Annals of Surgical Oncology

Impact of Sentinel Node Mapping in Decreasing the Risk of Lymphocele in Endometrial Cancer

Due to the growing evidence of sentinel lymph node (SLN) mapping in endometrial cancer (EC), our aim was to evaluate the impact of SLN mapping and other clinical-pathological variables in the risk of developing lymphocele. We retrospectively analyzed a series of patients with ECs who underwent lymph node staging with SLN mapping with or without systematic pelvic ± para-aortic lymphadenectomy from November 2012 to January 2020. The lymphocele diagnosis was performed by computed tomography or magnetic resonance imaging. Of 348 patients included, 178 underwent SLN mapping only and 170 underwent SLN mapping and systematic lymphadenectomy (46.5% pelvic only; 53.5% pelvic and para-aortic). Seventy-three (21%) patients had open surgery and 275 (79%) had a minimally invasive approach. After a median follow-up of 25.4 months, the overall prevalence of lymphocele was 8.6% (n = 30), with 29 cases in a pelvic location. Lymphocele was found in 3.4% (n = 6/178) of patients submitted to SLN mapping only, compared with 14.1% (n = 24/170) among those who underwent SLN with lymphadenectomy (p = 0.009). Among those patients with lymphocele, seven (23.3%) were symptomatic and five (16.6%) required drainage. All symptomatic cases occurred in lymphoceles larger than 4 cm (p = 0.001). Neither resected lymph node count nor the type of systematic lymphadenectomy were related to the presence of lymphocele. Systematic lymphadenectomy was the only factor that emerged as a risk factor for the presence of lymphocele in multivariate analysis (odds ratio 3.68, 95% confidence interval 1.39-9.79; p = 0.009). Our data suggest that SLN mapping independently decreases the risk of lymphocele formation compared with full lymphadenectomy in EC.

Robotic Recto-Sigmoid Resection with Total Intracorporeal Colorectal Anastomosis (TICA) in Recurrent Ovarian Cancer

Abstract Background About 70% of women affected by ovarian cancer experience relapse within 2 years of diagnosis. Traditionally, the standard treatment for recurrent ovarian cancer (ROC) has been represented by systemic chemotherapy.1 Recently, several retrospective studies have suggested that secondary cytoreductive surgery could provide better clinical outcomes than chemotherapy alone, in the case of complete tumor cytoreduction.2,3 About 50% of patients with ROC have a pelvic component of the disease and 22% of patients present isolated pelvic recurrence, often involving the rectum.4,5 Minimally invasive secondary cytoreductive surgery is a feasible option and is associated with favorable perioperative outcomes.6–8 It is crucial to fully explore the peritoneal cavity before starting cytoreductive procedures in order to confirm the absence of carcinomatosis.9 The robotic system facilitates the identification of anatomical structures and makes it easier to perform complex surgical steps in narrow spaces. It also allows the integrated use of surgical tools such as intraoperative ultrasound and indocyanine green application. Methods In this video, we present the case of a 64-year-old woman who experienced a rectal recurrence of ovarian cancer after a platinum-free interval of 12 months. We describe, in a step-by-step manner, the surgical procedure of a robotic rectosigmoid resection with totally intracorporeal colorectal anastomosis (TICA).10–12 Results Robotic secondary cytoreduction with complete gross resection was achieved. The patient did not report any intraoperative or postoperative complications. Final histology confirmed ROC. Conclusion Totally robotic rectosigmoid resection is a feasible option in isolated bowel recurrences. Thanks to continuous technical evolution, robot-assisted surgery has the potential to have a central role in the fight against solid tumors. Integration of multiple pre- and intraoperative technologies allows personalized surgery to be performed for each different patient.13,14

Expanding the Use of HIPEC in Ovarian Cancer at Time of Interval Debulking Surgery to FIGO Stage IV and After 6 Cycles of Neoadjuvant Chemotherapy: A Prospective Analysis on Perioperative and Oncologic Outcomes

Abstract Background Randomized data on patients with FIGO stage III ovarian cancer receiving ≤ 3 cycles of neoadjuvant chemotherapy (NACT) showed that hyperthermic intraperitoneal chemotherapy (HIPEC) after interval debulking surgery (IDS) improved patient’s survival. We assessed the perioperative outcomes and PFS of FIGO stage IV and/or patients receiving up to 6 cycles of NACT undergoing IDS+HIPEC. Methods Prospectively collected cases from January 1, 2019 to July 31, 2022 were included. Patients underwent HIPEC if: age ≥ 18 years but < 75 years, body mass index ≤ 35 kg/m2, ASA score ≤ 2, FIGO stage III/IV epithelial disease treated with up to 6 cycles of NACT, and residual disease < 2.5 mm. Results A total of 205 patients were included. No difference was found in baseline characteristics between FIGO Stage III and IV patients, whereas rate of stable disease after NACT (p = 0.004), mean surgical complexity score at IDS (p = 0.001), and bowel resection rate (p = 0.046) were higher in patients undergoing delayed IDS. A lower rate of patients with at least one G3–G5 postoperative complications was observed in FIGO stage IV versus FIGO stage III disease (5.3% vs. 14.0%; p = 0.052). This difference was confirmed at multivariable analysis (odds ratio [OR] 0.24; 95% confidence interval [CI] 0.07–0.80; p = 0.02), whereas age, SCS, bowel resection, and number of cycles did not affect postoperative complications. No difference in PFS was identified neither between FIGO stage III and IV patients (p = 0.44), nor between 3 and 4 versus > 4 cycles of NACT (p = 0.85). Conclusions Because of the absence of additional complications and positive survival outcomes, HIPEC administration can be considered in selected FIGO stage IV and patients receiving > 4 cycles of NACT.

Intraoperative Fluid Balance and Perioperative Complications in Ovarian Cancer Surgery

Abstract Background Fluid overload and hypovolemia promote postoperative complications in patients undergoing cytoreductive surgery for ovarian cancer. In the present study, postoperative complications and anastomotic leakage were investigated before and after implementation of pulse pressure variation-guided fluid management (PPVGFM) during ovarian cancer surgery. Patients and Methods A total of n = 243 patients with ovarian cancer undergoing cytoreductive surgery at the University Hospital Bonn were retrospectively evaluated. Cohort A (CA; n = 185 patients) was treated before and cohort B (CB; n = 58 patients) after implementation of PPVGFM. Both cohorts were compared regarding postoperative complications. Results Ultrasevere complications (G4/G5) were exclusively present in CA (p = 0.0025). No difference between cohorts was observed regarding severe complications (G3–G5) (p = 0.062). Median positive fluid excess was lower in CB (p = 0.001). This was independent of tumor load [peritoneal cancer index] (p = 0.001) and FIGO stage (p = 0.001). Time to first postoperative defecation was shorter in CB (CB: d2 median versus CA: d3 median; p = 0.001). CB had a shorter length of hospital stay (p = 0.003), less requirement of intensive medical care (p = 0.001) and postoperative ventilation (p = 0.001). CB received higher doses of noradrenalin (p = 0.001). In the combined study cohort, there were more severe complications (G3–G5) in the case of a PFE ≥ 3000 ml (p = 0.034) and significantly more anastomotic leakage in the case of a PFE ≥ 4000 ml (p = 0.006). Conclusions Intraoperative fluid reduction in ovarian cancer surgery according to a PPVGFM is safe and significantly reduces ultrasevere postoperative complications. PFEs of ≥ 3000 ml and ≥ 4000 ml were identified as cutoffs for significantly more severe complications and anastomotic leakage, respectively.

Role of Pelvic Lymph Node Resection in Vulvar Squamous Cell Cancer: A Subset Analysis of the AGO-CaRE-1 Study

Abstract Background As the population at risk for pelvic nodal involvement remains poorly described, the role of pelvic lymphadenectomy (LAE) in vulvar squamous cell cancer (VSCC) has been a matter of discussion for decades. Methods In the AGO-CaRE-1 study, 1618 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB or higher primary VSCC treated at 29 centers in Germany between 1998 and 2008 were documented. In this analysis, only patients with pelvic LAE (n = 70) were analyzed with regard to prognosis and correlation between inguinal and pelvic lymph node involvement. Results The majority of patients had T1b/T2 tumors (n = 47; 67.1%), with a median diameter of 40 mm (2–240 mm); 54/70 patients (77.1%) who received pelvic LAE had positive groin nodes. For 42 of these 54 patients, the number of affected groin nodes had been documented as a median of 3; 14/42 (33.3%) of these patients had histologically confirmed pelvic nodal metastases (median number of affected pelvic nodes 3 [1–12]). In these 14 patients, the median number of affected groin nodes was 7 (1–30), with a groin metastases median maximum diameter of 42.5 mm (12–50). Receiver operating characteristic analysis showed an area under the curve of 0.85, with 83.3% sensitivity and 92.6% specificity for the prediction of pelvic involvement in cases of six or more positive groin nodes. No cases of pelvic nodal involvement without groin metastases were observed. Prognosis in cases of pelvic metastasis was poor, with a median progression-free survival of only 12.5 months. Conclusion For the majority of node-positive patients with VSCC, pelvic nodal staging appears unnecessary since a relevant risk for pelvic nodal involvement only seems to be present in highly node-positive disease.

Prognostic Value and Risk Factors of Peritoneal Carcinomatosis Recurrence for Patients with Endometrial Cancer: A Multicenter Study from the FRANCOGYN Group

The prognosis for patients with endometrial cancer (EC) peritoneal carcinomatosis (PC) recurrence has received little study. This study aimed to determine specific risk factors and prognosis of EC with PC recurrence (PCR) versus no PC recurrence (NPCR). Data of all patients with EC who received primary surgical treatment between January 2000 and February 2017 were abstracted from the French FRANCOGYN Research Group database. Clinical and pathologic variables were compared between the two groups (PCR vs. NPCR). Multivariate analysis was performed to define prognostic factors for peritoneal recurrence. Overall survivals (OS) of patients after recurrence were compared using the Kaplan-Meier method. The study analyzed 1466 patients, and 257 of these patients (17.5%) had recurrence. At presentation, 63 of these patients had PC. International Federation of Gynecology and Obstetrics (FIGO) stages 3 and 4 disease were significantly associated with PCR versus NPCR (odds ratio 2.24; 95% confidence interval 1.23-4.07; p = 0.008). The death rate for the patients with PC was 47.6%, with a median survival of 12 months after diagnosis of recurrence. According to the histologic subtype, OS was 29 months (Q1-Q3, 13-NA) for endometrioid carcinomas, 7.5 months (Q1-Q3, 4-15) for serous carcinomas, and 10 months (Q1-Q3, 5-15) for clear cell carcinomas. Chemotherapy for treatment of PCR was associated with improved OS after recurrence (OSAR; p = 0.0025). An initial advanced stage of EC is a risk factor for PCR. For women with PCR, a diagnosis of type 1 EC recurrence more than 12 months after the initial treatment and management of PCR with chemotherapy is associated with improved OSAR. Prospective studies are needed to determine the precise optimal management required in this clinical situation and to assess the relevance of biomarkers to predict the risk of PCR for EC patients.

Radiation De-Escalation in Older Women with Early-Stage ER+/HER2– Invasive Breast Cancer

Abstract Background National recommendations since 2004 have allowed for omission of post-lumpectomy radiotherapy for patients ≥70 years old with early-stage estrogen receptor positive (ER+)/human epidermal growth factor receptor 2-negative (HER2–) breast cancer. Rates of omission in the era of abbreviated radiotherapy regimens are unknown. This study aimed (1) to determine contemporary trends in post-lumpectomy radiotherapy omission, (2) to determine trends in use of partial-breast (PB), ultra-hypofractionated (UHF), moderately hypofractionated (MHF), and conventionally fractionated (CF) radiotherapy regimens, and (3) to identify targetable factors to de-escalate radiotherapy in patients eligible for omission. Methods A retrospective cohort analysis was performed using the National Cancer Database. The study identified patients ≥70 years old with pT1, cN0 pNX-0, cM0 ER+/HER2– breast cancer who underwent lumpectomy from 2012 to 2021. Radiotherapy treatment strategies based on number of fractions received were evaluated and compared using multivariable analysis. Results The study included 121,160 patients: 51.0 % with no radiotherapy, 8.4 % with PB, 4.1 % with UHF, 30.2 % with MHF, and 6.3 % with CF radiotherapy. Radiotherapy omission decreased from 53.7 % to 46.8 % between 2012 and 2021. Whereas MHF radiotherapy doubled from 16.4 % to 32.9 %, CF radiotherapy decreased from 17.1 % to 2.0 %. A minority of patients received PB or UHF radiotherapy, although the rate of UHF increased from 4.6 % to 7.7 % between 2020 and 2021. Treatment at academic/research or Integrated Network Cancer Program facilities and higher-volume hospitals was associated with increased likelihood of treatment with abbreviated radiotherapy regimens. Conclusions Despite efforts to promote treatment de-escalation, rates for omission of post-lumpectomy radiotherapy have decreased over time. To avoid overtreatment, patients who are eligible for omission but opt to receive radiotherapy should be considered for PB or UHF radiotherapy regimens.

L1CAM Predicts Adverse Outcomes in Patients with Endometrial Cancer Undergoing Full Lymphadenectomy and Adjuvant Chemotherapy

L1 cell adhesion molecule (L1CAM) has been established as an important predictor of poor survival of early-stage endometrial cancer patients. We investigated whether L1CAM remains a significant predictor of poor survival of patients with advanced-stage endometrial cancer undergoing extensive surgical staging and adjuvant chemotherapy. We prepared tissue microarray (TMA) from surgical tissue specimens of 161 endometrial cancer patients who underwent full lymphadenectomy combined with adjuvant chemotherapy for patients at risk for recurrence, and evaluated expression of L1CAM using immunohistochemistry. The correlation between L1CAM positivity and clinicopathological factors and the prognostic significance of L1CAM expression was investigated. Among 161 cases who had a follow-up duration of over 3 years, 48 cases (29.8%) showed positive staining for L1CAM. L1CAM positivity was significantly correlated with non-endometrioid histology (p < 0.0001), vascular invasion (p = 0.0157), and positive cytology (p = 0.005), and was a significant predictor of poor survival among advanced-stage patients, but not early-stage patients in our cohort. L1CAM-positive patients showed a higher recurrence rate and frequency of distant failure than L1CAM-negative patients. Multivariate analysis revealed that para-aortic lymph node metastasis (PANM) and L1CAM positivity were independent predictors of poor survival. Overall survival can be stratified into three groups by the combination of PANM and L1CAM positivity. L1CAM is an independent predictor of poor survival in endometrial cancer patients undergoing full lymphadenectomy and adjuvant chemotherapy, thus indicating that L1CAM can be clinically used as a biomarker to identify those patients at increased risk of recurrence.

Breaking New Ground in Cervical Metastatic Carcinoma of Unknown Primary: Neoadjuvant Immunochemotherapy’s Pathologic Regression and Survival Advantage

Cervical metastatic carcinoma of unknown primary (CMCUP) poses significant therapeutic challenges because of its aggressive biology and the absence of standardized treatment protocols. While neoadjuvant immunochemotherapy (NICT) has demonstrated efficacy across various malignancies, its application in CMCUP remains poorly characterized. This retrospective cohort study evaluated 98 consecutive patients with CMCUP treated at a tertiary cancer center between 2015 and 2024. Patients were stratified into NICT (n = 33) or traditional therapy (n = 65). Primary endpoints included pathologic complete response and objective response rate; secondary endpoints comprised major pathologic response (mPR), extranodal extension, surgical margin status, 3 year recurrence-free survival (RFS), overall survival (OS), and treatment-related adverse events. The NICT cohort demonstrated favorable pathologic outcomes, with 45.5% achieving pathologic complete response and 69.7% attaining mPR. Radiologic assessment showed stable disease in 63.6% (objective response rate 36.4%), yet pathologic analysis revealed significant tumor regression in patients with mPR (11/23 with initial radiologic stable disease). NICT substantially reduced clinical extranodal extension (24.2% vs. 66.2%, p<0.001) and positive margin rates (9.1% vs. 27.7%, p = 0.03). Survival analysis favored NICT, with a 3 year RFS of 78.8% versus 49.2% (p = 0.011) and OS of 84.8% versus 61.5% (p<0.05). Multivariable analysis confirmed NICTs independent prognostic value for both RFS (hazard ratio 0.45; 95% confidence interval 0.24-0.87, p = 0.014) and OS (HR 0.55; 95% confidence interval 0.32-0.93,  p =  0.017). Treatment was well-tolerated, with grade 3/4 adverse events limited to vomiting, leukopenia, and pneumonia. NICT induces significant pathologic regression and improves survival outcomes in CMCUP, demonstrating dual benefits of enhanced resectability and disease control. These results support prospective evaluation of NICT in this high-risk population.

Postoperative Complications After Cytoreductive Surgery for Advanced Ovarian Carcinoma: A Single-Center Analysis Exploring the Value of the Comprehensive Complication Index and the Predictors of High Complications Burden

Abstract Background The comprehensive complication index (CCI) reflects the overall patient complication burden on a 0–100 scale. This single-institution retrospective analysis explores the accuracy of CCI in describing complications following cytoreductive surgery for advanced high-grade ovarian carcinoma (HGOC) and aims to identify predictive factors of high complication burden. Patients and Methods In total, 304 patients who underwent cytoreductive surgery for FIGO stage IIIA–IVB HGOC at our institution from 2015 to 2023 were analyzed. Each complication’s severity was graded using the Clavien–Dindo classification. The CCI was used to quantify the global complications burden, and patients were stratified into three groups: CCI-low (&lt; 26.2), CCI-intermediate (26 ≤ CCI &lt; 33.7), and CCI-high (≥ 33.7). Results Of the 200 patients (65.8%) with at least one complication, 127 (41.8%) were CCI-low, 32 (10.5%) CCI-intermediate, and 41 (13.5%) CCI-high. Median hospitalization duration (p &lt; 0.0001) and readmission rates (p &lt; 0.0001) correlated with CCI categories, reflecting increased CCI scores with greater surgical complexity, as assessed by the Aletti surgical complexity score (SCS). Univariate analysis showed a significant association between CCI-high and FIGO stage, surgical complexity, diaphragmatic procedures, multiple bowel resections, length of surgery and intraoperative blood loss. Multivariate analysis confirmed FIGO stage (odds ratio [OR] 2.57), multiple bowel resections (OR 5.61), and blood loss (OR 1.93) as independent risk factors for high complication burden. Conclusions The CCI is a good descriptor of postoperative complications in patients undergoing cytoreductive surgery for advanced HGOC by integrating both the severity and number of complications into a single, easily usable, and intuitive quantitative score. FIGO stage, multiple bowel resections, and blood loss—but not surgical timing—are independent predictors of a high complication burden.

Outcomes of Laparoscopic Radical Hysterectomy in Ia1-Ib1 Cervical Cancer Patients: A Multi-Center Study with 10 Years’ Experiences in the Real World

Abstract Background The aim of this retrospective study was to evaluate the outcomes of laparoscopic radical hysterectomy (LRH) for International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IA1 IB1 patients with low-risk cervical cancer (CC), which was defined as tumor ≤ 2cm, less than 1/2 stromal invasion and no lymph node involvement. Patients and Methods We performed a retrospective analysis of patients with CC who underwent radical hysterectomy across three hospitals between 2010 and 2020. The patients were stratified into low-risk and high-risk groups based on risk factors (tumor size, lymph nodes and stromal invasion depth). Within each group, the survival outcomes of open abdominal radical hysterectomy (OARH) and LRH were compared using the Kaplan–Meier analysis. Results In the low-risk group (LRH: N = 320; OARH: N = 525), LRH demonstrated equivalence to OARH regarding 5-year overall survival (OS; 98.6% versus 99.3%, P = 0.571) and 5-year progression-free survival (PFS; 97.6% versus 98.4%, P = 0.418). Subsequently, a stratified analysis based on lymphovascular space invasion (LVSI) status revealed no significant differences in 5-year OS and PFS between LRH and OARH in this group. Conversely, in the high-risk group (LRH: N = 355; OARH: N = 926), LRH exhibited significantly lower 5-year OS and PFS than OARH (91.3% versus 94.8%, P = 0.049; 84.0% versus 88.8%, P = 0.029). Conclusion Among FIGO 2018 stage IA1–IB1 patients with low-risk CC, LRH demonstrates survival outcomes comparable to OARH. For patients with early-stage and low-risk CC, the appropriate surgical approach (LRH) can be chosen based on preoperative enhanced magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) MRI, which is clinically feasible.

Integrative Analysis of Bulk Multiomics and Single-Cell Transcriptomics Elucidates Age-Related Molecular Landscape Alterations in Cervical Cancer

Young and elderly patients with cervical cancer represent two distinct demographic cohorts that have attracted considerable attention in clinical practice. However, the age-related molecular characteristics of these groups remain unclear. Data from 307 patients with cervical cancer, including clinical information and comprehensive bulk multiomics data, were obtained from The Cancer Genome Atlas (TCGA). Single-cell RNA-sequencing (scRNA-seq) data for 11 cervical cancer samples were retrieved from the Gene Expression Omnibus (GEO). The patients were stratified into three age groups: young (<30 years), middle (30-64 years), and old (≥65 years). Comparative analyses of survival outcomes, expression profiles, tumor immune microenvironment, genomic and epigenetic features, treatment responsiveness, and cellular composition were performed. Additionally, external validation was performed using bulk transcriptomic and genomic data from the GEO and MSK-IMPACT datasets. Young patients exhibited a transcriptional landscape characterized by pronounced aggressiveness and elevated expression of immunosuppressive molecules. Conversely, elderly patients exhibited an increased level of genomic instability and mutations accompanied by an elevated tumor mutation burden and neoantigen counts. Notably, the elderly cohort had a lower Tumor Immune Dysfunction and Exclusion (TIDE) score, whereas the young group had a higher radiosensitivity index and reduced imputed sensitivity scores for multiple chemotherapeutic agents. Additionally, scRNA-seq identified epithelial clusters 5 and 9 as subtypes associated with elderly and young patients, respectively, with cluster 5 displaying characteristics resembling cancer stem cells and cluster 9 exhibiting enhanced oncogenic activity and immunosuppressive capabilities. Significant molecular disparities were evident among the young, middle-age, and elderly patients. Thus, age-specific management strategies should be considered in cervical cancer treatment.

Cytoreductive Surgery Plus HIPEC in Recurrent or Newly Diagnosed Advanced Epithelial Ovarian Cancer: a Meta-analysis

Abstract Background In 2024, two randomized controlled trials (RCTs) were published, providing new high-quality evidence on HIPEC in epithelial ovarian cancer (EOC). Updating data on progression-free survival (PFS) and adverse events could offer a clearer understanding of the benefits and risks of HIPEC combined with cytoreductive surgery (CRS), with or without prior neoadjuvant chemotherapy (NACT). Patients and Methods An electronic search was conducted using PubMed, Web of Science, EBSCO, and CENTRAL up to 23 November 2024. We only included RCTs reporting PFS and adverse events of interval or secondary CRS, with or without HIPEC, in newly diagnosed or recurrent EOC. Results The meta-analysis included six RCTs. The addition of HIPEC to surgery significantly improved PFS in patients with newly diagnosed advanced-stage EOC who received NACT (HR 0.59; 95% CI 0.39–0.88; p = 0.01). No significant difference in PFS was observed between secondary CRS plus HIPEC and CRS alone in recurrent ovarian cancer without prior NACT (HR 1.22; 95% CI 0.82–1.83; p = 0.32). Regarding adverse events, a decrease in platelet count of any grade was more frequent in the HIPEC group (p = 0.03). The overall risk of acute kidney failure (AKF) was 10.6%, with a significantly higher incidence compared with CRS alone (p = 0.003). Conclusions The addition of HIPEC to CRS significantly improved PFS compared with surgery alone in patients with advanced EOC who received NACT. However, the treatment was associated with a higher incidence of AKF, which occurred in 10.6% of patients who underwent HIPEC.

Adjuvant Chemotherapy versus Concurrent Chemoradiotherapy for Surgically Treated T1b Uterine Cervical Cancer: A Propensity Score Matched Analysis of the JSOG Nationwide Data

The aim of this study was to assess the effect of postoperative chemotherapy on the survival of surgically treated patients with T1b uterine cervical cancer. Overall, 1687 patients with T1b cervical cancer who received concurrent chemoradiotherapy (CCRT) or chemotherapy as postoperative adjuvant therapy were retrospectively analyzed using the Japan Society of Obstetrics and Gynecology cancer registry program data from 2015 to 2016. After propensity score matching, overall survival (OS) was compared between 643 patients treated with CCRT and 643 patients treated with chemotherapy. OS was significantly higher in the chemotherapy group than in the CCRT group (hazard ratio [HR] 0.653, 95% confidence interval [CI] 0.448 - 0.953; p = 0.026). In the subgroup analysis, patients with squamous histology and large tumor size (>4 cm) and without lymph node metastasis can benefit from chemotherapy in terms of OS (HR 0.53, 95% CI 0.29-0.95; HR 0.49, 95% CI 0.25-0.95; and HR 0.54, 95% CI 0.33-0.88, respectively). Patients with cervical cancer with squamous histology, large tumor size and negative lymph node metastasis can benefit from postoperative chemotherapy in terms of survival. Tumor characteristics could be associated with the effect of postoperative adjuvant chemotherapy on survival.

