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1.
J Gynecol Oncol ; 2024 Jul 30.
Artículo en Inglés | MEDLINE | ID: mdl-39223945

RESUMEN

In this multicenter retrospective cohort study of 99 patients who underwent salvage hysterectomy for residual disease in the uterine cervix following the completion of definitive radiotherapy for cervical cancer across 25 Japan Clinical Oncology Group-affiliated centers from 2005-2014, (i) time duration from the completion of definitive radiotherapy to the diagnosis of residual disease in the uterine cervix, (ii) salvage hysterectomy surgical margin status, and (iii) extent of residual disease, were independently associated with progression-free survival (PFS). Specifically, (i) time duration to identify residual disease of >62 days was associated with decreased PFS compared to ≤62 days (4-year rates 21.8% vs. 55.0%, adjusted-hazard ratio [aHR]=2.69, 95% confidence interval [CI]=1.55-4.67); (ii) presence of tumor in the surgical margin of hysterectomy specimen was associated with 4 times increased risk of disease progression compared to tumor-free surgical margin (4-year PFS rates 0% vs. 45.3%, aHR=4.27, 95% CI=2.20-8.29); and (iii) hazards of disease progression was 4.5-fold increased when the residual disease extended beyond the uterine cervix compared to residual disease within the uterine cervix only (4-year PFS rates 11.1% vs. 50.6%, aHR=4.54, 95% CI=2.60-7.95). In the absence of these 3 prognostic factors, 4-year PFS rate reached nearly 80% (78.6%, SAL-HYS criteria). In sum, these data suggested that early detection of persistent, residual disease following definitive radiotherapy for cervical cancer may be the key to improve survival if salvage hysterectomy is considered as a tailored treatment option. Ideal surgical candidate would be uterine cervix-contained disease and assurance of adequate tumor-free surgical margin.

2.
Int J Gynecol Cancer ; 34(9): 1349-1358, 2024 Sep 02.
Artículo en Inglés | MEDLINE | ID: mdl-39107048

RESUMEN

OBJECTIVE: The objective of this study was to assess the oncologic outcome of surgically-treated patients with early-stage, intermediate-risk cervical cancer according to postoperative therapy modality. METHODS: This retrospective cohort study queried the Japanese Gynecologic Oncology Group's nationwide surgical data platform. The study population was 1084 patients with stage IB cervical cancer who underwent primary radical hysterectomy and lymphadenectomy from 2004 to 2008. Histology type-incorporated intermediate-risk factor patterns were clustered into three groups based on recurrence risk. Oncologic outcomes were assessed per postoperative therapy: external beam radiotherapy alone, concurrent chemo-radiotherapy, chemotherapy alone, and no treatment. RESULTS: Histology-incorporated intermediate-risk groups included: no lympho-vascular space invasion in any histology, or squamous cell carcinoma with lympho-vascular space invasion but no deep stromal invasion (n=559, 51.6%, group 1); squamous cell carcinoma with both lympho-vascular space invasion and deep cervical stromal invasion (n=281, 25.9%; group 2); and non-squamous histology with lympho-vascular space invasion (n=244, 22.5%; group 3). The 5-year disease-free survival rates were 93.3%, 89.3%, and 82.5% for group 1,-2, and -3, respectively (p<0.001), with group 3 exhibiting an almost three-fold increased recurrence risk compared with group 1 (adjusted-hazard ratio (aHR) 2.70, 95% confidence interval (CI) 1.70-4.32), followed by group 2 (aHR 1.67, 95% CI 1.01 to 2.75). Disease-free survival was similar across the postoperative therapy groups: 5 year rates for external beam radiotherapy alone, concurrent chemo-radiotherapy, chemotherapy alone, and no postoperative treatment, 94.8%, 87.2%, 93.6%, and 94.2% for group 1 (p=0.294); 85.0%, 93.3%, 87.3%, and 90.5% for group 2 (p=0.578); and 85.4%, 83.1%, 80.5%, and 83.3% for group 3 (p=0.876). The aHR for disease-free survival comparing no postoperative treatment to external beam radiotherapy alone was 1.10 (95% CI 0.37 to 3.28), 0.71 (95% CI 0.29 to 1.79), and 1.21 (95% CI 0.42 to 3.51) for group 1, group 2, and group 3, respectively. The observed exposure-outcome associations were similar for cause-specific survival (all, p>0.05). CONCLUSION: In this retrospective investigation in Japan, active surveillance without postoperative therapy following radical hysterectomy and lymphadenectomy was not associated with oncologic outcome in early-stage, intermediate-risk cervical cancer.


