Current Opinion in Oncology

Value of sentinel node ultrastaging and pathologic techniques in tumoral detection

Purpose of review Sentinel lymph node assessment is an option for patients with clinically early-stage vulvar cancer, endometrial cancer, cervical cancer, and, more recently, ovarian cancer. However, although ultrastaging is mandatory as part of the node evaluation, universally accepted pathology protocols are lacking. This review focuses on the current evidence for the most relevant aspects of sentinel lymph node evaluation, as well as some controversial topics like frozen section or one-step nucleic acid amplification. Recent findings The diagnostic accuracy of sentinel lymph node detection algorithms for patients with gynecologic neoplasms is high. However, the heterogeneity among the published studies and the absence of clear recommendations from most guidelines make it challenging to recommend one protocol over another. The minimum requirement from ultrastaging protocols (regarding the number of levels to be assessed, among others) to get the highest accuracy with a minor cost is unknown. Summary Sentinel lymph node evaluation is now part of the surgical management for most early-stage gynecologic neoplasms. However, a universally accepted ultrastaging pathology protocol is lacking in literature and clinical practice. This gap requires significant effort from the gynecologic oncology and pathology community to be closed and then to allow advancements in surgical management for early-stage gynecologic tumors to go forward.

Indications and technique of minimally invasive surgery in early-stage cervical cancer

Purpose of review This review explores the evolving role of minimally invasive surgery (MIS) in early-stage cervical cancer following the landmark LACC trial, which shifted the standard of care back to open surgery. We revisit critical evidence, dissect controversial subgroups, and highlight areas where MIS may still hold clinical value. Recent findings Subgroup analyses and recent prospective trials suggest that MIS may remain a viable option for selected patients with low-risk tumours (<2 cm), particularly when preceded by conisation and incorporating protective surgical strategies. The SHAPE trial demonstrated noninferiority of simple hysterectomy compared to radical hysterectomy in these cases, and post hoc analyses indicate comparable outcomes between MIS and open approaches in this context. Additional real-world studies, such as SUCCOR and SUCCOR-Cone, underscore the potential protective role of preoperative conisation and specific intraoperative techniques. Nonetheless, all these findings remain hypothesis-generating and require validation. Summary While open surgery remains the current standard for early-stage cervical cancer, evidence is emerging that selected patients with low-risk features might safely undergo MIS, especially within the framework of clinical trials. Ongoing studies are expected to redefine surgical paradigms and guide future practice.

Benefits of laparoscopic approach in early-stage ovarian cancer and ovarian masses

Purpose of review The aim of this review is to summarize the available evidence on the use and benefits of minimally invasive surgery (MIS) in the management of ovarian masses and early-stage ovarian cancer. Recent findings MIS did not negatively impact survival outcomes or increase perioperative complication rates in patients with early-stage ovarian cancer compared to open surgery, while providing the inherent benefits associated with this surgical approach. Regarding the type of MIS, both laparoscopic and robotic approaches can be used in well selected patients at specialized centers. Summary MIS appears to be a feasible and well tolerated surgical option for the evaluation of ovarian masses and for the comprehensive staging of early-stage ovarian cancer patients. Compared to open surgery, MIS offers several advantages, including significantly reduced blood loss, a lower need for transfusion, shorter hospital stays and faster postoperative recovery, without compromising surgical results. Furthermore, extensive retrospective studies have shown comparable survival outcomes between both approaches. However, high-quality evidence from randomized clinical trials is still needed to establish definitive conclusions and draw international recommendations.

Benefits of sentinel node detection in cervical cancer

Purpose of review Sentinel lymph node biopsy (SLNB) is a widely used technique in other gynaecological tumours but has not yet been implemented as the gold standard technique for nodal staging in cervical cancer. Since the majority of evidence is derived from retrospective studies, this review aims to summarize the most recent evidence on this relevant topic. Recent findings SLNB has demonstrated to be a well tolerated technique for lymph node staging in early-stage cervical cancer patients with promising future as exclusive lymph node assessment method avoiding full lymphadenectomy. Moreover, it allows ultrastaging and unfrequent drainage identification, which enables the detection of patients at a high risk of recurrence who would otherwise remain unnoticed. When compared with pelvic lymphadenectomy, SLNB is also associated with less intraoperative and postoperative complications, especially in terms of lymphedema formation. Summary The available evidence suggests that SLNB offers numerous advantages over the standard pelvic lymphadenectomy reducing morbidity rates and increasing diagnostic accuracy. Three ongoing prospective trials will likely answer the controversies over these questions.

Current limits of conservative treatment in ovarian cancer

Purpose of review Fertility-sparing surgery in ovarian cancer is an increasing need in gynecology–oncology clinical practice because of the frequent childbearing delay in developed countries. As the evidence in literature is based on observational studies, this review focuses on summarizing the most recent and relevant evidence for the conservative management of young patients with ovarian cancer. Recent findings Staging surgery is mandatory in epithelial ovarian tumors. In sex cord-stromal tumors, fertility-sparing surgery is only recommended in FIGO stage IA. Due to its good prognosis, conservative treatment is possible in some cases of advanced disease of germ cell tumors and borderline tumors. Cystectomy is a reasonable option in serous borderline tumors but is not recommended in other tumor subtypes. Successful conception rates after fertility-sparing surgery ranges from 30 to 60%. Summary Fertility-sparing surgery is a well tolerated option in young women with early-stage ovarian cancer with acceptable reproductive outcomes.

