Percutaneous-assisted laparoscopy for ovarian tissue cryopreservation: a single-center experience.

PURPOSE: To compare surgical and post-operative outcomes of patients submitted to traditional laparoscopy and percutaneous-assisted laparoscopy for ovarian tissue explant for cryopreservation. METHODS: This is a single-center retrospective comparative study conducted in IRCCS "Regina Elena" National Cancer Institute of Rome. Patients submitted to laparoscopic excision of ovarian tissue, before starting chemotherapy were enrolled. We compared the classic laparoscopic approach vs percutaneous-assisted laparoscopy, using the Percuvance grasping forceps. RESULTS: Fifty-nine young oncologic women were enrolled; 38 underwent a conventional laparoscopy (LAP), 21 received a percutaneous laparoscopy (PERC). The baseline characteristics were similar in both groups, furthermore no differences were found in terms of peri-operative complications, median estimated blood loss (p = 0.4), operative time (p = 0.2), recovery times (p = 0.1), median time to chemotherapy (p = 0.7), median area of collected samples (p = 0.9). The postoperative pain evaluated by VAS-score, was significantly lower in the PERC group vs LAP group, both the day of surgery (range 0-4 vs 0-2; p = 0.02) and after 1 (range 0-3 vs 0-2; p = 0.002) and 2 days (range 0-3 vs 0-1; p = 0.0001). Moreover, better aesthetic results were detected in the PERC group, 2 months after surgery (median 9 vs 10, range 7-10 vs 9-10; p = 0.0001). CONCLUSIONS: Percutaneous-assisted laparoscopy has proven to be an effective and safe procedure for the excision of ovarian tissue for cryopreservation, in young oncologic patients that want to preserve their fertility. The percutaneous procedure appears superior to conventional laparoscopy in terms of aesthetic outcomes and post-operative pain reduction. CLINICAL TRIAL ID: NCT05134090, 24th Nov 2021, retrospectively registered.

The giant steps in surgical downsizing toward a personalized treatment of vulvar cancer.

The present article aims to highlight the importance of changes of personalized surgical treatment for vulvar cancer. Current international literature regarding surgical treatment of vulvar cancer was evaluated. This included several studies and systematic reviews. Radical surgery approach, such as en bloc resection, was the first therapeutic option and the standard care for many years, even if burdened with a high complication rate and frequently disfiguring. Taussing and Way introduced radical vulvectomy approach with en bloc bilateral inguinal-femoral lymphadenectomy; modified radical vulvectomy was developed, with a wide radical excision of the primary tumor. The role of inguinofemoral lymphadenectomy (mono or bilateral) changed in the years too, particularly with the advent of SLN biopsy as minimally invasive surgical approach for lymph node staging, in patients with unifocal cancer <4 cm, without suspicious groin nodes. More personalized and conservative surgical approach, consisting of wide local or wide radical excisions, is necessary to reduce complications as lymphedema or sexual disfunction. The optimal surgical management of vulvar cancer needs to consider dimensions, staging, depth of invasion, presence of carcinoma at the surgical margins of resection and grading, with the goal of making the treatment as individualized as possible.

Development of new medical treatment for epithelial ovarian cancer recurrence.

Epithelial ovarian cancer (EOC) is the scariest gynaecological cancer. Many advances have been done with evolving knowledge, leading to the introduction of new drugs, most in maintenance setting. The antiangiogenic Bevacizumab and the three approved PARP-inhibitors-olaparib, niraparib and rucaparib-are gradually improving PFS of patients with EOC, with initial effects on OS too. But recurrence is still a heavy sentence and lethality continues to be high. Ovarian cancer is a complex disease, with different clinical presentation, histological aspect, and molecular expression, leading to disappointing results, when using a single drug. Implementation of biobanking and analysis of patients' tumour samples, before starting a treatment, could be a promising way to better understand molecular aspects of this disease, to identify markers predictive of response and to allow a better use of experimental drugs, as immunomodulators, targeted therapies, and combinations of these, to fight tumour growth and clinical progression. We reviewed the literature on the updated treatments for recurrent ovarian cancer, summarizing all the available drugs and combinations to treat patients with this diagnosis, and focusing the attention on the new approved molecules and the contemporary Clinical Trials, investigating new target therapies and new associations.

