Comparison of Peritoneal Carcinomatosis Scoring Methods in Predicting Resectability and Prognosis in Gynecologic Malignancies

Objective: Peritoneal carcinomatosis is a disease’s presentation in the advanced stages of many gynecologic tumours. The distribution and volume of the disease are the main factors in achieving complete debulking. Diagnostic laparoscopy is a technique to allow evaluation of the disease. This study’s objective is to compare two laparoscopic scores (Fagotti’s index and Sugarbaker’s peritoneal cancer index (PCI)) and assess the diagnostic accuracy to select patients for neoadjuvant treatment and reduce unnecessary laparotomies. Methods: A non-randomised retrospective cohort study was conducted in patients with peritoneal carcinomatosis (ovarian and endometrial origin) who underwent laparoscopy and subsequent laparotomy. We evaluated the scores’ ability to predict incomplete surgery and whether they were related to the patients’ prognosis. Results: We included 34 patients, of which 23.5% received neoadjuvant chemotherapy. The rate of complete cytoreductive surgery was 79.4% (n = 27 patients). The highest sensitivity was obtained with a PCI value greater than 20. It was the best parameter to determine incomplete debulking. Survival curves were analysed according to the “cut off” established for each score, and statically significant differences were found using PCI with respect to Fagotti’s Index. However, these differences were not found with Fagotti’s score. Conclusion: The best diagnostic method to classify patients with peritoneal cancer is the PCI. It could be adapted to each surgical team because it allows identifying the “cut off point”, which depends on incomplete surgery rate.

The Peritoneal Cancer Index is a Strong Predictor of Incomplete Cytoreductive Surgery in Ovarian Cancer

Background Extent of tumor load is an important factor in the selection of ovarian cancer patients for cytoreductive surgery (CRS). The Peritoneal Cancer Index (PCI) gives exact information on tumor load but still is not standard in ovarian cancer surgery. The aim of this study was to find a PCI cutoff for incomplete CRS. The secondary aims were to identify reasons for open-close surgery and to compare surgical complications in relation to tumor burden. Methods The study included 167 women with stage III or IV ovarian cancer scheduled for CRS. Possible predictors of incomplete surgery were evaluated with receiver operator curves, and a PCI cutoff was identified. Surgical complications were analyzed by one-way analysis of variance and Chi square tests. Results The median PCI score for all the patients was 22 (range 3–37) but 33 (range 25–37) for the patients with incomplete surgery (n = 19). The PCI predicted incomplete CRS, with an area under the curve of 0.94 (95% confidence interval [CI], 0.91–0.98). Complete CRS was obtained for 67.2% of the patients with a PCI higher than 24, who experienced an increased rate of complications (p = 0.008). Overall major complications were found in 16.9% of the cases. Only 28.6% of the patients with a PCI higher than 33 achieved complete CRS. The reason for open-close surgery (n = 14) was massive carcinomatosis on the small bowel in all cases. Conclusion The study found PCI to be an excellent predictor of incomplete CRS. Due to a lower surgical success rate, the authors suggest that neoadjuvant chemotherapy could be considered if the PCI is higher than 24. Preoperative radiologic assessment should focus on total tumor burden and not necessarily on specific regions.

Successful concurrent chemoradiotherapy with cisplatin plus etoposide after incomplete resection for advanced thymic carcinoma

The optimal therapy for advanced thymic carcinoma has long been controversial. Despite that complete (R0) resection is recommend as the first-line treatment, multidisciplinary approach including chemotherapy and radiotherapy should be considered for patients who lost the operation chance or received incomplete resection. Here, we present a case who received concurrent chemoradiotherapy (CCRT) after cytoreductive surgery. A complete response was observed and the patient has remained disease free for over 4 years. To our knowledge, this is the first report to demonstrate the efficacy of CCRT with cisplatin plus etoposide after incomplete surgery for advanced thymic carcinoma.

Endometriosis and the menopause: why the question merits our full attention

As an estrogen-dependent disease, endometriosis was thought to become less active or regress with the onset of the menopause. However, based on some new data, we are discovering that this pathology can emerge or reappear at this period of life. Clinicians must consider it as a possible cause for cases of pelvic pain, and heavy bleeding. Authors have described a possibility of transformation of the intraperitoneal proliferation into a malignant type with ovarian, bowel and even lung metastasis. The risk of transformation into an ovarian cancer is around 2 or 3%. The role of menopausal hormonal therapy will be discussed as in recurrence in the case of residue existence, especially after incomplete surgery. Is it possible to prescribe hormonal therapy to a menopausal women suffering climacteric symptoms as it could trigger a recurrence of endometriosis and even an increased risk of malignant degeneration? This remains unclear. It is an unresolved therapeutic dilemma; the choice between surgery or medical treatment?

