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

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

Impact of weight loss after treatment on survival outcomes of overweight and obese patients with early­stage endometrial cancer.

Despite the fact that obesity is the main risk factor for endometrial cancer, there is limited evidence regarding the effects of body weight change on overweight and obese women treated for early-stage endometrial can its impact on cancer outcomes. A retrospective cohort study was performed including all overweight and obese patients with early-stage type-I endometrial cancer that were treated at the Insular University Hospital of Las Palmas (Las Palmas de Gran Canaria, Spain) between January 2007 and December 2019. Body weight change at 12 months of treatment was evaluated, as well as its impact on cancer outcomes. Weight loss ≥5% was independently evaluated regarding its impact on survival. A total of 526 women were studied, of which 152 (28.90%) were overweight (BMI ≥25 and <30) and 374 (71.10%) were obese (BMI ≥30). The median follow-up was 76.17 months, during which time 77 (14.64%) women died. In the survivor group, body weight at initial diagnosis was 86.4±17.9 kg compared with 84.6±16.4 kg 1 year after treatment, which corresponded to a significant mean weight loss of 1.47 kg (P<0.001). However, in the group of non-survivors, body weight at initial diagnosis was 84.7±15.7 kg compared with 84.7±14.6 kg 1 year after treatment, which demonstrated a non-significant mean weight loss of 0.63 kg (P=0.180). When comparing between the patients who maintained or gained ≥5% weight and those who lost ≥5% weight, there were no significant differences taking into account the whole cohort and follow-up time; however, when adjusting for the period between 32 and 98 months, survival was significantly higher in those patients that lost ≥5% of their initial body weight (P=0.025; log-rank test). Based on the final univariate and cer and multivariate analyses, body weight change at 12 months was not indicated to be a factor significantly affecting overall survival; adjusted hazard ratio was 1.01 (95% CI 0.97-1.05, P=0.723). In conclusion, even if greater weight loss is observed in patients with endometrial cancer that survive the disease, no significant impact on survival outcomes is observed based on multivariate analysis.

Prognostic factors in young women with epithelial ovarian cancer: the Young Ovarian Cancer-Care (YOC-Care) study.

OBJECTIVE: To determine oncological outcomes and to identify prognostic factors in women aged <45 years with epithelial ovarian cancer. METHODS: A multicenter retrospective study was performed of patients treated for epithelial ovarian cancer aged <45 years between January 2010 and December 2019. RESULTS: A total of 998 patients with epithelial ovarian cancer from 55 different institutions in Spain were collected. The median age of the study population was 40.8 years (range 35.6-43.4). The grouped International Federation of Gynecology and Obstetrics (FIGO) stage distribution was 508 (50.9%) patients in initial stages (I and II) and 490 (49.1%) with advanced stages (III and IV). Three hundred and twenty-five (32.6%) patients presented with recurrent disease after a median follow-up of 33.1 months (range 16.1-66.4). The type of staging surgery (incomplete vs complete), type of initial treatment modality (primary cytoreduction vs interval surgery), and amount of residual disease were all significantly associated with overall survival. Tumor rupture was noted in 288 (27.9%) cases, but it was not associated with oncologic outcomes (p=0.11 for overall survival). In the multivariate analysis, the response based on radiological findings (HR 3.24, 95% CI 2.14 to 4.91 for partial response; HR 6.93, 95% CI 4.79 to 10.04 for progression), neoadjuvant chemotherapy (HR 1.42, 95% CI 1.04 to 1.94), and FIGO stage (HR 1.68, 95% CI 1.40 to 2.02) were identified as independent prognostic factors associated with worse oncologic outcomes (p<0.001). CONCLUSION: The partial and progression radiology-based response after chemotherapy, neoadjuvant chemotherapy, and advanced FIGO stage are independent prognostic factors associated with worse oncological outcomes in women aged <45 years with epithelial ovarian cancer.

Accuracy and Survival Outcomes after National Implementation of Sentinel Lymph Node Biopsy in Early Stage Endometrial Cancer.

