Recurrence factors in patients with cutaneous melanoma and positive sentinel lymph node treated in a single reference unit in Buenos Aires.

INTRODUCTION: Although therapeutic advances have improved results of cutaneous melanoma (CM), sentinel node-positive patients still have substantial risk to develop recurrent disease. We aim to investigate prognostic indicators associated with disease recurrence in positive-sentinel lymph node biopsy (SLNB) patients in a Latin-American population. METHODS: Retrospective analysis of CM patients and positive-SLNB (2010-2020). Patients were divided into two groups: Group A (completion lymph node dissection, CLND), Group B (active surveillance, AS). Association of demographics, tumor data and SLN features with recurrence-free (RFS), distant metastases-free (DMFS) and melanoma specific (MSS) survival was analyzed. RESULTS: Of 205 patients, 45 had a positive SLNB; 27(60%) belonged to Group A and 18(40%) to Group B. With a median follow-up of 36 months, 16 patients (12 in Group A and 4 in Group B) developed recurrent disease and estimated 5-yr RFS at any site was 60% (CI95%, 0.39 - 0.77) (44.5% in CLND group vs. 22% in AS group; P = 0.20). Estimated 5-yr DMFS and MSS: 65% (CI 95%, 0.44 - 0.81) and 73% (CI 95%, 0.59 - 0.89) with no differences between groups (p = 0.41 and 0.37, respectively). Independent predictors of poorer MSS were extranodal extension (ENE) and MaxSize > 2 mm of melanoma deposit in SLN. Factors independently associated with DMFS: Breslow depth > 2 mm, ENE, number (≥ 2) of positive SN and CLND status. CONCLUSION: Primary tumor and SN features in melanoma provide important prognostic information that help optimize prognosis and clinical management. AS is now the preferred approach for most positive-SLNB CM patients.

Introducción: Si bien los avances terapéuticos han permitido mejorar los resultados del melanoma cutáneo (MC), los pacientes con ganglio centinela positivo (BGCP) aún tienen riesgo elevado de desarrollar recurrencia de la enfermedad. Nuestro objetivo fue investigar indicadores pronósticos asociados a dicho evento en una población latinoamericana. Métodos: Análisis retrospectivo de pacientes con MC y BGCP entre 2010-2020. Los pacientes se dividieron en 2 grupos: Grupo A (linfadenectomía terapéutica) y Grupo B (Vigilancia activa, VA). Se analizaron datos demográficos, tumorales y características del GC junto con sobrevidalibre de recurrencia (SLR), libre de metástasis a distancia (SLMD) y específica de melanoma (SEM). Resultados: De 205 pacientes, 45 presentaron BGCP; 27 (60%) perteneció al Grupo A y 18 (40%) al Grupo B. Con una mediana de seguimiento de 36 meses, 16 pacientes (12 en Grupo A y 4 en Grupo B) desarrollaron enfermedad recurrente con una SLR a 5 años de 60% (IC95%: 0.39-0.77) (44.5% en Grupo B vs. 22% en Grupo A; P = 0.20). Las SLMD y SEM estimadas a 5 años fueron de 65% (CI 95%, 0.44 ­ 0.81) y 73% (CI 95%, 0.59 ­ 0.89) sin diferencias entre ambos grupos (p = 0.41 y 0.37, respectivamente). Los predictores independientes de peor SEM fueron: extensión extranodal (ENE) y MaxSize > 2mm de depósito tumoral en GC. Los factores asociados de forma independiente con SLMD fueron Breslow > 2mm, ENE, número (≥ 2) de GC positivos y el status (positividad) de la linfadenectomía. Conclusión: Características del tumor primario y del GC brindan información importante que ayuda a optimizar el pronóstico y manejo clínico de los pacientes con MC. La VA es actualmente el abordaje de elección para la mayoría de los pacientes con BGCP.

Ring closure outcome for laparoscopic ventral hernia repair (IPOM plus) in medium and large defects. Long-term follow-up.

BACKGROUND: Despite advances in laparoscopic ventral hernia repair (LVHR) with the Intra-peritoneal onlay mesh technique (IPOM), recurrence continues to be a frequent postoperative complication. The aim of this study is to analyze the long-term recurrence rate in two series, by incorporating in IPOM technique the laparoscopic closure of the defect (IPOM plus). We also want to determine the ring size cut-off point from which the recurrence risk increases in IPOM technique and determine if the cut-off point is modified with IPOM plus technique. METHODS: A comparative retrospective study was conducted analyzing patients who underwent LVHR. They were divided into 2 groups according to the surgical technique used: IPOM or IPOM plus. We determined in each group the cut-off point where the ring size presents a greater recurrence risk by calculating the better point of sensitivity/specificity relationship of the ROC curve. RESULTS: Between 2007 and 2018, 286 patients underwent LVHR. The ROC curve for IPOM technique has shown a cut-off point of higher recurrence risk for rings larger than 63 cm2. While the ROC curve in IPOM plus group showed an increase in the cut-off point, with a higher recurrence risk in rings > 168 cm2. Overall median ring size was 30 cm2 (range 4-225; IQR 16-61). However, when comparing the ring size between techniques we found a relatively larger size in IPOM plus (p: 0.013). The recurrence rate in the IPOM group was 19.51% while in the IPOM plus group was 3.57% (p: 0.005). CONCLUSIONS: For standard LVHR with IPOM technique, the greatest recurrence risk occurs in rings larger than 63 cm2. The addition of ring closure (IPOM plus) was associated with a recurrence risk reduction, which occurs in rings larger than 168 cm2. These findings would allow expanding the indication for LVHR, using the IPOM plus technique.

