Adjuvant Radiotherapy for Groin Node Metastases Following Surgery for Vulvar Cancer: A Systematic Review.

Background: Lymph node metastasis in vulvar cancer is a critical prognostic factor associated with higher recurrence and decreased survival. A survival benefit is reported with adjuvant radiotherapy but with potential significant morbidity. We aim to clarify whether there is high-quality evidence to support the use of adjuvant radiotherapy in this setting. Objectives: The aim of the study was to assess the effectiveness and safety of adjuvant radiotherapy to locoregional metastatic nodal areas. Search Methods: We conducted a comprehensive and systematic literature search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Google Scholar, ClinicalTrials.gov, and the National Cancer Institute. We considered only randomized controlled trials (RCTs). Main Results: We identified 1,760 records and finally retrieved only one eligible RCT (114 participants with positive inguinofemoral lymph nodes). All women had undergone radical vulvectomy and bilateral inguinal lymphadenectomy and had been randomized to adjuvant radiotherapy or to intraoperative ipsilateral pelvic lymphadenectomy without adjuvant radiotherapy. At 6 years, the overall survival (OS) was 51% versus 41% in favor of radiotherapy (HR 0.61; 95% CI 0.30-1.3) without significance and with very low certainty of evidence. At 6 year, the cumulative incidence of cancer-related deaths was 29% versus 51% in favor of adjuvant radiotherapy (HR 0.49; 95% CI 0.28-0.87). Recurrence-free survival at 6 years was 59% after adjuvant radiotherapy versus 48% after pelvic lymphadenectomy (HR 0.39; 95% CI 0.17-0.88). Three (5.3%) versus 13 (24.1%) groin recurrences were noted, respectively, in the adjuvant radiotherapy and pelvic lymphadenectomy groups. There was no significant difference in acute toxicities for pelvic lymphadenectomy compared to radiotherapy. In women with positive pelvic lymph nodes (20%), the OS at 6 year was 36% compared with 13% in favor of adjuvant radiotherapy. Late cutaneous toxicity rate appeared to be greater after radiotherapy (19% vs. 15%) but with less chronic lymphedema (16% vs. 22%). Conclusion: There is only very low-quality evidence on administering adjuvant radiotherapy for inguinal lymph node metastases. Although the identified study was a multicenter RCT, there was a reasonable imprecision and inconsistency because of small study numbers, wide confidence intervals in the data, and early trial closure, resulting in downgrading of the evidence.

En-bloc resection of the pelvis (EnBRP) in patients with stage IIIC-IV ovarian cancer: A 10 steps standardised technique. Surgical and survival outcomes of primary vs. interval surgery.

OBJECTIVE: In this study we describe the technique of the En-bloc resection of the pelvis (EnBRP) in 10 standardised and reproducible steps, whereby all pelvic organs, except the bladder, are removed together with the peritoneum. In addition, we compare the surgical and survival outcomes of patients who underwent upfront vs. interval surgery. METHODS: Retrospective analysis of patients with FIGO Stage IIIC-IV ovarian cancer treated with Visceral Peritoneal Debulking (VPD) who had EnBRP. The study population was divided into Group 1 (up-front VPD) and group 2 (VPD after neo-adjuvant chemotherapy). The aim was to assess the incidence of EnBRP. We also assessed rate of complete resection (CR), procedure-specific and overall morbidity, disease free and overall survival. Results were compared between group 1 and 2. RESULTS: Overall 92 out of 200 patients (46%) needed an EnBRP during the VPD. Forty-eight patients were in Group 1 and 44 patients in Group 2. CR was achieved in all patients. No intra-operative procedure specific morbidity was recorded. Dehiscence of bowel anastomosis was the only procedure specific morbidity. Rate was 2%, with 1 episode recorded in each group. Both patients were managed and settled with formation of a bowel diversion. The overall morbidity rate was 33%, 35% in group 1 and 31% in group 2. The mortality rate was 1%. Median disease free survival was 20months, 25 in group 1 vs. 15 in group 2 (P=0.009). CONCLUSIONS: EnBRP is a safe and effective technique to tackle the pelvic disease of patients with advanced ovarian cancer. The reduced blood loss, the high rate of clear margins and CR of the disease are accompanied by a low rate of surgical morbidity. These features are particularly suitable for patients who are due to start or re-start chemotherapy. The standardization of the technique will make it more reproducible and easier to be taught. In addition, it will facilitate comparison of results and the inclusion of this technique in the portfolio of procedures as part of debulking surgery.