Practical recommendations for gynecologic surgery during the COVID-19 pandemic.

Surgery in suspected/confirmed COVID-19 patients is a high-risk venture. In infected patients, COVID-19 is present in the body cavity. During surgery it could be nebulized in the spray generated by surgical instruments and could theoretically infect members of the surgical team. Nevertheless, some surgical gynecologic pathologies cannot be postponed. We present a list of the most frequent gynecologic diseases and recommendations on their surgical management during the COVID-19 pandemic, based on expert opinion, current available information, and international scientific society recommendations to support the work of gynecologists worldwide. In brief, any kind of surgical treatment should be scrutinized and postponed if possible. Nonoperative conservative treatment including pharmacological therapies for hormone-sensitive pathologies should be implemented. Health risk assessment by patient history and COVID-19 test before elective surgery are pivotal to protect both patients and healthcare providers. In confirmed COVID-19 patients or highly suspected cases, elective surgery should be postponed until full recovery.

Primary debulking surgery vs. interval debulking surgery for advanced ovarian cancer: review of the literature and meta-analysis.

INTRODUCTION: Epithelial ovarian cancer (EOC) is the seventh most common cancer among women in the world and the leading cause of death from gynecological malignancies. The standard treatment for advanced EOC consists of optimal primary debulking surgery (PDS) associated with an adjuvant chemotherapy. Neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) have been proposed in the management of advanced EOC to increase the rate of complete citoreductive surgery and to reduce morbidity and mortality. This systematic review and meta-analysis is conducted to compare the oncologic and postoperative outcomes of NACT and IDS with PDS followed by chemotherapy in patients with ovarian cancer. EVIDENCE ACQUISITION: We conducted a search on the electronic databases PubMed/Medline, Cochrane and Scopus. All randomized controlled trials, cohort and case-control studies comparing PDS and IDS in ovarian cancer published in English until 28 February 2019 were considered eligible. EVIDENCE SYNTHESIS: Twenty studies were included in the systematic review. As regards the meta-analysis, only studies that allowed the data we needed to be extracted were included: five were included for the evaluation of overall survival (OS) and PFS and 9 for the evaluation of major postoperative complications and days of hospital stay. CONCLUSIONS: From the meta-analysis of the current available literature, none of the two investigated procedures has proven to be superior in terms of OS and PFS in the treatment of advanced ovarian cancer. However surgical complexity and postoperative complications are reduced in the IDS group.

The prognostic significance of positive peritoneal cytology in endometrial cancer and its correlations with L1-CAM biomarker.

BACKGROUND: The aim of this study was to evaluate the prognostic role of positive peritoneal cytology (PPC) in a cohort of patients with endometrial cancer (EC). The secondary objective was to correlate the PPC and the expression of L1CAM in a group of patients with recurrence endometrial disease. METHODS: All women diagnosed with EC and who performed a peritoneal cytology at "Regina Elena" National Cancer Institute of Rome from 2001 to 2013 were included in the study. Patients were divided into two groups according to positivity at peritoneal cytology. Moreover, patients with a recurrence disease and whose a tissue microarray (TMA) tumor sample was available underwent a L1CAM analysis. RESULTS: Seven hundred sixty six patients underwent to EC staging in our Institute: 696 (90.8%) with negative and 70 (9.2%) with positive cytology. Five-year recurrence rate was higher in women with PPC (46.9% vs 18.4%, p = 0 < 0.0001) and, in particular, distant recurrence (86.7% vs 53.4%, p = 0.03). Moreover, we found an interesting pattern of recurrence disease in the group of early stage of EC with NPC and positive L1CAM. CONCLUSIONS: Our results support the data that PPC may be a potential prognostic factor in early EC, due to its significant association with other risk factors and its significant influence on survival. Our findings confirm the need for large studies that point out the role of PPC and new prognostic factors, including biomarkers as L1CAM.

