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Several techniques can be proposed as fertility sparing surgery in young patients treated for cervical cancer but uncertaincies remain concerning their outcomes. Analysis of oncological issues is then the first aim of this review in order to evaluate the best strategy.Data were identified from searches of MEDLINE, Current Contents, PubMed and from references in relevant articles from January 1987 to 15th of September 2021. We carry out an updated systematic review involving 5862 patients initially selected for fertility-sparing surgery in 275 series.In patients having a stage IB1 disease, recurrence rate/RR in patients undergoing simple conisation/trachelectomy, radical trachelectomy/RT by laparoscopico-vaginal approach, laparotomic or laparoscopic approaches are respectively: 4.1%, 4.7%, 2.4% and 5.2%. In patients having a stage IB2 disease, RR after neoadjuvant chemotherapy or RT by laparotomy are respectively 13.2% and 4.8% (p = .0035). After neoadjuvant treatment a simple cone/trachelectomy was carried out in 91 (30%) patients and a radical one in 210 (70%) cases. But the lowest pregnancy rate is observed in patients undergoing RT by laparotomy (36%).The choice between these treatments should be based above all, on objective oncological data that strike a balance for each procedure between the best chances for cure and the fertility results. In patients having a stage IB1 disease, oncological results are quite similar according to the procedure used. In patients having a stage IB2 disease, RT by open approach has the lowest RR. Anyway the lowest pregnancy rate is observed in patients undergoing RT by laparotomy.

The strategy of fertility preservation (FP) in cervical cancer has been challenged for several years and a therapeutic de-escalation seems to be necessary. In this context, we evaluated the oncological, fertility and obstetric outcomes of surgical techniques performed in our centre for FP.This retrospective uni centric trial included 75 patients, managed at the Gustave Roussy Institute between 1995 and 2020, for cervical cancer (stage IB1 FIGO 2018) and having conducted a fertility preservation project after a complete pre-therapy work-up. The objective of this study was to understand our results on fertility and obstetrical outcomes and to correlate them with oncological data and finally to evaluate the evolution of our surgical practices.54 patients benefited from an extended trachelectomy and no lymph node involvement was found. 1 patient received a complementary treatment postoperatively which did not allow to preserve her fertility. The recurrence rate was 4.8% (4/75) with one death described. 31 pregnancies were obtained, representing a pregnancy rate of 50%. 74% of pregnancies were obtained spontaneously and 60% of pregnancies were carried to term.Our results are similar to those in the literature. Despite a fertility preservation project, only half of the patients were able to achieve a pregnancy.

Low-grade serous ovarian cancer is a distinct, slow-growing entity that affects mainly young women. The objective of this study was to describe the clinical characterisitics and survival outcomes of a population of patients suffering from advanced stage CSBG.A retrospective study was carried out in patients with advanced stage ovarian CSBG (FIGO IIIb-IV) who had complete macroscopic cytoreductive surgery, at Gustave Roussy Institut, Villejuif, between 2004 and 2017.Thirty-four patients were included, who were mainly young women (mean age 41.3 years), diagnosed at FIGO stage IIIC (91 %). The median follow-up was 41 months. Neoadjuvant chemotherapy was administered in 16 patients (47.1 %), and complete response never occurred. Upper abdominal surgical procedures were necessary in 90 % of cases and a bowel resection was performed in more than 80 % of cases. Over 90 % of patients received adjuvant chemotherapy followed by maintenance treatment with bevacizumab in over 40 % of cases. During follow-up, 9 (26 %) deaths occurred. Five-year overall survival was 70 % and disease-free survival was 20 %.CSBG of the ovary has a low chemosensitivity and requires maximum surgical management, which should be performed in expert centers.

The treatment of cervical cancer patients relies on surgery and radiotherapy (according to the stage) and requires a multimodal discussion before any treatment to avoid adding the morbidities of each individual intervention and to optimize functional and oncological outcomes. The places of surgery and radiotherapy have been highlighted in recent international guidelines. For early stage tumors, an exclusive surgery with or without fertility sparing (according to well defined criteria) is the therapeutic standard. For tumors with risk factors (measuring more than 2cm in size and/or presence of lymphovascular invasion) a preoperative brachytherapy can be proposed to minimize the need for postoperative external beam radiotherapy and optimize local control. For locally advanced disease, the standard treatment relies on chemoradiation followed by a brachytherapy boost. A primary paraaortic lymph node dissection may guide radiotherapy volumes and is useful to identify patients requiring a para-aortic radiotherapy. The technical evolutions of surgical approaches and technological improvement of radiotherapy and brachytherapy should be analyzed in the context of prospective studies. We review the literature on the respective places of radiotherapy and surgery for the treatment of cervical cancer.

Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for all high-grade ovarian or Fallopian tube cancers, stage FIGO I-IIA (grade A). After a complete first surgery, it is recommended to deliver 6 cycles of intravenous (grade A) or to propose intraperitoneal (grade B) chemotherapy, to be discussed with patient, according to the benefit/risk ratio. After a complete interval surgery for a FIGO III stage, the hyperthermic intra peritoneal chemotherapy (HIPEC) can be proposed in the same conditions of the OV-HIPEC trial (grade B). In case of tumor residue after surgery or FIGO stage IV, chemotherapy associated with bevacizumab is recommended (grade A). For BRCA mutated patient, Olaparib is recommended (grade B).

Faced to an undetermined ovarian mass on ultrasound, an MRI is recommended and the ROMA score (combining CA125 and HE4) can be proposed (grade A). In case of suspected early stage ovarian or fallopian tube cancer, omentectomy (at least infracolonic), appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C) and pelvic and para-aortic lymphadenectomy are recommended (grade B) for all histological types, except for the expansive mucinous subtype where lymphadenectomy may be omitted (grade C). Minimally invasive surgery is recommended for early stage ovarian cancer, if there is no risk of tumor rupture (grade B). Laparoscopic exploration for multiple biopsies (grade A) and to evaluate carcinomatosis score (at least using the Fagotti score) (grade C) are recommended to estimate the possibility of a complete surgery (i.e. no macroscopic residue). Complete medial laparotomy surgery is recommended for advanced cancers (grade B). It is recommended in advanced cancers to perform para-aortic and pelvic lymphadenectomy in case of clinical or radiological suspicion of metastatic lymph node (grade B). In the absence of clinical or radiological lymphadenopathy and in case of complete peritoneal surgery during an initial surgery for advanced cancer, it is possible not to perform a lymphadenectomy because it does not modify the medical treatment and the overall survival (grade B). Primary surgery is recommended when no tumor residue is possible (grade B).

In ovarian, tubal and primary peritoneal cancers, older adults have an over-mortality due to more aggressive disease (NP4), surgical and chemotherapy under treatment (NP4) and co-morbidities (NP4). Older age is at higher risk for postoperative morbidity and mortality (NP4). Surgery is more often incomplete in this elderly population (NP4). Older age is a risk factor for lower dose intensity in adjuvant chemotherapy (NP4) and incomplete chemotherapy (NP4). Nevertheless, the benefit of a complete surgery remains identical to that of the younger population (NP2). Preoperative functional assessment identifies patients at risk for postoperative complications (NP4). The perioperative risk depends on three variables, the ASA score, the age and the complexity score of the surgery (NP4). It is recommended to perform cytoreduction surgery in an expert centre (grade C) and on the basis of geriatric expertise analysing functional and physical performance (grade C). The benefit/risk balance of surgery should be assessed on a case-by-case basis for the most at-risk (NP4) populations defined by: (i) age≥80 years, especially if albuminemia≤37g/L; (ii) age≥75 years and FIGO stage IV; (iii) age≥75 years, stage FIGO III and≥1 comorbidity. A comprehensive geriatric assessment is recommended prior to the management of an elderly person with primary ovarian, tubal or peritoneal cancer (grade C). The GVS (Geriatric Vulnerability Score) is used to identify vulnerable elderly patients (NP2). In fit elderly patients, it is recommended to perform intravenous chemotherapy identical to that of younger patients (ie platinum-based dual therapy) (grade B). In vulnerable elderly patients, various adapted chemotherapy regimens have been prospectively evaluated in non-comparative trials, and seem feasible considering specific and nonspecific toxicities: carboplatin monotherapy (NP2), carboplatin AUC2+paclitaxel 60mg/m

During the recent past years, the therapeutic management of locally advanced cervical cancer patients has consistently improved, with the integration of image guided brachytherapy and dose escalation strategies leading to an improvement of local control rates. In parallel, the evolution of external beam radiotherapy techniques and the better control of organs at risk doses in brachytherapy have contributed to decrease the probability of severe normal tissue complication. In case of advanced disease, patients prognosis remains however marked by a high risk of distant failure, and this finding has encouraged the assessment of various research pathways in order to better predict and/or prevent tumor relapse. Major studies are being conducted or have been published, and the place of chemoradiation and brachytherapy has been confirmed as first intent treatment in case of locally advanced disease. Numerous prospective or retrospective data, few of which are reviewed there, have been integrated as part of a strategy aimed at being more and more personalized. Next steps of therapeutic optimization will include the assessment of multiparameters radiological tools, but will also rely on a better understanding of radiobiological pathways involved in local or systemic response to irradiation, and the most promising of those is probably the anti-tumor immune response.

