Vasilios Pergialiotis

Diaphragmatic stripping in epithelial ovarian cancer at first diagnosis: Impact on morbidity and survival outcomes

Diaphragmatic stripping is a standard procedure that is performed in a significant proportion of patients undergoing surgical cytoreduction for advanced ovarian cancer. The objective of the present study is to evaluate morbidity and survival outcomes among patients offered diaphragmatic surgery for primary diagnosed optimally resected ovarian cancer. We conducted a retrospective cohort study, identifying patients that were offered surgery between 2016 and 2021 for primary diagnosis of ovarian cancer. Cases that had diaphragmatic stripping or partial diaphragmatic resection were selected and compared to cases that did not require this procedure. Kaplan-Meier and Cox-regression analyses were applied to evaluate survival outcomes. Overall, 61 patients that had diaphragmatic stripping were identified. Severe postoperative complications (Clavien-Dindo 3 + ) were noted in 19 patients (31 %). Survival analyses denoted that the stage of the disease at the time of diagnosis, as well as the timing of the surgical procedure (PDS vs IDS) and the completion of tumor debulking were factors that significantly affected the recurrence free and overall survival of patients. Severe postoperative morbidity was a significant predictor of the overall survival. Multivariate cox-regression analysis that was adjusted for the stage of the disease revealed that preoperative pleural effusion, optimal (compared to complete) tumor resection and the occurrence of postoperative complications significantly affected the overall survival of patients. Compared to patients that did not have diaphragmatic surgery, patients submitted to diaphragmatic stripping or resection had improved progression free and overall survival rates, irrespective of the stage of the disease at diagnosis or the adequacy of resection status. Diaphragmatic surgery is feasible in advanced ovarian cancer patients with acceptable morbidity that mainly refers to postoperative pleural effusion. Its positive impact on patients' survival requires further investigation.

Neoadjuvant Chemotherapy in Advanced Stage Endometrial Cancer: A Systematic Review and Meta-Analysis

Background and Objectives: Endometrial cancer is the most common gynecological malignancy in developed countries and is becoming increasingly prevalent. Early diagnosis and treatment may lead to lower rates of morbidity and mortality. The aim of the present meta-analysis is to investigate whether neoadjuvant chemotherapy (NACT) can enhance resectability, reduce tumor burden, and ultimately improve survival rates compared to primary surgery in patients with advanced endometrial cancer. Materials and Methods: All studies that examined the impact of NACT on survival outcomes of patients with advanced endometrial cancer were eligible for inclusion, including randomized and non-randomized interventional studies. Studies were identified by searching MEDLINE (1945–2024), Scopus (1941–2024), Google Scholar (2004–2024) and ClinicalTrials.gov (2000–2024). Data was selected and extracted by two reviewers based on the PRISMA guidelines. Results: Five retrospective studies with a cumulative total of 8658 patients were included. No statistically significant difference in overall survival was observed between patients who received NACT and those who underwent primary surgery (HR 0.91, 95% CI 0.79–1.04). NACT was associated with some perioperative advantages, though these did not translate into a survival benefit. Conclusions: The currently available evidence, which is limited to retrospective studies with significant heterogeneity, suggests that NACT does not confer a survival advantage over primary debulking surgery in advanced endometrial cancer. These findings should be considered hypothesis-generating, underscoring the need for prospective trials. NACT may still be a reasonable option for selected subgroups, such as frail patients, those with extensive peritoneal disease, or cases in which complete cytoreduction is unlikely with upfront surgery.

Survival outcomes of endometrial cancer patients with disease involving the lower uterine segment: A meta-analysis

Lower uterine segment (LUS) involvement is encountered in a small proportion of endometrial cancer patients and is associated with aggressive histological features. Despite the available evidence, there seems to be a lack of consensus concerning its actual impact on disease related survival. The search strategy involved the Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases. Nine studies were included in the present systematic review that recruited 3300 patients. Pooled hazard ratios (HR) were retrieved from Cox-regression analyses to limit the confounding effect of other factors that influence the course of the disease. Nine articles were included in the present meta-analysis that involved 3300 endometrial cancer patients. The meta-analysis revealed a significant difference in progression free survival that was found increased in patients without LUS involvement (HR 1.59, 95 % CI 1.22, 2.05, data from 9 studies). Similarly, a significantly smaller overall survival was observed among patients with LUS involvement (HR 1.69, 95 % CI, 1.34, 2.13, data from 7 studies). Sensitivity analysis revealed that there were no outliers in either outcome, however, the possibility of data manipulation could not be ruled out entirely. The results of this meta-analysis indicate that lower uterine segment involvement is associated with decreased survival outcomes. It remains unclear if these patients can benefit from adjuvant treatment in the absence of other negative prognostic indicators and this needs to be examined by future studies.