Dynamic Assessment of Local Abdominal Tissue Concentrations of Cisplatin During a HIPEC Procedure: Insights from a Porcine Model

Abstract Background This study aimed to establish a feasible large porcine model for dynamic assessment of cisplatin concentrations in carcinomatosis-relevant abdominal tissues using microdialysis during and after HIPEC combined with cytoreductive surgery. Methods In total, eight pigs underwent open abdominal cytoreductive surgery followed by HIPEC. Microdialysis was employed for dynamic cisplatin concentration sampling in abdominal organs and tissue. Cisplatin dialysate concentrations were analyzed using the UPLC-MS/MS method. STATA (version 18.0) was used to perform a two-compartment model with a zero-order distribution to analyze pharmacokinetic parameters. Results Detectable cisplatin concentrations in the evaluated target tissues persisted for at least 6 h post-HIPEC. Higher concentrations were found in superficial tissues; however, the difference was not statistically significant. The cisplatin concentrations were comparable for the stomach, rectum, and liver but higher in the peritoneal lining of the abdominal wall, with the lowest median average peak concentration (C max) in the rectum (0.50 µg/mL) and the highest median C max in the peritoneum (2.80 µg/mL). No statistically significant differences in cisplatin area under the curve from time zero to the time of the last sample collection (AUC0–last) were found between any of the abdominal compartments except the peritoneal lining of the abdominal wall, which was significantly higher compared with most of the other abdominal tissues {smallest difference; peritoneum 1/liver 2; 1.96 [95% confidence interval (CI) 0.90; 4.26, P = 0.09] and largest difference; peritoneum 3/rectum profound; 4.60 [95% CI 1.94; 10.90, P = 0.001]}. Conclusions Our investigation revealed comparable cisplatin concentrations across abdominal organ surfaces, except higher concentrations in the peritoneal lining of the abdominal wall than in the stomach, rectum, and liver. This model holds promise for future research into HIPEC interventions and anticancer effectiveness.

Combination Treatment with Spacer Placement Surgery Followed by Particle Radiotherapy for Lymph Node Metastasis from Uterine Cancer

Abstract Background The effectiveness of local treatment in lymph node metastasis from uterine cancer has been proven; the standard treatment is surgical intervention. Although radiotherapy, including particle radiotherapy (PRT), is an alternative local treatment, its application is often contraindicated owing to its proximity to the gastrointestinal tract. Combination treatment with spacer placement surgery followed by PRT is a potential solution to this problem. This study aimed to evaluate the outcomes of this combination treatment of lymph node metastases from uterine cancer. Patients and Methods Between December 2007 and March 2023, ten consecutive patients who underwent combination treatment comprising spacer placement surgery and subsequent PRT were assessed for treatment outcomes. Results The median survival time was 53.5 months; the 3- and 5-year overall survival rates were 76.2% and 38.1%, respectively. The 3- and 5-year local control rates in all patients were both 88.9%. The median volume irradiated at 95% of the treatment planning dose (V95%) of the gross tumor volume, clinical target volume, and planning target volume were 100.0%, 99.8%, and 92.2%, respectively. The median dose intensity covering 95% of the target volume (D95%) of the gross tumor volume/planned dose, clinical target volume/planned dose, and planning target volume/planned dose were 98.9%, 99.0%, and 87.2%, respectively. Conclusions Spacer placement surgery contributed to the optimized PRT dose distribution and might have contributed to favorable local control and survival rates. This innovative combination treatment might have a significant effect on the treatment of lymph node metastases from uterine cancers.

Accuracy and Survival Outcomes after National Implementation of Sentinel Lymph Node Biopsy in Early Stage Endometrial Cancer

Abstract Background Sentinel lymph node (SLN) biopsy has recently been accepted to evaluate nodal status in endometrial cancer at early stage, which is key to tailoring adjuvant treatments. Our aim was to evaluate the national implementation of SLN biopsy in terms of accuracy to detect nodal disease in a clinical setting and oncologic outcomes according to the volume of nodal disease. Patients and Methods A total of 29 Spanish centers participated in this retrospective, multicenter registry including patients with endometrial adenocarcinoma at preoperative early stage who had undergone SLN biopsy between 2015 and 2021. Each center collected data regarding demographic, clinical, histologic, therapeutic, and survival characteristics. Results A total of 892 patients were enrolled. After the surgery, 12.9% were suprastaged to FIGO 2009 stages III–IV and 108 patients (12.1%) had nodal involvement: 54.6% macrometastasis, 22.2% micrometastases, and 23.1% isolated tumor cells (ITC). Sensitivity of SLN biopsy was 93.7% and false negative rate was 6.2%. After a median follow up of 1.81 years, overall surivial and disease-free survival were significantly lower in patients who had macrometastases when compared with patients with negative nodes, micrometastases or ITC. Conclusions In our nationwide cohort we obtained high sensitivity of SLN biopsy to detect nodal disease. The oncologic outcomes of patients with negative nodes and low-volume disease were similar after tailoring adjuvant treatments. In total, 22% of patients with macrometastasis and 50% of patients with micrometastasis were at low risk of nodal metastasis according to their preoperative risk factors, revealing the importance of SLN biopsy in the surgical management of patients with early stage EC.

Clinical Outcomes Between Completion and Abandonment of Radical Hysterectomy in Early-Stage Cervical Cancer Patients with Lymph Nodal Involvement Identified During Surgery: A Systematic Review and Meta-Analysis

This study aimed to summarize the clinical outcomes of early-stage cervical cancer patients with lymph node metastasis found during surgery who completed radical hysterectomy, or abandoned surgery and switched to chemoradiotherapy, in hopes of providing evidence for clinical treatment. The PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases were searched from inception to 20 November 2023. The analysis was conducted using STATA 16.0. A total of eight studies with 2105 early-stage cervical cancer patients were included in this review. Meta-analysis found no significant difference between the completing radical hysterectomy surgery (CRS) group and the abandoning radical surgery (ARS) group regarding overall survival (OS; hazard ratio [HR] 1.35, 95% confidence interval [CI] 0.93-1.97; I Current evidence suggests that for early-stage cervical cancer patients with positive lymph nodes detected during surgery, CRS and ARS have similar survival outcomes, but completing radical surgery results in a lower incidence of pelvic recurrence. CRD42023480118.

History and Perspectives of Hyperradical, Laterally Extended Parametrectomy (LEP)

Cervical cancer has been and still is a major global health problem and a major treatment challenge for which surgical interventions have played a key role throughout the past century. In early stages (I/A2-II/B), where high-risk factors are not present, the efficacy of surgical and radiotherapy treatment has been considered equivalent with different (treatment modality specific) complications and quality of life consequences. Negative prognostic factors in early stages of the disease (pelvic lymph-node positivity) and in more advanced stages (parametrial and/or surgical margins' tumor involvement) forecast the deterioration of outlooks for good life expectancy. In these high-risk cases, when radio- or chemoradiotherapy is contraindicated, we investigated the potential role of a more radical surgical approach than the traditional radical hysterectomy. Twenty-five years ago, a hyperradical surgical procedure for the treatment of high-risk cervical cancer patients was introduced in Budapest. The procedure was named as laterally extended parametrectomy (LEP) in Budapest Hungary. The surgical intention was the complete removal of the fibro-fatty tissue content of the pelvis, which contains the lymphatic vessels, lymph nodes, and tumor-affected pelvic side wall structures. We initiated observational studies on the primary treatment in parametrium and/or lymph-node tumor-positive early-stage cases and on second-line surgical therapy of pelvic side wall recurrent tumors following radiotherapy. Promising results of our observational studies propose that prospective randomized trials are worth to be initiated to clarify the potential of this treatment modality in this poor prognosis cohort of patients.

Complete Laparoscopic Type C2 Radical Surgery for Cervical Stump Cancer: No-Look and No-Touch Techniques

Due to previous surgical history and subsequent adhesions between pelvic organs, surgery for cervical stump cancer (CSC) is technically more challenging than surgery for cervical cancer with an intact uterus. CLRS for six patients with CSC was performed from January 2021 to January 2022. We demonstrated the detailed skills of parametrial management during CLRS for CSC in case 5 by means of a video. A 58-year-old woman diagnosed with International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIA1 CSC received CLRS through five operative ports (Fig. 1). The magnetic resonance imaging (MRI) scans and gross appearance of the specimen are shown in Fig. 2. The median age and body mass index (BMI) of the six patients were 53 years and 23.8, respectively. The median blood loss was 275 mL; the median time of operation was 218 min; the median length of hospitalization was 15 days; and the median time to recover urinary function was 12 days. One patient underwent postoperative radiation for pathologically proven adenocarcinoma with deep stromal invasion, This study details the skills of CLRS for CSC, especially space development and the 'no-look, no-touch' tumor-free principle. It is helpful for clinicians to perform safe and standardized surgery on patients with early-stage CSC. Fig. 1 Trocar placement of complete laparoscopic type C2 radical surgery for early-stage CSC. CSC cervical stump cancer, S superior, I inferior, R right, L left, U umbilicus Fig. 2 MRI scans and gross appearance of the specimen for case 5 with CSC at FIGO 2018 stage IIA1. The tumor lesion on the cervical stump is indicated by yellow arrows. a Axial T2-weighted image; b DKI image; c ADC map; d sagittal T2-weighted image; e sagittal T1-weighted image; f gross appearance of the surgical specimen. MRI magnetic resonance imaging, CSC cervical stump cancer, FIGO International Federation of Gynecology and Obstetrics, DKI diffusional kurtosis imaging, ADC apparent diffusion coefficient Table 1 Clinicopathological characteristics, operative details, and outcomes of patients with cervical stump cancer Patient no. Age at diagnosis (years) BMI Reasons for subtotal hysterectomy FIGO 2018 stage Histology Operation Operation time (mins) Blood loss (mL) Urinary catheter (days) Hospital stay (days) Complications Depth of invasion LVSI LNs dissected TNM stage Tumor size (mm) Postoperative radiotherapy Follow-up (months) Recurrence Death 1 50 25.9 Uterine myoma IIA1 ASC CLRS+PLND 221 360 10 12 No Middle one-third N 13 T2a1N0M0 16 No 30 No No 2 55 17.3 Uterine myoma IB1 AC CLRS+PLND 191 270 20 12 No Deep one-third N 24 T1b1N0M0 10 Yes 20 No No 3 50 24.8 Uterine myoma IB1 SC CLRS+PLND 295 310 13 15 No Superficial one-third N 21 T1b1N0M0 15 No 25 No No 4 63 30.1 Uterine myoma IB1 SC CLRS+PLND 213 180 6 16 No Superficial one-third N 25 T1b1N0M0 15 No 19 No No 5 58 20.2 Postpartum hemorrhage IIA1 SC CLRS+PLND 220 100 11 14 No Middle one-third N 21 T2a1N0M0 15 No 24 No No 6 46 22.7 Uterine myoma IB1 SC CLRS+PLND 215 120 14 17 No Superficial one-third N 26 T1b1N0M0 12 No 23 No No BMI body mass index, FIGO International Federation of Gynecology and Obstetrics, ASC cervical adenosquamous carcinoma, AC cervical adenocarcinoma, SC cervical squamous carcinoma, CLRS+PLND complete laparoscopic radical surgery and pelvic node dissections, LVSI lymphovascular space invasion, N negative, LNs lymph nodes, TNM tumor node metastasis.

Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer

Hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment modality that aims to target the main site of tumor dissemination in ovarian cancer, the peritoneum, by combining the benefits of intraperitoneal chemotherapy with the synergistic effects of hyperthermia all during a single administration at the time of cytoreductive surgery. High-quality evidence currently only supports the use of HIPEC with cisplatin at the time of interval cytoreduction after neoadjuvant chemotherapy for stage III epithelial ovarian cancer. Many questions remain, including HIPEC's role at other timepoints in ovarian cancer treatment, who are optimal candidates, and specifics of HIPEC protocols. This article reviews the history of normothermic and hyperthermic intraperitoneal chemotherapy in ovarian cancer and evidence regarding HIPEC implementation and patient outcomes. Additionally, this review explores details of HIPEC technique and perioperative care, cost considerations, complication and quality of life data, disparities in HIPEC use, and unresolved issues.

Postoperative Outcomes After Staged Versus Coordinated Breast Surgery and Bilateral Salpingo-Oophorectomy

The objective of this study was to compare postoperative complication rates and healthcare charges between patients who underwent coordinated versus staged breast surgery and bilateral salpingo-oophorectomy (BSO). The MarketScan administrative database was used to identify adult female patients with invasive breast cancer or BRCA1/BRCA2 mutations who underwent BSO and breast surgery (lumpectomy or mastectomy with or without reconstruction) between 2010 and 2015. Patients were assigned to the coordinated group if a breast operation and BSO were performed simultaneously or assigned to the staged group if BSO was performed separately. Primary outcomes were (1) incidence of 90-day postoperative complications and (2) 2-year aggregate perioperative healthcare charges. Fisher's exact tests, Wilcoxon rank-sum tests, and multivariable regression analyses were performed. Of the 4228 patients who underwent breast surgery and BSO, 412 (9.7%) were in the coordinated group and 3816 (90.3%) were in the staged group. The coordinated group had a higher incidence of postoperative complications (24.0% vs. 17.7%, p < 0.01), higher risk-adjusted odds of postoperative complications [odds ratio (OR) 1.37, 95% confidence interval (CI) 1.06-1.76, p = 0.02], and similar aggregate healthcare charges before (median charges: $106,500 vs. $101,555, p = 0.96) and after risk-adjustment [incidence rate ratio (IRR) 1.00, 95% CI 0.93-1.07; p = 0.95]. In a subgroup analysis, incidence of postoperative complications (12.9% for coordinated operations vs. 11.7% for staged operation, p = 0.73) was similar in patients whose breast operation was a lumpectomy. While costs were similar, coordinating breast surgery with BSO was associated with more complications in patients who underwent mastectomy, but not in patients who underwent lumpectomy. These data should inform shared decision-making in high-risk patients.

HIPEC in the Consolidation Setting: A Consolation Prize for Chemorefractory Ovarian Cancer?

Role of Hyperthermic Intraperitoneal Chemotherapy Combined with Cytoreductive Surgery as Consolidation Therapy for Advanced Epithelial Ovarian Cancer

Patients with advanced epithelial ovarian cancer who undergo incomplete surgery followed by six cycles of chemotherapy could benefit from second-look or consolidation cytoreductive surgery (CCRS). The primary goal of this study was to evaluate the overall survival (OS) in patients undergoing complete CCRS and the factors affecting survival. The secondary goal was to study the benefit of hyperthermic intraperitoneal chemotherapy (HIPEC) in these patients. This was a retrospective analysis of 173 patients with CCRS with (n = 118) or without (n = 55) HIPEC treated at 12 French centers. Only patients having a completeness of cytoreduction (CC) 0/1 resection and a minimum of 5 years of follow-up were included. HIPEC was performed systematically for all patients except those treated at the four centers that did not perform HIPEC. The median Peritoneal Cancer Index was 6 (range 0-33). Closed HIPEC was performed in 59 (34.1%) patients and open HIPEC was performed in 56 (32.3%) patients. Grade 3-4 complications occurred in 64 (36.9%) patients. The median OS was 35.67 months (95% confidence interval [CI] 29.8-46.1) and was significantly longer for CCRS + HIPEC (31.4 months without HIPEC and 42.5 months with HIPEC; p = 0.022). On multivariate analysis, closed HIPEC (hazard ratio [HR] 0.46, 95% CI 0.29-0.73; p  65 years (HR 2.17, 95% CI 1.14-4.11; p = 0.018) and bowel resection (HR 1.98, 95% CI 1.27-3.08; p = 0.020) led to a shorter OS. On multivariate logistic regression analysis, closed HIPEC (odds ratio 0.18; p = 0.001) was associated with a lower risk of dying at 5 years. CCRS was performed with an acceptable morbidity and resulted in good overall survival. The role of HIPEC in addition to CCRS should be evaluated in prospective, randomized studies and the closed technique prospectively compared with the open technique.

ASO Author Reflections: Redefining Consolidation Cytoreductive Surgery for Ovarian Cancer

Visual Peritoneal Evaluation of Residual Disease After Neoadjuvant Chemotherapy in Advanced Ovarian Cancer Patients: The VIPER Study

Chemotherapy induces histopathological tumor necrosis and fibrosis which results in macroscopic tissue changes, making surgeons' intraoperative visual evaluation of the disease distribution more difficult to interpret. The aim of the study was to assess the sensitivity, specificity, and accuracy of intraoperative laparoscopic visual evaluation of the diaphragmatic peritoneum and compare it with histopathological examination. Patients receiving diaphragmatic peritonectomy at time of IDS were retrospectively included. The population was grouped based on the surgeon's assessment of the diaphragmatic peritoneum during diagnostic laparoscopy. Group 1 included patients with a "visually pathologic" diaphragmatic peritoneum, and group 2 included patients with a "visually dubious" diaphragmatic peritoneum. Sensitivity, specificity, predictive values, and accuracy were calculated considering the final formalin-fixed pathology as the reference standard. 155 patients were included (92 in group 1 and 63 in group 2). The accuracy rate of visual examination was 67.1%, the negative predictive value was 19%, specificity was 100%, and sensitivity was 64.3%. NACT strongly affects the ability of the surgeon to discern between peritoneal scars and truly pathologic peritoneum. The diaphragmatic laparoscopic visual examination showed a low overall accuracy. We propose an algorithm that can guide the surgeon towards a more tailored approach to diaphragmatic peritonectomy during IDS.

Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) Applied to Platinum-Resistant Recurrence of Ovarian Tumor: A Single-Institution Experience (ID: PARROT Trial)

Abstract Background We aimed to investigate the therapeutic efficacy and safety of Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) in platinum-resistant recurrence of ovarian cancer and peritoneal carcinomatosis, while our secondary endpoint was to establish any changes in quality of life estimated via the EORTC QLQ-30 and QLQ-OV28 questionnaires. Methods In this monocentric, single-arm, phase II trial, women were prospectively recruited and every 28–42 days underwent courses of PIPAC with doxorubicin 2.1 mg/m2 followed by cisplatin 10.5 mg/m2 via sequential laparoscopy. Results Overall, 98 PIPAC procedures were performed on 43 women from January 2016 to January 2020; three procedures were aborted due to extensive intra-abdominal adhesions. The clinical benefit rate (CBR) was reached in 82% of women. Three cycles of PIPAC were completed in 18 women (45%), and 13 (32.5%) and 9 (22.5%) patients were subjected to one and two cycles, respectively. During two PIPAC procedures, patients experienced an intraoperative intestinal perforation. There were no treatment-related deaths. Nineteen patients showed no response according to the Peritoneal Regression Grading Score (PRGS) and 8 patients showed minor response according to the PRGS. Median time from ovarian cancer relapse to disease progression was 12 months (95% confidence interval [CI] 6.483–17.517), while the median overall survival was 27 months (95% CI 20.337–33.663). The EORTC QLQ-28 and EORTC QLQ-30 scores did not worsen during therapy. Conclusions PIPAC seems a feasible approach for the treatment of this subset of patients, without any impact on their quality of life. Since this study had a small sample size and a single-center design, future research is mandatory, such as its application in addition to systemic chemotherapy.

ASO Author Reflections: Establishment of a Prediction Model for Recurrent Cervical Cancer During a 2-Year Follow-Up Period

ASO Author Reflections: Preoperative Staging for Nongynecological Peritoneal Malignancies Mimicking Ovarian Cancer—Making the Omelet without Breaking the Eggs

Prediction of Recurrent Cervical Cancer in 2-Year Follow-Up After Treatment Based on Quantitative and Qualitative Magnetic Resonance Imaging Parameters: A Preliminary Study

This study investigated predictors of cervical cancer (CC) recurrence from native T1 mapping, conventional imaging, and clinicopathologic metrics. In total, 144 patients with histopathologically confirmed CC (90 with and 54 without surgical treatment) were enrolled in this prospective study. Native T1 relaxation time, conventional imaging, and clinicopathologic characteristics were acquired. The association of quantitative and qualitative parameters with post-treatment tumor recurrence was assessed using univariate and multivariate Cox proportional hazard regression analyses. Independent risk factors were combined into a model and individual prognostic index equation for predicting recurrence risk. The receiver operating characteristic (ROC) curve determined the optimal cutoff point. In total, 12 of 90 (13.3%) surgically treated patients experienced tumor recurrence. Native T1 values (X1) [hazard ratio (HR) 1.008; 95% confidence interval (CI) 1.001-1.016], maximum tumor diameter (X2) (HR 1.065; 95% CI 1.020-1.113), and parametrial invasion (X3) (HR 3.930; 95% CI 1.013-15.251) were independent tumor recurrence risk factors. The individual prognostic index (PI) of the established recurrence risk model was PI = 0.008X1 + 0.063X2 + 1.369X3. The area under the ROC curve (AUC) of the Cox regression model was 0.923. A total of 20 of 54 (37.0%) non-surgical patients experienced tumor recurrence. Native T1 values (X1) (HR 1.012; 95% CI 1.007-1.016) and lymph node metastasis (X2) (HR 4.064; 95% CI 1.378-11.990) were independent tumor recurrence risk factors. The corresponding PI was calculated as follows: PI = 0.011X1 + 1.402X2; the Cox regression model AUC was 0.921. Native T1 values combined with conventional imaging and clinicopathologic variables could facilitate the pretreatment prediction of CC recurrence.

Primary Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy (HIPEC) (OVHIPEC-2)

Simultaneous Vaginoplasty with Acellular Dermal Matrix and Pedicled Omental Flap and Pull-Through Colon–Anal Anastomosis for Low Rectal Cancer with Vaginal Invasion

In distal locally advanced rectal cancer with vaginal invasion, simultaneous bowel and vaginal reconstruction is technically challenging. A 64-year-old woman was diagnosed with rectal mucinous adenocarcinoma 5 months ago. Colonoscopy showed that the tumor was located on the anterior rectal wall, with its lower edge adjacent to the dentate line. Pelvic MRI revealed that the tumor involved the posterior vaginal wall. The patient expressed a strong desire for sphincter preservation. Following a series of multidisciplinary team discussions for oncological feasibility, neoadjuvant chemotherapy (CapeOx, ycT4bN0M0, partial response) and subsequent radical sphincter-preserving surgery were conducted. The surgery mainly included laparoscopic-assisted intersphincteric dissection and extensive resection of posterior vaginal wall with partial external anal sphincter. The operative time was 250 min. The blood loss was 150 ml. Postoperative course was uneventful, and the patient was discharged 8 days after surgery. The pulled-through bowel was resected 3 weeks after surgery. Postoperative pathology confirmed a rectal mucinous adenocarcinoma with vaginal invasion (ypT4bN0M0). All margins were clear. We describe a feasible technique of simultaneous bowel and vaginal reconstruction for low rectal cancer with vaginal invasion.

Impact of BRCA1/2 Mutations on the Efficacy of Secondary Cytoreductive Surgery

Phase III trials evaluating the role of secondary cytoreductive surgery (SCS) in recurrent ovarian cancer have pointed to the importance of patient selection. Two studies showed conflicting results regarding the benefit of SCS in BRCA1/2 mutation carriers. Our aim was to evaluate the impact of SCS on recurrent ovarian cancer according to BRCA1/2 status. All patients with ovarian carcinoma with platinum-sensitive recurrent disease and tested for BRCA1/2 germline mutations were included. Cox regression and log rank test were used to evaluate the impact of SCS on progression-free survival (PFS) and the influence of BRCA1/2 mutations on the effect of SCS. 127 patients were included, 45.6% were treated with SCS and chemotherapy and 54.3% treated with chemotherapy only. Patients treated with SCS were younger, presented better performance status, had lower CA125, and had a longer platinum-free interval. In multivariate analysis SCS was associated with longer PFS (HR 0.42, 95% CI 0.25-0.72, p = 0.002). BRCA1/2 mutations were found in 35 patients (27.5%), and 11.8% of patients were treated with PARP inhibitors. Although not statistically significant, both BRCA1/2 wild type patients (PFS: 21.6 vs 18.4 months; p = 0.114) and BRCA1/2 mutation carriers (PFS: 23.1 vs 18.2 months, p = 0.193) appeared to derive benefit from SCS. The present study suggests a benefit of SCS irrespective of BRCA1/2 status among patients mostly not treated with PARP inhibitor. Further data on post hoc analysis from the phase III trials are warranted to confirm whether BRCA1/2 mutated patients should be selected for SCS.

Results After Conservative Surgery of Stage II/III Serous Borderline Ovarian Tumors

The aim of this study was to assess the outcomes of a large series of patients treated conservatively for stage II or III serous borderline tumors of the ovary (SBOTs) with a long-term follow-up. Patients with SBOTs and peritoneal implants, treated in or referred to our institution, were retrospectively reviewed. Outcomes of patients treated conservatively (preservation of the uterus and at least a part of one ovary) to promote subsequent fertility were specifically analyzed. Between 1971 and 2017, 212 patients were identified and followed-up. Among these patients, 65 underwent conservative treatment; eight patients had invasive implants. Among patients treated conservatively, 38 (58%) patients recurred. Twenty-eight recurrences were observed under the form of borderline tumor on the spared ovary and/or noninvasive implants, but eight patients had a recurrence under the form of invasive disease. Compared with radical surgery, the use of conservative treatment (p < 0.0001) was a prognostic factor on disease-free survival (DFS), but without an impact on overall survival (OS). Nevertheless, three deaths occurred. Twenty-four pregnancies (13 spontaneous) were observed in 20 patients (29 patients wanted to become pregnant). In this series collecting the largest number of patients undergoing conservative surgery for stage II/III SBOTs, spontaneous pregnancies can be achieved after conservative treatment of advanced-stage disease, but the recurrence rate is high and three deaths were observed. These patients were spared their fertility but with a high rate of recurrence. Uncertainties regarding the safety of conservative treatment should be exposed to these patients.

