Is it time to leave multi- for single-port laparoscopy in benign gynecologic surgery? A systematic review of randomized clinical trials.

INTRODUCTION: Conventionally, laparoscopic surgery in gynecology requires multiple accesses in the abdominal cavity. Laparo-endoscopic single-site surgery (LESS) is a more recent technique consisting in a laparoscopy in which the abdominal cavity is reached by a single umbilical incision. The aim of this systematic review is to summarize and comment the benefits and drawbacks in benign gynecological surgeries, including hysterectomy, myomectomy, and adnexal surgery, by LESS and conventional multiport laparoscopy (MPL), respectively. EVIDENCE ACQUISITION: A systematic review following the Preferred Reporting Items for Systematic reviews and Randomized Control Trials (PRISMA) was performed by researching articles in PubMed, Medline, Web of Science, and Cochrane library. The terms searched were "single port laparoscopy" or "laparo-endoscopic single site surgery" or "single site laparoscopy" or "single-incision laparoscopic surgery" and "hysterectomy," or "myomectomy," or "adnexal surgery". Only randomized-controlled trials (RCTs) comparing LESS and MPL in benign gynecology were included. EVIDENCE SYNTHESIS: Thirteen RCTs including 1088 women undergoing gynecological surgery for benign disease through LESS versus MPL were included in the analysis of which 620 underwent hysterectomy, 154 myomectomy, 314 adnexal surgery. LESS approach was performed in 531/1088 (48.8%) procedures. All studies compared the surgical outcomes for length of operative time, hemoglobin drop, length of hospitalization, rate of conversion, postoperative pain, intra and postoperative complications. For hysterectomy, a longer operating time and a higher conversion rate were shown in the LESS group, but no significant differences were found for the other outcomes. For myomectomy, the only significant difference was found for a higher conversion rate in the LESS group. For adnexal surgery, no significant differences were found. Globally there was no difference in pain based on the Visual Analog Scale Score. Cosmetic outcome was reported in 6/13 of the studies included, 4/6 demonstrated a superior cosmetic satisfaction in the LESS group. CONCLUSIONS: Despite cosmetic result is intuitively the main advantage for LESS technique, current evidence does not seem to demonstrate a clear superiority of LESS compared to MPL in benign gynecological surgery.

Risk factors for non-response and discontinuation of Dienogest in endometriosis patients: A cohort study.

INTRODUCTION: Progestins are commonly prescribed first-line drugs for endometriosis. High rates of non-response and intolerance to these drugs have been previously reported. However, no study to date has investigated the characteristics and comorbidities of patients taking progestins in relation to treatment outcomes, so identifying which patients will respond to or tolerate the treatment is currently impossible. The purpose of this study, therefore, was to identify risk factors for non-response and discontinuation of Dienogest (DNG) in women with endometriosis. MATERIAL AND METHODS: This is a retrospective cohort study including women currently taking, or newly prescribed, DNG for endometriosis-associated pain presenting in the Endometriosis Clinic of the University Hospital of Bern between January 2017 and May 2018. Women with initiation of treatment directly after surgery for endometriosis were excluded. For all participants the symptoms and comorbidities were documented. Effectiveness, tolerability and discontinuation of DNG were the primary end points. Univariate and multivariate binary logistic regression models were carried out to identify risk factors for non-response, intolerance and discontinuation of DNG. RESULTS: A sufficient or excellent treatment response was reported by 85/125 (68%) participants. Genital bleeding during the DNG treatment was negatively (OR 0.185, 95% CI 0.056-0.610, P = .006) and rASRM endometriosis stages III and IV were positively (OR 3.876, 95% CI 1.202-12.498, P = .023) correlated with the DNG response. When accounting for exclusively pretreatment factors, primary dysmenorrhea (OR 0.236, 95% CI 0.090-0.615, P = .003) and suspicion of adenomyosis (OR 0.347, 95% CI 0.135-0.894, P = .028) were inversely correlated with DNG response, and the latter was also correlated with treatment discontinuation (OR 3.189, 95% CI 1.247-8.153, P = .015). CONCLUSIONS: Genital bleeding during the DNG treatment and low rASRM stages are independent risk factors for DNG non-response. Before treatment initiation, primary dysmenorrhea and suspicion of adenomyosis correlate with DNG non-response. The results could assist the clinician first to provide detailed information to women before treatment initiation, second to identify and possibly modify in-therapy factors correlated to treatment effectiveness and lastly to switch treatment on time if needed.

Vitamin C as an Anticancer Agent: Regulation of Signaling Pathways.

Treatment options for effective treatment of cancer with minimum off-target effects and maximum clinical outcomes have remained overarching goals in the clinical oncology. Vitamin C has remained in the shadows of controversy since the past few decades; burgeoning evidence has started to shed light on wide-ranging anticancer effects exerted by Vitamin C to induce apoptosis in drug-resistant cancer cells, inhibit uncontrolled proliferation of the cancer cells and metastatic spread. Landmark achievements in molecular oncology have ushered in a new era, and researchers have focused on the identification of oncogenic pathways regulated by Vitamin C in different cancers. However, there are visible knowledge gaps in our understanding related to the ability of Vitamin C to modulate a myriad of transduction cascades. There are scattered pieces of scientific evidence about promising potential of Vitamin C to regulate JAK-STAT, TGF/SMAD, TRAIL and microRNAs in different cancers. However, published data is insufficient and needs to be investigated comprehensively to enable basic and clinical researchers to reap full benefits and promote result-oriented transition of Vitamin C into various phases of clinical trials. In this review, we will emphasize on available evidence related to the regulation of oncogenic cell signaling pathways by Vitamin C in different cancers. We will also highlight the conceptual gaps, which need detailed and cutting-edge research.

