Sérgio A. Triginelli

Phase 2 trial of erlotinib combined with cisplatin and radiotherapy in patients with locally advanced cervical cancer

Cisplatin‐based chemoradiation (CRT) is the standard treatment for patients with locally advanced cervical cancer. Epidermal growth factor receptor (EGFR) is frequently overexpressed in cervical cancer, and EGFR inhibition itself has antitumor effects and potentiates CRT. Results of a previous phase 1 trial of the EGFR inhibitor erlotinib combined with cisplatin‐based CRT (E + CRT) recommended a phase 2 erlotinib dose of 150 mg/day.

Clinicopathological features influencing pelvic lymph node metastasis and vaginal and parametrial involvement in patients with carcinoma of the cervix

Purpose: This study was undertaken to evaluate clinical and pathologic findings that predicted pelvic lymph node metastasis and parametrial and vaginal involvement in patients with stage IB carcinoma of the cervix. Methods: 71 patients with diagnosis of stage IB (FIGO) cervical cancer were prospectively studied from December 1997 to August 2002. The patient’s age, clinical stage (IB1 or IB2), histological classification, grade of differentiation, tumor volume, and lymphatic vascular space invasion (LVSI) were evaluated. Statistical methods included χ2 test and Fisher’s exact test to evaluate significant differences between the groups. The level of significance was set at p < 0.05. Results: The clinical stage was IB1 in 51 patients (71.8%) and IB2 in 20 patients (28.2%). The histological classification identified squamous cell carcinoma in 60 patients (84.5%) and adenocarcinoma in 11 patients (15.5%). The average tumoral volume was 22.8 ± 24.3 cm3 (0.3–140.0 cm3). The tumor was well differentiated (G1) in 8 (11.3%), moderately differentiated (G2) in 40 (56.3%) and poorly differentiated in 23 (32.4%) of the cases. The presence of LVSI was detected in 14 patients (19.7%) and was associated with pelvic lymph node metastasis and vaginal and parametrial involvement (p = 0.002, p = 0.001 and p < 0.001; respectively). The average number of positive pelvic lymph nodes was significantly higher in the patients with LVSI compared with patients without LVSI (2.47 ± 2.8 vs. 0.33 ± 0.74; p = 0.001). There was no association of age, clinical stage, histological classification, grade of differentiation or tumor volume with pelvic lymph node metastasis and vaginal and parametrial involvement. Conclusion: The presence of LVSI is significantly associated with pelvic lymph node metastasis and vaginal and parametrial involvement in patients with stage IB cervical carcinoma.

Uncommon complications of sacrospinous fixation for treatment of vaginal vault prolapse

ObjectiveThe present study was undertaken to evaluate uncommon complications following transvaginal sacrospinous colpopexy for treatment of vaginal vault prolapse.Case reportsA series of three patients who developed uncommon complications following sacrospinous fixation are reported. A 64-year-old patient undergoing bilateral sacrospinous colpopexy for the treatment of an ICS stage III vaginal vault prolapse developed a perineal necrotizing infection. Another patient, a 69-year-old woman with total vaginal vault prolapse and anterior vaginal wall defect (ICS stage II), underwent a right transvaginal sacrospinous colpopexy and anterior repair, presenting postoperatively with a perineal hernia. The third case consisted of a 71-year-old woman who underwent a right sacrospinous colpopexy with paravaginal repair, rectocele repair, and perineorrhaphy for treatment of an ICS stage III post-hysterectomy vaginal vault prolapse, stage II cystocele secondary to a bilateral paravaginal defect, and a stage II rectocele. Six months later the patient developed a left lateral enterocele, which was successfully repaired with a left sacrospinous ligament fixation.Discussion Etiological factors and treatment considerations for these uncommon complications of sacrospinous colpopexy are discussed in detail, and prophylactic measures, when applicable, are emphasized.

Pubovaginal sling in the treatment of stress urinary incontinence for urethral hypermobility and intrinsic sphincteric deficiency