Laparoscopic versus robotic hysterectomy in obese and extremely obese patients with endometrial cancer: A multi-institutional analysis.

OBJECTIVE: The aim of this study was to evaluate the surgical and oncological outcome of robotic surgical staging with hysterectomy (RH) plus or less pelvic and aortic lymphadenectomy, compared to the same procedures performed by laparoscopic surgery (LH) in obese patients (BMI≥30 kg/m2) with endometrial cancer. MATERIAL AND METHODS: From October 2001 to April 2017, obese patients (BMI > 30 kg/m2) with primary, histologically confirmed endometrial carcinoma who underwent LH or RH using the Da Vinci Si or Xi Surgical System® (Intuitive Surgical Inc®, 1266 Kifer Road, Building 101 Sunnyvale, CA) were eligible for the study. RESULTS: We identified 655 women with endometrial cancer and BMI >30 kg/m2. Out of 655 patients, 249 (38%) underwent RH and 406 (62%) underwent LH plus or less pelvic and aortic lymphadenectomy. Our study showed that, compared to the 406 patients treated in LPS, 249 patients treated in robotics have a statistically significant difference in terms of increased operating time and a decreased conversion rate. In addition, the rate of pelvic lymphadenectomies in robotic surgeries is twice the one reported in LPS surgeries. Furthermore, a reduction in hospital stay was observed in the robotic group. We observed that the oncological outcomes do not vary according to the surgical approach and BMI variation. CONCLUSIONS: robotic surgery in severely obese women with endometrial cancer is feasible, safe, and reproducible and could be a valid alternative to laparoscopy in the treatment of these patients. Prospective studies could confirm our results.

Correction to: Serum DNA integrity index as a potential molecular biomarker in endometrial cancer.

CORRECTION: In the publication of this article [1], there is an error in the first sentence of the Acknowledgements section.

Serum DNA integrity index as a potential molecular biomarker in endometrial cancer.

BACKGROUND: Circulating cell-free DNA (cfDNA) and its integrity index may represent a rapid and noninvasive "liquid biopsy" biomarker, which gives important complementary information for diagnosis, prognosis, and treatment stratification in cancer patients. The aim of our study was to evaluate the possible role of cfDNA and its integrity index as a complementary tool for endometrial cancer (EC) management. METHODS: Alu-quantitative real-time PCR (qPCR) analysis wasprformed on 60 serum samples from preoperative EC patients randomly recruited. Both cfDNA content and DNA integrity index were measured by qPCR-Alu115 (representing total cfDNA) and qPCR-Alu247 (corresponding to high molecular weight DNA) and correlated with clinicopathologic characteristics. Lymphovascular space invasion (LVSI) was detected by hematoxylin and eosin staining. In case of doubt, LVSI status was further evaluate by immunohistochemistry using anti-CD31 and anti-CD34 antibodies. RESULTS: Total cfDNA content significantly increases in high grade EC. A significant decrease of DNA integrity index was detected in the subset of hypertensive and obese high grade EC. Serum DNA integrity was higher in samples with LVSI. The ordinal regression analysis predicted a significant correlation between decreased integrity index values and hypertension specifically in tumors presenting LVSI. CONCLUSIONS: Our study supports the utility of serum DNA integrity index as a noninvasive molecular biomarker in EC. We show that a correlation analysis between cfDNA quantitative and qualitative content and clinicopathologic features, such as blood pressure level, body mass index (BMI) and LVSI status, could represent a potential predictive signature to help stratification approaches in EC.

Robotic single site radical hysterectomy plus pelvic lymphadenectomy in gynecological cancers.

