Impact of Medicaid expansion on women with gynecologic cancer: a difference-in-difference analysis.

BACKGROUND: Women with gynecologic cancer face socioeconomic disparities in care that affect survival outcomes. The Affordable Care Act offered states the option to expand Medicaid enrollment eligibility criteria as a means of improving timely and affordable access to care for the most vulnerable. The variable uptake of expansion by states created a natural experiment, allowing for quasi-experimental methods that offer more unbiased estimates of treatment effects from retrospective data than the traditional regression adjustment. OBJECTIVE: To use a quasi-experimental, difference-in-difference framework to create unbiased estimates of impact of Medicaid expansion on women with gynecologic cancer. STUDY DESIGN: We performed a quasi-experimental retrospective cohort study from the National Cancer Database files for women with invasive cancers of the uterus, ovary and fallopian tube, cervix, vagina, and vulva diagnosed from 2008 to 2016. Using a marker for state Medicaid expansion status, we created difference-in-difference models to assess the impact of Medicaid expansion on the outcomes of access to and timeliness of care. We excluded women aged <40 years owing to the suppression of the state Medicaid expansions status in the data and women aged ≥65 years owing to the universal Medicare coverage availability. Our primary outcome was the rate of uninsurance at diagnosis. Secondary outcomes included Medicaid coverage, early-stage diagnosis, treatment at an academic facility, and any treatment or surgery within 30 days of diagnosis. Models were run within multiple subgroups and on a propensity-matched cohort to assess the robustness of the treatment estimates. The assumption of parallel trends was assessed with event study time plots. RESULTS: Our sample included 335,063 women. Among this cohort, 121,449 were from nonexpansion states and 213,614 were from expansion states, with 79,886 posttreatment cases diagnosed after the expansion took full effect in expansion states. The groups had minor differences in demographics, and we found occasional preperiod event study coefficients diverging from the mean, but the outcome trends were generally similar between the expansion and nonexpansion states in the preperiod, satisfying the necessary assumption for the difference-in-difference analysis. In a basic difference-in-difference model, the Medicaid expansion in January 2014 was associated with significant increases in insurance at diagnosis, treatment at an academic facility, and treatment within 30 days of diagnosis (P<.001 for all). In an adjusted model including all states and accounting for variable expansion implementation time, there was a significant treatment effect of Medicaid expansion on the reduction in uninsurance at diagnosis (-2.00%; 95% confidence interval, -2.3 to -1.7; P<.001), increases in early-stage diagnosis (0.80%; 95% confidence interval, 0.2-1.4; P=.02), treatment at an academic facility (0.83%; 95% confidence interval, 0.1-1.5; P=.02), treatment within 30 days (1.62%; 95% confidence interval, 1.0-2.3; P<.001), and surgery within 30 days (1.54%; 95% confidence interval, 0.8-2.3; P<.001). In particular, large gains were estimated for women living in low-income zip codes, Hispanic women, and women with cervical cancer. Estimates from the subgroup and propensity-matched cohorts were generally consistent for all outcomes besides early-stage diagnosis and treatment within 30 days. CONCLUSION: Medicaid expansion was significantly associated with gains in the access and timeliness of treatment for nonelderly women with gynecologic cancer. The implementation of Medicaid expansion could greatly benefit women in nonexpansion states. Gynecologists and gynecologic oncologists should advocate for Medicaid expansion as a means of improving outcomes and reducing socioeconomic and racial disparities.

Vulvar melanoma: an analysis of prognostic factors and treatment patterns.

OBJECTIVE: Melanoma comprises 5% to 10% of vulvar cancers and prognosis is poor. The purpose of this study was to identify prognostic factors and treatment patterns for vulvar melanoma using the National Cancer Database (NCDB). METHODS: The NCDB was queried for patients with invasive vulvar melanoma from 2004-2015. Descriptive statistics were generated to describe clinical and treatment details. Multivariable Cox regression and the Kaplan-Meier method were used to examine overall survival (OS). RESULTS: 1,917 patients with vulvar melanoma met inclusion criteria. Median follow-up time was 32 months (range, 0-151 months). Older age, larger tumor size, advanced disease stage, increased Charlson-Deyo comorbidity score, and care at a non-academic center were independent predictors for decreased OS. Surgical management of the primary site, lymph node surgery, and insurance provided a significant survival benefit. Use of immunotherapy for vulvar melanoma has increased over time. Two-year OS with immunotherapy in patients with distant metastatic disease was higher, although this did not reach statistical significance (33% vs. 12%, p=0.054). CONCLUSIONS: Vulvar melanoma has a poor prognosis for those with regional and distant metastatic disease. Extent of disease, tumor size, and patient age are important prognostic factors. Other favorable factors included insurance and surgical management. The use of immunotherapy has increased over time and may improve survival in those with distant disease. These data support further investigation into the role of immunotherapy for vulvar melanoma to optimize outcomes.

