European Journal of Obstetrics & Gynecology and Reproductive Biology

Assessing the role of minimally invasive radical hysterectomy for early-stage cervical cancer

Surgery is the mainstay of treatment in the management of early-stage cervical cancer. Until the publication of the Laparoscopic Approach to Cervical Cancer (LACC) trial, minimally invasive radical hysterectomy was the recommended approach to treat patients with early-stage disease. The results of the LACC trial questioned the adoption of minimally invasive surgery in cervical cancer. In comparison with the open approach, minimally invasive surgery correlated with worse disease-free and cancer-specific survival. Similarly, other retrospective studies highlighted this correlation, thus corroborating the results of the LACC trials. In the present review, we evaluated current evidence and further prospective of the adoption of minimally invasive radical hysterectomy in cervical cancer. Moreover, we sought to assess some unsolved issues regarding the role of minimally invasive surgery in early-stage cervical cancer patients.

European consensus statement on expert colposcopy

Following the publication of the European consensus statement on standards for essential colposcopy in 2020, the need for standards relating to more complex and challenging colposcopy practice was recognised. These standards relate to colposcopy undertaken in patients identified through cervical screening and tertiary referrals from colposcopists who undertake standard colposcopy only. This set of recommendations provides a review of the current literature and agreement on care for recognised complex cases. With good uptake of human papillomavirus (HPV) immunisation, we anticipate a marked reduction in cervical disease over the next decade. Still, the expert colposcopist will continue to be vital in managing complex cases, including previous cervical intraepithelial neoplasia (CIN)/complex screening histories and multi-zonal disease. To provide expert guidance on complex colposcopy cases through published evidence and expert consensus. Members of the EFC and ESGO formed a working group to identify topics considered to be the remit of the expert rather than the standard colposcopy service. These were presented at the EFC satellite meeting, Helsinki 2021, for broader discussion and finalisation of the topics. The agreed standards included colposcopy in pregnancy and post-menopause, investigation and management of glandular abnormalities, persistent high-risk HPV+ with normal/low-grade cytology, colposcopy management of type 3 transformation zones (TZ), high-grade cytology and normal colposcopy, colposcopy adjuncts, follow-up after treatment with CIN next to TZ margins and follow-up after treatment with CIN with persistent HPV+, and more. These standards are under review to create a final paper of consensus standards for dissemination to all EFC and ESGO members.

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

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

A systematic review and meta-analysis of the use of ultrasound to diagnose borderline ovarian tumours

Borderline ovarian tumours (BOTs) are difficult to diagnose preoperatively. The ability to distinguish between BOTs and other ovarian cancer types prior to surgery could have a profound impact on patient childbearing counselling and surgical planning. Ultrasound (US) pattern recognition by an expert examiner can be an excellent tool for the discrimination of benign and malignant ovarian masses. With respect to US features, most studies were based on well-known risk models. Nevertheless, very few studies have solely evaluated the utility of ultrasound in diagnosing BOTs. We aimed to evaluate the use of US in identifying BOTs solely from benign and malignant ovarian tumours in isolation from risk models. We performed a systematic literature review to identify publications that evaluated the use of US to differentiate between BOTs and malignant and/or benign ovarian tumours using Pubmed, Web of Science and the Cochrane Library. We performed a meta-analysis of the diagnostic sensitivity and specificity studies. We computed the summary estimates for sensitivity and specificity of US in diagnosing BOTs using the bivariate approach of Reitsma in the mada package in R. The initial search resulted in 24,737 publications. Hundred and seven publications were screened, and five studies contained diagnostic data. Different US criteria applied to identify BOTs. Four out of five studies including 244 women with BOTs and 965 women with benign or malignant tumours were suitable for the meta-analysis. Pooling of the results from four studies showed an overall sensitivity of 0.660 (95 % CI: 0.597 - 0.718) and specificity of 0.854 (95 % CI: 0.728 - 0.927). The overall US accuracy was uniform in sensitivity and variable in specificity. A low false positive rate, 0.146 (95 % CI: 0.073 - 0.272) was observed. US correctly identified BOTs in more than six out of 10 women for potential ovarian sparing surgery, whereas it correctly identified the absence of BOTs in more than eight out of 10 symptomatic women. More carefully designed studies are needed to evaluate the use of pre-operative US for the diagnosis of BOTs.

The impact of human papillomavirus (HPV) vaccination on the risk of adverse obstetric outcomes: a data linkage study

Human papillomavirus (HPV) vaccination has reduced rates of cervical cancer. Research suggests that women with HPV, precancerous disease, and prior invasive treatments are at increased risk of preterm birth. This study aimed to determine if there is a reduction in adverse obstetric outcomes for HPV vaccinated women. This was a cohort study including data linkage of routinely collected pregnancy data, HPV vaccine status, colposcopy, histology diagnosis and subsequent cervical treatment for all women in Aberdeen, United Kingdom. The exposure was HPV vaccination. The association between adverse obstetric outcomes and HPV vaccination status were analysed using a generalised estimation equations (GEE) model. Spontaneous preterm birth (sPTB), low birth weight (LBW) and pre-labour preterm rupture of membranes (PPROM) were the primary outcomes. 9200 women (11174 spontaneous births) who had a pregnancy recorded within the Aberdeen, Scotland between 2006 and 2020 were included. There was no difference in sPTB according to HPV vaccination status [adjusted Odds Ratio (aOR) 1.00 (95 %CI 0.82 to1.22) p = 0.27]. Preterm prelabour rupture of membranes (PPROM) [aOR 0.52 (95 %CI 0.30 to 0.89); p = 0.03] and prelabour rupture of membranes at term (PROM) [aOR 0.25 (95 %CI 0.17 to 0.36); p < 0.01], pre-eclampsia [aOR 0.38 (0.28,0.51); p < 0.01] and antepartum haemorrhage (APH) [aOR 0.71 (0.59,0.85); p < 0.01] were significantly reduced in HPV-vaccinated women. Spontaneous preterm birth rate was unchanged when comparing women who were and were not vaccinated against HPV in this population. Our data however does suggest that other obstetric outcomes including PPROM, PROM, pre-eclampsia and antepartum haemorrhage may be significantly reduced in women with HPV vaccination.

Meta-analysis of the diagnostic accuracy of HE4 for endometrial carcinoma

To analyze and evaluate the value of serum human epididymis protein 4 (HE4) for the diagnosis of endometrial cancer (EC). Studies involving HE4 and the diagnosis of EC were retrieved from the following medical literature databases: Medline, PubMed, Web of Science, China National Knowledge Infrastructure, China Biology Medicine Disc, Vip Journal Integration Platform, and Wanfang Data Knowledge Service Platform. Quality assessment was performed independently by two reviewers using Review Manager 5.3 (Cochrane Collaboration Group). A quality table of included studies was made using Review Manager 5.3, and the pooled sensitivity (SEN), specificity (SPE), positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic accuracy, and receiver operating characteristic curve (SROC) were analyzed using Review Manager 5.3 and Meta-Disc 1.4 software. Of 887 studies, 17 passed quality assessment and were included in the final study. The pooled SEN was 0.65 (95 % confidence interval [CI]: 0.63-0.67), SPE was 0.913 (95 % CI: 0.92-0.95), PLR was 10.06 (95 % CI: 4.75-21.35), NLR was 0.41 (95 % CI: 0.33-0.50), diagnostic odds ratio (DOR) was 26.7 (95 % CI: 11.7-60.93), and the area under curve (AUC) of the receiver operating characteristic curve (SROC) curve was 0.75 (95 % CI: 0.81-0.87). HE4 is a potential biomarker for the diagnosis of EC with a high specificity and relatively low sensitivity. Considering high heterogeneity and selection bias, the value of HE4 for diagnosing EC should be further evaluated in strictly-designed diagnostic studies as well as in different pathological types and stages of EC.

Impact of time to radiation therapy in adjuvant settings in endometrial carcinoma: A multicentric retrospective study

Time to adjuvant treatment could have an impact on cancer prognosis. It is possible that robotic surgery lengthens the healing time of vaginal cuff after minimally invasive hysterectomy. The objective of this study was to state the impact of time to RT (TTR) on prognosis in endometrial carcinoma (EC) patients and to assess variables associated with TTR. We conducted a multicentric retrospective study in two cancer centers. We included EC patients, between January 1996 and January 2016. We searched variables associated with TTR and impact of TTR on end-points: local recurrence-free survival, metastatic-free survival, event-free survival and overall survival. 329 patients were included and 279 were analyzed for TTR impact. Robotic surgery was associated with shorter TTR (8 weeks, 8.9 w for laparotomy, 9.2 w for laparoscopy). Pelvic lymphadenectomy, para-aortic lymphadenectomy, discussion in multidisciplinary meeting and treatment center was independently associated with TTR. No impact of TTR was shown on metastatic-free survival, event-free survival and overall survival but there was a trend of a decreased local recurrence rate in case of prolonged TTR (HR Our study did not show any impact of treatment delay on survival end-points although prolonged TTR could moderate the benefit of radiotherapy on local control rate. Surgical route was not associated with TTR, particularly robot-associated laparoscopy did not lengthen treatment delay. TTR seems dependent of health-care organization and could represent a quality criterion of EC care for institutions.

Severe uterine haemorrhagic complications from gestational trophoblastic neoplasia

Gestational trophoblastic neoplasia are highly vascularized infiltrating lesions that can lead to severe haemorrhagic complications. The aim of this study was to describe the characteristics of patients with gestational trophoblastic neoplasia who experienced uterine haemorrhagic complications, and their management. This retrospective study analysed the histories of 2099 patients with gestational trophoblastic neoplasia registered at the French Reference Centre for Trophoblastic Disease between 1999 and 2023. Among 2099 patients with a confirmed diagnosis of gestational trophoblastic neoplasia, 38 patients who experienced uterine haemorrhagic complications requiring interventional treatment were identified. Among them, 23 (61%) had a low-risk tumour and 15 (39%) had a high-risk tumour according to their International Federation of Gynecology and Obstetrics score. Twenty (53%) patients experienced haemoperitoneum and 18 (47%) patients experienced massive vaginal bleeding. Seventeen (45%) patients experienced uterine rupture. Haemorrhagic treatment consisted of surgery for 26 (70%) patients, exclusive uterine embolization for six (16%) patients, embolization followed by surgery for four (11%) patients, and embolization after failure to control bleeding by aspiration for one (3%) patient. Of the five deaths (13%), one (3%) was related to the uterine haemorrhagic complication. Three of 15 (20%) patients treated conservatively reported subsequent pregnancies. There are no established guidelines for managing severe uterine haemorrhagic complications. The availability of interventional radiology resources could allow for increased use of fertility-preserving procedures, with encouraging results regarding subsequent pregnancies.

The incidence of occult ovarian neoplasia and cancer in BRCA1/2 mutation carriers after the bilateral prophylactic salpingo-oophorectomy (PBSO): A single-center prospective study

Due to ineffective ovarian cancer (OC) screening programs, prophylactic bilateral salpingo-oophorectomy (PBSO) is suggested for BRCA1/2 genes mutation carriers. The reported incidence of clinically occult neoplasia and OC detected during PBSO varies widely (2-17 %), reflecting differences in studies design. We aimed to prospectively evaluate the incidence of occult neoplasia in specimens collected during PBSO performed in a single tertiary center and to determine the effectiveness of this procedure in BRCA1/2 mutation carriers. Between January 2010 and October 2016 a total of 564 new germline BRCA1/2 mutation positive women were identified and 71 carriers underwent laparoscopic PBSO. Patients were prospectively followed-up after the surgery and data on operation, age, complications, histological reports and BRCA1/2 gene mutation types were collected and analyzed. Serous tubal intraepithelial carcinoma (STIC) was diagnosed in 7 (9.85 %) and OC in 4 (5.6 %) women (one advanced (FIGO IIIC) and 3 early (FIGO IA/C) stages); total incidence 15.5 %. Women's mean age at the time of surgery was 46.5 years. The mean age of women diagnosed with STIC and OC was 45.9 years (42-64). The mean follow up time for women being diagnosed with OC/STIC was 3.72 years; no recurrence was observed. The median time to perform laparoscopic PBSO was 43 min. (ranging from 25 to 65 min.), no surgical complications occurred during this operation. Interestingly, we found statistically significant (P = 0.0105) enrichment of STIC lesions in BRCA1 c.4035delA (an established Baltic founder mutation) carriers group. The incidence of pathological findings in BRCA1/2 mutation carries after PBSO is sufficiently high and our prospective study data supports PBSO as the most effective measure for reducing the risk of OC in BRCA1/2 mutation carriers. A novel finding of the enrichment of STIC lesions in BRCA1 c.4035delA carriers may show important biological differences in OC tumorigenesis between different BRCA1 mutations, which warrant further investigations.

The impact of body mass index on surgical complications in minimally invasive hysterectomy for uterine fibroids

We aimed to assess the impact of Body Mass Index (BMI) on 30-day postoperative complications in patients undergoing minimally invasive hysterectomy (MIH) for fibroids. Using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2012-2020), we analyzed major and minor 30-day postoperative complications, stratified by BMI, in patients with uterine fibroids who underwent MIH. Complications were stratified according to the Clavien-Dindo classification. Among 61,192 patients, overall complication rates ranged from 6.3 % to 8.1 %, with the highest rates in obesity class 3. Significant differences were observed in minor complication rates across BMI groups, though major complication rates did not significantly vary. Higher BMI classes correlated with longer operative times, with mean durations ranging from 127.1 min in the lowest BMI group to 158.1 min in the highest BMI group (p < 0.001). In multivariable regression, higher BMI was associated with increased odds of minor complications [</≥34.5 kg/m After adjusting for confounding factors, overweight, obesity class 2 and 3 are associated with a decreased risk of major complications compared to normal BMI. In contrast, BMI categories were not associated with any- or minor complications. Higher BMI classes were associated with longer operative times.

Therapeutic impact of eras protocol implementation in cytoreductive surgery for ovarian cancer

Enhanced recovery after surgery (ERAS) protocols have been increasingly adopted over the past decade in gynecological oncology. This study aimed to evaluate the impact of ERAS adherence on survival outcomes following cytoreductive surgery for epithelial ovarian carcinoma (EOC). A retrospective cohort study was conducted across two centers between 2011 and 2023. Patients undergoing laparotomic cytoreduction for EOC, FIGO 2014 stages IC to IV, followed by adjuvant or maintenance therapy, were included. Participants were classified into two groups based on adherence to ERAS protocols or conventional hospitalization (CH). Seventy-two patients met criteria for the ERAS group and 79 for the CH group. ERAS adherence was associated with shorter operative times (mean 218.2 vs. 242.1 min, p < 0.049) and less complex surgeries. Length of hospital stay was significantly reduced in the ERAS group (mean 8.5 vs. 10.4 days, p < 0.001). Delayed postoperative complications were also lower (7.0 % vs. 24.9 %, p < 0.007). At 36 months, recurrence rates were comparable (32 in ERAS vs. 36 in CH, p = 0.44), as were 60-month mortality rates (10 vs. 22 deaths, p = 0.77). Median return to intended oncologic therapy (RIOT) tended to be shorter in the ERAS group (36 vs. 42 days, p = 0.26), reaching near significance in the subgroup with optimal surgery excluding early stages (35.5 vs. 42 days, p = 0.084). ERAS protocol implementation in EOC surgery enhances postoperative recovery and shows a promising trend toward reducing RIOT, highlighting its potential role in optimizing oncologic management.

A challenging case of non-puerperal uterine inversion masquerading as cervical mass in a young female

Uterine inversion, also know as, uterine intussusception is defined as telescoping of fundus of the uterus through the uterine cavity, and is graded into four grades based in the inferior bowing of the fundus with respect to the cervical and/or vaginal introitus. It is a rare entity, with two distinct group, with respect to the inciting cause, puerperal and non-puerperal. Non-puerperal is rarer of the two and has an array of presentation, ranging from acute emergent life-threatening condition to a chronic pelvic mass with menstrual irregularities. Such diversified presentation along with non-specific findings on ultrasonography, causes a diagnostic dilemma. Magnetic resonance imaging (MRI) is the best imaging modality, not just to clinch the diagnosis, but also to access the possible cause of the inversion. Typical MRI findings include loss of normal convex fundal contour on sagittal images and target sign on axial images. Management is mostly hysterectomy, with conservative management reserved for young females with desire of future child bearing and underlying benign cause. In our case report we present a case with MRI findings of grade II uterine inversion and a fundal submucosal fibroid, who presented with chronic pelvic pain and irregular menses. The patient was conservatively managed.

The risk of recurrence of high-grade squamous intraepithelial lesions and its association with the number of colposcopic biopsies

Colposcopy is an important exam for diagnosing intraepithelial lesions and cervical cancer, but it has limitations. The sensitivity for detecting high-grade squamous intraepithelial lesions (HSIL) increases with the number of punch biopsy fragments collected. However, there is no consensus on the ideal number of fragments to be sampled, and current recommendations only aim to improve diagnostic accuracy. This study aimed to evaluate the association between the number of fragments obtained in colposcopic punch biopsy and the recurrence of these lesions. A retrospective, observational, and cross-sectional study was conducted between January 2005 and July 2017, evaluating 127 cases of HSIL surgically treated by excision of the transformation zone. Patients whose punch biopsy sampled 1 or 2 fragments were compared with those whose punch biopsy sampled 3 or more fragments. Sociodemographic data, obstetric history, surgical findings and histopathological characteristics were also analyzed to determine the risk of HSIL recurrence. Punch biopsies with only 1 or 2 fragments were associated with earlier and more frequent recurrences, with a hazard ratio (HR) of 10.229 (95 % CI: 1.315 to 79.583; p = 0.003). A greater number of fragments sampled in colposcopic punch biopsy is associated with a lower risk of HSIL recurrence in the uterine cervix.

Safety and feasibility of same-day myomectomy discharge in a community healthcare system

Myomectomy, a surgical procedure to remove uterine fibroids, traditionally requires an overnight hospital stay for postoperative monitoring of potential complications. However, there is growing interest in exploring the safety and feasibility of same-day discharge following myomectomy to reduce healthcare costs and improve patient satisfaction. This is a retrospective case series of all patients who received a myomectomy from March 2018 to December 2023. We included both open and minimally invasive approaches and studied several outcomes to determine safety and feasibility. Our primary outcomes that were studied were related to common complications following a myomectomy: blood transfusion, readmission, and/or reoperation. We identified a total number of 298 cases, 187 of which had a LOS > 0 day, and 111 cases were same-day discharge after myomectomy. The data from this study support the safety and feasibility of same-day discharge following a myomectomy, particularly in patients undergoing minimally invasive approaches. It also highlights the significant cost differences between open and minimally invasive myomectomies on the healthcare system. Implementation of standardized discharge criteria and patient education protocols is essential for optimizing outcomes and ensuring patient safety.

Novel glycovariant biomarkers of CA125 and CA15-3 and their diagnostic performance across histotypes of ovarian cancer: A multi-cohort study in Sweden and Finland

To evaluate diagnostic accuracy of novel nanoparticle immunoassays across different histotypes of tubo-ovarian carcinoma (TOC) at diagnosis. This multicenter observational study consisted of consecutive patients (n = 1,312) having surgery due to suspected ovarian pathology. Serum were analyzed with Sialyl-Thomsen-nouveau (STn) antibody and Macrophage-Galactose-Lectin (MGL) for the detection of cancer antigen 125 (CA125) and 15-3 (CA15-3) glycoforms using CA125 enzyme immunoassay (EIA), CA15-3 TOC was present in 596 patients and 716 had benign disease. CA125 The STn glycovariants of CA125 and CA15-3 have improved sensitivity at high specificity for high grade serous and mucinous ovarian carcinoma and often perform better than the commonly used biomarker CA125

Management of women with abnormal cervical cytology: Update of French guidelines after the implementation of HPV screening

To update the French national cancer institute (INCa) guidelines for the management of women with abnormal cervical cytology. In 2016, INCa published guidelines for the management of women with abnormal cervical cytology. In 2019, however, the national authority for Health (HAS) recommended that the test for human papillomavirus be used to screen for cervical cancer in women over 30. It therefore became necessary to update the initial management and follow-up of women who had a positive test followed by abnormal reflex cytology findings. We used modified Delphi methods. The 3 members of the organizing committee revised each decision tree and then presented them to 35 experts over 2 rounds, to obtain their agreement about their validity and clarity. This formalized consensus of experts allowed the creation of 17 decision trees instead of 15 previously: 13 on the diagnosis management of abnormal cytology, stratified by age, and 4 by therapeutic indications in abnormal histology. The median agreement scores were 89 % (interquartile range 81 %-97 %). These 17 decision trees present different situations encountered by various health professionals and guide them, depending on their specialties, in providing initial or follow-up management or delegating care.

Beyond the transformation zone: Outcomes in the management of CGIN over five years

Cervical Glandular Intraepithelial Neoplasia (CGIN) is the term used to describe endocervical glandular lesions that predispose to cervical adenocarcinoma. Colposcopy is an important step in the investigation and management of suspected glandular disease. Excisional biopsy is necessary given the nature of the condition, which may reside in the endocervix with no visible lesions at colposcopy. Once diagnosed, a cylindrical excision is recommended, the depth of which is dependent on age and type of transformation zone. Our aim was to analyse the management and outcomes in this cohort of patients, over a five year period. A retrospective chart review was performed in a tertiary colposcopy department over a five-year period. In total 109 patients diagnosed with CGIN were included. The incidence of CGIN was 0.95 %. The mean patient age at diagnosis with CGIN was 35.5 years (SD = 8+/-7.1). Abnormal cervical smear results were the most common reason for initial referral, with atypical squamous cells of undermined significance (ASCUS) the most frequent smear abnormality (19.3 %/n = 22). On initial colposcopic assessment, high-grade CIN was suspected in 58.7 % (n = 64) cases. An initial LLETZ (Large Loop Excision of the Transformation Zone) was performed, with clear margins achieved in 56.9 % (n = 62). A repeat LLETZ was performed in 54 % (n = 58) of cases, with clear margins achieved in 88.1 % (n = 52). Hysterectomy was ultimately performed in 15.6 % (n = 17) cases. Although cytological glandular abnormalities are significantly less common than squamous lesions, adenocarcinomas now comprise up to 25 % of cervical cancer diagnoses, which is continuing to rise. Findings from this study reinforce the critical role of comprehensive diagnostic evaluation, adequate excisional management, and structured follow-up protocols in the care of patients with cervical glandular intraepithelial neoplasia (CGIN). Despite high rates of disease resolution following treatment, ongoing surveillance is essential, as a substantial proportion of patients ultimately require definitive management with hysterectomy.

Immunotherapy combined with targeted therapy in advanced small cell carcinoma of the ovary of hypercalcemic type: A case of overall survival lasting for over 5 years

Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) is a rare but highly aggressive ovarian malignant neoplasm lacking a unified clinical management process. Most patients are diagnosed at an advanced stage and have an extremely poor prognosis with an overall probability of survival less than 10 %. Here, we describe the case of a patient with advanced SCCOHT achieved a survival of over 5 years after receiving multiple cycles of immunotherapy combined with anti-angiogenic therapy or CDK4/6 inhibitors. At the same time, we also summarized the case reports and clinical trials of immunotherapy in SCCOHT.

Combined therapy for LSIL with HR-HPV: CO2 laser and interferon α2a

Low-grade squamous intraepithelial lesions (LSIL) and high-risk human papillomavirus (HR-HPV) infection are precursors to cervical cancer. Although interferon α2a is widely used for treating HR-HPV infections, the efficacy of its combination with carbon dioxide (CO This retrospective study included 230 patients diagnosed with LSIL and HR-HPV infection from October 2021 to August 2023. According to different treatment methods, patients were assigned to either the Monotherapy Group (n = 108, receiving interferon α2a alone) or the Combined Group (n = 122, receiving CO The Combined Group demonstrated significantly higher clinical efficacy compared to the Monotherapy Group (116 (95.08 %) vs. 94 (87.04 %), P < 0.05). HPV clearance rates were higher, and viral loads were lower in the Combined Group at 3 and 6 months (P < 0.05). Additionally, the recurrence rate was significantly lower in the Combined Group compared to the Monotherapy Group (1 (0.82 %) vs. 9 (8.33 %), P < 0.05). No significant differences were observed in adverse events between the two groups. CO

“Combined use of Radiofrequency ablation and hysteroscopy in the treatment of uterine Myomas: An innovative approach”

To evaluate transvaginal radiofrequency ablation (TRFA) as a preoperative strategy to facilitate hysteroscopic resection in patients with complex submucosal fibroids desiring uterine preservation. Prospective case series. Single tertiary hospital (Puerta de Hierro University Hospital, Madrid, Spain), January 2021-June 2023. Thirteen women with a single symptomatic fibroid containing a submucosal component, Lasmar-STEPW score ≥ 5, and no pregnancy desire for at least one year. TRFA was performed under general anaesthesia in an outpatient setting. Hysteroscopic myomectomy was scheduled from the sixth month onward. Outcomes included fibroid volume reduction, symptom improvement (Uterine Fibroid Symptom and Quality of Life questionnaire [UFS-QoL]), and hysteroscopic resection feasibility. Median age was 43 years. All TRFA procedures were completed successfully. At 6 months, median fibroid volume reduction was 76.8 %. UFS-QoL significantly improved (median from 32 to 14; p = 0.004). Complete hysteroscopic resection was achieved in 12 of 13 patients (92.3 %). One patient without fibroid regression required laparotomic myomectomy, with final diagnosis of adenomyoma. No serious complications or symptom recurrence were observed at follow-up. TRFA is a safe, effective outpatient technique that significantly reduces fibroid volume and facilitates complete hysteroscopic resection in women with complex submucosal fibroids. This combined approach may expand the role of conservative vaginal surgery in selected patients.

Prevalence rate of high-grade cytological lesions of the cervix in women aged under 25 years in French Guiana

The incidence of cervical cancer in French Guiana is among the highest worldwide. It ranks 5th among all cancers and is the 2nd most common cancer in women after breast cancer. The primary objective of this study was to establish the proportion of high-grade cytological lesions of the cervix in women under 25 years of age who underwent a cervico-uterine smear (CUS) in French Guiana over a 10-year period. This cross-sectional, retrospective, and descriptive study included all female patients under 25 years of age who underwent CUS between January 1, 2010, and December 31, 2019, in French Guiana, regardless of the reason for consultation. A total of 17,275 CUS were selected for analysis of the results and study of squamous abnormalities, of which 15,421 (89.3%) showed no abnormality, and 1,854 (10.7%) showed a squamous abnormality. Only 3.9% of patients presented with atypical squamous cell evocating high grade lesions and 4.4% with high-grade squamous intraepithelial lesions. The prevalence and severity of the abnormalities increased with age; no cases of cancers were detected. In view of the results and the benefit/risk balance, systematic generalized early screening for those aged 25 and over does not appear to be warranted. Instead, screening should be targeted based on clinical history.

External validation of the IOTA two-step strategy in the preoperative characterization of ovarian masses

Preoperative sonographic evaluation of ovarian masses is crucial for improving outcomes. The Risk of Malignancy Index (RMI) has been a standard for malignancy triage, while the International Ovarian Tumor Analysis Group (IOTA) has proposed a two-step strategy to estimate the risk of malignancy and suggest management steps by translating risks to Ovarian Adnexal Reporting Data System (O-RADS) categories. This study compares the accuracy of RMI and the IOTA two-step strategy in predicting malignancy. We included patients with preoperative ultrasound and pathological reports. RMI and O-RADS scores based on the IOTA two-step strategy were assessed. Performance was evaluated using receiver operating characteristic (ROC) curves and calibration plots. A total of 453 cases were included. Of these, 90 (19.9 %) were malignant, 21 (4.6 %) were borderline tumors (BOT), and 342 (75.5 %) were benign. The area under the ROC curve (AUC) for the IOTA two-step strategy was 0.958 (95 % CI, 0.938-0.978), compared to 0.904 (0.865-0.943) for RMI with a > 200 cut-off. The IOTA two-step strategy had a sensitivity of 96.4 %, specificity of 79.7 %, positive predictive value (PPV) 60.2 %, and negative predictive value (NPV) 98.6 %, while RMI showed sensitivity of 70.4 %, specificity 93.4 %, PPV 79.2 %, and NPV 89.8 %. For predicting BOTs, the IOTA two-step AUC was 0.902, compared to 0.719 for RMI. The IOTA two-step strategy outperforms RMI in the preoperative assessment of adnexal masses, particularly in detecting BOTs. It should be implemented in routine clinical practice.

Global trends and geographical disparities in the incidence of uterine cancer from 1990 to 2021

Social and economic factors play significant roles in the incidence of uterine cancer. This study examined how age, time period and birth cohort affect incidence patterns across various regions. Data on the incidence of uterine cancer from 1990 to 2021 were obtained from the Global Burden of Disease Study 2021. An age-period-cohort (APC) model was applied to evaluate the effects and geographical variations. In 2021, there were 473,614 [95 % uncertainty interval (UI) 429,916-513,667] cases of uterine cancer globally, resulting in an age-standardized incidence rate (ASIR) of 10.4/100,000 (95 % UI 9.4-11.2). ASIR was highest in High-income North America and Europe (high-income regions), and lowest in South Asia and most African regions. The incidence of uterine cancer has surged disproportionately over time, especially in high-income regions and areas with rapid socio-economic changes. High-income Asia Pacific saw the fastest growth, with an annual net drift of 2.43 % (95 % confidence interval 2.29-2.57). Age is a critical determinant of the incidence of uterine cancer, with notable regional variation. Globally, the peak incidence of uterine cancer occurs at 70-74 years of age, or older, in most regions. However, earlier peaks in incidence are observed in East Asia and Asia Pacific (both 55-59 years), as well as Central Asia (60-64 years). The incidence of uterine cancer is increasing globally, with marked geographical disparities in age distribution, temporal trends and cohort effects. While Europe and North America have the highest incidence rates globally, Asia faces a triple challenge: rising incidence, disproportionate caseloads, and younger age at diagnosis. Addressing geographical disparities is crucial in tackling the surge in cases of uterine cancer.

Evaluation of the clinical and cost-effectiveness of transcervical ultrasound-guided radiofrequency ablation of leiomyomas (ESONATA): a prospective comparative cohort study

Intrauterine ultrasound-guided radiofrequency ablation with the Sonata® System is a minimally invasive option for uterine fibroids. Currently, comparative studies and cost-effectiveness data are lacking. This three-arm study aims to evaluate the clinical and cost-effectiveness of the Sonata® system versus laparoscopic or laparotomic myomectomy and laparoscopic hysterectomy. A single-center prospective comparative cohort study of 96 participants was conducted with 18 months of follow-up. Participants were allocated, based on patient preference, to Sonata treatment, myomectomy, or hysterectomy. The primary outcome was return to work (RTW). Secondary outcomes included symptom severity score (SSS), health-related quality of life (HRQoL), reintervention or redo rate, complications, satisfaction, and recommendation. For the economic evaluation, HRQoL, resource use and costs were evaluated after 12 months. Median RTW after Sonata treatment was 3.0 days (IQR 1.2-4.8), compared to 47.0 days (IQR 42.3-51.7) for myomectomy and 45.0 days (IQR 36.5-53.5) for hysterectomy. At 12 months SSS decreased by 22.2, 24.9, and 47.2 points for Sonata, myomectomy, and hysterectomy respectively. Correspondingly, HRQoL increased significantly by 31.1, 25.2, and 48.7 points. Surgical reintervention rates at 18 months were 27.3% for Sonata and 6.3% for myomectomy. Surgical redo rate following Sonata treatment was 24.2%. No complications were reported after Sonata, 11 complications were related to myomectomy and 2 to hysterectomy. After 18 months, satisfaction rates were slightly higher in the myomectomy (96%) and hysterectomy (97%) groups, compared to the Sonata group (85%). At 18 months, 97% of participants would recommend Sonata and hysterectomy, while 96% would recommend myomectomy. The economic evaluation showed the highest HRQoL gain after hysterectomy but at the highest cost. Conversely, myomectomy was less favorable than Sonata, as it yielded less HRQoL gain at a higher cost. Sonata leads to faster RTW compared to myomectomy and hysterectomy. SSS and HRQoL significantly improve following all treatments. Sonata is a cost-effective option compared to myomectomy. Although Sonata yields less HRQoL gain than hysterectomy, it is a lower-cost, uterus-preserving option, making it particularly valuable for premenopausal women. Despite a higher reintervention and redo rate, Sonata achieves high levels of patient satisfaction and recommendation.

Comparison of 5-ALA-PDT and LEEP for cervical squamous intraepithelial neoplasia: A systematic review and meta-analysis

The objective of the study was to assess the function of 5-aminolevulinic acid photodynamic therapy (5-ALA-PDT) versus loop electrosurgical excision procedure (LEEP) in the treatment of cervical squamous intraepithelial neoplasia (CIN). Following the PICO guidelines, a comprehensive literature review was carried out according to data from PubMed, Embase, and other related databases. Notably, only the randomized controlled trials (RCT) and retrospective clinical trials were included in this study and then analyzed. And the primary results were composed of the pathological regression rate, residual lesion rate, and HPV clearance rate at 3-6 months. The detailed review and meta-analysis in this study were composed of 7 relevant studies. A total of 851 patients were assigned in this study: 316 for the ALA-PDT group and 535 for the LEEP group. In the comparison of ALA-PDT and LEEP for the treatment of CIN, it showed no significant difference within the pathological regression and residual lesion. However, the HPV clearance of the ALA-PDT group was superior to the LEEP group. Both of the two groups in this study showed substantial clinical effectiveness in the management of CIN. Additionally, ALA-PDT showed a superior HPV clearance rate within patients with CIN. However, the meta-analysis, which included only one RCT, requires cautious interpretation of the results, and more RCT are needed to confirm these findings.

High risk human papillomavirus prevalence and genotype distribution in Reunion Island

The primary objective of this study was to assess the prevalence and genotypes of human papilloma virus (HPV) in Reunion Island. In this retrospective study, data were collected from the database of microbiology and anatomopathology laboratories from August 1st 2020 to July 31st 2021. The overall prevalence of human papillomavirus (HPV) in Reunion Island was 14.5 %. The most common HPV genotypes in Reunion Island, were as follows: cluster of HPV 56 + 59 + 66, representing 3.3 % of all samples, cluster of HPV 35 + 39 + 68 (3.2 %), HPV 16 (2.9 %), HPV 33 + 58 (2.3 %) and HPV 52 (2.2 %). HPV types contained in the vaccine accounted for 59.3 % of HPV-positive samples and significantly resulted in more severe cytological lesions compared to HPV types that were not included in the vaccine (p < 0.01). Cervical dysplasia were identified in 57.3 % of HPV-positive cases. Multiple infections were detected in 23.2 % of the cases and were more frequent among younger women (<30 years) and in pathological smears (p < 0.001). In this study, we highlighted that HPV genotypes contained in the vaccine are the most represented in Réunion Island and are the most likely to generate significant cytological abnormalities. Therefore, continuous efforts are necessary to increase HPV vaccination coverage, which is currently in the island among the lowest in developed countries, despite the high mortality rate associated with cervical cancer. Furthermore, considering the inequal offensive capacity of each HPV, identifying patients' HPV infection subtype, could allow customized management and follow-up.

Can contrast-enhanced ultrasound differentiate cervical lesions?

Assessment of whether contrast-enhanced ultrasound (CEUS) can be used to differentiate diverse cervical lesions. A retrospective analysis of ultrasonographic reports was conducted for patients with different cervical lesions, including 18 cases of chronic cervicitis, 28 cases of cervical intraepithelial neoplasia grade I (CIN1), 46 cases of cervical intraepithelial neoplasia grade II (CIN2), 100 cases of cervical intraepithelial neoplasia grade III (CIN3), 7 cases of carcinoma in situ (CIS), and 26 cases of cervical cancer (CC). Timing began with the contrast agent injection via the elbow vein, recorded separately when the myometrium and cervix began to be enhanced. The intensity of enhancement of the cervix was observed and recorded as hyper-enhancement, iso-enhancement, or hypo-enhancement with respect to the myometrium. The rate of regression of the cervix enhancement was also analyzed and classified as fast, synchronous, or slow relative to the myometrium. Quantitative data were analyzed using either one-way ANOVA or the Kruskal-Wallis H test, while qualitative data were analyzed using Fisher's exact test. Significant differences were further analyzed using post-hoc tests, logistic regression models, and ROC curves. Menopausal status affected longitudinal, anteroposterior, and transverse diameters of the cervix, in addition to cervical volume. Moreover, the time when the myometrium and cervix began to image was also different between the menopause group and the pre-menopause group (P < 0.05), whereas there was no significant variance of pulsatility index (PI), resistance index (RI), enhancement intensity of the cervix, or rate of the cervix fading. The study population was grouped according to their menopausal status, and then we discovered that in the pre-menopausal group, the cervical anteroposterior diameter (APD) differed in the six cervical lesion groups (P = 0.006), especially in CIN1 & CIN2, CIN1 & CIN3, and CIN1 & CC (P = 0.014, 0.045, 0.021, respectively). The enhancement start time (EST) of the cervix differed among the cervical lesion groups (P = 0.02). In particular, there was a significant difference in CC & CIN2 and CC & CIN3 (P = 0.04, 0.03, respectively). The subjects of the study were divided into two groups: those with cervical cancer and those with precancerous lesions. The discrepancy of cervical EST was still significant along with the sensitivity of 0.62, the specificity of 0.76 using a cutoff of 14.895 s, and the accuracy was 0.74. The cervical EST can serve as an indicator of malignancy, and CEUS can be a complementary tool for cervical cancer screening. However, it should be noted that qualitative CEUS analysis alone was unable to differentiate among various precancerous lesions.

Secondary cytoreductive surgery for ovarian cancer recurrence and first-line maintenance therapy: A multicenter retrospective study

To investigate surgical and oncologic outcomes of secondary cytoreductive surgery for ovarian cancer recurrence, considering the exposure to previous first-line maintenance therapy. We retrospectively identified all women who underwent secondary cytoreductive surgery for ovarian cancer recurrence with cytoreductive intent at three Italian Gynecologic Oncology centers (1997-2022). Data on clinical, surgical, and pathological characteristics, neoadjuvant, adjuvant, and maintenance therapy, as well as follow-up information, were retrieved from prospectively collected databases and medical records. We identified 189 patients. Maintenance therapy in the first-line setting was implemented in 108/189 (57 %) cases: bevacizumab in 77.7 % (84/108), PARP inhibitors (Olaparib, Niraparib, or Rucaparib) in 15.7 % (17/108), and bevacizumab + PARP-inhibitors in 4.6 % (5/108). Complete cytoreduction rate and perioperative complications in secondary surgery were not associated with previous maintenance therapy. Complete cytoreduction was achieved in 75 % (140/189) of patients, and any residual tumor was the strongest predictor of poor progression-free (Hazard ratio [HR] 3.91, 95 %CI 2.48-6.16) and cause-specific survival (HR 4.27, 95 %CI 2.36-7.70). First-line bevacizumab was independently associated with worse progression-free survival among patients with any residual tumor at secondary surgery. First-line PARP inhibitors were independently associated with worse progression-free and cause-specific survival regardless of complete cytoreduction. Second-line maintenance therapies were independently associated with better survival regardless of residual tumor after secondary surgery. Complete cytoreduction during secondary surgery for ovarian cancer recurrence is the strongest predictor of prognosis. First-line maintenance therapies do not appear to affect the safety and feasibility of secondary cytoreduction, although they may influence prognosis after secondary surgery.

Clinical Efficacy of Percutaneous Microwave Ablation in Treating Uterine Fibroids: A Comprehensive Systematic Review and Meta-Analysis

The objective of this systematic review and meta-analysis was to assess the clinical efficacy of percutaneous microwave ablation (PMWA) therapy for treating uterine fibroids and to explore regional variations in its effectiveness. PubMed, Google Scholar, and CochraneLibrary were searched using keywords such as "leiomyoma," "fibroid," and "microwave ablation" to identify clinical trials and observational studies involving women with symptomatic uterine fibroids treated with PMWA therapy. Data on the outcomes of symptom severity, quality of life, fibroid volume, and hemoglobin concentration were extracted to calculate weighted mean differences (WMD) with 95% confidence intervals. Subgroup analyses based on study type and location were conducted. The quality and risk of bias of the included studies were evaluated using the National Institutes of Health quality assessment tools. Heterogeneity was assessed using Higgins I Out of 1,068 initial records, 14 studies comprising 754 patients with symptomatic uterine fibroids were included. There was a significant reduction in symptom severity (WMD = -33.3; 95 %CI: -41.16, -25.46; p < 0.001; I The analysis suggests that PMWA therapy is an efficacious treatment for uterine fibroids, with consistent outcomes in both Asian and European populations. However, high heterogeneity among the included studies limits the interpretation of results.

Cervical cancer in young women: Does age impact survival in cervical cancer?

To evaluate the oncology outcomes in cervical cancer patients aged 25 years or younger and compare them with those in older patients. Cervical cancer patients were retrospectively analyzed and divided into two groups: young patients (≤25 years) and older patients (>25 years). For each young patient, two controls were selected from the database of cervical cancer patients aged over 25 years, matched by FIGO stage, treatment, and histologic type. A total of 138 patients were included, 46 patients aged 25 years or younger and 92 patients aged over 25 years. Of young patients, stage III was the most common, with 21 (45.5 %) patients, while stages I, II and IV occurred in 12 (26.2 %), 8 (17.4 %) and 5 (10.9 %) patients, respectively. The 5-year RFS (75 % and 73 %; P = 0.91) and 5-year OS (60 % and 67 %; P = 0.45) were not significantly different between the groups. After multivariate analysis age had no significant impact on OS (HR 1.25, 95 % CI 0.68-2.30; P = 0.46) or RFS (HR 0.95, 95 % CI 0.43-2.10; P = 0.91). Cervical cancer patients aged 25 years or younger did not present a worse OS and RFS compared to patients aged over 25 years.

Risk of cervical stenosis after cervical excision in postmenopausal patients

Cervical excision may cause cervical stenosis, leading to suboptimal follow-up of dysplasia and delayed diagnosis of cervical and endometrial pathology. This study aimed to quantify the risk of stenosis development after electrosurgical cervical excision in postmenopausal patients. Retrospective cohort study based on data collection from electronic medical records and the Danish National Pathology Data Bank. Patients aged ≥45 years who underwent electrosurgical cervical excision in the Gynecological Department, at Randers Regional Hospital from1 Of the 567 cervical excisions conducted within the study period, 300 patients (52.9 %) met the inclusion criteria. Among these, 79 postmenopausal patients (26.3 %) developed cervical stenosis after cervical excision. Patients with stenosis were significantly older (median 64 years) compared to those without stenosis (median 61 years) (p = 0.004). Patients aged >60 years at the time of cervical excision exhibited an increased risk of cervical stenosis (relative risk 1.51 (95 % confidence interval 1.08-2.18)) compared to those ≤60 years. More than one in four postmenopausal patients experienced the development of cervical stenosis following cervical excision. Patients should be adequately informed of the possible risk of cervical stenosis development prior to undergoing diagnostic or therapeutic cervical excision procedure.

Diagnostic accuracy of available methylation assays in advanced cervical intraepithelial neoplasia from high-risk HPV-positive women: A systematic review and network meta-analysis

Over the past decade, methylation has developed rapidly for the detection of multiple diseases, and several methylation assays have been studied and even applied in clinical practice. This study undertook diagnostic test accuracy (DTA) and network meta-analysis (NMA) to investigate the value of extensively validated methylation assays for use in clinical practice or research for triage of advanced cervical intraepithelial neoplasia (CIN) among high-risk human papillomavirus (HPV)-positive women. PubMed, Web of Science, the Cochrane Library and Scopus were searched for eligible studies. DTA and NMA were conducted using R Version 4.2.0 with a random-effects model. Twenty-eight studies with 16,256 patients were included. The DTA results showed that the pooled sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of all methylation assays for CIN grade 3+ (CIN3+) were 0.708 [95 % confidence interval (CI) 0.676-0.738], 0.780 (95 % CI 0.736-0.819), 0.436 (95 % CI 0.348-0.528) and 0.920 (95 % CI 0.885-0.945), respectively. The diagnostic odds ratio of CIN3+ was 8.828 (95 % CI 7.109-10.962), which was higher compared with that for CIN2+ (6.115, 95 % CI 4.604-8.123). NMA revealed that most methylation assays included in this study performed similarly to cytology. Among the available methylation assays, S5 classifier has a balanced performance in sensitivity and specificity overall. In conclusion, methylation assays are an effective and accurate triage strategy for advanced CIN among high-risk HPV-positive women. S5 classifier seems to be promising due to its triage performance. Cervi-M and GynTect are suitable for application in developing countries due to their superior specificity and PPV. However, more studies are needed to confirm these conclusions.

The relationship between HPV-Associated LSIL and HSIL lesions and overactive bladder in postmenopausal women

This study aims to investigate the relationship between HPV-associated LSIL and HSIL lesions and overactive bladder (OAB) symptoms in postmenopausal women, highlighting the role of severe histopathological lesions. A retrospective analysis was conducted on postmenopausal women aged 40-65 years who presented at Istanbul Bakırköy Sadi Konuk Training and Research Hospital between January 2021 and March 2023. The study included HPV-positive patients with low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL), as well as HPV-negative controls. OAB symptoms were assessed using the UDI-6, IIQ-7, and OAB-V8 questionnaires. Statistical comparisons were made between HPV-positive and HPV-negative groups, as well as between LSIL and HSIL subgroups. No significant differences were observed in UDI-6, IIQ-7, and OAB-V8 scores between HPV-positive and HPV-negative patients. However, HSIL patients exhibited significantly higher scores on these questionnaires compared to LSIL patients (p < 0.01), indicating a greater severity of OAB symptoms. Additionally, there was a significant positive correlation between questionnaire scores and variables such as age, gravida, parity, and menopause duration. HSIL in HPV-positive women is associated with increased severity of OAB symptoms, suggesting a role for HPV-induced inflammation in OAB pathogenesis.

Comparative analysis of Paiteling a traditional Chinese medicine (TCM) and CO2 laser therapy for high-risk HPV-associated with LSIL (CIN1) lesions

This study aims to evaluate the therapeutic outcomes of Paiteling and CO2 laser therapy on high-risk human papillomavirus. We retrospectively analyzed the data of 558 patients with HR-HPV low-grade squamous intraepithelial neoplasia (CIN1) from 2021 to 2023. Patients were selected and put into two groups: Paiteling and CO2 laser. Out of the 558 patients who were included in our final study, 239 (42.8 %) were treated with Paiteling, and 319 (57.2 %) were treated with CO2 laser vaporization. The mean age was 49.55 ± 12.10 years old. We observed that 27 (4.83 %) were younger than 30 years and 531 (95.1 %) were older than 30 years. We reviewed the patient's results at intervals of 3 months, 6 months, 12 months, and 24 months after each therapy. The results of the recurrence rate, effective viral clearance rate, and the effectiveness of both therapies on low-grade cervical lesions were determined using multivariate and univariate cox-regression analysis. The Kaplan-Meier curve was used to determine the HR-HPV conversion rate of each therapy. The median time for HR-HPV clearance was 6.00 months (95 % CI: 4.26-6.89) in the Paiteling group and 9.00 months (95 % CI: 15.92-22.67) in the CO2 laser group. There was a significant difference between the two groups (χ2 = 25.118, p-Value = 0.000). The HR-HPV clearance rate during 6-12 months for Paiteling and CO2 laser was 100 (55.6 %) and 80 (44.4 %), respectively. The clearance rate for both therapies from 6 to 18 months was statistically significant (6-12 months: p < 0.010, 12-18 months: p < 0.011). The Paiteling HR-HPV negative rate over 24 months 214 (89.5 %) is higher than CO2 laser 176 (55.2 %). Paiteling has a 5.4 % re-infection rate, which is marginally lower than the 5.6 % rate for CO2 lasers. The clearance rate for both therapies from 12 to 18 months [Paiteling: 20 (4.7 %) to 10 (3.6 %) and CO2 laser: 22 (8.4 %) to 15 (4.2 %)] was also significant (p < 0.011). The percentage of persistent Hr-HPV clearance rate for Paiteling patients was higher than carbon dioxide laser vaporization. No severe side effects were reported by the Paiteling patients compared to laser vaporization. This is due to the fact that Paiteling, as a traditional Chinese medicine, is a topical, non-invasive medicine, thus preserving the integrity of the cervix. Paiteling is an effective noninvasive therapy that can clear persistent HR-HPV associated with cervical low-grade squamous lesions in a relatively shorter period of time compared to CO2 laser ablation.

Smooth muscle tumors of uncertain malignant potential or atypical leiomyomas: A long-term evaluation of surgical outcomes and clinicopathological features

The Primary Objective of this study was to analyse reproductive outcomes in patients with STUMP (Smooth Muscle Tumour of Uncertain Potential) or ALM (Atypical Leiomyoma) who underwent fertility-preserving surgeries. Secondary Objectives were to analyse long-term prognosis for these patients and to study the basic demographic and pathological characteristics of patients with STUMP or ALM. This retrospective study was conducted at Amrita Institute of Medical Sciences. Cases of STUMP and ALM were retrieved from the hospital medical database between June 2014 and December 2022. Demographic parameters, clinical presentations, pathological features and clinical outcomes were analysed. Categorical variables were expressed in numbers and percentages. Normal distribution data were presented as mean while non-normal distribution was expressed as median and range. Thirty-eight patients were included in the study with a diagnosis of STUMP or ALM in postoperative histology. Seven patients (18.4%) were nulliparous. Myomectomy was performed in 9 (23.6%), while hysterectomy was done in 29 patients (76.3%). Fertility-preserving surgeries were performed on six patients (15.7%). Of these six patients, 4(66.6%) conceived spontaneously and had successful pregnancies. Recurrences were found in 3 patients (7.8%) out of which one had undergone fertility-sparing surgery. All the patients with recurrences had previous history of myomectomies. Morcellation was reportedly done in 2 of these three patients. Good reproductive outcomes have been demonstrated in patients diagnosed with STUMP or ALM and desiring fertility. However, these patients should be kept under follow-up care as they are prone for recurrences. Patients who have undergone morcellation mayhave an increased chance of recurrence.

Thinking in context: Fibroids-to-uterine volume ratio in pre-surgical fertility evaluation for intramural fibroids

To explore the utility of the total fibroids-to-uterine volume (FTUV) ratio as a simple, preoperative tool to assist in counseling patients seeking pregnancy who are undergoing myomectomy for intramural (IM) fibroids. This is an historical cohort study on reproductive-aged patients seeking pregnancy who underwent laparotomic myomectomy for intramural fibroids from January 2017 to December 2021. Only G3 to G5 fibroids, according to the 2011 International Federation of Gynecology and Obstetrics (FIGO) classification, were included. Pre-operative transvaginal ultrasound (TVUS) was performed to measure the volume of intramural myomas (diameter A total of 166 women with pre-surgical TVUS evaluation of IM fibroids were included, with a mean age of 36.22 ± 5.15 years. The FTUV ratio was identified as a positive predictor of clinical pregnancy after surgery (adjOR, 1.04; 95 % CI, 1.02-1.06; p = 0.0001), whereas age showed a negative association (adjOR, 0.90; 95 % CI, 0.83-0.98; p = 0.012). Endometrial cavity distortion prior to surgery was also positively associated with pregnancy post-surgery (adjOR, 3.50; 95 % CI, 1.51-8.08; p = 0.003). Consistent results were found for live births, with the FTUV ratio being a significant positive predictor of live birth after surgery (adjOR, 1.03; 95 % CI, 1.01-1.05; p = 0.001) and age showing a negative association (adjOR, 0.88; 95 % CI, 0.80-0.96; p = 0.004). Parity prior to surgery also positively impacted live birth post-surgery (adjOR, 2.65; 95 % CI, 1.30-5.40; p = 0.007). An FTUV ratio threshold of 53.39 % accurately predicted clinical pregnancy in 68.46 % of cases (sensitivity of 71.70 % and specificity of 66.67 %). For live births, a higher FTUV ratio threshold of 59.21 % predicted outcomes accurately in 69.13 % of cases (sensitivity of 65.85 % and specificity of 70.37 %). The use of the FTUV ratio in pre-operative ultrasound evaluation of IM fibroids may improve counseling for patients desiring to conceive after myomectomy. By providing a personalized assessment of the amount of myometrial volume occupied by fibroids, the FTUV ratio can help predict fertility outcomes after surgery, enabling better-informed decisions and treatment planning.

Letter to editor regarding the article “Brachytherapy and surgery versus surgery alone for IB2 (FIGO 2018) cervical cancers: A FRANCOGYN study”

Laparoscopic myomectomy for a large uterine fibroid: A video case report

Treatment characteristics, HPV genotype distribution and risk of subsequent disease among women with high-grade cervical intraepithelial neoplasia in Europe: A systematic literature review

High-grade cervical intraepithelial neoplasia (CIN), a premalignant lesion of the uterine cervix, is caused by persistent Human Papillomavirus (HPV) infection. CIN can be identified through screening programs and high-grade CIN is usually treated by ablation or excision. This study aimed to summarize the clinical management and outcomes among women with high-grade CIN in Europe. A systematic literature review was conducted to identify treatment methods and their frequency of use, report HPV genotype prevalence and distribution and summarize patterns for subsequent lesions after primary treatment, among women with high-grade CIN in Europe. Embase®, MEDLINE® and Cochrane databases were searched (1st January 2012 to 30th August 2022), along with relevant conference proceedings (2018-2022), inclusive. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) compliant methodology was adopted. Eligibility criteria included non-immunosuppressed female patients with CIN2+ from Europe (published in English). In total, n = 55 studies were included. CIN excisional therapy was the most received treatment approach (15.8-100 %, loop electrosurgical excision procedure/large loop excision of the transformation zone most common), followed by ablative therapies (1-43.3 %, cold coagulation most common). Other approaches included 'wait and watch' (4.8-52.6 %) and hysterectomy (4.8-16.2 %). HPV positivity rates ranged from 67.8-100 % pre-conization and 4.7-32.8 % post-conization. The most prevalent HPV genotypes reported (both pre- and post-treatment) were HPV16 and HPV18. In patients who received excisional or ablative procedures subsequent CIN was most frequently diagnosed ≤6 months after treatment. The overall rate of subsequent CIN reported was 0.5-20.9 %. Conization and ablation were the most common techniques, however, these procedures were associated with sub-optimal outcomes. Close clinical follow-up is important due to the risk of subsequent CIN or invasive cancer. This review serves as a reference point for the comparison of future treatment patterns as they evolve across Europe, following improved implementation of prophylactic HPV vaccination and screening.

Advancing women’s health: The imperative for public health screening of uterine fibroids for personalized care

Uterine fibroids represent the most prevalent genital tract tumours among women, with a disproportionately higher impact on ethnic minority groups, notably black women. These hormonally dependent monoclonal tumours, characterized by excessive extracellular matrix and influenced by genetic, epigenetic, and lifestyle factors, significantly affect women's quality of life and pose substantial economic burdens on healthcare systems. Recent advances in early detection and minimally invasive treatment options have shifted management paradigms towards personalized care, yet challenges in early diagnosis, education and access to treatment persist. This review synthesizes current knowledge on uterine fibroids, highlighting the impact of fibroids on women's health, risk factors, principles of screening, diagnostic tools, and treatment modalities. It emphasizes the importance of early screening and individualized management strategies in improving patient outcomes and reducing healthcare costs. The article also discusses the socio-economic and health disparities affecting the disease burden, underscoring the need for improved patient education, clinician training, and public health strategies to enhance fibroid management. This review proposes a pathway to not only ameliorate the quality of life for women with fibroids, but also to advance global women's health equity.

Meta-analysis of the efficacy of neoadjuvant chemotherapy for locally advanced cervical cancer

Neither improvements in surgical techniques and methods nor advances in radiotherapy equipment and techniques have significantly improved cervical cancer survival rates for quite some time. By comparing the effectiveness of neoadjuvant chemotherapy in the treatment of locally advanced cervical cancer, this study aimed to explore effective treatment methods for locally advanced cervical cancer, and provide a theoretical basis to guide clinical practice. A search of PubMed, Embase, Scopus, Web of Science and Cochrane databases was undertaken to identify randomized controlled trials on the efficacy of neoadjuvant chemotherapy for locally advanced cervical cancer, where the intervention in the experimental group was neoadjuvant chemotherapy. Based on the inclusion and exclusion criteria, the studies were evaluated for quality according to the Cochrane Quality Rating Scale. Baseline information, intervention information and outcome indicators of the included studies were extracted. Meta-analysis was performed using RevMan 5.4. Significant differences in overall survival [relative risk (RR) 1.63, 95 % confidence interval (CI) 0.69-2.57; p = 0.0007] and complete remission rate (RR 0.37, 95 % CI -0.49 to 1.23; p = 0.041) were found between the two groups. Heterogeneity of the objective response rate showed p < 0.0001 and I The use of neoadjuvant chemotherapy for the treatment of locally advanced cervical cancer improved the objective response rate and the complete remission rate of patients, but failed to improve overall survival and adverse effects.

A case of cervical rhabdomyosarcoma in a 17-year-old woman and literature review

Ovarian steroid cell tumour, not otherwise specified: A case report

The deadlock on HPV vaccination in Japan is almost broken!

Quality of life in long-term cervical cancer survivors compared with healthy women and women with benign gynecological disorders

The impact of cervical cancer treatment on the quality of life of long-term survivors compared with the general female population is controversial, and no studies have been conducted comparing patients with benign gynecological diseases. The aim of this study was to compare the quality of life of cervical cancer survivors with that of healthy controls. A case-control study was conducted to compare the quality of life of 106 cervical cancer survivors from a tertiary hospital and 185 women admitted to a gynecological outpatient clinic from the same health area for a healthy woman check-up (n 46) or for a benign gynecological disorder (symptomatic, n 113; asymptomatic, n 26). To measure quality of life, self-administered questionnaires, such as the Functional Assessment Cancer Therapy-cervix and World Health Organization quality of life-brief version, were employed. Baseline scores were collected when patients first reported, and further evaluations were completed at 0-6, 7-12, 13-24, 25-60, and more than 60 months. For the contrastive analysis hypothesis, we employed R statistical software. Except for the environment domain at 0-6, 7-12, and 13-24 months (51.52 vs. 60.73, p < 0.0001; 52 vs. 60.73, p < 0.0001; 49.81 vs. 60.73, p < 0.0001, respectively), we found no statistically significant differences in the quality of life between cervical cancer survivors and controls. We did find differences in the physical health domain scores at 0-6 months (60.22 vs. 72.42, p = 0.039) and the social relationships domain scores at 13-24 months (54 vs. 71.42, p = 0.017) between cases and asymptomatic controls. Except for physical well-being, environment and social relationships, which were substantially better for controls, especially in the asymptomatic, long-term cervical cancer survivorśquality of life did not vary from that of controls.

