Endometrial cancer: predictors and oncological safety of tumor tissue manipulation.

PURPOSE: The main goal of this study is to assess the impact of tumor manipulation on the presence of lympho-vascular space invasion and its influence on oncological results. METHODS: We performed a retrospective multi-centric study amongst patients who had received primary surgical treatment for apparently early-stage endometrial cancer. A multivariate statistical analysis model was designed to assess the impact that tumor manipulation (with the use of uterine manipulator or preoperative hysteroscopy) has on lympho-vascular development (LVSI) in the final surgical specimen. RESULTS: A total of 2852 women from 15 centers were included and divided into two groups based on the lympho-vascular status in the final surgical specimen: 2265 (79.4%) had no LVSI and 587 (20.6%) presented LVSI. The use of uterine manipulator was associated with higher chances of lympho-vascular involvement regardless of the type used: Balloon manipulator (HR: 95% CI 4.64 (2.99-7.33); p < 0.001) and No-Balloon manipulator ([HR]: 95% CI 2.54 (1.66-3.96); p < 0.001). There is no evidence of an association between the use of preoperative hysteroscopy and higher chances of lympho-vascular involvement (HR: 95% CI 0.90 (0.68-1.19); p = 0.479). CONCLUSION: Whilst performing common gynecological procedures, iatrogenic distention and manipulation of the uterine cavity are produced. Our study suggests that the use of uterine manipulator increases the rate of LVSI and, therefore, leads to poorer oncological results. Conversely, preoperative hysteroscopy does not show higher rates of LVSI involvement in the final surgical specimen and can be safely used.

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.

Lymphovascular Space Invasion in Early-Stage Endometrial Cancer (LySEC): Patterns of Recurrence and Predictors. A Multicentre Retrospective Cohort Study of the Spain Gynecologic Oncology Group.

The main aim is to compare oncological outcomes and patterns of recurrence of patients with early-stage endometrioid endometrial cancer according to lymphovascular space invasion (LVSI) status. The secondary objective is to determine preoperative predictors of LVSI. We performed a multicenter retrospective cohort study. A total of 3546 women diagnosed with postoperative early-stage (FIGO I-II, 2009) endometrioid endometrial cancer were included. Co-primary endpoints were disease-free survival (DFS), overall survival (OS), and pattern of recurrence. Cox proportional hazard models were used for time-to-event analysis. Univariate and multivariate logistical regression models were employed. Positive LVSI was identified in 528 patients (14.6%) and was an independent prognostic factor for DFS (HR 1.8), OS (HR 2.1) and distant recurrences (HR 2.37). Distant recurrences were more frequent in patients with positive LVSI (78.2% vs. 61.3%, p < 0.01). Deep myometrial invasion (OR 3.04), high-grade tumors (OR 2.54), cervical stroma invasion (OR 2.01), and tumor diameter ≥ 2 cm (OR 2.03) were independent predictors of LVSI. In conclusion, in these patients, LVSI is an independent risk factor for shorter DFS and OS, and distant recurrence, but not for local recurrence. Deep myometrial invasion, cervical stroma invasion, high-grade tumors, and a tumor diameter ≥ 2 cm are independent predictors of LVSI.

Rationalisation of the caesarean section rate in a tertiary referral hospital using the Robson classification.

The aim of this study was to implement the Robson Ten Groups Classification System (RTGCS) to identify the main contributors to the caesarean section (CS) rate and to evaluate whether the introduction of a plan of obstetrical interventions reduced this rate. An observational retrospective cross-sectional study was conducted during two time periods at Alicante University General Hospital. In the pre-implementation period (2009-2012), RTGCS was applied to identify the main groups contributing to the overall CS rate. In the post-implementation period (2013-2017), RTGCS was applied again to identify changing trends in CS rates. In all, 11,034 deliveries during the pre-intervention period and 11,453 during the post-intervention period were analysed. The overall CS rate was 23.9% and 20.9%, respectively. There were no changes in perinatal outcomes. In the post-intervention period, there was a significant decrease of the CS rate in the groups of targeted interventions 1, 2, 3, 4, 5, and 8B.Impact statementWhat is already known on this subject? High CS rates are becoming a public health problem because of risks, costs, excessive medicalisation, and abuse of resources. RTGCS provides a framework for auditing and analysing CS rates.What do the results of this study add? RTGCS can identify the groups that have the greatest impact on the CS rate and monitor changes in it consequent to policy changes.What are the implications of these findings for clinical practice? The introduction of a strategic plan with evidence-based clinical interventions may have a greater effect on the CS rate than other features justifying the increase in the incidence of CS.

Primary peritoneal clear cell carcinoma. A case report and literature review.

