Currently, the most frequent approach in the oncologic applications of positron emission tomography (PET) is detecting the hypermetabolic activity of the cancer tissue. A more specific approach, ...which may be complementary, is detecting the overexpression of receptors. In this review article, we aim to evaluate the results that are currently available for PET imaging of the sex hormone receptors in clinical oncology. The indication of PET and now PET/CT has been more disputed in breast carcinoma than in many other primary cancers (e.g., lung, head and neck, colorectal, lymphoma). 18F-fluorodeoxyglucose (FDG), the glucose analogue for PET imaging, has a limited sensitivity to detect the primary breast tumors in case of lobular or in situ forms or small sized tumors localised on systematic mammography, and to identify minimal node invasion in the axilla. Using 16α-¹⁸Ffluoro-17β-estradiol (FES), a fluorinated estradiol analogue, PET is able to detect the over-expression of the oestrogen receptor (ER) in lesions, at a whole-body level. FES and FDG appear complementary for a better diagnostic performance in staging locally advanced breast cancer or restaging recurrent or metastatic breast cancer. Another potential indication is predicting the response to starting or resuming hormone therapy in patients with metastatic breast cancer, in relation with the ER status of all lesions revealed by FES PET. In two retrospective studies, FDG PET was also able to predict the response to hormone therapy, on basis of a metabolic flare, observed either after 7-10 days of treatment or during an estradiol challenge. A prospective comparison of those approaches is warranted. One study reported predicting response to neoadjuvant chemotherapy thanks to a low value of FES SUV(max) or FES/FDG SUV(max) ratio. The presence of ER in uterine tumors, including the benign ones, in ovarian cancers or even in meningiomas, may have therapeutic consequences and FES PET could have a clinical utility in those settings; only initial results are available. The indication of PET and PET/CT has been even more disputed in prostate carcinoma, due to the lack of significant FDG uptake in most cases, at least before the castration-resistant stage. Using FDHT, a fluorinated testosterone analogue, PET is able to detect the over-expression of the androgen receptor (AR) in lesions, at a whole-body level. At least partly due to the rather large number of alternative tracers that are in development or even routinely available in some countries, few FDHT studies have been published until now. From absorbed dose values previously published for FES by the team of University of Washington School of Medicine at Seattle, and for FDHT by the teams of Memorial Sloan-Kettering Cancer Center at New York and of Washington University at St. Louis, we applied the coefficients of ICRP publication 103 and calculated an effective dose per unit of injected activity of 0.023 mSv/MBq for FES and 0.018 mSv/MBq for FDHT. The radiation exposure is of the same order of magnitude as with FDG.
An MRI is recommended for an ovarian mass that is indeterminate on ultrasound. The ROMA score (combining CA125 and HE4) can also be calculated (grade A). In presumed early-stage ovarian or tubal ...cancers, the following procedures should be performed: an omentectomy (at a minimum, infracolic), an appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C), and pelvic and para-aortic lymphadenectomies (grade B) for all histologic types, except the expansile mucinous subtypes, for which lymphadenectomies can be omitted (grade C). Minimally invasive surgery is recommended for early-stage ovarian cancer, when there is no risk of tumor rupture (grade B). For FIGO stages III or IV ovarian, tubal, and primary peritoneal cancers, a contrast-enhanced computed tomography (CT) scan of the thorax/abdomen/pelvis is recommended (grade B), as well as laparoscopic exploration to take multiple biopsies (grade A) and a carcinomatosis score (Fagotti score at a minimum) (grade C) to assess the possibility of complete surgery (i.e., leaving no macroscopic tumor residue). Complete surgery by a midline laparotomy is recommended for advanced ovarian, tubal, or primary peritoneal cancer (grade B). For advanced cancers, para-aortic and pelvic lymphadenectomies are recommended when metastatic adenopathy is clinically or radiologically suspected (grade B). When adenopathy is not suspected and when complete peritoneal surgery is performed as the initial surgery for advanced cancer, the lymphadenectomies can be omitted because they do not modify either the medical treatment or overall survival (grade B). Primary surgery (before other treatment) is recommended whenever it appears possible to leave no tumor residue (grade B).
Abstract Background Treatment of Advanced Ovarian Cancer (AOC) includes surgery with complete cytoreduction, one of the strongest prognostic factors. To achieve complete cytoreduction, diaphragmatic ...surgery is often required. There is currently a lack of information in the literature regarding the morbidity and impact of this type of surgery. The aim of this study is to report specific pulmonary morbidity and overall morbidity associated with diaphragmatic surgery in patients with AOC. Materials and methods We conducted a multicentric (6 centres), retrospective study that included 148 patients operated on between 2004 and 2008. Patient characteristics, surgical course and postoperative complications were collected. Results The complete cytoreduction rate was 84%. The surgery was categorised by timing as initial, interval or recurrence surgery in 38%, 51% and 11% of patients, respectively. In 69% of patients, one or more postoperative complications occurred: pulmonary complication (42%), digestive fistula (7%) or lymphocyst (18%). The pulmonary complications were pleural effusion (37%), pulmonary embolism (5%), pneumothorax (4%) and pulmonary infection (2%). These complications required revision surgery, pleural evacuation, or lymphocyst evacuation in 13%, 14%, and 11% of the cases, respectively. Postoperative mortality was 3%. Risk factors for pulmonary complications were the addition of extensive upper surgery to the diaphragmatic surgery ( p = 0.014) and the size of the diaphragmatic resection ( p = 0.012). Conclusions Diaphragmatic surgery achieved complete removal of the tumour but resulted in pulmonary complications in addition to complications of radical surgery.
