10 research outputs found
A radiologic-laparoscopic model to predict suboptimal (or complete and optimal) debulking surgery in advanced ovarian cancer: a pilot study
Introduction: Medical models assist clinicians in making diagnostic and prognostic decisions in complex situations. In advanced ovarian cancer, medical models could help prevent unnecessary exploratory surgery. We designed two models to predict suboptimal or complete and optimal cytoreductive surgery in patients with advanced ovarian cancer.
Methods: We collected clinical, pathological, surgical, and residual tumor data from 110 patients with advanced ovarian cancer. Computed tomographic and laparoscopic data from these patients were used to determine peritoneal cancer index (PCI) and lesion size score. These data were then used to construct two-by-two contingency tables and our two predictive models. Each model included three risk score levels; the R4 model also included operative PCI, while the R3 model did not. Finally, we used the original patient data to validate the models (narrow validation).
Results: Our models predicted suboptimal or complete and optimal cytoreductive surgery with a sensitivity of 83% (R4 model) and 69% (R3 model). Our results also showed that PCI>20 was a major risk factor for unresectability.
Conclusion: Our medical models successfully predicted suboptimal or complete and optimal cytoreductive surgery in 110 patients with advanced ovarian cancer. Our models are easy to construct, based on readily available laboratory test data, simple to use clinically, and could reduce unnecessary exploratory surgery in this patient group
A Case of Urethrocutaneous Fistula Following a Transobturator Tape Procedure for Stress Urinary Incontinence
The transobturator tape procedure (TOT) is a highly
effective
technique used to resolve cases of female stress
urinary
incontinence
and is a safe procedure with
relatively
few
per-operative
and early
post-operative
complications
compared to the tension free vaginal tape
(TVT). Recent studies, however, have demonstrated that
the late surgical sequelae following a TOT procedure are
relatively
common. Urethrocutaneous
fistula
is an
unusual
complication
in the female
population
that is
defined
as an abnormal
connection
between the urethra
and the skin, usually
affecting
the perineum. It may also
develop secondary to urethral strictures, repair of
hypospadias, prostate surgery, chronic untreated
periurethral abscesses, trauma etc. It is usually diagnosed
using retrograde urethrography and
fistulography.
We present a case of a 53 year old woman who developed
a urethrocutaneous
fistula
after
a TOT procedure four
years ago as a surgical treatment of female stress urinary
incontinence
which was diagnosed recently
after
presenting
various episodes of vulvar abscesse
Postoperative intestinal fistula in primary advanced ovarian cancer surgery
Background: Advanced ovarian cancer (AOC) requires an aggressive surgery with large visceral resections in order to achieve an optimal or complete cytoreduction and increase the patient’s survival. However, the surgical aggressiveness in the treatment of AOC is not exempt from major complications, such as the gastrointestinal fistula (GIF), which stands out among others due to its high morbidity and mortality.
Methods: We evaluated the clinicopathological features in patients with AOC and their association with GI. Data for 107 patients with AOC who underwent primary debulking surgery were analyzed retrospectively. Clinicopathological features, including demographic, surgical procedures and follow-up data, were analyzed in relation to GIF.
Results: GIF was present in 11% of patients in the study, 5 (4.5%) and 7 (6.4%) of colorectal and small bowel origin, respectively. GIF was significantly associated with peritoneal cancer index (PCI) > 20, more than 2 visceral resections, and multiple digestive resections. Overall and disease-free survival were also associated with GIF. Multivariate analysis identified partial bowel obstruction and operative bleeding as independent prognostic factors for survival. The presence of GIF is positively associated with poor prognosis in patients with AOC.
