Neoadjuvant chemotherapy in early-stage cervical cancer (<2 cm) before conization for fertility preservation: is there any advantage over upfront conization?

BACKGROUND: Neoadjuvant chemotherapy before fertility-sparing surgery is an accepted option for patients with cervical tumors between 2 cm and 4 cm. There is a paucity of data regarding its role in patients with tumors <2 cm. Our objective was to compare the oncological and obstetrical outcomes between patients who underwent neoadjuvant chemotherapy before cervical conization versus upfront cervical conization in patients with cervical cancer with tumors <2 cm. METHODS: We conducted a systematic literature review and searched MEDLINE, EMBASE, and CINAHL (from 1995 to March 2020) using the terms: uterine cervix neoplasms, cervical cancer, fertility-sparing surgery, fertility preservation, conization, cone biopsy, and neoadjuvant chemotherapy. We included manuscripts with information on patients with tumor size <2 cm, lymph node status, follow-up, oncological and obstetrical outcome, and toxicity related to neoadjuvant chemotherapy. We excluded review articles or articles with duplicated patient information. RESULTS: We identified 12 articles, including 579 patients. For final analysis, 261 patients met inclusion criteria. The most common histology was non-squamous cell carcinoma (62%). Median follow-up time was 63.5 (range 7-122) months for the neoadjuvant chemotherapy group and 48 (range 12-184) months for the upfront cervical conization group. There was no difference in either overall survival (neoadjuvant chemotherapy group 100% vs upfront cervical conization 99.7%, p=0.79) or disease-free survival (neoadjuvant chemotherapy 100% vs upfront cervical conization 98.9%, p=0.59) between the groups. Fertility preservation rate was 81.4% versus 99.1% (p<0.001) favoring upfront cervical conization. No statistically significant differences were seen in live birth rate or pregnancy loss. Also, we found that all neoadjuvant chemotherapy patients reported chemotherapy-related toxicity (30.7% grade 3 and 69.2% grade 1-2). CONCLUSIONS: There was no difference in disease-free survival or overall survival between patients who underwent neoadjuvant chemotherapy followed by conization and upfront cervical conization. Patients who underwent upfront cervical conization had a higher fertility preservation rate.

Same-Day Discharge in Minimally Invasive Surgery Performed by Gynecologic Oncologists: A Review of Patient Selection.

OBJECTIVE: To review the literature about same-day discharge (SDD) in minimally invasive surgery performed by gynecologic oncologists and identify factors associated with SDD and admission to provide selection criteria. DATA SOURCES: Systematic review of PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and SCOPUS between May 2007 and May 2019. The search included the following medical subject heading terms and keywords: "same day discharge," "patient discharge," "minimally invasive surgical procedures," "hysterectomy," "gynecologic malignancy," "gynecologic neoplasm," "cervical cancer," "ovarian cancer," and "endometrial cancer." METHODS OF STUDY SELECTION: Articles published in English about women who underwent minimally invasive procedures for benign and malignant conditions of the reproductive tract performed by gynecologic oncologists (robotic or laparoscopic) and who received SDD or admission were included. The following were described: SDD and admission rate, readmission or unscheduled evaluation rates within 30 days after surgery, and associated factors for each one. TABULATION, INTEGRATION, AND RESULTS: Nine studies with a total of 16 423 patients were included. The complication rates in the studies were variable, with only 2 studies showing advantages in the SDD group with respect to intraoperative complications and wound complications. There were no statistically significant differences in postoperative complications in the first 30 days after the adoption of SDD. There were no higher readmission rates within the first 30 days in the group of patients who were discharged on the same day vs those admitted. The common factors associated with admission were as follows: age <70 years, surgery after 1 PM, duration of surgery more than 2 hours, and intraoperative complications. Other factors to consider were the presence of comorbidities that require follow-up within the hospital after surgery, adequate postoperative evaluation, and the patient accepting SDD. CONCLUSION: SDD seems to be safe and feasible in minimally invasive surgery performed by gynecologic oncologists. The proposed selection criteria includes the following: younger than 70 years, surgery before 1 PM, procedure less than 2 hours, and no intraoperative complications.

Evolución de los sarcomas primarios de la mama: nuestra experiencia / Evolution of primary sarcomas of the breast: our experience

Resumen: Los sarcomas primarios de la mama son una rara entidad, representan menos del 1% de los tumores malignos de la mama. La bibliografía reporta pequeñas series, lo cual no proporciona la suficiente información para entender la evolución natural de estos tumores, sin existir consenso definitivo acerca del tratamiento adecuado. Se estudiaron retrospectivamente 13 sarcomas puros de la mama en el Servicio de Ginecología del Hospital Nacional de Clínicas de Córdoba entre marzo 1989 y agosto del 2012. A 12 pacientes se les realizó tratamiento quirúrgico primario y a 1 caso quimioterapia primaria neoadyuvante (en otra institución). Se analizaron edad de los pacientes, diagnóstico preoperatorio, cirugía realizada, diagnóstico definitivo mediante técnicas de inmunohistoquímica (IHQ), tamaño tumoral, características histológicas y terapias adyuvantes realizadas. Nueve de nuestros pacientes recibieron terapia radiante adyuvante y un caso quimioterapia adyuvante específica para tejidos blandos, debido al mal pronóstico tumoral. A la fecha se encuentran 6 pacientes vivos en seguimiento oncológico. Se concluye que los principales inconvenientes serían: Para el diagnóstico correcto definitivo se necesita de la IHQ en casos con problemas. El manejo quirúrgico con márgenes amplios y la utilización de terapias adyuvantes en casos de mal pronóstico son la base del tratamiento. Necesidad de estudios prospectivos multicéntricos para consenso en la toma de conductas terapéuticas definidas.

TCu 380A IUD: a reversible permanent contraceptive method in women over 35 years of age.

OBJECTIVE: The objective of the study was to evaluate the performance of the TCu 380A IUD in women who had been using the device for more than 10 years and who were 35 years of age or more on completion of the 10th year of IUD use. METHODS: A total of 228 women who had an IUD inserted between 1987 and 1992 were included in the study. The cutoff date for analysis was January 31, 2004. Clinical performance was evaluated by life-table analysis. The mean age of women at 10 years of use was 38.8+/-0.4 years and mean parity was 2.2+/-0.08 (mean+/-SD). The duration of follow-up beyond 10 years ranged from 1 to 72 months. No pregnancy was observed in 366 woman-years of observation beyond 10 years of use. The main reason for discontinuation was removal of the device because the clients had previously been informed that the IUD was not approved for use beyond 10 years. This reason accounted for a gross cumulative 6 years discontinuation rate of 42.5 per 100 women beyond 10 years. The other main reasons for discontinuation beyond 10 years of use were surgical sterilization, menopause and expulsion with gross cumulative 6-year termination rates of 19.2, 11.0 and 21.2 per 100 women, respectively. The cumulative continuation rate beyond 10 years was 67.0 at the end of the first year of follow-up and 21.2 at the end of the sixth year. CONCLUSION: We found no evidence that the TCu 380A IUD loses its effectiveness after 10 years of use. RESULTS: The concept that women who have insertion of a TCu 380A IUD at the age of 25 years or older could use this IUD as a reversible but permanent method of contraception up to the menopause continues to be supported by the accumulation of evidence, although definitive evidence remains to be obtained.