Day 3 :
- Cervical cancer
Vaginal/Vulvar cancer
Session Introduction
Melissa Joyner
University of Texas Medical Branch, USA
Title: Locally advanced vulvar cancer outcomes following chemoradiation: A retrospective review
Biography:
Melissa Joyner is a Radiation Oncologist specializing in the treatment of gynecologic, and breast cancers. She is an Assistant Professor of Radiation Oncology at the University of Texas Medical Branch. She completed her Radiation Oncology Training at the University of Texas Health Science Center in San Antonio (UTHSCSA). She also received her Doctorate of Medicine at UTHSCSA and is Board Certified in Radiation Oncology by the American Board of Radiology (ABR).
Abstract:
Purpose & Objectives: To review results from a single institution of preoperative chemoradiation therapy in patients with locally advanced vulvar cancer who are not surgical candidate due to extent of disease. Patients were treated with intent to improve local control with organ preservation. Materials & Methods: Historical chart review of 12 patients with an average age of 52 (range 40 to 72 years old) treated between 1997-2014, all with locally-advanced clinical stage T3 or T4 squamous cell carcinomas of the vulva not amenable to surgical resection. Two of 12 patients presented with locally advanced recurrent disease and nodal relapse. All patients were treated with external beam to 4760 cGy (1.7 Gy per fraction x 28 fractions) using an accelerated fractionation schema consistent with GOG 101 protocol with a planned treatment break in conjunction with concurrent Cisplatin and 5-FU. A single patient was treated with a modified fractionation schema after 1st cycle of radiation demonstrated superior treatment response which facilitated surgical resection and was then followed with additional radiation to treat residual microscopic disease. 7 out 12 patients (58.3%) also received a boost ranging from 7.2 Gy to 17.2 Gy with a single patient receiving 12 Gy SD via vaginal cylinder. Results: Patients studied had an average of 75 months of follow-up. Sustained local control was achieved in 8/12 (66.7%). A complete clinical response (cCR) was seen in 100% of patients following treatment. Despite extensive disease at presentation, only 2/12 (16.7%) failed in the vulva after treatment. A significant number of patients remained disease free with no evidence of distant metastases or evidence of any disease with 5 of 12 alive (58%), and an additional 2 of 12 patients who expired without evidence of disease. While 2 out of 12 patients exhibited evidence of active disease, the patients are alive and are undergoing additional therapy. Only 2 of 12 patients to date have expired with evidence of disease and 1 patient expired with disease status unknown. Biopsies were done of primary and/or node in 4/12 (33%) which were negative for disease. Organ preservation was achieved in 100% of patients. Conclusions: This treatment schema provided excellent tolerance with sustained local control. All patients obtained clinical complete response and were able to avoid pelvic exenteration surgery as well as maintain preservation of their bladder and rectal function.
Aleksandar Stefanovic
Clinic for Obstetrics and Gynecology, Clinical Center of Serbia
Title: Fertility sparing surgery in early stages of cervical cancer
Biography:
Aleksandar Stefanović finished Medical School University of Belgrade (1977), MD (1995), PhD (1996), and academic special studies Obstetrics and Gynecology (1994), with 25 years of clinical experiences, working at Clinic for Gynecology & Obstetrics Clinical Centre of Serbia, which is the biggest one in whole region. He worked as a gynecologist for 18 years. His present position at the Clinis is Chairman of Clinic for Obstetrics and Gynecology, Clinical Center of Serbia-President of Expert Committee for Cervical Carcinoma Prevention and Control, also Member of Advisory Board for the implementation of Screening and Early Detection of Breast, Cervical and Colorectal Carcinoma Programme. He is the Author of National Good Practice Guidelines for Diagnosis and Treatment of Cervical Carcinoma, - Member of Multidisciplinary Team for Gynecologic Oncology, Clinic for Obstetrics and Gynecology, Clinical Center of Serbia. His representative publications is about 50 publications in CC/SCI expanded and JCR indexed, and he is an active participant on more than 50 international congresses, with total number of publication about 150.
