Tratamiento de preservación de fertilidad en pacientes con cáncer de endometrio

El carcinoma endometrial (CE) en mujeres jóvenes es un hecho infrecuente, tan solo el 4% de los diagnósticos se realizan en menores de 40 años. El estándar para el tratamiento es la cirugía con una supervivencia global a 5 años en torno al 93%. Como alternativa, en casos en los que existe un gran deseo genésico, se puede plantear un tratamiento conservador alternativo basado en progestágenos orales, fundamentalmente acetato de medroxiprogesterona o acetato de megestrol y más recientemente, DIU de levonorgestrel. Esta opción se podría considerar en pacientes con diagnóstico histológico de CE bien diferenciado (o enfermedad premaligna como hiperplasia atípica) en estadio inicial, cuando no existe infiltración miometrial. El objetivo de esta tesis es la evaluación de la tasa de respuesta al tratamiento en mujeres con CE que desean preservar la fertilidad, así como la evaluación de los resultados reproductivos y obstétricos. Para ello se propuso un estudio retrospectivo multicéntrico con pacientes tratadas en centros españoles entre 2006 y 2019 en el que se incluyeron 72 mujeres. El 79,2% de las mujeres obtuvieron una respuesta completa (RC) durante el tratamiento. El 68,4% presentaron una respuesta mantenida y no recayeron nunca durante el seguimiento. El tiempo medio global hasta la RC fue de 5,6 meses. El 85,7% de las pacientes tratadas mediante DIU-LNG obtuvieron la RC respecto a un 70% con otros tratamientos, sin embargo, esta asociación no fue significativa (p=0,106). El 25% de las pacientes incluidas recayó, siendo el tiempo medio hasta la recaída de 32,1 meses. La cirugía definitiva se llevó a cabo en 42 mujeres. Cuatro mujeres progresaron o recayeron después de la cirugía definitiva. De ellas, tres fallecieron por la enfermedad, lo que supone una tasa de mortalidad del 4,2%. En cuanto al pronóstico oncológico a los 2 y 5 años, la supervivencia libre de enfermedad fue de 97,1% y 92,8% y la supervivencia global de 98,4% y 93,6% respectivamente. Globalmente, 39 mujeres intentaron gestar, de las cuales 29 lo consiguieron. la tasa de gestación fue del 74,4% en nuestra serie. De estas 29 mujeres, 25 consiguen un RN vivo lo que supone una tasa de RN vivo del 64,1%. Casi el 75% de las pacientes fueron derivadas a la Unidad de reproducción y fueron sometidas a un tratamiento de fertilidad. El 75,9% de las gestaciones se consiguió mediante técnicas de reproducción asistida (TRA). Concluimos que el tratamiento preservador de la fertilidad en estadios iniciales de CE es un manejo seguro y eficaz y pude plantearse cuando se cumplan de manera estricta los criterios y se realice una evaluación previa minuciosa. Además, hemos podido confirmar que la alternativa al tratamiento oral, el DIU-LNG, es una opción fiable y efectiva. Además, el pronóstico oncológico global es excelente y las mujeres sometidas a este tratamiento cumplen en un porcentaje aceptable su objetivo de ser madres y tener un recién nacido vivo

Feasibility of a Multimodal Prehabilitation Programme in Patients Undergoing Cytoreductive Surgery for Advanced Ovarian Cancer: A Pilot Study

Introduction: Treatment for advanced ovarian cancer (AOC) comprises cytoreductive surgery combined with chemotherapy. Multimodal prehabilitation programmes before surgery have demonstrated efficacy in postoperative outcomes in non-gynaecological surgeries. However, the viability and effects of these programmes on patients with AOC are unknown. We aimed to evaluate the feasibility and postoperative impact of a multimodal prehabilitation programme in AOC patients undergoing surgery. Methods: This single-centre, before-and-after intervention pilot study included 34 patients in two cohorts: the prehabilitation cohort prospectively included 15 patients receiving supervised exercise, nutritional optimisation, and psychological preparation from December 2019 to January 2021; the control cohort included 19 consecutive patients between January 2018 and November 2019. Enhanced Recovery After Surgery guidelines were followed. Results: The overall adherence to the multimodal prehabilitation programme was 80%, with 86.7% adherence to exercise training, 100% adherence to nutritional optimisation, and 80% adherence to psychological preparation. The median hospital stay was shorter in the prehabilitation cohort (5 (IQR, 4–6) vs. 7 days (IQR, 5–9) in the control cohort, p = 0.04). Differences in postoperative complications using the comprehensive complication index (CCI) were not significant (CCI score: 9.3 (SD 12.12) in the prehabilitation cohort vs. 16.61 (SD 16.89) in the control cohort, p = 0.08). The median time to starting chemotherapy was shorter in the prehabilitation cohort (25 (IQR, 23–25) vs. 35 days (IQR, 28–45) in the control cohort, p = 0.03). Conclusions: A multimodal prehabilitation programme before cytoreductive surgery is feasible in AOC patients with no major adverse effects, and results in significantly shorter hospital stays and time to starting chemotherapy

Feasibility of a Multimodal Prehabilitation Programme in Patients Undergoing Cytoreductive Surgery for Advanced Ovarian Cancer: A Pilot Study