Primary peritoneal malignant tumors are exceptional. Among them, clear cell carcinoma is extremely rare, being only thirteen cases previously reported in the literature since 1990. We report a case of a 48-year-old Caucasian woman who was treated at the University General Hospital of Alicante. She consulted because of progressive abdominal pain over the last seven months, with the initial diagnosis of renal-ureteral colic. Ultrasound and computed tomography of the abdomen and pelvis revealed a 25 × 15 cm, well-defined cystic lesion with papillary projections, centrally located in the abdomen. The radiology report suggested a primary ovarian tumor versus peritoneal implant as the first option. The patient underwent an exploratory laparotomy showing a large cystic mass located in the urinary bladder peritoneum, firmly attached to the mesentery. The entire abdominal tumor was completely excised, and total hysterectomy with bilateral salpingo-oophorectomy and infra-colical omentectomy were performed. The final histological study revealed a new case of primary peritoneal clear cell carcinoma located in the urinary bladder peritoneum, firmly attached to the mesentery. Grossly, it was well-circumscribed and multicystic with papillary growth involving part of the inner wall. Microscopically, it showed tubulocystic and papillary patterns with highly atypical tumor cells. After an extensive immunohistochemical analysis, the most relevant finding was an ARID1A loss that was corroborated by molecular analysis showing an ARID1A deletion. The patient received systemic chemotherapy with carboplatin and paclitaxel protocol (Å ~ 4 cycles). Patient follow-up after the eighth month showed peritoneal implants predominantly in the right diaphragmatic cupule that were histologically confirmed as recurrence. She has just received another six cycles of chemotherapy with carboplatin and paclitaxel. Recognition of primary peritoneal clear cell carcinoma in this uncommon location, and exclude metastasis from the ovary, represents a diagnostic challenge.

Does the Type of Surgical Approach and the Use of Uterine Manipulators Influence the Disease-Free Survival and Recurrence Rates in Early-Stage Endometrial Cancer?

OBJECTIVE: The purpose of this study was to compare the long-term safety, disease-free survival, and recurrence rate of total laparoscopic hysterectomy using uterine manipulator and abdominal hysterectomy in the surgical treatment in early-stage endometrial cancer. STUDY DESIGN: This was a cohort study of 147 patients with clinical endometrial cancer (laparoscopic surgery group, 77 women; laparotomy group, 70 women). Data were evaluated and analyzed by intention-to-treat principle, and survival data of stage I endometrial cancer (129 patients; 66 from laparoscopic surgery group and 60 from laparotomy group) were estimated by using the Kaplan-Meier curves. RESULTS: After a follow-up period of 60 months for both laparoscopic surgery and laparotomy groups, no significant difference in the cumulative recurrence rates (7.4% and 13.1%, P = 0.091) and overall survival (97.1% and 95.1%, P = 0.592) was detected between both groups of stage I endometrial cancer. Conversion to laparotomy occurred in 10.4% (8/77) of the laparoscopic procedures. Laparoscopic hysterectomy was associated with less use of pain medication (P = 0.001) and a shorter hospital stay (P < 0.001), but the procedure took longer than laparotomic hysterectomy (P < 0.001). The proportion of patients with intraoperative and long-term complications was not significantly different between both groups. The use of uterine manipulators did not have increased recurrence rate in patients treated with laparoscopic approach. CONCLUSIONS: The laparoscopic surgery approach to early-stage endometrial cancer using uterine manipulators is as safe and effective as the laparotomic approach.

Mastitis granulomatosa crónica idiopática / Chronic idiopathic granulomatous mastitis

La mastitis granulomatosa crónica idiopática (MGCI) es una enfermedad inflamatoria benigna con una baja incidencia. Se ha asociado a una respuesta inmunológica anormal, la utilización de anticonceptivos orales, así como la existencia de algún organismo infeccioso, como posible causante de una reacción alérgica de tipo cuerpo extraño. Afecta principalmente a mujeres en edad fértil. Generalmente es unilateral y se manifiesta por una o más masas inflamatorias. El aspecto mamográfico puede simular el desarrollo de un carcinoma intraductal, enfermedad de Paget o procesos inflamatorios mamarios de origen benigno de diferentes etiologías. Histopatológicamente se caracteriza por una lobulitis crónica, necrotizante, no caseificante, que presenta formación de granulomas. El diagnóstico de MGCI debe fundamentarse en este patrón histológico combinado con la exclusión de otras lesiones granulomatosas de la mama. Aunque se han planteado varias alternativas terapéuticas, tanto quirúrgicas como médicas, el tratamiento ideal de la MGCI no ha sido aún establecido. Las resecciones quirúrgicas del tejido afectado asociado o no con corticoides orales es la terapia más utilizada (AU)

Chronic idiopathic granulomatous mastitis (CIGM) is a benign inflammatory disease with a low incidence. This entity has been associated with an abnormal immune response, oral contraceptive use and the existence of an infectious organism as a possible cause of an allergic reaction to a foreign body. CIGM mainly affects women of childbearing age, is usually unilateral and is manifested by one or more inflammatory masses. The mammographic appearance may mimic the development of intraductal carcinoma, Paget's disease or benign inflammatory processes of the breast of various etiologies. Histopathologically, CIGM is characterized by chronic, necrotizing, non-caseating lobulitis, which shows formation of granulomas. The diagnosis of CIGM should be established on the basis of this pattern, combined with exclusion of other granulomatous lesions of the breast. Although various medical and surgical therapeutic options have been proposed, the optimal treatment of CIGM has not yet been established. The most commonly used treatment is surgical resection of affected tissue with or without oral corticosteroid therapy (AU)

