Comparison of Peritoneal Carcinomatosis Scoring Methods in Predicting Resectability and Prognosis in Gynecologic Malignancies.

OBJECTIVE: Peritoneal carcinomatosis is a disease's presentation in the advanced stages of many gynecologic tumours. The distribution and volume of the disease are the main factors in achieving complete debulking. Diagnostic laparoscopy is a technique to allow evaluation of the disease. This study's objective is to compare two laparoscopic scores (Fagotti's index and Sugarbaker's peritoneal cancer index (PCI)) and assess the diagnostic accuracy to select patients for neoadjuvant treatment and reduce unnecessary laparotomies. METHODS: A non-randomised retrospective cohort study was conducted in patients with peritoneal carcinomatosis (ovarian and endometrial origin) who underwent laparoscopy and subsequent laparotomy. We evaluated the scores' ability to predict incomplete surgery and whether they were related to the patients' prognosis. RESULTS: We included 34 patients, of which 23.5% received neoadjuvant chemotherapy. The rate of complete cytoreductive surgery was 79.4% (n = 27 patients). The highest sensitivity was obtained with a PCI value greater than 20. It was the best parameter to determine incomplete debulking. Survival curves were analysed according to the "cut off" established for each score, and statically significant differences were found using PCI with respect to Fagotti's Index. However, these differences were not found with Fagotti's score. CONCLUSION: The best diagnostic method to classify patients with peritoneal cancer is the PCI. It could be adapted to each surgical team because it allows identifying the "cut off point", which depends on incomplete surgery rate.

Number of paraaortic lymph node dissections as a prognostic factor in locally advanced cervical cancer / Número de ganglios extraídos en la linfadenectomía paraaórtica como factor pronóstico en el cáncer de cérvix localmente avanzado

BACKGROUND: Lymph node (LN) metastases are the most important prognostic factor in locally advanced cervical cancer. Paraaortic lymphadenectomy is the only method able to confirm the presence of metastasis and thereby help to determine the most adequate treatment approach. There is no standard regarding the minimal number of LNs that should be removed in paraaortic lymphadenectomy. Women with undiagnosed positive paraaortic LNs (false negatives) due to a low LN count do not receive extended-field radiation therapy, which may lead to worse survival outcomes. The aim of this study is to confirm LN metastases as poor prognosis and to assess whether in cases of locally advanced CC with negative paraaortic LN status, the number of paraaortic LN laparoscopically removed carries a prognostic value. METHODS: We analyzed 78 patients with locally advanced cervical cancer that underwent complete paraaortic lymphadenectomy. RESULTS: Fifteen (19.2%) women had paraaortic LN metastases. The mean number of LN extracted was 11.1 (SD 7.5). Patients with paraaortic LN metastases presented a worse overall survival (127.1 months [95% CI 111.7-142.4] vs. 59.6 months [95% CI 31.2-87.9]; p < 0.01). Nevertheless, there were no differences regarding disease-free survival. There were no prognostic differences according to the number of LNs resected in patients with negative lymphadenectomy. CONCLUSIONS: Patients with locally advanced cervical cancer and paraaortic LN metastases present worse survival. In women with negative paraaortic LN, the number of LNs removed does not imply shorter survival

ANTECEDENTES: Las metástasis linfáticas son el factor pronóstico más importante en el cáncer de cérvix localmente avanzado. La linfadenectomía paraaórtica es el único método capaz de confirmar la presencia de metástasis y, por lo tanto, ayudar a determinar el enfoque de tratamiento más adecuado. No existe una norma con respecto al número mínimo de ganglios que deben resecarse en la linfadenectomía paraaórtica. Las mujeres con ganglios paraaórticos positivos no diagnosticados (falsos negativos) debido a un bajo recuento no reciben radioterapia de campo extendido, lo que puede conducir a peores resultados de supervivencia. El objetivo de este estudio es confirmar las metástasis ganglionares como principal factor pronóstico y evaluar si, en los casos de cáncer de cérvix localmente avanzado sin metástasis ganglionares paraaórticas, el número de ganglios extraídos por laparoscopia tiene un valor pronóstico. MÉTODOS: Se analizaron 78 pacientes con cáncer cervical localmente avanzado que se sometieron a una linfadenectomía paraaórtica completa. RESULTADOS: Quince (19,2%) mujeres tuvieron metástasis ganglionares paraaórticas. El número medio de ganglios extraído fue de 11,1 (DE 7,5). Las pacientes con metástasis paraaórticas presentaron una peor supervivencia global (127,1 meses [IC del 95%: 111,7-142,4] frente a 59,6 meses [IC del 95%: 31,2 a 87,9]; p < 0,01). Sin embargo, no hubo diferencias en cuanto a la supervivencia libre de enfermedad. No hubo diferencias pronósticas según el número de ganglios resecados en pacientes con linfadenectomía negativa. CONCLUSIONES: Las pacientes con cáncer cervical localmente avanzado y metástasis paraaórticas presentan peor supervivencia. En las mujeres con linfadenectomía paraaórtica negativa, el número de ganglios extraídos no implica una supervivencia peor