ASO Author Reflections: Secondary Cytoreductive Surgery in Recurrent Ovarian Cancer

The Role of Secondary Cytoreductive Surgery in Recurrent Ovarian Cancer: A Systematic Review and Meta-Analysis

Phase 3 randomized clinical trials have been designed to compare secondary cytoreductive surgery followed by systemic therapy with systemic therapy alone for management of patients with recurrent ovarian cancer. This study aimed to compare differences in clinical outcomes between these two treatment approaches. The PRISMA statement was applied. Only phase 3 randomized clinical trials were included in the final analysis. Three randomized clinical trials (n = 1250 patients) were identified. Secondary cytoreductive surgery was associated with significantly better progression-free survival (PFS) improvement than systemic therapy alone (hazard ratio [HR], 95% CI, 0.61-0.78; p < 0.001). The PFS benefit was greater for the complete resection subpopulation (HR, 0.56; 95% CI, 0.48-0.66; p < 0.001). The HR of overall survival (OS) was similar between the groups (HR, 0.93; 95% CI, 0.78-1.10; p = 0.37), but it was 0.73 (95% CI, 0.59-0.91) in favor of the complete resection subpopulation. This meta-analysis showed secondary cytoreductive surgery as superior to systemic therapy alone in terms of PFS. The PFS and OS benefits were particularly observed for complete surgical resection. The impact on OS in the general population remains to be proven.

Editorial Response to Hepato-Biliary Disease Resection for Patients with Advanced Epithelial Ovarian Cancer: Prognostic Role and Optimal Cytoreduction

In Reference to Jonsdottir B et al. “The Peritoneal Cancer Index is a Strong Predictor of Incomplete Cytoreductive Surgery in Ovarian Cancer”

The Chicago Consensus on Peritoneal Surface Malignancies: Management of Ovarian Neoplasms

The Chicago Consensus Working Group provides multidisciplinary recommendations for the management of ovarian neoplasms specifically related to the management of peritoneal surface malignancy. These guidelines are developed with input from leading experts including surgical oncologists, medical oncologists, gynecologic oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

Should We Abandon Systematic Pelvic and Paraaortic Lymphadenectomy in Low-Grade Serous Ovarian Cancer?

Low-grade serous ovarian carcinoma (LGSOC) is a rare disease that accounts for 5% of all ovarian cancers and requires surgical complete debulking. To date, the prognostic value of pelvic and paraaortic lymphadenectomy remains unclear in this population. This retrospective cohort of patients with a diagnosis of LGSOC was registered in the Tumeurs Malignes Rares Gynécologiques national network, between January 2000 and July 2017, at 25 centers. All LGSOC were confirmed after pathological review and operated by primary debulking surgery (PDS) or interval debulking surgery after neoadjuvant chemotherapy (NACT-IDS). Primary endpoints were overall survival (OS) and progression-free survival (PFS). A total of 126 patients were included, 86.1% were stage III/IV, and 74.6% underwent lymph node dissection (LND). According to the Completeness of Cancer Resection (CCR) score, 83.7% had complete resection. Median OS was 130 months, and median PFS was 41 months. Pelvic and paraaortic LND had no significant impact on OS (p = 0.78) or DFS (p = 0.93), and this was confirmed in subgroups (advanced stages FIGO III/IV, CCR score 0/1 or 2/3, and timing of surgery PDS or NACT-IDS). Histological positive paraaortic lymph nodes had a significant negative impact on PFS in the whole population (HR 2.21, 1.18-4.39, p = 0.02) and in the CC0/CC1 population (HR, 2.28, 1.13-4.59, p = 0.02). Systematic pelvic and paraaortic LND in patients with LGSOC improved neither overall nor PFS. A prospective trial would be necessary to validate these results but would be difficult to conduct due to the rarity of this disease.

The Impact of Sarcopenia and Low Muscle Attenuation on Overall Survival in Epithelial Ovarian Cancer: A Systematic Review and Meta-analysis

Sarcopenia is defined as a progressive loss of skeletal muscle mass, strength and physical performance. Myosteatosis is an increase of intra- and intermuscular fat and can be measured radiologically by muscle attenuation. The study aim was to perform a systematic review and meta-analysis on the prognostic potential of sarcopenia and low muscle attenuation in relation to 3-year survival rates (3YSR) and 5YSR in epithelial ovarian cancer (EOC). A systematic literature search was conducted using the databases Ovid Medline, EMBASE, and Scopus, using PRISMA guidelines, from inception to 10th of May 2019. Studies evaluated the prognostic potential of sarcopenia and low muscle attenuation on 3YSR and 5YSR in EOC. Quality assessment of included studies was performed using the Methodological Index for Non-Randomised Studies criteria. A comprehensive search of databases resulted in the identification of 2194 studies, resulting in 1695 citations meeting the inclusion criteria. Six studies were included for systematic review. Sarcopenia was not significantly associated with improved 3YSR (OR 1.7, 95% CI 0.8-3.5, p = 0.15) or 5YSR (OR 1.8, 95% CI 1.0-3.2, p = 0.07) in meta-analysis. Normal muscle attenuation was associated with a favourable 3YSR (OR 3.0, 95% CI 2.0-4.5, p < 0.001) and 5YSR (OR 2.3, 95% CI 1.6-3.4, p < 0.001) compared to low muscle attenuation. Our meta-analysis indicated normal muscle attenuation was significantly associated with improved 3YSR and 5YSR in patients with EOC. Sarcopenia was not significantly associated with 3YSR or 5YSR in patients with EOC.

Extent of Peritoneal Resection for Peritoneal Metastases: Looking Beyond a Complete Cytoreduction

Completeness of cytoreduction is one of the most important prognostic factors impacting outcomes of cytoreductive surgery (CRS). To what extent the surrounding normal peritoneum needs to be removed is not known. We hypothesized that the extent of peritoneal resection should be different for different tumors and performed this study to find evidence to support this rationale. To determine the extent of resection of surrounding tissue for any tumor, the mechanisms of tumor development and spread, tumor morphology, the possibility of finding disease in the surrounding normal tissue, and the pattern of lymph node metastases should be known. Surgical resections also depend on patterns of recurrence and the impact of varying extent of resection on survival. We performed a review of literature pertaining to pathways and patterns of peritoneal cancer spread to determine the scientific basis for the extent of peritonectomy. We also reviewed studies comparing less and more extensive peritoneal resection. There is no consensus on the extent of lymphadenectomy required for most PM. Based on this review, we provide recommendations for the extent of peritoneal resection and the extent of lymph node dissection that should be performed for some common peritoneal tumors and identify areas that require further research. We propose that a systematic method of synoptic reporting of pathological specimens of CRS should be developed to capture information regarding the disease distribution within the peritoneal cavity and morphology of PM from different tumors. This can in future be used to establish standard guidelines for such resections.

The Safety of Iterative Cytoreductive Surgery and HIPEC for Peritoneal Carcinomatosis: A High Volume Center Prospectively Maintained Database Analysis

Offering iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for recurrence of peritoneal carcinomatosis (PC) poses a surgical dilemma. Safety of this repeated operation in the short and long term has not been largely investigated. Patients with PC who underwent 377 CRS/HIPEC procedures between 2007 and 2018 at our institution were included from a prospectively maintained database. Outcomes for patients who had singular CRS/HIPEC were compared with those for patients who had repeated CRS/HIPEC. Overall, there were 325 singular and 52 iterative CRS/HIPEC procedures performed during this time period. Age, sex, and ASA class were comparable between cohorts (p = NS). Optimal cytoreduction, mean operative time, mean length of hospital stay, 90-day major morbidity, and 90-day mortality were also similar. At a median follow-up of 24 months, there was no significant difference in recurrence rate (%, 60 vs 63, p = 0.76), disease-free survival (mean months, 19 vs 15, p = 0.30), and overall survival (mean months, 32 vs 27, p = 0.69). The iterative CRS/HIPEC group had significantly higher rates of major late complications than the singular CRS/HIPEC group (%, 18 vs 40, p < 0.01). Repeated CRS/HIPEC for PC has similar perioperative morbidity and mortality, as well as long-term oncological benefits, when compared with singular CRS/HIPEC. However, more than twice as many patients undergoing iterative CRS/HIPEC suffered from major late complications.

ASO Author Reflections: Expanding the Use of HIPEC in Ovarian Cancer at Time of Interval Debulking Surgery

Utilization and Treatment Patterns of Cytoreduction Surgery and Intraperitoneal Chemotherapy in the United States

Cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) is an effective treatment option for selected patients with peritoneal metastases (PM), but national utilization patterns are poorly understood. The objectives of this study were to (1) describe population-based trends in national utilization of CRS/IPC; (2) define the most common indications for the procedure; and (3) characterize the types of hospitals performing the procedure. The National Inpatient Sample (NIS) was used to identify patients from 2006 to 2015 who underwent CRS/IPC, and to calculate national estimates of procedural frequency and oncologic indication. Hospitals performing CRS/IPC were classified based on size and teaching status. The estimated annual number of CRS/IPC cases increased significantly from 189 to 1540 (p < 0.001). Overall, appendiceal cancer was the most common indication (25.7%), followed by ovarian cancer (23.3%), colorectal cancer (22.5%), and unspecified PM (15.0%). Remaining cases (13.5%) were performed for other indications. Most cases were performed in large teaching hospitals (65.9%), compared with smaller teaching hospitals (25.1%), large non-teaching hospitals (5.3%), or small non-teaching hospitals (3.2%). Patients were more likely to undergo CRS/IPC without a diagnosis based on level I evidence (appendiceal, ovarian, or colorectal) at large non-academic hospitals (odds ratio 2.00, 95% confidence interval 1.18-3.38, p = 0.010) compared with large academic hospitals. Utilization of CRS/IPC is increasing steadily in the US, is performed at many types of facilities, and often for a variety of indications that are not supported by high-level evidence. Given associated morbidity of CRS/IPC, a national registry dedicated to cases of IPC is necessary to further evaluate use and outcomes.

Clear Cell Borderline Ovarian Tumor: Clinical Characteristics, Prognosis, and Management

Clear cell borderline ovarian tumor (CCBOT) is one of the rarest subtypes of borderline ovarian malignancies. The aim of this study was to determine the prognosis of a series of CCBOT. A retrospective review of patients with CCBOT treated or referred to our institutions. A centralized histological review by a reference pathologist and data on the clinical characteristics, management, and outcomes of patients were required for inclusion. Nineteen patients were identified. Median age was 62 (range 36-83) years. Four patients underwent a conservative surgery and 14 a bilateral salpingo-oophorectomy +/- hysterectomy (unknown in 1 case). One patient had bilateral tumor, and all cases were stage-I disease. All CCBOTs showed an adenofibromatous pattern. Stromal microinvasion was observed in seven cases and intraepithelial carcinoma in two cases. Endometriosis was histologically associated in one case. The median follow-up was 76 (range 6-231) months. No recurrence occurred. Two patients died of intercurrent disease. Peritoneal staging procedures should always be associated, but restaging surgery could be omitted if there was no suspicious lesion in the peritoneum during initial surgery, since all patients reported had stage-I disease. Fertility-sparing surgery appears to be a safe alternative in young patients. Synchronous endometrial disorders with atypia are infrequent. Prognosis is generally excellent, and long-term risk of recurrence is low. The two recurrences described in literature occurred in stage-IC diseases, highlighting the importance of avoiding perioperative rupture.

Cytoreductive Surgery With or Without HIPEC After Neoadjuvant Chemotherapy in Ovarian Cancer: A Phase 3 Clinical Trial

Cytoreductive surgery (CRS) and administration of hyperthermic intraperitoneal chemotherapy (HIPEC) have shown their efficacy in multiple malignancies and also could offer a prognostic benefit for patients with advanced ovarian cancer. A prospective, single-center, parallel-group, randomized phase 3 clinical trial analyzed patients with a diagnosis of carcinomatosis from ovarian cancer treated with neoadjuvant systemic chemotherapy (NACT). In this trial, 71 patients were randomized to receive CRS alone (36 patients) or CRS with HIPEC (35 patients) using cisplatin (75 mg/m During a median follow-up period of 32 months, the median DFS was 12 months in the control group (CRS) and 18 months in the experimental group (CRS and HIPEC). The findings showed HIPEC to be an independent protective factor against the development of recurrence (hazard ratio [HR], 0.12, 95 % confidence interval [CI], 0.02-0.89; p = 0.038). The median OS was 45 months in the control group and 52 months in the experimental group. The respective morbidity rates for any grade (1 to 5) were respectively 58.3 % and 45.7 % (p > 0.05), with a mortality rates of 2.8 % and 2.9 % (p > 0.05). In the dimensions evaluated, CRS with or without HIPEC had no impact on QoL. For patients who had advanced ovarian cancer treated with NACT, CRS and HIPEC was associated with better DFS and OS, but without a difference in postoperative morbidity, mortality, or in the QoL evaluation.

Time to Evolve Terminology from “Debulking” to Cytoreductive Surgery (CRS) in Ovarian Cancer

Importance of Enhanced Recovery After Surgery (ERAS) Protocol Compliance for Length of Stay in Ovarian Cancer Surgery

Enhanced Recovery After Surgery (ERAS) programs include multiple perioperative care elements, which when implemented together are designed to improve recovery after surgery with subsequent reduction in hospital length of stay (LOS). The aim of this study is to examine the impact of ERAS protocol compliance on LOS in patients undergoing advanced ovarian cancer surgery within the context of a randomized clinical trial. Patients were enrolled in a prospective, consecutive, interventional randomized clinical trial between June 2014 and March 2018. Women with either suspected or confirmed advanced ovarian cancer with International Federation of Gynecology and Obstetrics (FIGO) stages IIB-IVA and recurrent ovarian cancer, who underwent cytoreduction surgery, were randomly assigned to either a conventional management (CM) protocol or an ERAS protocol. Demographic items, preoperative clinical data, and surgical characteristics of patients were recorded, as were LOS and ERAS protocol compliance. Negative binomial regression was used to model the relation between length of stay and ERAS protocol compliance. We included 49 patients in the CM group and 50 patients in the ERAS group. The overall rate of ERAS compliance was 92%. We observed that increasing ERAS protocol compliance was associated with shorter median LOS, and in patients who underwent higher complex surgeries, the length of stay reduction was greater. This study identifies a correlation between increasing ERAS protocol compliance and decreasing LOS in ovarian cancer surgery. This finding underlines the necessity to implement as many ERAS protocol elements as possible to achieve optimal clinical outcome improvements.

Differences in Sociodemographic Disparities Between Patients Undergoing Surgery for Advanced Colorectal or Ovarian Cancer

Cytoreductive surgery (CRS) for ovarian cancer with peritoneal metastases (OPM) is an established treatment, yet access-related racial and socioeconomic disparities are well documented. CRS for colorectal cancer with peritoneal metastases (CRPM) is garnering more widespread acceptance, and it is unknown what disparities exist with regards to access. This retrospective cross-sectional multicenter study analyzed medical records from the National Cancer Database from 2010 to 2015. Patients diagnosed with CRPM or ORP only and either no or confirmed resection were included. Patient- and facility-level characteristics were analyzed using uni- and multivariable logistic regressions to identify associations with receipt of CRS. A total of 6634 patients diagnosed with CRPM and 14,474 diagnosed with OPM were included in this study. Among patients with CRPM, 18.1% underwent CRS. On multivariable analysis, female gender (odds ratio [95% CI] 2.04 [1.77-2.35]; P < 0.001) and treatment at an academic or research facility (OR 1.55 [1.17-2.05]; P = 0.002) were associated with CRS. Among patients with OPM, 87.1% underwent CRS. On multivariable analysis, treatment at facilities with higher-income patient populations was positively associated with CRS, while age (OR 0.97 [0.96-0.98]; P < .0001), use of nonprivate insurance (OR 0.69 [0.56-0.85]; P = 0.001), and listed as Black (OR 0.62 [0.45-0.86]; P = 0.004) were negatively associated with CRS. There were more systemic barriers to CRS for patients with OPM than for patients with CRPM. As CRS becomes more widely practiced for CRPM, it is likely that more socioeconomic and demographic barriers will be elucidated.

Brenner Borderline Ovarian Tumor: A Case Series and Literature Review

Most frequent borderline ovarian tumors are serous and mucinous subtypes. Less frequent borderline diseases are endometrioid, clear-cell, and Brenner tumors (BBOT). Very little is known about the latter subtype, and most studies include very short series or case reports. The aim of this study is to determine the prognosis of a continuous series of BBOT and analyze data published in the literature on this rare entity. A retrospective review of patients with BBOT treated or referred to our institutions was conducted. A centralized histological review by a reference pathologist and data on the clinical characteristics, management, and outcomes of patients were required for inclusion. Overall, 17 patients were identified. Median age was 62 (range 42-85) years. Six patients underwent unilateral salpingo-oophorectomy, and 11 bilateral salpingo-oophorectomy +/- hysterectomy and/or staging surgery. In total, 16 patients had unilateral tumor, and all patients had stage I disease. Stromal microinvasion was observed in three cases. Median follow-up was 60 months (range 7-118 months). One patient developed a recurrence in contralateral ovary after unilateral salpingo-oophorectomy. One patient had previous history of urothelial tumor. Peritoneal staging surgery is not required because all patients reported had stage I disease. One recurrence occurred. When reviewing all the 82 cases reported in the literature (including ours), 9% had previous history or synchronous urothelial tumor, suggesting the need to carefully check for urological disease in patients with BBOT.

ASO Author Reflections: Rectosigmoid Mesorectal Sparing Resection: A Feasible Technique and a Viable Option in Advanced Ovarian Cancer Surgery

Oregovomab Plus Chemo in Newly Diagnosed Patients with Advanced Epithelial Ovarian Cancer Following Optimal Debulking Surgery (FLORA-5/GOG-3035)

ASO Author Reflection: Fertility-Sparing Surgery for Early-Stage Cervical Cancer—What Perspectives Between Oncological Prognosis and Obstetrical Future?

Robotic Radical Trachelectomy with Primary Vaginal Closure to Spare Fertility in Young Patients with Early-Stage Cervical Cancer

Our aim was to present the surgical technique of robotic radical trachelectomy (RRT) for early-stage squamous cell cervical cancer in women with a desire to preserve fertility. A surgical case to illustrate the entire surgical technique of RRT and sentinel lymph node dissection. Institutional Review Board approval was not required for this video presentation. University hospital. A 30-year-old patient with one child and no medical history. Pap smear and cervical biopsy were in favor of high-grade squamous intraepithelial lesion, and a conization procedure allowed the diagnosis of a 15 mm squamous cell carcinoma (International Federation of Gynecology and Obstetrics [FIGO] 1B1). An RRT was performed to preserve the fertility of this young patient, after bilateral sentinel lymph node dissection to ensure the absence of nodal metastasis. The trachelectomy specimen was negative at final pathology examination and the disease was confirmed as stage 1B1 (FIGO 2018). There were no surgical complications and no adjuvant treatment was indicated. Fertility-sparing surgery is acceptable for women of childbearing age who want to become pregnant. Minimally invasive surgery is safe, effective, and particularly adapted for women who wish to preserve their fertility without compromising oncological outcomes.1

Cancer Awareness and Stigma in Rural Assam India: Baseline Survey of the Detect Early and Save Her/Him (DESH) Program

India has an estimated incidence of more than one million cancers annually. Breast, oral, and cervical cancers account for over one-third of newly diagnosed cases. With the introduction of pilot cancer screening programs in India, little is known about current sociocultural barriers that may hinder acceptance of screening and treatment. We sought to identify knowledge gaps, misconceptions, and stigmas surrounding cancer diagnosis. A baseline survey was conducted in Assam, India, as part of the Detect Early and Save Her/Him program, a mobile screening program for breast, oral, and cervical cancer. Data were collected on participants' cancer knowledge, and attitudes towards screening, diagnosis, and treatment. Of the 923 residents who participated, a large majority (92.9%; n = 858) were neither aware of cancer screening availability nor had prior screening. Low-medium awareness was demonstrated regarding the carcinogenic effects of betel nuts (n = 433, 47%). Only one-third of participants recognized oral ulcers and dysphagia as cancer symptoms. Approximately 10% of respondents had misconceptions about cancer etiologies, and 42-57% endorsed statements reflecting a negative stigma towards cancer, including its long-term detrimental effects on personal, occupational, and familial life. However, the majority (68-96%) agreed with statements endorsing positive community support and medical care for cancer patients. This study identifies actionable targets for intervention in cancer education and awareness within a large rural Indian population. Education to address preventable causes of cancer and to correct misconceptions and stigma is a critical component in ensuring the successful implementation of cancer screening programs.

Is Conization a Protective Surgical Maneuver in Early Cervical Cancer?

ASO Author Reflections: Role of Adjuvant Surgery in Locally Advanced Cervical Cancer: An Unresolved Issue

Platinum-Based Chemotherapy Versus Secondary Cytoreductive Surgery Before Olaparib Maintenance Therapy for 259 Patients with BRCA Mutated Platinum-Sensitive Recurrent Ovarian Cancer: A Multicenter Retrospective Study: Comparative Effectiveness and Survival Outcomes Analysis

The benefit of secondary cytoreduction surgery (SeCRS) followed by olaparib maintenance therapy for recurrent ovarian cancer has not been clearly demonstrated. This study aimed to evaluate the role of SeCRS combined with olaparib for patients with BRCA-mutated platinum-sensitive recurrent ovarian cancer. This multi-center retrospective study analyzed patients with BRCA-mutated platinum-sensitive recurrent ovarian cancer treated between July 2015 and August 2024. Overall survival (OS) and progression-free survival (PFS) were used to measure treatment effectiveness. Adverse events were graded according to the National Cancer Institute's Common Terminology Criteria for Adverse Events, version 3.0. Among 259 patients, 124 were treated with SeCRS followed by platinum-based chemotherapy (the surgery group), and 135 were treated with platinum-based chemotherapy alone (the chemotherapy group). All patients received olaparib tablets until disease progression. The median PFS in the surgery group was significantly longer than in the chemotherapy group (27.2 vs. 18.2 months; hazard ratio [HR], 0.46; 95 % confidence interval [CI], 0.35-0.62; p < 0.001). The median OS was significantly longer in the surgery group than in the chemotherapy group (68.1 vs. 50.5 months; HR, 0.57; 95 % CI 0.42-0.78; p < 0.001). The incidence and severity grades of adverse events did not differ significantly between the two groups. The findings of this study suggest that SeCRS followed by platinum-based chemotherapy and olaparib maintenance therapy results in longer OS and PFS than platinum-based chemotherapy followed by olaparib maintenance therapy alone for patients with BRCA-mutated platinum-sensitive recurrent ovarian cancer.

A Deep Learning-Based Multimodal Clinico-Histology-Genomic Prognostic Model in Prostate Cancer

Germline BRCA1/2 Mutation Prevalence in Unselected ER-Low/HER2-Negative Breast Cancer

Safety and Efficacy of Cisplatin and Doxorubicin Pressurized Intraperitoneal Aerosolized Chemotherapy (PIPAC) in Patients with Ovarian Cancer with Peritoneal Metastases: A Multicenter US Phase I Trial

Abstract Background Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) is a novel, minimally invasive method of delivering intraperitoneal chemotherapy with promising peritoneal disease control in ovarian cancer. Methods This US multicenter prospective phase I trial (NCT04329494) evaluated the safety and efficacy of PIPAC cisplatin 10.5 mg/m 2 and doxorubicin 2.1 mg/m 2 (PIPAC-CD) every 6 weeks in ovarian cancer at three US centers. Primary endpoints were dose-limiting toxicities and adverse events. Secondary endpoints included response according to RECIST (Response Evaluation Criteria in Solid Tumors) criteria, laparoscopic peritoneal carcinomatosis index, histologic peritoneal regression grading score, progression-free survival (PFS), and overall survival (OS). Results In total, 15 patients were enrolled. The median prior lines of therapy was 3 (range 1–10). The PIPAC completion rate (≥2 PIPACs) was 86.7%. A total of 76.9% of patients had extraperitoneal disease at baseline. One patient discontinued treatment for toxicity because of deterioration of her baseline Eastern Cooperative Oncology Group 2 performance status. There was one grade 3 abdominal pain, one grade 3 anorexia, and no grade 4 or 5 adverse events. Laparoscopic best response (peritoneal carcinomatosis index) and histologic response (peritoneal regression grading score) occurred in 30.8% and 46.2%, respectively. Radiologic best response (RECIST) was 6.7%, with one partial response and a stable disease rate of 26.7%. Median PFS and OS were 2.3 months (95% confidence interval 1.7–3.2) and 17.1 months (95% confidence interval 5.6–not reached), respectively (n=15). Conclusions PIPAC-CD is feasible, safe, and well tolerated at academic US centers. OS and PFS were limited in patients with heavily pretreated ovarian carcinoma who underwent PIPAC-CD. Future trials should focus on optimizing PIPAC drug combinations and determining optimal patient selection criteria for ovarian cancer.

Uptake of Risk Reducing Mastectomy in Older BRCA1/2 and PALB2 Carriers Undergoing Genetic Testing after 60 Years of Age

Image-Guided Robotic Surgery for Sentinel Lymph Node Status Assessment in Uterine Cancers Using Ultrasound Drop-in Probe: Surgical Technique in 10 Steps

Abstract Introduction Recent guidelines recommend the sentinel lymph node (SLN) technique in uterine cancers, as it is associated with lower perioperative complications.1 Image-guided surgery can address some limitations of SLN procedures, such as low frozen-section accuracy and risk of empty packets,2–4 by providing real-time lymph node assessment.5,6 This video describes the surgical procedure of intraoperative robotic ultrasound examination for SLN assessment. Materials and Methods The Arietta L43K (2–12 MHz, Hitachi, Japan) drop-in robotic ultrasound probe was used to assist with SLN dissection. The procedure was performed on the da Vinci Xi platform. The probe, introduced through an accessory trocar, was manipulated by robotic instruments, providing real-time ultrasound imaging in split-view mode on the surgeon’s console. Ultrasound images, captured by the surgeon under the guidance of an experienced ultrasound examiner, were analyzed both in vivo and ex vivo.7 Results The procedure involves ten steps, detailed as follows. (1) The procedure begins with the cervical injection of indocyanine green. (2) The pelvic retroperitoneum is opened to allow access to anatomical landmarks. (3) Using near-infrared imaging mode, the lymphatic pathways are highlighted, allowing for the identification of the SLN. (4) Once identified, the drop-in ultrasound probe is introduced. (5) The console is switched to split-view mode, enabling the surgeon to observe ultrasound images alongside the endoscopic view. (6) In vivo imaging is conducted. (7) Both images and videos of the lymph node are captured. (8) The SLN is subsequently dissected. (9) SLN specimens are safely extracted. (10) Ex vivo ultrasound assessment is performed to further evaluate their characteristics. Conclusions Although its accuracy compared with histology as the gold standard is yet to be demonstrated, image-guided robotic lymph node ultrasound is a feasible and promising procedure for real-time SLN assessment. A prospective study is ongoing (R-LYNUS, NCT06621823) to clinically validate this technique.

