Prognostic value of isolated tumor cells in sentinel lymph nodes in low risk endometrial cancer: results from an international multi-institutional study.

OBJECTIVE: The prognostic significance of isolated tumor cells (≤0.2 mm) in sentinel lymph nodes (SLNs) of endometrial cancer patients is still unclear. Our aim was to assess the prognostic value of isolated tumor cells in patients with low risk endometrial cancer who underwent SLN biopsy and did not receive adjuvant therapy. Outcomes were compared with node negative patients. METHODS: Patients with SLNs-isolated tumor cells between 2013 and 2019 were identified from 15 centers worldwide, while SLN negative patients were identified from Mayo Clinic, Rochester, between 2013 and 2018. Only low risk patients (stage IA, endometrioid histology, grade 1 or 2) who did not receive any adjuvant therapy were included. Primary outcomes were recurrence free, non-vaginal recurrence free, and overall survival, evaluated with Kaplan-Meier methods. RESULTS: 494 patients (42 isolated tumor cells and 452 node negative) were included. There were 21 (4.3%) recurrences (5 SLNs-isolated tumor cells, 16 node negative); recurrence was vaginal in six patients (1 isolated tumor cells, 5 node negative), and non-vaginal in 15 (4 isolated tumor cells, 11 node negative). Median follow-up among those without recurrence was 2.3 years (interquartile range (IQR) 1.1-3.0) and 2.6 years (IQR 0.6-4.2) in the SLN-isolated tumor cell and node negative patients, respectively. The presence of SLNs-isolated tumor cells, lymphovascular space invasion, and International Federation of Obstetrics and Gynecology (FIGO) grade 2 were significant risk factors for recurrence on univariate analysis. SLN-isolated tumor cell patients had worse recurrence free survival (p<0.01) and non-vaginal recurrence free survival (p<0.01) compared with node negative patients. Similar results were observed in the subgroup of patients without lymphovascular space invasion (n=480). There was no difference in overall survival between the two cohorts in the full sample and the subset excluding patients with lymphovascular space invasion. CONCLUSIONS: Patients with SLNs-isolated tumor cells and low risk profile, without adjuvant therapy, had a significantly worse recurrence free survival compared with node negative patients with similar risk factors, after adjusting for grade and excluding patients with lymphovascular space invasion. However, the presence of SLNs-isolated tumor cells was not associated with worse overall survival.

Oncologic outcomes of endometrial cancer in patients with low-volume metastasis in the sentinel lymph nodes: An international multi-institutional study.

OBJECTIVE: To assess oncologic outcomes in endometrial cancer patients with low-volume metastasis (LVM) in the sentinel lymph nodes (SLNs). METHODS: Patients with endometrial cancer and SLN-LVM (≤2 mm) from December 3, 2009, to December 31, 2018, were retrospectively identified from 22 centers worldwide. Patients with International Federation of Gynecology and Obstetrics (FIGO) stage IV, adnexal involvement, or unknown adjuvant therapy (ATx) were excluded. RESULTS: Of 247 patients included, 132 had isolated tumor cell (ITC) and 115 had micrometastasis (MM). Overall 4-year recurrence-free survival (RFS) was 77.6% (95% CI, 70.2%-85.9%); median follow-up for patients without recurrence was 29.6 (interquartile range, 19.2-41.5) months. At multivariate analysis, Non-endometrioid (NE) (HR, 5.00; 95% CI, 2.50-9.99; P < .001), lymphovascular space invasion (LVSI) (HR, 3.26; 95% CI, 1.45-7.31; P = .004), and uterine serosal invasion (USI) (HR, 3.70; 95% CI, 1.44-9.54; P = .007) were independent predictors of recurrence. Among 47 endometrioid ITC patients without ATx, 4-year RFS was 82.6% (95% CI, 70.1%-97.2). Considering 18 ITC patients with endometrioid grade 1 disease, without LVSI, USI, or ATx, only 1 had recurrence (median follow-up, 24.8 months). CONCLUSIONS: In patients with SLN-LVM, NE, LVSI, and USI were independent risk factors for recurrence. Patients with any risk factor had poor prognosis, even when receiving ATx. Patients with ITC and grade 1 endometrioid disease (no LVSI/USI) had favorable prognosis, even without ATx. Further analysis (with more patients and longer follow-up) is needed to assess whether ATx can be withheld in this low-risk subgroup.