Role of Poly (ADP-Ribose) Polymerase inhibitors beyond BReast CAncer Gene-mutated ovarian tumours: definition of homologous recombination deficiency?

Purpose of reviewPARP inhibitors have transformed the management of BRCA mutant (BRCAmut) high-grade serous and endometroid ovarian cancer (HGOC). However, it is clear that the benefit can be extended beyond this subgroup, particularly to those cancers with homologous recombination repair deficiency (HRD). We review emerging molecular and clinical data to support the use of PARP inhibitors in HRD HGOC and discuss the advantages and disadvantages of different HRD assays.Recent findingsSeveral phase 3 trials support the use of PARP inhibitor maintenance therapy beyond those patients with BRCAmutin the first-line and platinum-sensitive relapse setting. Many of these studies included HRD testing and it is clear, regardless of the assay used, that an incremental reduction in benefit is observed from BRCAmuttumours to HRD to homologous recombination proficient tumours. However, although currently available HRD assays predict the magnitude of benefit from PARP inhibitors, they consistently fail to identify a subgroup of patients who do not benefit.SummaryClinical data support the use of PARP inhibitor maintenance therapy beyond BRCAmutpatients. Current HRD tests lack negative predictive value and more research is required to develop a composite HRD assay that provides a dynamic readout of HRD status.

Current opinion on laparoscopic surgery in gynecologic oncology: challenges and advances in elderly patients

Purpose of review As the global population ages rapidly, there is an increasing need to address the particular challenges faced by elderly women with gynecological cancers. This review focuses on the role of laparoscopic surgery (LPS) and highlights its benefits, limitations, and future directions in this vulnerable population. By examining recent findings, this study provides timely insights into the application of minimally invasive surgical techniques in the elderly. Recent findings Current literature underscores the benefits of LPS, including reduced blood loss, shorter hospital stays, and fewer postoperative complications, making it a viable option for elderly patients. However, challenges such as frailty, comorbidities, and the physiological effects of pneumoperitoneum remain significant. Advances in frailty assessment tools, enhanced recovery after surgery (ERAS) protocols, and robotic-assisted surgery (RAS) are transforming preoperative planning and surgical outcomes. Summary Laparoscopic surgery offers considerable advantages for elderly women with gynecologic cancers, balancing oncologic efficacy with reduced perioperative morbidity. Future research must focus on inclusive trials and geriatric-specific guidelines to optimize outcomes and broaden the applicability of minimally invasive techniques in this population.

HIPEC in advanced epithelial ovarian cancer: why is there controversy?

Purpose of review The randomized OVHIPEC study provided further evidence that adding heated intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery significantly improved recurrence-free and overall survival in stage III epithelial ovarian cancer (EOC) patients, who were ineligible for primary cytoreductive surgery due to extensive intraperitoneal disease. Because opinions have been divided as to whether HIPEC is now a new standard of care for advanced EOC, the pros and cons of this approach are examined. A comparison with the ongoing discussion about the role of intraperitoneal chemotherapy is made. Recent findings For both techniques, experience is crucial and a learning curve essential. Compared with intraperitoneal chemotherapy, intraoperative application of HIPEC provides superior distribution through the peritoneal cavity. HIPEC, as given in OVHIPEC, did not significantly increase adverse events, had no negative effect on quality of life and was cost-effective. Summary Despite the ongoing debate about HIPEC, an important first step in attempting to demonstrate the efficacy of HIPEC in the first-line setting has been made with OVHIPEC. Critics have been of value to optimize future trials with HIPEC in patients with EOC.

Role of sentinel lymph node biopsy with indocyanine green and site of injection in endometrial cancer

Purpose of review The aim of the present narrative review is to summarize the state of art on sentinel lymph node biopsy (SLNB) in endometrial cancer, with a special focus on indocyanine green (ICG) as adopted tracer. Recent findings Over the years, the surgical nodal staging in patients with endometrial cancer has been intensively investigated. Traditionally, systematic pelvic and para-aortic lymphadenectomy represented the gold standard surgical treatment to assess nodal involvement of the tumor. Through the last two decades, SLNB has gradually replaced lymphadenectomy as a more targeted procedure. A great heterogeneity of tracers and injection techniques have been proposed to perform SLNB. However, no universally accepted recommendations are still available. Summary SLNB has nowadays almost replaced pelvic lymphadenectomy in low-risk endometrial cancers, offering a better safety profile while being related to a comparable nodal involvement sensitivity. Currently, ICG is considered to be the most used tracer among others. Different injection sites have been proposed, with different detection features. While ICG cervical injection is nowadays the suggested technique for SLNB, noncervical injection techniques, such as hysteroscopic and combined procedures, seem to have a better accuracy in para-aortic nodal assessment, which have a role in high-risk endometrial cancers.