Tumor free distance from serosa and survival rates of endometrial cancer patients: A meta-analysis

Myometrial invasion and its extent have been directly associated with the risk of relapse as well as the overall survival of endometrial cancer patients. Tumor free distance from the serosal surface of the uterine wall has been investigated the last years by several studies, however, to date, its importance remains unknown. The present meta-analysis is based on a systematic search of the Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases and has been designed according to the PRISMA guidelines. Nine studies were included in the present systematic review that recruited pathology slides from 1,598 endometrial cancer patients and their meta-analysis indicated that TFD was significantly associated with the progression free survival of patients with endometrial cancer (OR 0.36, 95% CI 0.20, 0.65). The disease specific survival was not affected by the TFD (OR 0.30, 95% CI 0.09, 1.01). Sensitivity analyses revealed, however, that both the progression free and overall survival rates were associated with TFD. Significant discrepancies were observed in terms of histological subtypes and stage of the disease among included patients, hence, the actual importance of TFD in specific subgroups remains unknown. Future studies must evaluate the importance of this pathology marker particularly in patients with endometrioid subtypes and early-stage disease, as it is believed that in this group its importance will be more predictive as it will not be skewed by the presence of more important factors such as more aggressive histology and advanced stage disease.

The Impact of Positive Peritoneal Cytology on the Survival Rates of Early-Stage-Disease Endometrial Cancer Patients: Systematic Review and Meta-Analysis

Background and Objectives: The impact of positive peritoneal cytology has been a matter of controversy in early-stage endometrial cancer for several years. The latest staging systems do not take into consideration its presence; however, emerging evidence about its potential harmful effect on patient survival outcomes suggests otherwise. In the present systematic review and meta-analysis, we sought to accumulate current evidence. Materials and Methods: Medline, Scopus, the Cochrane Central Register of Controlled Trials CENTRAL, Google Scholar and Clinicaltrials.gov databases were searched for relevant articles. Effect sizes were calculated in Rstudio using the meta function. A sensitivity analysis was carried out to evaluate the possibility of small-study effects and p-hacking. Trial sequential analysis was used to evaluate the adequacy of the sample size. The methodological quality of the included studies was assessed using the Newcastle–Ottawa scale. Results: Fifteen articles were finally included in the present systematic review that involved 19,255 women with early-stage endometrial cancer. The Newcastle–Ottawa scale indicated that the majority of included studies had a moderate risk of bias in their selection of participants, a moderate risk of bias in terms of the comparability of groups (positive peritoneal cytology vs. negative peritoneal cytology) and a low risk of bias concerning the assessment of the outcome. The results of the meta-analysis indicated that women with early-stage endometrial cancer and positive peritoneal cytology had significantly lower 5-year recurrence-free survival (RFS) (hazards ratio (HR) 0.26, 95% CI 0.09, 0.71). As a result of the decreased recurrence-free survival, patients with positive peritoneal cytology also exhibited reduced 5-year overall survival outcomes (HR 0.50, 95% CI 0.27, 0.92). The overall survival of the included patients was considerably higher among those that did not have positive peritoneal cytology (HR 12.76, 95% CI 2.78, 58.51). Conclusions: Positive peritoneal cytology seems to be a negative prognostic indicator of survival outcomes of patients with endometrial cancer. Considering the absence of data related to the molecular profile of patients, further research is needed to evaluate if this factor should be reinstituted in future staging systems.

