Journal of Investigative Surgery

Sentinel Node Mapping in Endometrial Cancer

Value of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography and Sentinel Lymph Node Biopsy in Endometrial Cancer Patients: A Prospective Study

The aim of this study is to define the role of preoperative positron emission tomography/computed tomography (PET/CT) scan and sentinel lymph node (SLN) biopsy for nodal metastasis detection in Endometrial Cancer (EC) patients. From January 2014 to August 2016 patients affected by EC scheduled for surgery underwent PET/CT scan and SLN mapping with indocyanine-green. Patients with suspicious lymph nodes at FDG-PET/CT underwent selective pelvic lymphadenectomy. In case of undetectable SLN, no further lymphadenectomy was performed if PET/CT scan was negative. Basic descriptive statistics were used to describe outcomes. A total of 83 patients were enrolled in the study. PET/CT scan was suggestive of nodal involvement in 15 patients. SLN were detected bilaterally in 78% of patients. Detection rate was influenced by patients' BMI and surgical learning curve. Five patients were node-positive: all of these had hypermetabolic nodes on PET/CT scan; in one patient SLN was not detected. Ten out of 15 patients with suspicious nodes on PET/CT scan were node-negative. After a median follow up of 24 months all patients are alive. Four patients experienced recurrent disease. No nodal relapse was recorded. Lymphatic mapping with sentinel node biopsy is able to reduce morbidity associated with pelvic lymphadenectomy. Sentinel node assessment is a feasible and appealing procedure and should be performed in a specialized center. Detection rate strongly improves with learning curve, while is reduced in morbidly obese patients. PET/CT scan shows high sensitivity but moderate specificity for nodal metastasis and may help to avoid nodal dissection in patients with sentinel node mapping failure.

Lymphadenectomy in Primary Fallopian Tube Cancer is Associated with Improved Survival

Primary fallopian tube cancer (PFTC) shares the same diagnostic and management guidelines with epithelial ovarian cancer (EOC). The LION trail raised concerns regarding the role of systematic pelvic and para-aortic lymphadenectomy during debulking surgery. We aimed to evaluate the significance of lymphadenectomy in PFTC survival. This retrospective study analyzed the clinical features and survival of patients with PFTC who underwent primary surgery in our center between January 2013 and October 2020. Sixty-one patients diagnosed with PFTC were included in the study. Twenty-five (41.0%, 25/61) were diagnosed with FIGO (International Federation of Gynecology and Obstetrics) stages I/II and 36 (59.0%, 36/61) were diagnosed with stage III/IV. Twenty-nine (47.5%, 29/61) underwent pelvic lymphadenectomy with or without para-aortic lymphadenectomy, among which 12 (41.4%, 12/29) had lymph node metastasis confirmed by postoperative pathology. The mean progression-free survival was 60.4 months in the lymphadenectomy group and 37.8 months in the no-lymphadenectomy group ( PFTC is often diagnosed earlier and has a better prognosis than EOC. Most patients with PFTC would benefit from lymphadenectomy. However, the extent to which this association translates to a more diverse population needs to be further identified.

Feasibility of Cardiophrenic Lymphadenectomy During Interval Debulking Surgery for Advanced Ovarian Cancer: Early Evidence from Preliminary Data

Use of Vaginal Reconstructive Surgery in Cervical Cancer Patients to Prevent Vaginal Stump Contracture

