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Objectives The purpose of this study was to assess the effectiveness of ultrasound (US)-guided aspiration for the management of low-risk adnexal cysts. Methods A longitudinal cohort of women with a low-risk adnexal cyst who underwent transvaginal US-guided aspiration from January 2012 to April 2018 were included. All procedures were performed on an outpatient basis, without anesthesia, sedation, or antibiotics. The posttreatment follow-up protocol included transvaginal US at 3 and 12 months. Potential risk factors for recurrence (ie, age, menopausal status, comorbidities, symptoms, cyst diameter, incomplete emptying, and location) were analyzed by multiple logistic regression. Results A total of 156 patients were included. The median (interquartile range) cyst diameter was 66 (58-80) mm. Fifty-seven (36.5%) cases were resolved by US-guided aspiration. The median follow-up time was 556.5 (344-1070.25) days. The complication rate of the procedure was 2.6% (n = 4), with 3 cases of a major complication due to a pelvic abscess and 1 case of a minor complication due to self-limited vaginal spotting. A larger cyst size (odds ratio, 1.01; 95% confidence interval, 1.04-1.07; P = .002) and an older age (odds ratio, 1.01; 95% confidence interval, 1.03-1.05; P = .007) at diagnosis were independent factors related to recurrence. Conclusions Based on the low resolution rate, US-guided aspiration is not an effective option for the treatment of low-risk adnexal cysts. Risk factors associated with recurrence were age and cyst size at diagnosis. Larger randomized studies are necessary to assess predictive factors for cyst recurrence.

An umbilical cord knot is an unexpected event that should not change obstetric approach for delivery.

Resumen Objetivo Conocer la situacion actual de la cirugia locorregional y reconstruccion mamaria (RM) en pacientes con cancer de mama metastasico (CMM) en Espana. Metodo Desde abril a septiembre de 2016 se recogieron datos de una encuesta online difundida a medicos implicados en el tratamiento de este grupo de pacientes. Resultados Hubo un total de 124 encuestados: 46% cirujanos plasticos, 17,5% cirujanos generales, 30% ginecologos especializados en enfermedad mamaria y 6,5% de otras especialidades no quirurgicas. El 47,5% de los encuestados indico la cirugia locorregional en el CMM al diagnostico. El 80% de los encuestados acepto la RM en el CMM, de los cuales un 71,5% lo consideraria previa solicitud por la paciente. En pacientes que no recibiran radioterapia, el 84% de los encuestados opto por RM inmediata, el 72,5% mediante protesis. En pacientes radiadas, el 77,5% de los encuestados opto por reconstruccion autologa, un 74,5% con colgajo miocutaneo dorsal ancho; no hubo diferencias entre RM inmediata o RM diferida. Factores considerados para aceptar la RM fueron una expectativa de vida de al menos 2 anos, las comorbilidades, la carga tumoral, la respuesta al tratamiento sistemico o un tiempo de enfermedad estable superior a 6 meses. Motivos para no realizar la RM fueron un mal pronostico asociado y el riesgo de progresion metastasica ante la suspension temporal del tratamiento sistemico. Conclusion La mitad de los encuestados considero la RM en una paciente con CMM al diagnostico, valorando la carga tumoral, la expectativa de vida y la enfermedad estable. Se necesitan protocolos de actuacion al respecto.

ObjectiveThe purpose of this study is to asses the impact of lymphovascular space invasion (LVSI) present in early-stage endometrial cancer, regarding its therapeutic management and prognosis knowledge, based on a survey among Spanish oncologic gynecologist.Methods/MaterialsBetween October and November 2014, the Young Spanish Onco-gynecologist Group carried out a survey to perform a cross-sectional study about the management of LVSI. All active members in the oncology field of the Spanish Society of Gynecology and Obstetrics were invited to participate in the survey.ResultsMost respondents consider LVSI a bad prognosis factor for endometrial cancer (66%) and also consider that it should be included in the International Federation of Gynecology and Obstetrics classification (56%). Seventy-five percent of all gynecologists did not modify their surgical treatment. Regarding follow-up, 38% of the respondents do not change their surveillance, 28% modify it, and 31% reported any change only with additional factors. Forty-seven percent of respondents advise systemic treatment with chemotherapy.Data were dichotomized between less than or equal to 20 versus greater than 20 years of OB-GYN specialist and less than or equal to 5 versus greater than 5 years of main dedication to gynecology oncology, but it was not possible to show any significant differences among the groups. The response rate (34 individuals) was too low to expect any significant differences.ConclusionsResults suggest that LVSI remains a controversial issue in the management of patients with endometrial cancer. Acquiring a deeper knowledge and uniform criteria could avoid the risk of undertreatment and overtreatment in this group of patients with early-stage endometrial cancer. The identification of vascular pseudoinvasion is recommended, although the clinical and prognostic implications still need to be determined.

