HE4 as a serum biomarker for the diagnosis of pelvic masses: a prospective, multicenter study in 965 patients.

BACKGROUND: To evaluate the diagnostic value of adding human epididymis protein 4 (HE4), cancer antigen 125 (CA125) and risk of malignancy algorithm (ROMA) to ultrasound for detecting ovarian cancer in patients with a pelvic mass. METHODS: This was a prospective, observational, multicenter study. Patients aged > 18 years who were scheduled to undergo surgery for a suspicious pelvic mass had CA125 and HE4 levels measured prior to surgery, in addition to a routine transvaginal ultrasound scan. The diagnostic performance of CA125, HE4 and ROMA for distinguishing between benign and malignant adnexal masses was assessed using receiver operating characteristic (ROC) analysis and the corresponding area under the curve (AUC). RESULTS: Of 965 evaluable patients, 804 were diagnosed with benign tumors and 161 were diagnosed with ovarian cancer. In late-stage ovarian cancer, CA125, HE4 and ROMA all had an excellent diagnostic performance (AUC > 0.92), whereas in stage I and II, diagnostic performance of all three biomarkers was less adequate (AUC < 0.77). In the differential diagnosis of ovarian cancer and endometriosis, ROMA and HE4 performed better than CA125 with 99 and 98.1% versus 75.0% sensitivity, respectively, at 75.4% specificity. CONCLUSIONS: ROMA and HE4 could be valuable biomarkers to help with the diagnosis of ovarian cancer in premenopausal patients in order to differentiate from endometriosis, whereas CA125 may be more adequate for postmenopausal patients.

[Is There a Negative Night or Weekend Effect on the Child's Postnatal State Among Migrant Women?] / Gibt es einen negativen Nacht- oder Wochenendeffekt auf den kindlichen postnatalen Zustand bei Frauen mit Migrationshintergrund?

RESEARCH QUESTION: Is neonatal morbidity of women with a migration background (= a proxy variable for an increased risk of cultural/linguistic communication problems) increased in the sense of a "weekend effect"? METHODS: Data was collected at 3 Berlin maternity hospitals directly in the delivery room based on standardized interviews (questions on sociodemographics, care aspects, migration) and supplemented by maternal and clinical perinatal data. Surrogate markers for the child's morbidity were the Apgar score and umbilical cord pH value or transfer to a children's hospital. Descriptive and logistic regression analyses were carried out. RESULTS: The data sets of 2,014 1st-generation migrants, 771 2nd-generation migrants, and 2,564 women without a migrant background were included, including 39.7% so-called day-births (Monday - Friday, 7 a.m.-6 p.m.). In 2 models, the influence of birth time and various other parameters was examined for the 2 proxy parameters of childhood morbidity. The chances of unfavorable Apgar or umbilical pH levels were increased in births in the evening, at night, on weekends and public holidays (OR 1.84, 95% CI 1.23-2.76, p=0.003), in operative vaginal births (OR 3.36, 95% CI 2.07-5.46, p<0.001) or a secondary cesarean section (OR 1.94; 95% CI 1.28-2.96, p=0.002). The migration status of the woman giving birth was irrelevant. SUMMARY: Despite possible intercultural and linguistic communication problems, women with a migration background are treated as well as pregnant women without a migration background irrespective of the time of day or day of the week.

Follow-up after radical vaginal trachelectomy (RVT): patients' problems and physicians' difficulties.

PURPOSE: Patients after radical vaginal trachelectomy (RVT) need specific follow-up treatment because their problems differ from those of other gyneco-oncologic patients. Anatomic changes after surgery complicate examinations. Recognition and treatment of these issues require physician's expertise. PATIENTS AND METHODS: We evaluated the follow-up data of 70 patients who underwent RVT for early cervical cancer between 03/2010 and 12/2013. The follow-up interval in the first 2 years was 3 and 6 months in the following 2 years. We used a tailored protocol to describe the special problems after RVT. RESULTS: Cervical stenosis was one of the central problems independent of time interval to RVT. Physicians' most significant problem was to locate the exact position of the neo-cervix and thus to receive valid pap smears. CONCLUSIONS: Follow-up of patients after RVT needs special expertise because the symptoms differ from those after hysterectomy and examinations ensuring oncologic safety require special attention.

