MILACC study: could undetected lymph node micrometastases have impacted recurrence rate in the LACC trial?

OBJECTIVE: The etiology of inferior oncologic outcomes associated with minimally invasive surgery for early-stage cervical cancer remains unknown. Manipulation of lymph nodes with previously unrecognized low-volume disease might explain this finding. We re-analyzed lymph nodes by pathologic ultrastaging in node-negative patients who recurred in the LACC (Laparoscopic Approach to Cervical Cancer) trial. METHODS: Included patients were drawn from the LACC trial database, had negative lymph nodes on routine pathologic evaluation, and recurred to the abdomen and/or pelvis. Patients without recurrence or without available lymph node tissue were excluded. Paraffin tissue blocks and slides from all lymph nodes removed by lymphadenectomy were re-analyzed per standard ultrastaging protocol aimed at the detection of micrometastases (>0.2 mm and ≤2 mm) and isolated tumor cells (clusters up to 0.2 mm or <200 cells). RESULTS: The study included 20 patients with median age of 42 (range 30-68) years. Most patients were randomized to minimally invasive surgery (90%), had squamous cell carcinoma (65%), FIGO 2009 stage 1B1 (95%), grade 2 (60%) disease, had no adjuvant treatment (75%), and had a single site of recurrence (55%), most commonly at the vaginal cuff (45%). Only one patient had pelvic sidewall recurrence in the absence of other disease sites. The median number of lymph nodes analyzed per patient was 18.5 (range 4-32) for a total of 412 lymph nodes. A total of 621 series and 1242 slides were reviewed centrally by the ultrastaging protocol. No metastatic disease of any size was found in any lymph node. CONCLUSIONS: There were no lymph node low-volume metastases among patients with initially negative lymph nodes who recurred in the LACC trial. Therefore, it is unlikely that manipulation of lymph nodes containing clinically undetected metastases is the underlying cause of the higher local recurrence risk in the minimally invasive arm of the LACC trial.

Fertility-sparing surgery after neo-adjuvant chemotherapy in women with cervical cancer larger than 4 cm: a systematic review.

OBJECTIVE: The objective of this systematic review was to assess the oncologic and fertility outcomes of patients with cervix-confined cancer >4 cm who underwent neo-adjuvant chemotherapy followed by fertility-sparing surgery. METHODS: This study was registered in PROSPERO (registration number CRD42021254816). PubMed/MEDLINE, ClinicalTrials, EMBASE, Cochrane Central Register of Controlled Trials, SCOPUS, and OVID databases were searched from inception to July 2021. The included patients were those with cancer confined to the cervix and tumor diameter >4 cm (International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IB3) with squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma who underwent intra-venous neo-adjuvant chemotherapy followed by successful fertility-sparing surgery. RESULTS: The initial search identified 2990 articles. A total of 40 patients from 11 studies had attempted fertility preservation surgery (conization, simple or radical trachelectomy) and in 26 patients (65%) it was successful. All patients received platinum-based chemotherapy. A complete pathological response occurred in 56% of patients and two patients (7.7%) had a recurrence. The 4.5-year disease-free survival was 92.3% and the 4.5-year overall survival rate was 100%. Of six patients who tried to conceive, four (67%) achieved at least one pregnancy and three of the five pregnancies (60%) were pre-term deliveries (all after radical trachelectomy). All patients with recurrence received cisplatin and ifosfamide instead of cisplatin and paclitaxel, underwent non-radical surgery, and had residual disease in the final specimen. CONCLUSIONS: Evidence for fertility-sparing surgery after neo-adjuvant chemotherapy in patients with cervical cancer and tumors >4 cm is limited, and this approach should be considered as an experimental intervention. As the use of non-radical surgery could be a risk factor, if neo-adjuvant chemotherapy is used, patients should undergo fertility-sparing radical surgery.

Oncological outcomes of laparoscopic radical hysterectomy versus radical abdominal hysterectomy in patients with early-stage cervical cancer: a multicenter analysis.