PURPOSE This study was undertaken to evaluate the use of pubovaginal sling for the treatment of female stress urinary incontinence in patients with intrinsic sphincteric deficiency and patients with urethral hypermobility. MATERIALS AND METHODS Sixty-two patients aging 22 to 73 years-old (mean = 49.6) with a median parity of 4.1 (range 0 - 14) who underwent pubovaginal autologous fascial sling procedures for stress urinary incontinence from August/1999 to August/2002 were prospectively analyzed. Objective pre and postoperative urodynamic evaluation was performed in all cases. The patients were divided into 2 groups: thirty-nine patients (62.9%) with urethral hypermobility (Valsalva leak point pressure equal or superior to 60 cm of H(2)O) and twenty-three patients (37.1%) with intrinsic sphincteric insufficiency (Valsalva leak point pressure below 60 cm of H(2)O). RESULTS The average follow-up period was 24.8 months, ranging from 3 to 38 months. Three patients (4.8%) had detrusor overactivity before the operation, and 36 patients (58.1%) had voiding dysfunction before surgery. The postoperative objective cure rate was 88.7% for stress urinary incontinence. The study also showed that 32.2% of the patients had voiding dysfunction and 11.3% had detrusor overactivity. The mean hospital stay was 3.1 days (range 2 - 4). No difference in the above parameters was noticed between patients with intrinsic sphincteric deficiency and those with urethral hypermobility. CONCLUSION Construction of a pubovaginal sling is an effective technique for the relief of severe stress urinary incontinence, for both patients with urethral hipermobility and with intrinsic sphincteric deficiency, having a cure rate of 88.7%. The high frequency of postoperative voiding urgency was not related to the detrusor overactivity as evaluated by urodynamic studies.

Associação entre a expressão das proteínas p53 e Ki-67 e os achados clínico-patológicos em pacientes com carcinoma invasor do colo uterino

PURPOSE: to evaluate the association between p53 and Ki-67 expression in the tumor and clinicopathological features in patients with carcinoma of the cervix. METHODS: samples were taken from the tumor of 36 patients with stage IB (FIGO) cervical carcinoma submitted to radical hysterectomy. Tissue samples were taken from the tumor, fixed in formalin and embedded in paraffin. The specimens were analyzed by histopathology (hematoxylin and eosin) and immunohistochemically evaluated using monoclonal antibodies for p53 and Ki-67. Data were analyzed statistically by the c2 test to evaluate eventual differences between the groups. RESULTS: the age of the patients ranged from 27 to 73 years (48.7±10.4 years). Clinical stage (FIGO) was IB1 in 27 cases (75%) and IB2 in 9 cases (25%). A positive tumoral expression of the p53 protein was found in half of the cases. In relation to the Ki-67 expression, a high cell proliferation index was shown in 73.3% of the cases. There was no association between tumoral p53 and Ki-67 expression with age (p=0.091 and 0.900), clinical stage (p=0.054 and 0.667), histological classification (p=0.674 and 0.674), grade of differentiation (p=0.070 and 0.282), presence of lymphatic vascular space invasion (p=0.248 and 0.667), parametrial involvement (p=0.729 and 0.763) and pelvic lymph node metastasis (p=0.729 and 0.636, respectively). CONCLUSIONS: tumoral expression of p53 and Ki-67 was not associated with the clinicopathological features in patients with stage IB carcinoma of the cervix.

Cirurgia não ginecológica em pacientes com câncer de ovário

OBJECTIVE: to evaluate the incidence of non-gynecological surgical procedures used in the treatment of ovarian cancer, as well to describe their complications. METHODS: eighty-two patients with ages from 22 to 89 (mean = 54.1 ± 15.1 years), submitted to laparotomy for surgical treatment of ovarian cancer from February 1999 to October 2003 were retrospectively evaluated. This study included only patients with epithelial ovary carcinoma. The patients were divided into 2 groups, patients submitted exclusively to gynecological procedures and patients submitted to non-gynecological procedures. Statistical analysis was made with the Students t-test or the chi-square test. RESULTS: 5 patients (6.1%) were in stage (FIGO) I, 18 (21.9%) in stage II, 40 (48.8%) in stage III, and 19 (23.2%) in stage IV. Non-gynecological procedures were done in 35 cases (42.7%), including: 17 colostomies, 16 enterectomies, 8 peritonectomies, 7 colectomies, 5 partial diaphragm resections, 4 partial cystectomies, 4 splenectomies, 2 ileostomies, and 1 hepatectomy. All patients submitted to non-gynecological procedures were included in stages III and IV. This group of patients underwent longer-lasting surgeries (5.3 ± 1.4 versus 3.1 + 0,0 h; p < 0.001). There was no significant difference between these two groups regarding hemotransfusion requirement (42,2 versus 40%; p = 0.512) and hospitalization time (11.5 ± 7.2 versus 10 ± 9.9 days; p = 0.454). Patients submitted to non-gynecological surgeries developed higher rates of postoperative complications (37 versus 17.1%; p = 0.042), and two of them (2.4%) died. CONCLUSION: non-gynecological surgical procedures are frequently used in the treatment of patients with ovarian cancer. These procedures are associated with a longer-lasting surgery and higher rates of postoperative complications.

Quality of life and mental health in Brazilian women treated for invasive carcinoma of the cervix.

