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No randomised trials have addressed the value of systematic aortic and pelvic lymphadenectomy (SL) in ovarian cancer macroscopically confined to the pelvis. This study was conducted to investigate the role of SL compared with lymph nodes sampling (CONTROL) in the management of early stage ovarian cancer. A total of 268 eligible patients with macroscopically intrapelvic ovarian carcinoma were randomised to SL (N=138) or CONTROL (N=130). The primary objective was to compare the proportion of patients with retroperitoneal nodal involvement between the two groups. Median operating time was longer and more patients required blood transfusions in the SL arm than the CONTROL arm (240 vs 150 min, P<0.001, and 36 vs 22%, P=0.012, respectively). More patients in the SL group had positive nodes at histologic examination than patients on CONTROL (9 vs 22%, P=0.007). Postoperative chemotherapy was delivered in 66% and 51% of patients with negative nodes on CONTROL and SL, respectively (P=0.03). At a median follow-up of 87.8 months, the adjusted risks for progression (hazard ratio [HR]=0.72, 95%CI=0.46-1.21, P=0.16) and death (HR=0.85, 95%CI=0.49-1.47, P=0.56) were lower, but not statistically significant, in the SL than the CONTROL arm. Five-year progression-free survival was 71.3 and 78.3% (difference=7.0%, 95% CI=-3.4-14.3%) and 5-year overall survival was 81.3 and 84.2% (difference=2.9%, 95% CI=-7.0-9.2%) respectively for CONTROL and SL. SL detects a higher proportion of patients with metastatic lymph nodes. This trial may have lacked power to exclude clinically important effects of SL on progression free and overall survival. [ABSTRACT FROM AUTHOR]

Abstract Background Gynecological surgery, as radical hysterectomy or pelvic and aortic lymphadenectomy, accounts for more than 50% of iatrogenic injuries. In premenopausal women, an hysterectomy with ovarian sparing and concomitant lateral ovarian transposition is frequently performed. However, the fate of the retained ovary is complicated by the residual ovarian syndrome (ROS) and one of the most common postoperative complications of the lymphadenectomy procedure is the lymphocele, with an average incidence of 22–48.5%. The differential diagnosis of a postoperative fluid collection includes, in addition to a lymphocele, urinoma, hematoma, seroma or abscess and the computed tomography (CT) findings alone is not enough. Case presentation We describe a patient, affected by ROS concomitant with a asymptomatic lymphocele, initially confused with an aortic lymph nodes relapse, after abdominal radical hysterectomy. The patient was subjected to a surgical approach, included a diagnostic open laparoscopy and laparotomy with sovraombelico-pubic incision, wide opening of the pelvic peritoneum and retroperitoneum. Examination of the mass revealed, macroscopically, a ovary with multiloculated cystic masses filled with clear or yellow serous fluid and the layers were composed by flat or cuboidal mesothelial cells. Conclusion The tribute of this case illustrates the atypical appearance with uncertain aetiology after complex imaging. Gynecologist and radiologist should acquaint with the appearance of fluid collection (urinoma, lymphocele, seroma, hematoma, abscess) in gynecologic oncology follow-up to properly differentiated from tumor recurrence.

Reactive lymphoid hyperplasia (RLH) is a rare, benign, lymphocytic tumour-like lesion reported in various organs. It has been previously identified in 18 cases in the English-language literature, but only 5 of them were related to oncological disease. No previous cases have been described of RLH occurring in ovarian cancer patients. We describe a case of hepatic RLH which developed in a patient treated for ovarian cancer 11 years previously. Radiological features on computed tomography (CT) scan and PET-CT (positron emission tomography-computed tomography) were strongly suggestive of oncological disease, in contrast to magnetic resonance imaging (MRI); the volume increment of the nodular lesion and the rise in carbohydrate antigen 125 corroborated the hypothesis of malignancy. The patient was subjected to resection of the 7th segment of the liver and the final histological report showed RLH. RLH should be considered in the presence of hepatic lesions in suspected ovarian cancer recurrence. Imaging techniques should be thoroughly investigated to exclude tumor recurrence promptly, in order to avoid unnecessary surgery.

Most borderline ovarian tumors (BOT) occur in young women and exhibit a low malignant behavior. Nevertheless, an accurate long-term follow-up is required because, frequently, recurrence arises after many years from primary treatment, especially in patients affected by BOT with invasive peritoneal implants, which have a worse prognosis. We report the case of a pelvic recurrence of serous BOT firstly suspected by physical examination but misdiagnosed by ¹⁸F-fluorodeoxyglucose positron emission tomography and computed tomography and identified only by magnetic resonance imaging, 7 years after primary treatment. We also reviewed the literature concerning the role of ¹⁸F-fluorodeoxyglucose positron emission tomography in the management and follow-up of BOT.

Objective: It was the aim of this study to assess the role, feasibility and safety of consolidation intraperitoneal (IP) paclitaxel in patients affected by advanced ovarian cancer., Methods: Patients affected by advanced ovarian cancer with complete pathological response after standard treatment were enrolled in this study. The consolidation chemotherapy schedule consisted of 12-16 cycles of IP paclitaxel, 60 mg/mq weekly (group A). Chemotherapy was delivered with a direct puncture under ultrasonographic guidance at each cycle. Survival data of this group of patients were compared with those from a control group with analogous characteristics submitted to observation only (group B)., Results: Seventy patients were included in the study, 28 in group A and 42 in group B. Treatment-related toxicity was mild. In 3/28 patients (11%), technical difficulties in accessing the peritoneum were observed. Median time to recurrence was 25 months (range 4-64) in group A and 17.5 months (range 2-60) in group B. Estimated 3-year disease-free survival was 56 and 33% (p < 0.05) in group A and B, respectively; no significant difference in 3-year overall survival was observed (87 vs. 83%; p value not significant)., Conclusion: Weekly IP consolidation chemotherapy with paclitaxel 60 mg/mq is well tolerated and, in this experience, a prolongation of progression-free survival was observed., (Copyright 2010 S. Karger AG, Basel.)

Objective: Radiotherapy and/or pelvic exenteration represent the treatment of vaginal recurrence, but the prognosis remains unsatisfactory and with long-term complications. We investigated the possible role of vaginectomy for isolated vaginal relapse (IVR) in cervical cancer (CC)., Methods: Patients with vaginal CC recurrence were evaluated for surgical treatment consisting in vaginectomy. Data were prospectively collected and analyzed to identify independent prognostic factors., Results: Twenty-nine patients with IVR from CC were enrolled. Early and late complications were observed in 7 (24%) and 6 (21%) patients, respectively. After a median follow-up of 57.5 months (range, 8-100 months), 16 patients (55%) were disease-free. The 5-year overall survival and progression-free survival rates were 70.5% and 59.4%, respectively., Conclusions: In carefully selected patients, vaginectomy may be considered a therapeutic option for IVR. Older patients with long disease-free interval and small recurrences benefit the most from this bladder-sparing surgical technique.

