RESUMEN
OBJECTIVE: Management of endometrial cancer is advancing, with accurate staging crucial for guiding treatment decisions. Understanding sentinel lymph node (SLN) involvement rates across molecular subgroups is essential. To evaluate SLN involvement in early-stage (International Federation of Gynecology and Obstetrics 2009 I-II) endometrial cancer, considering molecular subtypes and new European Society of Gynaecological Oncology (ESGO) risk classification. METHODS: The SENECA study retrospectively reviewed data from 2139 women with stage I-II endometrial cancer across 66 centers in 16 countries. Patients underwent surgery with SLN assessment following ESGO guidelines between January 2021 and December 2022. Molecular analysis was performed on pre-operative biopsies or hysterectomy specimens. RESULTS: Among the 2139 patients, the molecular subgroups were as follows: 272 (12.7%) p53 abnormal (p53abn, 1191 (55.7%) non-specific molecular profile (NSMP), 581 (27.2%) mismatch repair deficient (MMRd), 95 (4.4%) POLE mutated (POLE-mut). Tracer diffusion was detected in, at least one side, in 97.2% of the cases; with a bilateral diffusion observed in 82.7% of the cases. By ultrastaging (90.7% of the cases) or one-step nucleic acid amplification (198 (9.3%) of the cases), 205 patients were identified with affected sentinel lymph nodes, representing 9.6% of the sample. Of these, 139 (67.8%) had low-volume metastases (including micrometastases, 42.9%; and isolated tumor cells, 24.9%) while 66 (32.2%) had macrometastases. Significant differences in SLN involvement were observed between molecular subtypes, with p53abn and MMRd groups having the highest rates (12.50% and 12.40%, respectively) compared with NSMP (7.80%) and POLE-mut (6.30%), (p=0.004); (p53abn, OR=1.69 (95% CI 1.11 to 2.56), p=0.014; MMRd, OR=1.67 (95% CI 1.21 to 2.31), p=0.002). Differences were also noted among ESGO risk groups (2.84% for low-risk patients, 6.62% for intermediate-risk patients, 21.63% for high-intermediate risk patients, and 22.51% for high-risk patients; p<0.001). CONCLUSIONS: Our study reveals significant differences in SLN involvement among patients with early-stage endometrial cancer based on molecular subtypes. This underscores the importance of considering molecular characteristics for accurate staging and optimal management decisions.
RESUMEN
OBJECTIVE: To analyze the success rate of external cephalic version (ECV) in pregnant women with a history of previous cesarean section, as well as to describe the rate of complications associated with the procedure. METHODS: A retrospective cohort study of women who were offered an ECV at "Virgen de la Arrixaca" Clinic University Hospital (Murcia, Spain) between January 2014 and December 2023. We collected data for previous cesarean delivery, obstetric history, fetal presentation, amniotic fluid volume, ECV success rate, complications related to ECV, mode of delivery, and neonatal outcomes. The study confidently performed ECV under sedation with propofol and tocolysis with ritodrine. Univariate and multivariate analyses were conducted to compare the success rate of ECV, ECV complications, and mode of delivery between women with and without previous cesarean sections. RESULTS: Of 1116 pregnant women who were offered ECV, 911 were included in the study, with 42 having a previous cesarean section. The success rate of ECV in pregnant women with a previous cesarean section was 78.6% (adjusted odds ratio 1.18; 95% confidence interval 0.49-2.86; P = 0.708), with a low complication rate of 9.5%, such as non-reassuring fetal heart rate (7.1%) or major vaginal bleeding (2.4%). Of the women who attempted a vaginal delivery after ECV, 80.8% were successful. CONCLUSIONS: These findings support that ECV is a safe and effective option for women with a previous cesarean section, with success rates comparable to those in women without a previous cesarean section.
Asunto(s)
Carcinosarcoma , Procedimientos Quirúrgicos de Citorreducción , Neoplasias Ováricas , Humanos , Femenino , Neoplasias Ováricas/cirugía , Neoplasias Ováricas/patología , Carcinosarcoma/cirugía , Carcinosarcoma/patología , Procedimientos Quirúrgicos de Citorreducción/métodos , Persona de Mediana Edad , Tratamiento Conservador/métodosRESUMEN
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.
