Pluvio J. Coronado

Comparison of perioperative outcomes and cost of robotic-assisted laparoscopy, laparoscopy and laparotomy for endometrial cancer

OBJECTIVE To analyze the perioperative outcomes and cost of three surgical approaches in the treatment of endometrial cancer: robotic, laparoscopy and laparotomy. STUDY DESIGN We studied 347 patients with endometrial cancer treated in a single institution: 71 patients were operated by robotics, 84 by conventional laparoscopy and 192 by laparotomy. All patients underwent total hysterectomy, bilateral salpingoophorectomy and pelvic and para-aortic lymphadenectomy depending on the pathological features. RESULTS Operative time was longer in the laparoscopy group as compared to robotics and laparotomy (218.2 min, 189.2 min, and 157.4 min respectively, p=0.000). The estimated blood loss was lower in the robotic group relative to the other groups (99.4 ml in robotic, 190.0 ml in laparoscopy and 231.5 ml in laparotomy, p=0.000). Similar findings were observed for the pre- and post-operative mean hemoglobin levels (-1.3g/dl, -2.3g/dl and -2.5 g/dl respectively, p=0.000), and transfusion rate (4.2%, 7.1% and 14.1% respectively, p=0.036). The length of hospital stay was higher in the laparotomy group compared to robotics and laparoscopy (8.1, 3.5 and 4.6 days respectively; p=0.000). The conversion rate to laparotomy was lower for robotics (2.4% for robotics and 8.1% for laparoscopy, p=0.181). Overall complications were similar for robotics and laparoscopy (21.1%, 28.5%) (p=0.079). Robotic complications were significantly lower as compared to laparotomy (21.2 vs 34.9% (p=0.036). No differences were found relative to disease-free or overall survival among the three groups. The global costs were similar for the three approaches (p=0.566). CONCLUSION Robotics is a safe alternative to laparoscopy and laparotomy for endometrial cancer patients, offering improved perioperative outcomes and similar cost as compared to the other two surgical approaches.

P53 overexpression predicts endometrial carcinoma recurrence better than HER-2/neu overexpression

OBJECTIVE to investigate the prognostic value of p53 and HER-2/neu overexpression in endometrial cancer. STUDY DESIGN p53 and HER-2/neu immunostaining was performed in 114 paraffin-embedded specimens of endometrial cancer diagnosed and treated between 1990 and 1997. Nuclear p53 and membrane HER-2/neu immunostaining were used. RESULTS p53 and HER-2/neu overexpression was observed in 17 cases (14.9%) and in 19 cases (16.7%), respectively. In univariate analysis p53 (P<0.001) and HER-2/neu (P=0.018) overexpression had a positive correlation with a high risk of recurrence. In multivariate analysis, age (P<0.001), FIGO stage (P<0.001), differentiation (P=0.013), non-endometrioid subtypes (P<0.001) and p53 overexpression (P<0.001), but not HER-2/neu overexpression, were independent prognostic indicators of recurrence. Simultaneous p53 and HER-2/neu overexpression made worse the prognostic (P<0.001). CONCLUSIONS p53 overexpression was an independent predictor of recurrent disease in endometrial cancer. HER-2/neu overexpression had a more limited effect but enhance the effect of p53.

Quality of life of advanced ovarian cancer patients in the randomized phase III study comparing primary debulking surgery versus neo-adjuvant chemotherapy