Closure of the cervical os in patients after fertility preserving treatment for early cervical cancer - results of a prospective observational study.

INTRODUCTION: Up to 50% of the infants delivered after radical vaginal trachelectomy (RVT) are born prematurely. An effective strategy to reduce this number could be the closure of the cervical os (CCO). PATIENTS AND METHODS: Fifteen pregnant patients who had a RVT due to early cervical cancer were included in this prospective case control study. All patients were scheduled for CCO early in the second trimester. CCO was performed in 12 patients. Their data were compared to data from 125 pregnancies after a RVT without CCO. RESULTS: The patients who had CCO were compared to patients without CCO. One patient had an early rupture of the amniotic membranes prior to CCO. Two patients chose not to undergo CCO. In 12 patients CCO was performed without complications. There was no early preterm delivery in the CCO group as compared to a rate of 5% in 125 pregnancies in the non-CCO group. DISCUSSION: We developed a protocol to reduce the risk of preterm deliveries after a RVT. Digital examinations should be avoided. Vaginal checks for pH can discover ascending infections - the main cause of preterm deliveries after a RVT. Infections should be treated adequately. CCO can further reduce the risk of preterm deliveries after a RVT.

Laparoscopic pelvic lymphadenectomy in 32 pregnant patients with cervical cancer: rationale, description of the technique, and outcome.

OBJECTIVE: Individualized treatment of pregnant patients with cervical cancer is mandatory; hence, information on nodal status is pivotal to allow a waiting strategy in early-stage disease.We aimed to verify the oncological safety and surgical reproducibility of a standardized laparoscopic pelvic lymphadenectomy in pregnant patients with cervical cancer. METHODS: We standardized laparoscopic pelvic lymphadenectomy during the first and second term of gestation in 32 patients with cervical cancer since 1999. According to gestational week (GW) of less than 16 GWs or more than 16 GWs, 2 different techniques were used. RESULTS: The International Federation of Gynecology and Obstetrics stages were IA in 10 patients, IB1 in 17 patients, IB2 in 4 patients, and IIA in 1 patient. Mean (SD) GW was 17.5 (5.1) weeks. Mean (SD) operative time was 105.4 (29) minutes. Mean (SD) blood loss was 5.3 (10.2) mL. There were no conversion to laparotomy and no intraoperative complications. A median number of 14 pelvic lymph nodes (range, 8-57) were harvested. Median hospital stay was 6 days. Median follow-up is 42.5 months (range, 17-164). Four patients had lymph node metastases. Five patients interrupted their pregnancy. Fourteen patients were given neoadjuvant platin-based systemic therapy. All patients are alive and disease free. All children born through cesarean delivery at a mean (SD) 34 (1.9) GWs are well and show normal clinical neurological development. CONCLUSIONS: To the best of our knowledge, this is the largest series so far reported on laparoscopic pelvic lymphadenectomy during pregnancy. This procedure is safe and associated with good oncological and obstetrical outcomes.

Isthmic-vaginal smear cytology in the follow-up after radical vaginal trachelectomy for early stage cervical cancer: is it safe?

