Roberta Massobrio

Nodal staging in high and high-intermediate risk endometrial cancer surgery: Which role in the molecular classification era?

Nodal staging contributes to risk group definition and the indication to adjuvant treatment in endometrial cancer (EC) patients. However, the role of nodal assessment evolved and requires redefinition. Primary outcome of the study was to assess the impact of surgical nodal staging in defining high-risk (HR) EC. Secondary outcome was to evaluate the contribution of nodal assessment to the decision for adjuvant treatment in both high-risk and high-intermediate risk (HIR) patients submitted to surgery. Clinical stage I-II EC patients with postoperative diagnosis of HR and HIR disease were included. The contribution of nodal staging in prognostic groups allocation was assessed by reviewing HR patients to identify those without any other feature of such class (non-endometrioid histology, p53abn immunohistochemistry, post-operative T3-T4 disease) and HIR cases to assess how nodal staging affected adjuvant treatment indication. Descriptive statistics were conducted to describe the two populations. Fifty-seven patients were included, 46 with HR and 11 with HIR disease. Chemotherapy and external-beam radiotherapy (EBRT) were proposed in 40 HR patients. Considering histology, immunohistochemical profile and FIGO stage, high risk classification was exclusively relied on nodal involvement in 2/46 cases (4.3 %). Omitting retroperitoneal staging, one of them would have been classified in the intermediate risk group and the other as HIR: without nodal staging, chemotherapy and EBRT would have been omitted in 1/40 (2.5 %) case. Among HIR patients, chemotherapy was proposed in 7/11 cases and EBRT in all cases. Adjuvant chemotherapy was indicated in 5/6 (83.3 %) and omitted in 1/6 (16.7 %) pN0 patient (stage Ib G2, substantial LVSI). In HIRpN0 patients, omitting nodal staging could have changed adjuvant treatment indication in 1/6 (16.7 %) case. In HIRpNx patients, adjuvant chemotherapy was omitted in one patient (stage II, grade 2 and LVSI negative): nodal staging unavailability might have changed indication to chemotherapy in 1/5 (20 %) case, without changing indication to EBRT. Unavailable nodal staging could globally be related to omission of chemotherapy in 2/57 (3.5 %) patients and of EBRT in 1/57 (1.8 %) patient. In this series, nodal staging had limited impact on definition of HR class and on the choice of adjuvant treatment in HR and HIR EC patients.

Waist-to-hip ratio measured with computed tomography as a predictor of surgical outcomes in minimally invasive procedures for early-stage endometrial cancer

This study aimed to determine if the waist-to-hip ratio, an emerging indicator of abdominal obesity, predicts poor outcomes, such as sentinel node mapping failure, post-operative complications, conversion to laparotomy, and increased operative time, in endometrial cancer surgery. This retrospective study included patients with apparent early-stage endometrial carcinoma who underwent minimally invasive surgery at the Mauriziano Umberto I Hospital in Turin, Italy from January 2021 to January 2025. The waist-to-hip ratio was calculated using pre-operative computed tomography scans with previously described methods. Two cohorts based on a waist-to-hip ratio cutoff of 0.85, as defined by the World Health Organization, were identified and compared with statistical tests as appropriate. Univariate and multi-variable linear regression models were fit to evaluate predictors of poor surgical outcomes. A total of 151 patients were included in the study. Abdominal obesity, as defined by an abnormal waist-to-hip ratio, was identified in 127 patients (84%), of whom 62 also had obesity according to the body mass index. Patients with abnormal waist-to-hip ratios were significantly older (median: 69 vs 61 years; p = .03), had higher body mass index (median: 29 vs 21 kg/m An abnormal waist-to-hip ratio was significantly associated with increased operative time during minimally invasive surgery for endometrial cancer, whereas body mass index was not. Further research is needed to determine the predictive potential of the waist-to-hip ratio for personalized surgical planning.

Ultrasonographic diagnosis of adnexal masses: interobserver agreement in the interpretation of videos, using IOTA terminology

Abstract Objectives Aim of this study is to estimate interobserver agreement in classifying adnexal tumors using IOTA terms, simple rules and subjective assessment. In addition, we related observers’ accuracy with their experience in gynecological ultrasonography and the year of IOTA certification. Methods Eleven observers with three different levels of experience evaluated videoclips of 70 adnexal masses, defining tumor type according to IOTA terms and definitions, classifying the mass using IOTA Simple rules and Subjective assessment as well as providing Color Score evaluation. Sensitivity, specificity and area under the ROC curve were calculated and the year of IOTA certification was related with operators’ accuracy through Pearson correlation coefficient. Interobserver agreement was estimated calculating percentage of agreement, Fleiss kappa and Cohen’s kappa. Results We found a positive correlation between the year of IOTA certification and operators’ accuracy (Pearson coefficient 0.694), especially among the observers with the least experience, the residents (p = 0.003). For tumor type classification, identification of papillary projections and classification of tumors using subjective assessment, agreement among all observers was moderate (Fleiss kappa 0.455, 0.552, and 0.476, respectively) and increased with the years of experience. Agreement in the application of Simple Rules was moderate in all examiners with IOTA certification, with Fleiss kappa in the range of (0.403, 0.498). For Color Score assignment interobserver agreement among all observers was fair (Cohen’s kappa 0.380). Conclusions Even among expert examiners, the results of adnexal lesion assessment can be inconsistent. Experience impacts on accuracy and agreement in subjective assessment, while the application of Simple Rules can mitigate the role of experience in interobserver agreement. The knowledge of IOTA models among residents seams to improve their diagnostic accuracy, showing the benefits of IOTA terminology for in training sonographers.