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Sábado, 01 de Enero de 2011 11:26

Para-aortic lymphadenectomy in endometrial cancer

Para-aortic lymphadenectomy in endometrial cancer

Lancet, Volume 376, Issue 9740, Pages 511 - 512, 14 August 2010 <Previous Article|Next Article>doi:10.1016/S0140-6736(10)61245-7Cite or Link Using DOI

Clare Griffin a, Ann Marie Swart a, Wendi Qian a, Henry Kitchener b

We were not surprised that the results of the retrospective cohort analysis of SEPAL1 differed from those of two randomised controlled trials.2, 3 With a hazard ratio for overall survival of 1·16 (favouring no lymphadenectomy) in ASTEC,2 it is extremely unlikely that conclusions would change with long-term follow-up because there would have to be a large, late effect which is not suggested by SEPAL. Lymphadenectomy significantly increases moderate and severe morbidity, particularly lymphoedema, and removing more lymph nodes might not be better (figure).

ASTEC effect of lymphadenectomy in centres grouped according to median nodes removed

O-E=observed minus expected. Outer bars show 99% CI, inner bars show 95% CI.

Lack of information about methods makes the results impossible to interpret, particularly patient selection and surgery details (operation length, blood loss, postoperative hospital stay, and related deaths). The median age of 56 years suggests substantial selection (median age was 63 years in ASTEC). Data were gathered over 18 years and information about the distribution of patients in each group across time and any time effect on survival is important. Bias due to differences between the hospitals cannot be excluded, with differing adjuvant protocols and almost double the number of pelvic nodes removed in some hospitals compared with others.

In women at intermediate or high risk of recurrence, the substantial difference in adjuvant chemotherapy received (77% vs 45%) is important. Chemotherapy reduces distal metastases,4 potentially improving survival and the effect of para-aortic lymphadenectomy. The benefit in high-risk patients receiving chemotherapy is only just significant. Since type of lymphadenectomy and adjuvant treatment were independent risk factors for overall survival, there are strong statistical arguments for sensitivity analyses excluding those receiving adjuvant treatment.

Aortic lymphadenectomy was not assessed in either randomised trial and the results of this observational study do not invalidate the conclusions of these trials nor provide conclusive evidence of a real treatment effect.

Sábado, 01 de Enero de 2011 11:24

Lymphadenectomy in endometrial cancer

Lymphadenectomy in endometrial cancer

The Lancet, Volume 373, Issue 9670, Pages 1169 - 1170, 4 April 2009 <Previous Article|Next Article>doi:10.1016/S0140-6736(09)60676-0Cite or Link Using DOI

Frédéric Amant a, Patrick Neven a, Ignace Vergote a

The ASTEC study group1 conclude that a systematic lymphadenectomy in endometrial cancer cannot be recommended as a routine procedure because of lack of benefit in terms of recurrence-free and overall survival. However, there are several reasons why the ASTEC trial did not show improved overall survival with routine lymphadenectomy.

First, the number of lymph nodes resected was insufficient in many patients. Although the median number resected overall was 12, 35% of patients in the lymphadenectomy group had nine or fewer lymph nodes removed. Cragun and colleagues2 showed that removal of more than 11 pelvic nodes had an effect on overall survival. Chan and colleagues3 showed that, in intermediate-risk and high-risk endometrial cancer, patients with more than 10 nodes harvested have an improved outcome.

Second, many patients with low-risk endometrial carcinoma, and hence a low risk of lymph-node involvement, were included (eg, only 41% had stage IC—IIB disease, and only 22% presented with poorly differentiated tumours). The high rate of inclusion of low-risk patients and the low number of lymph nodes removed are the reasons for the low rate of involved lymph nodes seen in the lymphadenectomy group (9%).

Third, the study group did not assess the para-aortic nodes. However, up to 67% of patients with lymph-node metastases have involved para-aortic nodes.4 Fourth, the ASTEC trial was too small to detect an overall survival difference because the expected proportion of isolated pelvic lymph-node recurrences is as low as 2—3% in early endometrial carcinoma.

In conclusion, we believe that there is still an indication to do a comprehensive lymphadenectomy to select patients at high risk of pelvic side wall recurrence. The selection of patients for a lymphadenectomy should be based on myometrial invasion, grade, and diameter of the tumour.5

We declare that we have no conflict of interest.