Objective: Endometrial polyps (EPs) are common pathological lesions in all women. The objective of this study was to evaluate the risk of malignancy of EPs and to investigate whether clinical parameters may predict the histopathologic features of these lesions., Study Design: A retrospective study was conducted from January 1995 to December 2006 and all consecutive 1242 cases with clinical EPs were included. The charts of all these women were reviewed and clinical data were related to histopathologic results., Results: Histologically, polyps were distinguished as benign, premalignant, and malignant. Overall, 95.2% benign polyps, 1.3% premalignant, and 3.5% malignant lesions were detected. When clinical variables were considered, patient age, menopause, presence of abnormal uterine bleeding, and hypertension were statistically significant characteristics related to premalignant and malignant features., Conclusion: Older menopausal bleeding patients with hypertension are at high risk for premalignant and malignant polyps. Therefore, besides abnormal bleeding symptoms, this kind of patient needs to have the polyps removed.

Background: Groin wound breakdown, lymphoceles, cellulitis, and chronic leg edema are the most frequent complications of inguinal lymphadenectomy, resulting in severe patient discomfort and significant lengthening of postoperative stay. Despite all innovations, complication rates are still high and inevitable. Our experience suggests that cutaneous flap preparation, identification of the Camper fascia, and preservation of the most lateral lymphatics decrease associated morbidity. The aim of this study is to analyze whether different cutaneous skin flap preparations and their different devascularization (above or below the inguinal ligament), resecting all the lymphofatty tissue, reduce groin wound complications, and whether the same therapeutic approach and number of lymph nodes removed are comparable., Methods: This prospective randomized clinical trial of 62 consecutive patients affected by vulvar carcinoma requiring inguinal lymphadenectomy compared skin inguinal incision carried out 3-4 cm above the inguinal ligament (group A) or below it (group B)., Results: Inguinal dehiscence was present in 17 of 53 (32.1%) patients in group B and in 9 of 54 (16.7%) in group A (P=0.10). Lymphocele was observed in 10 of 53 lymphadenectomies (18.9%) in group B and in 3 of 54 dissections (5.6%) in group A (P=0.07). Upper incision allows more precise identification of the Camper fascia, is less painful, and gives better cosmetic results. Moreover, there may be advantage, albeit not statistically significant, regarding flap length, wound dehiscence rate, and speed of wound healing. There was no difference in chronic leg edema, number of nodes removed, or hospital stay.

Background: Radiotherapy represents the standard treatment for patients affected by FIGO stage II vaginal cancer. Several authors have suggested that neoadjuvant chemotherapy followed by radical surgery might be a valid treatment option in patients affected by cervical cancer. The objective of this study was to analyse the feasibility and results obtained by neoadjuvant chemotherapy followed by surgery in patients affected by invasive vaginal cancer with paravaginal tissue involvement not reaching the pelvic side wall., Methods: Eleven patients affected by FIGO stage II vaginal cancer were treated with paclitaxel 175 mg/m(2) and cisplatin 75 mg/m(2) every 21 days for three courses followed by radical surgery., Results: All patients were subjected to the 3 planned chemotherapy courses. Three (27%) patients achieved a complete clinical response and seven (64 %) patients achieved a partial clinical response. All patients were subjected to radical hysterectomy and vaginectomy. At a median follow up of 75 months two (18%) patients suffered a disease recurrence and one of these died of disease., Conclusions: Neoadjuvant chemotherapy followed by radical surgery is a feasible therapeutic strategy with good short- and long-term results. In women affected by vaginal cancer, a larger series reporting the result of this therapeutic strategy or the results obtained by surgery alone will aid physicians to choose the best therapeutic strategy for each individual patient.

Microperforate hymen is a rare condition consisting of a tiny hymeneal orifice with normal female genitals. A woman had microperforate hymen in which diagnosis and treatment was performed after decades of urethral coitus.

Study Objective: To reveal the efficacy and feasibility of concomitant anterior colporrhaphy and tension-free vaginal tape-obturator to treat stress urinary incontinence (SUI) and concomitant cystocele., Design: Controlled trial without randomization (Canadian Task Force classification II-1)., Setting: University hospitals in Rome, Italy., Patients: Fifty consecutive patients with SUI associated with symptomatic cystocele were enrolled into the study. Exclusion criteria were: uterine prolapse greater than or equal to 1, rectocele greater than or equal to 1, overactive bladder, overactive bladder symptoms, intrinsic urethral sphincter deficiency, urinary retention, previous anti-incontinence and/or prolapse surgery, neurologic bladder, psychiatric disease, body mass index greater than 30, and elevated intraabdominal pressure. The preoperative evaluation consisted of: complete history, physical examination, 3-day voiding diary, and urodynamic testing. The International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) was used to subjectively quantify the patient perception of SUI symptom severity., Interventions: All patients underwent an ultralateral anterior colporrhaphy plus tension-free vaginal tape-obturator., Measurements and Main Results: In all, 43 (91%) and 46 (92%) patients were objectively cured for cystocele and SUI, respectively. The median operating time, blood loss, and hospitalization were 43 minutes (range 35-56), 64 mL (range 40-148), and 1 day (range 1-2), respectively. Overall early postoperative complication rate was 16%, although all were minor. Only 1 patient, at 12-month follow-up, developed tape erosion that required surgical removal. The ICIQ-UI SF questionnaire scores were 13.4 +/- 6.8 and 3.5 +/- 3.2 (p <.01) between preoperative and 12-month follow-up, respectively., Conclusion: Concomitant tension-free vaginal tape-obturator plus ultralateral anterior colporrhaphy are feasible and safe procedures for the treatment of SUI and with associated cystocele with a high success rate and low intraoperative and postoperative complications rate.

The cervix is a possible site of metastasis from any primary malignancy, but no specific indication on follow-up examination is present. We present an asymptomatic patient with isolated breast cancer cervical recurrence diagnosed by colposcopy after 11 years from primary disease. After a PubMed search and a review of current guidelines, no indication to follow-up examination regarding the cervix is present. The adoption of colposcopy in cancer survivors might be an aid to gynecologists in diagnosing cancer recurrence. Cancer survivors might benefit from a more thorough gynecologic examination as compared with the simple Papanicolaou test.

