Robotic surgery for cervical cancer.

UNLABELLED: The development of robotic technology has facilitated the application of minimally invasive techniques for the treatment and evaluation of patients with early, advanced, and recurrent cervical cancer. The application of robotic technology for selected patients with cervical cancer and the data available in the literature are addressed in the present review paper. The robotic radical hysterectomy technique developed at the Mayo Clinic Arizona is presented with data comparing 27 patients who underwent the robotic procedure with 2 matched groups of patients treated by laparoscopic (N = 31), and laparotomic radical hysterectomy (N = 35). A few other studies confirmed the feasibility and safety of robotic radical hysterectomy and comparisons to either to the laparoscopic or open approach were discussed. Based on data from the literature, minimally invasive techniques including laparoscopy and robotics are preferable to laparotomy for patients requiring radical hysterectomy, with some advantages noted for robotics over laparoscopy. A prospective randomised trial is currently being performed under the auspices of the American Association of Gyneoclogic Laparoscopists comparing minimally invasive radical hysterectomy (laparoscopy or robotics) with laparotomy. For early cervical cancer radical parametrectomy and fertility preserving trachelectomy have been performed using robotic technology and been shown to be feasible, safe, and easier to perform when compared to the laparoscopic approach. Similar benefits have been noted in the treatment of advanced and recurrent cervical cancer where complex procedures such as extraperitoneal paraortic lymphadenectomy and pelvic exenteration have been required. CONCLUSION: Robotic technology better facilitates the surgical approach as compared to laparoscopy for technically challenging operations performed to treat primary, early or advanced, and recurrent cervical cancer. Although patient advantages are similar or slightly improved with robotics, there are multiple advantages for surgeons.

Clinical and pathologic correlates in surgical stage II endometrial carcinoma.

OBJECTIVE: To identify the surgical, pathologic, and therapeutic factors that influence outcome in patients with surgical stage II endometrial adenocarcinoma. METHODS: All patients with comprehensively staged stage II endometrial adenocarcinoma were identified. Data regarding preoperative, surgical, pathologic, adjuvant therapy, and outcomes were collected. Factors were compared with the chi(2) test, and survival curves were generated and compared with the log rank test. RESULTS: Of 162 patients with surgical stage II endometrial cancer, the median age was 65 years, and the median body mass index was 31.2 kg/m(2). An extrafascial hysterectomy was performed in 75% of cases, whereas 25% of patients underwent radical hysterectomy. At least 10 nodes were recovered in more than 90% of cases. Stage IIA disease was present in 52% of cases, whereas stage IIB accounted for the remaining 48%. After staging, 48% of patients had adjuvant radiation therapy (16% with brachytherapy alone). The remainder received no adjuvant therapy. At a median follow-up of 26 months, 17% experienced disease recurrence. Five-year overall survival rate was 88% and disease-free survival rate was 81%. A significantly better 5-year disease-free survival rate was seen in patients undergoing radical hysterectomy compared with extrafascial hysterectomy (94% compared with 76%, P=.05). Adjuvant radiation did not lead to improved survival. CONCLUSION: In this large series of surgical stage II endometrial cancer cases, improved survival was noted relative to historical controls and in particular with radical compared with extrafascial hysterectomy.

Improved survival with an intact DNA mismatch repair system in endometrial cancer.

OBJECTIVE: To correlate survival and surgical-pathologic factors with DNA mismatch repair status in patients with endometrial cancer. METHODS: Specimens from 336 patients with endometrial cancer were used to create a tissue microarray. Immunohistochemistry with antibodies against the mismatch repair genes MLH1, MSH2, MSH6, and PMS2 were used to stain the tissue microarray. Clinical, pathologic, and survival data were collected and correlated with the immunohistochemistry results. RESULTS: Mismatch repair deficiency was seen in 29% (84 of 294) of cases. Correlation was noted between lack of expression of MLH1 and an increased risk for lymphvascular space involvement (32% versus 21%, P=.05) and cervical involvement (26% versus 14%, P=.02). Lack of expression of either MLH1 or MSH2 was associated with thinner patients (85% had a body mass index less than 40 versus 73% of patients with normal expression, P=.02), as well as with the absence of a history of previous primary malignancy (0 verus 13 cases [4%], P=.023). The estimated disease-free survival is 88%; despite a small number of recurrences, there was a nonsignificant improvement in disease-free survival in tumors with an intact mismatch repair system (P=.1). Significantly improved disease-free survival was seen in patients with normal MLH1 and MSH2 expression compared with those with abnormal expression (92% versus 81%, P=.035). CONCLUSION: Defects in DNA mismatch repair in endometrial cancer is correlated with negative prognostic factors and worse progression-free survival (without a difference in overall survival) compared with tumors with an intact mismatch repair system. LEVEL OF EVIDENCE: II-3.

Invasive cervical adenocarcinoma immediately following a cone biopsy for adenocarcinoma in situ with negative margins.

BACKGROUND: Cervical adenocarcinoma in situ is often diagnosed in younger women who may wish to preserve the potential for fertility. Given that the rate of recurrent adenocarcinoma in situ is relatively low and the risk of invasive adenocarcinoma is extremely rare, conservative management in this population after a cone biopsy demonstrates negative margins has been accepted as an appropriate management strategy. This case challenges the concept of conservative management of cervical adenocarcinoma in situ. CASE: A 42-year-old G2P2002 with previously normal annual cervical cytology had a Pap smear demonstrating atypical glandular cells of uncertain significance. A 1.5-cm lesion was noted at the endocervix, and a punch biopsy revealed adenocarcinoma in situ. A large cold knife cone biopsy confirmed cervical adenocarcinoma in situ with negative margins. Definitive therapy for in situ disease with an extrafascial hysterectomy was performed 12 days after conization, and demonstrated stage IB1 cervical adenocarcinoma. A radical parametrectomy, radical upper vaginectomy, and pelvic lymphadenectomy were without persistent disease. CONCLUSION: Conservative management of cervical adenocarcinoma in situ after a cone biopsy with negative margins does not exclude the possibility of concurrent invasive cervical adenocarcinoma. This case challenges the current balance between risk and benefit associated with the conservative management of cervical adenocarcinoma in situ.