 

Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study

The Lancet, Volume 373, Issue 9658, Pages 125 - 136, 10 January 2009 <Previous Article|Next Article>doi:10.1016/S0140-6736(08)61766-3Cite or Link Using DOI

Published Online: 13 December 2008

The writing committee on behalf of the ASTEC study group‡

Summary

Background

Hysterectomy and bilateral salpingo-oophorectomy (BSO) is the standard surgery for stage I endometrial cancer. Systematic pelvic lymphadenectomy has been used to establish whether there is extra-uterine disease and as a therapeutic procedure; however, randomised trials need to be done to assess therapeutic efficacy. The ASTEC surgical trial investigated whether pelvic lymphadenectomy could improve survival of women with endometrial cancer.

 

Adjuvant external beam radiotherapy in the treatment of endometrial cancer (MRC ASTEC and NCIC CTG EN.5 randomised trials): pooled trial results, systematic review, and meta-analysis

The Lancet, Volume 373, Issue 9658, Pages 137 - 146, 10 January 2009 <Previous Article|Next Article>doi:10.1016/S0140-6736(08)61767-5Cite or Link Using DOI

Published Online: 13 December 2008

The ASTEC/EN.5 writing committee on behalf of the ASTEC/EN.5 Study Group‡

Summary

Background

Early endometrial cancer with low-risk pathological features can be successfully treated by surgery alone. External beam radiotherapy added to surgery has been investigated in several small trials, which have mainly included women at intermediate risk of recurrence. In these trials, postoperative radiotherapy has been shown to reduce the risk of isolated local recurrence but there is no evidence that it improves recurrence-free or overall survival. We report the findings from the ASTEC and EN.5 trials, which investigated adjuvant external beam radiotherapy in women with early-stage disease and pathological features suggestive of intermediate or high risk of recurrence and death from endometrial cancer.

Methods

Between July, 1996, and March, 2005, 905 (789 ASTEC, 116 EN.5) women with intermediate-risk or high-risk early-stage disease from 112 centres in seven countries (UK, Canada, Poland, Norway, New Zealand, Australia, USA) were randomly assigned after surgery to observation (453) or to external beam radiotherapy (452). A target dose of 40—46 Gy in 20—25 daily fractions to the pelvis, treating five times a week, was specified. Primary outcome measure was overall survival, and all analyses were by intention to treat. These trials were registered ISRCTN 16571884 (ASTEC) and NCT 00002807 (EN.5).

The Evolving Role of Adjuvant Therapy in Endometrial Cancer

Crit Rev Oncol Hematol. 2011 May; 78(2):79-91; A Gadducci, C Greco

Abstract

Extra-fascial total hysterectomy and bilateral salpingo-oophorectomy with or without lymph node dissection is the initial treatment for endometrial cancer. Unresolved scientific controversy exists regarding the selection of patients who may benefit from lymphadenectomy, the magnitude of such benefit, and the role of adjuvant therapy. External pelvic irradiation has been shown to reduce loco-regional recurrences without improving survival. Meta-analyses of randomized trials indicate that external pelvic irradiation offers a significant benefit in terms of survival only in high-risk disease (i.e. stage Ic grade 3). Intermediate risk patients (i.e. stage Ib grade 3 disease), therefore, may be treated with adjuvant intravaginal brachytherapy alone to avoid the risk of side effects associated with pelvic irradiation. Overall, patients with clinically early endometrial cancer develop relapses in less than 20% of cases, mostly at distant sites.

 

Sábado, 30 de Abril de 2011 10:11

ACTA DE LA 1ª REUNIÓN INFORMATIVA DE LA SoGOCyL

ACTA DE LA 1ª REUNIÓN INFORMATIVA DE LA SoGOCyL

León 15 de Abril de 2011. Inicio 20:30 horas

Orden del día:

1. Bienvenida y Agradecimientos

En general a asistentes y ponentes.

En particular a los Dres. Peñalosa y Cabezas por la facilitarnos infraestructura de la SoGICyL para este Evento.

