Fertility sparing treatment in patients with endometrial cancer (FERT-ENC): a multicentric retrospective study from the Spanish Investigational Network Gynecologic Oncology Group (SPAIN-GOG).

OBJECTIVE: The primary objective was to evaluate the response rate of conservative treatment for endometrial cancer, and the secondary objective was to assess oncological, fertility and obstetric outcomes in patients who underwent fertility preservation treatment. MATERIAL AND METHODS: This multicentre, observational, retrospective study evaluated endometrial cancer patients who underwent fertility-sparing treatment in Spanish centres between January 2010 and January 2020. Seventy-three patients with stage IA endometrioid adenocarcinoma of the uterus were included in the study. RESULTS: The levonorgestrel intrauterine device (LNG-IUD) was the most common fertility-sparing treatment (53.4%), followed by megestrol acetate (20.5%) and medroxyprogesterone acetate (16.4%). During the 24-month follow-up period, the rate of complete response to fertility-sparing management was 74% (n = 54), and 8.2% (n = 6) of patients presented a partial response. Additionally, 13 (17.8%) patients presented with persistent disease and six (8.2%) relapsed after response. The LNG-IUD was associated with a higher complete response rate than the other methods (87.2 vs. 58.8%; p = 0.01). Surgical treatment (at least hysterectomy) was performed in 44 (60.3%) patients as the end of fertility-sparing treatment. Four (5.5%) patients presented relapse after surgery, associated with final FIGO stage III (p = 0.036), myometrial invasion > 50% (p = 0.018) and final tumour grade 2-3 (p = 0.018). The mean follow-up period was 57.8 (range 6-159) months. The 5-year relapse-free survival and overall survival rates were 92.6% [95% CI (81.3, 97.2)] and 93.5% [95% CI (80.7, 97.9)], respectively. During follow-up, three patients (4.1%) died of the disease after completion of surgical treatment. Up to 50.7% of patients included in the study attempted to get pregnant. Of these, the rate of pregnancy was 81.1% (n = 30/37), and reproductive techniques were used for this purpose in 78.4% of cases. CONCLUSIONS: Fertility-sparing management presented a high response rate in patients with endometrial cancer. LNG-IUD was associated with a better response rate compared to the other treatment options. Moreover, in patients using this management method, pregnancy could be achieved using reproductive techniques.

Role of hysteroscopy during conservative management of atypical endometrial hyperplasia and early-stage endometrial cancer in patients who desire pregnancy.

Twenty-five percent of cases of endometrial cancer appear in women with unfulfilled reproductive desires. An adequate selection of patients and a close hysteroscopic follow-up to monitor the endometrial response to the levonorgestrel-releasing intrauterine system (LNG-IUS) may be a valid and safe option for these patients. This is a case series and review of the literature study. We included eight patients diagnosed of complex endometrial hyperplasia with atypia (CEHA) or stage 1AG1 well-differentiated endometrial cancer without myometrial invasion who desired to get pregnant and opted for a conservative treatment. Follow-up was performed with hysteroscopy and directed biopsy at 3, 6 and 12 months. Of the 854 cases of complex endometrial hyperplasia with atypia (CEHA)/endometrial cancer were diagnosed, 2.3% were candidates for conservative management. We obtained a favourable regression of 71.2% at 6 months and 57% at one year with hormonal treatment. Conservative treatment in complex endometrial hyperplasia with atypia (CEHA)/low-grade endometrial cancer in reproductive age patients with a strong desire for pregnancy is feasible.

Lymphovascular Space Invasion in Early-Stage Endometrial Cancer (LySEC): Patterns of Recurrence and Predictors. A Multicentre Retrospective Cohort Study of the Spain Gynecologic Oncology Group.