Clinical course of coronavirus disease-2019 in pregnancy.

INTRODUCTION: The aim of this study is to report our clinical experience in the management of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the first 30 days of the coronavirus disease (COVID-19) pandemic. MATERIAL AND METHODS: We reviewed clinical data from the first 60 pregnant women with COVID-19 whose care was managed at Puerta de Hierro University Hospital, Madrid, Spain from 14 March to 14 April 2020. Demographic data, clinical findings, laboratory test results, imaging findings, treatment received, and outcomes were collected. An analysis of variance (Kruskal-Wallis test) was performed to compare the medians of laboratory parameters. Fisher's exact test was used to evaluate categorical variables. A correspondence analysis was used to explore associations between variables. RESULTS: A total of 60 pregnant women were diagnosed with COVID-19. The most common symptoms were fever and cough (75.5% each) followed by dyspnea (37.8%). Forty-one women (68.6%) required hospital admission (18 because of disease worsening and 23 for delivery) of whom 21 women (35%) underwent pharmacological treatment, including hydroxychloroquine, antivirals, antibiotics, and tocilizumab. No renal or cardiac failures or maternal deaths were reported. Lymphopenia (50%), thrombocytopenia (25%), and elevated C-reactive protein (CRP) (59%) were observed in the early stages of the disease. Median CRP, D-dimer, and the neutrophil/lymphocyte ratio were elevated. High CRP and D-dimer levels were the parameters most frequently associated with severe pneumonia. The neutrophil/lymphocyte ratio was found to be the most sensitive marker for disease improvement (relative risk 6.65; 95% CI 4.1-5.9). During the study period, 18 of the women (78%) delivered vaginally. All newborns tested negative for SARS-CoV-2 and none of them were infected during breastfeeding. No SARS-CoV-2 was detected in placental tissue. CONCLUSIONS: Most of the pregnant women with COVID-19 had a favorable clinical course. However, one-third of them developed pneumonia, of whom 5% presented a critical clinical status. CRP and D-dimer levels positively correlated with severe pneumonia and the neutrophil/lymphocyte ratio decreased as the patients improved clinically. Seventy-eight percent of the women had a vaginal delivery. No vertical or horizontal transmissions were diagnosed in the neonates during labor or breastfeeding.

The My Child Matters programme: effect of public-private partnerships on paediatric cancer care in low-income and middle-income countries.

In low-income and middle-income countries, an excess in treatment failure for children with cancer usually results from misdiagnosis, inadequate access to treatment, death from toxicity, treatment abandonment, and relapse. The My Child Matters programme of the Sanofi Espoir Foundation has funded 55 paediatric cancer projects in low-income and middle-income countries over 10 years. We assessed the impact of the projects in these regions by using baseline assessments that were done in 2006. Based on these data, estimated 5-year survival in 2016 increased by a median of 5·1%, ranging from -1·5% in Venezuela to 17·5% in Ukraine. Of the 26 861 children per year who develop cancer in the ten index countries with My Child Matters projects that were evaluated in 2006, an estimated additional 1343 children can now expect an increase in survival outcome. For example, in Paraguay, a network of paediatric oncology satellite clinics was established and scaled up to a national level and has managed 884 patients since initiation in 2006. Additionally, the African Retinoblastoma Network was scaled up from a demonstration project in Mali to a network of retinoblastoma referral centres in five sub-Saharan African countries, and the African School of Paediatric Oncology has trained 42 physicians and 100 nurses from 16 countries. The My Child Matters programme has catalysed improvements in cancer care and has complemented the efforts of government, civil society, and the private sector to sustain and scale improvements in health care to a national level. Key elements of successful interventions include strong and sustained local leadership, community engagement, international engagement, and capacity building and support from government.

