[Conservative treatment of endometrial cancer as a way to preserve fertility. Five-year experience at Instituto Nacional de Perinatilogía Isidro Espinoza de los Reyes]. / Tratamiento conservador del cáncer de endometrio como una opción para preservar la fertilidad. Experiencia de cinco años en el Instituto Nacional de Perinatología Isidro Espinosa de los Reyes.

BACKGROUND: Progestins have been used in the treatment of advanced and metastatic endometrial cancer since the early 1960s. There is evidence that progestins can be used in fertility-preserving treatments in young women diagnosed with well-differentiated clinical stage 1A(EC1A) endometrioid type endometrial carcinoma. OBJECTIVE: Describe a fertility preservation treatment in women with primary infertility and EC1A endometrioid type endometrial carcinoma. PATIENTS AND METHODS: A historical cohort study. We analyzed 6 cases of women under 35 years assisted at the Oncology and Reproductive Medicine Department of the Instituto Nacional de Perinatologia of Mexico who met our inclusion criteria. Five women were treated with 500 mg medroxyprogesterone acetate (MPA) every other day; one woman was treated with 40 mg/day megestrol acetate (MGA). The treatment was continued to a maximum period of 11 months, provided that women gave good response to the treatment. The change in endometrial histology was assessed at four and six months of treatment. The primary endpoint was pathological complete response (CR). RESULTS: Follow-up time averaged 31 months; 66.6% of women responded to the initial hormone treatment; the remaining 33.4% responded to a second period of progesterone with histology in endometrial biopsy negative for cancer. Average response time was 6.8 months. Two patients had recurrence at an average of 19.5 months. Endometrial routine was performed with a disease-free interval of 15 to 24 months during which assisted reproductive technologies (ART) could be applied. Two patients achieved full-term pregnancy thanks to ART. The remaining patients did not continue with ART on their own initiative. CONCLUSIONS: In young women diagnosed with well-differentiated endometrioid EC1A carcinoma, the fertility-preserving treatment with progestin may be proposed together with strict selection and close monitoring of the patient.

[Hormone therapy effect in postmenopausal women with history of endometrial cancer]. / Efecto de la terapia hormonal en mujeres posmenopáusicas con antecedente de cáncer de endometrio.

BACKGROUND: The increase of endometrial cancer survivors' incidence let the question if the management of postmenopausal hormone therapy will increase the risk of carcinogenesis. OBJECTIVE: To determine the recurrence rate, in postmenopausal patients managed with hormonal therapy (HT) compared with patients without HT treated in El Instituto Nacional de Perinatologia Isidro Espinosa de los Reyes. PATIENTS AND METHOD: Retrospective, analytical, historical cohort. We analyzed 29 patients who met the inclusion criteria from January 1, 2000 to December 31, 2008 RESULTS: The average age for diagnosis of endometrial cancer was 45 years. 100% of the patients had surgical treatment (82.8% routine endometrial open approach, laparoscopic 17.2%). The 93% of patients had criteria to begin HT, however, was administered alone to 37% due to medical criteria, 36% received tibolona, 64% received estrogen with an average administration time of 39 and 54 months for each one without affecting disease-free period. Patients who received hormonal therapy had no recurrence of disease-free period of 58 months. There was only one patient with recurrence for which no hormonal therapy was administered. CONCLUSIONS: Patients who were under hormonal therapy did not modify the rate of endometrial cancer recurrence compared with those without HT. Although we cannot conclude irrefutably the safety of hormone therapy, based on biological knowledge and the results of this study, hormone therapy can be safely administered in stage I and II.

[Adnexal tumor and pregnancy: diagnosis and treatment]. / Tumor anexial y embarazo: diagnóstico y tratamiento.