The main aim is to compare oncological outcomes and patterns of recurrence of patients with early-stage endometrioid endometrial cancer according to lymphovascular space invasion (LVSI) status. The secondary objective is to determine preoperative predictors of LVSI. We performed a multicenter retrospective cohort study. A total of 3546 women diagnosed with postoperative early-stage (FIGO I-II, 2009) endometrioid endometrial cancer were included. Co-primary endpoints were disease-free survival (DFS), overall survival (OS), and pattern of recurrence. Cox proportional hazard models were used for time-to-event analysis. Univariate and multivariate logistical regression models were employed. Positive LVSI was identified in 528 patients (14.6%) and was an independent prognostic factor for DFS (HR 1.8), OS (HR 2.1) and distant recurrences (HR 2.37). Distant recurrences were more frequent in patients with positive LVSI (78.2% vs. 61.3%, p < 0.01). Deep myometrial invasion (OR 3.04), high-grade tumors (OR 2.54), cervical stroma invasion (OR 2.01), and tumor diameter ≥ 2 cm (OR 2.03) were independent predictors of LVSI. In conclusion, in these patients, LVSI is an independent risk factor for shorter DFS and OS, and distant recurrence, but not for local recurrence. Deep myometrial invasion, cervical stroma invasion, high-grade tumors, and a tumor diameter ≥ 2 cm are independent predictors of LVSI.

Chylous Ascites Secondary to Retroperitoneal Para-Aortic Lymphadenectomy: A Case Report.

Chylous ascites is caused by an accumulation of lymphatic fluid in the peritoneal cavity secondary to a rupture or obstruction of the abdominal lymphatic ducts. It has a milky appearance and is rich in triglycerides. The most frequent etiologies are neoplasms, liver cirrhosis, and ruptured lymphatic vessels after abdominal surgery. Clinically, it manifests as abdominal distention and increased abdominal girth. The presence of triglycerides in ascites fluid is the most useful diagnostic criterion. Treatment consists of a high-protein diet with fat restriction and medium-chain triglyceride supplements. Surgery is reserved for refractory cases. We present the case of a 66-year-old patient with a diagnosis of chylous ascites secondary to retroperitoneal lymphadenectomy.

Squamous Cell Carcinoma Arising From a Mature Cystic Teratoma of the Ovary: A Case Report.

Germ cell tumors represent 20-25% of ovarian tumors, and 95% of them are benign. The most frequent type is the mature benign teratoma (dermoid cysts). The proportion of cases in which malignancy occurs is 0.17-2%. Seventy-five percent to 90% of malignancies are squamous cell carcinomas (SCC). We present a case of squamous cell carcinoma originating from a mature cystic teratoma that was diagnosed after intraoperative pathology study in a 64-year-old woman who consulted for an adnexal tumor causing abdominal pain. Laparoscopic surgery was scheduled, describing an enlarged right ovary (13 cm) which was included in the ipsilateral broad ligament and adhered to the posterior aspect of the uterus in its distal third as well as the rectum. It was converted to laparotomy and we performed a hysterectomy + double anexectomy + omentectomy + resection of sigma with end-to-end anastomosis after intraoperative pathological study reported for malignancy compatible with squamous cell carcinoma. It was labeled as FIGO III stage. Chemotherapy was decided as adjuvant therapy with carboplatin + paclitaxel (Carbo-Taxol) scheme. We review the existing literature to provide evidence on a rare pathology with important repercussions for our patients.

Uterine Primitive Neuroectodermal Tumor.

Uterine primitive neuroectodermal tumors (PNETs) are rare entities, with only around 70 cases published in the literature. Most of them are diagnosed in advanced stages with rapid progression and poor prognosis. Herein, we present a case of a 71-year-old patient with postmenopausal metrorrhagia and an ultrasound finding of endometrial thickening. The pathological diagnosis after an endometrial biopsy showed PNET. In the study of extension, possible distant dissemination with infiltration of the sigmoid and liver was observed. Chemotherapy treatment was proposed, but not begun due to the rapid progression of the disease. Four months after the initial diagnosis, the patient died of multiple organ failure. While there is no optimal chemotherapy treatment regimen for PNET, some studies have reported encouraging results. It is necessary to publish more studies emphasizing the follow-up and survival of the disease to establish which may be the best treatment option and thus improve the current poor prognosis.

Post-Conization FIGO stage IA1 squamous cell cervical carcinoma; is hysterectomy necessary?