Background: Gynecological surgery, as radical hysterectomy or pelvic and aortic lymphadenectomy, accounts for more than 50% of iatrogenic injuries. In premenopausal women, an hysterectomy with ovarian sparing and concomitant lateral ovarian transposition is frequently performed. However, the fate of the retained ovary is complicated by the residual ovarian syndrome (ROS) and one of the most common postoperative complications of the lymphadenectomy procedure is the lymphocele, with an average incidence of 22-48.5%. The differential diagnosis of a postoperative fluid collection includes, in addition to a lymphocele, urinoma, hematoma, seroma or abscess and the computed tomography (CT) findings alone is not enough., Case Presentation: We describe a patient, affected by ROS concomitant with a asymptomatic lymphocele, initially confused with an aortic lymph nodes relapse, after abdominal radical hysterectomy. The patient was subjected to a surgical approach, included a diagnostic open laparoscopy and laparotomy with sovraombelico-pubic incision, wide opening of the pelvic peritoneum and retroperitoneum. Examination of the mass revealed, macroscopically, a ovary with multiloculated cystic masses filled with clear or yellow serous fluid and the layers were composed by flat or cuboidal mesothelial cells., Conclusion: The tribute of this case illustrates the atypical appearance with uncertain aetiology after complex imaging. Gynecologist and radiologist should acquaint with the appearance of fluid collection (urinoma, lymphocele, seroma, hematoma, abscess) in gynecologic oncology follow-up to properly differentiated from tumor recurrence.

Cancer testis tumour associated antigens (C/T-TAAs) were investigated in several gynaecologic and non-gynaecologic neoplasms as possible prognostic markers and targets for immunotherapy. The objective of the present study was to evaluate C/T-TAA expression patterns and prognostic significance in patients affected by vulvar cancer. Melanoma antigen E (MAGE)-A1, MAGE-A4 and NY-ESO-1 expression was determined by immunohistochemistry in paraffin-embedded tissue specimens from 45 primary and 14 recurrent vulvar carcinomas treated with surgery. MAGE-A1, MAGE-A4 and NY-ESO-1 were expressed in 25 (42%), 38 (64%) and 40 (68%) of the 59 samples, respectively. MAGE-A4 was significantly more frequently expressed in tumours with lymph node metastases (p<0.002) and in recurrent tumours (p<0.02). NY-ESO-1 was more highly expressed by moderately or poorly differentiated tumours (p<0.01). This study demonstrates that vulvar cancer frequently expresses C/T-TAAs. Antigen expression correlates with the presence of lymph node metastases and poor tumour differentiation.

Objective: To describe the technique, feasibility and early complications of "Rome pouch" urinary diversion., Methods: Thirty-five consecutive patients affected by advanced or recurrent gynecological cancers who required anterior or total pelvectomy entered the study. Rome pouch technique starts with the transection of terminal ileum about 12 cm from the ileocecal valve; the large colon is transected 15-20 cm distal to the hepatic flexure. The intestinal wall tension and internal pressure are reduced using 5-8 transverse teniamyotomies of the cecum. The efferent segment of the pouch is created either with the appendix or with the distal ileum. Operative data, intra- and early postoperative complications were recorded., Results: Between February 2000 and March 2006, an ileocolonic urinary diversion (Rome pouch) was carried out in 35 patients affected by advanced or recurrent gynecologic malignancies. The average operative time to complete the anterior and total exenteration including reconstruction procedure was 285 (range, 230-350) and 320 (range 280-415) min, respectively. The average time in performing the Rome pouch technique was 60 min (range, 45-90). Overall postoperative complication rate (major and minor complications) was 82% (29 patients). Febrile morbidity occurred in 26 patients (74%). Wound complications and pelvic collection were found in 7 (20%) and 6 (17%) patients, respectively., Conclusion: Our experience demonstrated that Rome pouch technique represents a valid alternative in gynecology oncology for continent urinary diversion. This technique showed low rate of medical and early urologic complications. The simplicity of performing the procedure and the reduced operating time are the best goals reached by Rome pouch technique. Future comparative trials will better define the role that the Rome pouch will have in these patients.

The aim of this study was to evaluate the role of systematic lymphadenectomy, feasibility, complications rate, and outcome in epithelial ovarian cancer (EOC) patients with recurrent bulky lymph node disease. A prospective observational study of EOC patients with pelvic/aortic lymph node relapse was conducted between January 1995 and June 2005. After a clinical and laparoscopic staging, secondary cytoreduction, including systematic lymphadenectomy, were performed. The eligibility criteria were as follows: disease-free interval > or =6 months, radiographic finding suggestive of bulky lymph node recurrence, and patients' consent to be treated with chemotherapy. Forty-eight EOC patients with lymph node relapse were recruited. Twenty-nine patients were amenable to cytoreductive surgery. Postoperatively, all patients received adjuvant treatment. The median numbers of resected aortic and pelvic nodes were 15 (2-32) and 17 (8-47), respectively. The median numbers of resected aortic and pelvic positive lymph nodes were 4 (1-18) and 3 (1-17), respectively. The mean size of bulky nodes was 3.3 cm. Four patients (14%) experienced one severe complication. No treatment-related deaths were observed. After a median follow-up of 26 months, among cytoreduced patients, 18 women were alive with no evidence of disease, nine were alive with disease. Among the 11 patients not amenable to surgery, five women were alive with persistent disease, six patients died of disease, at a median follow-up of 18 months. Estimated 5-year overall survival and disease-free interval for operated women were 87% and 31%, respectively. In conclusion, patients with bulky lymph node relapse can benefit from systematic lymphadenectomy in terms of survival. The procedure is feasible with an acceptable morbidity rate.

More than two decades have passed since neoadjuvant chemotherapy has been introduced in the clinical practice. After several pilot studies, randomized trials and meta-analysis have confirmed the validity of this therapeutic strategy and in particular of neoadjuvant chemotherapy followed by radical surgery. Several open questions still remain unanswered and in particular no standard drug regiment is unanimously accepted. In this paper we describe how this treatment has evolved since its original introduction in the early eighties and describe possible drug regimens with their supporting evidence that can be adopted by physicians worldwide.

Background: Concomitant chemoradiotherapy represents the standard treatment for patients affected by locally advanced cervical cancer. Survival rates in patients affected by FIGO stage IVA disease remain poor. Some authors have suggested that neoadjuvant chemotherapy followed by radical surgery might be a valid alternative to standard treatment. The objective of this study was to analyze the feasibility and results obtained by neoadjuvant chemotherapy in patients affected by stage IVA disease., Methods: Eighteen patients affected by FIGO stage IVA cervical cancer were treated with 175 mg/m(2) paclitaxel and 75 mg/m(2) cisplatin every 21 days for three courses followed by radical surgery when feasible., Results: All patients were subjected to the three planned chemotherapy courses. Two patients achieved a complete clinical response, and 10 patients achieved a partial clinical response. Ten patients were subjected to anterior pelvic exenteration, whereas the remaining eight patients were treated with chemotherapy, radiotherapy, and concomitant chemoradiotherapy. The estimated 3-year and 5-year overall survival rates were 47.4% and 31.6%, respectively. Patients eligible for surgery benefited from significantly longer survival rates., Conclusions: Neoadjuvant chemotherapy followed by radical surgery is feasible in approximately half of patients affected by FIGO stage IVA cervical cancer. Overall survival rates appear similar to those reported with concomitant chemoradiotherapy. Patients who are amenable to radical surgery after chemotherapy may benefit from long-term survival rates.