BACKGROUND: The finding of adnexal masses during pregnancy is an exceptional event. Its reported incidence is less than 5% and most cases resolve spontaneously as the pregnancy progresses. OBJECTIVE: Describe a case series of patients with adnexal mass and pregnancy. MATERIAL AND METHODS: We retrospectively reviewed the medical records of patients who had diagnosis of pregnancy and adnexal over a period of five years. RESULTS: The incidence was 0.22%. The mean age was 26 +/- 7.3 years, mean gestational age was 17 +/- 6.6 weeks. The diagnosis was established by ultrasound (USG) in 95% of cases, 48% had cystic characteristics, the mean diameter of the tumor was 99 +/- 42 mm. Cistectomy was performed during pregnancy or trans-cesarean section in 30% and 58% of patients respectably. The mean tumor size was 118 mm (range 2 a 40 mm), weight 1,370 g (range 10 a 5,800 g). The most frequent histological diagnosis were serous cyst (40%), mature teratoma (28%), mucinous (6%), malignancy (4%). There were not complications related to the surgical procedure. CONCLUSIONS: The USG constitute a safe method for the diagnosis, but the image method with the highest positive predictive value is the MRI. Tumor markers (CA-125, AFP, GCH-B,DHL, ACE), are not useful during pregnancy. If the tumor doesn't achieve surgical criteria the recommended follow up is clinical observation and USG. If surgery is decided, it should be performed between 16 a 23 weeks of pregnancy, and it's recommended to send the tumor to histological diagnosis, in case of malignancy the surgery will continue according to the tumor stage. The time and delivery route will be decided by the obstetrician.

Genotipificación del virus del papiloma humano en mujeres que asisten a un hospital gineco-obstétrico de tercer nivel de la Ciudad de México / Genotyping of human papillomavirus in women attending a third-level of gynecological-obstetric hospital in Mexico City

Objetivo: Determinar la frecuencia de infección por el virus del papiloma humano en pacientes que acudieron a un hospital de tercer nivel de atención en la Ciudad de México. Método: Se realizó un estudio prospectivo, transversal y descriptivo que incluyó 65 mujeres entre 15 a 46 años que asistieron a consulta para atención gineco-obstétrica. A todas las participantes se les tomó una muestra cervical para la detección/genotipificación del papiloma virus mediante la prueba Linear Array HPV Genotyping Test in vitro® (Roche Molecular Systems, Inc., Branchburg, NJ). Resultados: Un total de 36 (55,4%) pacientes resultaron positivas al virus, en las que se identificaron 65 genotipos virales tanto en infección única (38,9%) como en infección por múltiples (61,1%) genotipos. El 29,2% de los genotipos identificados, fueron de alto riesgo. Los genotipos de alto riesgo más frecuentes fueron: VPH52 y 51; mientras que los genotipos de bajo riesgo más comunes fueron: VPH6 y 53. Un tercio de las pacientes con infección mostraron al menos un genotipo de alto riesgo. Conclusión: En este estudio, se observó una frecuencia relativamente baja de genotipos de alto riesgo del virus del papiloma humano, sin embargo se identificó un porcentaje importante de co-infección por múltiples genotipos. Por esta razón, se considera necesario dar seguimiento a mediano y largo plazo para monitorear la evolución de la infección.

Objective: To identify which are the most frequent genotypes of human papilloma virus among a group of gynecologic-obstetric patients at tertiary care hospital in Mexico City. Method: A prospective and descriptive cross-sectional study was carried out among a group of 65 women, aged 15-46 years, receiving gynecological-obstetric care. Cervical specimens were taken from all participants for direct HPV detection/ genotyping by means of a Linear Array HPV Genotyping Test in vitro® (Roche Molecular Systems, Inc., Branchburg, NJ). Results: Virus detection was achieved in 36 patients (55.4%), with a total of 65 genotypes, either as single (38.9%) or multiple-genotype (61.1%) infections. High risk genotypes accounted for only 29.2% of all genotype. The most frequent high risk genotypes were HPV52 and 51, while HPV6 and 53 were the most frequent low risk ones. At least one high risk genotype was present in one third of infected patients. Conclusion: The relative low frequency of oncogenic human papilloma virus genotypes among the women in this study was observed, however a significant percentage of co-infection with multiple genotypes were identified. Thus, mid- to long-term follow up might be necessary for those patients to monitor the evolution of the infection.