OBJECTIVE: To evaluate the feasibility and the safety of robotic single-site radical hysterectomy (RSSRH) plus pelvic lymphadenectomy (PL) in endometrial or cervical cancer. METHODS: Patients with endometrial cancer (EC) International Federation of Gynecology and Obstetrics (FIGO) stage II, early cervical cancer (ECC) FIGO stage IB1 or locally advanced cervical cancer (LACC) FIGO stage IB2-IIB with clinical response ≥50% after neo-adjuvant chemotherapy (NACT) were enrolled in a prospective cohort trial. All cases were performed using the da Vinci Si Surgical Single Site System®. RESULTS: Between April 2014 and November 2016, twenty patients were included in our pilot study. Three and 17 patients underwent type B1 or C1 RSSRH plus PL, respectively. The median age of patients was 46 years (range, 36-68 years) and the median body mass index was 23.5 kg/m² (range, 19.1-36.3 kg/m²). The median total operative time was 190 minutes (range, 90-310 minutes). The median blood loss was 75 mL (range, 20-700 mL) and the median number of pelvic lymph nodes removed was 16 (range, 5-27). No laparoscopic/laparotomic conversions were reported and the median time to discharge was 6 days (range, 4-16 days). No intra-operative complications occurred while 4 (20%) post-operative complications were reported: one pelvic abscess, one lymphorrea, one bowel perforation, and one vaginal dehiscence. CONCLUSION: RSSRH plus PL is technically feasible in patients affected by gynecological cancer.

The Patient and Observer Scar Assessment Scale to Evaluate the Cosmetic Outcomes of the Robotic Single-Site Hysterectomy in Endometrial Cancer.

OBJECTIVE: The objective of this study was to evaluate the cosmetic outcome of robotic single-site hysterectomy (RSSH) in early-stage endometrial cancer. METHODS: We prospectively collected patient demographics, operative times, complications, pathologic results, and length of stay on all patients who underwent RSSH for early-stage endometrial cancer. The Patient and Observer Scar Assessment Scale (POSAS) was used for the evaluation of the cosmetic outcome. RESULTS: Forty-five patients were included in our study from January 2012 to October 2015. The median age of patients was 63 years (range, 35-84 years), and the median body mass index was 26.5 kg/m (range, 18-39 kg/m). No laparoscopic/laparotomic conversion was registered. The median docking time, console time, and total operative time were 7 minutes (range, 4-14 minutes), 46 minutes (range, 20-100 minutes), and 90 minutes (range, 45-150 minutes), respectively. The median blood loss was 50 mL (range, 10-150 mL). Nine patients underwent pelvic lymphadenectomy, and the median number of pelvic lymph nodes was 13 (range, 10-32). The median time to discharge was 3 days (range, 2-6 days). No intraoperative complications occurred, whereas we did observe 1 early postoperative complication. The oncological outcome was directly comparable to the literature. Patients reported low pain scores and high satisfaction in terms of postoperative scarring. The POSAS scores confirmed excellent cosmetic outcome of RSSH. CONCLUSION: Robotic single-site hysterectomy provided an efficient option for gynecologic oncologic surgery. The POSAS revealed high objective and patient-evaluated outcome, and patients were highly satisfied with the overall outcome of the appearance of their scars.

Circulating cell-free DNA content as blood based biomarker in endometrial cancer.

BACKGROUND: Altered circulating cell-free DNA (cfDNA) levels are related to cancer development and aggressiveness. Up to now, very few studies have been performed for evaluating cfDNA content in endometrial cancer (EC). METHODS: First, we measured cfDNA release in blood serum of EC cancer patients collected before surgery and before the beginning of any treatment by SYBR Gold assay and correlated it with tumor aggressiveness. We also assessed the relative mitochondrial cell-free DNA (cfmtDNA) content by qRT-PCR. Next, we correlated cfDNA levels with BMI, age, hypertension and inflammation markers. RESULTS: CfDNA levels are higher in G2 and G3 compared with G1 EC sera. A significant modulation of cfDNA content was detected in sera from patients with BMI>30 compared with those with BMI<30. We observed a further and significant alteration in cfDNA level in hypertensive patients with G2-G3, but not in G1 EC. Analysis of preoperative neutrophil-to-lymphocyte (NLR) and monocyte-to-lymphocyte (MLR) ratios suggests a contribution of the host response in the altered cfDNA levels in EC. CONCLUSIONS: Our data indicate that assessment of total and mitochondrial cfDNA levels in blood sera and the relative NLR and MLR in blood obtained from preoperative patients may help clinical management and prognosis in EC.

