Patterns of First Recurrence and Oncological Outcomes in Locally Advanced Cervical Cancer Patients: Does Surgical Staging Play a Role?

BACKGROUND: We aimed to determine whether surgical aortic staging by minimally invasive paraaortic lymphadenectomy (PALND) affects the pattern of first recurrence and survival in treated locally advanced cervical cancer (LACC) patients when compared to patients staged by imaging (noPALND). METHODS: This study was a multicenter observational retrospective cohort study of patients with LACC treated at tertiary care hospitals throughout Spain. The inclusion criteria were histological diagnosis of squamous carcinoma, adenosquamous carcinoma, and/or adenocarcinoma; FIGO stages IB2, IIA2-IVA (FIGO 2009); and planned treatment with primary chemoradiotherapy between 2000 and 2016. Propensity score matching (PSM) was performed before the analysis. RESULTS: After PSM and sample replacement, 1092 patients were included for analysis (noPALND n = 546, PALND n = 546). Twenty-one percent of patients recurred during follow-up, with the PALND group having almost double the recurrences of the noPALND group (noPALND: 15.0%, PALND: 28.0%, p < 0.001). Nodal (regional) recurrences were more frequently observed in PALND patients (noPALND:2.4%, PALND: 11.2%, p < 0.001). Among those who recurred regionally, 57.1% recurred at the pelvic nodes, 37.1% recurred at the aortic nodes, and 5.7% recurred simultaneously at both the pelvic and aortic nodes. Patients who underwent a staging PALND were more frequently diagnosed with a distant recurrence (noPALND: 7.0%, PALND: 15.6%, p < 0.001). PALND patients presented poorer overall, cancer-specific, and disease-free survival when compared to patients in the noPALND group. CONCLUSION: After treatment, surgically staged patients with LACC recurred more frequently and showed worse survival rates.

A restrictive stoma policy after colorectal anastomosis in ovarian cancer based on ghost ileostomy use.

BACKGROUND: The incidence of anastomotic leak after colorectal anastomosis in ovarian cancer has been reported to be much lower than that in colorectal cancer patients. Regarding the use of protective manoeuvres (diverting ileostomy) as suggested by clinical guidelines, the goal should be the implementation of a restrictive stoma policy for ovarian cancer patients, given the low rate of anastomotic leakage in this population. MATERIAL AND METHODS: Patients who underwent cytoreduction surgery in a single centre (University Hospital La Fe, Valencia Spain) due to ovarian cancer between January 2010 and June 2023 were classified according to two groups: a non-restrictive stoma policy group (Group A) and a restrictive stoma policy group (Group B). RESULTS: A total of 256 patients were included in the analysis (group A 52 % vs group B 48 %). The use of protective diverting ileostomy was lower in the restrictive stoma policy group (14 % vs 6.6 %), and the use of ghost ileostomy was 32 % vs 87 % in groups A and B, respectively (p < 0.00001). No differences were found in the anastomotic leak rate, which was 5.2 % in the non-restrictive group and 3.2 % in the restrictive stoma policy group (p = 0.54). CONCLUSION: The use of a restrictive stoma policy based on the use of ghost ileostomy reduces the rate of diverting ileostomy in patients with ovarian cancer after colorectal resection and anastomosis. Furthermore, this policy is not associated with an increased rate of anastomotic leakage nor with an increased rate of morbi-mortality related to the leak.

Oncological outcomes of intraperitoneal chemotherapy in advanced ovarian cancer: BRCA mutation role.

INTRODUCTION: The knowledge of BRCA status offers a chance to evaluate the role of the intraperitoneal route in patients selected by biomolecular profiles after primary cytoreduction surgery in advanced ovarian cancer. MATERIALS AND METHODS: We performed a retrospective, multicenter study to assess oncological outcomes depending on adjuvant treatment (intraperitoneal [IP] vs intravenous [IV]) and BRCA status (BRCA1/2 mutated vs. BRCA wild type [WT]). The primary endpoint was to determine progression-free survival. The secondary objectives were overall survival and toxicity. RESULTS: A total of 288 women from eight centers were included: 177 in the IP arm and 111 in the IV arm, grouped into four arms according to BRCA1/2 status. Significantly better PFS was observed in BRCA1/2-mutated patients with IP chemotherapy (HR: 0.35; 95% CI, 0.16-0.75, p = 0.007), which was not present in BRCA1/2-mutated patients with IV chemotherapy (HR: 0.65; 95% CI, 0.37-1.12, p = 0.14). Significantly better OS was also observed in IP chemotherapy (HR: 0.17; 95% CI, 0.06-043, p < 0.0001), but was not present in IV chemotherapy in relation with BRCA mutation (HR: 0.52; 95% CI, 0.22-1.27, p = 0.15). For BRCA WT patients, worse survival was observed regardless of the adjuvant route used. The IP route was more toxic compared to the IV route, but toxicity was equivalent at the long-term follow-up. CONCLUSION: This retrospective study suggests that BRCA status can help to offer an individualized, systematic treatment after optimal primary surgery for advanced ovarian cancer, but is limited by the small sample size. Prospective trials are essential to confirm these results.

