Test Strip Platform Spin-Off for Telomerase Activity Detection: Development of an Electrochemical Biosensor

Telomerase overexpression has been associated directly with cancer, and the enzyme itself is recognized within the scientific community as a cancer biomarker. BIDEA's biosensing strip (BBS) is an innovative technology capable of detecting the presence of telomerase activity (TA) using electrochemical impedance spectroscopy (EIS). This BBS is an interdigital gold (GID) electrode array similar in size and handling to a portable glucose sensor. For the detection of the biomarker, BBS was modified by the immobilization of a telomere-like single strand DNA (ssDNA) on its surface. The sensor was exposed to telomerase-positive extract from commercially available cancer cells, and the EIS spectra were measured. Telomerase recognizes the sequence of this immobilized ssDNA probe on the BBS, and the reverse transcription process that occurs in cancer cells is replicated, resulting in the ssDNA probe elongation. This surface process caused by the presence of TA generates changes in the capacitive process on the electrode array microchip surface, which is followed by EIS as the sensing tool and correlated with the presence of cancer cells. The telomerases' total cell extraction protocol results demonstrate significant changes in the charge-transfer resistance (R ct) change rate after exposure to telomerase-positive extract with a detection limit of 2.94 × 104 cells/mL. Finally, a preliminary study with a small set of "blind" uterine biopsy samples suggests the feasibility of using the changes in the R ct magnitude change rate (Δ(ΔR ct/R cti)/Δt) to distinguish positive from negative endometrial adenocarcinoma samples by the presence or absence of TA.

Short- and long-term outcomes for single-port risk-reducing salpingo-oophorectomy with and without hysterectomy for women at risk for gynecologic cancer

INTRODUCTION

Risk-reducing salpingo-oophorectomy has been established as one of the most effective strategies in risk reduction for ovarian and breast cancers among women at increased genetic risk. However, there are limited data regarding the single-port laparoscopic platform in the field of risk-reducing surgery. Our objective was to describe outcomes after single-port risk-reducing salpingo-oophorectomy with or without hysterectomy for reduction of ovarian, breast, or endometrial cancer risk.

METHODS

A retrospective, single institution (Canadian Task Force Classification II.2) analysis was performed in women at high genetic or familial risk for ovarian/tubal/primary peritoneal cancer or with personal history of breast cancer who underwent single-port laparoscopic risk-reducing salpingo-oophorectomy with or without hysterectomy between October 2009 and December 2015. Data were collected on patient demographics, surgical procedure and characteristics, intra-operative findings, and post-operative outcomes.

RESULTS

In total, 187 single-port laparoscopic surgeries were performed with a median follow-up of 204 (IQR 25-749) days. BRCA1/2, Lynch syndrome, or Cowden syndrome was diagnosed in 64.0% of patients. Additionally, 32.1% had a personal history of breast cancer, and 3.2% reported strong family history of ovarian and/or breast cancer. Single-port risk-reducing salpingo-oophorectomy with hysterectomy was performed in 53.5% of patients. The rate of adverse outcomes, including conversion to multiport laparoscopy or laparotomy (1.6%), intra-operative injury (1.6%), deep vein thrombosis (0.5%), urinary tract infection (2.7%), and/or incisional cellulitis (4.3%) were low. Three patients (1.6%) were diagnosed with malignancy on final pathology. All three patients were BRCA1-positive and their CA125 values were significantly lower than those without malignancy (p=<0.0001).

CONCLUSIONS

Single-port laparoscopy is a safe option for patients undergoing risk-reducing salpingo-oophorectomy with or without hysterectomy. Standardized pre-operative evaluation criteria are needed to determine absolute risk of incidental malignancy, and the risk of identifying a malignancy should be reiterated to patients during pre-operative counseling.

Single-port laparoscopy in gynecologic oncology: seven years of experience at a single institution

BACKGROUND

Single-port laparoscopy has gained popularity within minimally invasive gynecologic surgery for its feasibility, cosmetic outcomes, and safety. However, within gynecologic oncology, there are limited data regarding short-term adverse outcomes and long-term hernia risk in patients undergoing single-port laparoscopic surgery.

OBJECTIVE

The objective of the study was to describe short-term outcomes and hernia rates in patients after single-port laparoscopy in a gynecologic oncology practice.

STUDY DESIGN

A retrospective, single-institution study was performed for patients who underwent single-port laparoscopy from 2009 to 2015. A univariate analysis was performed with χ² tests and Student t tests; Kaplan-Meier and Cox proportional hazards determined time to hernia development.