Asunto(s)
Carcinoma de Células Escamosas , Histerectomía , Estadificación de Neoplasias , Neoplasias del Cuello Uterino , Humanos , Femenino , Neoplasias del Cuello Uterino/patología , Neoplasias del Cuello Uterino/terapia , Estudios Retrospectivos , Persona de Mediana Edad , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/terapia , Carcinoma de Células Escamosas/cirugía , Adulto , Anciano , Escisión del Ganglio Linfático , Estudios de Cohortes , Recurrencia Local de Neoplasia/patología
4.
JAMA Netw Open ; 7(7): e2422634, 2024 Jul 01.
Artículo en Inglés | MEDLINE | ID: mdl-39042408

RESUMEN

Importance: Advancements in assisted reproductive technology (ART) have led to an increase in gestational carrier (GC) pregnancies. However, the perinatal outcomes of GC pregnancies remain understudied, necessitating a deeper understanding of their associated risks. Objective: To assess maternal characteristics and obstetric outcomes associated with GC pregnancies. Data Sources: A comprehensive systematic search of publications published before October 31, 2023, using PubMed, Web of Science, Scopus, and Cochrane Library databases was conducted. Study Selection: Two authors selected studies examining obstetric characteristics and outcomes in GC pregnancies with 24 or more weeks' gestation. Studies with insufficient outcome information, unavailable data on gestational surrogacies, and non-English language studies were excluded. Data Extraction and Synthesis: Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, 2 investigators extracted and synthesized both quantitative and qualitative data. Both fixed-effect and random-effect analysis were used to pool data. Main Outcomes and Measures: The primary outcomes were obstetric characteristics and outcomes, including hypertensive disorders, preterm birth, and low birth weight. Secondary outcomes included severe maternal morbidity and mortality associated with GC pregnancies. Results: Six studies from 2011 to 2023 involving 28 300 GC pregnancies and 1 270 662 non-GC pregnancies were included. GCs accounted for 2.5% of in vitro fertilization cycles (59 502 of 2 374 154 cycles) and 3.8% of ART pregnancies (26 759 of 701 047 ART pregnancies). GC pregnancies were more likely to be conceived by frozen embryo transfer compared with non-GC ART pregnancies (odds ratio [OR], 2.84; 95% CI, 1.56-5.15), and rates of single embryo transfer were similar between the 2 groups (OR, 1.18; 95% CI, 0.94-1.48). GCs were rarely nulliparous (6 of 361 patients [1.7%]) and were more likely to have multifetal pregnancies compared with non-GC ART patients (OR, 1.18; 95% CI, 1.02-1.35). Comparator studies revealed lower odds of cesarean delivery (adjusted OR [aOR], 0.42; 95% CI, 0.27-0.65) and comparable rates of hypertensive disorders (aOR, 0.86; 95% CI, 0.45-1.64), preterm birth (aOR, 0.82; 95% CI, 0.68-1.00), and low birth weight (aOR, 0.79; 95% CI, 0.50-1.26) in GC pregnancies vs non-GC ART pregnancies. Comparatively, GC pregnancies had higher odds of hypertensive disorders (aOR, 1.44; 95% CI, 1.13-1.84) vs general (non-GC ART and non-ART) pregnancies with comparable cesarean delivery risk (aOR, 1.06; 95% CI, 0.90-1.25). Preterm birth and low birth weight data lacked a comparative group using multivariate analysis. Severe maternal morbidity and maternal mortality were rare among GCs. Conclusions and Relevance: In this systematic review and meta-analysis, although GC pregnancies had slightly improved outcomes compared with non-GC ART pregnancies, they posed higher risks than general pregnancies. Contributing factors may include ART procedures and increased rates of multiple gestations which influence adverse perinatal outcomes in GC pregnancies.


Asunto(s)
Resultado del Embarazo , Humanos , Embarazo , Femenino , Resultado del Embarazo/epidemiología , Nacimiento Prematuro/epidemiología , Técnicas Reproductivas Asistidas/estadística & datos numéricos , Madres Sustitutas , Adulto , Recién Nacido
6.
Eur J Obstet Gynecol Reprod Biol ; 299: 1-11, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-38815411

RESUMEN

OBJECTIVE: To examine pregnancy characteristics and maternal morbidity at delivery among pregnant patients with a diagnosis of endometriosis. STUDY DESIGN: This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. Study population was 17,796,365 hospital deliveries from 2016 to 2020, excluded adenomyosis and uterine myoma. The exposure was endometriosis diagnosis. Main outcome measures were clinical and pregnancy characteristics and severe maternal morbidity at delivery related to endometriosis, assessed with multivariable regression model. RESULTS: Endometriosis was diagnosed in 17,590 patients. The prevalence of endometriosis increased by 24 % from one in 1,191 patients in 2016 to one in 853 patients in 2020 (adjusted-odds ratio [aOR] 1.24, 95% confidence interval [CI] 1.19-1.30). Clinical and pregnancy characteristics that had greater than two-fold association to endometriosis included polycystic ovary syndrome, placenta previa, cesarean delivery, maternal age of ≥30 years, prior pregnancy loss, and anxiety disorder. Pregnant patients with endometriosis were more likely to have the diagnosis of measured severe maternal morbidity during the index hospitalization for delivery (47.8 vs 17.3 per 1,000 deliveries, aOR 1.91, 95%CI 1.78-2.06); these associations were more prominent following vaginal (aOR 2.82, 95%CI 2.41-3.30) compared to cesarean (aOR 1.85, 95%CI 1.71-2.00) deliveries. Among the individual morbidity indicators, endometriosis was most strongly associated with thromboembolism (aOR 5.05, 95%CI 3.70-6.91), followed by sepsis (aOR 2.39, 95%CI 1.85-3.09) and hysterectomy (aOR 2.18, 95%CI 1.85-2.56). When stratified for endometriosis anatomical site, odds of thromboembolism was increased in endometriosis at distant site (aOR 9.10, 95%CI 3.76-22.02) and adnexa (aOR 7.37, 95%CI 4.43-12.28); odds of sepsis was most increased in endometriosis at multi-classifier locations (aOR 7.33, 95%CI 2.93-18.31) followed by pelvic peritoneum (aOR 5.54, 95%CI 2.95-10.40); and odds of hysterectomy exceeded three-fold in endometriosis at adnexa (aOR 3.00, 95%CI 2.30-3.90), distant site (aOR 5.36, 95%CI 3.48-8.24), and multi-classifier location (aOR 4.46, 95%CI 2.11-9.41). CONCLUSION: The results of this nationwide analysis suggest that pregnancy with endometriosis is uncommon but gradually increasing over time in the United States. The data also suggest that endometriosis during pregnancy is associated with increased risk of severe maternal morbidity at delivery, especially for thromboembolism, sepsis, and hysterectomy. These morbidity risks differed by the anatomical location of endometriosis.