A retrospective analysis of the pattern of care and survival in patients with malignant ovarian germ cell tumors

Objective: The objective of this study is to evaluate the pattern of care and survival outcome in patients with malignant ovarian germ cell tumors (MOGCTs). Materials and Methods: Between January 2004 and August 2017, 50 patients with MOGCT were identified at Amrita Institute of Medical Sciences and 48 included in analyses. Histologic subtypes were as follows: dysgerminoma 11; immature teratoma 16; yolk sac tumor 3; and mixed germ cell tumor 18. 31 (64.6% patients belonged to Stage I and 17 (35.4%) patients were advanced stage (Stage II-IV). Results: Median follow-up period was 34 months (range: 1–241 months). The 5- and 10-year disease-free survival (DFS) and overall survival (OS) for the entire cohort were 87.5% and 94.4%, respectively. DFS and OS of incomplete surgery Stage I patients 28.6% and 68.6%, respectively, were significantly lower than completely staged patients 100%. Out of 8 incomplete surgery patients, 5 recurred of which 2 died of disease within 4 and 9 months of recurrence. There was no survival difference with comprehensive surgical staging (CSS) and pediatric surgical staging (PSS) in Stage I MOGCT (DFS and OS 100%). Stage I dysgerminoma kept on active surveillance after PSS had equivalent survival of 100%. There was no survival difference in advanced stage MOGCT treated with primary debulking surgery and neoadjuvant chemotherapy (NAC) followed by fertility-sparing surgery (DFS and OS 100%). Conclusion: Incomplete surgery in Stage I MOGCT was associated with poor survival. There was no survival difference with CSS and PSS. NAC followed by surgery could be a reasonable option for patients of advanced stage MOGCT.

A 48 year old postmenopausal woman with dull aching lower abdominal pain and heaviness in the abdomen

<p><span>This article has no abstract. The first 100 words appear below:</span></p><p>A 48 year old postmenopausal lady, para-6 (alive) came to the outpatient department as a diagnosed case of ovarian tumor with history of incomplete surgery. The patient was reasonably well two years back, then she developed dull aching lower abdominal pain and heaviness in abdomen. For that reason, she went to a local doctor and diagnosed as a case of ovarian tumor by ultrasonography. She had laparotomy on 22 May 2016 at Mymensingh private clinic but the tumor was not removed completely due to extensive adhesion. Few tissues were taken and sent for histopathology and found fibroma of ovary.</p>

Successful Treatment of Acromegaly and Associated Hypogonadism with First-Line Clomiphene Therapy

Clomiphene citrate (CC) has been reported as an effective add-on therapy to somatostatin analogs and dopamine agonists in patients with acromegaly accompanied by hypogonadism; its use as a single agent to treat acromegaly and associated hypogonadism following incomplete surgery has not been previously reported. We report the first case in which clomiphene was utilized as a single agent for the dual management of acromegaly and hypogonadism, not controlled by pituitary surgery alone. The treatment was well tolerated and proved to be effective after a process of treatment withdrawal and reintroduction. We propose that clomiphene may be considered as a cost-effective oral treatment option in select cases of hypogonadal acromegaly.

The Future of Rectal Cancer Surgery: A Narrative Review of an International Symposium

Surgery remains the mainstay of curative treatment for primary rectal cancer. For mid and low rectal tumors, optimal oncologic surgery requires total mesorectal excision (TME) to ensure the tumor and locoregional lymph nodes are removed. Adequacy of surgery is directly linked to survival outcomes and, in particular, local recurrence. From a technical perspective, the more distal the tumor, the more challenging the surgery and consequently, the risk for oncologically incomplete surgery is higher. TME can be performed by an open, laparoscopic, robotic or transanal approach. There is a lack of consensus on the “gold standard” approach with each of these options offering specific advantages. The International Symposium on the Future of Rectal Cancer Surgery was convened to discuss the current challenges and future pathways of the 4 approaches for TME. This article reviews the findings and discussion from an expert, international panel.