Urinary symptoms and sexual function after hysterectomy secondary to cervical cancer: A prospective, cohort study

The estimated worldwide incidence of cervical cancer (CC) is half a million cases per year. Surgical treatment is the mainstay approach for this condition. To assess the effects of hysterectomy due to cervical cancer in urinary symptoms and sexual function and the disorder related impact on the quality of patients life. A cohort study was performed in Fortaleza/CE (Brazil) with 71 patients; of these, 31 were diagnosed with cervical cancer (G-CCU) and 40 with gynecological benign disease (G-PB). Sexual function (FSFI questionnaire), quality of life (SF-36 questionnaire) and urinary symptoms (KHQ instrument) were investigated in both groups at baseline (T0), one month (T1) and four months after surgery (T2). Both groups presented at baseline, similar urinary symptoms (p > 0.05), but this frequency doubled for the G-CCU group at T1 and remained unchanged at T2 (p = 0.012). G-PB's frequency of symptoms remained the same for 4 months after surgery. At baseline G-PB had higher risk for sexual dysfunction than G-CCU (82.5 % versus 54.8 %, p = 0.011). However for G-CCU, an increase of this percentage was perceived at T2.Women from the G-CCU group presented worse general and specific quality of life results. Women underwent to hysterectomy due to cervical cancer presented higher percentages of urinary symptoms, higher risk for sexual dysfunction and worse general and specific quality of life scores.

Current uptake and barriers to wider use of the International Ovarian Tumor Analysis (IOTA) models in Dutch gynaecological practice

Correct referral of women with an ovarian tumor to an oncology department remains challenging. The International Ovarian Tumor Analysis (IOTA) consortium has developed models with higher diagnostic accuracy than the alternative Risk of Malignancy Index (RMI). This study explores the uptake of the IOTA models in Dutch hospitals and factors that impede or promote implementation. Optimal implementation is crucial to improve pre-operative classification of ovarian tumors, which may lead to better patient referral to the appropriate level of care. In February 2021, an electronic questionnaire consisting of 37 questions was sent to all 72 hospitals in the Netherlands. One pre-selected gynaecologist per hospital was asked to respond on behalf of the department. The study had a response rate of 93% (67/72 hospitals). All respondents (100%) were familiar with the IOTA models with 94% using them in practice. The logistic regression 2 (LR2)-model, Simple ultrasound-based rules (SR) and Assessment of Different NEoplasias in the adneXa (ADNEX) model were used in respectively 40%, 67% and 73% of these hospitals. Respondents rated the models overall with an 8.2 (SD 1.8), 8.3 (SD 1.6) and 8.9 (SD 1.3) respectively for LR2, SR and ADNEX on a scale from 1 to 10. Moreover, 89% indicated to have confidence in the results of the IOTA models. The most important factors to improve further implementation are more training (43%), research on sensitivity, specificity and cost-effectiveness in the Dutch health care system (27%), easier usability (24%) and more consultation time (19%). The IOTA ultrasound models are adopted in the majority of Dutch hospitals with the ADNEX model being used the most. While Dutch gynecologists have a strong familiarity and confidence in the models, the uptake varies in reality. Areas that warrant improvement in the Dutch context are more uniformity, education and more research. These findings can be helpful for other countries considering adopting the IOTA models.

Topical delivery of drugs in the treatment of high-grade cervical squamous intraepithelial lesions: A meta-analysis

The present study aims to evaluate the efficacy and effect of localized delivery of drugs in the treatment of high-grade squamous intraepithelial lesion (HSIL) based on a meta-analysis. Databases including Cochrane Library, PubMed, Embase, Scopus, CNKI, and Wanfang were searched from their inception till August 2022. Randomized controlled trials (RCTs) that compared the efficacy of drugs and surgery in the treatment of HSIL were collected. A meta-analysis was performed using the software of Review Manager (version 5.4.1). Eight RCTs involving 523 patients were included in the meta-analysis. For HSIL, the rate of cervical lesions histological regression was 69.85 % in the surgery group and 59.88 % in the drug group, there was no significant difference between the two groups [OR = 0.45, 95 % CI (0.07, 3.03), P = 0.41]. The histological regression rate of cervical lesions in the placebo group was 37.76 %, and the difference between the drug group and the placebo group was statistically significant [OR = 4.94, 95 % CI (2.65, 9.20), P < 0.00001]. A total of four drugs were involved in the eight RCTS included in this study, which were imiquimod, 5-fluorouracil (5-FU), cidofovir and interferon. The results showed that although drug administration was effective in the histological regression of HSIL, the efficacy was less than about 10% of surgical treatment. Considering the recurrence of the disease after surgery and the problems of abortion, premature delivery and premature rupture of membranes after cervical conization in reproductive women, drug therapy can be used as a supplement to surgery or conservative treatment to promote the histological regression of cervical lesions in patients with HSIL.

Self-sampling for HPV testing in cervical cancer screening: A scoping review

Cervical cancer is the third most common gynecological cancer worldwide. Its origin is linked to intraepithelial lesions caused by high-risk Human Papillomavirus (HPV) types, detected in 99.7% of cases. Early screening is essential to prevent cancer development from these lesions. Molecular methods are more specific and offer the possibility of being performed through a self-collected sample by the patient, thus contributing to increasing screening coverage for this pathology. This study aim was to map the medical-scientific literature on existing protocols for self-sampling for HPV testing in cervical cancer screening. A search strategy was developed using the following keywords and their synonyms: "self-sampling," "professional sampling," and "HPV", on the databases: MEDLINE, Cochrane Library, Virtual Health Library - BVS, Scopus, National Institute for Health Research NHS EED, Web of Science, and EMBASE. The search strategy was formulated to identify relevant studies and describe their main characteristics, such as patient acceptance of self-sampling, cost differences between the tests used, and the accuracy of self-sampling compared to the gold standard test. A total of 876 studies were found, and 33 of those studies were included in this review. Out of these, 10 studies were domized clinical trials involving 46,751 patients, and 23 observational studies included 142,795 patients. Regarding acceptance, most studies reported a preference for self-sampling. Sensitivity analyses from various studies also showed that the low cost of self-sampling kits generally increased cost-effectiveness. The study concluded that using HPV testing on self-collected samples is a viable strategy for monitoring women with HPV.

Therapeutic management of uterine tumours resembling ovarian sex cord tumours including a focus on fertility: A systematic review

Uterine tumours resembling ovarian sex cord tumours (UTROSCTs) are extremely rare. To date, most patients with UTROSCTs have undergone hysterectomy and had a benign clinical course. Fertility-preserving surgery should be considered because some patients with UTROSCTs are aged < 40 years. This paper reviews the treatment and prognosis for patients with UTROSCTs, with a focus on fertility. PubMed, MEDLINE and Scopus were searched systematically for case reports and case series of UTROSCTs published in English from inception to December 2022, and initial treatment and recurrence rates were compared. The following data were extracted: age; symptoms; initial therapy; metastasis at diagnosis; disease-free survival (DFS); and recurrence. In total, 147 patients (72 studies) reporting the clinical course of UTROSCTs were analysed. The median age at diagnosis was 50 years, and 28 (19.0 %) patients were aged < 40 years. Most patients (n = 125, 85.0 %) underwent hysterectomy as the initial surgery, with a recurrence rate of 17.6 % (n = 22). The recurrence rate was 30 % (n = 6) in patients who underwent mass resection (n = 20). Among the 15 patients who underwent mass resection aged < 40 years, seven went on to achieve pregnancy (46.7 %) and six had successful deliveries (40.0 %). No significant differences in 5- and 10-year DFS were found between the hysterectomy and mass resection groups (p = 0.123 and 0.0612, respectively). Bilateral salpingo-oophorectomy in addition to hysterectomy was not significantly associated with 10-year DFS (p = 0.548). While total hysterectomy is the recommended treatment for UTROSCTs based on recurrence rates, mass resection is an acceptable treatment option for patients who wish to retain their childbearing potential. It is recommended that these women should plan for pregnancy and delivery as soon as possible after mass resection, and should undergo hysterectomy within 5 years.

O-RADS MRI scoring system has the potential to reduce the frequency of avoidable adnexal surgery

To assess the potential impact of the O-RADS MRI score on the decision-making process for the management of adnexal masses. EURAD database (prospective, European observational, multicenter study) was queried to identify asymptomatic women without history of infertility included between March 1st and March 31st 2018, with available surgical pathology or clinical findings at 2-year clinical follow-up. Blinded to final diagnosis, we stratified patients into five categories according to the O-RADS MRI score (absent i.e. non adnexal, benign, probably benign, indeterminate, probably malignant). Prospective management was compared to theoretical management according to the score established as following: those with presumed benign masses (scored O-RADS MRI 2 or 3) (follow-up recommended) and those with presumed malignant masses (scored O-RADS MRI 4 or 5) (surgery recommended). The accuracy of the score for assessing the origin of the mass was of 97.2 % (564/580, CI The use of O-RADS MRI scoring system could drastically reduce the number of asymptomatic patients undergoing avoidable surgery.

Asparaginase-like protein 1 as a prognostic tissue biomarker in clinicopathologically and molecularly characterized endometrial cancer

Prognostic stratification of endometrial cancer involves the assessment of stage, uterine risk factors, and molecular classification. This process can be further refined through annotation of prognostic biomarkers, notably L1 cell adhesion molecule (L1CAM) and hormonal receptors. Loss of asparaginase-like protein 1 (ASRGL1) has been shown to correlate with poor outcome in endometrial cancer. Our objective was to assess prognostication of endometrial cancer by ASRGL1 in conjunction with other available methodologies. This was a retrospective study of patients who underwent primary treatment at a single tertiary center. Tumors were molecularly classified by the Proactive Molecular Risk Classifier for Endometrial Cancer. Expression of ASRGL1, L1CAM, estrogen receptor, and progesterone receptor was determined by immunohistochemistry. ASRGL1 expression intensity was scored into four classes. In a cohort of 775 patients, monitored for a median time of 81 months, ASRGL1 expression intensity was related to improved disease-specific survival in a dose-dependent manner (P < 0.001). Low expression levels were associated with stage II-IV disease and presence of uterine factors, i.e. high grade, lymphovascular space invasion, and deep myometrial invasion (P < 0.001 for all). Among the molecular subgroups, low expression was most prevalent in p53 abnormal carcinomas (P < 0.001). Low ASRGL1 was associated with positive L1CAM expression and negative estrogen and progesterone receptor expression (P < 0.001 for all). After adjustment for stage and uterine factors, strong ASRGL1 staining intensity was associated with a lower risk for cancer-related deaths (hazard ratio 0.56, 95 % confidence interval 0.32-0.97; P = 0.038). ASRGL1 was not associated with the outcome when adjusted for stage, molecular subgroups, L1CAM, and hormonal receptors. When analyzed separately within the different molecular subgroups, ASRGL1 showed an association with disease-specific survival specifically in "no specific molecular profile" subtype carcinomas (P < 0.001). However, this association became nonsignificant upon controlling for confounders. Low ASRGL1 expression intensity correlates with poor survival in endometrial cancer. ASRGL1 contributes to more accurate prognostication when controlled for stage and uterine factors. However, when adjusted for stage and other biomarkers, including molecular subgroups, ASRGL1 does not improve prognostic stratification.

Human papillomavirus-mediated expression of complement regulatory proteins in human cervical cancer cells

This study aimed to evaluate the expression pattern of complement regulatory proteins (CRPs) CD46, CD59, and CD55 in HPV-positive (HPV We analysed the expression of CRPs in HPV 16-positive SiHa cell line, HPV 18-positive HeLa cell line, and HPV-negative cell line C33a using RT-qPCR, Western blotting, flow cytometry, and confocal microscopy. We observed a differential expression profile of CRPs in HPV The study demonstrates the differential expression of CRPs in both HPV

Atypical epithelioid trophoblastic lesion presenting as pseudocyst from the niche in the cesarean scar: A case report and review of the literature

In 2020, the WHO introduced Atypical Placental Site Nodule (APSN) into the new classification of female genital tract tumors, describing it as an intermediate lesion between placental site nodule (PSN) and epithelioid trophoblastic tumor (ETT). Unlike APSN which is typically a nodule, we present a case of a post Cesarean Section (CS) cyst and fistula formation with intermediate pathologic features between PSN and ETT. This type of lesion has earlier been described as "atypical epithelioid trophoblastic lesion". We aim to review similar cases in the literature to gather data on clinic, sonographic and histopathological characteristics. We conducted a search on PubMed and Web of Science databases. Given the novelty of the term atypical epithelioid trophoblastic lesion and its lack of validation, we broadened our search to the term 'APSN' including similar cases with unique clinicopathologic features, specifically those involving cyst and fistula formation after CS. Two reviewers independently screened articles and extracted relevant data. We describe a case of atypical epithelioid trophoblastic lesion presenting as a cystic lesion anterior to a cesarean scar niche. We found eight similar cases in literature. All presented with a cyst and/or fistula that occurred several months, or even years, after CS. Symptoms were vaginal bleeding (2), abdominal pain (2), hematuria (1), amenorrhea (3) and urinary frequency (1). Ki-67 proliferation indices exceeded 12 % in 4/8 (50 %) cases. Necrosis or mitotic figures were not observed in 7/8 (87.5 %) cases. No case displayed signs of recurrence during follow-up (range: 1-12 months). There are only eight cases in literature that display similar sonographic and histopathological features to the case of atypical epithelioid trophoblastic lesion we presented. Further molecular studies focusing on the gene signature of the lesion and gathered data from gestational trophoblastic disease registries could contribute to a better understanding of the origin and behavior of this specific intermediate lesion.

Delineating the clinico-oncological landscape: Pure Uterine Serous Cancer (P-USC) versus p53 Abnormal Grade 3-Endometrioid-Endometrial Carcinoma (p53 Abn G3-EEC)

This study compared the oncological outcomes of Pure Uterine Serous Carcinomas (p-USC) and p53-Abnormal Grade 3 Endometroid Endometrial Tumours (p53 Abn G3-EEC). A retrospective study was conducted at Amrita Institute of Medical Sciences from February 1, 2015, to December 31, 2020, analysing patients diagnosed with P-USC and p53 Abn G3-EEC. The primary objective was to compare the 5-year Progression-Free Survival (PFS) between two groups. Secondary objectives included comparing Overall Survival (OS), clinicopathological characteristics, the influence of Hormonal-Receptor (HR including ER/PR) positivity on patient survival, and determining the cut-off value of ER-positivity for our population. Kaplan-Meier survival curves and Cox regression analysis were used to evaluate outcomes. Clinicopathological characteristics were compared using t-tests and chi-square tests. Out of 116 patients, 32.7 % were categorised in the p53 Abn G3-EEC group, while 67.2 % were in the P-USC group. The median age of the patients was 58.5 years. The overall stage distribution was as follows: stage I (39.6 %), stage II (6 %), stage III (27.5 %), and stage IV (23.2 %). In the P-USC group, the majority of patients presented with stages III/IV (63.8 %), whereas most patients in the p53 Abn G3-EEC group (75.7 %) presented with stages I/II disease, indicating a significant difference in distribution (p = 0.02). After a median follow-up period of 37 months, the 5-year PFS rates were 56.6 % for the P-USC group and 81.4 % for the p53 Abn G3-EEC group (p = 0.01), which remained significant upon multivariate analysis (p = 0.04). The 5-year OS rates were 59.2 % for the P-USC group and 75.5 % for the p53 Abno G3-EEC group (p = 0.22). P-USC exhibited a significantly lower 5-year PFS rate than p53 Abn G3-EEC, but there was no significant difference in OS between the two subtypes.

Evaluating the clinical impact of the 2023 FIGO staging for endometrial cancer: Complexities and considerations

200 years of diagnosis and treatment of cervical precancer

The history of the diagnosis and treatment of cervical precancer is fragmentary. Findings in the English-speaking and German-speaking areas vary considerably. We aim to describe the history of clinical advances in diagnosis and treatment of cervical precancer and identify areas where further work is required. We conducted a search of PubMed and Google Scholar. Full article texts were reviewed. Reference lists were screened for additional articles and books. 9 basic articles in German and 13 basic articles in books were identified. The first images of the ectocervix were published by H. Lebert (1812-1879) in the middle of the nineteenth century. R. Meyer's (1864-1947) theory of erosions, which dominated cervical pathology in the nineteenth century, was later refuted in studies by C. A. Ruge (1846-1926) and J. Veit (1852-1917). In 1908 W. Schauenstein (1870-1943) recognized the step-by-step development of cervical cancer. H. Hinselmann (1884-1959) replaced the purely histopathological approach previously with the use of colposcopy. All conization methods applied today can be traced back to amputation of the ectocervix as first indicated by J. Marion Sims (1813-1883) in 1861. In 1928 M. N. Hyams was the first to describe an excision method that employed electrodiathermy. The method of cold knife conization is based on a publication by J.W. Scott from 1957. The final breakthrough to effective electrodiathermy was achieved with the publications of W. Prendiville. This paper is a step toward a better understanding of what we think and do today based on past findings of colposcopists and gynecopathologists.

A rare malignant transformation of endometriosis

Soluble heat-shock protein 27 in blood serum is a non-invasive prognostic biomarker for ovarian cancer

Ovarian cancer (OC) is the leading cause of death in gynecological oncology, primarily caused by limited prognostic and therapeutic options. The heat shock protein 27 (HSP27) is recognized as a prominent factor in OC, playing a pivotal role in cancer progression machinery such as treatment resistance. Thus, HSP27 may represent an appropriate biomarker for OC diagnosis, prognosis, and therapy response. Extracellular HSP27 levels were measured by enzyme-linked immunosorbent assay (ELISA) in serum samples of OC patients (n = 242) and compared to a non-malignant control group without any history of cancer (n = 200). Correlations between serum levels of HSP27 and clinical pathological parameters were analyzed by bivariate analysis. Survival analyses were carried out by Kaplan-Meier test. This study demonstrated that protein levels of HSP27 are comparable in the blood serum of healthy women and OC patients. However, HSP27 levels are significantly correlated with the volume of ascites, residual tumor mass, and age at first diagnosis in OC patients. Notably, elevated levels of HSP27 demonstrate significantly higher overall survival. Taken together, our findings demonstrate that high levels of circulating HSP27 in serum are associated with improved overall survival of OC patients. Even though functionality of secreted HSP27 is still unclear, serum levels of HSP27 represent a putative non-invasive prognostic biomarker candidate for OC progression.

Diagnostic value of Anti-Mullerian hormone in ovarian granulosa cell tumor: A meta-analysis

Granulosa cell tumor (GCT) is a rare type of ovarian malignancy with poor prognosis of recurrence. Anti-Mullerian hormone (AMH) is a promising serum biomarker for early diagnosis GCT, therefore we assessed its accuracy and clinical value. A meta-analysis was performed to estimate the diagnostic accuracy. We searched the PubMed, Cochrane Literature Library and EMBASE database. After filtering, five studies met our criteria. Two independent reviewers extracted data and total 421 serum samples (70 GCT serum samples and 351 controls) were included in our analysis. The pooled values of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and Summary receiver operating characteristic (SROC) were calculated to assess the accuracy. The pooled estimated for AMH were sensitivity: 0.89 (95 % CI 0.78-0.95), specificity: 0.93 (95 %CI 0.83-0.97). The area under the SROC was 0.93 (95 %CI 0.91-0.95). Serum AMH can be used as a biomarker in clinical diagnosis of GCT with high accuracy.

The diagnostic use of magnetic resonance imaging for acute abdominal and pelvic pain in pregnancy

Acute abdomino-pelvic pain in pregnancy represents a diagnostic challenge. In many cases, radiological and laparoscopic diagnostic modalities are hazardous or contraindicated. Magnetic Resonance Imaging (MRI) is not commonly used for this indication and the results are not widely published. A single-center retrospective observational study. 34 cases of pregnant women with abdomino-pelvic pain who underwent MRI as an additional modality when clinical, laboratory and ultrasound (USS) findings were indeterminate. Case notes were reviewed where pregnant women underwent a MRI investigation for abdominal-pelvic pain. Primary Obstetric indications for an MRI eg placenta accreta were excluded. The differential diagnosis after; 1) history and physical examination and 2) with the addition of USS and 3) with the further addition of an MRI were all individually compared to the eventual diagnosis. The diagnoses reached by MRI corresponded with the final diagnosis in 22 out of 23 cases. In the remaining 11 cases MRI accurately ruled out presence of pathology. MRI was inaccurate in 1 case. The additional use of MRI was more accurate than clinical assessment and USS combined. The accurate exclusion of pathology in 11 cases is particularly significant. MRI should be considered in cases of abdomino-pelvic pain in pregnant women.

Brachytherapy and surgery versus surgery alone for IB2 (FIGO 2018) cervical cancers: A FRANCOGYN study

Evaluation of the management by first brachytherapy followed by radical hysterectomy (Wertheim type) compared to radical hysterectomy alone (Wertheim type) for the treatment of IB2 cervical cancer. Data from women with histologically proven FIGO stage IB2 cervical cancer treated between April 1996 and December 2016 were retrospectively abstracted from twelve French institutions with prospectively maintained databases. Of the 211 patients with FIGO stage IB2 cervical cancer without lymph node involvement included, 136 had surgical treatment only and 75 had pelvic lymph node staging and brachytherapy followed by surgery. The surgery-only group had significantly more adjuvant treatment (29 vs. 3; p = 0.0002). A complete response was identified in 61 patients (81%) in the brachytherapy group. Postoperative complications were comparable (63,2% vs. 72%, p = 0,19) and consisted mainly of urinary (36vs. 27) and digestive (31 vs 22) complications and lymphoceles (4 vs. 1). Brachytherapy had no benefit in terms of progression-free survival (p = 0.14) or overall survival (p = 0.59). However, for tumors of between 20 and 30 mm, preoperative brachytherapy improved recurrence-free survival (p = 0.0095) but not overall survival (p = 0.41). This difference was not observed for larger tumors in terms of either recurrence-free survival (p = 0.55) or overall survival (p = 0.95). Our study found that preoperative brachytherapy had no benefit for stage IB2 cervical cancers in terms of recurrence-free survival or overall survival. For tumor sizes between 2 and 3 cm, brachytherapy improves progression-free survival mainly by reducing pelvic recurrences without improving overall survival.

Predictive tool for the risk of hypothermia during laparoscopic gynecologic tumor resection

Based on the machine learning algorithm, construct a hypothermia prediction model for gynecological tumor resection under laparoscopic general anesthesia. This research conducted a retrospective analysis, gathering data from individuals who had undergone minimally invasive surgical procedures for gynecological tumors in a Chinese Hospital, ranging from June 2018 to August 2024. During this timeframe, a total of 308 cases were examined for analysis, with 70% of the cases allocated to the modeling dataset and the remaining 30% designated for the validation dataset. The factors associated with intraoperative hypothermia were identified within the modeling dataset. Subsequently, three predictive models were established: a Classification and Regression Trees model, a Random Forest model, and a Support Vector Machine model. The incidence of intraoperative hypothermia in 308 cases was 30.84%. The results showed that age, body mass index, preoperative body temperature, preoperative albumin, operating room temperature and peritoneal lavage fluid volume were the influencing factors of intraoperative hypothermia. Using these variables, it was determined that the Random Forest model had demonstrated strong predictive performance. The prediction model developed using the random forest algorithm exhibits excellent predictive capabilities, which are highly significant for pinpointing the critical factors contributing to intraoperative hypothermia in patients undergoing laparoscopic procedures.

Clinical evaluation of a real-time optoelectronic device in cervical cancer screening

Early screening and intervention are crucial for the prevention and treatment of cervical cancer. TruScreen is a real-time, intelligent, pathological diagnostic technology designed for cervical cancer screening. The aim of this study was to evaluate the clinical value of TruScreen in screening for cervical lesions. A total of 458 women aged between 25 and 65 years were recruited to receive cervical cancer screening, including human papillomavirus (HPV) testing, cytological testing using the ThinPrep cytology test (TCT), and TruScreen from December 2018 to January 2020. The clinical performance of TruScreen, alone and in combination with HPV testing, was evaluated to detect cervical intraepithelial neoplasia grade 2 or worse (CIN2+ or CIN3+). For detection of CIN2+, the sensitivity and specificity of TruScreen were 83.78% and 78.86%, respectively. The specificity of TruScreen was significantly higher than those of HPV testing (50.59%, P < 0.001) and TCT (55.58%, P < 0.001). In high-risk HPV-positive women, the specificity of HPV testing combined with TruScreen was significantly higher than that of HPV testing combined with TCT (50% vs 39.9%, P = 0.004). The sensitivity of HPV testing combined with TruScreen was comparable to that of HPV testing combined with TCT (93.94% vs 87.88%, P = 0.625). Similar patterns were also observed for CIN3+ cases. TruScreen has the potential for screening high-grade cervical precancerous lesions and may replace cytological tests as a cervical cancer screening method in China to avoid subjectivity in the interpretation of cytological tests and requirements by pathologists.

Serous endometrial intraepithelial carcinoma (SEIC): Current clinical practice in The Netherlands

Serous endometrial intraepithelial carcinoma (SEIC) is a rare diagnosis, defined as an intraepithelial lesion with cells identical to serous type endometrial carcinoma. SEIC is considered to be potentially metastatic, however clear and robust data on prognosis are lacking, potentially leading to variability in clinical management. The aim is to establish the opinion of gynecologists on the optimal management of patients with SEIC. An online questionnaire with 15 multiple choice questions was sent to all gynecologists with expertise in gynecological oncology in 19 expert centers in The Netherlands. A total of 24 gynecologists participated. The majority of respondents (n = 18/24, 75%) do not consult a guideline regarding the treatment of SEIC. In current practice, 14 of the 24 respondents perform surgical staging in women with SEIC (58.3%) while seven choose hysterectomy with bilateral salpingo-oophorectomy (29.2%), and three (12.5%) have no firm preference. Eleven of the 14 respondents who perform a surgical staging procedure believe that this is certainly the optimal treatment. The majority of respondents have no firm opinion on whether lymph node sampling or lymph node dissection is preferable during surgical staging (n = 15/23, 65.2%). Most respondents do not give adjuvant therapy (n = 15/24, 62.5%), 25.0% recommend brachytherapy (n = 6/24). Follow-up is for 5 years in almost all cases (n = 23/24). There is no consensus on the optimal surgical treatment and the use of adjuvant therapy for patients with SEIC. Our research team is therefore conducting a nationwide cohort study in which treatment modality, morbidity and survival will be evaluated.

The results of different fertility-sparing treatment modalities and obstetric outcomes in patients with early endometrial cancer and atypical endometrial hyperplasia: Case series of 30 patients and systematic review

Increasing incidence of endometrial cancer and late motherhood enhance conservative management in clinical practice. Although different approaches to fertility-sparing treatment are possible, it is still unknown which patients will benefit more from systemic or local treatment. Aim of this paper is to analyze the effectiveness of different methods of conservative management and obstetric outcomes in patients with early endometrial cancer and atypical endometrial hyperplasia. 30 patients (10 with atypical endometrial hyperplasia, 20 with endometrial cancer) treated conservatively were included to retrospective analysis. 24 patients receiving progestins were divided into 2 groups according to the dose (low and high dose); 6 patients were treated with levonorgestrel releasing intrauterine device. Effectiveness of therapy (complete, partial or absent) and obstetric outcomes (number of pregnancies and live births) were assessed. Electronic databases (MEDLINE, Web of Science, Embase) were searched for articles according to criteria: 1) fertility-sparing treatment of endometrial cancer/atypical endometrial hyperplasia in patients of reproductive age, 2) assessment of pregnancy/obstetric results. The risk of bias was assessed with the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Series. Complete and partial remission were achieved in 21 and 3 patients, respectively. 6 patients did not respond to treatment. Relapse was diagnosed in 6 patients. Probability of complete remission according to low-, high-dose regimen and levonorgestrel-releasing intrauterine device were 55.6% (46.5%-64.7%), 73.3% (65.2%-81.4%) and 83.3% (76.5%-90.1%) respectively. 4 patients get pregnant and 3 of them born children. 25 studies (21 retrospective, 4 prospective) with 812 participants were included in the systematic review. The most studied was progestin based treatment. Complete and partial response to fertility-sparing management was diagnosed in 634 and 38 patients, respectively. Relapse was diagnosed in 170 patients. Median times of follow-up range from 17 (1-45) to 98 (35-176) months. The total number of pregnancies and live births were 352 and 246, respectively. Fertility-sparing treatment is a safe method of management in young women with endometrial cancer/atypical endometrial hyperplasia. While the main goal of conservative management is preserving the possibility of having children, only a small number of women will become pregnant and give birth.

Preoperative prediction of high-risk endometrial cancer by expert and non-expert transvaginal ultrasonography, magnetic resonance imaging, and endometrial histology

To identify women with high-risk endometrial cancers using expert and non-expert transvaginal ultrasonography (TVS) and MRI. Myometrial involvement was prospectively evaluated in patients with atypical hyperplasia or endometrial cancer on ultrasound by non-experts at first visit (non-expert-TVS: n = 266) and experts (expert-TVS: n = 188) at second visit. MRI (n = 175) was performed when high-risk cancer was suspected on non-expert-TVS. Preoperatively, high-risk cancer was defined as myometrial involvement ≥50 %, or preoperative unfavorable tumor histology (grade 3 endometrioid, non-endometrioid tumors, or tumor in cervical biopsies) obtained by endometrial sampling or hysteroscopic biopsies. Preoperative evaluations were compared with final histopathology obtained at surgery, high-risk cancer being defined as unfavorable tumor histology or patients with FIGO stage ≥1b. Preoperative unfavorable tumor histology was seen in 64 women and correctly identified 63 of 128 high-risk cancers. Preoperative diagnosis of unfavorable tumor histology or myometrial involvement ≥50 %, i.e. judged high-risk, had an area under the curve (AUC), sensitivity, and specificity of 79.5 %, 93.8 %, 65.2 % on non-expert-TVS; 85.5 %, 84.4 %, 86.5 % on expert-TVS, and 85.4 %, 89.6 %, 81.2 % on MRI. AUC values were not significantly different between MRI and expert-TVS, but lower on non-expert-TVS (p < 0.02). However, sensitivity was highest on non-expert-TVS, where a low cutpoint for myometrial involvement was used (included potentially deep and difficult evaluations) in contrast to an exact cutpoint of myometrial involvement ≥50 % used on expert-TVS and MRI. The highest AUC, 88.6 %, was seen when MRI was performed in patients with myometrial involvement ≥50 %, determined on non-expert TVS. Sensitivity was reduced to 85.9 %, while specificity increased to 91.3 %. Thus, MRI was needed for risk classification in only 104 (39 %) patients. Diagnostically, expert-TVS and MRI were comparable and superior to non-expert-TVS. However, non-expert-TVS classified all patients with unclear myometrial involvement ≥50 %, and thereby only misdiagnosed 6.2 % of high-risk cases. Non-expert-TVS combined with MRI when myometrial involvement was ≥50 % on non-expert-TVS was a simple and effective method comparable with expert imaging to identify low- and high-risk cancer and select patients for SLND. Addition of MRI to the diagnostic regimen was needed in only 39 % of our patients.

Vaginal metastasis in gestational trophoblastic neoplasia: Experience from Sheffield trophoblastic disease Centre and recommendations for management

Gestational trophoblastic neoplasia (GTN) is rare in the UK, with an estimated incidence of one in 50,000 live births. Cases of vaginal metastasis are even rarer, with only eight case series reporting 187 cases over the past 40 years. Management recommendations in the literature are scarce despite the potential risk of massive, potentially life-threatening vaginal haemorrhage. This retrospective cohort study with interval analysis was performed at Sheffield Trophoblastic Disease Centre. It included all patients diagnosed with GTN with documented evidence of vaginal metastases between 1 January 1974 and 31 December 2023. Twenty-five patients with GTN and vaginal metastases were identified during the study period, accounting for < 1 % of all GTN registrations during this period. All patients had chemotherapy representative of chemotherapeutic regimens employed at the time of diagnosis. Vaginal metastases were treated to resolution by chemotherapy alone in 76 % of cases. In addition to chemotherapy, 12 % of patients were managed with vaginal packing, 4 % underwent localized excision, 4 % underwent internal iliac embolization, and 12 % received targeted radiotherapy. Forty-four percent of patients had repeated blood transfusions due to persistent haemorrhage associated with the vaginal metastasis. One patient died from disease, 80 % achieved complete remission (cured), and 16 % (recently diagnosed) are in remission. The presence of vaginal metastases in patients with GTN has little prognostic significance, and their presence should not alter management plans. Tailored treatment should be determined by patient factors, with chemotherapeutic regimens based upon World Health Organization prognostic scores.A conservative management approach should be considered, as most cases will resolve with chemotherapy alone.

Advances in fertility preserving surgery for borderline ovarian tumors

Borderline ovarian tumor is a tumor with pathomorphological characteristics, biological behavior and prognosis between benign and malignant tumors. Preoperative diagnosis of ovarian cancer is usually based on imaging and tumor markers. Because of the early diagnosis and good prognosis of borderline ovarian tumors, fertility preserving surgery can be selected for patients with borderline ovarian tumors who have not completed fertility. Compared with radical surgery, fertility preserving surgery has a higher recurrence rate, but most of them are not malignant, which will not affect the overall survival rate, and the postoperative fertility rate is also very good. Patients with borderline ovarian tumors, especially those with BOT stage II or above, should get pregnant as soon as possible and be followed up closely for a long time.

Obstetric outcomes after conservative management of ovarian borderline tumors in women of reproductive age: A single center experience

The main goal of fertility-sparing treatment is pregnancy followed by live birth (i.e., successful pregnancy). The principal objective of our study was to evaluate the successful pregnancy rate in patients with borderline ovarian tumors (BOTs) after conservative treatment. The second goal was to evaluate the safety of the conservative approach. 110 patients with BOT were retrospectively evaluated. All patients underwent surgical treatment, sparing the uterus and part of at least one ovary. The median age was 28 years (range 17-40 years). Serous and mucinous tumors were found in 63 (57%) and 34 (31%) women, respectively. FIGO stage I, II, and III was diagnosed in 101 (91.8%), 3 (2.7%), and 6 (5.5%) patients, respectively. The 3- and 5-year progression-free survival was 82.5% and 78.2%, respectively. Recurrent disease was treated conservatively in 14 women, whereas 3 patients underwent radical surgery. Fifty-six (50.9%) patients got pregnant and had at least one live birth. A total of 83 children were born. A significant difference in the successful pregnancy rate was found in patients diagnosed ≤ 35 years vs. > 35 years old (55.6% vs. 9.1%, respectively; p = 0.003). Surgical approach (laparoscopy vs. laparotomy) did not influence the chance of childbirth. Pre-term delivery constituted 6.25% of all births. Fertility-sparing surgery should be proposed to young women wishing to preserve fertility. The rate of spontaneous pregnancy is approximately 50%.The risk of relapse is significant but always of borderline histology and may be successfully treated by the second surgery.

Cancer awareness in the general population varies with sex, age and media coverage: A population-based survey with focus on gynecologic cancers

There is a need for more knowledge about the public awareness and attitudes towards gynecologic cancers. We employed a research-purpose population-based citizen panel to assess how often people recall gynecologic cancers compared to other cancer types and to explore the relative importance of different information channels in relaying cancer information. We conducted an online survey using the Norwegian Citizen Panel (n = 1441 respondents), exploring associations between demographic factors and frequency of mentioning specific cancer types. We also searched The Norwegian Media Archive to assess the media coverage of different cancer types. Factors affecting likelihood of mentioning different cancers were assessed by multivariate regression. Only 41 % of respondents listed one or more cancers in female genital organs. Of the gynecological cancers, cervical cancer was most frequently mentioned (28 %), followed by ovarian (12 %) and endometrial cancer (11 %). Female responders were more likely to mention cervical (OR 2.47, 95 % CI 2.16-2.78) and ovarian cancer (OR 2.09, 95 % CI 1.60-2.58) than male responders, but not endometrial cancer. Family and friends who have had cancer (50 %) and different types of media coverage (41 %) were reported as the most common sources of cancer information. The three most frequently mentioned cancer types in our survey were breast (77 %), hematologic (76 %) and lung cancer (75 %), which also were the cancer types having most media coverage. Gynecological cancers are less frequently mentioned by Norwegian citizens when compared to several other cancer types such as breast-, hematologic- and lung cancer. Sex and age are important factors that affect awareness of cancer types. Media is likely to play an important role in what cancer types the public recalls.

Intrauterine adhesions after abdominal myomectomy: A systematic review

Abdominal myomectomy is associated with postoperative intrauterine adhesions, which can affect a patient's fertility. To evaluate the incidence and possible risk factors of intrauterine adhesions after abdominal myomectomy. A systematic search of PubMed, Embase and Web of Science was undertaken for cohort studies published in peer-reviewed journals up to 19 June 2023. The studies were assessed using the Newcastle-Ottawa scale. Eleven eligible studies were found. The frequency of postoperative intrauterine adhesions ranged from 1 % to 50 %. Due to the substantial clinical heterogeneity in these studies, a meta-analysis was not feasible. Intrauterine adhesions were seen in 98 of 758 patients overall [12.9 %, 95 % confidence interval (CI) 10.6-15.5]: 9.4 % (95 % CI 6.3-13.5) after minimally invasive surgery and 23.0 % (95 % CI 18.2-28.6) after open abdominal surgery. The adhesions were classified as severe in 34.6 % of cases. Only two studies found correlation between intrauterine adhesions and cavity breach, while four studies could not confirm an association. Fibroid features, such as size, number and submucous type, were found to be a risk factor in three studies. No other unanimous risk factors were identified. Abdominal myomectomy is associated with intrauterine adhesions. The incidence is probably underestimated and unpredictable, and may be an indication for follow-up hysteroscopy. Further studies are needed to evaluate the incidence, severity and risk factors for intrauterine adhesions after abdominal myomectomy.

Further evidence that endometriosis is related to tubal and ovarian cancers: A study of 271,444 inpatient women

To evaluate associations between endometriosis and tubal and ovarian cancers in a large population-based study. The Health Care Cost and Utilization Project - National Inpatient Sample databases from 2005 to 2014 were used in this study. Data on patients with a diagnosis of tubal or ovarian cancer and endometriosis (overall and subtypes including adenomyosis and pelvic endometriosis) using International Classification of Diseases, Ninth Edition, Clinical Modification codes were extracted. Logistic regression analysis was performed to evaluate associations between tubal and ovarian cancers and endometriosis. Adjustment was made for age, race, median income level, payment plan, hospital location and obesity. Of 38,800,139 women aged >18 years who were hospitalized between 2005 and 2014, 271,444 women with adenomyosis and/or pelvic endometriosis, 4289 women with tubal cancer and 133,253 women with ovarian cancer were identified. The rate of tubal cancer was three-fold higher in women with endometriosis compared with women without endometriosis (0.03 % vs 0.01 %). The odds ratio (OR) adjusted for age, race, obesity, income and insurance type was 4.02 [95 % confidence interval (CI) 3.17-5.11; p < 0.01]. The rate of tubal cancer was higher in women with adenomyosis (0.04 % vs 0.01 %; adjusted OR 4.88, 95 % CI 3.66-6.50; p < 0.01) and women with pelvic endometriosis (0.02 % vs 0.01 %; adjusted OR 2.80, 95 % CI 1.84-4.27; p < 0.01) compared with women without these conditions. Similar associations were found between ovarian cancer and pelvic endometriosis and ovarian cancer and adenomyosis. Both pelvic endometriosis and adenomyosis are strongly associated with tubal and ovarian cancers.

British Gynaecological Cancer Society (BGCS) ovarian, tubal and primary peritoneal cancer guidelines: Recommendations for practice update 2024

Cervical screening with self-sampling for postmenopausal women with molecular triage using extended genotyping and methylation

With the transition from cytology to human papilloma virus (HPV) testing in cervical cancer screening, it is possible to use self-sampling instead of professionally collected samples. Most studies have included women between 20 and 60 years age. Here we aimed to study postmenopausal women and investigate whether vaginal self-sampling is equally effective as professional sampling for detection of HSIL and the possibility to use a method for molecular triage directly on the screening sample. Postmenopausal women in Örebro county, Sweden, were invited (n = 7835) during 2018-2020 to participate in the study including both professional and self-sampling. In total 2258 women returned both sample types, that were analyzed for HPV followed by triage for cytology, HPV genotyping and methylation and clinical follow-up according to national guidelines. The prevalence of HPV was 3.4 % in the professionally collected samples and 12.6 % in the self-collected. All women with high-grade squamous intraepithelial lesion (HSIL) were HPV-positive in both professionally and self-collected samples. For self-collected samples, we compared different triage strategies. Cytology was the most efficient strategy. Among the molecular triage methods, the combination of methylation and genotyping was most efficient but resulted in twice as many colposcopy referrals as cytology. In conclusion, HPV self-sampling with molecular triage detects HSIL to the same extent as professional screening with cytological triage. The specificity of molecular triage is, however, unacceptably low, and to avoid overtreatment other triage methods following primary self-sampling need to be developed.

A novel approach using vaginal natural orifice transluminal endoscopic surgery (vNOTES) for a wide local excision vaginal intraepithelial neoplasia (VaIN)

Clinical analysis of 175 cases of vaginal intraepithelial neoplasia

To evaluate the risk factors related to vaginal intraepithelial neoplasia (VaIN) severity. This retrospective study included patients with histologically confirmed VaIN diagnosed at Hubei Provincial Maternal and Child Health Hospital, China, between January 2017 and October 2021. The primary outcomes were persistence, remission, progression, and recurrence. Multiple ordinal logistic regression analysis was used to analyze the risk factors of VaIN severity. A total of 175 patients were included, 135 (77.1%) with VaIN 1, 19 (10.9%) with VaIN 2, and 21 (12%) with VaIN 3. Patients with VaIN 3 were older than those with VaIN1 2 (P < 0.001). The ratio of patients with concomitant cervical lesions increased with VaIN grade (23.7%, 47.4%, and 47.6% for VaIN 1, 2, and 3, respectively). The proportion of patients with intraepithelial neoplasia (CIN) 3 increased with the VaIN grade (3.1%, 44.5%, and 80% for VaIN 1, 2, and 3, respectively, respectively; all P < 0.001). In patients with VaIN 1, 19.4% had regression (spontaneous regression in 90.5%) and 80.6% underwent laser ablation (regression in 93.1%). In patients with VaIN 2 and 3, 3.1% showed no regression, 53.1% underwent laser ablation (regression in 76.4%), and 73.8% underwent excision (regression in 78.7%). Age (OR = 1.05, 95 %CI: 1.01-1.10, P = 0.010) and concomitant cervical lesion (OR = 6.99, 95 %CI: 2.31-21.12, P = 0.001) were independent risk factors for the severity of VaIN. Age and cervical lesions might be the risk factors for VaIN severity.

Trends in incidence of invasive vaginal cancer in France from 1990 to 2018 and survival of recently diagnosed women – A population-based study

The aim of this study was to analyze trends in the incidence of vaginal cancer in France over a 28-year period and to present survival for recently-diagnosed women. French cancer registries provided data on invasive vaginal cancers diagnosed from 1990 to 2015 and followed up through June 2018. Trends in incidence were analyzed using a Poisson model with a bidimensional penalized spline of age and year at diagnosis. Net survival analysis was restricted to recently-diagnosed cases (2010-2015) and used a novel approach based on a bidimensional penalized spline of age and time-since-diagnosis to model excess mortality hazard. With 162 new cases estimated in France in 2018, vaginal cancer represented 0.9 % of genital cancers in French women. In 2018, the world population age-standardized incidence rate was 0.2 per 100,000 person-years, median age at diagnosis was 75 years. The standardized incidence rate decreased significantly by 3 % per year (95 % CI, -3.8; -2.2) between 1990 and 2018 (0.4 cases per 100,000 person-year in 1990, vs 0.2 in 2018). Age-standardized net survival at 1 and 5 years after diagnosis was respectively 74 % and 45 %. This study confirms that vaginal cancer is still a rare malignancy in France with 5-year net survival that remains low. We observed a consistent decrease in the incidence rate between 1990 and 2018. It may be too early to attribute these trends to a positive impact of vaccination campaigns against hrHPV infection, since vaginal cancer mainly affects older women and HPV vaccination has only been available since the early 2000s, and only targets young girls.

Clinical outcomes of laser vaporization for vaginal intraepithelial neoplasia – A 20-year retrospective review

The purpose of our study is to evaluate clinical outcomes of CO2 laser vaporization in patients with high-grade vaginal intraepithelial neoplasia (VAIN), and analyze potential risk factors for unfavourable outcome. A retrospective cohort study was carried out on all patients with high-grade VAIN treated by laser vaporization from Jan 2001 to Dec 2020 in a gynae-oncology training centre in Hong Kong. A total of 116 women underwent laser therapy for high-grade VAIN during the study period and the median follow-up time was 49.5 months. Disease regression was achieved in 75% of patients after first laser treatment. However, 23% of them had disease recurrence after initial regression. Regression rate declined significantly at subsequent laser treatment for disease persistence or recurrence, from 75% after the first laser, to 52.9% after the second laser and 26.5% after the third or more laser (p < 0.001). Eleven patients (9.4%) had disease progression to cancer during subsequent follow-ups. VAIN 3 was the only independent risk factor for unfavourable outcome after multivariable logistic regression (OR = 2.86, 95% CI 1.16-7.06, p = 0.023). CO2 laser vaporization is a safe and effective treatment modality for high-grade VAIN, but with high recurrence rate. Patients should be carefully counselled about treatment failure, recurrence risk, and the need for long-term surveillance for any progression to cancer. Alternative treatment modalities should be considered in patients who failed to regress after two episodes of laser treatment.

Parenchymal liver metastasis in advanced ovarian cancer: Can bowel involvement influence the frequency and the related mortality rate?

This retrospective study estimates the frequency of parenchymal liver metastasis (PLM) and the overall survival (OS) rate of patients with FIGO Stage IIIC-IV Advanced Epithelial Ovarian Cancer (EOC) with bowel involvement. Between November 2008 and July 2020, all consecutive patients with FIGO Stage IIIC-IV EOC who underwent Visceral Peritoneal Debulking and bowel resection(s) at the Gynaecological Oncology Unit of "Centro di Riferimento Oncologico (CRO)", Aviano, Italy, without evidence of PLM at pre-operative imaging assessment, were included in the study. The presence and the time of the onset of PLM during the follow-up period were detected by diagnostic imaging (CT-scan, Ultrasound and PET). The OS of patients with and without PLM was compared. Considering the bowel's layers, the association between depth of bowel involvement, number of PLM, and the relative OS rate was evaluated. The median follow-up period was 47.3 (12-138) months. PLM occurred in 24/72 (33.0%) cases; the average onset time of PLM was 13 months. PLM was associated with increased significant mortality risk and an average OS of 33.2 versus 56.8 months (p < 0.001). The risk of developing PLM correlated directly with the depth of bowel involvement. However, there was no statistical difference between the layers in terms of OS at the end of the observational period. PLM occurred more frequently among patients with EOC and bowel involvement. The PLM arose within 15 months of follow-up and the frequency increased according to the depth of involvement. Particularly, the difference is remarkably higher starting from muscular layer where the total number of PLM arose significantly (p = 0.02). Although there was no significant difference among the infiltrated bowel layers in terms of OS, patients with bowel involvement up to muscular had a dramatic reduction in the OS rate during the first 30 months of follow-up.

Robotic surgery in early and advanced ovarian cancer: Case selection for surgical staging and interval debulking surgery

During the last decade several case series have been published on robotic surgery in early and advanced stage ovarian cancer. Although most studies lack a significant oncological follow-up, more importantly criteria for patient selection for both robotic surgical staging (R-SS) and robotic interval debulking surgery (R-IDS) are not well defined. The objective of this study was to assess the surgical and oncological outcomes, using well-defined selection criteria, between robotic and open surgery in early and advanced stage ovarian cancer. Single-center retrospective case cohort study including 96 ovarian cancer patients. For early stage ovarian cancer, patients were selected for R-SS after laparoscopic salpingo-oophorectomy of a suspicious adnexal mass. For advanced stage ovarian cancer, only patients receiving neoadjuvant chemotherapy and IDS were included in the study. Exclusion criteria were the presence of residual peritoneal disease after NACT and/or patients requiring additional complex surgical procedures. For early stage ovarian cancer, similar median operative times were seen between R-SS and open surgical staging (O-SS), 132 min and 120 min respectively. Pelvic/para-aortic lymph node yield was similar between R-SS and O-SS, 22/11 nodes and 18/8 nodes respectively. Surgical upstaging occurred in 11.5% in the R-SS group and in 27.6% in the O-SS group. In advanced stage ovarian cancer, the BMI was significantly higher in the R-IDS group compared to the O-IDS group (27.8 vs 23.5; p =.006). The median follow was 52 months in the R-IDS group and 31 months in the O-IDS group. Recurrent disease occurred in 42.9% of the R-IDS group and in 45% of the O-IDS group. The length of hospitalization was significantly longer in the O-SS and O-IDS group (p <.00001). Patients with clinically early stage ovarian cancer, confirmed after laparoscopic removal of a suspicious adnexal mass, are candidates for R-SS whilst maintaining similar surgical and oncological outcome measures as O-SS. In advanced ovarian cancer, suitable candidates for R-IDS are those who receive NACT with good response and no residual peritoneal disease, especially in patients with a high BMI, but large prospective randomized trials with well-defined criteria are needed.

Post-Conization FIGO stage IA1 squamous cell cervical carcinoma; is hysterectomy necessary?

To compare and evaluate the results and suitability of two different approaches to the treatment of post-conization International Federation of Gynaecology and Obstetrics (FIGO) stage IA1 cervical carcinoma: a more radical approach, directly scheduling a second surgery versus a more conservative one, which consists of performing a cotest (PAP plus HPV-test) in a follow-up visit and deciding whether to apply a second surgery on the basis of the results. Retrospective descriptive study including 144 cases of stage IA1 cervical carcinoma diagnosed after a loop electrosurgical excisional procedure (conization), between 1987 and 2019 in the Mother-and-Child University Hospital of Gran Canaria (Spain). Selected patients were split into two groups for analysis: patients directly undergoing a second surgical intervention (hysterectomy or re-conization) after diagnosis and patients who were followed-up before making a decision whether to schedule a second surgery or continue to follow-up. 75% of women directly receiving a second surgical intervention (no post-conization follow-up) underwent hysterectomy, while 25% underwent re-conization. Histological outcomes from hysterectomized patients showed 65% negative results for intraepithelial lesions, 9% low-grade squamous intraepithelial lesions (LSIL), 16% high-grade squamous intraepithelial lesions (HSIL) and only 10.5% confirmed invasive lesions: hysterectomy complication rate was 7%. Histological studies from women subjected to re-conization showed 32% negative results, 37% LSIL, 5% HSIL and 26% malignancy. In the group of patients who were followed-up after diagnosis, 8.8% needed a second intervention; none of them showed negative histological results, while 100% hysterectomized and 25% patients with re-conization showed HSIL. No unnecessary hysterectomy procedures were conducted in this group. HPV-16 was the most common genotype in both groups. Conization proved to be a suitable alternative to hysterectomy as a treatment for post-conization stage IA1 cervical cancer. Our results showed that 65% hysterectomy procedures conducted without previously monitoring for residual disease corresponded to negative results and were therefore, unnecessary. We conclude that confirmation of the presence of residual disease by using cotest is essential to make a decision on further treatment and that a conservative management is often possible and, in our opinion, preferable.

The impact of radiation therapy on vaginal biomechanical properties

In women with cervical cancer (CC), treatment with radiation causes changes in vaginal biomechanical properties, anatomy and function. The aims of the current study were to objectively assess effects of radiotherapy (RT) on vaginal elasticity, wall mobility and contraction strength; and to evaluate associations of these changes with sexual function. This prospective cohort study was approved by our Institutional Review Board. Between May 2018 and June 2020, women with CC who were candidates for RT were eligible to participate. Participants underwent vaginal tactile imaging (VTI) evaluation and were asked to fill the Female Sexual Function Index (FSFI) questionnaire at the time of first RT session and at a 6-month post-treatment follow up visit. Women who underwent radical hysterectomy, or had pelvic side-wall, pelvic or distant organ metastasis were not included. A total of 25 women with locally advanced CC were included in the final analysis. The mean age was 39 ± 2.7 years, the mean BMI was 24.8 ± 2.2 kg/m Women with locally advanced CC who have been treated with RT exhibit persistent vaginal biomechanical changes that compromise sexual activity and result in considerable distress.

Laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator

To demonstrate the experience of laparoscopic radical hysterectomy for cervical cancer without the use of a uterine manipulator and investigate the feasibility and treatment effectiveness of this surgical approach. The laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator prevented the oppression of the uterine manipulator on the tumour. Vaginal ligation was performed below the lesion of cervical cancer, and the vagina was cut off below the ligation line. Consequently, the exposure of cancer tissues in the abdominal cavity was prevented, enabling a tumour-free operation. We reviewed the medical records of the 22 patients with stage IB1-IIA2 cervical squamous cell carcinoma who were treated at our hospital between May 2019 and February 2020. All the patients underwent the laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament. All the patients were informed about the different therapeutic schemes and surgical approaches as well as their advantages and disadvantages. Information about operative time, intraoperative blood loss, hospitalisation duration, postoperative complications, postoperative adjuvant therapy, prognosis and other data were recorded. All the surgical procedures were successfully completed without perioperative complications, such as vascular injury, pelvic injury and abdominal organ injury. The mean operative duration was 204 min, and the mean operative blood loss was 102 mL. The mean duration of postoperative hospital stay was 13 days. Nineteen patients received postoperative chemotherapy once before hospital discharge. Urinary retention was the major postoperative complication. All the patients were followed up for 14-23 months. The median follow-up time was 18 months. 21 of the 22 patients survived. No recurrence was detected in the patients during follow-up. One patient who had a pelvic lymph node metastasis but refused complete chemoradiotherapy died before the last follow-up. This surgical approach appears to be safe and feasible for patients with cervical cancer. A larger sample size and longer follow-up period are required to confirm whether this surgical approach can actually and effectively improve the prognosis.

Options for triage and implications for colposcopists within European HPV-based cervical screening programmes

The development of human papillomavirus (HPV)-based screening should detect more pre-cancerous changes and so reduce the incidence and mortality from cervical squamous carcinoma and cervical adenocarcinoma. However, many more women are high risk HPV (hrHPV) screen positive compared to cytology-based screening, especially in younger age-women. A variety of tests have become available which may triage into those hrHPV test-positive women who need immediate referral to colposcopy from those who need early repeat HPV tests or recall on the basis of their disease status. We performed a literature review of publications and a manual search from 2010, reporting cytology, HPV partial genotyping, dual-staining and DNA methylation for triage of hrHPV positive tests, including their comparative performance between these methods as well as the effectiveness of some triage combinations with reference to HPV-based screening services in Europe. Cost effectiveness and the structure of triage algorithms for colposcopists also have been considered. From one report evaluating four options for triage as single options or as combined algorithms, partial genotyping for HPV 16 and 18 with dual-staining yielded the highest risk of cervical intraepithelial neoplasia grade three or worse within an HPV positive population and with an acceptable colposcopy rate. From a separate paper, this option appeared cost effective. However, publications were difficult to compare objectively. All options have their merits but a combination triage involving any two of cytology, HPV partial genotyping or dual-staining seems most efficient at present. HPV vaccination may impact upon the performance of future partial genotyping. DNA Methylation may become an acceptable future option.

Primary prevention of cervical cancer in women: Human papillomavirus vaccine

Establishment and validation of a risk prediction model for high-grade cervical lesions

To establish and validate a risk prediction model for cervical high-grade squamous intraepithelial lesions (HSIL). This retrospective study included patients who underwent cervical biopsies at the Cervical Disease Centre of Maternal and Child Hospital of Hubei Province between January 2021 and December 2021. A total of 1630 patients were divided into the HSIL + cervical lesion group (n = 186) and the ≤ LSIL cervical lesions group (n = 1444). LSIL, ASC-H, HSIL and SCC, high-risk HPV, HPV16, HPV18/45, multiple HPV strains, acetowhite epithelium, atypical vessels, and mosaicity were independently associated with HSIL + lesions. These factors were used to establish a risk prediction model with a demonstrated area under the curve (AUC) of 0.851 and a C-index of 0.829. Calibration curve analysis showed that the model performed well, with a mean absolute error (MAE) of 0.005. The decision curve showed that the model created by combining the risk factors was more specific and sensitive than each predictive variable. The model for predicting HSIL demonstrated promising predictive capability and might help identify patients requiring biopsy and treatment.

Association between cardiometabolic index and prevalence of ovarian cancer among US adults: A cross-sectional NHANES study

To investigate the possible link between ovarian cancer and cardiometabolic index (CMI). A cross-sectional investigation was conducted using data from the National Health and Nutrition Examination Survey (NHANES) 1999-2018. Sensitivity analysis, smooth curve fitting, and weighted multivariate logistic regression were employed to explore the relationship between CMI and ovarian cancer. The effectiveness of CMI in detecting ovarian cancer was also assessed using eXtreme Gradient Boosting and receiver operating characteristic analysis. Furthermore, subgroup analysis and interaction tests were employed to examine the stability of the connection across different populations. In this study involving 8814 individuals aged ≥ 20 years, CMI was found to be positively correlated with ovarian cancer. Each unit increase in CMI was associated with 10 % increased odds of ovarian cancer in the fully adjusted model {odds ratio [OR] 1.10 [95 % confidence interval (CI) 1.02-1.17]}. The prevalence of ovarian cancer was higher in individuals in the highest CMI tertile [OR 3.68 (95 % CI 1.10-12.35)] compared with those in the lowest CMI tertile. There was a non-linear dose-response association (p for non-linearity = 0.004) between the odds of ovarian cancer and CMI. The results of subgroup analysis and interaction tests show that, apart from race, the relationship between CMI and ovarian cancer was consistent across subgroups. Increased prevalence of ovarian cancer is associated with elevated CMI levels. Improving cholesterol levels and management of dyslipidaemia may help reduce the odds of ovarian cancer.

