Noninvasive detection of microsatellite instability in patients with endometrial cancer.

The analysis of mismatch repair proteins in solid tissue is the standard of care (SoC) for the microsatellite instability (MSI) characterization in endometrial cancer (EC). Uterine aspirates (UAs) or circulating-DNA (cfDNA) samples capture the intratumor heterogeneity and provide a more comprehensive and dynamic molecular diagnosis. Thus, MSI analysis by droplet-digital PCR (ddPCR) in UAs and cfDNA can provide a reliable tool to characterize and follow-up the disease. The UAs, paraffin-embedded tumor tissue (FFPE) and longitudinal plasma samples from a cohort of 90 EC patients were analyzed using ddPCR panel and compared to the SoC. A high concordance (96.67%) was obtained between the analysis of MSI markers in UAs and the SoC. Three discordant cases were validated as unstable by ddPCR on FFPE samples. Besides, a good overall concordance (70.27%) was obtained when comparing the performance of the ddPCR assay on UAs and cfDNA in high-risk tumors. Importantly, our results also evidenced the value of MSI analysis to monitor the disease evolution. MSI evaluation in minimally invasive samples shows great accuracy and sensitivity and provides a valuable tool for the molecular characterization and follow-up of endometrial tumors, opening new opportunities for personalized management of EC.

Ascites-Derived Organoids to Depict Platinum Resistance in Gynaecological Serous Carcinomas.

Gynaecological serous carcinomas (GSCs) constitute a distinctive entity among female tumours characterised by a very poor prognosis. In addition to late-stage diagnosis and a high rate of recurrent disease associated with massive peritoneal carcinomatosis, the systematic acquisition of resistance to first-line chemotherapy based on platinum determines the unfavourable outcome of GSC patients. To explore the molecular mechanisms associated with platinum resistance, we generated patient-derived organoids (PDOs) from liquid biopsies of GSC patients. PDOs are emerging as a relevant preclinical model system to assist in clinical decision making, mainly from tumoural tissue and particularly for personalised therapeutic options. To approach platinum resistance in a GSC context, proficient PDOs were generated from the ascitic fluid of ovarian, primary peritoneal and uterine serous carcinoma patients in platinum-sensitive and platinum-resistant clinical settings from the uterine aspirate of a uterine serous carcinoma patient, and we also induced platinum resistance in vitro in a representative platinum-sensitive PDO. Histological and immunofluorescent characterisation of these ascites-derived organoids showed resemblance to the corresponding original tumours, and assessment of platinum sensitivity in these preclinical models replicated the clinical setting of the corresponding GSC patients. Differential gene expression profiling of a panel of 770 genes representing major canonical cancer pathways, comparing platinum-sensitive and platinum-resistant PDOs, revealed cellular response to DNA damage stimulus as the principal biological process associated with the acquisition of resistance to the first-line therapy for GSC. Additionally, candidate genes involved in regulation of cell adhesion, cell cycles, and transcription emerged from this proof-of-concept study. In conclusion, we describe the generation of PDOs from liquid biopsies in the context of gynaecological serous carcinomas to explore the molecular determinants of platinum resistance.

Improving the Management of Endometrial Cancer Patients through the Use of Liquid Biopsy Analyses: A Case Report.

Endometrial cancer (EC) is the 4th most common neoplasm of the female genital tract, with 15-20% of patients being of high risk of recurrence which leads to a significant decrease in patient survival. Current therapeutic options for patients with EC are poor, being the combined therapy of carboplatin and paclitaxel the standard of care, with limited efficacy. Therefore, new therapeutic options and better monitoring tools are needed to improve the management of the disease. In the current case report, we showcase the value of liquid biopsy analyses in a microsatellite instability EC patient with initially good prognosis that however underwent rapid progression disease within 6 months post-surgery; through the study of plasma cfDNA/ctDNA dynamics to assess the tumour evolution during treatment, as well as the study of the uterine aspirate as a valuable sample that captures the intra-tumour heterogeneity that allows a comprehensive genomic profiling of the disease to identify potential therapeutic options. Furthermore, preclinical models were generated at the time of tumour progression to assess the efficacy of the identified targeted therapies.