RESULTS

A total of 898 patients underwent 908 surgeries with a median follow-up of 37.2 months. The mean age and body mass index were 55.7 years and 29.6 kg/m², respectively. The majority were white (87.9%) and American Society of Anesthesiologists class II/III (95.5%). The majority of patients underwent surgery for adnexal masses (36.9%) and endometrial hyperplasia/cancer (37.3%). Most women underwent hysterectomy (62.7%) and removal of 1 or both fallopian tubes and/or ovaries (86%). Rate of adverse outcomes within 30 days, including reoperation (0.1%), intraoperative injury (1.4%), intensive care unit admission (0.4%), venous thromboembolism (0.3%), and blood transfusion, were low (0.8%). The rate of urinary tract infection was 2.8%; higher body mass index (P = .02), longer operative time (P = .02), smoking (P = .01), hysterectomy (P = .01), and cystoscopy (P = .02) increased the risk. The rate of incisional cellulitis was 3.5%. Increased estimated blood loss (P = .03) and endometrial cancer (P = .02) were independent predictors of incisional cellulitis. The rate for surgical readmissions was 3.4%; higher estimated blood loss (P = .03), longer operative time (P = .02), chemotherapy alone (P = .03), and combined chemotherapy and radiation (P < .05) increased risk. The rate of incisional hernia rate was 5.5% (n = 50) with a mean occurrence at 570.2 ± 553.3 days. Higher American Society of Anesthesiologists class (P = .04), diabetes (P < .001), hypertension (P = .043), increasing age (P = .017; hazard ratio [HR], 1.03), and body mass index (P < .001; HR, 1.08) were independent predictors for incisional hernia development. Previous abdominal surgeries (P = .24) and hand assist (P = .64) were not associated with increased risk for incisional hernia. Patients with American Society of Anesthesiologists class III/IV had a 3 year hernia rate of 12.8% (HR, 1.81). Patients with diabetes mellitus had a 3 year hernia rate of 23.0% (HR, 3.60).

CONCLUSION

In this large cohort of patients undergoing single-port laparoscopy, the incidence of short-term adverse outcomes is low. While the rate of incisional hernia was 5.5%, incidence reached 23.0% at 3 years in high-risk groups. Previous studies with short follow-up duration may underestimate the risk of hernia, especially in patients with significant comorbidities.

Utility of indocyanine green (ICG) intra-operative angiography to determine uterine vascular perfusion at the time of radical trachelectomy

OBJECTIVES

The aim of our study was to measure and analyze uterine perfusion utilizing laser angiography with ICG during uterine artery sparing and non-sparing radical trachelectomy.

METHODS

Data were collected from all patients diagnosed with early-stage cervical cancer that underwent laser angiography with ICG during open or laparoscopic radical trachelectomy from June 2012 to December 2015. Regression analysis was use to determine the p values and R-squares on fluorescence, surgical time, hospital stay, age and BMI; a p-value<0.05 was considered statistically significant.

RESULTS

A total of 20 patients met the inclusion criteria and were included in this study. Ten patients underwent uterine artery-sparing surgery, and ten patients underwent uterine artery non-sparing surgery. The most frequent stage for the entire cohort was IA2 (55%), and the most common histologic subtype was squamous cell carcinoma (49%). Lymph-vascular invasion was noted in 30% of the patients. There was no statistical significance difference in the mean ICG fundal fluorescence intensity between the uterine artery-sparing group 162.5 (range, 137-188) and the uterine artery non-sparing group 160.5 (range, 135-186), p=0.22. In both groups, 100% of the patients regained their menstrual function by postoperative week 8. A total of 4 (40%) pregnancies have occurred in the uterine artery-sparing group and 3 (30%) in the non-uterine artery-sparing group.

CONCLUSIONS

Based on our real-time intraoperative angiography observations, there is no need to preserve the uterine artery during radical trachelectomy to maintain uterine viability.

Laparoendoscopic single-site surgery for benign ovarian cystectomies

BACKGROUND

Single-port laparoscopy (LESS) utilizes a single, multichannel port in an attempt to decrease postoperative pain, while enhancing cosmesis and minimizing the potential risks and morbidities associated with the multiple ports used in conventional laparoscopy.

METHODS

We performed a retrospective study examining three tertiary care referral centers. From September 2009 until March 2013, 31 patients with ovarian cystic lesions were treated using the LESS technique. A control group of 57 patients who underwent conventional laparoscopic ovarian cystectomy was included for comparison.

RESULTS

All patients underwent a technically successful cystectomy. There were no statistically significant differences in the mean operative time or estimated blood loss between the two groups. Narcotic use during the recovery period was reported in less patients in the LESS group than in the laparoscopic group (p = 0.05).

CONCLUSIONS

The LESS technique can be used to safely perform cystectomies on women with benign ovarian cysts. Additional investigation is needed to evaluate the safety, cost-effectiveness and long-term outcomes of this new approach.

Small cell carcinoma of the uterine cervix: a case report and literature review

Small cell carcinoma of the uterine cervix is a rare and aggressive extra-pulmonary variant of small cell tumors. This carcinoma of the cervix comprises less than 5% of all cervical carcinomas and is know to be highly undifferentiated. It is associated with a poor prognosis and characterized by premature distant nodal involvement. The survival rate at all stages ranges from 17% to 67%. We describe the case of a 41 year old female patient with a rare, and aggressive, clinical stage IB1 small cell neuroendocrine carcinoma of the cervix. The goal of this case report is to describe this rare pathology and contribute information to the scant available data.

A phase II trial of paclitaxel, carboplatin, and bevacizumab in advanced and recurrent endometrial carcinoma (EMCA)

OBJECTIVE

To evaluate the effect of adding bevacizumab to adjuvant paclitaxel and carboplatin and as maintenance on progression-free survival (PFS) in advanced or recurrent endometrial carcinoma (EMCA).

METHODS

A phase II trial was conducted in patients with measurable disease. Paclitaxel (175mg/m(2)/3h), carboplatin (AUC 5) and bevacizumab (15mg/kg) were administered q 21 days. Patients with a complete response after 6-8cycles received maintenance therapy with bevacizumab 15mg/kg q 21 days for 16cycles. Based on GOG 177 which had a 6-month PFS rate of 59%, an increase in 6-month PFS to 72% with the treatment regimen was considered of clinical interest.

