Feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy.

OBJECTIVE: The aim of this study is to evaluate the feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy for cervical and endometrial carcinoma. METHODS: Seventy-six patients underwent extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy between February 1999 and September 2005. The lymph nodes dissected with the laparoscopic procedure included the inframesenteric para-aortic lymph nodes, the sacral lymph nodes, and the bilateral common iliac lymph nodes. The extraperitoneal laparoscopic operation was performed with pelvic open surgery using Lap Disc to ensure the safety of patients. RESULTS: The number of patients with cervical and endometrial carcinoma was 36 and 40, respectively. The median age of patients was 51 years (range 24-75 years). Conversion to open surgery was necessary in 8 patients. These include 3 patients who encountered blood loss of 400, 136 and 128 ml; 2 extremely obese women; and 3 patients who had peritoneal tears causing CO2 gas leakage. Among the remaining 68 patients, the median operating time for extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy was 75 min (range 45-145 min), and the median estimated blood loss was 5 ml (range 5-138 ml). The median total number of resected nodes was 14 (range 2-31), and 4 patients had lymph node metastasis. No patient encountered postoperative complications attributable to extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy. CONCLUSIONS: Extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy with pelvic open surgery using Lap Disc is a feasible procedure, particularly in the surgeons learning phase.

Difference of carboplatin clearance estimated by the Cockroft-Gault, Jelliffe, Modified-Jelliffe, Wright or Chatelut formula.

OBJECTIVE: Although the Calvert formula is the standard method to calculate the dose of carboplatin, there is no consensus how to determine the glomerular filtration rate (GFR) without using [51Cr]-ethylenediamine tetraacetic acid (51Cr-EDTA). Creatinine clearance (Ccr), calculated using the Cockroft-Gault, Jelliffe, Modified-Jelliffe or Wright formulae, has been used as a substitute for the GFR. In addition to these four formulae, the Chatelut formula has been proposed as a way to calculate carboplatin clearance. Among these formulae, Jelliffe formula does not include body surface area (BSA) or body weight to adjust the body size and thus may have greater bias than the other four formulae in estimating carboplatin clearance. The purpose of this study is to evaluate if these five formulae could equally estimate the carboplatin clearance. METHODS: : Carboplatin clearance was estimated in 253 patients with gynecologic cancer who received carboplatin-based chemotherapy between January 1996 and August 2004. Ccr was estimated using the Cockroft-Gault, Jelliffe, Modified-Jelliffe or Wright formulae. Carboplatin clearance was also calculated directly by using the Chatelut formula. The five estimations of carboplatin clearance were compared with each other using the post-hoc Wilcoxon signed rank test. The median percent error (MPE) and the median absolute percent error (MAPE) were evaluated by comparing carboplatin clearance. The relationships between BSA and ratios of estimated carboplatin clearance (Jelliffe/Cockroft-Gault, Jelliffe/Modified-Jelliffe, Jelliffe/Wright, Jelliffe/Chatelut) were evaluated by using simple regression. RESULTS: : The estimated carboplatin clearances were: Cockroft-Gault formula, 109.8 +/- 28.4; Jelliffe formula, 128.5 +/- 28.2; Modified-Jelliffe formula, 110.8 +/- 25.7; Wright formula, 112.2 +/- 24.3; Chatelut formula, 114.1 +/- 33.0. A statistically significant difference was observed between carboplatin clearance calculated using Jelliffe formula and that given by each of the other four formulae. Comparing the results of the Cockroft-Gault formula with the Jellife, Modified-Jelliffe, Wright and Chatelut formulae yielded MPEs of +19%, +2%, +3% and +3% and MAPEs of 27%, 5%, 6% and 6%, respectively. There was a significant correlation between BSA and ratio of estimated carboplatin clearance (Jelliffe/Cockroft-Gault, Jelliffe/Modified-Jelliffe, Jelliffe/Wright, Jelliffe/Chatelut), with Pearson correlation coefficients of 0.928, 0.847, 0.965 and 0.839 respectively. As the BSA of patient became smaller, the differences between the carboplatin clearance calculated by the Jelliffe formula from other four formulas became larger. CONCLUSIONS: : Estimates of carboplatin clearance calculated by the Jelliffe formula tend to have greater positive bias compared to the other four formulae, particularly when the BSA of the patient is small. In order to conduct collaborative international studies, it may be necessary to standardize the formula used to estimate carboplatin clearance to perform international collaboration studies.

[Endoscopic surgery for gynecologic malignancy--less invasive, more radical].

The development of endoscopic equipment and surgical skills make more complicated procedures possible laparoscopically. The application of these techniques to oncologic surgery, which used to be basically the most invasive procedure, has become an important issue when considering patient well-being. For cervical and endometrial cancer we can perform a simple hysterectomy, type II or a type II radical hysterectomy as well as a pelvic and para-aortic lymphadenectomy. For ovarian cancer endoscopic procedures are advantageous for surgical staging, and even debulking surgery is possible in selected cases. The short-term outcome is excellent because post-operative recovery is quick, resulting in no delays in adjuvant therapy and a quick return to normal activity. As for the long-term results, although the number of cases and the observation period are limited, at present the outcome does not differ greatly from the results of conventional laparotomy.

First-line intraperitoneal carboplatin-based chemotherapy for 165 patients with epithelial ovarian carcinoma: results of long-term follow-up.

OBJECTIVE: Currently, no long-term follow-up data are available on intraperitoneal (IP) carboplatin-based chemotherapy for ovarian carcinoma. In this study we evaluated retrospectively the survival and recurrence of a retrospective cohort of patients with epithelial ovarian cancer treated with first-line IP carboplatin-based therapy. METHODS: Records were reviewed of 174 patients with epithelial ovarian cancer who received IP carboplatin-based therapy between 1990 and 2000. All patients underwent surgical staging, and implantable port systems were placed regardless of residual tumor size. The pathological slides were submitted and reviewed, and then nine patients were excluded because of borderline malignancies (n = 8), and wrong histology (n = 1). Therefore, the records of 165 patients were analyzed for survival. Tumor grade was determined by the Universal grading system. Statistical analysis included tests for association between potential prognostic factors, and between prognostic factors and survival. Survival probabilities were estimated by Kaplan-Meier methods, and prognostic factors for survival were evaluated by a Cox regression model. RESULTS: The mean age of the patients was 53.7 years (range 21-83). The median follow-up was 41 months. The distribution by stage and histology was as follows: high risk (grade 2/3, clear cell, capsule rupture) stage I, 54; II, 21; III, 72; IV, 18; and serous, 75; clear cell, 30; mucinous, 27; endometrioid, 20; others, 13. The chemotherapy regimen was either carboplatin alone (n = 22) or in combination with cyclophosphamide (n = 116) or paclitaxel (n = 27). Catheter-related complications occurred in 16 (9.7%) cases. The chemotherapeutic response in 54 patients with measurable disease was 66.4%. The 5-year survival was 94.4% for stage I, and 87.9% for stage II. The median survival for optimal and suboptimal stage III/IV patients was 51 months and 34 months, respectively. The median survival of patients with stage III/IV disease was 51 months with carboplatin doses of 400 mg/m(2) or more, but it was only 25 months with carboplatin doses smaller than 400 mg/m(2). Poor prognostic factors, determined by Cox regression multivariate analysis, were clear cell histology (P < 0.001) and a carboplatin dose smaller than 400 mg/m(2) (P = 0.002). CONCLUSIONS: Survival of patients who underwent carboplatin-based IP chemotherapy was excellent when the dose of carboplatin was higher than 400 mg/m(2). A prospective evaluation of IP carboplatin therapy with modern combination is warranted.