Factores de pronóstico en los tumores uterinos con patrón sarcomatoso

Consultable des del TDXTítol obtingut de la portada digitalitzadaLos factores de pronóstico en los tumores uterinos con patrón sarcomatoso (TUPS) no han estado bien establecidos con la excepción del estadio. Asimismo, la radioterapia (RDT) de modo complementario a la cirugía no han sido un tratamiento consensuado. Con la hipótesis de que no se conoce con la suficiente precisión la influencia de los factores de pronóstico en la supervivencia global específica (SGE), supervivencia libre de enfermedad (SLE), supervivencia libre de recidiva local (SLRL) y supervivencia libre de metástasis (SLM), se ha estudiado la influencia de los diferentes factores de pronóstico en las diferentes supervivencias. Dicho estudio se ha efectuado estratificando a las pacientes por estadios. Así mismo, se ha evaluando el impacto de la radioterapia y se ha efectuado el estudio comparativo de los factores de pronóstico en estos tumores con los del cáncer de cérvix y el de endometrio. Material y métodos: 60 pacientes diagnosticadas y tratadas por TUPS entre 1975 y 1999 en el Hosp. Clínic de Barcelona. Factores de pronóstico estudiados: edad, tipo histológico, índice mitótico, invasión miometrial (IM), invasión vasculolinfática (IVL), necrosis, uni/multicentricidad, tamaño tumoral y la radioterapia. Análisis estadístico: Método actuarial de Kaplan y Maier, test de Log-rank y modelo de riesgo proporcional de Cox. Estudio de los factores pronósticos en la literatura: 21 publicaciones en TUPS entre 1966 y 2001, así como las publicaciones sobre factores de pronóstico en los últimos 10 años para el cáncer de cérvix y el de endometrio. Resultados: 1) En el análisis multivariado se evidenció: en estadios tempranos la influencia de la IVL y el tamaño tumoral mayor a 8 cm. en la SGE, de la invasión miometrial > 50% en la SLE y SLRL, y de la IVL en la SLM. En los estadios avanzados solo se constató la influencia del tipo histológico leiomiosarcoma en la SGE, lo cual pudo ser debido a una mayor incidencia de factores de mal pronóstico en los estadios avanzados. 2) No se evidenció impacto de la RDT en ninguna de las supervivencias; sin embargo, hubo una mayor incidencia de IM e IM > 50% entre las pacientes que recibieron RDT. El 100% de las pacientes con tamaños tumorales 50%, tamaño tumoral > 8 cm., IVL, Indice mitótico y tipo histológico deben de considerarse factores de mal pronóstico en los TUPS; el que tiene más relevancia en la literatura es la invasión miometrial. Conclusiones: El estadio es el factor pronóstico más importante en los TUPS. Al estratificar a las pacientes por estadios la IVL, la IM > 50% y el tamaño tumoral han sido los factores con impacto en los estadios tempranos. Todas las pacientes con IVL fallecieron con metástasis. Podría existir un beneficio de la irradiación en aquellos tumores 50%. En estadios avanzados influyo el tipo leiomiosarcoma. La mayor agresividad de los estadios avanzados podría justificarse por una mayor incidencia de factores de mal pronóstico en comparación con los tempranos, lo que además puede explicar la ausencia de efecto de la irradiación.Prognostic factors in uterine tumours with a sarcomatous component (UTSC) have not being well stablished with the exception of the stage. Moreover, there is not agreement between authors on the value of complementary radiotherapy to the surgery. The present study was performed with the hypothesis that there is not a precise knowledge of the influence of the different prognostic factors on the specific overall survival (OS), disease-free survival (DFS), local relapse-free survival (LRFS) and distant metastasis-free survival (DMFS). The study of the influence of the different prognostic factors in the different survivals was performed stratifying patients by stage. The impact of irradiation (RDT) was also analyzed and a comparative study of the literature on prognostic factors between cervical and endometrial cancer, and uterine tumours with a sarcomatous component was performed. Matherial and methods: Sixty patients diagnosed and treated at Clinic Hospital of Barcelona. Prognostic factors studied: age, pathologic type, mitotic index, myometrial invasion (MI), vascular and lymphatic space invasion (VLSI), necrosis, unicentricity / multicentriciy, tumoral size and radiotherapy. Statistics: Kaplan and Maier actuarial method, Log-rank method and Cox model of proportional risk. The study of prognostic factors in the literature was done using 21 publications in uterine sarcomas between 1966 and 2001 having more than 45 patients, and those articles on prognostic factors for cervical and endometrial cancer in the last 10 years. Results: 1) Multivariate analysis. In early stages, VLSI and tumor size > 8 cm. had impact on OS, MI > 50% on DFS and LRFS and VSLI on DMFS. Advanced stages: leiomyosarcoma type was the only prognostic factor with impact on OS; a higher incidence of other prognostic factors in advanced stages could have been the responsible. 2) RDT had no impact on the different survival results; nevertheless, there were a higher incidence of MI and MI > 50% in the radiotherapy group. The 100% of the patients having tumoral size 50%, tumoral size, VLSI, mitotic index and pathologic type should be considered as prognostic factors in uterine sarcomas; the most relevant in the litherature is MI. Conclusions: The most important prognostic factor in uterine sarcomas is the stage. When patients were stratified by stages VLSI, MI>50% and tumoral size > 8 cm. were prognostic factors with impact in early stages. All the patients having VLSI died by distant metastasis. A benefit of irradiation could be found in tumors >8 cm., MI > 50% and carcinosarcoma type. In advanced stages leiomyosarcoma type had impact on survival. The more aggresive behaviour in advanced stages could be explained by a higher incidence of bad prognostic factors in comparison to early stages