RESULTS

15 patients were enrolled on protocol when accrual to the study was discontinued due to the initiation of a national randomized phase II trial. A total of 127 courses (median 8, range 1-20) of carboplatin, paclitaxel, and bevacizumab combination therapy were administered. One patient suffered a bowel perforation after her first course of therapy and was inevaluable for response. Fourteen of the 15 patients (93%, 95% CI: 82-100) were progression free at 6months. The median follow-up was 36months (7-58+). The median PFS was 18months (CI: 11-25). Five complete responses and 6 partial responses were seen for an overall response rate of 73% (CI: 45-91). The median overall survival was 58months (CI: 48-68).

CONCLUSIONS

The bevacizumab, paclitaxel, and carboplatin regimen is active and tolerable in advanced and recurrent EMCA. Its impact awaits results of the recently completed randomized phase II trial.

Feasibility and optimal dosage of indocyanine green fluorescence for sentinel lymph node detection using robotic single-site instrumentation: preclinical study

The present study was performed to determine the optimal dosage of indocyanine green (ICG) to accurately differentiate the sentinel node from surrounding tissue and then to test this dosage using novel single-port robotic instrumentation. The study was performed in healthy female pigs. After induction of anesthesia, all pigs underwent exploratory laparotomy, dissection of the bladder, and colpotomy to reveal the cervical os. With use of a 21-gauge needle, 0.5 mL normal saline solution was injected at the 3- and 9-o'clock positions as control. Four concentrations of ICG were constituted for doses of 1000, 500, 250, and 175 μg per 0.5 mL. ICG was then injected at the 3- and 9-o'clock positions on the cervix. The SPY camera was used to track ICG into the sentinel nodes and to quantify the intensity of light emitted. SPY technology uses an intensity scale of 1 to 256; this scale was used to determine the difference in intensity between the sentinel node and surrounding tissues. The optimal dosage was tested using single-port robotic instrumentation with the same injection techniques. A sentinel node was identified at all doses except 175 μg, at which ICG stayed in the cervix and vasculature only. For both the 500- and 250-μg doses, the sentinel node was identified before reaching maximum intensity. At maximum intensity, the difference between the surrounding tissue and the node was 207 (251 vs 44) for the 500-μg dose and 159 (251 vs 92) for the 250-μg dose. Sentinel lymph node (SLN) biopsy was successfully performed using single-port robotic technology with both the 250- and 500-μg doses. For SLN detection, the dose of ICG is related to the ability to differentiate the sentinel node from the surrounding tissue. An ICG dose of 250 to 500 μg enables identification of a SLN with more distinction from the surrounding tissues, and this procedure is feasible using single-port robotics instrumentation.

Laparoendoscopic single-site radical hysterectomy with pelvic lymphadenectomy: initial multi-institutional experience for treatment of invasive cervical cancer

STUDY OBJECTIVE

To describe the feasibility, safety, and outcomes of women with stage I cervical cancer treated with laparoendoscopic single-site surgery radical hysterectomy (LESS-RH).

DESIGN

A retrospective descriptive study (Canadian Task Force classification III).

SETTING

Multiple academic teaching hospitals.

PATIENTS

Women with Fédération Internationale de Gynécologie et d'Obstétrique FIGO stage IA1 to IB1 cervical cancer.

INTERVENTIONS

LESS-RH as the primary therapy for cervical cancer performed by a gynecologic oncologist with expertise in LESS. A multichannel, single-port access device; a flexible-tipped 5-mm laparoscope; and a multifunctional instrument were used in all cases. Clinicopathologic, surgical, and perioperative outcomes were analyzed.

MEASUREMENTS AND MAIN RESULTS

Twenty-two women were identified in whom a LESS-RH was attempted; 20 (91%) successfully underwent the procedure, including 19 in whom pelvic lymphadenectomy (PLND) was completed. Of the 2 converted procedures, 1 patient underwent 2-port laparoscopy secondary to truncal obesity, and 1 patient underwent conversion to laparotomy secondary to external iliac vein laceration during PLND. The median age and body mass index were 46 years and 23.3 kg/m(2), respectively. The median number of pelvic lymph nodes removed was 22. One patient experienced an intraoperative complication, and no patient required reoperation. The margins of excision were negative. One patient with 2 positive pelvic nodes and 1 patient with microscopic parametrial disease received adjuvant chemosensitized radiation; 3 additional patients received adjuvant radiation therapy secondary to an intermediate risk for recurrence. After a median follow up of 11 months, no recurrences were detected.

CONCLUSION

LESS-RH/PLND is feasible and safe for select patients with stage I cervical cancer. Larger studies are needed to confirm whether the increased technical difficulty of this procedure justifies its use in routine gynecologic oncology practice.

Is sentinel lymph node dissection an appropriate standard of care for low-stage endometrial cancers? A review of the literature

BACKGROUND/AIMS

To review the literature and compare detection rates, false negative (FN) rates, and negative predictive values (NPVs) of sentinel lymph node (SLN) biopsy in endometrial cancer to those in breast and vulvar cancer. Secondary objectives were to evaluate techniques of SLN biopsy in endometrial cancer.

METHODS

The PubMed database was searched for applicable scientific articles. Detection rates, FN rates, and NPVs were calculated for all studies. Studies were stratified by techniques and compared.

