BACKGROUND: The purpose was to determine the factors influencing nodal involvement and topography of pelvic and paraaortic node involvement in ovarian carcinoma. STUDY DESIGN: Between 1985 and 2001, 276 women with epithelial ovarian carcinoma underwent systematic bilateral pelvic and paraaortic lymphadenectomy. RESULTS: The overall frequency of lymph node involvement was 44% (122 of 276). The frequency of pelvic and paraaortic metastases were 30% (82 of 276) and 40% (122 of 276), respectively. The frequency of lymph node metastases according to the stage of the disease (stages I, II, and III + IV) were: 20% (17 of 85), 40% (6 of 15), and 55% (99 of 176), respectively. In patients with stage IA, IB, and IC disease, the rates of nodal involvement were 13% (8 of 60), 33% (4 of 12), and 38% (5 of 13), respectively. None of 15 patients with stage IA grade 1 disease had nodal involvement. None of the 20 patients with mucinous tumors confined to the ovary(ies) (stage I disease) had nodal involvement. When paraaortic nodes were involved, the left paraaortic chain above the level of the inferior mesenteric artery was the most frequently involved site (70 patients, 63%). One of nine patients (11%) with a macroscopic stage I unilateral tumor and paraaortic involvement had contralateral metastases. CONCLUSIONS: Lymphadenectomy should be performed even in patients with stage IA disease. This procedure could be omitted in patients with mucinous apparent stage I disease and stage I grade 1 tumor. Lymphadenectomy should involve the whole pelvic and paraaortic chain up to the level of the left renal vein. A bilateral dissection should be performed even in cases of patients with a unilateral tumor.

Lymph node involvement in epithelial ovarian cancer: Analysis of 276 pelvic and paraaortic lymphadenectomies and surgical implications

Most guidelines about fertility preservation are predominantly focused on scientific evidence, but are less practically orientated. Therefore, practically oriented recommendations are needed to support the clinician in daily practice. A selective literature search was performed based on the clinical and scientific experience of the authors, focussing on the most relevant diseases and gynaecological cancers. This article (Part I) provides information on topics that are essential for the fertility preservation indication, such as disease prognosis, disease therapy and its associated risks to fertility, recommending disease-specific fertility preservation measures. Part II specifically focusses on fertility preservation techniques. In breast cancer patients, fertility preservation such as ovarian tissue and oocyte cryopreservation is especially recommended in low-stage cancer and in women < 35 years of age. In Hodgkin’s lymphoma, the indication is mainly based on the chemotherapy regime as some therapies have very low, others very high gonadotoxicity. In borderline ovarian tumours, preservation of fertility usually is achieved through fertility sparing surgery, ovarian stimulation may also be considered. In cervical cancer, endometrial cancer, rheumatic diseases and other malignancies such as Ewing sarcoma, colorectal carcinoma, non-Hodgkin lymphoma, leukaemia etc., several other factors must be considered to enable an individual, stage-dependent decision. The decision for or against fertility preservation depends on the prognosis, the risks to fertility and individual factors such as prospective family planning.

/pdf/practical-recommendations-for-fertility-preservation-in-1jdnf5b4sv.pdf

Practical recommendations for fertility preservation in women by the FertiPROTEKT network. Part I: Indications for fertility preservation.

Background The trend toward late childbearing has made fertility preservation a major issue for women who face gynecological cancer. New techniques in assisted reproductive medicine enable conception after primary treatment of these cancers. Here, we aimed to review the efficacy and safety of assisted reproductive techniques (ART) after fertility-preserving treatment of gynaecological cancers. Methods We conducted a systematic literature review of both prospective and retrospective studies in the PubMed, EMBASE, CENTRAL and SciSearch databases. In the retrieved studies, we evaluated live births, clinical pregnancies, overall survival and disease-free survival. Results We identified many prospective and retrospective studies on this topic, but no relevant randomized clinical trials. Fertility-sparing treatments with safe oncological outcomes are feasible in endometrial, cervical and ovarian cancer cases. After cancer treatment, ART seem safe and show variable obstetrical outcomes. Conclusions After fertility-preserving treatment for gynaecological cancers, ART can enable pregnancy to be achieved with apparent oncological safety. The success of such procedures should directly impact clinical practice and management of those patients who require fertility-sparing treatment.

Assisted reproductive techniques after fertility-sparing treatments in gynaecological cancers

Gynecologic malignancies account for 1,09 million new cancer cases worldwide consisting of about 12% of tumors affecting female population. About 10% of all female cancer survivors are younger than 40 years of age. Since cancers affecting female genital organs are usually treated by radical surgery, chemotherapy or chemoradiation approaches that induce permanent damage of reproductive functions, the development of strategies for fertility preservation represent one of the most important goals for gynecologic oncology. In this scenario, the newly defined oncofertility discipline acquires increasing interest, offering patients maximal chances to make an adequate decision about future fertility, based on their oncologic diagnosis and prognosis. However, the majority of physicians do not pay particular attention to these issues, even if impressive progresses have been made in this field in the last decades. Possibly, it is due to the lack of strong evidences from clinical trials without an adequate number of cases to establish safety and efficacy of these procedures. In this review we will discuss the most recently debated options for fertility preservation in gynecologic oncology, highlighting issues and controversies related to oncofertility.

