Bilateral negative sentinel nodes accurately predict absence of lymph node metastasis in early cervical cancer: results of the SENTICOL study.

PURPOSE: Sentinel lymph node (SLN) biopsy may be used to target lymph node metastases in patients with early cervical cancer. Whether SLN biopsy only is acceptable in the staging and surgical management of early cervical cancer remains unknown. This prospective multicenter study (SENTICOL [Ganglion Sentinelle dans le Cancer du Col]) assessed the sensitivity and negative predictive value (NPV) of SLN biopsy. PATIENTS AND METHODS: Adults with cervical carcinoma who met the International Federation of Gynecology and Obstetrics criteria for stage IA1 with lymphovascular space invasion to stage IB1 underwent technetium 99 lymphoscintigraphy and Patent Blue injection followed by laparoscopic lymph node mapping, SLN removal, and lymph node dissection. Only surgeons trained in SLN biopsy in cervical carcinoma participated in the study. SLNs and nonsentinel lymph nodes underwent routine staining. Negative SLNs were subjected to ultrastaging. The reference method was pelvic and/or para-aortic lymphadenectomy with histologic examination of all nodes. RESULTS: One hundred forty-five patients were enrolled, and 139 were included in a modified intention-to-diagnose analysis. Intraoperative radioisotope-blue dye mapping detected at least one SLN in 136 patients (97.8%; 95% CI, 93.8% to 99.6%), 23 of whom had true-positive results and two who had false-negative results, yielding 92.0% sensitivity (23 of 25; 95% CI, 74.0% to 99.0%) and 98.2% NPV (111 of 113; 95% CI, 74.0% to 99.0%) for node metastasis detection. No false-negative results were observed in the 104 patients (76.5%) in whom SLN were identified bilaterally. CONCLUSION: Combined labeling for node mapping was associated with high rates of SLN detection and with high sensitivity and NPV for metastasis detection. However, SLN biopsy was fully reliable only when SLNs were detected bilaterally.

Oncological safety of laparoscopic-assisted vaginal radical trachelectomy (LARVT or Dargent's operation): a comparative study with laparoscopic-assisted vaginal radical hysterectomy (LARVH).

OBJECTIVE: The aim of our study was to compare the results of radical trachelectomy (LARVT or Dargent's operation) to radical vaginal hysterectomy (LARVH) in terms of intraoperative and postoperative morbidity and mainly in terms of risk of tumor recurrence. Each technique is associated with laparoscopic pelvic lymph node dissection. Our objective was to know if performing radical trachelectomy in order to preserve the fertility of a young patient with an early cervical cancer is associated or not with an increased risk of operative morbidity or tumor recurrence. METHODS: Patient affected by early invasive cervical cancer who has been submitted to LARVT (n=118) in our Institute between December 1986 and December 2003 has been compared to patients treated by LARVH (n=139) in the same period. All patient's information, surgical and pathological data and oncological results have been prospectively collected. The associations between the discrete variables were assessed using chi(2) test with Yate's correction when appropriate. Fisher's exact test was used when it was necessary. Continuous variables were compared by Student's t test. p values less than 0.05 were considered statistically significant. Statistical analysis used the Kaplan-Meier method to calculate disease-free and overall survival. RESULTS: Between December 1986 and December 2003, 118 and 139 patients have undergone LARVT and LARVH, respectively, for FIGO stage I-IIA carcinoma of the cervix. The two populations (LARVT and LARVH) are comparable in terms of the main prognostic factors of cervical cancer. The rate of intraoperative complications has been similar in the two groups (2.5% for LAVRT and 5.8% for LAVRH, p=NS). Also the rate of postoperative complications has been similar in the two groups (21.2% for LAVRT and 19.4% for LAVRH, p=NS). When considering the risk of recurrence, the results in the two groups are also identical: 7 cases (5.2%) in patients treated with LAVRT and 9 cases (8.5%) in patients treated with LAVRH (p=NS). CONCLUSION: Our data demonstrate that early cervical cancer (less than 2 cm diameter) can be treated successfully with LARVT with similar efficacy and recurrence rates to LARVH. In our experience radical trachelectomy is a safe treatment for young women affected by early cervical cancer who want to conserve their fertility.

Clinical significance of lympho vascular space involvement and lymph node micrometastases in early-stage cervical cancer: a retrospective case-control surgico-pathological study.