Abstract:
The concept of fertility-preserving surgery in early cervical, radical trachelectomy with stage IA2 or IB disease. Trachelectomy is a conservative oncologic operation with aim to preserve fertility in early stages of cervical cancer female patients that have realized reproduction. Excised structures in trachelectomy are: cervix, upper 1/3 of vagina, parametria and paracolpia, with preservation of uterine corpus. After removing the vaginal fornix and cervix, uterovaginal anastomosis with non resorptive suture is performed. Indications for trachelectomy are, patients up to 45 years of age who which to conserve fertility with negative lymph nodes, no distant metastatic disease, FIGO stage cervical cancer staged IA1, IA2, IB1 (tumour size ≤ 2cm with negative lymph nodes ), with adequate cervical length, no evidence of expansion of malignat proces on the upper part of the cervical cannal, squamocellular carcinoma, rarely cervical adenocarcinoma, negative lymph nodes intraoperatively, no metastatic disease, clear resected margins. There is an ongoing debate regarding the need for uterine vessels preservation. Some authors have proved that the preservation of the uterine artery is associated with more favorable restoration of the reproductive function. Others claim that preservation of the uterine vasculature is not necessary for fertility as obstetrical outcomes are similar to those of the historical vaginal radical trachelectomy cohorts. Simple trachelectomy as alternative to radical trachelectomy in selected cases (parametrial involvement rate < 1% in patients with IB1 ≤ 2 cm, negative lymph nodes and stromal invasion ≤ 10 mm).
Karl R Aigner
Medias Klinikum GmbH & Co KG, Germany
Title: Isolated pelvic perfusion with chemofiltration for advanced stage IVa and recurrent cervical cancer
Biography:
Karl Reinhard Aigner is Medical Director of the Department of Surgical Oncology in Medias Klinikum Burghausen (Bavaria) / Germany. He had his surgical training in cardiovascular surgery at Friedrich-Alexander University in Erlangen. At Justus-Liebig University Giessen he specialized in surgical oncology, focusing on vascular techniques of drug delivery such as Implantofix and Jet Port catheters, and in 1981 first performed a technique of isolated perfusion of the liver with heart-lung machine in man. Furtheron he developed various techniques of segmental vascular isolation of body segments and organs, and the stopflow technique with adequately designed catheters. In 1982, together with Prof. Stephens from Sydney, he initiated the biannual International Congress of Regional Cancer Treatment (ICRCT) and from 1987 to 1991 was president of the International Society for Regional Cancer Therapy. From 1985 to 1998 he was managing editor of the International Journal Regional Cancer Treatment. He is author of numerous publications and book chapters, lectured and performed teaching operations on vascular perfusion techniques and oncological surgery in Europe the United States and Asia.
Abstract:
Introduction: In advanced or recurrent cervical cancer, radical resections with local irradiation may no longer be radical because of micro-invasion behind the resection margins. The more local tumor progression becomes evident, the more therapies are intensified until a point is reached where therapy-related toxicity may outweigh clinical benefit and quality of life. Material & Methods: In order to include the entire pelvis with regional lymphnodes into an isolated perfusion circuit, the femoral artery and vein were cannulated with balloon catheters under general anesthesia. Both balloons were placed above the aortic and vena cava bifurcation. Both upper thighs were blocked with pneumatic cuffs. Because of tenfold increased cytotoxicity of Adriamycin and Mitomycin, and unaffected cytotoxicity of Cisplatin under hypoxia, the 15 minutes isolation perfusion of this three drug combination was performed under hypoxic conditions followed by 30–45 minutes of chemofiltration for systemic detoxification. Results: In a patient with advanced stage IVa disease with tumor invasion of the bladder, lymphnodes and both parametria, after ineffective systemic chemotherapies, a histologically complete remission after hysterectomy was revealed after four courses of isolated pelvic perfusion. There was no significant systemic or local toxicity and the patient is in continuing complete remission after 11 years. In eight patients with advanced and pre-treated recurrent cervical cancers, after four isolated pelvic perfusions, the median progression-free survival was 202 days, the median overall survival time 245 days. Two patients actually survive recurrence-free for 20 and 36 months. Conclusion: Isolated hypoxic pelvic perfusion with chemofiltration is a valuable method for therapy of advanced or recurrent cervical cancers, refractory to conventional therapies.