Vulvar intraepithelial neoplasia: Classification, epidemiology, diagnosis, and management.

Vulvar intraepithelial neoplasia (VIN) is classified into two entities: differentiated (dVIN) and vulvar high-grade squamous intraepithelial lesions (vH-SIL). dVIN is a premalignant lesion that develops on an existing vulvar lesion such as lichen sclerosus, while vH-SIL is associated with HPV infection. The two entities differ in terms of pathophysiology, background, prognosis, and management. The incidence of VIN in young women is rising and recurrence is common, even after radical surgery, which can cause significant disfigurement. Alternative strategies include topical treatments, ablation, and a watch-and-wait approach. There is currently no consensus on how these lesions should be managed. We review the literature in this field.

Survival disparities in vulvar cancer patients in Commission on Cancer®-accredited facilities.

OBJECTIVES: To investigate survival disparities and prognostic factors in vulvar cancer by age at diagnosis. METHODS: Women who underwent surgery and were diagnosed with stage I-IV vulvar cancer from 2004 to 2014 in the National Cancer Database were eligible. Proportions were compared using Chi-Square test. Survival was evaluated using Cox analysis. RESULTS: There were 18,207 eligible women. Median age at diagnosis was 64 years, and 31% diagnosed ≥75 years old were categorized as elderly. Most vulvar cancers were diagnosed at stage I and with squamous histology. Diagnosis with higher stage or non-squamous histology was more common in elderly vs. non-elderly patients (P < 0.001). Survival was 3.5 times worse in the elderly than the non-elderly (P < 0.0001). Risk of death for each 5-year increment in age increased by 22% for non-elderly and 43% for elderly patients (P < 0.0001). The prognostic value of comorbidity score, stage, regional node assessment and histology was smaller in elderly vs. non-elderly women (each P < 0.05). Adjuvant chemoradiotherapy (CTRT) use in the elderly vs. non-elderly was rare for stage I-II disease (3% vs. 2%) and more common for stage III-IV disease (6% vs. 43%), respectively (P < 0.0001). The survival disadvantage for elderly patients persisted following no adjuvant therapy, radiotherapy or chemotherapy alone, or CTRT (P < 0.0001). In stage III-IV disease, survival was superior following CTRT vs. radiotherapy when diagnosed <75 years (HR = 0.80, 95% CI = 0.69-0.93) but not in the elderly (HR = 0.99, P > 0.05). CONCLUSIONS: Age-associated risk of death increased at different rates in vulvar cancer and was larger in elderly vs. non-elderly patients. The impact of other prognostic factors was smaller in elderly vs. non-elderly women. The survival benefit of CTRT over radiotherapy in stage III-IV did not extend to the elderly.

Mean medical costs associated with vaginal and vulvar cancers for commercially insured patients in the United States and Texas.

OBJECTIVE: To estimate the average medical costs for vaginal and vulvar cancers in a commercially insured population in the U.S. and Texas. METHODS: 2011-2014U.S. MarketScan databases were used to estimate the average medical costs associated with vaginal and vulvar cancers. Women with newly diagnosed vaginal or vulvar cancer were matched to a comparison group without cancer using propensity score. Year 1 and year 2 costs after index diagnosis date were estimated. A generalized linear model was used to estimate the cost for censored months. The differential costs between groups were defined as the net costs associated with cancer diagnosis and treatment. RESULTS: The analysis included 355 women with vaginal cancer and 997 with vulvar cancer in the U.S. The year 1 and year 2 costs for vaginal cancer were $86,995 and $51,107, respectively. The year 1 and year 2 costs for vulvar cancer were $37,657 and $19,139, respectively. The major factors associated with higher monthly vaginal and vulvar cancer costs were higher Charlson Comorbidity Index score and higher medical costs prior to cancer diagnosis. Monthly costs for vaginal and vulvar cancers decreased rapidly from month 1 to month 6 after diagnosis and then remained stable. CONCLUSIONS: Seventy to 75% of all vaginal and vulvar cancers are due to HPV infections and mean medical costs associated with these cancers are substantial. These data will serve as key cost parameters in the economic evaluation of HPV vaccination dissemination and estimation of the long-term net economic benefit of promoting HPV vaccination.