Asunto(s)
Endometriosis , Complicaciones del Embarazo , Humanos , Femenino , Endometriosis/epidemiología , Embarazo , Adulto , Estudios Transversales , Complicaciones del Embarazo/epidemiología , Estados Unidos/epidemiología , Parto Obstétrico/estadística & datos numéricos , Prevalencia , Adulto Joven
7.
Gynecol Oncol ; 186: 85-93, 2024 07.
Artículo en Inglés | MEDLINE | ID: mdl-38603956

RESUMEN

OBJECTIVE: To assess (i) clinical and pregnancy characteristics, (ii) patterns of surgical procedures, and (iii) surgical morbidity associated with cesarean hysterectomy for placenta accreta spectrum based on the specialty of the attending surgeon. METHODS: The Premier Healthcare Database was queried retrospectively to study patients with placenta accreta spectrum who underwent cesarean delivery and concurrent hysterectomy from 2016 to 2020. Surgical morbidity was assessed with propensity score inverse probability of treatment weighting based on surgeon specialty for hysterectomy: general obstetrician-gynecologists, maternal-fetal medicine specialists, and gynecologic oncologists. RESULTS: A total of 2240 cesarean hysterectomies were studies. The most common surgeon type was general obstetrician-gynecologist (n = 1534, 68.5%), followed by gynecologic oncologist (n = 532, 23.8%) and maternal-fetal medicine specialist (n = 174, 7.8%). Patients in the gynecologic oncologist group had the highest rate of placenta increta or percreta, followed by the maternal-fetal medicine specialist and general obstetrician-gynecologist groups (43.4%, 39.6%, and 30.6%, P < .001). In a propensity score-weighted model, measured surgical morbidity was similar across the three subspecialty groups, including hemorrhage / blood transfusion (59.4-63.7%), bladder injury (18.3-24.0%), ureteral injury (2.2-4.3%), shock (8.6-10.5%), and coagulopathy (3.3-7.4%) (all, P > .05). Among the cesarean hysterectomy performed by gynecologic oncologist, hemorrhage / transfusion rates remained substantial despite additional surgical procedures: tranexamic acid / ureteral stent (60.4%), tranexamic acid / endo-arterial procedure (76.2%), ureteral stent / endo-arterial procedure (51.6%), and all three procedures (55.4%). Tranexamic acid administration with ureteral stent placement was associated with decreased bladder injury (12.8% vs 23.8-32.2%, P < .001). CONCLUSION: These data suggest that patient characteristics and surgical procedures related to cesarean hysterectomy for placenta accreta spectrum differ based on surgeon specialty. Gynecologic oncologists appear to manage more severe forms of placenta accreta spectrum. Regardless of surgeon's specialty, surgical morbidity of cesarean hysterectomy for placenta accreta spectrum is significant.


Asunto(s)
Cesárea , Histerectomía , Placenta Accreta , Humanos , Placenta Accreta/cirugía , Femenino , Histerectomía/efectos adversos , Histerectomía/métodos , Histerectomía/estadística & datos numéricos , Embarazo , Adulto , Estudios Retrospectivos , Cesárea/efectos adversos , Especialidades Quirúrgicas/estadística & datos numéricos , Cirujanos/estadística & datos numéricos
9.
Fertil Steril ; 122(2): 233-242, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-38522502