The aim of this study was to examine the feasibility and to report the results of laparoscopic radical hysterectomy (LRH) after initial uterovaginal brachytherapy (BT) for stage IB1 cervical cancer.We retrospectively reviewed in two Comprehensive Cancer Centers patients who had undergone initial BT followed 6 to 8 weeks later by LRH and lymph node dissection.Between 2003 and 2010, 162 patients had undergone LRH. The procedure was feasible using this approach in 160 (98.8%) cases (2 conversions to laparotomy). Eight peroperative complications had occurred. Nineteen patients had nodal involvement. Peri- or postoperative ureteral morbidity had occurred in 10 (6%) patients. Twenty-four (15%) patients had experienced postoperative dysuria. Histologically, only 9 patients had residual cervical disease5 mm and only 1 patient had parametrial lymphovascular space involvement (associated with nodal spread). No patient had vaginal disease or involved surgical margins. After a median follow-up of 39 months (range, 3-118), 9 patients had relapsed. Five-year overall survival was 95% (88.2%-97.9%).Radical hysterectomy using a laparoscopic approach is feasible and reproducible after initial BT for stage IB1 cervical cancer and is associated with excellent survival. Morbidity is very close to that reported in patients treated using upfront surgery. In this large series, the morbidity associated with parametrial dissection and the fact that parametrial spread was observed in only 0.6% of the patients suggest that a simple extrafascial hysterectomy is perhaps sufficient in this context.

Laparoscopic para-aortic lymphadenectomy (PAL) is being used increasingly to stage patients with locally advanced cervical cancer (LACC) and to define radiation field limits before chemoradiation therapy (CRT). This study aimed to define clinical implications, review complications, and determine whether surgical complications delayed the start of CRT.We retrospectively reviewed a continuous series of patients with LACC, with no positive para-aortic (PA) nodes on positron emission tomography-computed tomography (PET-CT) and who had undergone a primary laparoscopic PAL.From November 2007 to June 2010, 98 patients with LACC underwent pretherapeutic PAL. Two patients did not undergo PAL: extensive carcinomatosis was discovered in one case and a technical problem arose in the other. No perioperative complications occurred. Seven patients had a lymphocyst requiring an imaging-guided (or laparoscopic) puncture. Eight patients (8.4%, which corresponds to the false-negative PET-CT rate) had metastatic disease within PA lymph nodes. In cases of suspicious pelvic nodes on PET-CT, the risk for PA nodal disease was greater (24.0% versus 2.9%). When patients with and without surgical morbidity were compared, the median delay to the start of treatment was not significantly different (15 days; range, 3-49 days versus 18 days; range, 3-42 days).The morbidity of laparoscopic PAL was limited and the completion of treatment was not delayed when complications occurred. Nevertheless, if PET-CT of the pelvic area is negative, the interest in staging PAL could be discussed because the risk for PA nodal disease is very low.

Lymphoceles are the most frequent complications following systematic lymphadenectomy in gynaecologic cancers. Some of them may have clinical significance with high morbidity. Through a review of literature, we describe surgical methods (way of surgery, lymphadenectomy type, sentinel lymph node, peritonization, drainages, lymphostasis, surgical patch) and medical methods (somatostatin analogs and nutrition treatment) which could prevent lymphoceles formation after pelvic and lumboaortic lymphadenectomy.

