The objective of this study is to evaluate the detection rate and diagnostic accuracy of sentinel lymph node (SLN) mapping using intra-operative cervical injection of filtered 99mTc-sulfur colloid (99mTc-SC) and patent blue in patients... more
The objective of this study is to evaluate the detection rate and diagnostic accuracy of sentinel lymph node (SLN) mapping using intra-operative cervical injection of filtered 99mTc-sulfur colloid (99mTc-SC) and patent blue in patients with endometrial cancer. Prospective evaluation of the first 100 endometrial cancer patients undergoing SLN mapping using cervical injection of patent blue combined with filtered 99mTc-SC in the operating room was done. Patients underwent robotic-assisted lymphatic mapping with frozen section, hysterectomy, BSO, and completion bilateral lymphadenectomy (including para-aortic nodes in grade 2 and 3 tumors). At least one SLN was detected in 92% of patients; in 66 of these (72%) bilateral SLN were detected, and in 15 cases the SLN was in the para-aortic area. Eleven percent of all patients had lymph node metastases, and 4 of which had pre-operative grade 1 tumor. The SLN was the only positive node in 44% of the cases with positive nodes. Sensitivity was 89% with 1 false negative result, yielding a negative predictive value of 99% (95% CI 93-100). Specificity was 100% (95% CI 94-100), and positive predictive value was 100% (95% CI 60-100). No complications or anaphylactic reactions were noted. Intra-operative SLN biopsy, using cervical injection of patent blue and filtered 99mTc-SC in endometrial cancer patients is feasible and yields adequate detection rates.
Research Interests: Medicine, Endometrial Cancer, Humans, Gynecologic Oncology, Female, and 15 moreCervical Cancer, Hysterectomy, Aged, Middle Aged, Pelvis, Adult, Lymph Node, Predictive value of tests, Injections, Lymph nodes, Neoplasm staging, Paediatrics and reproductive medicine, lymphadenectomy, Endometrial neoplasms, and coloring agents
Leiomyoma is the most common benign tumor occurring in the uterus and female pelvis. It is estimated that 25% of women over the age of 35 years have leiomyoma. i Symptomatic leiomyoma embellishes the spectrum of pelvic pain, pressure, and... more
Leiomyoma is the most common benign tumor occurring in the uterus and female pelvis. It is estimated that 25% of women over the age of 35 years have leiomyoma. i Symptomatic leiomyoma embellishes the spectrum of pelvic pain, pressure, and bleeding, as well as unexplained infertility or recurrent pregnancy losses. As women continue to delay their childbearing until the third and fourth decades of life, symptomatic leiomyoma will be encountered more frequently. Myomectomy is advocated for the treatment of symptomatic leiomyoma in women wishing to preserve their reproductive potential.
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To investigate the development of new technical approaches for improving the implementation of robotics in gynaecologic surgery, we conducted a prospective evaluation of five technical modifications developed during the implementation of... more
To investigate the development of new technical approaches for improving the implementation of robotics in gynaecologic surgery, we conducted a prospective evaluation of five technical modifications developed during the implementation of a robotics program that included 171 robotic endometrial staging procedures from December 2007 until May 2010. Modification of the use of a Hohl uterine manipulator by applying only the intravaginal component minimizes the theoretical risk of spillage of endometrial cancer cells, without losing the capability of delineating the vaginal fornices. Entry to the peritoneal cavity under visual control using a left upper quadrant approach and a 5-mm endoscope through a 5-mm Endopath(®) trocar is quick and decreases the risk of bowel or vessel injury. Use of 12-mm Endopath(®) trocars with blunt tips without closure of the fascia was not associated with post-operative hernias. Positioning the Da Vinci(®) Surgical System at a 30° angle at the side of the patient allows easy access to the vagina for removal of large surgical specimens and does not interfere with proper movements of the robotic arms. Use of a tissue specimen bag introduced via the vagina at completion of surgery allows removal of large uteri vaginally to avoid (mini-)laparotomy and its morbidities. Finally, suturing of the vault using interrupted delayed absorbable monofilament sutures was not associated with vaginal cuff dehiscence. Early evaluation of evolving minor technical and surgical approaches was associated with low morbidity, and appears to benefit patients undergoing robotic surgery for gynaecologic cancers.
