Surgery for Uterine Preservation in Placenta Accreta Spectrum: A Retrospective Cohort Study

Background: Owing to high risks of maternal morbidity, surgical complications, and loss of fertility, including psychological trauma caused by cesarean hysterectomy, innovative approaches for uterine preservation have been investigated. This study aimed to determine the efficacy of a novel eight-step surgical protocol for uterine preservation in placenta accreta spectrum (PAS) overlying the previous cesarean scar.Methods: We retrospectively studied consecutive patients with PAS overlying the cesarean scar, who were treated between December 2015 and October 2019 using the protocol. The depth and extension of placental invasion and severity of pelvic adhesion were assessed intraoperatively. Information regarding the gestational week at surgery, surgery duration, estimated blood loss (EBL), bladder injury, and post-procedural recovery was retrieved from the hospital database. Multiple linear regression was used to analyze factors influencing surgical blood loss. EBL was compared between the perioperative aortic balloon and non-balloon groups in severe cases using t-tests.Results: Overall, 115 patients with PAS were included. The mean EBL and surgery duration were 1666.1±1379.0 mL and 2.2±0.8 h, respectively. The uterus was successfully preserved in all patients with one surgery. Incidences of placenta accreta, increta, and percreta were 40 (35.8%), 46 (40.0%), and 29 (25.2%) cases, respectively. Extensive placental invasion and cervical involvement were observed in 41.7% and 28.7% of patients, respectively. EBL was significantly correlated with the extent of placental invasion, cervical involvement, and pelvic adhesion. No difference was seen in EBL between the balloon and non-balloon groups among the 44 patients with severe PAS.Conclusion: The eight-step protocol is effective for uterine preservation in PAS overlying the cesarean scar. EBL is affected by the extent of placental invasion, cervical involvement, and severity of pelvic adhesion. Perioperative aortic balloon should be used conservatively.

Pseudotumoral Tuberculosis of the Cervix: A Case Report

Aim: We aimed to present a rare case of pseudotumoral tuberculosis of the cervix. Introduction: Tuberculosis has many localizations. Urogenital and particularly cervical involvement is rare. Case Presentation: Our observation concerned a case of pseudotumoral tuberculosis of the uterine cervix simulating a cancer. The clinical signs were pelvic pain and metrorrhagia, which were non-specific. The ulcerative-bourgeons appearance of the cervix was suggestive of cancer. Histology allowed the diagnosis to be made by showing an inflammatory granuloma and the absence of malignant cells. Despite the absence of bacteriological evidence, the clinical, biological, and histological presumptive arguments and the good therapeutic response made it possible to correct the diagnosis. The prognosis of our patient was mainly functional due to the risk of infertility. Conclusion: The interest of this observation lay in the rarity of this tuberculosis localization, especially in an immunocompetent subject, and the predominant place of histology.

Preoperative Assessment of Cervical Involvement in Endometrial Cancer by Transvaginal Ultrasound and Magnetic Resonance Imaging: A Systematic Review and Meta-Analysis

Objective To compare the diagnostic accuracy of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) for detecting cervical infiltration by endometrial carcinoma using meta-analysis assessment. Methods An extensive search of papers comparing TVS and MRI for assessing cervical infiltration in endometrial cancer in the same set of patients was performed in Medline (Pubmed), Web of Science, and the Cochrane Database. Quality was assessed using QUADAS-2 tool (Quality Assessment of Diagnostic Accuracy Studies-2). Quantitative meta-analysis was performed. Results Our extended search identified 12 articles that used both techniques in the same set of patients and were included in the meta-analysis. The risk of bias for most studies was high for patient selection and index tests in QUADAS-2. Overall, the pooled estimated sensitivity and specificity for diagnosing cervical infiltration in women with endometrial cancer were identical for both techniques [69 % (95 % CI, 51 %–82 %) and 93 % (95 % CI, 90 %–95 %) for TVS, and 69 % (95 % CI, 57 %–79 %) and 91 % (95 % CI, 90 %–95 %) for MRI, respectively]. No statistical differences were found when comparing both methods. Heterogeneity was high for sensitivity and moderate for specificity when analyzing TVS and moderate for both sensitivity and specificity in the case of MRI. Conclusion TVS and MRI showed very similar diagnostic performance for diagnosing cervical involvement in women with endometrial cancer.

How do different histologic components of mixed endometrial carcinomas affect prognosis? Does it really matter?

