Tommaso Meschini

Determinants of adjuvant radiotherapy in early-stage cervical cancer: a retrospective analysis of the SUCCOR cohort

This study aimed to describe the patterns of adjuvant therapy use within the SUCCOR cohort, a large retrospective analysis comparing disease-free survival following minimally invasive versus open surgery in early-stage cervical cancer. Furthermore, to assess the factors associated with the indication for adjuvant radiotherapy after radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB (≤4cm) cervical cancer. A retrospective analysis was performed using the SUCCOR study database. We investigated patients with FIGO 2009 stage IB1, node-negative cervical cancer at final pathology. Univariate and multi-variable logistic regression were performed to determine factors associated with the administration of adjuvant radiation therapy. The study included a total of 572 patients. Of these, 340 patients (59.4%) did not receive adjuvant radiotherapy, including 45 (13.2%) who met the Sedlis criteria. Conversely, among the 232 patients (40.6%) who received adjuvant radiotherapy, 132 (56.9%) did not meet Sedlis criteria. In the univariate logistic regression, factors associated with adjuvant radiotherapy included tumor size >2 cm (p< .001), lymphovascular space invasion (p < .001) and a tumor grade G3 (vs G1-G2, p .01). Furthermore, the probability of receiving adjuvant radiotherapy was higher for patients with deep stromal invasion (p < .001), and with intermediate stromal invasion (p < .001) in comparison to those with superficial stromal invasion. At multiple logistic regression, open approach (odds ratio [OR] 1.63, p =.01) and G3 tumor grade (OR 1.64, p= .01) were independently associated with the administration of adjuvant radiotherapy. In addition, the presence of Sedlis criteria was associated with a 4 times higher probability of having adjuvant radiotherapy (OR 4.44, p < .001). While the Sedlis criteria should guide post-operative radiotherapy administration, we observed a significant variation in post-operative adjuvant treatment among institutions involved in the SUCCOR study. A call for a standardized recommendation of adjuvant radiation therapy is needed.

Identifying low-volume metastases through ultrastaging of negative pelvic nodes in recurrent early-stage cervical cancer: a case series and literature review

Ultrastaging has been shown to improve the detection of macrometastases (MACs), micrometastases (MICs) and isolated tumour cells (ITCs). This study evaluated the role of ultrastaging in the management of cervical cancer through a single-centre retrospective analysis, along with a systematic literature review. This retrospective study included patients surgically treated for FIGO 2009 stage IA1-IB1 cervical cancer between January 2011 and December 2023 with negative lymph nodes and no adjuvant therapy based on tumour risk factors. Cases with isolated lymph node recurrence during follow-up were examined. Ultrastaging of negative nodes was performed to detect low-volume metastases. Additionally, a systematic review was conducted following PRISMA guidelines, including a PubMed search of all indexed records up to 1 June 2024. Eligible studies included those with more than three patients who underwent either sentinel lymph node (SLN) biopsy or pelvic lymphadenectomy, and included both standard and ultrastaging analyses of negative SLNs. From a cohort of 161 patients, three (1.8 %) were included. At primary surgery, a median of 28 lymph nodes (range 12-55) were removed, all of which were negative on standard evaluation. Ultrastaging re-evaluation identified MICs in two cases. The systematic review included 13 studies. Ultrastaging detected metastases in 353 (18.1 %) patients: 147 (41.6 %) MACs, 132 (37.4 %) MICs, and 74 (21.0 %) ITCs, resulting in a median increase in the number of metastases of 5.6 % (2.4-9.6 %) compared with standard analysis. These findings highlight the critical role of ultrastaging in detecting metastases that would otherwise be missed with standard analysis, supporting adoption of the SLN technique for cervical cancer staging.

Enhanced recovery in gynecologic surgery: institutional challenges and implementation framework

Enhanced recovery after surgery (ERAS) protocols are evidence-based peri-operative care pathways that aim to reduce surgical stress, enhance patient recovery, and improve clinical outcomes. Despite well-documented benefits, real-world implementation remains inconsistent, with adherence rates varying widely across institutions and regions. This review offers practical insights, addressing core challenges in ERAS protocol compliance evaluation, including patient adherence, provider engagement, workflow integration, and documentation. We aim to provide a practical framework for other institutions seeking to adopt ERAS, offering actionable strategies to overcome common barriers and achieve long-term success with data-driven quality improvement. Peri-operative measures are outlined, highlighting implementation challenges and potential solutions. Successful ERAS implementation extends beyond protocol design. It requires sustained institutional support, clear and consistent communication, ongoing education, and pragmatic adaptation to the local infrastructure.

Enhanced Recovery After Surgery (ERAS) in gynecologic surgery: hot topic debates at the 2025 ERAS World Congress

The Enhanced Recovery After Surgery pathway has transformed peri-operative care in gynecologic surgery through multi-disciplinary, evidence-based protocols. However, real-world adherence to and interpretation of specific Enhanced Recovery After Surgery elements remain heterogeneous, with ongoing discussion about their feasibility and clinical relevance. During the 2025 Enhanced Recovery After Surgery World Congress in Turin, Italy, a rapid-fire debate session addressed 4 "hot topics" in gynecologic Enhanced Recovery After Surgery implementation. Peri-operative dysglycemia is associated with worse surgical outcomes, although the evidence favors a targeted rather than universal screening strategy. Universal hemoglobin A1c testing was considered impractical, with screening recommended for patients with diabetes, obesity, or cardiovascular disease to balance safety and oncologic timeliness. Although transversus abdominis plane blocks reduce opioid use and prolong analgesia, multi-layer wound infiltration remains a pragmatic and cost-effective alternative, especially in low-resource settings where expertise or ultrasound guidance is limited. In light of the overall risk profile and low bleeding rates, many patients undergoing laparotomy for adnexal masses are likely to benefit from pharmacologic prophylaxis. Development of gynecology-specific risk models remains an unmet research priority. Structured multi-disciplinary warming bundles can significantly reduce peri-operative hypothermia, but implementation must remain flexible to accommodate different institutional resources and thresholds. The 2025 Enhanced Recovery After Surgery World Congress debates reinforced that the evolution of Enhanced Recovery After Surgery in gynecologic surgery depends less on discovering new interventions than on refining, validating, and implementing existing evidence. Individualized standardization-adapting Enhanced Recovery After Surgery principles to patient and resource variability-remains the cornerstone of enhanced recovery progress.