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.

Oncological safety of hysteroscopy in endometrial cancer

OBJECTIVE

It has been suggested that the manipulation of neoplastic tissue during hysteroscopy may lead to dissemination of tumor cells into the peritoneal cavity and worsen prognosis and overall survival. The goal of this study was to assess the oncological safety comparing hysteroscopy to Pipelle blind biopsy in the presurgical diagnosis of patients with endometrial cancer.

METHODS

We performed a retrospective multicentric study among patients who had received primary surgical treatment for endometrial cancer. A multivariate statistical analysis model was used to compare relapse and survival rates in patients who had been evaluated preoperatively either by hysteroscopy or Pipelle biopsy. The relapse rate, disease-free survival, and overall survival were assessed as the main outcomes. The histological type, tumor size, myometrial invasion, International Federation of Gynecology and Obstetrics (FIGO) stage, surgical approach, use of a uterine manipulator, and adjuvant treatment were also included in the analysis.

RESULTS

A total of 1731 women from 15 centers were included: 1044 in the hysteroscopy group and 687 in the Pipelle sampling group. 225 patients relapsed during the 10 year follow-up period: 139 (13.3%) in the hysteroscopy group and 86 (12.4%) in the Pipelle sampling group. There is no evidence of an association between the use of hysteroscopy as a diagnostic method and relapse rate (HR 1.24, 95% CI 0.92 to 1.66; p=0.16), lower disease-free survival (HR 1.23, 95% CI 0.92 to 1.66; p=0.15), or overall survival (HR 0.95, 95% CI 0.70 to 1.29; p=0.76).

CONCLUSION

Hysteroscopy is a safe diagnostic method for patients with endometrial cancer with no impact on oncological outcomes when compared with sampling by Pipelle.

Prenatal diagnosis of cor triatriatum sinister associated with early pericardial effusion: A case report

BACKGROUND

Cor triatriatum sinistrum or cor triatriatum sinister is a rare congenital heart disease that accounts for approximately 0.1% of all cardiac abnormalities. It is defined as the presence of an anomalous septum that divides the left atrium into two cavities, and in most cases, it can be asymptomatic or less frequently very severe.

CASE SUMMARY

A 37-year-old pregnant woman visited our hospital. In the first trimester scan, we detected signs of fluid in the pericardium (pericardial effusion) that reached the atriums. In the third trimester, an anomalous septum in the left atrium suspicious of cor triatriatum sinister was detected. Expectant management was decided, the pregnancy evolved normally and resulted in uncomplicated delivery of a healthy child. The findings in the prenatal scan were confirmed by echocardiography and the diagnosis of cor triatriatum sinister was confirmed. The newborn was asymptomatic at all times.

CONCLUSION

We show expectant management of cor triatriatum sinister and suggest an association between this entity and early pericardial effusion.

Does Multidisciplinary Team Simulation-Based Training Improve Obstetric Emergencies Skills?

Clinical simulation in obstetrics has turned out to be a tool that can reduce the rate of perinatal morbidity and mortality. The objective of this study was to analyze the impact and evaluate the effects of training with high-fidelity simulation of obstetric emergencies on a multidisciplinary group. The quasi-experimental research study was structured in three phases: a first phase where the most important obstetric emergencies were determined, a second phase of design and development of the selected cases for simulation training, and a third and final phase where the abilities and satisfaction of the multidisciplinary team were analyzed. Three scenarios and their respective evaluation tools of obstetric emergencies were selected for simulation training: postpartum hemorrhage, shoulder dystocia, and breech delivery. The health professionals significantly improved their skills after training, and were highly satisfied with the simulation experience (p < 0.05). An inter-observer agreement between good and excellent reliability was obtained. Regarding conclusions, we can state that high-fidelity obstetric emergency simulation training improved the competencies of the health professionals.

Impact of uterine manipulator on oncological outcome in endometrial cancer surgery

BACKGROUND

There are limited data available to indicate whether oncological outcomes might be influenced by the uterine manipulator, which is used at the time of hysterectomy for minimally invasive surgery in patients with endometrial cancer. The current evidence derives from retrospective studies with limited sample sizes. Without substantial evidence to support its use, surgeons are required to make decisions about its use based only on their personal choice and surgical experience.

OBJECTIVE

To evaluate the use of the uterine manipulator on oncological outcomes after minimally invasive surgery, for apparent early-stage endometrial cancer.

STUDY DESIGN

We performed a retrospective multicentric study to assess the oncological safety of uterine manipulator use in patients with apparent early-stage endometrial cancer, treated with minimally invasive surgery. The type of manipulator, surgical staging, histology, lymphovascular space invasion, International Federation of Gynecology and Obstetrics stage, adjuvant treatment, recurrence, and pattern of recurrence were evaluated. The primary objective was to determine the relapse rate. The secondary objective was to determine recurrence-free survival, overall survival, and the pattern of recurrence.

RESULTS

A total of 2661 women from 15 centers were included; 1756 patients underwent hysterectomy with a uterine manipulator and 905 without it. Both groups were balanced with respect to histology, tumor grade, myometrial invasion, International Federation of Gynecology and Obstetrics stage, and adjuvant therapy. The rate of recurrence was 11.69% in the uterine manipulator group and 7.4% in the no-manipulator group (P<.001). The use of the uterine manipulator was associated with a higher risk of recurrence (hazard ratio, 2.31; 95% confidence interval, 1.27-4.20; P=.006). The use of uterine manipulator in uterus-confined endometrial cancer (International Federation of Gynecology and Obstetrics [FIGO] I-II) was associated with lower disease-free survival (hazard ratio, 1.74; 95% confidence interval, 0.57-0.97; P=.027) and higher risk of death (hazard ratio, 1.74; 95% confidence interval, 1.07-2.83; P=.026). No differences were found regarding the pattern of recurrence between both groups (chi-square statistic, 1.74; P=.63).

