Intraoperative Ketorolac and Outcomes after Ovarian Cancer Surgery.

INTRODUCTION: Surgery is the cornerstone of ovarian cancer treatment. However, surgery and perioperative inflammation have been described as potentially pro-metastagenic. In various animal models and other human cancers, intraoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) appears to have a positive impact on patient outcomes. MATERIALS AND METHODS: In this unicentric retrospective study, we provide an exploratory analysis of the safety and potential benefit of intraoperative administration of ketorolac on the outcome of patients undergoing surgery for ovarian cancer. The study population included all patients who were given a diagnosis of ovarian, fallopian tube or peritoneal cancer by the multidisciplinary oncology committee (MOC) of the Cliniques universitaires Saint-Luc between 2015 and 2020. RESULTS: We included 166 patients in our analyses, with a median follow-up of 21.8 months. Both progression-free survival and overall survival were superior in patients who received an intraoperative injection of ketorolac (34.4 months of progression-free survival in the ketorolac group versus 21.5 months in the non-ketorolac group (p = 0.002), and median overall survival was not reached in either group but there was significantly higher survival in the ketorolac group (p = 0.004)). We also performed subgroup analyses to minimise bias due to imbalance between groups on factors that could influence patient survival, and the group of patients receiving ketorolac systematically showed a better outcome. Uni- and multivariate analyses confirmed that administration of ketorolac intraoperatively was associated with better progression-free survival (HR = 0.47 on univariate analysis and 0.43 on multivariate analysis, p = 0.003 and 0.023, respectively). In terms of complications, there were no differences between the two groups, either intraoperatively or postoperatively. CONCLUSION: Our study has shown a favourable association between the use of ketorolac during surgery and the postoperative progression of ovarian cancer in a group of 166 patients, without any rise in intra- or postoperative complications. These encouraging results point to the need for a prospective study to confirm the benefit of intraoperative administration of ketorolac in ovarian cancer surgery.

Centralizing surgery for ovarian cancer in a 'non-centralizing' country (Belgium): the UNGO (UCLouvain Network of Gynaecological Oncology) experience.

OBJECTIVE: In Belgium there is no centralization of surgery for ovarian cancer, with more than 100 centers treating around 800 cases per year. In 2017 a network with several collaborating hospitals was established to centralize surgery for ovarian cancer (UCLouvain Network of Gynecological Oncology; UNGO) following publication of the European Society of Gynecological Oncology (ESGO) recommendations and quality criteria for surgery of advanced ovarian cancer. We obtained ESGO accreditation in 2019. METHODS: We retrospectively collected data associated with patients undergoing surgery in our institution from 2007 to 2016, before the creation of the network (cohort 1) and, following the establishment of UNGO (2017-2021), patients undergoing surgery were prospectively registered in a REDCap database (cohort 2). The outcomes of the two cohorts were compared. RESULTS: A total of 314 patients underwent surgery in our institution from 2007 and 2021: 7.5 patients/year in cohort 1 (retrospective, 2007-2016) and 40.8 patients/year in cohort 2 (after network creation, 2017-2021). Median disease-free survival was increased from 16.5 months (range 13.2-20.4) in cohort 1 to 27.1 months (range 21.5-33.2) in cohort 2 (p=0.0004). In cohort 2, the rate of patients with residual disease at the end of the surgery was significantly less (18.7% vs 8.8%, p=0.023), although more patients in cohort 1 received neoadjuvant chemotherapy (89% vs 54%, p<0.001). However, there was a higher rate of complications in the patients in cohort 2 (18.8% vs 30%, p=0.041). CONCLUSION: Our study shows that, with the help of ESGO and its recommendations, we have been able to create an efficient advanced ovarian cancer centralized network and this may provide an improvement in the quality of care.

Fetal umbilical-systemic shunt with a positive issue.

We herein report the case of abnormal umbilical-venous return in which the antenatal ultrasound enabled us to establish the diagnosis of umbilical-systemic shunt (Type 1 according to Achiron (Achiron and Kivilevitch, 2016)). Due to the concomitant associations of cardiomegaly, intrauterine growth retardation, oligohydramnios, and left-lobe hypoplasia with agenesis of the intrahepatic umbilical vein - left portal vein - ductus venosus, a poor prognosis (11.1% survival) was to be expected. In spite of development of pulmonary arterial hypertension at birth, which was promptly treated, the evolution was nevertheless good, both on clinical and ultrasound follow-up.

Added value of para-aortic surgical staging compared to 18F-FDG PET/CT on the external beam radiation field for patients with locally advanced cervical cancer: An ONCO-GF study.