Conclusion: Given the importance of successful cytoreductive surgery in AOC, the assessment of the amount of tumor and the aggressiveness of the surgery to avoid the occurrence of GIF become a priority in patients with AOC
Validation of three predictive models for suboptimal cytoreductive surgery in advanced ovarian cancer
The standard treatment for advanced ovarian cancer (AOC) is cytoreduction surgery and adjuvant chemotherapy. Tumor volume after surgery is a major prognostic factor for these patients. The ability to perform complete cytoreduction depends on the extent of disease and the skills of the surgical team. Several predictive models have been proposed to evaluate the possibility of performing complete cytoreductive surgery (CCS). External validation of the prognostic value of three predictive models (Fagotti index and the R3 and R4 models) for predicting suboptimal cytoreductive surgery (SCS) in AOC was performed in this study. The scores of the 3 models were evaluated in one hundred and three consecutive patients diagnosed with AOC treated in a tertiary hospital were evaluated. Clinicopathological features were collected prospectively and analyzed retrospectively. The performance of the three models was evaluated, and calibration and discrimination were analyzed. The calibration of the Fagotti, R3 and R4 models showed odds ratios of obtaining SCSs of 1.5, 2.4 and 2.4, respectively, indicating good calibration. The discrimination of the Fagotti, R3 and R4 models showed an area under the ROC curve of 83%, 70% and 81%, respectively. The negative predictive values of the three models were higher than the positive predictive values for SCS. The three models were able to predict suboptimal cytoreductive surgery for advanced ovarian cancer, but they were more reliable for predicting CCS. The R4 model discriminated better because it includes the laparotomic evaluation of the peritoneal carcinomatosis index
Neoadjuvant Chemotherapy plus Interval Cytoreductive Surgery with or without Hyperthermic Intraperitoneal Chemotherapy (NIHIPEC) in the Treatment of Advanced Ovarian Cancer: A Multicentric Propensity Score Study
Simple Summary Advanced ovarian cancer (Stages III-IV) continues to be one of the gynecological tumors with the highest mortality. Standard treatment consists of debulking surgery and subsequent adjuvant chemotherapy. Recently, some authors have postulated that the administration of hyperthermic chemotherapy during surgery could increase the survival of patients, especially in cases in which chemotherapy had already been administered before surgery to reduce tumor volume. Our study is important because it collects data from 11 tertiary hospitals in Spain, and the data are subjected to a statistical technique that reproduces the data that we would find in a prospective study but using retrospective data (propensity score matching). It also offers a current view of the status of ovarian cancer treatment in our country.Abstract Introduction: Epithelial ovarian cancer (EOC) is primarily confined to the peritoneal cavity. When primary complete surgery is not possible, neoadjuvant chemotherapy (NACT) is provided; however, the peritoneum-plasma barrier hinders the drug effect. The intraperitoneal administration of chemotherapy could eliminate residual microscopic peritoneal tumor cells and increase this effect by hyperthermia. Intraperitoneal hyperthermic chemotherapy (HIPEC) after interval cytoreductive surgery could improve outcomes in terms of disease-free survival (DFS) and overall survival (OS). Materials and Methods: A multicenter, retrospective observational study of advanced EOC patients who underwent interval cytoreductive surgery alone (CRSnoH) or interval cytoreductive surgery plus HIPEC (CRSH) was carried out in Spain between 07/2012 and 12/2021. A total of 515 patients were selected. Progression-free survival (PFS) and OS analyses were performed. The series of patients who underwent CRSH or CRSnoH was balanced regarding the risk factors using a statistical analysis technique called propensity score matching. Results: A total of 170 patients were included in each subgroup. The complete surgery rate was similar in both groups (79.4% vs. 84.7%). The median PFS times were 16 and 13 months in the CRSH and CRSnoH groups, respectively (Hazard ratio (HR) 0.74; 95% CI, 0.58-0.94; p = 0.031). The median OS times were 56 and 50 months in the CRSH and CRSnoH groups, respectively (HR, 0.88; 95% CI, 0.64-1.20; p = 0.44). There was no increase in complications in the CRSH group. Conclusion: The addition of HIPEC after interval cytoreductive surgery is safe and increases DFS in advanced EOC patients
Utilidad de la Enterografía por Tomografía Computarizada (ETC) en la valoración del carcinoma ovárico avanzado
