Fertility sparing surgery in early stage epithelial ovarian cancer

Antonino Ditto,Fabio Martinelli,Domenica Lorusso,Edward Haeusler,Marialuisa Carcangiu,Francesco Raspagliesi 대한부인종양학회 2014 Journal of Gynecologic Oncology Vol.25 No.4

Objective: Fertility sparing surgery (FSS) is a strategy often considered in young patients with early epithelial ovarian cancer. We investigated the role and the outcomes of FSS in eEOC patients who underwent comprehensive surgery. Methods: From January 2003 to January 2011, 24 patients underwent fertility sparing surgery. Eighteen were one-to-one matched and balanced for stage, histologic type and grading with a group of patients who underwent radical comprehensive staging (n=18). Demographics, surgical procedures, morbidities, pathologic findings, recurrence-rate, pregnancy-rate and correlations with disease-free survival were assessed. Results: A total of 36 patients had a complete surgical staging including lymphadenectomy and were therefore analyzed. Seven patients experienced a recurrence: four (22%) in the fertility sparing surgery group and three (16%) in the control group (p=not significant). Sites of recurrence were: residual ovary (two), abdominal wall and peritoneal carcinomatosis in the fertility sparing surgery group; pelvic (two) and abdominal wall in the control group. Recurrences in the fertility sparing surgery group appeared earlier (mean, 10.3 months) than in radical comprehensive staging group (mean, 53.3 months) p<0.001. Disease-free survival were comparable between the two groups (p=0.422). No deaths were reported. All the patients in fertility sparing surgery group recovered a regular period. Thirteen out of 18 (72.2%) attempted to have a pregnancy. Five (38%) achieved a spontaneous pregnancy with a full term delivery. Conclusion: Fertility sparing surgery in early epithelial ovarian cancer submitted to a comprehensive surgical staging could be considered safe with oncological results comparable to radical surgery group.

Investigating the role of immunotherapy in advanced/recurrent female genital tract melanoma: a preliminary experience

Alice Indini,Lorenza Di Guardo,Carolina Cimminiello,Domenica Lorusso,Francesco Raspagliesi,Michele Del Vecchio 대한부인종양학회 2019 Journal of Gynecologic Oncology Vol.30 No.6

Objective: immunotherapy with immune checkpoint inhibitors has become one of thestandard therapeutic modalities for patients with advanced melanoma. Melanoma of thefemale lower genital tract is a rare and aggressive disease, with poor long-term clinicaloutcomes. To date, no study evaluated the role of immunotherapy in metastatic melanoma ofthe lower genital tract. Methods: Data of women with metastatic melanoma of the lower genital tract wereprospectively collected. Survival outcomes over time was assessed using Kaplan-Meier model. Results: Seven cases of metastatic melanoma of the lower genital tract (vulva [n=2], vagina[n=4], and uterine cervix [n=1]) treated with immune checkpoint inhibitors are reviewed. Two patients had metastatic disease at diagnosis, while 5 patients developed metastaticdisease at a mean (standard deviation) time of 9.9 (±3.0) months from primary diagnosis. Four patients received an anti-cytotoxic T lymphocyte-associated antigen 4 (CTLA4)(ipilimumab) and 3 received an anti-programmed cell death 1 (PD-1) (pembrolizumab[n=2], nivolumab [n=1]) therapy. The response rate to immunotherapy was 28.5%. Patientsreceiving an anti-PD-1 experienced a better progression-free survival than patients treatedwith anti-CTLA4 (p=0.01, log-rank test). Although not reaching statistical significance,overall survival was better in patients having an anti-PD-1 therapy in comparison to anti-CTLA4 (p=0.15, log-rank test). Conclusion: Results from our series confirm the poor prognosis of women with metastaticmelanoma of the lower genital tract, thus supporting the need of exploring newtreatment modalities. Further studies are warranted to improve knowledge on the role ofimmunotherapy in metastatic melanoma of the lower genital tract.

A critical assessment on the role of sentinel node mapping in endometrial cancer

Giorgio Bogani,Antonino Ditto,Fabio Martinelli,Mauro Signorelli,Stefania Perotto,Domenica Lorusso,Francesco Raspagliesi 대한부인종양학회 2015 Journal of Gynecologic Oncology Vol.26 No.4

Endometrial cancer is the most common gynecologic malignancy in the developed countries. Although the high incidence of this occurrence no consensus, about the role of retroperitoneal staging, still exists. Growing evidence support the safety and efficacy of sentinel lymph node mapping. This technique is emerging as a new standard for endometrial cancer staging procedures. In the present paper, we discuss the role of sentinel lymph node mapping in endometrial cancer, highlighting the most controversies features.