Sentinel lymph node status in vulval cancer: systematic reviews of test accuracy and decision-analytic model-based economic evaluation.

BACKGROUND: Vulval cancer causes 3-5% of all gynaecological malignancies and requires surgical removal and inguinofemoral lymphadenectomy (IFL). Complications affect > 50% of patients, including groin wound infection, lymphoedema and cellulitis. A sentinel lymph node (SLN) is the first groin node with the highest probability of malignancy. SLN biopsy would be useful if it could accurately identify patients in whom cancer has spread to the groin, without removing all groin nodes. SLNs can be identified by isosulfan blue dye and/or technetium-99 ((99m)Tc) radioactive tracer during lymphoscintigraphy. The blue dye/(99m)Tc procedure only detects SLN, not metastases - this requires histological examination, which can include ultrastaging and staining with conventional haematoxylin and eosin (H&E) or immunohistochemistry. OBJECTIVES: To determine the test accuracy and cost-effectiveness of the SLN biopsy with (99m)Tc and/or blue dye compared with IFL or clinical follow-up for test negatives in vulval cancer, through systematic reviews and economic evaluation. DATA SOURCES: Standard medical databases, including MEDLINE, EMBASE, Science Citation Index and The Cochrane Library, medical search gateways, reference lists of review articles and included studies were searched to January 2011. METHODS: For accuracy and effectiveness, standard methods were used and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were to January 2011, with no language restrictions. Meta-analyses were carried out with Meta-Disc version 1.4 (Javier Zamora, Madrid, Spain) for accuracy; none was appropriate for effectiveness. The economic evaluation from a NHS perspective used a decision-tree model in DATA TreeAge Pro Healthcare 2001 (TreeAge Software, Inc., Williamstown, MA, USA). Six options (blue dye with H&E, blue dye with ultrastaging, (99m)Tc with H&E, (99m)Tc with ultrastaging, blue dye/(99m)Tc with H&E, blue dye/(99m)Tc with ultrastaging) were compared with IFL. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS: For accuracy, of the 26 included studies, most evaluated (99m)Tc/blue dye combined. Four studies had clinical follow-up only for test negatives and five had clinical follow-up for all and IFL for test negatives. Numbers with no SLN found were difficult to distinguish from those with negative SLN biopsies. The largest group of 11 studies using (99m)Tc/blue dye, ultrastaging and immunohistochemistry had a pooled sensitivity of 95.6% [95% confidence interval (CI) 91.5% to 98.1%] and a specificity of 100% (95% CI 99.0% to 100%). Mean SLN detection rates were 94.6% for (99m)Tc, 68.7% for blue dye and 97.7% for both. One study measured global health status quality of life (QoL) and found no difference between SLN biopsy and IFL. One patient preference evaluation showed that 66% preferred IFL rather than a 5% false-negative rate from SLN biopsy. For effectiveness, of 14,038 references, one randomised controlled trial, three case-control studies and 13 case series were found. Approximately 50% died from vulval cancer and 50% from other causes during follow-ups. Recurrences were in the ratio of approximately 4 : 2 : 1 vulval, groin and distant, with more recurrences in node-positive patients. No studies reported QoL. For cost per death averted, IFL was less costly and more effective than strategies using SLN biopsy. For morbidity-free survival and long-term morbidity-free survival, (99m)Tc with ultrastaging was most cost-effective. Strategies with blue dye only and H&E only were never cost-effective. The incremental cost-effectiveness ratio for (99m)Tc with ultrastaging compared with IFL was £4300 per case of morbidity-free survival and £7100 per long-term morbidity-free survival. LIMITATIONS: The main limitations of this study include the lack of good-quality evidence on accuracy, effectiveness and QoL. A large project such as this takes time to publish, so the most recent studies are not included. CONCLUSIONS: A sensitive and specific combined metastatic SLN detection test and information on generic QoL in vulval cancer is urgently required. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Racial disparities and changes in clinical characteristics and survival for vulvar cancer over time.