Endometrial Tumour Microenvironment.

Endometrial cancer (EC) is the most common gynaecological tumour in developed countries, and its incidence is increasing in part due to the prevalence of obesity and its related hormone dysregulation. As described in this chapter, the tumour microenvironment plays a principal role in unopposed oestrogen stimulation promoting tumour cell proliferation. Factors and cytokines secreted by the different cell types defining the reactive tumour stroma also determine the invasive abilities of the tumour cells. Cancer-associated fibroblasts and tumour-associated macrophages actively participate through SDF-1, TGF-b or HGF to promote epithelial-to-mesenchymal transition or to generate an appropriate tumour niche. Likewise, endothelial cells facilitate lymph node and vascular infiltration through VEGF. Finally, the possibility to balance the immunosuppressive phenotypes in advanced endometrial cancer through the tumour microenvironment will probably represent a main therapeutic strategy in the near future.

Liquid Biopsy in Endometrial Cancer: New Opportunities for Personalized Oncology.

The identification of new molecular targets and biomarkers associated with high risk of recurrence and response to therapy represents one of the main clinical challenges in the management of advanced disease in endometrial cancer. In this sense, the field of liquid biopsy has emerged as a great revolution in oncology and is considered "the way" to reach personalised medicine. In this review, we discuss the promising but already relatively limited advances of liquid biopsy in endometrial cancer compared to other types of tumours like breast, colorectal or prostate cancer. We present recent data analysing circulating tumour material in minimally-invasive blood samples, but also in alternative forms of liquid biopsy like uterine aspirates. Proteomic and genomic studies focused on liquid-based uterine samples are resulting not only in optimal diagnostic tools but also in reliable approaches to address tumour heterogeneity. Likewise, circulating tumour cells (CTCs) and circulating tumour DNA (ctDNA) represent an opportunity for the correct stratification of patients, for the assessment of early recurrent disease or for the real-time monitoring of therapy responses. Appropriately designed studies and implementation in clinical trials will determine the value of liquid biopsy for precision oncology in endometrial cancer.

Role of cfDNA and ctDNA to improve the risk stratification and the disease follow-up in patients with endometrial cancer: towards the clinical application.

BACKGROUND: There has been a rise in endometrial cancer (EC) incidence leading to increased mortality. To counter this trend, improving the stratification of post-surgery recurrence risk and anticipating disease relapse and treatment resistance is essential. Liquid biopsy analyses offer a promising tool for these clinical challenges, though the best strategy for applying them in EC must be defined. This study was designed to determine the value of cfDNA/ctDNA monitoring in improving the clinical management of patients with localized and recurrent disease. METHODS: Plasma samples and uterine aspirates (UA) from 198 EC patients were collected at surgery and over time. The genetic landscape of UAs was characterized using targeted sequencing. Total cfDNA was analyzed for ctDNA presence based on the UA mutational profile. RESULTS: High cfDNA levels and detectable ctDNA at baseline correlated with poor prognosis for DFS (p-value < 0.0001; HR = 9.25) and DSS (p-value < 0.0001; HR = 11.20). This remained clinically significant when stratifying tumors by histopathological risk factors. Of note, cfDNA/ctDNA analyses discriminated patients with early post-surgery relapse and the ctDNA kinetics served to identify patients undergoing relapse before any clinical evidence emerged. CONCLUSIONS: This is the most comprehensive study on cfDNA/ctDNA characterization in EC, demonstrating its value in improving risk stratification and anticipating disease relapse in patients with localized disease. CtDNA kinetics assessment complements current strategies to monitor the disease evolution and the treatment response. Therefore, implementing cfDNA/ctDNA monitoring in clinical routines offers a unique opportunity to improve EC management. TRANSLATIONAL RELEVANCE: The study demonstrates that high levels of cfDNA and detectable ctDNA at baseline are strong indicators of poor prognosis. This enables more accurate risk stratification beyond traditional histopathological factors, allowing clinicians to identify high-risk patients who may benefit from more aggressive treatment and closer monitoring. Moreover, longitudinal analysis of cfDNA/ctDNA can detect disease recurrence months before clinical symptoms or imaging evidence appear. This early warning system offers a significant advantage in clinical practice, providing a window of opportunity for early intervention and potentially improving patient outcomes.