RESULTS

Nineteen articles met criteria for this review. The overall detection rates ranged from 62 to 100%, the FN rate ranged from 0 to 50%, and the NPVs ranged from 95 to 100%. There is no technique that is definitively superior to any other with regard to surgical modality, injectant used, injection site, or pathologic techniques.

CONCLUSIONS

Studies on SLN biopsy in endometrial cancer have a large range of detection rates and FN rates, and larger studies including more patients with metastatic disease are needed for comparison with breast and vulvar cancers. While no techniques are definitively superior to others, minimally invasive surgery, cervical injection, and pathologic analysis utilizing HE staining, immunohistochemistry, and ultrastaging may be clinically advantageous.

Minimally invasive surgery in gynecologic oncology: a review of modalities and the literature

Minimally invasive surgery is one of the newest and most exciting areas of development in procedural medicine. This field shows tremendous potential to increase therapeutic benefit while minimizing some of the painful or dangerous side effects of surgical interventions. Minimally invasive surgery has strong historic ties to the field of gynecology and has come a long way as technology and techniques have improved. This has increasingly allowed the application of laparoscopy to more complex procedures and the treatment of gynecologic malignancies. Three laparoscopic approaches, traditional laparoscopy, robotic assisted laparoscopy and laparoendoscopic single-site surgery are reviewed here. We discuss the basic approaches to these three laparoscopic techniques, and then review their applications in gynecologic oncology. We also touch on the evidence behind outcomes associated with their use.

First 100 early endometrial cancer cases treated with laparoendoscopic single-site surgery: a multicentric retrospective study

OBJECTIVE

We sought to assess feasibility and perioperative outcomes for laparoendoscopic single-site surgery (LESS) in early endometrial cancer.

STUDY DESIGN

This was a retrospective multicentric study of 100 early endometrial cancer cases undergoing LESS from July 2009 through July 2011.

RESULTS

All patients underwent total hysterectomy and bilateral salpingo-oophorectomy by LESS. Pelvic and paraaortic lymphadenectomy were performed in 48 and 27 patients, respectively. A median of 16 pelvic lymph nodes (range, 1-33) and 7 paraaortic lymph nodes (range, 2-28) were retrieved. Both median operative time (129 minutes; range, 45-321) and estimated blood loss (70 mL; range, 10-500) were greater when staging lymphadenectomy was performed (P values = .001). Four intraoperative and 4 postoperative complications were observed. Conversion to standard laparoscopy and laparotomy was necessary for completion of 1 case each. Patients responded positively regarding cosmetic result and minimal postoperative pain control.

CONCLUSION

LESS further minimizes the invasive nature of surgery and is feasible for treatment of early-stage endometrial cancer.

Comparison of single-port laparoscopy, standard laparoscopy, and robotic surgery in patients with endometrial cancer

BACKGROUND

The aim of this study was to evaluate single-port laparoscopy (SPL) for the surgical treatment of presumed early-stage endometrial cancer and to compare surgical outcomes to laparoscopy and robotics.

METHODS

A multi-institutional, matched retrospective cohort study was performed. All patients with clinical stage I or occult stage II endometrial cancer who underwent SPL hysterectomy, bilateral salpingo-oophorectomy +/- lymphadenectomy from April 2009 to September 2010 were identified. Outcomes were compared with patients matched by age, body mass index (BMI), tumor histology, and grade, who underwent laparoscopy or robotic surgery. Data was analyzed using Kruskal-Wallis 1-way analysis of variance and chi-square test for frequency data. A P value of <.05 was considered significant.

RESULTS

A total of 90 matched patients (30 SPL, 30 LSC, and 30 robotic) were included in the study. There were no significant differences in median operating time or estimated blood loss between the 3 groups. The median number of pelvic lymph nodes obtained was significantly higher in the robotic (17.0 [8-36] and SPL group (16.0 [11-21]) compared with the laparoscopy group (13.0 [3-18]) P = .04. However, there was no significant difference in the median number of para-aortic nodes obtained between the 3 groups. There was no significant difference between the groups in length of hospital stay, comorbid conditions, complication rates, or operative times.

CONCLUSIONS

Our findings suggest SPL surgery for endometrial carcinoma is feasible with similar operating times, hospital length of stay, complication rates, and estimated blood loss when compared with laparoscopy and robotics.

Single-port gynecologic surgery with a novel surgical platform

BACKGROUND

Laparoendoscopic single-site surgery (LESS) allows better cosmesis and decreased pain when compared with traditional laparoscopy (TL). Instrument crowding and diminished triangulation are limitations. This study evaluates a novel single-port surgical platform (NSP) designed to facilitate the transition from TL to LESS (TransEnterix SPIDER, Durham, NC).

METHODS

NSP and TL were compared using standardized dry lab tasks. Feasibility of NSP in gynecology was assessed using the porcine model.

RESULTS

Completion times with NSP were longer for ring transfer (P = .025) and trended longer for disc cutting (P = .074). Disc cutting accuracy was lower with NSP versus TL (P = .008). NSP operative times for hysterectomy, pelvic and para-aortic node dissection were 22.3, 13.3, and 26 minutes, respectively, without complications. Fatigue and lack of integrated bipolar cautery were limitations of NSP.

CONCLUSION

While application of NSP to gynecology appears feasible, lower performance when compared with TL underscores the need for caution when applying NSP to humans.

Single-port surgery: laboratory experience with the daVinci single-site platform

This animal study demonstrates that single-port robotic surgery using the VeSPA platform can allow the performance of technically challenging procedures within acceptable operative times and without complications or insertion of additional trocars.