Study Objective: The aim of this study was to compare operative and early postoperative outcomes of laparoscopic-assisted vaginal hysterectomy (LAVH) and minilaparotomy in a randomized clinical trial including patients undergoing total hysterectomy for benign gynecologic disease and having 1 or more of the generally considered contraindications to vaginal route., Design: Prospective, randomized, multicenter trial (Canadian Task Force classification I)., Setting: Departments of Gynecology from 3 major university hospitals in Rome., Patients: Eighty-one patients who were candidates for abdominal hysterectomy., Interventions: Laparoscopic-assisted vaginal hysterectomy and minilaparotomy hysterectomy., Measurements and Main Results: Forty patients were randomized to LAVH and 41 to minilaparotomy. Characteristics of patients and indications for surgery in the 2 arms were comparable. In the minilaparotomy group, complications were as follows: 1 case (2.4%) of delayed laparotomy with 2 units of red blood cell transfusion, 2 cases (4.8%) of wound infection, and 3 cases (7.3%) of fever of unknown origin. No minor or major complications were observed in the LAVH group. Postoperative visual analog scale pain scores at days 1 and 2 were significantly lower in the LAVH group (p <.05). The complication rate between the 2 groups was significantly lower for LAVH (p = .026)., Conclusion: Because LAVH was associated with significantly lower early postoperative pain scores and complication rates, in general LAVH should be preferred to minilaparotomy hysterectomy when the vaginal approach cannot be used.

Objective: To determine advantages and disadvantages of minilaparotomy and laparoscopy in managing patients affected by benign adnexal masses., Study Design: Prospective, randomized, clinical trial on 127 patients affected by adnexal cysts. Patients were submitted to adnexal surgery through a laparoscopic or minilaparotomy approach on a random basis., Results: Hundred and twenty-seven patients were enrolled in the study and randomly assigned to laparoscopy (63 patients) or minilaparotomy (64 patients). Characteristics of the patients and of the cysts were homogeneous between the two groups. No significant differences between the two groups were recorded in terms of operative time, intraoperative complications, ileus, length of stay and recovery time. The intraoperative rupture rate of the cyst was significantly higher in the laparoscopy group only in a subgroup of patients affected by cysts greater than 7 cm in diameter (p=0.01). Three patients randomized to laparoscopy required conversion to laparotomy. Concerning postoperative outcomes, postoperative pain and minor complications were significantly less in patients undergoing laparoscopy (p=0.001 and 0.04)., Conclusions: Operative laparoscopy appears to be the preferable approach for the management of adnexal cysts. Minilaparotomy can be considered a mini-invasive approach as well, with acceptable operative and postoperative outcomes, and is a suitable alternative in case of contraindications to laparoscopy.

The Bartholin's gland cyst is a condition that occurs in approximately 2% of women, most of whom are of reproductive age. Although benign, it is associated with significant patient discomfort. Definitive treatment involves the surgical removal of the entire cyst. The objective of this study was to describe an alternative conservative surgical technique with CO(2) laser adopted in our institution and to evaluate the feasibility, complication rate, and results obtained with this technique in an office setting. Our study showed that CO(2) laser treatment of the Bartholin's gland cyst can be carried out safely in an outpatient setting, with minimum patient discomfort and high long-term cure rates.

Objective: To evaluate operative resectoscopy versus hysteroscopic bipolar electrode excision for the treatment of endometrial polyps., Design: Prospective, randomized study., Setting: Tertiary-care university hospital., Patient(s): One hundred consecutive patients with endometrial polyps., Intervention(s): Patients underwent diagnostic hysteroscopy, and after assignment on a random basis, they underwent polyp excision either by operative resectoscopy or by a bipolar electrode passed through the operating sheath of a small-caliber hysteroscope. MAIN OUTCOME MEASURE(S) AND RESULT(S): Operating times, difficulty of the operation, surgeon satisfaction with the procedure, intra- and postoperative complications, postoperative pain, and patient satisfaction were recorded. The two procedures did not differ in total surgery times. In subgroup analysis, the resectoscope was faster for large polyps (>2 cm) and for polyps with a fundal implant. The bipolar electric probe was faster for small polyps (<2 cm) and for polyps with a nonfundal implant., Conclusion(s): Operative resectoscopy appears to be the technique of choice for endometrial polyps >2 cm or with a fundal implant. Bipolar electrode excision appears to be preferable for smaller, nonfundal polyps.

Background: Secondary surgical cytoreduction (SCR) represents a promising therapeutic strategy for patients affected by ovarian cancer disease recurrence. The aim of this prospective observational trial was to analyze the role of SCR in patients with platinum-sensitive ovarian cancer., Methods: Patients with platinum-sensitive ovarian cancer underwent SCR by a single surgical team. Clinical and oncologic data were prospectively recorded. A total of 47 patients underwent SCR from 1999 to 2003., Results: The mean operating time was 210 minutes, and mean blood loss was 500 mL. The most frequent surgical procedures carried out were splenectomy, lymphadenectomy, bowel resection, and extensive peritonectomy. Optimal cytoreduction was achieved in 41 patients. Thirty-seven patients had no visible tumor at the end of SCR. Overall median survival was 49 months. Patients who achieved optimal residual disease had a median survival of 61 months, whereas patients who had residual disease >1 cm had a median survival of 19 months., Conclusions: Positive CA-125 (cancer antigen 125) was identified as a negative prognostic factor at multivariate analysis. After careful selection, optimal cytoreduction can be achieved in most patients who are subjected to SCR with acceptable morbidity. Residual tumor and CA-125 represent the most important prognostic factors.

