Fabrice Lecuru

To assess the feasibility of Microsatellite Instability (MSI) analysis in uterine cavity washings for detecting endometrial cancer in Lynch syndrome. This was a proof-of-concept study in Lynch syndrome patients, scheduled for hysterectomy. At the beginning of surgical procedure, uterine cavity washings were performed, and sent for MSI analysis. Pathological examination of the uterus was associated with mismatch repair protein expression and MSI analysis. Nine patients were included in the study. Uterine cavity washings were feasible and interpretable in all cases. Final histological report identified 2 endometrial cancers and 7 benign specimens. There was no atypical hyperplasia. Sensitivity, specificity, positive predictive value, and negative predictive value of MSI analysis in uterine washings reached 100% in all cases. Concordance of MSI presence or absence was absolute between uterine washings and final histology. MSI analysis in uterine cavity washings may be a promising screening tool for Lynch syndrome-associated endometrial cancer diagnosis.

We report on a case of synchronous endometrial and ovarian cancer in a patient with Lynch syndrome. An endometrial biopsy performed during routine screening revealed microsatellite instability (MSI) and loss of expression of human mutL homolog-1 (MLH1) and postmeiotic segregation increased-2 (PMS2) in a setting of complex hyperplasia. Whereas gynaecological screening including clinical examination, pelvic ultrasound, and endometrial biopsy, has not proven its benefit, our case report points out the place of MSI analysis and immunohistochemical investigation of mismatch repair protein expression in endometrial samples during gynaecological screening.

The objective is to assess the feasibility of laparoscopy in the treatment of endometrial carcinoma and to compare operating data and morbidity to laparotomy. Retrospective review of 70 consecutive patients with supposed early endometrial cancer managed between December 2000 and December 2005. Two groups were defined, whether they had been operated by laparoscopy (N = 44 ; LPS group) or by laparotomy (N = 21 ; LPM group). Both groups were comparable in mean age and body mass index. There was no significant difference in median operating time for LPS group (240 minutes [90-390]) and LPM group (195 minutes [120-600]), (p = 0.234). Intraoperative complications occurred in 2 LPS patients (4.7 %) and in 2 LPM cases (9.5 %). Women who underwent laparoscopy had more pelvic lymph nodes removed (11.5 [2-33] versus 7.5 [3-37], p < 0.05). There were comparable early and late postoperative complications in patients managed by laparoscopy (5 and 0 cases ; 27.8 and 0 %) and by laparotomy (5 and 2 cases ; 11.6 and 4.5 %), (p = 0.143 and p > 0.999). Hospital stay was longer in LPM group (9.5 days [6-39] versus 5.0 (4-27), p < 0.05). Patients who undergo laparoscopy have more pelvic lymph nodes removed, with comparable operating time, shorter hospital stay, and similar morbidity. Laparoscopic staging combined with vaginal hysterectomy appears to be a feasible alternative to conventional surgical approach in patients with endometrial carcinoma.

The objectives were to evaluate the impact of the surgical approach on the staging of borderline tumors and early-stage malignancies of the ovary. We retrospectively reviewed cases of borderline and invasive ovarian tumors stages Ia through Ic treated surgically between January 1, 1985 and December 31, 2001. We compared the rates of potentially harmful procedures according to the surgical approach. The quality of surgical staging was assessed by examining each required procedure and by determining a score. The influence of variables related to patient characteristics, preoperative workup, and initial surgery on staging quality was tested by univariate analysis. Variables independently associated with staging quality were entered in a logistic regression model. SPPS 7.5 and STATA 8 software was used for statistical tests. Of 118 patients with borderline tumors, 48 (41 %) underwent laparoscopic surgery, 54 (45 %) laparotomy, and 16 (14 %) laparoscopy converted to laparotomy. Surgery was conservative in 57 % of cases overall ; this proportion was significantly greater with laparoscopy than with laparotomy (p < 0.05) and in younger women (p < 0.001). Intraoperative tumor rupture occurred in 9 % of patients, with no significant difference across surgical approaches (p = 0.1). Bag extraction was used in 19 (40 %) of 48 laparoscopically treated patients. Staging was incomplete in 73 % of patients. By univariate analysis, bilateral adnexectomy and, to a lesser extent, age > 44 years, laparotomy, hysterectomy, and treatment after 1995 predicted at least partial staging. Factors independently associated with at least partial staging in the multivariate model were treatment after 1995, bilateral adnexectomy, and hysterectomy. Of 178 patients with invasive tumors, 34 underwent laparoscopic surgery, 114 laparotomy, and 30 conversion from laparoscopy to laparotomy. The laparotomy group was characterized by significantly older patient age and larger tumors, compared to the laparoscopy group. Staging was often inadequate after initial surgery, most notably with low rates of paraaortic lymphadenectomy (0 % in the laparoscopy group, 18 % in the laparotomy group, and 33 % in the conversion group). Staging is often less complete with laparoscopy than with laparotomy. In patients with invasive cancer, inadequate initial staging is common, most notably when laparoscopy is used. The surgeons training seems of major importance.

Early ovarian cancers account for 25 to 30% of cases. They constitute the only curable cases. There is no specific clinical symptom of early ovarian cancer. Paraneoplasic syndroms, especially phlebitis, are of major importance when they occur in young women. In most of cases, the diagnosis is performed during the management of a complex ovarian cysts. Quality of the preoperative work-up, especially sonography, and management by a specialised team are the best factors to provide an early diagnosis and a comprehensive staging. These two factors are known as predictive of good prognosis. Chemotherapy is frequently indicated post-operatively. In young women, a conservative management can be proposed to preserve their fertility.

Background. Vaginal hysterectomy (VH) is being performed increasingly by gynecologic surgeons. Thus, enlarged uteri are more frequently removed vaginally, requiring reducing techniques to allow vaginal extraction. Material and methods. We designed a randomized prospective study to compare bisection–morcellation and myometrial coring. Patients scheduled for VH or laparoscopically assisted vaginal hysterectomy (LAVH) were offered entry into the study. Endometrial cancer was an exclusion criterion. Uterine size was not a contraindication for vaginal surgery. We compared data from preoperative workup as well as from the operative and the postoperative course. Data were recorded prospectively. Results were analyzed with nonparametric tests and logistic regression models. Results. Thirty patients were included in the study. Patients were similar in both groups. No severe peroperative complication occurred in this series. Operating time was comparable in both groups. Uteri weighed more than 280 g in more than 70% of patients in both groups. Myometrial coring failed more often than bisection–morcellation (25% vs. 0%, p = 0.06). Patients and uteri characteristics had no influence on the risk of failure, except for narrow uteri, which were associated with an increased risk of failure in the myometrial coring group only (68.3 vs. 83.9 mm, p = 0.01). Postoperative courses were similar for the two techniques, except for an increased rate of fever in the myometrial coring group (28%, p = 0.03). Conclusion. Both techniques appeared safe in this trial. Myometrial coring failed more frequently than bisection–morcellation, especially in the case of a narrow uterus. Postoperative fever was significantly more common after myometrial coring. Both techniques should be taught to resident surgeons.