The aim of this study was to describe the clinical features of vaginal melanoma and treatments available.This is a retrospective review of patients with primary vaginal melanoma operated from 2000 to 2010 at Gustave-Roussy Institute.Six patients had surgery for a vaginal melanoma out of 37 patients operated for vaginal cancer in our institute in the same period (13.6%). Median age was 53.5 years [48-66]. The melanoma presented as a macroscopically visible nodular tumor in all case. Median tumour size was 5.4cm [1.5-15]. Five of the six patients had a [18F] fluoro-deoxy-glucose positron-emission tomography combined with integrated computed tomography (FDG-PET/CT) before surgery. Initial management included two conservative treatments and four colpectomy with one anterior exenteration. Two sigmoidcolpoplasties were performed. Lymph node metastases were found in only one patient. Median progression free survival was 10.5 months [4-51]. All patients have relapsed, three of them in the 6 months following surgery. Recurrences were local in three patients and distant in three patients. Local recurrences were surgically treated. In one case, electrochemotherapy was performed. One patient with locoregional disease underwent a pelvic isolated perfusion. One patient had a KIT mutation. Two patients died at 12 and 83 months.Vaginal melanoma had a poor prognosis. The 5-year overall survival is under 20% from literature data. Local and/or distant recurrences are frequent and new local and adjuvant treatments are currently evaluated.

[(18)F]fluoro-deoxy-glucose positron-emission tomography combined with integrated computed tomography (FDG-PET/CT) is commonly used for advanced stage cervical cancer but its efficiency is discussed in early stage. The aim of this study was to evaluate false negative rate of FDG-PET/CT in early-stage cervical and vaginal cancer.Patients treated between 2005 and 2008 for stage IB1 cervical cancer and stage I vaginal cancer who underwent a FDG-PET/CT followed by a pelvic lymphadenectomy were studied.Eighteen patients were included with bilateral pelvic lymphadenectomy (16 cervical cancer, two vaginal cancer). The median age of patients was 41 years. Radical hysterectomy was performed for 16 patients, by a laparoscopic approach in 15 cases and by a laparotomic approach in one case. One patient had a simple hysterectomy and one had exclusive radiotherapy. No patient had pelvic or para-aortic fixation on FDG-PET/CT. Three patients have proven pelvic involvement and one had para-aortic metastases. The false-negative rate and negative predictive value of FDG-PET/CT were 17% and 83% respectively.The accuracy of FDG-PET/CT imaging in predicting the pelvic nodal status is very low in patients with early-stage cervical and vaginal cancer and is not able to replace surgical exploration.

With tumour size, node involvement is the most important prognosis factor in advanced stage cervical cancer. Para-aortic (PA) disease is observed in 15 to 30% of these patients. CT scan and magnetic resonance imaging (MRI) are not efficient enough to detect these lesions and PET CT have false negatives. Surgical staging is useful to detect carcinosis associated and to adapt therapy (radiotherapy fields are extended if PA nodes are involved). Laparoscopy was crucial to develop this staging because its morbidity associated to chemoradiotherapy is limited. If prognosis impact of PA lymphadenectomy is well established, therapeutic impact is still discussed. The systematic extension of this staging to pelvic nodes that are included in the basic radiotherapy fields is debated because it does not modify therapeutic management and is morbid. Radiotherapy progress, especially with boost and combination to MRI (MRIT), will impact on future therapeutic management.

The aim of this study was to evaluate the prognostic factors of patients undergoing completion surgery for locally advanced-stage cervical cancer after initial chemoradiation therapy (CRT).Patients fulfilling the following inclusion criteria were studied: stage IB2-IVA cervical carcinoma; tumour initially confined to the pelvic cavity on conventional imaging; pelvic external radiation therapy with delivery of 45 Gy to the pelvic cavity and concomitant chemotherapy (cisplatin 40 mg/m(2) per week) followed by utero-vaginal brachytherapy; completion surgery after the end of radiation therapy including at least a hysterectomy.One-hundred and fifty patients treated between 1998 and 2007 fulfilled inclusion criteria. Nineteen patients had pelvic nodes involved and 19 had para-aortic nodes involved. Seventy-two patients (48%) had complete surgical sterilization of the cervix. Prognostic factors for overall survival in the multivariable analysis were the presence and level of nodal spread (positive pelvic nodes alone: HR = 2.03, positive para-aortic nodes: HR = 5.46; P001) and the presence and size of residual disease (RD) in the cervix (RD ≤ 1 cm: HR = 1.92, RD1cm: HR = 3.85; P = 02).In this series, the presence and size of RD and histologic nodal involvement were the strongest prognostic factors. Such results suggest that the survival of these patients could potentially be enhanced by improving the rate of complete response in the irradiated area and by initially detecting patients with para-aortic spread.