Intraperitoneal Intraoperative Chemotherapy in Advanced Ovarian Cancer: Rethinking the Future Beyond Complete Macroscopic Resection

The rationale for intraperitoneal chemotherapy after complete macroscopic cytoreduction (CC-0) is well-established for peritoneal surface malignancies. This study aimed to analyze prognostic factors for disease-free survival (DFS) of patients with high-grade serous ovarian cancer (HGSOC) undergoing interval CC-0 cytoreductive surgery (iCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). This retrospective multicenter study included 293 HGSOC patients treated between January 2010 and May 2023. All the patients received neoadjuvant platinum-based chemotherapy followed by CC-0 iCRS and HIPEC with cisplatin or paclitaxel. Prognostic factors for DFS were analyzed using Kaplan-Meier curves, log-rank tests, and Cox proportional hazards regression. The median DFS was 23 months, with 3- and 5-year survival rates of 39 % and 29 %, respectively. The patients with a peritoneal carcinomatosis index (PCI) of 15 or lower had significantly better DFS than those with a PCI greater than 15 (24 vs 15 months; p < 0.05). Paclitaxel-based HIPEC was associated with superior DFS compared with cisplatin (25 vs 16 months; p < 0.05). Multivariate analysis showed a PCI greater than 15 related to a lower DFS (hazard ratio [HR], 1.539; p = 0.048) and paclitaxel-based HIPEC as a factor associated with better DFS (HR, 0.663; p = 0.016). The patients treated with HIPEC-paclitaxel and with a PCI of 15 or lower demonstrated the best outcomes (median DFS, 33 months). In HGSOC, the PCI is the most significant determinant of DFS after CC-0 iCRS and HIPEC. Paclitaxel-based HIPEC showed better outcomes than cisplatin, particularly for patients with a PCI of 15 or lower. Further prospective studies are needed to confirm the role of paclitaxel and to evaluate BRCA mutation and homologous recombination deficiency status in treatment efficacy.

Integration of a Genetic Counselor into a Breast Health Center Improves Identification of Patients Needing Genetic Testing

Risk Factors for Anastomotic Leakage: A Comprehensive Single-Center Analysis of Colorectal Anastomoses for Ovarian and Gastrointestinal Cancers

Anastomotic leakage (AL) is a major complication in colorectal surgery, particularly following rectal cancer surgery, necessitating effective prevention strategies. The increasing frequency of colorectal resections and anastomoses during cytoreductive surgery (CRS) for peritoneal carcinomatosis further complicates this issue owing to the diverse patient populations with varied tumor distributions and surgical complexities. This study aims to assess and compare AL incidence and associated risk factors across conventional colorectal cancer surgery (CRC), gastrointestinal CRS (GI-CRS), and ovarian CRS (OC-CRS), with a secondary focus on evaluating the role of protective ostomies. A retrospective analysis was performed on 1324 patients undergoing CRC, GI-CRS, and OC-CRS between January 2015 and December 2022. Multivariate analysis was utilized to identify preoperative, intraoperative, and postoperative variables as potential AL risk factors. The overall AL rate was 3.0% (40/1324), with no significant differences among the three groups. Distinct risk factors were identified for each group: CRC (preoperative chemoradiotherapy), GI-CRS (ECOG score ≥ 2, preoperative albumin < 30 mg/dL), and OC-CRS (BMI < 18 kg/m AL, while rare, remains a serious postoperative complication in CRC and CRS. Key risk factors include preoperative nutritional status and surgical details such as blood supply and anastomosis level. Each patient group presents unique risks, which must be carefully weighed when considering protective ileostomy.

Robotic Surgery in Endometrial Cancer using Robot da Vinci® SP

Surgery through a minimally invasive approach is the mainstay of the initial management of endometrial cancer, while sentinel lymph node (SLN) technique enhances the already excellent outcomes of minimally invasive full surgical staging. We described a case of a patient diagnosed with endometrioid endometrial cancer, International Federation of Gynecology and Obstetrics (FIGO) grade 2 (p53 wild-type, mismatch repair-proficient). Preoperative findings suggested a presumed FIGO 2023 stage IA2. The patient underwent a full surgical staging including hysterectomy, bilateral salpingo-oophorectomy and bilateral SLN biopsy. The total operative time was 100 min, and the estimated blood loss was 30 mL. The surgical procedure was performed without complications. Pain assessment using the Visual Analog Scale (VAS) Robotic surgical staging for endometrial cancer using the da Vinci

Efficacy of Poly(ADP-ribose) Polymerase Inhibitors According to Clinical Risk in Newly Diagnosed, Advanced Ovarian Cancer: A Meta-analysis of Phase III Clinical Trials

Poly(ADP-ribose) polymerase (PARP) inhibitor maintenance therapy improves progression-free survival (PFS) in patients with advanced ovarian cancer, with greatest benefit observed in patients with BRCA alterations and homologous recombination deficiencies (HRD). This study evaluated PFS benefit of PARP inhibitors according to clinically relevant risk factors. A literature search was performed including Cochrane, Medline, Pubmed, Pubmed Central, clinicaltrials.gov, and Embase from January 2018 to January 2025. This was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Data was extracted and random effect models constructed using Review Manager (RevMan Version 7.2.0 The Cochrane Collaboration). Outcomes were reported as pooled hazard ratios (pHR) with 95% confidence intervals (95% CI). Clinically relevant subgroups were analyzed. A total of 6 studies comprising 3609 patients were selected for analysis. PARP inhibitors were beneficial regardless of patient age, Eastern Cooperative Oncology Group (ECOG) score, disease stage, timing of surgery, chemotherapy response, or high-risk classification. Patients with visible residual disease (VRD) after primary cytoreductive surgery (pCRS) derived significant benefit (pHR 0.61, 95% CI 0.48-0.77, p-value < 0.001). In contrast, no significant PFS benefit was observed for patients with VRD after interval cytoreductive surgery (iCRS) (pHR 0.63, 95% CI 0.36-1.09, p-value = 0.10). Although PARP inhibitors benefit various patient subgroups, our analysis did not demonstrate a PFS benefit in patients with VRD following iCRS. Residual disease status appears to be prognostically important for patients undergoing iCRS with maintenance PARP inhibitors. Further analyses of clinical risk factors stratified according to genetic subgroup is required. Prospero 2025 CRD420251007940, available at: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251007940.

Prognostic Evaluation of Fertility-Sparing Surgery in Patients with Epithelial Ovarian Cancer: A Population-Based Analysis

Indications of fertility-sparing surgery (FSS) for young women with early stage epithelial ovarian cancer (EOC) are controversial. We aimed to evaluate the impact of FSS on the prognosis of patients. Patients diagnosed with EOC, whose tumors were limited to unilateral ovaries and American Joint Committee of Cancer stage 1 or 2, were identified in the Surveillance, Epidemiology, and End Results database (2004-2017). Propensity score matching, restricted mean survival time, subgroup analysis, log-rank test, and two-stage test were used to evaluate the effect of FSS on cancer-specific survival (CSS). A total of 1836 patients with stage 1 or 2 were identified and divided into FSS and non-FSS groups. After propensity score matching, 172 pairs of patients were included. Before and after propensity score matching, log-rank test and restricted mean survival time results showed FSS had no significant effect on CSS at 3, 5, and 10 years. After propensity score matching, univariate and multivariate Cox regression analysis confirmed FSS was not a risk factor for CSS. The study population was stratified according to variables examined by Cox regression analysis (age, race, tumor grade, stage, chemotherapy). Subgroup analysis based on log-rank and two-stage test showed FSS had no significant effect on CSS in any subgroup except the subgroup of stage 2. Fertility-sparing surgery does not lead to worse outcomes than non-FSS among stage 1 EOC patients younger than 50 years. Thus, indications of FSS for early-stage EOC patients with a strong desire for fertility preservation should be appropriately broaden.

Quality of Life After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC): Cancer Survivors’ Perspective Through In-Depth Interviews

CRS/HIPEC patients face unique quality of life (QoL) challenges due to advanced disease (peritoneal carcinomatosis), the extent of procedure, and risk for long-term complications. Standard QoL questionnaires are generic, focusing on tumor type and standard treatments, and likely do not capture this select population's full experience, suggesting the need for tailored instruments. We aimed to characterize the QoL challenges faced by CRS/HIPEC cancer survivors and determine whether these were captured by a standard QoL questionnaire. An anonymous, semi-structured individual interview was conducted with CRS/HIPEC patients addressing their experience at diagnosis, challenges related to CRS/HIPEC, and access to CRS/HIPEC information. Verbatim transcripts were interpreted using thematic analysis. Code and theme identification was inductive. Questions addressing common themes that were not encompassed by a standard QoL questionnaire were developed. We interviewed eight patients. Median age was 55 (range 30-71) years and 75% (n = 6) were women. Primary tumor sites included appendix (n = 4), ovarian (n = 3), and peritoneal mesothelioma (n = 1). Median time from CRS/HIPEC was 40.1 (range 3.1-216.3) months. Overall, 133 codes were identified and categorized into 9 themes. The most recurring were physical symptoms after CRS/HIPEC (specifically gastrointestinal symptoms), adjusting to survivorship, mental health, expectations from CRS/HIPEC, and access to care. A total of 22 questions that did not overlap with a standardized QoL questionnaire were developed. There is an unmet need to understand the unique QoL challenges CRS/HIPEC patients encounter. Patient-centered QoL questionnaires based on CRS/HIPEC patient experiences can capture these unique challenges and help guide future studies and care.

Comparison of Outcomes in Bowel Resections by Gynecologic Oncologists Versus General Surgeons During Maximal Cytoreductive Surgery for Advanced Ovarian Cancer: Gynecologic Oncology Research Investigators Collaboration Study (GORILLA-3006)

This report describes the oncologic outcomes for patients with advanced ovarian cancer who had bowel surgery performed by gynecologic oncologists (GOs) and compares the outcomes with those for bowel surgery performed by general surgeons (GSs) during maximal cytoreductive surgery. Patients from six academic institutions who had FIGO stage III or IV ovarian cancer and underwent any bowel surgeries during maximal cytoreductive surgery were eligible for the study. The patients were divided into two groups according to whether bowel surgery was performed by a GO or a GS. In both groups, the GOs were mainly involved in extra bowel debulking procedures. Perioperative and survival outcomes were compared between the two groups. The 761 patients in this study included 113 patients who underwent bowel surgery by a GO and 648 who had bowel surgery by a GS. No discernible differences were observed in age, American Society of Anesthesiology (ASA) score, FIGO stage, histologic type, timing of cytoreductive surgery (primary or interval debulking surgery), or complications between the two groups. The GO group exhibited a shorter operation time than the GS group. Kaplan-Meier analysis showed no survival differences between the two groups. In the Cox analysis, non-serous cell types and gross residual diseases were associated with adverse effects on overall survival. However, performance of bowel surgery by a GO did not have an impact on survival. Performance of bowel surgery by a GO during maximal cytoreductive surgery is both feasible and safe. These results should be reflected in the training system for GOs regarding bowel surgery, and further research is needed to confirm that GOs can play a more leading role in performing extra-uterine procedures.

Impact of Ovarian Cancer Surgery Volume on Overall and Progression-Free Survival: A Population-Based Retrospective National French Study

Data are limited on the relationship between ovarian cancer surgery volume and outcomes in France. For this retrospective, population-based study, patients with ovarian cancer that was diagnosed between January 1, 2012 and December 31, 2016 were identified from the French National Health Data System (SNDS). Hospitals were classified in function of their ovarian cancer surgery volume. Patient, tumor, hospital, and hospital stay characteristics also were evaluated. The hospital procedure volume effect on 5-year overall survival (OS) and recurrence-free survival (RFS) was determined with Cox-proportional hazards models. This study included 8429 patients and 53.4% underwent cytoreductive surgery in hospitals with procedure volume < 20 cases/year. The 5-year OS rates were 63% and 60% in hospitals with procedure volume ≥ 20 and < 20 cases/year (p = 0.02). In multivariate analysis, OS and RFS were significantly increased when surgery was performed in hospitals doing ≥ 20 surgeries/year (vs. < 20) (hazard ratio HR = 1.18, 95% CI = 1.08-1.29 and HR = 1.10, 95% CI = 1.03-1.17). In the volume subgroup analysis, a difference was observed mainly between hospitals with < 10 surgeries/year and the other hospitals (HR = 1.27, 95% CI = 1.14-1.41 and HR = 1.14, 95% CI = 1.05-1.23). The patients' age and comorbidities, tumor stage, and hospital stay (duration, first cytoreduction surgery) were associated with OS. Ovarian cancer surgery volume ≥ 20 cases/year was significantly associated with improved OS and RFS but only with a limited clinical benefit. The biggest differences in OS and RFS were observed between hospitals with procedure volume < 10 cases/year and all the other hospitals.

Clinical Significance of Mesenteric Lymph Node Involvement in the Pattern of Liver Metastasis in Patients with Ovarian Cancer

Mesenteric lymph node (MLN) involvement is often observed in ovarian cancer (OC) with rectosigmoid invasion. This study aimed to investigate the clinical significance of MLN involvement in the pattern of liver metastasis in patients with OC. We included 85 stage II-IV OC patients who underwent primary or interval debulking surgery. Twenty-seven patients underwent rectosigmoid resection, whose status of MLN involvement was judged from hematoxylin and eosin (H&E) staining of resected specimens. The prognostic significance of clinicopathological characteristics, including MLN involvement, was evaluated using univariate and multivariate analyses. MLN involvement was detected in 14/85 patients with stage II-IV OC. Residual tumor status, cytology of ascites, and MLN involvement were independent prognostic factors for progression-free survival (PFS; p = 0.033, p = 0.014, and p = 0.008, respectively). When patients were classified into three groups (no MLN, one MLN, two or more MLNs), the number of MLNs involved corresponded to three distinct groups in PFS (p = 0.001). The 3-year cumulative incidence of liver metastasis of patients with MLN involvement was significantly higher than that of patients without MLN involvement (61.1% vs. 8.9%, p < 0.001). MLN involvement was significantly associated with liver metastasis of hematogenous origin (p < 0.001) compared with peritoneal disseminated origin. MLN involvement is an important prognostic factor in OC, predicting poor prognosis and liver metastasis of hematogenous origin.

ASO Author Reflections: Clinical Significance of Mesenteric Lymph Node Involvement in Patients with Ovarian Cancer

Oncological and Reproductive Outcomes of Cystectomy Compared with Unilateral Salpingo-Oophorectomy as Fertility-Sparing Surgery in Patients with Apparent Early Stage Pure Immature Ovarian Teratomas

To compare the oncological and reproductive outcomes of patients with apparent early stage pure ovarian immature teratomas (IMTs) treated with unilateral salpingo-oophorectomy (USO) or cystectomy. We retrospectively reviewed the medical records of patients with apparent early stage pure ovarian IMTs who received fertility-sparing surgery (FSS) between 1984 and 2019. FSS was defined as preservation of the uterus and at least one adnexa. Recurrence rates were compared between patients receiving USO and cystectomy. Reproductive outcomes and menstrual histories were assessed by telephone interview. A total of 124 patients were included, of whom 83 underwent USO and 41 underwent cystectomy. After a median follow-up of 70.6 months (range: 6.2-410.6 months), eight patients suffered recurrences (5 in the USO group and 3 in the cystectomy group). The median times to recurrence were 5.0 and 5.1 months in the USO and cystectomy groups, respectively (P = 0.764). All patients with recurrence were successfully salvaged by surgery, except for one death. Univariate analysis showed no difference in disease-free survival and overall survival between the groups (P = 0.781, 0.155). Of the 111 patients contacted by telephone, 97 resumed menstruation following the surgery. Of the 31 patients desiring pregnancy, 26 achieved 28 pregnancies. USO (83.3%), like cystectomy (85.7%), resulted in excellent pregnancy rates. A USO is the standard treatment for women with early stage pure IMTs who want to preserve fertility. However, a cystectomy with adjuvant chemotherapy may be a suitable fertility-sparing therapy when a cystectomy is the only surgical option.

ASO Author Reflections: Ovarian Cystectomy for Apparent Early-Stage Pure Immature Ovarian Teratomas

Disease Distribution at Presentation Impacts Benefit of IP Chemotherapy Among Patients with Advanced-Stage Ovarian Cancer

Ovarian cancer with miliary disease spread is an aggressive phenotype lacking targeted management strategies. We sought to determine whether adjuvant intravenous/intraperitoneal (IV/IP) chemotherapy is beneficial in this disease setting. Patient/tumor characteristics and survival data of patients with stage IIIC epithelial ovarian cancer who underwent optimal primary debulking surgery from 01/2010 to 11/2014 were abstracted from records. Chi-square and Mann-Whitney U tests were used to compare categorical and continuous variables. The Kaplan-Meier method was used to estimate survival curves, and outcomes were compared using log-rank tests. Factors significant on univariate analysis were combined into multivariate logistic regression survival models. Among 90 patients with miliary disease spread, 41 (46%) received IV/IP chemotherapy and 49 (54%) received IV chemotherapy. IV/IP chemotherapy, compared with IV chemotherapy, resulted in improved progression-free survival (PFS; 23.0 versus 12.0 months; p = 0.0002) and overall survival (OS; 52 versus 36 months; p = 0.002) in patients with miliary disease. Among 78 patients with nonmiliary disease spread, 23 (29%) underwent IV/IP chemotherapy and 55 (71%) underwent IV chemotherapy. There was no PFS or OS benefit associated with IV/IP chemotherapy over IV chemotherapy in these patients. On multivariate analysis, IV/IP chemotherapy was associated with improved PFS (HR, 0.28; 95% CI 0.15-0.53) and OS (HR, 0.33; 95% CI 0.18-0.61) in patients with miliary disease compared with those with nonmiliary disease (PFS [HR, 1.53; 95% CI 0.74-3.19]; OS [HR, 1.47; 95% CI 0.70-3.09]). Adjuvant IV/IP chemotherapy was associated with oncologic benefit in miliary disease spread. This survival benefit was not observed in nonmiliary disease.

Impact of Previous Gynecologic Surgical Procedures on Outcomes of Non-Gynecologic Peritoneal Malignancies Mimicking Ovarian Cancer: Less Is More?

Non-gynecologic rare peritoneal surface malignancies (PSMs) often are misdiagnosed as disseminated ovarian cancer and initially treated by gynecologic surgeons. This study aimed to assess whether these previous maneuvers (i.e., full surgical staging and/or cytoreductive attempts) affect outcomes after the definitive surgery performed in a tertiary center. The study reviewed 298 women affected by non-gynecologic PSM who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) after previous gynecologic surgery. Prior surgery was categorized as limited surgery (pLS: abdominal exploration with biopsy plus adnexectomy and/or appendectomy) or extended surgery (pES: full surgical staging or cytoreductive attempts including hysterectomy with bilateral salpingo-oophorectomy). Of the 298 patients, 143 had pLS and 153 had pES. Morbidity was similar between the groups (P = 0.143), but the pES group had more severe urinary tract injuries (19 vs. 3; P < 0.001), longer operating time (585.9 vs. 506.7; P = 0.027), and more patients needing more than two anastomoses (41 vs. 26; P = 0.033). Age older than 55 years (odds ratio [OR] 2.42; P = 0.009) and number of anastomoses (OR 3.17; P = 0.002) correlated with severe morbidity; pES correlated with urinary tract grades 3 and 4 injuries (OR 7.9; P = 0.001). The 5-year cumulative incidence of locoregional relapse was significantly higher in the pES group (0.41 vs. 0.27; P = 0.012; median follow-up period, 69 months). The multivariate analysis identified a Peritoneal Carcinomatosis Index (PCI) higher than 20 and pES as independent risk factors. For women undergoing CRS±HIPEC for non-gynecologic PSM, the risk for locoregional relapse and severe postsurgical urinary tract complications is increased by pES. Therefore, prior full surgical staging or cytoreductive attempts without definitive gynecologic histology should be avoided. Prophylactic ureteral stenting and stricter oncologic follow-up assessment must be considered in this scenario.

Rectosigmoid Mesorectal-Sparing Resection in Advanced Ovarian Cancer Surgery

Ovarian cancer is the most lethal of all gynecologic cancers.

Outcomes for Elderly Ovarian Cancer Patients Treated with Cytoreductive Surgery Plus Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC)

Women 65 years of age or older with epithelial ovarian cancer (EOC) are thought to have a worse prognosis than younger patients. However, no consensus exists concerning the best treatment for ovarian cancer in this age group. This report presents outcomes for patients treated with cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC). A prospective database of EOC patients treated with CRS/HIPEC (1998-2019) was analyzed. Perioperative variables were compared by treatment including upfront CRS/HIPEC, neoadjuvant chemotherapy plus CRS/HIPEC (NACT + CRS/HIPEC), and salvage CRS/HIPEC, and by age at surgery (< 65 and ≥ 65 years). Survival analysis was performed, and outcomes were compared. Of the 148 patients identified, 42 received upfront CRS/HIPEC, 48 received NACT + CRS/HIPEC, and 58 received salvage CRS/HIPEC. Each group was subdivided by age groups (< 65 and ≥ 65 years). The median overall survival (OS) after the upfront CRS/HIPEC was 69.2 months for the patients < 65 years of age versus 69.3 months for those ≥ 65 years of age. The OS after NACT + CRS/HIPEC was 26.9 months for the patients < 65 years of age versus 32.9 months for those ≥ 65 years of age, and the OS after salvage CRS/HIPEC was 45.6 months for the patients < 65 years of age versus 23.9 months for those ≥ 65 years of age. The median progression-free survival (PFS) after upfront CRS/HIPEC was 41.3 months for the patients < 65 years of age versus 45.4 months for those ≥ 65 years of age. The PFS after NACT + CRS/HIPEC was 16.2 months for the patients < 65 years of age versus 11.2 months for those ≥ 65 years of age, and the PFS after salvage CRS/HIPEC was 18.7 months for the patients < 65 years of age versus 10 months for those ≥ 65 years of age. The median follow-up period for the entire cohort was 44.6 months [95% confidence interval (CI) 34.7-60.6 months]. Age and feasibility of complete cytoreduction should be considered when treatment methods are selected for elderly patients. A carefully selected elderly population can benefit significantly from aggressive treatment methods.

The Debatable Role of HIPEC in Ovarian Cancer

Cytoreductive Surgery and Intraperitoneal Chemotherapy in Advanced Serous Epithelial Ovarian Cancer: A 14-Year French Retrospective Single-Center Study of 124 Patients

Ovarian cancer (OC) is the most lethal gynecological cancer. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy appears to increase survival, and normothermic intraperitoneal chemotherapy (IPC) could improve overall survival (OS). Furthermore, intraperitoneal epinephrine could decrease the toxicity of chemotherapy by decreasing the systemic absorption of chemotherapy. The goal of this study was to assess the effects of CRS and IPC with intraperitoneal epinephrine, as first-line therapy, on the survival of patients with serous epithelial OC (EOC) with peritoneal metastases. A prospective monocentric database was retrospectively searched for all patients with advanced serous EOC treated by interval or consolidative CRS plus IPC with intraperitoneal epinephrine after neoadjuvant chemotherapy. OS and disease-free survival (DFS), postoperative complications, and prognostic factors were analyzed. From January 2003 to December 2017, 124 patients with serous EOC were treated with interval (n = 58) or consolidative (n = 66) complete CRS plus IPC with intraperitoneal epinephrine. The median follow-up was 77.8 months, the median OS was 60.8 months, and the median DFS was 21.2 months. In our multivariate analysis, a higher Peritoneal Cancer Index (PCI) and positive lymph node status resulted in worse OS, while higher World Health Organization score, higher PCI score, and positive lymph node status were risk factors for worse DFS. Grade 3 or higher surgical morbidity occurred in 27.42% of cases; only 3.2% had grade 3 renal toxicity and mortality was 0.8%. CRS and IPC with intraperitoneal epinephrine in stage III EOC offer good OS and DFS with acceptable morbidity and mortality rates.

Histopathologic Validation of the Sentinel Node Technique for Early-Stage Cervical Cancer Patients

Abstract Background The sentinel lymph node (SLN) biopsy may be an alternative to systematic lymphadenectomy in early cervical cancer. The SLN biopsy is less morbid and has been shown to have high sensitivity for metastasis detection. However, the sensitivity of the SLN technique might be overevaluated because SLNs are examined with ultra-staging, and non-sentinel nodes usually are examined only with routine techniques. This study aimed to validate the negative predictive value (NPV) of the SLN technique by the ultra-staging of SLNs and non-sentinel nodes (NSLNs). Methods The SENTICOL 1 study data published in 2011 were used. All nodes (i.e., SLNs and NSLNs) were secondarily subjected to ultra-staging. The ultra-staging consisted of sectioning every 200 µm, in addition to immunohistochemistry. Moreover, the positive slides and 10% of the negative slides were reviewed. Results The study enrolled 139 patients, and SLNs were detected in 136 (97.8%) of these patiets. Bilateral SLNs were detected in 104 (76.5%) of the 136 patients. A total of 2056 NSLNs were identified (median, 13 NSLNs per patient; range 1–54). Of the 136 patients with SLNs, 23 were shown to have positive SLNs after serial sectioning and immunohistochemical staining. The NSLNs were metastatic in six patients. In the case of bilateral SLN detection, the NPV was 100%, with no false-negatives (FNs). Conclusions The pelvic SLN technique is safe and trustworthy for determining the nodal status of patients with early-stage cervical cancer. In the case of optimal mapping with bilateral detection, the NPV was found to be 100%.