Number of paraaortic lymph node dissections as a prognostic factor in locally advanced cervical cancer.

BACKGROUND: Lymph node (LN) metastases are the most important prognostic factor in locally advanced cervical cancer. Paraaortic lymphadenectomy is the only method able to confirm the presence of metastasis and thereby help to determine the most adequate treatment approach. There is no standard regarding the minimal number of LNs that should be removed in paraaortic lymphadenectomy. Women with undiagnosed positive paraaortic LNs (false negatives) due to a low LN count do not receive extended-field radiation therapy, which may lead to worse survival outcomes. The aim of this study is to confirm LN metastases as poor prognosis and to assess whether in cases of locally advanced CC with negative paraaortic LN status, the number of paraaortic LN laparoscopically removed carries a prognostic value. METHODS: We analyzed 78 patients with locally advanced cervical cancer that underwent complete paraaortic lymphadenectomy. RESULTS: Fifteen (19.2%) women had paraaortic LN metastases. The mean number of LN extracted was 11.1 (SD 7.5). Patients with paraaortic LN metastases presented a worse overall survival (127.1 months [95% CI 111.7-142.4] vs. 59.6 months [95% CI 31.2-87.9]; p<0.01). Nevertheless, there were no differences regarding disease-free survival. There were no prognostic differences according to the number of LNs resected in patients with negative lymphadenectomy. CONCLUSIONS: Patients with locally advanced cervical cancer and paraaortic LN metastases present worse survival. In women with negative paraaortic LN, the number of LNs removed does not imply shorter survival.

MicroRNAs and angiogenesis in endometriosis.

miRNAs function as important regulators of a wide range of cellular processes, such as angiogenesis and fibrinolysis, by postranscriptional modulation of gene expression. We present a review on the role of miRNAs and angiogenesis in endometriosis. Endometriosis, defined as the implantation of endometrial tissue outside the uterine cavity, is one of the most frequent benign gynecological diseases and it has important consequences on the quality of life and fertility of patients. Similarly to tumor metastasis, the ectopic endometrium acquires the capability to adhere, proliferate and infiltrate the extracellular matrix. Endometriosis is a multifactorial and polygenic disease in which angiogenesis and proteolysis may be involved, and emerging data provide evidence that a dysregulation of miRNA expression may be implicated in these processes. The detection of circulating miRNAs in plasma and other body fluids and their relative stability has raised the possibility that they might serve as non-invasive biomarkers for the diagnosis of the disease. On the other hand, the development of therapies that might block the expression or mimic the functions of miRNAs could represent new therapeutic strategies for the treatment of endometriosis.

Histerectomía total laparoscópica. Evolución de la técnica y comparación de resultados en 2 períodos / Total laparoscopic hysterectomy. Development of the technique and comparison of results in two periods

