Objectives

We report on a cohort of patients undergoing intrathoracic cytoreduction as part of primary debulking surgery (PDS), assessing safety and survival outcomes.

Methods

We conducted a single center, database review of patients with stage IIIB-IV ovarian carcinoma who underwent intrathoracic cytoreduction as part of PDS at our institution between 01/2001-12/2019. Patients were excluded if they received neoadjuvant chemotherapy.

Results

During the study, 179 patients had intrathoracic surgery as part of PDS. This represents 11% (179/1579) of patients who had a PDS at our institution during this time. Supradiaphragmatic/cardiophrenic lymph nodes were excised in 64% of patients (114/179); mediastinal (not cardiophrenic) nodes 13% (23/179); pleural nodules 7% (12/179); lung parenchyma 1% (2/179), and multiple intrathoracic areas 16% (28/179). Complete gross resection (CGR) was achieved in 73% of patients (127/179), 26% (44/179) had optimal cytoreduction (1-10 mm of residual disease (RD)), and 1% (2/179) underwent suboptimal cytoreduction (>10 mm of RD). Median length of follow-up among survivors was 55 months. Patients with an intrathoracic cytoreduction of carcinoma where CGR was achieved had a median OS of 97 months versus 54 months following an optimal cytoreduction with RD (p = 0.0036). Patients with an intrathoracic cytoreduction where CGR was achieved had a median PFS of 22.1 months versus 14.4 months following an optimal cytoreduction with RD (p = 0.04).

Conclusions

Intrathoracic cytoreduction during PDS for advanced ovarian cancer is safe and feasible. CGR can be obtained in patients with intrathoracic disease if properly selected. Resection of all gross RD including intrathoracic disease significantly improves both PFS and OS.

Objectives

To assess the oncological safety of uterine manipulators in apparent early-stage (FIGO I-II) endometrial cancer treated by MIS.

Methods

This is a single center retrospective study including patients who underwent endometrial cancer surgery for apparent early stage disease by either laparoscopy, robotics or laparoscopic assisted vaginal hysterectomy from 11-2012 to 12-2020. Data on manipulator type, isolated tumor cells (ITC), cytology, LVSI, free cancer cells in fallopian tubes (floaters), stage, histology and grade were collected. Primary outcome was cancer recurrence. Secondary outcome was disease specific death. Kaplan-Meier curves and multivariate logistic regression were used for statistical analysis.

Results

935 women with early-stage endometrial cancer were included; 794 (85%) had hysterectomy with uterine manipulator and 141 (15%) without, with a mean follow-up of 44,6 months (range 3-118). 84,7% had endometrioid histology, 84,5 % were grade 1 or 2 and 97,2% had stage I disease. Uterine manipulators were not associated with recurrence on univariate (OR 3,178; 95% CI, 0.984-10,261; p=0,0531) and multivariate analysis (OR 2,536; 95% CI 0,770-8,349; p=0,1259) and for disease specific death on both univariate (OR 1,88; 95% CI, 0.436-8,127; p=0,3970) and multivariate analysis (OR 0,770; 95% CI 0,158-3,741; p=0,7455), even when adjusted with adjuvant treatments and tumor characteristics. They were not associated with higher rates of positive cytology, LVSI and ITC. Intra-uterine balloon manipulators were associated with higher risk of floaters (OR 2.47; 95% CI, 1.17-5,23; p=0,0001).

Conclusions

Uterine manipulators in endometrial cancer MIS were not associated with higher recurrence rate and disease specific death in early-stage disease. Prospective trials must confirm our data.

Objectives

This study was to evaluate the role of lymphadenectomy by comparing survival outcomes for patients with clinically early epithelial ovarian cancer (eEOC) who underwent lymphadenectomy versus those who did not.

Methods

We conducted a multicenter retrospective study of patients diagnosed with eEOC by imaging study from 2007 to 2021. Clinicopathological characteristics and oncologic outcomes were compared between the lymphadenectomy group and the no lymphadenectomy group.

Results

In this study, out of 586 clinical eEOC patients, 453 (77.3%) had lymphadenectomy and 133 (22.7%) did not. The upstaging was 4/133 (3.0%) in the no lymphadenectomy group 30/453 (6.6%) in the lymphadenectomy group; the upstaging by lymph node metastasis was 21/453 (4.6%). Compared to the no lymphadenectomy group, the lymphadenectomy group had a longer operating time (P = 0.000), a higher EBL (P = 0.000), and a higher rate of postoperative adverse events (P = 0.004). Among histological subtypes of eEOC, serous carcinoma showed more improved PFS in the lymphadenectomy group compared to no lymphadenectomy group (P = 0.048). There was no difference in PFS in mucinous (P = 0.67), endometrioid (P = 0.41), and clear cell (P = 0.89) carcinomas between the two groups.

Conclusions

This study showed that in patients with clinical eEOC, histological subtype is associated with a survival benefit for lymphadenectomy. In serous carcinoma, lymphadenectomy showed improvement in PFS, but other histological subtypes did not differ significantly. Considering the higher risk of perioperative adverse events in lymphadenectomy, lymphadenectomy in patients with clinically eEOC can be selectively performed according to histological subtype.

Objectives

To evaluate the feasibility of laparo-endoscopic single-site staging surgery (LESS group) compared to conventional laparoscopic staging surgery (four-port group) for early-stage endometrial cancer.

Methods

Patients with clinical stage IA, IB, grade 1-3 endometrial cancer were randomly assigned to LESS group or four-port group. The primary endpoint was to confirm the non-inferiority of LESS in operation time and number of resected lymph nodes. Non-inferiority has considered if the LESS group showed difference in operating time (< 24 min) and the number of resected lymph nodes (< 5.2) within the lower limit of 20% compared to the four-port group.