The detrimental effect of adopting interval debulking surgery in advanced stage low-grade serous ovarian cancer

Giorgio Bogani,Umberto Leone Roberti Maggiore,Biagio Paolini,Antonino Diito,Fabio Martinelli,Domenica Lorusso,Francesco Raspagliesi 대한부인종양학회 2019 Journal of Gynecologic Oncology Vol.30 No.1

Objective: To examine outcomes of patients having treatments for newly diagnosed advanced stage low-grade serous ovarian cancer (LGSC). Methods: We conducted a retrospective case series of women affected by advanced stage (stage IIIB or more) LGSC undergoing surgery in a single oncologic center between January 2000 and December 2017. Survival outcomes were assessed using Kaplan-Meier and Cox models. Results: Data of 72 patients were retrieved. Primary cytoreductive surgery was attempted in 68 (94.4%) patients: 19 (27.9%) had residual disease (RD) >1 cm after primary surgery. Interval debulking surgery (IDS) was attempted in 15 of these 19 (78.9%) patients and the remaining 4 patients having not primary debulking surgery. Twelve out of 19 (63.1%) patients having IDS had RD. After a mean (±standard deviation) follow-up was 61.6 (±37.2) months, 50 (69.4%) and 22 (30.5%) patients recurred and died of disease, respectively. Via multivariate analysis, non-optimal cytoreduction (hazard ratio [HR]=2.79; 95% confidence interval [CI]=1.16–6.70; p=0.021) and International Federation of Obstetrics and Gynecologists (FIGO) stage IV (HR=3.15; 95% CI=1.29–7.66; p=0.011) were associated with worse disease-free survival. Via multivariate analysis, absence of significant comorbidities (HR=0.56; 95% CI=0.29–1.10; p=0.093) and primary instead of IDS (HR=2.95; 95% CI=1.12–7.74; p=0.027) were independently associated with an improved overall survival. Conclusion: LGSC is at high risk of early recurrence. However, owing to the indolent nature of the disease, the majority of patients are long-term survivors. Further prospective studies and innovative treatment modalities are warranted to improve patients care.

Morcellation of apparent benign uterine myoma: assessing risk to benefit ratio

Giorgio Bogani,Valentina Chiappa,Antonino Ditto,Fabio Martinelli,Mauro Signorelli,Domenica Lorusso,Francesco Raspagliesi 대한부인종양학회 2016 Journal of Gynecologic Oncology Vol.27 No.4

Treatment modalities for recurrent high-grade vaginal intraepithelial neoplasia

Giorgio Bogani,Antonino Ditto,Stefano Ferla,Biagio Paolini,Claudia Lombardo,Domenica Lorusso,Francesco Raspagliesi 대한부인종양학회 2019 Journal of Gynecologic Oncology Vol.30 No.2

Objective: We have investigated outcomes of women presenting with recurrent high-grade vaginal intra-epithelial neoplasia. Methods: Data of consecutive women diagnosed with recurrent high-grade vaginal intraepithelial neoplasia after primary treatment(s) were retrieved. Risk of developing new recurrence over the time was assessed using Kaplan-Meier and Cox models. Results: Data of 117 women were available for the analysis. At primary diagnosis, 41 (35%), 4 (3.4%) and 72 (61.6%) patients had had laser, pure surgical and medical treatments, respectively. Secondary treatments included: laser ablation and medical treatment in 95 (81.2%) and 22 (18.8%) cases, respectively. After a mean (standard deviation) follow-up of 72.3 (±39.5) months, 37 (31.6%) out of the entire cohort of 117 patients developed a second recurrence. Median time to recurrence was 20 (range, 5–42) months. Patients with recurrent high-grade vaginal intra-epithelial neoplasia undergoing medical treatments were at higher risk of developing a second recurrence in comparison to women having laser treatment (p=0.013, log-rank test). After we corrected our results for type of treatment used for recurrent disease, we observed that the execution of primary laser treatment was independently associated with a lower risk of developing new recurrences (hazard ratio [HR]=0.46; 95% confidence interval [CI]=0.21–0.99; p=0.050). The other variable that is independently associated with a new recurrence is the persistent infection from HPV16 or 18 (HR=3.87; 95% CI=1.15–13.0; p=0.028). Conclusion: Patients with recurrent high-grade vaginal intra-epithelial neoplasia are at high risk of developing new recurrences. Our data underline that the choice of primary treatment might have an impact of further outcomes.

Sentinel lymph node detection in endometrial cancer: make injection site the difference?

Giorgio Bogani,Fabio Martinelli,Antonino Ditto,Mauro Signorelli,Valentina Chiappa,Dario Recalcati,Domenica Lorusso,Francesco Raspagliesi 대한부인종양학회 2016 Journal of Gynecologic Oncology Vol.27 No.2

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Minimally invasive surgery improves short-term outcomes of nerve-sparing radical hysterectomy in patients with cervical cancer: a propensity-matched analysis with open abdominal surgery

Giorgio Bogani,Diego Rossetti,Antonino Ditto,Fabio Martinelli,Valentina Chiappa,Chiara Leone,Umberto Leone Roberti Maggiore,Domenica Lorusso,Francesco Raspagliesi 대한부인종양학회 2019 Journal of Gynecologic Oncology Vol.30 No.2

