Fabio Landoni

Genomic instability analysis in DNA from Papanicolaou test provides proof-of-principle early diagnosis of high-grade serous ovarian cancer

Late diagnosis and the lack of screening methods for early detection define high-grade serous ovarian cancer (HGSOC) as the gynecological malignancy with the highest mortality rate. In the work presented here, we investigated a retrospective and multicentric cohort of 250 archival Papanicolaou (Pap) test smears collected during routine gynecological screening. Samples were taken at different time points (from 1 month to 13.5 years before diagnosis) from 113 presymptomatic women who were subsequently diagnosed with HGSOC (pre-HGSOC) and from 77 healthy women. Genome instability was detected through low-pass whole-genome sequencing of DNA derived from Pap test samples in terms of copy number profile abnormality (CPA). CPA values of DNA extracted from Pap test samples from pre-HGSOC women were substantially higher than those in samples from healthy women. Consistently with the longitudinal analysis of clonal pathogenic TP53 mutations, this assay could detect HGSOC presence up to 9 years before diagnosis. This finding confirms the continual shedding of tumor cells from fimbriae toward the endocervical canal, suggesting a new path for the early diagnosis of HGSOC. We integrated the CPA score into the EVA (early ovarian cancer) test, the sensitivity of which was 75% (95% CI, 64.97 to 85.79), the specificity 96% (95% CI, 88.35 to 100.00), and the accuracy 81%. This proof-of-principle study indicates that the early diagnosis of HGSOC is feasible through the analysis of genomic alterations in DNA from endocervical smears.

Hysterectomy alone vs. hysterectomy plus sentinel node mapping in endometrial cancer: Perioperative and long-term results from a propensity-score based study

To compare outcomes after hysterectomy and hysterectomy plus sentinel node mapping (SNM) in endometrial cancer (EC) patients. This is a retrospective study, collecting data of EC patients treated between 2006 and 2016 in nine referral centers. The study population included 398 (69.5%) and 174 (30.5%) patients having hysterectomy and hysterectomy plus SNM. As the results of the adoption of a propensity-score matched analysis, we selected two homogeneous cohort of patients (150 having hysterectomy only vs. 150 having hysterectomy plus SNM). The SNM group had a longer operative time, but did not correlate with length of hospital stay and estimated blood loss. Overall severe complication rates were similar between groups (0.7% in the hysterectomy group vs. 1.3% in the hysterectomy plus SNM group; p = 0.561). No lymphatic-specific complication occurred. Overall, 12.6% of patients having SNM were diagnosed with disease harboring in their lymph nodes. Adjuvant therapy administration rate was similar between groups. Considering patients having SNM, 4% of patients received adjuvant therapy on the basis of nodal status alone; all the other patients received adjuvant therapy also on the basis of uterine risk factors. Five-year disease-free (p = 0.720) and overall (p = 0.632) survival was not influenced by surgical approach. Hysterectomy (with or without SNM) is a safe and effective method for managing EC patients. Potentially, these data support the omission of side specific lymphadenectomy in case of unsuccessful mapping. Further evidence is warranted in to confirm the role SNM in the era of molecular/genomic profiling.

Factors associated with bilateral sentinel lymph node mapping failure using indocyanine green in patients with apparent early-stage cervical cancer: An Italian retrospective multi-center study

The primary aim of this study was to assess the factors associated with bilateral mapping failure in patients with apparent early-stage cervical cancer undergoing sentinel lymph node (SLN) biopsy using indocyanine green (ICG). Secondary aims were sensitivity, negative predictive value and lymph node recurrence. Retrospective multi-center study. Patients with cervical cancer apparent FIGO stage IA1 to IIA2, treated with primary surgery between 04/2015 and 12/2023 and undergoing SLN mapping attempt with ICG injection, were included. Appropriate statistical analysis was performed to assess study endpoints. Timeframe was divided in first period 04/2015-12/2019 and second period 01/2020-12/2023. 618 patients were included. Bilateral SLN mapping was achieved in 531 (85.9 %) women (36 of them, 5.8 %, underwent cervical re-injection of ICG). SLN unilateral mapping and mapping failure was observed in 71 (11.5 %) and 16 (2.6 %), respectively. The sensitivity, negative predictive value and accuracy were 85.9 %, 98.1 % and 98.3 %, respectively. False negative rate was 4/68 (5.9 %) in patients with unilateral mapping versus 6/316 (1.9 %) in those with bilateral mapping (p = 0.061). BMI>30 (p = 0.001) and pathologic tumor diameter >20 mm (p = 0.023) were the only factors independently associated with bilateral SLN mapping failure. ICG re-injection increased the rate of bilateral SLN detection from 81.3 % to 85.9 %. The rate of bilateral detection was 82.8 % versus 88.3 % in the first versus second study period, respectively (p = 0.061). 3-year DFS and OS in all patients were 89.7 % and 98.2 %, respectively. Seven patients (1.2 %) had lymph node recurrence in the group of any SLN mapping versus 1 (6.3 %) in no mapping group (p = 0.190). High BMI and larger tumors were associated with bilateral SLN mapping failure using ICG. The ICG cervical re-injection increased the rate of bilateral mapping. No lymph node recurrence difference was found in patients undergoing SLN mapping versus patients with mapping failure.