In vivo verification of treatment source dwell times in brachytherapy of postoperative endometrial carcinoma: a feasibility study

Background: In brachytherapy, there are still many manual procedures that can cause adverse events which can be detected with in vivo dosimetry systems. Plastic scintillator dosimeters (PSD) have interesting properties to achieve this objective such as real-time reading, linearity, repeatability, and small size to fit inside brachytherapy catheters. The purpose of this study was to evaluate the performance of a PSD in postoperative endometrial brachytherapy in terms of source dwell time accuracy. Methods: Measurements were carried out in a PMMA phantom to characterise the PSD. Patient measurements in 121 dwell positions were analysed to obtain the differences between planned and measured dwell times. Results: The repeatability test showed a relative standard deviation below 1% for the measured dwell times. The relative standard deviation of the PSD sensitivity with accumulated absorbed dose was lower than 1.2%. The equipment operated linearly in total counts with respect to absorbed dose and also in count rate versus absorbed dose rate. The mean (standard deviation) of the absolute differences between planned and measured dwell times in patient treatments was 0.0 (0.2) seconds. Conclusions: The PSD system is useful as a quality assurance tool for brachytherapy treatments

Quality assurance in radiotherapy: analysis of the causes of not starting or early radiotherapy withdrawal.

BACKGROUND: The aim of this study was to analyse the reasons for not starting or for early of radiotherapy at the Radiation Oncology Department. METHODS: All radiotherapy treatments from March 2010 to February 2012 were included. Early withdrawals from treatment those that never started recorded. Clinical, demographic and dosimetric variables were also noted. RESULTS: From a total of 3250 patients treated and reviewed, 121 (4%) did not start or complete the planned treatment. Of those, 63 (52%) did not receive any radiotherapy fraction and 58 (48%) did not complete the course, 74% were male and 26% were female. The mean age was 67 ± 13 years. The most common primary tumour was lung (28%), followed by rectum (16%). The aim of treatment was 62% radical and 38% palliative, 44% of patients had metastases; the most common metastatic site was bone, followed by brain. In 38% of cases (46 patients) radiotherapy was administered concomitantly with chemotherapy (10 cases (22%) were rectal cancers). The most common reason for not beginning or for early withdrawal of treatment was clinical progression (58/121, 48%). Of those, 43% died (52/121), 35 of them because of the progression of the disease and 17 from other causes. Incomplete treatment regimens were due to toxicity (12/121 (10%), of which 10 patients underwent concomitant chemotherapy for rectal cancer). CONCLUSIONS: The number of patients who did not complete their course of treatment is low, which shows good judgement in indications and patient selection. The most common reason for incomplete treatments was clinical progression. Rectal cancer treated with concomitant chemotherapy was the most frequent reason of the interruption of radiotherapy for toxicity