ASO Authors Reflections: Vaginectomy as Surgical Treatment of Recurrent Cervical Cancer

Is a Vaginectomy Enough or is a Pelvic Exenteration Always Required for Surgical Treatment of Recurrent Cervical Cancer? A Propensity-Matched Study

Reporting the perioperative and survival outcomes of vaginectomy with respect to a matched series of pelvic exenteration (PE) in women with isolated recurrent cervical cancer. The records of vaginal recurrent cervical cancer patients admitted at Fondazione Policlinico "Agostino Gemelli" IRCCS in Rome from January 2010 to June 2019 were retrospectively analyzed. A propensity-matched score analysis was performed by age, clinical stage, disease-free interval, and R0 resection. Postsurgical complications and survival rates were evaluated. Fifteen women underwent vaginectomy, and 30 patients were submitted to PE. No statistical differences were observed between the two groups at baseline characteristics. The vaginectomy procedures were successfully performed in all women, and no case required conversion to PE. Moreover, a higher rate of major postoperative complications after PE with respect to vaginectomy (p = 0.027) was recorded. Among them, three women required reoperation within 30 postoperative days, and four experienced two or more complications. Twenty-five (55.6%) women experienced recurrence: 8 of 25 (32.0%) in the vaginectomy group, and 17 of 25 (68%) in the PE group, with a median progression-free survival of 20 months and 13 months, respectively (p = 0.169). In total, 5 of 15 (33.3%) died of disease in the vaginectomy group and 13/30 (43.3%) in the PE group, with a median overall survival of 39 and 18 months for vaginectomy and PE, respectively (p = 0.161). The vaginectomy seems to allow for salvage treatment, such as radiotherapy and/or PE, but with a minimal impact on the quality of life in appropriately selected women with local recurrent cervical cancer.

Adapting Radicality in Early Cervical Cancer When Quality of Life Becomes a Prominent Issue

ASO Author Reflections: Robotic Radical Hysterectomy for Patients with Early-Stage Cervical Cancer: Oncologic Outcomes

How to Select Early-Stage Cervical Cancer Patients Still Suitable for Laparoscopic Radical Hysterectomy: a Propensity-Matched Study

Recently, it was reported that minimally invasive surgery (MIS) has a negative impact on early-stage cervical cancer (ECC) patient survival. At the same time, advantages of MIS regarding quality of life and low rate of intra- and postoperative complications are well known. Therefore, it is essential to select patients who may benefit from MIS without worsening their oncologic outcomes. The aim of this study is to investigate which pathological factors could guide surgeons' choice about the best approach in ECC. Patients with 2009 FIGO stage from IA1 with lymphovascular space invasion (LVSI) to IB1/IIA1 treated by open or laparoscopic surgery were judged eligible for the study. Disease-free survivals (DFS) of both approaches were tested in subgroups, defined according to histology, tumor size, grading, LVSI, parametrial involvement, and nodal status. A total of 423 patients were enrolled (217 in the open and 206 in the laparoscopic group). No difference between open surgery and laparoscopy was found among subgroups defined according to histology, grading, LVSI, parametrial involvement, or nodal status. Among patients with tumor > 20 mm, laparoscopy showed a significantly higher relapse risk [hazard ratio (HR): 2.103, p = 0.030]. Among patients with tumor < 20 mm, laparoscopy showed DFS superimposable to open surgery (HR: 0.560, p = 0.128). Tumor size of 20 mm appeared as the only independent discrimination criterion in patients whose prognosis is affected by surgical approaches.

Carcinomatosis in Early-Stage Cervical Cancer Treated with Robotic Radical Hysterectomy: Recurrence Patterns, Risk Factors, and Survival

Minimally invasive radical hysterectomy has been associated with increased recurrence of disease and worse survival compared with open radical hysterectomy for early-stage cervical cancer. We evaluated patterns of recurrence and histopathologic risk factors in patients who underwent robotic radical hysterectomy (RRH). Patients who underwent RRH (4/2007-12/2018) were evaluated for specific locations of recurrent disease, disease-free survival, overall survival (OS), and histopathologic risk factors for recurrence. Inclusion criteria were follow-up ≥ 1 year, histology with adenocarcinoma, adenosquamous, or squamous carcinoma and clinical stage IA2 to IB ≤ 4-cm tumor size cervical cancers (FIGO-2018). A total of 140 patients underwent RRH and 112 met criteria. Median tumor size was 2.1 cm [interquartile range (IQR): 1.1-3.3]. Median follow-up was 61 months (IQR: 36-102). Fifty (45%) patients underwent adjuvant radiation ± cisplatin with either Sedlis' or Peters' risk factors. There were 11 (9.8%) recurrences with median disease-free survival of 12 (IQR 8.5) months. All patients with recurrence had measured tumor size ≥ 2 cm (median tumor size 3-cm (IQR: 2.6-4.0). Tumor size > 2 cm was associated with Sedlis' intermediate-risk factors (p  2 cm recurred. Five (4.5%) of patients had carcinomatosis representing 45% of all recurrences. Carcinomatosis was associated with reduced OS compared with other recurrence patterns (22 months vs. 7.8 years, p < 0.05). Carcinomatosis was observed in early-stage cervical cancers treated with RRH and was associated with reduced OS. All recurrences were associated with lesions ≥ 2 cm, and no recurrences were identified with negative conization margins.

ASO Author Reflections: Minimally Invasive Radical Hysterectomy in Cervical Cancer: A Brazilian Multicentric Cohort Study (CIRCOL)

Open Versus Minimally Invasive Radical Hysterectomy in Cervical Cancer: The CIRCOL Group Study

To analyze the survival outcomes of patients in a Brazilian cohort who underwent minimally invasive surgery (MIS) compared with open surgery for early stage cervical cancer. A multicenter database was constructed, registering 1280 cervical cancer patients who had undergone radical hysterectomy from 2000 to 2019. For the final analysis, we included cases with a tumor ≤ 4 cm (stages Ia2 to Ib2, FIGO 2018) that underwent surgery from January 2007 to December 2017. Propensity score matching was also performed. A total of 776 cases were ultimately analyzed, 526 of which were included in the propensity score matching analysis (open, n = 263; MIS, n = 263). There were 52 recurrences (9.9%), 28 (10.6%) with MIS and 24 (9.1%) with open surgery (p = 0.55); and 34 deaths were recorded, 13 (4.9%) and 21 (8.0%), respectively (p = 0.15). We noted a 3-year disease-free survival (DFS) rate of 88.2% and 90.3% for those who received MIS and open surgery, respectively (HR 1.32; 95% CI: 0.76-2.29; p = 0.31) and a 5-year overall survival (OS) rate of 91.8% and 91.1%, respectively (HR 0.80; 95% CI: 0.40-1.61; p = 0.53). There was no difference in 3-year DFS rates between open surgery and MIS for tumors ≤ 2 cm (95.7% vs. 90.8%; p = 0.16) or > 2 cm (83.9% vs. 85.4%; p = 0.77). Also, the 5-year OS between open surgery and MIS did not differ for tumors ≤ 2 cm (93.1% vs. 93.6%; p = 0.82) or > 2 cm (88.9% vs. 89.8%; p = 0.35). Survival outcomes were similar between minimally invasive and open radical hysterectomy in this large retrospective multicenter cohort.

Cancer Screening Programs in Low- and Middle-Income Countries: Strategies for Success

ASO Author Reflections: Conization Before Radical Hysterectomy Improves Disease-Free Survival in Early Stage Cervical Cancer

Protective Role of Conization Before Radical Hysterectomy in Early-Stage Cervical Cancer: A Propensity-Score Matching Study

The purpose of this study was to assess the prognostic role and the perioperative outcomes of conization performed before radical hysterectomy in early-stage cervical carcinoma. This multicenter, retrospective observational cohort study included patients with FIGO 2009 stage IB1 cervical carcinoma treated with radical hysterectomy between June 2004 and June 2019. Patients were divided into two groups according to conization before radical surgery. One-to-one case-control matching was used to adjust the baseline characteristics. A total of 332 patients were included after propensity matching (166, 50% in each group). Twenty-four of 166 (14.4%) and 142 of 166 (85.6%) conization patients had negative and positive surgical margins on the conization specimen, respectively. No difference in intra- and postoperative complications was noted between the two groups (p = 0.542 and p = 0.180, respectively). Patients undergoing conization before radical hysterectomy received less adjuvant treatment (p 20 mm and no conization before radical hysterectomy (p = 0.011 and p = 0.018, respectively). The only independent variable influencing OS was pathologic tumor diameter >20 mm (p = 0.020). Conization before radical hysterectomy was associated with improved DFS and lower probability of receiving adjuvant treatment. No difference in perioperative complications and OS was evident. Tumor diameter >20 mm was found to be the only independent risk factor affecting OS in both groups.

ASO Author Reflections: Is Residual Disease Predictable After Conization in Cervical Cancer?

Predictive Factors for Residual Disease After Conization in Cervical Cancer

The aim of this study was to evaluate predictive factors for the presence of residual disease after conization followed by definitive surgery in cervical cancer, and suggest a margin distance threshold that could predict residual disease. We retrospectively analyzed a series of 42 patients with early-stage cervical cancer who underwent primary conization before definitive surgical treatment from March 2009 to May 2020. All conization specimens were reviewed for endocervical, ectocervical, and radial margins. Cases with residual disease in magnetic resonance imaging before definitive surgery were excluded. Thirty-three (78.6%) patients underwent hysterectomies and 9 (21.4%) trachelectomies ± lymph node staging. Twelve (28.6%) cases were stage IA1, 5 (11.8%) cases were stage IA2, 13 (31%) cases were stage IB1, 11 (26.2%) cases were stage IB2, and 1 (2.4%) case was stage IIIC1 [International Federation of Gynecology and Obstetrics (FIGO) 2019]. We found residual disease in 17 (40.4%) surgical specimens. Of the 20 patients with negative margins, there were still 3 (15%) cases with residual disease. Conversely, residual disease was identified in 14 (63.6%) of the 22 patients with positive cone margins (p = 0.001). Tumor size [odds ratio (OR) 1.71, 95% confidence interval (CI) 1.02-1.33] and positive endocervical margin status (OR 33.6, 95% CI 3.85-293.3) were related to a higher risk of residual disease in multivariate analysis. Notably, all patients with tumors larger than 2 cm had residual disease, in contrast to 29.4% in lesions up to 2 cm (p = 0.002). We found that tumor size and positive margin were predictive factors for residual disease. We could not suggest a reliable minimum margin distance threshold that could predict residual disease.

ASO Author Reflections: Fertility-Sparing Treatment for Early-Stage Cervical Cancer 2 cm or Larger in Size: A Problem Still Open

ASO Author Reflections: Laparoscopic Ovarian Transposition for Locally Advanced Cervical Cancer—Tailoring the Treatment with the Standardization of a Surgical Procedure

ASO Author Reflections: Will Conization Become a Standard Maneuver Before Radical Hysterectomy?

Reclassification of Appendiceal Mucinous Neoplasms and Associated Pseudomyxoma Peritonei According to the Peritoneal Surface Oncology Group International Consensus: Clinicopathological Reflections of a Two-Center Cohort Study

Evaluating the Role of Hyperthermic Intraperitoneal Chemotherapy in Cytoreductive Surgery for Advanced-Stage Ovarian Cancer

Hyperthermic intraperitoneal chemotherapy (HIPEC) is used to eliminate minimal residual disease in patients with peritoneal surface malignancies, including advanced epithelial ovarian cancer (EOC). While some trials suggest potential benefits, the role of HIPEC during cytoreductive surgery (CRS) in EOC remains uncertain. This study aimed to evaluate outcomes for patients undergoing HIPEC during CRS for advanced-stage EOC in the United States (US). This multicenter, retrospective cohort study included women with stage III-IV EOC who underwent CRS with or without HIPEC between 2006 and 2021 at Commission on Cancer-accredited US facilities. Propensity score matching was used to create a control group of patients who underwent CRS only. Overall survival (OS) was analyzed using the Kaplan-Meier log-rank method and adjusted for confounding factors with Cox proportional hazards regression. Among 1400 patients identified, 700 underwent CRS with HIPEC and 700 underwent CRS only. Of these 1400 patients, 932 underwent interval CRS and 468 underwent primary CRS. No significant difference in median OS was observed between the overall CRS+HIPEC and CRS-only groups (57.6 vs. 47.6 months; p = 0.105). However, interval CRS+HIPEC was associated with significantly improved median OS compared with interval CRS-only (57.6 vs. 45.7 months; p = 0.003). After adjustment, HIPEC remained significantly associated with improved survival (hazard ratio 0.77, 95% confidence interval 0.64-0.92; p = 0.004). HIPEC is associated with improved OS in patients undergoing interval CRS for advanced-stage EOC. Further research should explore the selective use of HIPEC during interval CRS.

Impact of the American Society of Breast Surgeons’ Guidelines on Genetic Testing and Contralateral Prophylactic Mastectomy Rates

Cutting Edge Microscopic Intraoperative Tissue Assessment for Guidance in Oncologic Surgery: A Systematic Review of the Role of Optical Coherence Tomography

Comparison of Minimally Invasive and Open Surgery for the Treatment of Endometrial Cancer with a High Risk of Recurrence: A Propensity Score Matching Study in Korea and Taiwan

This study compared oncologic outcomes between minimally invasive surgery (MIS) and open surgery for the treatment of endometrial cancer with a high risk of recurrence. This study included patients with endometrial cancer who underwent primary surgery at two tertiary centers in Korea and Taiwan. Low-grade advanced-stage endometrial cancer (endometrioid grade 1 or 2) or endometrial cancer with aggressive histology (endometrioid grade 3 or non-endometrioid) at any stage was considered to have a high risk of recurrence. We conducted 1:1 propensity score matching between the MIS and open surgery groups to adjust for the baseline characteristics. Of the total of 582 patients, 284 patients were included in analysis after matching. Compared with open surgery, MIS did not show a difference in disease-free survival [hazard ratio (HR) 1.09; 95% confidence interval (CI) 0.67-1.77, P = 0.717] or overall survival (HR 0.67; 95% CI 0.36-1.24, P = 0.198). In the multivariate analysis, non-endometrioid histology, tumor size, tumor cytology, depth of invasion, and lymphovascular space invasion were risk factors for recurrence. There was no association between the surgical approach and either recurrence or mortality in the subgroup analysis according to stage and histology. MIS did not compromise survival outcomes for patients with endometrial cancer with a high risk of recurrence when compared with open surgery.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy to Treat Pseudomyxoma Peritonei of Ovarian Origin: A Retrospective French RENAPE Group Study

Abstract Background Ovarian pseudomyxoma peritonei (OPMP) are rare, without well-defined therapeutic guidelines. We aimed to evaluate cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) to treat OPMP. Methods Patients from the French National Network for Rare Peritoneal Tumors (RENAPE) database with proven OPMP treated by CRS/HIPEC and with histologically normal appendix and digestive endoscopy were retrospectively included. Clinical and follow-up data were collected. Histopathological and immunohistochemical features were reviewed. Results Fifteen patients with a median age of 56 years were included. The median Peritoneal Cancer Index was 16. Following CRS, the completeness of cytoreduction (CC) score was CC-0 for 9/15 (60%) patients, CC-1 for 5/15 (33.3%) patients, and CC-2 for 1/15 (6.7%) patients. The median tumor size was 22.5 cm. After pathological review and immunohistochemical studies, tumors were classified as Group 1 (mucinous ovarian epithelial neoplasms) in 3/15 (20%) patients; Group 2 (mucinous neoplasm in ovarian teratoma) in 4/15 (26.7%) patients; Group 3 (mucinous neoplasm probably arising in ovarian teratoma) in 5/15 (33.3%) patients; and Group 4 (non-specific group) in 3/15 (20%) patients. Peritoneal lesions were OPMP pM1a/acellular, pM1b/grade 1 (hypocellular) and pM1b/grade 3 (signet-ring cells) in 13/15 (86.7%), 1/15 (6.7%) and 1/15 (6.7%) patients, respectively. Disease-free survival analysis showed a difference (p = 0.0463) between OPMP with teratoma/likely-teratoma origin (groups 2 and 3; 100% at 1, 5, and 10 years), and other groups (groups 1 and 4; 100%, 66.6%, and 50% at 1, 5, and 10 years, respectively). Conclusion These results suggested that a primary therapeutic strategy using complete CRS/HIPEC for patients with OPMP led to favorable long-term outcomes.

ASO Author Reflections: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) for Platinum-Resistance Ovarian Cancer Patients

ASO Author Reflections: En Bloc Resection of Sentinel Lymph Nodes with the Hysterectomy Specimen in Endometrial Cancer

En Bloc Resection of Sentinel Lymph Nodes with the Hysterectomy Specimen in Endometrial Cancer

We demonstrate the surgical technique of removing the sentinel lymph nodes with its afferent lymphatic vessels attached to the hysterectomy specimen. Stepwise demonstration of the technique with narrated video footage. Sentinel lymph node sampling has been established as an acceptable staging method in endometrial cancer cases. Emerging evidence regarding diagnosis, characterization, and treatment of endometrial cancer has introduced a new era, based on minimally invasive techniques for staging through sentinel lymph node biopsy, molecular classification, and personalized treatment algorithms that include immune checkpoint inhibitors and targeted therapies. This novel surgical technique emphasizes the importance of anatomical knowledge and offers inspiration for studies with potential clinical benefit that should follow.

Probe-Based Confocal Laser Endomicroscopy in Gynecologic Surgical Oncology: Intraoperative Insights to Guide Surgical Resection

Ovarian cancer is a leading cause of cancer-related death in women. Cytoreductive surgery is the cornerstone of treatment, but frequently requires extensive surgical procedures. In vivo pCLE images and subsequent biopsies were acquired from various anatomical sites after injection of fluorescein. Each endomicroscopic sequence was analyzed by dedicated investigators highly experienced in pCLE imaging and compared with the histology of the corresponding specimen. Normal tissues exhibited uniform stromal fibers, consistent cellular architecture, and regular vascularization. In contrast, malignant nodules were identified by fluorescein leakage, reflecting abnormal vessel permeability and highlighting clusters of neoplastic cells. Preliminary data from our observations indicate a substantial concordance between pCLE findings and histology. pCLE is a promising intraoperative tool for real-time cellular analysis.

Cancer Stage-Shifting with Sentinel Lymph Node Biopsy in Low-Grade Endometrial Cancer

Predictive Score of Nodal Involvement in Endometrial Cancer Patients: A Large, Multicenter Series

ASO Author Reflections: How Long will We Perform Lymphadenectomy in Endometrial Cancer Patients?

ASO Author Reflections: Minimally Invasive Surgical Staging in Endometrial Cancer Diagnosed After Supracervical Hysterectomy - The Role of Cervical Injection to Detect Sentinel Lymph Node with Indocyanine Green

Association Between Adjuvant Therapy and Survival in Stage II–III Endometrial Cancer: Influence of Malignant Peritoneal Cytology

The aim of this study was to examine the survival effect of adjuvant therapy in stage II-III endometrial cancer based on peritoneal cytology results. The National Cancer Institute's Surveillance, Epidemiology, and End Results Program was retrospectively queried to examine 7467 women with stage II-III endometrial cancer who underwent hysterectomy, and with available peritoneal cytology results, from 2010 to 2016. A Cox proportional hazard regression model was fitted to assess the association between adjuvant therapy and all-cause mortality stratified by peritoneal cytology results. Malignant peritoneal cytology was reported in 1662 (22.3%) women and was associated with non-endometrioid histology, higher tumor stage, and nodal metastasis (p < 0.05). In a propensity score-weighted model, malignant peritoneal cytology was associated with increased all-cause mortality compared with negative peritoneal cytology (hazard ratio 1.35, 95% confidence interval 1.23-1.48). Adjuvant therapy types varied based on histology and peritoneal cytology results. In non-endometrioid histology, the combination of chemotherapy and whole pelvic radiotherapy (WPRT) was associated with improved overall survival compared with chemotherapy or WPRT alone irrespective of the peritoneal cytology results (p < 0.05). The combination of chemotherapy and WPRT was also associated with improved overall survival in women with endometrioid histology and malignant peritoneal cytology (p = 0.026). Women with endometrioid histology and negative peritoneal cytology represented the most common subpopulation (46.5%), and overall survival was similar regardless of which of the three adjuvant therapy modalities was used (p = 0.319). Malignant peritoneal cytology is prevalent and prognostic in stage II-III endometrial cancer. This study found that the surgeon's choice and benefit of adjuvant therapy for women with stage II-III endometrial cancer differed depending on the status of peritoneal cytology.

ASO Author Reflections: Malignant Peritoneal Cytology, Adjuvant Therapy Choice, and Survival in Advanced Endometrial Cancer

ASO Author Reflections: Sentinel Lymph Node Biopsy in Endometrial Cancer: Beyond Oncologic Outcomes

Adnexal Involvement in Endometrial Cancer: Prognostic Factors and Implications for Ovarian Preservation

To determine the risk factors related to adnexal involvement in endometrial cancer (EC) and its implications for ovarian preservation in young women. We analyzed a series of 802 patients who were treated at AC Camargo Cancer Center from July 1991 to July 2017. Patients who had peritoneal or systemic dissemination (stage IV) were excluded. Chi square and Fisher's exact tests were used to analyze the correlations between categories and clinicopathological variables. Multivariate analysis was performed by logistic regression. Forty-nine (6.2%) patients had adnexal involvement-43 (5.4%) ovarian and 24 (2.9%) tubal. After excluding the 14 (28%) cases with suspicious findings, 788 subjects were analyzed and adnexal involvement found in 35 (4.4%) cases. Adnexal involvement was statistically related to non-endometrioid histologies (12.6% vs. 3.1%; p < 0.001), lymph node metastasis (17% vs. 2.6%; p < 0.001), histological grade 3 tumors (9.4% vs. 2.1%; p < 0.001), presence of LVSI (14.2% vs. 2.4%; p < 0.001), and deep myometrial invasion (≥ 50%) (10.8% vs. 3.5%; p < 0.001). Although age younger than 45 years had higher risk of adnexal involvement, it was not statistically significant (8.9% vs. 4.2%; p = 0.13). Seven (14.2%) patients with adnexal involvement were aged < 45 years, 3 of whom (42.8%) had suspicious adnexal masses that were detected before surgery. Notably, all patients aged < 45 years and with adnexal involvement had at least 1 risk factor, such as presence of LVSI, grade 3 disease, node metastasis, or deep myometrial invasion. No patient with clinically normal ovaries and aged under 45 years, with endometrioid grades 1 and 2, superficial myometrial invasion, or node negativity had adnexal involvement. Ovarian preservation may be considered for patients younger than 45 years old with low-risk EC (grades 1 and 2 tumors, absence of LVSI, and myometrial invasion < 50%).

ASO Author Reflections: Could Ovarian Preservation be Considered for Young Women with Endometrial Cancer?

Size of Sentinel Node Metastasis Predicts Non-sentinel Node Involvement in Endometrial Cancer

To analyze the relationship between the size of metastatic sentinel lymph nodes (SLNs) and the risk of non-sentinel lymph node (non-SLN) metastasis in endometrial cancer. From a total of 328 patients with endometrial cancer who underwent SLN mapping from January 2013 to April 2019, 142 patients also underwent systematic completion pelvic ± paraaortic node dissections, and they form the basis of this study. The SLNs were examined by immunohistochemistry (IHC) when the hematoxylin-eosin stain was negative. The median age was 60 years. The overall detection rate for SLNs was 87.5%, and bilateral SLNs were observed in 66.2%, with a median of 2 SLNs resected (range 1-8). Twenty-nine (20.4%) cases had positive SLNs, with a median of one positive SLN. Regarding the size of SLN metastasis, 5 (3.5%) cases had isolated tumor cells (ITCs), 13 (9.2%) had micrometastases, and 11 (7.7%) had macrometastases. Notably, 14/29 (48.3%) had node metastases that were detected after IHC. Eight (27.6%) patients had positive non-SLNs, with a median count of 7 positive nodes (range 2-23). Regarding the size of SLN metastasis, non-SLN involvement was not present in cases with ITC (0/5) but was present in 15.4% (2/13) of cases with micrometastases and 54.5% (6/11) of cases with macrometastases. The only risk factor for positive non-SLNs was the size of SLN metastasis. Our data suggest that size of SLN metastasis is associated with the risk of non-SLN metastasis. No patients with ITCs in SLNs had another metastatic lymph node in this study.

Treatment Patterns and Prognosis of Cervical Cancer Patients Aged 65 and Older: A Population-Based Cohort Study

To describe treatment patterns and prognosis in elderly cervical cancer (CC) patients ( ≥ 65 years). A retrospective analysis was conducted using the Surveillance, Epidemiology, and End Results database (2000-2019). Propensity score matching (PSM) balanced baseline characteristics. Overall survival (OS) was assessed using Kaplan-Meier analysis and Cox models. The Cochran-Armitage trend test was used to examine age-related risks of cancer and noncancer-specific death. Among 45,447 CC patients, 7,026 (15.3%) were elderly. Compared with young (  0.05), whereas in unresectable LACC cases, radical surgery plus radiotherapy provided the highest 5 year OS rate (61.2%) and significantly improved survival (p Elderly CC patients present with more advanced stage disease and receive less intensive treatment compared to younger patients. Surgery is feasible, and individualized strategies considering surgical eligibility, postoperative risks, and noncancer mortality are essential to optimize outcomes.