Los estadíos avanzados de cáncer de ovario (COA) cursan con carcinomatosis peritoneal (CP), su adecuada cuantificación permite decidir el abordaje terapéutico. El Índice de Carcinomatosis Peritoneal (ICP) es útil como sistema de cuantificación y factor pronóstico. TCMD es una herramienta recomendable en la selección de pacientes, su principal limitación es subestimar la carga tumoral. Objetivo: Evaluar el desempeño diagnóstico de la Enterografía por TC (ETC), como técnica optimizada, en la cuantificación de enfermedad peritoneal secundaria a COA en pacientes sometidos a cirugía citorreductora y compararla con la TC Convencional (TCC). Material y métodos: Se realizó un estudio retrospectivo, se recopilaron los ICP radiológicos, quirúrgicos e histológicos de un total de 61 pacientes, 40 estudiadas mediante ETC y el resto mediante TCC; se compararon los ICP radiológicos con los patrones de referencia, tanto quirúrgicos como histológicos. Resultados: Buena correlación entre el ICP radiológico e ICP quirúrgico, muy buena correlación entre el ICP ETC y el ICP AP. Mayor sensibilidad y detección de afectación por la ETC comparado con la TCC.The advanced stages of ovarian cancer (COA) present with peritoneal carcinomatosis (PC), its adequate quantification allows to decide the therapeutic approach. The Peritoneal Carcinomatosis Index (PCI) is useful as a quantification and prognostic factor. TCMD is a recommended tool in patient selection, its main limitation is to underestimate tumor burden. Objective: To evaluate the diagnostic performance of the enterography CT technique as an optimized technique in the quantification of peritoneal disease secondary to COA in patients undergoing cytoreductive surgery. MATERIAL AND METHODS: A retrospective study was carried out. The radiological, surgical and histological PCIs were collected from a total of 61 patients, 40 of whom were studied with CTE and the rest with TC; radiological PCIs were compared with reference standards, both surgical and histological. Results: Good correlation between radiological ICP and surgical PCI, very good correlation between PCI ETC and ICP AP. Greater sensitivity and detection of affectation by the ETC compared to the CBT
CT Enterography for Preoperative Evaluation of Peritoneal Carcinomatosis Index in Advanced Ovarian Cancer
To compare the diagnostic performance of routine CT (rCT), CT enterography (CTE) and intraoperative quantification of PCI to surgical and pathological reference standards in patients with advanced ovarian cancer, a retrospective study of 122 patients who underwent cytoreduction surgery for ovarian peritoneal carcinomatosis was conducted. Radiological, surgical, and pathological PCIs were obtained from the corresponding reports, and the latter two were considered reference standards. The radiological techniques used were rCT: 64 MDCT (32 × 1 mm) (100 mL iopromide 370 i.v., 800 mL water p.o.), and CTE: 64 MDCT (64 × 0.5 mm) (130 mL iopromide 370 i.v., 1800 mL mannitol solution p.o., 20 mg buscopan i.v.). Data were grouped by imaging technique and analyzed using total PCI and stratified by tumor burden (low-PCI 20). Agreement, diagnostic performance and degree of cytoreduction were evaluated. Disappointing results for rCT and CTE were obtained when using a surgical referent, but better diagnostic performance and concordance (0.86 vs. 0.78 vs. 0.62, p < 0.05) was observed when using a pathological referent—surgical PCI overestimates and overstaged patients. PCI is underestimated by rCT rather than CTE. For high-PCI, the ROC curve was mediocre for CTE and useless for rCT, as it failed to identify any cases. For low-PCI, the ROC was excellent (86% CTE vs. 75% rCT). In four cases with low-PCI as determined by rCT, cytoreduction was suboptimal. CTE has a better diagnostic performance than rCT in quantifying PCI in patients with advanced ovarian cancer, suggesting that CTE should be used as the initial technique. Surgical-PCI could be considered as an imperfect standard reference
Hepatic epithelioid hemangioendothelioma: A great mimicker
INTRODUCTION: Epithelioid hemangioendothelioma is a malignant mesenchymal tumor of unknown etiology. They tend to be asymptomatic or with non-specific symptoms. The lesion is usually multiple and
variable size.
PRESENTATION OF CASE: We describe a clinical case of a 23-years-old patient diagnosed with a pelvic mass,
a possible uterine fibroid or adnexal mass, and multiple liver lesions that seemed an advanced ovarian
cancer presentation and after liver biopsy turned out to be a hepatic epithelioid hemangioendothelioma.
DISCUSSION: It may be confused with a metastatic process in diagnostic imaging. There have been
described some possible risk factors but the etiology remains unknown. The prognosis is usually lethal in
50% of cases. The surgical removal of the lesion and liver transplant appear to be the only hope for these
patients.
