Augusto Pereira

International Federation of Gynecology and Obstetrics staging classification for cancer of the ovary, fallopian tube, and peritoneum; Estimation of survival in patients with node-positive epithelial ovarian cancer

Objective The objective of this study was to determine the survival of patients with node-positive epithelial ovarian cancer according to the 2014 International Federation of Gynecology and Obstetrics (FIGO) staging system. Materials and Methods We performed a retrospective chart review. Data from all consecutive patients with node-positive epithelial ovarian cancer (stages IIIC and IV) who underwent cytoreductive surgery at the Mayo Clinic from 1996 to 2000 were reassessed to evaluate the prognostic significance of the new FIGO stages. Multivariate Cox regression was performed, and Kaplan-Meier survival curves constructed. Results The distribution of the restaged patients was as follows: IIIA1, 23 patients (IIIA1i, 9 patients; and IIIA1ii, 14 patients); IIIA2, 3 patients; IIIB, 4; IIIC, 67 patients; IVA, 4 patients; and IVB, 15 patients. In the univariate analysis, the relative risk for positive nodes greater than 10 mm on the longer axis was 2.57 and 3.00 for patients with microscopic peritoneal disease, compared with patients with microscopic positive nodes. However, the difference was not statistically significant. Moreover, the univariate analyses revealed statistically significant differences for 2014 FIGO stages (IIIA, IIIB, IIIC, and IVA-B), anatomical sites of peritoneal metastases, and disease staged at IIIC because of the presence of omental metastases. Multivariate analysis showed that survival was higher in patients restaged to IIIA-B than in those restaged to IIIC and IV (hazard ratios, 2.75 and 3.16, respectively; P = 0.002). The hazard ratio for patients with abdominal peritoneal metastases was 2.76 compared with patients with pelvic peritoneal metastases (P = 0.001). Conclusions The current 2014 FIGO staging system for ovarian cancer successfully correlates survival, anatomical location of peritoneal metastases, and extra-abdominal lymph node metastases.

The role of lymphadenectomy in node-positive epithelial ovarian cancer

Objective To evaluate the therapeutic role of pelvic and aortic lymphadenectomy in patients with epithelial ovarian cancer (EOC) and positive nodes (stages IIIC and IV). Methods Retrospective chart review. Data from all consecutive patients with EOC and positive retroperitoneal lymph nodes (stage IIIC and IV) in Mayo Clinic from 1996 to 2000 were included. To evaluate the impact of nodal metastases, the extent of lymphadenectomy was compared according to the number of nodes removed and positive nodes resected. Multivariable Cox regression and Kaplan-Meier survival curves were used for analysis. Results The median number of nodes removed was 31 (pelvic, 21.5, and aortic, 10), and the median number of positive nodes was 5. The 5-year overall survival was 44.8%. On multivariate analysis, only the extent of peritoneal metastases before surgery was a significant factor for survival (P = 0.001 for stage IIIC and P = 0.004 for stage IV). Analysis of 83 patients with advanced peritoneal disease more than 2 cm demonstrated before debulking, removal of more than 40 lymph nodes was a significant prognostic factor for overall survival (hazard ratio, 0.52; P = 0.032; 95% confidence interval, 0.29–0.35). In 29 patients with advanced peritoneal disease and no residual disease after debulking, removal of more than 10 positive was a factor for survival. Conclusions There was a survival benefit in patients with EOC with advanced peritoneal disease more than 2 cm before debulking when more than 40 lymph nodes were removed. There was an additional survival benefit in those patients with no residual disease after debulking when more than 10 positive nodes were removed.

Intelligent technique to search for patterns within images in massive databases

An image retrieval system for JET has been developed. The image database contains the images of the JET high speed visible camera. The system input is a pattern selected inside an image and the output is the group of frames (defined by their discharge numbers and time slices) that show patterns similar to the selected one. This approach is based on morphological pattern recognition and it should be emphasized that the pattern is found independently of its location in the frame. The technique encodes images into characters and, therefore, it transforms the pattern search into a character-matching problem.

Prospective evaluation of 18-fluoro-2-deoxy-D-glucose positron emission tomography for the discrimination of paraaortic nodal spread in patients with locally advanced cervical carcinoma.

Main Objective Patients with locally advanced cervical cancer (LACC) are usually treated with concurrent chemoradiotherapy. Extended-field chemoradiotherapy is indicated in cases of paraaortic nodal spread. Nowadays, 18-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) is considered to be the most accurate image method of detection of node or distant metastases. The goal of this study was to evaluate the accuracy of FDG-PET for detecting paraaortic lymph node (PALN) spread in patients with LACC. Methods Patients with LACC from 2 tertiary university hospitals in Madrid, Spain, were submitted to a laparoscopic infrarenal PALN dissection after FDG-PET evaluation. Based on pathologic results as gold standard, sensitivity, specificity, and positive and negative predictive values of FDG-PET were calculated thereafter for PALN metastasis. Results A total of 52 patients with LACC fulfilled the inclusion criteria. All of them underwent a laparoscopic infrarenal paraaortic lymphadenectomy. Eighteen patients (34.6%) had pathologically proven PALN metastases. Among them, 4 (12.5%) had negative FDG-PET (false negatives). Furthermore, 2 positive FDG-PET patients were not affected after histologic analysis (11.1% false positives). No complications occurred in our series. Sensitivity, specificity, and positive and negative predictive value of the FDG-PET were 77.7, 94.1, 87.5, and 88.9, respectively, for the detection of PALN metastases. Conclusions The sensitivity and specificity of FDG-PET remains limited, so PALN dissection should be part of the pretherapeutic staging in every patient with LACC before definitive concurrent chemoradiotherapy.