Procalcitonin and C-reactive protein as early markers of anastomotic leakage in intestinal resections for advanced ovarian cancer (EDMOCS).

INTRODUCTION: Serum levels of procalcitonin and C-reactive protein (CRP) have been used to predict anastomotic leakage after colorectal surgery, but information is scarce in advanced ovarian cancer (AOC) surgery with bowel resection. This study aimed to assess the predictive value of procalcitonin and CRP in detecting anastomotic leakage after AOC surgery with bowel resection. The study also aimed to determine the optimal postoperative reference values and the best day for evaluating these markers. MATERIAL AND METHODS: This prospective, observational and multicentric trial included 92 patients with AOC undergoing debulking surgery with bowel resection between 2017 and 2020 in 10 reference hospitals in Spain. Procalcitonin and CRP levels were measured at baseline and on postoperative days 1-6. Receiver operating characteristic analysis was performed to evaluate the predictive value of procalcitonin and CRP at each postoperative day. Sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: Anastomotic leakage was detected in six patients (6.5%). Procalcitonin and CRP values were consistently higher in patients with anastomotic leakage at all postoperative days. The maximum area under the curve (AUC) for procalcitonin was observed at postoperative day 1 (AUC = 0.823) with a cutoff value of 3.8 ng/mL (83.3% sensitivity, 81.3% specificity). For CRP, the maximum AUC was found at postoperative day 3 (AUC = 0.833) with a cutoff level of 30.5 mg/dL (100% sensitivity, 80.4% specificity). CONCLUSIONS: Procalcitonin and C-reactive protein are potential biomarkers for early detection of anastomotic leakage after ovarian cancer surgery with bowel resection. Further prospective studies with a larger sample size are needed to confirm these findings.

Accuracy of ICG compared with technetium-99 m for sentinel lymph node biopsy in vulvar cancer.

PURPOSE: Sentinel lymph node biopsy with radioactive tracer is the standard-of-care in lymph node status assessment in vulvar cancer. Indocyanine green fluorescence-ICG is a promising detection method, due to its advantages over technetium-99 m. In vulvar cancer, the procedure is controversial due to study heterogeneity and the small sample size in previous studies. This study evaluates ICG sentinel lymph node detection compared with the criterion-standard with technetium (dual modality method). METHODS: Preoperative technetium and intraoperative ICG for sentinel lymph node have been prospectively evaluated in early-stage vulvar cancer. The primary endpoint was to determine accuracy in the detection rate for ICG compared with technetium. Secondary objectives included tracer modality relationship with obesity, tumor size and location. RESULTS: In total, 75 patients participated at 8 centers; 38 had lateral and 37 had midline vulvar tumors. The overall sentinel lymph node detection rate was 85.3 % for technetium and 82.7 % for ICG. For lateral tumors, the detection rate was 84.2 % vs. 89.5 %, while it was 86.5 % vs. 75.7 % for middle tumors, using technetium and ICG, respectively. The median sentinel node harvest was 1.7 (range 1-4), with 24 % metastatic involvement. The sensitivity and positive predictive value for ICG based on the standard technique with technetium was 91.08 % (95 % CI, 83.76-95.84) and 94.8 % (95 % CI, 84.84-96.48), respectively. No significant differences were found comparing the two tracers in patients with midline lesions, obesity (body mass index ≥ 30) and tumor size ≥ 2-4 cm. CONCLUSION(S): ICG shows comparable performance parameters to the gold-standard of radioisotope localization.

Endometrial cancer: predictors and oncological safety of tumor tissue manipulation.