Correlation between Anatomical Segments of the Pudendal Nerve and Clinical Findings of the Patient with Pudendal Neuralgia.

BACKGROUND: The objective was to describe clinical findings and outcomes of patients with pudendal neuralgia in relation with the anatomical segment affected. METHODS: Fifty-one consecutive patients with chronic perineal pain (CPP) located in the areas supplied by the pudendal nerve (PN), from January 2011 to June 2012, were analyzed. RESULTS: The distribution of pain at perineal, dorsal clitoris and inferior anal nerves was 92.2, 31.4 and 25.5% respectively. The duration of pain was longer when the dorsal clitoris nerve (DCN) was affected (p < 0,003). The pain in the pudendal canal was frequently associated with the radiation of pain to the inferior members (p < 0.043). CONCLUSION: CPP and radiation of pain to lower limbs suggest a disorder at the second segment of PN. A positive Tinel sign in the third segment indicates a nerve entrapment. In terminal branches, pain was more frequent at the perineal nerve and more persistent at the DCN.

International Federation of gynecology and obstetrics staging classification for cancer of the ovary, fallopian tube, and peritoneum: estimation of survival in patients with node-positive epithelial ovarian cancer.

OBJECTIVE: The objective of this study was to determine the survival of patients with node-positive epithelial ovarian cancer according to the 2014 International Federation of Gynecology and Obstetrics (FIGO) staging system. MATERIALS AND METHODS: We performed a retrospective chart review. Data from all consecutive patients with node-positive epithelial ovarian cancer (stages IIIC and IV) who underwent cytoreductive surgery at the Mayo Clinic from 1996 to 2000 were reassessed to evaluate the prognostic significance of the new FIGO stages. Multivariate Cox regression was performed, and Kaplan-Meier survival curves constructed. RESULTS: The distribution of the restaged patients was as follows: IIIA1, 23 patients (IIIA1i, 9 patients; and IIIA1ii, 14 patients); IIIA2, 3 patients; IIIB, 4; IIIC, 67 patients; IVA, 4 patients; and IVB, 15 patients. In the univariate analysis, the relative risk for positive nodes greater than 10 mm on the longer axis was 2.57 and 3.00 for patients with microscopic peritoneal disease, compared with patients with microscopic positive nodes. However, the difference was not statistically significant. Moreover, the univariate analyses revealed statistically significant differences for 2014 FIGO stages (IIIA, IIIB, IIIC, and IVA-B), anatomical sites of peritoneal metastases, and disease staged at IIIC because of the presence of omental metastases. Multivariate analysis showed that survival was higher in patients restaged to IIIA-B than in those restaged to IIIC and IV (hazard ratios, 2.75 and 3.16, respectively; P = 0.002). The hazard ratio for patients with abdominal peritoneal metastases was 2.76 compared with patients with pelvic peritoneal metastases (P = 0.001). CONCLUSIONS: The current 2014 FIGO staging system for ovarian cancer successfully correlates survival, anatomical location of peritoneal metastases, and extra-abdominal lymph node metastases.

Hysteroscopy in pregnancy-related conditions: descriptive analysis in 273 patients.