The impact of waiting intervals on survival outcomes of patients with endometrial cancer: A systematic review of the literature

The purpose of the present systematic review is to summarize the available evidence concerning the impact of investigated intervals of treatment (diagnosis to surgery and surgical treatment to adjuvant therapy) on survival outcomes of endometrial cancer patients. We searched Medline, Scopus, Clinicaltrials.gov, EMBASE, and Google Scholar databases from inception until July 31st 2019. All observational studies were considered eligible for inclusion. Investigated outcomes were retrieved and analyzed as well as factors that influenced the extent of wait intervals. Overall, 12 articles were included that investigated the influence of wait intervals on survival outcomes of 773,185 patients. We observed that the proposed cut-off values for interval periods, the reported survival outcomes as well as the tumor characteristics of included patients varied significantly among the studies that were included. Given these differences, meta-analysis of survival outcomes was not possible. The most common cut-off for the time to surgery interval was 6 weeks and for the time to adjuvant treatment 9 weeks. The percentage of patients that was treated within this limit ranged between 24 and 74 %. Given this information we believe that the optimal interval between diagnosis and surgical treatment of endometrial cancer patients should not exceed eight weeks (keeping in mind that surgery within the first two weeks may be a negative prognostic factor), whereas between surgery and adjuvant therapy should be limited to a maximum of nine weeks. Future studies should evaluate factors that seem to influence the extent of waiting intervals to help determine the limitations of healthcare systems.

The impact of adjuvant hysterectomy on survival outcomes of patients with locally advanced cervical cancer: A network meta-analysis

Various articles have addressed the impact of hysterectomy on survival outcomes of patients with locally advanced cervical cancer (LACC). This study was designed to evaluate whether treatment modalities that include hysterectomy as an option for the treatment of LACC patients are superior to standard chemo-radiotherapy. Literature search was performed using the Medline, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Clinicaltrials.gov databases. Observational (prospective and retrospective) and randomized trials that included adjuvant hysterectomy in at least one treatment group. A network meta-analysis was carried out in R 3.4.3 using the pcnetmeta package, which uses a Bayesian hierarchical model. The credibility of evidence was appraised with the Confidence In Network Meta-Analysis (CINeMA) tool. Overall, 14 studies were included in the present systematic review that involved 2302 patients with LACC. Every potential combination of external beam radiotherapy, intracavitary brachytherapy, chemotherapy and surgery was considered to be eligible for inclusion. The results of the network meta-analysis suggested that the various treatment alternatives did not differ in terms of survival outcomes. Furthermore, the qualitative analysis revealed that hysterectomy was accompanied by considerable perioperative morbidity; therefore, rendering its addition to the treatment scheme of LACC patients inappropriate. Patients with LACC do not seem to benefit substantially by the addition of hysterectomy to standard chemo-radiotherapy. Moreover, the operation is accompanied by substantial perioperative morbidity, thus, its implementation in clinical practice should be avoided.

Perioperative blood transfusion and ovarian cancer survival rates: A meta-analysis based on univariate, multivariate and propensity score matched data

The negative impact of perioperative blood transfusion on survival outcomes has been reported in several cancer types. The purpose of the present study is to summarize existing evidence in ovarian cancer patients. We searched the Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases for observational and randomized trials that assessed the impact of perioperative blood transfusion on the disease-free survival (DFS) and overall survival (OS) of ovarian cancer patients that undergone debulking surgery were selected for inclusion. The methodological quality of the included studies was assessed by using the Newcastle-Ottawa Scale. Statistical meta-analysis was performed with the RevMan 5.3 software using the Der-Simonian Laird random effects model. Seven studies were identified which included 2341 ovarian cancer patients. Meta-analyses that were based on univariate and multivariate reporting revealed that perioperative blood transfusion had a significant negative impact on the patient`s OS rates (OR 1.78, 95 %CI 1.16, 2.74 and OR 1.31, 95 %CI 1.00, 1.71 respectively). Disease free survival rates were also influenced according to the results of the univariate analysis (OR 1.58, 95 %CI 1.14, 2.19), however, the effect was not significant in the multivariate analysis. The analysis that was based on propensity score matched populations did not reveal differences among transfused and non-transfused. Concluding, the findings of our meta-analysis suggest that transfusion of blood products during the perioperative period is not an independent factor that may affect survival outcomes of ovarian cancer patients. Nevertheless, it should be noted that patients that receive transfusion have several potential confounders that may affect their survival outcomes.