BACKGROUND: Isthmic-vaginal cytology is a follow-up method in patients who have undergone radical vaginal trachelectomy (RVT) for early cervical cancer. However, to the authors' knowledge, little is known regarding its ability to monitor patients and diagnose disease recurrence. Herein, the authors report their experience with cytology after RVT compared with cytology in patients after cone biopsy and women undergoing screening. METHODS: A database of 563 specimens from 303 patients was analyzed retrospectively (RVT in 361 specimens, conization in 102 specimens, and screening in 100 specimens). The following criteria were applied: Bethesda system, the presence of endocervical and metaplasia cells, regeneration criteria, vaginal flora, and morphological signs of human papillomavirus. The analysis was performed by 2 cytopathologists. Differences between the groups and correlation between the cytopathologists were analyzed. RESULTS: Smears without endocervical and metaplasia cells were significantly less frequent among the patients who underwent RVT. There was no difference in regeneration signs, vaginal flora, and morphologic signs of human papillomavirus between the groups. After RVT, 26/23 smears (cytopathologist 1/cytopathologist 2) smears were diagnosed as abnormal. Biopsies revealed 7 cases of dysplasia and 1 case of disease recurrence. After conization, 1 patient was diagnosed with a low-grade lesion on cytology; follow-up cytology was normal. In the screening, 10/13 smears were diagnosed with lesions on cytology; biopsy revealed dysplasia in 2 cases. The correlation between both cytopathologists was high. CONCLUSIONS: After RVT, histological verification of cytology is frequently needed. The reasons might include alterations of anatomy, regeneration, and inflammation process after RVT. Cytopathologists should become familiar with the spectrum of changes in post-RVT cytology and communication between cytopathologists and clinicians should be improved. This might reduce false-positive results.

Radical vaginal trachelectomy after laparoscopic staging and neoadjuvant chemotherapy in women with early-stage cervical cancer over 2 cm: oncologic, fertility, and neonatal outcome in a series of 20 patients.

OBJECTIVES: The aim of the study was to assess oncologic and fertility outcome of treatment in patients with cervical cancer of more than 2 cm seeking parenthood. METHODS: The regimen consisted of laparoscopic lymphadenectomy as a staging procedure to confirm no lymph node metastases before neoadjuvant chemotherapy (NACT) consisting of 2 or 3 cycles of paclitaxel/ifosfamide/cisplatin followed by radical vaginal trachelectomy (RVT). Oncologic and fertility outcome was evaluated prospectively. RESULTS: Twenty women were enrolled up to now. The mean age was 32 years (range, 26-41 years), and mean tumor size was 3 cm (range, 2.1-5.0 cm). Lymphadenectomy was performed before NACT without complications. During NACT, hematologic toxicity grade 3 was observed in 2 of 20 patients, and renal toxicity grade 3 in 1 of 20 patients. Radical vaginal trachelectomy was performed in 18 women until now with 2 intraoperative complications (ureter injury and injury of internal iliac vein). There were no severe postoperative or long-term complications. Complete pathologic remission was found in 9 of 18 patients. In 2 of 18 patients, chemoradiation was recommended because of insufficient pathologic response in the RVT specimen. After a mean follow-up of 23 months (range, 1-88 months), 1 relapse was observed. After RVT, 7 women tried to conceive until now. Seven pregnancies occurred in 5 women. Four children were born, 2 of whom were premature (31 weeks 2 days and 33 weeks 4 days of gestation); 1 pregnancy is ongoing. CONCLUSIONS: Laparoscopic lymphadenectomy followed by NACT and RVT in pN0 patients with cervical cancer of more than 2 cm seems to be an oncologically safe procedure with promising fertility outcomes.

Pattern of cancer recurrence in 320 patients after radical vaginal trachelectomy.

OBJECTIVE: The oncological outcome regarding disease-free survival and overall survival after radical vaginal trachelectomy (RVT) is the same as the rates after radical hysterectomy. We aim to analyze predictive and risk factors and death in patients with cervical cancer undergoing fertility preservation by laparoscopic lymphadenectomy and RVT. METHODS: Three hundred twenty patients with cervical cancer underwent RVT between March 1995 and February 2013. In our study, we examined recurrence rates analyzed by risk factors. We classified the presence of lymphovascular space invasion, depth of tumor infiltration, tumor size, and tumor grading as risk factors. The mean follow-up time was 48 months. RESULTS: Ten of the 320 patients had cancer recurrence. Recurrence appeared at a mean time of 26.1 months (3-108 months) after RVT. Five patients died within 8.8 months (4-15 months) after recurrence was diagnosed. Two of these 5 patients had distant metastasis at the time of recurrence. Five patients were treated successfully by surgery, and 4 patients were treated successfully by chemotherapy. The mean follow-up after the recurrence of these 5 patients is 76 months (6-120 months). None of the 10 patients with recurrences in our series showed significant high-risk factors. CONCLUSION: There seems to be no pattern in the recurrence of cancer after RVT. It is strictly mandatory to follow up the patients closely every 3 months after RVT to diagnose recurrence at an early stage so therapeutic options such as chemoradiation are still available. Once distant metastasis occurs, prognosis is not good.