Does mode of delivery impact the course of cervical dysplasia in pregnancy? A review of 219 cases

The prevalence of cervical intraepithelial neoplasia (CIN) in pregnancy is about 1%. The aim of this study was to analyze the regression, persistence and progression rates of cervical dysplasia in pregnancy and the impact of delivery mode. In this retrospective study, data from pregnant patients with abnormal cytology findings, who presented to a colposcopic outpatient clinic of a university hospital within the last 10 years, were analyzed. Information on cytology, histology and Human Papillomavirus (HPV) status during pregnancy and postpartum and mode of delivery was collected. 219 women, who were assessed with cytology and /or biopsy antepartum and postpartum between January 2010 and July 2020, were included in the study. Antepartum patients presented with low grade squamous intraepithelial lesions (LSIL) in 37% and high grade squamous intraepithelial lesions (HSIL) in 53%. During pregnancy biopsy was performed in 78 patients (36%). Postpartum evaluation revealed an overall regression rate of 39%. Persistence rates were especially high in the HSIL group with 70 %. HSIL regressed in 28 %. Progression to invasive disease was rare and seen in two patients postpartum only. 141 women delivered vaginally (VD) and 51 received a cesarean section (CS). Regression rates were similar: 36 % and 47 %. There was no significant difference in progression or persistence rates. Our study demonstrates that mode of delivery does not influence the course of SIL. SIL show high rates of regression and persistence, progression to invasive disease is rare.

Trends and characteristics of ovarian conservation at hysterectomy for young women with cervical cancer

The association between early surgical menopause and increased mortality has been well demonstrated. Prior studies have also demonstrated that ovarian conservation is not associated with worse oncologic outcomes in early-stage cervical cancer. This study examined the contemporary trends and characteristics of ovarian conservation at time of hysterectomy in young women with cervical cancer. This is a retrospective cohort study examining the National Inpatient Sample. The study population was 4900 women aged ≤50 years with cervical cancer who had hysterectomy-based surgical treatment from 10/2015 to 12/2018. The exposure allocation was the adnexal procedure status (ovarian conservation versus oophorectomy). The main outcome measures were temporal trends of ovarian conservation over time and per patient age. Multivariable binary logistic regression model was fitted to identify independent characteristics associated with ovarian conservation. A classification-tree was constructed by recursive partitioning analysis to examine the utilization patterns of ovarian conservation. A total of 2,940 (60.0%) women underwent ovarian conservation at hysterectomy. Ovarian conservation rates remained stable until age 37 years, ranging from 82.5% to 77.9% (P = 0.502), after which time the rate sharply and significantly decreased by 7.4% (95% confidence interval 5.4-9.3, P 80%). Increasing rates of ovarian conservation at the time of hysterectomy in women undergoing surgical management of cervical cancer is encouraging; however, the marked decrease noted in patients in their mid-30s as well as substantial variability in ovarian conservation based on patient, surgical, and hospital factors are striking and warrant further consideration in clinical practice guidelines.

In-transit metastatic lymph nodes in cervical cancer: A new staging and therapeutic concept

It has been reported that metastatic lymph nodes can be present in the parauterine lymphovascular (PULT) and in lateral paracervical lymphatic tissue as in-transit disease in patients with cervical cancer. This study aimed to clarify the understanding of in-transit positive lymph nodes in PULT and lateral paracervix and its clinical management in patients with cervical cancer, based on insights gathered from an international expert survey. A 29-question survey was emailed to experts identified through a systematic literature search related to sentinel lymph nodes in gynecological cancer. The survey was divided into four sections: 1. Resection of parauterine lymphovascular tissue; 2. Discontinuous lymphatic paracervical involvement; 3. Positive para-uterine or paracervical nodes in fertility-sparing surgery; 4. The impact of positive in-transit nodes on the extent of nodal staging. Consensus was defined as an agreement among at least 70% of the respondents. Responders where only corresponding or last authors of articles addressing sentinel lymph nodes procedures. Results show general agreement on referring to the areas as "para-uterine lymphovascular tissue (PULT)" (84.85 %), with lymph nodes in these regions considered sentinel nodes if stained with indocyanine green (80 %). However, there is no consensus on surgical staging for isolated positive lymph nodes. Most respondents favour adjuvant treatment for in-transit macro or micrometastases (>95 %) but acknowledge the lack of conclusive evidence. In fertility-sparing settings, most would remove PULT while preserving uterine arteries (59 %) and would remove lateral paracervical tissue in low-risk cases (66.7 %). For isolated metastasis, most would recommend chemoradiation over fertility-sparing options (81.8 %). Finally, if a positive in-transit node is found, experts would request additional imaging (80.3 %), though there is no consensus on aortic lymphatic dissection or extended-field radiation without prior aortic staging. The survey highlights expert awareness of the clinical importance of in-transit positive lymph nodes. However, it is essential for the international societies to urgently address the impact of these nodes on staging and treatment guidelines, as current recommendations and evidence are lacking.

Interest of para-aortic lymphadenectomy for locally advanced cervical cancer in the era of PET scanning

Treatment of locally advanced cervical cancer (LACC) involves pelvic chemoradiotherapy, using an extended field in the case of para-aortic involvement. 18-Fluoro-D-glucose positron emission tomography combined with computer tomography (PET-CT) is an accurate method for the detection of metastatic nodes. The objective of this study was to evaluate the performance of PET-CT for lymph node staging of LACC. This bicentric retrospective study included patients with LACC who had a PET-CT scan followed by para-aortic lymphadenectomy between January 2015 and December 2019. Based on pathological findings, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and false-negative (FN) rates of PET-CT for para-aortic node involvement were evaluated. Seventy-one patients who had undergone laparoscopic lymphadenectomy were included in this study. The intraoperative complication rate was 2.8%. Sensitivity, specificity, NPV and PPV for PET-CT were 55% [95% confidence interval (CI) 44.6-67.1], 84% (95% CI 75-92), 93% (95% CI 87-99) and 33% (95% CI 22-44), respectively. FN rates in the case of negative or positive pelvic PET-CT were 5.7% and 9.5%, respectively. Para-aortic lymphadenectomy is recommended for lymph node staging in the case of negative para-aortic PET-CT. In view of the low FN rate of PET-CT, surgical staging should be discussed regardless of pelvic status if the patient presents high surgical risk, or if this delays the commencement of chemoradiotherapy.

Clinicopathological characteristics and survival outcomes of patients with large cell neuroendocrine carcinoma of the uterine cervix: A systematic review and meta-analysis

Large cell neuroendocrine carcinoma (LCNEC) of the cervix represents a rare tumour entity associated with poor prognosis. Knowledge about carcinogenesis and therapeutic options is scarce, while novel therapeutic targeted approaches are limited. We performed a systematic review of four electronic databases from inception to June 2020. Eligible studies included all reports that addressed survival outcomes of women with LCNEC. A total of 31 case studies including 87 LCNEC patients were identified. Median patients' age was 41 years (range: 21-81). Most women (76.3%) had FIGO stage I-II disease. Overall, 72.0% had surgery, 70.1% received chemotherapy and 50.7% received radiotherapy. Of 13 patients with known HPV-status, 15% were HPV negative. Median overall survival (OS) was 24 months (range: 0.5-151), with 3- and 5-year OS of 42% and 29%, respectively. In multivariate analyses, only surgery and lymphadenectomy significantly associated with survival (Surgery OS: HR 0.14; 95% C.I:0.03-0.71, p = 0.018 / Surgery PFS: HR 0.23, 95% C.I. 0.06, 0.92, p = 0.037 / Lymphadenectomy OS: HR 0.26, 95% C.I. 0.07-0.98, p = 0.046 / Lymphadenectomy PFS: HR 0.30, 95% C.I. 0.09-0.98, p = 0.046). Age, chemotherapy or radiotherapy did not significantly impact survival, but lower stage was associated with improved survival. Cervical LCNECs overall have a poor prognosis, despite their relatively early-stage initial presentation. Surgery and lymphadenectomy appear to significantly affect survival in contrast to chemotherapy and radiotherapy, which appear to have no significant effect on prognosis. Prospective multicentre cancer registries are warranted to improve treatment options for this rare disease.

Clinical characteristic and risk factors for post-operative complications in women undergoing laparoscopy myomectomy

To assess clinical characteristic and risk factors for post-operative complications in women undergoing laparoscopic myomectomy using the Clavien-Dindo classification system. A retrospective cohort study was conducted at Soroka University Medical Center, Beer Sheva, Israel, between 2010 and 2020, including women who underwent laparoscopic myomectomy. Postoperative adverse events were classified using the Clavien-Dindo system. The study population was divided into two groups: those with complications (Clavien-Dindo classification ≥ 1) and those without complications (Clavien-Dindo classification = 0). Risk factors were compared between the groups and analyzed for statistical significance using univariate and multivariate logistic regression. A total of 111 women who underwent laparoscopic myomectomy were included. Of these, 26 experienced complications (study group) and 85 did not (comparison group); all complications were minor. Women in the study group had a higher incidence of pre-operative symptoms (76.9 % vs. 55.3 %). Additionally, the duration of surgery was significantly longer in the study group (137 min vs. 97 min, p  100 mL was found to be independently associated with complications (aOR 4.4, 95 % CI 1.5-12.5). Laparoscopic myomectomy is a safe and effective surgical option for women, with a low rate of minor complications. Although longer surgeries and increased blood loss were associated with complications, the overall risk remains minimal. Proper identification of risk factors such as pre-operative symptoms and intraoperative blood loss can help optimize patient outcomes. Future research should further explore the relationship between anemia and surgical outcomes, as no significant differences in anemia were observed in this study.

Nutritional assessment in gynecological cancers: Experience from an Indian tertiary care center

Assessment of parameters associated with ovarian function recovery in premenopausal women with early breast cancer and chemotherapy-induced amenorrhea in real-world clinical practice

Assessing the role of low volume disease in endometrial cancer

The role of retroperitoneal staging in endometrial cancer is still unclear. Although the prognostic value of lymphadenectomy has been demonstrated no data support the therapeutic value of nodal dissection. Sentinel node mapping represents an evolution of lymphadenectomy. Sentinel node mapping allows a more accurate identification of low-volume diseases (i.e., micrometastasis and isolated tumor cells) that are not always detectable via conventional histopathological evaluation. Adjuvant therapy might play a role in patients with low-volume disease. However, the presence of isolated tumor cells alone seems to not impact outcomes of endometrioid endometrial cancer patients. Hence, the choice to deliver adjuvant therapies has to be tailored based on uterine factors only. The introduction of molecular and genomic profiling would be useful in selecting appropriate surgical and adjuvant treatments. The molecular-integrated risk profile should be integrated in clinical practice to overcome the need of retroperitoneal staging (in case of non-bulky nodes) in patients at low risk.

Phlegmasia cerulea dolens – A rare presentation of ovarian malignancy

Prognostic factors for ovarian immature teratoma and significance of alpha-fetoprotein in recurrent cases

To analyze clinical characteristics of ovarian immature teratoma patients and to explore prognostic factors of recurrence-free survival. Fifty-eight cases with ovarian immature teratoma who underwent surgery in Fudan University Shanghai Cancer Center from January 2008 to January 2023, were retrospectively analyzed. The potential risk factors of recurrence were investigated. Subgroup analysis was conducted in stage I patients and in recurrent cases. The median age of diagnosis was 24.5 years (range, 7∼40 years), twenty-eight patients relapsed after a median follow-up of 72.3 months, with a 5-year recurrence-free survival and disease-specific survival rate of 81.0 % and 89.7 %, respectively. Multivariate analysis showed that adjuvant chemotherapy (HR = -1.556, 95 %CI 0.056∼0.793, P = 0.021), stage II-III (HR = 1.549, 95 %CI 1.572∼14.086, P = 0.006) and unknown residual lesions (HR = 1.591 95 %CI 1.602∼15.039P = 0.005) were risk factors of recurrence. Subgroup analysis was conducted in 32 stage I patients, the recurrence-free survival rate between adjuvant chemotherapy and surveillance group were statistically significant (P < 0.05). There was significant difference in AFP level between 15 cases with immature recurrence and 10 cases with mature recurrence(P = 0.015), a cut-off value of 25.67 ng/ml was found to be predictive for immature recurrence of ovarian immature teratoma with an area under the curve of 0.793, sensitivity and specificity were 53.3 % and 100 %, respectively. Adjuvant chemotherapy, stage II-III and unknown residual lesions were the prognostic factors for ovarian immature teratoma. Surveillance is not a substitute for adjuvant chemotherapy in stage I patients of any grade. Serum AFP level exceeding 25.67 ng/ml can be a predictor of immature recurrence.

The Great Masquerader: Accessory Cavitating Uterine Mass (ACUM). Evaluation, diagnosis, and surgical management

Accessory cavitating uterine masses (ACUM) are rare, cystic uterine anomalies associated with an otherwise normal uterus and reproductive tract. They are diagnosed via a presence of a noncommunicating accessory cavity lined by endometrium and surrounded by uterine smooth muscle [1]. MRI and 3D ultrasound are preferred imaging modalities for evaluation, as misdiagnosis is common [2]. Medical therapy is aimed at menstrual suppression and pain management, however these masses are likely to fail medical management. Surgical management leads to virtual complete remission of symptoms [3]. As these are uncommon, this surgical video aims to inform practitioners on diagnosis and key elements of surgical management of an accessory cavitating uterine mass (ACUM). Intraoperative videography. All patients [2] diagnosed with ACUM at an academic medical center from December 2023 to May 2024 were included. Two reproductive-aged females with dysmenorrhea found to have ACUM after imaging (3D ultrasound and MRI pelvis). Laparoscopic and robotic-assisted resection of ACUM along with diagnostic hysteroscopy, chromopertubation, and excision of endometriosis. Restoration of normal uterine anatomy and improved patient symptoms. ACUM is a rare and largely misdiagnosed Mullerian anomaly. Early recognition and surgical intervention improves patients' quality of life. Key intraoperative and postoperative considerations must be taken with surgical revision of ACUM. More data is needed on the gynecologic and obstetric outcomes associated with surgical resection of ACUM.

vNOTES retroperitoneal sentinel lymph node biopsy and pelvic lymph node dissection for surgical staging of endometrial cancer: A single-center experience

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has shown favourable outcomes in benign gynaecology, but its oncological application remains underexplored. This study aimed to evaluate the technique, operative outcomes and oncological feasibility of vNOTES retroperitoneal sentinel lymph node biopsy (SLNB) and/or pelvic lymph node dissection (PLND) for endometrial cancer staging. A retrospective review was conducted of consecutive patients who underwent vNOTES THBSO with SLNB and/or PLND for endometrial malignancy at Singapore General Hospital between August 2023 and August 2024. Demographic, peri-operative and postoperative outcomes were analysed. 19 patients were included, with a median age of 59 years [IQR 56.5-70.7] and median BMI 25.2 kg/m vNOTES SLNB and PLND are feasible, safe, and effective for endometrial cancer staging in selected patients.

Distinguishing mature from immature ovarian teratoma in the pre-operative setting

To identify clinical, sonographic and laboratory findings that might distinguish mature from immature ovarian teratoma in a pre-operative setting. A retrospective case-control study performed in a tertiary medical center between 1995 and 2023. The study group comprised of 22 women who were surgically diagnosed with immature ovarian teratoma. A control group of 44 women with a mature ovarian teratoma was created, matched two-to-one according to age and year of surgery. Women in the study group were younger (mean 17.7 (8.7) vs 23.2 (7.7), p = 0.01) and more commonly were symptomatic (abdominal pain 95.5 % vs. 61.4 %, p  10 cm (OR 10.6, CI [2.7-40.9]) and ascites (OR 12.9 CI [1.1-151.6]) were independent factors associated with immature ovarian teratoma. Tumor size > 10 CM and presence of ascites might aid in the pre-operative differentiation between mature and immature ovarian teratomas, possibly contributing to surgical approach planning.

Reproductive outcomes following chemotherapy for gestational trophoblastic neoplasia: experience from a tertiary care center

Gestational trophoblastic neoplasia (GTN) affects reproductive-age women and is highly chemosensitive, with excellent survival outcomes. However, concerns remain regarding the impact of chemotherapy-particularly multiagent regimens-on reproductive and menstrual health. This retrospective, observational study included 78 women treated for GTN between 2011 and 2022. Data on demographics, disease characteristics, treatment history, menstrual changes, fertility outcomes, and pregnancy course were collected from medical records and patient interviews. Comparative analysis was performed between women who received single-agent (Group I) and multiagent chemotherapy (Group II). Logistic regression was used to identify independent predictors of live birth. The median age was 28 years (range: 17-71, IQR: 24-34). Of the 78 women, 30 (38.5 %) received single-agent and 48 (61.5 %) received multiagent chemotherapy. Menstrual abnormalities occurred in 14.1 % overall (13.3 % in Group I vs. 14.6 % in Group II; p = 0.99). Post-treatment, 35 women (44.8 %) conceived, and 30 (38.5 %) achieved at least one live birth. Cesarean delivery occurred in 46 % of live births. Among women desiring pregnancy, 20.5 % reported infertility. On logistic regression, age (OR 0.77; p = 0.009) and receipt of ≤7 cycles of combination chemotherapy (EMACO) (OR 6.03; p = 0.043) were significantly associated with live birth. Chemotherapy type was not an independent predictor. Most GTN survivors retain reproductive potential, regardless of chemotherapy type. Younger age and lower chemotherapy burden were associated with higher chances of live birth. These findings support fertility preservation counseling and tailored follow-up, particularly for high-risk patients undergoing multiagent chemotherapy.

Endometrial polyps. An evidence-based diagnosis and management guide

To provide an updated practice guideline for the management of patients with endometrial polyps. A committee of six expert researchers draw the recommendations according to AGREE II Reporting Guideline. An electronic search was performed querying the following databases MEDLINE (accessed through PubMed), Scopus, PROSPERO, EMBASE, CINAHL, Cochrane Library (including the Cochrane Database of Systematic Reviews), Scielo.br, Google Scholar, from inception to May 2020. A combination of text-words and Medical Subject Headings (MeSH) regarding endometrial polyps, diagnosis, management and treatment was used. Trials were assessed for methodologic rigor and graded using the United States Preventive Services Task Force classification system. Transvaginal ultrasonography (TVUS) should be the imaging modality of choice for the detection of endometrial polyps in woman of fertile age (level B). Its accuracy increases when color-doppler, 3D investigation and contrast are used (level B). Dilation and Curettage (D&C) should be avoided for the diagnosis and management of polyps (level A). In office hysteroscopy showed the highest diagnostic accuracy in infertile patients with suspected endometrial polyps (level B). Polyps might alter endometrial receptivity, and embryo implantation reducing pregnancy rates (level C). Hysteroscopic polypectomy is feasible and safe with negligeble risk of intrauterine adhesion formation (level B). Polypectomy does not compromise reproductive outcomes from subsequent IVF procedures but the removal of polyps as a routine practice in sub-fertile women is not currently supported by the evidence (level B). Cost-effectiveness analysis suggest performing office polypectomy in women desiring to conceive (level B). Saline infused sonohysterography is highly accurate in detecting polyps in asymptomatic postmenopausal women (level B). Postmenopausal women with vaginal bleeding and suspected endometrial polyp should be offered diagnostic hysteroscopy with hysteroscopic polypectomy if endometrial polyps are present (level B). In-office hysteroscopy has the highest diagnostic accuracy with high cost-benefits ratio for premalignant and malignant pathologies of the uterine cavity (level B). Due to risk of malignancy, histopathological analysis of the polyp is mandatory (level B). Blind D&C should be avoided due to inaccuracy for the diagnosis of focal endometrial pathology (level A). Expectant management is not recommended in symptomatic patients especially in postmenopausal women (level B). In case of atypical hyperplasia or carcinoma on a polyp, hysterectomy is recommended in all post-menopausal patients and in premenopausal patients without desire of future fertility (level B). Asymptomatic endometrial polyps in postmenopausal women should be removed in case of large diameter (> 2 cm) or in patients with risk factors for endometrial carcinoma (level B). Excision of polyps smaller than 2 cm in asymptomatic postmenopausal patients has no impact on cost-effectiveness or survival (level B). Removal of asymptomatic polyps in premenopausal women should be considered in patients with risk factors for endometrial cancer (level B).

Full-term delivery after antepartum vaginal myomectomy for prolapsed myoma causing uterus distortion: A case report and literature review

Prolapsed cervical myoma with uterine distortion during pregnancy are rare. A 45-year-old woman at 30 weeks of gestation presented with a prolapsed mass and vaginal fluid leakage. A 9 × 8 × 8 cm Prolapsed myoma with uterine distortion during pregnancy are extremely rare. Antepartum vaginal myomectomy should be considered with caution to reduce the risk of preterm births.

Whether hysteroscopy contributes to intraperitoneal cell dissemination, progression and recurrence in endometrial cancer: Systematic review and meta-analysis

To assess the oncologic safety of hysteroscopy in patients with endometrial cancer by evaluating its impact on positive peritoneal cytology (PPC), disease-free survival (DFS), and overall survival (OS). This systematic review and meta-analysis adhered to PRISMA guidelines and was registered in PROSPERO (CRD42024591414). We searched PubMed, the Cochrane Library, ClinicalTrials.gov, Google Scholar, and MEDLINE for studies published through April 2025. Eligible studies enrolled women with confirmed endometrial cancer who underwent hysteroscopy. The primary outcome was PPC; secondary outcomes were DFS and OS. Pooled risk ratios (RRs) were calculated under fixed-effects models, and heterogeneity was assessed using the I The meta-analysis showed no significant difference in PPC between hysteroscopy and control groups in retrospective/prospective studies (p = 0.13) or in randomized controlled trials (p = 0.61). Twelve studies reported DFS data; pooled analysis demonstrated no significant difference between groups (RR = 0.88; 95 % CI, 0.75-1.05; p = 0.16). Heterogeneity was moderate to high (I Hysteroscopy does not significantly affect PPC, DFS, or OS in patients with endometrial cancer, supporting its oncologic safety. Future research should stratify outcomes by cancer subtype and implement standardized hysteroscopy protocols (e.g., defined examination duration and fluid pressure).

Oncological and reproductive outcomes of fertility-sparing surgery in young women with early-stage ovarian clear cell carcinoma: A retrospective cohort study

Fertility-sparing surgery for early-stage ovarian clear cell carcinoma (OCCC) remains controversial. In this study, we evaluated the oncological and reproductive outcomes of young patients with stage I OCCC who underwent fertility-sparing surgery. This retrospective cohort study included patients diagnosed with stage I OCCC treated at Peking Union Medical College Hospital between January 2010 and December 2020 who underwent surgical staging. Baseline demographics, surgical details, and outcomes were collected. Fertility-sparing surgery was defined as the preservation of the uterus, with or without the contralateral ovary. Progression-free and overall survival were estimated using the Kaplan-Meier method and compared using the log-rank test. Fifty-five patients were enrolled, of whom 21 underwent fertility-sparing surgery and 34 underwent radical surgery. Forty-four patients (80 %) were classified as stage IA/C1, while 11 (20 %) were classified as stage IC2/C3. There were no stage IB cases. After a median follow-up of 54 months (range: 5-117 months), recurrence occurred in one patient (4.6 %) in the fertility-sparing group and six patients (17.8 %) in the radical surgery group (p = 0.232). Three patients (5.4 %) in the radical surgery group died from disease progression. No significant differences were observed in 5-year progression-free survival (94.7 % vs. 78.8 %; p = 0.13) or 5-year overall survival (100 % vs. 87 %; p = 0.16) between the groups. Among six patients who attempted conception, two (33.3 %) achieved term pregnancies. Fertility-sparing surgery may be a viable option for young women with early-stage OCCC who wish to preserve fertility.

Pain perceived during hysteroscopic morcellation by vaginoscopy versus standard technique in an outpatient setting: a randomized controlled trial

To compare pain perceived in women undergoing polyp or fibroid morcellation with a 5.5 mm MyoSure hysteroscope by vaginoscopy vs standard technique, both under sedation in an outpatient setting. Women between the ages 18-52 years; with a clear indication for operative hysteroscopy such as a polyp or type 0/1 fibroid measuring <2 cm, or <4 cm total when more than one lesion was present. Randomized controlled trial. Patients were randomized into two groups: Group 1 underwent hysteroscopic morcellation using the standard technique, while Group 2 underwent the procedure via vaginoscopy. The primary outcome measured was the participants' self-rated pain perception using the 10-point visual analog scale. The secondary outcomes included duration of the intervention, blood loss, complication at one week follow-up and pregnancy rate at 6 and 12 months. The study was conducted in an outpatient fertility clinic in a tertiary university hospital. A total of 78 patients were included in the final analysis, with 39 patients per group. Participant baseline characteristics were similar in each group. In an intention-to-treat analysis, the standard technique was found to be significantly less painful than vaginoscopy (mean score 4.0 vs 5.9; difference in means 1.9; p = 0.001). No differences were demonstrated for operative time, postprocedural bleeding, or complication rate. Pregnancy outcomes, including pregnancy rate and pregnancy loss at 6 and 12 months, were not statistically different between the two groups. Standard technique for polyps or fibroids removal is less painful than vaginoscopy in women under sedation in an outpatient setting using 5.5 mm MyoSure hysteroscope. Therefore, it should be considered the technique of choice.

Surgical staging for ovarian sex cord-stromal tumors: What procedural steps are needed?

The recommended surgical procedure for adult ovarian stromal tumors is based on NCCN guidelines but yield of staging steps has not been evaluated. Previous studies have shown poor compliance by surgeons for epithelial and germ cell tumors. This review was undertaken to examine yield of staging components and surgical compliance in ovarian stromal tumors. Comparison with the Children's Oncology Group's (COG) more limited staging for ovarian germ cell tumors was performed. Retrospective review of compliance with surgical staging and pathologic findings in patients with ovarian sex-cord stromal tumors enrolled in the International OTST and International PPB/DICER1 Registries (Registries). 148 patients, diagnosed from 1985 to 2021, with ovarian sex cord-stromal tumors aged 2 days-60 years at diagnosis with medical records available were identified. Operative and pathology reports were available for 145 patients. Tumor spread was documented in 6 % of peritoneal fluid, 6 % of omentum, 10 % of peritoneal surface, and 3 % of lymph nodes. No samples that appeared normal to the surgeon contained tumor. Seventeen percent had complete staging using NCCN guidelines, whereas 41 % had complete staging using COG guidelines. Sampling of normal appearing tissue did not show tumor spread. Tumor was found in 3-10% of samples obtained and only from grossly abnormal tissue, confirming continued need for inspection and assessment and documentation of these sites. Future studies focused on determining patterns of spread could inform staging recommendations to capture key elements that predict spread of disease and relapse.

Paraneoplastic syndromes in ovarian carcinoma: A study on clinical spectrum, treatment and survival perspectives

Paraneoplastic syndromes (PNS) are rare, immune-mediated conditions that may precede or accompany malignancies. Their presence in ovarian cancer is infrequent and underreported, and hence often underdiagnosed. This study evaluates the clinical presentation, management, and survival outcomes of patients with ovarian carcinoma and associated PNS. We retrospectively analyzed data from 376 patients diagnosed with ovarian carcinoma between 2012 and 2024.Among them, 38 patients (10.1%) were identified with co-existing paraneoplastic syndromes. Data were collected in six domains: clinical profile, laboratory parameters including antibody profiles, imaging and diagnostic modalities, oncologic treatment, PNS management, and survival outcomes. Kaplan-Meier methods were used for survival analysis. The median age of 38 ovarian cancer patients with PNS was 55 years. Serous histology was most common (73.7 %), and 76.3 % were diagnosed at advanced stages. Neurological PNS was present in 50 %, gastrointestinal in 15.8.%, dermatologic 13.2 % and endocrine/metabolic in 21 %, and Treatment included neoadjuvant chemotherapy (55.3 %) and surgery (34.2 %). PNS management involved steroids (28.9 %), IVIG (15.8 %), and plasmapheresis (7.9 %). Median overall survival was 28.5 months, with 1-year, 3-year, and 5-year survival rates of 95 %, 40 %, and 18 %. Paraneoplastic syndromes are present in approximately 10% of ovarian cancer patients. PNS is a clinically significant condition in ovarian cancer, with neurological manifestations being the most common. Despite multimodal treatment approaches, these patients face poor long-term survival. Recognizing and managing PNS early may influence outcomes. Further studies are needed to refine treatment strategies for both ovarian cancer and PNS to improve long-term outcomes for affected patients.

The nodal cancer index (NCI): An objective approach for systematic lymph node dissection in ovarian carcinomatosis

Ovarian cancer is the deadliest gynaecological malignancy, often diagnosed at an advanced stage with widespread peritoneal dissemination and lymph node involvement, particularly in retroperitoneal and pelvic regions. The Peritoneal Cancer Index(PCI) is used to assess peritoneal disease but does not address nodal metastasis, an important prognostic factor. The Nodal Cancer Index(NCI) was developed to quantify lymph node burden, improving surgical precision. The primary aim was to assess the NCI as a score for objectively evaluating systemic lymph node dissection in ovarian cancer. Secondary objectives included evaluating its prognostic value and survival outcomes. This study included 211 patients with advanced ovarian cancer(FIGO stages III and IV) who underwent cytoreductive surgery(CRS) from 2015 to 2020. The NCI divided the abdomen and pelvis into 13 nodal zones zones(6 retroperitoneal and 6 pelvic, plus an extra-abdominal zone). Each zone was scored based on lymph node size, with higher scores indicating more extensive disease. The NCI score was correlated with clinical outcomes, including survival rates. The cohort's median age was 51 years, with most patients at advanced stages (FIGO III: 73.9 %, IV: 26.1 %). Histologically, 83.4 % had serous carcinoma. Treatment included 23.7 % upfront surgery and 76.3 % neoadjuvant chemotherapy (NACT) with interval cytoreductive surgery (CC-0: 88.1 %). Lymph node involvement occurred in 46.4 % of cases. Survival analysis showed that patients with low, moderate, and severe NCI scores had median OS of 57.70, 47.58, and 36.37 months, respectively, with lower NCI scores linked to better survival. The NCI provides an objective framework for assessing lymph node metastasis in ovarian cancer, aiding in surgical planning, prognostication, and treatment decisions.

Upfront and interval debulking surgery in advanced/metastatic endometrial cancer in the era of molecular classification

To evaluate oncologic outcomes and prognostic factors of the different molecular subtypes of advanced/metastatic endometrial cancer treated with primary debulking surgery (PDS) or neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). We conducted a retrospective analysis of patients with endometrial cancer and peritoneal carcinomatosis and/or "bulky" nodal metastasis surgically treated between September 2010 and February 2024. Survival outcomes were compared across four molecular subtypes (p53-mutant, MMR-deficient, NSMP, and POLE-mutant) and surgical approaches. Overall, 51 patients with stage IIIC-IVB endometrial cancer underwent surgical treatment. Thirty-six (70.5 %) patients had PDS followed by adjuvant chemotherapy, while fifteen (29.5 %) received NACT followed by IDS. Most patients in both groups had FIGO stage IVB disease: 24 (66.6 %) in the PDS group and 14 (93.3 %) in the IDS group. Complete cytoreduction was achieved in 83.3 % of the PDS group and 40 % of the IDS group, with no significant differences in postoperative morbidity between the groups. Molecular profiling data were available for most patients, with p53-mutated tumors being the most common subtype (36.1 % in the PDS group and 46.6 % in the IDS group), followed by MMR-deficient tumors (30.5 % in the PDS group and 26.6 % in the IDS group). The type of surgical approach (PDS vs. IDS) did not show a statistically significant correlation with disease-free survival (p = 0.523, log-rank test) or overall survival (p = 0.123, log-rank test). Similarly, molecular classification did not predict patient outcomes in terms of disease-free survival (p = 0.397, log-rank test) or overall survival (p = 0.797, log-rank test). Oncologic outcomes for patients with advanced endometrial cancer remain poor. Neoadjuvant chemotherapy continues to be a viable treatment option for patients with unresectable disease. A personalized approach to neoadjuvant therapy, taking into account histologic and molecular profiles, may improve survival outcomes in this patient population.

The effect of intramyometrial injection of terlipressin versus carbetocin on hemoglobin and blood loss during open myomectomy operations without using haemostatic tourniquets: Double blinded randomized placebo-controlled trial

Uterine fibroids are a significant worldwide health problem due to their high prevalence among women during the reproductive period. Conservative surgery such as myomectomy has been of increasing interest. However, intraoperative blood loss represents a challenge to the surgeons. Therefore, the aim of this study was to assess the efficacy of Intramyometrial injection of terlipressin and carbetocin in reducing intraoperative bleeding and preserving the hemoglobin level. We conducted the randomized, double-blind, placebo-controlled trial from February 2022 to April 2024, in the El-Resala and Al-Aseema hospitals under the direction of the National Research Center. A total of 99 eligible female patients out of 119 (13werenotmeetingtheinclusioncriteria) with uterine fibroid were recruited into the study and allocated into three groups (n = 33): terlipressin group (A), carbetocin group (B), and saline group (C). Blood loss was significantly different among groups (P < 0.001), being significantly lower in the Terlipressin group than the carbetocin group (mean = 321 vs 418 ml) and significantly lower in both groups than the saline (mean = 969 ml). The Terlipressin group required significantly less blood transfusion than the saline group (P < 0.05). The operative time and side effects were not statistically different among the three groups (P < 0.05). The operative time and side effects were not statistically different among the three groups. Our study provided evidence that terlipressin is effective in reducing blood loss during myomectomy with advantages over carbetocin. Based on our results, we recommend the adoption of terlipressin to improve myomectomy outcomes and enhance patient safety, further studies with a larger sample size is recommended to confirm our findings.

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy for Pseudomyxoma peritonei originating from ovarian teratomas: A single-center case series and literature review

Pseudomyxoma peritonei (PMP) is a complex malignant peritoneal tumor which generally originates from appendiceal mucinous tumors, but can more rarely arise from ovarian mature teratomas. Herein, we evaluated the treatment efficacy and safety of cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for PMP derived from ovarian mature teratomas. This study retrospectively analysed the clinical data of four patients with a mean age of 50.25 years treated between January 2021 and December 2024. The data included general patient information, surgical details, postoperative pathology, adjuvant therapies, and outcomes. Pathological findings confirmed ovarian mature teratomas in all cases. Peritoneal lesions included one case of acellular mucin, two cases of low-grade PMP, and one case of high-grade PMP with signet-ring cells. All patients underwent CRS with HIPEC treatment with no surgical complications. However, none achieved optimal cytoreduction. During follow-up, the patient with high-grade PMP and signet-ring cells had a postoperative survival time of 12 months, while the remaining patients continue to show good postoperative outcomes. Overall, CRS with HIPEC is a safe and effective treatment strategy for PMP originating from ovarian mature teratomas; even without achieving optimal cytoreduction, this therapy can extend survival and improve quality of life. However, high-grade PMP may require more aggressive treatment.

An effective surgical approach to treat obese patients with gynecological disease using a subcutaneous abdominal wall-retraction device to perform low-pressure laparoscopy: A prospective, single-center study

Laparoscopic surgery of obese patients still represents a real challenge in clinical practice. High-pressure pneumoperitoneum and steep Trendelenburg position are the main anesthesiologic indications to laparotomic conversion. The aim of this prospective study was to assess effectiveness and safety of low-pressure laparoscopic (LPL) procedures using a subcutaneous abdominal wall-retraction (LaparoTenser ®). We enrolled obese patients (BMI ≥ 30 kg/m A total of 33 patients were included in this study. The median age was 69 (range: 40-83), with a median BMI of 39 kg/m LPL technique using the LaparoTenser ® device is feasible and safe in morbidly obese patients. The wall-lifting device enables adequate viscera exposure creating a large intra-abdominal operative space avoiding the disadvantages of intraperitoneal high-pressure and CO

Sonographic features of ovarian malignancies in children and young adults – A case control study

To investigate whether ovarian cancer in children and young adults, display the same accepted sonographic features that raise suspicious of ovarian malignancy among adults, and whether sonographic features predict clinical behavior. A matched case-control study. The study group comprised all youngsters < 25 years of age diagnosed with ovarian cancer in a tertiary university hospital between the years 1995-2023. A control group with benign ovarian masses was matched according to age and year of diagnosis in a 2:1 ratio. Clinical data, sonographic features and disease outcomes were compared. The study group included 30 youngsters, 24 (80 %) of them had germ cell tumors, 4 (13.3 %) sex-cord tumors and two (6.7 %) were epithelial tumors. The control group included 60 youngsters, of them 27 (45 %) with mature teratomas, 25 (41.6 %) serous cystadenomas and 8 (13.4 %) with other benign ovarian tumors. In a univariate analysis, Palpation of mass (43.3 % vs. 15 %, p < 0.01), vomiting (33.3 % vs. 13.3 %, p = 0.02) and elevated tumor markers (79.3 % vs.21.6 %, p < 0.01) were more common in the study group. Malignant masses were larger (mean of maximal diameter 159 mm vs. 88 mm, p < 0.01), were more likely to contain a solid component (60 % vs. 21.7 %, P < 0.01), to have ascites (33.3 % vs. 3.3 %, P < 0.01) and to have a high color content on Doppler examination (50 % vs. 11.7 %, p < 0.01). These features remained significant also in a multivariable analysis. Disease recurrence was not associated with any sonographic parameters. sonographic features suspicious for ovarian mass malignancy among adult women are valid also among the young population. However, none of these features are associated with a worse clinical course.

Safety of niraparib-based regimens in patients with ovarian cancer: A systematic review and meta-analysis

Niraparib is approved as a maintenance treatment for ovarian cancer due to its potential to prolong progression-free survival. However, its widespread use is challenged by concerns about its safety profile. This systematic review and meta-analysis assesses the safety profile of niraparib in ovarian cancer treatment. A thorough literature search was done from inception to August 2024 using Embase, Cochrane Central Library, MEDLINE, and ClinicalTrials.gov. Randomized controlled trials (RCTs) and cohorts assessing the safety of niraparib in ovarian cancer were included. The primary outcome was adverse events. Review Manager was used to pool risk ratios (RR) with 95% confidence intervals (CIs) using the Mantel-Haenszel method for a random-effects analysis. Eight studies were included in this meta-analysis, consisting of 4 Phase III RCTs and 4 observational studies with 2344 patients. Niraparib was associated with a higher risk of adverse events (RR = 1.05; 95 % CI: 1.02-1.09). Although subgroup analyses for the primary outcome did not show significant variations, secondary outcomes revealed notable findings. It also increases the risk of hematological toxicities, including thrombocytopenia (RR 2.75, 95 % CI 0.62-12.20), anemia (RR 1.74, 95 % CI: 1.06-2.86), and neutropenia (RR 1.63, 95 % CI: 1.04-2.54) with increased rates of treatment interruptions (RR 2.05, 95 % CI: 0.85-4.96) and dose reductions (RR = 2.35, 95 % CI: 0.89-6.17). Our meta-analysis suggests that niraparib is associated with a tolerable safety profile in ovarian cancer maintenance treatment, with hematological toxicities being the primary concern. Further large-scale RCTs are essential to validate these findings and develop standardized safety protocols.

Mucinous ovarian carcinoma: Impact of ovarian stimulation, hormonal contraception, and hormone replacement therapy

Unlike high-grade serous carcinoma (HGSC), which mainly affects postmenopausal women, mucinous ovarian carcinoma (MOC) affects younger patients, with a median age at diagnosis of 53 years, and is rare among premenopausal women. After they receive anticancer treatment, these women encounter specific issues involving fertility preservation (FP) and/or pregnancy, which potentially require assisted reproductive technology (ART) as well as the prescription of hormonal contraception (HC) or hormone replacement therapy (HRT). We reviewed the available literature in PubMed/Medline concerning the risks of the development of ovarian cancer (OC), including MOC, associated with ART, HC and HRT, and literature on the impact of ovarian stimulation in the context of FP and/or ART, HC and HRT in women previously treated for OC, including MOC. MOC is usually a nonhormone-sensitive tumour. In the context of ART, ovarian stimulation is not associated with an increased OC risk. However, data that evaluate the impact of ovarian stimulation in the context of FP or ART after OC, including after MOC, are still scarce. Oral contraception, contraceptive implant or levonorgestrel intrauterine device use are associated with decreased OC risk. This protective effect does not seem to occur in MOC, and no data have been published concerning contraceptive use after OC. HRT is associated with an increased risk of OC, but the risk of MOC is not modified in HRT users when considering histological subtypes. HRT after OC is associated with better overall survival but does not seem to affect disease-free survival. However, since the data are insufficient, it is not feasible to draw robust conclusions in the specific context of MOC. Overall, data on the impact of oral contraceptive and HRT use on the risk of MOC are reassuring. Despite little specific data on the impact of HRT after MOC, data on OC (all histological types) survivors are encouraging. Data concerning the effects of contraceptive use and ovarian stimulation in the context of FP or ART in OC survivors are still lacking. Therefore, the findings from prospective or larger studies in these two groups would help to counsel MOC survivors on contraceptive and fertility options.

CD63 as a potential biomarker for patients with ovarian cancer

Exosomes play an important role in regulating physiological processes and mediating the systemic dissemination of various types of cancer. We investigated the association of exosomal tetraspanins CD9, CD63, and CD81 in patients with ovarian cancer (OC). We measured the plasma tetraspanins CD9, CD63, and CD81 by enzyme-linked immunosorbent assay in 91 patients who underwent treatment for OC between April 2018 and March 2024. Additionally, we analyzed clinical pathologic factors, chemotherapy response, and prognosis. In terms of stages, CD63 expression was significantly higher in patients with stage IV compared to those with stage I OC (p = 0.003). In terms of histological type, CD63 expression was significantly higher in high-grade serous carcinoma (HGSC) than in clear cell carcinoma (CCC) with OC (p = 0.009). Furthermore, CD63 levels were significantly higher in advanced-stage, HGSC than in patients with early-stage, non-HGSC and early-stage, HGSC OC (p = 0.045 and p = 0.002, respectively). In the Neoadjuvant chemotherapy (NAC) of 12 patients with OC assessed as having either a partial response (PR) or complete response (CR), CD63 was significantly decreased (p = 0.043), whereas perforin was significantly increased (p = 0.001). In the NAC of 16 patients with OC, CD63 of the response rate to chemotherapy tended to differ between the progressive disease (PD) and PR/CR groups (p = 0.056). A moderate inverse correlation was observed between CD63 and perforin levels (R = 0.638, R CD63 could be a potential biomarker for all types of OC patients.

Risk factors for venous thromboembolism in patients undergoing neoadjuvant chemotherapy as treatment for ovarian cancer

During the treatment of ovarian cancer, the risk of venous thromboembolism (VTE) post operatively is well established, however, patients may be at even greater risk during neoadjuvant chemotherapy (NACT). This study aimed to determine the incidence and timing of VTE amongst patients undergoing NACT, whether there was an association with survival, and examine risk factors associated with the development of VTE. This was a retrospective cohort study of patients diagnosed with ovarian, fallopian tube and primary peritoneal cancer receiving neoadjuvant chemotherapy betweenApril 2011 and April 2022 at a gynaecological cancer centre in England. Clinical factors examined included: age at diagnosis, Body Mass Index (BMI), presence of inflammatory co-morbidity, tumour morphology, stage of disease, pelvic mass,ascites,retroperitoneal lymphadenopathy, Khorana score, serum albumin levels, chemotherapy regime, bevacizumab administration and Ca 125 levels. Of 304 patients analysed, 73 (24%) patients developed venous thromboembolism. Of the patients who developed VTE, fifty-five patients developed pulmonary embolism (75%) and the stage of treatment at which most VTEs were diagnosed was neoadjuvant chemotherapy (32%). There was no correlation observed, between the incidence of VTE and any risk factors, including Khorana score, with the exception of low albumin (<35 g/L)(odds ratio (OR):2.1(95%CI 1.1-3.9; p = 0.06) and patients who did not receive paclitaxel chemotherapy (OR:2.04(95%CI 1.02-4.05; p = 0.08). There was no difference in survival rates between the VTE group and the non-VTE group. This study demonstrates high rates of VTE, especially pulmonary embolism, in ovarian cancer patients undergoing NACT. The present study, amongst others in the literature also suggest that the risk of VTE in ovarian cancer patients undergoing NACT is underestimated by current risk stratification models. Therefore, prospective trials dedicated to ovarian cancer patients specifically, and a development of a risk model that takes into account factors established by higher levels of evidence, are strongly recommended.

Haematological toxicity of PARP inhibitors in advanced ovarian cancer: A systematic review and meta-analysis

Poly (ADP-ribose) polymerase inhibitors (PARPis) are effective treatment options for patients with advanced ovarian cancer (OC). A typical adverse event (AE) of these agents is haematological toxicity, which represents the leading cause of treatment modification and discontinuation. This systematic review and meta-analysis aimed to analyse the risk of haematological AEs, including anaemia, neutropenia and thrombocytopenia due to the use of PARPis in patients with OC. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. PubMed, EMBASE and Cochrane databases, and international meeting abstracts were searched systematically for clinical trials concerning the use of PARPis in patients with OC. The search deadline was 30 March 2024. The pooled incidence of all grades and grade 3or more (≥G3) anaemia, neutropenia and thrombocytopenia were analysed. Subsequently, risk ratios (RRs) were calculated for all grades and ≥G3 AEs of PARPis compared with non-PARPis from randomized controlled trials. In total, 12 phase II/III trials with olaparib, niraparib and rucaparib were included in this study. Anaemia was the most common all grade (28.8 %) and ≥G3 (12.1 %) AE. The administration of PARPis increased the risk of developing all grade anaemia [risk ratio (RR) = 2.44], neutropenia (RR = 3.15) and thrombocytopenia (RR = 4.66) significantly compared with non-PARPis. Similarly, a significant increase in the risk of ≥G3 anaemia (RR = 5.73) and thrombocytopenia (RR = 5.44), and a non-significant increase in the risk of neutropenia (RR = 3.41) were detected. In patients with advanced OC, PARPis increase the risk of haematological toxicity compared with other treatments (high-quality evidence). Clinicians should be aware of this risk and the correct management, as these drugs are highly employed in these patients.

Laparoscopic surgical access in morbidly obese women undergoing endometrial cancer surgery: Repurposing the left upper quadrant approach

The study purpose was to report the outcomes of patients undergoing endometrial cancer surgical staging with laparoscopic abdominal access entry using a left upper quadrant (LUQ) access technique. This was a retrospective cohort study conducted from 1 January 2013 to 1 January 2018. The setting was an academic, single institution gynecologic oncology service with a high volume of minimally invasive surgery (MIS). The patient cohort included obese (defined as BMI > 30 kg/m In total, 317 patients were included with a median age of 54 years (range, 24-79) and median BMI 42.5 kg/m A LUQ abdominal technique is a safe and reliable method of laparoscopic access in morbidly obese women undergoing MIS for endometrial cancer staging. This may be the preferred method of laparoscopic access for women with a panniculus or central adiposity, given the caudal displacement of the umbilicus and poor correlation with intraperitoneal anatomic landmarks in this setting.

Ultra-radical surgery versus standard-radical surgery for the primary cytoreduction of advanced epithelial ovarian cancer; long-term tertiary center experiences

To compare overall survival (OS) and morbidity outcomes in patients with advanced epithelial ovarian/tubal/peritoneal cancer undergoing standard-radical (SR) and ultra-radical (UR) surgical procedures based on NICE classification. This retrospective study analyzed data from 282 patients with 2014 FIGO stage III-IV epithelial ovarian cancer operated on between January 2006 and January 2019. The study compared OS, progression-free survival (PFS), and morbidity between SR and UR surgeries. Parameters influencing OS, including preoperative, postoperative, and post-adjuvant chemotherapy CA-125 values, surgical procedures, post-surgical residual tumor, histopathological grade, and FIGO surgical stage, were assessed. Out of 282 patients, 256 met the inclusion criteria. SR surgery was performed in 48 %, and UR surgery in 52 %. The mean preoperative CA-125 value was 1200 ± 1914.83, decreasing to 240.32 ± 373.87 postoperatively. The mean follow-up period was 63.01 ± 47.56 months. UR surgery correlated with significantly higher postoperative complications (p < 0.001), histopathological grade (p = 0.023), FIGO stage (p < 0.001), three-year death rates, and overall mortality rates (p = 0.035). FIGO stage and total metastatic lymph nodes emerged as independent prognostic factors for overall and PFS. In the treatment of epithelial ovarian cancer, evaluating the extent of the tumor before the surgery and showing maximal effort to minimize the residual tumor volume instead of applying UR procedures as the first choice seems to be the most important factor that can affect survival.

Optimization of HPV-positive women triage with p16/Ki67 dual staining cytology in an organized cervical cancer screening program in the center region of Portugal

Organized cervical cancer (CxCa) screening is the most effective secondary prevention method to decrease the disease incidence and mortality. Screening for infection with 14 high-risk HPV genotypes (hrHPV) is recommended as primary screening test. Since only ca. 6 % of HPV-positive (HPV+) women will develop a high-grade lesion in 5 years, triage is critical for risk stratification and management of colposcopy resources. Dual staining (DS) p16/Ki67 cytology is an alternative to Papanicolau cytology (PAP) for triage of HPV+women, with potential improvements in sensitivity and specificity, and optimization of colposcopy referrals. To compare PAP vs DS cytology in terms of (i) optimization of referrals for colposcopy and (ii) risk stratification to better define the follow-up interval. Retrospective analysis of the CxCa screening database of Centro Hospitalar Universitário de Coimbra (CHUC), one of the centralized diagnostic laboratories for the CxCa screening program of the central region of Portugal, between July 2019 and May 2023. At CHUC, since July 2019, all samples from hrHPV+women have been triaged with liquid PAP and tested with DS cytology. At baseline (1032 HPV+women), 1028 women were tested with DS: 739 women were DS negative (DS-) [70.7 % with normal PAP cytology (NILM) and 29.3 % with abnormal PAP cytology (ASC-US+)], and 289 were DS positive (DS+) (1.1 % NILM and 98.6 % ASC-US+). DS positivity as referral criterion for colposcopy instead of ASC-US+would have reduced the number of colposcopies by 39.4 % overall and by 48.3 % for other 12 hrHPV, while improving the number of colposcopies per HSIL (3.9 vs. 2.4 overall and 4.9 vs. 2.9 for other 12 hrHPV). In this cohort, if the follow-up interval for women positive for other 12 hrHPV+and DS- would have been extended from 1 to 3 years, 799 follow-up consultations, 799 HPV re-tests, and 277 colposcopies (-64.7 %) would have been avoided, with an overall risk of missed HSIL lesions of 2.2 %. Triage with DS allows the optimization of colposcopy referrals and a safe extension of the follow-up interval to 3 years for other 12 hrHPV+/DS- women, eliminating the need for annual re-testing for many women.

Exploring metastasis and recurrence patterns in low-risk grade 3 endometrial cancer: A multicenter retrospective cohort study

Females with low-risk endometrial cancer typically have low lymph node metastasis risk and promising prognosis without lymphadenectomy. However, the impact of grade 3 endometrial cancer on nodal involvement, recurrence, and prognosis within this specific subgroup remains unclear. Therefore, in this study, we aimed to investigate the prognosis, patterns of metastasis, and recurrence in a subgroup of females with grade 3 early-stage low-risk endometrioid endometrial cancer. We identified patients from the endometrial cancer cohorts of seven institutional hospitals. The study included patients who underwent hysterectomy between January 2013 and December 2021 with preoperative endometrioid histological type, less than half myometrial invasion, no tumor spread outside the corpus on imaging, normal CA-125 level, and histological grade 3. The clinicopathological characteristics and survival outcomes of the patients were collected. Recurrence-free survival was estimated using the Kaplan-Meier method and compared using the log rank test. Overall, 36 patients were included in this analysis. Of the 33 patients who underwent lymphadenectomy, 1 (1/33, 3.0 %) had lymph node metastasis and 27 (75.0 %) received adjuvant therapy. At a median follow-up of 58 months, three females (8 %) had recurrence and all cases involved lymph nodes. The 5-year recurrence-free survival was 88.7 %. No significant difference was observed in the recurrence-free survival between females who did and did not undergo lymphadenectomy (p = 0.554). Females diagnosed with low-risk grade 3 endometrial cancer typically have favorable prognosis. However, lymph node metastasis and recurrence risks still exist, with all recorded instances of recurrence involving lymph nodes.

Empowering gynaecologists with Artificial Intelligence: Tailoring surgical solutions for fibroids

In recent years, the integration ofArtificial intelligence (AI) into various fields of medicine including Gynaecology, has shown promising potential. Surgical treatment of fibroid is myomectomy if uterine preservation and fertility are the primary aims. AI usage begins with the involvement of LLM (Large Language Model) from the point when a patient visits a gynecologist, from identifying signs and symptoms to reaching a diagnosis, providing treatment plans, and patient counseling. Use of AI (ChatGPT versus Google Bard) in the surgical management of fibroid. Identifyingthe patient's problems using LLMs like ChatGPT and Google Bard and giving a treatment optionin 8 clinical scenarios of fibroid. Data entry was done using M.S. Excel and was statistically analyzed using Statistical Package for Social Sciences (SPSS Version 26) for M.S. Windows 2010. All results were presented in tabular form. Data were analyzed using nonparametric tests Chi-square tests or Fisher exact test.pvalues < 0.05 were considered statistically significant. The sensitivity of both techniques was calculated. We have used Cohen's Kappa to know the degree of agreement. We found that on the first attempt, ChatGPT gave general answers in 62.5 % of cases and specific answers in 37.5 % of cases. ChatGPT showed improved sensitivity on successive prompts 37.5 % to 62.5 % on the third prompt. Google Bard could not identify the clinical question in 50 % of cases and gave incorrect answers in 12.5 % of cases (p = 0.04). Google Bard showed the same sensitivity of 25 % on all prompts. AI helps to reduce the time to diagnose and plan a treatment strategy for fibroid and acts as a powerful tool in the hands of a gynecologist. However, the usage of AI by patients for self-treatment is to be avoided and should be used only for education and counseling about fibroids.

Stage II endometrial cancer: The diagnostic power of hysteroscopic excisional biopsy and MRI in the pre-operative cervical stroma assessment

Stage II Endometrial cancer (EC) accounts only for 12% of cases. Recent evidences redraw the weight of radicality in this stage as it would seem to have no impact on survival outcomes claiming for radicality when free surgical margins are not ensured to be achieved by simple hysterectomy. Thus, an accurate pre-operative evaluation might be crucial. This study aims to estimate the diagnostic power of Hysteroscopic excisional biopsy (HEB) of cervical stroma alone and combined with Magnetic resonance imaging (MRI) to predict the stage and concealed parametrial invasion in patients with preoperative stage II EC. From January 2019 to November 2023, all patients evaluated at the Department of Gynaecology Oncology of Humanitas, Istituto Clinico Catanese, Catania, Italy, with a diagnosis of EC and evidence of cervical stromal diffusion on preoperative MRI and/or office hysteroscopy evaluation, considered suitable for laparoscopic modified type B hysterectomy, were consecutively included in the study. These underwent endometrial and cervical hysteroscopy excisional biopsy (HEB) for histological evaluation before definitive surgery. The data obtained were compared with the definitive histological examination (reference standard). Sixteen patients met the including/excluding criteria and were considered into the study. Stage II endometrial cancer were confirmed in 3 cases (18.7%). We reported 2 (12,5%) parametrial involvement (IIIB), 4 (25%) cases of lymph nodes metastasis (IIIc), 7 (43,7%) cases of I stage. MRI had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy (95% CIs) of 71%, 44%, 50%, 66% and 56.2 % respectively. HEB showed sensitivity, specificity, PPV, NPV and accuracy (95 % CI) of 85 %, 89 %, 85 %, 88 % and 87 % respectively. Comparing HEB + MRI to HEB alone, no statistical differences were noted in all fields. Considering parametrial invasion, MRI had better sensitivity but there were no statistical differences to HEB in other fields, showing both a worthy NPV. HEB was accurate in all fields for cervical stroma assessment and had a fine NPV to exclude massive cervical involvement up to parametrial. Considering the new FIGO staging a preoperative molecular and histological evaluation of the cervical stroma may be useful. Operative hysteroscopy seems to be a feasible and accurate method for this purpose.

Evaluation of serum CA125, HE4 and CA724 and the risk of ovarian malignancy algorithm score in the diagnosis of high-grade serous ovarian cancer

To develop a new algorithm for the detection of high-grade serous ovarian cancer (HGSOC). Patients diagnosed with HGSOC, borderline ovarian tumours (BOTs) or benign ovarian masses (BOMs) were enrolled between February 2019 and December 2020. Patients with BOTs or BOMs were grouped as non-HGSOC. The cases were divided randomly into a training cohort (two-thirds of cases) and a validation cohort (one-third of cases). Logistic regression was used to find risk factors for HGSOC and to create a new algorithm in the training cohort. Receiver operating characteristic curves were used to compare the diagnostic value of tumour biomarkers. Sensitivity and specificity of tumour markers and the new algorithm were calculated in the training cohort and validation cohort. This study found significant differences in age; BRCA1/2 mutation status; CA125, CA724 and HE4 levels; and Risk of Ovarian Malignancy Algorithm score between the two groups.Logistic regression analysis showed that CA125 and BRCA1/2 were risk factors for HGSOC. A new algorithm combining CA125 and BRCA1/2 increased the specificity of CA125 for diagnosis of HGSOC. The new algorithm had sensitivity of 81.08% and specificity of 93.10% in the training cohort. The new algorithm using CA125 and BRCA1/2 helped to distinguish between patients with HGSOC and patients with non-HGSOC.