Intratumor genetic heterogeneity and clonal evolution to decode endometrial cancer progression.

Analyzing different tumor regions by next generation sequencing allows the assessment of intratumor genetic heterogeneity (ITGH), a phenomenon that has been studied widely in some tumor types but has been less well explored in endometrial carcinoma (EC). In this study, we sought to characterize the spatial and temporal heterogeneity of 9 different ECs using whole-exome sequencing, and by performing targeted sequencing validation of the 42 primary tumor regions and 30 metastatic samples analyzed. In addition, copy number alterations of serous carcinomas were assessed by comparative genomic hybridization arrays. From the somatic mutations, identified by whole-exome sequencing, 532 were validated by targeted sequencing. Based on these data, the phylogenetic tree reconstructed for each case allowed us to establish the tumors' evolution and correlate this to tumor progression, prognosis, and the presence of recurrent disease. Moreover, we studied the genetic landscape of an ambiguous EC and the molecular profile obtained was used to guide the selection of a potential personalized therapy for this patient, which was subsequently validated by preclinical testing in patient-derived xenograft models. Overall, our study reveals the impact of analyzing different tumor regions to decipher the ITGH in ECs, which could help make the best treatment decision.

Haemodynamic-dependent arrest of circulating tumour cells at large blood vessel bifurcations as new model for metastasis.

Homing of circulating tumour cells (CTC) at distant sites represents a critical event in metastasis dissemination. In addition to physical entrapment, probably responsible of the majority of the homing events, the vascular system provides with geometrical factors that govern the flow biomechanics and impact on the fate of the CTC. Here we mathematically explored the distribution of velocities and the corresponding streamlines at the bifurcations of large blood vessel and characterized an area of low-velocity at the carina of bifurcation that favours the residence of CTC. In addition to this fluid physics effect, the adhesive capabilities of the CTC provide with a biological competitive advantage resulting in a marginal but systematic arrest as evidenced by dynamic in vitro recirculation in Y-microchannels and by perfusion in in vivo mice models. Our results also demonstrate that viscosity, as a main determinant of the Reynolds number that define flow biomechanics, may be modulated to limit or impair CTC accumulation at the bifurcation of blood vessels, in agreement with the apparent positive effect observed in the clinical setting by anticoagulants in advanced oncology disease.

Genomic Profiling of Uterine Aspirates and cfDNA as an Integrative Liquid Biopsy Strategy in Endometrial Cancer.

The incidence and mortality of endometrial cancer (EC) have risen in recent years, hence more precise management is needed. Therefore, we combined different types of liquid biopsies to better characterize the genetic landscape of EC in a non-invasive and dynamic manner. Uterine aspirates (UAs) from 60 patients with EC were obtained during surgery and analyzed by next-generation sequencing (NGS). Blood samples, collected at surgery, were used for cell-free DNA (cfDNA) and circulating tumor cell (CTC) analyses. Finally, personalized therapies were tested in patient-derived xenografts (PDXs) generated from the UAs. NGS analyses revealed the presence of genetic alterations in 93% of the tumors. Circulating tumor DNA (ctDNA) was present in 41.2% of cases, mainly in patients with high-risk tumors, thus indicating a clear association with a more aggressive disease. Accordingly, the results obtained during the post-surgery follow-up indicated the presence of ctDNA in three patients with progressive disease. Moreover, 38.9% of patients were positive for CTCs at surgery. Finally, the efficacy of targeted therapies based on the UA-specific mutational landscape was demonstrated in PDX models. Our study indicates the potential clinical applicability of a personalized strategy based on a combination of different liquid biopsies to characterize and monitor tumor evolution, and to identify targeted therapies.

Retraction and triangulation with neodymium magnetic forceps for single-port laparoscopic cholecystectomy.