Aida Moeini
University of Southern California, USA
Title: Combined vagino-abdominal approach for management of Vesicovaginal fistulas: A 10 years' experience
Biography:
Aida Moeini is Specialist in University of Southern California, USA. She is extending his valuable service as a Specialist and has been a recipient of many award and grants. Her research experience includes various programs, contributions and participation in different countries for diverse fields of study. Her research interests as a Specialist reflect in her wide range of publications in various national and international journals.
Abstract:
Background: Vesicovaginal fistulas (VVF) are an uncommon but serious complication of gynecological surgery. Aim: The aim of this study was to report our experience with the repair of VVF using combined vaginal and extraperitoneal abdominal approaches. Materials & Methods: Between 2000 and 2012, 15 consecutive females with VVF were managed with combined vaginal and extraperitoneal abdominal procedures. After assessment by voiding cystourethrography and urethrocystoscopy, the operation was performed at the standard lithotomy position. Result: Fifteen patients were included in this study with mean age 51.8±11.9 years. The mean fistula size was 2.1±0.7 cm and all of them were located in supra-trigonal region except one case that fistula defect extend to the bladder trigon. 14 patients reported complete resolution of urinary incontinence during mean follow up of 3.5 years. Fistula was recurred in one female, 1 year after repair due to cancer recurrence and radiotherapy treatment. No intraoperative complication including massive bleeding or ureteral damage was observed. Conclusion: Our experiment with combined vaginal and extraperitoneal abdominal repair of a vesicovaginal fistula shows its feasibility and safety with good results.
Tommy Nai-Jen Chang
Chang Gung Memorial Hospital, Taiwan
Title: Pedicle perforator flaps in vulvar reconstruction – Restore the cosmesis and life quality with new generation reconstruction
Biography:
Tommy Nai-Jen Chang finished his training in the Department of Plastic and Reconstructive Surgery in Chang-Gung Memorial Hospital in Taiwan and now is now a staff and assistant professor in the department. Dr. Chang has involved in clinical practices relate to micro-vascular and micro-peripheral nerve surgeries for ten years. Dr. Chang is also experiencing in perineal reconstruction using different perforator flaps.
Abstract:
Vulvar reconstruction is challenging. Early postoperative mobilization tethers the wound, making it easily break down. Inevitable urine, stool and vaginal discharge contaminate the wound easily, resulting in infection and subsequent partial or total flap loss and may indicate further surgical debridement. Both function and aesthetic results determine satisfactory outcome. With advanced microsurgical technique, reconstructive surgeons are now able to close the wound with a perforator-based flap, and provide better restoration of its function as well as its original appearance. Different perforator flaps have been introduced in vulvar reconstruction from lower abdomen, vulvo-perineal, buttock and thigh. We recommended the use of perforator flaps from medial thigh with multiple advantages. Using perforator flaps reduces donor site morbidities by retrograde dissection of the perforator to the main pedicle without sacrificing the muscles. Harvesting the flaps from neighbor region of vulvar eliminates the requirement of microsurgical vascular anastmosis. The nature of the medial thigh provides tissue that restores similar bulk of vulvar and enhances postoperative cosmesis. Different perforators are available, including deep femoral perforator flap (also known as profunda artery perforator flap), medial ciecumflex femoral artery perforator flap, deep external pudendal artery perforator flap, and internal pudendal artery perforator flaps. In particular, the medial thigh is a region rich of perforators. Free style perforator flaps without knowing origins can also be designed safely with nice backup. Post-operative life quality was assessed using FATC-G and FATC-V questionnaires with satisfied respons. The presentation will conclude a new generation of vulvar reconstruction using the most updated technique
Yan Bin
Hubei Maternity and Child Health Hospital, China
Title: The study of the effect of tumor-infiltrating neutrophils in predicting the recurrence of cervical cancer
Biography:
Yan Bin has completed her PhD from Tongji Medical College, Huazhong University of Science and Technology (HUST) in China. Currently, she is working as a resident in the Department of Gynecologic Oncology, Hubei Maternity and Child Health Hospital in China.