Comparison of survival outcome of patients with primary peritoneal and fallopian tube carcinoma treated with neoadjuvant chemotherapy versus primary debulking surgery.

This study examines the overall survival of primary peritoneal cancer (PPC), in those patients who had primary debulking surgery (PDS) followed by six cycles of chemotherapy versus those who had neoadjuvant chemotherapy (NACT). This was a prospective observational study performed at Oxford Gynaecological Cancer Centre, over a 5-year period. Eighty-seven patients were clinically suspected of having PPC. Histology confirmed that 64 of these were PPC, with the balance being tubal in origin. PDS was performed in 31 cases. Although NACT was planned in 56 patients, 4 patients didn't receive NACT and therefore excluded from the survival analysis. The overall median survival was 34 months. However, the 5-year survival was 12%. Survival in the PDS group was 46 months versus 24 months in the NACT (p = .011). The conclusion drawn from this study is that patients affected by PPC, selected for PDS have a greater survival advantage than those who had NACT.

Porta hepatis peritonectomy and hepato-celiac lymphadenectomy in patients with stage IIIC-IV ovarian cancer: Diagnostic pathway, surgical technique and outcomes.

OBJECTIVE: To report the surgical technique of ovarian cancer resection at the porta hepatis (PH) and hepato-celiac lymph nodes (HCL). To assess surgical and survival outcomes. Define the accuracy of an integrated diagnostic pathway. METHODS: Patients with FIGO stage IIIC-IV ovarian cancer that underwent Visceral-Peritoneal Debulking (VPD). Data of patients with disease at the PH/HCL during VPD were extracted from our database. The CT scan findings were compared with the exploratory laparoscopy. Accuracy of CT scan, intra- and post-operative morbidity, rate of complete resection (CR), disease free and overall survival are reported. RESULTS: Thirty one patients out of 216 (14.3%) had tumor at the PH and/or HCL. In 8 patients out of 31 (25.8%) it was only found with the aid of the exploratory laparoscopy. CR was achieved in 28 patients out of 31 (90.3%). Pathology confirmed disease in the PH/HCL specimens of all but one patient. Overall morbidity relating to the VPD was 29.2%. No complication was specifically related to the PH/HCL. Median disease free survival was 19months and median overall survival was 42months. CONCLUSION: PH/HCL surgery was required in 15% of patients with FIGO stage IIIC-IV. The surgery was feasible, safe and significantly contributed to CR. CT scan failed to identify the disease in 31% of the patients. CT and laparoscopy correctly identified all patients.

Diaphragmatic peritonectomy vs. full thickness resection with pleurectomy during Visceral-Peritoneal Debulking (VPD) in 100 consecutive patients with stage IIIC-IV ovarian cancer: A surgical-histological analysis.

OBJECTIVE: To compare the surgical and histological outcomes of diaphragmatic peritonectomy vs. full thickness resection with pleurectomy during Visceral-Peritoneal Debulking. METHODS: Service evaluation protocol (Trust number 3265). All patients with stage IIIC-IV ovarian cancer who had diaphragmatic surgery between April 2009 and November 2013 were included. Clinical notes and histology reports were reviewed. Additional histology sections were undertaken. Patients were divided in Groups 1 (peritonectomy) and 2 (pleurectomy). The outcomes of interest were: surgical (intra- and post-operative morbidity, pulmonary morbidity, mortality, rate of complete resection) and histological (rate of diaphragmatic peritoneum, muscle and pleural involvement, rate of microscopic diaphragmatic free margins). RESULTS: Sixty four patients had diaphragmatic peritonectomy (Group 1), 36 patients full thickness diaphragmatic resection with pleurectomy (Group 2). There was no significant difference in the rate of mortality (3% in both groups), overall intra- and post-operative morbidity (32.8% vs. 38.8%), pulmonary morbidity (9.3% vs. 19%, P=0.14). Histology showed tumor invasion in the diaphragmatic peritoneum (96%), muscle (28%) and pleura (19.4%). Microscopic free margins were seen in 86% vs. 92% in Groups 1 and 2. CONCLUSIONS: Our study demonstrated that, in patients with ovarian cancer, diaphragmatic involvement extends to the muscle in almost 30% and to the pleura in 20% of the patients. Overall and specific morbidity was not significantly different when comparing peritonectomy vs. pleurectomy.