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Research Interests: Medicine, HUMAN PAPILLOMAVIRUS, Humans, Female, Risk factors, and 14 moreColposcopy, Cervical Cancer, Middle Aged, Carcinogenesis, Genotype, Adult, Risk Factors, Cervical Intraepithelial Neoplasia, HPV Infection, Papillomavirus Infections, Uterine Cervical Neoplasms, mass Screening, Medical and Health Sciences, and Vaginal smears
To optimize the management of adnexal masses and to assist primary care physicians and gynaecologists determine which patients presenting with an ovarian mass with a significant risk of malignancy should be considered for gynaecologic... more
To optimize the management of adnexal masses and to assist primary care physicians and gynaecologists determine which patients presenting with an ovarian mass with a significant risk of malignancy should be considered for gynaecologic oncology referral and management. Laparoscopic evaluation, comprehensive surgical staging for early ovarian cancer, or tumour debulking for advanced stage ovarian cancer. To optimize conservative versus operative management of women with possible ovarian malignancy and to optimize the involvement of gynaecologic oncologists in planning and delivery of treatment. Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified by searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. 1. Primary care physicians and gynaecologists should always consider the possibility of an underlying ovarian cancer in patients in any age group who present with an adnexal or ovarian mass. (II-2B) 2. Appropriate workup of a perimenopausal or postmenopausal woman presenting with an adnexal mass should include evaluation of symptoms and signs suggestive of malignancy, such as persistent pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating. In addition, CA125 measurement should be considered. (II-2B) 3. Transvaginal or transabdominal ultrasound examination is recommended as part of the initial workup of a complex adnexal/ovarian mass. (II-2B) 4. Ultrasound reports should be standardized to include size and unilateral/bilateral location of the adnexal mass and its possible origin, thickness of septations, presence of excrescences and internal solid components, vascular flow distribution pattern, and presence or absence of ascites. This information is essential for calculating the risk of malignancy index II score to identify pelvic mass with high malignant potential. (IIIC) 5. Patients deemed to have a high risk of an underlying malignancy should be reviewed in consultation with a gynaecologic oncologist for assessment and optimal surgical management. (II-2B).
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Research Interests: Fertility, Chemotherapy, Medicine, Case Report, Humans, and 14 moreFertility preservation, Gynecologic Oncology, Female, Cervical Cancer, Adult, Young Women, Neoadjuvant Chemotherapy, Gynecologic, Adjuvant Chemotherapy, neoadjuvant therapy, Trachelectomy, Neoplasm staging, Uterine Cervical Neoplasms, and Paediatrics and reproductive medicine
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Research Interests: Ovarian Cancer, Medicine, Cell line, Humans, Metformin, and 15 moreGynecologic Oncology, Female, Phosphorylation, AMPK, Cisplatin, Adenylate Kinase, Clinical Study, Growth Inhibition, Pyrazoles, Cancer Risk, Gynecologic, epithelial ovarian cancer, Drug synergism, Paediatrics and reproductive medicine, and Ovarian Neoplasms
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Aim: The present, was a feasibility study of extended-field (EF) external-beam radiotherapy (EBRT) and vaginal brachytherapy (VBT) given sequentially following complete staging and adjuvant chemotherapy for patients with advanced-stage... more
Aim: The present, was a feasibility study of extended-field (EF) external-beam radiotherapy (EBRT) and vaginal brachytherapy (VBT) given sequentially following complete staging and adjuvant chemotherapy for patients with advanced-stage endometrial carcinoma (EC). Patients and methods: A cohort study was carried out in 38 patients with stage IIIC and IVB EC treated by surgery, six cycles of paclitaxel-carboplatin chemotherapy followed by EF EBRT and VBT. Results: A total of 60% of the patients had non-endometrioid histology, 45% had both pelvic and para-aortic lymph node metastases. Two patients experienced recurrence in the previously irradiated field. Five-year overall and progression-free survival were 77% and 72.5%, respectively. Grade 1 diarrhea and grade 1 cystitis were the most common acute and delayed side-effects. Conclusion: EF EBRT and VBT following complete staging and adjuvant chemotherapy is a safe and effective treatment for patients with advanced-stage EC. Compared to historical data, our study suggests an improved progression-free and overall survival with acceptable acute and delayed side-effects.
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To compare the immediate operating room (OR), inpatient, and overall costs between three surgical modalities among women with endometrial cancer (EC) and Class III obesity or higher.
