Telemedicine in post-molar follow-up: is it a useful tool?

BACKGROUND: Telemonitoring is an alternative to in-person appointments and overcomes geographic distance barriers. OBJECTIVE: The primary objective of this study was to evaluate adherence to post-molar follow-up using both WhatsApp and in-person appointments compared with standard care. The secondary objective was to evaluate the rate of completion of post-molar follow-up of complete moles, considering 6 and 3 months of duration. METHODS: This retrospective cohort study was conducted at the Gestational Trophoblastic Disease Center, São Paulo Hospital. Patients with complete or partial mole treatment between January 1, 2009 and December 31, 2018 were included in two groups: group 1 (patients from 2009 to 2013) and group 2 (from 2014 to 2018), before and after telemonitoring implementation, respectively. Complete follow-up was considered if after the first normal human chorionic gonadotropin (hCG) level (<5 mIU/mL), the patient was followed up for an additional 30 days (partial mole) or 180 days (complete mole). Loss to post-molar follow-up with positive hCG was also evaluated. Statistical analysis was performed using Pearson's Χ2 test, 5% significance level (p=0.05), and R version 4.0.2. RESULTS: A total of 308 patients were included in the study, 92 of them were assessed in group 1 and 216 patients in group 2. There was no difference between the rates of complete follow-up after telemonitoring implementation (complete mole: 42/72=58.3% group 1 vs 85/163=52.1% group 2; p=0.38; partial mole: 16/20=80% group 1 vs 37/53=69.8 group 2; p=0.3), and no increase of loss to post-molar follow-up with positive hCG (8/92=8.7% group 1 vs 14/216=6.5% group 2; p=0.49). The shortening of follow-up of complete moles to 90 days increased the rate of complete post-molar follow-up (from 127/235=54.0% to 189/235=80.4%, p<0.001). CONCLUSIONS: The association of telemonitoring with in-person appointments could have had an advantage in post-molar follow-up since it did not reduce adherence to hormonal surveillance. Shortening post-molar follow-up after complete mole to 90 days after the first normal hCG level increased the rate of complete post-molar follow-up.

Uterine Rescue in High-Risk Gestational Trophoblastic Neoplasia Treated with EMA-CO by Uterine Arteries Embolization due to Arteriovenous Malformations.

Complete hydatidiform mole (CHM) is a rare type of pregnancy, in which 15 to 20% of the cases may develop into gestational trophoblastic neoplasia (GTN). The diagnostic of GTN must be done as early as possible through weekly surveillance of serum hCG after uterine evacuation. We report the case of 23-year-old primigravida, with CHM but without surveillance of hCG after uterine evacuation. Two months later, the patient presented to the emergency with vaginal bleeding and was referred to the Centro de Doenças Trofoblásticas do Hospital São Paulo. She was diagnosed with high risk GTN stage/score III:7 as per The International Federation of Gynecology and Obstetrics/World Health Organization (FIGO/WHO). The sonographic examination revealed enlarged uterus with a heterogeneous mass constituted of multiple large vessels invading and causing disarrangement of the myometrium. The patient evolved with progressive worsening of vaginal bleeding after chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) regimen. She underwent blood transfusion and embolization of uterine arteries due to severe vaginal hemorrhage episodes, with complete control of bleeding. The hCG reached a negative value after the third cycle, and there was a complete regression of the anomalous vascularization of the uterus as well as full recovery of the uterine anatomy. The treatment in a reference center was essential for the appropriate management, especially regarding the uterine arteries embolization trough percutaneous femoral artery puncture, which was crucial to avoid the hysterectomy and allow GTN cure and maintenance of reproductive life.

Mola hidatiforme completa (MHC) é um tipo raro de gravidez, na qual 15 a 20% dos casos podem desenvolver neoplasia trofoblástica gestacional (NTG). O diagnóstico de NTG deve ser feito o mais cedo possível, pelo monitoramento semanal do hCG sérico após esvaziamento uterino. Relatamos o caso de uma paciente primigesta, de 23 anos de idade, com MHC, sem vigilância de hCG após esvaziamento uterino. Dois meses depois, a paciente compareceu na emergência com sangramento vaginal, sendo encaminhada ao Centro de Doenças Trofoblásticas do Hospital São Paulo, onde foi diagnosticada com NTG de alto risco, estádio e score de risco III:7 de acordo com a The International Federation of Gynecology and Obstetrics/Organização Mundial de Saúde (FIGO/OMS). O exame ultrassonográfico revelou útero aumentado com uma massa heterogênea constituída por múltiplos vasos volumosos invadindo e desestruturando o miométrio. A paciente evoluiu com piora progressiva do sangramento vaginal após quimioterapia com o regime etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO). Ela foi submetida a transfusão de sangue e embolização das artérias uterinas devido aos episódios graves de hemorragia vaginal, com completo controle do sangramento. O hCG atingiu valor negativo após o terceiro ciclo, havendo regressão completa da vascularização uterina anômala, assim como recuperação da anatomia uterina. O tratamento em um centro de referência permitiu o manejo adequado, principalmente no que se refere à embolização das artérias uterinas através da punção percutânea da artéria femoral, que foi crucial para evitar a histerectomia, permitindo a cura da NTG e a manutenção da vida reprodutiva.

Immunohistochemical expression of heparanases 1 and 2 in benign tissue and in invasive neoplasia of the endometrium: a case-control study.