Background and Objectives:

The purpose of this study was to evaluate the feasibility and validity of a dedicated da Vinci single-port platform in the porcine model in the performance of gynecologic surgery.

Methods:

This pilot study was conducted in 4 female pigs. All pigs had a general anesthetic and were placed in the supine and flank position. A 2-cm umbilical incision was made, through which a robotic single-port device was placed and pneumoperitoneum obtained. A data set was collected for each procedure and included port placement time, docking time, operative time, blood loss, and complications. Operative times were compared between cases and procedures by use of the Student t test.

Results:

A total of 28 surgical procedures (8 oophorectomies, 4 hysterectomies, 8 pelvic lymph node dissections, 4 aorto-caval nodal dissections, 2 bladder repairs, 1 uterine horn anastomosis, and 1 radical cystectomy) were performed. There was no statistically significant difference in operating times for symmetrical procedures among animals (P=0.3215).

Conclusions:

This animal study demonstrates that single-port robotic surgery using a dedicated single-site platform allows performing technically challenging procedures within acceptable operative times and without complications or insertion of additional trocars.

Single-port laparoscopic pelvic and para-aortic lymph node sampling or lymphadenectomy: development of a technique and instrumentation

BACKGROUND AND OBJECTIVES

Innovations in minimally invasive surgery have allowed surgeons to perform increasingly complex surgeries through smaller incisions. We describe the feasibility and the technique of single-port laparoscopic pelvic and para-aortic lymph node sampling or lymphadenectomy in gynecologic malignancies.

METHODS

The study was approved by the institutional review board at the Cleveland Clinic (Cleveland, Ohio). Inclusion criterion was patients with apparent early-stage gynecologic malignancies who required pelvic and/or para-aortic lymph node sampling or lymphadenectomy and were candidates for single-port laparoscopy. Procedures were performed through a single 2.0- to 3.0-cm umbilical incision using a single-port device, deflecting-tip laparoscope, and multifunctional instrumentation.

RESULTS

Twenty-one patients underwent single-port surgery/staging performed during the study period. The median patient age was 58 years (range, 17-80 years), and the median patient body mass index was 30 mg/kg² (range, 19-46 mg/kg²). Median overall operating time was 120 minutes (range, 60-185 minutes). Median pelvic and para-aortic node counts were 14 (range, 7-19) and 6 (range, 2-14), respectively.

CONCLUSIONS

In this preliminary report, the technique was feasible, and no morbidity was noted. Further studies are needed to better define the ideal gynecologic oncology procedures for single-site surgery and to assess the relative benefits of this new technique compared with more conventional minimally invasive approaches.

Laparoendoscopic single-site surgery in gynaecology: A new frontier in minimally invasive surgery

REVIEW OBJECTIVE:

To review the recent developments and published literature on laparoendoscopic single-site (LESS) surgery in gynaecology.

RECENT FINDINGS:

Minimally invasive surgery has become a standard of care for the treatment of many benign and malignant gynaecological conditions. Recent advances in conventional laparoscopy and robotic-assisted surgery have favorably impacted the entire spectrum of gynaecological surgery. With the goal of improving morbidity and cosmesis, continued efforts towards refinement of laparoscopic techniques have lead to minimization of size and number of ports required for these procedures. LESS surgery is a recently proposed surgical term used to describe various techniques that aim at performing laparoscopic surgery through a single, small-skin incision concealed within the umbilicus. In the last 5 years, there has been a surge in the developments in surgical technology and techniques for LESS surgery, which have resulted in a significant increase in utilisation of LESS across many surgical subspecialties. Recently published outcomes data demonstrate feasibility, safety and reproducibility for LESS in gynaecology. The contemporary LESS literature, extent of gynaecological procedures utilising these techniques and limitations of current technology will be reviewed in this manuscript.

CONCLUSIONS:

LESS surgery represents the newest frontier in minimally invasive surgery. Comparative data and prospective trials are necessary in order to determine the clinical impact of LESS in treatment of gynaecological conditions.

Evaluation of a novel single-port robotic platform in the cadaver model for the performance of various procedures in gynecologic oncology

OBJECTIVES

The purpose of this protocol was to evaluate the feasibility and reproducibility of a dedicated da Vinci® single-port robotic platform in cadavers for the performance of various gynecologic oncology procedures.

METHODS

Three fresh frozen female cadavers were used to evaluate the feasibility, reproducibility, and to develop the correct docking of the robotic column and trocars. Procedures performed in this training protocol included (hysterectomy, bilateral salpingo-oophorectomy, modified radical hysterectomy, six pelvic lymph node dissections, and one para-aortic node dissection). A data set was collected for each procedure, operative times were compared between cases and procedures by use of Wilcoxon rank sum test, a p-value <0.05 was considered significant.

RESULTS

All the procedures were technically successful with no need of additional ports or conversions to a standard laparoscopy. The median time of port insertion and BMI was 6 min range (4-10) and 33 min range (25-56) respectively. The median time for a left and right pelvic lymph node dissection was 22 min range (22-23) and 28 min range (26-38) respectively. There was significant difference in operating times for symmetrical procedures (pelvic lymphadenectomy), p=0.049.

CONCLUSION

This preliminary data demonstrates that the performance of various oncology procedures using the new da Vinci® single-site robotic platform is feasible, and more importantly, reproducible in the cadaver model.