Abstract:
Objective: To investigate the prognostic effect of the tumor-infiltrating neutrophils in cervical cancer, and the effect of bone marrow neutrophils on the growth and angiogenesis of U14 mice cervical cancer cell lines. Method: International Federation of Gynecology and Obstetrics (FIGO) stage I B and II A treatment-naive cervical cancer patients (N=46) were assessed for tumor-infiltrating CD66b+ neutrophils by immunohistochemistry. Results were correlated with recurrence-free survival (RFS) as end point. Bone marrow neutrophils separated form naive and tumor-bearing mouse were used to co-inoculate with the U14 mice cervical cancer cell line to observe the effect of neutrophils on the growth and angiogenesis of U14 cell line. Result: The group with a density of CD66b+ neutrophils above median in the tissue of cervical cancer was associated with shorter RFS than the group with a density of CD66b+ neutrophils below median, and the 2 groups had a statistic difference (P=0.021). The bone marrow neutrophils from the tumor-bearing mouse had the ability to promote tumor growth and angiogenesis of U14 cervical cancer cell line. Conclusion: The increasing number of the tumor-infiltrating neutrophils in cervical cancer tissues was correlated with the short recurrence free survival of the patients of cervical cancer, and the tumor environment could change the neutrophils to act in a way that favors tumor angiogenesis and tumor growth.
Yuanqing Yao
PLA General Hospital, China
Title: Robotic nerve-sparing radical hysterectomy for locally advanced cervical cancer after neo-adjuvant chemotherapy
Biography:
Yao Yuan-Qing is a professor in Department of Obstetrics and Gynecology, General Hospital of PLA, China and a professor in Nankai University, China. Professor Yao is a member of executive committee of Society of Reproductive Medicine of Chinese Medical Association. Professor Yao’s clinical expertise and research interests are minimally invasive surgery of gynecological cancer, assisted reproductive techniques and molecular mechanism of preimplantation embryo development. He performed the first case of robotic radical hysterectomy in China. Professor Yao’s research has supported by National Natural Science Foundation of China, Major State Basic Research Development Program of China
Abstract:
Objective: To evaluate the feasibility and safety of robotic nerve-sparing radical hysterectomy for Locally Advanced Cervical Cancer (LACC). Methods: In a retrospective study, data were analyzed for patients treated for cervical cancer at a center in Beijing, China, between December 2011 and September 2013. Patients were subdivided into those with early-stage disease (FIGO stage IA2–IB1) who were treated by robotic surgery (group 1), and those with LACC (stage IB2–IIB) who were treated by robotic surgery after neo-adjuvant chemotherapy (NACT). Therapeutic outcomes and complications were compared. Results: Group 1 included 32 patients and group 2 included 22 patients. Two patients in group 2 did not respond to NACT and did not undergo surgery. The operative outcomes and incidences of complications did not differ significantly between the two groups (p>0.05 for all). There were no differences in nodal yield, lengths of parametrium removed, or vaginal cuff length (p>0.05 for all). During a mean follow-up of 26 months, no patient experienced recurrence. Conclusion: Robotic nerve-sparing radical hysterectomy was found to be feasible and safe for LACC after NACT. A larger case series with longer follow-up data is needed to justify its widespread application.