PURPOSE: The main goal of this study is to assess the impact of tumor manipulation on the presence of lympho-vascular space invasion and its influence on oncological results. METHODS: We performed a retrospective multi-centric study amongst patients who had received primary surgical treatment for apparently early-stage endometrial cancer. A multivariate statistical analysis model was designed to assess the impact that tumor manipulation (with the use of uterine manipulator or preoperative hysteroscopy) has on lympho-vascular development (LVSI) in the final surgical specimen. RESULTS: A total of 2852 women from 15 centers were included and divided into two groups based on the lympho-vascular status in the final surgical specimen: 2265 (79.4%) had no LVSI and 587 (20.6%) presented LVSI. The use of uterine manipulator was associated with higher chances of lympho-vascular involvement regardless of the type used: Balloon manipulator (HR: 95% CI 4.64 (2.99-7.33); p < 0.001) and No-Balloon manipulator ([HR]: 95% CI 2.54 (1.66-3.96); p < 0.001). There is no evidence of an association between the use of preoperative hysteroscopy and higher chances of lympho-vascular involvement (HR: 95% CI 0.90 (0.68-1.19); p = 0.479). CONCLUSION: Whilst performing common gynecological procedures, iatrogenic distention and manipulation of the uterine cavity are produced. Our study suggests that the use of uterine manipulator increases the rate of LVSI and, therefore, leads to poorer oncological results. Conversely, preoperative hysteroscopy does not show higher rates of LVSI involvement in the final surgical specimen and can be safely used.

Sensibilización cutánea a aero alérgenos en niños con rinitis y asma / Skin sensitization to aero-allergens in children with rhinitis and asthma

Introducción: Las enfermedades alérgicas son muy comunes en la población pediátrica. Entre las causas frecuentes se encuentran los aeroalérgenos del ambiente, y la identificación de estos es de gran ayuda tanto para el diagnóstico como para el tratamiento. Objetivos: Determinar la frecuencia de aeroalérgenos, por medio de la determinación de Inmunoglobulina E (IgE) específica a alérgenos comunes por la prueba de sensibilidad cutánea en pacientes pediátricos con síntomas de asma y rinitis alérgica. Materiales y Métodos: Diseño observacional, descriptivo, prospectivo, transversal, población de pacientes de 4 a 17 años con síntomas compatibles con asma y rinitis alérgica que acudieron a un centro asistencial pediátrico en el periodo de estudio. Se realizó por medio de las Pruebas de punción cutánea (PCP). Resultados: La edad media de los pacientes fue de 8 años, 57% pacientes de sexo masculino y 43% de sexo femenino. El 53% de los pacientes presenta rinitis y asma, 45% solo rinitis y el 2% solo asma. El 79% de los pacientes presentó reacción positiva de sensibilización alérgica por medio de la PCP. Teniendo en cuenta la sensibilización por tipo de aeroalérgenos se tuvo que el 64% de los pacientes tuvo reacción positiva a ácaros, 19% a animales 18% a cucarachas, 8% a pólenes y 6% a hongos. Conclusión: La gran mayoría de pacientes con asma padecía rinitis alérgica concomitante y los ácaros del polvo fueron los aeroalérgenos más frecuentemente determinados en las pruebas cutáneas de alergia en niños con asma y rinitis de nuestra población.

Introduction: Allergic diseases are very common in the pediatric population. Among the frequent causes are aeroallergens from the environment and the identification of these is a great help for diagnosis and treatment. Objectives: To determine the frequency of aeroallergens, through the determination of Immunoglobulin E (IgE) specific to common allergens by the skin sensitivity test in pediatric patients with symptoms of asthma and allergic rhinitis. Materials and Methods: Observational, descriptive, prospective, cross-sectional design, population of patients from 4 to 17 years old with symptoms compatible with asthma and allergic rhinitis who attended a pediatric care center during the study period. It was carried out by means of Skin Puncture Tests (PCP). Results: The mean age of the patients was 8 years, 57% male patients and 43% female. 53% of the patients presented Rhinitis and Asthma, 45% only Rhinitis and 2% only Asthma. 79% of the patients presented a positive allergic sensitization reaction through PCP. Taking into account the sensitization by type of aeroallergens, 64% of the patients had a positive reaction to mites, 19 % to animals 18% to cockroaches, 8% to pollens and 6% to fungi. Conclusion: The vast majority of patients with asthma suffered from concomitant allergic rhinitis and dust mites were the most frequently determined aeroallergens in allergic skin tests in children with asthma and rhinitis in our population.