Novel robotic da Vinci instruments for laparoendoscopic single-site surgery

OBJECTIVES

To describe novel robotic laparoendoscopic single-site surgery (R-LESS) instruments, and present the initial laboratory experience in urology.

METHODS

The VeSPA surgical instruments (Intuitive Surgical, Sunnyvale, CA) were designed to be used with the DaVinci Si surgical system. A multichannel port and curved cannulae were inserted through a single 3.5-cm umbilical incision. The port allowed 1 scope, 2 robotic instruments, and a 5- to 12-mm assistant instrument. Four pyeloplasties (right 2, left 2), 4 partial nephrectomies (right 2, left 2), and 8 nephrectomies (right 4, left 4) were performed in 4 female farm pigs (mean weight, 34.5 kg). Technical feasibility and efficiency were assessed in addition to perioperative outcomes.

RESULTS

All 16 R-LESS procedures were performed successfully without the addition of laparoscopic ports or open conversion. Mean total operative time was 110 minutes (range, 82-127), and mean blood loss was 20 mL (range, 10-100). Mean warm ischemia time for partial nephrectomy was 14.8 minutes (range, 12-20). There were no intraoperative complications. No robotic system failures occurred, and robotic instrument clashing was found to be minimal. One needle driver malfunctioned and assistant movement was limited.

CONCLUSIONS

R-LESS kidney surgery using the VeSPA instruments is feasible and efficient in the porcine model. The system offers a wide range of motion, instrument and scope stability, improved ergonomics, and minimal instrument clashing. Although preliminary experience is encouraging, further refinements are expected to optimize urological applications of this robotic technology.

First Report on the Occurrence of Grapevine leafroll-associated virus 5 in Chilean Grapevines

Grapevine leafroll is one of the most widespread and economically damaging viral diseases of grapevines. At least eight distinct Grapevine leafroll-associated viruses (GLRaVs), all members of the Closteroviridae family, have been associated with this disease (4). GLRaV-5 was recently reported in vineyards from Argentina (2). To determine if GLRaV-5 was present in Chilean grapevines, in addition to the previously reported GLRaV-1, -2, -3, -4, -7, and -9 (1), 45 dormant cane samples from 12 different cultivars were collected from different geographic regions of Chile and screened by reverse transcription-PCR. Two of the forty-five samples (cvs. Sauvignon Blanc and Superior) collected from the III (700 km north of Santiago) and VI (150 km south of Santiago) regions of Chile, respectively, were found to be infected with GLRaV-5 using two different pairs of virus-specific primers. The first pair of primers, LR5-1F: 5'-CCCGTGATACAAGGTAGGACA-3' and LR5-1R: 5'-CAGACTTCACCTCCTGTTAC-3' (3), was used to amplify a 690-bp fragment corresponding to a partial region of the coat protein gene. The sequences obtained from the two positive samples (GenBank Accession Nos. HM214148 and HM214149) shared 97 and 94% of nucleotide identities, respectively, with the corresponding fragment of a reference GLRaV-5 isolate (GenBank Accession No. EU815935). Both samples shared 99% of amino acid identity with the same reference isolate. A second pair of primers, LR5upF: 5'-CTCTGCTTTTCTGCTGGCA-3' and LR5doR: 5'-TATCTTTTATCTCCCGATAAACGAG-3' (4) that amplified a 160-bp fragment of the HSP70h gene was also used. The positive Chilean samples (GenBank Accession Nos. HM214150 and HM214151) shared in both cases 98% nucleotide and 98% amino acid identities with the corresponding fragment of a reference GLRaV-5 isolate (Accession No. AF039552). The two GLRaV-5-positive plants were additionally infected with other viruses previously reported in Chile (1). The cv. Sauvignon Blanc sample was also infected with GLRaV-2, Grapevine fleck virus, and Grapevine rupestris stem pitting-associated virus. The cv. Superior sample was also infected with GLRaV-3, GLRaV-4, and Grapevine virus A. References: (1) E. A. Engel et al. J. Virol. Methods 163:445, 2010. (2) S. Gomez et al. Virus Genes 38:184, 2009. (3) X. Good and J. Monis. Phytopathology 91:274, 2001. (4) V. I. Maliogka et al. J. Virol. Methods 154:41, 2008.

Single-port risk-reducing salpingo-oophorectomy with and without hysterectomy: surgical outcomes and learning curve analysis

OBJECTIVE

Based on considerable prospective data, risk-reducing salpingo-oophorectomy (RRSO) is one of the most beneficial interventions available to reduce ovarian/breast cancer risk in BRCA carriers and high-risk women. The purpose of this study was to describe the initial surgical outcomes and learning curve analysis associated with laparoendoscopic single-site (LESS) RRSO with and without hysterectomy.

METHODS

A retrospective, multi-institutional analysis of BRCA carriers and women at high risk for breast/ovarian cancer who underwent LESS RRSO with and without hysterectomy in 2009 was performed. Data collected included age, BMI, procedure, operative time, length of hospital stay, postoperative pain scores, and post operative complications. Student t-test, Pearson correlation coefficient, and multivariate linear regression were used for analysis.