Vaginal-assisted laparoscopic radical hysterectomy (VALRH) versus laparoscopic-assisted radical vaginal hysterectomy (LARVH) in the treatment of cervical cancer: surgical results and oncologic outcome.

PURPOSE: The aim of this study was to compare the morbidity and survival rates of patients with early-stage cervical cancer treated by vaginal-assisted laparoscopic radical hysterectomy (VALRH) with pair-matched laparoscopic-assisted vaginal radical hysterectomy (LARVH) controls. METHODS: One hundred nine patients who underwent VALRH for cervical cancer stage FIGO Ia1, L1 to IIb between 2007 and 2009 and 200 patients who underwent LARVH between 1994 and 2002 were analysed in their entirety and in a group of matched pairs. RESULTS: In both groups, there was no conversion to laparotomy due to an intraoperative complication. Prevalence of blood transfusions was significantly lower in the VALRH group (2 vs. 39 patients; P < 0.001). Bladder function resumed sooner (P < 0.001), and patients were discharged earlier after VALRH (P < 0.001). There were no intraoperative injuries in the VALRH group. In the LARVH group, the most common intraoperative injury occurred to the bladder (7.0 %). Postoperatively, the most common complication in the VALRH group was ureterovaginal fistula (2.7 %) and fever (2.7 %) and in the LARVH ureterostenosis (3.5 %), uretero/bladder fistula (1 %), and fever (7 %). For patients with tumour stage Ib1 the 5-year recurrence-free survival was 92.8 % and 5-year overall survival 95.2 % following VALRH and 88.2 and 90.5 %, respectively, following LARVH. No significant difference in the survival rate was found (log rank, P = 0.740). CONCLUSION: VALRH is a feasible and oncologically safe surgical option for patients with early-stage cervical cancer. We believe the complication rate is lowered in VALRH by the combination of the laparoscopic and vaginal approach.

Neonatal outcome in infants of patients with radical vaginal trachelectomy.

OBJECTIVE: Radical vaginal trachelectomy (RVT) as a fertility-preserving surgery in patients with early-stage cervical cancer is proven to be oncologically safe. After RVT, pregnancy rates vary between 40 % and 80 %. Outcome of infants is complicated by a preterm delivery rate of 30 ­ 50 %. We investigated pregnancy and neonatal outcome after RVT. METHODS: A total of 154 patients with cervical cancer underwent RVT between March 1995 and February 2008. Desire to conceive, pregnancy data, and neonatal outcome were prospectively recorded. Infants' data were pair-matched to data of a control group according to weeks of gestation. Bayley scales of infant development scores were recorded in the group of preterm-delivered infants. RESULTS: Fifty-five women who underwent RVT gave birth to 58 children. Twenty-five (43 %) pregnancies were complicated by preterm rupture of membranes. Thirty infants (52 %) were born preterm, of with 17 (29 %) were < 32 gestational weeks (GW) and seven (12 %) were < 28 GW. There were significantly more premature rupture of membranes in pregnancies after RVT. Despite a higher occurrence of postnatal infections in newborns of mothers who underwent RVT, long-term outcomes are not affected negatively. Regarding overall morbidity, a trend to fewer postnatal complications, compared with the control group, was found. CONCLUSION: Postnatal morbidity in infants of women who underwent RVT, based on trend, is decreased compared with controls. Intense medical observation and treatment during pregnancy, birth, and neonatal period may explain this finding. Neonates in the RVT group have a non-significantly elevated risk for postnatal infections. They do not show an additional risk due to the maternal operation. Their long-term postnatal outcome is not affected negatively.

Volatile organic compounds (VOCs) in exhaled breath of patients with breast cancer in a clinical setting.