INTRODUCTION: Recent evidence has shown adverse oncological outcomes when minimally invasive surgery is used in early-stage cervical cancer. The objective of this study was to compare disease-free survival in patients that had undergone radical hysterectomy and pelvic lymphadenectomy, either by laparoscopy or laparotomy. METHODS: We performed a multicenter, retrospective cohort study of patients with cervical cancer stage IA1 with lymph-vascular invasion, IA2, and IB1 (FIGO 2009 classification), between January 1, 2006 to December 31, 2017, at seven cancer centers from six countries. We included squamous, adenocarcinoma, and adenosquamous histologies. We used an inverse probability of treatment weighting based on propensity score to construct a weighted cohort of women, including predictor variables selected a priori with the possibility of confounding the relationship between the surgical approach and survival. We estimated the HR for all-cause mortality after radical hysterectomy with weighted Cox proportional hazard models. RESULTS: A total of 1379 patients were included in the final analysis, with 681 (49.4%) operated by laparoscopy and 698 (50.6%) by laparotomy. There were no differences regarding the surgical approach in the rates of positive vaginal margins, deep stromal invasion, and lymphovascular space invasion. Median follow-up was 52.1 months (range, 0.8-201.2) in the laparoscopic group and 52.6 months (range, 0.4-166.6) in the laparotomy group. Women who underwent laparoscopic radical hysterectomy had a lower rate of disease-free survival compared with the laparotomy group (4-year rate, 88.7% vs 93.0%; HR for recurrence or death from cervical cancer 1.64; 95% CI 1.09-2.46; P=0.02). In sensitivity analyzes, after adjustment for adjuvant treatment, radical hysterectomy by laparoscopy compared with laparotomy was associated with increased hazards of recurrence or death from cervical cancer (HR 1.7; 95% CI 1.13 to 2.57; P=0.01) and death for any cause (HR 2.14; 95% CI 1.05-4.37; P=0.03). CONCLUSION: In this retrospective multicenter study, laparoscopy was associated with worse disease-free survival, compared to laparotomy.

Role of pelvic and para-aortic lymphadenectomy in abandoned radical hysterectomy in cervical cancer.

BACKGROUND: Cervical cancer (CC) occupies fourth place in cancer incidence and mortality worldwide in women, with 560,505 new cases and 284,923 deaths per year. Approximately, nine of every ten (87%) take place in developing countries. When a macroscopic nodal involvement is discovered during a radical hysterectomy (RH), there is controversy in the literature between resect macroscopic lymph node compromise or abandonment of the surgery and sending the patient for standard chemo-radiotherapy treatment. The objective of this study is to compare the prognosis of patients with CC whom RH was abandoned and bilateral pelvic lymphadenectomy and para-aortic lymphadenectomy was performed with that of patients who were only biopsied or with removal of a suspicious lymph node, treated with concomitant radiotherapy/chemotherapy in the standard manner. METHODS: A descriptive and retrospective study was conducted in two institutions from Mexico and Colombia. Clinical records of patients with early-stage CC programmed for RH with an intraoperative finding of pelvic lymph, para-aortic nodes, or any extracervical involvement that contraindicates the continuation of surgery were obtained. Between January 2007 and December 2012, 42 clinical patients complied with study inclusion criteria and were selected for analysis. RESULTS: In patients with CC whom RH was abandoned due to lymph node affectation, there is no difference in overall survival or in disease-free period between systematic lymphadenectomy and tumor removal or lymph node biopsy, in pelvic lymph nodes as well as in para-aortic lymph nodes, when these patients receive adjuvant treatment with concomitant radiotherapy/chemotherapy. CONCLUSIONS: This is a hypothesis-generator study; thus, the recommendation is made to conduct randomized prospective studies to procure better knowledge on the impact of bilateral pelvic and para-aortic lymphadenectomy on this group of patients.