RESUMEN

OBJECTIVE: To assess national-level trends, characteristics, and outcomes of pregnancies with Turner syndrome in the United States. DESIGN: Cross-sectional study. SETTING: The Healthcare Cost and Utilization Project's National Inpatient Sample. SUBJECTS: A total of 17,865,495 hospital deliveries from 2016-2020. EXPOSURE: A diagnosis of Turner syndrome, identified according to the World Health Organization's International Classification of Disease 10th revision code of Q96. MAIN OUTCOME MEASURES: Obstetrics outcomes related to Turner syndrome, assessed with inverse probability of treatment weighting cohort and multivariable binary logistic regression modeling. RESULTS: The prevalence of pregnant patients with Turner syndrome was 7.0 per 100,000 deliveries (one in 14,235). The number of hospital deliveries with patients who have a diagnosis of Turner syndrome increased from 5.0 to 11.7 per 100,000 deliveries during the study period (adjusted-odds ratio [aOR] for 2020 vs. 2016; 2.18, 95% confidence interval [CI] 1.83-2.60). Pregnant patients with Turner syndrome were more likely to have a diagnosis of pregestational hypertension (4.8% vs. 2.8%; aOR 1.65; 95% CI 1.26-2.15), uterine anomaly (1.6% vs. 0.4%; aOR, 3.01; 95% CI 1.93-4.69), and prior pregnancy losses (1.6% vs. 0.3%; aOR 4.70; 95% CI 3.01-7.32) compared with those without Turner syndrome. For the index obstetric characteristics, Turner syndrome was associated with an increased risk of intrauterine fetal demise (10.9% vs. 0.7%; aOR 8.40; 95% CI 5.30-13.30), intrauterine growth restriction (8.5% vs. 3.5%; aOR 2.11; 95% CI 1.48-2.99), and placenta accreta spectrum (aOR 3.63; 95% CI 1.20-10.97). For delivery outcome, pregnant patients with Turner syndrome were more likely to undergo cesarean delivery (41.6% vs. 32.3%; aOR 1.53; 95% CI 1.26-1.87). Moreover, the odds of periviable delivery (22-25 weeks: 6.1% vs. 0.4%; aOR 5.88; 95% CI 3.47-9.98) and previable delivery (<22 weeks: 3.3% vs. 0.3%; aOR 2.87; 95% CI 1.45-5.69) were increased compared with those without Turner syndrome. CONCLUSIONS: The results of contemporaneous, nationwide assessment in the United States suggest that although pregnancy with Turner syndrome is uncommon this may represent a high-risk group, particularly for intrauterine fetal demise and periviable delivery. Establishing a society-based approach for preconception counseling and antenatal follow-up would be clinically compelling.


Asunto(s)
Resultado del Embarazo , Síndrome de Turner , Humanos , Síndrome de Turner/epidemiología , Síndrome de Turner/diagnóstico , Síndrome de Turner/complicaciones , Embarazo , Femenino , Adulto , Estudios Transversales , Resultado del Embarazo/epidemiología , Estados Unidos/epidemiología , Adulto Joven , Complicaciones del Embarazo/epidemiología , Complicaciones del Embarazo/diagnóstico , Prevalencia , Factores de Riesgo , Parto Obstétrico/estadística & datos numéricos
10.
Int J Gynecol Cancer ; 34(4): 510-518, 2024 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-38316444

RESUMEN

OBJECTIVE: To examine the association between intrauterine manipulator use and pathological factors and oncologic outcomes in patients with endometrial cancer who had laparoscopic hysterectomy in Japan. METHODS: This was a nationwide retrospective cohort study of the tumor registry of the Japan Society of Obstetrics and Gynecology. Study population was 3846 patients who had laparoscopic hysterectomy for endometrial cancer from January 2015 to December 2017. An automated 1-to-1 propensity score matching with preoperative and intraoperative demographics was performed to assess postoperative pathological factors associated with the intrauterine manipulator. Survival outcomes were assessed by accounting for possible pathological mediators related to intrauterine manipulator use. RESULTS: Most patients had preoperative stage I disease (96.5%) and grade 1-2 endometrioid tumors (81.9%). During the study period, 1607 (41.8%) patients had intrauterine manipulator use and 2239 (58.2%) patients did not. In the matched cohort, the incidences of lymphovascular space invasion in the hysterectomy specimen were 17.8% in the intrauterine manipulator group and 13.3% in the non-manipulator group. Intrauterine manipulator use was associated with a 35% increased odds of lymphovascular space invasion (adjusted odds ratio 1.35, 95% confidence interval (CI) 1.08 to 1.69). The incidences of malignant cells identified in the pelvic peritoneal cytologic sample at hysterectomy were 10.8% for the intrauterine manipulator group and 6.4% for the non-manipulator group. Intrauterine manipulator use was associated with a 77% increased odds of malignant peritoneal cytology (adjusted odds ratio 1.77, 95% Cl 1.29 to 2.31). The 5 year overall survival rates were 94.2% for the intrauterine manipulator group and 96.6% for the non-manipulator group (hazard ratio (HR) 1.64, 95% Cl 1.12 to 2.39). Possible pathological mediators accounted HR was 1.36 (95%Cl 0.93 to 2.00). CONCLUSION: This nationwide analysis of predominantly early stage, low-grade endometrial cancer in Japan suggested that intrauterine manipulator use during laparoscopic hysterectomy for endometrial cancer may be associated with an increased risk of lymphovascular space invasion and malignant peritoneal cytology. Possible mediator effects of intrauterine manipulator use on survival warrant further investigation, especially with a prospective setting.