The aim of this study is to evaluate and compare outcomes of patients with mixed and pure endometrial carcinomas (MEC). We reviewed data of patients with MEC, endometroid (EC), serous (SC), and clear cell (CC) carcinomas between 2002 and 2015. Overall survival (OS) and disease-free (DF) survival rates were evaluated, according to the percentage of histologic components. Clinicopathological variables and treatment strategies were assessed. Furthermore, χ2 tests were used to compare proportions and Kaplan–Meier curves to compare recurrence and survival. Sample consisted of 302 cases with mean age 66.3 years. Early-stage disease was recorded in EC compared with CC and SC. Adnexal involvement was more frequent in MEC compared with EC (p=0.043). Extra uterine metastasis was more frequent in the SC compared to the EC group, while lymphovascular space involvement was more frequent in the MEC and CC compared to the SC (p=0.001). EC had less omentum involvement compared to CC (p=0.035) and SC (p<0.001). Furthermore, cervical involvement was more frequent in CC compared to EC (p=0.011). Recurrence (p=0.265) and OS (p=0.533) were found to be similar in MEC compared with CC, SC, and EC. Moreover, recurrence and OS were similar between EC-CC and EC-SC. There were no differences in recurrence and survival in MEC with a type II component larger than 10% or 20% (p>0.05).

Langerhans cell histiocytosis in the occipital condyle: a case study and a brief review of the literature

We present a case study of a 5-year-old patient, who presented with left-sided torticollis. Due to persistence of problems, a CT and an MRI were made showing a single osteolytic lesion centred on right occipital condyle. After an open biopsy, histology confirmed it to be Langerhans cell histiocytosis (LCH). Torticollis or restricted range of motion is a presenting feature in 76% of children with LCH with cervical involvement. There remains much debate on the best treatment strategy. The clinical and radiological outcomes of the case study presented on this article support the treatment of LCH with chemotherapy in cases with solitary involvement of the occipital condyle.

Neoadjuvant radiotherapy and brachytherapy in endometrial cancer with gross cervical involvement: a CHIRENDO research group study

BackgroundHistorically, radical hysterectomy followed by adjuvant radiotherapy has been offered to patients with endometrial cancer who have gross cervical involvement; however, this approach is known to carry considerable morbidity. Neoadjuvant radiotherapy followed by extra-fascial hysterectomy has been proposed as an alternative treatment but has been poorly studied to date.ObjectiveTo evaluate the locoregional control rate associated with neoadjuvant radiotherapy followed by extra-fascial hysterectomy.MethodsA retrospective cohort study of 30 patients with endometrial cancer with gross cervical involvement treated between May 2006 and January 2016 was performed. Eligible patients were those aged >18 years with non-metastatic endometrial adenocarcinoma and gross cervical disease treated with curative intent at the Centre hospitalier de l’Université de Montréal. Treatment protocol consisted of pelvic neoadjuvant radiotherapy and high-dose rate brachytherapy followed by extra-fascial hysterectomy. Kaplan-Meier curves were used for survival analysis.ResultsThe median age was 60 (range 37–82) and median body mass index was 32 kg/m2 (range 16–55). Twenty-four (80%) patients were diagnosed with a positive cervical/endocervical biopsy. Clinical staging confirmed 36.7% (n=11) as stage II, 20% (n=6) stage IIIB, 30% (n=9) stage IIIC1, and 13.3% (n=4) stage IIIC2. Seventy-seven per cent (n=23) of patients had an endometrioid histology. Locally advanced disease was identified by imaging alone in six patients. Rates of parametrial, adnexal, vaginal, and nodal invasion were 10% (n=3), 6.7% (n=2), 13.3% (n=4), and 43.3% (n=13) at diagnosis, respectively. All patients completed pelvic radiotherapy (13.3% extended field) and 90% received brachytherapy. Twenty per cent (n=6) of surgeries were performed using minimal invasive technique. On surgical specimen, 63.3% (n=19) had complete cervical response, 90% (n=27) had negative margins, and 10% (n=3) had residual nodal involvement. Median follow-up time was 62 months (range 1–120). Six recurrences were identified; all except one involved distant failure, and two with locoregional failure. Five-year locoregional control rate, disease-free, overall, and disease-specific survival were 90.5%, 78.5%, 92.6%, and 96.2%, respectively. Two patients (6.7%) had grade 3+ acute radiation-related complications (all grade 3). Grade 3+ post-operative morbidity was noted in 2 (6.7%) patients.ConclusionsNeoadjuvant radiotherapy followed by extra-fascial hysterectomy offers good locoregional control with low treatment-related morbidity in patients with endometrial cancer with overt cervical involvement.