Immunotherapy in rare ovarian cancer

Purpose of review Ovarian cancer (OC) is a heterogeneous disease and a mounting body of evidence shows that a ‘one-size-fits-all’ approach is obsolete. Differences in epidemiology, tumor biology, genetic profiles and treatment responses of these different types necessitate a tumor and patient-specific approach. Ninety percentage consists of epithelial OC with 70% being high-grade serous OC. The other rarer subtypes are low-grade serous (5%), clear cell (12%), endometrioid (11%) and mucinous carcinoma (3%). The remaining 10% are nonepithelial rare OCs: germ cell (3%) and sex-cord stromal tumors (7%). Recent findings Over the past few decades, the 5-year survival rates have only improved modestly, therefore novel therapies are urgently needed. Recently, immunotherapy has been introduced into clinical practice in a number of solid tumors. Although preclinical data confirm the presence of an immunogenic microenvironment in a number of ovarian tumor types, no single-agent immune checkpoint inhibitor has been approved hitherto. Identifying suitable treatment combinations, adequate patient selection and thus correct implementation of immunotherapy remain major challenges. Summary In this review, we focus on the rationale of incorporating immune therapy in rare OC, we summarize the recent developments with preclinical data and results of clinical trials, with particular focus on rare ovarian histological subtypes.

Importance of guidelines and networking for the management of rare gynecological cancers

Purpose of review Guidelines are essential to support appropriate medical management. The objective of our paper is to highlight the need for such recommendations, to reinforce strategies in place and to promote the creation of multidisciplinary networks to provide the most appropriate care to patients and to improve it. Recent findings Gynecological rare cancers are not that rare since they represent around 50% of all gynecological cancers. Surgery remains the cornerstone of management for all subtypes. Apart from malignant ovarian germ-cell tumors for which conventional chemotherapy was proven to be efficient, response to standard systemic treatment for other gynecological cancers are disappointing. Better understanding of these pathologies is needed and requires more adapted management. Summary Rare cancers are substantially heterogeneous but raise the need of integrating new cases in dedicated networks to enhance and homogenize medical practices. Centralized diagnosis, improved medical practice based on regularly updated international guidelines, and inclusion in innovative clinical trials linked to preclinical studies are essential to contribute to the promotion of improvement in patient care.

Is less more in the surgical treatment of early-stage cervical cancer?

Purpose of review This article discusses recent developments towards less radical surgical treatment for early-stage cervical cancer. Recent findings Surgery is the standard treatment for early-stage cervical cancer. In the last decades, new treatment strategies have been developed aiming to reduce morbidity, without hampering oncological safety. We provide an update of the latest knowledge on safety and morbidity following less radical surgical procedures in early-stage cervical cancer. In cervical cancer with a tumour size of 2 cm or less, radical surgery (simple hysterectomy or fertility-sparing conisation) may be a well tolerated option. For patients with larger lesions (>2 cm) and wishing to preserve fertility, administration of neoadjuvant chemotherapy followed by less extensive surgery appears to be a feasible and well tolerated alternative to abdominal trachelectomy. With regard to lymph node assessment, increasing evidence shows the feasibility of the sentinel lymph node procedure instead of full pelvic lymphadenectomy. Prospective trials reporting on oncological safety are awaited. It is important to exercise caution when new surgical strategies are introduced. Despite promising retrospective data, prospective randomized studies may present unexpected results, for instance, minimally invasive radical hysterectomy showed inferior results compared to laparotomy. Summary There is a shift towards less radical treatment for early-stage cervical cancer. This review explores whether and when less is really more.

Minimally invasive surgery in advanced and recurrent ovarian cancer: current evidence and future directions

Purpose of review The use of minimally invasive surgery (MIS) in advanced ovarian cancer management following neoadjuvant chemotherapy yields potential benefits in patient recovery and quality of life compared with traditional open surgery. MIS techniques, including robot-assisted procedures, have been increasingly utilized in recent years despite ongoing debates about their oncologic safety. Recent findings Recent prospective and retrospective studies indicate that MIS for interval debulking after neoadjuvant chemotherapy can achieve similar cytoreductive outcomes (no visible residual disease, CC-0) to laparotomy in carefully selected patients. Key reported advantages include reduced perioperative morbidity, lower blood loss, and shorter hospital stays. Nonetheless, current data are limited by patient selection bias, power of the studies to detect differences, and concerns about accurately detecting small-volume disease laparoscopically. Ongoing randomized controlled trials, such as the LANCE trial, are expected to provide robust evidence to clarify oncologic outcomes of MIS. Additionally, early studies indicate MIS might be feasible for selected cases of recurrent ovarian cancer. Summary MIS is emerging as a viable and potentially advantageous alternative to open surgery for advanced ovarian cancer after neoadjuvant chemotherapy, provided careful patient selection and surgical expertise. Definitive conclusions about long-term oncologic outcomes and recurrence require results from randomized clinical trials.