BACKGROUND: Sentinel lymph node (SLN) biopsy has recently been accepted to evaluate nodal status in endometrial cancer at early stage, which is key to tailoring adjuvant treatments. Our aim was to evaluate the national implementation of SLN biopsy in terms of accuracy to detect nodal disease in a clinical setting and oncologic outcomes according to the volume of nodal disease. PATIENTS AND METHODS: A total of 29 Spanish centers participated in this retrospective, multicenter registry including patients with endometrial adenocarcinoma at preoperative early stage who had undergone SLN biopsy between 2015 and 2021. Each center collected data regarding demographic, clinical, histologic, therapeutic, and survival characteristics. RESULTS: A total of 892 patients were enrolled. After the surgery, 12.9% were suprastaged to FIGO 2009 stages III-IV and 108 patients (12.1%) had nodal involvement: 54.6% macrometastasis, 22.2% micrometastases, and 23.1% isolated tumor cells (ITC). Sensitivity of SLN biopsy was 93.7% and false negative rate was 6.2%. After a median follow up of 1.81 years, overall surivial and disease-free survival were significantly lower in patients who had macrometastases when compared with patients with negative nodes, micrometastases or ITC. CONCLUSIONS: In our nationwide cohort we obtained high sensitivity of SLN biopsy to detect nodal disease. The oncologic outcomes of patients with negative nodes and low-volume disease were similar after tailoring adjuvant treatments. In total, 22% of patients with macrometastasis and 50% of patients with micrometastasis were at low risk of nodal metastasis according to their preoperative risk factors, revealing the importance of SLN biopsy in the surgical management of patients with early stage EC.

Oncological outcomes among young women with non-epithelial ovarian cancer: the YOC-Care study (Young Ovarian Cancer - Care).

OBJECTIVE: To determine oncological outcomes and associated prognostic factors in women younger than 45 years diagnosed with non-epithelial ovarian cancer. METHODS: A retrospective, multicenter Spanish study was performed including women with non-epithelial ovarian cancer younger than 45 years between January 2010 and December 2019. All types of treatments and stages at diagnosis with at least 12 months of follow-up were collected. Women with missing data, epithelial cancers, borderline or Krukenberg tumors, and benign histology, as well as patients with previous or concomitant cancer, were excluded. RESULTS: A total of 150 patients were included in this study. The mean±SD age was 31.45±7.45 years. Histology subtypes were divided into germ cell (n=104, 69.3%), sex-cord (n=41, 27.3%), and other stromal tumors (n=5, 3.3%). Median follow-up time was 58.6 (range: 31.10-81.91) months. Nineteen (12.6%) patients presented with recurrent disease with a median time to recurrence of 19 (range: 6-76) months. Progression-free survival and overall survival did not significantly differ among histology subtypes (p=0.09 and 0.26, respectively) and International Federation of Gynecology and Obstetrics (FIGO) stage (I-II vs III-IV) with p=0.08 and p=0.67, respectively. Univariate analysis identified sex-cord histology with the lowest progression-free survival. Multivariate analysis showed that body mass index (BMI) (HR=1.01; 95% CI 1.00 to 1.01) and sex-cord histology (HR=3.6; 95% CI 1.17 to 10.9) remained important independent prognostic factors for progression-free survival. Independent prognostic factors for overall survival were BMI (HR=1.01; 95% CI 1.00 to 1.01) and residual disease (HR=7.16; 95% CI 1.39 to 36.97). CONCLUSIONS: Our study showed that BMI, residual disease, and sex-cord histology were prognostic factors associated with worse oncological outcomes in women younger than 45 years diagnosed with non-epithelial ovarian cancers. Even though the identification of prognostic factors is relevant to identify high-risk patients and guide adjuvant treatment, larger studies with international collaboration are essential to clarify oncological risk factors in this rare disease.

SUCCOR quality: validation of ESGO quality indicators for surgical treatment of cervical cancer.