Regular follow-up with cervical cytology is of questionable value following surgical treatment of microinvasive cervical cancer

To assess the follow-up smears and their outcomes of patients with conservatively managed early-stage cervical cancer as per UK guidelines within our service. To evaluate whether intensive follow-up can detect pre-cancer early compared to the standard 3 yearly follow-up. Retrospective review. All patients treated for early stage (stage 1A1 and 1A2) with cervical cancer from 01/2002 to 01/2020 at University Hospitals of Derby and Burton were included. Patients who had initial hysterectomy were excluded from our analysis. Review conducted using electronic patient records for treatment, histology, and follow-up smears. Number of abnormal follow-up smears and number of recurrent cervical cancers were considered the main outcome measures. 98 cases were identified. 81 (82.65 %) were stage 1A1 and 17 (17.35 %) were stage 1A2. 74 (75.51 %) patients had squamous histology and 24 (24.49 %) had adenocarcinomas. Median follow-up was 11.08 years (4043 days). 510 follow-up smears were performed, of which 33 (6.47 %) were abnormal. 5 of these abnormal smears showed low grade dyskaryosis (0.98 %) and 2 smears showed high grade dyskaryosis (0.39 %). The positive predictive value of follow-up smears to detect pre-cancerous changes was 5.71 %. There were no recurrent cancers detected. Microinvasive cervical cancer is effectively managed with conservative surgery. There were no recurrent cancers detected in our cohort during follow-up and there were only 2 high grade dyskaryoses detected (n = 2/510, 0.39 %). We therefore believe that reducing the intensity of follow up of these patients should be considered.

Chemotherapy response score as a predictor of survival in ovarian cancer patients

The chemotherapy response score (CRS) has been widely adopted as a predictive tool for ovarian cancer survival. In the present study, we seek to define differences in survival rates among patients grouped in the traditionally established three-tiered system and those who have not been offered debulking surgery. We designed a retrospective cohort study involving women treated with chemotherapy and offered interval or late debulking surgery for ovarian cancer. Twenty-eight women were not considered for a debulking procedure for various reasons. Of the 89 women who were finally offered interval debulking or late debulking surgery, 28 had a CRS 1 score, 34 had a CRS 2 score and 27 had a CRS 3 score. Significant differences were noted in the progression-free survival (PFS) and overall survival (OS) of patients based on the CRS stratification, although survival rates were considerably longer for all three groups compared to those of patients who were not offered surgery. Cox regression univariate analysis revealed that suboptimal debulking and CRS 1 or no surgery had a significant negative impact on PFS and OS rates. The binary stratification of CRS (CRS 1-2 vs CRS 3) revealed comparable differences in the PFS and OS to those in the groups that were stratified as platinum resistant and platinum sensitive. The chemotherapy response score is a significant determinant of ovarian cancer survival that helps evaluate the risk of early disease relapse and death and may soon be useful in guiding patient-tailored treatment.

Oncologic and reproductive outcomes after fertility-sparing surgery for bilateral borderline ovarian tumors: A retrospective study

To investigate the oncological safety and fertility outcomes of different fertility-sparing surgery procedures for bilateral borderline ovarian tumors (BOTs) and to identify the safest and most effective approach to help patients conceive with minimal risk. A retrospective study of 144 patients (≤40 years) with pathologically confirmed bilateral BOTs were included in the study.The effects of surgery type on fertility outcome and recurrence were compared. Cox regression analysis was employed to determine potential prognostic factors. Survival analysis utilized the Kaplan-Meier method. Three therapeutic modalities were applied in our study, including bilateral ovarian cystectomy (BOC; n = 29), unilateral adnexectomy + contralateral cystectomy (UAC; n = 4) and radical surgery (n = 61). Totally 33 cases (22.9 %) relapsed during the follow-up period. In 37 % of cases administered conservative surgery, relapses were diagnosed in the first 2 years. Only conservative surgery and adjuvant chemotherapy were risk factors for recurrence. Meanwhile, a pregnancy rate of 55.4 % was obtained in patients with bilateral BOTs. The pregnancy rate was slightly higher but no significant (P = 0.539) difference in patients treated with BOC (n = 17, 63 %) compared with UAC (n = 29, 55.8 %) group. GnRHa treatment significantly improved the clinical pregnancy rate in this study(P = 0.029). Satisfactory pregnancy rate can be achieved after conservative surgery in patients with bilateral BOTs. BOC is worth recommending for bilateral borderline ovarian tumors and a critical factor in fertility is the preservation of maximum healthy ovarian tissue. Patients should make a pregnancy plan in 2 years after the first surgery. GnRHa increase the rate of successful clinical pregnancies.

A systematic review of association between use of hair products and benign and malignant gynecological conditions

Hair products often contain chemicals like para-phenylenediamine (PPD) and endocrine-disrupting chemicals (EDCs); giving rise to concerns about the possible adverse effects such as hormonal disturbances and carcinogenicity. The objective of this systematic review was to evaluate the association between the use of different hair products and benign and malignant gynecological conditions. Studies were identified from three databases including PubMed, Embase, and Scopus, and evaluated in accordance with PRISMA guidelines. The risk of bias was assessed using the Newcastle-Ottawa Scale. A total of 17 English-language studies met the inclusion criteria. Associations of hair relaxer or hair dye use with breast and ovarian cancer were observed in at least one well-designed study, but these findings were not consistent across studies. Further sub-analysis showed 1.08 times (95 % CI: 1.01-1.15) increased risk of breast cancer in females with permanent hair dye use. Chang et al. reported strong association between uterine cancer risk and hair relaxer use (HR 1.8, 95 % CI: 1.12-2.88), with no observed association with hair dye use. Studies conducted by Wise et al. and James-Todd et al. for benign gynecological conditions; including uterine leiomyoma (IRR 1.17, 95 % CI: 1.06-1.30), early onset of menarche (RR 1.4, 95 % CI: 1.1-1.9), and decreased fecundability (FR 0.89, 95 % CI: 0.81-0.98) revealed positive associations with hair relaxer use, but these findings were based on small sample sizes. In summary, the available evidence regarding personal use of hair products and gynecological conditions is insufficient to determine whether a positive association exists.

Assessment of oncological safety and utility of hysteroscopy in high grade endometrial cancers: Results from an Israel gynecologic oncology group study

To compare survival measures of women with Stage I high-grade endometrial cancer who underwent either hysteroscopy or a non-hysteroscopic procedure as a diagnostic procedure. 298 patients with stage I high grade endometrial cancer who underwent surgery between 2002 and 2014. Patients were divided into two groups: hysteroscopy and non-hysteroscopy (curettage or office endometrial biopsy). Clinical, pathological, and survival measures were compared between the groups. High grade histology included endometroid grade -3, uterine serous papillary carcinoma, clear cell carcinoma, and carcinosarcoma. There were 71 patients in the hysteroscopy group and 227 patients in the non-hysteroscopy group. The median follow-up was 52 months (range 12-120 months). There were no differences between the groups in the 5-year recurrence-free survival (73.9 % vs. 79.7 %; p = 0.65), disease-specific survival (79.3 % vs. 83.6 %; p = 0.87), and overall survival (65.7 % vs. 80.3 %; p = 0.35). Hysteroscopic diagnosis in women with early-stage and high-grade endometrial cancer does not adversely affect the survival outcomes.

Detection and dissection of sentinel nodes in endometrial endometrioid cancer with indocyanine green using PinPoint laparoscopy: Analysis of the learning curve

Early-stage endometrial endometrioid adenocarcinoma is managed through laparoscopic total hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Detection of positive nodes is rare, and lymphadenectomy may involve complications. Pelvic sentinel lymph node dissection can prevent complete dissection. Herein, we evaluated the learning curve of sentinel lymph node dissection using indocyanine green. All surgeries for endometrial endometrioid adenocarcinoma were performed laparoscopically with indocyanine green to detect sentinel nodes. The primary outcome was the ability to identify and resect sentinel lymph nodes on each side. The secondary outcome was correspondence between the frozen section histology of the nodes with the final histology. Among 31 patients with endometrial endometrioid adenocarcinoma treated between October 2018 and August 2020, 29 who underwent laparoscopy using indocyanine green were enrolled. Complete lymphadenectomy was performed in 16 patients. Failure to recognize sentinel nodes on right and left sides occurred in 10.34% and 0% of cases, respectively. The median number of recognized and dissected sentinel nodes was 1 on both sides (range 0-5). One patient had a lymph node positive for malignancy on histology (3.45%) on both sides. There were 13 and 14 cases of negative frozen sections on the right and left sides, respectively, and 1 case of a positive frozen section with positive whole pelvic lymph nodes. Sentinel node dissection using indocyanine green in endometrial endometrioid adenocarcinoma has a distinct learning curve; however, it is practical and achievable for skilled surgeons.

Relaxin as a potential diagnostic biomarker for ovarian cancer- A prospective study

Ovarian cancer is a leading cause of female mortality worldwide. Although novel approaches on this disease have been developed, overall survival rates remain moderate due to the lack of scientific evidence promoting screening at early stages of the disease. A number of biomarkers have been suggested as predictive for this type of cancer. The role of relaxin in endometrial cancer is well documented but the scientific evidence is lacking with regards to ovarian cancer. We studied patients with ovarian cancer, benign ovarian cyst and healthy patients too. The levels of relaxin have been found to be an adequate diagnostic biomarker for ovarian cancer. We also presented the different range of Ca125, HE4 and ROMA in these three groups. Randomised control trials need to be conducted though, in order to elucidate the true role of relaxin in these cases.

A systematic review and meta-analysis of hormone receptor expression in low-grade serous ovarian carcinoma

Serous ovarian carcinoma is the most common histological type of ovarian cancer, with high-grade serous ovarian carcinoma (HGSOC) being more common than low-grade serous ovarian carcinoma (LGSOC). Despite pathogenic and clinical differences, both grades of serous ovarian carcinoma share the propensity to express receptors for the female hormones - oestrogen (ERs) and progesterone receptors (PRs) - albeit in differing frequencies. Systematic review and meta-analysis of studies reporting the expression of hormone receptors in LGSOC, and comparison with expression in HGSOC. Expression of ERs is observed in 80.7 % of patients with LGSOC [95 % confidence interval (CI) 72.2-89.1 %] and 61.5 % of patients with HGSOC (95 % CI 38.8-84.1 %). Expression of PRs is observed in 54.4 % of patients with LGSOC (95 % CI 44.3-64.4 %) and 30.7 % of patients with HGSOC (95 % CI 15.7-45.7 %). A higher percentage of LGSOCs are positive for ER expression compared with HGSOCs. Similarly, a higher percentage of LGSOCs are positive for PR expression, although PR expression is lower than ER expression. Expression of hormone receptors may represent a therapeutic opportunity for treatment with agents that block their activity, especially in LGSOC which is less responsive to chemotherapy and therapeutic options are limited.

Risks factors for anastomotic leakage in advanced ovarian cancer: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to summarise the available evidence on the pre- and intra-operative risk factors for anastomotic leakage (AL) after bowel resection and anastomosis for ovarian cancer (OC). We searched online databases from Pubmed, Scopus, ScienceDirect, and Cochrane Library from inception to October 2020. Pre- and intra-operative risk factors for AL were considered as the primary outcomes. Research heterogeneity and bias were evaluated by I The overall AL rate after OC surgery (median ± SD) was 5.3 ± 12% (277 AL on 5178 anastomoses). Thirteen non-randomised studies were included in the meta-analysis enrolling a total of 3274 patients. Pre albumin level ≤ 3 gr/dl, multiple bowel resections and primary cytoreductive surgery were associated with a significantly high risk of AL with a pooled OR of 5.29 (95% CI: 1.51-18.59), OR = 4.4 (95% CI: 1.19-16.66) and OR = 1.71 (95% CI: 1.05-2.77), respectively. Optimal cytoreduction, ASA score, ascites, and protective stoma were not associated with an increased risk of AL. Based on the best available evidence, preoperative albumin level <3 gr/dl, multiple bowel resections and primary cytoreductive surgery were associated with an increased risk for AL after bowel surgery for OC.

Long-term post-recurrence survival outcomes in young women receiving fertility-sparing surgery for epithelial ovarian cancer

The aim of this study was to investigate long-term post-recurrence survival outcomes in young women receiving fertility-sparing surgery (FSS) to verify the feasibility of the limited surgery for epithelial ovarian cancer (OvCa). We performed a regional multicenter retrospective study from January 1986 and March 2020, using clinical data corrected under the central pathological review system. Patients with recurrent tumor after surgery for stage I epithelial OvCa, aged equal or younger than 45 years were included for this study. We evaluated effect of FSS regarding long-term post-recurrence survival with statistical adjustment of propensity score-based method. With the Kaplan-Meier method, original and adjusted survival curves were estimated for recurrence-after survival of patients with (n = 14) and without FSS (n = 26). Median time to disease-specific death was 18.6 months. In both original and adjusted cohorts, there were no significant difference between the two groups (log rank test; P > 0.05). Hazard ratio of disease-specific death was 1.264 (95% confidence interval, 0.563-2.836; P = 0.570) in original and 1.354 (95% confidence interval, 0.702-2.611; P = 0.366) in adjusted population. This result indicated that patients with FSS was not associated with poorer prognosis for recurrence-after survival than those without. When comparing patients not receiving FSS, patients receiving FSS with recurrence at spared ovary followed not significantly different survival outcome as well as those with extra-ovarian recurrence. There was no significant difference of long-term post-recurrence survival outcomes between patients of epithelial OvCa with and without FSS in young women of reproductive age.

Extragonadal teratomas in women and adolescent girls: A systematic review

Extragonadal teratomas (EGTs) are rare and the commonest intra-abdominal subtype is omental. We present two cases: 1) a parasitic omental teratoma likely secondary to auto-amputation of an ovarian teratoma with subsequent omental reimplantation and 2) an omental immature teratoma likely due to parthenogenetic activation of displaced primordial germ cells. We subsequently conduct a systematic review to characterise EGTs. We sourced for English, peer-reviewed case reports of extragonadal teratomas in women and female adolescents aged 11 and above published from inception of each database through 31st June 2020 following PRISMA guidelines. Two authors reviewed each case for appropriateness and each case was graded for methodological quality utilising a modified Newcastle Ottawa Scale. PROSPERO Registration Number: CRD42020190131 RESULTS: Upon literature review between 1920-2020, from an initial screen of 818 articles, 67 articles were selected featuring 70 cases. One case featured an immature teratoma while the remaining were mature. Omental EGTs were the most common (56.5 %) followed by Pouch of Douglas and uterosacral ligament (23.2 %) and upper abdomen (14.5 %). There were statistically significant differences in EGT mean sizes between each location with the largest being in the upper abdomen (10.9 cm) and the smallest being in the adnexa or hernia (6.2 cm). Auto-amputation was deemed the commonest cause amongst omental EGTs (55.3 %) and Pouch of Douglas and uterosacral ligament EGTs (37.5 %) while 70 % of upper abdominal EGTs were likely due to displaced primordial germ cells. We characterise clinical features associated with each pathogenic mechanism and imaging characteristics of EGTs. Characterisation of EGT tumour marker profiles was limited as only 42.9 % of cases reported them but 19.2-25.0 % had raised tumour markers. The main risks are torsion, rupture, immature components and potential malignant change of the cell lines. Treatment is largely surgical. The mean size of EGTs approached laparoscopically and via laparotomy was 5.23 cm and 9.16 cm respectively. While rare, EGTs should be considered when evaluating pelviabdominal masses with imaging characteristics consistent with teratomas. Confirmation is usually intraoperative and a laparoscopic approach is reasonable if there is good surgeon comfort and the size is about 5 cm.

Postoperative adjuvant dose-dense chemotherapy with bevacizumab and maintenance bevacizumab after neoadjuvant chemotherapy for advanced ovarian cancer: A phase II AGOG/TGOG trial

The objective of this study is to evaluate the safety and efficacy of adding bevacizumab to dose-dense adjuvant chemotherapy with bevacizumab maintenance after neoadjuvant chemotherapy (NAC) and interval debulking surgery (IDS) for stage III/IV ovarian, tubal, and primary peritoneal cancer. This phase II clinical trial using Simon's minimax two-stage design was conducted. At the first stage, 13 subjects were enrolled, and the trial would proceed to second stage if ≤3 subjects discontinued treatment for study-defined significant adverse events (AEs). Patients with stage III/IV ovarian, tubal, and primary peritoneal cancer deemed not feasible for primary cytoreductive surgery were enrolled after 3-4 cycles of NAC and IDS without disease progression. NAC could be either weekly paclitaxel (80 mg/m Of the 22 enrolled subjects, 13 (59.1 %) had no gross lesion after IDS. Of the 13 subjects enrolled on the 1 st stage, one study-defined significant AE occurred, therefore the trial proceeded to the 2nd stage (n = 9). The median progression-free survival (PFS) was 22.1 months (95 % confidence interval [CI], 13.7-30.5), and the median overall survival (OS) was 49.2 months (95 % CI, 33.8-64.6). Peritoneal Cancer Index score at entering abdomen during IDS was significant for PFS (>12 vs ≤ 12: p = 0.003). One of the 22 subjects did not receive any study treatment. In the safety analysis (n = 21), grade 3/4 AEs included thrombocytopenia of 38.1 %, neutropenia 71.4 %, and anemia 28.6 %. Study-defined significant AEs of bowel perforation, poor-healing wound, and hypertension were found in 1 case each, respectively. This phase II trial demonstrated adding bevacizumab to dose-dense adjuvant chemotherapy with bevacizumab maintenance after NAC was feasible with tolerable toxicity and comparable PFS/OS as compared to other studies using bevacizumab in the NAC phase or dose-dense scheduling throughout.

Transvaginal excision of vaginal paraurethral leiomyoma: A video case report

Vaginal leiomyomas are uncommon benign tumors of the genital district that appear as a circumscribed, mobile, and nontender mass along the vaginal tube. The gold standard of vaginal leiomyoma management is surgical treatment. We aimed to present a clinical case of vaginal leiomyoma successfully treated throughout a transvaginal excision and layered repair. A 44-year-old woman was referred to our division for vaginal bulging symptoms and dyspareunia. Clinical examination revealed a 4-5 cm hard bulging mass in the anterior vaginal wall, below the urethra, compatible with vaginal leiomyoma. After proper counseling, the patient was admitted to transvaginal leiomyoma excision plus primary layered repair. No surgical complications were observed. The indwelling catheter was removed the day after the surgery. The patient was successfully discharged home on postoperative day 1. The patient is currently asymptomatic and there are no signs of recurrence. The procedure was successful in obtaining anatomical repair and relieving symptoms. This approach represents a valid procedure for the surgical management of this uncommon condition.

Laboratory parameters as predictors of prognosis in uterine cervical neoplasia

The aims of study were to assess platelet counts, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), RWD (red cells distribution width) and fasting glucose in patients with cervical intraepithelial neoplasia (CIN) and invasive cervical cancer; and to relate these parameters to prognostic factors and survival in cervical cancer. We evaluated the patients with confirmed diagnosis of invasive cervical cancer (n = 102), and CIN (n = 102). Histological type, NLR, PLR, RDW, platelets count, fasting glucose, staging, overall survival (OS), and disease-free survival (DFS) were evaluated. The results of laboratory parameters were assessed by Mann-Whitney test. A receiver operating characteristic (ROC) curve was used to determine the best cut-off values. Survival was verified by the Kaplan-Meyer method followed by the Gehan-Breslow test. Multivariate analysis was performed using Cox regression. The level of significance was less than 0.05. Comparing CIN and invasive malignancies, higher values of NLR, PLR, RDW and fasting glucose were found in cancer patients (p < 0.0001, p = 0.011, p = 0.0153 and p = 0.0096, respectively). In cervical cancer, higher NLR and PLR values were found at stage II to IV when compared to stage I (p = 0.0066 and p = 0.005, respectively). ROC curves were performed. In invasive neoplasms, the cut-off values for NLR and PLR in the comparison between stage I and greater than I were 4 and 165.45, respectively. For survival curves, there was lower OS and DFS in patients with NLR greater than 4 (p = 0.0004 and p = 0.0153, respectively) and PLR greater than 165.45 (p = 0.0319 and p = 0.0362, respectively). After multivariate analysis, only NLR remained as an independent factor in DFS (HR = 6.095, 95 % CI = 1.120-33.177, p = 0.037) and OS (HR = 4.522, 95 % CI = 1.241-16.479, p = 0.022) CONCLUSION: Higher NLR is associated to lower OS and DFS in invasive uterine cervical neoplasia, and can be considered an independent factor of worse prognosis.

Impact of lymph node staging in presumed early-stage ovarian carcinoma

Our objective was to analyze the prevalence of lymph node metastasis in early-stage ovarian carcinoma after systematic lymph node dissection and its impact on indication of adjuvant chemotherapy. We evaluated a series of 765 patients diagnosed with ovarian carcinoma who underwent surgical treatment from February 2007 to December 2019. Patients with peritoneal disease and incomplete surgical staging were excluded. All cases underwent systematic pelvic and para-aortic lymphadenectomy up to the renal vessels. A total of 142 cases were analyzed. Median pelvic and para-aortic lymph node dissected were 30 (range, 6-81) and 21 (range, 3-86), respectively. Twelve (8.4%) patients had metastatic lymph nodes - high-grade serous, 10.4% (5/48); clear cell, 17.2% (5/29) and endometrioid, 5.7% (2/35). Any other histology (low grade serous, mucinous, carcinosarcoma or mixed) had lymph node metastasis. Notably, 50% of patients with positive lymph nodes had preoperative suspicious lymph nodes in imaging. The median hospital stay length was 6 days (range, 2-33) and 4.2% cases had grade ≥ 3 complications. A total of 110 (77.6%) patients underwent adjuvant chemotherapy and all cases had indication of adjuvant chemotherapy after histological type, despite the lymph node status. After a median follow-up of 52.5 months, we noted 24 (16.9%) recurrences. The 5-year recurrence-free survival and overall survival were 86.4% and 98.1%, respectively. High grade histology was the only variable that negatively impacted disease-free survival in univariate analysis [HR 4.70 (95%CI: 1.09-20); p = 0.037]. We found a positive lymph node rate of less than 10% after lymphadenectomy in presumed early-stage ovarian carcinoma. Lymph node status was not determinant for adjuvant chemotherapy.

Needleoscopic-assisted risk-reducing bilateral salpingo-oophorectomy in BRCA1/2 mutation carriers: Peri-operative outcomes and psychological impact

To investigate the role of needleoscopic-assisted laparoscopy in terms of surgical impact and psychological outcomes in RR-BSO for BRCA1/2 patients. Prospective monocentric trial conducted at the Division of Gynecologic Oncology, "Fondazione Policlinico Universitario A. Gemelli" IRCSS in Rome. Between March 2016 and March 2018, 26 consecutive patients were prospectively enrolled in the study and underwent RR-BSO. Peri-operative surgical variables were collected. The psychological interview was performed at the discharge and during the first post-operative follow-up visit (between 30 and 60 days after surgery). We reported a median OT of 18.5 min (range, 15-37), a median EBL of 0 mL (0-20), and no conversion to laparoscopy or laparotomy. The median VAS score was "at rest" of 2, 3, and 1; while under "Valsalva maneuver" was 4, 3, 2, respectively at 2, 4, and 24 h. 77% (20/26) of the whole population had a previous diagnosis of breast cancer. All patients expressed great cosmetic satisfaction both at discharge and after 30/60 days, with an 84.6% of score 5 and a 15.4% of score 4. The highest number of "score 5", concerning the cosmetic outcomes, were clustered in the subgroup of breast cancer survivors with a 95% of score 5 versus 50% of score 5 in patients with no previous breast cancer (p = 0.0073). Similarly, the maximal psychological advantage of the ultra-MIS approach was revealed in the breast cancer survivors (70% of score 5 versus 16% of score 5, p = 0.02). The use of 2.4 mm instruments raises the possibility of decreasing post-operative incisional pain, reducing hospitalization, and ensuring better cosmetic and psychological outcomes without increasing complications. The full psychosomatic benefit of ultra-MIS within BRCA mutation carriers is revealed in breast cancer survivors, probably due to the comparison with the mutilating and invasive previous breast surgery.

Surgical management and outcomes for stage 1 malignant ovarian germ cell tumours: A UK multicentre retrospective cohort study

To describe the current surgical management of stage 1 malignant ovarian germ cell tumours and correlated oncological outcomes. We undertook a retrospective study of all stage 1 primary ovarian germ cell tumours treated in four major UK gynaecology oncology centres over 12 years. We assessed route of surgery, fertility-sparing approaches, ovarian cystectomy alone, and surgical staging and correlated these with clinical outcomes. Eighty-six patients were followed-up for a median of 4.4 years (IQR 4.3). The median age was 26 (range 11-47). There were 24 (27.9%) dysgerminomas, 13 (15.1%) yolk sac tumours, 10 (11.3%) mixed germ cell tumours, and 39 (45.3%) immature teratomas. Overall survival was 96.6% (OS, 95% CI 91.9-100%), with event free survival of 81.8% (EFS, 95% CI 72.5-92.3) at 5 years. The majority had fertility-sparing surgery (93%, n = 80). In a subset of patients with immature teratoma, there was no significant difference in recurrence or survival if patients underwent unilateral cystectomy only or salpingo-oophorectomy. Laparotomy was the most common approach (n = 66, 76.7%), used more frequently for larger tumours > 10 cm. Surgical staging procedures were undertaken in 42 (48.6%) patients with no significant difference in rates of staging across histological subtypes. Peritoneal biopsies were taken in 11 (12.7%), omental assessment in 40 (46.5%) and lymphadenectomy in 10 (11.6%). There was no significant difference in EFS between patients who underwent staging procedures (83%, CI 71-98%) versus those that did not (84%, CI 72-98%). There was no significant difference in the rate of staging procedures in paediatric (42.1% 8/19) and adult (57.9% 34/67) populations. Across all histologies and ages, the absence of surgical staging did not impact upon disease free or overall survival in this cohort. This study also raises the possibility of a role for ovarian cystectomy in immature teratoma. These findings warrant investigation in larger prospective studies.

Clinical outcomes of vaginectomy and laser ablation for the treatment of post-hysterectomy women with vaginal high-grade squamous intraepithelial lesions: A retrospective study

To evaluate the clinical outcomes of vaginectomy and laser ablation for the treatment of vaginal high-grade squamous intraepithelial lesion (HSIL) patients who underwent previous hysterectomy for cervical HSIL or cancer. The clinicopathologic data and follow-up information of 167 post-hysterectomy vaginal HSIL patients who underwent laser ablation or vaginectomy were retrospectively reviewed from 2010 to 2018 at the Obstetrics and Gynecology Hospital of Fudan University. Of the 167 vaginal HSIL patients enrolled, 74 patients underwent vaginectomy, and 93 patients underwent laser ablation. At a median follow-up of 15 months, 13 (7.8 %) patients experienced progression to vaginal cancer, and 22 (13.2 %) patients had persistent/recurrent disease. Upon multivariate analysis, laser ablation (OR: 5.16, p = 0.02), cytology indicating HSIL (OR: 25.45, p = 0.00), and a shorter interval between previous hysterectomy and vaginal HSIL diagnosis (< 24 vs ≥ 24 months, OR: 0.10, p = 0.02) were associated with disease persistence/recurrence. In post-hysterectomy for cervical HSIL patients, the vaginectomy group had a significantly higher recurrence-free survival rate (RFS, 94.5 % vs 69.0 %, p = 0.00) and a similar progression-free survival rate (PFS, 96.4 % vs 91.4 %, p = 0.17) compared with the laser ablation group. Among post-hysterectomy for cervical cancer patients, RFS (89.5 % vs 65.7 %, p = 0.04) and PFS (100.0 % vs 82.9 %, p = 0.05) were both higher in the vaginectomy group than in the laser ablation group. Compared with laser ablation, vaginectomy resulted in better clinical outcomes among vaginal HSIL patients who had undergone previous hysterectomy for cervical neoplasia.

Discrepancies between ESTRO/ESGO/SIOPE and NCCN guidelines in the management of vaginal cancer: a call for harmonization

Current vaginal cancer guidelines need refining. First of all: Cancer can only be called vaginal if there is no cervical or vulval involvement or in case of a prior anogenital cancer were the HPV type(s) between the cancers are different. Secondly: Surgery, accompanied by SLN mapping, should be the first-line treatment for early-stage vaginal cancer. Thirdly: HPV testing and typing should be part of both pretreatment evaluation and follow-up.

National guidelines for management of cervical squamous intraepithelial lesion: A survey of European Federation for colposcopy members

The management of women with cervical squamous intraepithelial lesions (SIL) is fundamental to prevention of cervical cancer in an organized cervical screening programme. Clinical guidance should improve quality of care and clinical effectiveness if developed and implemented appropriately. This survey provides an update on the current situation of national guidelines for management of cervical SIL amongst member countries of European Federation for Colposcopy (EFC). A questionnaire was sent to representatives of each member country of EFC. The questionnaire contained questions on: guidelines for management of cervical SIL of the National Societies/Associations of Colposcopy or others national societies/associations including the development and the consultation processes, guidelines for management of lower genital tract diseases and the regulations in each country for colposcopy practice. We received responses from all 34 member countries. Thirty countries reported a national guideline for management of cervical SIL that were developed by, or in conjunction with, their national societies or associations of colposcopy. In most cases there was adherence to the recommended steps for guideline development: they were developed by a multi-disciplinary group of specialists (29 countries) and society members were consulted before publication (21 countries). A small number of countries (8) reported to have guidelines for the management of lower genital tract dysplasia (e.g. vulval disease) developed by other national societies. In most countries (26) the colposcopists are obliged to follow the guidelines but this is regulated in only 6 and in 12 countries the colposcopists need to be certified by the national society of colposcopy in order to practice. There are advances in the development and provision of country specific guidance on the management of cervical SIL. Most EFC member countries have appropriate national guidelines that were developed using a clear methodology, are updated according to progresses in the field and are accessible online to current practitioners. These guidelines support colposcopists to follow evidence-based practice and provides understanding of best practice in guideline development and access.

European consensus statement on essential colposcopy

This European consensus statement on essential colposcopy provides standards for the general colposcopist seeing women referred for colposcopy with an abnormal cervical screening test (including cytology and HPV tests) or with a clinically suspicious cervix. The article gives guidance regarding the aims and conduct of colposcopy. Recommendations are provided on colposcopy technique, the management of common colposcopy issues, treatment and follow-up of after treatment of CIN or early stage cervical. Colposcopists should make an informed decision on the management of each individual that is referred and organize appropriate follow-up. Cervical cancer is still a major health issue and the quality of care can only improve if there is a structured guidance for women with an abnormal smear or suspicious cervix.

British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice

Cervix cancer in many countries is declining and screening programmes and immunisation will reduce the incidence in the next few decades. This guideline attempts to cover management of invasive disease reflecting diagnosis and imaging including new imaging and sentinel lymph node biopsies. Smaller volume disease is usually managed surgically whereas advanced disease is treated with (chemo)- radiation. It also includes discussion of fertility sparing procedures. Practices are changing frequently for all aspects of care usually in attempts to reduce complications and improve quality of life. The management of advanced disease is treated by chemotherapy and the use of newer agents is also discussed. Other sections discuss specialist situations such as cancer in pregnancy, rare cervical tumours, late effects and supportive measures and fertility preserving approaches.

The impact of the CervicalCheck controversy on provision of colposcopy services in Ireland: A cohort study

In 2018, an inquiry into the Irish Cervical Cancer screening programme (CervicalCheck) was initiated, following publicised cases of non-disclosure regarding internal audit results of cytology screening in women diagnosed with cervical cancer. The inquiry attracted widespread media coverage and the government offered women free, out of programme screening. We investigated whether the controversy led to an increase in referrals based on clinical suspicion and the impact on waiting times for abnormal cytology. A retrospective cross-sectional analysis was performed, including all colposcopy referrals to The National Maternity Hospital, Dublin, before (March 2016-2018) and after (March 2018-2020) the media coverage. Chi-squared (χ2) and independent one-tailed t-tests were used to perform between-group analyses. Post-controversy, suspicious cervix referrals increased (10.1 %-14.2 %; p = 0.037 × 10 This study highlights the profound impact that the CervicalCheck Controversy had on the women attending colposcopy and clinicians performing the screening tests, and the direct impact on women with confirmed cytological abnormalities. The increase in suspicious cervix referrals reflects a lack of confidence in both clinical practice and screening test results. The importance of public trust in the effective delivery of screening services cannot be ignored. Increased resources are required to ensure all women are seen within recommended time frames. Heightened anxiety and increased surveillance does not necessarily lead to better clinical outcomes for patients but can result in unnecessary distress for low-risk patients and delays to diagnosis for high-risk patients with concerning abnormalities.

Using technology to harmonise treatment approaches in colposcopy in the face of a changing environment

The overall numbers of precancerous lesions are expected to fall as human papillomavirus (HPV) vaccinated women enter the cervical screening programme. Juxtaposed against an increase in referrals from the introduction of primary high-risk HPV screening, colposcopists expect to see a decreasing incidence of high-grade cervical intraepithelial neoplasia (CIN). Correct identification of lesions will become more challenging, as the prevalence of high-grade lesions becomes minimal and conventional colposcopy is subject to a lower sensitivity. In this review, we explore the scenarios where adjunct technologies could support colposcopists to manage referrals and diagnose treatable lesions with more confidence.

Human papillomavirus genotyping on Reunion Island: A cross-sectional study of stored tissue samples

We aim to illustrate and evaluate the prevalence and distribution pattern of cervical human papilloma virus (HPV) genotypes on La Réunion Island, a French overseas territory, with the aim to guide future vaccination policies. Between January 2008 and July 2012, files of women undergoing gynaecological examination were retrospectively evaluated at the University Hospital, Reunion Island. Inclusion criteria required cervical biopsies with histopathological diagnosis of high-grade lesions or cancer and ASCUS Pap Smears (atypical squamous cells undetermined significance) results. The INNO-LIPA HPV Genotyping Extra® test was used for HPV genotyping. A total of 401 ASCUS Pap Smears and 94 cervical biopsies were analyzed, of which 162 smears and 63 biopsies were HPV DNA positive (40.4 % and 67 % respectively). Detailed breakdowns of HPV genotype-specific distribution reported prevalence of HPV 16, 31, 33, 51 and 52. Of the 63 HPV-positive biopsies, 61 (96.8 %) contained at least one HPV genotype that is contained in the 9-valent HPV vaccine. The incremental preventable fraction of HPV infections that could have been added by the new 9-valent vaccine to the current bivalent vaccine was estimated at 26.2 %. Immunization with 9-valent vaccine should be effective, and in the long term, may reduce cervical cancer incidence in Reunion Island. Nevertheless, vaccination rates and coverage need to be maintained and improved.

The safety and effectiveness of preserving the ascending uterine artery in a modified fertility-sparing abdominal radical trachelectomy

To evaluate the outcome of preserving the ascending uterine artery in a modified fertility-sparing abdominal radical trachelectomy and understand whether preserving uterine arteries during abdominal radical trachelectomy is helpful for patients. From September 2005 to September 2019, 31 early uterine cervical cancer patients who underwent modified fertility-sparing abdominal radical trachelectomy were enrolled in this study, and were followed up in our cancer center. Computed tomography (CT) of the abdomen and pelvis was advised as the initial investigation to evaluate the ascending uterine artery in 11 patients. The major outcomes were recurrence, mortality, CT results and obstetric outcomes. During the median follow-up of 56 months, two recurrences were recorded. Among 11 patients who underwent CT, none of them showed uterine arteries occlusion. Fifteen patients attempted to conceive, and 5 pregnancies were achieved in 5 patients. Hence, the pregnancy rate among patients who attempted to conceive was 33.3 %. There was only one artificial first-trimester abortion. Three pregnancies resulted in live births, and two of them got full-term births. The modified fertility-sparing abdominal radical trachelectomy in preserving uterine arteries is effective, and it is recommended that surgeon should retain the uterine artery as much as possible during operation.

Identification of European-wide clinical priorities for guideline development in the management of pre-invasive cervical disease

Addressing management controversies in the treatment of pre-invasive cervical disease is a key priority for the European Federation for Colposcopy/European Society of Gynaecologic Oncology who aim to develop a practical handbook of European centred guidelines to address areas where there is a lack of high-quality evidence or identifiable practice variation. Clinical opinion across the EFC network was sought to identify topics likely to have the most impact on clinical practice for systematic review and development of practice recommendations. A scoping exercise comprising of a three-iteration modified Delphi with representation from each member society of the EFC was conducted in 2018. Round one identified 19 potential topics which were scored for importance using a five-point Likert scale by EFC members in round two and ranked. Results from round two were discussed at an open EFC satellite meeting resulting in exclusion of five topics. A third round of the 14 remaining topics was conducted to allow members to modify scores after viewing the second-round rankings. Responses were analysed and topics were allocated a weighted score. Strategies for management of persistent HPV infection in the context of normal colposcopy and negative cytology was the highest overall weighted topic (4.40) followed by identification of appropriate length of follow up for ASCUS or LSIL prior to excisional treatment (3.95) and the impact of length of excision on patient outcomes (3.95). Topics to identify best practice for management of challenging topics scored highly including optimising follow up strategies for cervical stenosis (3.91) and management of HSIL in the under 25 year olds (3.64) or pregnancy (3.64). A European wide systematic modified-Delphi has prioritised six topics for systematic review and generation of clinical practice recommendations aiming to assist management in areas of controversy in pre-invasive cervical disease.

Vaginal fertility-sparing surgery and laparoscopic sentinel lymph node detection in early cervical cancer. Retrospective study with 15 years of follow-up

The aim of this study was to evaluate the oncological outcomes of vaginal fertility-sparing surgery plus laparoscopic sentinel lymph node biopsy in patients with early cervical cancer over a 15-years period. From March 2005 to April 2018, 38 patients diagnosed with early stage cervical cancer underwent vaginal fertility-sparing surgery at the Hospital Clínic, Barcelona, Spain. Patients with FIGO stage IA1 with lymphovascular space invasion and stage IA2 underwent simple trachelectomy and patients with stage IB1 underwent radical vaginal trachelectomy. All cases underwent laparoscopic sentinel lymph node biopsy. In the first 19 cases, laparoscopic bilateral pelvic lymphadenectomy was completed immediately after sentinel lymph node biopsy. Clinical and oncological follow-up data were collected. The median age at diagnosis was 33.5 years (range 22-44). Simple trachelectomy was performed in seven cases (18.4%) and vaginal radical trachelectomy in 31 (81.6%). Nineteen patients were exclusively treated with laparoscopic sentinel lymph node biopsy and 19 with sentinel lymph node biopsy plus laparoscopic bilateral pelvic lymphadenectomy. There were no significant differences between the two lymph node assessment groups regarding histology and tumour size. The median follow-up was 73 months (range 1-160 months). There were 4 recurrences (3 patients with IB1 and 1 with IA2). Two occurred in the sentinel lymph node biopsy group and 2 in the sentinel lymph node biopsy plus laparoscopic bilateral pelvic lymphadenectomy group. All the recurrences were diagnosed in patients with adenocarcinoma and in 3 patients without lymphovascular space invasion. Vaginal fertility-sparing surgery combined with laparoscopic sentinel lymph node biopsy seems to be a safe oncological procedure in selected patients with early stage cervical cancer. Further studies are needed to clarify the role of sentinel lymph node biopsy in fertility- sparing surgery in cervical cancer. Adenocarcinoma histology seems to be an important risk factor for recurrence.

Impact of introduction of endocervical brush on cytologic detection of cervical epithelial cell abnormalities: A clinical audit of 13-years’ experience at a cancer research centre

To study the temporal trends in cytologic detection of cervical epithelial cell abnormalities (ECA) and to evaluate the impact of introduction of endocervical brush sampling on detection of ECA. This was a cross-sectional study of conventional cervical smears collected over a 13 year period (2006-2018). The study was divided into two time periods (TP)-TP1 (2006-2014, 67,437 smears) using only extended tip Ayre's spatula and TP2 (2015-2018; 36,746 smears) when Cytobrush Papsmear kit (Ayre's spatula + endocervical brush) was used. The unsatisfactory rate and detection rate of ECA was compared between the two TPs. The unsatisfactory rate reduced from 4.7 % in TP 1-1.5% in TP2 (P < 0.001). The frequency of ECA was 1.5 % in TP1 and 1.9 % in TP2 (P < 0.001). A significantly higher number of ASC-H and HSIL were detected in TP2. There was a substantial improvement (3.7 times) in detection of glandular abnormalities overall (P < 0.001), as also for both the qualifiers AGC- NOS (4.4 times) and AGC- FN (3.3 times) in TP2. Cervical sampling using combined spatula and endocervical brush reduces the unsatisfactory rate and improves the detection of both squamous and glandular precancerous lesions. Hence, this sampling procedure should be recommended for all laboratories practicing conventional cervical cytology.

Recurrent disease after treatment for cervical intraepithelial neoplasia—The importance of a flawless definition of residual disease and length of follow-up

To evaluate adherence to national guidelines for follow-up, and assess residual and recurrent disease after treatment for cervical intraepithelial neoplasia grade 2 or worse (CIN2+). In a case-series design women aged 25-69 years treated for primary CIN2+ in 2006-2011 (n = 752) were followed through August 9, 2019 for residual or recurrent disease, i.e., CIN2+ diagnosed before or after, respectively, two consecutive, normal post-treatment cytology results. We used the Chi-Square test to assess predictive factors of adherence to post-treatment follow-up and residual disease, and survival analyses to assess the cumulative incidence of residual and recurrent disease. Strict adherence to post-treatment follow-up was low . However, 702 (95 %) women attended at least one post-treatment follow-up visit within the suggested time window. Forty-two women (5.6%) were diagnosed with residual disease, 38 (91 %) of whom were diagnosed within 2 years of treatment. Among the 637 (85 %) women with two consecutive, normal post-treatment cytology results, cumulative incidence of recurrent disease was 1.0 (95 % confidence interval [CI]: 0.2-1.8) and 2.5 (95 % CI: 1.2-3.8) per 100 women-years within 42 and 78 months of treatment, respectively. Three women with residual and two with recurrent disease were diagnosed with cervical cancer within 78 months of treatment. Women with not-free resection margins at treatment had a significantly increased risk of residual and recurrent disease. Using a 2-year definition for residual disease would misclassify 3 of 5 cancer cases as recurrent disease when they were true cases of residual disease. This study emphasizes the importance of properly distinguishing between residual and recurrent disease after treatment for CIN2 + . Many women with residual disease could benefit from an earlier colposcopy, cervical biopsy, or diagnostic conization during post-treatment follow-up in order to detect occult cervical cancer. The cumulative incidence of recurrent disease within 78 months of treatment was low.

Influence of age on treatment and prognosis of invasive cervical cancer

Invasive cervical cancer is considered a young women's disease, however up to 20 % of cases develop cervical cancer at advanced ages. The aim was to characterize invasive cervical cancer in women aged 65 and older assessing age-specific survival differences. A retrospective study including cervical cancer patients was conducted at Hospital del Mar Barcelona from July-2007 to December-2016. Women were stratified: <65 or ≥65years. Clinical and pathological data were collected. Multivariate analysis was used to compare outcomes. Adjusted hazard ratios with 95 % confidence intervals for disease-free survival, and overall survival were estimated using Cox proportional hazards models. 124 patients with invasive cervical cancer (n = 87 < 65years and n = 37 ≥ 65years) were included. At diagnosis, 48.3 % of <65years patients were diagnosed at advanced stages, while 64.9 % in ≥65years (p = 0.018). Standard treatment was given to 83.9 % of patients in <65years group compared to 62.2 % in ≥65years (p = 0.015). Disease-free survival and overall survival showed no significant differences between groups. Age ≥65 did not predict worse disease-free survival (HR: 0.3 95 %CI, 0.04-3.1, p = 0.347) or overall survival (HR: 0.82 95 %CI, 0.3-2.3, p = 0.729). Invasive cervical cancer was diagnosed at advanced stages and was treated less frequently with radical intention in patients ≥65years; overall survival and disease-free survival were similar to those cervical cancer diagnosed at younger ages.

What is the value of pre-surgical variables in addition to cone dimensions in predicting cone margin status?

Previous studies have shown associations between independent pre-conization variables (e.g. smoking, age, cytological grade, menopause) and positive or negative cone margins. However, it is not clear if these pre-surgical variables add predictive value to cone dimensions in the prediction of cone margin status. This study aimed to compare different models predicting positive ecto- or endocervical margins to assess whether pre-conization variables provide significant added value compared with cone dimensions alone. One hundred and sixty-one consecutive women with high-grade cervical intra-epithelial neoplasia on cone specimens were analysed retrospectively. The sample was divided into women with positive ecto- or endocervical cone margins and women with negative ecto- or endocervical cone margins. Pre-conization clinical features, cone volume and cone length were included among the study variables. Multivariate stepwise regression analysis was used to create different models predicting incomplete cervical excision. The added value of pre-conization predictors was measured with receiver operating characteristic (ROC) curve comparisons. Fifty-seven (35.4 %) women had incomplete cervical excision. Multivariate analysis showed that a positive ectocervical margin was significantly associated with low-grade cervical cytology [odds ratio (OR) = 0.25, 95 % confidence interval (CI) 0.09-0.70] and cone length (OR = 0.69, 95 % CI 0.58-0.82, criterion <9 mm). The area under the curve (AUC) of the combined model for prediction of a positive ectocervical margin was 0.78 (95 % CI 0.70-0.84, p < 0.001). A positive endocervical margin was associated with cone length (OR=0.78, 95 % CI 0.65-0.93, criterion <9 mm) and age (OR=1.07, 95 % CI 1.02-1.11, criterion ≥45 years). The AUC of the combined model for prediction of positive endocervical margin was 0.75 (95 % CI 0.66-0.82, p < 0.001). Comparison of ROC curves showed that the addition of pre-conization variables to cone length did not yield significant predictive results for either ecto- or endocervical cone margins (p = 0.228 and 0.349, respectively). The addition of pre-conization clinical variables to cone dimensions did not improve the prediction of cone margin status significantly in the study cohort. Among cone dimensions, cone length was the best predictor of come margin status.

Vulvar Paget’s disease: prognostic factors and survival outcomes from a retrospective cohort analysis

Vulvar Paget's disease (VPD) is a rare intra-epithelial neoplasm with a high recurrence rate and uncertain prognostic factors. This retrospective study aimed to evaluate disease-free survival (DFS) and overall survival (OS) in 27 patients diagnosed with VPD, assessing the impact of surgical type, disease extent, resection margins, lymphadenectomy, wound dehiscence and age. Kaplan-Meier analysis and Cox proportional hazards regression were used to determine survival outcomes and prognostic factors. The results revealed that surgical type had a significant influence on OS, with patients undergoing simple excision/vulvectomy achieving better survival outcomes than those who underwent radical vulvectomy (p = 0.036). Age was also identified as a significant predictor of OS, with increasing age associated with reduced risk of mortality (p = 0.017). However, no significant associations were found between DFS and any of the clinical factors examined, except for borderline significance for wound dehiscence (p = 0.061). The literature review confirmed the high recurrence rate and heterogeneity in outcomes. These findings reinforce the need for individualized treatment, as radical surgery did not confer a survival advantage. Given the emerging role of molecular biomarkers such as HER2 and PD-L1 in VPD, future studies should explore targeted therapies to optimize treatment strategies. Larger, multi-centric studies with extended follow-up are needed to refine prognostic factors and improve patient outcomes.

Case series on the management and outcomes of Bartholin gland carcinoma

To evaluate the management and outcomes of Bartholin gland cancer at a single tertiary institution. A single institution retrospective review of 9 cases of BGC between 2004 and 2022 was conducted. Demographics, pathological characteristics, treatment, follow up and oncologic outcomes were extracted from clinical records. Data are summarised using descriptive statistics and survival probabilities are presented with Kaplan Meier graphs. Ten cases of BGC were identified at our institution over a period of 18 years. Nine out of ten clinical records were available for analysis. Eight patients presented with vulval swelling and four were treated initially for Bartholin cyst or abscess. One patient had a histological diagnosis of adenoid cystic carcinoma while the remaining were squamous cell carcinomas. With the exception of stage I disease chemoradiation was the primary mode of treatment. Adverse events included skin desquamation (4/9), venous thrombo-embolism (2/9), gastro-intestinal (1/9) and neurotoxicity (1/9). Median follow up was 60 months with a 5-year recurrence free and overall survival at 76 % and 64 % respectively. BGC may present after a long duration of symptoms and at advanced stages. Primary chemoradiation appears to be a feasible treatment option in advanced disease with the benefit of decreased morbidity.

British Gynaecological Cancer Society (BGCS) vulval cancer guidelines: An update on recommendations for practice 2023

British Gynaecological Cancer Society (BGCS) vulval cancer guidelines: Recommendations for practice

The purpose of this guideline is to collate evidence and propose evidence-based guidelines for the diagnosis and management of adult patients with vulva carcinoma treated in the UK. Malignant melanoma may present via similar routes and will be discussed. The reader is referred to the Ano-uro-genital Mucosal Melanoma Full Guideline [1] for more detailed recommendations. The management of vulval sarcoma is outside of the scope of this guideline. For further information, including details of guideline development and GRADE of recommendations, please see BGCS website for details (https://www.bgcs.org.uk/professionals/guidelines-for-recent-publications/).

Risk factors associated with the persistence of human papillomavirus after cervical excision in patients with high-grade squamous intra-epithelial neoplasia

To evaluate risk factors associated with the persistence of human papillomavirus (HPV) after cervical excision in patients with high-grade squamous intra-epithelial neoplasia (HSIL). A retrospective cohort study enrolled 550 patients who underwent cervical excision for HSIL between January 2015 and January 2018. The effects of various factors were assessed using univariate and multi-variate analyses. The mean age of patients was 42.6 [standard deviation (SD) 8.7, range 22-64] years, and the mean duration of follow-up was 29.0 (SD 4.8, range 24-36) months. Persistent HPV infection after cone excision was detected in 78 (14.2%) patients. Univariate logistic regression analysis revealed that advanced age (>35 years), menopausal status, HPV type (HPV16/18), abnormal vaginal micro-ecological morphology, type of excision (loop electrosurgical excision procedure) and positive margin were closely associated with the persistence of HPV. Multi-variate analysis indicated that menopausal status [odds ratio (OR) 4.708, 95% confidence interval (CI) 2.770-8.001; p < 0.001], abnormal vaginal micro-ecological morphology (OR 2.320, 95% CI 1.372-3.922; p = 0.002) and positive margin (OR 3.346, 95% CI 1.261-8.876; p = 0.015) were significant risk factors for the persistence of HPV after treatment. Furthermore, infection with HPV16/18 increased the risk of persistent infection, and a higher rate of HPV persistence was found in patients who were infected with HPV18 (OR 1.020, 95% CI 0.415-2.505) or co-infected with HPV16/18 (OR 2.064, 95% CI 0.272-2.041) compared with HPV16. Persistent HPV infection after surgical treatment for HSIL is considered to be strictly related to the recurrence and progression of disease. Patients who are at increased risk of HPV persistence should receive intensive follow-up after surgery, especially in the first year.

The prognostic factors in 384 patients with FIGO 2014 stage IB cervical cancer: What is the role of tumor size on prognosis?

To define the relationship of tumor size with surgico-pathological factors and oncological outcome in FIGO 2014 stage IB cervical cancer. This study retrospectively evaluated 384 FIGO 2014 Stage IB cervical cancer patients who underwent radical hysterectomy and lymphadenectomy. Tumor size was stratified according to 2 cm (≤ 2cm, 2-≤4 cm, >4 cm) and 4 cm (≤4 cm, >4 cm), and the relationship with poor prognostic factors, and the effects on survival were examined. The distribution of prognostic factors was compared between three subgroups: ≤2 cm vs. 2-≤4 cm; 2-≤4 cm vs. > 4 cm and ≤ 2 cm vs. > 4 cm. Survival rate was evaluated using the Kaplan-Meier method and compared with the log-rank test. Multivariate analysis was performed using Cox proportional-hazards regression. Stratification of tumor size according to 4 cm was found to better determine pelvic lymph node determination. Parametrial involvement, uterine involvement and deep cervical stromal invasion were correlated with increasing tumor size. Lymph node involvement and uterine involvement were an independent prognostic risk factor for recurrence and cancer-specific survival. Tumor size showed no association with prognosis. There is no meaningful cut-off value for tumor size determining all surgico-pathological factors. There was also seen to be no association between tumor size and recurrence or disease-related mortality.

A combination of second trimester oral metronidazole and no sexual intercourse during second and third trimester may reduce late miscarriage and premature delivery after fertility sparing radical trachelectomy

Women with a previous trachelectomy have an increased risk of premature delivery and second trimester miscarriage. In this study we aim to evaluate factors and regimes possibly affecting the risk for prematurity following fertility sparing robotic radical trachelectomy (RRT) in cervical cancer. A retrospective study of the reproductive outcome following RRT with a cervical cerclage performed at one of four academic centers between 2007 and 2019. Factors possibly related to premature delivery, such as postoperative non-pregnant cervical length, previous vaginal deliveries, preservation of the uterine arteries, and the use of a second trimester oral metronidazole/no sexual intercourse regime, were assessed. 109 women remained for analyses after excluding recurrences before pregnancy (n = 8), secondary hysterectomy (n = 2), and women with less than six months follow up (n = 10). 74 pregnancies occurred in 52/71 women attempting to conceive, 56 of which developed past the first trimester. Two of 22 women (9%) who were prescribed an oral metronidazole regime (400 mg × 2 from gestational week 15 + 0 to 21 + 6 and abstaining from sexual intercourse for the duration of the pregnancy) had a premature delivery, compared with 13/31 (42%) where the regime was not applied (p = 0.009). The association remained after regression analyses including possible contributing factors as of above, none of which associated with prematurity at regression analyses (p = 0.001). The observed four-fold reduction in premature delivery indicates that an oral metronidazole/no sexual intercourse regime may reduce second trimester miscarriage and premature deliveries following an RRT. No association was observed for other investigated factors.

Human papillomavirus (HPV) in pregnancy – An update

Human papilloma viruses (HPV) are small epitheliotropic DNA viruses, of which there are 200 genotypes, 40 of which are known to cause genital infections and are also oncogenic. HPV is the most common sexually transmitted infection. Clinical features vary from asymptomatic (identified at routine cervical cancer screening) to large lesions on the vulva, vagina, cervix and some extragenital sites. Its prevalence in pregnancy varies from 5.5% to 65% depending on age, geography and gestational age (increasing with gestational age). Infection in pregnancy has been associated with adverse outcomes such as spontaneous miscarriage, preterm birth, placental abnormalities and fetal growth restriction. However, the evidence for these adverse outcomes is varied. Besides being oncogenic (and thus associated with cancer of the cervix in pregnancy), vertical transmission to the fetus/neonate can cause neonatal infections, especially juvenile-onset recurrent oral and respiratory papillomatosis (JORRP). Where there are very large lesions on the vulva, delivery may be obstructed. Diagnosis in pregnancy is mainly by viral PCR or from the clinical appearance of the characteristic lesions on the vulva. Treatment is local by either surgical or laser excision or application of trichloroacetic acid. Podophyllin/podophyllotoxin is contraindicated in pregnancy. HPV Infection is not an indication for caesarean delivery as this has not been shown to prevent vertical transmission. For those diagnosed at routine cervical cancer screening, management should follow guidelines for cervical cancer screening in pregnancy. Vaccination is currently not recommended for pregnant women, although studies on those inadvertently vaccinated in pregnancy have not shown any adverse effects on either the fetus or mother.

The utility of pretreatment systemic inflammatory response biomarkers on overall survival of cervical cancer patients stratified by clinical staging

Inflammation plays a crucial role in the initiation and progression of many cancers. This study aimed to investigate the utility of pretreatmentneutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), derived neutrophil-lymphocyte ratio (dNLR), and a combination of PLR and NLR in predicting the risk of death according to clinical staging in cervical cancer (CC) patients. A cohort study of women with CC, diagnosed and treated at a single cancer referral center in Brazil, from 2006 to 2009. A multivariate Cox regression analysis and ROC curve analysis accessed the predictive value of inflammatory response biomarkers in overall survival (OS). The median values of the biomarkers were used as cut-off points. A total of 1,266 patients were included in the study, 76.0% with locally advanced disease. After adjusting for clinical variables, NLR > 2.57, PLR ≥ 146.70, dNLR ≥ 1.778 and PLR + NLR in combination had equivalent performance in predicting worse OS, but only among patients with locally advanced disease (adjusted Hazard Ratio [aHR] = 1.453, 95% Confidence Interval [CI] = 1.227-1.722; p < 0.001; aHR = 1.429; 95% CI = 1.209-1.688; p < 0.001; aHR = 1.486, 95% CI = 1.257-1.756, p < 0.001, aHR = 1.731; 95% CI = 1.411-2.123; p < 0.001, respectively). In conclusion, PLR, NLR, dNLR and PLR + NLR in combination presented equivalent performance in predicting OS in locally advanced CC patients. They are simple and readily available from routine blood tests, not entailing additional costs. PLR, NLR, dNLR and PLR + NLR in combination are strong prognostic biomarkers candidates in locally advanced CC and should be further explored in prospective trials.

Invasive cervical cancer following treatment of pre-invasive lesions: A potential theory based on a small case series

The aim of this study is to present a single department's experience on cervical cancer cases following previous excision of cervical intraepithelial neoplasia (CIN) and to discuss potential pathogenesis. Nine cervical cancer cases meeting the inclusion criteria, with available pathological and follow-up data, were considered eligible for this study. The majority (7/9) have had clear excisional margins. The interval between initial treatment and cancer diagnosis ranged from 7 to 17 years. In all cases cancer diagnosis was "unexpected", as the prior cytological and/or colposcopic evaluation was not suggestive of significant cervical pathology. All cancers were squamous, and 5/9 at stage I. The long interval between initial CIN treatment and final diagnosis as well as the normal post-treatment follow-up may suggest a 'de novo' underlying but 'hidden' carcinogenesis process. It might be that dysplastic cells entrapped within crypts (or normal metaplastic affected by the same predisposing factors) continue undergoing their evolution, undetectable by cytology and colposcopy until they invade stroma and surfaces (endo- and/or ectocervical) approximately a decade later. Heavy cauterisation of cervical crater produced post excision might be a potential culprit of this entrapment.

