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Pareja R.,Institute Cancerologia Las Americas | Rendon G.J.,Institute Cancerologia Las Americas | Vasquez M.,Hospital Universitario San Vicente Of Paul | Echeverri L.,Institute Cancerologia Las Americas | And 3 more authors.
Gynecologic Oncology | Year: 2015

Radical trachelectomy is the treatment of choice in women with early-stage cervical cancer wishing to preserve fertility. Radical trachelectomy can be performed with a vaginal, abdominal, or laparoscopic/robotic approach. Vaginal radical trachelectomy (VRT) is generally not offered to patients with tumors 2 cm or larger because of a high recurrence rate. There are no conclusive recommendations regarding the safety of abdominal radical trachelectomy (ART) or laparoscopic radical trachelectomy (LRT) in such patients. Several investigators have used neoadjuvant chemotherapy in patients with tumors 2 to 4 cm to reduce tumor size so that fertility preservation may be offered. However, to our knowledge, no published study has compared outcomes between patients with cervical tumors 2 cm or larger who underwent immediate radical trachelectomy and those who underwent neoadjuvant chemotherapy followed by radical trachelectomy. We conducted a literature review to compare outcomes with these 2 approaches. Our main endpoints for evaluation were oncological and obstetrical outcomes. The fertility preservation rate was 82.7%, 85.1%, 89%; and 91.1% for ART (tumors larger than > 2 cm), ART (all sizes), NACT followed by surgery and VRT (all sizes); respectively. The global pregnancy rate was 16.2%, 24% and 30.7% for ART, VRT, and NACT followed by surgery; respectively. The recurrence rate was 3.8%, 4.2%, 6%, 7.6% and 17% for ART (all sizes), VRT (all sizes), ART (tumors > 2 cm), NACT followed by surgery, and VRT (tumors > 2 cm). These outcomes must be considered when offering a fertility sparing technique to patients with a tumor larger than 2 cm. © 2015 Elsevier Inc. All rights reserved.


PubMed | Pontifical Bolivarian University, University of Houston, Institute Cancerologia Las Americas, Group of Hospitals and Clinica Las Americas
Type: Journal Article | Journal: Gynecologic oncology | Year: 2016

The goal of our study was to report on the feasibility of outpatient laparoscopic radical hysterectomy in patients with early-stage cervical cancer.We included all patients who underwent a laparoscopic radical hysterectomy at the Instituto de Cancerologa - Las Americas in Medellin, Colombia, between January 2013 and July 2015. The control group was a similar cohort of patients who were admitted after their surgery.Seventy-six patients were included [outpatient (31) and admitted (45)]. There were no statistically significant differences between groups regarding age, clinical stage, histology, nodal count, need of adjuvant treatment, visual pain scores at discharge or follow up time. All patients underwent a transversus abdominis plane block. The median operative time was 150min (range, 105-240) in the outpatient group vs. 170min (range, 97-300) in the admitted group (p=0.023). The median estimated blood loss was 50ml (range, 20-150) in the outpatient group vs. 120ml (range, 20-1000) in the admitted group (p=0.001). All patients were able to void spontaneously and tolerate a diet before discharge. In patients who were admitted, the median hospital stay was 1day, (range; 1-6), and 39 (87%) were discharged at postoperative day 1. There were 6 postoperative complications, 3 in each group. There were no recurrences in the follow-up period in the outpatient group, and there were 3 (6.6%) recurrences in the admitted group.Outpatient laparoscopic radical hysterectomy is feasible and can be performed safely in a developing country in well-selected patients.


PubMed | University of Houston, Institute Cancerologia Las Americas, Group of Hospitals, Hospital San Jose and Hospital Universitario San Vicente Of Paul
Type: Journal Article | Journal: Gynecologic oncology | Year: 2015

Radical trachelectomy is the treatment of choice in women with early-stage cervical cancer wishing to preserve fertility. Radical trachelectomy can be performed with a vaginal, abdominal, or laparoscopic/robotic approach. Vaginal radical trachelectomy (VRT) is generally not offered to patients with tumors 2cm or larger because of a high recurrence rate. There are no conclusive recommendations regarding the safety of abdominal radical trachelectomy (ART) or laparoscopic radical trachelectomy (LRT) in such patients. Several investigators have used neoadjuvant chemotherapy in patients with tumors 2 to 4cm to reduce tumor size so that fertility preservation may be offered. However, to our knowledge, no published study has compared outcomes between patients with cervical tumors 2cm or larger who underwent immediate radical trachelectomy and those who underwent neoadjuvant chemotherapy followed by radical trachelectomy. We conducted a literature review to compare outcomes with these 2 approaches. Our main endpoints for evaluation were oncological and obstetrical outcomes. The fertility preservation rate was 82.7%, 85.1%, 89%; and 91.1% for ART (tumors larger than >2cm), ART (all sizes), NACT followed by surgery and VRT (all sizes); respectively. The global pregnancy rate was 16.2%, 24% and 30.7% for ART, VRT, and NACT followed by surgery; respectively. The recurrence rate was 3.8%, 4.2%, 6%, 7.6% and 17% for ART (all sizes), VRT (all sizes), ART (tumors>2cm), NACT followed by surgery, and VRT (tumors>2cm). These outcomes must be considered when offering a fertility sparing technique to patients with a tumor larger than 2cm.


