Vaginal treatment of endometrial cancer: role in the elderly

BACKGROUND: To compare abdominal hysterectomy, the most currently used for treating cancer of the endometrium, to the vaginal hysterectomy in term of survival, morbidity and failure rates. METHODS: We retrospectively analyzed 68 cases divided into two sub-groups. A study group of 31 cases received vaginal surgery; a control group of 37 cases was treated with a laparotomy. Mean operative time, median hospital stay, intra- and post-operative complications, DFS and OS time as well as occurrence of local or distant recurrences have been evaluated and reported. Cases included patients with a higher rate of medical morbidities (p = 0.01) than controls. RESULTS: Mean age was 76.2 and 70.4 years in the vaginal (V) group and abdominal (A) group respectively. Mean operative time was longer for the group A. Group V patients had a lower mean post-operative hospital stay (p < 0.05). Differences in the two groups regarding intra- and post-operative complications, occurrence of local or distant recurrences and DFS time were not statistically significant. Disease specific survival time at 5 years scored 97% for group V, and 97% for group A. CONCLUSIONS: Results show how vaginal approach had a similar outcome in selected patients. Vaginal surgery could therefore be the proper choice in patients with early stages and lower surgical risk, in addition to elderly patients exposed to a higher surgical risk

Sarcomi uterini: esperienza monocentrica e review della letteratura

I sarcomi costituiscono un gruppo numericamente inferiore ma dalla prognosi sfavorevole nei tumori del corpus uteri. I tumori mesenchimali comprendono un ampio spettro di neoplasie dal punto di vista istologico. A causa delle loro caratteristiche non ancora del tutto chiare e del loro comportamento altamente aggressivo rappresentano una sfida per i medici e per i patologi. La loro bassa incidenza costituisce un limite nell’attuazione di trials clinici su ampia scala, attualmente non esistono evidenze a supporto di uno specifico trattamento e l’approccio chirurgico resta il gold standard terapeutico. In questo lavoro presentiamo 7 casi di sarcoma uterino trattati presso il nostro centro con una review della letteratura

Trattamento chirurgico del carcinoma della mammella nella paziente anziana: nostra esperienza

Obiettivi. Nonostante l’aumento delle diagnosi di carcinoma della mammella in età avanzata, il management di queste pazienti non è ancora standardizzato. In questo studio vengono analizzate le differenti opzioni chirurgiche e l’outcome nel gruppo di pazienti affette da carcinoma mammario e di età maggiore di 70 anni che sono state trattate nella UO di Ostetricia e Ginecologia dell’ospedale Universitario Sant’ Andrea di Roma. Materiali e metodi. 21 pazienti si sono rivolte al nostro centro per visita specialistica nella unità senologica del nostro dipartimento. 14 di questi casi sono stati sottoposti ad intervento chirurgico e, pertanto, arruolati nello studio. L’età media del gruppo in studio era di 76,6 anni. Patologie associate alla diagnosi di carcinoma mammario sono state identificate in 8 pazienti (58%). Un approccio chirurgico conservativo con quadranctectomia è stato attuato in 9 casi (64%); una mastectomia è stata invece l’intervento scelto per 4 casi (29%). In 5 casi (36%) il primo approccio è stato l’individuazione del linfonodo sentinella mentre nel 57% si è proceduto direttamente con una resezione dei linfonodi ascellari. Il tempo operatorio medio è stato di 30,6 minuti per la mastectomia, di 19,9 minuti per la quadranctectomia; la individuazione e resezione del linfonodo sentinella ha richiesto mediamente 7,8 minuti mentre la resezione ascellare ne ha richiesti mediamente 20,2. Nessuna complicazione post-operatoria è stata riscontrata per i casi sottoposti a chirurgia conservativa associata ad asportazione del linfonodo sentinella; un caso di anemia precoce post-chirurgica è stato riscontrato dopo mastectomia associata a resezione ascellare totale; un caso di linfocele si è verificato dopo esecuzione di quadranctectomia associata a resezione ascellare totale. Il tempo medio di ospedalizzazione è stato di 5,4 giorni per la mastectomia; 5,2 giorni per la quadranctectomia, 3,4 giorni per la resezione del linfonodo sentinella e 6 giorni per la resezione ascellare totale. Conclusioni. I nostri risultati, in accordo con la letteratura internazionale, suggeriscono che nella paziente anziana il rischio di trattamento chirurgico inappropriato, sia esso in eccesso o in difetto rispetto alla reali necessità, dovrebbe essere evitato da una valutazione preoperatoria particolarmente accurata. La situazione clinica, l’aspettativa di vita, i desideri della paziente e la possibilità di accesso ai differenti tipi di trattamento devono essere accuratamente considerati per ogni caso al fine di identificare una strategia terapeutica personalizzata