Tumor phyllodes / Phyllodes tumours

El tumor phyllodes es una neoplasia fibroepitelial rara; constituye el 0.3 al 0.9% de tumores de mama y 2-3% de los tumores fibroepiteliales de mama. Puede presentarse a cualquier edad y no hay características confiables para predecir su comportamiento clínico. Se deben evaluar varios parámetros, incluyendo la celularidad estromal, atipia, mitosis, crecimiento estromal excesivo, infiltración de bordes y presencia o ausencia de necrosis. La mayor parte de estos tumores son benignos, pero hasta 30% pueden presentar tejido conectivo maligno. Las metástasis generalmente son hematógenas más que linfáticas y se presentan en un 13% de los casos. La disección de ganglios axilares generalmente no se recomienda. El tumor phyllodes benigno y maligno recurre de manera local en el 25%, por lo que se recomienda el seguimiento de los casos.

Phyllodes tumors is a rare fibroepithelial neoplasm; constitute about 0.3-0.9% of breast tumors and 2-3% of fibroepithelial breast tumors. They usually occur in middle-aged to elderly women but can occur at any age. No single feature is reliable to predict clinical behavior of phyllodes tumors. Several histological parameters should be evaluated, including stromal cellularity, atypia, mitoses, stromal overgrowth, infiltrative borders, and presence or absence of necrosis. Most of these tumors are benign, but up to 30% show malignant stroma. Metastases usually are hematogenous rather than lymphatic have been reported to occur at a rate of 13% as malignant phyllodes tumors usually spread by a hematogenous rather than a lymphatic route; axillary lymph node dissection is generally not recommended. The benign and malignant tumors phyllodes resort locally in 25% and follow up of patients is recomended.

Enfermedad de Paget extensa de la vulva: Presentación de un caso y propuesta de manejo conservador / Extensive Paget's disease of the vulva: Case report and a conservative management proposal

La enfermedad de Paget extramamaria (EPE) es una patología maligna observada, sobre todo, en áreas donde existe alta densidad de glándulas apocrinas. Presentamos el caso clínico de una paciente de 68 años de edad, atendida en la Clínica de Colposcopia del Servicio de Oncología, del Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, con diagnóstico de enfermedad de Paget a nivel vulvar, vagina, región de periné y región perianal, manejada con sesiones de vaporización con láser, con evolución satisfactoria. Dado que es una enfermedad poco frecuente, más común en el sexo femenino y en la raza blanca, con mayor incidencia en la séptima década de la vida, como es el caso de nuestra paciente, el objetivo de este trabajo es presentar una revisión de la evaluación clínica, haciendo énfasis en el diagnóstico diferencial, uso de colposcopia para diagnóstico y tratamiento conservador fraccionado con vaporización de láser. La baja incidencia de la enfermedad de Paget de la vulva, vagina, periné y región perianal, así como la ausencia de informes sobre la posibilidad de tratamiento no quirúrgico, motivan a informar a la comunidad científica sobre el manejo con vaporización láser, con la intención de evitar la morbilidad que puede traer consigo el manejo quirúrgico convencional.

Extramammary Paget's disease (EPD) is a malignant disease observed, especially in areas with high density of apocrine glands. We report a case of a patient of 68 years old, attended at the Colposcopy Clinic of Oncology, National Institute of Perinatology Isidro Espinosa de los Reyes, diagnosed with Paget's disease of the vulva, vagina, perineum region and perianal region, and managed with laser vaporization sessions with satisfactory outcome. Since it is a rare disease, more common in females and in whites, with the highest incidence in the seventh decade of life, as is the case of our patient, propose in this paper to present a review of the clinical evaluation with emphasis on the differential diagnosis, use of colposcopy for diagnosis and dividing up conservative treatment with laser vaporization of the disease. The low incidence of Paget's disease of the vulva, vagina, perineum and perianal region, and the absence of reports on the possibility of nonsurgical treatment encouraged to inform the scientific community about the management with laser vaporization, with the intention of avoiding morbidity that can lead to the conventional surgical maneuvers.