Objective The objective of this study was to compare the quality of life (QOL) and mental health (MH) of women surviving at least 2 years after treatment for invasive carcinoma of the cervix by radical hysterectomy (RH), chemotherapy and/or radiotherapy, or by surgery followed by adjuvant therapy (RH + chemotherapy and/or radiotherapy). The QOL/MH of a control group of women with no history of malignancy was also assessed for comparison with the treated groups. Methods The levels of QOL and MH were assessed in 114 Brazilian women (57 patients with an average of 4 years since treatment completion and 57 control subjects). The 36-item Medical Outcomes Study Short-Form Health Survey, the State-Trait Anxiety Inventory, the 12-item General Health Questionnaire, the Life Events Inventory, and a general survey for the assessment of sociodemographic data were applied to each participant of the study. Results No differences were noted among the 3 treatment groups or between these and the control group concerning the levels of QOL (either physical or MH aspects), anxiety, general health, or life events. However, lower levels of anxiety were detected in cancer survivors when compared with the control group (P = 0.035). Conclusions After at least 2 years, the QOL and the MH of Brazilian women treated for invasive carcinoma of the cervix were similar to those of women without malignancy and were not affected by the modality of treatment.

Repercussões hemodinâmicas do posicionamento em litotomia exagerada para histerectomia vaginal em paciente cardiopata: relato de caso

JUSTIFICATIVA E OBJETIVOS: A tecnica de histerectomia vaginal possibilita menor tempo operatorio e o uso do bloqueio do neuro-eixo, com os beneficios de melhor analgesia pos-operatoria e menor resposta sistemica ao procedimento cirurgico. O objetivo deste relato foi descrever as alteracoes hemodinâmicas decorrentes do posicionamento em litotomia exagerada em paciente cardiopata. RELATO DO CASO: Paciente de 33 anos, G0P0A0, com historia de sangramento uterino anormal e anemia. A ultra-sonografia evidenciava utero miomatoso com volume estimado de 420 cm3. Ela era portadora de trombofilia e miocardiopatia dilatada, com passado de dois acidentes vasculares encefalicos isquemicos e dois infartos agudos do miocardio. Foi monitorizada com pressao arterial invasiva e cateter de arteria pulmonar com medida de debito cardiaco continuo. Realizada raquianestesia com bupivacaina hiperbarica e morfina. A paciente foi posicionada em litotomia exagerada sendo realizada histerectomia total pela tecnica de Heaney e salpingectomia bilateral. Como intercorrencia intra-operatoria apresentou diminuicao do indice cardiaco e aumento das pressoes de câmaras direitas apos o posicionamento, necessitando do uso de dobutamina. CONCLUSOES: O posicionamento em litotomia exagerada pode ocasionar alteracoes hemodinâmicas que devem ser consideradas na escolha da tecnica cirurgica.BACKGROUND AND OBJECTIVES Vaginal hysterectomy shortens surgery duration and may be performed with neuraxial block, which promotes better postoperative analgesia and lower systemic response to surgical procedure. This report aimed at describing hemodynamic changes promoted by exaggerated lithotomy position in cardiac patient. CASE REPORT Female patient, 33 years old, with history of abnormal uterine bleeding and anemia. Ultrasound revealed myomas of approximately 420 cm(3). Patient had thrombophilia and dilated cardiomyopathy, with history of two ischemic strokes and two acute myocardial infarction. Monitoring consisted of invasive blood pressure and pulmonary artery catheter for continuous cardiac output measurement. Spinal anesthesia was performed with hyperbaric bupivacaine and morphine. Patient was placed in exaggerated lithotomy position being total hysterectomy performed by the Heaney technique and bilateral salpingectomy. Intraoperative intercurrences were post-positioning decreased cardiac output and increased right chambers pressure requiring dobutamine. CONCLUSIONS Exaggerated lithotomy position may promote hemodynamic changes which should be considered when choosing the surgical technique.

[Hemodynamic repercussions of exaggerated lithotomy position for vaginal hysterectomy in cardiac patient: case report.].