OBJECTIVE: Several studies have shown that lympho vascular space involvement (LVSI) and lymph node micrometastases (LNmM) may be risk factors for recurrence in early-stage cervical cancer with no apparent lymph node metastases. We performed a retrospective case-control study to reassess whether the presence of lymph node micrometastases and LVSI is predictive of subsequent recurrence following surgical resection of early-stage cervical cancer. METHODS: In a series of 292 patients diagnosed with early cervical cancer and treated by the same surgical procedure (laparoscopic-vaginal radical hysterectomy) during the same time period, two paired series were selected. The first series consisted of 26 cases who recurred in a median time of 36.8 months and the second series were 26 cases matched for age, histological sub-type, surgico-pathological stage and maximal tumor diameter, who did not recur after a median follow-up of 122 months. Sections taken from the hysterectomy specimens were reassessed for LVSI. All the lymph node blocks which have initially been considered as uninvolved were submitted to serial sectioning. Immunohistochemical staining using anti-cytokeratins AE1 and AE3 was used for identifying LNmM. RESULTS: LVSI was twice more frequent and LNmM ten-fold more frequent in the group of patients who recurred: 20/26 (77%) versus 9/26 (35%) and 11/26 (42%) versus 1/26 (4%) respectively. The relative risk of recurrence is 2.64 (1.67-5.49, P < 0.01) in the presence of LVSI and 2.44 (1.58-3.78, P < 0.01) in the presence of LNmM. All the patients with LNmM were LVSI positive. At bivariate analysis, the true LNmM (deposits more than 200 um in size) was the only independent risk factor. CONCLUSIONS: LNmM is an important risk factor of tumor recurrence in patients with early cervical cancer with no apparent lymph node metastases. LNmM seems to occur only in LVSI positive tumors. These data may lead to improve management of early-stage cervical cancer to reduce the risk of recurrence in those cases.

Laparoscopic lymphadenectomy and sentinel node biopsy in uterine cancer.

This article discusses laparoscopic lymphadenectomy and sentinel node biopsy in uterine cancer.

[Clinical practice guidelines: Standards, Options and Recommendations for first line medical treatment of patients with ovarian neoplasms (summary report)]. / Recommandations pour la pratique clinique Standards, Options et Recommandations 2003 pour le traitement médical de première ligne des patientes atteintes de tumeurs épithéliales malignes de l'ovaire, mise à jour (rapport abrégé).

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, which started in 1993, is a collaboration between the French Federation of Cancer Centers (FNCLCC), the 20 French Regional Cancer Centers, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. OBJECTIVE: To update clinical practice guidelines for first line medical treatment of patients with ovarian neoplasms in collaboration with the French Society for Gynaecologica Oncology. METHODS: The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts. The CPGs are defined following the definitions of the Standards, Options and Recommendations project. Once the guideline has been developed, the document is submitted for review by independent reviewers. RESULTS: This article is a summary version of the full document presenting the clinical practice guidelines with algorithms. After surgery, most patients with ovarian neoplasms need adjuvant medical treatment. These guidelines concern the initial medical treatment (chemotherapy, hormone treatment and immunotherapy) and potential consolidation treatment. To complete the indications, two alternative treatment strategies are taken into account: no treatment and radiotherapy. This updated version concerns the indications and the modalities of chemotherapy. The main modifications are: 1) first-line chemotherapy for ovarian neoplasm can be taxane-platinum or carboplatine alone; 2) poly-chemotherapy is no longer a standard; 3) for early stages, except for stage IA grade I non-clear-cell tumours, adjuvant chemotherapy should be preferred to no treatment; 4) chemotherapy is standard for all stage III tumours, irrespective of the surgical result; 5) for stage IA G2-3 to IIA tumours, complete surgical staging and determination of the histological grade are standards.

Pregnancy after trachelectomy: a high-risk condition of preterm delivery. Report of a case and review of the literature.

BACKGROUND: Trachelectomy is a conservative but locally radical procedure associated with a high risk of preterm delivery. CASE: A 28-year-old patient with cervical cancer FIGO stage IB1 was treated with laparoscopic pelvic lymphadenectomy followed by trachelectomy. Three years later, she conceived spontaneously. In consideration of the high risk of preterm delivery, the cervical status was evaluated by transvaginal ultrasonography. At 16 weeks' gestation, we observed the cerclage suture correctly placed at the level of the internal cervical os and a "neo-cervical" segment length of 1.5 cm. Thereafter, serial ultrasound measurements showed preservation of the cervical competence. The patient achieved an uneventful pregnancy and delivered by elective cesarean section at 37 weeks. CONCLUSION: Transvaginal scans to evaluate the competence of the "neo-cervix" may contribute to the management and counseling of patients after trachelectomy.

Sentinel lymph node biopsy is not accurate in predicting lymph node status for patients with cervical carcinoma.