BACKGROUND: Carcinogenic products in the exhaled breath of cancer patients are of growing medical interest as they can serve as noninvasive disease markers. Breath analysis can be used as an alternative or complementary diagnostic tool in breast cancer patients who have a different pattern of chemical composition in their breath. This study aims to verify the existence of specific volatile organic compounds (VOCs) in the breath of breast cancer patients. METHODS: This prospective study included ten patients suffering from breast cancer and ten healthy pair-matched women. Breath samples of each member of the two respective groups were taken and scanned by gas chromatography/mass spectometry for the presence of volatile organic compounds such as alkanes, ketones, halogenated hydrocarbon, aldehydes, and esters. RESULTS: The spectrum of VOCs differed significantly within the two groups. Five specific VOCs could be identified as typical discriminatory markers in the breath samples. Four VOCs were elevated in the healthy controls, one specific VOC was found to be elevated in women affected by breast cancer CONCLUSIONS: This pilot study revealed a specific VOC pattern using gas chromatography in the breath of breast cancer patients. Five specific breast cancer-VOCs were identified. At relatively low cost the identification of VOCs may be used to detect breast cancer.

Fertility outcome after radical vaginal trachelectomy: a prospective study of 212 patients.

OBJECTIVE: For treatment in patients with early-stage cervical cancer, radical vaginal trachelectomy (RVT) as a fertility-preserving surgery can be put on a par with radical hysterectomy as to oncologic safety. Our aim was to investigate the fertility concerns and outcome. METHODS: Prospective collection of fertility data of patients treated with RVT. The data were collected on personal communication, by telephone, or e-mail correspondence. Descriptive statistical analysis was performed. RESULTS: Between March 2005 and April 2010, 212 patients were followed up after RVT. Only 76 patients (35.9%) were seeking parenthood currently. Sixty pregnancies occurred in 50 women. Five patients (8.3%) had first-trimester miscarriage, 3 had second-trimester miscarriage (5.0%), 2 patients decided for pregnancy termination (3.3%), and 1 patient (1.7%) had an ectopic pregnancy. Three women (5.0%) delivered prematurely before 28th weeks of gestation, 15 (25.0%) delivered between 28 and 36 weeks, and 27 women (45.0%) reached full term. Four pregnancies are ongoing. CONCLUSIONS: Preservation of childbearing function is a great advantage for patients with early-stage cervical cancer. Many patients do not seek parenthood immediately. We see no impairment of fertility and have solid data on pregnancy outcome. Premature labor is the main problem in pregnancy after RVT.

Radical vaginal trachelectomy (RVT) combined with laparoscopic lymphadenectomy: prospective study of 225 patients with early-stage cervical cancer.

OBJECTIVE: The aim of the study was to prove the surgical and oncological safety of radical vaginal trachelectomy (RVT) and laparoscopic lymphadenectomy for patients with early-stage cervical cancer who are seeking parenthood. METHODS: A database of 225 patients with early-stage cervical cancer and intention to treat by RVT after laparoscopic lymphadenectomy was prospectively maintained. A total of 212 patients were treated according to the protocol. The procedure was preformed in a standardized manner, and life table analysis was applied. RESULTS: In the cohort of patients treated according to protocol, 8 recurrences occurred and 4 patients died from recurrence. The median follow-up time was 37 months (range, 0-171 months). The 5-year recurrence-free and overall survival was 94.4% and 97.4%, respectively. Perioperative and short-term postoperative complications were rare (2.8% and 7.5%, respectively). No severe long-term complications occurred. CONCLUSIONS: Radical vaginal trachelectomy combined with laparoscopic lymphadenectomy is a safe method for treatment of patients with early-stage cervical cancer who are seeking parenthood.

Addressing concerns about cisplatin application during pregnancy.