Caracterización clínica de insuficiencia cardiaca en pacientes internados en el Instituto Nacional de Cardiología, Paraguay

Introducción: la insuficiencia cardiaca es una de las enfermedades cardiovasculares más prevalentes en la población general y el estadio obligatorio de todas las patologías cardiovasculares, la cual irá en aumento a medida que crezca la expectativa de vida de la población. Objetivo: determinar las características de pacientes con insuficiencia cardiaca internados en el Instituto Nacional de Cardiología de Paraguay, durante un periodo de tres meses del año 2020. Metodología: estudio descriptivo de una muestra de 140 pacientes con diagnóstico de insuficiencia cardiaca. Los criterios para establecer este diagnóstico fueron clínicos y/o ecocardiográficos. Resultados: la media de edad fue 66 años, 57% del sexo masculino. El 88% de los pacientes presentaron hipertensión arterial. La etiología más frecuente fue la isquémica (26%), la mayoría consultó en clase funcional III y presentó fracción de eyección reducida, calculándose una prevalencia institucional 7,2%. Conclusión: el perfil del paciente con diagnóstico de insuficiencia cardiaca que consulta en este servicio es de un hombre de aproximadamente 66 años en clase funcional III, con fracción de eyección reducida y de etiología isquémica, cuyas patologías de base son hipertensión arterial y diabetes mellitus.

Introduction: Heart failure is one of the most prevalent cardiovascular diseases in the general population and the mandatory stage of all cardiovascular pathologies, which will increase as the life expectancy of the population grows. Objective: To determine the characteristics of patients with heart failure hospitalized at the National Institute of Cardiology of Paraguay, during a period of three months of the year 2020. Methodology: Descriptive study of a sample of 140 patients diagnosed with heart failure. The criteria to establish this diagnosis were clinical and/or echocardiographic. Results: The average age was 66 years, 57% male, and 88% of the patients had arterial hypertension. The most frequent etiology was ischemic (26%), the majority consulted in functional class III and presented reduced ejection fraction, calculating an institutional prevalence of 7.2%. Conclusion: The profile of the patient with a diagnosis of heart failure who consults in this service is that of a man of approximately 66 years old, in functional class III, with reduced ejection fraction and ischemic etiology, whose underlying pathologies are arterial hypertension and diabetes mellitus.

Evaluación de resultados en una serie de pacientes con trasplante cardiaco: experiencia en el Instituto Nacional de Cardiología

Exponemos la experiencia del Instituto Nacional de Cardiología de una serie de casos de pacientes sometidos a trasplante cardiaco entre mayo de 2016 y junio 2022. Se realizaron 14 trasplantes, 13 fueron del sexo masculino. La edad osciló entre 19 y 62 años. Las etiologías fueron cardiopatías de tipo idiopática en 57% y valvular en 21%. El 50% se trasplantó en INTERMACS 4 (Interagency Registry for Mechanically Assisted Circulatory Support), 21% INTERMACS 3 y solo 28% en INTERMACS 2. Tres pacientes se trasplantaron con asistencia circulatoria tipo membrana circulación extracorpórea. Las complicaciones más frecuentes fueron las infecciosas. La mortalidad hospitalaria fue 35,7%. Hubo un fallecido en el seguimiento tras 5 años de trasplante.

We present the experience of the National Institute of Cardiology of a series of cases of patients undergoing heart transplantation between May 2016 and June 2022. Fourteen transplants were performed, 13 of the patients were male. The age ranged between 19 and 62 years. The etiologies were idiopathic heart disease in 57% and valvular heart disease in 21%. Fifty percent was transplanted in INTERMACS 4 (Interagency Registry for Mechanically Assisted Circulatory Support), 21% in INTERMACS 3 and only 28% in INTERMACS 2. Three patients were transplanted with membrane type extracorporeal circulation circulatory support. The most frequent complications were infectious. Hospital mortality was 35.7%. There was one patient who died during follow-up after 5 years of transplantation.

Comparation between the Bricker ileal conduit vs double-barrelled wet colostomy after pelvic exenteration for gynaecological malignancies.