STUDY OBJECTIVE: To describe the feasibility of office hysteroscopy in patients with pregnancy-related problems such as retained trophoblastic tissue, persistent molar tissue, pregnancy with in situ intrauterine device (IUD), isthmocele, embryoscopy, and osseous metaplasia. DESIGN: Retrospective cohort chart review of use of hysteroscopy in 273 patients with pregnancy-related conditions (Canadian Task Force classification II-2). SETTING: University tertiary-care hospital. PATIENTS: Office hysteroscopy with the indication of pregnancy-related conditions such as retained trophoblastic tissue, pregnancy with IUD, molar pregnancy, cesarean scar defects, and fetal death were studied. The study included 273 patients: 185 with retained trophoblastic tissue, 14 with persistent molar tissue, 7 with an in situ IUD, 22 with symptomatic isthmocele, 41 with embryoscopy, and 4 with osseous metaplasia. INTERVENTION: Diagnostic and operative office hysteroscopy. MEASUREMENTS AND MAIN RESULTS: Variables studied included resolution of abnormal uterine bleeding in patients with persistent trophoblastic tissue, normalization of ß-human chorionic gonadotropin levels in patients with persistent molar tissue, continuation of pregnancy after retrieval of lost IUDs, resolution of postmenstrual bleeding in patients with symptomatic isthmocele, rate of uncontaminated embryonic tissue after embryoscopic biopsy, and successful extraction of bony tissue in patients with osseous metaplasia. Office hysteroscopy enabled resolution of most cases of retained trophoblastic tissue (91.8%) and all 14 cases of persistent molar tissue. 7 IUDs were extracted from pregnant patients. Fifteen isthmoceles resolved with office hysteroscopy, and 7 were resected in the operating room. A normal karyotype was obtained in 37 embryoscopies (90.2%). Four osseous metaplasia cases resolved with either office hysteroscopy (75%) or resectoscopy in the operating room (25%). CONCLUSION: Office hysteroscopy is a safe and minimally invasive treatment for pregnancy-related conditions, with good clinical and functional results.

Prospective evaluation of 18-fluoro-2-deoxy-D-glucose positron emission tomography for the discrimination of paraaortic nodal spread in patients with locally advanced cervical carcinoma.

MAIN OBJECTIVE: Patients with locally advanced cervical cancer (LACC) are usually treated with concurrent chemoradiotherapy. Extended-field chemoradiotherapy is indicated in cases of paraaortic nodal spread. Nowadays, 18-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) is considered to be the most accurate image method of detection of node or distant metastases. The goal of this study was to evaluate the accuracy of FDG-PET for detecting paraaortic lymph node (PALN) spread in patients with LACC. METHODS: Patients with LACC from 2 tertiary university hospitals in Madrid, Spain, were submitted to a laparoscopic infrarenal PALN dissection after FDG-PET evaluation. Based on pathologic results as gold standard, sensitivity, specificity, and positive and negative predictive values of FDG-PET were calculated thereafter for PALN metastasis. RESULTS: A total of 52 patients with LACC fulfilled the inclusion criteria. All of them underwent a laparoscopic infrarenal paraaortic lymphadenectomy. Eighteen patients (34.6%) had pathologically proven PALN metastases. Among them, 4 (12.5%) had negative FDG-PET (false negatives). Furthermore, 2 positive FDG-PET patients were not affected after histologic analysis (11.1% false positives). No complications occurred in our series. Sensitivity, specificity, and positive and negative predictive value of the FDG-PET were 77.7, 94.1, 87.5, and 88.9, respectively, for the detection of PALN metastases. CONCLUSIONS: The sensitivity and specificity of FDG-PET remains limited, so PALN dissection should be part of the pretherapeutic staging in every patient with LACC before definitive concurrent chemoradiotherapy.

Follow-up in women with vaginal agenesis after laparoscopic creation of neovagina.

STUDY OBJECTIVE: To compare 2 different methods to create a neovagina in patients with Rokitansky syndrome and to describe their functional results during the follow-up. DESIGN: Descriptive study on functional outcome in 32 patients with Rokitansky syndrome (Canadian Task Classification Force II-2). SETTING: University tertiary Hospital. DESIGN AND PATIENTS: 18 patients (group 1) underwent our original technique. 14 patients (group 2) were operated on with the modified technique. INTERVENTION: Comparison between 2 different techniques of laparoscopic approach. RESULTS: Both groups had excellent surgical outcomes. The modified technique (group 2) obtained an optimal vaginal depth in fewer days than in the first group (p < .001). Consequently, the hospital stay was shorter in the second group (p < .001). Follow-up was 85 months for group 1 and 17.2 months for group 2. Functional outcome was excellent during the follow-up in both groups. CONCLUSION: Laparoscopic creation of a neovagina is a safe, minimally invasive treatment with good functional and sexual results.