Complicaciones asociadas a histerectomía radical con linfadenectomía pélvica en mujeres con cáncer de cérvix en el Instituto de Cancerología - Clínica Las Américas, Medellín, Colombia: estudio de cohorte / Complications associated to radical hysterectomy and pelvic lymph node dissection in patients with cervical cancer at instituto de Cancerología Clínica Las Américas. Medellín, Colombia: a cohort study

Objetivo: describir las complicaciones intraquirúrgicas y posquirúrgicas inmediatas de la histerectomía radical total abdominal más linfadenectomía pélvica y los resultados anatomo-patológicos en pacientes con cáncer de cérvix en estadio temprano del Instituto de Cancerología – Clínica Las Américas en un periodo de ocho años.Materiales y métodos: cohorte histórica descriptiva de mujeres con diagnóstico de cáncer de cérvix confirmado histológicamente, y que al momento de la cirugía se encontraban en estadios entre IA2 a IIA1 según la clasificación FIGO, y sometidas a histerectomía radical tipo II o III entre agosto de 2003 y julio de 2011 en el Instituto de Cancerología – Clínica Las Américas, institución de salud de carácter privado, centro de referencia de alta complejidad en Medellín (Colombia), donde se atienden pacientes del régimen contributivo y subsidiado. Se hizo muestreo consecutivo. Las variables evaluadas fueron edad, índice de masa corporal, tiempo quirúrgico, estancia hospitalaria, sangrado intraoperatorio, estadio clínico, histología, infiltración estromal, compromiso linfovascular, compromiso parametrial, márgenes, conteo y compromiso ganglionar, transfusión sanguínea, complicaciones intraoperatorias, complicaciones posoperatorias, terapia adyuvante. La información se resumió por medio de medidas de tendencia central y dispersión para variables continuas y proporciones para variables categóricas u ordinales.Resultados: se incluyeron 199 pacientes. La mediana de edad fue de 46 años (28-75), 183 pacientes (92%) fueron diagnosticadas en estadio IB1. El diagnóstico histológico más frecuente fue el escamocelular en 125 casos (62,8%), el adenocarcinoma se presentó en 66 casos (33,1%). El tiempo quirúrgico promedio fue de 188 min (90-315); el sangrado estimado en promedio fue 316 cc (30-2000), 19 pacientes (9,5%) requirieron transfusión sanguínea; el promedio de ganglios extraídos fue 22 (9-61); la estancia hospitalaria fue de 2,44 días (1-31) en promedio. La tasa de complicaciones intraoperatorias fue de 9,5%, todas relacionadas con sangrado intraoperatorio y lesiones vasculares. Se presentaron 73 complicaciones posoperatorias (36,7%). La complicación posoperatoria más frecuente fue la fístula urinaria (6,5 %). Un total de 97 (48,7%) pacientes requirieron terapia adyuvante.Conclusiones: la histerectomía radical abdominal realizada en la población de estudio es un procedimiento seguro, reproducible, con una frecuencia de complicaciones intra y posoperatorias dentro de lo esperado para dicha cirugía.

Objective: To describe intra-operative and immediate post-operative complications of total radical abdominal hysterectomy with pelvic lymph node dissection, and the pathology results in patients with early-stage cervical cancer at the Instituto de Cancerología - Clínica de Las Américas, over a 8-year period.Materials and methods: Descriptive historical cohort of women with a diagnosis of histologically confirmed cervical cancer, who were diagnosed as stages IA2 to IIA1 according to the FIGO classification at the time of surgery, undergoing type II or III radical hysterectomy between August 2003 and July 2011 at the Instituto de Cancerología - Clínica Las Américas, a private high-complexity referral center in Medellin, Colombia, that provides care to patients of the contributive and subsidized health insurance regimes. A consecutive sample was used. Assessment variables included body mass index, duration of surgery, hospital stay, intraoperative bleeding, clinical stage, histology, stromal infiltration, lymphovascular involvement, parametrial involvement, margins, node count and lymph node involvement, blood transfusion, intra-operative complications, post-operative complications, adjuvant therapy. Information was summarized on the basis of central trend and scatter measurements for continuous variables, and proportions for categorical or ordinal variables.Results: Overall, 199 patients were included with a median age of 46 years (28-75). Of them, 183 (92%) were diagnosed as stage IB1. The most frequent histological diagnosis was squamous cell carcinoma in 125 cases (62.8%), while adenocarcinoma occurred in 66 cases (33.1%). The mean duration of the surgical procedure was 188 min (90-315); average estimated blood loss was 316 cc (30-2000), and 19 patients (9.5%) required a blood transfusion; in average, 22 lymph nodes (9-61) were removed; median hospital stay was 2.44 days (1-31). The rate of intra-operative complications was 9%, all of them associated with vascular lesions and intraoperative bleeding. There were 73 post-operative complications (36.7%), the most frequent of which was urinary fistula (6.5%). Overall, 97 patients (48.7%) required adjuvant therapy.Conclusions: Abdominal radical hysterectomy performed in the study population is a safe, feasible and reproducible, with a frequency of operative and posoperative complications as is expected for that surgery.