OBJECTIVE: To evaluate whether compliance with European Society of Gynaecological Oncology (ESGO) surgery quality indicators impacts disease-free survival in patients undergoing radical hysterectomy for cervical cancer. METHODS: In this retrospective cohort study, 15 ESGO quality indicators were assessed in the SUCCOR database (patients who underwent radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage 2009 IB1, FIGO 2018 IB1, and IB2 cervical cancer between January 2013 and December 2014), and the final score ranged between 0 and 16 points. Centers with more than 13 points were classified as high-quality indicator compliance centers. We constructed a weighted cohort using inverse probability weighting to adjust for the variables. We compared disease-free survival and overall survival using Cox proportional hazards regression analysis in the weighted cohort. RESULTS: A total of 838 patients were included in the study. The mean number of quality indicators compliance in this cohort was 13.6 (SD 1.45). A total of 479 (57.2%) patients were operated on at high compliance centers and 359 (42.8%) patients at low compliance centers. High compliance centers performed more open surgeries (58.4% vs 36.7%, p<0.01). Women who were operated on at centers with high compliance with quality indicators had a significantly lower risk of relapse (HR=0.39; 95% CI 0.25 to 0.61; p<0.001). The association was reduced, but remained significant, after further adjustment for conization, surgical approach, and use of manipulator surgery (HR=0.48; 95% CI 0.30 to 0.75; p=0.001) and adjustment for adjuvant therapy (HR=0.47; 95% CI 0.30 to 0.74; p=0.001). Risk of death from disease was significantly lower in women operated on at centers with high adherence to quality indicators (HR=0.43; 95% CI 0.19 to 0.97; p=0.041). However, the association was not significant after adjustment for conization, surgical approach, use of manipulator surgery, and adjuvant therapy. CONCLUSIONS: Patients with early cervical cancer who underwent radical hysterectomy in centers with high compliance with ESGO quality indicators had a lower risk of recurrence and death.

SUCCOR cone study: conization before radical hysterectomy.

OBJECTIVE: To evaluate disease-free survival of cervical conization prior to radical hysterectomy in patients with stage IB1 cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2009). METHODS: A multicenter retrospective observational cohort study was conducted including patients from the Surgery in Cervical Cancer Comparing Different Surgical Aproaches in Stage IB1 Cervical Cancer (SUCCOR) database with FIGO 2009 IB1 cervical carcinoma treated with radical hysterectomy between January 1, 2013, and December 31, 2014. We used propensity score matching to minimize the potential allocation biases arising from the retrospective design. Patients who underwent conization but were similar for other measured characteristics were matched 1:1 to patients from the non-cone group using a caliper width ≤0.2 standard deviations of the logit odds of the estimated propensity score. RESULTS: We obtained a weighted cohort of 374 patients (187 patients with prior conization and 187 non-conization patients). We found a 65% reduction in the risk of relapse for patients who had cervical conization prior to radical hysterectomy (hazard ratio (HR) 0.35, 95% confidence interval (CI) 0.16 to 0.75, p=0.007) and a 75% reduction in the risk of death for the same sample (HR 0.25, 95% CI 0.07 to 0.90, p=0.033). In addition, patients who underwent minimally invasive surgery without prior conization had a 5.63 times higher chance of relapse compared with those who had an open approach and previous conization (HR 5.63, 95% CI 1.64 to 19.3, p=0.006). Patients who underwent minimally invasive surgery with prior conization and those who underwent open surgery without prior conization showed no differences in relapse rates compared with those who underwent open surgery with prior cone biopsy (reference) (HR 1.94, 95% CI 0.49 to 7.76, p=0.349 and HR 2.94, 95% CI 0.80 to 10.86, p=0.106 respectively). CONCLUSIONS: In this retrospective study, patients undergoing cervical conization before radical hysterectomy had a significantly lower risk of relapse and death.

Radical hysterectomy in early cervical cancer in Europe: characteristics, outcomes and evaluation of ESGO quality indicators.