PURPOSE The aim of this study was to compare technetium radiocolloid (Tc99(m)) + blue dye (BD) versus Indocyanine green (ICG) fluorescent dye in terms of the overall detection rate and bilateral sentinel lymph node (SLN) mapping in patients with endometrial carcinoma. METHODS Patients from five European centers with apparently confined clinical stage I endometrial cancer were reviewed. A comparison was made between women who received SLN mapping with pelvic and/or aortic lymphadenectomy (LND), and women who underwent SLN algorithm (SA), was also performed between the two groups. RESULTS Three hundred and forty-two (342) women were involved (147 in the Tc99(m) + BD group and 195 in the ICG group). The overall detection rate of SLN biopsy was 97.3% (143/147) for women in the Tc99(m) + BD group and 96.9% (189/195) for women in the ICG group (p = 0.547). The bilateral mapping rate for ICG was 84.1%-significantly higher with respect to the 73.5% obtained with Tc99(m) + BD (p = 0.007). No differences in overall sensitivity (OS) and overall false negative rate (FNR) were seen between LND and SA (p value = 0.311), whereas the negative predictive value (NPV) was in favor of SA group (p value = 0.030). CONCLUSIONS In this study, fluorescent mapping using ICG resulted equivalent to the standard combined radiocolloid and BD, but real-time SLN mapping achieves a higher bilateral detection rate. The added value that this fast emerging technology promises to give certainly warrants future studies to further consolidate the advantages there are over the standard technique.

ObjectiveThe aim of this study was to analyze the prognostic factors related to the recurrence rate and overall survival of vulval melanoma patients by means of a subgroup analysis of the VULvar CANcer study.MethodsThe international multicenter VULvar CANcer study involved 100 international centers, which contributed 2453 vulvar cancer cases. Of the 1727 patients finally included in the study, 42 were suffering from vulvar melanoma (2.4%).ResultsThe mean follow-up for vulval melanoma patients was 44.1±35.7 months. Recurrence rate was 50%, and the mean recurrence-free survival was 43.5±6.6 months. For local recurrences, the mean recurrence-free interval was 63.3±8.6 months; for metastasis, 33.5±3.5 months. The 5-year recurrence-free survival rate was 28.6%. The mean overall survival for vulvar melanomas was 45.9±4 months and the 5-year overall survival rate was 78.6%. The only factor with prognostic significance regarding local recurrence of vulvar melanoma was tumor size (P = 0.003). American Joint Committee on Cancer staging was the only prognostic factor associated with metastatic disease at recurrence (P < 0.001). Finally, age of patient was significantly associated with overall survival (P < 0.001).ConclusionsTumor size and American Joint Committee on Cancer stage were independent prognostic factors associated with local and distant recurrence, respectively. Patients’ age was the only independent prognostic factor associated with overall survival.

Women who carry a mutation in the BRCA1 or BRCA2 genes not only have an increased lifetime risk of developing breast and ovarian cancer, but also a complicated reproductive future. Based on the hypothesis that BRCA germline mutations (BRCAm) are associated with accelerated follicular loss and early menopause, the aim of this paper is to discuss and review the most outstanding recently published articles about BRCA gene and fertility.A literature research in PubMed was conducted, using the keywords "anti-Müllerian hormone", "BRCA1/2 gene", "female fertility", "ovarian reserve" and "premature ovarian failure", selecting outstanding articles published since 2010.BRCA genes, mainly BRCA1, play a role in the maintenance of double-stranded DNA breaks and telomere length, a factor associated with reproductive lifespan and early depletion of ovarian reserve. BRCAm women have a decreased ovarian reserve and worse response in fertility preservation. In the case of being given chemotherapy or tamoxifen, that would increase the apoptosis of follicular reserve. Low Anti-Müllerian hormone serum concentrations have not been shown to affect natural fecundability and fertility in BRCAm women below 30 s, but it does in women above that threshold. Surgical risk reduction salpingo-oophorectomy implies another important limitation in reproductive possibilities. Removal of the fallopian tubes with delayed oophorectomy could be a reasonable strategy in high-risk premenopausal women in the context of a clinical trial.BRCAm women should not delay pregnancy, especially if they are BRCA1, older than 35 years or with previous gonadotoxic treatments. Future prospective studies on infertility outcomes in this population are needed.