The life quality of cervical cancer patients is severely compromised due to the vaginal stump contracture after surgery combined with radiotherapy. Therefore, our study focuses on ameliorating or preventing postoperative vaginal contracture. The objectives of this study were (1) to evaluate the method of ileal graft with vascular pedicle to extend the length of vagina and (2) to investigate the effect of the operation to prevent vaginal stump contracture after cervical cancer surgery combined with radiotherapy. Twenty-five patients with vaginal stump contracture after cervical cancer radical resection with sequential radiotherapy were recruited for the study between 2011 and 2014. The therapy includes releasing the adhesion between vaginal stump and rectum as well as bladder, resecting the vaginal stump but reserving the exterior orifice of vagina, and extending the vaginal length using vascularized ileal graft. No postoperative complications such as infection and bleeding were observed in all 25 patients. The patients were satisfied with the length and width of vagina after extension; the discharge of reconstructed vagina was acceptable. All patients had sexual intercourse on the follow-up examination, and five patients complained of vaginal bleeding during or after sexual intercourse, although no abnormality was found on colposcopy. The patients demonstrated a high level of safety, efficacy, and satisfaction with the ileal-vaginal extension for treating vaginal stump contracture after cervical cancer surgery combined with radiotherapy, suggesting that this method is valid for broad clinical application to improve the life quality of cervical cancer patients after surgery.

The Impact of Minimally Invasive Surgery on Treating Patients with Early Cervical Adenocarcinoma

To explore the impact of minimally invasive surgery on treating patients with early cervical adenocarcinoma (CA). From April 2016 to December 2019, patients with early CA and underwent surgery were prospectively included in this study. They were randomly divided into 2 groups: the minimally invasive surgery (MIS) group and conventional laparotomy (CL) group. The baseline characteristics, pathological features, surgical related parameters, serum tumor markers, complications and prognosis were analyzed and compared between the 2 groups. The risk factors for disease free survival (DFS) and overall survival (OS) were also analyzed with logistic regression analyses. The baseline characteristic and pathological features had no statistical difference between the 2 groups. The mean operation duration in MIS group was significantly longer than CL group (262.39 ± 34.98 vs 241.29 ± 36.98 min, Extensive hysterectomy with MIS was equally efficacy and safe to CL.

Expression Significance and Prognostic Value of GPR27 in Ovarian Cancer

This study explored the prognostic role of GPR27 and its predictive value to platinum-based therapy in ovarian cancer. A survival analysis of GPR27, and the therapeutic response to platinum in ovarian cancer was investigated using data from the cancer genome atlas (TCGA) and Gene Expression Omnibus (GEO) databases. GPR27 expression was assessed using reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. Database analysis and RT-PCR revealed over-expression of GPR27 mRNA in ovarian cancer tissues compared to normal ovarian tissues. Ovarian cancer patients with up-regulated GPR27 transcription were associated with better overall survival and disease-free survival compared to those with downregulated GPR27 mRNA in the TCGA dataset and Kaplan-Meier plot database ( GPR27 was up-regulated in ovarian cancer, compared with that of normal ovarian tissue, and was strongly correlated with survival outcomes and response to platinum-based therapy. GPR27 may serve as a reliable biomarker for platinum -based therapy in ovarian cancer patients.

The Feasibility of Cardiophrenic Lymphnode Assessment and Removal in Patients Requiring Diaphragmatic Resection During Interval Debulking Surgery for Ovarian Cancer

Several studies have demonstrated the feasibility and role of bulky cardiophrenic lymph nodes (CPLNs) resection during primary debulking surgery (PDS) for stage IV ovarian cancer (OC). However, no studies, to date, investigated the accuracy and feasibility of CPLNs assessment and removal during interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT). A retrospective analysis of consecutive stage IV OC patients who underwent NACT followed by IDS with CPLNs assessment and/or resection from July 2017 to June 2018. Bulky CPLNs were considered for excision when a full-thickness diaphragmatic resection was required in order to achieve complete tumour resection. A total of 21 ovarian cancer stage IV patients treated with NACT followed by IDS were identified. Seven (33.3%) patients underwent CPLNs resection due to bulky appearance of the CPLNs at the intraoperative palpation. The final histological examination of the CPLNs reported metastatic disease in four (57%) of seven patients. Complete cytoreduction without residual disease was achieved in five cases (71.4%) while in two case (28.6%) optimal cytoreduction was performed. Intra-operative surgical complications occurred in one patient. One patient had a major postoperative complication (Clavien-Dindo 3). Two cases of postoperative cardiac arrhythmia were observed. CPLNs intraoperative assessment is less accurate during IDS compared to previous PDS studies. CPLNs removal during IDS after NACT for stage IV OC could be safely performed to achieve a complete resection.