Special issues in fertility preservation for gynecologic malignancies

Total laparoscopic radical trachelectomy in the treatment of early squamous cell cervical cancer: A retrospective study with 8-year follow-up

As a result of the trend toward late childbearing, fertility preservation has become a major issue in young women with gynaecological cancer. Fertility-sparing treatments have been successfully attempted in selected cases of cervical, endometrial and ovarian cancer, and gynaecologists should be familiar with fertility-preserving options in women with gynaecological malignancies. Options to preserve fertility include shielding to reduce radiation damage, fertility preservation when undergoing cytotoxic treatments, cryopreservation, assisted reproduction techniques, and fertility-sparing surgical procedures. Radical vaginal trachelectomy with laparoscopic lymphadenectomy is an oncologically safe, fertility-preserving procedure. It has been accepted worldwide as a surgical treatment of small early stage cervical cancers. Selected cases of early stage ovarian cancer can be treated by unilateral salpingo-ophorectomy and surgical staging. Hysteroscopic resection and progesterone treatment are used in young women who have endometrial cancer to maintain fertility and avoid surgical menopause. Appropriate patient selection, and careful oncologic, psychologic, reproductive and obstetric counselling, is mandatory.

/pdf/fertility-preserving-surgical-procedures-techniques-1qunq7k8l2.pdf

Fertility-preserving surgical procedures, techniques

Objective The aim of the study was to report on the oncologic outcome of the disease spread to celiac lymph nodes (CLNs) in advanced-stage ovarian cancer patients. Methods All patients who had CLN resection as part of their cytoreductive surgery for epithelial ovarian, fallopian, or primary peritoneal cancer were identified. Patient demographic data with particular emphasis on operative records to detail the extent and distribution of the disease spread, lymphadenectomy procedures, pathologic data, and follow-up data were included. Results The median follow-up was 26.3 months. The median overall survival values in the group with positive CLNs and in the group with negative CLNs were 26.9 months and 40.04 months, respectively. The median progression-free survival values in the group with metastatic CLNs and in the group with negative CLNs were 8.8 months and 20.24 months, respectively (P = 0.053). Positive CLNs were associated with progression during or within 6 months after the completion of chemotherapy (P = 0.0044). Tumor burden and extensive disease distribution were significantly associated with poor progression-free survival, short-term progression, and overall survival. In multivariate analysis, only the CLN status was independently associated with short-term progression. Conclusions Disease in the CLN is a marker of disease severity, which is associated to a high-risk group of patients with presumed adverse tumor biology, increased risk of lymph node progression, and worst oncologic outcome.

https://ijgc.bmj.com/content/ijgc/24/1/48.full.pdf

Prognostic relevance of celiac lymph node involvement in ovarian cancer.

Endometrial cancer staging is based on surgery. No matter the age of the patient, the surgical staging includes at least a total hysterectomy with bilateral salpingo-oophorectomy. Twenty to 25% of the patients diagnosed with endometrial cancer are younger than 45 years. Although some discrepancies among series may be observed, in this population, endometrial cancers are mainly of lower grade, confined to the uterus (without ovarian involvement) and of better prognosis compared to older patients. The impact of premature menopause on the quality of life, cardiovascular and bone systems should not be neglected. This raises the issue of the systematic bilateral oophorectomy legitimacy while staging endometrial cancer staging in young patient. Considering the literature, eligibility criteria to ovarian preservation in endometrial cancer would be: young patients, low-grade endometrioid tumor, disease limited to the uterus (absence of any extrauterine disease). The risk of occult ovarian lesions, either synchronous or metastatic, would than be close to 1%. The effects of residual hormonal stimulation are considered low. Nevertheless, bilateral oophorectomy should remain the standard. Oophorectomy preservation in endometrial cancer should be considered as an exception, and proposed as an individualized plan of care for patients with strict eligibility criteria.

Ovarian preservation during treatment of early stage endometrial cancer

Due to feeding modifications, the rate of obese patients is increasing in North America, in Europe but also in developing countries. Obesity is serious, common and costly for the health system. Obesity increases the risk of different cancers, especially endometrial cancer. In France, the new endometrial cancer guideline has changed, with the extension of lymphadenectomies to para-aortic area in case of high risk cancer. This procedure is feasible in laparoscopy with the use of extra peritoneal approach. Laparoscopy reduces operative risks and morbidity for obese patients compared to open surgery. Gynecologic oncologists must master aortic lymphadenectomies in order to treat obese patients and respect guidelines in high risk endometrial cancer. Mots cles Laparoscopie Obese Cancer de l’endometre Curage aortique

Utilisation de la voie laparoscopique extra-péritonéale pour la réalisation des lymphadenectomies aortiques chez des patientes obèses Extraperitoneal laparoscopic para-aortic lymph nodes dissection in obese patients

Best Practice & Research Clinical Obstetrics and Gynaecology

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