OBJECTIVES: Our purpose was to compare the expression of heparanase isoforms, in normal and in neoplastic endometrium. In a pioneering way, we sought to evaluate the expression of heparanase 1 (HPSE1) and heparanase 2 (HPSE2) in glandular and in stromal tissues. METHODS: This is a case-control study, conducted retrospectively in a public hospital, using paraffin blocks of endometrial tissue from patients admitted from 2002 to 2011 with and without endometrial cancer, with regard to the immunohistochemical expression of HPSE1 and HPSE2. The paraffin blocks were used for tissue microarray analysis and immunohistochemistry study in glandular and stromal tissues. RESULTS: In the study period, 195 participants were enrolled, 75 with and 120 without cancer. There was no significant difference between them regarding HPSE1 expression, both in gland and in stromal tissues. Heparanase 1 expression in the glandular tissue was more frequent among those with high-grade carcinoma, compared with patients with carcinoma type I. The difference in the expression of HPSE2 was significant between groups: it was less frequent in the controls than in the patients with cancer in the glandular tissue. In the stromal tissue, HPSE2 expression was significantly higher in the controls than in the patients with cancer and different when patients of the secretory endometrium subgroup were compared with those with hypotrophic, proliferative endometriums or with architectural disorders. No significant difference was found in the heparanase expressions in patients with cancer according to prognosis factors. CONCLUSIONS: Heparanase 1 is more intensely expressed in the glandular tissue of high-grade compared with type I carcinomas. Heparanase 2 is more intensely expressed in the glandular tissue of cancer than in nonneoplastic endometrium, whereas the HPSE2 expression in the stromal tissue is higher in the nonneoplastic controls compared with the group of patients with cancer mainly in the secretory endometrium. This suggests that HPSE2 might be stimulated by progesterone, with a possible antineoplastic role, antagonist to HPSE1, to be further investigated.

Indicações e complicações da exenteração pélvica no câncer ginecológico / Indications and complications of pelvic exenteration in gynecological cancer

Exenteração pélvica é o tratamento cirúrgico radical para diferentes neoplasias pélvicas malignas. Consiste na retirada de todos os órgãos comprometidos pelo câncer, incluindo margens livres de doença. Recidivas ou persistências de tumor maligno na pelve após tratamento radioquimioterápico são a principal indicação, mas pode também ser o tratamento primário do câncer ginecológico localmente avançado. O procedimento apresenta mortalidade perioperatória de 5 a 10% e morbidade média de 50%. As complicações mais relatadas são fístulas intestinais e urinárias, infecções de sítio cirúrgico e fenômenos tromboembólicos. A sobrevida em 5 anos varia de 30 a 70%, com média de 50% nas maiores séries. Os critérios prognósticos mais importantes são, além da ressecção total ?R0? do tumor com margens cirúrgicas livres, a presença de metástases linfonodais, sobretudo extrapélvicas, e o comprometimento de parede pélvica lateral. Idade e índice de massa corpórea não devem ser considerados como fatores de risco isolados. A exenteração pélvica com intuito paliativo, apesar de indicação ainda discutível, pode ser considerada para alívio da sintomatologia local e consequente melhora na qualidade de vida. Portanto, quando realizada em pacientes cuidadosamente selecionadas, em instituições oncológicas com suporte multidisciplinar, pode oferecer controle da neoplasia pélvica em longo prazo.(AU)

Pelvic exenteration is a radical surgical treatment indicated as the treatment various malignant pelvic neoplasms. It consists of the removal of all organs affected by cancer, including diseasefree margins. treatment are the main indications, but it can also be the primary treatment of locally advanced gynecologic cancer. The procedure presents perioperative mortality of 5 to 10% and an average morbidity of 50%. The most commonly reported complications are intestinal and urinary fistulas, surgical site infections and thromboembolic phenomena. The 5-year survival ranges from 30 to 70%, averaging 50% in the larger series. The most important prognostic criteria are, in addition to the total ?R0? resection of the tumor with free surgical margins, the presence of lymph node metastases, especially extrapelvic, and the affection of the lateral pelvic wall. Age and body mass index should not be considered as isolated risk factors. Pelvic exenteration with palliative intent, although still a debatable indication, may be considered for relief of local symptoms and consequent improvement in quality of life. Therefore, when performed in carefully selected patients in oncological institutions with multidisciplinary support, it can provide the control of pelvic neoplasm in the long term.(AU)

Aspectos de imagem das lesões vulvo-vaginais / Imaging of the vagina and vulva

Na pratica ginecológica diária, a vulva e a vagina são examinadas durante inspeção visual, entretanto, há situações em que isso não é possível ou que se necessita determinar a extensão de umalesão através de métodos de imagem. A ressonância magnética é um método excelente e cada vez é mais indicado na avaliação de alterações da vulva e vagina, em virtude da sua capacidade deavaliação multiplanar e alto contraste tecidual, fornecendo informações que auxiliam o ginecologista. Outros métodos de imagem que podem ser indicados são a ultra-sonografia e a tomografia computadorizada da pelve. Este trabalho pretende, de forma sintética, analisar as principais alterações vulvo-vaginais que podem ser identificadas e diagnosticadas pelo radiologista.

In gynecological daily practices, the vulva and vagina are examined during physical examination, however there are situations where this is not possible or it is needed to determine the extension of an injury through imaging methods. The magnetic resonanceimaging is an excellent cross-sectional modality for evaluation the alterations of vulva and vagina due its multiplanar evaluation and high tecidual contrast. Other cross-sectional modalities are ultrasound and enhanced computed tomography. This paper intends togive an overview of vaginal and vulvar pathology that can be identifiedby the radiologist.