The video aims to show the Maylard technique, an extended transverse incision characterized by bilateral ligation of the deep inferior epigastric vessels and transection of the anterior rectus abdominis muscles.[1][1] It is an easy and advantageous alternative to mid-line laparotomy.[1 2][1] The

BACKGROUND Surgery for the primary tumor in metastatic breast cancer is usually not recommended, assuming that local therapy provides no advantage. Recent reports suggest a survival improvement after locoregional treatment, but this is still controversial. We aimed to evaluate the effectiveness of locoregional treatment in primary metastatic breast cancer and to determine associated factors. METHODS A retrospective analysis of 39 women with de-novo metastatic breast cancer at La Paz University Hospital, from January 2012 to June 2016, grouped by locoregional treatment (n=23) or not (n=16). Multivariate assessment of prognostic factors was performed using Cox regression analysis. RESULTS Mean tumor size was 6 cm. Eighteen patients (46.2%) had multifocal tumors, 29 (74.4%) multicentric and 10 (25.7%) bilateral breast cancer. Eighteen patients (46.2%) had an oligometastatic disease and 21 (53.8%) multiorgan metastatic disease. The average time from diagnosis to surgery was 7.7 months, without delay in the start of systemic treatment compared to the no-surgery group. The main surgical procedure was mastectomy in 18 (78.3%) patients. Half of the patients survived 48 months (95% CI: 39-57). In the multivariate analysis, we have not detailed differences in survival by age, chemotherapy, neoadjuvancy, number of systemic treatment lines, radiotherapy, and tumor histology or grade. However, surgery (HR=0.2; 95% CI: 0.07-0.57) and high tumor burden (HR=2.96, 95% CI: 1.23-7.13) have acted as a protective and a risk factor respectively. CONCLUSIONS Our cohort supports that locoregional treatment in selected patients with de-novo MBC significantly improved survival, so it might be considered in combination with systemic therapy.

Background: The purpose was to analyze the casuistry of pelvic floor reconstruction (PFR) with biological mesh (BM) after exenterative radical surgery. Methods: Six patients treated with radical surgery and reconstruction of the perineal defect, conducted with a BM, since April 2011 to June 2016, are described. Results: A total of 5 pelvic exenterations and an anterior pelvic supralevator exenteration were performed, 2 cases included a radical vulvectomy. In 5 patients the BM was placed intraoperatively, combined with myocutaneous bilateral gracilis flap or omentoplasty. Another case required deferred mesh placement due to evisceration through the perineal hole. Mean surgical time was 510 minutes and a median hospitalization of 26 days. Complications were mainly due to infections and abdominal wall dehiscence. There were no pelvic organ prolapses and no mesh had to be removed. The mean follow-up was 8.5 months; halfof the patients are free of disease. Conclusion: Though limited evidence, BM can be a safe and feasible option in cases of radical surgical gynecological procedures with a wide loss of soft tissue. More data is required.

Breast reconstruction (BR) in metastatic breast cancer (MBC) patients is a growing demand. We considered that properly selected patients would benefit from BR. Our aim was to provide recommendations based on our experience and according to the published literature. A retrospective review of the cases of 5 MBC women who underwent BR at Hospital Universitario La Paz, from April 2012 to March 2016, was made. The average age was 47.2 years. All patients had bone metastases, multicentric breast tumor and axillary involvement at diagnosis. Chemotherapy as first-line therapy was given to 80% and radiotherapy in 60% of BR patients. All women undergone modified radical mastectomy and axillary lymphadenectomy, and 3 patients received immediate BR and 2 deferred. The types of BR performed were 3 latissimus dorsi myocutaneous flap (combined with an implant or expander), an expander and a Becker expander implant. Two patients had complications, and 66.7% of expanders were removed. During an average follow-up of 31.5 months, 2 patients died and only one had a local relapse. In selected patients with MBC at diagnosis and after assessing response to systemic treatment, BR could be performed, upon request and acceptance. Individualized surgery is recommended, trying to choose the least aggressive surgical procedure as possible. A protocol with a unified approach is required considering an increased demand of this kind of procedure in anticipation of a major future requirement.