INTRODUCTION: Comprehensive updated information on cervical cancer surgical treatment in Europe is scarce. OBJECTIVE: To evaluate baseline characteristics of women with early cervical cancer and to analyze the outcomes of the ESGO quality indicators after radical hysterectomy in the SUCCOR database. METHODS: The SUCCOR database consisted of 1272 patients who underwent radical hysterectomy for stage IB1 cervical cancer (FIGO 2009) between January 2013 and December 2014. After exclusion criteria, the final sample included 1156 patients. This study first described the clinical, surgical, pathological, and follow-up variables of this population and then analyzed the outcomes (disease-free survival and overall survival) after radical hysterectomy. Surgical-related ESGO quality indicators were assessed and the accomplishment of the stated recommendations was verified. RESULTS: The mean age of the patients was 47.1 years (SD 10.8), with a mean body mass index of 25.4 kg/m2 (SD 4.9). A total of 423 (36.6%) patients had a previous cone biopsy. Tumor size (clinical examination) <2 cm was observed in 667 (57.7%) patients. The most frequent histology type was squamous carcinoma (794 (68.7%) patients), and positive lymph nodes were found in 143 (12.4%) patients. A total of 633 (54.8%) patients were operated by open abdominal surgery. Intra-operative complications occurred in 108 (9.3%) patients, and post-operative complications during the first month occurred in 249 (21.5%) patients, with bladder dysfunction as the most frequent event (119 (10.3%) patients). Clavien-Dindo grade III or higher complication occurred in 56 (4.8%) patients. A total of 510 (44.1%) patients received adjuvant therapy. After a median follow-up of 58 months (range 0-84), the 5-year disease-free survival was 88.3%, and the overall survival was 94.9%. In our population, 10 of the 11 surgical-related quality indicators currently recommended by ESGO were fully fulfilled 5 years before its implementation. CONCLUSIONS: In this European cohort, the rate of adjuvant therapy after radical hysterectomy is higher than for most similar patients reported in the literature. The majority of centers were already following the European recommendations even 5 years prior to the ESGO quality indicator implementations.

Prevalence and genotype distribution of cervical human papilomavirus infection in the pre-vaccination era: a population-based study in the Canary Islands.

OBJECTIVE: National Spanish studies show that prevalence of cervical human papillomavirus (HPV) infection in the female population is increasingly frequent, with an overall estimate of 14% in women aged 18-65 years. The objective of this study is to know the prevalence and distribution of HPV types in the female population of the Canary Islands prior to the introduction of HPV vaccines and to investigate the associated clinical and sociodemographic factors. METHODS: Based on the Primary Health Care database, a sample of adult women (aged 18-65 years) of Gran Canaria (GC) and Tenerife (TF) stratified into nine age groups was carried out between 2002 and 2007. Women were contacted by postal letter and telephone call and were visited in their primary care centre. A clinical-epidemiological survey was completed and cervical samples were taken for cytological study and HPV detection. HPV prevalence and its 95% CI were estimated, and multivariate analyses were performed using logistic regression to identify factors associated with the infection. RESULTS: 6010 women participated in the study, 3847 from GC and 2163 from TF. The overall prevalence of HPV infection was 13.6% (CI 12.8%-14.5%) and 11.1% (CI 10.3%-11.9%) for high-risk types. The most frequent HPV type was 16 followed by types 51, 53, 31, 42 and 59. HPV types included in the nonavalent vaccine were detected in 54.1% of infected women. Factors associated with an increased risk of infection were: young ages (18-29 years), the number of sexual partners throughout life, not being married, being a smoker, and having had previous cervical lesions or genital warts. CONCLUSIONS: It is confirmed that prevalence of HPV infection in the female population of the Canary Islands is high, but similar to that of Spain, HPV 16 being the most frequent genotype. The determinants of infection are consistent with those of other populations.

SUCCOR study: an international European cohort observational study comparing minimally invasive surgery versus open abdominal radical hysterectomy in patients with stage IB1 cervical cancer.