The aim of this study was to evaluate the safety and efficacy of liposome-encapsulated doxorubicin citrate (LEDC) in patients affected by recurrent/metastatic gynecological malignancies scheduled for palliative chemotherapy. Inclusion criteria were proven recurrent/advanced gynecological neoplasms, measurable/assessable disease, adequate organ function, left ventricular ejection fraction >50% as determined by echocardiography, informed consent. LEDC was administered intravenously over 1 h at the dose of either 75 mg/m(2) or 60 mg/m(2) (every 3 weeks until disease progression or toxicity prohibiting further therapy). From May 2003 to September 2005, 36 patients were enrolled. Primary disease was ovarian, endometrial, and cervical cancers in 15 (42%), 11 (30%), and 10 (28%) patients, respectively. LEDC was employed as third- or fourth-line chemotherapy in 25 (70%) and 11 (30%) patients, respectively. The median number of courses of LEDC received was 3 (range 2-9). Six patients (17%) achieved a partial response to treatment lasting 27 weeks and 10 patients (28%) experienced stable disease lasting 18 weeks. The predominant toxicity was hematological, especially neutropenia. Among patients receiving a dose of 75 mg/m(2), two (11%) suspended therapy for febrile neutropenia, and nine (50%) required a dose reduction of 25%. As a result, the next 18 patients were treated at a reduced dose (60 mg/m(2)) of LEDC. Severe neutropenia (G3-G4) was significantly less common in this group (61% versus 22%; P= 0.04). LEDC has shown antineoplastic activity in previously treated recurrent/metastatic gynecological cancer patients and the toxicity profile could be considered acceptable at a 60 mg/m(2) dosage.

Background: Ovarian cancer disease recurs predominantly in the abdomen, with the spleen usually involved as part of a vast spread of upper-abdominal disease or, less frequently, as an isolated site of disease recurrence. Very few reports are available in the literature on the outcome of patients subjected to splenectomy during secondary cytoreduction. The aim of this study was to identify prognostic factors and to review surgical and clinical data in order to identify those patients who would benefit the most from splenectomy during secondary cytoreduction., Methods: This was a retrospective review of platinum-sensitive recurrent epithelial ovarian cancer patients who underwent splenectomy as part of secondary cytoreduction. Surgical and survival data were recorded., Results: Twenty-four patients were identified. Multiple site disease recurrence was observed in 15 patients. The spleen was involved at the hilus in 12 patients; surface and intraparenchymal metastases were equally present. Optimal cytoreduction was achieved in all patients. At a median follow-up of 30 months, median progression-free and overall survival from the time of secondary surgery were 34 and 56 months, respectively. Overall survival was significantly correlated to residual disease at secondary surgery, disease-free survival, consolidation chemotherapy, and type of adjuvant therapy., Conclusions: Splenectomy as part of secondary cytoreduction is a feasible and safe procedure. Secondary cytoreduction in selected groups of patients is confirmed to be associated with high long-term survival rates even when aggressive surgery of the upper abdomen is required.

Objective: To compare transperitoneal, extraperitoneal and laparoscopic pelvic lymphadenectomy in terms of feasibility and morbidity in patients affected by cervical cancer undergoing radical hysterectomy., Methods: Consecutive patients affected by stage IB-IIB cervical carcinoma scheduled for radical surgery entered the study. Patients were randomly assigned to transperitoneal (TPL), extraperitoneal (EPL) or laparoscopic pelvic lymphadenectomy (LPL). All patients underwent classical radical hysterectomy. Perioperative data were recorded. Follow up examinations were performed at the 15th, 30th and 60th day after surgery., Results: 168 patients entered the study. The mean operative times were: 63+/-7.6, 54+/-6.7 and 75+/-8.4 min (TPL vs EPL P<0.001; EPL vs LPL P<0.001; TPL vs LPL P<0.001) for TPL, EPL and LPL respectively. The feasibility of the procedures, analyzed on an intention-to-treat basis, was 96%, 93% and 95% for TPL, EPL and LPL group respectively (P=ns). The average hospitalizations were: 5.6+/-0.9, 3.2+/-0.4 and 3.1+/-0.3 days (TPL vs EPL P<0.001; TPL vs LPL P<0.001) for TPL, EPL and LPL respectively., Conclusions: EPL and LPL are as feasible and effective as TPL and can be adequately performed with a reasonable complication rate. LPL showed a statistically significant longer operative time. However, both EPL and LPL can minimize some postoperative complications reducing length of stay.

Background: Isolated gastric recurrence due to ovarian cancer is a rare event and is usually associated with gastrointestinal symptoms., Case Report: We report a case of an isolated gastric recurrence of ovarian carcinoma in an otherwise asymptomatic 42-year-old woman in whom diagnosis was made using the FDG-PET/CT scan followed by laparoscopy., Conclusions: In rare cases, ovarian cancer can directly recur on the stomach without any symptoms. FDG-PET/CT scan and diagnostic laparoscopy are effective in leading to an early diagnosis of disease recurrence.

The epidemiologic pattern of cancers in developing countries differs in many aspects from that of industrialized nations. Cancer natural history, microbiologic environment, patient's immune system, and drug availability may differ as well. Four of five new cases of cervical cancer and most of cervical cancer deaths occur in developing countries. Where chemoradiation and supportive care facilities are unavailable, it would be logical to consider an inexpensive effective drug. In locally advanced cases, neoadjuvant chemotherapy followed by surgery should be considered the treatment of choice. For ovarian cancer, it may be reasonable to maintain a secure supply of platinum and/or taxanes. For endometrial cancer, platinum compounds are proved active chemotherapic single agents. Oral medroxyprogesterone acetate (MPA) may represent a good chance for treating an advanced or recurrent disease. For vulvar/vaginal cancer, the role of chemotherapy alone is currently considered limited, and it is mostly used as palliative treatment in advanced or recurrent cases. Whenever possible, standard western chemotherapic regimens should be applied in developing countries as well. When standard therapies are unavailable, drugs of choice should be easily accessible, inexpensive, and effective. The most commonly used drugs are cisplatin, cyclophosphamide, and MPA.

Background: Ovarian cancer groin lymph nodes metastases are rare. Only one case of disease spread isolated to the groins has been reported in the English literature. We report the case of a patient with bilateral inguinal lymphadenopathy due to tumor metastases and in which tumor origin was diagnosed using [(18)F]fluorodeoxyglucose positron emission tomography (PET)., Case Report: This is the first case of bilateral groin lymph nodes as sole site of metastases from ovarian cancer. Primary origin was identified using PET., Conclusions: In rare cases, the ovaries can directly metastasis to the groin even in a relatively initial tumor growth phase. PET may play a role in the diagnosis of occult ovarian tumors.