RESULTS

A total of 58 patients were evaluated; 36 (63%) were BRCA1/2 carriers and 38 (63%) had breast cancer. Patients' mean age and BMI were 46 years and 27 kg/m(2), respectively. Most patients were Caucasian (76%), and at the time of prophylactic surgery, 53% of patients were undergoing active breast cancer treatment. Mean operative time was 38.1 minutes (16-80 minutes). All cases were performed successfully via the LESS approach, and there were no surgical complications. Multivariate linear regression analysis was done, and after controlling for study site, previous abdominal surgery, active cancer treatment, and BMI, operative time was only influence by number of cases performed, p=0.019.

CONCLUSIONS

LESS RRSO is feasible and safe with favorable surgical and cosmetic outcomes. In our experience, surgical proficiency is possible after 10-15 cases. The LESS approach may be ideal for BRCA mutation carriers and breast cancer patients because of a short convalescence, permitting minimal interruption in any ongoing cancer treatment and the potential psychological benefits from improved cosmesis and pain control. Prospective studies are needed to assess the relative benefits of LESS compared with more conventional minimally invasive approaches.

Robotic-assisted laparoendoscopic single-site surgery in gynecology: initial report and technique

Robotic surgery has greatly improved surgeon dexterity and ergonomics but has substantially increased the number and size of ports required. The typical robotic surgical procedure will use three 8-mm ports and two 12-mm ports. Single-port laparoscopy, also known as Laparo-Endoscopic Single Site (LESS) surgery, is an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery.We present our initial clinical experience and technique with robotic-assisted single-port surgery in gynecology.

First Detection of Grapevine leafroll-associated virus 4 in Chilean Grapevines

Grapevine leafroll is one of the most widespread and economically relevant viral diseases of grapevines. At least nine distinct Grapevine leafroll-associated viruses (GLRaVs), all members of the Closteroviridae family, have been associated with this disease in grapevine. Grapevine leafroll-associated virus 4 (GLRaV-4), currently classified as a Closteroviridae member under the Ampelovirus genus, was initially described in California. To determine if GLRaV-4 was present in Chilean grapevines, in addition to the previously reported GLRaV-1, -2, -3, -7, and -9 (1,2), 35 dormant cane samples from 12 different cultivars were collected from different regions of Chile and screened by reverse transcription-PCR. Two of the 35 samples (both cv. Thompson Seedless) collected from the III and VI regions of Chile were found to be infected with GLRaV-4 using two different pairs of GLRaV-4 specific primers. The first pair of primers, HSPV-F: 5'- ACA TTC TCC ACC TTG TGC TTT T -3' and HSPC-R: 5'- CAT ACA AGC GAG TGC AAT TAC -3' (3), was used to amplify a 321-bp fragment corresponding to a partial region of the HSP70h gene. The sequence (GenBank Accession Nos. EU746618 and EU746619) from both positive samples shared 98.4% nucleotide identity and approximately 99% identity with the corresponding fragment of a Californian GLRaV-4 isolate (GenBank Accession No. AF039553). Since there are no commercial antibodies available for GLRaV-4 detection, a second pair of primers, LR4CPINT-F: 5'- GAG AGT GAC AAG CAC CAG GTG C -3' and LR4CPFIN-R: 5'- TCA CCT CCT GTT GCC CA -3' (4), that amplified a 492-bp fragment of the coat protein gene was also used. The sequences of the 492-bp fragment from both Chilean samples (GenBank Accession Nos. EU746620 and EU746621) shared 99.6% nucleotide identity with one another and had 96.5% identity with an Israeli GLRaV-4 isolate (GenBank Accession No. AM176759). To our knowledge, this is the first report of GLRaV-4 in Chile. Further studies will help to establish the effects and incidence of this virus in Chilean grapevines. References: (1) E. Engel et al. Plant Dis. 92:1252, 2008 (2) N. Fiore et al. J. Plant Pathol. 90:125, 2008. (3) F. Osman et al. J. Virol. Methods 141:22, 2007. (4) P. Saldarelli et al. J. Plant Pathol. 88:203, 2006.

Heterotopic pregnancy presenting at 18 weeks' gestational age: a case report

BACKGROUND

Heterotopic pregnancy is a rare event that usually presents in the first 6-8 weeks of pregnancy.

CASE

A 35-year-old primigravida was referred to the hospital at 18+ weeks' gestational age for evaluation of chronic abdominal pain. Ultrasound revealed a heterotopic pregnancy. The patient underwent surgery for removal of the ectopic pregnancy.

CONCLUSION

Heterotopic pregnancy can present at any time during pregnancy and should be considered in any pregnant woman with abdominal pain.

Which ovarian masses need intervention?

Ovarian cancer is deadly if not detected early, but it is only one of many causes of pelvic masses, which are common. The physician's job is to determine if a mass is likely to be malignant and needing surgical evaluation. The best predictors of malignancy are a combination of factors that include the patient's age, family history, menopausal status, symptoms, findings on physical examination and imaging studies, and blood level of the cancer biomarker CA125.

The 2003 Revised TNM Staging System for Breast Cancer: Results of Stage Re-classification on Survival and Future Comparisons among Stage Groups

BACKGROUND

Changes to TNM staging criteria for breast cancer, introduced in 2003, have resulted in stage re-classification for some tumors. The most frequently implemented change has resulted in tumors associated with more than three positive axillary nodes being upstaged. We hypothesize these TNM staging changes would result in more TNM Stage IIB, IIIA, and IIIB tumors and that disease-specific survival estimates would change under the new staging system.