OBJECTIVE: The purpose of this study was to examine changes over time in survival for African-American (AA) and white women diagnosed with squamous cell carcinoma of the vulva. STUDY DESIGN: The Surveillance, Epidemiology, and End Results (SEER) Program for 1973-2009 was used for this analysis. We evaluated racial differences in survival between AA and white women. Kaplan-Meier and Cox proportional hazards survival methods were used to assess differences in survival by race by decade of diagnosis. RESULTS: The study sample included 5867 women, including 5379 whites (91.6%) and 488 AA (8.3%). AA women were younger (57 vs 67 years; P < .001) and had a higher rate of distant metastasis (6.1% vs 3.7%; P < .001). AA women had surgery less frequently (84.2% vs 87.6%; P = .03) and more frequently radiotherapy (24.2% vs 20.6%; P < .001). AA women had a hazard ratio (HR) of 0.84 (95% confidence interval [CI], 0.74-0.95) of all-cause mortality and 0.66 (95% CI, 0.53-0.82) of vulvar cancer mortality compared with whites. Adjusting for SEER Registry, marital status, stage, age, surgery, radiotherapy, grade, lymph node status, and decade, AA women had an HR of 0.67 (95% CI, 0.53-0.84) of vulvar cancer-related mortality compared with whites. After adjusting for the same variables, there was a significant difference in survival between AA and whites in the periods of 1990-1999 (HR, 0.62; 95% CI, 0.41-0.95) and 2000-2009 (HR, 0.46; 95% CI, 0.30-0.72) but not earlier. CONCLUSION: AA presented at a significantly younger age compared with white women and had better survival compared with whites.

Bartholin's gland carcinoma: epidemiology and therapeutic management.

Primary carcinoma of the Bartholin's gland is a very rare malignancy of the vulva. Of the utmost importance in the management of these tumors is the management by specialized gynecological oncologist at referral centres. Gynecologists should always consider these unusual neoplasms as a differential diagnosis of potentially benigns lesions of Bartholin's gland. Treatment modality must be tailored to each patient: each histological type of these unusual neoplasms has their natural history and may require a different level of operative aggressiveness to obtain the optimal outcome. Given the rarity of this disease, there have been no prospective randomized trials to evaluate optimal treatment. Therapeutic principles in the management of median vulvar cancer are applicable for Bartholin's gland carcinoma. In this review, we aim to update the current knowledge on the treatment of Bartholin's gland carcinoma.

Economic burden of vulvar and vaginal intraepithelial neoplasia: retrospective cost study at a German dysplasia centre.

BACKGROUND: Human papillomavirus is responsible for a variety of diseases including grade 2 and 3 vulvar and vaginal intraepithelial neoplasia. The aim of this study was to assess parts of the burden of the last diseases including treatment costs. The direct medical resource use and cost of surgery associated with neoplasia and related diagnostic procedures (statutory health insurance perspective) were estimated, as were the indirect costs (productivity losses) associated with surgical treatment and related gynaecology visits for diagnostic purposes. METHODS: Data from 1991-2008 were retrospectively collected from patient records of the outpatient unit of the Gynaecological Dysplasia Clinic, Heinrich Heine University, Dusseldorf, Germany. Two subgroups of patients were analysed descriptively: women undergoing one surgical procedure related to a diagnosis of vulvar and/or vaginal intraepithelial neoplasia, and women undergoing two or more surgical procedures. Target measures were per-capita medical resource consumption, direct medical cost and indirect cost. RESULTS: Of the 94 women analysed, 52 underwent one surgical intervention and 42 two or more interventions (mean of 3.0 interventions during the total period of analysis). Patients undergoing one surgical intervention accrued €881 in direct costs and €682 in indirect costs; patients undergoing more than one intervention accrued €2,605 in direct costs and €2,432 in indirect costs. CONCLUSIONS: The economic burden on German statutory health insurance funds and society induced by surgical interventions and related diagnostic procedures for grade 2/3 vulvar and vaginal neoplasia should not be underrated. The cost burden is one part of the overall burden attributable to human papillomavirus infections.