Monitoring serum estradiol in premenopausal women with hormone receptor-positive breast cancer on adjuvant LHRH agonists

Purpose of review To review the current evidence and inform clinical guidance on the implications of incomplete ovarian function suppression (OFS), the utility of serum estradiol (E2) monitoring, and appropriate management strategies in premenopausal women with early breast cancer (eBC) receiving adjuvant luteinizing hormone-releasing hormone agonist (LHRHa)-based therapy for OFS. Recent findings A universally accepted definition of incomplete OFS is currently lacking. Although biologically it is plausible that incomplete OFS may compromise the efficacy of endocrine therapy, its actual impact on clinical outcomes remains unclear. Currently, the reliability of E2 monitoring is limited by considerable variability in assay methods and reference ranges, raising concerns about its analytical validity. Notably, in a recent international survey of 205 oncologists managing patients with eBC, 43% reported routinely and 27% occasionally assessing E2 levels in premenopausal patients treated with LHRHa, suggesting inconsistent clinical practice. Standard immunoassays were the most frequently used (65%). However, interpretation of E2 values and subsequent management decisions varied widely, highlighting the absence of standardized clinical guidelines. Summary Although not currently supported by high-level evidence, serum E2 monitoring is widely adopted in clinical practice. Prospective studies and evidence-based recommendations are urgently needed. Emerging strategies to overcome incomplete OFS include LHRH antagonists (e.g., degarelix) and oral SERDs.

Gynecological sarcomas: literature review of 2020

Purpose of review This article, focus on recently published data of the last 18 months on the management of gynecologic sarcomas. Recent findings Different tools have been studied to identify the differences between benign from malignant uterine conjonctive tumor. Molecular biology impact more and more on the diagnosis of uterine sarcoma with new definitions of very specific groups. This will make it possible to better define the last group of endometrial sarcoma which has been defined as undifferentiated. In several articles, surgical approaches and fertility-sparing surgery were described including the role of surgery for recurrences. Some other articles have evaluated the potential benefice of adjuvant therapy for uterine sarcoma with early stages. Several new targeted therapies are in development. Notably deoxyribonucleic acid repair machinery in uterine leiomyosarcoma and also immune therapies, transforming growth factor beta pathway, mechanistic target of rapamycin inhibitor, anti angiogenics, etc. Summary This last year the potential interest for uterine sarcoma increased, demonstrated by the increasing number of publications in the literature compared to previous years. Despite this greater interest over time, the standard of care for uterine sarcoma does not change and we are always waiting for new innovative therapies able to change routine practice and survival of patients. Currently, the result of different clinical trials, which include new options as targeted molecular approach or immune checkpoint inhibitors are closed to be reported.

Progress in the management of endometrial cancer (subtypes, immunotherapy, alterations in PIK3CA pathway): data and perspectives

Purpose of reviewChanges in molecular classification together with a deeper knowledge of both immune disregulation and phosphatidylinositol-3 kinase (PI3K) pathway alterations are leading to a new endometrial cancer treatment paradigm. This review will address the cutting-edge data in this field.Recent findingsThis article will cover the updated data in endometrial cancer molecular classification and its correlation with the outcomes in randomized clinical trials (e.g., PORTEC-3). Moreover, we will review the latest data regarding checkpoint blockade molecules (CPB) in the recurrent setting and how they are changing the treatment landscape. In addition, the role of the PI3K inhibitors, their activity, and toxicity profile will be described.SummaryAs result of the incorporation of molecular classification in our daily practice, the adjuvant treatment in endometrial cancer is rapidly evolving and leading to a new paradigm. The promising data observed with CPB in the recurrent setting have led to the food and drug administration approval of pembrolizumab as monotherapy and in combination with lenvatinib. Additionally, the current outcomes achieved with PI3K inhibitor agents encourage us to continue our clinical research to identify those patients who may benefit the most.

New developments in rare vulvar and vaginal cancers

Purpose of review To provide the latest insight on the rare vulvar and vaginal malignancies, able to impact on clinical practice, and to outline new potential research developments. Recent findings Many efforts are being made to produce technical and scientific advances in the fields of vulvar and vaginal carcinoma, including imaging work-up, interventional procedures and minimally invasive surgical approach, as well as molecular profiling and identification of new target treatments. Summary In the evaluation of lymph node status, ultrasound has demonstrated promising results because of high predictive value, low risk and low cost. Positron Emission Tomography-Computed Tomography is confirmed to be reliable and should be prospectively investigated for its potential applications in radiomics, whilst Fusion-US could allow a precision guidance in diagnostics and interventional procedures. Regarding interventional procedure, surgery is becoming less invasive with the aim to increase quality of life; in carefully selected patients it would be possible to overcome the current strict criteria in the use of sentinel node biopsy. Future research should focus on potential target therapy, on the basis of tumor-specific biological features. Rare cancers should be referred to experienced centers with a high case flow, able to offer a full range of diagnostic and therapeutical options and a multidisciplinary approach. Networking should be encouraged to promote research opportunities and enable data sharing and multicenter trials.