Three-dimensional angioultrasonography for the prediction of malignancy in ovarian masses.

OBJECTIVE: To determine the efficacy of the angiographic indexes of 3D power Doppler angiography (3D-PDA) for the diagnosis of malignancy in complex ovarian masses. METHODS: A prospective, observational study of 72 patients with complex adnexal mass. RESULTS: In the morphological study, 3D ultrasound showed sensitivity, specificity, PPV, NPV, PLHR and NLHR of 84.6%, 81.9%, 85.1%, 81.8%, 4.65 and 0.19. No differences in vascular indexes (VI, FI, VFI) between malignant and benign masses were found: VI 5.38 (CI 95% 3.06-7.7) vs. 6.29 (CI 95% 4.41-8.17) (p = 0.53); FI 29.6 (CI 95% 25.17-34.08) vs. 33.8 (CI 95% 30.03-37.3) (p = 0.15); VFI 1.68 (CI 95% 0.94-2.42) vs. 2.37 (CI 95% 1.49-3.25) (p = 0.24). When analysed according to different stages, VI was higher in patients with more advanced stages of disease; 4.34 (95% CI 2.21-6.47) vs. 7.38 (95% CI 4.7-10.06) (p = 0.11). FI was significantly lower in patients with early stages of disease; FI 29.07 (95% CI 21.49-36.68) vs. 36.46 (95% CI 32.31-40.62) (p = 0.04). For VFI, differences were not significant, although there was a strong trend; VFI 1.47 (95% CI 0.67-2.28) vs. 2.86 (95% CI 1.57-4.16) (p = 0.11). 3D-PDA indexes were significantly higher in patients with positive adenopathies. CONCLUSION: 3D-PDA values increase progressively, but not significantly, with the stage of the disease.

Thermodynamic evaluation of viscosity behavior for CaO-SiO2-Al2O3-MgO slag systems examined at the temperatures range from 1500 to 1700 °C.

This work showed an application of computational tools to understand systematically the behavior of viscosity on CSAM systems relevant to industrial uses. Consequently in this study, the viscosity experimental data obtained from the literature were compared with the thermodynamic calculated results via the software FactSage v.7.3 for melts in CaO-SiO2-Al2O3-MgO slag system with the range of compositions slags cover 0-100 wt% CaO, 0-100 wt% SiO2, 0-100 wt% Al2O3 and 0-15 wt% MgO at temperature ranges of 1500-1700 °C. Using open-source software in Python, the results of viscosity, liquid, and solid fraction of the slag, as a function of composition and temperature, are represented by multiple color maps and by iso-viscosity contours. The results of the viscosity values indicated that the effect of all the oxides in the CSAM slag system follows the well-known behavior trend observed in the literature. Viscosities of the slag were found to increase with increasing SiO2 contents and decrease with increasing basicities (high CaO). The increase in Al2O3 content increases the viscosity values. An increase of 0-15% MgO depolymerized the slag melt and decreases the viscosity. However, above 5% MgO content occur a decrease in the liquid zone (single phase) and a liquid fraction (two-phase region) of the slag. For a constant MgO concentration, the increase in temperature generates an expansion of low-viscosity zones associated with an increase in the liquid phase of the slag. From the comparison between the calculated and experimental viscosities data keeps up within 30% average relative deviation (Δ), the predictions are considered acceptable for viscosity in the CSAM slag system at high temperatures.

Managing Vulvodynia with Central Sensitization: Challenges and Strategies.