BACKGROUND: Minimally invasive surgery in cervical cancer has demonstrated in recent publications worse outcomes than open surgery. The primary objective of the SUCCOR study, a European, multicenter, retrospective, observational cohort study was to evaluate disease-free survival in patients with stage IB1 (FIGO 2009) cervical cancer undergoing open vs minimally invasive radical hysterectomy. As a secondary objective, we aimed to investigate the association between protective surgical maneuvers and the risk of relapse. METHODS: We obtained data from 1272 patients that underwent a radical hysterectomy by open or minimally invasive surgery for stage IB1 cervical cancer (FIGO 2009) from January 2013 to December 2014. After applying all the inclusion-exclusion criteria, we used an inverse probability weighting to construct a weighted cohort of 693 patients to compare outcomes (minimally invasive surgery vs open). The first endpoint compared disease-free survival at 4.5 years in both groups. Secondary endpoints compared overall survival among groups and the impact of the use of a uterine manipulator and protective closure of the colpotomy over the tumor in the minimally invasive surgery group. RESULTS: Mean age was 48.3 years (range; 23-83) while the mean BMI was 25.7 kg/m2 (range; 15-49). The risk of recurrence for patients who underwent minimally invasive surgery was twice as high as that in the open surgery group (HR, 2.07; 95% CI, 1.35 to 3.15; P=0.001). Similarly, the risk of death was 2.42-times higher than in the open surgery group (HR, 2.45; 95% CI, 1.30 to 4.60, P=0.005). Patients that underwent minimally invasive surgery using a uterine manipulator had a 2.76-times higher hazard of relapse (HR, 2.76; 95% CI, 1.75 to 4.33; P<0.001) and those without the use of a uterine manipulator had similar disease-free-survival to the open surgery group (HR, 1.58; 95% CI, 0.79 to 3.15; P=0.20). Moreover, patients that underwent minimally invasive surgery with protective vaginal closure had similar rates of relapse to those who underwent open surgery (HR, 0.63; 95% CI, 0.15 to 2.59; P<0.52). CONCLUSIONS: Minimally invasive surgery in cervical cancer increased the risk of relapse and death compared with open surgery. In this study, avoiding the uterine manipulator and using maneuvers to avoid tumor spread at the time of colpotomy in minimally invasive surgery was associated with similar outcomes to open surgery. Further prospective studies are warranted.

Should the Presence of Metastatic Para-Aortic Lymph Nodes in Locally Advanced Cervical Cancer Lead to More Aggressive Treatment Strategies?

STUDY OBJECTIVE: To evaluate risk factors in patients with locally advanced cervical cancer (LACC) undergoing pretherapeutic laparoscopic para-aortic lymphadenectomy (LPL) as well as the progression-free and overall survival rates specifically in the subgroup of patients with metastatic para-aortic lymph nodes (PLNs). DESIGN: Retrospective study conducted on demographic data, pathologic and surgical findings, complications, and disease status recorded for LACC patients undergoing LPL during the period 2009 to 2015. SETTING: Department of Gynecologic Oncology of the Complejo Hospitalario Universitario Insular-Materno Infantil, Canary Islands, Spain (Canadian Task Force Classification II-3). PATIENTS: Women with LACC undergoing pretherapeutic LPL. All patients were treated with definitive chemoradiotherapy after surgery, and those with metastatic PLN received extended lumboaortic radiation therapy. INTERVENTIONS: Survival analysis was performed with the Kaplan-Meier method. Statistical significance was considered for p <.05. MEASUREMENTS AND MAIN RESULTS: The study included 139 patients. The median age was 48 years (range, 28-73). The most frequent histologic type was squamous cell carcinoma (77%), and the most frequent 2009 FIGO stage was IIB (48.2%). LPL identified metastatic PLN in 18.7% of patients (n = 26). The mean overall survival for the whole population, after 23 months of follow-up, was 68.2 months (95% CI, 63-73.4). For patients without para-aortic metastases, the mean survival time was 76.9 months (95% CI, 70.3-80.4), whereas for patients with positive PLNs the median survival time was 21 months (95% CI, 6.1-35.9; p <.0001). A logistic regression analysis revealed that the presence of metastatic PLNs and tumor size (>5 cm) were both independent risk factors for poor survival (OR, 117.5; 95% CI, 11.6-990.2; p <.0001, and OR, 21.5; 95% CI, 2-230.3; p = .01, respectively). CONCLUSION: LACC patients with metastatic PLNs had a poor prognosis and low survival rate. We postulate that this finding could be accounted for by the presence of hidden systemic disease and high recurrence rate after therapy. Efforts should be made to improve available therapeutic strategies for this particular subgroup of patients.