Objective: Optimal primary cytoreductive surgery (OPCS) plus adjuvant chemotherapy (AC) represents the standard management for patients with advanced ovarian cancer (AOC). Recently, some authors have suggested the use of neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) in patients with unresectable AOC. This study has been started to evaluate the role of diagnostic open laparoscopy (DOL) in predicting who are the best candidates to OPCS., Methods: All patients newly diagnosed as affected by AOC were submitted to DOL in order to establish the possibility of OPCS considered as no residual tumor left after operation. Patients considered not susceptible of OPCS were submitted to three cycles of NACT, administered every 3 weeks (Carboplatin, targeted AUC = 6, plus paclitaxel 175 mg/mq), followed by IDS and adjuvant chemotherapy., Results: From January 2000 to March 2004, 87 patients with AOC underwent DOL. Fifty-three patients (61%) were judged operable and therefore submitted to primary cytoreductive surgery (Group A). Optimal debulking rate in this group of patients was 96%. Thirty-four patients were judged affected by disease not cytoriducible to absent residual tumor and therefore scheduled for NACT-IDS-AC (Group B). Twenty-five patients were judged with partial clinical response and were therefore scheduled for IDS and AC. Optimal debulking rate (no residual tumor ) in Group B patients was 80%. No major perioperative complications, due to laparoscopy, occurred. All Group B patients received the first cycle of chemotherapy the day after DOL. In 34 patients (39%), an explorative laparotomy was avoided. With a median follow-up of 22 months (range 2-49 months), the proportions surviving were 87% and 60% in Group A and Group B patients, respectively., Conclusion: DOL could be considered a valid diagnostic tool in evaluating the extent of disease in AOC. Our data suggest that the use of DOL leads to decrease the rate of primary cytoreductive surgery for AOC; on the other hand, a higher optimal debulking rate (no residual tumor) at primary surgery is achieved.

Objective: To evaluate the use of mechanical bowel preparation (MBP) before gynecologic laparoscopy, using as the primary endpoint the appropriateness of the surgical field as judged by the surgeon., Design: Prospective, randomized, single-blind clinical trial., Setting: Academic department specializing in gynecologic surgery., Patient(s): One-hundred sixty-two patients scheduled for laparoscopy., Intervention(s): The evening before laparoscopy, patients were randomized to either MBP with 90 mL of oral sodium phosphate (NaP) or no bowel preparation., Main Outcome Measure(s): Patient discomfort was evaluated with a visual analogue scale. Bowel preparation was evaluated by a surgeon (blind to bowel-preparation status) using a 5-point scale. Surgical difficulty, operating times, and postoperative complications were recorded., Result(s): Preoperative discomfort was significantly greater in the MBP group. No significant difference in the evaluation of the surgical field, operative difficulty, operative time, and postoperative complications was present between the two groups., Conclusion(s): Bowel preparation with oral NaP does not offer any significant advantage in patients undergoing laparoscopy for benign gynecologic conditions. In addition, MBP significantly increases preoperative discomfort.

Background: The stripping technique for endometriomas excision has been reported to be associated with follicular loss. The objective of this trial was to evaluate the presence and nature of ovarian tissue adjacent to the endometrioma cyst wall obtained by stripping with different techniques., Methods: Forty-eight patients with ovarian endometrioma were enrolled in two consecutive independent randomized trials. Two different techniques were analysed at the initial adhesion site (circular excision and subsequent stripping versus immediate stripping). Two different techniques were analysed at the ovarian hilus (stripping versus coagulation and cutting). Histology analysis was performed in three portions of the cyst wall (initial adhesion site, intermediate part of the specimen, ovarian hilus)., Results: Recognizable ovarian tissue was inadvertently excised together with the endometrioma cyst wall in most cases. At initial adhesion sites more ovarian tissue was removed with the circular excision technique (< 0.001). No significant difference in quality of ovarian tissue (number and type of follicles) was found between specimens obtained with different surgical techniques at the initial or at the final part of the procedure. At the initial adhesion site and at the intermediate part of the cyst wall, the ovarian tissue removed along with the endometrioma wall was mainly constituted by tissue with no follicles or only primordial follicles (60% and 48% of the specimens from the initial part with both techniques, and from the intermediate part, respectively, had no follicles or only primordial follicles). Close to the ovarian hilus the ovarian tissue removed along with the endometrioma wall mostly consisted of tissue which contained primary and secondary follicles (69% of the cases, combining the two groups)., Conclusions: Ovarian tissue is inadvertently excised together with the endometrioma wall in most cases. The excised tissue is at normal functional development stages only near the ovarian hilus. The different techniques used do not influence significantly the quality of the resected tissue.

Objective: To evaluate by serial ultrasound scans how long a Ringer's lactate instillation remains in the peritoneal cavity after laparoscopy., Design: Prospective, randomized, double blind, clinical trial., Setting: Tertiary care, university hospital., Patient(s): Thirty-six patients undergoing diagnostic or minor operative laparoscopy., Intervention(s): At the end of laparoscopy, the patients were tilted to an anti-Trendelenburg position and all fluid was aspirated. The patients were then randomized to receive an instillation of 300 mL of Ringer's lactate or no fluid instillation. Serial transvaginal ultrasound scans were performed at the end of surgery and at 24, 48, and 96 hours after the surgery., Main Outcome Measure(s): Through direct measurements of scalar fluid volumes instilled in the operating room and real-time ultrasound comparisons, an empiric formula was calculated to correlate actual intraperitoneal volumes to ultrasonically derived measurements of fluid pockets. With this formula, the volume of intraperitoneal fluid at 24, 48, and 96 hours after surgery was calculated., Result(s): Twenty-four hours after surgery, a mean volume of 184 mL was present in the Ringer's lactate group versus 46 mL in the control group. At 48 hours after surgery, the mean volumes were 78 mL versus 30 mL, respectively. No statistically significant differences were found after 96 hours., Conclusion(s): Peritoneal absorption of instilled crystalloids is traditionally reported to be 30 to 60 mL/hour. We report detecting statistically significant amounts of fluid at 24 and 48 hours after surgery, after infusion of 300 mL of Ringer's lactate. This suggests that fluid remains in the peritoneal cavity longer than traditionally believed.

Background: Laparoscopic surgery has become the gold-standard treatment for ovarian endometriomas. The objective of this trial was to evaluate different procedures for the laparoscopic excision of ovarian endometriomas with the stripping technique., Methods: Forty-eight patients with ovarian endometrioma were enrolled in two consecutive independent randomized trials. Two different techniques were analysed at the initial adhesion site (circular excision and subsequent stripping versus immediate stripping). Two different techniques were analysed at the ovarian hilus (stripping versus coagulation and cutting). Operative time and technical difficulties were prospectively evaluated. Histological analysis was performed in three portions of the cyst wall and the results of the histologic study are reported separately., Results: At the initial part of the stripping procedure, the technique of circular excision and subsequent stripping appeared to be more easily performed than the technique of direct stripping (P < 0.01), although operative times were comparable between the two techniques. At the hilus, the two techniques utilized appeared to be comparable both for easiness of procedure and operating times., Conclusions: In this prospective, randomized study, different techniques used during the stripping procedure appeared to be comparable in terms of operative times and complications. One technique used at the beginning of the procedure (circular excision followed by stripping) was easier to perform.