Introduction: Treatment for advanced ovarian cancer (AOC) comprises cytoreductive surgery combined with chemotherapy. Multimodal prehabilitation programmes before surgery have demonstrated efficacy in postoperative outcomes in non-gynaecological surgeries. However, the viability and effects of these programmes on patients with AOC are unknown. We aimed to evaluate the feasibility and postoperative impact of a multimodal prehabilitation programme in AOC patients undergoing surgery. Methods: This single-centre, before-and-after intervention pilot study included 34 patients in two cohorts: the prehabilitation cohort prospectively included 15 patients receiving supervised exercise, nutritional optimisation, and psychological preparation from December 2019 to January 2021; the control cohort included 19 consecutive patients between January 2018 and November 2019. Enhanced Recovery After Surgery guidelines were followed. Results: The overall adherence to the multimodal prehabilitation programme was 80%, with 86.7% adherence to exercise training, 100% adherence to nutritional optimisation, and 80% adherence to psychological preparation. The median hospital stay was shorter in the prehabilitation cohort (5 (IQR, 4-6) vs. 7 days (IQR, 5-9) in the control cohort, p = 0.04). Differences in postoperative complications using the comprehensive complication index (CCI) were not significant (CCI score: 9.3 (SD 12.12) in the prehabilitation cohort vs. 16.61 (SD 16.89) in the control cohort, p = 0.08). The median time to starting chemotherapy was shorter in the prehabilitation cohort (25 (IQR, 23-25) vs. 35 days (IQR, 28-45) in the control cohort, p = 0.03). Conclusions: A multimodal prehabilitation programme before cytoreductive surgery is feasible in AOC patients with no major adverse effects, and results in significantly shorter hospital stays and time to starting chemotherapy

SUCCOR quality: validation of ESGO quality indicators for surgical treatment of cervical cancer

Objective To evaluate whether compliance with European Society of Gynaecological Oncology (ESGO) surgery quality indicators impacts disease-free survival in patients undergoing radical hysterectomy for cervical cancer. Methods In this retrospective cohort study, 15 ESGO quality indicators were assessed in the SUCCOR database (patients who underwent radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage 2009 IB1, FIGO 2018 IB1, and IB2 cervical cancer between January 2013 and December 2014), and the final score ranged between 0 and 16 points. Centers with more than 13 points were classified as high-quality indicator compliance centers. We constructed a weighted cohort using inverse probability weighting to adjust for the variables. We compared disease-free survival and overall survival using Cox proportional hazards regression analysis in the weighted cohort. Results A total of 838 patients were included in the study. The mean number of quality indicators compliance in this cohort was 13.6 (SD 1.45). A total of 479 (57.2%) patients were operated on at high compliance centers and 359 (42.8%) patients at low compliance centers. High compliance centers performed more open surgeries (58.4% vs 36.7%, p<0.01). Women who were operated on at centers with high compliance with quality indicators had a significantly lower risk of relapse (HR=0.39; 95% CI 0.25 to 0.61; p<0.001). The association was reduced, but remained significant, after further adjustment for conization, surgical approach, and use of manipulator surgery (HR=0.48; 95% CI 0.30 to 0.75; p=0.001) and adjustment for adjuvant therapy (HR=0.47; 95% CI 0.30 to 0.74; p=0.001). Risk of death from disease was significantly lower in women operated on at centers with high adherence to quality indicators (HR=0.43; 95% CI 0.19 to 0.97; p=0.041). However, the association was not significant after adjustment for conization, surgical approach, use of manipulator surgery, and adjuvant therapy. Conclusions Patients with early cervical cancer who underwent radical hysterectomy in centers with high compliance with ESGO quality indicators had a lower risk of recurrence and death

SUCCOR quality: validation of ESGO quality indicators for surgical treatment of cervical cancer

Objective To evaluate whether compliance with European Society of Gynaecological Oncology (ESGO) surgery quality indicators impacts disease-free survival in patients undergoing radical hysterectomy for cervical cancer. Methods In this retrospective cohort study, 15 ESGO quality indicators were assessed in the SUCCOR database (patients who underwent radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage 2009 IB1, FIGO 2018 IB1, and IB2 cervical cancer between January 2013 and December 2014), and the final score ranged between 0 and 16 points. Centers with more than 13 points were classified as high-quality indicator compliance centers. We constructed a weighted cohort using inverse probability weighting to adjust for the variables. We compared disease-free survival and overall survival using Cox proportional hazards regression analysis in the weighted cohort. Results A total of 838 patients were included in the study. The mean number of quality indicators compliance in this cohort was 13.6 (SD 1.45). A total of 479 (57.2%) patients were operated on at high compliance centers and 359 (42.8%) patients at low compliance centers. High compliance centers performed more open surgeries (58.4% vs 36.7%, p<0.01). Women who were operated on at centers with high compliance with quality indicators had a significantly lower risk of relapse (HR=0.39; 95% CI 0.25 to 0.61; p<0.001). The association was reduced, but remained significant, after further adjustment for conization, surgical approach, and use of manipulator surgery (HR=0.48; 95% CI 0.30 to 0.75; p=0.001) and adjustment for adjuvant therapy (HR=0.47; 95% CI 0.30 to 0.74; p=0.001). Risk of death from disease was significantly lower in women operated on at centers with high adherence to quality indicators (HR=0.43; 95% CI 0.19 to 0.97; p=0.041). However, the association was not significant after adjustment for conization, surgical approach, use of manipulator surgery, and adjuvant therapy. Conclusions Patients with early cervical cancer who underwent radical hysterectomy in centers with high compliance with ESGO quality indicators had a lower risk of recurrence and death