Safety and Feasibility Analysis of Laparoscopic Lymphadenectomy in Pelvic Gynecologic Malignancies: A Prospective Study.

OBJECTIVE: The aims of this study were to evaluate prospectively the safety and feasibility of laparoscopic lymphadenectomy in gynecologic oncology and to analyze risk factors associated with surgical adverse events. MATERIALS AND METHODS: This study included 444 consecutive laparoscopic lymphadenectomy procedures conducted in 358 consecutive gynecologic oncology patients, between 2007 and 2014. Surgical adverse events were classified into intraoperative, early postoperative (≤6 weeks after surgery), and late postoperative (>6 weeks after surgery). Logistic regression analysis was used to assess the independent effects of different variables on the probability of complications. Differences were considered to be statistically significant for P values less than 0.05. RESULTS: Two hundred forty-four pelvic lymphadenectomy and 200 aortic lymphadenectomy procedures were carried out during the studied period. All pelvic lymphadenectomy procedures were conducted with a transperitoneal approach, whereas 94.5% of aortic lymphadenectomy procedures were conducted with an extraperitoneal approach. A total of 52.2% of tumors were found to originate in the cervix, 38% in the endometrium, 6.4% in the ovary, 2.8% were sarcoma, and 0.6% were in a different region. The laparotomy conversion rate was 2.8%. The rate of intraoperative adverse events was 1.9%, the most frequent ones being vascular injuries followed by ureteral, bowel, or neurologic injuries. The rate of early-postoperative adverse events was 3.3%, the most frequent one being incisional hernia followed by hemoperitoneum, pelvic abscess, intestinal injury, and paralytic ileus. One patient with endometrial cancer died after surgery due to sepsis of unknown origin. The rate of late-postoperative adverse events was 3.6% and consisted mainly of symptomatic lymphocele or lymphedema. A logistic regression analysis showed that factors associated with increased risk of lymphadenectomy surgical complications were surgical bleeding and operative time (odds ratio, 2.6; 95% confidence interval, 1.1-6; P = 0.02 and odds ratio, 2.6; 95% confidence interval, 1-6.7; P = 0.04). CONCLUSIONS: Laparoscopic lymphadenectomy is a safe and feasible procedure in gynecologic oncology but not free of complications. We postulate that gynecologic oncologists should be properly trained in the management of such complications and be aware of the importance of adequate hemostasis and operating time during surgery.

Bariatric Surgery: Does It Play a Role in Fertility-Preserving Treatment Among Obese Young Women With Endometrial Cancer?

We present the case of a 17-year-old nulliparous woman with a history of obesity (body mass index 36.2 kg/m(2)), type 2 diabetes, and polycystic ovary syndrome, who was diagnosed with grade 1 endometrioid adenocarcinoma without radiological evidence of myometrial invasion or metastatic disease. After failure of a fertility-preserving treatment with a levonorgestrel-releasing intrauterine device, bariatric surgery was proposed to treat the obesity and improve control of her type 2 diabetes in an attempt to increase the chances of obtaining response to local treatment. Nine months after laparoscopic sleeve gastrectomy and 18 months after insertion of the intrauterine device, the patient reached normal body weight (body mass index 20.3 kg/m(2)) and showed complete response to treatment. As far as we know, this is the first published case of an adolescent obese patient treated with bariatric surgery concomitantly with fertility-preserving management of endometrial cancer. We propose that bariatric surgery may play a role as an adjuvant therapy in fertility-preserving treatment of endometrial cancer with local progestin, in which it could enhance remission rates and reduce recurrence.

Renovascular hypertension as a rare complication of laparoscopic extraperitoneal paraaortic lymphadenectomy.

We describe the case of a 35-year-old woman who presented with renovascular hypertension caused by a compressive hematoma, which was caused by polar artery injury occurred during a laparoscopic extraperitoneal paraaortic lymphadenectomy procedure. To our knowledge, this is the first description of a renovascular disorder associated with this increasingly common procedure. We propose that the occurrence of vascular injury during laparoscopic extraperitoneal paraaortic lymphadenectomy requires an early image control study aimed at monitoring for compressive disorders, which could lead to abnormal renal function.