Genome-wide Copy-number Alterations in Circulating Tumor DNA as a Novel Biomarker for Patients with High-grade Serous Ovarian Cancer

Abstract Purpose: High-grade serous epithelial ovarian cancer (HGS-EOC) is defined by high levels of somatic copy-number alterations (SCNA) with marked spatial and temporal tumor heterogeneity. Biomarkers serving to monitor drug response and detect disease recurrence are lacking, a fact which reflects an unmet clinical need. Experimental Design: A total of 185 plasma samples and 109 matched tumor biopsies were collected from 46 patients with HGS-EOC, and analyzed by shallow whole-genome sequencing (sWGS). The percentage of tumor fraction (TF) in the plasma was used to study the biological features of the disease at the time of diagnosis (T0) and correlated with patients' survival. Longitudinal analysis of TF was correlated with CA-125 levels and radiological images to monitor disease recurrence. Results: Gain in the clonal regions, 3q26.2 and 8q24.3, was observed in the 87.8% and 78.05% of plasma samples, suggesting that plasma sWGS mirrors solid biopsies. At T0, multivariate analysis revealed that plasma TF levels were an independent prognostic marker of relapse (P < 0.022). After platinum (Pt)-based treatment, circulating tumor DNA (ctDNA) analysis showed a change in the heterogeneous pattern of genomic amplification, including an increased frequency of amplification, compared with before Pt-based treatment in the 19p31.11 and 19q13.42 regions. TF in serially collected ctDNA samples outperformed CA-125 in anticipating clinical and radiological progression by 240 days (range, 37–491). Conclusions: Our results support the notion that sWGS is an inexpensive and useful tool for the genomic analysis of ctDNA in patients with HGS-EOC to monitor disease evolution and to anticipate relapse better than serum CA-125, the routinely used clinical biomarker. See related commentary by Dhani, p. 2372

Copy number alterations in stage I epithelial ovarian cancer highlight three genomic patterns associated with prognosis

Stage I epithelial ovarian cancer (EOC) encompasses five histologically different subtypes of tumors confined to the ovaries with a generally favorable prognosis. Despite the intrinsic heterogeneity, all stage I EOCs are treated with complete resection and adjuvant therapy in most of the cases. Owing to the lack of robust prognostic markers, this often leads to overtreatment. Therefore, a better molecular characterization of stage I EOCs could improve the assessment of the risk of relapse and the refinement of optimal treatment options. 205 stage I EOCs tumor biopsies with a median follow-up of eight years were gathered from two independent Italian tumor tissue collections, and the genome distribution of somatic copy number alterations (SCNAs) was investigated by shallow whole genome sequencing (sWGS) approach. Despite the variability in SCNAs distribution both across and within the histotypes, we were able to define three common genomic instability patterns, namely stable, unstable, and highly unstable. These patterns were based on the percentage of the genome affected by SCNAs and on their length. The genomic instability pattern was strongly predictive of patients' prognosis also with multivariate models including currently used clinico-pathological variables. The results obtained in this study support the idea that novel molecular markers, in this case genomic instability patterns, can anticipate the behavior of stage I EOC regardless of tumor subtype and provide valuable prognostic information. Thus, it might be propitious to extend the study of these genomic instability patterns to improve rational management of this disease.

Particle Beam Re-irradiation in Oligo Recurrent Gynecological Malignancies

This study aimed to evaluate the efficacy and safety of proton beam radiotherapy (PBRT) and carbon ion radiotherapy (CIRT) as salvage treatments for oligorecurrent gynecological cancers. A retrospective analysis was performed on consecutive patients treated with PBRT or CIRT for recurrent gynecological tumors. The primary endpoints included the objective response rate (ORR) as well as 1- and 2-year local control (LC) survival rates. Toxicity was assessed as a secondary endpoint and graded according to the Common Terminology Criteria for Adverse Events (CTCAE) 5.0 scale. Actuarial outcomes were evaluated using the Kaplan-Meier method, and predictors were identified with the Log-rank test. A total of 27 patients (median age: 64.5 years; IQR = 56.0, 69.0) with 28 recurrent lesions were treated with either PBRT (N = 12) or CIRT (N = 16), without concurrent systemic therapies. The majority of patients were treated for recurrences of cervical cancer (N = 8, 29%), endometrial cancer (N = 7, 25%), and ovarian cancer (N = 6, 21%). The most frequent site of recurrence was lymph nodes (N = 14, 50%). Lesions treated with CIRT had a larger volume (median volume 118 [IQR = 66, 233.5] vs. 99 [IQR = 54, 152.3]) and lower alpha/beta ratios (median = 3.8 [IQR = 3.5, 4.5] vs. 7.3 [IQR = 3.5, 10.0]). The overall ORR was 68% within 6 months and did not significantly vary between the groups (p = 0.687). The 1- and 2-year LC rates were 100% and 100% for PBRT, compared to 83% and 62% for CIRT (p = 0.075). Larger lesion volumes (p = 0.035) and failure to achieve an ORR (p = 0.009) were associated with worse LC outcomes, while lymph node recurrences (p = 0.052) and lower alpha/beta ratios (p = 0.078) were potentially linked to better LC. Both treatments were well tolerated, with no grade ≥3 toxicities observed. PBRT and/or CIRT appeared as an effective and safe option for recurrent gynecological cancers in a real-world setting. Larger cohorts and longer follow-up are needed for further validation and refining patient selection.