Background: Vulvodynia is defined as a chronic idiopathic vulvar pain condition. This study aimed to investigate the effect of central sensitization on the prognosis of neuromodulator treatment for vulvodynia. Method: A total of 105 patients with vulvodynia who underwent pelvic mapping pain exploration were included and scored according to the Convergence PP Criteria for pelvic pain and central sensitization. The patients were treated according to chronic pelvic pain guidelines, and their response to treatment was evaluated. Results: A total of 35 out 105 patients (33%) with vulvodynia had central sensitization, which was associated with comorbidities, dyspareunia, pain with micturition, and pain with defecation. Dyspareunia and pain with defecation were independent prognostic factors for central sensitization. Patients with central sensitization experienced more pain during intercourse, urination, or defecation, had more comorbidities, and responded worse to treatment. They required more treatment, with a longer response time (over 2 months). Patients with localized vulvodynia were treated with physiotherapy and lidocaine, while patients with generalized vulvodynia were treated with neuromodulators. Amitriptyline was effective in treating patients with generalized spontaneous vulvodynia and dyspareunia. Conclusions: Overall, this study highlights the importance of considering central sensitization in the diagnosis and treatment of vulvodynia and the need for individualized treatment based on the patient's symptoms and underlying mechanisms. Vulvodynia patients with central sensitization had more pain during intercourse, urination, or defecation, and responded worse to treatment, requiring more time and medication.

The role of lymphadenectomy in node-positive epithelial ovarian cancer.

OBJECTIVE: To evaluate the therapeutic role of pelvic and aortic lymphadenectomy in patients with epithelial ovarian cancer (EOC) and positive nodes (stages IIIC and IV). METHODS: Retrospective chart review. Data from all consecutive patients with EOC and positive retroperitoneal lymph nodes (stage IIIC and IV) in Mayo Clinic from 1996 to 2000 were included. To evaluate the impact of nodal metastases, the extent of lymphadenectomy was compared according to the number of nodes removed and positive nodes resected. Multivariable Cox regression and Kaplan-Meier survival curves were used for analysis. RESULTS: The median number of nodes removed was 31 (pelvic, 21.5, and aortic, 10), and the median number of positive nodes was 5. The 5-year overall survival was 44.8%. On multivariate analysis, only the extent of peritoneal metastases before surgery was a significant factor for survival (P = 0.001 for stage IIIC and P = 0.004 for stage IV). Analysis of 83 patients with advanced peritoneal disease more than 2 cm demonstrated before debulking, removal of more than 40 lymph nodes was a significant prognostic factor for overall survival (hazard ratio, 0.52; P = 0.032; 95% confidence interval, 0.29-0.35). In 29 patients with advanced peritoneal disease and no residual disease after debulking, removal of more than 10 positive was a factor for survival. CONCLUSIONS: There was a survival benefit in patients with EOC with advanced peritoneal disease more than 2 cm before debulking when more than 40 lymph nodes were removed. There was an additional survival benefit in those patients with no residual disease after debulking when more than 10 positive nodes were removed.

Clustering Molecular Subtypes in Breast Cancer, Immunohistochemical Parameters and Risk of Axillary Nodal Involvement.

(1) Background: To establish similarities in the risk of axillary lymph node metastasis between different groups of women with breast cancer according to immunohistochemical (IHC) parameters. (2) Methods: Data was collected retrospectively, from 2000 to 2013, of 1058 node-positive breast tumours. All patients were divided according to the St Gallen 2013 criteria and IHC features. The proportion of axillary involvement (pN > pN0; pN > pN1mi; pN > pN1) was calculated for each group. Similarities in axillary nodal dissemination were explored by cluster analysis and association between IHC and risk of axillary disease was studied with multivariate analysis. (3) Results: Among clinico-pathological surrogates of intrinsic subtypes, axillary involvement was more frequent in Luminal-B like HER2 negative (45.8%) and less frequent in Luminal-B HER2 positive (33.8%; p = 0.044). Axillary macroscopic involvement was more frequent in Luminal-B like HER2 negative (37.9%) and HER2 positive (37.8%) and less frequent in Luminal-B HER2 positive (25.5%) and Luminal-A like (25.6%; p = 0.002). Axillary involvement ≥pN2 was significantly less frequent in Luminal-A like (7.4%; p < 0.001). Luminal-A with Luminal-B HER2 positive, and triple-negative with Erb-B2 overexpressing tumours were clustered together regarding any axillary involvement, macroscopic disease or ≥pN2. Among the defined subgroups, axillary metastases were more frequent when Ki67 was higher. In a multivariate analysis, Ki67>14% were associated with a risk of axillary metastases (HR: 1.31; 95% CI, 1.51−6.80; p < 0.037). (4) Conclusions: there are two lymphatic drainage pathways of the breast according to the expression of hormone receptor-related genes. Positive-ER tumors are associated with lower axillary involvement and negative-ER tumors and Ki67 > 14% with higher nodal involvement.