Asunto(s)
Ganglio Linfático Centinela , Neoplasias de la Vulva , Femenino , Humanos , Biopsia del Ganglio Linfático Centinela/métodos , Tecnecio , Neoplasias de la Vulva/diagnóstico por imagen , Neoplasias de la Vulva/cirugía , Neoplasias de la Vulva/patología , Colorantes , Ganglio Linfático Centinela/patología , Verde de Indocianina , Obesidad/cirugía , Ganglios Linfáticos/patologíaAsunto(s)
Neoplasias Ováricas , Ganglio Linfático Centinela , Humanos , Femenino , Ganglio Linfático Centinela/cirugía , Ganglio Linfático Centinela/patología , Ganglios Linfáticos/cirugía , Ganglios Linfáticos/patología , Neoplasias Ováricas/patología , Biopsia del Ganglio Linfático Centinela , Escisión del Ganglio Linfático , Estadificación de NeoplasiasRESUMEN
Lateral pelvic sidewall involvement by gynecological tumors has been considered traditionally an absolute contraindication to curative resection.1 Moreover, the involvement of the pelvic sidewall at the time of relapse in cervical cancer after primary or adjuvant pelvic radiation occurs in 8.3% of patients.2,3 Laterally extended endopelvic resection (LEER), based on the ontogenetic compartment theory, provides a potential surgical option for patients for whom palliative therapy is the only alternative.4 This complex and ultraradical, surgical technique allows a high rate of complete resection in more than 70% of patients with gynecological cancers and lateral pelvic sidewall involvement. An adequate selection of patients and a deep knowledge of pelvic anatomy are crucial to obtain acceptable morbimortality rates and improved overall survival in this population.5 To deconstruct this complex procedure, we show a detailed step-by-step technique to facilitate the easy learning curve of this surgical technique. We review the Höckel original technique with different site-relapse adapted steps. We provide a pedagogical high-quality video (Video 1) and anatomical outline drawings (Fig. 1) to understand lateral pelvic wall anatomy and standardize this surgical technique. Our purpose is to bring this knowledge to gynecologists and pelvic surgeons in which pelvic lateral approach may be useful beyond gynecological oncologic surgery (Table 1).
Asunto(s)
Exenteración Pélvica , Neoplasias del Cuello Uterino , Femenino , Humanos , Recurrencia Local de Neoplasia/cirugía , Neoplasias del Cuello Uterino/cirugía , Neoplasias del Cuello Uterino/patología , Pelvis/cirugía , Exenteración Pélvica/métodos , RecurrenciaRESUMEN
OBJECTIVE: Bladder endometriosis is the presence of stroma and endometrial glands in the thickness of the detrusor muscle. The main symptoms it produces are dysuria and hematuria whose intensity is directly proportional to the size of the nodule. It is a difficult entity to diagnose for which physical examination is essential. Treatment can be medical, with hormonal therapies, or surgical by transurethral resection of the nodule and laparoscopic partial cystectomy. METHODS: To show a clinical case and review the literature about the technique used. RESULTS: A 29-year-old patient diagnosed with bladder endometriosis in which a combined approach was decided by laparoscopic partial cystectomy after transurethral resection: the patient came to our office for chronic pelvic pain, dysuria, dysmenorrhea, and a physical examination that showed a painful nodule on the anterior side of the vagina. A transvaginal ultrasound, magnetic resonance imaging, and cystoscopy confirm the diagnosis of bladder endometriosis. After a review of the literature on the management of this entity, the patient's clinic, and reproductive desires, the combined approach with excellent results was decided. Dysmenorrhea and dysuria disappeared, preserving the fertility of the patient who became pregnant 6 months after the intervention. CONCLUSION: The use of the combined approach allows to reduce the limitations of both techniques separately.