Use of staging for sex cord stromal tumours

Purpose of review Sex cord-stromal tumours (SCSTs) are rare ovarian cancers. As in the literature, only small case series or case reports are published, gathering solid evidence about their management is challenging. Surgery plays a pivotal role, and accurate staging is one of the most important prognostic factors. This review focuses on the current evidence for surgical staging in the management of SCSTs. Recent findings Staging procedures have been inferred by epithelial ovarian cancers; however, they are often only partially performed, and most SCSTs therefore end up incompletely staged, raising the issue of the need for restaging or further treatments. In addition, some parts of the staging procedure have been questioned over the years, and lymphadenectomy is now considered unnecessary for SCSTs. The generally favourable prognosis of SCSTs, the introduction of minimally invasive surgery and fertility-sparing approaches is empowering the question of which staging procedures are beneficial for these patients. We reviewed the role of each staging procedure proposed by the guidelines in light of new scientific updates. Summary Surgical staging should always be performed. It includes peritoneal samplings (peritoneal washing, multiple peritoneal biopsies, omental biopsy and biopsy of any suspicious area), whereas lymphadenectomy could be omitted. Laparoscopy may be considered a feasible approach.

Endoscopic inguinal lymphadenectomy for vulvar cancer, is it feasible?

Purpose of review The evaluation of lymph node status is crucial for the correct staging of patients with vulvar carcinoma and to assess whether adjuvant treatment is necessary. Classically, this procedure is performed with an open approach to the inguinal region; however, this procedure is associated with a significant complication rate. For this reason, the video-endoscopic approach to inguinal lymph node assessment has been proposed in recent years. This review aimed to provide an overview on the feasibility and outcomes of the video-endoscopic inguinal lymphadenectomy (VEIL). Recent findings VEIL appeared to be a viable alternative to the open approach, with similar outcomes in terms of the number of lymph nodes removed and blood loss. While the postoperative complications rate was lower in the VEIL group, operative times tended to be longer. This may be due to the lack of standardization of the technique and to the variability in video-endoscopic approaches (laparoscopic vs robotic). Sentinel lymph node biopsy with endoscopic approach has also been described. Summary VEIL appears to be feasible and safe, adding benefits in terms of postoperative complications. Nevertheless, few studies are available and further data is needed to confirm these findings.

Future of sentinel node biopsy in ovarian cancer

Purpose of review The rationale on the use of sentinel lymph node (SLN) biopsy in the surgical staging of apparent early-stage ovarian cancer (OC) is supported by the fact that diagnostic and prognostic role of systematic staging lymphadenectomy has been determined but its therapeutic significance is still matter of controversy. Moreover, SLN biopsy represents an option to decrease intra- and postoperative morbidity. The present review aims to provide an overview on the current and future role of SLN in OC. Recent findings Most recent evidence shows that the overall mean per patient SLN detection rate in case of indocyanine green (ICG) alone was 58.6% compared with 95% in case of ICG + technetium, and with 52.9% in case of technetium alone or in combination with blue dye (P < 0.001). Site of injection has been reported to be in both ovarian ligaments in majority of studies (utero-ovarian ligament and infundibulo-pelvic ligament), before or after ovarian mass removal, at time of primary or re-staging surgery and by minimally invasive or open approach. Cervical injection has been recently proposed to replace utero-ovarian injection. SLN detection rate in patients with confirmed ovarian malignancy varied across different studies ranging between 9.1% and 91.3% for the injection in the utero-ovarian ligament and migration to pelvic lymph nodes and between 27.3% and 100% for the injection in the infundibulo-pelvic ligament and migration to para-aortic lymph nodes. No intra- or postoperative complication could be attributed directly to SLN biopsy. The sensitivity and the accuracy of SLN in detecting lymphatic metastasis ranged between 73.3–100% and 96–100%, respectively. In up to 40% of positive SLNs, largest metastatic deposit was classified as micro-metastasis or isolated tumor cells, which would have been missed without ultrastaging protocol. Summary SLN biopsy represents a promising tool to assess lymph node status in apparent early-stage OC. The type and volume of injected tracer need to be considered as appear to affect SLN detection rate. Ultrastaging protocol is essential to detect low volume metastasis. Sensitivity and accuracy of SLN biopsy are encouraging, providing tracer injection in both uterine and ovarian ligaments.

Ovarian preservation in gynecologic oncology: current indications and techniques

Purpose of review Early menopause represents a relevant clinical issue for women. Nevertheless, this issue should be balanced with the risks of ovarian metastasis, ovarian recurrence, and the risk of recurrence in hormone-sensitive gynecological cancers. The purpose of this review was to provide an overview on current indications and techniques of ovarian preservation in patients with gynecological cancers. Recent findings The potential discussion about ovarian conservation could be proposed to patients with FIGO-stage IA grade 1-2 endometrioid endometrial cancer aged 40 years or less, FIGO-stage IB1-IB2 node-negative cervical cancer with squamous cell carcinoma and HPV-associated adenocarcinoma, FIGO-stage IA-IC grade 1-2 serous, endometrioid, mucinous expansile pattern ovarian cancer, any stage germ cell ovarian tumors, and FIGO-stage IA sex cord-stromal tumors. Technique to perform ovarian transposition in cervix cancer is also reported. Summary Ovarian conservation is a surgical approach that involves preserving one or both ovaries during the treatment of gynecologic cancers. This approach has gained popularity in recent years, as it offers several benefits to the patient, including the preservation of hormonal function and fertility. The decision to perform ovarian conservation depends on several factors, such as the stage and type of cancer, the patient's age, fertility desire, and should be carefully discussed with patients.