Three-Dimensional Angioultrasonography for the Prediction of Malignancy in Ovarian Masses

Objective: To determine the efficacy of the angiographic indexes of 3D power Doppler angiography (3D-PDA) for the diagnosis of malignancy in complex ovarian masses. Methods: A prospective, observational study of 72 patients with complex adnexal mass. Results: In the morphological study, 3D ultrasound showed sensitivity, specificity, PPV, NPV, PLHR and NLHR of 84.6%, 81.9%, 85.1%, 81.8%, 4.65 and 0.19. No differences in vascular indexes (VI, FI, VFI) between malignant and benign masses were found: VI 5.38 (CI 95% 3.06-7.7) vs. 6.29 (CI 95% 4.41-8.17) (p = 0.53); FI 29.6 (CI 95% 25.17-34.08) vs. 33.8 (CI 95% 30.03-37.3) (p = 0.15); VFI 1.68 (CI 95% 0.94-2.42) vs. 2.37 (CI 95% 1.49-3.25) (p = 0.24). When analysed according to different stages, VI was higher in patients with more advanced stages of disease; 4.34 (95% CI 2.21-6.47) vs. 7.38 (95% CI 4.7-10.06) (p = 0.11). FI was significantly lower in patients with early stages of disease; FI 29.07 (95% CI 21.49-36.68) vs. 36.46 (95% CI 32.31-40.62) (p = 0.04). For VFI, differences were not significant, although there was a strong trend; VFI 1.47 (95% CI 0.67-2.28) vs. 2.86 (95% CI 1.57-4.16) (p = 0.11). 3D-PDA indexes were significantly higher in patients with positive adenopathies. Conclusion: 3D-PDA values increase progressively, but not significantly, with the stage of the disease.

The impact of peritoneal metastases in epithelial ovarian cancer with positive nodes.

Objective: The objective of the study was to evaluate the impact of the extent of intraperitoneal disease, presurgical and postsurgical debulking, in patients with epithelial ovarian cancer (EOC) stages IIIC and IV with nodal metastases. Methods: This was a retrospective chart review of 101 patients with EOC treated at the Mayo Clinic between 1996 and 2000. All patients had positive retroperitoneal lymph nodes (stages IIIC and IV). Patients were divided into complete or incomplete debulking, according to no visible or visible residual disease after debulking. Patients with incomplete debulking were subclassifed into residual disease less than 0.5, 0.6 to 1, 1.1 to 1.5, 1.6 to 2, and more than 2 cm. All patients received adjuvant chemotherapy with platinum-based regimen. Results: The mean patients age was 61.8 years. The mean length of follow-up was 3.5 years. The 5-year overall survival rates were 52.9% and 38.7% for International Federation of Gynecology and Obstetrics stages IIIC and IV, respectively. Significant prognostic factors were the presence of peritoneal metastases before debulking (P = 0.01), the presence of visible residual tumor after debulking, (P = 0.007), and International Federation of Gynecology and Obstetrics stage (P = 0.049). Conclusion: The extent of peritoneal metastases before debulking is a significant factor for survival in patients with node-positive EOC.

Defining the optimal lymphadenectomy cut-off value in epithelial ovarian cancer staging surgery utilizing a mathematical model of validation

OBJECTIVE Since 1985 International Federation of Gynecology and Obstetrics includes pelvic and aortic lymphadenectomy as part of the surgical staging in epithelial ovarian cancer (EOC). There is no consensus on the overall number of nodes needed in a systematic lymphadenectomy. The aim of this study is to calculate the optimal cut-off value using a mathematical modeling approach. METHODS Data was collected retrospectively, from 1996 to 2000, of 120 consecutive Mayo Clinic patients with EOC and positive nodes. All patients was underwent pelvic and/or aortic lymphadnectomy during surgical staging. To mathematically predict the probability of a positive node in EOC patients we used a predictive mathematical model (PMM). The mathematical analysis consisted: creation of a new PMM according to our purposes, application of PMM to describe the experimental data in order to build the polynomial regression curves in each lymphatic area and determine the optimal point for each curve. RESULTS The mean number of lymph nodes and metastatic nodes removed were 35 and 7.8, respectively; the mean percentage of positive nodes was 28.3%. The optimal point of each fitting curves were: 7 nodes for unilateral aortic nodal sampling (at least 3 infrarenal or 5 inframesenteric) and 15 nodes for unilateral pelvic lymphadenectomy (at least 5 external iliac). CONCLUSIONS We can mathematically predict the probability to obtain a positive node in EOC surgical staging. Our results have shown the need to obtain at least 22 lymph nodes between pelvic and aortic lymphadenectomy.