Neoadjuvant Chemotherapy Followed by Radical Surgery versus Concurrent Chemo-Radiotherapy in the Treatment of Locally Advanced Cervical Cancer: A Multicenter Retrospective Analysis

This study aims to evaluate oncological outcomes in women affected by locally advanced cervical cancer (LACC) treated by neoadjuvant chemotherapy before radical surgery (NACT + RS) or concurrent chemo-radiotherapy (CCRT). This was a multicenter retrospective analysis of data related to women with LACC (FIGO stage IB2-IVA), who were treated by NACT + RS or CCRT between November 2006 and January 2018. The first endpoints were the evaluation of disease-free survival (DFS) and overall survival (OS); univariate and multivariate analyses were performed for identifying the prognostic factors independently associated with these oncological outcomes. Overall, 106 women were included in the analysis; 55 of them (51.9%) underwent NACT + RS and 51 (48.1%) CCRT, respectively. Patients in the NACT + RS group had a significant better five-year DFS and five-year OS than those in the CCRT group (77.4% vs. 33.4%, This retrospective study demonstrated an improved survival outcome for patients undergoing NACT + RS compared with those undergoing CCRT. Our findings seem to support the use of NACT before RS as an effective alternative option to CCRT standard therapy.

Laparoscopic Interval Debulking Surgery for Ovarian Cancer: Fagotti versus PCI Score for Patients’ Selection

Factors Correlated with the Accuracy of Colposcopy-Directed Biopsy: A Systematic Review and Meta-Analysis

Colposcopy-directed cervical biopsy has played a major role in diagnosing cervical lesions. The precision of colposcopy-guided biopsy has been questioned. We analyzed several factors that may be correlated with the accuracy of biopsy. PubMed, EMBASE were searched from January 1, 1998 to March 1, 2020. Odds ratio with 95% confidence intervals (CIs) were calculated. Included studies evaluated factors correlated with the accuracy of biopsy and patients' final diagnosis was established by histological examination of the specimen obtained by conization, loop electrosurgical excision procedure (LEEP), or colpohysterectomy. A total of 10 studies were selected for the systematic review and meta-analysis. The pooled analysis indicated that the diagnostic inaccuracies of colposcopy-directed cervical biopsy were magnified in women who were 50 years of age or older. Postmenopausal status and transformation zone 3 type were also associated with the diagnostic inaccuracies of colposcopy-directed biopsy. High-grade squamous intraepithelial lesions had better concordance rates than low-grade squamous intraepithelial lesions. The number of vaginal deliveries, number of biopsies, and HPV type were associated with biopsy underdiagnosis and biopsy overestimation. This meta-analysis found that the correlation between the histological findings at biopsy and after surgical treatment was influenced by women's age, menopausal status, and the transformation zone type. The diagnostic efficacy was also better for high-grade squamous intraepithelial lesions than for low-grade squamous intraepithelial lesions. Further large-scale randomized clinical trials are required to analyze the factors correlated with biopsy underdiagnosis and biopsy overestimation.

Vaginal Stenosis After Cervical Cancer Treatments: Challenges for Reconstructive Surgery

Minimally Invasive Surgery for Cervical Cancer: Should We Look beyond Squamous Cell Carcinoma?

Survival Benefit of Patients with Advanced Primary Fallopian Tube Cancer Undergoing Systematic Lymphadenectomy? Dilemmas and Queries

Association Between Adenomyosis and Cervical Cancer: A Retrospective Cohort Study