INTRODUCTION: Cervical cancer in second trimester of pregnancy is an oncologic challenge. Cisplatin is recommended to prevent cancer progression. This is a series correlating in vivo cisplatin concentration in the fetomaternal compartment and in breast milk with child development. METHODS: Eight consecutive patients with cervical cancer diagnosed during the second trimester underwent conization/biopsy and/or pelvic laparoscopic lymphadenectomy (LAE). Delay of pregnancy in combination with neoadjuvant monochemotherapy was performed. After 2-4 cycles of cisplatin monochemotherapy cesarean section followed by radical hysterectomy was performed above 31 weeks of gestation. Synchronous samples from maternal blood, umbilical cord blood, and amniotic fluid were taken and analyzed. A probe of breast milk was taken from three patients. Pediatric aftercare was done every three months postpartum. RESULTS: Laparoscopic LAE was uncomplicated in all patients. In seven out of eight patients lymph nodes were tumor free. Nine healthy babies were delivered. Pediatric follow-up showed normal development. Cisplatin concentrations in the umbilical cord and amniotic fluid were 31-65% and 13-42% of the amount in maternal blood, respectively. In breast milk, cisplatin was detectable in 1-10% of maternal blood concentration. CONCLUSION: Knowledge of significant lower cisplatin concentrations in fetal compartment and normal child growth provides additional security to apply cisplatin in pregnancy. Breastfeeding cannot be recommended.

Prevalence of lymph nodes in the parametrium of radical vaginal trachelectomy (RVT) specimen.

OBJECTIVE: In order to evaluate radicality in fertility preserving surgery in women with early invasive cervical cancer we analyzed the parametrium of specimens of patients treated by radical vaginal trachelectomy for the presence of lymph nodes. We tried to identify morphologic factors associated with the presence of parametrial lymph nodes. METHODS: We analyzed surgical specimens of 112 patients who underwent radical trachelectomy between June 2004 and April 2009 at the Department of Gynecologic Oncology at Charité Campus Benjamin Franklin and Campus Mitte. All parametrial tissue was step sectioned and a total of 1878H&E stained histological sections were analyzed. RESULTS: In 8 patients (7.1%) a total of 13 lymph nodes were detected. Five lymph nodes in four patients had been primarily detected by routine histological examination. In one of these patients (0.9%) a 2mm lymph node metastasis was found. Serial sectioning revealed additional seven lymph nodes in four patients. The thickness of parametrium correlated significantly with the presence of lymph nodes in the parametrium. CONCLUSION: The presence of small lymph nodes in the parametrium of specimens of radical trachelectomy is low. In patients with early-stage cervical cancer, the incidence of metastasis is less than 1%. Preoperative assessment of the volume of the parametrium may indicate which patients need parametrial resection.

Pregnancy after lymphadenectomy and neoadjuvant chemotherapy followed by radical vaginal trachelectomy in FIGO stage IB1 cervical cancer.

OBJECTIVE: To report a case of full-term delivery after laparoscopic lymphadenectomy and neoadjuvant chemotherapy followed by radical vaginal trachelectomy in bulky stage IB1 cervical cancer. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 27-year-old woman with adenosquamous cervical cancer stage IB1 (4 cm in diameter) that was diagnosed in December 2005. She expressed a wish for fertility-sparing treatment. INTERVENTION(S): A laparoscopic pelvic and para-aortic lymphadenectomy was performed and showed no evidence of lymphatic metastasis. The patient subsequently received chemotherapy with Paclitaxel 200 mg/m2 and Cisplatin 100 mg/m2. The treatment cycle was repeated after 3 weeks with Cisplatin reduced to 50 mg/m2, because of creatinine-increase. Radical vaginal trachelectomy was then performed. After histologic examination, carcinoma of only 2 mm in diameter was found in the final specimen. MAIN OUTCOME MEASURE(S): Oncologic and fertility outcome after neoadjuvant chemotherapy and radical vaginal trachelectomy. RESULT(S): The patient resumed a normal menstrual pattern 6 weeks after surgery. In December 2008, she conceived and carried and infant to full term. Antenatally, she reported no problems during pregnancy except for gestational insulin-dependent diabetes. She gave birth to a baby boy at 38 weeks' gestation by caesarean section. The newborn (weight, 3500 g; length, 52 cm; Apgar scores, 5/8/10; pH value, 7.28) was monitored in a neonatal ward for 24 hours. The patient is currently under outpatient review and has had 5 years of follow-up with no evidence of recurrence. CONCLUSION(S): Neoadjuvant chemotherapy followed by a fertility-sparing surgery may become a valuable option for women with bulky-stage cervical cancer who wish to preserve their fertility potential.