BACKGROUND: After exhausting other therapeutic options, pelvic exenteration is performed in patients who suffer from relapsed gynaecologic tumours, with most of them requiring some sort of urinary diversion. MATERIAL AND METHODS: The main objective of this study was to assess the short- and medium/long-term urinary complications associated with the Bricker ileal conduit versus double-barrelled wet colostomy after performing a pelvic exenteration for gynaecologic malignancies. RESULTS: A total of 61 pelvic exenterations were identified between November 2010 and April 2022; 29 Bricker ileal conduits and 20 double-barrelled wet colostomies were included in the urinary diversion analysis. Regarding the specific short-term urinary complications, no differences were found in the rate of urinary leakage (3 vs 0 %; p = 1), urostomy complications (7 vs 0 %; p = 0.51), acute renal failure (10 vs 20 %; p = 0.24) or urinary infection (0 vs 5 %; p = 0.41). Up to 69 % of patients with Bricker ileal conduits and 65 % of double-barrelled wet colostomies (p = 0.76) presented specific medium/long-term urinary complications. No differences in the rates of pyelonephritis (59 vs 53 %; p = 0.71), urinary fistula (0 vs 12 %; p = 0.13), ureteral stricture (10 vs 6 %; p = 1), conduit failure and reconstruction (7 vs 0 %; p = 0.53), renal failure (38 vs 29 %; p = 0.56) or electrolyte disorders (24 vs 18 %; p = 0.72) were found. CONCLUSIONS: There are no significant differences in the rate of complications between double-barrelled wet colostomy and the Bricker ileal conduit. The long-term complications related to urinary diversion remained high regardless of the type of technique. In this context, the double-barrelled wet colostomy presents advantages such as the single stoma placement and the simplicity of the technique.

Molecular Management of High-Grade Serous Ovarian Carcinoma.

High-grade serous ovarian carcinoma (HGSOC) represents the most common form of epithelial ovarian carcinoma. The absence of specific symptoms leads to late-stage diagnosis, making HGSOC one of the gynecological cancers with the worst prognosis. The cellular origin of HGSOC and the role of reproductive hormones, genetic traits (such as alterations in P53 and DNA-repair mechanisms), chromosomal instability, or dysregulation of crucial signaling pathways have been considered when evaluating prognosis and response to therapy in HGSOC patients. However, the detection of HGSOC is still based on traditional methods such as carbohydrate antigen 125 (CA125) detection and ultrasound, and the combined use of these methods has yet to support significant reductions in overall mortality rates. The current paradigm for HGSOC management has moved towards early diagnosis via the non-invasive detection of molecular markers through liquid biopsies. This review presents an integrated view of the relevant cellular and molecular aspects involved in the etiopathogenesis of HGSOC and brings together studies that consider new horizons for the possible early detection of this gynecological cancer.

OVA-LEAK: Prognostic score for colo-rectal anastomotic leakage in patients undergoing ovarian cancer surgery.

OBJECTIVE: The objective of the present study was to define and validate an anastomotic leak prognostic score based on previously described and reported anastomotic leak risk factors (OVA-LEAK: https://n9.cl/ova-leakscore) and to establish if the use of OVA-LEAK score is better than clinical criteria (surgeon's choice) selecting anastomosis to be protected with a diverting ileostomy. MATERIAL & METHODS: This is a retrospective, multicentre cohort study that included patients who underwent cytoreductive surgery for primary advanced or relapsed ovarian cancer with colorectal resection and anastomosis between January 2011 and June 2021. Data from patients already included in the previous predictive model were not considered in the present analysis. To validate the performance of our logistic regression model, we used the OVA-LEAK formula (Annex I: https://n9.cl/ova-leakscore) for estimating leakage probabilities in a new independent cohort. Then, receiver operating characteristic (ROC) analysis was performed and area under the curve (AUC) was used to measure the performance of the model. Additionally, the Brier score was also estimated. 95% confidence intervals (CI) for each of the estimated performance measures were also calculated. RESULTS: 848 out of 1159 recruited patients were finally included in the multivariable logistic regression model validation. The AUC of the new cohort was 0.63 for predicting anastomotic leak. Considering a cut-off point of 22.1% to be 'positive' (to get a leak) this would provide a sensitivity of 0.45, specificity of 0.80, positive predictive value of 0.09 and negative predictive value of 0.97 for anastomotic leak. If we consider this cut-off point to select patients at risk of leak for bowel diversion, up to 22.5% of the sampled patients would undergo a diverting ileostomy and 47% (18/40) of the anastomotic leaks would be 'protected' with the stoma. Nevertheless, if we consider only the 'clinical criteria' for performing or not a diverting ileostomy, only 12.5% (5/40) of the leaks would be 'protected' with a stoma, with a rate of diverting ileostomy of up to 24.3%. CONCLUSIONS: Compared with subjective clinical criteria, the use of a predictive model for anastomotic leak improves the selection of patients who would benefit from a diverting ileostomy without increasing the rate of stoma use.