Metastatic adenocarcinoma of mammary-like glands of the vulva successfully treated with surgery and hormonal therapy.

Vulvar cancer is a rare malignancy; most tumors are squamous cell type while adenocarcinomas are rare. Primary adenocarcinomas of the vulva predominantly include extramammary Paget's disease and sweat gland carcinomas. Greene first described a rare form of adenocarcinoma in 1936, which was called adenocarcinoma of mammary-like glands of the vulva because of its morphologic and immunohistochemical resemblance to breast adenocarcinomas. In the management of this entity, varying combinations of surgery, radiation therapy, systemic chemotherapy and/or hormonal therapy may be used, as in patients with orthotopic breast carcinoma. However, hormonal therapy leads the way in patients with positive hormonal receptors, where other therapies cannot be used due to comorbidities or advanced age. We present the first reported case of an elderly patient with metastatic vulvar adenocarcinoma arising from mammary-like glands, successfully treated with a combination of surgery and hormonal therapy.

Laparoscopic extraperitoneal para-aortic lymphadenectomy in the staging of locally advanced cervical cancer: is it a feasible procedure at a peripheral center?

OBJECTIVE: The study's aim was to evaluate the feasibility of laparoscopic extraperitoneal para-aortic lymphadenectomy at a peripheral center for the staging of patients with locally advanced cervical cancer (LACC). METHODS: From March 2009 to January 2011, 30 patients with LACC underwent laparoscopic extraperitoneal para-aortic lymphadenectomy. All patients were treated with definitive radiotherapy tailored according to the staging results. Data on demographics, pathologic findings, surgery, complications, and disease status at follow-up are presented. RESULTS: Patients' mean age was 47.6 years (range, 28-67 years). The mean body mass index was 26.3 (range, 19.1-35.6). Mean operative time was 118.7 minutes (range, 77-195 minutes) with an average of 14.2 lymph nodes removed (range, 5-34). Intraoperative complications were a lumbar artery injury and a bowel injury. No postoperative complications occurred. Mean postoperative hospital stay was 1.9 days (range, 1-6 days). Pathological examination revealed that 26.7% (8/30) of patients had metastatic disease in para-aortic lymph nodes. Two patients with disease at the para-aortic level died 5 and 12 months after diagnosis; both of them developed pulmonary and hepatic metastases. The rest of the patients were free of disease, after completion of the treatment, during a mean follow-up time of 15.6 months (range, 5-27 months). CONCLUSIONS: Laparoscopic extraperitoneal aortic lymphadenectomy is a feasible procedure, even at peripheral centers, that is useful to identify patients with LACC and para-aortic disease and to tailor their treatment. Gynecologic oncologists are encouraged to learn this procedure and offer it to their patients.

Follow-up after LLETZ: a study of 682 cases of CIN 2-CIN 3 in a single institution.

OBJECTIVE: To evaluate the importance of resection margins in the risk of persistent/recurrent lesions and to investigate other factors such as detection of high-risk HPV, which could potentially predict persistent/recurrent disease before patients engage in follow-up. STUDY DESIGN: 682 women with a histologically confirmed diagnosis of CIN 2-3 treated by loop electrosurgical excision procedure (LEEP) were included, between January 2000 and December 2006. Age, high-risk HPV detection determined by Hybrid Capture II and cone margins were evaluated as possible predictors of persistent/recurrent disease. RESULTS: The mean age at diagnosis was 37.8 years (range 18-73). The mean follow-up period was 39.9 months (SD 25.8). 6.6% of patients (45/682) were lost to follow-up. 64.7% of patients (441/682) had clear margins in the specimen and 20.1% of patients had positive surgical margins (137/682). In 8.6% of patients (59/682) the resection margins were uncertain. Positive endocervical sweep was found in 10.8% of cases (73/682). Residual/recurrent disease was demonstrated by colposcopy-guided biopsy in 13.9% of patients (88/637); 77.3% (68/88) of them developed CIN 1 while only 22.7% (20/88) developed high-grade premalignant lesions or carcinomas during the follow-up. We found significant differences in the frequency of persistent/recurrent disease depending on the status of margins: 24.8% of cases with positive margins vs 11.1% of cases with negative margins (p<0.0001). Multivariate analysis showed that only post-treatment high-risk HPV detection and status of the cone margins were significantly predictive of persistent/recurrent disease (OR 4.1, 95%CI 2.4-7.3, p<0.0001 and OR 2.7, 95%CI 1.5-4.7, p=0.001; respectively). CONCLUSION: The combination of histological examination of resection margins plus post-treatment tests for HPV detection would help to classify LEEP-treated patients into categories at different risk of recurrence.