Comparison of robotic and conventional laparoendoscopic single-site hysterectomy for large uterus using da Vinci Xi system: A propensity score matching analysis

The robotic surgical system equipped with enhanced visualization, flexible instruments, tremor filtration, and improved ergonomics can greatly address difficulties encountered in conventional laparoendoscopic single-site surgery. This study aimed to evaluate whether robotic laparoendoscopic single-site surgery performed by da Vinci Xi system was an optimal approach in performing benign hysterectomy for large uterus. This was a single-center retrospective cohort study. Between May 2021 and September 2023, patients who underwent transumbilical single-site hysterectomy with or without da Vinci Xi system indicated for uterine myoma or adenomyosis with uterine weight exceeding 280 g were enrolled. After conducting propensity score matching to balance the baseline characteristics, perioperative outcomes were compared between the two groups. After 1:1 propensity score matching, 74 patients were included in each group. No patient required additional ports, conversion to laparotomy or multi-port laparoscopy. The robotic group showed significantly longer exhaust time (2.4 ± 0.7 vs 2.0 ± 0.7 days, p < 0.001) and lower postoperative complication rate (4.1 % vs 13.5 %, p = 0.042) compared to the conventional group. No significant differences were found in operative time (183.6 ± 53.6 vs 178.2 ± 55.4 min, p = 0.546), blood loss (100.0 vs 50.0 mL, p = 0.296) and intraoperative complication (1.4 % vs 0, p = 1.000) even though the robotic group had heavier uterine weights (412.5 vs 394.0 g) and a higher rate of severe adhesion (33.8 % vs 17.6 %). Robotic and conventional laparoendoscopic single-site hysterectomy for large uterus were both feasible and safe with satisfying surgical outcomes. However, the laparoendoscopic single-site surgery was easier to be mastered and more likely to handle challenging conditions with assistance of da Vinci Xi system.

Optimal treatment strategies for small cell carcinoma of the uterine cervix: A retrospective multi-center study (KROG 19-03)

This multi-institutional study aimed to identify the optimal treatment strategy for small cell carcinoma of the cervix. We retrospectively collected the medical records of 166 patients diagnosed with small cell carcinoma of the uterine cervix from January 2000 to December 2015 from 13 institutions of the Korean Radiation Oncology Group. After excluding 18 (10.8 %) patients who initially had distant metastasis, the treatment outcomes of 148 patients were analyzed. After a median 46.4 (1.4-231.9) months of follow-up, the 5-year progression-free survival (PFS) and overall survival (OS) rates of all patients were 45.9 % and 63.5 %, respectively. Distant metastasis was the dominant pattern of failure occurring in 67 patients (45.3 %). We stratified the patients according to the primary local treatment: primary surgery (n = 119), primary radiotherapy (RT) (n = 26), and no local treatment group (n = 3). Although the primary RT group had advanced disease (FIGO stage ≧ IIB) more frequently than the primary surgery group (80.8 % vs. 47.9 %), the PFS and OS did not differ between the groups in multivariate analysis. Definitive RT is a reasonable local treatment option for small cell cervical cancer, particularly for advanced cases. Given the high rates of distant relapse, an effective systemic therapy protocol is warranted for small cell cervical cancer patients.

Screen-and-treat approach in managing cervical cancer precursor lesions: An observational study with 524 women

To detect factors related to overtreatment with the "Screen-and-treat" approach (S&T) in women with suspicious cervical precancerous lesions. A retrospective observational study of 524 women with high-grade squamous intraepithelial lesions (HSIL) or more severe (HSIL+) in cytology, treated by the Large Loop Excision of the Transformation Zone (LLETZ): 161 without a previous biopsy (S&T group) and 363 with a previous biopsy (biopsy group) from January 2017 to July 2020. The main outcome was a diagnosis of LLETZ: negative (negative or low-grade squamous intraepithlelial lesion LSIL) or HSIL+. A negative diagnosis was interpreted as "overtreatment." Results were analyzed as a function of the S&T approach (whether previous biopsy or not). Variables were obtained from medical records, and were compared with Chi-square or Fisher's exact test (p, p-value), to estimate the chances of a logistic regression analysis (Odds Ratio, OR, or admitting a Confidence Interval (CI) of 95 %). No differences were observed in groups regarding menopausal status, smoking, hormonal contraceptive use, colposcopy findings, LLETZ diagnosis, and recurrence. Comparing biopsy vs S&T groups, the frequency of women over 40 years was 28.4 % vs 39.7 % (p = 0.011), and transformation zone type 3 was 12.2 vs 26.8 % (p < 0.001), respectively. In women managed by S&T, when compared to a LLETZ diagnosis, an HSIL+ result was more frequent in women presenting with TZ 1 (93.1 % TZ1 vs 78.5 % TZ2 vs 73.8 % TZ3, p = 0.008) and in women with abnormal colposcopy (92.9 % abnormal vs 38.1 % negative, p < 0.001). Multiple regression analysis found that women with negative colposcopic findings presented a higher risk for negative LLETZ diagnosis (LSIL/Negative final histology) (18.6; 6.18-56.02). No difference was observed in the LLETZ diagnosis in women who did or did not use the S&T approach: it was adequate for women referred by cytological HSIL along with high-grade colposcopic findings.

Comparison of CT and MRI for contouring active bone marrow in bone marrow sparing IMRT of carcinoma cervix and its effects on functional outcomes

Intensity-modulated radiotherapy (IMRT) has been used to reduce dose to bone marrow (BM) irradiation during pelvic conformal radiotherapy by contouring bone marrow and sparing it during radiotherapy planning. The present study was done to compare CT & MRI for contouring bone marrow to spare functional bone marrow for Intensity-modulated radiotherapy (IMRT) in carcinoma cervix and to assess its effect on functional outcome. This prospective, observational study included newly diagnosed carcinoma cervix patients treated by radical chemoradiation. Patients were distributed in two arms i.e. CT arm and MRI for contouring bone marrow. Regions taken into consideration for bone marrow volumes contouring were 4th and 5th Lumbar vertebrae, whole pelvis and proximal femur upto lesser trochanter. In CT arm bone marrow regions were contoured using freehand method with window adjusted to bone range (Window - 2500/ Level - 400) and in MRI arm BM regions on the MR images that had pixel values similar to muscle or IDEAL IQ sequence based on fat fractions present in bone marrow (BM) was used to contour. 17 patients in CT arm and 19 patients in MRI arm were included. There was no significant difference between the groups in terms of Bone Marrow Volume (cm Dosimetric parameters of bone marrow V10 and V30 were found to be associated with absolute neutrophil and total leucocyte nadir respectively. Haematological toxicity was observed more in MRI arm but more propspective studies are required for further validation.

Highly active antiretroviral therapy (HAART) and outcome of cervical lesions and high-risk HPV in women living with HIV (WLHIV): A systematic review and meta-analysis

Collating evidence on the impact of highly active antiretroviral therapy (HAART) on the outcome of cervical lesions or human papillomavirus (HPV) infection among women living with HIV (WLHIV) is essential to inform cervical cancer prevention in this vulnerable group. We performed a systematic review and meta-analysis of cohort studies that were conducted between January 1, 1996 and January 31, 2022 and reported on the association of HAART with any of the outcomes: incidence, progression, or regression of cervical lesions or acquisition or clearance of HPV infection in WLHIV. Random-effect analysis was used for summary statistics and heterogeneity was assessed through I Among 11 studies, the summary estimate of incident cervical lesions was lower in WLHIV on HAART (0.81, 95% CI 0.60-1.08). HAART was associated with lower risk of cervical lesion progression (0.76, 95% CI 0.64-0.92, I This review provides evidence that HAART assists in reducing the incidence and progression of cervical lesions and enhancing their regression in women living with HIV. Hence, the HAART regime should be recommended to all WLHIV with advice for adherence to allow for early immune reconstitution.

High-grade uterine cancer with ambiguous features – a clinicopathological study

Endometrial endometrioid carcinoma FIGO grade 3 (EC3) and endometrial serous carcinoma (SEC), sometimes present diagnostic challenges due to overlapping and ambiguous features. The prognostic significance of assigning histological subtype remains debatable due to conflicting clinical outcome data. This study examined definite and ambiguous EC3 and SEC cases to compare clinicopathologic characteristics and prognosis. This is a retrospective study of 129 patients diagnosed with EC3 and SEC at a single tertiary center between 2006-2022. Pathological slides were revised and classified as definite or ambiguous for EC3 and SEC. Survival, progression-free survival, and associations between tumor histologic type and clinicopathologic characteristics were analyzed. Definite SEC displayed higher mortality compared to definite EC3 (68.2 % vs. 41.4 %, p = 0.023) as well as a non-significant trend towards lower 5-year survival (p = 0.096). Ambiguous SEC also showed higher mortality compared to ambiguous EC3 (68.8 % vs. 37.5 %, p = 0.020) and a non-significant trend towards lower 5-year survival (p = 0.098). Several parameters suggest that ambiguous cases are intermediate between the definite EC3 (lower) and definite SEC (higher) groups. Rates of lymph node metastases (EC3 6.9 %; ambiguous 16.4 % and SEC 29.5 %; p = 0.013), broad ligament involvement (EC3 0 %; ambiguous 1.8 % and SEC 11.4 %; p = 0.016), and omental involvement (EC3 3.4 %; ambiguous 10.9 % and SEC 29.5 %; p = 0.002). A similar trend was observed for ovarian involvement, but it did not reach statistical significance (EC3 6.9 %; ambiguous 12.7 % and SEC 22.7 %; p = 0.055). Ambiguous cases may represent an intermediate group that displays clinicopathologic features which are more aggressive than in EC3, yet more favorable than in SEC. These results hold implications for managing patients with high-grade endometrial carcinomas, as identifying an intermediate group may inform treatment strategies and prognostic evaluations.

Prognostic significance of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios in predicting response to neoadjuvant chemotherapy in advanced high-grade serous ovarian cancer: a prospective study

To evaluate whether the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) can predict pathological and clinical responses to neoadjuvant chemotherapy (NACT) in patients with advanced-stage high-grade serous ovarian carcinoma (HGSOC). In this prospective cohort study, 80 patients with FIGO stage III-IV HGSOC received three cycles of platinum-based neoadjuvant chemotherapy. The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were measured before and after the neoadjuvant treatment. Treatment response was evaluated using RECIST 1.1, chemotherapy response score (CRS), and the Completeness of cytoreduction score (CC score). The associations between these inflammatory markers and outcomes were analyzed using appropriate statistical tests. Following neoadjuvant chemotherapy, patients who achieved a good histopathological response (CRS 3) showed significantly lower baseline and post-NACT NLR and PLR values compared to those with CRS 1-2 (p  5.5 (Sensitivity: 94.7 %, Specificity: 86.9 %), PLR > 177 (Sensitivity: 94.7 %, Specificity: 88.5 %) predicted poor histopathological response (CRS1). Pre- and post-NACT NLR and PLR may serve as valuable, non-invasive biomarkers for predicting histopathologic response to chemotherapy in advanced serous ovarian carcinoma. Incorporating these inflammatory markers into preoperative assessment may improve patient stratification and surgical planning.

Outcomes and cost-effectiveness of vNOTES vs conventional laparoscopic ovarian cystectomy for ovarian teratoma (dermoid cysts): A comparison of two minimal access routes of surgery

Laparoscopic ovarian cystectomy is the benchmark surgical treatment for ovarian teratoma but vNOTES is emerging as an alternative with avoidance of abdominal scars, less pain and more rapid recovery. This study aimed to compare outcome data and expenditure for two minimally invasive routes in the surgical management of ovarian teratoma. Case control study of vNOTES vs laparoscopic ovarian cystectomy (n = 21 in each group). Data collected included age, BMI, teratoma size, duration of surgery, estimated blood loss, length of stay and peri-operative complications. Expenditure for the procedures were calculated using unit costs verified with NHS England Cost Collection website. Mean age (38.42 vs 39.80 yrs), BMI (29.38 vs 27.90 kg/m Shorter theatre duration and length of stay, better cosmesis, less pain and rapid recovery, allied with lower cost support the adoption of vNOTES as a viable option for minimally invasive adnexectomy for ovarian teratoma.

Concurrent vNOTES risk reducing bilateral salpingo-oophorectomy at the time of mastectomy in women with breast cancer and BReast CAncer (BRCA) gene mutation

Women with breast cancer and BRCA gene mutation should be offered bilateral risk reducing salpingo-oophorectomy (RRBSO) due to lifetime ovarian cancer risk. Laparoscopic BSO, either concurrently or following index mastectomy, is benchmark but vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) gaining traction as an alternative route. We report three novel cases of simultaneous "dual site" surgery in women with breast cancer and BRCA inheritance. vNOTES RRBSO is performed prior to breast surgery during the "dual site" procedure. As recommended by National Comprehensive Cancer Network, salpingectomy was completed to the level of cornu and ovarian pedicle was excised distally to include 2 cm margin. Peritoneal cytology was obtained and bowel, omentum, appendix and pelvic organs were inspected. Data collected included age, BMI, Ca-125 levels, duration of surgery, estimated blood loss, length of stay, 24 hour VAS, peri-operative complications, sexual function (FSFI-6), and recovery status (RI-10). Three women underwent concomitant vNOTES RRBSO and mastectomy. Median operative time and postoperative stay were 45 mins and 26 hours and there were no complications. Sexual function appeared unaffected by the vNOTES approach (FSFI-6 median score 6 vs 4) and normal activity resumed within 23 days. Histology of fallopian tubes and ovaries was benign. Concomitant vNOTES RRBSO and mastectomy avoids a second surgical admission and repeat anaesthesia and does not appear to delay recovery. Findings support adoption of vNOTES as a patient-friendly alternative which can be performed concurrently with mastectomy.

Niraparib combined with anlotinib after PARPi resistance in ovarian cancer: A single-center retrospective study from China

The first real-world experience of niraparib plus anlotinib after Poly(ADP-ribose) polymerase inhibitors (PARPi) resistance from China were investigated in patients with ovarian cancer. Patients treated with niraparib plus anlotinib after PARPi resistance in The Affiliated Cancer Hospital of Nanjing Medical University between December 2019 and February 2023 were enrolled. Eligible patients had histologically confirmed high-grade serous ovarian cancer. Objective response rate (ORR) and disease response rate (DCR) were evaluated by response evaluation criteria in solid tumours, version 1.1 (RECIST 1.1). Progression-free survival (PFS) and serum tumor marker fluctuations of Cancer Antigen 125 (CA125) and Human Epididymis Protein 4 (HE4) were also evaluated. Adverse events (AEs) were assessed by Common Terminology Criteria for Adverse Events (CTCAE 5.0). Twenty-three patients treated with niraparib plus anlotinib had treated a median of two lines of chemotherapy. Most (73.9 %) of enrolled participants were BRCA-wildtype. The ORR and DCR of evaluable patients were 8.3 % and 83.3 %, respectively. The median PFS were 7.230 months for all patients. The median PFS of patients with different platinum status (8.465 months vs. 6.700 months, p = 0.343, initial dose of anlotinib (6.700 months vs. 7.930 months, p = 0.739) and prior use of bevacizumab or not (7.230 months vs. 7.030 months, p = 0.639) were similar. The most common grade 3-4 AEs were hand-foot syndrome and hypertension. No drug related death was reported. Niraparib combined with anlotinib had promising antitumor activity and manageable AEs in the treatment of ovarian cancer after PARPi resistance.

IL-8 and ER-α gene polymorphisms as potential risk factors for leiomyoma

In this study, we aimed to investigate the difference between ICAM-1, IL-8, and ER-α gene polymorphisms and the effects of the formation of leiomyomas by measuring serum levels of IL-8 and ICAM-1 in uterine leiomyoma and control patients. The roles of ERS-1, TNSFIP2, ICAM-1, and IL-8 gene polymorphisms in leiomyoma development were investigated using TaqMan SNP genotyping assay. In addition, serum IL-8 and ICAM-1 levels of leiomyoma and control group individuals were measured using the ELISA method. The sample included in the study consisted of 75 people diagnosed with uterine leiomyoma (leiomyoma group) and 75 healthy volunteers without ovarian pathology (control group) who came to Sivas Cumhuriyet University Medical Faculty Gynaecology and Obstetrics Clinic. TNFAIP2 rs8126, ICAM-1 rs5498 and ESR-1 rs17847075 polymorphisms were not associated with leiomyoma disease. In addition, individuals carrying heterozygous genotypes of ESR-1 rs9322331 (p = 0.01, OR = 2.4), IL-8 rs4073 (p = 0.02, OR = 2.4) and IL-8 rs2227306 (p = 0.01, OR = 2.246) polymorphisms may be at risk for leiomyoma. Similarly, mutant alleles of ESR-1 rs9322331 (p = 0.005, OR = 2.172), IL-8 rs4073 (p = 0.01, OR = 2.204) and IL-8 rs2227306 (p = 0.004, OR = 2.2) polymorphisms were found to be risk alleles. Furthermore, it was observed that IL-8 serum levels increased more in the leiomyoma group (1.83 ± 0.4 pg/mL) compared to the control group (1.02 ± 0.2 pg/mL). Likewise, a significant decrease in ICAM-1 levels was found in the leiomyoma group (1595.5 ± 80 ng/mL) compared to the control group (2939.3 ± 104 ng/mL). In this context, it was concluded that polymorphisms of IL-8 and ESR-1 genes, which are thought to be risk factors in leiomyoma harvests, and factors affecting IL-8 and ICAM-1 expression should be further investigated.

Comparative analysis of Boria’s and Suidan’s predictive models for complete cytoreduction in advanced ovarian cancer using 18F-FDG PET/CT

To validate the authors' previously described score (Boria's predictive score) for predicting complete cytoreduction at primary debulking surgery using A multicentre, observational, retrospective study was undertaken to evaluate patients who underwent primary cytoreductive surgery for advanced ovarian cancer at three Spanish centres between January 2017 and January 2022. Inclusion criteria were: histological confirmation of invasive epithelial ovarian carcinoma; preoperative International Federation of Gynecology and Obstetrics stage III or IV; upfront cytoreductive surgery; and In total, 78 patients who had undergone primary debulking surgery and With only four variables, Boria`s predictive score showed comparable accuracy to Suidańs score for predicting complete resection at primary debulking surgery.

Sentinel lymph node biopsy in early stage ovarian cancer: A prospective observational study

Sentinel lymph node (SLN) biopsy is a technique to assess lymph node status in various cancers to avoid systematic lymphadenectomy and limit morbidity. This study aimed to evaluate the role of SLNB in epithelial ovarian cancer using a combination of radioactive tracer and blue dye. This prospective observational study included 29 patients with suspected stage I and II epithelial ovarian cancer. The tracer was injected subperitoneally at the utero-ovarian and infundibulopelvic ligaments. SLNs were identified followed by systematic lymphadenectomy. SLNs were subjected to ultrastaging. Detection rate, sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of SLNB was calculated. SLN detection was performed using combination of tracers for 10 cases while SLN detection was performed using methylene blue alone for 19 cases. The SLN detection rate was 100 % using both tracers while it was 89.5 % using methylene blue alone. Detection rate was 37.9 % (n = 11/29) in the para-aortic region alone, 20.7 % (n = 6/29) in the pelvic region alone and 34.5 % (n = 10/29) in both. There were 21 cases with malignant histology while there were 4 cases each of benign and borderline histology. The overall sensitivity, specificity, positive predictive value, and negative predictive value of SLNB were 100 % when sentinel node was detected in a patient. Ultrastaging detected isolated tumor cells (ITC) in five cases. No complications related to SLNB were observed. SLNB is a feasible and accurate technique to assess lymph node status in epithelial ovarian cancer using a combination of radioactive tracer and blue dye. Ultrastaging detected ITCs, however their clinical implication is not yet known.

Recurrence rate and quality of life in women with borderline ovarian tumours, according to surgical approach

To assess the recurrence rate and quality of life (QOL) in women with a history of borderline ovarian tumours (BOTs) based on the type of surgery (conservative vs non-conservative) in Spain. A retrospective analysis was conducted of 85 women treated for BOTs between 2007 and 2023 at two hospitals. QOL questionnaires were administered face-to-face to eligible patients. Individuals with dementia, living in an institution, or residing outside the region were excluded from this study. General characteristics and the recurrence rate were analysed retrospectively. Three validated questionnaires - European Organisation for Research and Treatment of Cancer (EORTC) core QOL questionnaire for patients with cancer (QLQ-C30), EORTC QOL questionnaire for patients with ovarian cancer (QLQ-OV28) and Menopause Rating Scale II (MRS II) - were used to assess QOL in eligible patients. The recurrence rate was low (5.9 %) and the disease-specific overall survival rate was high with only two (2.4 %) deaths. International Federation of Gynecology and Obstetrics stage III disease [odds ratio (OR) 58.5, 95 % confidence interval (CI) 6.02-568.53; p < 0.0001] and positive peritoneal cytology (OR 26, 95 % CI 2.68-252.68; p = 0.005] were associated with recurrence. No association was found between the type of surgery (conservative vs non-conservative) and QOL. Older age was associated with poorer sexual function scores on QLQ-OV28. This study highlights the need for careful evaluation of each case. The current evidence does not recommend conservative surgery to improve QOL.

Association between polycystic ovary syndrome and the risk of malignant gynecologic cancers (ovarian, endometrial, and cervical): A population-based study from the U.S.A. National Inpatient Sample 2016–2019

This study aimed to systematically examine the relationship between polycystic ovary syndrome and ovarian, endometrial, and cervical cancers using the National Inpatient Sample (NIS) database. We utilized the International Classification of Diseases (ICD-10) system to identify relevant codes from the NIS database (2016-2019). Univariate and multivariable regression analyses (adjusted age, race, hospital region, hospital teaching status, income Zip score, smoking, alcohol use, and hormonal replacement therapy) were conducted to evaluate association between PCOS and gynecologic cancers. Results were summarized as odds ratio (OR) with 95% confidence intervals (CI). Overall, 15,024,965 patients were analyzed, of whom 56,183 and 14,968,782 patients were diagnosed with and without PCOS, respectively. Among the patients diagnosed with gynecologic cancers (n = 91,599), there were 286 with PCOS and 91,313 without PCOS. Univariate analysis revealed that PCOS was significantly associated with higher risk of endometrial cancer (OR = 1.39, 95 % CI [1.18-1.63], p < 0.0001), but lower risk of ovarian cancer (OR = 0.55, 95 % CI [0.45-0.67], p < 0.0001) and cervical cancer (OR = 0.68, 95 % CI [0.51-0.91], p = 0.009). In contrast, after Bonferroni correction, multivariable analysis depicted that PCOS remained significantly associated with higher risk of endometrial cancer (OR = 3.90, 95 % CI [4.32-4.59], p < 0.0001). There was no significant correlation between PCOS and risk of ovarian cancer (OR = 1.09, 95 % CI [0.89-1.34], p = 0.409) and cervical cancer (OR = 0.83, 95 % CI [0.62-1.11], p = 0.218). This first-ever NIS analysis showed that patients with PCOS exhibited unique gynecologic cancer risk profiles, with higher risk for endometrial cancer, and no significant risk for ovarian or cervical cancers.

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

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

Discriminative diagnosis of ovarian endometriosis cysts and benign mucinous cystadenomas based on the ConvNeXt algorithm

The objective of this study was to develop a deep learning model, using the ConvNeXt algorithm, that can effectively differentiate between ovarian endometriosis cysts (OEC) and benign mucinous cystadenomas (MC) by analyzing ultrasound images. The performance of the model in the diagnostic differentiation of these two conditions was also evaluated. A retrospective analysis was conducted on OEC and MC patients who had sought medical attention at the Fourth Affiliated Hospital of Harbin Medical University between August 2018 and May 2023. The diagnosis was established based on postoperative pathology or the characteristics of aspirated fluid guided by ultrasound, serving as the gold standard. Ultrasound images were collected and subjected to screening and preprocessing procedures. The data set was randomly divided into training, validation, and testing sets in a ratio of 5:3:2. Transfer learning was utilized to determine the initial weights of the ConvNeXt deep learning algorithm, which were further adjusted by retraining the algorithm using the training and validation ultrasound images to establish a new deep learning model. The weights that yielded the highest accuracy were selected to evaluate the diagnostic performance of the model using the validation set. Receiver operating characteristic (ROC) curves were generated, and the area under the curve (AUC) was calculated. Additionally, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, and odds ratio were calculated. Decision curve analysis (DCA) curves were plotted. The study included 786 ultrasound images from 184 patients diagnosed with either OEC or MC. The deep learning model achieved an AUC of 0.90 (95 % CI: 0.85-0.95) in accurately distinguishing between the two conditions, with a sensitivity of 90 % (95 % CI: 84 %-95 %), specificity of 90 % (95 % CI: 77 %-97 %), a positive predictive value of 96 % (95 % CI: 91 %-99 %), a negative predictive value of 77 % (95 % CI: 63 %-88 %), a positive likelihood ratio of 9.27 (95 % CI: 3.65-23.56), and a negative likelihood ratio of 0.11 (95 % CI: 0.06-0.19). The DCA curve demonstrated the practical clinical utility of the model. The deep learning model developed using the ConvNeXt algorithm exhibits high accuracy (90 %) in distinguishing between OEC and MC. This model demonstrates excellent diagnostic performance and clinical utility, providing a novel approach for the clinical differentiation of these two conditions.

Association between treatment center volume and survival of endometrial cancer patients: A multicenter study: A Francogyn group study

Endometrial cancer (EC) is the fourth most common cancer in women worldwide. The quality of care for EC patients may vary depending on the treatment center volume. The present study aimed to investigate the impact of center volume on the survival of EC patients. This multicenter retrospective study analyzed a large cohort of EC patients with type 1 and type 2 tumors treated between 2001 and 2020 in France. The study analyzed the impact of center volume on overall survival, as well as the impact of other factors such as age, FIGO stage, lymph node involvement, laparoscopic surgery, and overall recurrence. The study found that treatment center volume had a significant impact on the overall survival of type 1 EC patients but not on type 2 EC patients. Other factors such as age, FIGO stage, lymph node involvement, laparoscopic surgery, and overall recurrence also impacted survival. Our study provides important insights into the quality of care for EC patients in France. The study's results highlight the impact of treatment center volume and other factors on survival and underscore the importance of high-quality care for all EC patients.

Do PET-positive supradiaphragmatic lymph nodes predict overall survival or the success of primary surgery in patients with advanced ovarian cancer?

Compared to conventional computed tomography (CT), fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) detects higher rates of lymph node and distant metastases in patients with ovarian cancer. However, FDG-PET/CT is not routinely performed during preoperative work-up. Therefore, we investigated the prognostic value of preoperative FDG-PET/CT in advanced epithelial ovarian cancer (EOC) and its predictive value for surgical resection in patients with no residual disease. The potential significance of PET-positive supradiaphragmatic lymph nodes (SDLNs) for these parameters was evaluated. All patients with FIGO IIA-IVB EOC diagnosed between March 2014 and January 2021 at our certified gynaecological cancer centre, who underwent FDG PET/CT before primary surgery were retrospectively included. Fifty-three consecutive patients were included in the study. Eighteen (34 %) patients had PET-positive SDLNs. We could not demonstrate a significant correlation between PET-positive SDLNs and median overall survival (OS; SDLN-positive: 58.76 months, SDLN-negative: 60.76 months; p = 0.137) or intra- or perioperative outcomes. FDG PET/CT has a higher detection rate for SDLNs in patients with ovarian cancer than CT has, as described in the literature. Moreover, PET-positive SDLNs failed to predict intraoperative outcomes or overall survival.

Retrospective analysis of uterine involvement in low grade serous ovarian carcinoma

Low grade serous ovarian carcinoma (LGSOC) accounts for 2.5% of all ovarian carcinoma more affects younger women than high grade serous ovarian carcinoma. Hysterectomy is performed routinely for LGSOC treatment, but fertility sparring surgery (FSS) is feasible for some early stages. Currently, there is no study about uterine involvement in LGSOC. We evaluate uterine involvement in LGSOC patients and aim to identify pre-operative predictive factors. Retrospective observational study of LGSOC patients treated between January 2000 and May 2022 in the Hospices Civils de Lyon. All cases were viewed, reviewed or approved by an expert pathologist. Among 535 serous ovarian carcinomas, 26 were included. Most patients (73 %) had FIGO III disease. Median OS was 115 months and median PFS was 42 months. Uterine involvement was found in 58 % patients who underwent hysterectomy (14/24), serosal involvement was the most frequent type of involvement (n = 13, 54 %). Myometrial involvement was found in 8 patients (33 %) and was associated with serosal involvement (7/8). Among patients with a macroscopic disease-free uterus during exploratory laparoscopy, 31 % had a microscopic serosal involvement. None patient with presumed early stage (FIGO I) were upstaged due to uterine involvement (serosal or myometrial). In patients with stage FIGO IIII, 72 % of uterine involvement were found. Univariate analysis did not show any predictive factor of myometrial involvement. There was no difference on OS nor PFS between patients with or without myometrial involvement. In early stages LGSOC, FSS may be considered for selected patients. In advanced stages, hysterectomy should be performed routinely, since no predictive factor for uterine involvement were identified.

Is p53 immunohistochemistry alone useful for delineating adjuvant endometrial treatment in low-middle-income countries?

Endometrial cancer (EC) treatment changed substantially with the introduction of molecular classification. Low-middle income (LMIC) countries will face barriers to including molecular classification to guide treatment. This study aims to analyse the value of p53 immunohistochemistry to delineate adjuvant treatment in FIGO stages I and II. Patients with EC treated between 2010 and 2016 were retrospectively evaluated. Patients included in this analysis must have reviewed FIGO stage I/II high-grade histologies (endometrioid grade 3, serous, clear cell, carcinosarcoma, mixed and undifferentiated). Samples were subjected to p53 immunohistochemistry. Recurrence-free and overall survival were analysed using the Kaplan-Meier method and log-rank test. Cox proportional hazards regression was performed for multivariable analysis. From 2010 to 2016, 265 patients met the inclusion criteria. Patients with aberrant p53 (71.4 %) were associated with older age (59.7 % vs 77.8 % with more than 60 years), relapse (12.5 vs 29.6 %) and death (22.2 vs 46.7 %). The pattern of relapse was not different, with most being at extrapelvic sites (55.5 % vs 62.3 % for p53 wild type and aberrant, respectively). The median overall survival was not reached versus 92.2 months for p53 wild type and aberrant, respectively (p = 0.003). In multivariate analysis, chemotherapy decreased death (p = 0.014) in p53 aberrant tumours, a benefit not seen in the wild-type cohort (p = 0.22). This retrospective analysis corroborates the finding of worse outcomes for p53 aberrant tumours in stage I/II EC and the benefit of more aggressive adjuvant treatment (systemic therapy and radiotherapy). Although not ideal as a sole molecular marker, p53 immunohistochemistry could complement the classical anatomopathological features and be part of the decision-making process with patients in LMIC.

The efficacy of adjuvant chemotherapy on the survival of early stage endometrial cancer

No consensus exists on the adjuvant chemotherapy for the International Federation of Gynecology and Obstetrics (FIGO) Stage I-II endometrial cancer with risk factors for recurrence. This study evaluated adjuvant chemotherapy's efficacy in improving these patients' survival. We conducted a retrospective chart review of patients with FIGO Stage I-II endometrial cancer with recurrence risk factors. The patients received no adjuvant therapy at the National Cancer Center Hospital (NCCH) but received platinum-based chemotherapy at Shiga University of Medical Science (SUMS). Six hundred thirty-eight patients with endometrial cancer were identified. Of these, 118 met the inclusion criteria, 321 were excluded from NCCH, while 49 met the inclusion criteria, and 150 were excluded from SUMS. Multivariate analyses of age, surgery, para-aortic lymphadenectomy, omentectomy, histological type, myometrial invasion, cervical stromal invasion, and adjuvant therapy revealed that in patients aged > 60 years with type II histology, the outer half of myometrial invasion, cervical stromal invasion, and positive peritoneal cytology had significantly worse recurrence-free survival (RFS) rates, and patients aged > 60 years with type II histology, outer half of myometrial invasion, and positive peritoneal cytology had significantly worse overall survival (OS) rates. Patients that received adjuvant chemotherapy showed equivalent effects on RFS (hazard ratio [HR] = 2.13; 95% confidence interval [CI] = 0.82-5.53) and worse on OS ([HR = 5.20; 95 %CI = 1.26-21.50) than patients who did not. This study did not show that adjuvant chemotherapy for FIGO Stages I-II endometrial cancer with recurrence risk factors has survival benefit. Further large-scale studies are necessary to validate our findings.

Beyond the Image: Performance of O-RADS, ADNEX, IOTA Simple Rules &amp; RMI 4 in differentiating benign and malignant adnexal masses – An Indian perspective

To prospectively and externally validate O-RADS (Ovarian-Adnexal Reporting and Data System), RMI 4 (Risk of Malignancy Index), IOTA SR (International Ovarian Tumour Analysis Group Simple Rules) and ADNEX Rules (Assessment of Different NEoplasias in the adneXa), and compare their diagnostic accuracy in differentiating benign and malignant Adnexal Masses (AM) in the Indian population. This single-centre diagnostic accuracy study included 100 consecutive consenting women with AM presenting to the gynaecology department at a tertiary care centre in Northern India. Every AM was classified as benign or malignant using O-RADS, RMI4, IOTA SR, and the ADNEX model (with CA 125). The reference standard was histopathological diagnosis. Sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios and overall accuracy were determined for all systems among various age groups and histopathological subtypes. Of the 100 women (mean age 42 ± 16.8 years) recruited, 45 had histopathologically benign lesions, 41 malignant and 14 borderline AM. O-RADS showed the highest sensitivity at 98 % (95 % CI: 87.4-99.5), followed by IOTA SR at 95 % (95 % CI: 83.8-98.6), RMI 4 at 88 % (95 % CI: 74.4-94.6), and ADNEX at 87.8 % (95 % CI: 73.8 %-95.9 %). However, ADNEX demonstrated the maximum specificity at 93 % (95 % CI: 81.7 %-98.6 %), followed by RMI 4 at 89 % (95 % CI: 76.5-95.1), IOTA SR at 87 % (95 % CI: 73.82-93.74), and O-RADS at 53 % (95 % CI: 39.1-67.1). Overall, ADNEX and IOTA SR showed the highest and similar diagnostic accuracy at 91 % (95 % CI: 82.7-95.2), followed by RMI 4 at 88 % (95 % CI: 79.9-93.5) and O-RADS at 74 % (95 % CI: 64.2-82.4). The O-RADS, IOTA Simple Rules and ADNEX performed well in distinguishing benign from malignant adnexal masses in an Indian population among various age groups and histopathological subtypes. While O-RADS was the most sensitive, the ADNEX model showed the best specificity. Additionally, RMI 4 is a robust diagnostic tool with strong diagnostic accuracy, outlining the importance of its application in low-resource settings.

Fertility-sparing strategies in borderline and malignant ovarian tumors: a comparative analysis of international guideline recommendations

To compare recommendations across international guidelines on fertility-sparing surgery (FSS) for borderline and malignant ovarian tumors. A systematic literature search in PubMed and five major oncology organization websites was conducted for the identification of relevant guidelines, and data on FSS issue were extracted and compared. In total, 7 guidelines (NCCN, ESGO-ESHRE-ESGE, BGCS, SEOM-GEICO, ESGO-ESMO-ESP, ESMO, and LGSOC-consensus) were included in final analysis. The guidelines unanimously recommend ascites/peritoneal lavage cytology, omentectomy/omental biopsy, and random peritoneal biopsy for staging borderline and malignant ovarian tumors. However, discrepancies emerged regarding the necessity of lymphadenectomy, appendectomy, and endometrial evaluation in different histologic subtypes. Not all guidelines address FSS eligibility, and controversy exists. Only three guidelines (NCCN/BGCS/ESGO-ESHRE-ESGE) provide recommendations for post-childbearing completion surgery in patients receiving FSS. For BOTs, NCCN guideline recommends routine post-childbearing completion surgery, while ESGO-ESHRE-ESGE guideline advises against it, and BGCS guideline advocates individualization. For MGCTs, both NCCN and BGCS guidelines recommend routine post-childbearing completion surgery, whereas ESGO-ESHRE-ESGE guideline recommends against it. For EOCs and MSCSTs, NCCN guideline recommends to consider routine completion surgery after finishing childbearing. In contrast, ESGO-ESHRE-ESGE guideline only recommends that patients with a family history of genetic high-risk EOCs and patients with granulosa cell tumors undergo completion surgery, while individualized management should be applied to other EOC and MSCST patients. Interguideline variability exists in FSS recommendations in borderline and malignant ovarian tumors, and harmonizing evidence-based criteria for FSS is critical to optimize fertility preservation without compromising oncologic outcomes in these populations.

Role of preoperative serum CA-125 and fibrinogen levels in predicting lymph node metastasis, myometrial invasion, and lymphovascular space invasion in patients with endometrial cancer

To evaluate whether preoperative serum levels of cancer antigen 125 (CA-125) and fibrinogen could provide clinical guidance for surgical planning and treatment management in patients with endometrial cancer. A retrospective study was conducted, including 582 patients who underwent surgery for endometrial cancer between October 2020 and December 2024 at a tertiary centre. Preoperative CA-125 and fibrinogen levels, clinical variables, and postoperative pathological findings were collected from electronic medical records. The primary outcome was lymph node metastasis (LNM). The secondary outcomes were myometrial invasion (MI) ≥ 50% and the presence of lymphovascular space invasion (LVSI). Independent predictors of LNM, MI ≥ 50% and LVSI were evaluated using multivariable logistic regression based on TRIPOD-aligned preoperative and postoperative modelling frameworks. Model performance was assessed through area under the receiver operating characteristic curve (ROC-AUC), calibration metrics, and decision curve analysis. Optimal biomarker thresholds were determined using ROC analysis and the Youden index. Sensitivity analyses examined the diagnostic performance of the Mayo low-risk criteria and the additional value of incorporating CA-125 ≥ 29.1 U/ml. MI ≥ 50%, LVSI and LNM were identified in 37.3%, 33.2% and 13.2% of patients, respectively. An elevated CA-125 level was significantly associated with MI ≥ 50%, LVSI and LNM (all P < 0.001), while the fibrinogen level only differed between LNM groups (P = 0.009). In univariable analyses, multiple clinicopathological factors - including age, body mass index (BMI), tumour grade, histological subtype, cervical stromal involvement, lower uterine segment involvement, tumour size, MI ≥ 50%, LVSI, CA-125 and fibrinogen - were associated with LNM. In the preoperative model (Model 1), CA-125 [odds ratio (OR) 1.02; P < 0.001], older age (OR 1.05; P = 0.001) and lower BMI (OR 0.92; P = 0.001) were independent predictors of LNM, yielding an AUC of 0.805. In the postoperative model (Model 2), LVSI was the strongest predictor (OR 20.46; P < 0.001), and the model demonstrated improved predictive performance (AUC 0.889). CA-125 remained independently associated with LNM in both models. CA-125 alone achieved an AUC of 0.740 with an optimal cut-off of 29.1 U/ml. For the secondary outcomes, age, tumour size, grade and LVSI independently predicted MI ≥ 50% (AUC 0.862), whereas BMI, histological subtype, cervical stromal involvement, MI ≥ 50% and tumour size independently predicted LVSI (AUC 0.886). Fibrinogen did not have independent predictive value for MI or LVSI. In a sensitivity analysis, the addition of CA-125 ≥ 29.1 U/ml to the Mayo low-risk criteria improved the detection of LNM in cases initially classified as low risk. Preoperative CA-125 level in patients with endometrial cancer is associated with MI, LVSI and LNM. CA-125 remained an independent predictor of LNM in both the preoperative and postoperative models, whereas fibrinogen did not retain independent significance in multivariable analyses. Incorporating CA-125 into the Mayo low-risk criteria increased sensitivity for detecting LNM. These findings suggest that combining biochemical markers with clinical and pathological variables may enhance surgical planning, and support the personalization of postoperative treatment strategies.

Urinary incontinence management in patients with primary endometrial cancer: A cross-sectional study by the European Network of Young Gynaecologic Oncologists (ENYGO)

Urinary incontinence is a common issue yet frequently overlooked in patients with endometrial cancer, especially post-treatment. Both advanced age and obesity as shared risk factors for endometrial cancer and urinary incontinence compound this burden. We hypothesized that there is insufficient awareness and suboptimal integration of urinary incontinence management into endometrial cancer care. The European Network of Young Gynaecologic Oncologists (ENYGO) team conducted a cross-sectional online survey from February to November 2024 using SurveyMonkey, targeting healthcare professionals involved in gynecologic oncology care. The 31-item questionnaire covered demographics, diagnostics, treatment protocols, and urinary incontinence-related practices. Statistical analysis was performed using SPSS V28.0, including descriptive statistics, normality testing, and appropriate reporting of mean ± SD or median with interquartile ranges. Our final analysis included 85 complete responses. Respondents were from 31 countries, with a median age of 38 years, and 55.3% of them were female. Although 65.9% of institutions had urogynecologists, only 3.5% of respondents had formal urogynecology training. Urinary incontinence was most frequently discussed before surgery (27.1%) and least before targeted therapy (9.4%). Radiation therapy was identified by 75.4% as the main contributor to urinary incontinence. While 96.5% asked about urinary incontinence during follow-up, only 14.1% managed it post-treatment. Major barriers included lack of training (54.1%) and resources (31.8%). Notably, 58.8% expressed interest in further training. Despite high reported awareness of urinary incontinence, proactive assessment and management remain inconsistent in endometrial cancer care. Structured education, interdisciplinary collaboration, and guideline development are needed to optimize quality of life outcomes.

Systematic literature review and meta-analysis of postoperative complications of surgical management of vulvar cancer: what is the impact of frailty factors?

Vulvar cancer surgery is associated with high rates of morbidity. Preventing or minimizing these morbidities is an important objective, as they impact on patients' quality of life, and are highly deleterious in frail, aged patients, who represent the majority of those affected by this disease. This systematic literature review and meta-analysis assesses post-operative complications in vulvar cancer surgery, and attempts to identify the impact of frailty factors. A Pubmed search was conducted to identify studies reporting data on complications of vulvar cancer surgery in frail patients, from January 2000 to April 2022, following the recommendations of the PRISMA, and registered in PROSPERO (CRD 42024503036). The evaluation criteria were: age, frailty, and complications. Statistical heterogeneity of results was assessed by graphical representations of confidence intervals (CI) on forest plot and by a Chi2 heterogeneity test. Frailty related to age > 70 years increases the risk of inguinal disunion (OR = 1.89, 95%CI [1.12-3.20]). Frailty (due to age and obesity) does not increase the risk of lymphocele. Frailty factors, such as obesity, are risk factors for inguinal cellulitis (OR = 1.86, 95%CI [1.12-3.08]), and diabetes is a risk factor for inguinal infection. This literature review and meta-analysis precludes drawing any significant clinical conclusion regarding the impact of frailty, in particular age-related frailty, on the occurrence of complications. This is due to different definitions of complications, a lack of precision in the data provided, the variety of surgical techniques performed, the absence of an age group or a frailty group.

Classification of patients with adenomyosis based on clusters of coexisting diseases: An illustration of clinical diversity

Adenomyosis (AM) is a complex disease with poorly understood pathogenesis and considerable clinical phenotypic heterogeneity. Cluster analysis of coexisting diseases may help identify distinct clinical subtypes of AM and explore the potential association between AM and its coexisting diseases. In this study, data were extracted from a cross-sectional questionnaire. AM patients were clustered by Ward's method according to the coexisting diseases. Cluster of patients with similar coexisting diseases pattern was captured and characterized. Subsequently, the clinical characteristics of these clusters were compared. Data from 2080 AM patients were collected. Sixteen types of coexisting diseases were included in the cluster analysis, resulting in six distinct clusters: cluster 1 (leiomyoma of the uterus); cluster 2 (endometrial lesions); cluster 3 (benign breast and thyroid masses); cluster 4 (pelvic inflammatory disease); cluster 5 (benign ovarian cyst); cluster 6 (low burden of comorbidity). Identifying patient clusters with similar coexisting diseases pattern can improve our understanding of the multidimensional nature of AM, reveal the complex inter-disease relationship, aid in early screening for specific diseases in particular subgroups, support the identification of risk factors for AM prevention, and guide the development of tailored management strategies for different subgroups.

Pregnancy outcomes after laparotomic or laparoscopic myomectomy: A multicenter retrospective cohort study

Expend knowledge about pregnancy rate, live birth rate and outcomes after laparotomic or laparoscopic myomectomy. In four hospitals in the Netherlands patients with a FIGO type 3-7 myoma who underwent laparoscopic or laparotomic myomectomy between January 2007 and April 2022, were retrospectively identified. Indication for the myomectomy was abnormal uterine bleeding, bulk-related symptoms and/or infertility. Baseline characteristics, data of the myomectomy and outcomes including pregnancy rates, live birth rates and complications during pregnancy or delivery, were extracted from electronic patient records. Logistic regression analysis was used to identify factors influencing the live birth rate. One hundred sixty four patients were included. Sixty one patients had 94 pregnancies after the myomectomy (pregnancy rate: 37 %), resulting in 64 deliveries in 50 patients (30 %). The most common mode of delivery was caesarean section (CS) (n = 40, 62 %). Forty-six patients had a live birth after the myomectomy (live birth rate: 28 %), together they had 60 children. No major complications related to the myomectomy occurred during pregnancy or delivery. Patients who had been pregnant before the myomectomy and patients with infertility as primary symptom, had a higher probability of live birth after myomectomy. Patients who underwent a laparotomic or laparoscopic myomectomy have a live birth rate of 28%, with a pregnancy rate of 37%. The most common mode of delivery is CS. No major complications were found during delivery. Patients with a pregnancy prior to the myomectomy or with infertility as primary symptom had an increased probability of live birth after myomectomy.

Application and validation of AI-driven methods to explore patient experiences of pre-cervical cancer

We sought to apply novel natural language processing (NLP) tools to explore patient experiences of pre-cervical cancer on social media and validate the performance of these tools. All posts and comments were extracted from the forum r/PreCervicalCancer on social media platform Reddit. Using BERTopic, posts were clustered into topics according to their semantic similarity, which were manually reviewed. Topic headings were derived using a large language model (LLM) and compared to manually curated headings. Clustering outliers were reassigned by BERTopic, an LLM and by manual methods in parallel and compared. Post and comment sentiment were quantitatively analysed using VADER. Post upvote scores and comments counts were analysed to measure community engagement. 4592 posts were extracted from r/PreCervicalCancer. Posts clustered into 10 different topics using BERTopic with 88.0% accuracy. 80.0% of topic headings generated by GPT-4o mini were deemed appropriate. Reassignment of clustering outliers by BERTopic and GPT-4o mini was limited, 52.8% and 41.1% accuracy, respectively. Key clinical findings reflect several common concerns among patients, particularly regarding specific lasting physical and psychological impact of procedures like LEEP, result anxiety, and challenges in healthcare navigation. Comments had less negative sentiment than posts (Cohen's d = 0.46), suggesting support. In this cross-sectional study, we validated NLP tools to analyse content, sentiment and reactions to 4592 posts on pre-cervical cancer. Our findings suggest that, with minimal human oversight, automated methods can accurately conduct large-scale analyses of similar clinical content, unlocking new insights of patient experiences using non-traditional data sources.

Risk factors for hospital readmission following staging surgery for endometrial cancer

Endometrial cancer is the most common gynecologic malignancy, with surgical staging being the primary treatment. Despite generally favorable outcomes, postoperative complications frequently lead to unplanned hospital re-admissions, adversely affecting patient well-being and healthcare resource utilization. This study aimed to identify factors associated with hospital readmission following staging surgery for endometrial cancer. A retrospective cohort study of women undergoing staging surgery for endometrial cancer conducted between January 2016 and December 2022 at a single tertiary center. The primary outcome was hospital re-admission within 30 days of surgery. Demographics, clinical, laboratory data and pre intra and postoperative data were collected from electronic records. Univariate and multivariable logistic regression analyses were performed to identify independent predictors of readmission. Among 470 patients, 36 (7.7 %) were readmitted within 30 days. Multivariable analysis identified four independent risk factors for readmission: Intraoperative complications (OR 15.94; 95 % CI 3.22-78.88; p < 0.001), preoperative hemoglobin < 10 g/dL (OR 5.52; 95 % CI 1.23-24.81; p = 0.026), prior abdominal surgery (OR 3.26; 95 % CI 1.29-8.74; p = 0.012) and ASA physical status classification ≥ 3 (OR 3.17; 95 % CI 1.30-7.74; p = 0.011). Most causes of readmission were fever (30.5 %), pain (22.3 %), and bleeding (16.6 %), while surgical site infections accounted for 5.6 of readmitted patients. Prolonged hospitalization was more common among readmitted patients but was not an independent predictor. Our findings confirm that previous abdominal surgery, ASA physical status classification ≥3, and preoperative anemia independently predict 30-day readmission after endometrial cancer staging surgery. These findings underscore the importance of risk stratification, optimization of preoperative status and enhanced postoperative monitoring to reduce avoidable readmissions and improve patient outcomes.

Ninety-day surgery-related outcomes of laparoscopic hysterectomy, bilateral salpingo-oophorectomy and sentinel node mapping in apparent early-stage endometrial cancer: a secondary analysis of a prospective single-arm study

Limited prospective data are available on the outcomes and performance of sentinel node mapping (SNM) in patients with endometrial cancer (EC). This study aimed to describe the surgical outcomes related to laparoscopic staging and the performance of SNM in patients with apparent early-stage EC. This is a secondary analysis of a prospective single-arm study focusing on predictors of nodal disease in apparent early-stage EC. This analysis focused on 90-day surgical outcomes of patients undergoing laparoscopic surgery, including hysterectomy, bilateral salpingo-oophorectomy and SNM. Overall, 210 patients were evaluated: 178 (84.8 %) patients had endometrioid EC and 32 (15.2 %) patients had non-endometrioid EC. No conversions to open surgery were reported at the time of SNM. Two (1 %) patients converted to open surgery for completion of hysterectomy. Unilateral mapping was achieved in all patients (n = 210, 100 %), with a bilateral pelvic detection rate of 93.8 % (n = 197). Sentinel nodes in the para-aortic area were detected in 19 patients (9 %). The majority of sentinel nodes were located in the external iliac area (55.7 % on the right side and 58.6 % on the left side), followed by the obturator area (26.1 % on the right side and 22.9 % on the left side) and internal iliac area (11.9 % on the right side and 8.1 % on the left side). Overall, 41 patients (19.5 %) had positive nodes detected, with low-volume disease observed in 21 (10 %) patients. Eight (3.8 %) patients had moderate (grade 2) 90-day complications. Three (1.4 %) patients had severe (grade 3) 90-day complications. Laparoscopic surgical staging for apparent early-stage endometrial cancer is safe and effective. Long-term data are needed to assess oncological outcomes.

Efficacy and safety of different doses of mifepristone in the treatment of uterine fibroids: A meta-analysis

To systematically assess the safety and effectiveness of mifepristone at doses of 2.5 mg, 5 mg, 10 mg, 25 mg, and 50 mg in the treatment of uterine fibroids. The protocol is registered with INPLASY (registration number is INPLASY202460075). Computer retrieval PubMed, the Cochrane Library, Embase database related (mifepristone group) compared to placebo and mifepristone or conventional treatment (control group) in the treatment of uterine fibroids randomized controlled trial (RCT), retrieve the time limit for a Library to in October 2023, Refer to the Cochrane faced the quality evaluation of the literature of included in the 6.0 and uses the RevMan 5.4.1 software Meta-analysis and sensitivity analysis. There were 18 studies with a total of 2066 patients as participants. A meta-analysis found that the patients in the mifepristone group had lower uterine volume or uterine fibroid volume than the control group, with a statistically significant difference. Mifepristone treatment for 3 months uterine volume smaller is better than 6 months the difference is statistically significant. Compared with the control group, mifepristone can improve pelvic pain, pelvic pressure, bladder pressure, urinary symptoms, lower back pain, dyspareunia, rectal pain, menorrhagia, hypermenorrhea, and other clinical symptoms. The Mifepristone group had hot flashes, endometrium thickness increases, the incidence of hepatic transaminases associated is significantly higher than the control group, the patients in the 10 mg/d mifepristone group had endometrial thickness that was greater than those in the 5 mg/d mifepristone group. Mifepristone reduces fibroid volume and improves clinical symptoms, and 5 mg/day of mifepristone for three months may be the optimal clinical regimen.

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

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

Survival outcomes of sentinel lymph node biopsy alone versus back-up systematic lymph node dissection in high-risk endometrial Cancer: A Turkish Gynecologic Oncology group study (TRSGO-SLN-007)

Investigate whether there is an oncological benefit of performing back up systematic lymphadenectomy in addition to bilateral sentinel node biopsy. This multicentre retrospective study included patients with high-risk endometrial cancer treated at four gynaecological oncology clinics in Turkey between 2014 and 2023. Patients were stratified according to both conventional and ESGO risk criteria, and within each category were divided into two groups respectively "Sentinel Lymph Node Biopsy Group (SLN-only)" and "Back-up Lymphadenectomy Group (Back-up LND)". Disease-free survival (DFS) and overall survival (OS) were compared using univariate and multivariable Cox regression analyses. 56 patients in the SLN-only group and 158 patients in the Back-up LND group comprised of the Conventional High-Risk Group (CONV-HR) in the analysis. There was no significant difference statistically in terms of DFS (Log-Rank P = 0.29) and OS (Log-Rank P = 0.99). The European Society of Gynaecologic Oncology (ESGO) High-Risk Group (ESGO-HR) consisted of 44 patients in the SLN-only group and 133 patients in the Back-up LND group were included. The median follow-up periods were 27 months (IQR = 15-38) and 28 (IQR = 16-38) months, respectively. Recurrence rate was 14.1 % and mortality rate was 9.6 %. There was no significant difference statistically in terms of DFS (Log-Rank P = 0.342) and OS (Log Rank P = 0.488). Sentinel lymph node biopsy is a safe and effective method for lymph node assessment in high-risk and clinical early-stage endometrial cancer. The addition of systematic lymphadenectomy did not provide any oncological benefit in terms of survival outcomes.

Trend and characteristics of endometrial cancer in Guangzhou from 2000 to 2020

To explore temporal trends in the age of endometrial cancer in Guangzhou over the past 21 years. We conducted a retrospective analysis of women diagnosed with endometrial cancer from 2000 to 2020 at a major teaching hospital in Guangzhou, China. One-way analysis of variance was utilized to compare the average age of onset for each year, while the t-test was employed to compare groups A (2000-2009) and B (2010-2020) over the 21-year period. Stratified analysis was conducted based on age group and pathological type. Chi-square and Fisher's exact tests were utilized to compare histopathological types across different groups. Multiple linear regression analysis was used to analyze the independent factors. The number of endometrial cancer cases increased annually over the 21-years period. A total of 610 patients were included in the study. The age of onset ranged from 14 to 89 years, with a mean age of 52.9 ± 9.3 years. One-way variance analysis revealed no statistically significant difference in the mean age between years (F = 1.518, p = 0.069). When grouped into decades, the mean ages of the 2000-2009 and 2010-2020 were 53.91 ± 10.23 years and 52.69 ± 9.79 years respectively, with no statistically significant difference observed (p = 0.23). From 2000 to 2020, patients aged ≤ 45 years accounted for 18.4 % of cases, with a significant increasing trend observed over time (F= 11.10, p< 0.001). However, there was no statistically significant difference in the composition ratio of patients aged ≤ 45 years (χ The mean age of endometrial cancer in this region remained relatively stable over the past 21 years, with no observable trend towards younger or older. The proportion of young patients in this region was higher than that of other countries.

Obesity, an independent predictor of pre and postoperative tumor grading disagreement in endometrial cancer

Obesity is a known independent risk factor for endometrial cancer (EC), and obese patients have a 4.7-fold increased risk compared to the general population to develop the neoplasm. To date, a general pre and postoperative tumor grading agreement from 53 % to 82 % is reported for endometrial analysis, and a consensus on which factors might influence the tumor grading discordance is still absent. Furthermore, although obesity alters the endometrial microenvironment, no studies investigated the role of obesity in the grading agreement of EC patients. This study aims to analyze the role of obesity in the pre and postoperative tumor grading agreement. A retrospective analysis was conducted on EC cancer women subjected to surgical treatment. Upgrading discordance was defined as higher tumor grading on final pathological analysis compared to tumor grading on the preoperative examination. Downgrading discordance was defined as a lower tumor grading at the postoperative surgical specimen analysis compared to the preoperative biopsy. Of the 293 selected patients, 245 were included in the analysis. One hundred and forty nine (60.8 %) patients were tumor grade G1, 52 (21.2 %) G2, and 44 (18.0 %) G3. Grading agreement was 83.9 % for G1 patients, 51.9 % for G2 patients, and 83.3 % for G3 patients. The multivariate analysis showed obesity (BMI > 30 kg/m Our study for the first time showed obesity as the only factor in the multivariate analysis lowering the pre and postoperative tumor grading concordance. Grade 2 tumor was the factor that most frequently disagreed with the final surgical specimen analysis both in the general and in obese patients.

Risk factors for atypical hyperplasia or endometrial cancer in premenopausal women aged ≤ 45 years with abnormal uterine bleeding

To assess the prevalence and risk factors for atypical hyperplasia (AH) or endometrial cancer (EC) in premenopausal women aged ≤ 45 years with abnormal uterine bleeding (AUB). This was a retrospective study of premenopausal patients aged 18 to 45 years who underwent hysteroscopy, dilation and curettage, or pipelle sampling at Inha University Hospital, South Korea, from 2014 to 2023. We used multivariable logistic regression analysis to identify risk factors and calculate the predicted probabilities of AH or EC with various combinations of these factors. Of 821 patients included in the study, 6.0 % were diagnosed with AH or EC. The significant risk factors identified were nulliparity (odds ratio (OR): 4.75, 95 % confidence interval (CI): 2.11-10.70), PCOS (OR: 2.72, 95 % CI: 1.34-5.52), and multiple polyps (OR: 2.33, 95 % CI: 1.23-4.41). The predicted probabilities of developing AH or EC increased with the number of risk factors present, ranging from 1 % to 33.6 %. The predicted probabilities within combinations of risk factors may be considered helpful in making better clinical decisions regarding endometrial sampling for patients ≤ 45 years with AUB.