Bedoya A.M.,University of Antioquia | Tate D.J.,Louisiana State University Health Sciences Center | Baena A.,University of Antioquia | Cordoba C.M.,University of Antioquia | And 9 more authors.
Gynecologic Oncology | Year: 2014

Introduction. Cervical cancer is characterized by an immunosuppressive microenvironment and a Th2-type cytokine profile. Expression of arginase (ASE), the enzyme that converts L-arginine into L-ornithine and urea, is stimulated by Th2-type cytokines. Objective. To assess the association of ASE activity and L-Arg metabolism products with cervical cancer.Methods. Sera of 87 and 41womenwith histologically confirmed by colposcopy-directed biopsy SCC and CIN3 respectively and 79 with normal cytology or Low-Grade Squamous Intraepithelial Lesion (LSIL), were evaluated. Cytokines were measured using Milliplex Human cytokine/chemokine kit. Arginase (ASE) activity was determined using an enzymatic assay. Levels of L-arginine, L-ornithine, putrescine and spermine were determined by HPLC.Results. Significantly higher levels of ASE activitywere observed inwomenwith CIN3 (age-adjusted OR: 24.3; 95%CI: 3.82-155) and SCC (AOR: 9.8; 95%CI: 2.34-40.8). As expected, possibly due to high levels of ASE activity, higher levels of L-Arg were negatively associated with CIN3 (AOR: 0.03; 95%CI: 0.004-0.19) and SSC (AOR: 0.06; 95%CI: 0.02-0.24). Consistent with the role of ASE in the conversion of L-arginine to L-ornithine and polyamine production therefrom, women with cervical cancer had higher levels of spermine and putrescine. A correlation analysis revealed a significant albeit weak relationship between high levels of IL-10 and high levels of ASE (Pearson r = 0.32, p-value = 0.003) in women with cervical cancer.Conclusion. This study indicates that ASE activity and L-Arg degradation mechanisms of immunosuppression are present in cervical cancer. The results foster research in the design of possible strategies to inhibit ASE activity for therapy of cervical cancer. © 2014 Elsevier Inc.


Pareja R.,Institute Cancerologia Las Americas | Rendon G.J.,Institute Cancerologia Las Americas | Sanz-Lomana C.M.,Hospital Quiron | Monzon O.,Hospital San Jose | Ramirez P.T.,University of Houston
Gynecologic Oncology | Year: 2013

Objective. Radical trachelectomy is a standard treatment for selected patients with early-stage cervical cancer. Outcomes arewell established for vaginal radical trachelectomy (VRT), but not for abdominal radical trachelectomy (ART). Methods. We searchedMEDLINE, EMBASE, and CINAHL (October 1997 through October 2012) using the terms: uterine cervix neoplasms, cervical cancer, abdominal radical trachelectomy, vaginal radical trachelectomy, fertility sparing, and fertility preservation.We included original articles, case series, and case reports. Excluded were review articles, articles with duplicate patient information, and articles not in English. Results. We identified 485 patients. Ages ranged from 6 to 44 years. Themost common stage was IB1 (331/464; 71%), and the most common histologic subtype was squamous cell carcinoma (330/470; 70%). Operative times ranged from 110 to 586 min. Blood loss ranged from 50 to 5568 mL. Three intraoperative complications were reported. Forty-seven patients (10%) had conversion to radical hysterectomy. One hundred fifty-five patients (35%) had a postoperative complication. The most frequent postoperative complication was cervical stenosis (n = 42; 9.5%). The median follow-up time was 31.6 months (range, 1-124). Sixteen patients (3.8%) had disease recurrence. Two patients (0.4%) died of disease. A total of 413 patients (85%) were able tomaintain their fertility. A total of 113 patients (38%) attempted to get pregnant, and 67 of them (59.3%) were able to conceive. Conclusion. ART is a safe treatment option in patients with early-stage cervical cancer interested in preserving fertility. © 2013 Elsevier Inc. All rights reserved.