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OBJECTIVE Surgical staging for apparent early stage ovarian cancer includes systematic pelvic and paraaortic lymph node evaluation to detect occult stage III disease1. Though lymphadenectomy procedure is associated with increased duration... more
OBJECTIVE Surgical staging for apparent early stage ovarian cancer includes systematic pelvic and paraaortic lymph node evaluation to detect occult stage III disease1. Though lymphadenectomy procedure is associated with increased duration of surgery and a 13 percent risk of lymphocyst formation2. Sentinel lymph node (SLN) biopsy is still investigational, and no standardized approach has been studied. Recent mounting evidence has approved the applicability of SLN technique in early stage ovarian cancer3,4. The objective of this video is to demonstrate a surgical technique for robotic performance of SLN biopsy in presumed early-stage ovarian cancer. DESIGN Stepwise demonstration of the robotic technique for SLN sampling in presumed early stage ovarian cancer. This video report is part of an institutional, Investigational Review Board-approved study. SETTING An academic tertiary referral center. INTERVENTIONS This video presents our team's robotic technique for SLN sampling in a 37-year-old woman who presented to our center with 10 cm right complex adnexal mass, suspicious for malignancy. A 27-gauge spinal needle was inserted through the abdominal wall under direct visualization. We injected 0.5 mL of dilute indocyanine green (ICG) solution (Novadaq Technologies, Mississauga, ON, Canada) (1.25 mg/mL) subperitoneally into the utero-ovarian ligament. The SLN was checked with the fluorescence-guided camera of the Xi DaVinci robotic system (Sunnyvale, California). 8-10 minutes after the injection, a right para-aortic SLN was identified and dissection was performed. After dissection, the node was extracted and sent to pathologic evaluation by ultra-staging. Final pathology revealed a stage IA low grade serous ovarian cancer. CONCLUSION SLN sampling appears to be feasible in presumed early-stage ovarian cancer and may allow the avoidance of systematic lymph node dissection in this set of patients.
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OBJECTIVE To evaluate if the prognostic value of lymphovascular space invasion (LVSI) is different in endometrial cancer patients with negative lymph nodes following sentinel lymph node (SLN) mapping or lymph node dissection (LND) as... more
OBJECTIVE To evaluate if the prognostic value of lymphovascular space invasion (LVSI) is different in endometrial cancer patients with negative lymph nodes following sentinel lymph node (SLN) mapping or lymph node dissection (LND) as staging procedure. MATERIAL AND METHODS A retrospective study of 510 patients diagnosed with endometrial carcinoma in our institution between 2007 and 2014. We excluded patients that were diagnosed with positive nodes (Stage IIIc). We compared patients' characteristics and survival outcomes as function of their LVSI status (positive LVSI vs negative LVSI subgroups) in each cohort separately. RESULTS 413 patients met the inclusion criteria, out of whom 239 underwent SLN and 174 patients underwent LND only. In the SLN group, life table analysis showed 5-year OS and PFS of 80% and 72% in patients with LVSI compared to 96%, and 93% without LVSI. Same trend was observed among patients with LND with 5-year OS and PFS of 74% and 64% in patients with LVSI compared to 97%, and 90% without LVSI. On multivariable analysis, adjusted for age, FIGO stage, grade and maximal tumor size, the favorable survival of negative LVSI remained only in the LND cohort (SLN cohort: HR 1.2, CI [0.3-4.0], P = 0.8 and HR 1.7, CI [0.7-4.3], p = 0.2 for OS and PFS, respectively; LND cohort: HR 3.1, CI [1.4-6.5], p < 0.001 and HR 2.5, CI [1.2-4.9], p = 0.01 for OS and PFS, respectively). CONCLUSIONS The prognostic value of LVSI disappears when patients undergo staging with SLN and are found to have negative nodes in contrast to those who have undergone LND. Future studies should confirm our observation on patients with negative sentinel nodes, and plan on tailoring adjuvant treatment to this specific subgroup.
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Research Interests: Evidence Based Medicine, Global Health, Adolescent, Medicine, HUMAN PAPILLOMAVIRUS, and 15 moreCanada, Humans, Child, Letters, Female, Cervical Cancer, Adult, Cost Benefit Analysis, Herd Immunity, Primary Prevention, Immunization Programs, Randomized Controlled Trials as Topic, Papillomavirus Infections, Uterine Cervical Neoplasms, and Medical and Health Sciences
We present a hitherto unreported case of vulvar phyllodes tumor which displayed morphologically malignant stroma including rhabdomyosarcomatous cellular elements. Clinically, the 61-year-old patient is free of recurrence 1 year after wide... more
We present a hitherto unreported case of vulvar phyllodes tumor which displayed morphologically malignant stroma including rhabdomyosarcomatous cellular elements. Clinically, the 61-year-old patient is free of recurrence 1 year after wide local excision.