Oncologic and Perioperative Outcomes of Robot-Assisted Versus Conventional Laparoscopy for the Treatment of Clinically Uterine-Confined High-Grade Adenocarcinoma

The aim of this study was to compare oncologic and perioperative outcomes of robot-assisted laparoscopy (RA) and conventional laparoscopy (LSC) in apparent clinically uterine-confined, high-grade adenocarcinoma. A retrospective review was conducted to identify patients with newly diagnosed high-grade uterine adenocarcinoma treated at our institution between 1 January 2009 and 30 June 2021. Exclusion criteria included bulky extrauterine disease, no lymph node assessment, or synchronous tumors. Clinicopathologic details were obtained from medical records. Postoperative complications were classified using the Memorial Sloan Kettering Cancer Center Surgical Secondary Events system, and statistical analysis was performed using appropriate tests. Of 901 patients identified, 748 (83%) underwent RA and 153 (17%) underwent LSC. Median age was 65 years (range 25-92) and median body mass index was 30 kg/m RA demonstrated comparable oncologic outcomes to LSC in patients with high-grade endometrial carcinoma, with no significant difference in postoperative complications or long-term survival.

The 2022 PSOGI International Consensus on HIPEC Regimens for Peritoneal Malignancies: Epithelial Ovarian Cancer

We report the results of an international consensus on hyperthermic intraperitoneal chemotherapy (HIPEC) regimens for epithelial ovarian cancer (EOC) performed with the following goals: To define the indications for HIPEC To identify the most suitable HIPEC regimens for each indication in EOC To identify areas of future research on HIPEC To provide recommendations for some aspects of perioperative care for HIPEC METHODS: The Delphi technique was used with two rounds of voting. There were three categories of questions: evidence-based recommendations [using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system with the patient, intervention, comparator, and outcome (PICO) method], an opinion survey, and research recommendations. Seventy-three (67.5%) of 108 invited experts responded in round I, and 68 (62.9%) in round II. Consensus was achieved for 34/38 (94.7%) questions. However, a strong positive consensus that would lead to inclusion in routine care was reached for only 6/38 (15.7%) questions. HIPEC in addition to interval cytoreductive surgery (CRS) received a strong positive recommendation that merits inclusion in routine care. Single-agent cisplatin was the only drug recommended for routine care, and OVHIPEC-1 was the most preferred regimen. The panel recommended performing HIPEC for a minimum of 60 min with a recommended minimum intraabdominal temperature of 41°C. Nephroprotection with sodium thiosulfate should be used for cisplatin HIPEC. The results of this consensus should guide clinical decisions on indications of HIPEC and the choice and various parameters of HIPEC regimens and could fill current knowledge gaps. These outcomes should be the basis for designing future clinical trials on HIPEC in EOC.

ASO Author Reflections: Which HIPEC Regimens Should be Used in Patients with Epithelial Ovarian Cancer? In the Clinic and in Randomized Trials

Residual Tumor Volume, Not Percent Cytoreduction, Matters for Surgery of Neuroendocrine Liver Metastasis

National Guidelines for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Peritoneal Malignancies: A Worldwide Systematic Review and Recommendations of Strength Analysis

Abstract Background National guidelines (GLs) for surgical cytoreduction (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the management of peritoneal malignancies (PMs) vary across countries, scientific societies, and government agencies. This study aimed to systematically review and compare the recommendations for CRS/HIPEC in the treatment of ovarian cancer (EOC), gastric cancer, colorectal cancer (CRC), mesothelioma, and pseudomyxoma peritonei (PMP). Methods Medical databases, search engines, and national websites of 193 countries were queried using artificial intelligence (AI)-powered software for scientific societies and/or government agencies guidelines. The study excluded consensus statements and guidelines without appropriate references. Non-English guidelines were translated, and data, including GRADE strength of recommendations, were extracted. Results The study analyzed 138 guidelines, 24 for gastric cancer, 36 for colorectal cancer, 29 for primary ovarian cancer (p-)EOC, 28 for recurrent ovarian cancer (r-)EOC, 10 for mesothelioma, and 11 for PMP. Guidelines were retrieved from 51 (26.4%) nations, mostly from developed countries (62.1%; p &lt; 0.001). The CRS procedure received robust positive recommendations (GRADE I/IIa) for CRC (74.2%), p-/r-EOC (100%/78.5%), PMP (90.9%), and mesothelioma (90.0%). Conversely, CRS was not indicated for gastric cancer (61.6%, GRADE III; p &lt; 0.001). The HIPEC procedure had robust positive recommendations for PMP (90.9%) and mesothelioma (90.0%), but was controversial for p-EOC (42.3%) and CRC (38.0%) and contraindicated for r-EOC (80.0%) and gastric cancer (62.4%) (p &lt; 0.001). Conclusion National guidelines concordantly recommend CRS for colorectal cancer, ovarian cancer, PMP, and mesothelioma. In contrast, HIPEC recommendations are less homogeneously shared, except for PMP and mesothelioma. No positive concordance exists among guidelines on gastric cancer for CRS nor HIPEC. Furthermore, high-level evidence is needed to strengthen future guidelines on peritoneal metastases.

Fertility-Sparing Treatment for Early-Stage Cervical Cancer ≥ 2 cm: Can One Still Effectively Become a Mother? A Systematic Review of Fertility Outcomes

Abstract Background Fertility-sparing treatments (FSTs) have played a crucial role in the management of early-stage cervical cancer (ECC); however, there is currently no standard of care for women with ECC ≥ 2 cm who wish to preserve their fertility. The current orientation of the scientific community comprises upfront surgical techniques and neoadjuvant chemotherapy (NACT) followed by minor surgery such us conization. However these approaches are not standardized. This systematic review aimed to collect the evidence in the literature regarding the obstetric outcomes of the different techniques for applying FSTs in ECC ≥ 2 cm. Methods A systematic review was performed in September 2022 using the Pubmed and Scopus databases, from the date of the first publication. We included all studies containing data regarding pregnancy, birth, and preterm rates. Results Fifteen studies fulfilled the inclusion criteria, and 352 patients were analyzed regarding fertility outcomes. Surgery-based FST showed the pregnancy rate (22%), birth rate (11%), and preterm rate (10%). Papers regarding FST using the NACT approach showed a pregnancy rate of 44%, with a birth rate of 45% in patients who managed to get pregnant. The preterm rate amounted to 44%, and pregnancy rates and birth rates were significantly different between the two groups (p &lt; 0.001). Conclusion Fertility preservation in patients with ECC &gt; 2 cm is challenging. The endpoint for evaluating the best treatment should include oncological and fertility outcomes together. From this prospective, NACT followed by less radical surgery could be a reasonable compromise.

An Easy Learning Approach to a Complex Surgical Technique: A Step-by-Step Site-Relapse Lateral Extended Endopelvic Resection (LEER)

AbstractLateral pelvic sidewall involvement by gynecological tumors has been considered traditionally an absolute contraindication to curative resection.1 Moreover, the involvement of the pelvic sidewall at the time of relapse in cervical cancer after primary or adjuvant pelvic radiation occurs in 8.3% of patients.2,3 Laterally extended endopelvic resection (LEER), based on the ontogenetic compartment theory, provides a potential surgical option for patients for whom palliative therapy is the only alternative.4 This complex and ultraradical, surgical technique allows a high rate of complete resection in more than 70% of patients with gynecological cancers and lateral pelvic sidewall involvement. An adequate selection of patients and a deep knowledge of pelvic anatomy are crucial to obtain acceptable morbimortality rates and improved overall survival in this population.5 To deconstruct this complex procedure, we show a detailed step-by-step technique to facilitate the easy learning curve of this surgical technique. We review the Höckel original technique with different site-relapse adapted steps. We provide a pedagogical high-quality video (Video 1) and anatomical outline drawings (Fig. 1) to understand lateral pelvic wall anatomy and standardize this surgical technique. Our purpose is to bring this knowledge to gynecologists and pelvic surgeons in which pelvic lateral approach may be useful beyond gynecological oncologic surgery (Table 1).

SUCCOR Nodes: May Sentinel Node Biopsy Determine the Need for Adjuvant Treatment?

Abstract Background The SUCCOR cohort was developed to analyse the overall and disease-free survival at 5 years in women with FIGO 2009 stage IB1 cervical cancer. The aim of this study was to compare the use of adjuvant therapy in these women, depending on the method used to diagnose lymphatic node metastasis. Patients and Methods We used data from the SUCCOR cohort, which collected information from 1049 women with FIGO 2009 stage IB1 cervical cancer who were operated on between January 2013 and December 2014 in Europe. We calculated the adjusted proportion of women who received adjuvant therapy depending on the lymph node diagnosis method and compared disease free and overall survival using Cox proportional-hazards regression models. Inverse probability weighting was used to adjust for baseline potential confounders. Results The adjusted proportion of women who received adjuvant therapy was 33.8% in the sentinel node biopsy + lymphadenectomy (SNB+LA) group and 44.7% in the LA group (p = 0.02), although the proportion of positive nodal status was similar (p = 0.30). That difference was greater in women with negative nodal status and positive Sedlis criteria (difference 31.2%, p = 0.01). Here, those who underwent a SNB+LA had an increased risk of relapse [hazard ratio (HR) 2.49, 95% confidence interval (CI) 0.98–6.33, p = 0.056] and risk of death (HR 3.49, 95% CI 1.04–11.7, p = 0.042) compared with those who underwent LA. Conclusions Women in this study were less likely to receive adjuvant therapy if their nodal invasion was determined using SNB+LA compared with LA. These results suggest a lack of therapeutic measures available when a negative result is obtained by SNB+LA, which may have an impact on the risk of recurrence and survival.

The Peritoneal Cancer Index is a Strong Predictor of Incomplete Cytoreductive Surgery in Ovarian Cancer

Abstract Background Extent of tumor load is an important factor in the selection of ovarian cancer patients for cytoreductive surgery (CRS). The Peritoneal Cancer Index (PCI) gives exact information on tumor load but still is not standard in ovarian cancer surgery. The aim of this study was to find a PCI cutoff for incomplete CRS. The secondary aims were to identify reasons for open-close surgery and to compare surgical complications in relation to tumor burden. Methods The study included 167 women with stage III or IV ovarian cancer scheduled for CRS. Possible predictors of incomplete surgery were evaluated with receiver operator curves, and a PCI cutoff was identified. Surgical complications were analyzed by one-way analysis of variance and Chi square tests. Results The median PCI score for all the patients was 22 (range 3–37) but 33 (range 25–37) for the patients with incomplete surgery (n = 19). The PCI predicted incomplete CRS, with an area under the curve of 0.94 (95% confidence interval [CI], 0.91–0.98). Complete CRS was obtained for 67.2% of the patients with a PCI higher than 24, who experienced an increased rate of complications (p = 0.008). Overall major complications were found in 16.9% of the cases. Only 28.6% of the patients with a PCI higher than 33 achieved complete CRS. The reason for open-close surgery (n = 14) was massive carcinomatosis on the small bowel in all cases. Conclusion The study found PCI to be an excellent predictor of incomplete CRS. Due to a lower surgical success rate, the authors suggest that neoadjuvant chemotherapy could be considered if the PCI is higher than 24. Preoperative radiologic assessment should focus on total tumor burden and not necessarily on specific regions.

Adjuvant Use of PlasmaJet Device During Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: Results of the PlaComOv-study, a Randomized Controlled Trial in The Netherlands

Abstract Objective Standard surgical treatment of advanced-stage ovarian carcinoma with electrosurgery cannot always result in complete cytoreductive surgery (CRS), especially when many small metastases are found on the mesentery and intestinal surface. We investigated whether adjuvant use of a neutral argon plasma device can help increase the complete cytoreduction rate. Patients and Methods 327 patients with FIGO stage IIIB–IV epithelial ovarian cancer (EOC) who underwent primary or interval CRS were randomized to either surgery with neutral argon plasma (PlasmaJet) (intervention) or without PlasmaJet (control group). The primary outcome was the percentage of complete CRS. The secondary outcomes were duration of surgery, blood loss, number of bowel resections and colostomies, hospitalization, 30-day morbidity, and quality of life (QoL). Results Complete CRS was achieved in 119 patients (75.8%) in the intervention group and 115 patients (67.6%) in the control group (risk difference (RD) 8.2%, 95% confidence interval (CI) –0.021 to 0.181; P = 0.131). In a per-protocol analysis excluding patients with unresectable disease, complete CRS was obtained in 85.6% in the intervention group and 71.5% in the control group (RD 14.1%, 95% CI 0.042 to 0.235; P = 0.005). Patient-reported QoL at 6 months after surgery differed between groups in favor of PlasmaJet surgery (95% CI 0.455–8.350; P = 0.029). Other secondary outcomes did not differ significantly. Conclusions Adjuvant use of PlasmaJet during CRS for advanced-stage ovarian cancer resulted in a significantly higher proportion of complete CRS in patients with resectable disease and higher QoL at 6 months after surgery. (Funded by ZonMw, Trial Register NL62035.078.17.) Trial Registration Approved by the Medical Ethics Review Board of the Erasmus University Medical Center Rotterdam, the Netherlands, NL62035.078.17 on 20-11-2017. Recruitment started on 30-1-2018.

ASO Author Reflections: The PlasmaJet® Device Contributes to an Increase in the Number of Complete Cytoreductive Surgeries for Ovarian Cancer Patients

Risk Factors for Anastomotic Leakage in Advanced Ovarian Cancer Surgery: A Large Single-Center Experience

Abstract Background Cytoreductive surgery is currently the main treatment for advanced epithelial ovarian cancer (OC), and several surgical maneuvers, including colorectal resection, are often needed to achieve no residual disease. High surgical complexity carries an inherent risk of postoperative complications, including anastomosis leakage (AL). Albeit rare, AL is a life-threatening condition. The aim of this single-center retrospective study is to assess the AL rate in patients undergoing colorectal resection and anastomosis during primary surgery for advanced epithelial OC through a standardized surgical technique and to evaluate possible pre/intra- and postoperative risk factors to identify the population at greatest risk. Methods A retrospective analysis of clinical and surgical characteristics of 515 patients undergoing colorectal resection and anastomosis during primary or interval debulking surgery between December 2011 and October 2019 was performed. Several pre/intra- and postoperative variables were evaluated by multivariate analysis as potential risk factors for AL. Results The overall anastomotic leakage rate was 2.9% (15/515) with a significant negative impact on postoperative course. Body mass index &lt; 18 kg/m2, preoperative albumin value lower than 30 mg/dL, section of the inferior mesenteric artery at its origin, and medium–low colorectal anastomosis (&lt; 10 cm from the anal verge) were identified as independent risk factors for AL on multivariate analysis. Conclusions AL is confirmed to be an extremely rare but severe postoperative complication of OC surgery, being responsible for increased early postoperative mortality. Preoperative nutritional status and surgical characteristics, such as blood supply and anastomosis level, appear to be the most significant risk factors.

Minimally Invasive Approaches in Locally Advanced Cervical Cancer Patients Undergoing Radical Surgery After Chemoradiotherapy: A Propensity Score Analysis

Abstract Purpose Chemoradiation (CT/RT) followed by radical surgery (RS) may play a role in locally advanced cervical cancer (LACC) patients with suboptimal response to CT/RT or in low-income countries with limited access to radiotherapy. Our aim is to evaluate oncological and surgical outcomes of minimally invasive radical surgery (MI-RS) compared with open radical surgery (O-RS). Patients and Methods Data for stage IB2–IVA cervical cancer patients managed by CT/RT and RS were retrospectively analyzed. Results Beginning with 686 patients, propensity score matching resulted in 462 cases (231 per group), balanced for FIGO stage, lymph node status, histotype, tumor grade, and clinical response to CT/RT. The 5-year disease-free survival (DFS) was 73.7% in the O-RS patients and 73.0% in the MI-RS patients (HR 1.034, 95% CI 0.708–1.512, p = 0.861). The 5-year locoregional recurrence rate was 12.5% (O-RS) versus 15.2% (MI-RS) (HR 1.174, 95% CI 0.656–2.104, p = 0.588). The 5-year disease-specific survival (DSS) was 80.4% in O-RS patients and 85.3% in the MI-RS group (HR 0.731, 95% CI 0.438–1.220, p = 0.228). Estimated blood loss was lower in the MI-RS group (p &lt; 0.001), as was length of hospital stay (p &lt; 0.001). Early postoperative complications occurred in 77 patients (33.3%) in the O-RS group versus 88 patients (38.1%) in the MI-RS group (p = 0.331). Fifty-six (24.2%) patients experienced late postoperative complications in the O-RS group, versus 61 patients (26.4%) in the MI-RS group (p = 0.668). Conclusion MI-RS and O-RS are associated with similar rates of recurrence and death in LACC patients managed by surgery after CT/RT. No difference in early or late complications was reported.

Prognostic Impact of Mesenteric Lymph Node Status on Digestive Resection Specimens During Cytoreductive Surgery for Ovarian Peritoneal Metastases

Abstract Background The most common mode of ovarian cancer (OC) spread is intraperitoneal dissemination, with the peritoneum as the primary site of metastasis. Cytoreductive surgery (CRS) with chemotherapy is the primary treatment. When necessary, a digestive resection can be performed, but the role of mesenteric lymph nodes (MLNs) in advanced OC remains unclear, and its significance in treatment and follow-up evaluation remains to be determined. This study aimed to evaluate the prevalence of MLN involvement in patients who underwent digestive resection for OC peritoneal metastases (PM) and to investigate its potential prognostic value. Methods This retrospective, descriptive study included patients who underwent CRS with curative intent for OC with PM between 1 January 2007 and 31 December 2020. The study assessed MLN status and other clinicopathologic features to determine their prognostic value in relation to overall survival (OS) and progression-free survival (PFS). Results The study enrolled 159 women with advanced OC, 77 (48.4%) of whom had a digestive resection. For 61.1% of the patients who underwent digestive resection, MLNs were examined and found to be positive in 56.8%. No statistically significant associations were found between MLN status and OS (p = 0.497) or PFS ((p = 0.659). Conclusions In anatomopathologic studies, MLNs are not systematically investigated but are frequently involved. In the current study, no statistically significant associations were found between MLN status and OS or PFS. Further prospective studies with a systematic and standardized approach should be performed to confirm these findings.

Usefulness of Geriatric Parameters in Preoperative Evaluation of Patients Undergoing Minimally Invasive Surgery for Endometrial Cancer: A Retrospective Cohort Study

Abstract Introduction Patients operated for endometrial cancer (EMCA) are typically elderly with multiple comorbidities, potentially impacting surgical outcomes and survival. This study evaluated the prognostic value of frailty and frailty-related scores in predicting perioperative morbidity and survival in EMCA patients undergoing minimally invasive surgery. Methods This retrospective cohort study included 289 patients from the Sentinel Database treated for EMCA at Bern University Hospital (2012–2020). Patients underwent minimally invasive hysterectomy with sentinel lymph node dissection (39%) or additional radical lymphadenectomy (61%). Frailty was assessed using the Age-Adjusted Charlson Comorbidity Index (ACCI), modified Frailty Index (mFI), 5-item mFI (mFI-5), American Society of Anesthesiologists (ASA) scores, and independent parameters. Primary outcomes included perioperative complications, hospital stay, recurrence-free survival (RFS), and overall survival (OS). Results Median age was 65 years (range 26–94) and median follow-up was 41 months (0–105). ACCI &gt; 4 (23.2%) was the strongest predictor of postoperative complications (p = 0.025), prolonged hospitalization (p = 0.03), and reduced OS (hazard ratio [HR] 2.57, 95% confidence interval [CI] 1.18–5.60; p = 0.018). Multivariable analysis confirmed ACCI &gt; 4 (HR 2.24, 95% CI 1.02–4.90; p = 0.044), European Society for Medical Oncology (ESMO) risk group (HR 1.61, 95% CI 1.24–2.07; p &lt; 0.001), hemoglobin (HR 1.03, 95% CI 1.00–1.05; p = 0.033), and congestive heart failure (HR 6.29, 95% CI 1.35–29.27; p =0.019) were significant predictors of OS. Radical lymphadenectomy (p &lt; 0.001), ACCI &gt; 4 (p = 0.025), and age &gt; 70 years (p = 0.034) increased complication risks. Conclusions ACCI &gt; 4 is a practical tool for preoperative risk assessment and predicting surgical tolerance and survival, and is therefore applicable for guiding surgical decisions and personalized care in patients with EMCA.

Prospective Multicenter Trial Assessing the Impact of Positive Peritoneal Cytology Conversion on Oncological Outcome in Patients with Endometrial Cancer Undergoing Minimally Invasive Surgery with the use of an Intrauterine Manipulator

Abstract Background Minimally invasive surgery is the standard approach in early-stage endometrial cancer according to evidence showing no compromise in oncological outcomes, but lower morbidity compared with open surgery. However, there are limited data available on the oncological safety of the use of intrauterine manipulators in endometrial cancer. Patients and Methods This prospective multicenter study included patients with endometrial cancer undergoing laparoscopic staging surgery with the use of an intrauterine manipulator. We obtained three different sets of peritoneal washings: at the beginning of the surgical procedure, after the insertion of the intrauterine manipulator, and after the closure of the vaginal vault. The rate of positive peritoneal cytology conversion and its association with oncological outcomes was assessed. Results A total of 124 patients were included. Peritoneal cytology was negative in 98 (group 1) and positive in 26 (group 2) patients. In group 2, 16 patients presented with positive cytology at the beginning of the surgery (group 2a) and 10 patients had positive cytology conversion during the procedure (group 2b). Recurrence rate was significantly different among the study groups, amounting to 9.2%, 25.0%, and 60.0% for groups 1, 2a, and 2b, respectively (p &lt; 0.001). Group 1 showed the best recurrence-free and overall survival, followed by group 2a, while patients in group 2b had the worst oncological outcomes (p = 0.002 and p = 0.053, respectively). Peritoneal cytology was an independent predictor of recurrence and death on multivariable analysis. Conclusion A total of 8.1% of patients with endometrial cancer undergoing minimally invasive surgery with intrauterine manipulation showed positive peritoneal cytology conversion associated with significantly worse oncological outcome.

ASO Author Reflections: Is It Safe to Use Intrauterine Manipulators in Laparoscopic Surgery for Endometrial Cancer?

A Multicenter Study on the Relationship of Tumor Lesion Location with Bilateral Parametrial Involvement and Pelvic Lymph Node Metastasis in Cervical Squamous Cell Carcinoma

Abstract Background This study aimed to explore the relationship of cervical tumor lesion location (CTLL) with bilateral parametrial involvement (PI) and pelvic lymph node metastasis (LNM). Methods The study retrospectively analyzed the clinicopathologic and imaging data of patients with cervical squamous cell carcinoma (SCC) retrieved from multiple centers. According to the CTLL, patients were allocated to three groups: a middle one third group, a unilaterally dominant group, and the entire-region group. Uni- and multivariate logistic regression analyses were performed to explore the preoperative risk factors related to PI and pelvic LNM. The rates of PI and pelvic LNM at the tumor-ipsilateral side and the tumor-contralateral side were compared using the Wilcoxon test. Results The study enrolled 776 cases. The CTLL was an important preoperative risk factor for both PI and pelvic LNM. Parametrial involvement occurred solely on the tumor-ipsilateral side (3.57 %) in the unilaterally dominant group, whereas the rate of pelvic LNM on the tumor-ipsilateral side was 11.22 %, significantly higher than on the contralateral side (5.1 %), with no pelvic LNM found on the tumor-contralateral side of patients with tumors smaller than 3.5 cm. Conclusions Cervical SCC exhibits the characteristic of more accessible tumor-ipsilateral PI and pelvic LNM. When evaluation by magnetic resonance imaging (MRI) shows that the tumor lesion does not involve the contralateral one third of the cervix, a reduction in the resection scope of the contralateral parametrium can be considered, avoiding resection of the para-aortic lymph nodes, and if the tumor is smaller than 3.5 cm, a reduction in the resection scope of the tumor-contralateral pelvic lymph nodes also can be considered.

Sentinel Lymph Node Mapping in Endometrial Cancer after Supracervical Hysterectomy

Abstract Background Occult endometrial cancer after supracervical hysterectomy is uncommon. Even if optimal management of those rare cases is still unproven, to guide the need for adjuvant treatment, restaging should be recommended in this situation. Methods The study was approved by institutional review board (DIPUSVSP-27-07-20107). We report the case of a 52-year-old woman with occult grade 2 endometrioid endometrial adenocarcinoma (pT1a) with negative surgical margin and smooth uterine muscle of uncertain malignant potential after supracervical hysterectomy and bilateral salpingo-oophorectomy performed for pelvic pain and uterine fibroids in a local hospital. Preoperative CT scan of chest-abdomen-pelvis did not show any lymphadenopathy or distant metastasis. Pelvic US scan revealed a normal cervical stump and a hypoechoic 18-mm right parametrial nodule. We describe the feasibility of laparoscopic sentinel lymph node identification with cervical stump injection of indocyanine green. Results The patient underwent laparoscopic radical trachelectomy, left pelvic sentinel lymph node biopsy, right pelvic lymphadenectomy, peritoneal washing. Patient did not report any intraoperative or postoperative complication. At final histology cervix, SLN (ultrastaging) and pelvic lymph nodes were negative, while parametrial nodule was reported as metastasis from endometrial adenocarcinoma. Surgical margins were clear. Patient was staged as FIGO IIIB and underwent adjuvant chemo-radiation. She is now alive and disease-free, 12 months after the surgery. Conclusions This video (Video 1) underlines the fact that SLN mapping with cervical injection is a feasible and safe technique also without the uterine corpus after supracervical hysterectomy. The unilateral mapping could be due to the presence of metastatic parametrium on the right side.