Objetivo. Se analiza la infuencia de la curva de aprendizaje y de la técnica quirúrgica en los resultados de las histerectomías totales laparoscópicas (HTL) realizadas por patología benigna en 2 períodos. Material y métodos. Entre los años 2000 y 2008 fueron intervenidas 500 pacientes que dividimos en 2 períodos, ya que empleamos técnicas quirúrgicas diferentes. Se comparan entre los grupos los datos epidemiológicos, las indicaciones quirúrgicas, los resultados operatorios y la tasa de complicaciones. Resultados. Las características epidemiológicas y las indicaciones quirúrgicas fueron similares en ambos grupos. El tiempo quirúrgico no presentó diferencias entre los 2 grupos. En el período 2005-2008 hubo una disminución significativa de los días de estancia hospitalaria (2,7 vs 2,4 días; p<0,01) y del descenso de los valores de la hemoglobina preintervención (1,9g/dl vs 1,7g/dl; p<0,05) en comparación con el período 2000-2005. En el período 2005-2008 el peso medio de los úteros intervenidos fue significativamente mayor (288g vs 203g; p<0,01), hubo una disminución de la tasa total de complicaciones (8,5% vs 3,6%; p<0,05) y de la tasa de complicaciones mayores (5,4% vs 1,8%; p<0,05). Conclusiones. La HTL es una técnica segura, eficaz y reproducible tras una adecuada curva de aprendizaje. La mayor experiencia del grupo y la modificación de la técnica quirúrgica han reducido de forma significativa la tasa de complicaciones, con tiempos quirúrgicos aceptables incluso en úteros voluminosos (AU)

Objective. To analyze the influence of the learning curve and surgical technique on the results of total laparoscopic hysterectomies (TLH) for benign conditions in two study periods. Material and methods. A total of 500 patients underwent surgery between 2000 and 2008, divided in two periods as different surgical techniques were used. Epidemiological data, surgical indications, operative results and complication rates were compared between the two groups. Results. The epidemiological characteristics and surgical indications were similar between the two groups. There were no significant differences in operating time. Hospital stay was significantly lower (2.7 vs 2.4 days; P<.01), and there was a lower drop in hemoglobin levels (1.9g/dl vs 1.7g/dl; P<.05) from 2005-2008 compared with 2000-2005. In the second period, uterine weight was significantly higher (288g vs 203g; P<.01) and both the overall complications rate (8.5% vs 3.6%; P<.05) and major complications rate (5.4% vs 1.8%; P<.05) were lower. Conclusions. TLH is a safe, feasible and reproducible technique, after an appropriate learning curve. Greater experience of the surgical team and modifications in the surgical technique significantly reduced the complications rate, with acceptable operating times even for bulky uterus (AU)

Histeroscopia y cáncer: respuesta a las cuestiones planteadas tras dos décadas de experiencia / Hysteroscopy and cancer: response to questions arising after two decades of experience

Objetivos. Estudiamos, retrospectivamente, tanto las histeroscopias diagnósticas realizadas por nuestro grupo, en las últimas dos décadas, como los cánceres diagnosticados por ellas. Exponemos nuestra clasificación morfológico-histeroscópica y damos respuesta a diversas cuestiones relacionadas con el tema: fiabilidad del método, predicción de estadio, predicción de grado histológico, valor de la biopsia ciega en las lesiones focales, valor de la histeroscopia en el estadio II, riesgo de diseminación tras estudio histeroscópico y riesgo del tamoxifeno. Sujetos y métodos. Estudiamos 329 cánceres endometriales diagnosticados en las 8.927 histeroscopias realizadas por nuestro grupo entre los años 1991 y 2007. Hallamos sensibilidad, especificidad y valores predictivos positivo y negativo de la histeroscopia frente al cáncer. Sujetos y métodos. Presentamos nuestra clasificación morfológico-histeroscópica. Comparamos el patrón histeroscópico tanto con el estadio definitivo (304 pacientes) como con el grado histológico (318 pacientes). Mostramos los hallazgos histeroscópicos de 734 pacientes asintomáticas, menopáusicas avanzadas y con líneas endometriales ecográficas > 4mm. Calculamos el valor de la biopsia ciega endometrial, tanto en los 329 cánceres endometriales estudiados como en el subgrupo de 94 cánceres focales. Deducimos, en 283 pacientes, la concordancia de la histeroscopia en el diagnóstico de la invasión del canal endocervical. Expresamos nuestros resultados de 278 lavados peritoneales posthisteroscopia. Por último, analizamos las condiciones de 8 casos de cáncer con tamoxifeno. Resultados. Demostramos el valor de la histeroscopia como patrón oro en el diagnóstico del cáncer endometrial, así como la validez de nuestra clasificación para prever estadio y grado histológico. Comprobamos que la sensibilidad y la especificidad de la histeroscopia en el diagnóstico de la invasión de canal son significativamente superiores a las de la resonancia magnética. Demostramos la idoneidad de la histeroscopia en los cánceres focales y las carencias de la biopsia ciega en éstos. Por último, desdramatizamos tanto el riesgo de la diseminación tubárica como el del uso de tamoxifeno. Conclusiones. La histeroscopia con biopsia dirigida es el patrón de oro en el diagnóstico del cáncer endometrial. Proporciona datos estadísticamente significativos, tanto sobre la estadificación como del grado histológico. Supera al resto de métodos en el diagnóstico del estadio II y, sin ella, es prácticamente imposible detectar las lesiones focales. Afirmamos que la diseminación de células cancerosas es nula en condiciones normales. Finalmente, ratificamos el protocolo actual de realizar un control histeroscópico únicamente a las pacientes sintomáticas tratadas con tamoxifeno (AU)