CONCLUSION

In this study, the use of a uterine manipulator was associated with a worse oncological outcome in patients with uterus-confined endometrial cancer (International Federation of Gynecology and Obstetrics I-II) who underwent minimally invasive surgery. Prospective trials are essential to confirm these results.

Molybdenum Cofactor Deficiency: Mega Cisterna Magna in Two Consecutive Pregnancies and Review of the Literature

The molybdenum cofactor deficiency is an autosomal recessive disease, characterized by rapidly progressive and severe neurological damage that mimics a hypoxic-ischemic encephalopathy due to the accumulation of toxic metabolites that cause rapid neurodegeneration after the delivery. It is eventually lethal, in a similar way to the rare isolated sulfite oxidase deficiency. This serious pathology usually causes death in the immediate neonatal period in the more severe variants. We report a case of two consecutive pregnancies with enlarged cisterna magna as the only prenatal pathological finding since 26 weeks of gestation (WG) and the subsequent death of the newborns in the first week after birth. After the second pregnancy, we reached the diagnosis of molybdenum cofactor deficiency due to MOCS1 gene mutation. According to the cases reported in the literature, this is the case with the earliest neuroimage prenatal findings.

Prenatal diagnosis and molecular cytogenetic characterization of a de novo duplication of 15q24.3-q26.1

Reported cases of distal 15q interstitial duplications are uncommon and do not result in a recognizable pattern of abnormalities. Some studies report prenatal overgrowth, while others describe growth retardation. We present molecular cytogenetic characterization of a 14 Mb interstitial duplication, encompassing 81 Online Mendelian Inheritance in Man (OMIM) genes, in a fetus with single umbilical artery and short limbs. We propose that growth restriction, previously described and present in our patient, may be due to duplication of a gene or genes contained in the 15q24 region.

[Severe pelvic inflammatory disease. Response to ertapenem]

Pelvic inflammatory disease (PID) is an important health problem. Delay in diagnosis and effective treatment contributes to inflammatory sequelae with risk of future fertility problems and chronic pelvic pain. Treatment regimens must provide empiric, broad-spectrum coverage of likely pathogens but also take into account patient's risk profile. In this article we report the case of a young woman affected by a rare genital malformation who required the creation of a neovagina made of abdominal skin. Years later, the patient presented with symptoms that support the diagnosis of PID. There was no clinical analytical response to classical parenteral antimicrobial regimen, even after surgical intervention for tubal abscess. Peptostreptococci isolated in abdominal cavity culture showed an infrequent clindamycin resistance, so we started monotherapy treatment with ertapenem, with excellent results. In conclusion, more clinical trials are needed to discover the pathogens usually involved in PID in our setting and their antibiotic resistance to re-evaluate standard antimicrobial regimens and perhaps recommend new agents, such as ertapenem.

[Immunomodulatory treatment with beta-interferon in patients with cervical intraepithelial neoplasia and human papillomavirus infection: long-term follow-up]

The aim of this study was to evaluate the long-term efficacy of beta-interferon treatment in the management of cervical intraepithelial neoplasia associated with human papillomavirus (HPV) infection in a selected group of patients. Thirty-nine patients who had histologically proven cervical intraepithelial neoplasia I or II with concurrent HPV infection were administered 27,000,000 IU of intramuscular beta-interferon. Periodical controls were carried out based on Papanicolaou smears and/or colposcopic examination and DNA HPV determination was performed by hybridation test, for a maximum of 8 years' follow-up. An initial complete response rate of 75% was obtained, with a recurrence rate of 25%, cervical intraepithelial neoplasia with late manifestation was of higher grade. Treatment interruption due to side-effects was not necessary. Associated viral infections appeared to be a recurrence risk factor, but not smoking or parity. While immunomodulatory treatment with beta-interferon has good long-term results in cervical intraepithelial neoplasia I/II treatment, wider randomized studies are required to obtain conclusive results.

Multivariate analysis of the morphometric characteristics of tumours as prognostic factors in the survival of patients with uterine cervix cancer treated with radical surgery

OBJECTIVES

To analyse the influence of tumour size and anatomopathological characteristics in the prognosis of patients with early-stage cancer of the uterine cervix treated with radical surgery.

STUDY DESIGN

A historical study of 114 patients treated at the Maternity Hospital "La Fe" in Valencia was undertaken during the period 1971-1989. The influence of the principal risk factors on prognosis were studied and their effect adjusted using a multivariate analysis based on the Cox proportional hazards model.

RESULTS

A greater dimension of the tumour, tumour area, tumour volume, tumour-cervix quotient and stromal invasion depth all have a highly significant and negative correlation with survival and disease-free survival intervals. In the multivariate analysis, tumour volume and stromal invasion depth maintained their significance as indicators of an adverse prognosis regarding the disease-free survival interval, as did the stromal invasion depth in the case of survival.

CONCLUSIONS

The most important prognostic factor in the evolution of patients with a cervical carcinoma is the stromal invasion depth followed by tumour size.

Meigs' syndrome with elevated CA125: case report and review of the literature

A 51-year-old woman presented with acute ascites and hydrothorax is reported. Pelvic ultrasound showed two pelvic solid masses and serum CA125 level was elevated (577 IU/ml). Pathology revealed bilateral ovarian fibromas. We present this case of Meigs' syndrome and discuss its diagnostic problems and a review of the literature.

Prune belly syndrome: early antenatal diagnosis

A case of prune belly syndrome diagnosed by ultrasonography during the thirteenth week of gestation is described. Pathogenic data and the importance of antenatal diagnosis are discussed.