Tumor del estroma gastrointestinal en el tabique rectovaginal, un desafío diagnóstico / Gastrointestinal stromal tumor of the rectovaginal septum: a diagnostic challenge

Los tumores del estroma gastrointestinal (GIST) del tabique rectovaginal son entidades muy poco frecuentes, que cuando aparecen plantean grandes dificultades por su escasa sospecha diagnóstica. En la mayoría de los casos, se suelen confundir con leiomiomas o leiomiosarcomas, por su consistencia y tamaño similar, por lo que desempeña un papel clave el análisis histológico e inmunohistoquímico a la hora de planificar el abordaje terapéutico de estas pacientes. Presentamos el caso de una paciente de 75 años con un tumor GIST en el tabique rectovaginal, a la que se realizó resección total de la lesión y posterior tratamiento con Glivec (R) (mesilato de imatinib) (AU)

Gastrointestinal stromal tumors (GIST) of the rectovaginal septum are highly infrequent entities that pose a challenge due to the lack of diagnostic suspicion. These tumors are often misdiagnosed as leiomyomas or leiomyosarcomas because of the similarity in their structure and size. Histological analysis and immunochemistry play a key role in the choice of therapeutic strategy in these patients. We report the case of a 75-year-old woman with a GIST tumor in the rectovaginal septum. Tumor enucleation was performed and subsequent treatment with imatinib mesylate (Gleevec(R)) was established (AU)

Tratamiento del cáncer de endometrio sin histerectomía / Treatment of endometrial cancer without hysterectomy

El cáncer de endometrio es el tumor ginecológico maligno más frecuente en la mujer.El tratamiento protocolizado consiste en la cirugía (histerectomía total y doble anexectomía; en algunos casos debe añadirse linfadenectomía pélvica y paraaórtica, dependiendo de los factores de riesgo de afectación linfática); pero en mujeres jóvenes con cáncer de endometrio bien diferenciado, que debidamente informadas aceptan los riesgos y desean preservar su fertilidad, se puede realizar un tratamiento conservador con resección histeroscópica (RH), hormonoterapia y un seguimiento estricto.Presentamos un caso de una paciente de 29 años, nuligesta, en la que se realizó tratamiento conservador del cáncer de endometrio con resección histeroscópica y hormonoterapia con resultado satisfactorio en el primer año (AU)

Endometrial cancer is the most common gynecological malignancy diagnosed in women.AbstractThe standard therapy for endometrial cancer consists of a staging surgery (total hysterectomy and bilateral salpingo-oophorectomy; in some cases pelvic and paraaortica lymphadenectomy should be added depending on the risk factors for lymphatic involvement); but in young women with well-differentiated endometrial cancer, that properly informed accept the risks and wish to preserve their fertility, it is possible to realize a conservative treatment with hysteroscopic resection, hormonal therapy and a strict follow-up.AbstractWe have reported the case of endometrial cancer in a 29 years old woman, who was treated with hysteroscopical resection and hormonal therapy with satisfactory results during the first year follow-up (AU)

Estudio de patología vulvar en pacientes menopáusicas / Study of vulvar pathology in menopausal women

Objetivo: Estudiar la patología vulvar de las pacientes en edad menopáusica remitidas a una unidad del tracto genital inferior (UCTI). Material y métodos: Estudio observacional y descriptivo de las pacientes menopáusicas con patología vulvar remitidas a la UTGI del Hospital General Universitario de Alicante entre enero de 2000 y diciembre de 2007. Se evaluaron las patologías más frecuentes, el tipo de lesión, la localización, el diagnóstico y el tratamiento. Resultados: Se estudió a 189 pacientes mayores de 55 años; 68 (36%) presentaban patología vulvar. El liquen escleroso fue la más frecuente (46%), con prurito como síntoma principal (64%) y localizado principalmente en los labios mayores. El tratamiento instaurado con más frecuencia fueron los corticoides de alta potencia (64%).Conclusiones: La patología vulvar más frecuente en las pacientes menopáusicas de nuestra UTGI es el liquen escleroso, que se presenta habitualmente como prurito. Los corticoides de alta potencia fueron el tratamiento más efectivo (AU)

Objective: Study the pathology of the vulva found in menopausal patients referred to a lower genital tract unit (LGTU).Materials and methods: An observational and descriptive study of menopausal patients with vulvar pathology from the LGTU of Hospital General Universitario de Alicante (Spain), between January 2000 and December 2007. We assessed the more common diseases, lesion type, location, diagnosis and treatment. Results: We evaluated 189 patients (that were older than 55 years). Of these, 68 had vulvar pathology (36%), and lichen sclerosus (46%) the most frequent disease. The treatment most often established was with high-powered steroids (64%),which was also the most effective. Conclusions: The most common vulvar pathology in postmenopausal patients of our LGTU is the lichen sclerosus. Pruritus was the main symptom. High-powered steroids were the most effective treatment (AU)