Management options for vulvar carcinoma in a low resource setting.

BACKGROUND: Vulvar carcinoma is a rare tumor of the female genital tract. In Nigeria, very few studies have looked at the management options for vulvar carcinoma. The objective of this study was therefore, to describe the management options available and the challenges in treating this malignancy in Nigeria. METHODS: A descriptive study of all vulvar cancer cases managed at the Nnamdi Azikiwe University Teaching Hospital, Nnewi over a 12 year period (1998-2009). The theatre, ward register, histo-pathologic records and case notes of all women who had surgery for vulvar carcinomas were retrieved and socio-demographic characteristics, clinical presentation, type of surgery, histologic type and complications of treatment were retrieved and analyzed. RESULTS: There were 867 gynecological malignancies and vulval carcinoma accounted for 11 cases, giving a prevalence of 1.27%. The ages ranged from 54 to 79 years with a mean of 61.2 years. Parity was 2-14, with a mean of 6.7 ± 2.33. Most of the patients were of low socio-economic class. All the 11 patients had surgery as 1st line treatment. Radical vulvectomy was done for 6 cases since they presented in the advanced stage. The complications of surgery included hemorrhage (18.2%), chronic lymphedema, wound infection and anesthetic complications. There were no hospital mortalities. Late presentation, with stage III (45.4%) was the commonest stage at presentation while the majority of the vulvar carcinomas (72.7%) were of epithelial origin. Squamous cell carcinoma predominated (63.6%). CONCLUSION: Carcinoma of the vulva is a rare gynecological malignancy in Nigeria. Surgery and radiotherapy remains the mainstay of this disease in Nigeria and can be highly successful if patients present early.

Healthcare resource use and costs associated with cervical, vaginal and vulvar cancers in a large U.S. health plan.

OBJECTIVES: To estimate healthcare resource utilization and costs of cervical, vulvar and vaginal cancers in a large U.S. health plan. METHODS: We estimated incremental ambulatory visits, hospitalizations, prescription fills and healthcare costs for cancer cases relative to population controls. Data for cervical (n=2788), vulvar (n=621) and vaginal cancer (n=254) cases and an identical number of controls were obtained from a large U.S. health plan. Cases were identified via diagnostic codes on a healthcare claim and matched to controls. Incremental resource use was assessed using a two-stage regression method developed by Carides, with costs analyzed using Lin's regression method. RESULTS: Through 4 years of follow-up, cervical cancer patients had incremental resource use of 12.0 ambulatory visits, 0.6 hospital admissions and 7.0 prescription fills per case. Cumulative 4-year incremental healthcare costs per case ranged from $8236 for vulvar cancers to $18,799 for cervical cancers. When adjusted to cervical, vulvar and vaginal cancer excess mortality rates observed within the U.S. Surveillance Epidemiology and End Results program, estimated incremental costs were $29,649 for cervical, $11,356 for vulvar and $21,963 for vaginal cancers. There was a significant upward trend in costs with increasing age for cervical cancer, however trends were less consistent for vulvar and vaginal cancers. CONCLUSIONS: Direct medical costs associated with cervical, vulvar and vaginal cancers were observed to be substantial. These data can help inform evaluations of the economic burden and cost-effectiveness of prevention of these cancers, particularly for vulvar and vaginal disease, where such data have not been previously reported.

Demographic, clinical, and treatment trends among women diagnosed with vulvar cancer in the United States.

OBJECTIVE: Describe the treatment and survival patterns among a population-based sample of vulvar cancer patients diagnosed in the United States in 1999. METHODS: Cases were identified for the National Cancer Institute's Patterns of Care Study (POC) using the Surveillance, Epidemiology, and End Results Program (SEER). A stratified random sample of non-Hispanic white, non-Hispanic black, and Hispanic women age 20 years and older was selected from cases reported by 11 SEER registries. Analyses of the association between vulvar cancer and key demographic, clinical, and hospital characteristics by stage were performed. Cox proportional hazards was used to estimate the odds of death due to cancer. All estimates were weighted, and analyses were conducted with SUDAAN. RESULTS: Ninety percent of cases were diagnosed with in situ or early-stage invasive disease. Older patients were more likely to present at advanced stages. Twenty-five percent of women with Stage III-IV vulvar cancer received chemotherapy plus radiation. We noted widespread use of radical local excision among women with Stage I/II cancer, but 46-54% with invasive disease underwent a radical or total vulvectomy. Factors associated with cancer death were limited to age and stage. Women 75 years and older were at higher risk compared to women aged 20-49 years and the risk of death increased with advancing stage. CONCLUSIONS: Vulvar cancer is diagnosed at early stages. Late-stage disease is associated with a significant increase in mortality. Radical surgery was still commonly performed in 1999. Radiation was more common in women diagnosed at late stage, while the use of chemoradiation remained limited.

