GCT with vertebral metastasis is presented. Radiologic studies were helpful in documenting the presence of an invasive tumor destroying the vertebral body of T7. Bone scintigraphy excluded other metastatic sites. Diagnosis could not be established by CT-scan-directed fine-needle aspiration cytology or trocar biopsies. Since the lesion was isolated and resectable, aggressive surgery with complete tumoral excision was performed followed by local radiation therapy. Megestrol acetate was given as systemic treatment. CONCLUSION: Multiple treatments of GCT may alter the pattern of recurrence. Every symptom should be thoroughly evaluated. Bone metastases may be treated aggressively.

Phase II feasibility study of sequential couplets of Cisplatin/Topotecan followed by paclitaxel/cisplatin as primary treatment for advanced epithelial ovarian cancer: a National Cancer Institute of Canada Clinical Trials Group Study.

PURPOSE: Despite the improved results in advanced ovarian cancer achieved with the addition of paclitaxel to frontline therapy, there remains room for improvement. One approach is to add new agents such as topotecan. Because myelosuppression limits the delivery of topotecan with paclitaxel/cisplatin in a three-drug combination, we explored giving sequential couplets of cisplatin/topotecan followed by paclitaxel/cisplatin. PATIENTS AND METHODS: Forty-four patients with residual epithelial ovarian carcinoma after primary surgery were studied. Cisplatin 50 mg/m(2) on day 1 and topotecan 0.75 mg/m(2) on days 1 through 5 were administered at 21-day intervals for four cycles, followed by interval debulking surgery (if optimal debulking was not achieved with primary surgery), and then paclitaxel 135 mg/m(2) over 24 hours on day 1 and cisplatin 75 mg/m(2) on day 2 at 21-day intervals for four cycles. RESULTS: Such sequential couplets are feasible. Myelotoxicity was the major toxic effect, but it was of short duration. The granulocyte nadir with topotecan/cisplatin occurred late (median, day 18), so retreatment on day 21 was not always possible. There was no unexpected nonhematologic toxicity. The regimen was active in this group of patients who had undergone largely suboptimal debulking surgery. In 34 patients with clinically measurable disease, the overall response rate was 78%, and 30 (77%) of the 39 patients with elevated CA 125 levels at baseline had normalization of CA 125 levels by the end of therapy. CONCLUSION: Sequential couplets of cisplatin/topotecan followed by paclitaxel/cisplatin are feasible. The efficacy data in this suboptimal group of patients has encouraged us to proceed with a randomized study based on this approach.

[The future of retroperitoneal lymph node dissection]. / L'avenir de la dissection ganglionnaire rétropéritonéale.

Over the past decades, retroperitoneal lymph node dissection has been included in most gynecology oncological surgeries. Today, its usefulness is questioned. Recent studies on cervical, ovarian and endometrial cancer have attempted to redefine the role of retroperitoneal lymph node dissection. Despite theses studies, it appears obvious that dissection only has a minor impact on survival while increasing morbidity to a certain extent. The future of these procedures appears to be related to their prognostic value. The immediate goals today would be to target and remove only the necessary lymph nodes and to decrease the morbidity associated with the procedures. To reach these goals, two new approaches are presently studied: laparoscopic dissection and sentinel lymph node identification.

Ovarian serous papillary cystadenocarcinoma stage IIIC in a 19-year-old.

In mature women, the most common histological cell type of ovarian cancer is of epithelial origin. In children and adolescents, germ cell tumors are the most frequent. We report a case of a serous papillary cystadenocarcinoma FIGO stage IIIC in a 19-year-old female. She presented with a 6-month history of vague lower abdominal pain. Preoperative CA-125 was elevated at 296 kU/liter. At laparotomy, she was found to have stage IIIC disease. A debulking procedure including total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymph node sampling was performed. The immediate postoperative course was complicated by fulminant disseminated intravascular coagulopathy. She was subsequently treated with six courses of cyclophosphamide and carboplatin. Twenty-four months after surgery, the patient has no evidence of disease despite an increased CA-125 of 51 kU/liter.

Laparoscopic staging of early ovarian cancer.

The relevance of staging in early ovarian carcinoma is reviewed in light of the advances in surgical laparoscopy. Data from the literature suggest that a lymphadenectomy should be performed instead of a sampling. We have realized the former through laparoscopy. In this paper we propose a detailed surgical technique, similar to the laparotomy approach, that ensures an adequate nodal evaluation. Ten patients underwent a completion of staging by laparoscopy, including peritoneal washings for cytology, peritoneal and ovarian biopsies, an infracolic omentectomy, and a lymph node dissection. The use of laparoscopy for staging of early ovarian carcinoma appears to be a valuable alternative to traditional surgical staging.

Metastatic gestational trophoblastic disease: a comparison of prognostic classification systems.

The records of 53 consecutive patients with metastatic gestational trophoblastic disease (MGTD) treated at the University of Southern California/Los Angeles County Medical Center since 1970 were analyzed. Forty-eight were evaluable for this study. Treatment during the study period was based predominantly on the NIH good-prognosis-poor-prognosis system, employing single-agent therapy (methotrexate or actinomycin D) for the good-prognosis patients and methotrexate, actinomycin D, cyclophosphamide (MAC) for the poor-prognosis patients. The overall survival rate was 83.3%. The study patients were retrospectively classified according to the FIGO, NIH, and WHO systems to test each system's accuracy in predicting outcome and the appropriateness of single-agent or multiagent chemotherapy as the initial treatment in each category. None of the systems as currently used is clearly superior to the others. Analysis of the WHO scoring system showed that 21 of the 25 (84.0%) study patients with a point score less than 8 were treated primarily with a single-agent regimen. All of 21 of these patients achieved a complete sustained remission although 3 (14.3%) required multiagent chemotherapy. The 4 patients in this point category whose initial therapy was a multidrug regimen were also cured. The 23 patients in the WHO high-risk category (greater than 7) had treatment initiated with combination chemotherapy. There were no deaths among the 11 patients in the 8-12 point group, although 3 (27.3%) were salvaged by alternate multiagent chemotherapy after failing on MAC. There were 8 deaths in the 12-patient greater than 12 point WHO category (66.7%). On the basis of this analysis we recommend that the WHO scoring system be utilized for reporting results of treatment for MGTD, but the risk categories should be redefined: low, less than 8 points; medium, 8-12 points; high, greater than 12 points.

Low-risk metastatic gestational trophoblastic disease.

Low-risk metastatic gestational trophoblastic disease is almost uniformly curable with chemotherapy if the diagnosis is correct. Recent clinical investigations have focused on reducing the toxicity and cost of chemotherapy. This article discusses the diagnosis and current management.