Background: The role of systematic aortic and pelvic lymphadenectomy in patients with optimally debulked advanced ovarian cancer is unclear and has not been addressed by randomized studies. We conducted a randomized clinical trial to determine whether systematic aortic and pelvic lymphadenectomy improves progression-free and overall survival compared with resection of bulky nodes only., Methods: From January 1991 through May 2003, 427 eligible patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIB-C and IV epithelial ovarian carcinoma were randomly assigned to undergo systematic pelvic and para-aortic lymphadenectomy (n = 216) or resection of bulky nodes only (n = 211). Progression-free survival and overall survival were analyzed using a log-rank statistic and a Cox multivariable regression analysis. All statistical tests were two-sided., Results: After a median follow-up of 68.4 months, 292 events (i.e., recurrences or deaths) were observed, and 202 patients had died. Sites of first recurrences were similar in both arms. The adjusted risk for first event was statistically significantly lower in the systematic lymphadenectomy arm (hazard ratio [HR] = .75, 95% confidence interval [CI] = 0.59 to 0.94; P = .01) than in the no-lymphadenectomy arm, corresponding to 5-year progression-free survival rates of 31.2 and 21.6% in the systematic lymphadenectomy and control arms, respectively (difference = 9.6%, 95% CI = 1.5% to 21.6%), and to median progression-free survival of 29.4 and 22.4 months, respectively (difference = 7 months, 95% CI = 1.0 to 14.4 months). The risk of death was similar in both arms (HR = 0.97, 95% CI = 0.74 to 1.29; P = .85), corresponding to 5-year overall survival rates of 48.5 and 47%, respectively (difference = 1.5%, 95% CI = -8.4% to 10.6%), and to median overall survival of 58.7 and 56.3 months, respectively (difference = 2.4 months, 95% CI = -11.8 to 21.0 months). Median operating time was longer, and the percentage of patients requiring blood transfusions was higher in the systematic lymphadenectomy arm than in the no-lymphadenectomy arm (300 versus 210 minutes, P<.001, and 72% versus 59%; P = .006, respectively)., Conclusion: Systematic lymphadenectomy improves progression-free but not overall survival in women with optimally debulked advanced ovarian carcinoma.

Objective: Several authors have proposed the use of a less aggressive surgery (i.e., modified or type 2 radical hysterectomy) for patients affected by early stages cervical carcinoma. However, little attention has been given to the evaluation of adverse prognostic factors before selecting the surgical approach. The aim of this study is to evaluate the feasibility and safety of tailoring parametrectomy on the basis of specific prognostic factors preoperatively assessed., Methods: Patients with cervical carcinoma FIGO IA2-IB1 entered the study. Eligibility criteria were: age < 75 years, no contraindications for surgery, informed consent, expected cooperation for follow-up. Tumor size was preoperatively assessed by pelvic examination under anesthesia and pelvic MRI. Patients were submitted to systematic lymphadenectomy of superficial obturator, external iliac, and interiliac nodes by laparotomy or laparoscopy. Lymph nodes were sent for frozen section. Node-negative patients were submitted to modified radical hysterectomy (type 2). Patients with nodal metastases underwent classical radical hysterectomy (types 3-4) and systematic pelvic and aortic node dissection up to the inferior mesenteric artery. Survival rates were calculated using the Kaplan-Meier product-limit method., Results: Eighty-three patients were enrolled in the study. Among these, 63 patients were node-negative at frozen section, and therefore submitted to modified radical hysterectomy (Group A); 20 patients were found having nodal metastases intra-operatively, and therefore submitted to classical radical hysterectomy (Group B). Median follow up was 30 months. Five years overall survival was 95% for Group A, and 74% for Group B., Conclusions: Pre-treatment evaluation of adverse prognostic factors in patients affected by cervical cancer FIGO stages IA2-IB1 is feasible and mandatory to determine if a less radical surgery is applicable and safe.

Objective: The aim of this study was to evaluate acute and long-term morbidity, recurrence rate, and overall survival in patients with multiple groin lymph node metastases treated with postoperative chemotherapy., Methods: Patients affected by FIGO stages III, IVA, and IVB (pelvic lymph nodes only) submitted to surgery were then treated with four cycles of cisplatin 100 mg/m(2) given 21 days apart. Toxicity, overall, and disease-free survival were evaluated., Results: Fourteen patients were evaluated. Median patients age was 58 (range 48-82). Median performance status was 0 (0-2). All patients completed the treatment. No treatment-related deaths occurred. Only two patients suffered from grade 4 neutropenia during chemotherapy. Three patients suffered from long-term severe lymphedema. Four patients suffered a disease recurrence. Three of these patients were subjected to surgery with no severe postoperative complications. Two of the latter patients are still alive. At a median follow-up of 57.5 months (range 23-79 months) actuarial 3-year overall survival and progression-free survival are 86% and 71%, respectively., Conclusions: In patients affected by vulvar cancer with multiple lymph node metastases, radical surgery followed by chemotherapy is a feasible strategy, with an acceptable short- and long-term complication rate. Results in terms of overall survival and disease-free survival are promising. Furthermore, due to absence of local long-term tissue toxicity, this strategy allows physicians to surgically treat regional lymph node recurrence safely.

Study Objective: To evaluate, by means of serial transvaginal ultrasound (US) examinations, the ovary after laparoscopic excision of endometriomas with the stripping technique., Design: Prospective, controlled, single-blind clinical trial (Canadian Task Force classification II-1)., Setting: Tertiary care university hospital., Patients: Forty-seven patients, from 21- to 35-years old, undergoing laparoscopic excision of a monolateral ovarian endometrioma., Intervention: The patients underwent serial US scans performed by a blinded observer during the first, third, and sixth menstrual cycle after surgery., Measurements and Main Results: At the first follow-up US examination, an abnormal finding, namely the presence of an ovarian cyst on the operated ovary, was diagnosed in five of 47 patients (10.6%; p = .03 when compared with the nonoperated ovary). In the remaining 42 patients (89.4%), no gross abnormalities were evident. No differences were present between the two ovaries as to ovarian volume or follicular development pattern. During the third follow-up US, in 47 patients (100%) no gross abnormalities were present., Conclusion: The US follow-up of ovaries operated on for endometriomas by laparoscopy demonstrates that the evidence of an ovarian cyst in the early postoperative period is not an uncommon event. This finding, occurring in approximately 10% of cases, seems to be a transient one occurring during ovarian healing after surgery, since no evidence of such anomaly was present on subsequent US scans. Therefore, treatment for US evidence of recurrence of an ovarian endometrioma should be deferred for at least 3 to 6 months if the diagnosis of recurrence is made in the early postoperative period. Apart from this finding, the operated ovary is indistinguishable from the contralateral one, even 1 month after surgery.