Vieira M.A.,Barretos Cancer Hospital | Rendon G.J.,Institute Cancerologia Las Americas | Munsell M.,University of Houston | Echeverri L.,Institute Cancerologia Las Americas | And 6 more authors.
Gynecologic Oncology | Year: 2015

Objectives Radical trachelectomy is considered standard of care in patients with early-stage cervical cancer interested in future fertility. The goal of this study was to compare operative, oncologic, and fertility outcomes in patients with early-stage cervical cancer undergoing open vs. minimally invasive radical trachelectomy. Methods A retrospective review was performed of patients from four institutions who underwent radical trachelectomy for early-stage cervical cancer from June 2002 to July 2013. Perioperative, oncologic, and fertility outcomes were compared between patients undergoing open vs. minimally invasive surgery. Results A total of 100 patients were included in the analysis. Fifty-eight patients underwent open radical trachelectomy and 42 patients underwent minimally invasive surgery (MIS = laparoscopic or robotic). There were no differences in patient age, body mass index, race, histology, lymph vascular space invasion, or stage between the two groups. The median surgical time for MIS was 272 min [range, 130-441 min] compared with 270 min [range, 150-373 min] for open surgery (p = 0.78). Blood loss was significantly lower for MIS vs. laparotomy (50 mL [range, 10-225 mL] vs. 300 mL [50-1100 mL]) (p < 0.0001). Nine patients required blood transfusion, all in the open surgery group (p = 0.010). Length of hospitalization was shorter for MIS than for laparotomy (1 day [1-3 days] vs. 4 days [1-9 days]) (p < 0.0001). Three intraoperative complications occurred (3%): 1 bladder injury, and 1 fallopian tube injury requiring unilateral salpingectomy in the MIS group and 1 vascular injury in the open surgery group. The median lymph node count was 17 (range, 5-47) for MIS vs. 22 (range, 7-48) for open surgery (p = 0.03). There were no differences in the rate of postoperative complications (30% MIS vs. 31% open surgery). Among 83 patients who preserved their fertility (33 MIS vs. 50 open surgery), 34 (41%) patients attempted to get pregnant. Sixteen (47%) patients were able to do so (MIS: 2 vs. laparotomy: 14, p = 0.01). The pregnancy rate was higher in the open surgery group when compared to the MIS group (51% vs. 28%, p = 0.018). However, median follow-up was shorter is the MIS group compared with the open surgery group (25 months [range, 10-69] vs. 66 months [range, 11-147]). To date, there has been one recurrence in the laparotomy group and none in the MIS group. Conclusions Our results suggest that radical trachelectomy via MIS results in less blood loss and a shorter hospital stay. Fertility rates appear higher in patients undergoing open radical trachelectomy. © 2015 Elsevier Inc.


PubMed | University of Houston, Institute Cancerologia Las Americas and Barretos Cancer Hospital
Type: Journal Article | Journal: Gynecologic oncology | Year: 2015

Radical trachelectomy is considered standard of care in patients with early-stage cervical cancer interested in future fertility. The goal of this study was to compare operative, oncologic, and fertility outcomes in patients with early-stage cervical cancer undergoing open vs. minimally invasive radical trachelectomy.A retrospective review was performed of patients from four institutions who underwent radical trachelectomy for early-stage cervical cancer from June 2002 to July 2013. Perioperative, oncologic, and fertility outcomes were compared between patients undergoing open vs. minimally invasive surgery.A total of 100 patients were included in the analysis. Fifty-eight patients underwent open radical trachelectomy and 42 patients underwent minimally invasive surgery (MIS=laparoscopic or robotic). There were no differences in patient age, body mass index, race, histology, lymph vascular space invasion, or stage between the two groups. The median surgical time for MIS was 272min [range, 130-441min] compared with 270min [range, 150-373min] for open surgery (p=0.78). Blood loss was significantly lower for MIS vs. laparotomy (50mL [range, 10-225mL] vs. 300mL [50-1100mL]) (p<0.0001). Nine patients required blood transfusion, all in the open surgery group (p=0.010). Length of hospitalization was shorter for MIS than for laparotomy (1day [1-3 days] vs. 4days [1-9 days]) (p<0.0001). Three intraoperative complications occurred (3%): 1 bladder injury, and 1 fallopian tube injury requiring unilateral salpingectomy in the MIS group and 1 vascular injury in the open surgery group. The median lymph node count was 17 (range, 5-47) for MIS vs. 22 (range, 7-48) for open surgery (p=0.03). There were no differences in the rate of postoperative complications (30% MIS vs. 31% open surgery). Among 83 patients who preserved their fertility (33 MIS vs. 50 open surgery), 34 (41%) patients attempted to get pregnant. Sixteen (47%) patients were able to do so (MIS: 2 vs. laparotomy: 14, p=0.01). The pregnancy rate was higher in the open surgery group when compared to the MIS group (51% vs. 28%, p=0.018). However, median follow-up was shorter is the MIS group compared with the open surgery group (25months [range, 10-69] vs. 66months [range, 11-147]). To date, there has been one recurrence in the laparotomy group and none in the MIS group.Our results suggest that radical trachelectomy via MIS results in less blood loss and a shorter hospital stay. Fertility rates appear higher in patients undergoing open radical trachelectomy.