Menopause in Nonhuman Primates: A Comparative Study with Humans

Although menopause is a phenomenon predominantly studied in humans or laboratory animals, this chapter discussed the case of nonhuman primates (NHPs), not only with the objective of employing them as study models but also to better understand phylogenetic divergence among species. Those taxonomic differences are reflected in reproductive processes that may be similar to those of human beings, with the presence of a defined cycle or periods of estrus, but perhaps at different ages as well, where menopause plays a crucial role. First, it is important to delimit the concept of menopause by considering its anatomical, physiological, and biochemical parameters, including the cessation of menstrual bleeding or perineal swelling—when present—or follicular depletion and hormonal changes. Thus, the aim of this chapter is to discuss some of the similarities between NHPs and human females, during the menopause period. Studying these phenomena should help us achieve a better understanding of the social, physiological, and environmental factors without adopting any particular cultural view of menopause

Preliminary results of a vaginal constraint for reducing G2 late vaginal complications after postoperative brachytherapy in endometrial cancer: A proepective analysis

Purpose: To evaluate the preliminary results of the use of 68 Gy EQD2(α/β=3 Gy) as a dose limit to the lowest dose in the most exposed 2 cm3 of the vagina in order to reduce G2 late vaginal problems in postoperative endometrial carcinoma (EC). Methods: From November 2016 to October 2019, 69 postoperative EC patients receiving vaginal brachytherapy (VBT) ± external beam radiotherapy (EBRT) were prospectively analyzed. The median EBRT dose was 45 Gy (range: 44-50.4 Gy), 1.8-2 Gy/day, 5 fractions(Fr)/week. VBT was administered with the following schedule: 1Fr of 7 Gy after EBRT and 2 daily Fr × 7.5 Gy in exclusive VBT. The dose was prescribed at 0.5 cm from the applicator surface with an active length of 2.5 cm; 56 patients were treated with vaginal cylinders (49-3.5 cm, 6-3 cm, and 1-2.5 cm) and 13 with the colpostat technique. The overall VBT dose was adjusted to meet the vaginal restriction of < 68 Gy EQD2(α/β=3 Gy) at 2 cm3. Late toxicity was prospectively assessed using RTOG scores for bladder and rectum, and the objective LENT-SOMA criteria for vagina. Results: With a median follow-up of 31.0 months, no vaginal-cuff recurrences were found. Late toxicity: only 1G1(1.4%) rectal toxicity; 21G1(30.4%) and 3G2(4.3%) vaginal complications. Only one (1.4%) of 3 G2 manifested as vaginal shortening. Conclusions: In postoperative EC patients treated with VBT, only one developed G2 vaginal stenosis with the use of 68 Gy EQD2(α/β=3 Gy) as a dose constraint. These preliminary results seem to indicate the value of this dose limit for reducing G2 vaginal stenosis. Nonetheless, these findings should be confirmed in a larger number of patients with longer follow-up. Keywords: Brachytherapy; Postoperative endometrial cancer; Vaginal complications; Vaginal constraint

EQD2 Analyses of Vaginal Complications in Exclusive Brachytherapy for Postoperative Endometrial Carcinoma

Background: To evaluate whether EQD2(α/β = 3Gy) at 2 cm3 of the most exposed area of the vagina is related to late vaginal toxicity in postoperative endometrial cancer (PEC) patients (p) treated with exclusive brachytherapy (BT). Methods: From 2014 to 2017, 43p were included in this study. BT was administered: 3-fractions of 6Gy in 37p and 2-fractions of 7.5Gy in 6p. The dose was prescribed at a depth of 5 mm from the applicator surface with dose-point optimization based on distance. The active treatment length was 2.5 cm. CTV-D90 and the dose to the most exposed 2 cm3 of the vagina was calculated for each patient. Late toxicity of the bladder and rectum was assessed using Radiation Therapy Oncology Group (RTOG) criteria, and vaginal toxicity by objective Late Effects Normal Tissue Task Force (LENT)-Subjective, Objective, Management, Analytic (SOMA) (LENT-SOMA) criteria. Statistics: frequency tables, mean, median, range, standard deviation, and box plot. Results: The median follow-up was 51 months (12-68). 20 p (46.5%) and 2 p (4.7%) developed G1 and G2 vaginal complications, respectively. Only 1/2 p-G2 receiving EQD2(α/β = 3Gy) at 2 cm3 >68Gy presented vaginal shortening and 18/20 p-G1 received doses < 68Gy. Conclusions: PECp receiving exclusive brachytherapy with doses < 68Gy EQD2(α/β = 3Gy) at 2 cm2 of the vagina presented only G0-G1 vaginal toxicity, except for one with bleeding telangiectasias. Larger prospective studies are necessary to confirm the present results