Sandeep Singh
Gajra Raja Medical College, India
Title: Tele-cytology: An innovative approach for cervical cancer screening in resource-poor settings
Biography:
Dr Sandeep Singh has completed his MBBS from Gajra Raja Medical College, Gwalior affiliated to Jiwaji University, Gwalior, India from 2007-2013. He is presently associated with, Shitla sahai institute of medical science Gwalior, India. He has published 16 National and International research articles in various reputed journals and delivered paper presentations at various platforms. His core area of interest includes cervical cancer screening, generation of new screening tools and policy framing. He is actively associated with NGOs to provide health care to the underserved communities.
Abstract:
Objective: Carcinoma cervix remains a leading cause of cancer mortality among women in countries lacking any screening program. The existing screening policy and approach via conventional cytology centered mainly in Tertiary Care Center, is totally unaffordable to Indian women, especially in the remote areas. This suggests the need of depolarizing the resources via generating the near real time modalities which could be used at the door step of the needy ones. For any screening modality to be effective, it should be adequately sensitive, specific, reproducible, cheap, simple, affordable, and the most important, it should be real time to ensure wide coverage and curtail loss to follow-up. Incorporating telecytology as a screening tool could make the dream come true. Methods: Telecytology is the interpretation of cytology material at a distance using digital images. Use of mobile telecytology unit housed in a van carrying satellite equipment and the automated image capturing systems is the central theme behind this idea. The imaging equipment would be carrying out the imaging of Papanicolaou smears prepared at the screening site and sending the images to the central laboratories situated at some tertiary care level. Results: This concept could overcome the hindrance of trained cytology infrastructure in the resource poor settings and could provide an efficient and economical way of screening patients. Conclusion: There is possibility that the designed approach may not detect the entire women positive for the disease but if the desired objective was to diagnose as many cases as possible in resource poor setting, then this process offers an advantage over no screening at all.
Vincent Balaya
University Paris Descartes, France
Title: Pelvic nerve injury during radical hysterectomy for cervical cancer : Key anatomical zone
Biography:
Vincent Balaya is resident of Obstetrics/Gynecology in the departement of gynecological, oncological and breast surgery at Georges Pompidou European Hospital in Paris and researcher at the Human Anatomy departement at University Paris Descartes. Fabrice LECURU is University professor at the University Paris Descartes and head chief of departement since 2007. Its main poles of interest are the mini-invasive surgery applied to the gynecological cancers, and the surgery of the advanced cancers of the ovary. He developed these various techniques in the department of the HEGP, so offering to the women of the less noxious effective treatments for them. He also developed a very strong activity of clinical research and teaching on these themes. The department of the HEGP was certified by the AP-HP, " Expert Center " for the breast cancer treatment and the gynecological cancers
Abstract:
Objectives: By using 3D reconstruction, to provide key-points of surgical neuroanatomy of the female pelvis to improve nerve-sparing radical hysterectomy. Method: Computer-assisted anatomical dissection of three human female pelvis fetus of 12,15 and 24 weeks of gestation, a classic dissection of a 88-years-old woman and a review of the surgical literature up to 2014 on Medline. Results: The Superior Hypogastric Plexus (SHP) divides underneath the promontory into two Hypogastric Nerves (HN). HN descend along the lateral side of the rectum, then run postero-medially to the ureter and in the lateral part of the uterosacral ligament until the superior angle of the Inferior Hypogastric Plexus (IHP). Pelvic Splanchnic Nerves (PSN) emerge from ventral rami of S2, S3 and S4 and run on the postero lateral side of the rectum until the posterior edge of the IHP. IHP extend from the anterolateral face of the rectum and passes lateral to the cervix and the vaginal fornix. Efferences of the IHP are constituted by vesical, vagino-rectal and inferior rectal plexus. Discussion: Preservation of SHP necessitates an approach on the right side of the aorta and a blunt dissection of the promontory before lomboaortic lymphadenectomy. To preserve HN only the medial fibrous part of the uterosacral ligament should be resected. The middle rectal artery, the deep uterine vein and the ureter should be identified to preserve PSN and IHP during resection of paracervix. Vesical branches can be preserved by blunt dissection of the posterior layer of the vesico-uterine ligament after identifying the inferior vesical vein.