OBJECTIVE: Extended field chemoradiation is recommended for patients with locally advanced cervical cancer (LACC) and para-aortic lymph node (PALN) metastases. The radiation planning may be based on PET/CT while others recommend to rely on surgical staging. We report the rate of patients for whom the radiation field defined on PET/CT was modified by the histological PALN status. METHODS: Between March 2010 and December 2016, 168 consecutive patients with LACC underwent a pre-therapeutic PET/CT and PALN dissection. The data were reviewed retrospectively. The diagnostic performance of the PET/CT for definition of PALN status was calculated. We determined the percentage of patients for whom PALN dissection altered the external beam radiotherapy (EBRT) field defined on the PET/CT basis. RESULTS: Of 151 patients with negative PALNs on PET/CT, 26 had histological PALN metastases. Of 17 patients with positive PALNs on PET/CT, 9 were negative on histology of which 7 were located in the common iliac region. Sensitivity, specificity, positive and negative predictive value of PET/CT were 23.5, 93.3, 47.1 and 82.8% respectively. In total, 35 out of 168 patients underwent EBRT - field adaptation (pelvic vs extended field). The rate of radiation field modification (27,7%) was particularly high in the subgroup of patients with metastatic pelvic lymph nodes (PLNs) on PET/CT. CONCLUSION: Para-aortic surgical staging contributes significantly to individualize the radiation treatment of patients with LACC, particularly for those with positive PLNs at PET/CT. Indication of surgical staging deserves particular attention when the PET/CT suggests positive LNs in the common iliac region.

Self-expanding metallic stents in benign postoperative biliary strictures: a difficult surgical obstacle?

BACKGROUND/AIMS: To report the hazards of surgical management in patients suffering from benign postoperative biliary strictures (BBS) previously treated with self-expanding metallic stents (SEMS). METHODOLOGY: Five patients with BBS were treated by SEMS (Wallstent in 3 patients and Gianturco stent in 2) through an endoscopic (2 patients) or a percutaneous transhepatic route (3 patients). Metallic stent obstruction due to intraprosthetic epithelial hyperplasia was observed in all patients, being responsible for severe cholangitis and intrahepatic stones in 3 and 2 patients respectively. RESULTS: One patient remains free of symptoms but presented with right posterior liver atrophy. Difficult biliary repair was encountered in 3 patients, requiring excision and reconstruction of the main biliary convergence for severely damaged biliary wall and epithelium by metallic stents. One patient with a SEMS extended upward the right secondary biliary divisions required a right hemihepatectomy. CONCLUSIONS: The surgical management of benign biliary strictures is severely complicated by the presence of metallic stents. Thus, SEMS should not be employed for treating BBS in healthy patients with a low operative risk.

Iron overload enhances epithelial cell proliferation in endometriotic lesions induced in a murine model.

BACKGROUND: Iron deposits are characteristic of endometriotic lesions, and pelvic iron concentrations are higher in endometriosis patients than in women without endometriosis. In this study, the effect of iron overload and iron chelation on the development of endometriosis in a murine model was investigated. METHODS: Human menstrual endometrium was injected i.p. into nude mice, either alone (controls) or supplemented with erythrocytes or desferrioxamine (DFO), an iron chelator. After 5 days, the iron load of endometriosis-like lesions and peritoneal macrophages and fluid was evaluated. Lesions were quantified by immunohistochemical morphometry, and their proliferative activity was assessed. RESULTS: Injection of erythrocytes into the pelvic cavity caused iron overload in lesions (P < 0.025) and peritoneal macrophages (P < 0.01) and fluid (P < 0.05), whereas DFO effectively reduced iron status in lesions (P < 0.05) and macrophages (P < 0.01) compared with controls. No difference was observed in the number or surface area of lesions between the three groups. Erythrocytes increased (P < 0.05) and DFO significantly decreased (P < 0.01) the proliferative activity of lesions. CONCLUSIONS: Iron overload does not appear to affect lesion establishment but may contribute to the further growth of endometriosis by promoting cell proliferation of lesions. Iron chelator treatment could therefore be beneficial in endometriosis to prevent iron overload in the pelvic cavity and decrease cellular proliferation of lesions.

Quantification of endometriotic lesions in a murine model by fluorimetric and morphometric analyses.

BACKGROUND: In animal models of endometriosis, the identification and quantification of lesions originating from human endometrium is often hampered by the small size of the implants and their embedding in murine tissue. The purpose of the present study was to develop two new methods of quantifying endometriosis-like lesions in a nude mouse model: fluorimetry and morphometry. METHODS: Human menstrual endometrium was labelled using a fluorescent tracker, carboxyfluorescein diacetate, succinimidyl ester (CFDA-SE), and transplanted into the pelvic cavity of mice by injection through the peritoneum after performing a cutaneous incision. After 5 days, lesions were recovered by laparotomy. The fluorescence of the recovered endometriotic lesions was measured. Endometrial stroma and glands were immunostained in lesion sections with anti-CD10 and anti-CK22 antibodies, and their surface area was evaluated by morphometric analysis. RESULTS: Fluorescent labelling allows identification of lesions not visible macroscopically. A good correlation was observed between fluorimetry and morphometry (r=0.88) applied for lesion quantification. CONCLUSIONS: Fluorimetric evaluation combined with morphometric analysis of endometriosis-like lesions allows objective and reliable recording of endometriosis development in a nude mouse model. This quantification method could therefore be useful for future pharmacological and toxicological studies.

Orthopaedic concerns in children with growth hormone therapy.

Growth hormone (GH) therapy is widely used in children; it may have various severe orthopaedic complications. Slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, scoliosis and carpal tunnel syndrome may occur with GH treatment. Before beginning GH therapy, it is important to take into account all the risk factors of the individual patient, as some conditions could contraindicate GH treatment. During GH treatment, close monitoring with both clinical and radiographic examination is mandatory. The paediatric orthopaedic surgeon will frequently be asked about the management of these complications and about the necessity for treatment arrest. The authors review the orthopaedic complications which the orthopaedic surgeon may encounter in patients treated with GH.