BACKGROUND: The authors evaluated the accuracy of sentinel lymph node biopsy in predicting lymph node status for patients with early cervical carcinoma. In particular, the authors set out to determine the false-negative rate associated with sentinel lymph node biopsy in this setting. METHODS: Twenty-nine consecutive patients with early cervical carcinoma who were treated with pelvic laparoscopic lymphadenectomy and radical surgery underwent sentinel lymph node biopsy following lymphatic mapping with patent blue dye. All sentinel and nonsentinel lymph nodes were evaluated for micrometastases via multilevel sectioning followed by immunohistochemical staining. RESULTS: At least one sentinel lymph node was identified for each patient. On routine pathologic evaluation, 3 patients (10%) were found to have positive lymph nodes. Among the remaining 26 patients, multilevel sectioning in conjunction with immunohistochemical analysis identified 5 patients (19%) who had micrometastases in the pelvic lymph nodes. Two of these five patients had micrometastases in a sentinel lymph node; however, the more notable finding was that the other three patients had micrometastases in nonsentinel pelvic lymph nodes despite having negative findings on sentinel lymph node biopsy. Thus, the negative predictive value of sentinel lymph node biopsy in the current study was 87.5%. CONCLUSIONS: Multilevel sectioning followed by cytokeratin immunohistochemistry may identify additional patients who have lymph node micrometastases; in the current study, this technique identified cases in which micrometastases were present in nonsentinel lymph nodes even when sentinel lymph nodes were found to be negative for disease on biopsy. This high false-negative rate associated with sentinel lymph node biopsy, raises questions regarding the validity of the sentinel lymph node concept in cervical carcinoma.

First case of a centropelvic recurrence after radical trachelectomy: literature review and implications for the preoperative selection of patients.

BACKGROUND: To report the first case of a centropelvic recurrence in a patient who underwent a radical trachelectomy (RT) for a stage IB1 cervical carcinoma. CASE: A 32-year-old woman presented with a stage IB1 adenocarcinoma that was treated by radical trachelectomy. The tumor measured 21 x 20 mm. Minimal lymphatic space involvement was observed close to the tumor associated with 30 negative nodes and free margins. The upper free margin measured only 5 mm. Twenty-six months after the surgical procedure, the patient became pregnant. Clinical examination and pap smears were normal 2 months prior. During the first trimester, ultrasonography depicted a suspicious lesion in the bladder. Abdomino-pelvic magnetic resonance imaging (MRI) demonstrated a suspicious 20-mm tumor in the bladder associated with suspicious common iliac nodes. Cystoscopy and biopsies were carried out which confirmed recurrent disease. The patient received external radiation therapy combined with concomitant chemotherapy. CONCLUSIONS: More data are required to establish what is the safety distance between the tumor and the uterine transection. A distance of 5 mm or less is likely to be too limited for radical trachelectomy to be accepted as treatment for cervical cancer.

Laparoscopic assessment of the sentinel lymph nodes in early cervical cancer. Technique--preliminary results and future developments.

Laparoscopic assessment of the sentinel node (SN) in early stage cervical cancer is both feasible and safe. The technique is described. The data concerning the 70 first assessed patients are reported. Failure in identification of the SN occurred in 14 of the 139 attempted dissections. One only SN was detected in 121 dissections and two SN in four dissections. A systematic pelvic lymphadenectomy was carried out after removal of the SN. A metastatic involvement of the SN was put in evidence in 19 of the 129 retrieved SN. The other regional lymph nodes were. The data concerning the 70 first assessed patients are reported. Failure in identification of the SN occurred in 14 of the 139 attempted dissections. One only SN was detected in 121 dissections and two SN in four dissections. A systematic pelvic lymphadenectomy was carried out after removal of the SN. A metastatic involvement of the SN was put in evidence in 19 of the 129 retrieved SN. The other regional lymph nodes were involved in 13 cases and not involved in six cases. In the 110 cases where the SN was not involved all the other regional nodes were free from metastasis. At the condition larger series confirm the preliminary results the laparoscopic retrieval of the SN could change the strategy to be used in the management of early stage cervical cancer: no systematic lymphadenectomy-radiotherapy for the SN+ patients--vaginal radical hysterectomy for the SN- patients. Another condition should be the SN is submitted to superstaging using immunochemical staining and/or molecular biology.

Laparoscopic management of adnexal masses in pregnancy: a case series.