Asunto(s)
Endometriosis , Laparoscopía , Enfermedades de la Vejiga Urinaria , Embarazo , Femenino , Humanos , Adulto , Cistectomía/métodos , Vejiga Urinaria/cirugía , Endometriosis/diagnóstico , Endometriosis/cirugía , Endometriosis/complicaciones , Dismenorrea/etiología , Dismenorrea/cirugía , Disuria , Laparoscopía/métodos , Enfermedades de la Vejiga Urinaria/diagnóstico , Enfermedades de la Vejiga Urinaria/cirugía , Enfermedades de la Vejiga Urinaria/complicacionesAsunto(s)
Fístula Vesicovaginal , Femenino , Humanos , Fístula Vesicovaginal/cirugía , Colgajos QuirúrgicosRESUMEN
Low-grade endometrial stromal sarcoma (LG-ESS) usually exhibits indolent behavior, often misdiagnosed and is associated with a favorable prognosis [1]. Despite the indolent nature of LG-ESS, recurrence is common, the risk is as high as 1 in 3 to 1 in 2 [2]. The behavior of such tumors can lead to invade blood vessels [3]. An intravascular tumor is associated with direct risk of sudden death from pulmonary embolism. There are very few reported cases with clinically obvious intravascular extension. Chemotherapy, radiotherapy and hormone therapy are adjuvant treatments that have not been able to demonstrate a definitive benefit in survival [4]. We want to take advantage of the opportunity, so far unpublished, to demonstrate with this case the surgical challenge described step by step, as well as to demonstrate the importance of surgery as the only curative treatment even in extended intravascular disease [5]. Here in, we present the surgical challenge of a LG-ESS in a 59-year old woman with iliac and cava vein tumoral thrombus extension. We performed a tumoral thrombectomy and vascular repair, with a pelvic exenteration and double barrel wet colostomy. After performing pelvic exenteration, the thrombus with intravascular involvement was addressed at 2 points: inferior cava vein and right common iliac vein with the extraction of the entire thrombus. These defects are corrected by angioplasty and venorrhaphy, respectively. The surgery got a complete cytoreduction. It lasted 290 minutes, with 430 mL blood loss. In patients with LG-ESS, cytoreduction is a reliable option even in extended metastatic disease.
Asunto(s)
Neoplasias Endometriales , Exenteración Pélvica , Sarcoma Estromático Endometrial , Trombosis , Femenino , Humanos , Persona de Mediana Edad , Neoplasias Endometriales/cirugía , Neoplasias Endometriales/diagnóstico , Sarcoma Estromático Endometrial/cirugía , Pronóstico , Trombosis/cirugíaRESUMEN
La afectación del ligamento redondo por endometriosis es infrecuente, oscilando según la bibliografía entre un 0,3 a un 14 % de las pacientes afectadas por endometriosis. Se localiza mas frecuentemente en el lado derecho y en su porción extrapélvica. Produce efecto masa y dolor variable con el ciclo. Generalmente hay afectación del compartimento posterior pélvico. La sospecha diagnóstica se basa en la anamnesis y exploración física, donde se objetiva una masa en región inguinal dolorosa. El diagnóstico por imagen a través de ecografía y resonancia magnética presenta una lesión ocupante de espacio con las mismas características que las lesiones endometrió-sicas pélvicas. Su manejo en la mayoría de las veces implica cirugía para su exéresis. Presentamos un caso de endometriosis sobre el ligamento redondo extrapélvico en el contexto de una endometriosis compleja en una paciente de 23 años con uropatía obstructiva
Endometriosis of the round ligament is a rare entity, it accounts for 0.3 to 14 % of patients affected by endome-triosis. The right side at extrapelvic slice is the most usual affected area. It cause swelling and changing mens-trual pain. Inguinal endometriosis is usually associated with posterior compartment of pelvis affectation. The diagnostic approach is base on accurate anamnesis and physical examination with a painful groin swelling. An space occupying lesion with the same properties as endometriosis pelvics injuries is show in Ultrasonography and Nuclear Magnetic Resonance. En-bloc resection surgery is the treatment of choice almost always. We report on a case of endometriosis of extrapelvic round ligament in a complex endometriosis 23 years-old patient, with obstructive uropathy context