Is There a Survival Benefit of Adjuvant Chemotherapy in Stage IC1 Epithelial Ovarian Cancer Patients? A Meta-Analysis

The purpose of the present systematic review is to clarify whether adjuvant chemotherapy improves survival rates in women with stage IC1 ovarian cancer. We searched Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar. We considered comparative observational studies and randomized trials that investigated survival outcomes (progression-free (PFS) and overall survival (OS)) among women with intraoperative rupture of early-stage epithelial ovarian cancer who received adjuvant chemotherapy and those that did not. Eleven studies, which recruited 7556 patients, were included. The risk of bias was defined as moderate after assessment with the Risk of Bias in non-Randomized Trials tool. Meta-analysis was performed with RStudio. Seven studies investigated the impact of adjuvant chemotherapy on recurrence-free survival of patients experiencing intraoperative cyst rupture for otherwise stage I ovarian cancer. The outcome was not affected by the use of adjuvant chemotherapy as the effect estimate was not significant (HR 1.24, 95% CI 0.74, 2.04). The analysis of data from 5 studies similarly revealed that overall survival rates were comparable among the two groups (HR 0.75, 95% CI 0.54, 1.05). This meta-analysis did not detect any benefit from adjuvant chemotherapy for stage IC ovarian cancer patients with cyst rupture. However, conclusions from this investigation are limited by a study population which included multiple histologic subtypes, high and low grade tumors and incompletely staged patients.

Quality of life of ovarian cancer patients treated with combined platinum taxane chemotherapy: a systematic review of the literature

Chemotherapy is the cornerstone of adjuvant therapy in ovarian cancer. Its impact on the quality of life (QoL) has been addressed in several studies; however, several misperceptions concerning this affect patient counseling and physicians' ability to overcome patient fears. In the present systematic review, we sought to accumulate current evidence in the field in order to help establish robust information that will help physicians answer patients' questions. The present systematic review is based on the PRISMA guidelines. Studies that evaluated patient QoL pre-, during, and post-chemotherapy with the use of the QLQC-30 were selected for inclusion. Their methodological quality was assessed with the before-after studies tool that is proposed by the National Institute of Health (NIH). Ten studies that involved 5181 patients were included in the present systematic review. The risk of bias and methodological quality of included studies was of good and fair overall quality. Retrieved data suggest there is substantial evidence that points toward improved global QoL among ovarian cancer patients treated with taxanes-platinum combination therapy. Individual outcomes evaluated with the QLQ-C30 also provide positive results, although underreporting was noted. Despite the significant heterogeneity in outcome reporting, the findings of this study reveal the significant benefit of combined platinum taxane chemotherapy on the QoL of ovarian cancer patients and can be used for patients counseling in order to reduce refusals that arise from fear of adverse effects that may negatively affect QoL. Graphical abstract.

Management options for vaginal intraepithelial neoplasia

Vaginal intraepithelial neoplasia (VaIN) is a rare disease of the lower genital tract, strongly associated with HPV infection, which may progress to vaginal carcinoma. The aim of this review is to summarise current treatment options, evaluate their efficacy and make provide recommendations on the optimal management of the disease. A comprehensive search of the literature was performed using the PubMed database for articles referring to the treatment of VaIN. We restricted our search only in articles written in English with publication dates within the last 10 years. Surgical approach included local excision, CO The choice of treatment depends upon many factors. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Topical agents are useful for persistent, multifocal lesions or for women that cannot undergo surgical treatment. Brachytherapy is associated with high morbidity rates and should be reserved for women who have multifocal disease, are poor surgical candidates and/or have failed other treatments. CO

Incidence and impact on survival outcomes of postoperative radiological evidence of residual disease in women with advanced stage ovarian cancer undergoing debulking surgery: a meta-analysis

The present systematic review and meta-analysis aims to assess the proportion of patients with radiological findings of residual disease following debulking surgery and determine its impact on survival outcomes. We systematically searched the international literature using the Medline, Scopus, Clinicaltrials.gov, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar until July 2025 for studies that evaluated the proportion of patients with radiological evidence of residual disease following debulking surgery. The review was registered in PROSPERO prior to its conduct (CRD420251065596). Eleven studies were found eligible for inclusion in the present systematic review. Proportion meta-analysis indicated that 40% of patients had radiologic evidence of residual disease postoperatively (Generalized Mixed Linear Model 40%, 95% CI 33%, 48%). Differences in progression free survival were significantly worse among patients with residual disease (HR 2.08, 95% CI 1.42, 3.05). Similar findings were observed in the overall survival of patients (HR 1.93, 95% CI 1.49, 2.52). The proportion of patients with radiological criteria of residual disease following debulking surgery appears to be significant. There seem to be evidence that indicate a negative impact on survival outcomes of patients with epithelial ovarian cancer, although these should be interpreted cautiously given the heterogeneity and limitations of the available evidence, but may be relevant during preoperative patient counseling to help establish realistic expectations.