Serous and mucinous borderline ovarian tumors: are there real differences between these two entities?

OBJECTIVE: To evaluate the clinical outcome and pathological features of patients with borderline ovarian tumors (BOT) with special emphasis on serous and mucinous histology. STUDY DESIGN: Medical and anatomopathological records were reviewed in the Gynecological Oncology Department of the Canarian University Hospital between 1990 and 2005. Survival rates were analyzed by using the Kaplan-Meier technique. RESULTS: The study included 163 patients. Serous tumors corresponded to 68 cases and mucinous tumors to 91 cases. Eighty-nine percent of patients were at FIGO stage I, 1.2% at stage II and 9.8% at stage III. Serous histology was significantly related to the presence of peritoneal implants (22.4% vs 3.6%; p=0.001), positive peritoneal cytology (35.7% vs 8.5%; p=0.001) and bilaterality (27.9% vs 1.1%, p<0.0001). Event-free survival (EFS) rates at 2, 5 and 10 years were 96.7%, 92.7% and 90.5%, respectively, with a mean survival time of 183 months (CI 95% 172-193). Thirteen recurrence cases were found (7.9%) with a mean time to recurrence of 39.6 months (range 4-140). Overall survival (OS) rates at 2, 5 and 10 years were 100%, 96.4% and 93.6%, respectively, with a mean time of 189 months (CI 95% 179-198). Mucinous BOT were associated with significantly lower OS rates than serous BOT (10 years OS: 88.5% vs 98.2%; p=0.01). CONCLUSIONS: Serous tumors present more unfavorable anatomopathological characteristics but are associated with better prognosis than mucinous tumors. If mucinous BOT diagnosis is retained physicians should be aware that their aggressive potential is not negligible.

Pure papillary serous tumors of the endometrium: a clinicopathological analysis of 61 cases from a single institution.

OBJECTIVE: The aim of this study was to evaluate the clinicopathological data and prognosis factors corresponding to patients with papillary serous carcinoma of the endometrium treated at a single institution. METHODS: Medical and anatomopathological records were reviewed in the Department of Gynecological Oncology of the Canarian University Hospital between 1989 and 2006. Only pure cases of papillary serous carcinoma of the endometrium were included. Survival rates were analyzed using the Kaplan-Meier technique. RESULTS: The study included 61 patients. Stages I, II, III, and IV were identified in 32.8%, 19.7%, 31.1%, and 8.2% of patients, respectively. Event-free survival rates after 5 and 10 years were 59% and 40%, respectively, with a median time of 83 months (95% confidence interval, 63-110). Relapse occurred in 40.5% of the patients. Overall survival rates after 5 and 10 years were 37.7% and 29%, respectively, with a median time of 55 months (95% confidence interval, 40-70). A univariate analysis showed that prognosis factors were tumor markers, stage, myometrial infiltration, lymphovascular invasion, and ganglia involvement. A multivariate analysis showed that tumor markers, stage, and myometrial infiltration had an independent influence on overall survival. CONCLUSIONS: Papillary serous carcinoma of the endometrium is a very aggressive type of endometrial carcinoma that behaves more similar to ovarian carcinoma than to endometrial carcinoma. Tumor markers at diagnosis, stage, and myometrial infiltration mainly determine prognosis at our institution.