Preoperative anemia predicts poor prognosis in patients with endometrial cancer: A systematic review and meta-analysis

To systematically and meta-analytically pool the existing evidence regarding the prognostic impact of preoperative anemia (hemoglobin level <12 mg/dl) in patients with endometrial cancer. Four (PubMed, Embase, Scopus and Web of Science) databases were searched from inception to 20-August-2020. We assessed the risk of bias using the Newcastle-Ottawa Scale. We estimated the pooled prevalence of preoperative anemia in the included studies. We pooled odds ratios (ORs) and hazard ratios (HRs) with their 95 % confidence intervals (95 % CIs) to evaluate the correlation between preoperative anemia and its impact on clinicopathologic parameters and survival outcomes. Analyses were performed under random- or fixed-effects meta-analysis models depending on data heterogeneity. Seven studies met the inclusion criteria comprising 1495 patients with endometrial cancer. Nearly all studies had low risk of bias. The pooled prevalence of preoperative anemia was 26.5 % (95 % CI: 18.6%-36.2%). Preoperative anemia significantly correlated with advanced FIGO stage III-IV (OR = 5.14, 95 % CI [3.36, 7.86], p < 0.00001), ≥50 % myometrial invasion (OR = 1.95, 95 % CI [1.36, 2.78], p = 0.0003), lymph node metastasis (OR = 4.46, 95 % CI [2.39, 8.30], p < 0.00001), non-endometrioid histology (OR = 3.25, 95 % CI [1.89, 5.60], p < 0.0001), adnexal involvement (OR = 5.88, 95 % CI [3.05, 10.23], p < 0.001), cervical involvement (OR = 2.91, 95 % CI [1.65, 5.11], p = 0.0002), positive peritoneal cytology (OR = 3.24, 95 % CI [1.41, 7.44], p = 0.006), preoperative thrombocytosis (OR = 6.66, 95 % CI [3.05, 14.52], p < 0.00001) and lymphovascular space invasion (OR = 3.50, 95 % CI [1.82, 6.74], p = 0.0002). High tumor grade II-III was increased in patients with preoperative anemia, yet this effect was not statistically significant (OR = 2.12, 95 % CI [0.97, 4.66], p = 0.06). Consistently, the five-year overall survival (OS) and disease-free survival (DFS) rates were significantly lower in patients with preoperative anemia when compared to those without preoperative anemia. Pooled HR showed that preoperative anemia was significantly associated with reduced DFS at univariate (HR = 3.22, 95 % CI [1.28, 8.11], p = 0.01) and multivariate (HR = 1.02, 95 % CI [1.00, 1.05], p = 0.03) analyses. Preoperative anemia predicts poor clinicopathologic and survival outcomes in patients with endometrial cancer.

A tricky case of endometrial cancer arising from adenomyosis

Reassessment of low- and intermediate-risk endometrial cancer reports by gynecological pathologists increases risk classification without impacting outcome

A lack of agreement is often observed in pathological reviews performed by specialized and general pathologists. Four histopathological variables influence the risk classification of endometrial cancer: histological type; histological grade; myometrial invasion; lymph-vascular space invasion (LVSI). This study aimed to evaluate if changes in the risk classification after a specialized pathological review of low- and intermediate-risk endometrial cancer (LIREC) samples may impact disease-free survival (DFS). A retrospective cohort of 195 patients diagnosed with LIREC at Barretos Cancer Hospital was obtained. Two gynecologic pathologists re-evaluated the pathological reports. Through the histology report reviewed, we could determine their new risk classification. The Kappa concordance score was used to verify the concordance between the general's and specialized pathologists' reports, and the new risk classification was correlated with the patients' DFS. The final reports led to changes in the histological type, histological grade, myometrial invasion, and lymphovascular space invasion in 13.3 %, 62,8%, 18.3 %, and 11.1 % of cases, respectively. The Kappa concordance score for all variables was less than 0.7. In 54 patients (30 %), the risk classification was modified (κ = 0.396), of which 30 (55.5 %) cases upstaged. There was no difference in DFS for patients who had an upstaging in their European Society of Medical Oncology modified classification compared to those who maintained their initial risk classification (86.7 % vs 88.0 %, p = 0.77). Despite the differences in the reports reassessed by expert gynecological pathologists and the change (30%) in patients' risk classification, there was no difference in their DFS.

Reproductive and pregnancy outcomes of fertility-sparing treatments for early-stage endometrial cancer or atypical hyperplasia: A systematic review and meta-analysis

To report the pregnancy outcomes of women with prior endometrial cancer and endometrial hyperplasia managed with fertility-sparing treatments. Medline and Embase databases were searched. Inclusion criteria were studies reporting the pregnancy outcomes of women who had undergone fertility-sparing treatments for endometrial hyperplasia or early endometrioid endometrial cancer. Outcomes explored were pregnancy, miscarriage and livebirth rates according to the type of progestin treatment used. Subgroup analyses according to the type of diagnostic follow-up were also performed. Meta-analyses of proportions using a random effects model were used to combine data. Twenty-nine studies (1036 women) were included, and 82.8% [95% confidence interval (CI) 72.3-91.2] of women achieved complete remission. Pregnancy rates were 56.3% (95% CI 41.6-70.5) with megestrol (MA) or medroxyprogesterone acetate (MPA), 63.1% (95% CI 37.0-85.6) with levonorgestrel-releasing intrauterine device (LNG-IUD), 57.9% (95% CI 37.7-76.8) with MA or MPA and metformin, 59.8% (95% CI 48.3-70.7) with MPA and LNG-IUD, 15.4% (95% CI 4.3-42.2) with gonadotropin-releasing hormone analogue (GnRHa) combined with LNG-IUD or letrozole, and 40.7% (95% CI 24.5-59.3) with LNG-IUD and GnRHa. Miscarriage rates were 17.4% (95% CI 12.2-23.4), 14.3% (95% CI 6.4-24.7), 57.9% (95% CI 37.7-76.8), 26.9% (95% CI 14.6-39.3), 100% (95% CI 34.0-100) and 18.2% (95% CI 5.1-47.7), respectively, and livebirth rates were 68.8% (95% CI 56.0-80.3), 80.8% (95% CI 69.5-90.0), 69.9% (95% CI 56.1-82.0), 25.97 (95% CI 14.6-39.3), 0% (95% CI 0-66.0) and 81.8% (95% CI 52.3-94.8), respectively. Finally, stratifying the analysis considering the endometrial sampling method alone, the pregnancy rate was 68.6% (95% CI 51.2-83.6; 10 studies, I Fertility-sparing treatment in women with endometrial cancer or hyperplasia is associated with an overall good response to therapy, good chance of achieving pregnancy and a good livebirth rate. Diagnostic follow-up with hysteroscopy was associated with a higher pregnancy rate, although this requires confirmation in adequately powered randomized trials.

Real-time detection of premalignant cervical lesion using Artificial Intelligence (AI) model in multispectral imaging system

Cervical cancer is the fourth most common cancer among women globally. The early diagnosis of cervical cancer can significantly improve prognosis and effective prevention. The accuracy of the cervical examination varies due to inter-clinician variability. This work is aimed to develop a real-time and static AI model integrated in Multispectral imaging System (GynoSight) with Graphical User Interface to assist the clinician in detecting abnormal blood vessels, acetowhite uptake, and iodine negative regions during the cervix screening. In this study, the dataset is acquired from the Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry between February 2024 to December 2024. The colposcopy images were acquired from the subjects between the age group of 22-65 years after smearing normal saline, 3 % acetic acid, and Lugol's Iodine. The preprocessing steps are applied on all images and the dataset is framed with 609 images, 196 normal saline-smeared cervix images,212 acetic acid-smeared cervix images, and 201 Lugol's iodine-smeared cervix images which were used to train and validate the model. The EfficientNet architecture AI model was implemented to identify the atypical blood vessel, dense acetic acid uptake and negative uptake of Lugol's iodine. The transvaginal imaging probe (GynoSight) was used to perform real-time detection of region of interest using a trained TensorFlow model. The proposed model achieved an accuracy of 86.67% for the identification of Iodine negative regions and an F1 score of 90% and mAP (50%) of 91.1%. The updated proposed model implemented for the detection of the acetic acid uptake was reported with an improvement of accuracy from 57% to 85.71% after applying segmentation algorithm which indicates the reliability and robustness of the system. Furthermore, the detection of atypical blood vessels, acetowhite region, and Iodine negative uptake regions by the AI system is compared with clinician interpretation followed by the biopsy results. The AI-assisted real-time detection system may assist the clinician during screening, which will reduce the number of unnecessary biopsies for the patients, reducing the inter-clinician variability.

Minimally invasive approach in endometrial cancer with lower uterine segment involvement in stage ≥ II: A retrospective study

To compare oncological outcomes in women with lower uterine segment involvement (LUSI) in endometrial carcinoma (EC) stage ≥ II - staged by a minimally invasive surgery (MIS) versus laparotomy. A retrospective multi-center cohort study. Univariate analysis, Kaplan-Meier survival and Cox proportional hazard analysis were performed to compare between women staged by MIS and those staged by laparotomy. Over a median follow-up period of 3 years (interquartile range, 1.5-6 years) 212 women were included, 68 (32.1%) were surgically staged by MIS. Stages of disease did not vary between MIS and laparotomy and were 32.1%, 51.9%, and 16.0%, in stages II, III and IV - respectively. Adjuvant radiation and chemotherapy rate did not differ between groups. Overall recurrence rate was comparable (p = 0.084). Locoregional recurrence rate was higher in the MIS group odds ratio 2.17, 95% confidence interval 1.19-4.20). Overall and progression free survival were similar in both groups (log rank test p = 0.08 and p = 0.912 respectively). In Cox regression model adjusting for age, comorbidities, tumor grade, stage and adjuvant therapy, route of surgery (MIS vs. laparotomy) was not associated with overall survival (p = 0.169). In women with advanced EC and LUSI, although MIS is associated with locoregional recurrences, survival is comparable to laparotomy.

Factors predicting morbidity in surgically-staged high-risk endometrial cancer patients

To investigate factors predicting the risk of developing 90-day postoperative complications and lymphatic-specific morbidity in patients undergoing surgical staging for high-risk endometrial cancer. This is a multi-institutional retrospective cohort study. Patients affected by apparent early-stage high-risk endometrial cancer (endometrioid FIGO grade 3 with deep myometrial invasion and non-endometrioid endometrial cancer) undergoing surgical staging between 2007 and 2019. Complications were graded according to the Clavien-Dindo classification system. Martin criteria were applied to improve quality of complications reporting. Charts of 279 patients were evaluated. Lymphadenectomy, sentinel node mapping (SNM), and SNM followed by back-up lymphadenectomy were performed in 83 (29.7%), 50 (17.9%), and 146 (52.4%) patients, respectively. The former group of patients included 13 patients who had lymphadenectomy after the failure of the SNM technique. Thirteen (4.6%) patients developed severe postoperative events (grade 3 or worse). At multivariate analysis, body mass index (OR: 1.08 (95%CI: 1.01, 1.17)) and open abdominal surgery (OR: 2.27 (95%CI: 1.02, 5.32)) were the two independent factors predictive of surgery-related morbidity. Seven severe lymphatic complications occurred. The adoption of laparoscopic approach (p < 0.001, log-rank test) and SNM (p = 0.038, log-rank test) correlated with a lower risk of developing surgery-related events. Independently, open abdominal surgery was associated with an increased risk of developing lymphatic morbidity (OR: 37.4 (95%CI: 4.38, 319.5); p = 0.001). The adoption of the laparoscopic approach and SNM technique were associated with lower 90-day complication rates than open surgery in high-risk endometrial cancer undergoing staging surgery.

Preoperative leukocytosis correlates with unfavorable pathological and survival outcomes in endometrial carcinoma: A systematic review and meta-analysis

To meta-analytically examine the frequency and prognostic impact of preoperative leukocytosis in endometrial carcinoma (EC). Five major databases were searched till 01-February-2021. Studies that evaluated the frequency of preoperative leukocytosis or its correlation with pathological and survival outcomes in EC patients were included. Data were pooled as mean differences (MD), odds ratios (OR), or hazard ratios (HR) with 95% confidence intervals. Nine retrospective studies, with low risk of bias, were included. The pooled prevalence of preoperative leukocytosis was 11.2% (95% CI: 8.2-14.3). There was a significant correlation between preoperative leukocytosis and FIGO stage III-IV (OR = 2.10, 95% CI: 1.60-2.75), ≥50% myometrial invasion (OR = 1.32, 95% CI: 1.02-1.72), lymph node involvement (OR = 1.83, 95% CI: 1.29-2.59), cervical involvement (OR = 2.29, 95% CI: 1.68-3.13), adnexal involvement (OR = 2.17, 95% CI: 1.42-3.31), and tumor size (MD = 1.10 cm, 95% CI: 0.63-1.58). However, preoperative leukocytosis did not significantly correlate with tumor grade II-III, non-endometrioid histology, peritoneal cytology, and lympho-vascular space involvement (p > 0.05). Additionally, preoperative leukocytosis correlated with higher rates of death (OR = 2.85, 95% CI: 2.03-4.00), tumor recurrence (OR = 2.36, 95% CI: 1.21-4.61), and worse overall survival at univariate and multivariate analyses (HR = 2.90, 95% CI: 2.24-3.75 and HR = 2.16, 95% CI: 1.59-2.94, respectively). As for disease-free survival, preoperative leukocytosis emerged as an independent prognostic factor on univariate (HR = 1.27, 95% CI: 1.16-1.39) but not multivariate (HR = 1.08, 95% CI: 1.00-1.18) analyses. Preoperative leukocytosis is common and correlates with poor pathological and survival outcomes in EC patients.

Maximizing sentinel node detection in endometrial cancer with dual cervical and transcervical fundal indocyanine green injection: 5-year single-center prospective study

The aim of this study was to describe our latest results using dual cervical and fundal indocyanine green injection for detection of sentinel lymph node (SLN) in endometrial cancer. A prospective observational study was conducted between 26 June 2014 and 31 December 2019 with 278 patients that underwent laparoscopic surgery for endometrial cancer at our institution. In all cases, we performed SLN biopsy with dual cervical and fundal indocyanine green injection. All SLNs were processed with an ultrastaging technique. A total of 128 patients also underwent total pelvic and paraaortic lymphadenectomy. The detection rates were as follows: 93.5 % (260/278) overall for SLNs; 90.7 % (252/278) overall for pelvic SLNs; 68.0 % (189/278) for bilateral SLNs; 66.9 % (186/278) for paraaortic SLNs, and 2.9 % (8/278) for isolated paraaortic SLNs. We found macroscopic lymph node metastasis in 26 patients (10.0 %) and microdisease in lymph nodes in another 48 patients, raising the overall rate of lymph node involvement to 16.2 %. There was one false negative (negative SLN biopsy but positive lymphadenectomy). Applying the SLN algorithm, the sensitivity of detection was 97.9 % (95 % CI 89.1-99.6), specificity 100 % (95 % CI 98.2-100), negative predictive value 99.5 % (95 % CI 97.4-99.9), and positive predictive value 100 % (95 % CI 92.4-100). Dual sentinel node injection is a feasible technique that achieves adequate detection rates. Additionally, this technique allows a high rate of aortic detection, identifying a non-negligible percentage of isolated aortic metastases. Aortic metastases in endometrial cancer are possible and we should not give up actively looking for them.

Comparison of two intraoperative examination methods for the diagnosis of sentinel lymph node metastasis in clinically early stage endometrial cancer: A Turkish Gynecologic Oncology Group Study (TRSGO-SLN-003)

This study evaluated diagnostic accuracy of intraoperative sentinel lymph node (SLN) frozen section examination and scrape cytology as a possible solution for management of SLN positive patients. Clinically early-stage endometrial cancer patients who underwent SLN algorithm and intraoperative SLN examination were analyzed. Findings were compared with final pathology results and diagnostic accuracy of frozen section and scrape cytology were evaluated. Of the 208 eligible patients, 100 patients (48 %) had frozen section examination and 108 (52 %) had scrape cytology of the SLN. Intraoperative examination and final pathology were negative for metastasis in 187/208 (90 %) cases. The rest 21 cases had metastatic SLNs according to final pathology. 12 of 21 (57 %) metastases were classified as macrometastasis. Intraoperative examination of SLNs correctly identified 13 cases (true positive) and missed 8 cases (false negative). Five of 8 false negative cases had micrometastasis or isolated tumor cells. Considering identification of macrometastasis, sensitivity and negative predictive value were 85.71 % and 98.94 %, respectively, for the frozen section and 60.00 % and 98.15 %, respectively, for the scrape cytology. Frozen section examination of SLN has higher sensitivity in detecting macrometastasis compared to scrape cytology and it could help the surgeon in decision for further lymphadenectomy intraoperatively.

Obesity and visceral fat: Survival impact in high-grade endometrial cancer

Obesity is an important risk factor for the development of endometrial cancer (EC). Recent data showed that body fat distribution might be more relevant than Body Mass Index (BMI). High visceral fat percentage was shown to be an independent predictor for survival in EC, but mainly included grade 1-2 EC. To evaluate body fat distribution and its relation to outcome in high-grade endometrial cancer. Retrospective study in women diagnosed with high-grade EC between February 2006 and August 2017 at the Royal Cornwall Hospital who had abdominal CT-scan as part of routine diagnostic work-up. Subcutaneous abdominal fat volumes and visceral abdominal fat volumes were quantified based on CT-scan measurements, and visceral fat percentage calculated. A total of 176 patients with high-grade EC were included. The median age was 70 years and median BMI was 29.4 kg/m In high-grade EC, high visceral fat percentage was an independent predictor of poor survival only in NEEC. The strong correlation between high visceral fat and obesity-related comorbidities might be reflective of an unhealthy macroenvironment.

Molecular characterization in the prediction of disease extent in endometrial carcinoma

Patients with endometrial carcinoma are usually triaged to staging lymphadenectomy selectively based on estimated risk of lymphatic spread. The risk is generally assessed by the presence of uterine risk factors, but their preoperative and intraoperative identification remain a challenge. The objective of this study was to assess the capability of molecular classification, described by The Cancer Genome Atlas (TCGA), to predict the stage of endometrial carcinoma. Sequencing of polymerase-ε (POLE) and immunohistochemistry of mismatch repair (MMR) proteins and p53 were performed to stratify endometrial carcinomas into subgroups of POLE exonuclease domain mutation (EDM), MMR deficiency, abnormal p53 (p53 abn) and 'no specific molecular profile' (NSMP). NSMP was the reference subgroup for comparisons. Associations of molecular subgroups and uterine risk factors with stage were examined in univariable and multivariable analyses. Six hundred and four patients were included in the study. None of the POLE EDM tumours extended beyond the uterine cervix. In an unadjusted analysis, p53 abn was associated with increased risk for stage IIIC-IV disease [odds ratio (OR) 4.6, 95% confidence interval (CI) 2.3-9.2; p < 0.0005]. When controlling for uterine risk factors (histotype and grade, depth of myometrial invasion, tumour size, lymphovascular space invasion), p53 was not an independent predictor of advanced disease. In contrast, POLE EDM independently predicted local disease (OR 0.12, 95% CI 0.015-0.99; p = 0.049 for stage II-IV cancer). Of the molecular subgroups, p53 abn was most strongly associated with the presence of high-risk uterine factors (ORs between 2.2 and 19; p ≤ 0.010). Of the TCGA-based molecular subgroups, POLE EDM independently predicted early-stage endometrial carcinoma. Although p53 abn was not an independent predictor of advanced disease, its association with uterine risk factors could allow utilization of molecular data in deciding the type of staging surgery if knowledge of uterine factors is deficient.

Efficacy and safety of relugolix therapy for symptomatic uterine fibroids: a systematic review and meta-analysis

Uterine fibroids are the most common benign tumors in premenopausal women and often necessitate fertility-sparing treatments. Relugolix, an oral GnRh antagonist has emerged as a promising non-surgical option. This systematic review and meta-analysis evaluate the efficacy and safety of relugolix for symptomatic uterine fibroids. We searched PubMed, Embase, Cochrane CENTRAL, Scopus, and ClinicalTrials.gov through March 2025. Six studies (n = 511) were included in accordance with the PRISMA guidelines. Data were analysed using random-effects models in R (v4.5.0). Risk of Bias was assessed using ROB 2 tool. Continuous outcomes were reported as mean differences (MDs), dichotomous outcomes as odds ratios (ORs) or proportions, and heterogeneity using I Pooled analysis revealed a myoma volume reduction (MVR) of -30.18 %, with similar findings when compared to placebo (-28.50 %; p-value = 0.0070). Uterine volume decreased by -27.22 %. When compared with placebo, uterine volume significantly reduced by -30.31 (p-value = 0.0028). Amenorrhea was achieved by 63 % of patients, with relugolix-treated patients showing 31-fold higher odds versus controls (31.07 %; p-value < 0.0001). Haemoglobin levels improved in 46.3 % patients, while relugolix-treated patients achieved significant pain relief compared to controls (OR 9.02; p = value < 0.0001). Subgroup analyses showed that relugolix monotherapy produced greater reductions in myoma and uterine volumes than combination therapy, although both regimens were effective. Treatment as generally well-tolerated, with hot flushes being the most common adverse event. A small proportion reported persistent menorrhagia without indicating treatment failure. Other adverse events, such as headache, were also reported, though discontinuation rates were comparable to controls. Relugolix significantly reduces fibroid burden and symptoms with favourable safety profile. It offers a well-tolerated, fertility-preserving alternative to surgery. Further large-scale RCTs are needed to confirm these findings and optimize treatment protocols.

Hysteroscopic resectoscope-directed biopsies and outpatient endometrial sampling for assessment of tumor histology in women with endometrial cancer or atypical hyperplasia

To evaluate and compare the diagnostic efficiency of outpatient endometrial sampling (OES) and hysteroscopic resectoscope-directed biopsies (HY Patients with AH or EC (n = 266) among 1013 patients consecutively referred because of postmenopausal bleeding were included. Identification of EC versus AH, and unfavorable tumor types (endometrioid grade 3 or non-endometrioid tumors) using OES and HY OES had only sufficient tissue samples in 72.7% of intended samples. Even when OES did provide sufficient material, addition of HY Addition of HY

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

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

Robotic indocyanine green-guided sentinel lymph node mapping in early-stage cervical cancer: The fluorescent robotic indocyanine endoscopic node detection series (FRIENDS)

To describe the implementation of robotic indocyanine green (ICG)-guided sentinel lymph node (SLN) mapping for nodal staging in early-stage cervical cancer and to report mapping outcomes, anatomical distribution of SLNs, and perioperative morbidity. This single-centre cohort study included women with presumed early-stage cervical cancer who underwent robotic ICG-guided SLN mapping between 2015 and 2025. SLN mapping was performed with or without pelvic lymphadenectomy according to a side-specific algorithm. Institutional practice evolved over time from routine SLN mapping with lymphadenectomy to selective SLN-only staging. Outcomes included SLN detection rates, anatomical distribution of SLNs, nodal metastases, and postoperative morbidity. A total of 161 women underwent robotic SLN mapping. SLN detection was achieved in all patients, with bilateral mapping in 145 (90.1 %). Sixteen women (9.9 %) had nodal metastases; all metastatic disease was identified within sentinel lymph nodes. SLNs were most frequently located in the obturator and external iliac regions, with occasional upper pelvic and para-aortic drainage when lymphatic channels extended cranially. Lymphoedema occurred in 18 women (11.2 %) and was observed only in those who underwent pelvic lymphadenectomy. This study describes long-term, real-world implementation of robotic ICG-guided SLN mapping in early-stage cervical cancer. The findings demonstrate consistent SLN detection, characteristic patterns of lymphatic drainage, and a lower observed incidence of lymphoedema when lymphadenectomy is avoided, supporting the role of SLN-guided nodal staging within contemporary, algorithm-based surgical practice.

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

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

Comparing clinical characteristic with uterine artery embolization versus laparoscopic hysterectomy in symptomatic uterine fibroids – A prospective, single-institution study

This study aimed to identify clinical indications for uterine fibroid (UF) treatment by comparing patient characteristics and imaging findings in cases treated with uterine artery embolization (UAE) or total laparoscopic hysterectomy (TLH). This prospective cohort study was conducted at a single center in Fukushima, Japan, and included 80 women who underwent UAE and 119 who underwent TLH for symptomatic UF between October 1, 2020, and May 31, 2025. Treatments, including hormonal therapy, myomectomy, hysterectomy, and UAE, were selected based on individual patient needs. Clinical and magnetic resonance imaging (MRI) findings were compared between groups. MRI parameters included uterine length (LU), depth (DU), number of fibroids (NF), and largest fibroid diameter (LFD). Receiver operating characteristic (ROC) curves were generated using UAE as the outcome variable for significantly different continuous variables, and cutoff values were derived from the area under the curve (AUC). A higher proportion of patients in the TLH group had a history of delivery (87.4 %) compared to the UAE group (57.5 %). The UAE group had significantly higher median values for LU (126 mm vs. 94 mm), DU (91 mm vs. 65 mm), NF (6 vs. 2), and LFD (69 mm vs. 47 mm) (all p < 0.01). ROC analysis showed the AUC for DU was 0.79, with a cutoff value of 82 mm (sensitivity 0.70, specificity 0.76). The findings indicate distinct clinical and imaging characteristics associated with UAE and TLH. These parameters may assist gynecologists in identifying suitable candidates for UAE in the management of symptomatic uterine fibroids.

Association of country of birth and persistent anemia from initial follow-up to surgery in women with symptomatic uterine fibroids

To evaluate the association between preoperative anemia and country of birth among women undergoing surgery for uterine fibroids. Retrospective cohort study. Two urban hospitals in Montréal, Canada. 642 women who underwent surgical treatment for uterine fibroids between 2017 and 2022. Medical records were reviewed for hemoglobin levels at the start of follow-up and within 7 days before surgery, as well as demographic, clinical, surgical, and socioeconomic data. Statistical analysis was conducted using RStudio (version 2024.09.0 + 375). Among the 419 women with hemoglobin result available at the beginning of follow-up, those with anemia were less likely to have been born in North America compared to those without anemia (39 % vs 60 %). Mean initial hemoglobin levels varied significantly by region of birth; women born in North America had higher levels than the cohort mean (117.01 g/L vs 111.30 g/L). North American birth remained an independent protective factor against anemia, even after adjusting for age, fibroid characteristics, and comorbidities. Among the 221 women with hemoglobin measured within seven days before surgery, 71 % showed hemoglobin improvement. Although patients born in North America continued to have higher preoperative hemoglobin levels (126.39 g/L vs 123.23 g/L; p = 0.045), the difference was smaller than at baseline. Hemoglobin improvement was consistent across all region groups. Birthplace outside North America is independently associated with preoperative anemia in women undergoing fibroid surgery. While hemoglobin improved over time, regional disparities persisted. Early identification and targeted intervention are essential to optimize surgical outcomes in diverse patient populations.

Clear cell borderline ovarian tumor: A retrospective study and literature review

Clear cell borderline ovarian tumor is a rare subtype of borderline ovarian tumor for which the clinicopathological characteristics, management, and prognosis remain unclear. Herein, we describe the clinical features, treatment options, and prognosis of clear cell borderline ovarian tumors. This was a retrospective study of nine patients with pathologically confirmed clear cell borderline ovarian tumors treated at Peking Union Medical College Hospital between 2006 and 2023. Data regarding the patients' clinicopathological features, management, and prognosis were analyzed. We also reviewed previously published studies in English of patients with clear cell borderline ovarian tumors who underwent fertility-sparing surgery. The median age at diagnosis was 52 years (range, 35-72) and the median tumor size was 6.5 cm (range, 2.7-13). Seven patients had unilateral tumors and two patients had bilateral tumors. Seven patients underwent radical surgery and two patients underwent fertility-preserving surgery. All patients had stage I disease. Pathological analysis revealed synchronous endometriosis or adenomyosis in five patients. Endometrial hyperplasia with atypia was found in two of the seven patients who underwent hysterectomy. During a median follow-up time of 54 months (range, 14-200), only one patient suffered a recurrence, which was treated successfully with secondary surgery. The prognosis of clear cell borderline ovarian tumors is favorable, and fertility-sparing surgery is acceptable for young patients who may desire future pregnancies. Unilateral salpingo-oophorectomy is recommended for patients in whom ovarian cystectomy was the initial surgery.

Women undergoing uterine artery embolization with transradial vs transfemoral access: A systematic review and meta-analysis

Uterine artery embolization (UAE) is a minimally invasive alternative to surgical intervention for symptomatic uterine fibroids. Transradial access (TRA) is gaining attention as a feasible approach compared with transfemoral access (TFA) due to its potential benefits in patient safety and comfort. However, comparative evidence regarding efficacy and safety remains limited. This systematic review and meta-analysis was conducted in accordance with the PRISMA guidelines and was registered in PROSPERO. Databases including PubMed, Google Scholar and the Cochrane Library were searched. Studies comparing TRA and TFA in patients undergoing UAE were included. Data extraction and risk-of-bias assessment (using RoB 2.0 and Newcastle-Ottawa tools) were conducted. Statistical analyses were performed using RevMan 5.4.1 with random-effects models, and heterogeneity was assessed using the I Seven studies involving 710 patients (355 TRA, 355 TFA) were included. TRA demonstrated a comparable procedural time [mean difference (MD) -2.74 min, 95 % confidence interval (CI) -10.16 to 4.69; p = 0.47) and fluoroscopy time (MD 0.14 min, 95 % CI -2.32 to 2.61; p = 0.91) with TFA. Radiation exposure showed no significant difference overall; however, sensitivity analysis revealed a significant reduction with TRA (MD -0.16 Gy; 95 % CI -0.24 to -0.07; p = 0.0002). No significant difference in major access site complications was observed [risk ratio (RR) 0.85; p = 0.73], while a non-significant trend favoured TRA for fewer minor complications (RR 0.59; p = 0.07). Microcatheter use was slightly higher in the TRA group, but the difference was not significant (RR 1.13; p = 0.09) CONCLUSION: TRA is a safe and effective alternative to TFA for UAE, with potential advantages including reduced radiation exposure and fewer minor access site complications.

Myoma expulsion after minimally invasive therapeutic strategies: a systematic review

Uterine leiomyomas are very common benign tumors of the myometrium which often occur in women in fertile age. They can cause pain, heavy bleeding, fertility impairment. Historically, the treatment available for this condition was only the surgical one. During the last decades, several new therapeutic possibilities became available to treat fibroids in a minimally invasive way, with the aim to avoid surgery and its possible complications. The aim of this review is to focus on these new techniques and on their complications, with particular regard to myoma expulsion. This study consists of a systematic review of the most recent scientific Literature, focusing on the final outcomes of minimally invasive treatments. We tried to answer the question if these uterus sparing approaches effectively were decisive for patients without any further treatments. In fact, the slice of patients who is mainly affected by myomas is the one of women in their fertile age, in which hysterectomy is obviously not suggested (in order let them complete the family planning) but the treatment of myomas should be pursued to relieve the symptoms and also to improve fertility. Another question we analyzed is the correlation between these minimally invasive techniques and spontaneous myoma expulsion. We conducted bibliographic research on scientific databases, identifying no. 35 papers which suited to our study. The overall expulsion rate in patients minimally - invasive treated was 14.4%, and among the different non - surgical minimally invasive techniques, MrgFUS seems to be related to the highest rate of myoma expulsion. Fibroid expulsion is resolutive in most cases, but in 1.4% of cases additional medical care to remove residual fibroid tissue is required. Severe adverse events of these procedures (utero - enteric fistule, uterine necrosis, sepsis) were observed in 0.9% of women. Fibroids expulsion can be considered not an adverse but a favorable event after fibroids' treatment. The expulsion (that in some cases can be asymptomatic or mild symptomatic) can lead to improvement of symptoms, and in the end turns out to be resolutive in most cases. Further studies are needed, especially to evaluate the efficacy and the fibroid expulsion rate of the newest minimally invasive techniques.

Is gestational trophoblastic neoplasia more common among women with recurrent hydatidiform moles and biallelic NLRP7 mutations? a 17-years prospective study from India

Recurrent hydatidiform moles (RHM) is a rare entity defined by the occurrence of two or more hydatidiform moles (HM) in a woman. We present data of women with RHM from a tertiary care institute in North India with respect to the incidence of Gestational Trophoblastic Neoplasia (GTN), subsequent reproductive outcome and genetic analysis in this cohort. Women who presented with RHM and no prior live birth were enrolled from 2005 to 2022 and analysed for the presence of pathogenic or likely pathogenic (P/LP) variants in genes responsible for RHM. They were followed-up for occurrence of post-molar GTN as per FIGO and WHO guidelines, and subsequent reproductive outcomes. Of the 23 women with RHM, 22 (95.6 %) had biallelic P/LP variants in three genes, 20 in NLRP7 (87 %), one in KHDC3L (4 %), and one in TOP6BL (4 %). Of the 20 women with NLRP7 variants, 10 (50 %) developed GTN, mostly low-risk, which is approximately 2 to 3 times higher than the rate of GTN among women with sporadic HM at similar ages. Three of these women had recurrent GTN. Among the 22 women with biallelic P/LP variants, only one had a spontaneous live birth, and four underwent IVF with donated ova, of whom three had live births. Only one woman was negative for recessive causative variants in the known genes or any novel gene and she subsequently had two spontaneous live births. Our data indicate a high incidence of biallelic P/LP NLRP7 variants among Indian women with RHM and no live birth. These women appeared to be at a higher risk for developing GTN and had a very low chance of a spontaneous live birth, and these two concerns may be mitigated by avoiding a spontaneous pregnancy and having donor ovum IVF. All women with RHM should have genetic testing and counseling specifically due to their higher risk of GTN.

PURE vs. mixed clear cell ovarian carcinomas: Is there any impact on survival?

Our primary aim in this study is to define the clinical characteristics of patients with clear-cell ovarian carcinoma and evaluate the prognostic factors affecting survival. Records of 85 patients, operated between 2000 and 2018, for an adnexal mass and whose final pathology reported clear cell ovarian carcinoma were reviewed. The study considered demographic data, clinical characteristics of the patients, as well as pure and mixed-type clear cell histology. The patients' follow-up time, disease-free and overall survival recorded. The primary outcomes were disease-free survival (DFS) and overall survival (OS). The median age of the patients at diagnosis was 52. In 64.7 % of the cases, clear cell histology was pure, while the others (35.3 %) were mixed. Patients with ovarian endometriosis constituted 27.1 % of the whole population. The median OS for the entire population was 92 months (95 %CI:72-124). On univariate and multivariate analyses, advanced age was found to have a significant independent impact on OS and DFS (p  0.05). This retrospective study showed that although mixed type histological origin was associated with higher OS and DFS rates compared to pure type in patients with CCOC, the difference was not statistically significant. Advanced age and the presence of endometriosis was found to have a significant independent effect on OS and DFS and was associated with a worse prognosis. Overall, this study provides useful insights into the clinical characteristics of patients with CCOC and identifies important prognostic factors affecting survival.

Should men whose female partners have cervical high grade intraepithelial lesion (HSIL) be screened?

The subject of screening for genital HPV lesions in the male partner of women with cervical high-grade squamous intraepithelial lesions (HSIL) remains a topic of discussion. The present study evaluated the prevalence of penile high-grade squamous intraepithelial lesion (HSIL) clinical lesions in 196 men whose female partners had been diagnosed with cervical low-grade and high-grade intraepithelial lesions (LSIL, HSIL) in Ile-de-France. In cases involving couples where the female partner had been diagnosed with a cervical LSIL or HSIL lesion, the male partner underwent examination using the peniscopy method. The presence of clinical identified HPV lesions was confirmed by biopsy proven histological analysis. The mean age of the 196 couples was 33.4 years for women and 35.6 years for men. Among the 196 women, 125 (64 %) had cervical LSIL and 71 (36 %) had cervical HSIL detected by colposcopy and confirmed by histology. Among 196 men, 65 (33 %) HPV lesions were identified and confirmed by histology. Of these, 44/196 (22 %) were penile LSIL and 21/196 (11 %) were penile HSIL. The risk of penile HSIL increased twofold (Fisher test 1.9) if the female partner had cervical HSIL (11/71, 15.5 %) versus cervical LSIL (10/125, 8 %). A man with a partner who has cervical HSIL is twice as likely to have penile HSIL than if his partner has LSIL cervical. This suggests that peniscopy should be offered to this population. It could avoid the persistence or recurrence of cervical HSIL of their partner.

The Gustave Roussy immune score as a novel scoring system for predicting platinum resistance in advanced high-grade serous ovarian cancer

This study was designed to investigate the relationship between the Gustave-Roussy immune score (GRIm-score) and platinum resistance in patients with advanced high-grade serous ovarian cancer (HGSOC). We conducted a retrospective study of patients diagnosed with advanced HGSOC between January 2017 and December 2020. A nomogram was developed to predict the risk of platinum resistance. Receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA) were used to validate the nomogram. Bootstrap analysis was utilized for internal validation. Additionally, we analyzed the risk factors for platinum resistance in patients who received neoadjuvant chemotherapy (NACT). A total of 232 patients with advanced HGSOC were included, 52 (22.4 %) of whom experienced relapse with platinum resistance. Multivariate logistic regression analysis revealed that high GRIm-score (OR = 4.174, P  260 (OR = 2.233, P = 0.037) and non-R0 (OR = 2.526, P = 0.012) were independent risk factors for platinum resistance. The area under the curve (AUC) of the model was 0.802 (95 % CI 0.736-0.868), and the internally validated AUC of 1000 bootstrap samples was 0.798 (95 % CI 0.725-0.862). In NACT-treated patients, univariate and multivariate logistic regression analyses revealed that a low KELIM score (OR = 10.405, P = 0.001) and PLT > 260 (OR = 4.611, P = 0.014) were independent risk factors for platinum resistance. The GRIm-score and PLT count are important prognostic factors in patients with HGSOC. For precision treatment, the status of partially platinum-sensitive patients should also be considered.

Is routine gastrointestinal endoscopy required in every woman with mucinous ovarian cancer? An analysis of survival rates and metastatic tumours in a cancer centre

Mucinous ovarian cancer (MOC) represents a rare entity of ovarian malignant neoplasms. The true incidence could be as low as 3% of all ovarian cancers. The aim of this study is to compare and understand the clinicopathological characteristics of patients with mucinous ovarian cancer, report on the survival rates and evaluate the role of gastrointestinal (GI) endoscopy as part of the peri-operative investigations and the impact it has on the survival rates. This is a retrospective data collection on patients with MOC operated in Nottingham gynaecological oncology centre over a 10-year period. Data were analysed using SPSS software. 43 cases were included in the final analysis. The median maximal tumour diameter was 180 mm. 32 (74.5 %) and 11 (25.5 %) women presented with unilateral and bilateral tumours respectively. 30 patients (69.7 %) presented with stage 1 disease, 1 (2.3 %) presented with stage 2 disease, 7 women (16.4 %) had stage 3 disease and 1 woman (11.6 %) had stage 4 disease. 41 women had staging surgical procedures and 2 women had limited surgery due to poor performance status. After final histology, 5 cases found to have metastatic disease to the ovary rather than primary MOC. 14 women had GI endoscopy as part of their investigation. The total estimated cost of the endoscopies that have been performed is £5635. Primary GI cancer was diagnosed in 1 case during the endoscopy (1 case of gastric cancer). The 5-year overall survival of the women included in this study is 62.8 %. The 5-year overall survival of the women in the endoscopy and non-endoscopy groups was 60 % and 64.3 % respectively (p-value: 0.767). The findings of this study show that the survival rates of patients treated for mucinous ovarian cancer in our centre are similar to other published studies. Our findings do not support the routine use of GI endoscopy in the peri-operative investigations of every patient with MOC due to the non-statistically significant difference in the overall survival.

Unveiling the advantages of laparoscopic myomectomy: A comprehensive systematic review and meta-analysis of outcomes and complications compared with traditional open surgery

To compare the outcomes of laparoscopic myomectomy (LM) and open myomectomy (OM) by reviewing the frequency, type and severity of complications reported by the Clavien-Dindo classification. In addition, this study evaluated differences in blood loss, length of operative time and hospital stay between these two surgical approaches. A systematic search of electronic databases was conducted from their inception to January 2024 to identify studies comparing LM and OM with detailed surgical complications reported. The random effect model was applied, and the odds ratio was used for the main outcomes, with effect sizes presented alongside 95 % confidence intervals (CI). A p-value < 0.05 was considered to indicate significance. Of 296 studies identified, nine studies (total 224 patients) were included. LM was found to be associated with significantly lower rates of overall postoperative complications compared with OM. With no statistical heterogeneity between the studies (I LM offers favourable outcomes compared with OM for the treatment of uterine myomas. Despite a slightly longer operative time, LM was found to be associated with lower rates of postoperative complications and reduced hospital stay. These findings support the preference for LM for the treatment of uterine myomas, highlighting its potential to improve patient outcomes and recovery.

Female sexual function in long-term cervical cancer survivors compared with healthy women and women affected by benign gynecological disorders

To compare the female sexual function between cervical cancer survivors and healthy women or with benign gynecological diseases. From January 1, 2010 to January 31, 2019, a case-control study was conducted to compare the female sexual function of 106 cervical cancer survivors from a tertiary hospital and 185 women admitted to a gynecological outpatient clinic from the same health area for a routine gynecological examination (n=46) or for a benign gynecological disorder (symptomatic, n=113; asymptomatic, n=26). We prospectively assessed the female sexual function using the Female Sexual Function Index (FSFI). For the contrastive analysis hypothesis, we employed R statistical software. Cervical cancer survivors reported lower sexual activity rates than controls, in general, did (47.12% vs. 88.65%, p=0.0001), and, particularly, compared with healthy and symptomatic controls (47.12% vs. 82.61%, p=0.003; 47.12% vs. 87.61%, p=0.0001, respectively). Sixty and fifty-eight hundredths percent of the cervical cancer survivors experienced female sexual dysfunction, mainly due to hypoactive sexual desire (93.27%). Female sexual dysfunction was diagnosed in 64.32% of the controls, with sexual arousal disorders being the most common diagnosis (44.86%). Compared with controls, cervical cancer survivors exhibited considerably lower FSFI total scores and in sexual desire and lubrication domains (p <0.000; p <0.0001; p=0.023). Cervical cancer survivors had worse female sexual function and less sexual activity than controls did, although scores in both groups were in range of FSD. Rates of female sexual dysfunction were similar across cervical cancer survivors and controls, with hypoactive sexual desire and sexual arousal disorders as the most common diagnoses, respectively.

Construction and efficacy test of a survival prediction model for locally advanced cervical cancer based on anti-angiogenesis

This study aimed to develop and evaluate an anti-angiogenesis-based model for predicting the survival and the potential benefits of targeted therapy for patients with localized advanced cervical cancer. We collected clinical data from 163 patients with cervical cancer who received paclitaxel and cisplatin (TP) or TP plus bevacizumab during or after radiotherapy from June 2017 to February 2023. We analyzed the clinical measures of recent efficacy and overall survival (OS) using univariate and logistic multivariate and Cox regression methods, respectively. We constructed a nomogram model and evaluated its efficacy using the c-index, the area under the curve (AUC), a calibration curve, and the clinical decision curve (DCA). We found that targeted agents and hemoglobin were independent determinants of near-term efficacy (P < 0.05), while targeted agents and stage were independent factors of OS (P < 0.05). We developed a predictive model for an OS prognostic nomogram and performed internal validation 1000 times using the Bootstrap re-sampling method. The c-index was 0.81, and the AUC was 0.84 (P < 0.01).The calibration curves showed a good agreement between the projected and actual values. The DCA curve indicated that the model had a high positive predictive accuracy. We developed a novel anti-angiogenesis-based survival prediction model for patients with locally advanced cervical cancer. This model could estimate the benefit of targeted therapy before treatment, and it had good validation.

The great debate: Surgical outcomes of laparoscopic versus laparotomic myomectomy. A meta-analysis to critically evaluate current evidence and look over the horizon

Myomectomy is one of the most common surgical procedure in the field of gynecology. However, the role of laparoscopic myomectomy is still debated for many factors, including surgical considerations, safety and fertility concerns, long-term outcomes, and cost-related issues. The aim of this study is to evaluate the surgical peri- and post-operative outcomes of laparoscopic and abdominal myomectomy. A systematic search for studies was performed up to June 2023 through MEDLINE, Pubmed, Embase. Studies reporting the comparison of surgical and obstetrical outcomes in laparoscopic versus laparotomic myomectomy were included for the following outcomes: time of surgery, estimated blood loss, decrease of postoperative hemoglobin, hospital stay, intra-operative complication rates, postoperative complications rates, postoperative analgesic use, postoperative pain at 24 h and pregnancy rate. The meta-analysis was performed using the Cochrane Review software. Fifty-six relevant articles were retrieved through the process of evidence acquisition. Eleven articles met inclusion criteria, for a total of 2,133 patients undergoing laparoscopic or laparotomic myomectomy. The estimated blood loss [standard mean differences (SMD) 0.72, IC 95 % 0.22 to 1.22], the hospital stays [SMD 3.12, IC 95 % 0.57 to 4.28], were significantly lower in laparoscopic than in open group. No statistically significant difference in intra-operative and post-operative complication rates, in pregnancy rate and others obstetrical outcomes between two surgical approaches were found. The findings of present metanalysis suggest that laparoscopic myomectomy offers multiple benefits, including reduced blood loss, shorter hospital stays, and less postoperative analgesic need, without a significant increase in complication rates and similar results in obstetrical outcomes when compared to abdominal myomectomy. However, the presence of few randomized studies on selected population may limit the generalizability of the findings to the entire population. Therefore, more well-designed studies or large population programdata to draw definitive conclusions are therefore warranted.

Immunohistochemical markers Ki67 and P16 help predict prognosis in locally advanced cervical cancer

To investigate the relationship between Ki-67 and P16 expression levels after neoadjuvant chemotherapy, and the clinicopathological characteristics and prognosis of patients with locally advanced cervical cancer. Patients with FIGO 2009 stage IB2 or IIA2 cervical cancer, who underwent neoadjuvant chemotherapy combined with radical hysterectomy at the First Affiliated Hospital of Chongqing Medical University between January 2015 and December 2019, were identified retrospectively to correlate postoperative Ki-67 and P16 expression levels with clinicopathological factors. The optimal threshold for predicting recurrence was analysed using receiver operating characteristic (ROC) curves for the Ki-67 index, and univariate and multi-factorial Cox regression analysis were used to investigate the association between clinicpathological features including Ki-67 and P16 and recurrence-free survival. In total, 334 patients were included after screening. The cut-off value of Ki-67 for determining recurrence was 67.5 % according to the ROC curve. On multi-factorial Cox analysis, lymphatic vascular space (p = 0.003) and Ki-67 index (p = 0.005) were shown to increase the risk of recurrence, and were independent prognostic factors for recurrence, while the expression of P16 was not significantly associated with the risk of recurrence (p = 0.097, odds ratio = 0.319). Patients with cervical cancer in the high Ki-67 expression group (Ki-67 ≥ 67.5 %) had lower recurrence-free survival and overall survival than patients in the low Ki-67 expression group (Ki-67 < 67.5 %) (p = 0.001 and 0.036, respectively). The expression levels of Ki-67 and P16 after neoadjuvant chemotherapy for locally advanced cervical cancer correlated with tumour differentiation. High expression of Ki-67 (Ki-67 ≥ 67.5 %) may indicate poorer recurrence-free survival and overall survival.

Prevalence of high-grade anal intraepithelial neoplasia in immunocompetent women treated for high-grade cervical intraepithelial neoplasia

The aim of the study was to evaluate the prevalence of high-grade anal intraepithelial neoplasia (AIN2-3) among immunocompetent women treated for high-grade cervical intraepithelial neoplasia (CIN2-3). Such knowledge is strongly needed to establish whether a screening program should be recommended in this group of patients. This prospective study included a cohort of consecutive women with no known causes of immunosuppression treated with LEEP (loop electrosurgical excision procedure) for a histopathological diagnosis of CIN2-3 in our center between 2019 and 2021. Following the procedure, all patients were invited to undergo anal cytology and anal high-risk HPV-DNA testing (aHPV-DNA). In cases in which one or both tests resulted positive, a high-resolution anoscopy with a biopsy of suspicious lesions was performed. All women also completed a questionnaire on sexual habits. At total of 100 women were enrolled in the study. Among these, eight patients had a concomitant or past diagnosis of anogenital warts, while one patient had received a previous diagnosis of high-grade vaginal intraepithelial neoplasia. Anal Pap smears were positive for low-grade lesions in three patients, while 73 women tested positive for aHPV-DNA. Histological examinations revealed the presence of AIN2-3 lesions in four patients (6.5%; 95% C.I., 1.8 to 15.7%), who subsequently underwent excisional treatment. Women with a history of high-grade cervical intraepithelial neoplasia have an intermediate risk of developing high-grade anal intraepithelial neoplasia. Future studies are needed in order to assess an ideal screening approach for this condition.

Feasibility of sending a direct send HPV self-sampling kit to long-term non-attenders in an organized cervical screening program

Non-participation in screening is a main risk factor for cervical cancer. Human-papillomavirus (HPV) self-sampling may be an alternative to repeated invitations for non-attenders. Several studies have concluded that participation among non-attenders increases significantly when offering self-sampling kits for HPV. However, participation rates are highly variable between settings, and therefore pilots to determine optimal implementation strategy have been recommended before routine roll out. All women who had not participated in the organized screening program for at least 10 years aged 33-62 in one Swedish county were identified through screening registers. HPV self-sampling kits were sent to all eligible women. Participation was defined as returning a self-sample kit or attending routine screening within 6 months. Women who did not submit the kit within 8 weeks were randomized to receive a written reminder. HPV-positive women were referred directly to colposcopy without prior triage. Biopsies for histopathologic confirmation were used as gold standard. Among eligible women, 150/741 (20.2%) returned the self-sample kit or attended routine screening. A randomized written reminder was sent out to 319/591 non-responders and another 11 women returned the kit. In total, 23/147 (16.3%) of returned kits were HPV positive. Out of the 23 HPV-positive women, 17 (74%) attended colposcopy; 10/17 (59%) had a histopathological high-grade squamous intraepithelial lesions (HSIL) or cervical cancer. The most common HPV type was HPV 52, and 2 out of 3 women with HPV 16 had a histopathologically confirmed cancer. The direct send kit strategy and referral of all HPV-positive women to colposcopy without prior triage appears to be feasible if resources are available and should be prioritized given the high prevalence of HSIL lesions and cancer among non-attenders. A written reminder might further increase attendance.

Diagnostic workup of patients with benign or inconclusive reports on office endometrial biopsy after first episode of postmenopausal blood loss

Postmenopausal bleeding carries a risk of endometrial cancer, and office endometrial sampling (OES) is often the first diagnostic approach. Whether further diagnostic procedures such as hysteroscopy or saline infusion sonography (SIS) are required to rule out polyps and malignancies is uncertain. The objective of this study is to evaluate whether clinicians perform further diagnostic tests when OES is benign or inconclusive. Secondary outcomes include the patient characteristics associated with the likelihood of performing further diagnostic tests and the incidence of endometrial intraepithelial neoplasia and endometrial malignancy. We performed a multicenter, prospective cohort study, evaluating patients with a first episode of postmenopausal bleeding, with an endometrial thickness of >4 mm on 2D vaginal sonography and a benign or inconclusive result of an OES. Patients who underwent further diagnostic or therapeutic procedures (hysteroscopy or SIS) were compared to patients who did not. Univariate and multivariate analyses were performed to identify predictive factors for additional diagnostic procedures and the diagnosis of endometrial malignancy. Of the 350 eligible patients, 197 (56 %) underwent further diagnostic procedures. These patients had a thicker endometrium (median 8.6 mm vs. 6.0 mm; p < 0.001), more frequent suspicion of intracavitary abnormalities (34.0 % vs. 14.4 %; p < 0.001), and more frequent insufficient aspiration samples (20.8 % vs. 11.8 %; p = 0.025) compared to patients who received expectant management. Multivariate regression analysis confirmed these findings. The underlying risk of malignancy was 2.7 % with benign samples and 6.8 % with insufficient samples. Overall, malignancy incidence was higher in those who underwent further diagnostic workup (p = 0.04). In this prospective study, just over half of patients underwent further diagnostic procedures. Endometrial thickness, suspicion of intracavitary abnormality or an insufficient endometrial sample were predictive for further diagnostic workup. The incidence of malignancy was higher in patients who underwent diagnostic workup, which argues for a risk-based strategy in clinical decision-making. Central study approval was obtained at the Erasmus MC (MEC 2015-740). The study was registered in the Dutch trial register (www.onderzoekmetmensen.nl, NL7608).

A case-controlled cost and clinical outcomes analysis comparing transvaginal radiofrequency conservative treatment of uterine myomas and surgical treatment by myomectomy or hysterectomy in a teaching hospital

Surgical options for symptomatic uterine myomas include myomectomy (fertility-sparing), hysterectomy (radical surgery) and uterine artery embolization (conservative with questions about fertility). Myolysis (including radiofrequency ablation) which uses thermal energy, is an emerging minimally invasive alternative. The aim of this study was to perform a cost analysis comparing transvaginal radiofrequency ablation and traditional surgeries for uterine myomas. This single-center, retrospective, case-control and age-stratified cost analysis study included women who underwent transvaginal radiofrequency ablation for uterine myomas in a teaching hospital between October 2022 and June 2024. Matched controls included women under 42 who underwent open or laparoscopic myomectomy, and women over 42 who underwent open or laparoscopic hysterectomy. Cost, clinical outcomes, and complications were analyzed and compared between groups. A total of 73 radiofrequency ablation were performed: 48 in women under 42 and 25 in women over 42. Regardless of age group, radiofrequency ablation resulted in shorter surgical duration and hospital stay, as well as reduced blood loss. The total cost of the procedure, including the price of the non-reusable electrode, was significantly lower in the radiofrequency ablation group. The initial sick leave was significantly shorter in the radiofrequency ablation group (mean sick leave: 3.9 to 4.8 days for radiofrequency ablation vs 26.4 to 30.6 days for open or laparoscopic myomectomy or hysterectomy). Risk of readmission or reintervention were comparable between groups. Radiofrequency ablation emerges as a promising, less invasive alternative to conventional surgery for the first-line treatment of symptomatic uterine fibroids, offering a lower overall cost.

Quality of life after myomectomy according to the surgical approach and MED12 mutation status

Molecular status of uterine leiomyomas has been shown to affect both tumor characteristics and treatment response. Mutations in mediator complex subunit 12 (MED12), the most prevalent alterations in leiomyomas, are associated with tumor size and number of leiomyomas. Myomectomy can be performed by laparoscopy or by open abdominal surgery, depending on the size and number of leiomyomas removed. The aim of this study was to examine the association between MED12 mutation status and surgical approach of myomectomy. We also evaluated myomectomy patients' quality of life after laparoscopic or abdominal surgery and according to the MED12 mutation status. The prospective cohort study included 104 women who underwent laparoscopic or abdominal myomectomy at the Helsinki University Hospital during 2015-2019. Patients filled in the validated Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire before the operation and 6 and 12 months after the operation. Medical records were reviewed to collect clinical data. Leiomyoma tissue samples were collected and screened for MED12 mutations. Patients undergoing abdominal myomectomy had larger and more numerous leiomyomas compared to patients with laparoscopic myomectomy (10 cm vs 7.4 cm, p < 0.001 and 3 vs 1 leiomyomas, p < 0.001, respectively). A mean change of over 20 points was seen in UFS-QOL scores at 6 months after both laparoscopic and abdominal myomectomy (p < 0.001). MED12 mutations were detected in 178/242 (74 %) of leiomyomas. Of the patients, 45/97 (46 %) had only MED12 positive leiomyomas, while 39/97 (40 %) had only MED12 wild type leiomyomas. The number of leiomyomas removed was higher among patients with MED12 positive leiomyomas than in patients with MED12 wild type tumors (p < 0.001). Laparoscopic approach was equally common in both groups (62 % and 64 %), and there was no statistically significant difference in the UFS-QOL scores. Both laparoscopic and abdominal myomectomy significantly improved the quality of life. While MED12 mutations were related with multiple leiomyomas and therefore potentially generated a greater leiomyoma burden, they were not associated with the surgical approach. Pre- and postoperative quality of life was comparable between patients regardless of MED12 status.

Preterm birth and uterine fibroid necrosis: The clinical presentation illustrated in a case series

Uterine fibroids increase the risk of preterm birth. The current study highlights uterine fibroid necrosis as a possible cause of (extreme) preterm birth. Retrospective cohort study in one Dutch academic hospital. Cases were selected from the 526 participants of the MyoFert study (Netherlands Trial Register, NL7990), which included patients who presented between 2004 and 2018 and were between the age of 18 and 45 years at the time of diagnosis of uterine fibroids. Of these participants, 414 women became pregnant. A retrospective chart review of the first pregnancies was performed. The main outcomes were (imminent) preterm birth and signs of fibroid necrosis on ultrasound. In women with signs of fibroid necrosis, the following data were collected systematically: fibroid characteristics, clinical presentation, pregnancy outcome, and postpartum period. In total, 66 women had a preterm birth (16 %, 66/414), of which 25 pregnancies ended between 16 and <24 weeks (38 %, 25/66) and 41 pregnancies ended between 24 and <37 weeks of gestation (62 %, 41/66). Of all women with preterm birth and available ultrasound images, 15 % (7/48) had fibroid necrosis at the time of labour. These seven patients, supplemented with three patients with fibroid necrosis during their first pregnancy and at least one episode of imminent preterm birth, are described in more detail. In these ten patients, the fibroids increased substantially in size during the first and second trimester, leading to severe abdominal pain in all patients and hospital admission in seven patients. Ultrasound examination of the fibroids showed heterogenic changes and focal transonic areas in the fibroid, which are characteristics that indicate fibroid necrosis. In four patients, myomectomy was performed and necrosis was confirmed histologically. Fibroid necrosis during pregnancy is likely associated with (imminent) preterm birth. Clinicians are advised to structurally evaluate the myometrium in pregnancy, specifically in women presenting with abdominal pain in the second trimester.