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LBA5503 Background: The aim of this 2 stage randomized trial was to evaluate whether women undergoing neoadjuvant IV chemotherapy followed by delayed debulking surgery benefit from the addition of IP/IV treatment after surgery. Methods:... more
LBA5503 Background: The aim of this 2 stage randomized trial was to evaluate whether women undergoing neoadjuvant IV chemotherapy followed by delayed debulking surgery benefit from the addition of IP/IV treatment after surgery. Methods: Stage 1 was a randomized 3-arm design including 2 IP platinum regimens: 153 women who received 3-4 courses of IV platinum-based chemo for stage IIB-III (IV pleural effusion only) EOC followed by optimal debulking surgery ( &lt; 1 cm) were randomized to: ARM1 D1 IV paclitaxel (pacli) 135mg/m2 + IV Carboplatin AUC 5/6 with d8 pacli IV 60 mg/m2 Q 21d X3; ARM 2 D1 IV pacli 135mg/m2 + IP cisplatin (Cis) 75 mg/m2 and d8 IP pacli 60 mg/m2 Q21d X3; or ARM 3 d1 IV pacli 135mg/m2+ IP Carboplatin AUC 5/6 and d8 IP pacli 60mg/m2 Q21dX3. A planned DSMC review confirmed dropping ARM2 (IP cis) and continuing study as an expanded phase II comparing 200 patients randomized to ARMs 1 and 3, which has 80% power to detect a 19% difference in progression rate at 9 mo (PD9, primary endpoint), 2-sided α = 0.05. Progression free survival (PFS) and overall survival (OS) are secondary efficacy endpoints. Results: Between 2009 and May 2015, 275 patients were accrued: n = 101 Arm 1, 72 Arm 2, 102 Arm 3. Median age was 62; 81.8%s had stage 3 C disease; 12.7% stage IV. Baseline characteristics were balanced between arms. Median number of cycles was 3 all arms; completion rates Arm 1, 93.7% and Arm 3, 84.8%. Intention to treat PD9 rates: Arm 1: 38.6% (95% CI 29.1%- 48.8%) and Arm 3: 24.5% (95% CI 16.5%-34.0%); p = 0.065 stratified; p = 0.03 unstratified. Per protocol (eligible, received &gt; one dose of protocol therapy) PD9 rates: Arm 1: 42.2% (95% CI 31.9%- 53.1%), Arm 3: 23.3% (95% CI 15.1%-33.4%); p = 0.03 stratified; p = 0.01 unstratified. Median PFS 11.3 mo (Arm1) and 12.5 mo (Arm 3); HR 0.82 (95% CI 0.57 - 1.17); p = 0.27. Median OS: 38.1 mo (Arm 1) and 59.3 mo (Arm 3); HR 0.80 (95% CI 0.47-1.35) p = 0.40. Adverse events &gt; Gr 3 rates: 23% (Arm 1) and 16% (Arm 3) (p = 0.24). Conclusions: The IP carboplatin based regimen, post neoadjuvant chemotherapy and debulking surgery, is well tolerated and associated with a lower PD9 rate compared to IV therapy. Clinical trial information: NCT00993655.
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Minimally invasive surgery for the treatment of macroscopic cervical cancer leads to worse oncologic outcomes than with open surgery. Preoperative conization may mitigate the risk of surgical approach. Our objective was to describe the... more
Minimally invasive surgery for the treatment of macroscopic cervical cancer leads to worse oncologic outcomes than with open surgery. Preoperative conization may mitigate the risk of surgical approach. Our objective was to describe the oncologic outcomes in cases of cervical cancer initially treated with conization, and subsequently found to have no residual cervical cancer after hysterectomy performed via open and minimally invasive approaches. This was a retrospective cohort study of surgically treated cervical cancer at 11 Canadian institutions from 2007 to 2017. Cases initially treated with cervical conization and subsequent hysterectomy, with no residual disease on hysterectomy specimen were included. They were subdivided according to minimally invasive (laparoscopic/robotic (MIS) or laparoscopically assisted vaginal/vaginal hysterectomy (LVH)), or abdominal (AH). Recurrence free survival (RFS) and overall survival (OS) were estimated using Kaplan–Meier analysis. Chi-square and...