Encuesta sobre conocimientos y uso de terapias alternas a la hormonal en mujeres menopáusicas de Medellín (Colombia) 2009 / A survey about knowledge and use of alternative therapies to that of traditional hormone replacement in menopausal women in Medellín (Colombia) 2009

Objetivo: describir el conocimiento y uso de las terapias alternativas a la hormonal en mujeres menopáusicas. Materiales y métodos: durante 2009, se realizó un estudio descriptivo de corte transversal en mujeres menopáusicas de la ciudad de Medellín, Colombia.Los criterios de inclusión fueron edad ≥40 años, haber finalizado sus ciclos menstruales al menos un ano antes y no tener antecedente de histerectomía. Resultados: un total de 274 mujeres fueron haber finalizado sus ciclos menstruales al menos un encuestadas. Un 10,6% de las mujeres utilizaban año antes y no tener antecedente de histerectomía. hormonas naturales y un 46,0% emplea productos a base de soya. Con respecto a las terapias médicas alternativas y complementarias para la sintomatología de la menopausia, diferentes a las hormonas naturales, el 32,8% de las mujeres manifestó haber oído hablar de alguna de ellas, siendo más conocidas la homeopatía (18,6%), el yoga (16,8%) y la terapia de relajación (12,0%). Conclusión: un alto porcentaje de mujeres menopáusicas conocen y utilizan terapias alternas a la hormonal para el manejo de la sintomatología asociada a la menopausia, especialmente la de consumo de fitoestrógenos y productos a base de soya.

Objective: describing knowledge about and the use of alternative therapies to traditional hormone replacement in menopausal women. Materials and methods: a cross-sectional, descriptive study of menopausal women was carried out in the city of Medellín, Colombia, during 2009. Inclusion criteria were: being aged ≥40, having finished their menstrual cycles at least one year beforehand and having no background of hysterectomy. Women who agreed to participate in the study answered a questionnaire requiring that they give anonymous information about socio-demographic variables, the date of their last menstruation, symptomatology during the menopause and the use and characteristics of alternative therapies and hormone replacement therapy during menopause. Results: 274 women were surveyed; 10.6% of them were using natural hormones and 46.0% used soy-based products. Regarding alternative and complementary medical therapies for menopausal symptomatology different to natural hormones, 32.8% of the women stated that they had heard of some of them, the most well-known being homeopathy (18.6%), yoga (16.8%) and relaxation therapy (12.0%). Conclusion: a high percentage of menopausal women in the survey knew about and used alternative therapies to that of traditional hormone replacement for managing menopauseassociated symptomatology, especially consuming phytoestrogens and soy-based products.

Sindrome de ovario poliquístico: del diagnóstico ecográfico al molecular / Polycystic ovary syndrome: from clinical and echographic to molecular diagnosis

El síndrome de ovario poliquístico es una endocrinopatía común y de etiología desconocida, que afecta hasta el 10% de las mujeres, y cuyas manifestaciones clínicas incluyen irregularidades menstruales, signos de hiperandrogenismo y obesidad. Se ha encontrado asociación con resistencia a la insulina, con incremento del riesgo de diabetes mellitus tipo 2 y eventos cardiovasculares. Así mismo, se describe riesgo de preeclampsia, hiperplasia endometrial, cáncer endometrial e infertilidad. Este síndrome es un desorden heterogéneo, con evidencia genética basada en estudios de familias con herencia autosómica dominante y se ha identificado un alto número de genes candidatos, tres de los más estudiados han sido el gen del receptor de insulina, la región codificadora de globulina fijadora de hormonas sexuales y el gen relacionado con el receptor de andrógenos.