Objective To evaluate the efficacy of one-step nucleic acid amplification (OSNA) for the diagnosis of sentinel lymph node (SLN) metastasis compared with histopathological examination in patients with endometrial carcinoma. Methods A total of 94 SLNs from 34 patients with endometrial carcinoma were enrolled. The central 1-mm portion of each node was subjected to semi-serial sectioning, sliced at 200-μm intervals and examined by hematoxylin and eosin and cytokeratin 19 (CK19) immunohistochemical staining, and the remaining tissue was analysed by OSNA using CK19 mRNA. The accuracy of the OSNA assay was evaluated based on histopathological diagnosis. Results Histologically, 89 SLNs were determined to be metastasis negative, and the remaining five SLNs were metastasis positive. Using the breast cancer cutoff value for detecting lymph node metastasis (OSNA criteria for breast cancer, >250copies/μl) the sensitivity of the OSNA assay was 100%; specificity was 87.6%; diagnostic accuracy was 88.3%. Discordant results were recorded for 11 of 94 SLNs. In all 11 cases, a positive result was given by the OSNA assay but not by histopathological examination. In two SLNs from the same patient, histopathological examination revealed the presence of benign epithelial inclusions that were CK19 positive; both SLNs yielded a positive result in the OSNA assay (true–false positive). All remaining nine histologically-negative/OSNA-positive SLNs were classified as micrometastasis (+) by the OSNA assay. Conclusion The OSNA assay shows high sensitivity and specificity, which suggests its utility as a novel tool for the molecular detection of SLN metastasis in patients with endometrial carcinoma.

Objective To identify prognostic factors associated with recurrence and overall survival among patients with invasive vulvar Paget disease. Methods An analysis was conducted of patients with invasive vulvar Paget disease included in VULCAN, an international multicenter retrospective study of patients diagnosed with vulvar cancer between January 1, 2001, and December 31, 2005. Data regarding diagnosis, treatment, and follow-up were obtained from the patients' medical records. Univariate and multivariate analyses were performed. Results Among 1727 patients registered in the VULCAN database, 38 patients had invasive vulvar Paget disease. The mean follow-up time for these patients was 44.1 ± 35.7 months, the overall recurrence rate (local lesions and distant metastases) was 58%, and the mean overall survival time was 58.5 ± 0.5 months. Case load at the treating center inversely correlated with local recurrence (P = 0.01). Tumor size and FIGO stage were associated with the presence of distant metastases (P < 0.001 for both). Adjuvant therapy (radiotherapy or chemotherapy) was associated with a reduced risk of distant metastases and increased overall survival (P < 0.001 for both). Conclusion Local recurrences of invasive vulvar Paget disease were associated with the case load at the treating center. Distant recurrences were associated with tumor size and FIGO stage. It is possible that adjuvant radiotherapy or chemotherapy could offer patients benefits by increasing overall survival rates.

Background: Synchronous endometrial and ovarian cancer (SEOC) account from 50% to 70% of all synchronous female genital tract malignancies. The incidence of SEOC is among 5% of women with endometrial cancer (EC) and 10% with ovarian cancer (OC). SEOC are more frequent in younger, obese, premenopausal and nulliparous women. It has been proved that SEOC has a better prognosis than a singleorgan disease with metastasis. Aim: Our aim is to describe clinicopathologic characteristics and factors associated with SEOC, by reviewing the recent literature published and describing a very representative case.

Key Clinical Message One of the main risk factors for relapse in vulvar cancer after lymph‐node metastases is free surgical margins. In the case of a relapse, radical vulvectomy with perineal reconstruction is the first choice. Perineal reconstruction is usually indicated in relapse and unusual for a first surgery, except extensive damage 1, 2, 3, 4, 5.