Single-access laparoscopic approach in the surgical treatment of endometrial cancer: A single-institution experience and review of literature.

BACKGROUND: The aim of this study was to assess the surgical and oncological outcome for the management of endometrial cancer (EC) by laparoendoscopic single-site surgery (LESS). PATIENTS AND METHODS: We performed a retrospective chart review of patients who underwent a LESS for EC. All the patients were treated by the same surgical team between July 2009 and June 2013 at the Gynaecologic Oncologic Unit, Regina Elena National Cancer Institute, Rome, Italy. RESULTS: A total of 50 women were included, with a median age of 45 years (range, 39-84 years) and a median body mass index (BMI) of 21.8 kg/m2 (range, 19-48 kg/m2). Median operative time was 100 min (range, 50-240 min), median blood loss was 90 mL (range, 10-300 mL) and median hospital stay was 3 days (range, 2-9 days). The median number of pelvic lymph nodes retrieved was 14 (range, 5-20). No intraoperative complications occurred, but there were 4 postoperative complications. Two patients required a laparoscopic conversion. The median follow-up was 36 months (range, 16-62 months) and no recurrence occurred. CONCLUSION: Our report showed that the LESS approach in the treatment of early EC can be a safe and reliable technique in terms of surgical and oncological outcomes.

Robotic single site versus robotic multiport hysterectomy in early endometrial cancer: a case control study.

OBJECTIVE: To compare surgical outcomes and cost of robotic single-site hysterectomy (RSSH) versus robotic multiport hysterectomy (RMPH) in early stage endometrial cancer. METHODS: This is a retrospective case-control study, comparing perioperative outcomes and costs of RSSH and RMPH in early stage endometrial cancer patients. RSSH were matched 1:2 according to age, body mass index, comorbidity, the International Federation of Gynecology and Obstetric (FIGO) stage, type of radical surgery, histologic type, and grading. Mean hospital cost per discharge was calculated summarizing the cost of daily hospital room charges, operating room, cost of supplies and length of hospital stay. RESULTS: A total of 23 women who underwent RSSH were matched with 46 historic controls treated by RMPH in the same institute, with the same surgical team. No significant differences were found in terms of age, histologic type, stage, and grading. Operative time was similar: 102.5 minutes in RMPH and 110 in RSSH (p=0.889). Blood loss was lower in RSSH than in RMPH (respectively, 50 mL vs. 100 mL, p=0.001). Hospital stay was 3 days in RMPH and 2 days in RSSH (p=0.001). No intraoperative complications occurred in both groups. Early postoperative complications were 2.2% in RMPH and 4.3% in RSSH. Overall cost was higher in RMPH than in RSSH (respectively, $7,772.15 vs. $5,181.06). CONCLUSION: Our retrospective study suggests the safety and feasibility of RSSH for staging early endometrial cancer without major differences from the RMPH in terms of surgical outcomes, but with lower hospital costs. Certainly, further studies are eagerly warranted to confirm our findings.

Surgical and Oncological Outcome of Robotic Surgery Compared With Laparoscopic and Abdominal Surgery in the Management of Locally Advanced Cervical Cancer After Neoadjuvant Chemotherapy.