Clinical Management of Chronic Pelvic Pain in Endometriosis Unresponsive to Conventional Therapy.

BACKGROUND: Although several treatments are currently available for chronic pelvic pain, 30-60% of patients do not respond to them. Therefore, these therapeutic options require a better understanding of the mechanisms underlying endometriosis-induced pain. This study focuses on pain management after failure of conventional therapy. METHODS: We reviewed clinical data from 46 patients with endometriosis and chronic pelvic pain unresponsive to conventional therapies at Puerta de Hierro University Hospital Madrid, Spain from 2018 to 2021. Demographic data, clinical and exploratory findings, treatment received, and outcomes were collected. RESULTS: Median age was 41.5 years, and median pain intensity was VAS: 7.8/10. Nociceptive pain and neuropathic pain were identified in 98% and 70% of patients, respectively. The most common symptom was abdominal pain (78.2%) followed by pain with sexual intercourse (65.2%), rectal pain (52.1%), and urologic pain (36.9%). A total of 43% of patients responded to treatment with neuromodulators. Combined therapies for myofascial pain syndrome, as well as treatment of visceral pain with inferior or superior hypogastric plexus blocks, proved to be very beneficial. S3 pulsed radiofrequency (PRF) plus inferior hypogastric plexus block or botulinum toxin enabled us to prolong response time by more than 3.5 months. CONCLUSION: Treatment of the unresponsive patient should be interdisciplinary. Depending on the history and exploratory findings, therapy should preferably be combined with neuromodulators, myofascial pain therapies, and S3 PRF plus inferior hypogastric plexus blockade.

Understanding the Female Physical Examination in Patients with Chronic Pelvic and Perineal Pain.

(1) Background: The objective was to compare the exploration of chronic pelvic pain syndrome (CPPS) patients in different locations and establish the role of physical examination in CPPS patients. (2) Methods: We reviewed clinical data from 107 female patients with CPPS unresponsive to conventional therapies at Puerta de Hierro University Hospital Madrid, Spain, from May 2018 to June 2022. Patients were classified into three groups: (a) pelvic pain; (b) anorectal pain; or (c) vulvar/perineal pain. (3) Results: Although the demographics of patients with CPPS were different, their physical examinations were strikingly similar. Our study observed a comorbidity rate of 36% and 79% of central sensitization of pain. Seventy-one percent of patients had vulvar allodynia/hyperalgesia. Pain on examination was identified in any pelvic floor muscle, in any pelvic girdle structure, and neuropathic pain in 98%, 96%, and 89%, respectively. Patients with vulvar and perineal pain were more different from the other groups; these patients were younger and had fewer comorbidities and less central sensitization, less anorectal pain, more pain during intercourse, and greater nulliparity (p = 0.022; p = 0.040; p = 0.048; p = 0.000; p = 0.006; p = 0.005). (4) Conclusions: The findings of this study are related to the understanding of the pathophysiology of CPPS. The physical examination confirms the central sensitization of female patients with CPPS, helps us to determine the therapeutic management of the patient, and can be considered as a prognostic factor of the disease.

Does MIS Play a Role in the Treatment of Advanced Ovarian Cancer?