INTRODUCTION: There have been attempts to minimize the invasiveness of laparoscopic cholecystectomy by reducing the size and/or the number of the operating ports and instruments. These attempts create technical challenges related principally to retraction and triangulation necessary to expose the surgical field for a safe surgery. A new technique based on retraction and triangulation with magnetic instruments for single port laparoscopic surgery is presented. METHODS: Between March 2007 and December 2008, 40 laparoscopic cholecystectomies were performed with single-port laparoscopic surgery with the assistance of magnetic forceps (IMANLAP project). The surgical technique is described, and the intraoperative and postoperative course of the patients is assessed. RESULTS: There were no intraoperative complications, no need to convert to open surgery, and no need to add a second port. Depending on the patient's anatomy, a 1-mm needle was added in some cases. There were no interactions observed between the magnetic devices and the anesthetic monitoring and the rest of the devices of the operation room. CONCLUSIONS: This new procedure is feasible and safe. The main goal is control of the magnetic field, allowing enough controlled strength for retraction and sufficient triangulation for adequate exposure of the surgical field. This allows for the use of a single port through which an optic device with a working channel can perform the operation with safety. Finally, the procedure can be performed in a manner similar to the traditional laparoscopic cholecystectomy, and it also appears to be simple to learn.

Extracellular Vesicles-Based Biomarkers Represent a Promising Liquid Biopsy in Endometrial Cancer.

Tumor-derived extracellular vesicles (EVs) are secreted in large amounts into biological fluids of cancer patients. The analysis of EVs cargoes has been associated with patient´s outcome and response to therapy. However, current technologies for EVs isolation are tedious and low cost-efficient for routine clinical implementation. To explore the clinical value of circulating EVs analysis we attempted a proof-of-concept in endometrial cancer (EC) with ExoGAG, an easy to use and highly efficient new technology to enrich EVs. Technical performance was first evaluated using EVs secreted by Hec1A cells. Then, the clinical value of this strategy was questioned by analyzing the levels of two well-known tissue biomarkers in EC, L1 cell adhesion molecule (L1CAM) and Annexin A2 (ANXA2), in EVs purified from plasma in a cohort of 41 EC patients and 20 healthy controls. The results demonstrated the specific content of ANXA2 in the purified EVs fraction, with an accurate sensitivity and specificity for EC diagnosis. Importantly, high ANXA2 levels in circulating EVs were associated with high risk of recurrence and non-endometrioid histology suggesting a potential value as a prognostic biomarker in EC. These results also confirmed ExoGAG technology as a robust technique for the clinical implementation of circulating EVs analyses.

Oportunidad de la gastroenteroanastomosis en el tratamiento paliativo del cáncer de páncreas / Opportunity of the gastrojejunostomy in the palliative treatment of pancreatic cancer

En una serie consecutiva de 60 enfermos con anastomosis biliodigestiva por carcinomas irrescables de la cabeza del páncreas, se analizó la oportunidad de una gastroenteroanastomosis. En 11 fue hecha por obstrucción duodenal y en 1 profilácticamente. En los otros 48 enfermos sólo 2 (4,5%) la requirieron a los 12 y 18 meses. Se concluye que cuando no hay obstrucción duodenal no se justifica una gastroenteroanastomosis profiláctica de rutina

Influencia de la temperatura local en las lesiones agudas gástricas experimentales / Influence of local temperature in experimental acute gastric lesions

En 40 ratas con estrés por sujeción, se investigó la influencia de lavados a distintas temperaturas sobre la evolución de las lesiones agudas gástricas, siguiendo un puntaje preestablecido. No hubo diferencias entre el grupo control sin lavado y los que fueron lavados con soluciones a temperatura ambiente, a 4*C y a 50*C.