Provision of screening services for cervical and breast cancer – A scientific study commissioned by the European Board &amp; College of Obstetrics and Gynaecology (EBCOG)

Cancer screening can play an important role in early detection, improving treatment outcomes and reducing morbidity and mortality. Breast and cervical cancers belong to the most common gynaecological cancers group. Countries provide different screening programmes on its eligible population basis centred on different health care policies. This scientific study aims to assess and understand the health inequalities in the member countries of the European Board & College of Obstetrics and Gynaecology (EBCOG) as regards screening programmes of gynaecological cancer, with a special focus on breast and cervical cancers' screening strategies. A descriptive questionnaire-based study was conducted, addressed to EBCOG member countries. Ninety-one percent of the countries have an organized national or regional screening programme for cervical cancer. Of these, 45% of countries use both cytology and testing for Human Papilloma Virus (HPV) as screening test, 31% use cytology exclusively and 17% only perform HPV testing. Considerable differences were found regarding the interval of screening test: there are countries performing HPV detection triennially, while others perform only conventional cytology every 5 years. Sixty-nine percent of countries included in this study begin screening for cervical cancer in women aged 25 to 29 years, four of them using HPV detection as the screening test. Six countries begin cervical cancer screening before the age of 25. As regards vaccination against HPV, almost all countries have implemented national HPV vaccination programme, except in Poland and Turkey. The 9-valent HPV vaccine is the most frequently offered (77% of countries) and the majority vaccination programmes include both girls and boys. As regards breast cancer screening, all thirty-two countries have an implemented screening programme. All countries perform mammography as the screening test, 62.5% of them begin in women aged 50 to 54, with a 2-yearly interval in the majority. In five countries, screening programmes are performed biennially, starting between 45 and 49 years old. Seven countries start in women aged 41 to 44. There are discrepancies around gynaecological cancer screenings provision among EBCOG member countries. It is important to establish European recommendations about screening for gynaecological cancers, in order to standardize the access to equitable better health care in gynaecological cancers within Europe.

EBCOG position statement on Inequalities in screening for cervical and breast cancer

Gynaecological cancers, namely breast and cervical cancer represent a high burden in women's health. It is well established that cervical and breast cancer screening programmes are effective in reducing morbidity and mortality. It is of the most importance to define strategies to provide a universal access to screening. In European countries, significant progress has been made over the past years concerning screening strategies, namely the choice of screening test, its frequency as well as the age to start and stop the screening. Introduction of Human Papillomavirus vaccination programmes is also making a measurable impact to reduce cervical cancer prevalence and mortality. Our survey has shown a variation among European countries in delivery of cervical and breast cancer screening programmes. These variations can be due to organizational, economic or cultural reasons. The European Board and College of Obstetrics and Gynaecology calls for an implementation of a unified policy of prevention, screening and early detection of cervical and breast cancer across Europe to optimize clinical outcomes and reduce variations.

Pre treatment and post treatment positron emission tomography–computed tomography (PET–CT) to evaluate treatment response in tuberculous Tubo-Ovarian masses

Female genital Tuberculosis (FGTB) causes infertility and formation of Tubo-ovarian (TO) masses. The study showed treatment response of PET-CT in evaluation of anti-tubercular treatment response in patients of infertility with tuberculous TO masses. It's a Prospective study on 47 confirmed cases of FGTB with infertility having TO masses. All patients were subjected to 18F-FDGPET/CT to see the glucose uptake by the TO mass and extent of the disease. Category I treatment under DOTS was given for 6 months. All underwent follow-up of PET/CT to see the response to ATT. Results of pre ATT PET/CT were compared with post ATT PET/CT. TO masses was in 42 (89.36%); bilateral in 18 (38.29%) FDG uptake in 14 (29.78%) and without FDG uptake in 4 (8.51%) cases. Right sided mass in 13 (27.65%) FDG uptake in 9 (19.14%) and without FDG uptake in 4 (8.51%) cases. Left sided mass in 11 (23.40%) FDG uptake in 7 (14.89%) and without FDG uptake in 4 (8.51%) cases. Post ATT, there was significant decrease in most parameters. Repeat PET-CT done in 44 cases showed TO mass in 9 (20.45%); bilateral in 4 (9.09%) (FDG uptake in 2.27%) (p < 0.001), right sided in 3 (6.85%) (FDG uptake in 2.27%) (p < 0.002) and left side in 2 (2.27%) FDG uptake in 1 case (p < 0.004). Pelvic and mesenteric lymphadenopathy without FDG uptake was in 1 case (p value = 0.03) while omental and peritoneal deposits without FDG uptake in 1 and 2 cases, respectively. PET-CT is useful in treatment response evaluation of tubercular TO masses.

Stapled diaphragm resection: A new approach to diaphragmatic cytoreductive surgery for advanced-stage ovarian cancer

To evaluate a novel technique for diaphragmatic full-thickness resection (DFTR) using a vascular stapler to perform cytoreductive surgeries in patients with advanced ovarian cancer. Single-center retrospective analysis of consecutive patients with advanced-stage ovarian cancer undergoing stapled diaphragmatic full-thickness resections (S-DFTRs) as part of cytoreductive surgeries between January 2018 and June 2022, according to the IDEAL recommendations. Fifteen patients underwent cytoreductive surgeries with S-DFTRs. The median operative time was 300 (114-547) minutes. Cytoreduction was considered complete in all cases. All S-DFTRs were performed on the right diaphragm. Concomitant left diaphragmatic peritoneal stripping was performed in 5 cases (33.3%) and was associated with a conventional DFTR in 1 case (6.7%). Prophylactic intraoperative tube thoracostomy was never required. Four patients (26.7%) were admitted to the intensive care unit. Pleural effusion was observed in 9 patients (60.0%), and 4 (26.7%) required a postoperative pigtail catheter thoracostomy. Three patients (20.0%) required catheter placement on the right hemithorax (ipsilaterally to the S-DFTR) and 2 patients (13.3%) required catheters on the left hemithorax (contralaterally to the S-DFTR). Pneumothorax requiring tube thoracostomy was observed in 1 case (6.7%) on the left hemithorax (contralaterally to the S-DFTR). Pulmonary embolism and pneumonia were both observed once (6.7%). The median hospitalization length was 14 (5-36) days. During the follow-up, 6 patients (40.0%) had a recurrence, but none involved the pleura or the diaphragm. According to the IDEAL classification, this study could be ranked as stage 2a (development). This technique appears to be a fast and safe method for performing diaphragmatic cytoreductive surgeries and could reduce postoperative complications.

Impact of Human papillomavirus 9-valent vaccine on viral clearance after surgical treatment: A single-center retrospective observational study

The effectiveness of post-treatment HPV vaccination with the Human papillomavirus 9-valent (9vHPV) vaccine in women treated with loop electrosurgical excision procedure (LEEP) for high-grade cervical intraepithelial neoplasia (CIN2-3) or laser ablation (LA) for low-grade lesions (CIN1) remains a topic of ongoing research. This single-center retrospective observational study included 326 women aged 25 to 65 years who underwent surgical treatment between 2020 and 2024. Participants were divided into two groups: vaccinated (V) and non-vaccinated (NV). A further stratification was then reported by age < 40 years (n = 174) and ≥ 40 years (n = 152). The primary outcomes were HPV test results and colposcopy findings 6-15 months post-treatment, evaluating the potential adjuvant effect of HPV vaccination. The vaccinated group (V-group) comprised 68 % (222/326) of participants, while 32 % (104/326) were unvaccinated (NV-group). Among women treated for CIN1, a positive HPV test was detected in 38 % of unvaccinated women compared to 18 % in vaccinated women (p = 0.0169). Among those treated for CIN2-3, 18 % of unvaccinated women had a positive HPV test, compared to 8 % in the vaccinated group (p = 0.0353). Vaccination, also in women with an age ≥ 40-year-old had a statistically significant effect in reducing the proportion of women with a positive HPV test (p = 0.0100). Human papillomavirus 9-valent vaccine was associated with a significant reduction in the proportion of women with a positive HPV test. These findings support its potential role in tertiary prevention of HPV-related cervical disease, particularly in reducing HPV persistence after surgical treatment.

Increased detection of high grade CIN, when using electrical impedance spectroscopy as an adjunct to routine colposcopy, is maintained when used across international boundaries: Prospective data from nine European countries

To evaluate the performance of EIS (ZedScan) with colposcopy in the detection of high grade CIN (HG-CIN) in different health care settings. Pooled analysis of data from 26 colposcopy centres in 9 countries. All women underwent colposcopy and ZedScan examination. Data was recorded prospectively via a proforma. Indications for referral to colposcopy were according to national guidelines. Pathology was reported according to national guidelines. 5257 women were examined by 82 colposcopists, median 93 women per centre (range 41 - 2684), 3 users per centre (range 1-8). Referral indications were; 19.3% high grade cytology, 50.4% low grade, 30.3% clinical or HPV positive / cytology negative. The prevalence of HG-CIN was 26.5%; 79.1% in high grade referrals, 16.7% low grade, 9.4% clinical or HPV positive / cytology negative. The use of ZedScan detected an extra 269 cases of high grade CIN (24% increase) (7.5% increase for high grade referrals, 57.9% for low grade and 52% for clinical or HPV positive/cytology negative). Based upon colposcopic impression (CI), the sensitivity of colposcopy for CIN2 + was 74.1% compared with 91.6% for colposcopy with ZedScan (Chi The addition of EIS (ZedScan) increases detection of HG-CIN with the PPV for a ZedScan directed biopsy consistent with the published literature. Results were similar in multiple healthcare settings. With more women being referred to colposcopy at low risk of HG-CIN, due to HPV vaccination and primary HPV screening, this study confirms the value of a real time adjunctive technology.

Alternatives to surveillance for persistent human papillomavirus after a positive cervical screen: A systematic review and meta-analysis

In 2021, the World Health Organisation (WHO) updated its guidelines for cervical screening from cytology testing to primary high-risk human papillomavirus (HR-HPV) testing. This change in testing has effectively led to a 'new disease' as women are now aware of having a virus that induces changes that can cause cancer, which they would have been unaware of previously. While current management involves a 'watch and wait' approach and no active treatment, the anxiety associated with having HR-HPV may prompt some women to seek 'treatments' outside the screening programme. ● to identify potential treatment options available for women with persistent HR-HPV and/or low-grade cervical intraepithelial neoplasia (CIN), i.e. ≤CIN 1. ● to determine the clinical effectiveness of these treatments, namely by: ◦ HR-HPV clearance rate, and/or: ◦ CIN regression. We searched MEDLINE, PubMed, EMBASE, Web of Science and the Cochrane Library. We included cohort studies and randomised controlled trials (RCTs) only. Records (n = 2135) were screened in Rayyan by two independent reviewers. Quality assessment was conducted using the ROBINS-I tool and the ROB-2 tool. 12 studies (four cohort studies and eight RCTs) were included: six oral medications, two topical medications, one vaccination, and three non-surgical device treatments. Meta-analysis revealed that some therapeutic interventions, including vaginal gels, photodynamic therapy, and some oral medications, may lead to earlier resolution of persistent HR-HPV and regression of low-grade CIN when compared with natural clearance. This review can better inform discussions with HR-HPV+ women and answer their questions about alternatives to surveillance.

Intraoperative rupture and chemotherapy use in stage I ovarian cancer

The risk factors for premalignant and malignant endometrial polyps in premenopausal and postmenopausal women and trends over the past decade: A retrospective study in a single center, South Korea

To assess the prevalence and risk factors for premalignancy and malignancy in endometrial polyps and to evaluate trends over the past decade. This was a retrospective study of patients who underwent hysteroscopic polypectomy at Inha University Hospital, South Korea between January 2013 and June 2023. The demographic and clinical characteristics of the patients reviewed to identify risk factors for premalignancy and malignancy in endometrial polyps included the following: age, parity, body mass index, menopausal status, abnormal uterine bleeding symptoms, diabetes mellitus, hypertension, polycystic ovarian syndrome, use of menopausal hormonal therapy or oral contraceptives, tamoxifen treatment in patients with breast cancer, and the number of polyps. In total, 725 patients were enrolled, among whom 52 (7.2 %) had premalignant and malignant lesions. In logistic regression analysis, menopause (OR: 8.37, 95 % CI [3.33-21.04]), abnormal uterine bleeding (OR: 7.42, 95 % CI [2.13-25.86]), obesity (OR: 3.22, 95 % CI [1.53-6.77]), multiple polyps (OR: 2.86, 95 % CI [1.39-5.88]) and nulliparity (OR: 2.64, 95 % CI [1.13-6.19]) were significantly associated with premalignancy and malignancy in polyps. Annual trends during the study period showed an increase in the number of patients with three of the five risk factors (obesity, multiple polyps, and nulliparity) and an increase in the prevalence of premalignancy and malignancy in polyps. Menopause, abnormal uterine bleeding, obesity, multiple polyps, and nulliparity increase the risk of premalignancy and malignancy in endometrial polyps. The prevalence of premalignant and malignant polyps has been increasing over the past decade. The risk factors that have contributed to this trend were obesity, nulliparity, and multiple polyps.

Extra-abdominal ovarian cancer presenting with breast metastases at diagnosis: Case report and literature review

Malignant ovarian tumours are diagnosed at an advanced stage in the majority of cases. However, only a small percentage present as extra-abdominal, non-lymph-node solid metastases, as in the breast, and they are usually cases of relapse. The discovery of mono- or bilateral breast lesions with peritoneal carcinosis and/or abdomino-pelvic lesions can be cumbersome in the differential diagnosis of primary tumours. This article aims to summarize current evidence on the detection of breast metastases at diagnosis of ovarian cancer. A systematic review of the literature in Scopus, PubMed/MEDLINE, ScienceDirect and the Cochrane Library, including case reports and case series, was undertaken. Data regarding study features; population characteristics; clinical, radiological and histological assessment of the disease; treatment and follow-up were collected. In addition, a case report of a patient managed at the authors' centre is provided. According to the search strategy, 16 articles (18 patients) were included in this review. Serous ovarian, fallopian tube or primary peritoneal cancer was detected in 61% of cases, while another type or a non-specified type of epithelial ovarian cancer was detected in 27.7% of cases; there was one case with granulosa cell tumour of the ovary and one case with mucinous ovarian tumour of low malignant potential. Breast metastases were mainly monolateral (66.6%), with other extra-abdominal sites of disease in the majority of the cases. A minority of patients (16.6%) received treatment for primary breast cancer with a subsequent diagnosis of ovarian cancer. Concomitant breast and abdominal surgery can be an option. PAX8, WT1 and CA125 immunohistochemical staining can aid in differential diagnosis. Breast metastases of malignant ovarian tumours must be promptly recognized to ensure proper treatment. Specific immunohistochemical analysis can be a decisive assessment in uncertain cases.

Ultrasound for assessing tumor spread in ovarian cancer. A systematic review of the literature and meta-analysis

In this review, we aimed to assess the diagnostic performance of ultrasound for assessing the tumor spread in the abdomen in women with ovarian cancer. A search for studies evaluating the role of ultrasound for assessing intrabdominal tumor spread in women with ovarian cancer compared to surgery from January 2011 to March 2023 was performed in PubMed/MEDLINE, Web of Science, and Scopus databases. The Quality Assessment of Diagnostic Accuracy Studies 2 evaluated the quality of the studies (QUADAS-2). All analyses were performed using MIDAS and METANDI commands in STATA 12.0 software. We identified 1552 citations. After exclusions, five studies comprising 822 women were included. Quality of studies were considered as good, except for patient selection as all studies were considered as having high risk of bias. The pooled sensitivity and specificity could be calculated for three anatomical areas (recto-sigma, major omentum and root of mesentery) and the presence of ascites. The pooled sensitivity and specificity for detecting disease in the recto-sigma, major omentum and root of mesentery were 0.83 and 0.95, 0.87 and 0.87, and 0.29 and 0.99, respectively. The pooled sensitivity and specificity for detecting ascites was 0.95 and 0.91, respectively. There is evidence that ultrasound offers good diagnostic performance for evaluating the intra-abdominal extent of disease in women with suspected ovarian cancer.

Systematic Review and Meta-analysis of laparoscopic radical hysterectomy vs. Robotic assisted radical hysterectomy for early stage cervical cancer

Following compelling evidence that open techniques may be related to better survival and disease free survival rates, many gynecologic oncologists in the US have turned away from performing laparoscopic radical hysterectomy (LRH) and robotic radical hysterectomy (RRH) for the treatment of early-stage cervical cancer. While this may be warranted as a safety concern, there is little high-quality data on the head-to-head comparison of LRH and RRH and therefore little evidence to answer the question of where this decrease in patient survival is originating from. In our systematic review, we aimed to compare the complications and outcomes of LRH against those of RRH. We searched PubMed, Cochrane CENTRAL, Medline, ClinicalTrials.Gov, SCOPUS, and Web of Science from database inception until February 1st, 2022. A total of 676 studies were identified and screened through a manual three-step process. Ultimately 33 studies were included in our final analysis. We included all studies that compared LRH and RRH and included at least one of our selected outcomes. We included retrospective cohorts, prospective cohorts, case-control, and randomized clinical trials. Data was independently extracted manually by multiple observers and the analysis was performed using Review Manager Software. PRISMA guidelines were followed. We analyzed homogenous data using a fixed-effects model, while a random-effects model was used for heterogeneous outcomes. We found that following RRH, women had a decreased hospital stay (MD = 0.80[0.38,1.21],(P < 0.002). We found no differences in estimated blood loss (MD = 35.24[-0.40,70.89],(P = 0.05), blood transfusion rate ((OR = 1.32[0.86,2.02],(P = 0.20), rate of post-operative complications (OR = 0.84[0.60,1.17],(P = 0.30), the operative time (MD = 6.01[-4.64,16.66],(P = 0.27), number of resected lymph node (MD = -1.22[-3.28,0.84],(P = 0.25) intraoperative complications (OR = 0.78[0.51,1.19],(P = 0.25), five-year overall survival (OR = 1.37[0.51,3.69],(P = 0.53), lifetime disease free survival (OR = 0.89[0.59,1.32],(P = 0.55), intraoperative and postoperative mortality (within 30 days) (OR = 1.30[0.66,2.54],(P = 0.44), and recurrence (OR = 1.14[0.79,1.64],(P = 0.50). RRH seems to result in the patient leaving the hospital sooner after surgery. We were unable to find any differences in our ten other outcomes related to complications or efficacy. These findings suggest that the decreased survival seen in minimally invasive RH in previous studies could be due to factors inherent to both LRH and RRH. CRD42022273727.

Relation between naked eye Swede score and the outcomes of atypias of undetermined significance

Cervical cancer precursor lesions occur due to persistent infection caused by human papillomavirus (HPV). One of the challenges of the Pap test is detecting lesions at a high risk of evolving into cancer. In this context, differentiating patients at low and high risk of developing cervical cancer becomes necessary. The Swede score, a standardized point system assigned based on colposcopy, is the most commonly used method to evaluate suspicious lesions. However, access to colposcopy is limited in low-income countries. It is, therefore, important to assess the applicability of less costly diagnostic methods in these situations to avoid a late diagnosis of cervical cancer. To analyze histological outcomes of cytology tests with atypical squamous cells of undetermined significance (ASC-US and ASC-H) and to compare the performance of the Swede score with and without colposcopy. The study was approved by the Ethics Committee via Plataforma Brasil (CAAE no. 41958320.6.0000.5259) and conducted by applying colposcopy score and naked eye score to patients with cytology alterations (ASC-US and ASC-H), with posterior analysis of cytological and histological results and comparison between the scores. A total of 34 women aged ranging from 24 to 65 years, with results of atypia with undetermined significance (ASC-US and ASC-H), were included in the study. The receiver operating characteristic curve was calculated for the naked eye inspection Swede score. The cut-off of 6 was considered to indicate the best sensitivity and specificity (55.56% and 93.75%, respectively). Then, the positive and negative predictive values were 90.91% and 65.22%, respectively. By increasing the cut-off to 7, specificity increased to 100%. For the colposcopic inspection, a cut-off of 6 indicates better specificity and positive predictive value (both 100%), whereas the negative predictive value was 57.14%. The correlation between the colposcopic and naked-eye Swede scores was statistically significant (0.82). Further studies with larger samples are important to establish the actual applicability of the naked eye method; however, in the absence of colposcopy, this appears to be an effective and very helpful method to make diagnostic decisions regarding HPV-induced lesions.

Ovarian Sertoli–Leydig cell tumours: A systematic review of relapsed cases

To synthesize the evidence on Sertoli-Leydig cell tumour (SLCT) relapses, and identify the clinicopathological characteristics and prognosis of patients with recurrent SLCT. A literature search was undertaken of all published cases of SLCT relapse found in PubMed, Embase and Web of Science databases between January 1998 and January 2021. All articles in English reporting at least one case of SLCT relapse and mentioning the relapse location or the follow-up data were included. All reported data on relapsed cases were extracted. Student's t-test and Chi-squared test were used for the descriptive analysis, and the Kaplan-Meier statistical method was applied for survival analysis. Eighty-five patients from 33 articles were included in this review. The median age was 20 years (range 3-76 years) with a median time to relapse of 14 months (range 1-168 months). Forty-eight percent (36/75) of relapses were local and 52% (39/75) were distant. In the subgroup of conservative primary surgery, contralateral ovarian SLCT events (metachronous or recurrent) were more frequent in the paediatric population than in the adult population (58.3 vs 18.2%; p = 0.005). Eleven cases had multiple relapses. Twenty-one percent (12/57) of cases were treated with conservative surgery after recurrence, and 64.9% (37/57) of cases were treated with radical surgery which tends to have a better 2-year survival rate (78.5% vs 61.0%; p = 0.177). Overall median survival was 48 months after recurrence (95% confidence interval ±21.0 months) with overall 5-year survival of 38.9%. The mean survival time was significantly higher for patients diagnosed at an early stage (I and II) compared with patients diagnosed at an advanced stage (p = 0.003). The results showed that SLCT relapses have a poor prognosis and occur mainly in young patients, soon after the initial diagnosis. The majority of SLCT relapses are located in the abdominopelvic region. Contralateral ovarian SLCT events (metachronous or recurrent) occurred more frequently in paediatric cases. Multi-modal treatment with surgery and chemotherapy appears to be the best approach. The best chemotherapeutic regimen has yet to be defined.

Aggressive angiomyxoma of female pelvis and perineum: Retrospective study of 17 cases

Aggressive angiomyxoma is an uncommon mesenchymal neoplasm characterized by a high recurrence rate, usually observed in the lower genital tract of women during their reproductive age. Seventeen cases of aggressive angiomyxoma confirmed by pathology from January 2007 to December 2021 in Beijing Chao-yang Hospital were included. We collected clinical data and summarized the clinical and immunohistochemical features. All seventeen included patients were females, aged between 23 and 57 years (mean, 37.7 years; median, 42 years). Fourteen patients were newly diagnosed and three were recurrent. The tumors were located in vulva (58.8 %), vagina (23.5 %), buttock (11.8 %), and cervix (5.9 %). The tumors size were 2 to 15 cm in greatest dimension (mean 8 ± 4.4 cm, median 6 cm). Follow-up data was available for nine patients, which ranged from 25 to 124 months (mean, 82 months; median, 80 months). At the end of follow-up, no other recurrence or metastasis was reported. Immunohistochemical analysis showed immunoreactive for estrogen (10/11) and progesterone (8/11) receptor, desmin (6/8), smooth muscle actin (4/10), and vimentin (4/4), S-100 (1/8) and CD34 (1/7). The Ki67 level was less than 5 % in five cases. AAM is a hormone-sensitive, distinct rare mesenchymal neoplasm with high incidence of local recurrence. Surgery is the preferred treatment, with complete resection being an essential prerequisite for minimizing the risk of recurrence.

Uterine tumor resembling ovarian sex-cord tumor: Conservative surgery with successful delivery and case series

Uterine tumor resembling ovarian sex-cord tumor (UTROSCT) is a rare distinct cancer included in the current World Health Organization classification of endometrial stromal tumors. A battery of immunohistochemical markers are necessary for accurate diagnosis. Although few case reports and case series have been documented and therefore providing robust prognostic information several authors agree to consider UTROSCT as a low malignant potential tumour. In literature only five cases of conservative management were reported. We reported our experience and a review of conservative cases of literature. In this article we describe a series of 10 cases of UTROSCT and their clinical and pathologic feature. We report two cases of conservative surgical approach obtaining a successfully pregnancies. All of the patients are still alive. In conclusion, fertility sparing surgery should be offered to patients who wish preserve their fertility however radical surgery must be considerate after childbirth. Close follow-up is required for all patients due to the lack of prognostic biomarkers and long follow up is needed to evaluate safety of conservative surgery.

A novel laparoscopy-based model for the prediction of optimal cytoreduction and prognosis of epithelial ovarian cancer in a Chinese population

This study aimed to investigate the predictive value of laparoscopy for the prediction of optimal cytoreduction and prognosis of epithelial ovarian cancer (EOC) in a Chinese population. This study enrolled 162 EOC patients in Obstetrics and Gynecology Hospital of Fudan University from January 2015 to December 2016. All patients underwent preoperative CT scans and laparoscopic assessments. Each patient was scored according to the CT-based predictive model by Bristow and laparoscopy-based predictive model by Fagotti. The specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC) of each model were calculated. The predictive scores and clinicopathologic factors were all analyzed using the Kaplan-Meier method and multivariate Cox analysis. A prognostic predictive nomogram was formulated in R software. The AUCs of the laparoscopy-based predictive model and CT-based predictive model was 0.955 and 0.755 respectively. At a laparoscopic score ≥ 10, the possibility of optimal cytoreduction was 0, and the risk of unnecessary explorative attempts was 6%. Additionally, laparoscopic score, independent of residual tumor size and FIGO stage, was an independent prognostic factor for both overall survival (OS) and recurrence-free survival (RFS) in EOC. Notably, the predictive nomogram that we established further confirmed the prognostic value of laparoscopy for prognostic predictions in EOC. Laparoscopy has a better discriminating performance than CT in the prediction of optimal cytoreduction in EOC. Moreover, the laparoscopic score is directly correlated with the survival of EOC patients. The laparoscopic score-based nomogram we established showed good potential to predict the prognosis of EOC patients.

A functional polymorphism in the poly(ADP-ribose) polymerase-1 gene is associated with platinum-based chemotherapeutic response and prognosis in epithelial ovarian cancer patients

To explore the effects of two functional genetic variants of poly(ADP-ribose) polymerase-1 (PARP-1) on the susceptibility to epithelial ovarian cancer (EOC), the platinum-based chemotherapeutic response, and the prognosis of northern Chinese patients. This case-control study included 710 EOC patients in the case group and 700 healthy women in the control group. Two polymorphisms (rs1136410 and rs8679) of PARP-1 were genotyped by polymerase chain reaction and ligase detection reaction. The genotype frequencies of rs1136410 and rs8679 were not significantly different between the case and control groups. However, the CC genotype of rs1136410 was significantly associated with a favorable response to platinum drugs. Compared with the TT genotype, the CC genotype of rs1136410 was related to a reduced risk of platinum resistance (adjusted OR: 0.40; 95% CI = 0.24-0.67; P = 0.001). In addition, multivariable analysis containing clinical variables showed that patients who carried the rs1136410 CC genotype had a significantly improved progression-free survival compared with patients who carried the TT genotype (HR = 0.67, 95% CI = 0.47-0.97, P = 0.031). The rs1136410 polymorphism may serve as a potential marker for predicting the response to platinum agents and prognosis of EOC patients treated with surgery and platinum-based chemotherapy.

Does uterine preservation affect survival outcomes of patients with stage I ovarian sex cord-stromal cell tumours? A multi-institutional study

Sex cord-stromal tumours of the ovary are relatively uncommon neoplasms that account for 3 % of all ovarian cancers. Uterine preservation with careful staging is achievable; however, conservative surgery remains controversial. This study examined the prognostic effects of uterine preservation in patients with stage I sex cord-stromal tumours. This retrospective cohort study was undertaken between January 1986 and February 2019, and the clinicopathological data of 4897 women with malignant ovarian tumours were collected. Seventy-seven patients with stage I sex cord-stromal tumours were eligible for inclusion. The characteristics and survival outcomes of these patients were examined. To investigate the prognostic effects of uterine-preserving surgery, baseline imbalances between patients with and without uterine-preserving surgery were adjusted using an inverse probability of treatment weighting with propensity scores composed of independent clinical variables. The mean ages of patients in the uterine-preserving surgery and non-uterine-preserving surgery groups were 39.8 and 57.8 years, respectively. After inverse probability of treatment weighting adjustments, no significant differences in overall survival (p = 0.205) or recurrence-free survival (p=0.071) were observed between the uterine-preserving surgery and non-uterine-preserving surgery groups. Estimated 10-year overall survival rates were 98.7 % in the uterine-preserving surgery group and 95.9 % in the non-uterine-preserving surgery group, and 10-year recurrence-free survival rates were 87.2 % in the uterine-preserving surgery group and 78.2 % in the non-uterine-preserving surgery group. Uterine-preserving surgery did not significantly affect the site of tumour recurrence. Uterine-preserving surgery may be a feasible surgical option for patients with stage I sex cord-stromal tumours. Further research is needed to guarantee prognostic accuracy and develop effective therapeutic approaches for sex cord-stromal tumours.

Fertility preservation after fertility-sparing surgery in women with borderline ovarian tumours

To present a case series of women with borderline ovarian tumours (BOTs) who underwent oocyte vitrification in addition to fertility-sparing surgery. Observational study of all women referred to a French fertility preservation unit between 2015 and 2019 for counselling regarding a fertility preservation (FP) strategy after BOT fertility-sparing surgery. All eligible women underwent one or more cycles of controlled ovarian stimulation (COS) using an antagonist protocol, followed by oocyte retrieval. Metaphase II (MII) oocytes were vitrified. Twenty-five women with BOTs were referred during the study period. Among them, 11 women underwent at least one cycle of COS. One hundred and seven MII oocytes were vitrified. The mean number of vitrified MII oocytes per woman was 9.7 (standard deviation 5.2). Five live births were reported during follow-up of four women with vitrified oocytes: three spontaneous pregnancies, one in-vitro fertilization cycle with fresh embryo transfer, and one live birth after return of vitrified oocytes. Conservative surgery for BOTs offers a high spontaneous pregnancy rate but has a higher risk of relapse than radical treatment. Furthermore, women who undergo conservative BOT surgery have a higher risk of surgery-induced premature ovarian failure. Oocyte cryopreservation after COS appears to be an effective technique after the conservative management of BOTs in women of reproductive age. Although the available short-term data are reassuring, further long-term studies evaluating the safety and cost-effectiveness of this systematic FP strategy after BOT fertility-sparing surgery are required.

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

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

Total extraperitoneal access for parietal peritonectomy for peritoneal surface malignancy: The ‘cocoon’ technique

Complete surgical cytoreduction is the most important prognostic factor of survival in patients with peritoneal metastases from various cancers, including ovarian cancer. In order to achieve the optimum result, surgeons use extensive procedures that involve peritonectomies and multivisceral resections. Cytoreductive surgery (CRS) aims to eliminate all macroscopic disease by achieving complete cytoreduction. This article describes a surgical approach designed to achieve total extraperitoneal access for parietal peritonectomy. Visceral resections and parietal peritonectomy procedures must be conducted for complete removal of all visible malignancy. This article presents a technique that combines existing surgical approaches (anterolateral parietal peritonectomy, complete pelvic peritonectomy with sleeve resection of the sigmoid colon, and right and left upper quadrant peritonectomies) to achieve access to the upper abdomen, the lateral abdomen and the pelvis while keeping the peritoneum intact. This approach facilitates the peritonectomies necessary for complete cytoreduction, and improves access to difficult sites such as the pelvis and the subdiaphragmatic areas in a standardized manner that can be reproduced safely by an experienced surgical team.

Isolated lymph node recurrence in epithelial ovarian cancer: Recurrence with better prognosis?

The aim of this study was to compare overall survival (OS) between women with isolated lymph node recurrence (ILNR) and those with isolated peritoneal localization of recurrence (ICR), in patients managed for epithelial ovarian cancer. Data from 1508 patients with ovarian cancer were collected retrospectively from1 January 2000 to 31 December 2016, from the FRANCOGYN database, pooling data from 11 centres specialized in ovary treatment. Median overall survival was determined using the Kaplan-Meier method. Univariate and multivariate analyses were performed to define prognostic factors of overall survival. Patients included had a first recurrence defined as ILNR or ICR during their follow up. 79 patients (5.2 %) presented with ILNR, and 247 (16.4 %) patients had isolated carcinomatosis recurrence. Complete lymphadenectomy was performed more frequently in the ILNR group vs. the ICR group (67.1 % vs. 53.4 %, p = 0.004) and the number of pelvic lymph nodes involved was higher (2.4 vs. 1.1, p = 0.008). The number of involved pelvic LN was an independent predictor of ILNR (OR = 1.231, 95 % CI [1.074-1.412], p = 0.0024). The 3-year and 5-year OS rates in the ILNR group were 85.2 % and 53.7 % respectively, compared to 68.1 % and 46.8 % in patients with ICR. There was no significant difference in terms of OS after initial diagnosis (p = 0.18). 3- year and 5-year OS rates after diagnosis of recurrence were 62.6 % and 15.6 % in the ILNR group, and 44 % and 15.7 % in patients with ICR (p = 0.21). ILNR does not seem to be associated with a better prognosis in terms of OS.

Management of adnexal mass: A comparison of five national guidelines

General gynecologists are often the first to face a newly diagnosed adnexal mass. Bothering mass symptoms, fertility issues, and the effect of a possible surgical intervention on fertility in term of mechanical factor and ovarian follicular reserve are all considerations that should be accounted for. This study summarizes and compares five different adnexal mass management guidelines, enabling clinicians to peruse consensus and controversy issues, thus choosing the optimal management method. We retrieved, reviewed and compared the most recent national guidelines of adnexal mass management from the national societies of the United States (American College of Obstetricians and Gynecologists), England (the Royal College of Obstetricians and Gynecologists), Canada (the Society of Obstetricians and Gynaecologists of Canada), Australia (the Royal Australian College of General Practitioners), and France (French College of Gynaecologists and Obstetricians). There is a broad consensus regarding the role of transvaginal ultrasound as part of the initial evaluation of an adnexal mass and the radiological characteristics suggesting it being malignant. The role of transabdominal ultrasound or doppler mode is controversial. The use of MRI in cases of indeterminate adnexal masses is widely accepted. Ultrasound-guided aspiration is generally not recommended. There is a broad consensus that CA-125 should not be used as an ovarian cancer disease screening tool, though its role in the initial evaluation of adnexal masses is controversial. Risk prediction models are generally accepted, particularly the 'International Ovarian Tumor Analysis simple rules' and the 'Risk of Malignancy Index'. Adnexal mass management national guidelines, though similar, had noticeable variations in the content, references cited, and recommendations made. While this variation might raise a concern as to the reproducibility of synthesizing literature, it can help practitioners present all spectra of recommendations and available data.

Letter to the Editor on "A retrospective study comparing the efficacy of dose-dense chemotherapy, intraperitoneal chemotherapy and dose-dense chemotherapy"

Impact of neoadjuvant chemotherapy cycles on survival of patients with advanced ovarian cancer: A French national multicenter study (FRANCOGYN)

The purpose of this study was to compare two groups of patients presenting advanced ovarian carcinoma benefiting from neoadjuvant chemotherapy (NAC) followed by cytoreductive surgery: after 3-4 cycles (group 1) or ≥ 5 cycles (group 2), regarding overall survival (OS) and progression-free survival (PFS), complications related to surgery as well as the extent of cytoreduction were assessed. We conducted a retrospective, multicenter cohort study in nine referral centers of France, reviewing the charts of all patients who underwent NAC between January 2000 and June 2017. We performed an OS analysis using multivariate Cox regression models adjusted for potential confounders. We also analyzed PFS and surgery-related morbidity. Of 501 patients included, 236 (47.1 %) benefited from ≤ 4 NAC cycles and 265 (52.9 %) from ≥ 5 NAC cycles. Characteristics data were similar in both groups. The rate of achievement of complete surgery was similar in both groups (p = 0.28). Surgical morbidity and postoperative complications showed no significant differences between both groups. The median OS was 54.2 months, 64 months for group 1 and 49.2 months for group 2. The 5-year survival rate was 45.6 % and 27.6 %. This difference was not statistically significant [HR 1.81 (0.89-3.71), p = 0.09]. Five-year PFS was 19.7 % and 11.7 % respectively (p = 0.31). In a large series of advanced ovarian cancer, patients receiving late IDS (≥ 5 NAC cycles) seem to show a poorer prognosis than patients operated on earlier. The survival appears to be mainly determined by optimal resection and response to chemotherapy.

A retrospective study comparing the efficacy of dose-dense chemotherapy, intraperitoneal chemotherapy and dose-dense chemotherapy with hyperthermic intraperitoneal chemotherapy in the treatment of advanced stage ovarian carcinoma

Hyperthermic intraperitoneal chemotherapy (HIPEC), intraperitoneal chemotherapy (IP) and dose-dense (DD) chemotherapy have been employed with varying success in the treatment of advanced stage ovarian carcinoma. Despite the clinical benefits associated with these specific forms of chemotherapy administration, they have not been comparatively analyzed, vis-à-vis their efficacy. Advanced stage ovarian cancer patients who were treated with platinum/taxane chemotherapy via a DD regimen (n = 100), IP approach (n = 81) or a DD regimen in conjunction with HIPEC (n = 64) were retrospectively evaluated. The clinical variables of interest were patient age, body mass index, surgery and pathology data, chemotherapy regimen, inclusion of maintenance therapy, and progression free/overall survival. Progression free survival (PFS) was significantly more pronounced in the HIPEC (34.9 months) and IP (34.0 months) patients, compared to the DD group (27.6 months) (P = 0.005). A cox-proportional hazards regression model indicated that there was a decreased risk of disease progression accorded to the patients who were treated with IP chemo or HIPEC and DD chemotherapy (HR, 0.43; 95 % CI: 0.21-0.88; P = 0.022) and the subjects who underwent optimal cytoreductive surgery (HR, 2.42; 95 % CI: 1.22-4.80; P = 0.011). Positive BRCA status (HR, 0.434; 95 % CI: 1.59-3.44; P = 0.001) and number of chemotherapy regimens (HR, 1.36; 95 % CI: 1.159-1.61; P = 0.001) were significantly correlated with improved OS although we did not discern a survival benefit associated with any of the chemotherapy treatments (P = 0.136). We observed PFS advantages conferred to the ovarian cancer patients treated with HIPEC and IP chemotherapy compared to DD chemotherapy. However, an overall survival advantage related to the chemotherapy regimens was not borne out, possibly due to the retrospective nature of the study or differing time periods wherein the specific patient cohorts underwent treatment.

Ovarian cancer risk management in BRCA-mutation carriers: A comparison of six international and national guidelines

Germline mutations in the BRCA gene account for most hereditary ovarian and breast cancer. Management of healthy carriers aims to prevent and allow early detection of breast and ovarian cancer. This study compares six different hereditary ovarian cancer management guidelines, highlighting areas of controversy between different societies. We aim to compare international and national guidelines regarding BRCA carriers' management. A comparative study. We retrieved, reviewed, and compared the most recent guidelines of BRCA mutation carriers from the specializing societies NCCN (National Comprehensive National network) and ESMO (European society of medical oncology), and national societies of the United States (American College of Obstetricians and Gynecologists), England (the Royal College of Obstetricians and Gynecologists), Canada (the Society of Obstetricians and Gynaecologists of Canada) and Spain (Sociedad Española de Oncología Médica). There is a broad consensus regarding the limited role of screening for early ovarian cancer detection (4 out of 6) (4/6) and regarding the recommendation for implementation of Risk-reducing salpingo-oophorectomy (RRSO) (6/6), some variations exist for age at RRSO. It is widely accepted that risk reducing salpingectomy should be performed only as part of research (5/6), and that the addition of risk-reducing hysterectomy should be individualized (3/6). Not all guidelines address fertility issues, and controversy exists regarding hormone replacement therapy (HRT) recommendations in unaffected young BRCA-mutation carriers following RRSO. BRCA carrier's management guidelines consist of well-agreed topics such as the ineffective screening for early detection of ovarian cancer and the recommendation of RRSO. HRT remains controversial. Conforming unified recommendations is needed for providing evidence-based recommendations.

Correlation between ultrasonographic findings and histopathological and molecular characteristics in endometrial cancer: A multicenter study

Accurate preoperative assessment of endometrial cancer is crucial for tailoring surgical and therapeutic management. Identifying correlations between ultrasonographic features and tumor histopathological and molecular profiles may help improve the accuracy of presurgical staging. This multicenter retrospective study aimed to evaluate the association between ultrasonographic features, histopathological characteristics and molecular profiles in endometrial cancer to improve preoperative assessment and risk stratification. A total of 156 women from three Italian centers underwent standardized transvaginal or transrectal ultrasound following IETA criteria prior to hysterectomy. Ultrasonographic parameters, including endometrial thickness, echogenicity, junctional zone integrity, and vascularity assessed by Doppler, were analyzed. Postoperative histopathology and molecular classification (p53, MMR, POLE, NSMP) were performed. Statistical analyses evaluated correlations among ultrasound features, pathology, and molecular data. Endometrioid histotype was detected in 88.46 % of cases, mostly low-grade and early-stage. Cases in the early stage (i.e. lesions confined to the uterine corpus) accounted for 77.27 % of all cases. Ultrasound staging was consistent with the final staging in 65.5 % of cases, with errors primarily involving the overestimation of p53-abnormal tumors and the underestimation of MMRd tumors. Increased endometrial thickness was associated with a higher stage and grade (median 20 mm for stage III, p = 0.007). An irregular junctional zone was associated with high-grade tumors (p = 0.016). Complex and multifocal vascular patterns were significantly linked to advanced stages, high grade, and molecular aggressiveness, such as p53 mutations and MMR deficiency. Tumors with scattered vessels showed a higher risk of extensive lymphovascular space invasion. Ultrasound features, particularly vascularity, junctional zone irregularity, and endometrial thickness, are significantly associated with tumor stage, grade, and molecular profiles. Incorporating detailed ultrasonographic assessment into preoperative evaluation can help identify high-risk endometrial cancers and guide personalized management strategies. Larger prospective studies are needed to validate these findings.

Patients’ and medical specialists’ attitudes on follow-up care and climate impact in gynaecological oncology: a nationwide survey

With rising healthcare costs, workforce shortages and concerns about healthcare's climate impact, sustainable alternatives to traditional outpatient follow-up schedules are needed to optimize care efficiency. Understanding attitudes of patient and medical specialists is essential when redesigning follow-up care. This study explores their attitudes towards alternative follow-up approaches in gynaecological cancer care and their willingness to consider sustainability in care decisions. A nationwide cross-sectional study was conducted using two self-developed surveys - one for patients and one for medical specialists. The surveys assessed experiences with current follow-up, openness to alternative approaches, and views on healthcare's impact on climate change, both generally and in gynaecologic oncology follow-up care. A total of 121 respondents filled out the surveys, comprising 68 patients and 53 medical specialists. Only four out of 53 medical specialists (8%) were satisfied with current follow-up practices. 87% of 68 patients supported at least one alternative follow-up approach, including reduced follow-up frequency, telemedicine, or involving nurses or general practitioners, although 60% preferred not to reduce the number of consultations. Although many patients expressed reluctance to reducing consultations, medical specialists perceived potential benefits, including more patient-friendly care, reduced costs, lower workload and environmental benefits. Healthcare's climate impact ranked high among medical specialists' priorities, whereas patients did not consider it a major factor for modifying follow-up practices. Both patients and medical specialists in gynaecological oncology are open to alternative approaches to follow-up care, although there is a discrepancy in their attitudes. Medical specialists express greater climate concerns, whereas patients responses indicate a need for individualized care. This study highlights the importance of re-designing follow-up care to meet patient's, healthcare system's, and our planet's needs.

Benign primary vaginal leiomyoma– A diagnostic challenge: Rare case report

Attitudes of Israeli gynecologists towards risk reduction salpingo-oophorectomy at hysterectomy for benign conditions and the use of hormonal therapy

To investigate the perspectives and attitudes of gynecologists towards risk reduction bilateral salpingo-oophorectomy (RRBSO) in average-risk women at the time of hysterectomy procedure for benign indications divided by age groups, and whether they recommend the use of hormonal therapy post oophorectomy. A questionnaire was distributed during staff meetings either by a printed questionnaire or by a link to a total number of 360 gynecologists include seniors and practitioners. Three hundred and one gynecologists participated in a national survey. Participants completed a structured questionnaire including three different scenarios. The subject group included both attending (senior) and second-year and above resident gynecologists, from divergent subspecialties. The demographic information of the survey responders included sex, age, years of experience, working domain, and subspecialty. There was a 95% consensus rate among Israeli gynecologists, in favor of the ovarian conservation approach among 45-year-old women, elected for hysterectomy due to benign indications. Whereas in 50-year-old perimenopause women, without any evident family history of ovarian cancer, 39% of gynecologists advocated BSO at the time of hysterectomy, for benign indications. As for 46-year-old women, with a first-degree relative diagnosed with ovarian cancer at the age of 65 years old, 70.4% voted for prophylactic BSO. For the second part of the questionnaire regarding the utilization of hormone therapy (HT) after BSO, 66.1% of our responders proclaimed they would always encourage the use of HT in 45-year-old-women, while 52.8% recommended HT in 46-year-old-women with a family history of ovarian cancer and 39.5% for 50-year-old perimenopause women. Our national survey confirms the wide variability in attitudes among gynecologists towards performing RRBSO at hysterectomy for a benign indication in women aged 45-50, with family history being a major factor in the decision.

EBCOG position statement: Gender neutral HPV vaccination for young adults

Human Papilloma Virus (HPV) has been implicated in the initiation of several types of cancers in both females and males. Therefore, it is imperative that national immunization programs should ensure that both young women and young men receive full immunization for herd immunity in their teenage years. A recent review confirmed that vaccination of boys and girls would be most cost-effective under the circumstances that both individual costs and coverage are low. By doing so, it would be possible to reduce the incidence of HPV-related malignancies to a large extent at later age in both sexes.

Implementation of enhanced recovery after surgery in gynaecologic oncology surgery: where should we start?

Compliance with elements of an enhanced recovery after surgery (ERAS) protocol is associated with better outcomes, including decreased length of hospital stay (LHS), but complete implementation is challenging. This study aimed to identify the role of individual ERAS elements on LHS to facilitate the implementation process. This retrospective single-centre study included 233 women with gynaecological cancers who underwent surgery between 1 February 2021 and 31 July 2023. The first 120 consecutive patients after implementation of the ERAS programme were defined as the ERAS group, and the other patients were in the pre-ERAS group. The groups were compared in terms of LHS. Univariate and multi-variate analyses were used to define independent predictors of decreased LHS (≤5 days). The median LHS was 6 [interquartile range (IQR) 1-29] days for the ERAS group and 7 (IQR 3-23) days for the pre-ERAS group (p = 0.006). Avoidance of mechanical bowel preparation (p = 0.007), avoidance of surgical site drainage (p < 0.001), removal of urinary drainage before postoperative day 3 (p = 0.02), regular diet initiation on postoperative day 0 (p = 0.02), and reduction in total opioid dose (p = 0.006) were significantly associated with LHS ≤ 5 days on univariate analysis. On multi-variate analysis, avoidance of surgical site drainage (p = 0.014), removal of urinary drainage before postoperative day 3 (p = 0.037), and reduction in total opioid dose (p = 0.045) remained significant for LHS ≤ 5 days. Avoidance of surgical site drainage, removal of urinary drainage before postoperative day 3, and reduction in total opioid dose were found to be independent predictors of decreased LHS among ERAS items. Special consideration should be given to these items during the adoption of ERAS programmes.

Comparison of women with possible endocervical and non-cervical glandular neoplasms detected in liquid-based cervical cytology- incidence, clinical characteristics and outcomes: A cohort study

To compare the incidence, demographics and clinical outcomes of women presenting with possible non-cervical (NC) and endocervical (EC) glandular neoplasms in their cervical smears. Retrospective analysis of a prospective cohort within the NHS Greater Glasgow and Clyde- the largest health organisation in Scotland, UK. Cases identified from the Scottish Cervical Call Recall System between January 2013 and December 2017. Incidence and clinical trajectories of NC and EC were reviewed. Two-hundred-and-thirty cases (NC = 41; EC = 189) from 486,240 smears were evaluated. The incidence was 8.4 and 38.9 per 100,000 smear-year for NC and EC, respectively. Compared to women with EC, women with NC were significantly older (p < 0.0001), had higher body mass index (p < 0.0001), more likely to present with symptoms (58.5 % vs 10.5 %; p < 0.0001), had cancers (48.8 % vs 13.8 %; p < 0.0001) and died from their diseases (9.8 % vs 0.5 %; p < 0.0001). Even in the asymptomatic screen-detected NC group, almost a quarter (23.5 %) had endometrial cancer. Age was not associated with high-risk histology (p = 0.289). High-risk colposcopic appearance had good positive predictive value (90.0 %; 95 %CI: 81.2-95.6 %) for high-risk histology, but poor negative predictive value (41.3 %; 95 %CI: 29-54 %). Negative excision margin was associated with favourable outcomes. NC and EC are rare, but they are distinct and should be reported separately in future studies. The risks of malignancies are high, particularly in women with NC, even if they are asymptomatic. Thus, prompt and thorough investigations and treatments are required to prevent and treat malignancies.

Prognostic factors influencing pelvic, extra-pelvic, and intraperitoneal recurrences in lymph node-negative early-stage cervical cancer patients following radical hysterectomy

The aim of this study was to evaluate the clinicopathologic factors influencing pelvic, extra-pelvic, and intraperitonal recurrences and survival in patients with lymph node-negative early-stage cervical cancer treated with abdominal/laparoscopic/robotic radical hysterectomy (ARH/LRH/RRH). We retrospectively reviewed clinicopathologic data of 342 patients with FIGO stage IB-IIA cervical cancer (2018 FIGO staging) treated with RH and retroperitonal lymphadenectomy between February 2000 and November 2018. Several clinicopathologic factors such as surgical methods including LRH/RRH-vaginal colpotomy (VC) and LRH/RRH-intracorporeal colpotomy (IC), surgical resection margin, and parametrial/endomyometrial infiltration were selected. Univariate and multivariate Cox proportional hazard regression and logistic regression models were used to determine prognostic factors. The median follow-up time was 54 months (range, 6-202 months). In multivariate analysis, positive endomyometrial infiltration (HR, 13.576; 95 % CI, 2.917-63.179; P = 0.001), positive parametrial resection margin (HR, 32.648; 95 % CI, 2.774-384.181; P = 0.006), and LRH/RRH-IC (HR, 4.752; 95 % CI, 1.154-19.578; P = 0.031) were significantly related to overall survival. Six (26.3 %) out of 21 patients with endomyometrial infiltration showed extra-pelvic recurrences associated with lung, liver, and brain. Three (50.0 %) out of 6 patients with positive parametrial margin showed both pelvic and extra-pelvic metastases, such as pelvis and supraclavicular/paratracheal lymph nodes. Five (62.5 %) out of the eight relapsed patients who received LRH/RRH-IC showed intraperitoneal recurrences including omentum, liver surface, colon serosa, and splenic hilum. Three risk factors including parametrial margin, endomyometrial infiltration, and laparoscopic IC appear to be involved in pelvic, extra-pelvic, and intraperitoneal recurrences in node-negative early-stage cervical cancer patients following RH. In particular, endomyometrial infiltration may be one of the strongest independent prognostic factors for extra-pelvic recurrence. Adjuvant systemic therapy may be indicated for lymph node-negative early-stage cervical cancer patients with endomyometrial infiltration.

Oral contraceptives use and risk of cervical cancer—A systematic review &amp; meta-analysis

Role of Oral Contraceptive (OC) as a risk factor for cervical cancer remained controversial and unclear. To evaluate risk of cervical cancer in OC users and non-users through a comprehensive systematic review. Literature search conducted in databases from January 1990 till August 2019 using various search terms. Primary research studies that evaluated and assessed the association of OC use with cervical cancer with study design of case control or cohort types published in English language. PRISMA guided review was done by two independent researchers. Effect size estimated by pooled Odds ratio with 95 % Confidence Interval (CI) in random effect models on OC pill use for the risk of cervical cancer. Review included 19 studies. Overall risk of invasive cancer on OC use was found to be significant with unknown status of HPV OR (95 % CI) as 1.51 (1.35, 1.68) and for unknown HPV as 1.66 (1.24, 2.21). Adenocarcinoma, squamous cell carcinoma and carcinoma in situ had significant association with OR (95 % CI) of 1.77 (1.4, 2.24), 1.29 (1.18, 1.42) and 1.7 (1.18, 2.44) respectively. OC pills use had a definite associated risk for developing cervical cancer specially for Adenocarcinoma and longer duration of OC pills use.

Evaluation of uterine cervical cancer in pregnancy: A cross-sectional study

Evaluate the prevalence and the regression rate of cytological alteration in pregnant patients below the recommended age by the Brazilian Guidelines for the Screening of Uterine Cervical Cancer Guideline in the prenatal service of Maternidade Escola da Universidade Federal do Rio de Janeiro. We included the cytopathological exams of all pregnant patients that attended on the outpatient from January 2010 to May 2016. For the identification of the pregnant women, the Management and Integrated System and the Uterine Cervical Cancer Information System of the institution were used. We performed X The study totaled 5825 cytopathological exams, of which 1822 were from pregnant patients ≤ 24 years of age. Only 4.06 % (74/1822) of altered results were found (p < 0.05). The most frequent change was low-grade squamous intraepithelial lesion with a prevalence of 1.92 % (35/1822) whereas high-grade squamous intraepithelial lesion had 0.16 % (3/1822). The regression rate in pregnant patients ≤24 years of age was 34,32 %. There was a low prevalence of cytological abnormalities in pregnant patients ≤ 24 years, low frequency of high-grade squamous intraepithelial lesion among the altered cytologies and a high spontaneous regression rate, therefore screening is not recommended before the age determined by the Brazilian Guideline.

Immunohistochemical and serum profile of squamous cell carcinoma of the vulva: The Dual Vulvar Panel (DVP) project

This study aimed to evaluate the expression of selected immunohistochemical (IHC) markers and serum squamous cell carcinoma antigen (SCC-Ag) in vulvar squamous cell carcinoma (VSCC), and to investigate associations with recurrence and death using molecular clustering and diagnostic performance analyses. This single-centre prospective study included 27 patients with histologically confirmed VSCC. Tumour specimens were assessed for expression of p16, p53, programmed death-ligand 1 (PD-L1), CD44 and epidermal growth factor receptor (EGFR). Serum SCC-Ag was measured and correlated with clinical outcomes. Statistical analyses comprised Pearson's correlation, logistic regression, receiver operating characteristic curve analysis, diagnostic performance metrics, and unsupervised hierarchical clustering integrating IHC and SCC-Ag data. No significant associations were observed between individual IHC markers and clinical outcomes. Serum SCC-Ag showed a positive trend towards association with recurrence (r = 0.462; p = 0.071), with an increased odds ratio (OR) (OR = 2.7). When analysed as a binary variable, SCC-Ag demonstrated sensitivity of 50%, specificity of 76%, and overall accuracy of 70%. As a continuous variable, SCC-Ag achieved an area under the curve value of 0.83. The combination of SCC-Ag and p53 improved sensitivity to 83% and negative predictive value to 89%. Unsupervised hierarchical clustering identified three biological subgroups, with the cluster characterized by high SCC-Ag and EGFR expression and low p16 expression associated with recurrence more frequently. Serum SCC-Ag showed superior prognostic performance compared with individual IHC markers, and may be useful for postoperative risk stratification in VSCC. Combined biomarker panels, including p53, PD-L1, EGFR and p16, yielded promising sensitivity, supporting future strategies.

Enhancing outcomes in vulvar cancer surgery: A comprehensive approach to complication prevention

This study aimed to identify and synthesize strategies that reduce surgical complications in vulvar cancer, focusing on preoperative, intraoperative, and postoperative measures. A literature review was conducted by searching PubMed, Scopus, and ScienceDirect databases. Studies from 2000 to 2024 published in English and Spanish language were included. Articles were included if they addressed preoperative assessment, surgical approaches, lymph node management, wound care, or psychosocial support in vulvar cancer patients. Conservative surgical techniques-particularly the triple-incision approach and sentinel lymph node biopsy (SLNB)-demonstrate lower morbidity while maintaining acceptable oncologic control, especially in early-stage disease. Video endoscopic inguinal lymphadenectomy has shown promise in further reducing wound complications, although its adoption is limited to specialized centers with technical expertise. Optimizing patients preoperatively through glycemic control, nutritional support, and smoking cessation can decrease the risk of wound infection and dehiscence. Postoperative interventions such as meticulous wound care, negative-pressure wound therapy, and early lymphatic drainage techniques help prevent chronic lymphedema. Additionally, psychosocial and sexual counseling emerges as crucial for addressing the significant emotional and functional challenges associated with vulvar surgery. A multidisciplinary, patient-centered approach is essential to mitigate the high morbidity traditionally linked to vulvar cancer surgery. Ongoing research into advanced surgical methods, standardized perioperative protocols, and holistic patient support will be key to further improving outcomes, preserving quality of life, and reducing the burden of long-term complications in this rare but challenging malignancy.

Identification of groin node metastasis in squamous cell vulval cancer using preoperative [18F] FDG-PET/CT. Can unnecessary lymphadenectomy be prevented?