Asunto(s)
Neoplasias Endometriales , Laparoscopía , Femenino , Humanos , Estudios Retrospectivos , Estudios Prospectivos , Neoplasias Endometriales/cirugía , Neoplasias Endometriales/patología , Histerectomía/efectos adversos , Laparoscopía/efectos adversos , Estadificación de Neoplasias
11.
Jpn J Clin Oncol ; 54(2): 146-152, 2024 Feb 07.
Artículo en Inglés | MEDLINE | ID: mdl-37935434

RESUMEN

OBJECTIVE: This study aimed to investigate the prognostic significance of tumor size and number of positive pelvic lymph nodes (PLN) in International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIIC1 cervical cancer patients. METHODS: Clinical data from 626 women with cervical cancer treated at Osaka International Cancer Center in 2010-2020 were retrospectively reviewed. Using the cutoff value obtained on the receiver operating characteristic analysis, the prognostic significance of tumor size and number of positive PLN in stage IIIC1 patients was first evaluated via uni- and multivariate analyses. Then, the impact of incorporating tumor size and number of positive PLN into the FIGO staging system was investigated using the Kaplan-Meier method. RESULTS: Among 196 women with Stage IIIC1 disease, larger tumors (>4 cm) and multiple PLN metastases (≥4) were independent predictors of progression-free survival (PFS) in patients with stage IIIC1 cervical cancer. The PFS of patients with stage IIIC1 disease was inversely associated with the number of risk factors. Although patients with stage IIIC1 disease had significantly increased survival rates compared to those with stage IIIA or IIIB disease in the original FIGO 2018 staging system, this reversal phenomenon was resolved by incorporating larger tumors (>4 cm) and multiple PLN metastases (≥4) into the revised staging system. CONCLUSIONS: Incorporating tumor size and number of metastatic lymph nodes into the FIGO staging system allows additional risk stratification for women with stage IIIC1 cervical cancer and improves survival prediction performance.


Asunto(s)
Neoplasias del Cuello Uterino , Humanos , Femenino , Estadificación de Neoplasias , Neoplasias del Cuello Uterino/patología , Estudios Retrospectivos , Pronóstico , Ganglios Linfáticos/patología
13.
Curr Oncol ; 30(11): 9428-9436, 2023 Oct 24.
Artículo en Inglés | MEDLINE | ID: mdl-37999102

RESUMEN

The aim of the current study is to investigate the survival outcome of stage IVB SCNEC of the uterine cervix in comparison to major histological subtypes of cervical cancer. A population-based retrospective cohort study was conducted using the Osaka Cancer Registry data from 1994 to 2018. All FIGO 2009 stage IVB cervical cancer patients who displayed squamous cell carcinoma (SCC), adenocarcinoma (A), adenosquamous cell carcinoma (AS), or small-cell neuroendocrine carcinoma (SCNEC) were first identified. The patients were classified into groups according to the types of primary treatment. Then, their survival rates were examined using the Kaplan-Meier method. Overall, in a total of 1158 patients, clearly differential survival rates were observed according to the histological subtypes, and SCNEC was associated with shortest survival. When examined according to the types of primary treatments, SCNEC was associated with significantly decreased survival when compared to SCC or A/AS, except for those treated with surgery. In patients with FIGO 2009 stage IVB cervical cancer, SCNEC was associated with decreased survival when compared to SCC or A/AS. Although current treatments with either surgery, chemotherapy or radiotherapy have some therapeutic efficacies, to improve the prognosis, novel effective treatments specifically targeting cervical SCNEC need to be developed.


Asunto(s)
Carcinoma Neuroendocrino , Carcinoma de Células Pequeñas , Carcinoma de Células Escamosas , Neoplasias del Cuello Uterino , Femenino , Humanos , Neoplasias del Cuello Uterino/terapia , Neoplasias del Cuello Uterino/patología , Estudios Retrospectivos , Estadificación de Neoplasias , Carcinoma de Células Pequeñas/terapia , Análisis de Supervivencia , Carcinoma de Células Escamosas/patología , Carcinoma Neuroendocrino/terapia , Carcinoma Neuroendocrino/patología
14.
Cancers (Basel) ; 15(18)2023 Sep 08.
Artículo en Inglés | MEDLINE | ID: mdl-37760440

RESUMEN

Randomized clinical trials assessing the efficacy of neoadjuvant chemotherapy (NACT) for advanced epithelial ovarian cancer have predominantly included women with high-grade serous carcinomas. The response rate and oncological outcomes of NACT for malignant ovarian germ cell tumors (MOGCT) are poorly understood. This study aimed to examine the effects of NACT on women with MOGCT by conducting a systematic review of four public search engines. Fifteen studies were identified, and a further descriptive analysis was performed for 10 original articles. In those studies, most women were treated with a bleomycin, etoposide, and cisplatin regimen, and one to three cycles were used in most studies. Four studies comparing NACT and primary debulking surgery showed similar complete response rates (n = 2; pooled odds ratio [OR] 0.90, 95% confidence interval [CI] 0.15-5.27), comparable overall survival (n = 3; 87.0-100% versus 70.0-100%), disease-free survival (n = 3; 87.0-100% versus 70.0-100%), recurrence rate (n = 1; OR 3.50, 95%CI 0.38-32.50), and adverse events rate from chemotherapy between the groups. In conclusion, NACT may be considered for the management of MOGCT; however, possible candidates for NACT use and an ideal number of NACT cycles remain unknown. Further studies are warranted to validate the efficacy of NACT in advanced MOGCT patients.