A case of high-grade leiomyosarcoma of the bladder with delayed onset and very poor prognosis

Mesenchymal tumors represent a small number of bladder cancer cases. Leiomyosarcoma is the most common histology with over 100 cases reported in the whole literature. This tumor is been historically considered as highly aggressive and showing a poor prognosis. Despite very low survival rates showed in older reports, some authors indicate that some patients could have a better outcome. We report a review of the literature and a case of high-grade LMS of the bladder in a 68 years old woman. Diagnosis was delayed and disease was locally advanced. Symptoms and imaging of our case first oriented to a gynecologic condition with an adnexal or uterine origin of the mass, and, a genitourinary origin could be unveiled only intra-operatively

A case of high-grade leiomyosarcoma of the bladder with delayed onset and very poor prognosis

Abstract Mesenchymal tumors represent a small number of bladder cancer cases. Leiomyosarcoma is the most common histology with over 100 cases reported in the whole literature. This tumor is been historically considered as highly aggressive and showing a poor prognosis. Despite very low survival rates showed in older reports, some authors indicate that some patients could have a better outcome. We report a review of the literature and a case of high-grade LMS of the bladder in a 68 years old woman. Diagnosis was delayed and disease was locally advanced. Symptoms and imaging of our case first oriented to a gynecologic condition with an adnexal or uterine origin of the mass, and, a genitourinary origin could be unveiled only intra-operatively.</p

Gynecologic sarcoma: A clinico-pathological review

Most of the cases showing good prognosis in literature are probably intermediate tumors between benign and malignant of undetermined malignant potential (UMP) and other tumors with intermediate features which are currently not considered among sarcomas. Misdiagnosis of a malignant lesion as a benign one has a tragic outcome for the patient. Best therapic choice for sarcomas remains surgery, while chemotherapy (CTX) and radiation therapy (RT) could be used in adjuvant settings. A major effort should be played in the understanding of biological features and behavior of the disease to address a better clinical practice. Uterine sarcomas are rare gynecological tumors; their incidence has been increasing during the last few years

Obturator Dislocation of the Hip with Associated Femoral Head Impaction and Medial Wall Fracture of the Acetabulum.

Introduction The combination of traumatic obturator dislocations and a femoral head impaction is rare and the treatment challenging. This report describes the successful management of this rare injury in a young patient. Case Report A 22-year-old truck driver involved in a ski accident sustained an obturator dislocation of the right hip associated with a femoral head impaction in the weight-bearing zone and a medial wall fracture of the acetabulum. After an initial closed reduction within 6 hours after the accident, for the definitive treatment, the hip joint was exposed through a Kocher-Langenbeck approach with trochanter flip osteotomy and surgical hip dislocation. A closing wedge intertrochanteric osteotomy was performed aiming to turn the head impaction out of the weight-bearing zone and the large head defect filled with the bone block removed from the osteotomy. The medial wall fragment was fixed, and the graft and osteotomies were stabilized with screws and a blade plate. The patient was mobilized with partial weight-bearing for 3 months then he progressively started full weight-bearing and normal daily activities. 5 years after the injury, the patient was completely asymptomatic, and radiographs demonstrated union of all osteotomies, osseous integration and remodeling of the bone graft as well as correct congruity of the hip joint. Conclusion The intertrochanteric osteotomy aims to turn the impacted zone out of the weight-bearing area. Bone grafting of the defect helps to restore congruence and containment of the hip and additionally reinforces the femoral neck. To manage all the lesions present, a trochanteric flip approach with surgical hip dislocation is mandatory

Surgical Treatment of Mild to Severe Hallux Valgus Deformities With a Percutaneous Subcapital Osteotomy Combined With a Lateral Soft Tissue Procedure.