Objectives. We retrospectively studied both the diagnostic hysteroscopies carried out by our group in the last two decades and the cancers diagnosed by this procedure. We describe our morphological-hysteroscopic classification and discuss several issues related to this procedure, namely: the reliability of the method, prediction of stage, prediction of histological grade, value of blind biopsy in focal lesions, value in stage II lesions, risk of dissemination, and risk of tamoxifen. Subjects and methods. We studied 329 endometrial cancers diagnosed in 8927 hysteroscopies performed by our group between 1991 and 2007. We determined the sensitivity, specificity and positive and negative predictive values of hysteroscopy in endometrial cancer. Subjects and methods. A morphological-hysteroscopic classification was formulated. The hysteroscopic pattern was compared with both the definitive stage (304 patients) and the histological grade (318 patients). Hysteroscopic findings in 734 asymptomatic women with advanced menopause and ultrasound endometrial lines larger than 4mm were assessed. The value of blind endometrial biopsy in the 329 endometrial cancers studied and in a subgroup of 94 focal cancers was determined. In 283 of the patients, the concordance of hysteroscopy in the diagnosis of invasion of the endocervical channel was calculated. A descriptive analysis was performed on 278 post-hysteroscopy peritoneal lavages and on eight cases of cancer treated with tamoxifen. Results. Our results indicate the value of hysteroscopy as the gold standard in the diagnosis of endometrial cancer, as well as the validity of our classification in predicting stage and histological grade. The sensitivity and specificity of hysteroscopy in the diagnosis of endocervical channel invasion are significantly superior to those of magnetic resonance imaging. Hysteroscopy is a suitable procedure in focal cancers, while blind biopsy shows deficiencies. Lastly, we found that the risks of both tubal dissemination and tamoxifen have been overstated. Conclusions. Hysteroscopy with directed biopsy is the gold standard in the diagnosis of endometrial cancer and provides statistically significant data on both staging and histological grade. This method offers advantages over other methods in the diagnosis of stage II cancers and is practically the only method that detects focal lesions. Under normal conditions, dissemination of cancer cells is null. In women treated with tamoxifen, hysteroscopic follow-up is only required in those presenting symptoms (AU)

Laparoscopic approach to right diaphragmatic endometriosis with argon laser: case report.

Diaphragmatic involvement by an endometriotic cyst is a rare entity that may be responsible for chronic thoracic pain. Herein we present a case report of a 6-cm right diaphragmatic endometrioma treated using laparoscopic partial excision and argon laser coagulation of the inner cyst wall. The laparoscopic approach to upper abdomen endometriosis is feasible and safe when accurate evaluation of the case is performed.