OBJECTIVE: To determine the feasibility, safety, limiting factors, and advantages of laparoscopic management of adnexal masses in pregnancy. STUDY DESIGN: During a 12-year period, 48 laparoscopic procedures were performed in 47 patients with adnexal masses in pregnancy. Laparoscopic surgery was done during the first trimester of pregnancy in 17 cases, the second trimester in 27 cases and the third trimester in four cases. All the procedures were performed with general anesthesia and curarization. The laparoscopic cystectomies were performed either with the intra-peritoneal or the trans-peritoneal technique. RESULTS: The indications were: persistant or sonographically abnormal ovarian cyst (36 cases), torsion or rupture of ovarian cyst (8 cases), and symptomatic pelvic mass (3 cases). Two borderline tumors were discovered. The laproscopic procedure could not be performed in two cases due to dense adhesions and difficulty of hemostasis. No patient encountered complications during the intra- and post-operative periods. The mean hospital stay was 3.8 days. The outcome of the pregnancy was normal in all cases except one fetal loss 4 days after the laparoscopy. CONCLUSION: Laparoscopic management of adnexal masses in pregnancy by an experienced team, is a safe and effective procedure that allows, compared to the traditional surgery, a shorter hospital stay, a reduced rate of post-operative complications and a decreased maternal and fetal morbidity.

[Carcinomatous transformation of an atypical polypoid adenomyofibroma of the uterus]. / Transformation carcinomateuse d'un adénomyofibrome polypoïde atypique de l'utérus.

We report a case of an atypical polypoid adenomyofibroma (APA) with carcinomatous transformation that occurred in a nulliparous 32 year-old woman treated with estroprogestatives. The well-differentiated mucinous adenocarcinoma was in continuity with the APA, showed a deep myoinvasion and extended to the upper part of the cervix. No hormonal receptor was expressed by tumor cells. Because of the risk of carcinomatous transformation, complete excision of APA(s) is warranted.

Long-term outcome of a randomized study comparing three techniques of conization: cold knife, laser, and LEEP.

OBJECTIVE: To evaluate the long-term recurrence rates and complication of different techniques of cervical ablation. METHODS: A randomized trial of three techniques of conization (cold knife, laser, and loop electrosurgical excisional procedure (LEEP)) for cervical intraepithelial neoplasia (CIN) in which 110 patients had been recruited. RESULTS: Eighty-six patients were followed-up for more than 3 years. Of these 28 had been treated with the cold knife, 29 with LEEP and 29 by laser. Five recurrences were observed, one in the cold knife group, two in the LEEP group and two in the laser group (P=NS). The only observed complication was cervical stenosis: zero cases in the laser group, one case in the LEEP group and four cases in the cold knife group (laser versus cold knife: P=0.03; LEEP versus cold knife: P=0.06). Fifty pregnancies were observed in 39 patients. First and second trimester outcomes of pregnancy were without complications. One patient treated with the LEEP presented with a premature rupture of membranes and premature labor at 36 weeks. A total of nine cesarean sections were performed with two cases for cervical dystocia. CONCLUSION: There is no major difference in obstetrical outcome between the three techniques.

[Gynecological cancers and pregnancy: the point of view of the oncology gynecologist]. / Cancers gynécologiques et grossesse: le point de vue du gynécologue oncologue.

Cervical cancer and nonepithelial ovarian cancer are the most frequent gynecological tumors diagnosed during the pregnancy. The management of patients with a malignant tumor discovered during her pregnancy depends on the type of the tumor, the tumor stage and the term of the pregnancy. In most of cases, a conservative management of the pregnancy could be offered without affect the optimal approach for the treatment of the tumor nor the survival of the patient. But such management needs to be determined in a multidisciplinary staff with oncologists, neonatologists, obstetricians but also the point of view of the patient.

[Extended trachelectomy relapse: plea for patient involvement in the medical decision]. / La trachélectomie élargie, risque de rechute plaidoyer pour un protocole de décision partagée.

A series of 96 radical trachelectomies performed between April 1987 and May 2002 at Hospital Edouard Herriot in Lyon is reported. One second cancer (bilateral suprarenal glands cancer) and four recurrences were observed. The retrospective unifactorial analysis demonstrated that the maximal tumoral diameter (2 cm or more) and the depth of infiltration (1 cm or more) were the two only significant factors of risk (p = 0.001 et p = 0.002 respectively). Age less than 30 years and presence of lymphovascular spaces involvement were likely to be factors of risk as well but the level of statistical significance was not reached (p = 0.006). Histotype other than squamous, infiltration of the parametrium and infiltration of the vaginal cuff had no prognosis impact. Adjuvant radiotherapy did not seem to lessen the risk. The chances for recurrence were 19% for the patients affected by a tumor 2 cm or more and 25% for the patients affected by a tumor 2 cm or more with a depth of infiltration 1 cm or more. Should these patients be excluded from the indications of radical trachelectomy? The chances for failure do not seem lower if the radical option is chosen rather than the conservative one. The authors play for a shared decision making.