Distal metatarsal (MT) osteotomies have been used in mild or moderate cases of hallux valgus (HV) and proximal MT osteotomy has been considered the treatment of choice for severe deformities. A distal osteotomy could achieve a greater degree of correction by the addition of a distal soft-tissue procedure and be used to treat also severe deformity. Limited evidence about the use of the percutaneous subcapital osteotomy (SCOT); a type of MT osteotomy, in combination of a soft tissue procedure, is available. We evaluated this procedure routinely used in our clinic. A total of 30 consecutive patients treated in our hospital from September 2012 to April 2015 with SCOT combined with lateral soft tissue release were included in this retrospective review. Outcomes assessed included radiological parameters: HV angle (HVA) and intermetatarsal angle (IMA), clinical evaluation using the American Orthopaedic Foot and Ankle Society (AOFAS) score, and complication rate. In 12 of the 30 patients included, the pathology was bilateral, comprising a total of 42 cases. The overall correction of the angles was statistically significant (P < .001), changing from a HVA of 28.2° and IMA of 13.5° preoperatively to 8.0° and 6.0° postoperatively, respectively. The cases were divided into mild-moderate (34/42) and severe (8/42). Both groups showed a statistically significant correction in the angles, 3 months after surgery (P < .001). The AOFAS score showed a median of 49 points (n = 24) preoperatively and of 95 points (n = 40) at the end of follow-up. The complication rate at end of follow-up was 19% (8/42). After a minimum follow-up of 1 year, our technique for HV correction results in a clinically relevant improvement of the radiological parameters and AOFAS score in mild to severe deformities. Combination with lateral release could be a meaningful surgical alternative for the treatment of severe cases to help decrease the risk of recurrence. Levels of Evidence: Level IV

Epigenetic modifications of primordial reproductive tract. A common etiologic pathway for Mayer-Rokitansky-Kuster-Hauser Syndrome and endometriosis?

Dear Editor, we read with great interest the paper by Alcolado [1], published in your prestigious Journal. This work conforms ‘‘the fetal basis of adult disease’’ hypothesis, which proposes that prenatal exposure to certain forms of environmental stress can cause increased susceptibility to clinical disorders, modulating the gene expression later in life (the so-called ‘‘epigenetic imprinting”). During embryogenesis, it was already shown that homeobox (Hox) genes are strictly involved in the differentiation of the paramesonephric duct into the mature female reproductive system [2]. Two weeks after birth, Hoxa9, Hoxa10, Hoxa11 and Hoxa13 develop their characteristic spatial distribution throughout the Müllerian ducts [3]. Moreover, it was demonstrated that the loss of Hoxa10 function provokes dysregulation during decidualization and implantation, resulting in female infertility [4]. Although clear data about the role of Hoxa gene clusters in infertility remain to be elucidated, we know that Hoxa10 specifically mediates the progesterone regulation of two prostaglandin E2 receptors (EP3 and EP4) in uterine stroma [5]. Moreover, another well-known family of genes that influence remarkably the organogenesis of the Müllerian reproductive tract is Wnt (wingless-type MMTV integration site family). Failures in Wnt signaling are associated with infertility, endometriosis, endometrial cancer and gestational trophoblastic disease such as choriocarcinomas [6]. Basing on these data, it is possible that epigenetic disturbance(s) during the Müllerian reproductive tract development may lead to modified intercellular communications, dysregulation of common downstream targets and, finally, to defect of organogenesis. Considering that the dysregulation of Wnt and/or Hox genes may affect cell migration during organogenesis and differentiation of Müllerian structures of the female reproductive tract, these altered pathways can underlie the well-known Mayer-Rokitansky-Kuster-Hauser Syndrome [7], clinically characterized by a physiological development of the secondary sexual characters and by a normal female karyotype 46 XX, with a congenital aplasia of the uterus and of 2/3 superior parts of vagina. A similar etiologic machinery was already hypothesized for endometriosis [8], a gynecological condition characterized by the breakdown of peritoneal immune homeostasis [9–11] and related symptoms and signs [12–14] due to the pro-inflammatory profile of pelvic as well as intrauterine microenvironment