OBJECTIVE: The primary aim is to evaluate the surgical and oncological outcome of robotic radical hysterectomy (RRH) plus pelvic lymphadenectomy in locally advanced cervical cancer (LACC) after neoadjuvant chemotherapy (NACT). The secondary aim is to compare the surgical and oncological results of RRH after NACT with a historical cohort of patients undergoing laparoscopic radical hysterectomy or abdominal radical hysterectomy plus pelvic lymphadenectomy for LACC after NACT. METHODS: We enrolled a total of 41 patients in this study with LACC undergoing RRH, who achieved a clinical partial or complete response to NACT. The surgical and oncological outcomes of 2 historical groups were compared: the laparoscopic group (41 patients) with the laparotomic group (43 patients). RESULTS: The median estimated blood loss, operative time, and length of hospital stay were statistically significant and in favor of the robotic group. No conversion to laparotomy in the robotic group was necessary. There were no significant differences between the 3-year overall survival and disease-free survival rates in the minimally invasive groups; nevertheless, the robotic group showed the same recurrence rate of laparoscopic in a short-interval follow-up. CONCLUSIONS: The robotic approach could be considered a feasible and safe alternative to other surgical options. Multicenter randomized clinical trials with longer follow-ups are necessary to evaluate the overall oncologic outcomes of this procedure.

Laparoscopic Debulking Surgery in the Management of Advanced Ovarian Cancer After Neoadjuvant Chemotherapy.

OBJECTIVE: The purpose of this study was to evaluate the feasibility and morbidity of total laparoscopic debulking surgery in the treatment of advanced ovarian cancer after neoadjuvant chemotherapy. METHODS/MATERIALS: We performed a retrospective review of laparoscopic approach in patients with histologically confirmed epithelial ovarian cancer (International Federation of GynaecologyObstetrics stages IIIC-IV) who received 3 courses of neoadjuvant chemotherapy, from January 2010 to December 2014, at the Gynaecologic Oncologic Unit, "Regina Elena" National Cancer Institute, Rome, Italy. RESULTS: A total of 30 patients were included. The median age was 50 years (range, 26-73 years), median body mass index was 24.5 kg/m (range, 19-39 kg/m). All patients had good clinical response to 3 cycles of neoadjuvant chemotherapy. All women underwent a complete debulking surgery with no residual disease. The median operating time was 152 minutes (range, 70-335 minutes), the median blood loss was 70 mL (range, 50-200 mL). The median number of removed pelvic lymph nodes was 15 (range, 13-25). There was 1 (3.3%) intraoperative complication and 2 (6.6%) postoperative short-term complications. The median length of hospital stay was 4 days (range, 3-13 days). The median follow-up was 15 months (range, 2-54 months). Twenty-six patients are free from recurrence at the time of this report. CONCLUSIONS: Laparoscopic cytoreduction in patients with advanced ovarian cancer after neoadjuvant chemotherapy, when performed by skilled surgeons, seems feasible and may decrease the impact of aggressive surgery on high-morbidity patients, such as on women after chemotherapy.

Robotic single-site hysterectomy in low risk endometrial cancer: a pilot study.

BACKGROUND: To evaluate the feasibility and the safety of robotic single-site hysterectomy (RSSH) in low risk early endometrial cancer. METHODS: Patients with clinical low risk early endometrial cancer were enrolled onto a prospective cohort trial. All surgical procedures were performed through a single 2-2.5 cm umbilical incision, with a multichannel system consisting of a five-lumen port providing access for two single-site instruments (da Vinci Si Surgical System, Intuitive Surgical, Sunnyvale, CA), the 8.5 mm 3D HD endoscope, a 5/10 mm accessory port, and an insufflation adaptor. RESULTS: Between December 2011 and June 2012, a total of 17 patients were included in our pilot study. The median age of the patients was 64 years (range, 42-84 years), and median body mass index was 26.6 kg/m(2) (range, 18-52 kg/m(2)). One patient was excluded from the study as a result of pelvic metastasis during inspection of abdominal cavity, and another patient was converted to vaginal surgery as a result of problems of hypercapnia. The median docking time, console time, and total operative time was 8 min (range, 5-14 min), 48 min (range, 45-51 min), and 90 min (range, 70-147 min), respectively. The median blood loss was 75 mL (range, 50-150 mL). No laparoscopy/laparotomy conversion was registered. The median time to discharge was 2 days (range, 1-3 days). Neither intraoperative nor postoperative complications occurred. At a median of 7.5 months' follow-up, all patients were disease-free. CONCLUSIONS: RSSH is technically feasible in patients affected by low risk early endometrial cancer. Additional studies with gynecologic oncologic cases should be performed to explore the possible benefits of RSSH.