Neumotórax catamenial / Catamenial pneumothorax

Resumen El síndrome de endometriosis torácica (TES) es un trastorno poco común caracterizado por la presencia de tejido endometrial ectópico en la cavidad torácica. La manifestación clínica típica es un neumotórax espontáneo, que generalmente se presenta con dolor torácico, disnea y/o tos. El diagnóstico requiere un alto nivel de sospecha clínica junto con una historia ginecológica completa. Los estudios de imáge nes pueden ayudar con el diagnóstico, pero el gold standard es la cirugía toracoscópica videoasistida (VATS). Se ha demostrado que el tratamiento quirúrgico en combinación con al menos 6 meses de tratamiento médico hormonal mejora el pronóstico y reduce la recurrencia de esta entidad. Presentamos el caso de una paciente de 40 años con antecedentes de endometriosis pélvica y múltiples episodios de neumotórax, que consultó en nuestra institución por un nuevo episodio de neumotórax espontáneo. Se realizó una VATS donde se identificaron nódulos en la pleura parietal y orificios diafragmáticos. En el postoperatorio continuó con tratamiento hormonal. A los 6 meses de seguimiento refirió mejoría del dolor y no presentó nuevos episodios de neumotórax.

Abstract. Thoracic endometriosis syndrome (TES) is a rare disorder characterized by the presence of ectopic endometrial tissue in the chest cavity. The typical clinical manifestation is a spontaneous pneumothorax, which usually presents with chest pain, dyspnea, and/or cough. The diagnosis requires a high level of clinical suspicion and a complete gynecological history. Imaging studies can help with the diagnosis, although the gold standard is video-assisted thoracoscopic surgery (VATS). Surgical treatment in combination with at least 6 months of hormonal medical treatment has been shown to improve the prognosis and reduce the recurrence of this entity. We present the case of a 40-year-old patient with a history of pelvic endometriosis and multiple episodes of pneumothorax, who consulted at our institution for a new episode of spon taneous pneumothorax. A VATS was performed where nodules in the parietal pleura and diaphragmatic orifices were identified. In the postoperative period, she continued with hormonal treatment. At 6 months of follow-up, she reported improvement in pain and did not present new episodes of pneumothorax.

[Catamenial pneumothorax]. / Neumotórax catamenial.

Thoracic endometriosis syndrome (TES) is a rare disorder characterized by the presence of ectopic endometrial tissue in the chest cavity. The typical clinical manifestation is a spontaneous pneumothorax, which usually presents with chest pain, dyspnea, and/or cough. The diagnosis requires a high level of clinical suspicion and a complete gynecological history. Imaging studies can help with the diagnosis, although the gold standard is video-assisted thoracoscopic surgery (VATS). Surgical treatment in combination with at least 6 months of hormonal medical treatment has been shown to improve the prognosis and reduce the recurrence of this entity. We present the case of a 40-year-old patient with a history of pelvic endometriosis and multiple episodes of pneumothorax, who consulted at our institution for a new episode of spontaneous pneumothorax. A VATS was performed where nodules in the parietal pleura and diaphragmatic orifices were identified. In the postoperative period, she continued with hormonal treatment. At 6 months of follow-up, she reported improvement in pain and did not present new episodes of pneumothorax.

El síndrome de endometriosis torácica (TES) es un trastorno poco común caracterizado por la presencia de tejido endometrial ectópico en la cavidad torácica. La manifestación clínica típica es un neumotórax espontáneo, que generalmente se presenta con dolor torácico, disnea y/o tos. El diagnóstico requiere un alto nivel de sospecha clínica junto con una historia ginecológica completa. Los estudios de imágenes pueden ayudar con el diagnóstico, pero el gold standard es la cirugía toracoscópica videoasistida (VATS). Se ha demostrado que el tratamiento quirúrgico en combinación con al menos 6 meses de tratamiento médico hormonal mejora el pronóstico y reduce la recurrencia de esta entidad. Presentamos el caso de una paciente de 40 años con antecedentes de endometriosis pélvica y múltiples episodios de neumotórax, que consultó en nuestra institución por un nuevo episodio de neumotórax espontáneo. Se realizó una VATS donde se identificaron nódulos en la pleura parietal y orificios diafragmáticos. En el postoperatorio continuó con tratamiento hormonal. A los 6 meses de seguimiento refirió mejoría del dolor y no presentó nuevos episodios de neumotórax.