Impact of Sodium Thiosulfate on Prevention of Nephrotoxicities in HIPEC: An Ancillary Evaluation of Cisplatin-Induced Toxicities in Ovarian Cancer

Abstract Purpose Hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin confers a survival benefit in epithelial ovarian cancer (EOC) but is associated with renal toxicity. Sodium thiosulfate (ST) is used for nephroprotection for HIPEC with cisplatin, but standard HIPEC practices vary. Methods A prospective, nonrandomized, clinical trial evaluated safety outcomes of HIPEC with cisplatin 75 mg/m2 during cytoreductive surgery (CRS) in patients with EOC (n = 34) and endometrial cancer (n = 6). Twenty-one patients received no ST (nST), and 19 received ST. Adverse events (AEs) were reported according to CTCAE v.5.0. Serum creatinine (Cr) was collected preoperatively and postoperatively (Days 5–8). Progression-free survival (PFS) was followed. Normal peritoneum was biopsied before and after HIPEC for whole transcriptomic sequencing to identify RNAseq signatures correlating with AEs. Results Forty patients had HIPEC at the time of interval or secondary CRS. Renal toxicities in the nST group were 33% any grade AE and 9% grade 3 AEs. The ST group demonstrated no renal AEs. Median postoperative Cr in the nST group was 1.1 mg/dL and 0.5 mg/dL in the ST group (p = 0.0001). Median change in Cr from preoperative to postoperative levels were + 53% (nST) compared with − 9.6% (ST) (p = 0.003). PFS did not differ between the ST and nST groups in primary or recurrent EOC patients. Renal AEs were associated with downregulation of metabolic pathways and upregulation of immune pathways. Conclusions ST significantly reduces acute renal toxicity associated with HIPEC with cisplatin in ovarian cancer patients. As nephrotoxicity is high in HIPEC with cisplatin, nephroprotective agents should be considered.

ASO Author Reflections: Preventing Nephrotoxicities in Ovarian Cancer Patients Undergoing HIPEC

Hepatobiliary Disease Resection in Patients with Advanced Epithelial Ovarian Cancer: Prognostic Role and Optimal Cytoreduction

Abstract Objective The purpose of this study was to evaluate the feasibility and safety in terms of prognostic significance and perioperative morbidity and mortality of cytoreduction in patients affected by advance ovarian cancer and hepato-biliary metastasis. Methods Patients with a least one hepatobiliary metastasis who have undergone surgical treatment with curative intent of were considered for the study. Perioperative complications were evaluated and graded with Accordion severity Classification. Five-year PFS and OS were estimated using the Kaplan–Meier curve. Results Sixty-seven (20.9%) patients had at least one metastasis to the liver, biliary tract, or porta hepatis. Forty-four (65.7%) and 23 (34.3%) patients underwent respectively high and intermediate complexity surgery according. Complete cytoreduction was achieved in 48 (71.6%) patients with hepato-biliary disease. In two patients (2.9%) severe complications related to hepatobiliary surgery were reported. The median PFS for the patients with hepato-biliary involvement (RT = 0 vs. RT &gt; 0) was 19 months [95% confidence interval (CI) 16.2–21.8] and 8 months (95% CI 6.1–9.9). The median OS for the patients with hepato-biliary involvement (RT = 0 vs. RT &gt; 0) 45 months (95% CI 21.2–68.8 months) and 23 months (95% CI 13.9–32.03). Conclusions Hepatobiliary involvement is often associated with high tumor load and could require high complex multivisceral surgery. In selected patients complete cytoreduction could offer survival benefits. Morbidity related to hepatobiliary procedures is acceptable. Careful evaluation of patients and multidisciplinary approach in referral centers is mandatory.

ASO Author Reflections: Use of Peritoneal Cancer Index (PCI) to Evaluate Carcinomatosis in Ovarian Cancer

Clinical Impact of Pathologic Residual Tumor in Locally Advanced Cervical Cancer Patients Managed by Chemoradiotherapy Followed by Radical Surgery: A Large, Multicenter, Retrospective Study

Abstract Background Exclusive chemoradiation (E-CT/RT) represents the standard of treatment for locally advanced cervical cancer (LACC). Chemoradiation (CT/RT) followed by radical surgery (RS) may play a role for patients with a suboptimal response to CT/RT or in low-income countries with limited access to radiotherapy. Histologic assessment of residual tumor after CT/RT and RS allows accurate definition of prognostic categories. Methods Data on patients with FIGO stages 1B2 to 4A cervical cancer managed by CT/RT and RS from June 1996 to March 2020 were retrospectively analyzed. Pathologic response on the cervix was defined as complete (pCR), microscopic (persistent tumor foci ≤ 3 mm) (pmicroR), or macroscopic (persistent tumor foci &gt; 3 mm) (pmacroR). Lymph node (LN) residual tumor was classified as absent or present. Results The 701 patients in this study underwent CT/RT and RS. Of the 701 patients, 293 (41.8%) had pCR, 188 (26.8%) had pmicroR, and 220 (31.4%) had pMacroR. Residual tumor was found in the pelvic lymph nodes of 66 (9.4%) patients and the aortic lymph nodes of 29 (4.1%) patients. The 5-year DFS and OS were respectively 86.6% and 92.5% in the pCR cases, 80.3% and 89.1% in the pmicroR cases, and 56.2% and 68.8% in the pmacroR cases. Among the patients with lymph node residual tumor, the 5-year DFS and OS were respectively 16.7% and 40% in the pCR cases, 35.4% and 53.3% in the pmicroR cases, and 31.7% and 31.1% in the pmacroR cases. Cervical residual tumor,, positive pelvic LNs, and positive aortic LNs were associated with worse DFS and OS in both the uni- and multivariate analyses. Conclusions Persistence of pathologic residual tumor on the cervix and LNs after CT/RT are reliable predictors of survival for LACC patients undergoing CT/RT and adjuvant surgery.

Implications of Homologous Recombination Deficiency for Neoadjuvant Platinum-Based Chemotherapy in Pancreatic Cancer: A Narrative Review

Abstract Background Pancreatic ductal adenocarcinoma (PDAC) remains a highly lethal malignancy, with a 5 year survival rate of approximately 13%. Survival is extended for the few patients who undergo surgical resection with curative intent, whereas most patients succumb to distant disease recurrence. Neoadjuvant platinum-based chemotherapy has emerged as a promising strategy to improve resectability rates and survival outcomes for PDAC patients. However, treatment-related toxicities, unpredictable clinical responses, and associated risk of tumor progression during neoadjuvant therapy may delay or preclude curative resection.As a result, predictive biomarkers are needed to identify patients most likely to benefit from neoadjuvant platinum-based chemotherapy. Discussion Alterations in the homologous recombination (HR) DNA repair pathway are reported in 3.0–19.5% of PDAC patients. These types of alterations can sensitize tumors to platinum-based chemotherapy in PDAC as well as other cancers including ovarian, colorectal, and prostate cancers. Retrospective and prospective studies in locally advanced/metastatic PDAC demonstrate higher response rates and longer survival outcomes among HR-deficient (HRD) patients receiving platinum-based chemotherapy. A growing body of evidence in the neoadjuvant setting suggests a potential benefit for HRD-PDAC patients in terms of enhanced tumor downstaging, higher resectability, and improved survival outcomes compared with HR-proficient patients. However, prospective ad hoc studies are still warranted to confirm these findings Conclusions Homologous recombination deficiency represents a promising biomarker to guide patient selection for neoadjuvant platinum-based chemotherapy in PDAC. Incorporation of HR deficiency-testing into neoadjuvant treatment schemes will enable a more personalized therapeutic approach, supporting the implementation of precision oncology for early-stage PDAC patients.

Effect of Diaphragmatic Resection Versus Stripping in Advanced Ovarian Cancer: Impact on Patient Complications in a Large Retrospective Cohort Study at a Tertiary Referral Center

Abstract Background Complete cytoreductive surgery is crucial in advanced ovarian cancer (OC) treatment. Diaphragmatic surgery, including stripping (DS) and resection (DR), is often necessary for optimal cytoreduction. However, postoperative complications and the timing of adjuvant chemotherapy initiation remain critical concerns. This study evaluates the impact of DR and DS on surgical outcomes, chemotherapy timing, and survival. Patients and methods This retrospective, monocentric study analyzed 215 patients with International Federation of Gynecology and Obstetrics (FIGO) stage III–IV OC undergoing DS or DR between 2011 and 2023. Clinical, surgical, and survival data were collected; complications were graded using the Clavien–Dindo system. Statistical analysis included contingency and survival tests. Results A total of 215 patients underwent diaphragmatic surgery: 122 patients (56.7%) underwent DR and 93 (43.3%) DS. No significant differences existed between groups regarding age, body mass index (BMI), histological subtype, American Society of Anesthesiologists (ASA) score, or primary/interval debulking surgery distribution ( p = 0.122). DR was more common in patients with greater peritoneal disease ( p = 0.003), higher pleural involvement ( p = 0.002), and longer operative times ( p = 0.018). Postoperatively, DR was associated with increased thoracic complications (87.7% versus 52.7%, p &lt; 0.001), greater oxygen supplementation needs (55.7% versus 35.5%, p = 0.003), and elevated liver enzymes. However, no significant differences emerged in severe complications ( p = 0.077), reoperation rates ( p = 0.227), or time to chemotherapy initiation ( p = 0.742). A decreasing trend in thoracostomy tube placement was observed since 2018. Progression-free and overall survival were similar between groups. Conclusions Despite requiring greater intraoperative effort and resulting in higher postoperative morbidity, DR is not associated with an increased incidence of severe complications (grade 3+) or delayed chemotherapy initiation compared with DS. These findings support the feasibility of DR for achieving complete cytoreduction in advanced OC.

Robotic Secondary Cytoreduction with 3D Reconstruction for Isolated Recurrent Ovarian Cancer: A Stepwise Approach to Splenectomy

Abstract Background Isolated parenchymal splenic relapse is a rare condition experienced by patients presenting with recurrent ovarian cancer (ROC).1–3 In such cases, complete secondary cytoreductive surgery (SCS) followed by chemotherapy offers significant overall survival benefits for platinum-sensitive ROC patients. Randomized trials such as DESKTOP-3 and SOC-1 described splenectomy during SCS in 6–15% of patients.4,5 Robotic-assisted surgery (RAS) and advanced three-dimensional (3D) imaging reconstruction can be integrated when choosing minimally invasive surgery (MIS) to reduce the risks associated with splenic procedures.6–8 Methodology The case of a 70-year-old BRCA2-mutated patient with single-site splenic ROC is presented. Computed tomography (CT) scan was reviewed by an expert radiologist during a multidisciplinary tumor board. The images were manually segmented using 3D Slicer software to obtain the final 3D reconstruction.9 Using the da Vinci Xi™ robot (Intuitive Surgical, Sunnyvale, CA, USA), a medial-to-lateral spleen dissection was performed. Several key surgical steps were followed to avoid tumor manipulation and subsequently minimize potential neoplastic spread. Results Intraoperative ultrasound confirmed lesion localization, and advanced robotic instruments facilitated precise hilum control, reducing the risk of bleeding and pancreatic tail injury. Robotic SCS with complete tumor resection was achieved. No intraoperative or postoperative complications were reported. Final histology confirmed the diagnosis of high-grade ROC. Conclusion RAS represents a viable option for SCS in ROC patients with isolated parenchymal localization. The integration of 3D reconstruction with RAS allows for a tailored approach in complex cases. A high-level of expertise and appropriate identification of candidates for MIS-SCS are required to achieve the best outcomes for ROC patients.

ASO Author Reflections: In Which Patients Should We Coordinate Breast Surgery and Bilateral Salpingo-oophorectomy?

Laparoscopic-Assisted Vaginal Trachelectomy with Prophylactic Cerclage: A Safe Fertility-Sparing Treatment for Early Stage Cervical Cancer

In recent years fertility-sparing treatments are increasingly developing in patients with early stage cervical cancer. The first laparoscopic time is dedicated to the safe opening of the vesicouterine and rectovaginal spaces until the medial pararectal fossa. Ureters are found and bilateral ureterolysis performed under vision. Colpotomy is then vaginally achieved, and the cervix is closed in a vaginal cuff to avoid tumor spread. Careful dissection of the anterior and posterior septa is carried out until reunification with laparoscopic dissection. Bilateral parametrectomy is performed. Vaginal trachelectomy is finalized with a negative deep margin at the frozen section. In the second laparoscopic time a monofilament polypropylene sling cerclage is bilaterally positioned from posterior to anterior through the broad ligaments and fixed anteriorly on the uterine isthmus to prevent an eventual preterm delivery. Laparoscopic-assisted vaginal trachelectomy is a feasible procedure combining the conservative advantages of the vaginal approach and the oncological safety of laparoscopic spaces dissection with possible good obstetric outcomes.

Status of Surgical Management of Borderline Ovarian Tumors in France: are Recommendations Being Followed? Multicentric French Study by the FRANCOGYN Group

Abstract Background Borderline ovarian tumors (BOTs) are tumors with a favorable prognosis but whose management by consensus is essential to limit the risk of invasive recurrence. This study aimed to conduct an inventory of surgical practices for BOT in France and to evaluate the conformity of the treatment according to the current French guidelines. Methods This retrospective, multicenter cohort study included nine referral centers of France between January 2001 and December 2018. It analyzed all patients with serous and mucinous BOT who had undergone surgery. A peritoneal staging in accordance with the recommendations was defined by performance of a peritoneal cytology, an omentectomy, and at least one peritoneal biopsy. Results The study included 332 patients. A laparoscopy was performed in 79.5% of the cases. Treatment was conservative in 31.9% of the cases. The recurrence rate was significantly increased after conservative treatment (17.3% vs 3.1%; p &lt; 0.001). Peritoneal cytology was performed for 95.5%, omentectomy for 83.1%, and at least one biopsy for 82.2% of the patients. The overall recurrence rate was 7.8%, and the recurrence was invasive in 1.2% of the cases. No link was found between the recurrence rate and the conformity of peritoneal staging. The overall rate of staging noncompliance was 22.9%. Conclusion The current standards for BOT management seem to be well applied.

ASO Author Reflections: Personalized Surgery in Recurrent Ovarian Cancer Patients

Are There Survival Differences Between Women with Equivalent Residual Disease After Interval Cytoreductive Surgery Compared with Primary Cytoreductive Surgery for Advanced Ovarian and Peritoneal Cancer?

The aim of this study was to investigate survival differences between equivalent residual disease [complete gross resection (CGR), minimal residual disease (MRD), suboptimal] at the time of primary debulking surgery (PDS) and interval debulking surgery (IDS). The National Cancer Database was used to identify patients from 2010 to 2015 with stage IIIC/IV primary peritoneal or ovarian cancer who had residual disease recorded. Propensity score matching (PSM) was used to correct for differences in characteristics between the PDS and IDS groups. Of 8683 patients with advanced ovarian cancer, 4493 (52%), 2546 (29%), and 1644 (19%) had CGR, MRD, or suboptimal resection, respectively. From 2010 to 2015, the number of patients undergoing IDS increased 27% (p The use of IDS continues to rise in the US, and is associated with improved surgical outcomes but not necessarily similar oncologic outcomes. There should be continued efforts to improve cytoreductive outcomes in women with advanced ovarian and peritoneal malignancies.

ASO Author Reflections: Ultra-Radical Resection in Ovarian Cancer: Where Are We and Where Are We Going?

Reply to Fabio Carboni, MD, PhD and Mario Valle, MD, FACS Regarding Our Recently Published Article “Peritoneal Cancer Index is a Strong Predictor of Incomplete Cytoreductive Surgery in Ovarian Cancer”

Total Parietal Peritonectomy Can Be Performed with Acceptable Morbidity for Patients with Advanced Ovarian Cancer After Neoadjuvant Chemotherapy: Results From a Prospective Multi-centric Study

Total parietal peritonectomy (TPP) removes areas of "normal-appearing" parietal peritoneum bearing microscopic residual disease and has the potential to improve survival of patients undergoing interval cytoreductive surgery (CRS) for advanced serous epithelial ovarian cancer. This report presents the morbidity outcomes for the first 50 patients enrolled in TORPEDO (CTRI/2018/12/016789), a prospective study. All the patients underwent a TPP during interval CRS. A surgical protocol that includes a description of the boundaries for each of the five peritonectomies was followed. The common toxicology criteria for adverse events (CTCAE) classification was used to record 90-day morbidity and mortality. The median Peritoneal Cancer Index (PCI) for 50 patients was 15 (range, 5-37). A complete cytoreduction (CC-0 resection) was obtained in 80%, a CC-1 resection in 16%. A bowel resection was performed in 70% of the patients. Grade 3 or 4 complications were seen in 11 patients (22%), and one patient died within 90 days after surgery due to intraperitoneal hemorrhage. The most common complications were postoperative fluid collection requiring aspiration (n = 5), intraperitoneal hemorrhage (n = 2), abdominal wound dehiscence (n = 2), pseudo-obstruction (n = 1), urinary sepsis (n = 2), and ileostomy-related complications (n = 2). No bowel fistulas or anastomotic leaks occurred. Microscopic disease in 'normal appearing' peritoneum adjacent to tumor nodules was observed in 46% of the patients, and in regions given a lesion score of 0 in 34%. The parietal peritoneal regions (0-8) had a higher incidence of residual disease (p < 0.001) and occult disease (p < 0.001). During interval CRS, TPP can be performed with acceptable morbidity and mortality. The pathologic findings further support this therapeutic rationale. Survival outcomes should determine the future role of such a procedure in routine clinical practice.

ASO Author Reflections: Total Parietal Peritonectomy During Interval Cytoreductive Surgery for Advanced Ovarian Cancer—Proof-of-Principle and Analysis of Morbidity

Impact of BRCA Mutation Status on Tumor Dissemination Pattern, Surgical Outcome and Patient Survival in Primary and Recurrent High-Grade Serous Ovarian Cancer: A Multicenter Retrospective Study by the Ovarian Cancer Therapy-Innovative Models Prolong Survival (OCTIPS) Consortium

Abstract Background This study seeks to evaluate the impact of breast cancer (BRCA) gene status on tumor dissemination pattern, surgical outcome and survival in a multicenter cohort of paired primary ovarian cancer (pOC) and recurrent ovarian cancer (rOC). Patients and Methods Medical records and follow-up data from 190 patients were gathered retrospectively. All patients had surgery at pOC and at least one further rOC surgery at four European high-volume centers. Patients were divided into one cohort with confirmed mutation for BRCA1 and/or BRCA2 (BRCAmut) and a second cohort with BRCA wild type or unknown (BRCAwt). Patterns of tumor presentation, surgical outcome and survival data were analyzed between the two groups. Results Patients with BRCAmut disease were on average 4 years younger and had significantly more tumor involvement upon diagnosis. Patients with BRCAmut disease showed higher debulking rates at all stages. Multivariate analysis showed that only patient age had significant predictive value for complete tumor resection in pOC. At rOC, however, only BRCAmut status significantly correlated with optimal debulking. Patients with BRCAmut disease showed significantly prolonged overall survival (OS) by 24.3 months. Progression-free survival (PFS) was prolonged in the BRCAmut group at all stages as well, reaching statistical significance during recurrence. Conclusions Patients with BRCAmut disease showed a more aggressive course of disease with earlier onset and more extensive tumor dissemination at pOC. However, surgical outcome and OS were significantly better in patients with BRCAmut disease compared with patients with BRCAwt disease. We therefore propose to consider BRCAmut status in regard to patient selection for cytoreductive surgery, especially in rOC.

ASO Author Reflections: Validation Based on Low-Volume Metastasis of the Sentinel Lymph Node Biopsy in Early-Stage Cervical Cancer

ASO Author Reflections: Risk Factors for Anastomotic Leakage in Advanced Ovarian Cancer Surgery—What We Know and Future Perspectives

Post-Publication Discussion Regarding Cytoreductive Surgery with or Without HIPEC After Neoadjuvant Chemotherapy in Ovarian Cancer

Prevalence of Tumor Genomic Alterations in Homologous Recombination Repair Genes Among Taiwanese Breast Cancers

Deleterious germline BRCA1/2 mutations are among the most highly pathogenic variants in hereditary breast and ovarian cancer syndrome. Recently, genes implicated in homologous recombination repair (HRR) pathways have been investigated extensively. Defective HRR genes may indicate potential clinical benefits from PARP (poly ADP ribose polymerase) inhibitors beyond BRCA1/2 mutations. We evaluated the prevalence of BRCA1/2 mutations as well as alterations in HRR genes with targeted sequencing. A total of 648 consecutive breast cancer samples were assayed, and HRR genes were evaluated for prevalence in breast cancer tissues. Among 648 breast cancers, there were 17 truncating and 2 missense mutations in BRCA1 and 45 truncating and 1 missense mutation in BRCA2, impacting 3% and 5% of the study population (collectively altered in 6%) with cooccurrence of BRCA1/2 in 7 breast cancers. On the other hand, HRR genes were altered in 122 (19%) breast cancers, while TBB (Talazoparib Beyond BRCA) trial-interrogated genes (excluding BRCA1/2) were mutated in 107 (17%) patients. Beyond BRCA1/2, the most prevalent HRR mutant genes came from ARID1A (7%), PALB2 (7%), and PTEN (6%). Collectively, 164 (25%) of the 648 Taiwanese breast cancer samples harbored at least one mutation among HRR genes. The prevalence of BRCA1/2 mutations was far below one tenth, while the prevalence of HRR mutations was much higher and approached one-fourth among Taiwanese breast cancers. Further opportunities to take advantage of defective HRR genes for breast cancer treatment should be sought for the realization of precision medicine.

Combining HIPEC to Interval Surgery in Ovarian Cancer? One Step Forward with a Second Randomized Study: Comment on “Cytoreductive Surgery with or Without HIPEC After Neoadjuvant Chemotherapy in Ovarian Cancer—A Phase 3 Clinical Trial”

Letter to the Editor: Comment on ‘‘Cytoreductive Surgery with or without HIPEC After Neoadjuvant Chemotherapy in Ovarian Cancer: A Phase 3 Clinical Trial’’

ASO Author Reflections: Minimally Invasive Secondary Cytoreductive Surgery for Ovarian Cancer Lymph Node Recurrence: Shaping Treatment with All Arrows in our Quiver

Minimally Invasive Secondary Cytoreductive Surgery for Superficial Celiac and Cardio-Phrenic Isolated Nodal Recurrence of Ovarian Cancer

ASO Author Reflections: HIPEC with Cisplatin Improves Prognosis in Advanced Ovarian Cancer after Neoadjuvant Chemotherapy

The Landmark Series: Minimally Invasive Surgery for Cervical Cancer

Cervical cancer incidence and mortality have declined in developed countries during the past few decades as a result of screening programs and vaccination. However, it remains a significant cause of cancer-related mortality in young women. Early-stage cervical cancer, defined as disease limited to the cervix, has traditionally been treated with abdominal radical hysterectomy via laparotomy. Although most early-stage cervical cancers can be cured with open radical hysterectomy, the morbidity associated with open radical hysterectomy is significant compared with simple extrafascial hysterectomy. Since the early 1990s, minimally invasive surgery has been explored for the treatment of this disease, with the goal of minimizing the morbidity associated with open surgery, as reported for endometrial cancer surgery. This report reviews the landmark studies describing and evaluating minimally invasive surgery in the treatment of patients with early-stage cervical cancer.

ASO Author Reflections: Minimally Invasive Adjuvant Surgery in Locally Advanced Cervical Cancer: Which Role?

Oncologic Outcomes of Robotic Radical Hysterectomy (RRH) for Patients with Early-Stage Cervical Cancer: Experience at a Referral Cancer Center

To evaluate oncologic outcomes of early stage cervical cancer patients who underwent robotic radical hysterectomy (RRH) in a referral center, a retrospective analysis was performed. From January 2010 to December 2018, medical records of stage IA2-IIA1 cervical cancer patients, who underwent radical hysterectomy at our institute, were retrospectively reviewed. We focused our analysis on those who underwent RRH. A total of 198 patients were included in the final analysis. Median follow up was 52 months. At last follow-up, 188 (94.9%) women were disease-free, 9 (4.5%) had died, and 1 (0.5%) was alive with recurrent disease. At 4.5 years, PFS was 93.1% (SE ± 2.1) and OS was 95.1% (SE ± 1.8). Stratified by tumor size, PFS for tumor < 2 cm versus tumor ≥ 2 cm was statistically different (96.8% ± 2.3 and 87.9% ± 4.1 respectively, p = 0.01), as well as OS (100% and 89.8% ± 40 respectively, p = 0.01).Stratified by evidence of tumor at time of robotic surgery, PFS was statistically different in women with no residual tumor after conisation versus those with residual disease (100% ± 2.5 and 90.8% ± 2.8 respectively, p = 0.04). A recurrence occurred in 11 patients (5.6%). Based on our results, we could speculate that robotic approach, along with some technical precautions to avoid spillage, might be safe as primary treatment of early-stage cervical cancer, especially for tumor < 2 cm and in case of no evidence of disease at time of radical hysterectomy after previous conisation.