15.
Am J Obstet Gynecol MFM ; 5(10): 101115, 2023 10.
Artículo en Inglés | MEDLINE | ID: mdl-37543142

RESUMEN

BACKGROUND: Previous cesarean delivery is a risk factor for developing placenta accreta spectrum in a subsequent pregnancy and patients with antenatally suspected placenta accreta spectrum frequently undergo planned cesarean hysterectomy. There is a paucity of data regarding unsuspected placenta accreta spectrum among patients undergoing trial of labor after cesarean delivery for attempted vaginal birth after cesarean delivery. OBJECTIVE: This study aimed to investigate the incidence, characteristics, and delivery outcomes of patients with placenta accreta spectrum diagnosed at the time of vaginal birth after cesarean delivery. STUDY DESIGN: The Healthcare Cost and Utilization Project's National Inpatient Sample was retrospectively queried to examine 184,415 patients with a history of low transverse cesarean delivery who had vaginal delivery in the current index hospital admission between 2017 and 2020. Those with placenta previa, previous vertical cesarean delivery, other uterine scars, and uterine rupture were excluded. This study identified placenta accreta spectrum cases using the World Health Organization International Classification of Disease, Tenth Revision, codes of O43.2. Coprimary outcomes were (1) the incidence rate of placenta accreta spectrum at vaginal birth after cesarean delivery; (2) clinical and pregnancy characteristics related to placenta accreta spectrum, assessed with multivariable binary logistic regression model; and (3) delivery outcomes associated with placenta accreta spectrum by fitting propensity score adjustment. The secondary outcome was to conduct a systematic literature review using 3 public search engines (PubMed, Cochrane, and Scopus). Data on incidence rate and maternal morbidity related to placenta accreta spectrum at vaginal birth after cesarean delivery were evaluated. RESULTS: The incidence rate of placenta accreta spectrum at vaginal birth after cesarean delivery was 8.1 per 10,000 deliveries. Most placenta accreta spectrum cases were placenta accreta (83.3%). In a multivariable analysis, older maternal age, tobacco use, preeclampsia, multifetal pregnancy, fetal anomaly, preterm premature rupture of membrane, chorioamnionitis, low-lying placenta, and preterm delivery were associated with an increased risk of placenta accreta spectrum (all, P<.05). Of these factors, low-lying placenta had the largest odds for placenta accreta spectrum (526.3 vs 7.3 per 10,000 deliveries; adjusted odds ratio, 35.02; 95% confidence interval, 18.19-67.42). Patients in the placenta accreta spectrum group were more likely to have postpartum hemorrhage (80.0% vs 5.5%), blood product transfusion (23.3% vs 1.0%), shock or coagulopathy (20.0% vs 0.2%), and hysterectomy (43.3% vs <0.1%) than those without placenta accreta spectrum (all, P<.001). In a systematic literature review, a total of 212 studies were screened, and none of these studies examined the incidence and morbidity of placenta accreta spectrum at vaginal birth after cesarean delivery. CONCLUSION: This nationwide assessment suggests that although placenta accreta spectrum with vaginal birth after cesarean delivery is uncommon (1 of 1229 cases), the diagnosis of placenta accreta spectrum at vaginal birth after cesarean delivery is associated with significant maternal morbidity. In addition, the data suggest that low-lying placenta in the setting of previous low transverse cesarean delivery warrants careful evaluation for possible placenta accreta spectrum before a trial of labor.


Asunto(s)
Placenta Accreta , Nacimiento Prematuro , Parto Vaginal Después de Cesárea , Embarazo , Femenino , Recién Nacido , Humanos , Placenta Accreta/diagnóstico , Placenta Accreta/epidemiología , Placenta Accreta/etiología , Parto Vaginal Después de Cesárea/efectos adversos , Estudios Retrospectivos , Cesárea/efectos adversos , Parto Obstétrico , Nacimiento Prematuro/etiología
16.
Int J Gynecol Cancer ; 33(10): 1633-1644, 2023 10 02.
Artículo en Inglés | MEDLINE | ID: mdl-37524496

RESUMEN

Placenta accreta spectrum encompasses cases where the placenta is morbidly adherent to the myometrium. Placenta percreta, the most severe form of placenta accreta spectrum (grade 3E), occurs when the placenta invades through the myometrium and possibly into surrounding structures next to the uterine corpus. Maternal morbidity of placenta percreta is high, including severe maternal morbidity in 82.1% and mortality in 1.4% in the recent nationwide U.S. statistics. Although cesarean hysterectomy is commonly performed for patients with placenta accreta spectrum, conservative management is becoming more popular because of reduced morbidity in select cases. Treatment of grade 3E disease involving the urinary bladder, uterine cervix, or parametria is surgically complicated due to the location of the invasive placenta deep in the maternal pelvis. Cesarean hysterectomy in this setting has the potential for catastrophic hemorrhage and significant damage to surrounding organs. We propose a step-by-step schema to evaluate cases of grade 3E disease and determine whether immediate hysterectomy or conservative management, including planned delayed hysterectomy, is the most appropriate treatment option. The approach includes evaluation in the antenatal period with ultrasound and magnetic resonance imaging to determine suspicion for placenta previa percreta with surrounding organ involvement, planned cesarean delivery with a multidisciplinary team including experienced pelvic surgeons such as a gynecologic oncologist, intra-operative assessment including gross surgical field exposure and examination, cystoscopy, and consideration of careful intra-operative transvaginal ultrasound to determine the extent of placental invasion into surrounding organs. This evaluation helps decide the safety of primary cesarean hysterectomy. If safely resectable, additional considerations include intra-operative use of uterine artery embolization combined with tranexamic acid injection in cases at high risk for pelvic hemorrhage and ureteral stent placement. Availability of resuscitative endovascular balloon occlusion of the aorta is ideal. If safe resection is concerned, conservative management including planned delayed hysterectomy at around 4 weeks from cesarean delivery in stable patients is recommended.