Cirugía radical por cáncer cervicouterino invasor: análisis de 416 casos / Radical surgery for invasive cervicouterine carcinoma

Entre 1980 y 1989 se realizaron 416 cirugías radicales por cáncer cervicouterino invasor en el Servicio de Oncología del Hospital General de México, SS, de las que 274 fueron histerictomías con linfadenectomía pélvica como procedimiento terapéutico de elección y 142, cirugías por recurrencias postradioterapia exenteraciones pélvicas y 10 histerectomía radical. Se presentaron como complicaciones más importantes de la histerectomía radical, la atonía vesical (27%), fístulas vesicovaginales (6.5%) y ureterovaginales (4.3%). Cierto veintún pacientes de 135 en estadio lb (89.6%) tuvieron una evolución a dos años sin evidencia de cáncer, cifra que correspondió a 29 de 40 (72.5%) para los estadios lla (p<0.05). Como fatores pronósticos en este grupo destacaron el tamaño del tumor primario, el tipo histológico y la diferenciación celular. Un estudio comparativo a dos años con y sin radioterapia postoperatoria en pacientes de riesgo para desarrollar recurrencias tumorales mostró diferencias estadísticas significativas a favor del grupo radiado cuando hubo tres o más ganglios metastásicos (5/6, 83.3% vs 1/6, 16.6% p=0.040); lo mismo que al comparar el porcentaje de recurrencias locales (1/22, 4.5% vs 9/25, 36%:p=0.012). Cuatro de 68 pacientes con exenteraciones anteriores (5.8%) y seis de 62 con exenteraciones totales desarrollaron complicaciones que las llevaron a la muerte. Evolucionaron sin evidencia de enfermedad a dos años el 58.3% de las exenteraciones anteriores, el 42.1% de las totales, 0 de dos pasteriores y cinco de siete histerectomías radicales. Otros factores de importancia pronóstica fueron el haber tenido previamente lesiones invasoras tempranas o no y la presencia o no de tres o más ganglios metastásico.

Exenteraciones pélvicas por ca. cervicouterino (factores pronósticos) / Pelvice exenterations for cervical cancer (prognosis factors)

Se muestra el análisis de los factores que influyeron en el prónostico de 104 pacientes sometidas a exenteraciones pélvicas por cáncer cérvico-uterino recurrente a radiación, en el Servicio de Oncología del Hospital General de México, S.S., que sobrevivieron a la cirugía y que tuvieron un mínimo de seguimiento de tres años. Influyeron significativamente en el pronóstico de esta serie, la edad menor o mayor a 35 años: 15/22 68.1 por ciento vs 36/82, 43.9 por ciento, P=0.03; el reporte previo a la cirugía de tumor localizado al cérvix y/o vagina: 17/22, 77.2 por ciento vs. el informe de tumor parametrial fijo: 11/39, 28.2 por ciento, P=0.008, el reporte de urografía normal, 9/13, 69.2 por ciento, vs, el de hidronefrosis o exclusión renal: 2/13, 15.3 por ciento, P=0.01; la presencia o ausencia de invasión vesical y/o rectal: 15.41, 36.5 por ciento vs. 36/63, 57.1 por ciento, P=0.03; la presencia o ausencia de invasión al miometrico con o sin metástasis a ovarios, 2/15, 13.0 por ciento vs. 49/89, 55.5 por ciento, P=0.03 y la ausencia de metástasis ganglionares, 40/68, 58.8 por ciento vs. la presencia de 3 o más ganglios metastásicos, 4/15, 26.6 por ciento, P=0.01. No tuvo influencia estadísticamente significativa para el pronóstico, el tipo de radioterapia administrada, el tipo de exenteración efectuada, ni el tiempo transucrrido entre la terminación de la radioterapia y la cirugía. (Un año o menos)