Ramirez P.T.,University of Houston | Pareja R.,Institute Cancerologia Las Americas | Rendon G.J.,Institute Cancerologia Las Americas | Millan C.,Hospital Quiron | And 2 more authors.
Gynecologic Oncology | Year: 2014

The standard treatment for women with early-stage cervical cancer (IA2-IB1) remains radical hysterectomy with pelvic lymphadenectomy. In select patients interested in future fertility, the option of radical trachelectomy with pelvic lymphadenectomy is also considered a viable option. The possibility of less radical surgery may be appropriate not only for patients desiring to preserve fertility but also for all patients with low-risk early-stage cervical cancer. Recently, a number of studies have explored less radical surgical options for early-stage cervical cancer, including simple hysterectomy, simple trachelectomy, and cervical conization with or without sentinel lymph node biopsy and pelvic lymph node dissection. Such options may be available for patients with low-risk early-stage cervical cancer. Criteria that define this low-risk group include: squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma, tumor size < 2 cm, stromal invasion < 10 mm, and no lymph-vascular space invasion. In this report, we provide a review of the existing literature on the conservative management of cervical cancer and describe ongoing multi-institutional trials evaluating the role of conservative surgery in selected patients with early-stage cervical cancer. © 2013 Elsevier Inc.


PubMed | Hospital Quiron, Institute Cancerologia Las Americas and University of Houston
Type: Journal Article | Journal: Gynecologic oncology | Year: 2014

The standard treatment for women with early-stage cervical cancer (IA2-IB1) remains radical hysterectomy with pelvic lymphadenectomy. In select patients interested in future fertility, the option of radical trachelectomy with pelvic lymphadenectomy is also considered a viable option. The possibility of less radical surgery may be appropriate not only for patients desiring to preserve fertility but also for all patients with low-risk early-stage cervical cancer. Recently, a number of studies have explored less radical surgical options for early-stage cervical cancer, including simple hysterectomy, simple trachelectomy, and cervical conization with or without sentinel lymph node biopsy and pelvic lymph node dissection. Such options may be available for patients with low-risk early-stage cervical cancer. Criteria that define this low-risk group include: squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma, tumor size <2 cm, stromal invasion <10mm, and no lymph-vascular space invasion. In this report, we provide a review of the existing literature on the conservative management of cervical cancer and describe ongoing multi-institutional trials evaluating the role of conservative surgery in selected patients with early-stage cervical cancer.


PubMed | Institute Cancerologia Las Americas
Type: Journal Article | Journal: Gynecologic oncology | Year: 2013

Radical trachelectomy is a standard treatment for selected patients with early-stage cervical cancer. Outcomes are well established for vaginal radical trachelectomy (VRT), but not for abdominal radical trachelectomy (ART).We searched MEDLINE, EMBASE, and CINAHL (October 1997 through October 2012) using the terms: uterine cervix neoplasms, cervical cancer, abdominal radical trachelectomy, vaginal radical trachelectomy, fertility sparing, and fertility preservation. We included original articles, case series, and case reports. Excluded were review articles, articles with duplicate patient information, and articles not in English.We identified 485 patients. Ages ranged from 6 to 44 years. The most common stage was IB1 (331/464; 71%), and the most common histologic subtype was squamous cell carcinoma (330/470; 70%). Operative times ranged from 110 to 586 min. Blood loss ranged from 50 to 5568 mL. Three intraoperative complications were reported. Forty-seven patients (10%) had conversion to radical hysterectomy. One hundred fifty-five patients (35%) had a postoperative complication. The most frequent postoperative complication was cervical stenosis (n=42; 9.5%). The median follow-up time was 31.6 months (range, 1-124). Sixteen patients (3.8%) had disease recurrence. Two patients (0.4%) died of disease. A total of 413 patients (85%) were able to maintain their fertility. A total of 113 patients (38%) attempted to get pregnant, and 67 of them (59.3%) were able to conceive.ART is a safe treatment option in patients with early-stage cervical cancer interested in preserving fertility.

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