OBJECTIVE The EORTC 55971 trial compared primary debulking surgery (PDS) versus neo-adjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). The impact of both treatment arms on quality of life (QOL) is reported. METHODS Patients with stages IIIc or IV ovarian cancer completed the EORTC QLQ-C30 before treatment, at the third and sixth cycle of chemotherapy, and at 6- and 12-month follow-up. RESULTS Data of 404 patients (N=201 PDS arm; N=203 IDS arm) were included in the QOL analysis. Between treatment arms no statistically significant differences were found in any of the QOL functioning scales. Patients showed a clinically relevant improvement (>10 points) on the global health/QOL, role functioning, emotional functioning and social functioning scales during and after treatment independent of the type of treatment. Clinically relevant differences from baseline to the follow-up assessments were noted for fatigue, pain, insomnia, appetite loss, constipation, diarrhea indicating symptom control in both treatment arms. Institutions with good QOL compliance were associated with better outcomes. There was a statistical significant difference in the overall debulking status with 39.9% optimal debulking surgery in institutions with good QOL compliance compared to 19.9% in institutions with poor QOL compliance (p=0.0011). Overall survival (median 32.30 versus 23.29 months; p=0.0006) and progression free survival (median 12.35 versus 9.92 months; p=0.0002) were also significantly better. CONCLUSIONS Survival and QOL after NACT followed by surgery was similar to survival and QOL after PDS followed by chemotherapy. However, institutions with good QOL compliance had better survival outcomes.

2013 Up-date of the consensus statement of the Spanish Menopause Society on postmenopausal osteoporosis.

Postmenopausal osteoporosis is a major female health problem that increases morbidity, mortality and healthcare system costs. Considering that gynecologists are the primary health practitioners involved in the treatment of women with osteoporosis in our country, a panel of experts from the Spanish Menopause Society met to establish a set of criteria and procedures for the diagnosis and treatment of this disease based on the best available evidence and according to the model proposed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to elaborate clinical practice guidelines and to classify the quality of the evidence and the strength of the recommendations. These recommendations should be a reference to gynecologist and other health professionals involved in the treatment of postmenopausal women.

Comparison of perioperative outcomes and cost between robotic-assisted and conventional laparoscopy for transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL).

STUDY OBJECTIVE To compare perioperative outcomes and cost of robotic-assisted and laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL) for treatment of gynecologic malignant conditions. DESIGN Prospective non-randomized study (Canadian Task Force classification II-2). SETTING Tertiary center for womens health. PATIENTS Sixty-two patients with gynecologic cancer operated on by the same surgical team. INTERVENTIONS Thirty-two patients underwent TIPAL via robotic-assisted laparoscopy, and 30 via conventional laparoscopy. Comparison analyses of perioperative outcomes and estimated costs were performed. MEASUREMENTS AND MAIN RESULTS There were no differences between robotic-assisted and laparoscopy insofar as age, body mass index, presurgical morbidity, operating time (92.5 minutes for robotics vs 96.6 minutes for laparoscopy), number of aortic nodes (12 vs. 12), hospitalization stay (2 vs. 2 days), or rate of complications (12.5% vs. 13.3%). Blood loss tended to be lower in the robotic group (75.0 vs. 92.5 mL; p = .08). Surgical cost was higher in the robotic group (

Impact of the lymphadenectomy in high-risk histologic types of endometrial cancer: a matched-pair study.

3.42 vs.

Correlating the Accuracy of Colposcopy with Practitioner Experience when Diagnosing Cervical Pathology Using the Dynamic Spectral Imaging System

2.55; p < .001), although hospitalization cost was similar. CONCLUSION Robotic-assisted and laparoscopy provide similar perioperative outcomes. However, the robotic-assisted approach is associated with higher surgical cost.