Prognostic Value and Therapeutic Implication of Laparoscopic Extraperitoneal Paraaortic Staging in Locally Advanced Cervical Cancer: A Spanish Multicenter Study

To assess the impact of laparoscopic extraperitoneal paraaortic staging in therapeutic planning and prognosis of patients with locally advanced cervical cancer (LACC) as compared with imaging staging. Retrospective multicenter study of stage IB2 and IIA2 to IVA (FIGO 2009) LACC patients who were candidates for primary chemoradiotherapy. The study (surgical) group included 634 patients undergoing laparoscopic/robotic extraperitoneal paraaortic staging treated with extended-field radiotherapy (EFRT) if lymph node involvement was confirmed. The control (imaging) group included 288 patients treated with EFRT when lymph node involvement was suspected on positron emission tomography-computed tomography scans and/or magnetic resonance imaging. In the study group, a median of 13 (range 9-17) lymph nodes were removed, with a rate of positive paraaortic nodes of 18%, with metastatic size ≤ 5 mm in 20.4% of cases. Paraaortic EFRT was administered to 18% of patients in the study group and in 58% of controls. In 34% of patients from the surgical group, EFRT was modified according to surgical findings with respect to imaging staging. The median follow-up in the study and control groups was 3.7 and 4.8 years, respectively. In both groups, the overall survival and cancer-specific disease-free survival were similar. The time interval between diagnosis and starting EFRT was 18 days longer in the study group, without differences in overall survival as compared with controls (hazard ratio 1.00, 95% confidence interval 0.998-1.005; p = 0.307). Laparoscopic extraperitoneal paraaortic staging in LACC patients is safe and modified therapeutic planning, allowing better selection of candidates for EFRT.

Insurance Status Predicts Survival in Women with Breast Cancer: Results of Breast and Cervical Cancer Treatment Program in California

The Breast and Cervical Cancer Treatment Program (BCCTP) Act, passed by Congress in 2000, provides time-limited coverage to uninsured breast or cervical cancer patients. We examine survival differences between BCCTP cases and insured controls. Stage I-III breast cancer patients, covered under California's BCCTP from 2005 to 2009 (N = 6343), were 1:1 matched with California Cancer Registry controls on age, race/ethnicity, and cancer stage. Overall and disease-specific (OS and DSS) survival were compared using multivariate regression. BCCTP cases were more often unmarried [odds ratio (OR) 2.47, 95% confidence interval (CI) 2.30-2.66], with poorly/undifferentiated tumors (OR 1.26, CI 1.13-1.40), classified as ER negative (OR 1.10, CI 1.02-1.20) and/or PR negative (OR 1.09, CI 1.01-1.17). Cases were more likely to undergo mastectomy (OR 1.13, CI 1.05-1.21) or no surgery (OR 1.64, CI 1.31-2.05) versus lumpectomy. Cases were also more likely to undergo radiation (OR 1.11, CI 1.03-1.19). Endocrine therapy rates were marginally lower in cases (OR 0.93, CI 0.86-1.00). OS and DSS were shorter in BCCTP cases on multivariate analysis (HR 1.29, CI 1.17-1.42 and HR 1.27, CI 1.14-1.42, respectively). When stratified by socioeconomic status (SES), cases had significantly shorter OS and DSS except in the lowest quintile. When stratified by stage, cases had significantly shorter OS and DSS, except for stage I. The BCCTP provides uninsured breast cancer patients with comprehensive and timely care. Although our results suggest that BCCTP delivers quality care, BCCTP patients have shorter survival rates, even after accounting for SES and stage differences. Further assistance to vulnerable populations is warranted, including longer duration of treatment coverage, and surveillance adhering to NCCN compliant surveillance programs.

How to Perform Bilateral Sentinel Lymph Node Biopsy in Vulvar Cancer with Indocyanine Green by Video-Endoscopic Approach

Abstract Background The standard surgical treatment of early stage vulvar carcinoma  &lt; 4 cm consists of resection of the vulvar tumor with sentinel lymph node (SLN) biopsy (Oonk in Int J Gynecol Cancer 33:1023–1043, 2023). Video-endoscopic inguinal SLN biopsy with indocyanine green (ICG) has been described (Capomacchia et al. in Int J Gynecol Cancer, 2024). However, ICG induces fleeting mapping of lymphatic pathways, making bilateral SLN mapping more challenging. The aim of this video is to show how to perform bilateral inguinal SLN biopsy with ICG by video-endoscopic approach. Patients and Methods We present the case of an 81-year-old patient with a 3.8 cm midline vulvar cancer. Bilateral inguinal SLN biopsy was performed by video-endoscopic approach using ICG along with radioactive tracer. The surgery was performed in a tertiary cancer center. Results The day before the surgery, radioactive tracer was injected in the peritumoral area. The procedure began with the placement of a 12 mm trocar at the apex of the femoral triangle and two 5 mm trocars in both thighs. The working space was developed, and a blunt dissection was bilaterally performed up to the inguinal ligament. ICG was then injected into the four cardinal points around the tumor. SLNs were bilaterally visualized and then resected. A gamma camera was used to ensure that the ones removed were the correct SLNs. There were no intra- or post-operative complications. Conclusions To minimize the fleeting uptake of ICG, dye injection should be performed after bilateral positioning of the trocars and development of surgical spaces. A double check with a gamma camera is needed as radioactive tracer is still considered the standard approach for SLN biopsy in vulvar cancer.

Author’s reply to correspondence on “Expanding the Use of HIPEC in Ovarian Cancer at Interval Debulking Surgery to FIGO Stage IV and After 6 Cycles of Neoadjuvant Chemotherapy: A Prospective Analysis and Perioperative and Oncologic Outcomes” by Mukurdipi Ray et al.

Home-Based Trimodal Prehabilitation in Patients with Peritoneal Carcinomatosis Undergoing Cytoreductive Surgery: Effect on Functional Walking Capacity and Skeletal Muscle Mass

Correspondence on “Expanding the Use of HIPEC in Ovarian Cancer at Interval Debulking Surgery to FIGO Stage IV and After 6 Cycles of Neoadjuvant Chemotherapy: A Prospective Analysis and Perioperative and Oncologic Outcomes” by Valentina Ghirardi et al.

ASO Author Reflections: Mesenteric Lymph Node Involvement in Ovarian Cancer Peritoneal Metastases

Upgrade Rates and Breast Cancer Development Among Germline Pathogenic Variant Carriers with High-Risk Breast Lesions

ASO Author Reflections: Pseudomyxoma Peritonei of Ovarian Origin—Modern Approach and Perspectives

Multidisciplinary Surgical Approach to Increase Survival for Advanced Ovarian Cancer in a Tertiary Gynaecological Oncology Centre

The purpose of this paper is to report on changes in overall survival, progression-free survival, and complete cytoreduction rates in the 5-year period after the implementation of a multidisciplinary surgical team (MDT). Two cohorts were used. Cohort A was a retrospectively collated cohort from 2006 to 2015. Cohort B was a prospectively collated cohort of patients from January 2017 to September 2021. This study included 146 patients in cohort A (2006-2015) and 174 patients in cohort B (2017-2021) with FIGO stage III/IV ovarian cancer. Median follow-up in cohort A was 60 months and 48 months in cohort B. The rate of primary cytoreductive surgery increased from 38% (55/146) in cohort A to 46.5% (81/174) in cohort B. Complete macroscopic resection increased from 58.9% (86/146) in cohort A to 78.7% (137/174) in cohort B (p < 0.001). At 3 years, 75% (109/144) patients had disease progression in cohort A compared with 48.8% (85/174) in cohort B (log-rank, p < 0.001). Also at 3 years, 64.5% (93/144) of patients had died in cohort A compared with 24% (42/174) of cohort B (log-rank, p < 0.001). Cox multivariate analysis demonstrated that MDT input, residual disease, and age were independent predictors of overall (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.203-0.437, p < 0.001) and progression-free survival (HR 0.31, 95% CI 0.21-0.43, p < 0.001). Major morbidity remained stable throughout both study periods (2006-2021). Our data demonstrate that the implementation of multidisciplinary-team, intraoperative approach allowed for a change in surgical philosophy and has resulted in a significant improvement in overall survival, progression-free survival, and complete resection rates.

Fertility-Sparing Treatment for Early-Stage Cervical Cancer ≥ 2 cm: A Problem with a Thousand Nuances—A Systematic Review of Oncological Outcomes

Abstract Background Fertility-sparing treatments (FSTs) have played a crucial role in the management of early-stage cervical cancer (ECC). The guidelines have recognized various approaches, depending on the tumor stage and other risk factors such as histotype and lymphovascular positivity. Much more debate has centered around the boundary within which these treatments should be considered. Indeed, these are methods to be reserved for ECC, but tumor size may represent the most significant limitation. In particular, there is no consensus on the strategy to be adopted in the case of ECC ≥ 2 cm. Therefore, this systematic review was to collect the literature evidence regarding the management of these patients. Methods Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the Pubmed and Scopus databases was conducted in April 2022, from the date of the first publication. We made no limitation on the country. We included all studies containing data on disease-free survival, overall survival, recurrence rate (RR), or complete response rate (CRR) to chemotherapy. Results Twenty-six studies fulfilled the inclusion criteria, and 691 patients were analyzed regarding FST. Surgery-based FST showed an RR of between 0 and 42.9%, which drops to 12.9% after excluding the vaginal or minimally invasive approaches. Furthermore, papers regarding FST based on the neoadjuvant chemotherapy (NACT) approach showed a CRR of between 21.4 and 84.5%, and an RR of between 0 and 22.2% Conclusion This paper focused on the significant heterogeneity present in the clinical management of FST of ECC ≥ 2 cm. Nevertheless, from an oncological point of view, approaches limited to the minimally invasive or vaginal techniques showed the highest RR. Vice versa, the lack of standardization of NACT schemes and the wealth of confounders to be attributed to the histological features of the tumor make it difficult, if not impossible, to set a standard of treatment.

Nomogram Based on Pan-Immune Inflammation Value and Clinicopathological Parameters for Predicting the Recurrence of Endometrial Cancer and Providing Postoperative Prognostic Management

Evaluation of preoperative pan-immune inflammation value (PIV) combined with clinicopathological parameters in predicting postoperative recurrence of endometrial cancer (EC) and development of a prognostic model for optimized recurrence risk assessment. This retrospective study analyzed a training cohort of 1,275 patients and a validation cohort of 656 patients. Prognostic factors associated with recurrence-free survival (RFS) were identified through univariate and multivariate Cox regression analyses, and a nomogram model was subsequently constructed. The discriminative ability and accuracy of the model were evaluated by using the C-index, area under the curve (AUC), and calibration curve. Patients were stratified into low-risk and high-risk groups based on nomogram, and the clinical utility of the model was validated through Kaplan-Meier survival analysis, providing a robust foundation for clinical decision-making. Cox regression analysis revealed that age (P = 0.012), International Federation of Gynecology and Obstetrics (FIGO) stage (P < 0.001), Ca125 (P = 0.012), lymphovascular space invasion (LVSI) (P = 0.007), myometrial invasion (P < 0.001), histological type (P < 0.001), p53 expression (P = 0.001), adjuvant therapy (P < 0.001), and PIV (P < 0.001) were independent prognostic factors for RFS in EC. We developed a predictive model integrating clinicopathological parameters and PIV, which demonstrated superior performance in predicting 1-, 3-, and 5-year RFS compared with single-indicator models and other conventional models. This nomogram demonstrates high predictive accuracy for RFS in EC patients, offering a robust tool to guide personalized therapeutic strategies in clinical practice.

ECP-GAN: Generating Endometrial Cancer Pathology Images and Segmentation Labels via Two-Stage Generative Adversarial Networks

Endometrial cancer is one of the most common tumors of the female reproductive system and ranks third in the world list of gynecological malignancies that cause death. However, due to the privacy and complexity of pathology images, it is difficult to obtain pathology images and corresponding annotation, which affect the accuracy of pathology image segmentation and analysis. To address this issue, this paper proposes a two-stage endometrial cancer pathology images- and labels-generating network, which can generate pathology images and corresponding segmentation labels. In the images-to-images network, a pathological style feature information fusion normalization module is proposed, which decouples the original style feature into style feature vectors to provide independent style feature information. In the images-to-labels network, a pathological prior features guidance loss block is proposed, which improves the ability of the model in feature extraction, the segmentation label-generation accuracy, and the boundary sensitivity to the target region. Training ECP-GAN in the solid tumor endometrial cancer pathological dataset, by physician recognition and experiments on the medical image segmentation tasks, shows that the ECP-GAN network generates realistic images and significantly improves the accuracy of segmentation tasks, which improves about 20% of the segmentation evaluation indicators. Through comparative analysis, the experimental results show that the proposed method effectively improves the robustness and accuracy of the model in segmentation tasks. Particularly when dealing with the complex morphological features of pathology images, this method enhances the model's ability to adapt to various changes, significantly improving.

Conversion from Minimally Invasive Surgical Approaches to Open Surgery Among Patients with Endometrial Cancer in the SGO Clinical Outcomes Registry

Abstract Background Endometrial cancer (EC) ranks as the most common gynecologic malignancy in the USA. While minimally invasive surgical (MIS) techniques have revolutionized EC management, conversion to laparotomy remains a concern due to the loss of laparoscopic benefits such as fewer surgical site infections and shorter hospital stays with reported rates varying widely. Factors influencing this conversion, including patient characteristics and tumor attributes, have not been fully understood. Our study aims to provide a framework for identifying patients at higher risk of conversion, thereby helping to inform surgical decision-making and patient counseling Addressing this gap, our study employs a national registry to analyze patient- and tumor-related factors associated with the transition from MIS to open surgery in EC. Patients and Methods We queried the SGO Clinical Outcomes Registry (COR) to identify all patients with EC who underwent surgical management. The COR indeed validated clinical data from 29 sites collected between 2014 and 2018. The primary outcome was to assess the conversion rate from MIS to open surgery. Descriptive statistics using means with standard deviations or frequency with percentages were used. Chi-squared analysis was used to examine the bivariate relationship between group status and the subjects’ demographic and clinical variables. Results A total of 3.4% (135/4028) of patients underwent conversion from MIS to open surgery. Demographic characteristics were balanced between the groups. Conversion was more prevalent in patients with obesity (29%) and morbid obesity (37%) than in patients who are underweight (2%), normal weight (16%), and overweight (16%). Similarly, conversion was more prevalent in patients with prior abdominal surgery (63% versus 52%; P = 0.001). Endometrioid (EC) predominated (59%) in the converted group, with higher-than-expected non-endometrioid rates (serous carcinoma 16%, clear cell carcinoma 4%, carcinosarcoma 5%, mixed histology 12%; all P &lt; 0.01). Advanced International Federation of Gynecology and Obstetrics (FIGO) stages were more common in patients who converted to open surgery (stage II: 5%, stage III: 25%, stage IV: 9%; all P &lt; 0.001). Type II (24%) and type III (5%) hysterectomies were more frequent in patients who converted to open (P &lt; 0.001). Logistic regression indicated body mass index (BMI), prior surgery, FIGO stage, histology, and hysterectomy type affected conversion (P &lt; 0.001), explaining 12.3% of the variance in the conversion outcome. Indications for conversion included uterine size, adhesions, and disease extent. Conclusions The adoption of MIS has become increasingly common standard of care for managing EC, attributed to enhanced perioperative outcomes. Factors associated with conversion such as uterine size, prior abdominal surgeries, surgical complexity, disease extent, and histologic types can affect the surgeon’s choice. Ultimately, a personalized surgical approach, tailored to individual patient attributes, remains pivotal for optimizing outcomes in EC management.

Laparoscopic Ovarian Transposition with Extraperitonealization of the Infundibulopelvic Ligament for Cervical Cancer in Ten Steps

AbstractPreservation of ovarian function is important for the physical and psychosexual well-being of young patients with cancer. Patients with pelvic malignancies such as cervical or rectal cancer planned for radiotherapy may benefit from ovarian transposition with the aim of moving the ovaries outside the radiation field.1 Different surgical techniques have been reported previously.2,3 With the present video, we aim to standardize the surgical technique of laparoscopic ovarian transposition in ten steps. We present the case of a 30-year-old nulliparous woman diagnosed with grade 3 squamous cell cervical carcinoma having a largest tumor diameter of 41 mm on magnetic resonance imaging (MRI) scan. The tumor was staged as FIGO 2018 stage IIIC1r with a common iliac lymphadenopathy reported on both MRI and positron emission tomography (PET)/computed tomography (CT) scan. The multidisciplinary team recommended exclusive chemoradiation extended to paraaortic area. The patient underwent laparoscopic bilateral salpingectomy and bilateral ovarian transposition with extraperitonealization of the infundibulopelvic ligament. The procedure was divided into the following ten steps: division of uteroovarian ligament, incision of lateral pelvic peritoneum, identification of ureter, incision of medial pelvic peritoneum, skeletonization of the infundibulopelvic ligament, retroperitoneal tunnel in paracolic gutter, creating the window (as high as possible), mobilization of the ovary without torsion, intraperitonealization of the ovary, and fix ovary with clips (Fig. 1). Surgical time was 30 min, with minimal estimated blood loss. No intra- or postoperative complication was recorded. The patient started radiotherapy 14 days after the procedure. In conclusion, we showed that laparoscopic ovarian transposition in cervical cancer before radiotherapy can be standardized in ten steps with encouraging perioperative results, making it an easily reproducible procedure. Ovarian function is reported to be preserved in 62–65% of cases undergoing ovarian transposition and radiation therapy.4,5

SUCCOR Risk: Design and Validation of a Recurrence Prediction Index for Early-Stage Cervical Cancer

Abstract Objective Based on the SUCCOR study database, our primary objective was to identify the independent clinical pathological variables associated with the risk of relapse in patients with stage IB1 cervical cancer who underwent a radical hysterectomy. Our secondary goal was to design and validate a risk predictive index (RPI) for classifying patients depending on the risk of recurrence. Methods Overall, 1116 women were included from January 2013 to December 2014. We randomly divided our sample into two cohorts: discovery and validation cohorts. The test group was used to identify the independent variables associated with relapse, and with these variables, we designed our RPI. The index was applied to calculate a relapse risk score for each participant in the validation group. Results A previous cone biopsy was the most significant independent variable that lowered the rate of relapse (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.17–0.60). Additionally, patients with a tumor diameter &gt;2 cm on preoperative imaging assessment (OR 2.15, 95% CI 1.33–3.5) and operated by the minimally invasive approach (OR 1.61, 95% CI 1.00–2.57) were more likely to have a recurrence. Based on these findings, patients in the validation cohort were classified according to the RPI of low, medium, or high risk of relapse, with rates of 3.4%, 9.8%, and 21.3% observed in each group, respectively. With a median follow-up of 58 months, the 5-year disease-free survival rates were 97.2% for the low-risk group, 88.0% for the medium-risk group, and 80.5% for the high-risk group (p &lt; 0.001). Conclusion Previous conization to radical hysterectomy was the most powerful protective variable of relapse. Our risk predictor index was validated to identify patients at risk of recurrence.

Medicaid Expansion and Postoperative Mortality in Women with Gynecologic Cancer: A Difference-in-Difference Analysis

The association between Medicaid expansion and postoperative mortality after surgery for gynecologic cancer is unknown. Our objective was to compare 30- and 90-day postoperative mortality after gynecologic cancer surgery before and after 2014 in states that did and did not expand Medicaid. We searched the National Cancer Database for women aged 40-64 years old between 2010 and 2016 who underwent surgery for a primary gynecologic malignancy. We used pre/post and quasi-experimental difference-in-difference (DID) multivariable logistic regressions to evaluate mortality pre-2014 (2010-2013) and post-2014 (2014-2016) for states that did and did not expand Medicaid in January 2014. We completed univariable logistic regressions for covariates of interest. Among 169,731 women, 30-day postoperative mortality in expansion states after 2014 significantly decreased for endometrial cancer (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.26-0.67) and ovarian cancer (OR 0.67, 95% CI 0.46-0.99) and increased for cervical cancer (OR 3.82, 95% CI 1.12-13.01). Compared with non-expansion states, expansion states had improved 30-day postoperative mortality for endometrial cancer after 2014 (DID OR 0.54, 95% CI 0.31-0.96). Univariable analysis demonstrated improved 30-day postoperative mortality for Black women with endometrial cancer in expansion states (DID OR 0.22, 95% CI 0.05-0.95). There was improved 90-day postoperative mortality for endometrial cancer in expansion states (OR 0.66, 95% CI 0.50-0.85), and improved 90-day postoperative mortality for Midwestern women with ovarian cancer in expansion states on univariable analysis (DID OR 0.48, 95% CI 0.26-0.91). State Medicaid legislation was associated with improved postoperative survival in women with endometrial cancer and subgroups of women with endometrial and ovarian cancer.

Racial Disparities in Surgical Outcomes Among Women with Endometrial Cancer

Endometrial cancer (EC) is the most common gynecological cancer among women in the United States. Despite well-documented racial/ethnic disparities in EC incidence and mortality rates, limited data exist regarding disparities in hysterectomy surgical outcomes. We evaluated associations of race/ethnicity with postoperative complications, serious adverse events (SAEs), and length of hospital stay among women undergoing EC-related hysterectomy. Using National Surgical Quality Improvement Program (NSQIP) data, we identified women (≥18 years) undergoing hysterectomy to treat EC between 2014 and 2020. We used multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations of race/ethnicity (white, black, and Latina) with postoperative complications and SAEs. We used Poisson regression with robust standard errors to calculate incidence rate ratios (IRRs) and 95% CIs for the association of race/ethnicity with length of hospital stay. Of 22,778 women undergoing EC-related hysterectomy, 3.1% developed postoperative complications. Black (adjusted OR: 1.62; 95% CI 1.05-2.48) and Latina women (adjusted OR: 1.79; 95% CI 1.04-3.09) had higher postoperative complication risks than white women. The overall SAE incidence was 5.0%. Black women (adjusted OR: 1.55, 95% CI 1.13-2.15) had higher SAE risks than white women. Length of hospital stay was significantly longer for black women than white women (IRR: 1.18; 95% CI 1.07-1.30). We observed racial/ethnic disparities in EC-related hysterectomy surgical outcomes in a large, diverse sample of U.S. women between 2014 and 2020. Studies to elucidate the underlying mechanisms of these racial disparities, with a focus on social context remain necessary.

Endometrioid Borderline Ovarian Tumor: Clinical Characteristics, Prognosis, and Managements

Endometrioid borderline ovarian tumor (EBOT) is a rare subtype of borderline ovarian malignancies. This study was designed to determine the prognosis of a series of EBOT. This is a retrospective review of patients with EBOT treated in or referred to our institutions and a centralized, histological review by a reference pathologist. Data on the clinical characteristics, management (surgical and medical), and oncologic outcomes of patients were required for inclusion. Forty-eight patients were identified. Median age was 52 years (range 14-89). Fourteen patients underwent a conservative surgery and 32 a bilateral salpingo-oophorectomy (unknown in 2 cases). Two patients had bilateral tumors. Forty-three patients had stage I disease, and five patients had stage II disease (10%). Stromal microinvasion and intraepithelial carcinoma was observed in 6 (12%) and 13 (27%) patients respectively. Endometriosis was histologically associated in 12 patients (25%). Synchronous endometrial disease was found in 7 (24%) of 29 patients with endometrial histological evaluation. The median follow-up was 72 months (range 6-146). Two patients developed a recurrence after cystectomy in form of borderline disease (5%). No death related to EBOT occurred. Peritoneal restaging surgery should be performed if not realized initially, because 5% of EBOTS are diagnosed at stage II-III. Fertility-sparing surgery seems a safe option in selected patients. Because synchronous endometrial diseases, including endometrial carcinoma are frequent, systematic hysterectomy (or endometrial sampling in case of fertility-sparing surgery) is mandatory. Prognosis is generally excellent. Recurrence is a rare event (6%), but it can occur in the form of invasive disease.

Predictive Score of Nodal Involvement in Endometrial Cancer Patients: A Large Multicentre Series

Sentinel lymph node (SLN) biopsy is considered the standard of care in early-stage endometrial cancer (EC). For SLN failure, a side-specific lymphadenectomy is recommended. Nevertheless, most hemipelvises show no nodal involvement. The authors previously published a predictive score of lymphovascular involvement in EC. In case of a negative score (value 3-4), the risk of nodal metastases was extremely low. This multicenter study aimed to analyze a predictive score of nodal involvement in EC patients. The study enrolled patients with EC who had received comprehensive surgical staging with nodal assessment. A preoperative predictive score of nodal involvement was calculated for all the patients before surgery. The score included myometrial infiltration, tumor grading (G), tumor diameter, and Ca125 assessment. The STARD (standards for Reporting Diagnostic accuracy studies) guidelines were followed for score accuracy. The study analyzed 1038 patients and detected 155 (14.9%) nodal metastases. The score was negative (3 or 4) for 475 patients and positive (5-7) for 563 of these patients. The score had a sensitivity of 83.2%, a specificity of 50.8%, a negative predictive value of 94.5%, and a diagnostic value of 55.7%. The area under the curve was 0.75. The logistic regression showed a significant correlation between a negative score and absence of nodal metastasis (odds ration [OR], 5.133, 95% confidence interval [CI], 3.30-7.98; p < 0.001). The proposed predictive score is a useful test to identify patients at low risk of nodal involvement. In case of SLN failure, the application of the current score in the SLN algorithm could allow avoidance of unnecessary lymphadenectomies.

Contemporary Incidence of Medical Inoperability in Clinical Stage I Endometrial Cancer

Minimally invasive surgical (MIS) staging is the standard treatment approach for clinical stage I endometrial cancer. Historical rates of inoperability in endometrial cancer are approximately 10%. Given surgical and medical advancements against increasing population obesity, we aimed to describe a contemporary incidence of medical inoperability in clinical stage I endometrial cancer. Patients diagnosed with clinical stage I endometrial cancer of any histology from April 2014 to December 2018 were included in this retrospective cohort study. The primary outcome, medical inoperability, was defined as (1) patients deemed inoperable by a gynecologic oncologist at initial consultation, (2) patients deemed inoperable during preoperative clearance, or (3) an aborted hysterectomy. Fisher's exact or χ Overall, 767 patients were included, of which 4.6% (35/767) were determined to be inoperable. The inoperable group had a higher body mass index (52.7 vs. 33.9, p 95% of patients with newly diagnosed endometrial cancer treated at a high-volume center. Complication rates were comparable to other trials evaluating the safety of MIS staging for endometrial cancer.