Neoadjuvant chemotherapy followed by interval surgery versus primary debulking surgery in FIGO stage III-IV epithelial ovarian cancer: A systematic review and meta-analysis.

To compare survival and perioperative outcomes of Primary debulking surgery (PDS) versus neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) in newly diagnosed FIGO stage III-IV ovarian cancer. Primary outcomes were overall survival (OS) and progression-free survival (PFS). MEDLINE, Embase, CENTRAL, Web of Science, Scopus, Cochrane Library, major conference proceedings (inception to July 13, 2025) STUDY SELECTION: Phase-III randomized trials comparing survival outcomes between PDS and NACT-IDS, enrolling adults with newly diagnosed stage III-IV epithelial ovarian, fallopian tube, or primary peritoneal cancer. Following PRISMA, two reviewers independently screened, extracted and assessed risk-of-bias (RoB 1). Random-effects meta-analysis estimated pooled hazard ratios (HRs) for OS/PFS and risk ratios (RRs) for binary endpoints. Heterogeneity was quantified with the I² statistic. PROSPERO (CRD420251056445). Five RCTs (n = 2380 women), including one conference-only report, met criteria. NACT-IDS yielded no difference in OS (HR 1.00; 95 % CI 0.90-1.12; I² = 16 %) and PFS (HR 1.03; 95 % CI 0.92-1.16; I² = 39 %) versus PDS. Grade ≥ 3 perioperative complications were significantly less frequent with NACT-IDS (RR 0.43; 95 % CI 0.25-0.74; I² = 75 %) while CC-0 rates were higher (RR 2.02; 95 % CI 1.26-3.24; I² = 94 %). In FIGO stage III-IV, NACT-IDS achieves survival endpoints similar to PDS, while increasing the likelihood of complete macroscopic resection and reducing severe perioperative morbidity. Upfront surgery in advanced ovarian cancer management should likely be reserved for patients with feasible complete resection and presumed low morbidity.

The paradigm shift in advanced ovarian cancer: Outcomes of extensive primary cytoreductive surgery. A single-center retrospective analysis

The standard surgical treatment of advanced ovarian carcinoma is primary debulking surgery (PDS) aiming to complete cytoreduction. The need to achieve complete cytoreduction has shifted the surgical paradigm to more complex procedures, whose impact on morbidity is controversial. The objective of this retrospective analysis is to explore the impact of extensive PDS on morbidity and oncologic outcomes in a real-world scenario. A retrospective single-center analysis was performed on 137 patients with advanced high-grade ovarian carcinoma (HGOC) who received PDS in 2015-2020. Patients treated in 2015-2017 (Group 1) were compared to patients treated in 2018-2020 (Group 2). The two periods were chosen according to the higher complexity of surgical procedures introduced in 2018. The increase in complete cytoreduction observed in Group2 (RD 0: 33 % vs 61 %, p = 0,008) was related to a higher surgical complexity (Aletti Score: 4 vs 6, p = 0,003) and did not reflect an increase in peri-operative complications (CCI: 20,9 vs 20,9, p = 0,11). After a median FUP of 44 months, PFS and OS at 24 months were 33,60 % vs 47,33 % (p = 0,288) and 72,10 % vs 80,37 % (p = 0,022) in Group 1 and 2, respectively. An extensive surgical effort leads to a significant increase in complete cytoreduction with acceptable morbidity. Arm-in-arm with novel maintenance therapies, it contributes to increasing the outcomes of patients with advanced HGOC.

Accuracy of Human Papillomavirus (HPV) Testing on Urine and Vaginal Self-Samples Compared to Clinician-Collected Cervical Sample in Women Referred to Colposcopy

In the context of cervical cancer prevention, where human papillomavirus (HPV) infection is pivotal, HPV testing is replacing Pap Smear in primary screening. This transition offers an opportunity for integrating self-sampling to enhance coverage. We evaluated the accuracy of HPV testing using self-collected urine and vaginal samples, comparing them to physician-collected cervical swabs. From a cohort of 245 women with abnormal cytology, we collected self-sampled vaginal, urine, and clinician-administered cervical specimens. Employing Anyplex™II HPV28 assay, outcomes revealed HPV positivity rates of 75.1% (cervical), 78.4% (vaginal), and 77.1% (urine). Significant, hr-HPV detection concordance was observed between self-taken cervical samples and clinical counterparts (k = 0.898 for vaginal; k = 0.715 for urine). This study extends beyond accuracy, highlighting self-collected sample efficacy in detecting high-grade cervical lesions. The insight underscores self-sampling’s role in bolstering participation and aligns with WHO’s goal to eliminate cervical cancer by 2030.