Breast and axillary surgery in malignant breast disease: a review focused on literature of 2018 and 2019.

PURPOSE OF REVIEW: There have been fundamental changes in the surgical approach to breast cancer management over the last decades. The primary objective of achieving locoregional control, however, remains unchanged. RECENT FINDINGS: In addition to strategies optimizing systemic treatment and radiotherapy, current discussions focus on improving the surgical approach to breast cancer. Especially in view of the increasingly pivotal role of neoadjuvant chemotherapy NAT/NAC (NACT), gauging the extent of tissue removal in the breast and the width of resection margins in breast-conserving surgery is highly important, as is the extent of axillary surgery. Although sentinel lymph node (SLN)-positive patients always underwent axillary lymph node dissection in the past, this paradigm has been challenged in recent years. Targeted axillary dissection (TAD) has emerged as a new staging option in biopsy-proven node-positive patients who convert to clinical node negativity (cN0) after NACT. TAD combines the removal of the SLN and of the target lymph node marked prior to NACT. The accuracy of axillary staging both before and after NACT plays an important role for prognostication and multidisciplinary treatment plans, while its extent has significant effects on patients' arm morbidity and quality of life. SUMMARY: The current review focuses on recent evidence regarding surgical management of the breast and axilla in patients with primary breast cancer based on a PubMed and EMBASE literature search for publication years 2018 and 2019.

Sentinel node biopsy for treatment of endometrial cancer: current perspectives.

The risk of lymph nodal metastases in endometrial cancer varies greatly according to the characteristics of the primary tumor. Surgical staging with a systematic lymphadenectomy in endometrial cancer is debated since three decades. On one hand, it provides important pathological information on the spread of the tumor allowing for an appropriate decision making on adjuvant treatment but on the other side it is characterized by a non-negligible short and long-term morbidity. In the past decade, various efforts have been made in the attempt to apply the concept of the sentinel lymph node mapping in endometrial cancer. The sentinel lymph node mapping has the potential to provide the necessary pathological lymph nodal information at a reasonable cost in terms of morbidity. In this review, the most relevant aspects of the sentinel lymph node mapping in endometrial cancer are summarized. Furthermore, the performance in terms of false negative rates and detection rates, the clinical value of the pathological ultrastaging, its clinical applicability in different scenarios including patients preoperatively considered to be at low or at high risk are discussed. Oncological outcome of the patients who have been submitted to a sentinel lymph node mapping as compared to a full lymhadenectomy are presented as well as technical aspects to improve the performance of the surgical technique.

Bulky mesonephric adenocarcinoma of the uterine cervix treated with neoadjuvant chemotherapy and radical surgery: report of the first case.

AIMS AND BACKGROUND: Malignant mesonephric adenocarcinoma of the uterine cervix is a rare occurrence with few cases described in the literature. Although surgery seems to be effective in the treatment of early-stage tumor, no cases describing outcomes of locally advanced stage are available. METHODS: We report the first case of a patient with International Federation of Obstetrics and Gynecologists stage IIB mesonephric adenocarcinoma undergoing neoadjuvant chemotherapy and radical surgery. CONCLUSIONS: Despite the inherent limitation of a single description of a case, our experience supports the utilization of neoadjuvant chemotherapy in patients with malignant mesonephric adenocarcinoma of the uterine cervix. Further prospective multi-institutional studies are needed.

Implementation of laparoscopic approach for type B radical hysterectomy: a comparison with open surgical operations.

OBJECTIVE: To investigate the safety, feasibility and effectiveness of laparoscopic approach in the management patients undergoing modified radical hysterectomy for early stage cervical cancer. METHODS: Consecutive data of 157 women who had class II radical hysterectomy, for stage IA2 and stage IB1 <2 cm cervical cancer, were prospectively collected. Data of patients undergoing surgery via laparoscopy (LRH) were compared with those undergoing open surgical operations (RAH). A propensity-matched comparison (1:1) was carried out to minimize as possible selection biases. Post-operative complications were graded per the Clavien-Dindo classification. Five-year survival outcomes were assessed using Kaplan-Meier model. RESULTS: After the exclusion of 37 (23.5%) patients on the basis of propensity-matching, 60 patients undergoing LRH were compared with 60 patients undergoing RAH. No between-group differences in baseline, disease and pathological variables were observed (p > 0.05). Patients undergoing surgery via laparoscopy experienced longer operative time than patients undergoing RAH; while LRH correlated whit shorter length of hospitalization and lower blood loss in comparison to RAH. Intra- and post-operative complication rate was similar between groups (p = 1.00). The execution of LRH or RAH did not influence site of recurrence (p > 0.2) as well as survival outcomes, in term of 5-year disease-free (p = 0.29, log-rank test) and overall survivals (p = 0.50, log-rank test). CONCLUSION: Laparoscopic approach is a safe procedure, upholds the results of RAH, reducing invasiveness of open surgical operations. Further large prospective investigations are warranted.