Comparison of survival outcome of patients with primary peritoneal and fallopian tube carcinoma treated with neoadjuvant chemotherapy versus primary debulking surgery

Surgery in Advanced Ovary Cancer: Primary versus Interval Cytoreduction

Primary debulking surgery (PDS) has remained the only treatment of ovarian cancer with survival advantage since its development in the 1970s. However, survival advantage is only observed in patients who are optimally resected. Neoadjuvant chemotherapy (NACT) has emerged as an alternative for patients in whom optimal resection is unlikely and/or patients with comorbidities at high risk for perioperative complications. The purpose of this review is to summarize the evidence to date for PDS and NACT in the treatment of stage III/IV ovarian carcinoma. We systematically searched the PubMed database for relevant articles. Prior to 2010, NACT was reserved for non-surgical candidates. After publication of EORTC 55971, the first randomized trial demonstrating non-inferiority of NACT followed by interval debulking surgery, NACT was considered in a wider breadth of patients. Since EORTC 55971, 3 randomized trials—CHORUS, JCOG0602, and SCORPION—have studied NACT versus PDS. While CHORUS supported EORTC 55971, JCOG0602 failed to demonstrate non-inferiority and SCORPION failed to demonstrate superiority of NACT. Despite conflicting data, a subset of patients would benefit from NACT while preserving survival including poor surgical candidates and inoperable disease. Further randomized trials are needed to assess the role of NACT.

Feasibility of laparoscopic diaphragmatic peritonectomy during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer

OBJECTIVE

To describe the surgical technique and evaluate the safety, feasibility and efficacy of laparoscopic diaphragmatic peritonectomy during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer (OC).

METHODS

This report is part of a Service Evaluation Protocol (Trust number 3267) on laparoscopy in patients with OC following neo-adjuvant chemotherapy. Between April 2015 and November 2017, all patients underwent to exploratory laparoscopy and a selected court was offered laparoscopic VPD. Laparoscopic diaphragmatic surgery was considered if there was no full thickness involvement. Primary endpoints of this part of the study were the safety, feasibility and efficacy of laparoscopic diaphragmatic peritonectomy. We report the surgical technique and outcomes.

RESULTS

Ninety-six patients underwent diaphragmatic surgery during the study period. Fifty patients (52.1%) had intra-operative exclusion criteria and/or full thickness diaphragmatic resection, 46 (47.9%) had peritonectomy and were included in the study. Laparoscopic diaphragmatic peritonectomy was performed in 21 patients (45.4%, group 1), while in 25 patients (54.6%, group 2) laparotomy was necessary. Extent of disease and complexity of surgery were similar. Reasons for conversions were disease coalescing the liver to the diaphragm preventing safe mobilization (22 patients) and accidental pleural opening (3 patients). Overall, intra- and post-operative morbidity was lower in group 1 and pulmonary specific morbidity was very low.

CONCLUSION

Diaphragmatic peritonectomy can be safely accomplished by laparoscopy in almost half of the patients with OC whose disease is limited to the diaphragmatic peritoneum.

Clear cell degeneration associated with endometriosis of abdominal wall after cesarean section: A case report and systematic review of literature

AIM

The scar of cesarean section (CS) is the most common site of abdominal wall endometriosis (AWE), whose tumor degeneration has been reported in an increasing number of cases; the most frequent histological type is clear cell carcinoma (CCC).

METHODS

We conducted a systematic research of the literature, collecting data regarding the evidence on tumor degeneration from AWE after CS. Moreover, we reported a case of clear cell borderline tumor (CCBT) originating from AWE.

RESULTS

We included data of 37 patients with diagnosis of CCC. The average time between the last CS and the diagnosis of CCC was around 15 years. Overall, 26.0% and 73.9% patients received exclusive local abdominal resection of the lesion and additional surgery, respectively. Lymph nodes involvement was detected in 26.0 % patients and adjuvant chemotherapy was administered in 52.0 % cases. During follow-up period, 15.2% patients died of disease, 32.6% had no evidence of disease, and 17.4% recurred. We diagnosed a CCBT arose in a patients with AWE and a personal history of several surgical procedures for endometriosis, a CS and a subsequent transverse laparotomy. We performed an open bilateral ovariectomy and a large excision of the endometriotic abdominal lesion.

CONCLUSION

Tumor degeneration from AWE seems to be a real occurrence with an increasing number of events. Considering the lack of risk factors and diagnostic instruments for tumor degeneration, the removal of AWE localization could be advisable, even though there was long average time between the trigger surgery and the tumor finding.

Extra-abdominal ovarian cancer presenting with breast metastases at diagnosis: Case report and literature review

OBJECTIVE

Malignant ovarian tumours are diagnosed at an advanced stage in the majority of cases. However, only a small percentage present as extra-abdominal, non-lymph-node solid metastases, as in the breast, and they are usually cases of relapse. The discovery of mono- or bilateral breast lesions with peritoneal carcinosis and/or abdomino-pelvic lesions can be cumbersome in the differential diagnosis of primary tumours. This article aims to summarize current evidence on the detection of breast metastases at diagnosis of ovarian cancer.

STUDY DESIGN

A systematic review of the literature in Scopus, PubMed/MEDLINE, ScienceDirect and the Cochrane Library, including case reports and case series, was undertaken. Data regarding study features; population characteristics; clinical, radiological and histological assessment of the disease; treatment and follow-up were collected. In addition, a case report of a patient managed at the authors' centre is provided.

RESULTS

According to the search strategy, 16 articles (18 patients) were included in this review. Serous ovarian, fallopian tube or primary peritoneal cancer was detected in 61% of cases, while another type or a non-specified type of epithelial ovarian cancer was detected in 27.7% of cases; there was one case with granulosa cell tumour of the ovary and one case with mucinous ovarian tumour of low malignant potential. Breast metastases were mainly monolateral (66.6%), with other extra-abdominal sites of disease in the majority of the cases. A minority of patients (16.6%) received treatment for primary breast cancer with a subsequent diagnosis of ovarian cancer. Concomitant breast and abdominal surgery can be an option. PAX8, WT1 and CA125 immunohistochemical staining can aid in differential diagnosis.

CONCLUSION

Breast metastases of malignant ovarian tumours must be promptly recognized to ensure proper treatment. Specific immunohistochemical analysis can be a decisive assessment in uncertain cases.

Medical diligence uncovers fallopian tube cancer after abnormal Pap test

The fallopian tube has received attention as an origin of high-grade pelvic malignancies. This is a case of bilateral fallopian tube cancer discovered after an abnormal Pap test. A 62-year-old woman with a history of one term delivery had atypical glandular cells on a Pap test. She had an unsatisfactory colposcopy and a normal transvaginal ultrasound. A loop electrode excision procedure and hysteroscopy with dilation and curettage revealed atypical glandular cells concentrated in floating balls. CA-125 was 10 U/mL. A robotic hysterectomy revealed histopathological stage IIIA serous carcinoma arising from both fallopian tubes. She received six cycles of carboplatin and paclitaxel. After chemotherapy, she has no evidence of disease at 5 years. Fallopian tube carcinoma is a differential diagnosis of abnormal glandular cells on a Pap test. Diagnosis by systematic pursuit of abnormal tests can lead to successful treatment of a small disease burden.