Colposcopy combined with dynamic spectral imaging. A prospective clinical study

Objective The aim of this study is to assess the impact of lymphadenectomy (LND) on morbidity, survival, and cost for high-risk histologic types of endometrial cancer (EC). Materials and Methods We analyzed a multicenter retrospective cohort of 389 women with high-risk histotypes of EC (poor differenced tumors [G3], clear cell, serous papillary, and mixed mesodermal tumors) preoperatively confined to the corpus and diagnosed between 2000 and 2013. All patients underwent hysterectomy and bilateral salpingo-oophorectomy. A matched-pair analysis identified 97 pairs (97 with LDN and 97 without) equal in age, body mass index, comorbidities, International Federation of Gynecology and Obstetrics stage, and adjuvant treatment. Demographic data, pathologic examination results, perioperative morbidity, and survival were abstracted from medical records. Cost was provided by the cost unit of the local hospital. Disease-free and overall survival were analyzed using the Kaplan-Meier curves and Cox multivariable regression analysis. Results Both study groups were homogeneous in demographic data and pathologic examination results. At a median follow-up of 24.5 months (range, 5.4–146.3), disease-free survival (hazard ratio, 1.09; 95% confidence interval, 0.70–1.90) and overall survival (hazard ratio, 0.86; 95% confidence interval, 0.56–1.33) were similar in both groups regardless of nodal count. Positive nodes were found in 23.7%. Predictor factors of nodal involvement were advanced age (P = 0.024), deep myometrial invasion (P < 0.001), and high CA 125 levels (P = 0.003). In the LDN group, operating time, late postoperative complications, and surgical cost were higher (P < 0.05). There were no statistical differences between both groups relative to surgical morbidity. Early postoperative complications and hospital stay were lower in the LDN group. The global cost was similar for both groups (6027€ for the LND group and 5772€ for the no-LND group). Conclusions Lymphadenectomy in high-risk histotypes of EC does not increase perioperative morbidity or global cost and has not benefit on survival.

Influence of gravidity and foetal gender on the value of screening variables in the first trimester of pregnancy.

Background/Aims: To assess the performance of colposcopists and correlate it with their experience when diagnosing cervical pathology by reviewing conventional colposcopy (CC) digital images and the Dynamic Spectral Imaging System (DySIS) cervical map. Methods: Images from 50 women with normal and abnormal cervix collected during CC and the corresponding DySIS maps were projected consecutively to 63 participating colposcopists. Participants were asked for their diagnosis (normal, abnormal findings or cancer). The clinical experience of the participants was divided into low (n = 27), medium (n = 18) and high (n = 18), considering the number of colposcopies each one performed routinely. Results: The mean of overall correct diagnoses was significantly higher with DySIS than CC for the low and medium experience group (20.4 vs. 24.4, and 21.9 vs. 26.0, respectively; p < 0.001), but not in the high experience group. The correct diagnosis was significantly higher with DySIS than CC for all experience groups in cases with a normal cervix and cervical intraepithelial neoplasia 2+ (CIN2+), but not for those with CIN1. All groups agreed that DySIS guides biopsies better, offers more information and allows performing colposcopy even without extensive experience. Conclusions: The results of evaluating projected colposcopy images were more successful with DySIS than with CC in the diagnosis of cervical pathology, especially among less experienced colposcopists.

Platinum-based adjuvant chemotherapy on moderate- and high-risk stage I and II epithelian ovarian cancer patients. Long-term single institution experience and literature review

OBJECTIVE To analyze the value of dynamic spectral imaging (DSI) compared to, and as an adjunct to, conventional colposcopy (CC) in the diagnosis of cervical intraepithelial neoplasia (CIN). STUDY DESIGN Four hundred seventy-nine women referred for colposcopy after an abnormal Pap-smear (≥ASC-US) to the Low Genital Tract Unit of the San Carlos Clinical Hospital in Madrid, Spain during the years 2012-2014 were examined simultaneously by CC and DSI. Thirty-six cases (8.1%) were excluded because the DSI map was not calculated. The gold standard for comparisons was the final histological diagnosis performed by punch biopsy or LEEP. RESULTS Out of the 443 cases, 293 were found to be negative for CIN, 109 had CIN1 and 41 were found with CIN2+. The sensitivity of CC to detect those with CIN2+ lesions was 73.2% and the specificity 92.3%. Using the DSI map as an adjunct, led to a statistically significant increase of the sensitivity to 87.8% with a concomitant drop in specificity to 85.6%. The adjunctive use of DSI increased the sensitivity for CIN2+ also in the high-risk group of the 65 cases with an identified HPV16/18 infection; CC had a sensitivity of 88.9%, which increased to 100%. The specificity dropped from 91.1% to 87.5%. CONCLUSIONS Combining conventional colposcopy with DSI mapping improves the capability to detect cervical lesions.