¿Pueden los factores clínicopatológicos mejorar la predicción de metástasis en ganglios linfáticos no centinelas en pacientes con cáncer de mama?

Introduction: To determine whether clinicopathological characteristics can improve the prediction of metastasis to nonsentinel lymph nodes (NSLNs) over the use of only mRNA copy number in sentinel lymph node (SLN) biopsies. Methods: This was a retrospective, observational study that included a total of 824 patients with T1-3 breast cancer who had clinically negative, ultrasound-negative axilla without evidence of metastasis and who underwent one-step nucleic acid amplification in SLN biop-sies. Results: 118 required a complete axillary lymph node dissection (ALNhD). About 35.6% (42/118) had metastases to a NSLN, and 64.4% (76/118) had no metastasis to a NSLN. The ROC curve of the total tumor load (TTL) presented an area under the curve (AUC) of 0.651 (95%; CI: 0.552-0.751). The 7294 copies of CK19 mRNA were established as the optimal cutoff point, with sensitivity: 93%, specificity: 63%, positive predictive value: 44%, and negative predictive value: 91%. By as-sociating the clinicopathological parameters (multicentricity, pooled immunohistochemistry [IHC], and progesterone receptors), the AUC went up to 0.752 (95% CI: 0.663-0.841). Conclusions: Clinicopathological factors should be considered together with the total CK19 mRNA copy number (the TTL) of the SLNs to improve the predictive capacity of metastatic involvement of the NSLNs

Clinical and Economic Evaluation after Adopting Contingent Cell-Free DNA Screening for Fetal Trisomies in South Spain.

Contingent cell-free (cf) DNA screening on the basis of the first-trimester combined test (FCT) results has emerged as a cost-effective strategy for screening of trisomy 21 (T21). Objectives: To assess performance, patients’ uptake, and cost of contingent cfDNA screening and to compare them with those of the established FCT. Methods: This is a prospective cohort study including all singleton pregnancies attending to their FCT for screening of T21 at 2 university hospitals in South Spain. When the FCT risk was ≥1:50, there were major fetal malformations, or the nuchal translucency was ≥3.5 mm, women were recommended invasive testing (IT); if the risk was between 1:50 and 1:270, women were recommended cfDNA testing; and for risks bellow 1:270, no further testing was recommended. Detection rate (DR), false-positive rate (FPR), patients’ uptake, and associated costs were evaluated. Results: We analyzed 10,541 women, including 46 T21 cases. DR of our contingent strategy was 89.1% (41/46) at 1.4% (146/10,541) FPR. Uptake of cfDNA testing was 91.2% (340/373), and overall IT rate was 2.0%. The total cost of our strategy was €1,462,895.7, similar to €1,446,525.7 had cfDNA testing not been available. Conclusions: Contingent cfDNA screening shows high DR, low IT rate, and high uptake at a similar cost than traditional screening.pre-print133 K

Intra and interobserver variability of intrapartum transperineal ultrasound measurements with contraction and pushing

The aim of this study was to evaluate the inter- and intraobserver correlation of the different intrapartum-transperineal-ultrasound-parameters(ITU) (angle of progression (AoP), progression-distance (PD), head-direction (HD), midline-angle (MLA) and head-perineum distance (HPD)) with contraction and pushing. We evaluated 28 nulliparous women at full dilatation under epidural analgesia. We performed a transperineal ultrasound evaluating AoP and PD in the longitudinal plane, and MLA and HPD in the transverse plane. Interclass correlation coefficients (ICC) with 95% CIs and Bland–Altman analysis were used to assess intra- and interobserver measurement’s repeatability. The ICC of the ITU for the same observer was adequate for all the parameters (p < .005) AoP 0.98 (95%CI, 0.96–0.99), PD 0.98 (95%CI, 0.97–0.99), MLA 0.99 (95%CI, 0.97–0.99), HPD 0.96 (95%CI, 0.88–0.99). The ICC of the ITU for interobserver was: AoP 0.93 (95%CI, 0.79–0.98), PD 0.92 (95%CI, 0.76–0.97), MLA 0.77 (95%CI, 0.42–0.92), HPD 0.47 (95%CI, −0.12–0.8). The HD had an interobserver correlation of 0.53 (95%CI, 0.1–0.9) (Kappa C). The mean difference of the AoP was 2.42°, of the PD 1 mm and 0.28° MLA (Bland–Altman test). ITU has an adequate intra- and interobserver correlation for its use with contraction and pushing under epidural analgesia.Impact statement What is already known on this subject: The intrapartum transperineal ultrasound parameters can be used with contraction and pushing under epidural analgesia. What the results of this study add to what we know: ITU may be used to evaluate the difficulty of instrumental delivery/to evaluate the difficulty of instrumentation in vaginal operative deliveries and this study concludes that ITU is reproducible during uterine contraction with pushing. What the implications are of these findings for clinical practice and/or further research: Therefore, ITU could be used without difficulty with an adequate intra- and interobserver correlation for the prediction of instrumentation difficulty in operative vaginal deliveries

A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation.