Comparison of HE4, CA125, ROMA and CPH-I for Preoperative Assessment of Adnexal Tumors

(1) OBJECTIVE: To assess the performance of CA125, HE4, ROMA index and CPH-I index to preoperatively identify epithelial ovarian cancer (EOC) or metastatic cancer in the ovary (MCO). (2) METHODS: single center retrospective study, including women with a diagnosis of adnexal mass. We obtained the AUC, sensitivity, specificity and predictive values were of HE4, CA125, ROMA and CPH-I for the diagnosis of EOC and MCO. Subgroup analysis for women harboring adnexal masses with inconclusive diagnosis of malignancy by ultrasound features and Stage I EOC was performed. (3) RESULTS: 1071 patients were included, 852 (79.6%) presented benign/borderline tumors and 219 (20.4%) presented EOC/MCO. AUC for HE4 was higher than for CA125 (0.91 vs. 0.87). No differences were seen between AUC of ROMA and CPH-I, but they were both higher than HE4 AUC. None of the tumor markers alone achieved a sensitivity of 90%; HE4 was highly specific (93.5%). ROMA showed a sensitivity and specificity of 91.1% and 84.6% respectively, while CPH-I showed a sensitivity of 91.1% with 79.2% specificity. For patients with inconclusive diagnosis of malignancy by ultrasound features and with Stage I EOC, ROMA showed the best diagnostic performance (4) CONCLUSIONS: ROMA and CPH-I perform better than tumor markers alone to identify patients harboring EOC or MCO. They can be helpful to assess the risk of malignancy of adnexal masses, especially in cases where ultrasonographic diagnosis is challenging (stage I EOC, inconclusive diagnosis of malignancy by ultrasound features)

LDR brachytherapy offers superior tumor control to single-fraction HDR prostate brachytherapy: A prospective study

[Purpose]: To compare the clinical outcomes of single-fraction high-dose-rate (HDR) brachytherapy and single-fraction low-dose-rate (LDR) brachytherapy as the sole treatment for primary prostate cancer. [Material and Methods]: A quasi-randomized study that allocated, from March 2008 to February 2012, 129 low and intermediate risk prostate cancer patients to one single-fraction HDR of 19 Gy (61 patients) or to a 145 Gy 125I LDR permanent implant (68 patients. Biochemical relapse-free survival (bRFS) and overall survival (OS) were compared using the Kaplan–Meier method and Cox regression analysis. [Results]: After a median follow-up of 72 months in the HDR group, 26 patients relapsed, and after a median follow-up of 84 months in the LDR group, 7 patients relapsed (p < 0.0001). The 5-year bRFS was significantly better for the LDR group than for the HDR group (93.7% and 61.1%, respectively) (p < 0.0001). The 5-year OS also was significantly better in the LDR group (95.5% vs. 89.9%) (p = 0.0436). [Conclusions]: Permanent LDR prostate implant brachytherapy offers better clinical outcomes than single-fraction HDR for prostate cancer.Peer reviewe

Endoluminal brachytherapy in the treatment of oesophageal cancer. Technique description, case report and review of the literature.

Endoesophageal brachytherapy is a useful technique for the palliative treatment of dysphagia in advanced oesophageal cancer. This technique offers good results on dysphagia control and quality of life.We report the case of a patient treated with this technique presenting complete response to the dysphagia. We describe endoesophageal brachyterapy technique and we comment on the literature