Asunto(s)
Placenta Accreta , Placenta Previa , Femenino , Embarazo , Humanos , Placenta Accreta/terapia , Placenta Accreta/patología , Placenta , Placenta Previa/patología , Placenta Previa/cirugía , Miometrio/patología , Cesárea , Histerectomía/métodos , Estudios Retrospectivos
17.
Clin Case Rep ; 11(7): e7391, 2023 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-37397581

RESUMEN

Key Clinical Message: Recently, the number of minimally invasive surgeries (MIS) is increasing; however, a specific postoperative complication of MIS such as port-site hernia needs to be recognized. A persistent postoperative ileus after MIS is rare and such symptoms need to be recognized as a probable sign of a port-site hernia. Abstract: Recently, minimally invasive surgery (MIS) approaches for early endometrial cancer have shown non-inferior oncologic outcomes with better perioperative morbidity than open approaches. Nevertheless, port-site hernias are a rare but specific surgical complication of MIS. Knowing the clinical presentation, surgery for port-site hernias could help clinicians manage this condition.

18.
JAMA Netw Open ; 6(6): e2318602, 2023 06 01.
Artículo en Inglés | MEDLINE | ID: mdl-37326992

RESUMEN

Importance: Randomized clinical trials examining the effectiveness of neoadjuvant chemotherapy (NACT) for advanced ovarian cancer predominantly included patients with high-grade serous carcinomas. The use and outcomes of NACT in less common epithelial carcinomas are understudied. Objective: To investigate the uptake and survival outcomes in treatment with NACT for less common histologic subtypes of epithelial ovarian cancer. Design, Setting, and Participants: A retrospective cohort study and systematic literature review with meta-analysis was conducted using the National Cancer Database from 2006 to 2017 and the National Cancer Institute's Surveillance, Epidemiology, and End Results Program from 2006 to 2019. Data analysis was performed from July 2022 to April 2023. The evaluation included patients with stage III to IV ovarian cancer with clear cell, mucinous, or low-grade serous histologic subtypes who received multimodal treatment with surgery and chemotherapy. Exposures: Exposure assignment per the sequence of treatment: primary debulking surgery (PDS) followed by chemotherapy (PDS group) or NACT followed by interval surgery (NACT group). Main Outcomes and Measures: Temporal trends and characteristics of NACT use were assessed using multivariable analysis, and overall survival (OS) was assessed with the inverse probability of treatment weighting propensity score. Results: A total of 3880 patients were examined in the National Cancer Database including 1829 women (median age, 56 [IQR, 49-63] years) with clear cell, 1156 women (median age, 53 [IQR, 42-64] years) with low-grade serous, and 895 women (median age, 57 [IQR, 48-66] years) with mucinous carcinomas. NACT use increased in patients with clear cell (from 10.2% to 16.2%, 58.8% relative increase; P < .001 for trend) or low-grade serous (from 7.7% to 14.2%, 84.4% relative increase; P = .007 for trend) carcinoma during the study period. This association remained consistent in multivariable analysis. NACT use also increased, but nonsignificantly, in mucinous carcinomas (from 8.6% to 13.9%, 61.6% relative increase; P = .07 for trend). Across the 3 histologic subtypes, older age and stage IV disease were independently associated with NACT use. In a propensity score-weighted model, the NACT and PDS groups had comparable OS for clear cell (4-year rates, 31.4% vs 37.7%; hazard ratio [HR], 1.12; 95% CI, 0.95-1.33) and mucinous (27.0% vs 26.7%; HR, 0.90; 95% CI, 0.68-1.19) carcinomas. For patients with low-grade serous carcinoma, NACT was associated with decreased OS compared with PDS (4-year rates, 56.4% vs 81.0%; HR, 2.12; 95% CI, 1.55-2.90). Increasing NACT use and histologic subtype-specific survival association were also found in the Surveillance, Epidemiology, and End Results Program cohort (n = 1447). A meta-analysis of 4 studies, including the current study, observed similar OS associations for clear cell (HR, 1.13; 95% CI, 0.96-1.34; 2 studies), mucinous (HR, 0.93; 95% CI, 0.71-1.21; 2 studies), and low-grade serous (HR, 2.11; 95% CI, 1.63-2.74; 3 studies) carcinomas. Conclusions and Relevance: Despite the lack of data on outcomes of NACT among patients with less common carcinomas, this study noted that NACT use for advanced disease has gradually increased in the US. Primary chemotherapy for advanced-stage, low-grade serous ovarian cancer may be associated with worse survival compared with PDS.