JUSTIFICATIVA E OBJETIVOS: A tecnica de histerectomia vaginal possibilita menor tempo operatorio e o uso do bloqueio do neuro-eixo, com os beneficios de melhor analgesia pos-operatoria e menor resposta sistemica ao procedimento cirurgico. O objetivo deste relato foi descrever as alteracoes hemodinâmicas decorrentes do posicionamento em litotomia exagerada em paciente cardiopata. RELATO DO CASO: Paciente de 33 anos, G0P0A0, com historia de sangramento uterino anormal e anemia. A ultra-sonografia evidenciava utero miomatoso com volume estimado de 420 cm3. Ela era portadora de trombofilia e miocardiopatia dilatada, com passado de dois acidentes vasculares encefalicos isquemicos e dois infartos agudos do miocardio. Foi monitorizada com pressao arterial invasiva e cateter de arteria pulmonar com medida de debito cardiaco continuo. Realizada raquianestesia com bupivacaina hiperbarica e morfina. A paciente foi posicionada em litotomia exagerada sendo realizada histerectomia total pela tecnica de Heaney e salpingectomia bilateral. Como intercorrencia intra-operatoria apresentou diminuicao do indice cardiaco e aumento das pressoes de câmaras direitas apos o posicionamento, necessitando do uso de dobutamina. CONCLUSOES: O posicionamento em litotomia exagerada pode ocasionar alteracoes hemodinâmicas que devem ser consideradas na escolha da tecnica cirurgica.BACKGROUND AND OBJECTIVES Vaginal hysterectomy shortens surgery duration and may be performed with neuraxial block, which promotes better postoperative analgesia and lower systemic response to surgical procedure. This report aimed at describing hemodynamic changes promoted by exaggerated lithotomy position in cardiac patient. CASE REPORT Female patient, 33 years old, with history of abnormal uterine bleeding and anemia. Ultrasound revealed myomas of approximately 420 cm(3). Patient had thrombophilia and dilated cardiomyopathy, with history of two ischemic strokes and two acute myocardial infarction. Monitoring consisted of invasive blood pressure and pulmonary artery catheter for continuous cardiac output measurement. Spinal anesthesia was performed with hyperbaric bupivacaine and morphine. Patient was placed in exaggerated lithotomy position being total hysterectomy performed by the Heaney technique and bilateral salpingectomy. Intraoperative intercurrences were post-positioning decreased cardiac output and increased right chambers pressure requiring dobutamine. CONCLUSIONS Exaggerated lithotomy position may promote hemodynamic changes which should be considered when choosing the surgical technique.

Repercusiones hemodinámicas de la posición de litotomía exagerada para histerectomía vaginal en una paciente con cardiopatía: relato del caso

JUSTIFICATIVA E OBJETIVOS: A tecnica de histerectomia vaginal possibilita menor tempo operatorio e o uso do bloqueio do neuro-eixo, com os beneficios de melhor analgesia pos-operatoria e menor resposta sistemica ao procedimento cirurgico. O objetivo deste relato foi descrever as alteracoes hemodinâmicas decorrentes do posicionamento em litotomia exagerada em paciente cardiopata. RELATO DO CASO: Paciente de 33 anos, G0P0A0, com historia de sangramento uterino anormal e anemia. A ultra-sonografia evidenciava utero miomatoso com volume estimado de 420 cm3. Ela era portadora de trombofilia e miocardiopatia dilatada, com passado de dois acidentes vasculares encefalicos isquemicos e dois infartos agudos do miocardio. Foi monitorizada com pressao arterial invasiva e cateter de arteria pulmonar com medida de debito cardiaco continuo. Realizada raquianestesia com bupivacaina hiperbarica e morfina. A paciente foi posicionada em litotomia exagerada sendo realizada histerectomia total pela tecnica de Heaney e salpingectomia bilateral. Como intercorrencia intra-operatoria apresentou diminuicao do indice cardiaco e aumento das pressoes de câmaras direitas apos o posicionamento, necessitando do uso de dobutamina. CONCLUSOES: O posicionamento em litotomia exagerada pode ocasionar alteracoes hemodinâmicas que devem ser consideradas na escolha da tecnica cirurgica.BACKGROUND AND OBJECTIVES Vaginal hysterectomy shortens surgery duration and may be performed with neuraxial block, which promotes better postoperative analgesia and lower systemic response to surgical procedure. This report aimed at describing hemodynamic changes promoted by exaggerated lithotomy position in cardiac patient. CASE REPORT Female patient, 33 years old, with history of abnormal uterine bleeding and anemia. Ultrasound revealed myomas of approximately 420 cm(3). Patient had thrombophilia and dilated cardiomyopathy, with history of two ischemic strokes and two acute myocardial infarction. Monitoring consisted of invasive blood pressure and pulmonary artery catheter for continuous cardiac output measurement. Spinal anesthesia was performed with hyperbaric bupivacaine and morphine. Patient was placed in exaggerated lithotomy position being total hysterectomy performed by the Heaney technique and bilateral salpingectomy. Intraoperative intercurrences were post-positioning decreased cardiac output and increased right chambers pressure requiring dobutamine. CONCLUSIONS Exaggerated lithotomy position may promote hemodynamic changes which should be considered when choosing the surgical technique.