Results

Each of 54 patients were assigned to LESS group (n=54) and four-port group (n=54). There were no differences between LESS and four-port groups in clinical factors including age, body mass index, gravida, menopause, previous abdominal surgery, and in pathologic factors including histologic type, histologic grade, lympho-vascular space invasion, and stage of the disease. There was no clinically significant difference in total operation time (LESS group vs. four-port group, 154.96±40.81 min vs 158.19±48.77 min, P = 0.712), and in the number of resected lymph nodes (LESS group vs. four-port group, 17.81±8.73 vs 22.41±10.56, P = 0.016). After median follow-up time of 34 months (range, 2 – 242 months), each one patient in each group had a recurrence, and one patient in LESS group died of the disease.

Conclusions

LESS surgical staging was feasible for surgical management of patients with early-stage endometrial cancer. It was comparable to conventional laparoscopic surgical staging in perioperative and oncologic outcomes.

Objectives

Endometrial cancer (EC) is a molecularly driven disease, and prognostic and treatment paradigms are transitioning to focus on molecular subtyping. Surgical staging and the role of lymphadenectomy has similarly evolved over time, however current lymph node (LND) algorithms do not account for molecular subtyping. The objective of this study was to evaluate the association of microsatellite instability (MSI) and lymph node metastases (LNM).

Methods

This was a retrospective cohort study of patients undergoing surgery for EC between 2010-2021. All EC patients at our institution undergo immunohistochemistry testing for mismatch repair (MMR) proteins and next generation sequencing per clinician discretion. Sarcomas were excluded. Mutations were classified as microsatellite instability high (MSI-H) or MMR proficient (MMRp).

Results

367 patients were included. Of these, 273 were MMRp and 94 were MSI-H. An average of 6.1 LND were removed and there was no difference in the average LND removed between groups (p= 0.91). LNM were identified in 8% (n=31) of the entire cohort. There was a statistically significant difference in the average LNM between MMRp and MSI-H patients (p<0.0001), with 1% (n=2) of the MMRp cohort and 30% (n=28) of the MSI-H cohort having LNM. Within the MSI-H cohort, all LNM occurred within the MMR deficient, MLH1 hypermethylated subgroup – representing a LNM rate of 41%.

Conclusions

There is a significant association between MSI status and LNM. Molecular classification, which is obtainable from preoperative biopsy, may be used to guide intraoperative decision making and should be evaluated in the context of sentinel LND protocols.

Objectives

MIRRORS (Minimally Invasive Robotic surgery, Role in optimal debulking Ovarian cancer, Recovery & Survival) is the largest prospective cohort study of robotic interval CRS in women with advanced-stage epithelial ovarian cancer to date. MIRRORS has investigated the feasibility of consenting, the acceptability and success of robotic interval CRS and its impact on short-term surgical outcomes and quality of life.

Aim: to establish the feasibility and safety of a proposed randomised controlled trial (RCT) of robotic interval cytoreductive surgery (CRS) for advanced ovarian, fallopian tube and peritoneal cancer (EOC) using MIRRORS-protocol.

Methods

Eligibility: Women with Stage IIIc-IVb EOC undergoing neoadjuvant chemotherapy, suitable for interval CRS with a pelvic mass ≤8cm. Robot-assisted laparoscopic assessment proceeding to robotic/open interval CRS (MIRRORS protocol). 6-month post-op surveillance.

Results

Recruitment: 23/24 eligible women(95.83%). Following MIRRORS-protocol, completed 20 robotic, 3 open interval CRS. All patients achieved CRS to R<1, robotic: R0 =47.4%, open R0 =0.0%. Conversion rate to open: 0.0%. Median estimated blood loss robotic: 50ml, open: 2026ml; length of stay 1.5 days robotic vs 6 days open, time to chemotherapy robotic: 18.5 days vs open: 25 days. 6 month OS and PFS are non-inferior compared with concurrent and retrospective control groups.

Conclusions

Robotic interval CRS is safe and feasible in women with a pelvic mass up to 8cm. A prospective RCT is required to assess whether patients undergoing MIRRORS-protocol have non-inferior overall-survival compared to open interval CRS.

Objectives

To identify the clinicopathologic prognostic factors associated with pelvic recurrence for patients with 2018 FIGO stage IA2 and IB1 cervical cancer treated with laparoscopic/robotic radical hysterectomy (LRH/RRH).

Methods

A total of 117 FIGO stage IA2 and IB1 cervical cancer patients was identified between April 2006 and January 2021. One patient with lung metastasis was excluded. Sites of disease recurrence and all possible clinicopathologic factors related to the risk of pelvic recurrence were analyzed. Disease-free survival (DFS) was estimated using the Kaplan-Meier method. Based on Cox proportional hazard regression model with a backward elimination method were used to determine prognostic factors for DFS.

Results

Of the 116 patients, 8 (6.9 %) showed disease recurrence (4 vaginal stump, 2 pelvic lymph nodes, 2 peritoneum). Five-year DFS rates were 92.9%. In multivariate analysis, the risk factors associated with pelvic recurrence during and after surgery were intracorporeal colpotomy (P < 0.044, odds ratio 5.281, 95% confidence interval 1.046–26.665), and the size of residual tumor after conization (P < 0.003, odds ratio 4.081, 95% confidence interval 1.611–10.340), ; conversely preoperative conization reduced the risk of pelvic recurrence (P < 0.044, odds ratio 0.092, 95% confidence interval 0.009–0.943).

Conclusions

There is no guarantee that minimally invasive surgery is safe in FIGO stage IB1 patients with tumors less than 2 cm in size. Intracorporeal colpotomy should not be performed even in patients with tumors less than 2 cm in diameter. In addition, preoperative conization might be associated with a lower recurrence rate in minimally invasive radical hysterectomy.