Vaginal-assisted laparoscopic radical hysterectomy: rationale, technique, results.

OBJECTIVE: Total laparoscopic radical hysterectomy (TLRH) makes it difficult to resect adequate vaginal cuff according to tumor size and to avoid tumor spread after opening the vagina. Laparoscopic-assisted radical vaginal hysterectomy (LARVH) is associated with higher risk for urologic complications. METHODS: The vaginal-assisted laparoscopic radical hysterectomy (VALRH) technique comprises 3 steps: (1) comprehensive laparoscopic staging, (2) creation of a tumoradapted vaginal cuff, and (3) laparoscopic transsection of parametria. We retrospectively analyzed data of 122 patients who underwent VALRH for early stage cervical cancer (n=110) or stage II endometrial cancer (n=12) between January 2007 and December 2009 at Charité University Berlin. RESULTS: All patients underwent VALRH without conversion. Mean operating time was 300 minutes, and mean blood loss was 123cc. On average, 36 lymph nodes were harvested. Intra- and postoperative complication rates were 0% and 13.1%, respectively. Resection was in sound margins in all patients. After median follow-up of 19 months, disease-free survival and overall survival for all 110 cervical cancer patients was 94% and 98%, and for the subgroup of patients (n=90) with tumors ≤pT1b1 N0 V0 L0/1 R0, 97% and 98%, respectively. CONCLUSION: VALRH is a valid alternative to abdominal radical hysterectomy and LARVH in patients with earlystage cervical cancer and endometrial cancer stage II with minimal intraoperative complications and identical oncologic outcomes.

Laparoscopic approach for correction of chylous fistula after pelvic and paraaortic lymphadenectomy.

Chylous fistula is an uncommon but challenging complication after lymphadenectomy for treatment of gynecologic cancers. Its presence contributes substantially to increased morbidity and may retard the onset of adjuvant therapies. Treatment options include dietary modifications or surgical intervention. A 68-year-old woman with renal insufficiency developed chylous ascites after pelvic und para-aortic laparoscopic lymph node dissection followed by chemoradiation for treatment of class IIb cervical cancer. Conservative treatment failed, and the patient underwent laparoscopic exploration. The leakage was identified near the cisterna chyle, and was closed with sutures. There was no evidence of recurrence after 2-month follow-up. This case demonstrates successful laparoscopic management of chylous ascites after para-aortic lymphadenectomy and chemoradiation, using suturing.

Laparoscopic pelvic lymphadenectomy in a patient with cervical cancer stage Ib1 complicated by a twin pregnancy.

Cervical cancer is the most frequently observed malignancy during pregnancy. The presence of nodal metastasis is the most important negative predictor factor, and its assessment is crucial in deciding whether the pregnancy can safely continue. To our knowledge, this is the first report of a twin pregnancy complicated by cancer of the uterine cervix that was successfully treated with laparoscopic pelvic lymphadenectomy and subsequently with neoadjuvant chemotherapy. A 35-year-old woman, gravida 2, para 1, with a dichorionic-diamniotic twin pregnancy underwent laparoscopic staging of the pelvic lymph nodes at 17 weeks of gestation. Cervical adenocarcinoma, grade 2, stage 1b1 with lymphovascular space invasion was diagnosed. Nineteen negative nodes were removed, and the patient was counseled to continue the pregnancy. On the basis of tumor size and detection of lymphovascular space invasion, cisplatin as neoadjuvant chemotherapy was administered until week 32 of gestation, when a cesarean section delivery was performed, along with radical hysterectomy. No complications to the neonates or to the mother due to the therapy were observed. This case demonstrates the safety of operative nodal staging during gestation, even in a twin pregnancy. Exclusion of nodal metastasis may improve oncologic outcomes, and neoadjuvant chemotherapy should be administered when indicated.