The polycystic ovary syndrome is a common endocrine disorder of unknown etiology, which affects 10% of the women, whose clinical manifestations include menstrual irregularities, signs of hyperandrogenism and obesity. It has been found associations with resistance to the insulin with increase risk of type 2 diabetes mellitus and cardiovascular disease. Likewise risk is described of preeclampsia, endometrial hyperplasia, endometrial cancer and infertility. This syndrome is a heterogeneous disorder, with genetic evidence based on studies of families with inheritance autosomal dominant and has themselves identifying a high candidates genes number. Three of the most studied have been the gene of the receiver of insulin, the region encode of sex hormone binding globulin and the gene related to the receiver of androgens.

Enfermedad e insuficiencia renal cronica: segunda parte / Disease and chronic renal failure: part two

La enfermedad renal cronica (ERC), se define como un proceso fisiopatológico de etiología múltiple, que produce pérdida progresiva e inexorable del numero funcional de nefronas, con la posibilidad de dar lugar a una condición denominada Insuficiencia Renal Cronica (IRC), la cual, a su vez, conduce al paciente a depender permanentemente de una terapia de reemplazo renal...

Chronic Kidney Disease, is defined as a pathophysiologic process with multiple etiologies, that produces a progressive and ineludible lost ofthe number of functional nephrones, with the possibility ofgiving place to a condition called Chronic Renal Failure, which itself drives the patient to permanent1y depend on Renal Replacement Therapy...

Factores de riesgo de estilos de vida para enfermedad cardiovascular en estudiantes de la Escuela de Ciencias de la Salud de la Universidad Pontificia Bolivariana / Risk factors for lifestyle cardiovascular disease in students at the School of Health Sciences at the Universidad Pontificia Bolivariana

Las enfermedades cardiovasculares, son causa frecuente de enfermedad y muerte en nuestro pais. Existe suficiente evidencia cientifica, que muestra que los estilos de vida saludables previenen su aparicion. Objetivo: establecer la frecuencia de exposición a factores de riesgo de estilos de vida, para enfermedad cardiovascular en los estudiantes de la escuela de ciencias de la salud, con el fin de tenar información que ayude a desarrolar estrategias que tiendan al mejoramiento de estas conductas...

Introduction: Heart diseases are a frequent cause of illness and death in our country. There is enough scientific evidence that shows that healthy life styles prevent the appearing of those diseases. Objective: To establish the frequency of exposition to risky factors concerning heart diseases for HealthSciences School's students, aiming to acquire information that helps in the development of strategies foravoiding those factors.

Factores de riesgo para enfermedad cardiovascular en alumnos de enfermería de la Universidad Pontificia Bolivariana de Medellín, Colombia / Risk factors for cardiovascular disease in nursing students of the Universidad Pontificia Bolivariana in Medellín, Colombia

Objetivo. Establecer la prevalencia de exposición a factores de riesgo relacionados con estilos de vida, para enfermedades cardiovasculares (ECV) en estudiantes de enfermería de la Universidad Pontificia Bolivariana (UPB) de Medellín (Colombia). Método. Estudio observacional, descriptivo y transversal en los alumnos de enfermería de la UPB matriculados en el curso del año 2004. Se utilizó un cuestionario autoaplicado basado en el II Estudio de Factores de Riesgo para Enfermedades Crónicas. Se consideraron los siguientes factores de riesgo: fumar, sobrepeso y obesidad, actividad física, antecedentes de hipertensión arterial o hiperlipidemias y percepción del estado actual. Resultados. Respondieron al cuestionario 222 alumnos (96% del total de las matrículas). La media de edad de los alumnos fue de 20,7 años, y el 97,7% eran mujeres. El 52% no realizaba ejercicio, el 17% fumaba, el 9% tenía sobrepeso y el 1,4% obesidad. Conclusión. Una proporción considerable de los estudiantes de enfermería tenía estilos de vida inadecuados, lo que significa riesgos aplazados para el desarrollo futuro de enfermedad cardiovascular, por lo que se recomienda el diseño de estrategias tendentes a reforzar hábitos de vida saludables