Estudio comparativo de dos técnicas laparoscópicas de sacrocolpopexia / Comparative study of two laparoxcopic techniques in sacrocolpopexy procedures

Objetivos: Estudio clínico descriptivo de 2 técnicas laparoscópicas para el tratamiento del prolapso de cúpula vaginal: una realizada de forma combinada (vaginal y laparoscópica) y otra sólo por vía laparoscópica. Material y métodos: Un total de 23 pacientes diagnosticadas de prolapso de cúpula vaginal posthisterectomía, entre enero de 2000 y febrero de 2006, en la Unidad de Ginecología del Hospital Arnau de Vilanova de Valencia. En las primeras 10 pacientes se realizó una técnica de sacrocolposuspensión combinada, y en las 13 siguientes la sacrocolpopexia se llevó a cabo completamente por vía laparoscópica. Resultados: El tiempo quirúrgico fue significativamente menor en la técnica combinada. Pero no se observaron diferencias en otras variables, como la pérdida de hematocrito y el valor de hemoglobina, los días de estancia hospitalaria y las complicaciones intraoperatorias y postoperatorias. Conclusiones: La sacrocolpopexia realizada completamente por vía laparoscópica aporta ventajas anatómicas y funcionales sobre la vía combinada en la reparación total de la fascia endopélvica

Objectives: Descriptive study of two laparoscopic techniques for treatment of vaginal vault prolapse. One combinated technique (vaginal and laparoscopic times) and another one with laparoscopic time only. Material and methods: A total of 23 women with vaginal vault prolapse posthysterectomy were diagnosed from January of 2000 to February of 2006 in the Gynaecologic Unit of Arnau de Vilanova Hospital, in Valencia, Spain. In first 10 patients were applicated the combinated technique, whereas in the remainig ones were applicated the technique with laparoscopic time only. Results: Surgical time were significantly minor in the combinated technique. No differences in the drop of haemoglobine and haematocrit, hospitalization days and intra or postoperative complications. Conclusion: Sacrocolpopexy, using laparoscopic technique only offer anathomical and functional advantages over the combinated technique, in the total repair of endopelvic fascia

Clasificación morfológico-histeroscópica del cáncer endometrial / Morphological-hysteroscopic classification of endometrial cancer

Objetivo: Valorar la nomenclatura morfológico-histeroscópica del cáncer endometrial, empleada por nuestro grupo, para demostrar las diferencias entre los distintos patrones, tanto morfológicas como relativas a su grado histológico, y la estadificación diagnóstica. Sujetos y métodos: Presentamos 272 casos de pacientes con cáncer endometrial diagnosticados histeroscópicamente, a los que hemos podido agrupar, según nuestra clasificación, en 3 patrones (seudohiperplásico, nodular y malignización de pólipo) y un subpatrón (avanzado). Comparamos, a continuación, dichos patrones con la estadificación y el grado histológico definitivos. Resultados: Los patrones seudohiperplásico y malignización de pólipo, sin signos avanzados, se relacionan con estadios más precoces y grados histológicos diferenciados. Los patrones nodulares se relacionan con grados histológicos poco diferenciados. Finalmente, los subpatrones avanzados, de cualquier patrón básico, se diagnostican en estadios más tardíos. Conclusiones: En la actualidad está aceptado el valor de la histeroscopia en el diagnóstico del cáncer endometrial y su extensión intracavitaria. Demostramos, en este estudio, la utilidad y la validez de nuestra clasificación morfológico-histeroscópica, ya que con ella damos nombre y forma al cáncer diagnosticado, aventurando, incluso, un relativo pronóstico relacionado tanto con la estadificación como con el grado de diferenciación histológico

Objective: To assess the morphological-hysteroscopic nomenclature for endometrial cancer used by our group by evaluating the differences between distinct patterns, both morphological and those related to histological grade and stage at diagnosis. Material and methods: We analyzed 272 patients with hysteroscopically-diagnosed endometrial cancer. Using our classification, we grouped the tumors into three patterns (pseudohyperplasial, nodular, and malignant transformation of polyps) and one subpattern (advanced). We next compared these patterns with the surgical stage and the final histological grades. Results: When advanced signs were lacking, the patterns of pseudohyperplasia and malignant transformation of polyps were related to earlier stages and differentiated histological grades. Nodular patterns were related to scarcely differentiated histological grades. Finally, advanced subpatterns, irrespective of the basic pattern to which they belonged, were diagnosed at later stages. Conclusions: Currently, the value of hysteroscopy in the diagnosis of endometrial cancer and intracavity involvement is widely accepted. This study demonstrates the utility and validity of our morphological-hysteroscopic classification; the nomenclature described can be used to give a name to the malignancies diagnosed and even to hazard a prognosis related to their stage and grade of histological differentiation