Lesiones asociadas al carcinoma de vesícula / Lesions associated with gallbladder carcinoma

La incidencia de carcinomas en 700 colecistectomías fue de 5,4%. Se estudió la mucosa adyacente al tumor en 21 preparados histológicos correspondientes a carcinomas invasivos de la vesícula. Las lesiones proliferativas vecinas al tumor fueron 14 hiperplasias con displasia, 8 carcinomas in situ y 7 hiperplasias epiteliales. Se discute la posibilidad de que estas lesiones proliferativas se originen a partir de la litiasis y de la colecistitis crónica. En la mucosa se producen alteraciones progresivas donde las hiperplasias desarrollarían cambios atípicos que podrían concluir en un carcinoma. Por lo tanto estas lesiones pueden ser consideradas potencialmente neoplásicas

Colonización de catéteres endovenosos por bacteriemia experimental / Colonization of intravenous catheters by experimental bacteremia

Para estudiar la colonización de un catéter ubicado en una vena central después de una bacteriemía, se canalizaron la vena femoral derecha y la arteria femoral izquierda de 9 conejos. Por la vena femoral se perfundió Dextrosa al 5% y por la arteria 9 x 10 bacterias de una cepa conocida de Escherichia coli que no forma parte de la flora habitual del conejo. Se tomaron hemocultivos que demostraron la bacteriemia en todos los animales y a las 6 horas se cultivó el extremo de los catéteres venosos. Sólo 1 de los 9 tenía colonizado su extremo con la Escherichia coli inyectada. Por lo tanto, después de una bacteriemia no se justifica que el catéter sea retirado sistemáticamente. Sólo cuando se han descartado todas las otras posibilidades debe pensarse en la colonización del extremo del catéter como origen de sepsis

Diarreas como secuela de la vagotomia troncular. / Diarrhea as sequela of truncal vagotomy

Se analizo la evolucion de 217 operados con vagotomia troncular y avenamiento gastrico por ulcera duodenal. La secuela mas frecuente fue la diarrea que encontramos en el 28% de los casos. La etiologia mas probable es la denervacion de la via biliar. Los enfermos con resultados "no satisfactorios" tuvieron diarreas que comenzaron en el post-operatorio inmediato y duraron varios anos. Solo el 1,4% pertencieron al grado IV de Visick

Secuelas gastricas y extragastricas de la vagotomia troncular. / Gastric and extragastric sequelae of truncal vagotomy

Se investigaron algunas secuelas en 217 operados por ulcera duodenal con vagotomia troncular mas avenamiento gastrico. Las alteraciones de la evacuacion gastrica en el 8,8% fueron debidas mas a fallas de avenamiento gastrico, que a la denervacion del estomago. La incidencia de "dumping" (2,8%) fue de caracteristicas poco graves.La aparicion de litiasis biliar postvagotomia (entre 1 y 10 anos del postoperatorio) se presento en el 6,9%. Un solo enfermo con sintomas de reflujo gastroesofagico y uno con disfagia, demuestran la minima influencia de la vagotomia sobre los mecanismos funcionales de la region cardial. El 86,6% de los enfermos entraron en las categorias I y II de la gradacion de Visik modificada (resultado excelente y muy bueno). Se ratifica asi la poca gravedad que tienen en nuestro pais las alteraciones provocadas por la vagotomia troncular en el funcionamiento del aparato digestivo

Desarrollo experimental de una técnica de gastrostomía diferida / Experimental development of a technique for differed gastrostomy

Se desarrolló una técnica de gastrostomía diferida, investigada en 10 conejos sin complicaciones ni muertes. La efectividad fue controlada con estudios radiológicos contrastados. Como aplicación práctica, puede utilizarse al finalizar laparotomías en enfermos que potencialmente requerirían una gastrostomía

Impermeabilización de suturas intestinales con un adhesivo sintético / Impermeabilization of intestinal sutures with an synthetic adhesive

Se investigó in vitro el valor de un adhesivo sintético (cianoacrilato) colocado sobre anastomosis de intestino delgado en un plano y se midió la resistencia a la filtración. Con el adhesivo se observó una resistencia estadísticamente mayor que en las suturas sin adhesivo

Estudio prospectivo de un año sobre seguridad en el quirófano / A year prospective study on safety in the operating room

En un trabajo prospectivo se registraron todos los hechos no esperados ocurridos durante el acto quirúrgico en un año, en una clínica privada con condiciones edilicias y equipamiento adecuados, personal entrenado y médicos con título de especialistas. En 2.752 operaciones se detectaron 10 (0.36%) problemas que por su poca jerarquía hubieran pasado inadvertidos, pero sirvieron para hacer correcciones y aumentar las medidas de seguridad