Robotic transperitoneal aortic lymphadenectomy in gynecologic cancer: a new robotic surgical technique and review of the literature.

BACKGROUND: Lymph node status is a prognostic factor for gynecologic cancer. We describe a new developing strategy for robotic transperitoneal aortic lymphadenectomy without relocating the robotic column or the patient. METHODS: Patients with histologically confirmed cervical cancer, early ovarian cancer, or endometrial carcinoma with suspected risk factors indicating aortic lymphadenectomy were eligible for the robotic transperitoneal aortic lymphadenectomy using the Da Vinci robotic system as part of the surgical treatment of gynecologic malignancies. RESULTS: The mean operating time was 224 min (range 160-300 min), and the mean console time for aortic lymphadenectomy was 43 min (range 30-75). The median hemoglobin fall was 1.3 g/dL range (0.8-2 g/dL), the median number of removed aortic lymph nodes was 12.5 (range 7-17), and the median length of the hospital stay was 2 days (range 1-4 days). We experienced an intraoperative complication, but no conversion to laparotomy was necessary. No patients received a blood transfusion. CONCLUSIONS: This initial experience demonstrates the feasibility of robotic aortic lymphadenectomy with good accuracy and safety without relocating the robotic column or the patient.

Use of SAND balloon catheter for laparoscopic management of extremely large ovarian cysts.

The objective of the study was to assess the feasibility and outcome of laparoscopic surgery for management of extremely large ovarian cysts using the SAND balloon catheter. From January 2006 to December 2009, 25 patients with large cystic adnexal tumors underwent laparoscopic-assisted surgery using the SAND balloon catheter. Median (range) patient age was 43 (20-68) years, body mass index was 25 (19-32), mass size was 26 cm (15-60 cm), duration of the surgical procedure was 60 (30-300) minutes), and blood loss was 30 (10-100) mL. There were no major surgical complications. Intra-abdominal leakage of cyst fluid was observed in only 1 case (4%). With proper patient selection, the SAND balloon catheter can be extremely useful in laparoscopic removal of very large adnexal masses, without intraperitoneal spillage.

Progression of conservatively treated endometrial complex atypical hyperplasia in a young woman: a case report.

OBJECTIVE: To describe a case of progression of endometrial complex atypical hyperplasia (CAH) to extrauterine endometrioid adenocarcinoma in a patient who had requested fertility-sparing management. DESIGN: Case report. SETTING: Division of Gynecologic Oncology, National Cancer Institute "Regina Elena," Rome, Italy. PATIENT(S): A nulliparous 36-year-old woman with endometrial CAH who decided on a conservative approach. INTERVENTION(S): Conservative hysteroscopic resection of the lesion, the surrounding endometrium, and underlying myometrium plus hormone therapy regimen of megestrol acetate (160 mg) daily for 6 months. MAIN OUTCOME MEASURE(S): Failure of the conservative therapy and progression of disease. RESULT(S): Eighteen months after fertility-sparing management, a laparoscopic operation revealed grade 2 endometrium adenocarcinoma with superficial myometrial invasion and a microscopic metastasis of the left ovary and Douglas peritoneum. The patient underwent adjuvant chemotherapy followed by external beam radiation of the pelvis and brachytherapy. Twenty-five months after, she was free of disease. CONCLUSION(S): Conservative therapy is feasible in carefully selected young women with endometrial CAH. However, close follow-up is required because of possible progression to endometrial cancer.