Neoadjuvant chemotherapy allows a minimally invasive approach for interval debulking in patients with ovarian cancer considered unresectable to no residual disease by laparotomy at diagnosis. The aim of the study was to evaluate the type of surgical approach at interval debulking (ID) after three courses of carboplatin and taxol in patients with unresectable ovarian cancer at diagnosis compared with the type of surgical approach at primary debulking (PD). A secondary objective was to compare the perioperative outcomes of MIS vs. laparotomy at ID. A retrospective review of the type of surgical approach at ID following three courses of carboplatin and taxol was compared with the surgical approach at PD, and a review of the perioperative outcomes of MIS vs. open at ID was performed during the period from 21 January 2012, through 21 February 2013, for stage IIIC > 2 cm or IV epithelial ovarian cancer (EOC) unresectable at diagnosis and the surgical approach at PD. During the study period, 127 patients with stage IIIC or IV EOC met the inclusion criteria. Minimally invasive surgery (MIS), laparoscopic or robotic, was used in 21.6% of patients at ID and in 23.3% of patients at PD. At ID, MIS patients had a shorter hospital stay as compared to laparotomy (2 vs. 8 days; p < 0.001). At 5 year follow-up, 31.5% of EOC patients were alive (ID MIS: 47.5% vs. ID open: 30%; PD MIS: 41% vs. PD open: 28%), while 24.4% had no evidence of disease (ID MIS: 39% vs. ID open: 19.5%; PD MIS: 32% vs. PD open: 22%). Among living patients, 22% had evidence of disease. Neoadjuvant chemotherapy is a form of chemo-debulking and allows a minimally invasive approach at interval debulking in about one-fifth of the patients, with initial disease deemed unresectable to no residual tumor at initial diagnosis.

Granulomatosis with Polyangiitis-Mimicking Advanced Gynecological Cancer: A Case Report and Systematic Review of the Literature.

(1) Background: Granulomatosis with polyangiitis (GPA) is a necrotizing vasculitis that mimics gynecologic cancer. In GPA patients, the genitourinary system is affected in <1%. The objective of the study was to provide a systematic review of the literature of GPA patients with gynecological involvement. (2) Methods: PubMed and Embase were searched from inception to July 2021 for GPA patients with gynecological involvement Medical Subject Headings (MeSH) and free-text terms. Exclusion criteria were other language, review articles, pregnancy, fertility, or male patients. Data were extracted on clinical evolution, symptoms, examinations findings, diagnosis delay, treatment, outcome, patient status, and follow-up. (3) Results: Seventeen studies included data from patients with GPA and primary or relapsed gynecological involvement. 68% of the authors of this review thought the patient had cancer. The main gynecological symptom is bleeding, but exclusive gynecologic symptomatology is rare (ENT: 63%, lungs: 44%, kidneys-urinary tract: 53%). GPA could affect all areas of the genital tract, but the most frequent location is the uterine cervix. Medical treatment for GPA is effective. (4) Conclusions: GPA of the female genital tract must be considered when biopsies of an ulcerated malignant-appearing cervical or vaginal mass are negative for malignancy even when they are unspecific. Rheumatology consultation is indicated.

Psychological Profile in Women with Chronic Pelvic Pain.

(1) Background: Chronic Pelvic Pain (CPP) is a prevalent medical condition with a complex treatment due to different variables that influence its clinical course. (2) Methods: Psychological variables such as depression, anxiety, catastrophizing or neuroticism have been described as influencing CPP. This is a cross-sectional study of 63 patients with CPP sent for a psychological evaluation due to participation in group therapy for CPP. The main purpose of this study was to characterize the baseline psychological characteristics of women with CPP. The NEO Five Factor Inventory (NEO-FFI), State and Trait Anxiety Inventory (STAI), Beck Depression Inventory-Fast Screen (BDI-FS), Pain Catastrophizing Scale (PCS) and Chronic Pain Acceptance Questionnaire (CPAQ) were performed. (3) Results: The personality profile of patients (NEO FFI) shows high neuroticism, low extraversion and low conscientiousness. The 25.4% of patients had moderate or severe depression according to BDI-FS results, almost half of the patients had high levels of anxiety trait (>P75, 49.2%) and more than half the patients had high levels of anxiety state (>P75, 59.5%). Punctuations of PCS and CPAQ are similar to patients with fibromyalgia. (4) Conclusions: CPP is associated with high levels of depression, anxiety, neuroticism, catastrophizing and low pain acceptance. It is important to develop interventions that can modify these psychological factors in order to improve the clinical course of CPP.