Robot-assisted laparoscopic staging compared to conventional laparoscopic staging and laparotomic staging in clinical early stage ovarian carcinoma

Purpose of review Robot-assisted laparoscopic staging (RALS) is increasingly used for staging epithelial ovarian cancer (EOC). Evidence of its safety is limited. The aim of this review is to compare the efficacy and safety of RALS in clinical early-stage EOC to conventional laparoscopy and laparotomy and to assess the level of evidence that is currently available to adopt this surgical technique. Recent findings Only retrospective studies comparing staging by minimally invasive surgery (MIS) to laparotomy are available. Both RALS and conventional laparoscopic staging shorten length of hospital stay (LHS, mean -2.9 days) and decrease estimated blood loss (EBL, mean -79 ml less) compared to laparotomy. Complication rates and number of lymph nodes collected are similar in all surgical staging techniques. Survival outcomes after staging by MIS cannot be compared to staging by laparotomy because of the lack of evidence but RALS is probably noninferior to conventional laparoscopic staging. Summary RALS probably improves perioperative outcomes in patients with clinical early stage EOC similar to conventional laparoscopic staging. Whether oncologic outcomes of RALS are comparable to open and conventional approaches is uncertain as there is only level C evidence and randomized controlled trials are urgently needed to confirm the current retrospective findings.

Surgical treatment for clinical early-stage expansile and infiltrative mucinous ovarian cancer: can staging surgeries safely be omitted?

Purpose of review Mucinous ovarian cancers (MOCs) are categorized into infiltrative and expansile subtypes. These subtypes have different characteristics and prognoses. Patients with clinical early-stage disease of both subtypes currently undergo surgical staging (peritoneal washing, biopsies, omentectomy). Peritoneal and lymph node metastases of expansile MOC are rare, but whereas lymph node sampling (LNS) is omitted in these patients, peritoneal staging is not. Therefore, we collected all available MOC data to determine whether staging surgeries could safely be omitted in clinical early-stage expansile and infiltrative MOC. Recent findings Current literature confirms that peritoneal metastases are rare in expansile MOC: more than 90% of patients have early-stage disease. Only 3.4% of the patients with clinical early-stage expansile MOC had positive peritoneal washings at surgical staging. Patients with infiltrative MOC were diagnosed more frequently with advanced-stage disease (21–54%). Moreover, upstaging clinical early-stage infiltrative MOC based on positive cytology, peritoneum and omentum metastases occurred in 10.3% of the patients. Therefore, we recommend that patients with early-stage infiltrative MOC undergo peritoneal staging and LNS. However, in addition to omitting LNS, we can also safely recommend omitting peritoneal staging in patients with clinical early stage expansile MOC. Summary Peritoneal metastases are rare in clinical early-stage expansile MOC and peritoneal staging can therefore safely be omitted.

Advances in immunotherapy for cervical cancer

Purpose of review Novel therapies are needed for the treatment of recurrent cervical cancer. The best chemotherapy regimen to date has a response rate of 48% with an overall survival of 17 months, with limited options for second-line chemotherapy. Immunotherapy can induce a strong immune response in cervical cancer due to retained viral antigens and is reviewed in this article. Recent findings Current clinical trials include treatment with Listeria that elicits an immune response against the E7 oncoprotein and active vaccines against the E7 oncoprotein. Although the response rates to programmed cell death 1 (PD-1) inhibition alone have been modest, the landmark survival reported in these trials suggests the activity of these agents may not be measured by RECIST criteria. The KEYNOTE-158 trial has led to the approval of pembrolizumab in recurrent programmed cell death ligand 1 (PD-L1) positive cervical cancer. Combinations of programmed cell death 1 and anticytotoxic T-lymphocyte-associated protein 4 inhibitors (CTLA4) inhibitors have shown promising and durable activity. There is active research with new combinations of checkpoint inhibitors, as well as combinations of these drugs with chemotherapy and radiation, and other novel approaches. Summary Immune therapy has broad activity in cervical cancer. Responses to immunotherapy can be dramatic and durable. Continued work to find the optimal combination and setting for immunotherapy is ongoing.

Impact of sentinel node use in lymphedema formation among gynecologic cancer patients

Purpose of review The most common surgical procedure associated with lymphedema formation is the regional lymphadenectomy. One of the advantages of sentinel node biopsy is the reduction of the risk of lymphedema formation. The purpose of this review is to collect and analyze the most relevant and recent evidence of the use of sentinel node biopsy and its implication on the development of postoperative lymphedema in gynecological cancer. Recent findings The current evidence of the use of sentinel node biopsy in cervical cancer to reduce lymphedema is heterogeneous and more data is needed to establish its role. Sentinel lymph node biopsy in endometrial cancer is a staging procedure with lower surgical complications, as well as lymphedema formation; while the results of prospective trials evaluating its impact on quality of life are still lacking. Sentinel lymph node biopsy in vulvar cancer minimizes the need for extensive dissection and reduces the incidence of complications associated with overharvesting of lymph nodes such as lymphedema without compromising oncological outcomes. Summary The prevalence of lymphedema in gynecological cancer varies based on the surgical treatment or additional therapies applied. Over the past years, one of the most important surgical modifications to decrease lymphedema formation has been implementation of sentinel lymph node technique mainly in vulvar cancer patients.