Abstract Objective The purpose of this study was to investigate the risk of carcinoma in patients with a diagnosis of papilloma of the breast made on ultrasound large core biopsy or stereotactic ...vacuum-assisted biopsies. Material and methods This retrospective database review (2000–2007) included 130 patients with a papilloma diagnosed on preoperative biopsies or excisional surgery specimen. The mean patient age was 52 years (range, 20–80 years). The examinations included mammography and ultrasonography in all 130 patients. The final surgical histology was compared to preoperative biopsy diagnosis, and then factors associated with underestimation of malignancy were evaluated in univariate and multivariate analyses. Results The preoperative histology was available for 63 patients. Benign papilloma had been identified by ductography in 34 patients and by preoperative biopsy in 48 patients. Mammography showed microcalcifications in 25 cases and nipple discharge was present in 59 patients. Malignancy was found on final histology in 8% of patients with initial diagnosis of benign papilloma. In this study group, age of more than 50 years, presence of nipple discharge and microcalcifications were found to be significantly related to the risk of malignancy ( p = 0.001, 0.05 and 0.02, respectively). Conclusion Since benign papilloma can be associated to malignancy at excisional biopsy, we still recommend surgical excision for papilloma especially when associated to identified risk factors of malignancy.
Despite the advantages of the vaginal and laparoscopic approaches, most hysterectomies carried out involve laparotomy. The objective of this prospective observational multicentre study was to examine ...the routes and complications of hysterectomy for benign disorders. METHODS: Of the 15 university hospitals belonging to Collégiale de Gynécologie-Obstétrique de Paris-Ile de France, 12 participated in this study that took place between June and December 2004. We analysed the characteristics of the patients, the indications for hysterectomy and intra- and post-operative complications (and their determinants) according to the surgical approach. RESULTS: In total, 634 women underwent hysterectomy for benign disorders during the study period. The patients’ mean age (±SD), BMI, parity and previous Caesarean sections were 51.4 ± 10.3 years, 25 ± 5.7 kg/m2, 2 ± 1.6 children and 0.2 ± 0.6, respectively. Hysterectomy was performed by the laparoscopic, laparoscopically assisted vaginal hysterectomy (LAVH), laparotomic and vaginal routes in 19.1, 8.2, 24.4 and 48.3% of cases, respectively. The operating time was shorter with the vaginal route than with laparoscopy, laparotomy and LAVH (P < 0.0001). Intra- and post-operative complications were significantly more frequent in the laparotomic group (18%) compared with the vaginal group (8.2%), the laparoscopic group (5.8%) and the LAVH group (8.2%) (P < 0.0001). In a multivariate logistic regression model, obesity odds ratio (OR): 2.84, 95% confidence interval (CI): 1.53–5.27, P = 0.001, history of pelvic surgery (OR: 2.47, 95% CI: 1.39–4.39, P = 0.002) and history of Caesarean section (OR: 2.04, 95% CI: 1.01–4.1, P = 0.046) were significantly associated with intra- and post-operative complications. Laparoconversion was necessary in 36 cases (7.5%) overall and was more frequent with laparoscopy and LAVH than with the vaginal route (P < 0.0001). CONCLUSIONS: This study confirms that the vaginal route is increasingly used for hysterectomy in France and that it is the route of choice for benign disorders.
The aim was to review the clinical impact of lymph node ratio (LNR) of groin metastatic nodal disease in women with vulvar squamous cell carcinoma.
Cohort study of women with vulvar squamous cell ...carcinoma, managed between January 2005 and December 2015, in five institutions in France with prospectively maintained databases (French multicenter tertiary care centers).
In total, 636 women managed for VSCC of whom 508 (79.9%) underwent surgical groin nodal staging.
Comparison of overall and recurrence free survival between women according to LNR.
In total, 176 women (34.6%) had at least one positive lymph node (LN). There was a significant differences for the 5-year overall survival and recurrence free survival rates between women with LNR>0.2 and women with LNR<0.2.
LNR seems to be a significant prognostic factor in women with vulvar squamous cell carcinoma.
Adjuvant chemotherapy by carboplatin and paclitaxel is recommended for all high-grade ovarian and tubal cancers (FIGO stages I-IIA) (grade A). After primary surgery is complete, 6 cycles of ...intravenous chemotherapy (grade A) are recommended, or a discussion with the patient about intraperitoneal chemotherapy, according to her risk-benefit ratio. After complete interval surgery for FIGO stage III, hyperthermic intraperitoneal chemotherapy (HIPEC) can be proposed, in accordance with the modalities of the OV-HIPEC trial (grade B). In cases of postoperative tumor residue or in FIGO stage IV tumors, chemotherapy associated with bevacizumab is recommended (grade A).
Abstract Objective The aim of our study is to compare the Mammotome and Vacora methods of stereotactic directional vacuum-assisted biopsy in terms of pain and complications. Materials and methods ...From June 2001 to May 2005, 1114 consecutive patients underwent directional stereotactic vacuum-assisted breast biopsy (DVAB) for nonpalpable mammographically detected breast lesions (BI-RADS 3, 4 or 5). Respectively 967 and 147 patients underwent the Mammotome and Vacora procedures. Pain was evaluated with a visual analog scale. Immediate and late complications were recorded. Results The mean ± S.D. (range) pain scores in the Mammotome and Vacora groups were 1.7 ± 1.8 (0–9) and 2.9 ± 2.3 (0–10), respectively ( p < 0.001). Patient age and operator experience were the main determinants of pain. Immediate complications were significantly more frequent in the Mammotome group ( p = 0.003), and so were late hematomas ( p = 0.04). Moderate and severe complications occurred exclusively in the Mammotome group. Conclusion The Mammotome technique is associated with a higher risk of immediate and late complications, while the Vacora technique is associated with more frequent severe pain. Patient age was the major factor influencing pain. Further prospective studies are needed to clarify factors incriminated in pain or complications after DVAB procedures.
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