The main purpose of the study was to explore the clinicopathological features and survival outcomes of patients with cervical cancer (CC) and adenomyosis and without the latter and to gain insight into the timely association between adenomyosis and CC. 991 patients with CC and adenomyosis and 3964 patients without the latter were included in this retrospective cohort study. The clinicopathological characteristics including tumor size, depth of stromal invasion, presence of lymphovascular space invasion (LVSI), infiltration into vagina or uterine body, status of surgical vaginal margin, parametrial involvement, and pelvic or para-aortic lymph nodes metastasis were compared between the CC patients with/without coexisting adenomyosis by Student's t-tests, chi-square or Fisher's exact tests. The Cox proportional hazards model was employed to evaluate potential risk factors. Survival curves were constructed using the Kaplan-Meier method. Among the cervical cancer cohort, the coexistence of adenomyosis is associated with a lower likelihood of deep stromal invasion (50.2% vs 54.6%, CC patients with coexistent adenomyosis were associated with less aggressive tumor behavior including deep stromal invasion and vaginal infiltration. However, adenomyosis was not a prognostic factor for CC survival.

Comprehensive Assessment of ERα, PR, Ki67, P53 to Predict the Risk of Lymph Node Metastasis in Low-Risk Endometrial Cancer

According to international guidelines, selective lymph node dissection can be performed on patients with early-stage endometrial cancer. However, some patients at early stage have already occurred lymph node metastasis at the time of diagnosis. This study was aimed to find a method to predict the risk of lymph node metastasis in this part of patient. We collected data from 571 patients as training cohort and 351 patients as validation cohort for this study. Then we performed univariate and multivariate analyses to confirm the correlation of frequently used factors and lymph node metastasis. Combined analysis of four commonly indicators (ERα, PR, P53 and Ki67) from pathological parameter sources was mainly carried out, and the combined ratio is defined as (ERα + PR)/(Ki67 + P53). Then the accuracy of the combined ratio and other factors in prediction were compared by AUC value. Also, the optimal truncation value was searched. Finally, patients followed up for more than two years were divided into groups by the threshold value, and their difference in survival was explored. This study showed that CA125, grade, LVSI, ERα, PR, P53, Ki67 have statistical significance (P-value <0.05). The AUC value of combined ratio is 0.876, which is the best. The best cutoff value of combined ratio is 1.38. The combined ratio cutoff value of 1.38 in this study can be used for prediction of risk of lymph node metastasis in early-stage endometrial cancer patients and provide a reference for therapeutic planning.

Recurrence and Survival Rates of Patients Who Undergo Minimally Invasive Surgery for Endometrial Carcinoma with Different Prognostic Risk Groups

To compare the recurrence rate and prognosis between minimally invasive surgical (MIS) approach and open surgical approach of endometrial carcinoma (EC) patients with different prognostic risk groups. A retrospective analysis of all cases undergoing EC surgery between January 2011 and March 2018 was performed. The patients were grouped according to the management guidelines of EC patients jointly formulated by the ESGO/ESTRO/ESP 2020. Different surgical approaches were compared with regard to tumor characteristics, recurrence rate, disease-free survival (DFS), and overall survival (OS). A total of 665 patients met the inclusion criteria of which 196 patients underwent MIS (29.5%), and 469 patients underwent open surgery (70.5%). In the MIS group, there was a significant higher rate of recurrence (17.3% vs 6.6%, For patients with EC at moderate and high prognostic risk, MIS is associated with poorer DFS compared to open surgery, but OS was similar across prognostic risk groups. The application of MIS in patients with moderate and high-risk EC needs further research and analysis.

Effect of Laparoscopic Nerve-Sparing Radical Hysterectomy on Bladder Function Recovery

Serum Albumin as a Predictor of Survival after Interval Debulking Surgery for Advanced Ovarian Cancer (AOC): A Retrospective Study