METHODS

A review of data was completed for patients diagnosed with breast cancer between 1 January 1995 and 31 December 2000. Tumors that would have been staged differently under the 2003 system were identified and re-classified. Clinical outcomes were determined and disease-specific survival estimates were compared relative to TNM Stage using the old and new staging systems. Data were analyzed using the log-rank test and the method of Kaplan and Meier was used to generate survival curves.

RESULTS

Data were available for 2492 tumors, of which 919 were candidates for re-classification, including 829 old Stage II, 59 old Stage III, and 31 old Stage IV. Of these 919, 159 (17%) underwent stage re-classification using the new system. Separate survival estimates for patients who had been under old stage IIA/B, IIIA/B were generated; patients upstaged from IIA or IIB demonstrated a significant difference in survival.

CONCLUSIONS

Stage specific survival curves indicated decreased survival for patients whose tumors had been upstaged from IIA or IIB under the old system; survival for all other patients remained unchanged.

Optical coherence tomography as a diagnostic aid to visual inspection and colposcopy for preinvasive and invasive cancer of the uterine cervix

The purpose of this study was to determine the sensitivity and specificity of optical coherence tomography (OCT) under two well-defined clinical settings. First, as an aid to cervical cancer screening, using visual inspection with acetic acid (VIA) in low-resource settings, and the second, as an adjunct to the traditional management of abnormal cervical cytology with colposcopy and biopsy. Patients referred for colposcopy with > or = atypical squamous cells of undetermined significance were accrued for the study. Each subject underwent VIA and colposcopy. OCT was performed in all VIA- and colposcopy-positive areas and at the squamocolumnar junction in all four quadrants. The sensitivity of VIA for > or = cervical intraepithelial neoplasia 2 was 76% (95% CI 58-88). When OCT was applied to VIA as a secondary screen, the specificity improved from 34% (95% CI 27-41) to 61% (95% CI 60-74). With liberal diagnostic criteria for the majority of the colposcopy examinations, OCT showed an even greater relative improvement in specificity. OCT proved to be a fair diagnostic modality (receiver operating characteristic curve 0.73) adjunctive to VIA and colposcopy. On the basis of the above findings, we believe that this technology could potentially show greatest utility in the management of cervical dysplasia in low-resource settings where a single episode of care is most desirable.

HER2 status in bilateral breast cancer

BACKGROUND

The purpose of this study was to identify correlates of HER2 status for patients with bilateral breast cancer.

METHODS

Data were collected prospectively in our institutional review board approved patient registry for all patients with asynchronous (ABBC) and synchronous (SBBC) bilateral infiltrating breast cancer whose HER2 assays were performed at our laboratory using FISH. Data were analyzed using the Wilcoxon rank sum and Chi-square test.

RESULTS

Data were available for 98 tumors in 49 patients. Patients diagnosed with SBBC were more likely to be white (P = 0.023); to have bilateral HER2 non-amplified tumors (P = 0.022) and to be older at diagnosis (P = 0.025) compared to those with ABBC. Patients with one HER2 amplified tumor were likely to have at least one tumor be hormone receptor negative and to have ABBC.

CONCLUSIONS

Only 16% of patients in this study had one tumor that was HER2 amplified; no patient had bilateral HER2 amplified tumors.

Hypoxia Enhances Lysophosphatidic Acid Responsiveness in Ovarian Cancer Cells and Lysophosphatidic Acid Induces Ovarian Tumor MetastasisIn vivo

Lysophosphatidic acid (LPA) is elevated in ascites of ovarian cancer patients and stimulates growth and other activities of ovarian cancer cells in vitro. Tissue hypoxia is a critical factor for tumor aggressiveness and metastasis in cancers. We tested whether the ascites of ovarian cancer is hypoxic and whether hypoxia influences the effects of LPA on ovarian cancer cells. We found that ovarian ascitic fluids were hypoxic in vivo. Enhanced cellular responsiveness to LPA, including migration and/or invasion of ovarian cancer cells, was observed under hypoxic conditions. This enhancement could be completely blocked by geldanamycin or a small interfering RNA targeting hypoxia-inducible factor 1 alpha (HIF1 alpha). LPA-induced cell migration required cytosolic phospholipase A(2) (cPLA(2)) and LPA stimulates cPLA(2) phosphorylation in a HIF1 alpha-dependent manner under hypoxia conditions. Furthermore, we show for the first time that exogenous LPA enhances tumor metastasis in an orthotopic ovarian cancer model and HIF alpha expression in tumors. 17-Dimethylaminoethylamino-17-demethoxygeldanamycin (an inhibitor of the heat shock protein 90) effectively blocked LPA-induced tumor metastasis in vivo. Together, our data indicate that hypoxic conditions are likely to be pathologically important for ovarian cancer development. HIF1 alpha plays a critical role in enhancing and/or sensitizing the role of LPA on cell migration and invasion under hypoxic conditions, where cPLA(2) is required for LPA-induced cell migration.

Docetaxel in ovarian cancer

Docetaxel, a semisynthetic taxane, is a potent inhibitor of cell replication and, similar to paclitaxel, promotes in vitro assembly of stable microtubules and, therefore, prevents the depolymerisation process. Docetaxel has a higher affinity for the tubulin subunit and is associated with a 100-fold greater phosphorylation of BCL-2 inducing apoptosis. Docetaxel in combination with carboplatin demonstrates similar activity to paclitaxel/carboplatin in the upfront management of advanced ovarian cancer with less neurological, but greater haematological toxicity. This article reviews the rationale and indications for the use of docetaxel in ovarian cancer.