OBJECTIVE: To compare and evaluate the results and suitability of two different approaches to the treatment of post-conization International Federation of Gynaecology and Obstetrics (FIGO) stage IA1 cervical carcinoma: a more radical approach, directly scheduling a second surgery versus a more conservative one, which consists of performing a cotest (PAP plus HPV-test) in a follow-up visit and deciding whether to apply a second surgery on the basis of the results. STUDY DESIGN: Retrospective descriptive study including 144 cases of stage IA1 cervical carcinoma diagnosed after a loop electrosurgical excisional procedure (conization), between 1987 and 2019 in the Mother-and-Child University Hospital of Gran Canaria (Spain). Selected patients were split into two groups for analysis: patients directly undergoing a second surgical intervention (hysterectomy or re-conization) after diagnosis and patients who were followed-up before making a decision whether to schedule a second surgery or continue to follow-up. RESULTS: 75% of women directly receiving a second surgical intervention (no post-conization follow-up) underwent hysterectomy, while 25% underwent re-conization. Histological outcomes from hysterectomized patients showed 65% negative results for intraepithelial lesions, 9% low-grade squamous intraepithelial lesions (LSIL), 16% high-grade squamous intraepithelial lesions (HSIL) and only 10.5% confirmed invasive lesions: hysterectomy complication rate was 7%. Histological studies from women subjected to re-conization showed 32% negative results, 37% LSIL, 5% HSIL and 26% malignancy. In the group of patients who were followed-up after diagnosis, 8.8% needed a second intervention; none of them showed negative histological results, while 100% hysterectomized and 25% patients with re-conization showed HSIL. No unnecessary hysterectomy procedures were conducted in this group. HPV-16 was the most common genotype in both groups. CONCLUSION: Conization proved to be a suitable alternative to hysterectomy as a treatment for post-conization stage IA1 cervical cancer. Our results showed that 65% hysterectomy procedures conducted without previously monitoring for residual disease corresponded to negative results and were therefore, unnecessary. We conclude that confirmation of the presence of residual disease by using cotest is essential to make a decision on further treatment and that a conservative management is often possible and, in our opinion, preferable.

Lower-Limb Lymphedema after Sentinel Lymph Node Biopsy in Cervical Cancer Patients.

BACKGROUND: To prospectively assess LLL incidence among cervical cancer patients treated by uterine surgery complemented by SLN biopsy, without PLND. METHODS: A prospective study in 150 patients with stage IA1-IB2 cervical cancer treated by uterine surgery with bilateral SLN biopsy. Objective LLL assessments, based on limb volume increase (LVI) between pre- and postoperative measurements, and subjective patient-perceived swelling were conducted in six-month periods over 24-months post-surgery. RESULTS: The cumulative incidence of LLL at 24 months was 17.3% for mild LLL (LVI 10-19%), 9.2% for moderate LLL (LVI 20-39%), while only one patient (0.7%) developed severe LLL (LVI > 40%). The median interval to LLL onset was nine months. Transient edema resolving without intervention within six months was reported in an additional 22% of patients. Subjective LLL was reported by 10.7% of patients, though only a weak and partial correlation between subjective-report and objective-LVI was found. No risk factor directly related to LLL development was identified. CONCLUSIONS: The replacement of standard PLND by bilateral SLN biopsy in the surgical treatment of cervical cancer does not eliminate the risk of mild to moderate LLL, which develops irrespective of the number of SLN removed.

Two Patients With Meigs' Syndrome and Elevated Serum CA-125: A Case Report.

Patients with Meigs' syndrome and elevated serum CA-125 are not frequently reported. A 59-year-old woman and a 48-year-old woman sought help because of progressive shortness of breath caused by pleural effusion. The presence of a pelvic mass was noted in both the patients and was thought to be the cause of the effusion. Both patients had elevated serum CA-125, which raised the possibility of malignancy. After complete resection of the tumors, the pathologic reports confirmed a benign and a low-grade malignant ovarian neoplasia, respectively. We comment on the outcome and follow-up of these two cases and briefly review Meigs' syndrome.