To evaluate the morbidity rate in patients following completion surgery (hysterectomy±lymphadenectomy) after chemoradiation therapy (CRT) for an advanced stage cervical cancer.Patients fulfilling the following inclusion criteria were studied: (1) stage IB2-IVA cervical carcinoma; (2) tumor initially confined to the pelvic cavity; (3) pelvic external radiation therapy with delivery of 45Gy with concomitant chemotherapy (cisplatin 40mg/m(2)/week) followed by utero-vaginal brachytherapy; (4) completion surgery after the end of radiation therapy including at least a hysterectomy.One-hundred and fifty patients treated between 1998 and 2007 fulfilled inclusion criteria. Thirty-seven (25%) patients had 55 post-operative complications (17 had severe complications requiring surgical or radiological treatment). Two deaths related to postoperative morbidity had occurred. The risk of complications was increased with a radical hysterectomy (OR=2.4; P=0.04) and the presence of residual cervical disease (≤1cm: OR=4.3,1cm: OR=2.5; P=0.01).In the present study, the morbidity of completion surgery (based on hysterectomy with or without lymphadenectomy) is very high in patients treated with initial CRT for locally advanced cervical cancer whereas the therapeutic value of such surgery remains unproven.

The treatment of the advanced ovarian adenocarcinoma, most frequently stage at diagnostic, relies on association of surgery and chemotherapy. The current standard is the association carboplatine-paclitaxel. In spite of this treatment, relapses are frequent, and the prognosis thus remains very reserved. Presently the current areas of research aim at both improving the efficiency of treatments and decreasing their toxicity. So the various trials dealt with the use of the other cytotoxics having proved efficiency against relapses either in double-agent therapy or in association in the current standard, or in the administration of the chemotherapy by intra peritoneal way. They also investigated the possibility of pursuing the therapeutic sequence by a treatment of maintenance or consolidation. As for numerous cancerous pathologies, the targeted therapies, notably the antiangiogenic one, represent an important hope in the treatment of the ovarian cancer.

Upper abdomen cytoreduction is an important and challenging surgery that should be considered only if a macroscopically complete cytoreduction is expected. Techniques of the main procedures are addressed herein, as well as their respective morbidity and indications. Given its complexity, this surgery should be reserved to specialized teams, working in specialized centers.

Uterine cancer can metastasize to both the pelvic and para-aortic levels. No one questions the diagnostic and prognostic value of lymphadenectomy, but its therapeutic value is still open to debate. In early cervical cancer (4 cm.), pelvic lymphadenectomy is a routine part of radical hysterectomy. If pelvic lymph nodes show involvement, one can propose an extension of the lymphadenectomy to the para-aortic level. Studies of sentinel lymph node identification and biopsy at this level are currently under way. The standard treatment of cervical cancer4 cm is radiotherapy. A pre-radiation laparoscopy to investigate lymph node involvement at the lumbo-aortic level may help to define the extent of the radiation field. For endometrial cancer, the role and benefit of lymphadenectomy are much less clear since these patients often have major co-morbidities which increase the risk of complications from an extended lymph node dissection.

Early stage of cervical cancer is defined by disease confined to the cervix and upper vagina (stage IA to IIA). For early stage, no treatment has demonstrated clear superiority. Treatment options for women with early stage include either exclusive radiotherapy, or radical surgery, or brachytherapy before radical surgery. Radical hysterectomy or trachelectomy include the resection of the parametrium. The rational of parametrectomy is to remove occult disease in the parametrium and its removal is the cause of much of the morbidity of the surgery, specially urinary complications. This surgery can be performed by laparascopy with quality of life improvement and less blood loss but urinary morbidity is still important. The question is if it's possible to be less radical and still oncologically safe. Parametrial invasion is rare in patients with small tumours without lymphovascular space involvement and negative pelvic nodes (no poor prognostic factors). Sentinel node negative could be a strong criteria to predict parametrial involvement. This review reports studies exploring the safety of omitting parametrectomy in these low risk patients and the future possibilities to evaluate these new indications.

We present the case of large desmoid tumor of the anterior chest wall with pleural involvement, which persistently progressed despite hormonotherapy, chemotherapy and surgery. After many years of therapeutic failures, given the tumor size and its hemodynamic repercussions, the patient was presumed to be incurable and only supportive measures were given. One year later, the desmoid tumor had completely disappeared. Even though wide surgical excision is an essential element in the treatment of desmoid tumors, spontaneous regression may occur in very advanced disease.