Forceps delivery is associated with a high rate of levator ani muscle (LAM) trauma (avulsion) at 35%-65% whereas data on avulsion rates after vacuum delivery vary greatly. Nevertheless, a common characteristic of all previous studies carried out to evaluate the association between instrumental deliveries (forceps and vacuum) and LAM avulsion, is the fact that characteristics of the instrumentation have not been described or evaluated. The objective of this study is to compare the rate of LAM avulsion between forceps and vacuum deliveries according to the characteristics of the instrumentation. Prospective, observational study, including 263 nulliparous women, who underwent an instrumental delivery with either Malmström vacuum or Kielland forceps. The characteristics of the instrumentation, position (anterior position and other position) and height of the fetal head at the moment of instrumentation (low instrumentation [vertex at +2 station] and mid-instrumentation [head is involved but leading part above +2 station]) were assessed. Evaluation of LAM avulsion was performed at 6 months postpartum by three-/four-dimensional transperineal ultrasound. Using the multi-view mode, a complete avulsion was diagnosed when the abnormal muscle insertion was identified in all three central slices, that is, in the plane of minimal hiatal dimensions and the 2.5-mm and 5.0-mm slices cranial to this one. To detect a 30% or 15% difference in the LAM injury rate, with 80% power and 5% α-error, we needed, respectively 42 and 99 women per study group. In all, 263 nulliparous individuals have been evaluated (162 vacuum deliveries, 101 forceps deliveries). Instrumentation in an occipito-anterior position was more frequent in vacuum deliveries (75.3% vs 56.4%, P = .002), whereas other positions were more frequent in the forceps deliveries group (24.7% vs 43.6%). No statistically significant differences were noted regarding the height of the fetal head at the moment of instrumentation. No statistically significant differences were found in the presence of LAM avulsion (41.4% vs 38.6%) between vacuum and forceps deliveries. The univariate analysis of the crude odds ratio was 1.17, 95% CI 0.67-1.98, P = .70 for the avulsion of the LAM and the multivariate of the adjusted OR 0.90, 95% CI; 0.53-1.55, P = .71. We consider that, in our population, LAM avulsion rate should not be a factor taken into account when choosing the type of instrumentation (Malmström vacuum or Kielland forceps) in an operative delivery

Association between sexual dysfunction and avulsion of the levator ani muscle after instrumental vaginal delivery.

The effects of levator ani muscle (LAM) avulsion after instrumental delivery on the sexual function of patients are currently unknown. Therefore, the objective of our study was to use a validated questionnaire, namely, the Female Sexual Function Index (FSFI), to compare the sexual function in patients with and without LAM avulsion after instrumental vaginal delivery. This was a prospective observational study of 112 primiparous women after instrumental (vacuum or forceps) vaginal delivery. The obstetric and general characteristics of the population were studied. At 6 months postpartum, the contraceptive method used and the occurrence of LAM avulsion (using four-dimensional transperineal ultrasound) were determined, and the FSFI was administered. A total of 100 patients (62 without avulsion and 38 with avulsion) completed the study. Thirty-eight (38%) were diagnosed with avulsion (42.1% after Kielland forceps delivery, 57.9% after Malmström vacuum delivery; P = .837). Women with LAM avulsion had significantly lower scores for desire (2.9 ± 1.2 vs 3.4 ± 1.1; P = .049), arousal (2.8 ± 1.7 vs 3.6 ± 1.4; P = .014), lubrication (2.3 ± 1.4 vs 3.0 ± 1.2; P = .011), orgasm (2.6 ± 1.6 vs 3.3 ± 1.2; P = .006) and satisfaction (3.1 ± 1.8 vs 3.9 ± 1.5; P = .051) than did women without LAM avulsion. The overall FSFI score was lower in patients with avulsion (16.7 ± 8.9 vs 20.7 ± 6.9, P = .033). These results were obtained after controlling for confounders (delivery mode, induced labor, birthweight, perineal tears, avulsion degree, contraceptive method and group assignment for the parent study) in the multivariate analysis (F = 4.974, P = .001). Patients with LAM avulsion present a higher degree of sexual dysfunction compared wiith patients without avulsion at 6 months after instrumental vaginal delivery

Association between sexual dysfunction and avulsion of the levator ani muscle after instrumental vaginal delivery

The effects of levator ani muscle (LAM) avulsion after instrumental delivery on the sexual function of patients are currently unknown. Therefore, the objective of our study was to use a validated questionnaire, namely, the Female Sexual Function Index (FSFI), to compare the sexual function in patients with and without LAM avulsion after instrumental vaginal delivery. This was a prospective observational study of 112 primiparous women after instrumental (vacuum or forceps) vaginal delivery. The obstetric and general characteristics of the population were studied. At 6 months postpartum, the contraceptive method used and the occurrence of LAM avulsion (using four-dimensional transperineal ultrasound) were determined, and the FSFI was administered. A total of 100 patients (62 without avulsion and 38 with avulsion) completed the study. Thirty-eight (38%) were diagnosed with avulsion (42.1% after Kielland forceps delivery, 57.9% after Malmström vacuum delivery; P = .837). Women with LAM avulsion had significantly lower scores for desire (2.9 ± 1.2 vs 3.4 ± 1.1; P = .049), arousal (2.8 ± 1.7 vs 3.6 ± 1.4; P = .014), lubrication (2.3 ± 1.4 vs 3.0 ± 1.2; P = .011), orgasm (2.6 ± 1.6 vs 3.3 ± 1.2; P = .006) and satisfaction (3.1 ± 1.8 vs 3.9 ± 1.5; P = .051) than did women without LAM avulsion. The overall FSFI score was lower in patients with avulsion (16.7 ± 8.9 vs 20.7 ± 6.9, P = .033). These results were obtained after controlling for confounders (delivery mode, induced labor, birthweight, perineal tears, avulsion degree, contraceptive method and group assignment for the parent study) in the multivariate analysis (F = 4.974, P = .001). Patients with LAM avulsion present a higher degree of sexual dysfunction compared wiith patients without avulsion at 6 months after instrumental vaginal delivery