Neoadjuvant chemotherapy for patients with locally advanced vulvar cancer

Purpose of review Studies on treatment options for patients with locally advanced vulvar cancer (LAVC) are scarce, and high-level evidence for a primary treatment choice is lacking. Furthermore, current treatment options are associated with extensive morbidity and high complication rates. More effective treatment options are urgently needed. This review describes current treatment possibilities, focusing on literature regarding neoadjuvant chemotherapy (NACT) followed by surgery. Recent findings Although data are heterogeneous and limited, NACT followed by surgery might be an effective and well tolerated treatment alternative associated with lower morbidity compared with current treatment options, such as excenterative surgery or definitive chemoradiation. Summary Up until now, several studies describe an overall response rate of 40–86%. Surgery turned out to be possible in 40–90% of the LAVC patients who received NACT. Prospective studies on the efficacy and safety of NACT followed by surgery with a homogeneous chemotherapy regimen are urgently awaited. NACT should, at this point, still be considered investigational.

New boundaries for fertility sparing management in endometrial cancer

Purpose of review The increasing rates of endometrial cancer in premenopausal women that accompanies modern lifestyle options that enhance the prevalence of obesity as well as the trend of delayed childbearing are expected to increase the need for fertility sparing techniques. Currently, the cornerstone of fertility sparing treatment is hormonal handling with progestin treatment and is reserved for women with well differentiated endometrioid lesions that are limited in the myometrial layer. Recent findings Innovative approaches in the surgical treatment of patients with the use of operative hysteroscopy seem to offer decreased intervals to remission of lesions and longer progression free survival. Recent small case series also dictate that patients with endometrioid lesions of medium differentiation as well as those with superficial myometrial invasion may be adequately treated with the use of operative hysteroscopy. Moreover, the novel classification system may help better understand patients that will likely respond better to hormonal treatment. Summary In the near future, further data from clinical trials will be available that will help optimize patient selection as well select surgical and medical options that will help establish a personalized approach of fertility preservation in endometrial cancer patients.

Implementation of sentinel node biopsy in high-risk endometrial cancer

Purpose of review Endometrial cancer is the most common gynecologic malignancy and sentinel lymphnode biopsy is accepted as a valid alternative to lymphadenectomy for staging purposes. Recently, sentinel node biopsy has been also extended to high-risk disease where risk of nodal involvement is higher. Recent findings Our review focuses on the definition of high-risk disease and how there are different concepts of high-risk in the scientific community. While the sensitivity of sentinel node biopsy has been established and accepted in lower risk endometrial cancers, only in recent years retrospective and prospective evidence has been published. Ultrastaging allows to identify more nodal disease that would normally be overlooked by traditional staging, allowing proper adjuvant therapy to be administered. The longstanding question of whether lymphadenectomy in high-risk settings is a therapeutic or a staging procedure remains open. Retrospective data, however, show that oncologic outcomes are not compromised by sentinel node biopsy. Summary Sentinel node biopsy is a valid alternative to traditional, more extensive nodal staging: with the addition of ultrastaging, it has more sensitivity than lymphadenectomy with less surgical morbidity. Ongoing trials will definitively establish if oncological outcomes are affected by sentinel node biopsy, but retrospective data are encouraging.

Different tracers for sentinel node detection in gynecologic oncology

Purpose of review In the past decade, sentinel lymph node (SLN) mapping has progressively substituted full lymphadenectomies in gynecologic oncology. In this article, we review the most relevant and the latest literature on this topic Recent findings In endometrial and cervical cancer, the current evidence further support the value of indocyanine green (ICG) as tracer of choice for SLN mapping. Experience in vulvar cancer is more limited, with ICG used together with technetium-99 m (Tc-99m) as a dual tracer but ICG, so far, has not been a game changer in this setting as it has been for cervical and endometrial cancer. Summary For most gynecologic cancers, ICG fluorescence imaging is considered now a days the tracer of choice for lymphatic mapping. However, in early-stage vulvar cancer, SLN biopsy with radioactive tracer continues to be the standard-of-care in lymph node status assessment.

Application of single-port techniques in endometrial cancer

Purpose of review The increasing adoption of minimally invasive techniques has transformed the surgical management of endometrial cancer. Among these, single-port techniques, including laparoendoscopic single-site surgery (LESS), robotic single-port laparoscopy (RSPL), and vaginal natural orifice transluminal endoscopic surgery (vNOTES), have emerged as promising alternatives to conventional multiport laparoscopy. This review aims to evaluate recent evidence regarding the feasibility, perioperative outcomes, and oncologic safety of these techniques, with a focus on their role in endometrial cancer staging and management. Recent findings Current literature highlights the advantages of single-port techniques, such as reduced postoperative pain, shorter hospital stays, and improved cosmetic outcomes compared to multiport laparoscopy. LESS and RSPL offer enhanced visualization and improved ergonomics, addressing some of the technical challenges associated with single-site surgery. Meanwhile, vNOTES has demonstrated feasibility for hysterectomy and sentinel lymph node mapping, with studies reporting high detection rates and promising perioperative outcomes. However, concerns remain regarding long-term oncologic safety, standardization of SLN procedures, and technical feasibility in obese patients. While preliminary data are reassuring, particularly for RSPL and vNOTES, mature evidence on recurrence and survival outcomes remains limited. Summary Single-port techniques and vNOTES represent viable, minimally invasive alternatives in the surgical management of endometrial cancer. Their benefits in perioperative recovery and cosmetic outcomes are well documented, but their widespread adoption is limited by technical challenges, standardization issues, and a lack of long-term oncologic data. Large, multicentric, and randomized trials are necessary to further validate these approaches and establish their role in routine clinical practice.