Clinical trials in gynecological cancer.

The Gynecologic Cancer Intergroup is comprised representatives from international gynecological cancer trials organizations, which collaborate in multicenter studies to answer the clinical challenges in gynecological cancer. This review article highlights the key clinical questions facing clinical trialists over the next decade, the information and infrastructure resources available for trials, and the methods of trial development. We cover human papillomavirus (HPV)-associated neoplasia, including cervical cancer, together with endometrial cancer, ovarian cancer, and vulvar cancer. Infrastructure for clinical trials includes a database for trials, templates for protocol development, patient educational material, and financial support for clinical trials. Other critical issues include support from government and charities and government regulations.

The prevention and management of treatment related morbidity in vulval cancer.

The traditional and the most common management of primary vulval cancer is radical surgery of the vulva and radical groin lymphadenectomy (unilateral or bilateral). Adjuvant radiotherapy is used in poor prognosis cases. Rare vulval cancers, locally advanced cancers and recurrent vulval cancers often are treated with a combination of surgery, radiation therapy and chemotherapy. The treatments, while often curative, are associated with considerable morbidity, which, until recently, has not been well publicized or quantified. Increasingly, younger patients are presenting with extensive and often multi-focal pre-invasive disease and with vulval cancer. Long-term post-treatment physical, sexual and psychological morbidity is of major concern. There is more onus on clinicians to provide less radical but equally curative treatment, while also reducing morbidity. There is also the need to provide treatment and treatment modification based on supporting evidence. For a rare disease such as vulval cancer it is more difficult to generate data and to conduct trials on treatment modifications. Although surgical modifications have been made, the morbidity of radical surgery for vulval cancer is considerable. The prevention and management of treatment-related morbidity will continue to challenge the gynaecological oncology team.

Standards for the management of cervical and vulval carcinoma.

OBJECTIVE: To examine the feasibility of achieving designated target standards for the management of women with cervical and vulval cancer. DESIGN: Retrospective casenote review. SETTING: The Gynaecological Oncology Centre at Hammersmith Hospital, London. POPULATION: Sixty-one women with cervical and vulval cancer presenting to the gynaecological oncology clinic at the Hammersmith Hospital during 1996 and 1997. Various aspects of the management of those women were compared with standards suggested by a multidisciplinary panel of local experts. Targets included the referral and treatment process, the accuracy of staging, and measures of surgical performance. RESULT: The target interval of seven days between receipt of the referral and the first visit at the cancer centre was achieved in 93% of women. Surgical treatment was administered to 92% of the women within the target of 20 working days from the first clinic appointment. Tumour close to or involving the margins of the specimen was noted in 13% of cervical and 9% of vulval cancers. The node count fell below the target standards in 13% of pelvic and 10% of groin dissections. Appropriate imaging investigations for staging were not undertaken in 15 of 39 cases (38%) of cervical cancer and in 5 out of 22 (23%) of vulval cancers. CONCLUSION: The suggested targets of process and surgical performance are reasonable and achievable. These standards would be appropriate for national use. The area most clearly identified where these targets were not achieved was the requesting of complementary staging investigations. This could be addressed by the use of a simple investigation protocol to be included in each patient's notes and available at specialist clinics and gynaecology wards.

[Cancer of the vulva. Supplementary analysis of its incidence at our hospital (1973-1978)]. / Cáncer de vulva. Epicrisis de su incidencia en nuestro hospital (1973-1978).

The author studies the cases of carcinoma of the vulva seen in the Service of Gynecology of the "Ciudad Sanitaria 'José Antonio; de la Seguridad Social" in Zaragoza, analyzing their incidence, epidemiology, pathologic anatomy, symptomatology, topography, classification and therapy. The author shows his results.