Asunto(s)
Adenocarcinoma Mucinoso , Cistadenocarcinoma Seroso , Neoplasias Ováricas , Neoplasias Peritoneales , Femenino , Humanos , Persona de Mediana Edad , Adenocarcinoma Mucinoso/patología , Carcinoma Epitelial de Ovario/patología , Quimioterapia Adyuvante/métodos , Cistadenocarcinoma Seroso/patología , Terapia Neoadyuvante/métodos , Estadificación de Neoplasias , Neoplasias Ováricas/patología , Neoplasias Peritoneales/tratamiento farmacológico , Estudios Retrospectivos , Adulto , Anciano
19.
Biomedicines ; 11(6)2023 May 25.
Artículo en Inglés | MEDLINE | ID: mdl-37371617

RESUMEN

The placenta has several crucial physiological functions that help maintain a normal pregnancy. Although approximately 2-4% of pregnancies are complicated by abnormal placentas, obstetric outcomes remain understudied. This study aimed to determine the outcomes and prevalence of patients with abnormal placentas by conducting a systematic review of 48 studies published between 1974 and 2022. The cumulative prevalence of circumvallate placenta, succenturiate placenta, multilobed placenta, and placenta membranacea were 1.2%, 1.0%, 0.2%, and 0.004%, respectively. Pregnancies with a circumvallate placenta were associated with an increased rate of emergent cesarean delivery, preterm birth (PTB), and placental abruption compared to those without a circumvallate placenta. The succenturiate lobe of the placenta was associated with a higher rate of emergent cesarean delivery, whereas comparative results were observed in terms of PTB, placental abruption, and placenta previa in comparison to those without a succenturiate lobe of the placenta. A comparator study that examined the outcomes of multilobed placentas found that this data is usually unavailable. Patient-level analysis (n = 15) showed high-rates of abortion (40%), placenta accreta spectrum (40%), and a low term delivery rate (13.3%) in women with placenta membranacea. Although the current evidence is insufficient to draw a robust conclusion, abnormal placentas should be recognized as a high-risk factor for adverse outcomes during pregnancy.

20.
Am J Obstet Gynecol MFM ; 5(9): 101056, 2023 09.
Artículo en Inglés | MEDLINE | ID: mdl-37330009

RESUMEN

BACKGROUND: Although intrauterine devices provide effective contraceptive protection, unintentional pregnancy can occur. Previous studies have shown that a retained intrauterine device during pregnancy is associated with adverse pregnancy outcomes but there is a paucity of nationwide data and analysis. OBJECTIVE: This study aimed to describe characteristics and outcomes of pregnancies with a retained intrauterine device. STUDY DESIGN: This serial cross-sectional study used data from the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population comprised 18,067,310 hospital deliveries for national estimates from January 2016 to December 2020. The exposure was retained intrauterine device status, identified by the World Health Organization's International Classification of Diseases, Tenth Revision, code O26.3. The co-primary outcome measures were incidence rate, clinical and pregnancy characteristics, and delivery outcome of patients with a retained intrauterine device. To assess the pregnancy characteristics and delivery outcomes, an inverse probability of treatment weighting cohort was created to mitigate the prepregnant confounders for a retain intrauterine device. RESULTS: A retained intrauterine device was reported in 1 in 8307 hospital deliveries (12.0 per 100,000). In a multivariable analysis, Hispanic individuals, grand multiparity, obesity, alcohol use, and a previous uterine scar were patient characteristics associated with a retained intrauterine device (all P<.05). Current pregnancy characteristics associated with a retained intrauterine device included preterm premature rupture of membrane (9.2% vs 2.7%; adjusted odds ratio, 3.15; 95% confidence interval, 2.41-4.12), fetal malpresentation (10.9% vs 7.2%; adjusted odds ratio, 1.47; 95% confidence interval, 1.15-1.88), fetal anomaly (2.2% vs 1.1%; adjusted odds ratio, 1.71; 95% confidence interval, 1.03-2.85), intrauterine fetal demise (2.6% vs 0.8%; adjusted odds ratio, 2.21; 95% confidence interval, 1.37-3.57), placenta malformation (1.8% vs 0.8%; adjusted odds ratio, 2.12; 95% confidence interval, 1.20-3.76), placenta abruption (4.7% vs 1.1%; adjusted odds ratio, 3.24; 95% confidence interval, 2.25-4.66), and placenta accreta spectrum (0.7% vs 0.1%; adjusted odds ratio, 4.82; 95% confidence interval, 1.99-11.65). Delivery characteristics associated with a retained intrauterine device included previable loss at <22 weeks' gestation (3.4% vs 0.3%; adjusted odds ratio, 5.49; 95% confidence interval, 3.30-9.15) and periviable delivery at 22 to 25 weeks' gestation (3.1% vs 0.5%; adjusted odds ratio, 2.81; 95% confidence interval, 1.63-4.86). Patients in the retained intrauterine device group were more likely to have a diagnosis of retained placenta at delivery (2.5% vs 0.4%; adjusted odds ratio, 4.45; 95% confidence interval, 2.70-7.36) and to undergo manual placental removal (3.2% vs 0.6%; adjusted odds ratio, 4.81; 95% confidence interval, 3.11-7.44). CONCLUSION: This nationwide analysis confirmed that pregnancy with a retained intrauterine device is uncommon, but these pregnancies may be associated with high-risk pregnancy characteristics and outcomes.


Asunto(s)
Dispositivos Intrauterinos , Nacimiento Prematuro , Recién Nacido , Embarazo , Humanos , Femenino , Estudios Transversales , Placenta , Resultado del Embarazo/epidemiología , Nacimiento Prematuro/diagnóstico , Nacimiento Prematuro/epidemiología , Nacimiento Prematuro/etiología
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