Optimal cytoreduction: is a CT's picture worth a surgeon's word?

INTRODUCTION: The presence of residual disease after cytoreductive surgery is subjectively determined by the surgeon at the end of the operation. Nevertheless, in up to 21-49% of CT scans, residual disease can be found. The aim of this study was to establish the relationship between post-surgical CT findings after optimal cytoreduction in patients with advanced ovarian cancer and oncological outcome. MATERIAL AND METHODS: Patients with advanced ovarian cancer (FIGO II and IV), diagnosed between 2007 and 2019 in Hospital La Fe Valencia, in whom cytoreductive surgery was performed, achieving R0 or R1, were assessed for eligibility (n = 440). A total of 323 patients were excluded because a post-operative CT scan was not performed between the third and eighth post-surgery week and prior to the start of chemotherapy. RESULTS: 117 patients were finally included. The CT findings were classified into three categories: no evidence, suspicious or conclusive of residual tumour/progressive disease. 29.9% of CT scans were "conclusive of residual tumour/progressive disease". No differences were found when the DFS (p = 0.158) and OS (p = 0.215) of the three groups were compared (p = 0.158). CONCLUSION: After cytoreduction in ovarian cancer with no macroscopic disease or residual tumour < 1 cm result, up to 29.9% of post-operative CT scans before chemotherapy found measurable residual or progressive disease. Notwithstanding, a worse DFS or OS was not associated with this group of patients.

Low-grade endometrial stromal sarcoma with intravenous thrombus extension: a multidisciplinary surgical challenge.

Low-grade endometrial stromal sarcoma (LG-ESS) usually exhibits indolent behavior, often misdiagnosed and is associated with a favorable prognosis [1]. Despite the indolent nature of LG-ESS, recurrence is common, the risk is as high as 1 in 3 to 1 in 2 [2]. The behavior of such tumors can lead to invade blood vessels [3]. An intravascular tumor is associated with direct risk of sudden death from pulmonary embolism. There are very few reported cases with clinically obvious intravascular extension. Chemotherapy, radiotherapy and hormone therapy are adjuvant treatments that have not been able to demonstrate a definitive benefit in survival [4]. We want to take advantage of the opportunity, so far unpublished, to demonstrate with this case the surgical challenge described step by step, as well as to demonstrate the importance of surgery as the only curative treatment even in extended intravascular disease [5]. Here in, we present the surgical challenge of a LG-ESS in a 59-year old woman with iliac and cava vein tumoral thrombus extension. We performed a tumoral thrombectomy and vascular repair, with a pelvic exenteration and double barrel wet colostomy. After performing pelvic exenteration, the thrombus with intravascular involvement was addressed at 2 points: inferior cava vein and right common iliac vein with the extraction of the entire thrombus. These defects are corrected by angioplasty and venorrhaphy, respectively. The surgery got a complete cytoreduction. It lasted 290 minutes, with 430 mL blood loss. In patients with LG-ESS, cytoreduction is a reliable option even in extended metastatic disease.

Histerectomía total laparoscópica vs. histerectomía vaginal: análisis de costes y resultados operatorios / Total laparoscopic hysterectomy vs vaginal hysterectomy. Analysis of costs and surgical outcomes

Objetivo. Analizar y comparar los resultados perioperatorios y los costes económicos de la histerectomía total laparoscópica (HTL) y de la histerectomía vaginal (HV). Sujetos y métodos. Estudio retrospectivo realizado durante 2013 que incluye pacientes con similar perfil sometidas a HV (n = 20) o HTL (n = 29). La principal indicación quirúrgica fue útero miomatoso. Se recogen datos epidemiológicos, resultados perioperatorios y datos económicos. Resultados. Las características basales de las pacientes fueron similares. En resultados perioperatorios, el tiempo quirúrgico fue menor en HV (64,8 ± 14,5 min) que en HTL (102,8 ± 20,5 min) p < 0,01. No se encontraron diferencias significativas en peso uterino, caída de la hemoglobina y estancia hospitalaria. El coste medio de la HTL (2.036 ± 307 euros) fue significativamente mayor al de la HV (1.604 ± 346 euros). Conclusiones. En la elección de la vía quirúrgica, la HV parece ser un procedimiento más económico y con similares resultados perioperatorios que la HTL. No obstante, es importante individualizar según las características de la paciente. Son necesarios estudios con mayor tamaño muestral para confirmar los resultados (AU)

Objective. To evaluate and compare surgical outcomes and the overall costs of total laparoscopic hysterectomy (TLH) and vaginal hysterectomy (VH). Subjects and methods. A retrospective study was conducted that compared surgical outcomes and hospital costs obtained during 2013 in patients with similar profiles undergoing VH (n = 20) or TLH (n = 29). Epidemiological data, perioperative results and economic data were compared between the two groups. Results. Baseline characteristics were similar between the two groups. The mean operating time was shorter in the VH group (64.8 ± 14.5 min) than in the TLH group (102.8 ± 20.5 min) p < 0.01. No differences were found between the two groups in uterine weight, decrease in hemoglobin or length of hospital stay. The mean cost was significantly higher for TLH (Euros 2036 ± 307) than for VH (Euros 1603 ± 346). Conclusions. Our data suggest that VH is less expensive than TLH and has similar perioperative outcomes. Nevertheless, the choice of surgical route should be based on the patient's characteristics. Further studies with larger samples are required to confirm our data (AU)

Embarazo ectópico sobre cicatriz de cesárea / Ectopic caesarean scar pregnancy

El embarazo ectópico sobre cicatriz de cesárea previa ha aumentado su incidencia en los últimos años, debido probablemente al aumento en el número de cesáreas realizadas. Su importancia se debe a las potenciales graves consecuencias que pueden surgir en caso de progreso del embarazo. El anidamiento embrionario en esta zona se ha explicado aludiendo a que la liberación de diferentes factores, como citocinas, y la expresión de distintos receptores de superficie facilitarían la adhesión embrionaria, favorecida en las cicatrices de cirugías endometriales por su gran atracción quimiotáctica secundaria al proceso inflamatorio y de reparación tisular que allí se produce. Su manejo resulta controvertido por el escaso número de casos publicados, lo que hace difícil establecer un protocolo de actuación. Se han descrito varios tipos de tratamiento, tanto quirúrgicos como farmacológicos, con buenos resultados. Presentamos un caso en el que fue diagnosticada ecográficamente una gestación ectópica sobre cicatriz de cesárea, resuelta con tratamiento farmacológico con metotrexate. En este caso, se evidencia la importancia del seguimiento, tanto clínico como ecográfico y del nivel de beta-HCG, hasta su resolución completa (AU)

Ectopic caesarean scar pregnancy has increased in incidence in recent years, probably as a result of the rise in the number of caesarean sections performed. Its importance is due to the potentially serious consequences that can arise if the pregnancy progresses. It has been suggested that the embryonic nesting in this area may be due to the release of factors such as cytokines, and the expression of different surface receptors. These factors would facilitate the embryonic adherence, favoured in endometrial surgery scars for their great chemotactic attraction, which is secondary to the inflammatory process and tissue repair that occurs there. Its management remains controversial as the low number of reported cases makes it difficult to establish a protocol. Several types of treatment, surgical as well as pharmacological, have been described with good results. We report a case of caesarean scar pregnancy diagnosed on ultrasound, and resolved with conservative treatment with methotrexate. In this case, it demonstrates the importance of monitoring the clinical condition, as well as using ultrasound and beta-HCG levels until its full resolution (AU)