Advantages of robotic surgery in obese patients with endometrial cancer

Purpose of review Endometrial cancer is the most common gynecological cancer among women in high-income countries and the prevalence is projected to increase worldwide because of the obesity epidemic. Surgery is a key step in the management of endometrial cancer. Performing surgery and delivering care to obese patients (BMI ≥ 30 kg/m2) and especially to morbidly obese patients (BMI ≥ 40 kg/m2) is challenging. This review focuses on the advantages of robotic surgery in obese patients with endometrial cancer. Recent findings The emergence of robotic surgery is associated with increasing rates of minimally invasive surgery for endometrial cancer. Robotic surgery offers several advantages over conventional laparoscopy, especially in obese patients with endometrial cancer which has led to decreasing rates of conversion to laparotomy. The approach allows surgical staging on obese and morbidly obese patients without increasing complication rates or the length of hospital stay, while improving ergonomics for the surgeon. Summary Robotic surgery should be the preferred approach for obese patients with endometrial cancer. Current data confirm its safety and benefits for this group of women, particularly for obese patients with a BMI ≥ 40 kg/m2.

Less is more in endometrial cancer (SLN, conservative treatment, radical hysterectomy, molecular classification)

Purpose of review The management of endometrial cancer has known many evolutions within the last decades. In this review, we aim to summarize recent evolutions (mainly toward less aggressive management) that have occurred in the management of endometrial cancer. Recent findings Enhanced by molecular classification, the determination of lymph node status, in young women, in case of cervical invasion, the treatment is evolving toward a less aggressive strategy. Summary The predictive value and the safety of sentinel lymph node biopsy explain why most societies propose to abandon systematic pelvic and para aortic lymphadenectomy. For young women, the safety of fertility preservation is now well established and efficient protocols have been validated. In stage II endometrial cancer (stromal cervical invasion), radical hysterectomy appears excessive. The Cancer Genome Atlas classification increases prognostic evaluation in association with the traditional pathological classification and permits to tailor adjuvant treatment more accurately.

Advances in management of nonendometrioid endometrial carcinoma, with an emphasis on the sentinel lymph node technique

Purpose of review During the last few years there have been important advances in our understanding of endometrial cancer biology, staging, and therapy. In this article, we discuss updates and controversies in the treatment of nonendometrioid endometrial carcinoma (non-EEC), with an emphasis on the role of sentinel lymph node (SLN) biopsy. Recent findings Lymph node involvement is an important factor in determining prognosis and guiding adjuvant therapy in endometrial carcinoma. SLN biopsy has emerged as a less morbid alternative to lymphadenectomy in surgical staging, and it has generally gained acceptance in the setting of low-grade endometrial carcinoma; however, its role in the setting of high-grade disease remains a topic of debate. Several prospective studies have demonstrated the accuracy of SLN biopsy in detecting nodal metastasis in high-grade endometrial carcinoma. Retrospective series have compared oncologic outcomes of patients with high-grade disease, surgically staged by SLN biopsy, to those staged with lymphadenectomy, and have reported similar survival outcomes. Prospective data on survival is lacking. Summary Currently, there is sufficient data to support the diagnostic accuracy of SLN biopsy in the surgical staging of non-EEC. The retrospective evidence demonstrates similar survival for SLN biopsy versus lymphadenectomy.

New imaging modalities to distinguish rare uterine mesenchymal cancers from benign uterine lesions

Purpose of review Uterine sarcomas are rare and are often challenging to differentiate on imaging from benign mimics, such as leiomyoma. As functional MRI techniques have improved and new adjuncts, such as machine learning and texture analysis, are now being investigated, it is helpful to be aware of the current literature on imaging features that may sometimes allow for preoperative distinction. Recent findings MRI, with both conventional and functional imaging, is the modality of choice for evaluating uterine mesenchymal tumors, especially in differentiating uterine leiomyosarcoma from leiomyoma through validated diagnostic algorithms. MRI is sometimes helpful in differentiating high-grade stromal sarcoma from low-grade stromal sarcoma or differentiating endometrial stromal sarcoma from endometrial carcinoma. However, imaging remains nonspecific for evaluating rarer neoplasms, such as uterine tumor resembling ovarian sex cord tumor or perivascular epithelioid cell tumor, primarily because of the small number and power of relevant studies. Summary Through advances in MRI techniques and novel investigational imaging adjuncts, such as machine learning and texture analysis, imaging differentiation of malignant from benign uterine mesenchymal tumors has improved and could help reduce morbidity relating to misdiagnosis or diagnostic delays.