CONCLUSION: Epithelioid hemangioendothelioma must be part of our differential diagnosis when we find
a liver tumour, especially in young women. Treatment is excision of the tumour in limited disease. In the
case of unresectable disease are candidates for liver transplantation
Predictive model for major complications after extensive abdominal surgery in primary advanced ovarian cancer
Background
Surgery for advanced ovarian cancer (AOC) frequently results in serious complications. The present study aimed to determine the importance of various factors and complications in cytoreductive surgery for AOC.
Patients and methods
The present study included 90 patients with AOC who underwent primary cytoreductive surgery in a single institution from January 2013 to August 2017. Demographic and clinicopathologic characteristics, surgical procedures, residual disease, and follow-up data were analyzed. Cytoreductive surgery was defined as complete (no residual tumor), optimal (residual tumor 1 cm in diameter). Grade III–IV complications were considered major. Patients were evaluated every 3–6 months.
Results
Surgical outcome was complete in 75 (82%), optimal in 5 (6%), and suboptimal in 11 (12%) patients. Major complications occurred in 28 (31%) patients. Independent risk factors for major complications were ≥five visceral resections, rectosigmoid resection, glissectomy, and pelvic peritonectomy. A score created by weighing the multivariate OR for each risk factor correctly predicted major complications in 67% of cases. A score cut-off of >2 discriminated between patients with and without complications in 79% of cases (95% CI: 70%–86%, P<0.001). Adjuvant chemotherapy was performed as planned in 67 patients (74%), including 50 (75%) without major complications and 17 (25%) with major complications.
Conclusion
Risk factors for major complications in cytoreductive surgery for AOC are ≥five visceral resections, rectosigmoid resection, glissectomy, and pelvic peritonectomy. Our model predicts morbidity based on major and minor classifications of complications
Protocol for the examination of surgical specimens from patients with peritoneal carcinomatosis originating in ovary, fallopian tube and peritoneum
La carcinomatosis peritoneal (CP) es una entidad tumoral con una alta tasa de morbimortalidad, considerada la evolución común de varias neoplasias abdominopélvicas, entre ellas, el carcinoma de ovario, trompa uterina y peritoneo. Aunque muchos de estos tumores son sensibles a quimioterapia sistémica, el pronóstico es desfavorable por la elevada tasa de recurrencia. La cirugía de citorreducción (CC) se emplea como tratamiento de primera línea en los estadios avanzados, ya que aumenta la supervivencia de los pacientes cuando la CC es óptima. El procedimiento terapéutico descrito por Sugarbaker para el carcinoma de colon en la década de los 80, que incluye CC y quimioterapia intraperitoneal ha sido adaptado a la CP de origen ginecológico. El estudio anatomopatológico de esta cirugía empieza a ser una práctica habitual en algunos de nuestros servicios. Es un procedimiento complejo, que requiere especialización y sistematización para valorar un gran número de piezas quirúrgicas, cuantificando de forma lo más objetiva posible la carga tumoral.
El objetivo de este trabajo es mostrar la experiencia inicial en nuestro servicio de anatomía patológica con pacientes diagnosticadas de CP de origen ovárico, tubárico y peritoneal y sometidas a cirugía citorreductora, destacando el papel del patólogo. Mostramos el esquema de trabajo utilizado en nuestro servicio y resumimos los resultados iniciales de 31 pacientes intervenidas entre enero de 2013 y julio de 2014.Peritoneal carcinomatosis (PC) is a malignant entity with a high rate of morbimortality. It is considered an end-stage common to several abdominal and pelvic malignant tumours, such as epithelial ovarian, fallopian tubal and peritoneal cancer. Although many of these tumors have a good response to chemotherapy, prognosis is poor due to the high rate of recurrence. Surgeons, gynecologists and oncologists are increasingly concerned with improving the survival. The surgical technique described by Sugarbaker in the eighties is a plausible option. It aims for a complete resection of macroscopic carcinomatosis (cytoreductive surgery) followed by intraoperative or perioperative intraperitoneal chemotherapy.
This therapeutic option necessarily involves specific multidisciplinary units; histopathology of specimens from this surgical technique is now more frequent in our department.
We describe our initial experience with PC originating from epithelial ovarian, tubal and peritoneal cancer treated with the modified Sugarbaker surgery employed in our hospital. We outline our protocol designed to achieve uniformity in procedure, and summarize the initial results