To investigate the impact of serum albumin (at diagnosis and pre-operatively) on survival in patients undergoing cytoreductive surgery for advanced ovarian cancer(AOC) and whether improvement in albumin achieved following neoadjuvant chemotherapy (NACT) affects overall survival (OS). Outcomes of 441 patients who underwent cytoreduction for AOC were reviewed. Albumin was recorded at diagnosis and pre-operatively. Further analysis was performed if patients were hypoalbuminaemic at diagnosis.Analysis was stratified according to whether the patientreceived primary debulking surgery (PDS) or interval debulking surgery (IDS) and if their albumin was corrected. 308 patients had a serum albumin level at diagnosis and 400 patients had a pre-operative albumin available for analysis. For patients with an albumin at diagnosis ≤ 35g/L and ≥36 g/L, median OS was 31.5 (95% CI 23.5-39.5) and 50.4 (95% CI 38.9-61.9) months respectively (P = 0.003). Followingmultivariate analysis (MVA), albumin at diagnosis remained statistically significant as an independent marker for survival, even after adjusting for cytoreductive outcome, stage and grade(p = 0.04, Hazard ratio 1.38, 95% CI 1.01-1.89).Hypoalbuminaemic patients at diagnosis achieved complete cytoreduction in 53% of cases.For PDS patients, median OS was 19.7 months (95% CI 11.5-27.9). For IDS patients, median OS was 27.9 months (n = 1).IDS patients with a corrected albumin had a median OS of 42.9 months (95% CI 31.5-54.3) (p > 0.05). Hypoalbuminaemia at diagnosis is a poor prognostic factor in AOC. Normalization of serum albumin after NACT is a potential predictor of survival.

How Should we Perform a Preoperative Multidimensional Assessment of Elderly Patients with Advanced Ovarian Cancer?

Interval Debulking Surgery for Advanced Ovarian Cancer in Elderly Patients (≥70 y): Does the Age Matter?

Elderly ovarian cancer (OC) patients are more likely to be managed suboptimally, with worse clinical outcomes as a result. Strategies to decrease morbidity are lacking. A total of 153 patients were referred during the study period. 114 patients underwent IDS after NACT (74.5%), 46 in Group 1 and 68 in Group 2. Elderly patients were more likely to receive more than three cycles of NACT prior to IDS compared to younger patients (39% vs. 19%, Older age should not preclude clinicians from offering ultra-radical resection to patients with advanced OC after NACT. In our series, elderly patients received the same treatment with similar outcomes to the younger group. Clinicians should be encouraged to use CPET for patients' selection following NACT.

Complete Laparoscopic Interval Debulking Surgery for Advanced Ovarian Cancer Achieves Similar Survival Outcomes to Open Approach: A Propensity-Matched Study

To assess the laparoscopic interval debulking surgery (IDS) outcomes compared to laparotomy, by analyzing the overall survival (OS) and the progression free survival (PFS), as well as the intra- and post-operative morbidity. In this retrospective propensity-score-matched cohort study, all patients with stage III or IV FIGO (International Federation of Gynecology and Obstetrics) serous ovarian cancer, undergoing complete IDS after neoadjuvant chemotherapy, from January 1st of 2009 to June 1st 2019, were included. Thirty-seven patients were included in the laparoscopy group and 40 in the laparotomy group. There was no significant difference in terms of median OS between laparoscopy and laparotomy (23.1 months [95% CI 15.7-29.7] versus 26.3 months [95% CI 21.7-31.7], respectively,

Investigating the Role of Minimally Invasive Radical Hysterectomy in Cervical Cancer

Significance of the Number of Intermediate-Risk Factors in Cervical Cancer Patients Treated with Radical Hysterectomy: A Retrospective Study of 976 Patients

This study aimed to investigate the impact of intermediate-risk factors (IRFs) on the prognosis of stage I-II cervical cancer (CC) patients, and evaluate the necessity of adjuvant treatment based on investigation. Medical records of 976 negative high-risk factors' CC patients were retrospectively reviewed. Clinicopathologic characteristics and adjuctive therapy were analyzed using Kaplan-Meier analysis and log-rank tests to identify significant factors. The multivariate Cox proportional hazards regression analysis was performed to identify the independent prognostic factors. For patients with none, single and multiple IRFs, the 3-year recurrence-free survival rates were 97.8%, 86.3%, and 68.0% respectively ( The number of IRFs was demonstrated with higher predictive efficacy on survival of CC than individual IRF. Patients with multiple IRFs had significantly worse survival outcomes than patients with none or one. Different adjuvant treatment plans should be formulated based on the number of present IRFs. The prognostic management of patients with multiple IRFs should be pay more attention.