Fertility considerations in the management of gynecologic malignancies

Review

Nicole Noyes (a), Jaime M. Knopman (a), Kara Long (b), Jaclyn M. Coletta (c), Nadeem R. Abu-Rustum (b)

(a) Division of Reproductive Endocrinology, New York University School of Medicine, New York, NY, USA. (b) Division of Gynecologic Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. (c) Division of Maternal Fetal Medicine, Columbia University Medical Center, New York, NY, USA

Keywords: Fertility preservation, Oocyte cryopreservation, Cancer, Parenthood, Quality-of-life

Goals. Gynecologic cancers represent a significant proportion of malignancies affecting women. Historically, cancer treatment focused primarily on eradicating disease, irrespective of the impact on fertility. The implementation of early detection protocols and advanced treatment regimens has resulted in improved prognosis for gynecologic cancer patients. With this improvement, more attention is now paid to quality-oflife issues. Fertility preservation (FP) has become an integral component in the selection and execution of gynecological cancer management. In this report we address gynecologic malignancies as they relate to future fertility potential.

Methods. We review reproductive principles such as ovarian reserve, uterine function, cervical competence, and early obstetrical management, as well as available FP methods. In addition, we discuss the potential damage that cancer and cancer treatments can impart on the female reproductive system. We offer general recommendations regarding baseline screening tests useful in assessing the feasibility of FP. Lastly, cancer-specific FP methods are presented.

Sentinel lymph node biopsy in the management of early-stage cervical carcinoma ☆

A prospective no-randomized clinical trial

John P. Diaz (a),1, Mary L. Gemignani (a), Neeta Pandit-Taskar (b), Kay J. Park (c), Melissa P. Murray (c=, Dennis S. Chi (a), Yukio Sonoda (a), Richard R. Barakat (a), Nadeem R. Abu-Rustum (a)

(a) Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA, (b) Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA, (c)-   Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

Gynecologic Oncology 120 (2011) 347–352

Keywords: Sentinel lymph nodes, Micrometastasis, Cervical cancer

Objectives. We aimed to determine the sentinel lymph node detection rates, accuracy in predicting the status of lymph node metastasis, and if pathologic ultrastaging improves the detection of micrometastases and isolated tumor cells at the time of primary surgery for cervical cancer.

Methods. A prospective, non-randomized study of women with early-stage (FIGO stage IA1 with lymphovascular space involvement — IIA) cervical carcinoma was conducted from June 2003 to August 2009. All patients underwent an intraoperative intracervical blue dye injection. Patients who underwent a preoperative lymphoscintigraphy received a 99 m Tc sulfur colloid injection in addition. All patients underwent sentinel lymph node (SLN) identification followed by a complete pelvic node and parametrial dissection. SLN were evaluated using our institutional protocol that included pathologic ultrastaging.

Axillary Dissection vs No Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastasis

A Randomized Clinical Trial

Armando E. Giuliano, MD, Kelly K. Hunt, MD, Karla V. Ballman, PhD, Peter D. Beitsch, MD, Pat W. Whitworth, MD, Peter W. Blumencranz, MD, A. Marilyn Leitch, MD, Sukamal Saha, MD, Linda M. McCall, MS, Monica Morrow, MD.

JAMA, February 9, 2011—Vol 305, No. 6

Context Sentinel lymph node dissection (SLND) accurately identifies nodal metas-tasis of early breast cancer, but it is not clear whether further nodal dissection affects survival.

Objective To determine the effects of complete axillary lymph node dissection (ALND) on survival of patients with sentinel lymph node (SLN) metastasis of breast cancer.

Lunes, 31 de Enero de 2011 17:02

Acta Nº1 SoGOCyL: Reunión Constituyente

Asamblea Constitutiva de la SoGOCyL, con fecha de 28/1/2011.

En Valladolid, siendo las 17.40 horas del día 28 de enero de 2011, se reúnen la Junta Directiva de la SoGOCyL propuesta y otros ginecólogos de la Comunidad Autónoma de Castilla y León en la sala de Conferencias del Hospital Universitario Río Hortega.

El objeto de la reunión es celebrar la Asamblea Constituyente de la SoGOCyL –Sociedad de Ginecología Oncológica y Patología Mamaria de Castilla y León–. Actúa como Presidente de la Junta Directiva el Dr. Alfonso Fernández Corona y como Secretario con carácter accidental el Dr. Ignacio González Blanco. El vocal Dr. Ángel García Iglesias no acude y presenta previamente su renuncia a la vocalía, por lo que se propone en su sustitución a la Dra. Verónica Sancho de Salas. Entre los asistentes a la Reunión se encuentra además, como representante, asesor y participante activo el Presidente de la SoGICyL –Sociedad Ginecológica de Castilla y León–, Dr. Luis Peñalosa Ruíz.

 

 

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VII Reunión de la Sociedad de Ginecología Oncológica y Patología Mamaria de Castilla y León

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