The impact of pelvic retroperitoneal invasion and distant nodal metastases in epithelial ovarian cancer

BACKGROUND The absence of disease after debulking surgery is the most important prognostic factor in the treatment of advanced epithelial ovarian cancer (EOC). Occasionally, the presence of extra-abdominal disease complicates the ability to obtain a complete surgery, considering some locations of the metastatic disease as unresectable. The objective of the study was to estimate the survival impact of pelvic retroperitoneal invasion and extrapelvic and aortic distant nodal metastases in EOC patients. The anatomical landmarks of primary cytoreductive surgery will be discussed. MATERIAL AND METHODS We reviewed data from 116 consecutive Mayo Clinic patients with epithelial ovarian cancer (EOC) stage IIIC and IV, undergoing primary cytoreduction surgery between 1996 and 2000. Univariate and multivariate analysis for patients with positive distant nodes and pelvic retroperitoneal invasion was performed, including 57 patients with no residual disease after surgery. Kaplan-Meier curves were used to estimate the probability of survival. RESULTS The median patients age was 65 years (range 24-87 years). The 5 years overall survival was 44.8% (range 30.1-57.9 months) and the median length of survival was 39.9 months (range 0.13-60 months, 95% confidence interval: 30.1-57.9). Pelvic retroperitoneal invasion was present in 22 EOC patients (18.9%) and distant positive nodes were noted in 11 (9.5%): suprarenal/celiac (5.2%), inguinal (4.3%) and supraclavicular (0.9%). Univariate and multivariate Cox regression analysis, identified distant positive lymph nodes and pelvic retroperitoneal invasion as factors statistically associated with overall survival (p = 0.002 and p = 0.025, respectively). CONCLUSIONS Metastatic distant nodes and pelvic retroperitoneal invasion are independent prognostic factors for survival in patients with advanced EOC.

Correlation between the extent of intraperitoneal disease and nodal metastasis in node-positive ovarian cancer patients

AIMS To investigate correlations between extent of disease (ED), frequency and location of nodal metastases in node-positive EOC patients. METHODS Data were collected from 116 consecutive patients who underwent systematic lymphadenectomy during primary surgery. Patients were grouped in ED1 (disease confined in pelvis), ED2 (disease extended to abdomen), and ED3 (distant metastases). Univariate and multivariate analysis were performed for overall survival and progression-free survival (PFS). RESULTS Correspondence analysis revealed associations between ED1 and negative nodes, ED2 and positive aortic/pelvic nodes, and ED3 and positive external and common iliac nodes. The most representative group for nodal metastases in ED1 was aortic nodes (77.8%). The number of positive pelvic nodes increased with ED; the RR was 0.58 for ED2 and 0.25 for ED3 (p = 0.004). The RR for positive external iliac nodes was 0.66 in ED2 and 0.31 in ED3 (p = 0.002); the RR for positive common iliac nodes was 0.76 and 0.17, respectively (p = 0.001). Multivariate analysis revealed that aortic nodal metastasis was associated with PFS (p = 0.03; HR, 1.95). CONCLUSION Distribution and percentage of nodal metastases varied with ED. The risk of pelvic nodal metastasis, increased with ED. Location of positive nodes was correlated with PFS.

Chronic perineal pain: analyses of prognostic factors in pudendal neuralgia.

Objectives:To establish the prognostic factors and outcomes of patients with pudendal neuralgia (PN). Materials and Methods:A total of 51 patients with PN treated at the Puerta de Hierro University Hospital of Madrid between January 2011 and June 2012 were included in this study. Patients were compared in relation to pain intensity and response to the first-line treatment of neuropathic pain. Univariate and multivariable Cox regression analyses were used. Results:The median for patients’ age, duration, and intensity of pain evaluated by visual analogue scale were 40.9, 3.6, and 7.6 years, respectively. Among 45 patients, there were 19 good responders to first-line treatment for neuropathic pain and 26 nonresponders. The 19 responders measured their improvement at 47%. Tramadol was used for nonresponding patients, 30.8% of whom expressed a 35% improvement. Analysis of 45 patients with PN demonstrated that the pain intensity was associated with dorsal clitoris nerve damage (15.4% vs. 52.2%; P=0.035; odds ratio 4.5; 95% confidence interval [CI], 1.11-18.1) and with sensory deficit at the S2-S4 dermatome map (57.7% vs. 87%; P=0.05; odds ratio 3.7; 95% CI, 0.80-16.8). The pain located at the dorsal clitoris nerve was a significant prognostic factor for having no response to the first-line treatment of neuropathic pain (28% vs. 53%; P=0.033; odds ratio 4.5; 95% CI, 1.06-19.6). Discussion:A mixed analgesic ladder for chronic pain showed improvement in 73% of the patients with PN. Pain restricted to the dorsal clitoris nerve and small fibers in the S2-S4 dermatome were classified as bad prognostic factors. A longer duration of pain was also correlated with a worse prognosis.