Objectives: Nerve-sparing radical hysterectomy has been implemented in order to reduce pelvic floor dysfunctions in women undergoing radical surgery for cervical cancer. Here, we aimed to investigate if the adoption of laparoscopic surgery impacts on patients' outcomes. Methods: Data of consecutive patients affected by cervical cancer who had laparoscopic nerve-sparing radical hysterectomy were matched 1:1 with an historical cohort of patients undergoing open procedure. A propensity-score matched algorithm was applied. Results: Thirty-five patients' pairs (70 patients: 35 undergoing laparoscopic vs. 35 undergoing open abdominal nerve-sparing radical hysterectomy) were included. Demographic and baseline oncologic characteristics were balanced between groups. Patients undergoing laparoscopic surgery had similar operative time than patients undergoing open abdominal procedures (249 [±91.5] vs. 223 [±65.0] minutes; p=0.066). Laparoscopic approach correlated with lower blood loss (30.5 [±11.0] vs. 190 [90.4] mL; p<0.001) and shorter hospital stay (3.2 [±1.2] vs. 5.4 [2.0] days; p=0.023). Patients undergoing laparoscopy experienced a lower 30-day pelvic floor dysfunction rate than patients having open surgery. Moreover, they experienced shorter recovery of bladder function than patients having open procedures (median, 7 vs. 9 days; p=0.004, log-rank test). Conclusion: Laparoscopic approach resulted in a faster recovery of bladder function in comparison to open surgery for patients undergoing nerve-sparing radical hysterectomy.

Oncologic effectiveness of nerve-sparing radical hysterectomy in cervical cancer

Antonino Ditto,Giorgio Bogani,Umberto Leone Roberti Maggiore,Fabio Martinelli,Valentina Chiappa,Carlos Lopez,Stefania Perotto,Domenica Lorusso,Francesco Raspagliesi 대한부인종양학회 2018 Journal of Gynecologic Oncology Vol.29 No.3

Objective: Nerve-sparing radical hysterectomy (NSRH) was introduced with the aim to reduce pelvic dysfunctions related to conventional radical hysterectomy (RH). Here, we sought to assess the effectiveness and safety of NSRH in a relatively large number of the patients of cervical cancer (CC) patients undergoing either primary surgery or neoadjuvant chemotherapy (NACT) followed by surgery. Methods: Outcomes of consecutive patients undergoing NSRH and of a historical cohort of patients undergoing conventional RH were retrospectively reviewed. Results: This study included 325 (49.8%) and 327 (50.2%) undergoing NSRH and RH, respectively. Via a multivariable model, nodal status was the only factor predicting for DFS (hazard ratio [HR]=2.09; 95% confidence interval [CI]=1.17–3.73; p=0.01). A trend towards high risk of recurrence was observed for patients affected by locally advanced cervical cancer (LACC) undergoing NACT followed by surgery (HR=2.57; 95% CI=0.95–6.96; p=0.06). Type of surgical procedures (NSRH vs. RH) did not influence risk of recurrence (p=0.47). Similarly, we observed that the execution of NSRH rather than RH had not a detrimental effect on OS (HR=1.19; 95% CI=0.16–9.01; p=0.87). Via multivariable model, no factor directly correlated with OS. No difference in early complication rates was observed between the study groups. Conversely, a significant higher number of late complications was reported in RH versus NSRH groups (p=0.02). Conclusion: Our data suggested that NSRH upholds effectiveness of conventional RH, without increasing recurrence and complication rates but improving pelvic dysfunction rates.

Artificial intelligence weights the importance of factors predicting complete cytoreduction at secondary cytoreductive surgery for recurrent ovarian cancer

Giorgio Bogani,Diego Rossetti,Antonino Ditto,Fabio Martinelli,Valentina Chiappa,Lavinia Mosca,Umberto Leone Roberti Maggiore,Stefano Ferla,Domenica Lorusso,Francesco Raspagliesi 대한부인종양학회 2018 Journal of Gynecologic Oncology Vol.29 No.5

Objective: Accumulating evidence support that complete cytoreduction (CC) at the time of secondary cytoreductive surgery (SCS) improves survival in patients affected by recurrent ovarian cancer (ROC). Here, we aimed to determine whether artificial intelligence (AI) might be useful in weighting the importance of clinical variables predicting CC and survival. Methods: This is a retrospective study evaluating 194 patients having SCS for ROC. Using artificial neuronal network (ANN) analysis was estimated the importance of different variables, used in predicting CC and survival. ANN simulates a biological neuronal system. Like neurons, ANN acquires knowledge through a learning-phase process and allows weighting the importance of covariates, thus establishing how much a variable influences a multifactor phenomenon. Results: Overall, 82.9% of patients had CC at the time of SCS. Using ANN, we observed that the 3 main factors driving the ability of achieve CC included: disease-free interval (DFI) (importance: 0.231), retroperitoneal recurrence (importance: 0.178), residual disease at primary surgical treatment (importance: 0.138), and International Federation of Gynecology and Obstetrics (FIGO) stage at presentation (importance: 0.088). Looking at connections between different covariates and overall survival (OS), we observed that DFI is the most important variable influencing OS (importance: 0.306). Other important variables included: CC (importance: 0.217), and FIGO stage at presentation (importance: 0.100). Conclusion: According to our results, DFI should be considered as the most important factor predicting both CC and OS. Further studies are needed to estimate the clinical utility of AI in providing help in decision making process.