Background: The objective of the current study was to evaluate the incidence of long-term bladder dysfunction after type 3-4 radical hysterectomy in patients with locally advanced cervical carcinoma treated with neoadjuvant chemotherapy (NACT)., Methods: A case-control study was conducted to evaluate the occurrence of long-term bladder dysfunction in 76 patients with International Federation of Gynecology and Obstetrics Stage IB-IIA (> 4 cm), Stage IIB, and Stage III cervical carcinoma who underwent type 3-4 radical hysterectomy after NACT. Preoperative assessment included acquisition of a standardized urogynecologic history, evaluation of severity of urinary incontinence symptoms, maintenance of a 3-day voiding diary, pelvic examination, urogynecologic physical examination, urodynamic assessment, and estimation of hydronephrosis. Follow-up was carried out at least 12 months after surgery., Results: Urinary symptoms (sensory loss, difficult micturition, severe urinary incontinence) were reported by 20 patients (26%). Eighteen patients (24%) had a normal urodynamic profile, 16 patients (21%) had detrusor overactivity, 22 patients (29%) had urodynamic stress incontinence, 2 patients (2%) had aconctractile detrusor, and 18 patients (24%) had mixed urinary incontinence. The length of vagina removed was significantly greater among patients who had detrusor overactivity and mixed urinary incontinence compared with patients who had a normal diagnosis., Conclusions: The observed rate of bladder dysfunction was higher than the corresponding rate reported in the literature (76%). Three main disturbances were found: detrusor overactivity (21%), mixed urinary incontinence (24%), and de novo stress incontinence (21%). Detrusor overactivity was related to a prevalence of hypertonic bladder. Among patients who underwent type 4 radical hysterectomy, the extent of caudal resection of rectovaginal ligaments and vaginal tissue was found to be more strongly associated with bladder dysfunction than was the extent of lateral parametrial resection. Despite the fact that 76% of patients had abnormal urodynamic parameters, most patients were satisfied with their voiding condition., (Copyright 2004 American Cancer Society.)

Functional disorders of the lower urinary tract are the most common long-term complications following radical surgery for cancer of the uterine cervix (8-80%). These disturbances were associated to the partial interruption of the autonomic fibers innervating the bladder during the resection of anterior, lateral and posterior parametrium and vaginal cuff. The pathophysiology of these changes is actually debated. The nature of the surgical damage appears to be a decentralization rather than a complete denervation and bladder dysfunctions may be either the unmasking of intrinsic detrusor activity, characterized by a loss of beta-adrenergic innervation and a consequent alfa-adrenergic hyperinnervation or the influence of remaining sympathetic innervation. No data on long-term bladder function in patients who underwent class 4 radical hysterectomy have been reported. In our experience on long-term vesical function in 38 patients with locally advanced cervical cancer treated with neoadjuvant chemotherapy and 4 Piver type radical hysterectomy, urinary symptoms were reported in 11 patients (29%), while a normal urodynamic finding was recorded in only nine patients (24%). The most common bladder dysfunction was the storage dysfunction (47%). The voiding dysfunction was present in one patient (3%) and stress urinary incontinence in 20 patients (53%). The parametrial and vaginal resections were compared among the urodynamic diagnosis The size of lateral parametria measured on the giant sections did not differ among the groups of urodynamic diagnosis, while the length of vagina removed was significantly longer in patients with detrusor dysfunctions (storage and voiding dysfunctions) than in patients with normal diagnosis or genuine stress incontinence.

In 1984 the first pilot study on neoadjuvant chemotherapy in cervical cancer was reported. Since then, many investigators have studied the possible role that this therapeutic strategy could achieve in patients. Different chemotherapic combinations are constantly being attempted in order to obtain the maximum tumour response. At the same time few randomised studies have demonstrated the superiority of this treatment when adopted before radical surgery, in terms of overall survival compared to radiotherapy alone. Recently a detailed meta-analysis has been performed and the results confirmed what previously was achieved by the randomised trials. Since the beginning of all the phase III trials, the standard treatment of locally advanced disease has been modified from radiotherapy alone to concomitant radio-chemotherapy. For this reason the EORTC group has launched a trial with the objective of comparing neoadjuvant chemotherapy followed by radical surgery versus concomitant chemo-radiotherapy.

Background: Cutaneous lymphangitis carcinomatosis from cervical carcinoma is a very rare form of tumor metastatization; only anecdotal cases are reported in the literature. Most of the patients with skin relapse experienced metastasis as a single or multiple nodules., Case: A case of cutaneous lymphangitis carcinomatosis mimicking contact dermatitis was diagnosed at our institution in a patient affected by cervical carcinoma stage IIB. Palliative chemotherapy with paclitaxel was started and the patient experienced complete clinical response. The hypothetical mechanism of spread and the unusual manifestation of relapse are described., Conclusion: In a woman with a history of cervical cancer, a diffuse pruritic skin eruption should alert the clinician to the possibility of cutaneous carcinomatous lymphangitis. If a lymphangitis carcinomatosis is diagnosed, systemic intravenous chemotherapy should be considered.

Objective: Increased glucose uptake and utilization is a known phenomenon exhibited by malignant cells. Overexpression of the glucose transporter protein family is thought to be the principal mechanism by which these cells achieve up-regulation. Our purpose is to determine glucose transporter-1 (GLUT 1) expression in squamous carcinoma of the cervix and precursor lesions., Methods: Archival histologic sections were obtained from 31 cases of invasive squamous cell carcinoma (SCC) of the uterine cervix, 15 cases of high-grade cervical intraepithelial neoplasia, 5 cases of low-grade, and 9 normal cervices. Immunohistochemistry for GLUT 1 protein was performed using polyclonal GLUT 1 antibody (Dako, Carpinteria, CA) and the labeled streptavidin-biotin procedure., Results: Compared to the internal control, the pattern of staining varied from weak (1+) to strong (3+) reactions. In normal cervix, 1+ GLUT 1 staining was seen in the basal cells of the squamous epithelium. All 31 (100%) cases of SCC were positive for GLUT 1. Positive reactions seemed more intense in tumor cells that were farther away from the stromal blood supply. There was a correlation between intensity of reaction for GLUT 1 and histologic grade of tumor (P = 0.0027) and with progression from normal or dysplastic lesions to invasive cancer (P = 0.0001). Intensity was a predictor of the presence of poorly differentiated tumor type. Low-grade CIN staining was seen in less than one-third of the epithelium, while in high-grade lesions the reaction was present in over one-half of the epithelium., Conclusions: GLUT 1 is overexpressed in cervical carcinoma. The process appears to be related to grade of tumor but not to the progression from preneoplastic lesions. The results suggest that GLUT 1 overexpression is a late phenomenon in cellular transformation. Furthermore, the possible relation of expression to tumor blood supply suggests that the malignant cells may have an adaptive environmental ability to compensate for a compromised microenvironment.