Objective. To determine the prevalence of exposure to lifestyle-related risk factors to cardiovascular disease in nursing students of the Universidad Pontificia Bolivariana (UPB) de Medellín (Colombia). Method. An observational, descriptive, cross sectional study was performed in nursing students of the UPB registered in 2004. A self-administered questionnaire based on the II Study of Risk Factors for Chronic Diseases was used. The risk factors included were: smoking, overweight and obesity, physical activity, a history of hypertension or hyperlipidemia, and current perceived health status. Results. A total of 222 students responded (96% of all students registered). The mean age of the students was 20.7 years and 97.7% were women. Fifty-two percent did not take any physical exercise, 17% smoked, 9% was overweight and 1.4% was obese. Conclusion. A substantial proportion of nursing students have unhealthy lifestyles, representing a risk for the future development of cardiovascular disease. Consequently, strategies designed to reinforce healthy lifestyles should be developed

Enfermedad e insuficiencia renal cronicas: primera parte / Disease and chronic renal failure: part I

La Enfermedad Renal Crónica (ERC) se define como un proceso fisiopatológico de etiología múltiple que produce pérdida progresiva e inexorable del número funcional de nefronas, con la posibilidad de dar lugar a una condición denominada Insuficiencia Renal Crónica (IRC), la cual a su vez, conduce al paciente a depender permanentemente de una terapia de reemplazo renal. La ERC se define como: daño renal por ≥ 3 meses, definida por daño estructural o funcional con o sin disminución de la Rata de Filtración Glomerular (RFG), manifestada por anormalidades patológicas o marcadores de daño renal y por RFG < 60 m.l/min/1.73m2 por ≥ 3 meses, con o sin marcadores de daño renal; este es el parámetro que determina el estadío de la enfermedad renal (estadío 1- 5). Para el 2002 y basados en las estimaciones realizadas en la población norteamericana, aproximadamente ocho millones de personas presentaban una RFG menor a 60rnl/min/1.73m2 , lo cual corresponde a una enfermedad renal en estadío 3 o mayor. En números absolutos, la población con IRC en edades comprendidas entre los 45 y 64 años continúa creciendo y la incidencia total desde 1981 se ha cuadruplicado (de 82 a 334 por millón de habitantes). Sin importar la enfermedad renal subyacente (enfermedad primaria o secundaria), la progresión de la ERC deriva en un punto común, caracterizado por glomérulos escleróticos no funcionales, atrofia tubular y fibrosis intersticial, con la acumulación de "toxinas urémicas". Sin embargo, después de 150 años de ser descritas por vez primera, continúa siendo elusiva su adecuada caracterización. La ERC se acompaña de condiciones comórbidas como síndrome anémico, síndrome malnutrición-inflamación, acidemia/acidosis metabólica, dislipidemia, y enfermedad ósea que incrementan la morbi-mortalidad fundamentalmente de origen cardiovascular en este grupo de pacientes...

Chronic Kidney Disease is defined as a pathophysiologic process with multiple etiologies that produces a progressive and ineludible lost of the number of functional nephrones, with the possibility of giving place to a condition called Chronic Renal Failure, which itself drives the patient ro permanently depend on Renal Replacement Therapy. Chronic Renal disease is defined as: renal damage lasting 3 or more months, defined as structural or functional damage with or without decline in Glomerular filtration Rate (GFR), evidenced by pathological abnormalities or renal damage markers or GFR < 60ml/min/1.73 73m2 lasting 3 or more months, with or without renal damage markers. This is the parameter that establishes the stage of renal disease.In 2002 based on the estimates carried out in the North American population, approximately eight million people had a GFR < 60ml/min/1.73 111 2, which corresponds to a Renal Disease at least in Stage 3. In absolute numbers, the population with CRF between ages of 45 and 64 keeps growing and the total incidence since 1981 is four times bigger (82 to 334 per million habitants). Regardless of the underlying renal disease (primary or secondary), the progression of Chronic RenalDisease ends in a common point, characterized by sclerotic and non-functioning glomeruli, tubular atrophyand interstitial fibrosis, with the accumulation of «uremic toxins¼. Even though, after 150 years of being described for the first time, its adequate characterization is still elusive. Chronic Renal Disease has some associated conditions like anemic syndrome, malnutrition-inflammation syndrome, metabolic acidosis, dyslipidemia and bone disease that increases the morbimonality mainly cardiovascular morbilmortality, in this group of patients...