Vulval cancer is the 4th most common gynaecological cancer. The International Federation of Gynaecology and Obstetrics(FIGO) staging requires a histopathological dissection of the primary tumour and the inguinofemoral lymph nodes(IFLN).However, radiological methods of IFLN assessment often lack accuracy, leading to unnecessary IFLN dissections carrying significant morbidity. To determine its accuracy of [ The predictive value of PET/CT in preoperative assessment of the groin node metastasis was assessed retrospectively in patients with vulval cancer, treated in St. James's Hospital Dublin (2010-2022). SUVmax of the nodal uptake of each inguinal area (if present) was calculated and correlated to histologically confirmed groin metastasis. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of PET/CT in predicating groin node metastasis were calculated. Overall survival was also calculated. Out of the 200 patients 107(53.3%) had a full histopathological assessment of inguinal area and a PET/CT. Patients had either bilateral or unilateral IFLN histology, yielding 197 groins. The sensitivity of PET/CT for IFLN metastasis was 60.0% and specificity was 92.10%. The PPV was 74.30% and the NPV was 88.60 %. The mean SUVmax was 7(range 1.6-30.0 for metastatic nodes (true positive) and 2.18(range 1.9-3.1) for histologically negative nodes (false positive). This study showed that PET/CT has a moderate sensitivity to identify those at risk of lymph node metastasis. Further prospective studies are required to validate the use of PET-CT in discriminating metastatic from non-metastatic IFLN.

Surgery as primary treatment improved overall survival in vulvar squamous cancer: A single center study with 108 women

To describe a single-center experience managing women with vulvar squamous cancer and analyze factors influencing their survival. It is an observational longitudinal retrospective study that reviewed medical records of patients admitted for treatment at the University of Campinas between 2010 and 2019, followed up until June 2022. The final sample was 108 cases. The main outcomes were disease-free survival (DFS) and overall survival (OS). Other variables were age, stage, relapse, and race. Vital status was accessed by medical records, active search, or public online register. Survival analysis was performed by the Kaplan-Meier method and Log-rank Test, and Regression Cox-Model assessed risks. The mean age in stages IA and IB were 65.0 years, and in stages II + III + IVA 71.1 years. Women 70 years or older were more related to diagnosis in stages II + III + IVA (p = 0.019). Progression was observed in 7 (16.7 %) patients in stage IB and 30 (65.2 %) in stage II + III + IVA. Both five-year (5y) DFS and OS were significantly different in stage IB and II + III + IVA (5y-DFS 70.5 % and 39.3 %, p = 0.024; 65.1 % and 24.3 %, p < 0.001). In stages II + III + IVA, most deaths happened before 24 months of follow-up. The primary treatment was surgery in 81.0 % of stage IB and 47.8 % of stage II + III + IVA. A higher OS was observed in patients treated primarily by surgery compared to radiotherapy in stage IB (p = 0.008), and in stages II + III + IVA (p = 0.013). Surgery followed or not by adjuvant radiotherapy was independently associated with a 60 % adjusted death protection compared to radiotherapy alone as primary treatment (0.40, 0.23;0.70). Half of the patients have been diagnosed in stage I. The progression rate was high in the advanced stages of the disease. Overall survival by stage was improved when surgery was the primary treatment. Surgery was independently associated with death.

Accuracy of ICG compared with technetium-99 m for sentinel lymph node biopsy in vulvar cancer

Sentinel lymph node biopsy with radioactive tracer is the standard-of-care in lymph node status assessment in vulvar cancer. Indocyanine green fluorescence-ICG is a promising detection method, due to its advantages over technetium-99 m. In vulvar cancer, the procedure is controversial due to study heterogeneity and the small sample size in previous studies. This study evaluates ICG sentinel lymph node detection compared with the criterion-standard with technetium (dual modality method). Preoperative technetium and intraoperative ICG for sentinel lymph node have been prospectively evaluated in early-stage vulvar cancer. The primary endpoint was to determine accuracy in the detection rate for ICG compared with technetium. Secondary objectives included tracer modality relationship with obesity, tumor size and location. In total, 75 patients participated at 8 centers; 38 had lateral and 37 had midline vulvar tumors. The overall sentinel lymph node detection rate was 85.3 % for technetium and 82.7 % for ICG. For lateral tumors, the detection rate was 84.2 % vs. 89.5 %, while it was 86.5 % vs. 75.7 % for middle tumors, using technetium and ICG, respectively. The median sentinel node harvest was 1.7 (range 1-4), with 24 % metastatic involvement. The sensitivity and positive predictive value for ICG based on the standard technique with technetium was 91.08 % (95 % CI, 83.76-95.84) and 94.8 % (95 % CI, 84.84-96.48), respectively. No significant differences were found comparing the two tracers in patients with midline lesions, obesity (body mass index ≥ 30) and tumor size ≥ 2-4 cm. ICG shows comparable performance parameters to the gold-standard of radioisotope localization.

100 years of iodine testing of the cervix: A critical review and implications for the future

We aim to describe the history of iodine testing of the cervix and identify areas where further work is required. We conducted a search of PubMed and Google Scholar. Full article texts were reviewed. Reference lists were screened for additional articles and books. 37 basic articles in journals including ones written in German and three basic articles in books were identified. Glycogen staining of the ectocervical squamous epithelium with iodine goes back to Paul Ehrlich (1854-1915). Walter Schiller (1887-1960) examined nearly 200 different dyes and found that vital staining of the cervical squamous epithelium was best achieved with Lugol's iodine solution, which was indicated by Jean Guillaume Lugol (1786-1851) for disinfection of the vagina. In 1928 W. Lahm observed that the glycogen content of a squamous epithelium cell decreases as anaplasia increases. From the outset, H. Hinselmann included the iodine test in the minimum requirements for colposcopy. In 1946 H. J. Wespi first mentioned the finding of an "uncharacteristic iodine negative area." The first international colposcopic terminology from Graz in 1975 lists the "iodine light area" among the different colposcopy findings. The IFCPC nomenclatures from Rome 1990, Barcelona 2002, and Rio de Janeiro 2011 have evaluated the iodine test and classified their findings differently. A breakthrough to effective cervical cancer screening in resource-limited settings in Africa, India, and Latin America was achieved with R. Sankaranarayanan's publication on naked-eye visual inspection of the cervix after application of Lugol's iodine. This paper is a step toward a better understanding of what we think and do today with iodine testing and what problems and upcoming tasks will arise in future.

If prophylactic HPV vaccination is considered in a woman with CIN2+, what is the value and should it be given before or after the surgical treatment?

Since the introduction of human papilloma virus (HPV) vaccination, the number of precancerous lesions has decreased in countries with a high HPV vaccination coverage. Currently women who present with a precancerous cervical lesions (CIN2 + ), are often not vaccinated or not vaccinated with the latest vaccine. Although resection of the precancerous lesion is the standard approach, the guidelines regarding vaccination are not clear. Vaccination will be valuable in reducing the risk of recurrence. Therefore, it is beneficial to understand the importance of vaccination or revaccination with the nonavalent vaccine in these cases. Furthermore, the timing of vaccination, either before or after surgery, should be determined. To answer these questions, twelve studies regarding vaccination and conization were reviewed. The inconsistency of study designs and inclusion criteria between the different studies introduced a considerable risk of bias. Nevertheless, the analysis showed that 43 women needed to be vaccinated and treated for CIN2 + lesions to prevent a recurrence. The ideal timing could not be established, but theoretically vaccination before the start of treatment was most logic. Although the data is not level 1 evidence, these recommendations should be used during counseling in the clinical setting until results of ongoing randomized controlled trials become available.

Misoprostol and estradiol to enhance visualization of the transformation zone during cervical cancer screening: An integrative review

The purpose of this integrative literature review was to appraise studies conducted worldwide using misoprostol and estradiol in converting Type 3 transformation zone (TZ) of the cervix into Types 1 or 2 and to assess which regimen could be more feasible in low-and-middle-income countries (LMICs). We reviewed the English language literature for peer-reviewed studies that evaluated strategies to convert Type 3 TZs to Types 1 or 2 for cervical cancer screening. Web of Science and PubMed searches were performed up to July 2020. Search terms included: "cervical colposcopy," "inadequate colposcopy", "cervical cancer screening", "transformation zone," "estrogen", "estradiol", and "misoprostol." Inclusion criteria were articles published in the English language, original research, and peer reviewed articles. A total of 127 articles were abstracted, 24 articles were reviewed, and 9 articles met all inclusion criteria. We found that intravaginal misoprostol, intravaginal estradiol, and oral estradiol can successfully convert Type 3 TZ to Types 1 or 2. A single dose of vaginal misoprostol had a similar maximum response rate (20-80%) to a multi-dose regimen over several days or weeks of both intravaginal estradiol (64-83%) and oral estradiol (50-70%). Misoprostol administration was associated with more side effects such as abdominal cramping and vaginal bleeding compared to estradiol, although these were generally mild. In conclusion, Oral estradiol, intravaginal estradiol, and intravaginal misoprostol can be used to convert Type 3 TZ to Types 1 or 2. Intravaginal misoprostol is well tolerated and more feasible in LMICs due to availability and shorter treatment schedule compared to oral or intravaginal estradiol.

HPV RNA and DNA testing in Polish women screened for cervical cancer – A single oncological center study

To evaluate the incidence of HPV infection, and the frequency of the various genotypes, using mRNA and DNA testing; to assess their relationship with the cervical lesions and women's age in the Polish patients. A group of 1840 women, most of whom had abnormal cytology, from the Franciszek Łukaszczyk Oncology Centre in Bydgoszcz, Poland were screened for presence of at least one of 13 high risk HPV. Following that, 545 HPV DNA positive women were tested for HPV infection using HPV mRNA with the Nucleic Acid Sequence-Based Amplification Assay (NASBA) method. In our study group, 70.1% had DNA HPV positive results. Only 4% of the women had normal cytology. Among 545 HPV DNA positive patients, 36.3% had HPV mRNA positive tests. Moreover, 48% of the HPV mRNA positive patients were infected with HPV 16, followed by 18 (12.6%), 31 (10.1%), 33 (8.6%%), 45 (4.5%), and 16.2% of HPV mRNA positive women were infected with more than one HPV genotype. Furthermore, we found that in women under 30, HPV DNA positivity was higher than HPV mRNA positivity, supporting the hypothesis that younger women's infections are mostly temporary. The differences in HPV prevalence and genotype distribution observed in our study may have an impact on the efficacy of HPV vaccinations for cervical cancer and the development of screening programs, which should be examined further in future studies.

Screening for HPV and dysplasia in transgender patients: Do we need it?

Aim of this study was the evaluation of prevalence of HPV infection and resulting genital dysplasia to assess the necessity and reasonability of pap smears and HPV testing in transgender patients. HPV is the most common sexually transmitted infection and responsible for the majority of genital dysplasias and malignancies. However, few data exist about the prevalence of HPV and dysplasia in transgender people. This retrospective data analysis of prospectively collected data includes all patients seen in our specialized outpatient clinic for transgender people. Gynecologic exam, colposcopy, cellular swabs and HPV typing were carried out. Primary endpoint was the prevalence of HPV and genital dysplasias in transgender patients. Secondary endpoints were the subtypes of HPV, demographic data, sexual orientation and co-morbidities in these patients. We investigated overall 98 patients whereof 53 were transwomen and 45 transmen. Of those, 10.2 % had positive HPV tests and 10.2 % dysplastic changes in the PAP and one case of invasive anal carcinoma (1.02 %). Comorbidities included recurrent urinary tract infections, psychologic comorbidies and other, possibly hormone replacement related conditions. The results underline the necessity of a routine gynecological examination including PAP and/or HPV screening and vaccinating, respectively, no matter of sexual orientation or comorbidities. Monitoring the existent anatomy may prevent invasive carcinoma requiring more invasive therapies. Moreover, concomitant pathologies are present and require long-term care of these patients almost all using hormone therapy and carrying several specific risk factors. Transgender-focused guidelines to take into account these peculiarities are needed.

Quality of life and long-term clinical outcome following robot-assisted radical trachelectomy

Quality of Life and long-term clinical outcome following robot-assisted radical trachelectomy. To evaluate quality of life (QoL) and long-term clinical outcome following robot-assisted radical trachelectomy (RRT). Prospectively retrieved clinical data were rereviewed on all women planned for a fertility sparing RRT for early stage cervical cancer at Skåne University Hospital, Sweden between 2007 and 2020. QoL was assessed using the validated questionnaires EORTC QLQ-C30, QLQ-CX24 and the Swedish LYMQOL. Data was analyzed from 49 women, 42 with a finalised RRT and seven with an aborted RRT due to nodal metastases (n = 3) or insufficient margins (n = 4). At a median follow-up time of 54 months one recurrence (2%) occurred (aborted RRT). According to QLQ-C30 the median global health status score was 75. The disease specific QLQ-C24 showed an impact on symptoms related to sexual function where sexual/vaginal functioning had a median score of 25 and 48% of patients reported worry that sex would cause physical pain. Despite this the functional items sexual activity and sexual enjoyment both had a median score of 66.7. Lymphoedema was reported in 45%, where 9% reported severe symptom with an impact on their QoL. No intraoperative complications and no postoperative complications ≥ Clavien Dindo grade III were observed. Twenty-two of 28 (79%) women who attempted to conceive were successful. A metronidazole/no intercourse regimen was applied between GW 15 + 0-21 + 6 in 26 of 28 pregnancies beyond first trimester resulting in a 92% term (≥GW 36 + 0) delivery rate. Although robot-assisted radical trachelectomy in this cohort was associated with a low recurrence rate, a high fertility rate and an exceptionally high term delivery rate, women's quality of life was affected postoperatively, particularly with regards to their sexual well-being and lymphatic side-effects.

Diagnostic performance of ultrasound reporting systems in evaluation of adnexal masses: A prospective observational study

To evaluate and compare diagnostic performance of ultrasound-based reporting systems IOTA SR, ADNEX, GIRADS, ORADS for discrimination between benign and malignant adnexal masses. A prospective observational study in a tertiary care hospital's Obstetrics and Gynaecology department evaluated pre-operative ultrasound imaging for adnexal masses in 80 cases, comparing various reporting systems' sensitivity and specificity against histopathology as gold standard using STATA version 17.0 for data analysis. Among the 80 masses, 55 % (44/80) were confirmed as benign on histopathology, while 45 % were identified as malignant. The sensitivity and specificity of SR was 100 % (95 %CI: 90.0-100) and 97.1 % (95 %CI: 84.7-99.9) respectively. Eleven masses (13.8 %) were inconclusive, reducing specificity to 75 % (95 %CI:59.7-86.8).In ADNEX optimal cut-off for risk of malignancy was 34.1 % with sensitivity of 86.1 % (95 % CI: 70.5-95.3) and specificity of 90.9 % (95 % CI: 78.3-97.5). Considering GIRADS 4-5 and risk threshold of ≥10 % (ORADS 4-5) as predictors of malignancy sensitivity was 100 % (95 %CI: 90.3-100) and specificity was 70.5 % (95 %CI: 54.8-83.2) for GIRADS and ORADS. All reporting systems were comparable (p = 0.7). ADNEX identified 72.7 % (8/11) of inconclusive cases, outperforming GIRADS/ORADS which correctly classified 27.2 % (3/11) cases. When applied to misclassified GIRADS/ORADS 4-5 category, ADNEX demonstrated superior performance by correctly classifying 76.9 % (10/13) masses, while SR achieved correct classification in only 38.5 % (5/13) masses. All classification systems showed comparable accuracy in malignancy risk identification on imaging. GIRADS/ORADS tended to overestimate malignancy risk. The present study recommends a two-step strategy, leveraging higher specificity of ADNEX model for improved stratification of adnexal masses.

Pembrolizumab for metastatic squamous cell carcinoma arising from mature teratoma of the ovary: A letter to the editor

Factors associated with successful intraoperative oocyte retrieval for fertility preservation during open pelvic surgery for gynecologic indications

Fraction of cancers attributable to and prevented by reproductive factors and exogenous hormones use in Italy

Endogenous and exogenous hormonal factors have been associated with female breast, genital, and colorectal cancer risk. The aim of the present study is to conduct an evidence-based evaluation of the fraction of cancers attributable to and prevented by exogenous hormonal (i.e., combined oral contraceptives [COC] and combined estrogen-progestogen menopausal therapy [CEPMT]) and reproductive factors (i.e., parity and breastfeeding) in Italy. We calculated the population attributable and prevented fractions combining relative risks and prevalence of exposure in Italian women. Italian cancer incidence and mortality data were extracted from national sources and used to estimate the number of cancer cases and deaths attributable to reproductive factors and exogenous hormones in Italy in 2020. For long-term effects, a 20-year latency period was considered. COC were responsible for 4.4 % of breast and 10.9 % of cervical cancers in women aged 15-44, but also avoided 6.4 % of endometrial, 5.6 % of ovarian, and 2.9 % of colorectal cancers in women of all ages. Overall, COC use prevented 1174 cancer diagnoses and 577 cancer deaths. CEPMT caused 0.4 % of breast cancers at age 45-69. Low parity accounted for 8.1 %, 11.8 % and 15.5 % of breast, endometrial and ovarian cancers, respectively (6267 cases, 1796 deaths). Breastfeeding avoided 6.4 % of breast cancers (3775 cases, 897 deaths). Our analysis quantified the complex effects of hormonal and reproductive factors on cancer burden in Italian women.

Perspective on postoperative hormone replacement therapy and fertility preservation in Swyer syndrome with dysgerminoma: a case series and literature review

46,XY complete gonadal dysgenesis (Swyer syndrome) is a rare disorder of sex development. Affected individuals present with a female phenotype but have streak gonads. They are at high risk of developing malignant germ cell tumours, such as dysgerminoma. Long-term hormone replacement therapy (HRT) is required after gonadectomy, but the safety of HRT in patients with malignant tumours is not clear. Case series and long-term follow-up of two phenotypic female adolescents with Swyer syndrome (46,XY karyotype) and dysgerminoma/gonadoblastoma (treated with fertility-sparing surgery + adjuvant bleomycin, etoposide and cisplatin chemotherapy + individualized oestrogen-progestogen HRT). Outcomes (tumour recurrence, uterine development, safety of HRT) were assessed over 6 and 10 years. A systematic review of 17 published studies (24 patients with Swyer syndrome, 30 pregnancies) was also conducted to analyse pregnancy-related outcomes. Neither of the two patients experienced tumour recurrence or significant HRT-related adverse events; uterine dimensions increased to near-normal adult size (Case 1: 3.2 × 3.1 × 1.6 cm → 4.4 × 3.6 × 2.1 cm; Case 2: 3.4 × 2.5 × 1.9 cm → 3.6 × 2.9 × 3.8 cm) with preserved secondary sexual characteristics. The systematic review revealed: high maternal comorbidity [83.3 % of pregnancies with complications, including 11 major events such as uterine rupture and haemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome]; elevated preterm birth (35.7 %) and caesarean delivery (89.3 %) rates; and generally favourable neonatal outcomes (mean ± standard deviation birth weight 2704 ± 733 g, two fetal losses). Long-term postoperative HRT (6 and 10 years) in adolescents with Swyer syndrome and dysgerminoma (following curative surgery + chemotherapy) is safe, facilitates near-normal uterine development, and supports potential fertility without recurrence. Fertility-sparing surgery is feasible, and individualized HRT dosing is warranted. The systematic review further confirms high pregnancy-related complications but favourable neonatal outcomes in patients with Swyer syndrome. Vigilant long-term surveillance and large-scale prospective studies are needed to validate long-term safety.

Cytoreductive surgery and perioperative intraperitoneal chemotherapy in recurrent ovarian cancer: 18 years of experience

To identify the clinical and pathological factors associated with relapse in women who had undergone secondary cytoreductive surgery due to locally advanced recurrent ovarian cancer. Women with locally advanced recurrent ovarian cancer who had undergone cytoreduction between 2000 and 2018 were included in this study. Demographic, clinical and biochemical intraoperative findings were recorded for each woman. All factors were assessed in order to identify which correlated with the outcomes of interest (i.e. disease relapse, mortality and morbidity). In total, 181 women who had undergone secondary cytoreduction were analysed. The hospital mortality rate was 1.7 % (n = 3) and the morbidity rate was 32.1 % (n = 58). Recurrence was recorded in 101 (55.8 %) women. Infiltration of large bowel lymph nodes was a negative prognostic indicator of morbidity (p = 0.029). A prior surgical score of 1 (PSS-1) [odds ratio (OR) 0.465] and complete cytoreduction (OR 0.518) were found to be significant independent predictors for disease relapse. Median overall survival was greater for patients with PSS-1 (151.3 vs 59.4 vs 44.1 months; p = 0.049) and patients with complete cytoreduction (137.6 vs 36.2 vs 10.0 vs 27.4 months; p < 0.001). Complete cytoreduction and PSS-1 are associated with reduced disease relapse and increased overall survival. Infiltration of large bowel lymph nodes is associated with increased morbidity.

A comparison of the clinical and histological appearances after treatment of advanced stage ovarian cancer with PlasmaJet® device

To compare the clinical appearance of "no residual disease" to the histological assessment of the same tissue when treated with PlasmaJet®. To determine if the treated tissue with a clinical appearance of "no residual disease" demonstrated histologically apparent damage to underlying structures. The main aims of the study were to compare the clinical appearance of 'no residual disease' to the histological assessment of the same tissue and to assess whether treatment with PlasmaJet® to produce a clinical appearance of 'no residual disease' causes no histologically apparent damage to the underlying structures. This prospective cohort study was conducted in Liverpool Women's NHS Foundation Trust between January 2019 and June 2020. Women with a diagnosis of advanced or presumed advanced stage ovarian cancer were approached and 20 women were recruited into the study. Tissue samples were collected from women with stage 3 or 4 ovarian cancer at either primary or interval debulking surgery. The clinical appearance of no residual disease was confirmed histologically in 84 % (n = 16) of cases. Fat was the only underlying tissue seen damaged in 21 % (n = 4) of cases. Bowel resection with stoma formation was needed in one case (5.26 %). PlasmaJet® ablated the malignant tissue in majority of the cases without causing any significant damage to the underlying tissue, it also reduced the need for stoma formation. This is a small study with encouraging results. PlasmaJet® could be a valuable tool in ovarian cancer surgery, it potentially could reduce the need for bowel surgery and allow treatment of significant mesenteric disease with reduced morbidity for the patient.

A rare case report of bullous pemphigoid caused by paclitaxel treatment for endometrial cancer

Counselling and management of women with genetic predisposition to gynaecological cancers

To review the literature with reference to counselling and management of women with genetic predisposition to gynaecological cancers. Histochemical analysis, ultrasound, blood investigations, genetic testing, screening and risk-reducing surgery (RRS) are important tools for the management of gynaecological cancers and mortality reduction. Counselling can assist in timely management of gynaecological cancers. Systematic reviews, review articles, observational studies and clinical trials on PubMed, published in the English language, were included in this review. The management of women with genetic predisposition to gynaecological cancers through screening tests and RRS has led to a significant decrease in the risk of malignancy through RRS in cases with BRCA1 and BRCA2 gene mutations. RRS and screening have also been found to reduce the mortality rate and increase the survival rate in women with BRCA1 and BRCA2 gene mutations. The efficacy of endometrial cancer surveillance in women with Lynch syndrome is still unproven. RRS has not been reported to be effective in women with Cowden syndrome. The risk of ovarian malignancies in individuals with germline mutations remains minimal in the general population in comparison with genetic mutations. Genetic testing and RRS should be implemented in addition to genetic counselling for proper management and mortality reduction of women predisposed to gynaecological cancers.

Evolving treatment landscape of advanced endometrial cancer – A current perspective from a German tertiary referral center for gynecological oncology

Intermediate-risk endometrial cancer treated with adjuvant brachytherapy using single dosimetric planning: long-term outcome and toxicity assessment

Brachytherapy of the vaginal dome is the recommended adjuvant treatment for intermediate-risk endometrial cancer. This study assessed the results of dosimetric planning of high-dose-rate brachytherapy exclusively in the first treatment session. This retrospective study included all patients who underwent hysterectomy for endometrial cancer followed by adjuvant brachytherapy of the vaginal dome between 2012 and 2015. Local recurrence rates, overall survival (OS) rates, recurrence-free survival (RFS) rates, and related acute and late toxicity rates were evaluated. This analysis included 250 patients, of whom 208 were considered to be at high-intermediate risk of disease recurrence. After a median follow-up of 56 months, the cumulative incidence of local recurrence was 4.8% at 3 years [95% confidence interval (CI) 2.8-8.3] and 7.8% at 5 years (95% CI 4.8-12.6). The 5-year OS rate was 86.2% (95% CI 80.6-90.3), and the 5-year RFS rate was 77.5% (95% CI 71.1-82.7). Acute toxicity occurred in 20 (8%) patients, of which two patients had grade ≥3 toxicity. Only one patient (0.4%) presented with late grade ≥3 toxicity. These findings confirm the tolerability of this brachytherapy approach, indicating minimal cases of late grade ≥3 toxicity, associated with a good 5-year OS rate. With the advent of molecular prognostic factors, the current focus revolves around discerning those individuals who gain the greatest benefit from adjuvant therapy, and tailoring treatment more effectively.

Brain metastasis as a first clinical presentation of endometrial cancer: A case report

Unravelling the mystique of recurrence: A comparative analysis of surgical approaches for early-stage endometrial cancer

This study aims to compare long-term survival differences and recurrence patterns between robotic and open surgery for early-stage endometrial cancer (EC). This study was conducted retrospectively from 1st January 2015 to 30th June 2021 on all patients with stage I or stage II EC (FIGO 2023 Staging), irrespective of histology. The primary objective was to compare 3-year Recurrence-Free Survival (RFS) rates between robotic and laparotomy surgical approaches in patients with early-stage endometrial cancer. In a study of 297 patients, 81.5 % underwent robotic surgeries and 18.5 % underwent open surgeries. Median age was 47.5 years. After a median follow-up period of 36 months, RFS rates of 92.5 % and 86.1 % in robotic and laparotomy groups, respectively (p = 0.6). Most recurrences were found at distant sites (77 %). No significant differences in recurrence sites between surgical groups (p > 0.05), but vaginal vault and para-aortic lymph node recurrences were exclusive to the robotic group. Median time to recurrence was significantly shorter in open group than robotic group (p = 0.01). Patients with focal LVSI (lymphovascular space invasion) had significantly higher recurrence rates compared to THOSE without LVSI (p = 0.04). No significant difference in RFS rates between two surgical approaches. However, robot-assisted surgery leads to a longer median time before recurrence. Most recurrences are distant, and focal LVSI is significantly associated with these recurrences. It's important to consider focal LVSI in histopathology reports, and patients with early-stage endometrial cancer should be monitored for potential recurrences.

Which is the best surgical approach for endometrial cancer treatment in elderly women? A systematic review and meta-analysis

To compare the surgical outcomes between laparoscopy, laparotomy and robotic surgery in young (<65 years) and elderly (≥65 years) women for treatment of endometrial cancer (EC). In addition, the secondary outcomes included a comparison of these surgical methods for EC management in patients aged <70 years and ≥70 years. Operative time, blood loss, requirement for blood transfusion, intra-operative and postoperative complications, and length of hospital stay were evaluated in the two groups of patients. The meta-analysis included 10 trials between 2000 and 2024. Quantitative variables were meta-analysed using the mean difference (MD), while qualitative variables were analysed using the risk ratio (RR). The Dersimonian-Laird random effects models included a point estimate with 95 % confidence intervals (CI). The Cochran Q test and I Regarding women aged <65 years, for total operative time, overall heterogeneity was 38.96 % and overall MD was -7.48 (95 % CI -23.67 to 8.71; p = 0.16). For length of stay, overall heterogeneity was 72.21 % and overall MD was 0.65 (95 % CI 0.36-0.94; p < 0.001). For blood loss, overall heterogeneity was 0 % and overall RR was -6.75 (95 % CI -35.72 to 22.22; p = 0.30). Moreover, for the requirement for blood transfusion, overall heterogeneity was 59.36 % and overall RR was 1.39 (95 % CI 0.96-2.01; p = 0.04). For intra-operative complications, overall heterogeneity was 56.93 % and overall RR was 1.61 (95 % CI 1.31-1.98; p = 0.02). Finally, for postoperative complications, overall heterogeneity was 15.48 % and overall RR was 1.03 (95 % CI 0.84-1.27; p = 0.35). No significant differences in these surgical outcomes were found between the three surgical approaches (p = 0.16, 0.31, 0.36, 0.79, 0.28 and 0.18, respectively). In women aged < 70 years, for total operative time, overall heterogeneity was 13.07 % and overall MD was 1.19 (95 % CI -11.16 to 13.54; p = 0.43). For length of stay, overall heterogeneity was 53.73 % and overall MD was 0.98 (95 % CI 0.32-1.65; p = 0.09). For blood loss, overall heterogeneity was 0 % and overall MD was 1.22 (95 % CI 0.78-1.91; p = 0.0.98). For intra-operative complications, overall heterogeneity was 0 % and overall MD was 1.00 (95 % CI 0.77-1.30; p = 0.96). Finally, for postoperative complications, overall heterogeneity was 43.36 % and overall MD was 1.21 (95 % CI 0.89-1.64; p = 0.13). No significant differences in these surgical outcomes were found between the three surgical approaches (p = 0.12, 0.08, 0.28, 0.91 and 0.81, respectively). This systematic review and meta-analysis on different surgical approaches to treat EC found no significant differences in operative outcomes between minimally invasive surgery and laparotomy. Efforts to reduce related morbidity are crucial, and a multidisciplinary strategy is the optimal treatment pathway in elderly women.

Beyond the number—Age as a prognostic indicator in endometrial cancer

The integration of molecular classification into endometrial cancer (EC) staging has advanced targeted therapies, yet patient demographics-especially age-remain vital in understanding risk factors, cancer characteristics, and treatment outcomes. As the age of diagnosis decreases, distinguishing the unique needs of patients aged ≤50 versus >50 is crucial for tailored treatment strategies. A single-institution retrospective study was conducted in the Department of Gynaecological Oncology between January 2015 and June 2021, including 381 surgically treated patients with available electronic medical records, to examine EC distribution, clinical-pathological factors, and survival in women aged ≤50 and >50 years. Women ≤ 50 years were more likely to have non-aggressive tumours confined to the uterus, with higher ER and PR positivity. In contrast, those >50 years had more aggressive tumours, advanced-stage disease, greater myometrial invasion, LVSI, and a higher incidence of P53 mutations. The older group had a higher proportion of high-risk patients and received more adjuvant therapy (63 % vs. 29 %, p  50 showed a trend toward worse 5-year OS (78 % vs. 98 %, p = 0.09) and DFS (70 % vs. 92 %, p = 0.05). The study underscores the unique histopathological and molecular features of each age group. Including elderly patients in trials is essential for real-world data, while prognostic markers in younger patients are key to individualised treatment strategies.

Survival disparities in women with endometrial cancer based on metastasis size in the sentinel lymph node: A tertiary cancer centre observational cohort study

The adoption of sentinel lymph node (SLN)-mapping with ultrastaging for patients with endometrial cancer has led to increased rates of metastatic nodal disease due to the detection of low-volume metastases (LVM), i.e. micrometastasis and isolated tumour cells (ITCs). Exploring their association with survival can aid risk stratification and personalised treatment approaches. To evaluate disease-free and disease-specific survival based on SLN metastasis size in patients with endometrial cancer. This observational cohort study included patients with endometrial cancer who underwent robot assisted laparoscopic (RAL) hysterectomy with SLN-mapping following the Memorial Sloan Kettering Cancer Center (MSKCC) algorithm between 2015-2024 at the Royal Marsden Hospital (RMH), a tertiary cancer institute in the United Kingdom (UK). Survival analyses employed Kaplan-Meier curves, logrank tests and Cox proportional hazard models, with endpoints being disease-specific and overall survival. 401 patients were included, with a mean BMI of 29.4 kg/m Patients with LVM in the SLN had similar survival outcomes to node-negative patients when treated with adjuvant therapy. Further prospective research is needed.

Diagnostic performances of hysteroscopy in post-remission surveillance of patients treated conservatively for endometrial cancer and atypical hyperplasia: a cohort study

Hysteroscopy is commonly used for diagnosing benign endometrial conditions, but its diagnostic performance in malignancies post-treatment surveillance has not been evaluated. This study evaluated the correlation between hysteroscopic appearance and histological outcomes in patients in remission after conservative treatment for atypical hyperplasia (AH) or early-stage endometrial cancer (EC). Multicenter retrospective cohort study utilizing data from the French national register of fertility-sparing management for AH/EC (PREFERE database) from May 2015 to December 2020. The study included patients over 18 years with a prior diagnosis of AH or stage IA1 EC, who achieved remission following progestin-based fertility-sparing treatment. Hysteroscopy and endometrial biopsy were performed for post-remission surveillance. Hysteroscopic appearances were categorized, and the corresponding histopathological results were reviewed as the gold standard for detecting recurrence or remission. Non-suspicious findings (normal or atrophic) and suspicious findings (thickened, polypoid, polyp-like or atypical vessels presence) in hysteroscopy were evaluated for concordance with biopsy results. The study followed 47 patients in remission yielding in 121 hysteroscopy-biopsy pairings, of which 63 were non-suspicious. Diagnostic accuracy of hysteroscopy was 63 % (95 % CI: 54-71 %), with sensitivity of 71 % (95 % CI: 52-86 %) and specificity of 60 % (95 % CI: 49-70 %). The positive predictive value was 38 %, and the negative predictive value was 86 %. Non-suspicious hysteroscopic findings correlated better with normal histopathology, while suspicious findings were less predictive of recurrence. The findings highlight the necessity of combining hysteroscopic findings with biopsy for reliable post-treatment monitoring in fertility-sparing management of AH/EC. Hysteroscopy alone lacks sufficient accuracy which aligns with current guidelines and underscores the importance of follow-up protocols to detect recurrence in this high-risk population. Integrating advanced imaging modalities or diagnostic tools based on artificial intelligence may enhance the accuracy of recurrence detection in this patient population.

Multimodal management of peritoneal sarcomatosis in uterine sarcoma: Long term outcomes from a single institute in India

To assess the outcomes of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal sarcomatosis (PS) from uterine sarcoma at a tertiary oncology center in India. A retrospective analysis of uterine sarcoma patients with PS who underwent CRS + HIPEC. Key outcomes included survival, completeness of cytoreduction (CC score), and postoperative morbidity. Median patient age was 53 years, with uterine leiomyosarcoma and endometrial stromal sarcoma as the predominant histology. All patients received preoperative chemotherapy, mainly gemcitabine/docetaxel or ifosfamide. The median Peritoneal Carcinomatosis Index (PCI) was 12, with 85 % of patients having PCI < 15. Complete cytoreduction (CC-0) was achieved in 94 %. Median overall survival (OS) was 34 months, with 1-year, 3-year, and 5-year OS rates of 78 %, 53 %, and 35 %. Disease recurrence remained high (67 %), with a median progression-free survival (PFS) of 14 months. CRS + HIPEC is a promising therapeutic approach for select uterine sarcoma patients with PS, offering high cytoreduction rates and extended survival. Further studies are needed to optimize patient selection and refine treatment protocols.

The association of endogenous sex hormones with endometrial cancer risk: A systematic review and meta-analysis

The role of endogenous sex hormones in the risk of endometrial cancer (EC) remains contradictory across the studies. This meta-analysis was carried out to investigate the relation of circulating concentrations of sex hormones and sex hormone-binding globulin (SHBG) to EC risk. A search of the PubMed, Web of Science, and Scopus databases was conducted to include relevant studies. We used odds ratios (OR) with 95% confidence intervals (CI) to pool effect sizes using a random effects model. The analysis included 16 studies with 292,695 participants. SHBG levels showed an inverse relationship with EC (OR: 0.67). In contrast, higher circulating levels of total testosterone (OR: 1.70), free testosterone (OR: 1.75), dehydroepiandrosterone sulfate (OR: 1.39), and androstenedione (OR: 1.58) were positively associated with EC risk. Estrogens also demonstrated significant associations, so that estrone (OR: 1.55), unconjugated estrone (OR: 1.86), estradiol (OR: 1.38), unconjugated estradiol (OR: 2.14), estriol (OR: 1.75), and unconjugated estriol (OR: 1.99) were linked to increased EC risk, while conjugated estrogens showed no significant associations. A non-linear dose-response relationship was found for SHBG, estrone, estradiol, and total testosterone. The results were significantly affected by age, cancer type, geographic region, menopausal status, study type, and the level of adjustments for covariates. For all hormones, the significant associations were found only for postmenopausal women. This study found an inverse association between SHBG and EC, while identified a direct relationship between sex hormones, except for conjugated estrogens, and EC risk only in postmenopausal women.

Comparative analysis of European guideline-based clinicopathological risk groups and the International Federation of Gynecology and Obstetrics staging system for endometrial cancer

To investigate the correlation between endometrial cancer risk groups, as defined by the 2021 European guidelines, and the 2023 International Federation of Gynecology and Obstetrics (FIGO) staging system. Further, we aimed to evaluate the additional prognostic capability of the staging system within individual risk groups. This retrospective cohort study included patients who underwent primary treatment for endometrial cancer at a single tertiary center. Each case was classified into a molecular-integrated risk group according to the 2021 joint guidelines from the European Society of Gynaecological Oncology (ESGO), the European Society for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP). Staging was performed using the FIGO 2023 criteria with molecular classification. Data from 1044 patients were analyzed. Median follow-up was 70 months. Stage IA2, stage IB, and stage IVB were the most prevalent stages among the ESGO-ESTRO-ESP low-risk, intermediate risk, and advanced-metastatic groups, accounting for 80 %, 75 %, and 54 % of the cases, respectively. The stage distribution was more heterogeneous in the high-intermediate risk and high-risk groups, with stage IIA comprising 36 % and stage IICm ESGO-ESTRO-ESP high-intermediate risk and high-risk endometrial cancers exhibited the greatest variability in terms of stage distribution and survival outcomes. Stage IIC, the most heterogeneous stage concerning risk groups, showed an association between risk groups and survival.

Causal effect of breast cancer on endometrial cancer risk: A two-sample Mendelian randomization study

Observational studies have indicated a higher incidence of endometrial cancer in individuals with breast cancer. However, to date, there is a dearth of Mendelian randomization (MR) studies that explore the causal relationship between breast cancer and the risk of endometrial cancer. We conducted MR to investigate the causal relationship between breast cancer and endometrial cancer risk in European populations. A total of 112 valid instrumental variables (IVs) were included in the analysis. Our research has revealed a compelling causal association between genetic predisposition for breast cancer and an augmented likelihood of developing endometrial cancer (Inverse variance weighted (IVW) method, odds ratio (OR) = 1.105, 95 % confidence interval (CI): 1.025 to 1.181, p = 0.003; Weighted median method, OR = 1.109, 95 % CI: 1.020 to 1.205, p = 0.015; Weighted mode method, OR = 1.101, 95 % CI: 1.013 to 1.195, p = 0.025). To our knowledge, this study is the first to report a causal association between breast cancer and endometrial cancer risk. Robust results were obtained through rigorous testing for heterogeneity and pleiotropy. Our findings indicate a causal effect of breast cancer on the risk of endometrial cancer.

12-Year follow up after successful treatment of stage IVC endometrial cancer with bone metastasis: A case report

Prognostic significance of lymphadenectomy in uterine leiomyosarcomas and endometrial stromal sarcomas: Systematic review and meta-analysis

The clinical value of lymph node dissection remains controversial. This study aimed to evaluate the impact of lymphadenectomy on the prognosis of patients with uterine leiomyosarcomas (uLMS) or endometrial stromal sarcomas (ESS). PubMed, EMBASE and the Cochrane Library were searched for studies describing the prognostic significance of lymphadenectomy in uLMS or ESS. Quality assessments were performed using the Newcastle-Ottawa Scale, relative hazard ratios and a random-effects model. Thirty-two retrospective cohort studies that included 26,693 patients in total were enrolled. Patients with uLMS or low-grade ESS (LG-ESS) had no survival benefits from lymphadenectomy. However, patients with high-grade ESS (HG-ESS), did show survival benefits of lymphadenectomy, with no heterogeneity. No significant evidence of publication bias was found. Lymphadenectomy had little prognostic effect on patients with early-stage uLMS or LG-ESS. The best treatment for HG-ESS is early, comprehensive hysterectomy with lymph node dissection.

Should we prioritise proper surgical staging for patients with Atypical endometrial hyperplasia (AEH)? Experience from a single-institution tertiary care oncology centre

The study aimed to evaluate the incidence of concurrent endometrial cancer (EC) and lymph node positivity in patients with Atypical Endometrial Hyperplasia (AEH) who underwent surgical staging with sentinel lymph node evaluation. It also sought to identify the risk factors associated with detecting concurrent endometrial cancer in patients with a preoperative diagnosis of AEH. A retrospective study was conducted at Amrita Institute of Medical Sciences, involving 54 cases of AEH diagnosed on pre-operative biopsy specimens and undergoing staging surgery between January 1, 2015, and December 31, 2020. The study analysed demographic parameters, clinical presentations, pathological features, and clinical outcomes. Categorical variables were expressed in numbers and percentages, normal distribution data were presented as mean, and non-normal distribution data were presented as median and range. Fifty-four patients diagnosed with AEH underwent surgical staging. The median age was 54 years. Final HistoPathology Report (HPR) showed 48.14 % with AEH and 51.85 % with concurrent EC. Among those with concurrent EC, 96.4 % had type I EC, and one patient was upgraded to type 2 EC. Among them, 17.8 % patients belonged to high-intermediate and high-risk categories. Patients with AEH and concurrent EC were more likely to be diabetic (OR: 3.56, p = 0.04), have a BMI ≥25 kg/m2 (OR: 1.47, p = 0.04), exhibit a thickened endometrial lining of ≥9 mm (OR: 3.13, p = 0.05) on ultrasound, and undergo preoperative biopsy at a non-oncology centre (OR: 8.33, p = 0.001) whereas experiencing heavy menstrual bleeding had a substantially lower likelihood (OR: 0.29, p = 0.01) of developing concurrent EC. The study revealed that more than half of patients undergoing staging surgery for AEH were found to be at risk of having concurrent EC in their final HPR. The research also pointed out that surgical staging can help identify both low-risk and high-risk ECs, which may require additional treatment. Higher BMI, diabetes mellitus, and an endometrial thickness of ≥9 mm were identified as significant risk factors for concurrent EC. Additionally, heavy menstrual bleeding was associated with a decreased risk of concurrent EC.

Fertility-sparing treatment in MSI-H/MMRd endometrial carcinoma or atypical endometrial hyperplasia: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to describe the oncological and reproductive outcomes of patients with MSI-H/MMRd endometrial carcinoma (EC) or atypical endometrial hyperplasia (AEH) undergoing fertility-sparing treatment. The study protocol was registered with the PROSPERO database (No: CRD42024530406). A systematic literature search in major electronic databases (PubMed, Embase, and Cochrane Library) was conducted from January 1, 2013 to August 10, 2024. The primary outcomes were complete remission (CR) rate and recurrence rate. Other outcomes included oncological outcomes in patients with Lynch syndrome and overall patient fertility status. The study included ten retrospective studies summarizing 66 patients with MSI-H/MMRd undergoing fertility-sparing treatment. The publication bias analysis was low. The length of follow-up varied from 3 to 164 months according to the different studies analyzed. After fertility-sparing treatment, 61.8 % of patients achieved CR, and 41.2 % of patients relapsed. Twelve patients were identified with germline mutations in Lynch syndrome, nine (75 %) achieved CR, and seven (77.8 %) relapsed. Only one study with active use of assisted reproductive technology reported a 1-year cumulative pregnancy rate of more than 60 % and more than half live births, while the remaining five studies assessed fertility outcomes and reported only one live birth. EC and AEH patients with the MSI-H/MMRd subtype had a low remission rate and high recurrence rate compared to conservative treatment. Caution is recommended when evaluating fertility-sparing therapy for patients with the MSI-H/MMRd subtype.

When is it necessary to perform biopsy in asymptomatic postmenopausal women with incidental finding of thickened endometrium?

To determine the cutoff value for endometrial thickness (ET) that prompts a biopsy in asymptomatic postmenopausal women with an incidental finding of thickened endometrium, and to develop a risk prediction model. This is a retrospective cohort analysis of the clinical records of the Hysteroscopic Center of Fu Xing Hospital, Capital Medical University, Beijing, China. We collected asymptomatic postmenopausal women who presented with an ET of ≥4 mm (double-layer) as an incidental finding. We stratified the participants into non-malignant and malignant groups based on pathology results and assessed differences between the two groups. A receiver operating characteristic curve (ROC) was used to identify the cutoff value of ET for predicting endometrial malignancy. Logistic regression models were also constructed to predict the risk of malignancy. A total of 581 consecutive eligible cases were included. The optimal cutoff value for ET was 8 mm, with a maximum area under the curve (AUC) of 0.755 (95 % CI: 0.645-0.865). In addition to ET, the regression model incorporated diabetes, blood flow signal, BMI, and hypertension to predict the risk of malignancy. A ROC curve constructed for the model yielded an AUC of 0.834 (95 % CI: 0.744-0.924). It is reasonable to offer hysteroscopy and visually-directed endometrial biopsy for asymptomatic postmenopausal women when ET is 8 mm or above. For those with an ET between 4 and 8 mm, further decision to perform biopsy should be determined on an individual basis, considering risk factors and blood flow signals of the endometrium.

Does the presence of single compared to multiple endometrial polyps alter the risk of cancer in post-menopausal women?

To evaluate the relative rates of malignancy in women with single and multiple polyps presenting to a UK Cancer Centre with postmenopausal bleeding (PMB). A retrospective review of patients treated at Royal Derby Hospital (RDH) for PMB who underwent outpatient hysteroscopy based on ultrasonographic suspicion of endometrial polyps between May 2014 to December 2019. The main outcome measure was the rates of precancerous and malignant histology for single or multiple polyps. The secondary outcomes assessed the influence of risk factors on the rates of malignancy within the single and multiple polyps groups. The study population was 851 women of which 533 were in the single polyp group and 318 in the multiple polyps group. The multiple polyps group (mean age 65.2 years) was older compared to the single polyp group (mean age 62.1 years), P = 0.0001. Elevated rates of cancer was driven most significantly by endometrioid cancer in the multiple polyps compared to single polyp group, with rates of 50/314 (16 %) and 28/512 (5.5 %) respectively, P= 0.05). Significantly more endometrial hyperplasia with atypia (AEH) was found in the multiple polyps compared to single polyp group, with rates of 18/314 (5.7 %) and 15/512 (2.9 %) respectively, P = 0.046. Our study found increased rates of endometrioid cancer and its precursor, AEH within the multiple polyps compared to the single polyps groups. Future risk predicting algorithms should consider incorporating single and multiple polyps as part of their risk model.

Predictive factors of endometrial lesions in patients with abnormal uterine bleeding

To explore the risk factors of endometrial lesions in patients with abnormal uterine bleeding(AUB) and establish prediction models which can discriminate between different endometrial etiologies of AUB. We conducted this cross-sectional study in consecutive 778 women with AUB who received ultrasound examination and endometrial histopathological examination. Models were developed to distinguish between normal endometrium and (1) endometrial lesions, (2) endometrial polyps, (3) endometrial hyperplasia without atypia, (4) endometrial atypical hyperplasia and endometrial carcinoma. 274 (35.2%) women had normal endometrium; 504 (64.8%) had endometrial lesions, including 337(43.3%) endometrial polyps, 139(17.9%) endometrial hyperplasia without atypia, 28(3.6%) endometrial atypical hyperplasia and endometrial carcinoma. Age (OR = 1.122, 95%CI 1.002-1.257, P < 0.001), ET (endometrial thickness, OR = 2.702, 95%CI 1.629-4.402, P < 0.001), and CA125(U/ml) (OR = 1.007, 95%CI 1.003-1.021, P < 0.001) are independent risk factors of endometrial lesions in women with AUB. BMI(OR = 1.109, 95%CI 1.067-1.433,P = 0.038), ET(OR = 20.741, 95%CI 16.136-98.842, P < 0.001), age(OR = 1.182, 95%CI1.031-1.433,P = 0.016)、CA125(U/ml) (OR = 1.690, 95%CI 1.506-1.929,P = 0.001), prevalence of hypertension(OR = 1.350, 95%CI 1.051-67.82, P = 0.014) and diabetes(OR = 1.108, 95%CI 1.008-20.194,P = 0.001) were independent risk factors for atypical hyperplasia and endometrial carcinoma in patients with AUB. The model we built could predict atypical hyperplasia and endometrial carcinoma with the sensitivity of 87.5%, specificity of 80.7% and the AUC of 0.921. In women with AUB, the new-built model based on age, BMI, endometrial thickness, hypertension, diabetes and CA125 could discriminate reliable between atypical hyperplasia, endometrial carcinoma and normal women. The model may be useful for management of AUB.

Incidental damage of obturator nerve during laparoscopic pelvic lymphadenectomy in endometrial cancer – Demonstration of a successful repairing procedure

In order to highlight the importance of intraoperative complications and their management, we demonstrate a video of an iatrogenic left obturator nerve lesion during a pelvic lymphadenectomy for endometrial cancer staging. The repair was promptly performed using an intracorporeal laparoscopic suture for an end-to-end tension-free nerve anastomosis. Stepwise demonstration of the technique with narrated video footage. A 70-year-old woman with a stage IB grade I endometrial adenocarcinoma was submitted to a surgical laparoscopic staging with total hysterectomy(TH), bilateral adnexectomy(BA), and bilateral pelvic and lomboaortic lymphadenectomy. After an uneventful retroperitoneal lomboaortic lymphadenectomy, the left paravesical space was dissected until the obturator fossae and a left pelvic lymphadenectomy followed, during which the left obturator nerve was accidentally transected with LigaSure™. A careful inspection revealed an almost complete transection (80%) of the nerve, with both proximal and distal cut ends identifiable and no fraying of the edges. The thickness of the non-sectioned nervous portion was less than 3 mm, but a tension-free reattachment of both edges seemed manageable. The edges were oriented towards each other and a single stitch suture was placed using a 5-0 prolene, providing an epineural end-to-end coaptation. To reinforce the suture, a Fibrin sealant Tissucol® was applied. The contralateral pelvic lymphadenectomy was then performed, followed by TH and BA. The pieces were removed through the vagina using an endobag. The patient was discharged on the second postoperative day. During the follow-up, there were no signs of diminished adductor function, and neither there was any other detectable residual neuropathy or neurologic deficit involving the left thigh. It is crucial to identify intraoperative complications and to develop abilities to manage them. This video proves that it is possible to repair a transected obturator nerve using laparoscopy, when performed by an experienced onco-gynecologist, with extremely good functional results.

Clinical outcomes of levonorgestrel-releasing intrauterine device present during controlled ovarian stimulation in patients with early stage endometrioid adenocarcinoma and atypical endometrial hyperplasia after fertility-sparing treatments: 10-year experience in one tertiary hospital in China

To evaluate the oncologic and pregnancy outcomes of patients with early stage endometrioid adenocarcinoma (EMC) and atypical endometrial hyperplasia (AEH) treated with controlled ovarian stimulation (COS) with or without levonorgestrel-releasing intrauterine device (LNG-IUD) after fertility-sparing treatment (FSTs). A total of 67 patients with EMC or AEH who achieved complete response after FSTs and underwent COS between January 2010 and December 2019 were retrospectively reviewed. Univariate and multivariate Cox regression analyses were used to evaluate the risk factors for recurrence after COS. The average age was 32.9 ± 3.46 years. 23.9 % of these patients relapsed after COS during the follow-up period. The 2-year cumulative recurrence rate was 14.9 % (9.1 % and 20.6 % in the LNG-IUD and control groups, respectively). Compared with the control group, the recurrence rate was lower in patients with LNG-IUDs present during COS (12.1 % vs 35.5 %, p = 0.027). The clinical pregnancy (42.4 % vs 52.9 %, p = 0.392) and live birth (21.2 % vs 29.4 %, p = 0.444) rates were similar between the LNG-IUD and control groups. Age, body mass index (BMI), histology, FST type and time to complete response were not related to prognosis after COS. After adjusting for age and BMI in a multivariate Cox regression model, the use of LNG-IUD during COS was a favorable factor for better oncologic outcomes after COS (HR 0.263, 95 %CI 0.084-0.822, p = 0.022). Patients with early stage EMC and AEH treated with assisted reproductive technology after FSTs might benefit from LNG-IUDs present during COS.

Association between sentinel lymph node biopsy and micrometastasis in endometrial cancer

Sentinel lymph node (SLN) biopsy is increasingly utilized at surgical staging for early endometrial cancer. This study examined the association between SLN biopsy and micrometastasis in endometrial cancer. This is a retrospective cohort study examining the National Cancer Institute's Surveillance, Epidemiology, and End Result Program. The study population was 6,414 women with T1-2 endometrial cancer who underwent primary hysterectomy and surgical nodal evaluation. Exclusion criteria included cases with isolated tumor cells. Exposure assignment was surgical nodal evaluation (SLN biopsy or lymphadenectomy). Main outcome measure was micrometastasis, assessed by inverse probability of treatment weighting propensity score in a stage-specific fashion. In T1a disease (n = 4,608), SLN biopsy was performed in 1,164 (25.3%) cases. SLN biopsy was associated with a 90% increased likeliness of identifying micrometastasis compared to lymphadenectomy (1.3% versus 0.7%, odds ratio 1.90, 95% confidence interval 1.02-3.55, P = 0.040). In T1b disease (n = 1,369), 270 (19.7%) cases had SLN biopsy. The incidence of micrometastasis was significantly higher in the SLN biopsy group compared to the lymphadenectomy group (8.4% versus 5.0%, odds ratio 1.74, 95% confidence interval 1.06-2.86, P = 0.028). In T2 disease (SLN biopsy in 57 [13.0%] of 437 cases), the incidence of micrometastasis was similar between the two groups (7.9% versus 7.0%, odds ratio 0.88, 95% confidence interval 0.30-2.60, P = 0.818). This study suggests that SLN biopsy protocol may identify more micrometastasis in the regional lymph nodes of T1 endometrial cancer. Whether national-level increase in the utilization of SLN biopsy for early endometrial cancer results in a stage-shifting to advanced disease on a population-basis warrants further investigation.

Relevance of sentinel lymph node biopsy in early endometrial cancer: A series of 249 cases

We aimed to evaluate the impact of the sentinel lymph node (SLN) biopsy on adjuvant therapy, recurrence and survival in early endometrial cancer (EC). We retrospectively included all patients who underwent SLN biopsy for EC between February 2007 and March 2018. Of the 249 EC patients included, the overall SLN detection rate was 91 %. SLNs were positive in 36 (14.4 %) cases. Nine of the 13 preoperative low-risk patients with positive SLNs were re-operated and 22 % presented positive non-SLNs. No second surgery was required for the 10 patients upstaged to intermediate risk after negative SLN biopsy. Nine of the 11 preoperative intermediate-risk patients with positive SLNs were re-operated and 33 % presented positive non-SLNs. Eleven of the 24 preoperative high-risk patients with negative SLNs were re-operated and 27 % presented positive non-SLNs. For the whole population, 3-year overall survival was 99 % (CI 95 % (97-1)) and 3-year recurrence-free survival (RFS) was 92 % (CI 95 % (0.87-0.95)). Our study supports the feasibility of the SLN procedure for assessing risk recurrence in patients with early-stage EC. SLN biopsy should lead to major reductions in secondary staging and better adaptation of adjuvant therapy.

Endometrial hyperplasia in pre-menopausal women: A systematic review of incidence, prevalence, and risk factors

Hormonal therapies have been associated with a range of effects on the endometrium, including endometrial hyperplasia (EH). With many medicinal products being developed for pre-menopausal women, epidemiological data regarding the population background risk could meaningfully supplement comparative risk data gathered in clinical trials. However, epidemiological studies on EH often focus on post-menopausal women. We aimed to assess the available observational evidence on the incidence and prevalence of EH among pre-menopausal women and to investigate the influence of specific risk factors. We conducted systematic literature searches on 27 August 2021, using the Embase and PubMed databases. Searches were designed to identify studies of EH epidemiology, published in English on or after 1 January 1995, in populations of predominantly pre-menopausal women. Studies were required to report diagnostic histopathology data for at least 500 women. Relevant outcomes were the prevalence and incidence of EH, and/or the impact of pre-specified risk factors including age, body mass index (BMI) and diabetes mellitus. In total, 3785 records were screened, and 31 references, describing 29 different studies, were included in the review. The incidence of EH among pre-menopausal women increased with age and was as high as 121 and 270 cases per 100,000 woman-years in South Korean women aged 46-50 years and US women aged 45-49 years, respectively. The prevalence of EH was highly dependent on the population studied. Estimates of EH prevalence in 14 studies of pre-menopausal women with abnormal uterine bleeding (AUB) ranged from 3.4% to 265%, higher than the reported prevalence in two studies of women with infertility (0.9% and 3.0%). Studies of risk factors found increasing age, BMI and diabetes to be associated with an increased prevalence of EH. Published data on the epidemiology of EH in pre-menopausal women are heterogeneous, with considerable variation in study methodology and populations, and in how EH subtypes are reported. The main factors affecting the reported prevalence and incidence of EH are the reason a biopsy was performed - particularly whether patients had AUB, a key symptom associated with EH - and the presence of known risk factors.

“Long-term outcome in endometrial cancer patients after robot-assisted laparoscopic surgery with sentinel lymph node mapping”

Sentinel Lymph Node (SLN) mapping is increasingly used as an alternative to lymphadenectomy in endometrial cancer. There is, however, limited data regarding the clinical outcome and survival after SLN mapping. The aim of the study was to determine long-term outcome data in endometrial cancer patients undergoing robot-assisted laparoscopic surgery and SLN mapping. Retrospective cohort study of 108 patients with primary endometrial cancer who underwent robot-assisted laparoscopic surgery and sentinel lymph node mapping using the Memorial Sloan Kettering Cancer Center (MSKCC) algorithm with near-infrared fluorescence detection of indocyanine green for endometrial cancer, from November 20th 2012 to January 1st 2016 at St. Olav's Hospital in Norway. The primary endpoint was recurrence-free survival. Secondary endpoints were overall survival and treatment complications. Among 108 patients operated in accordance with the SLN algorithm, 17 (16%) had lymph node metastases. Adjuvant chemotherapy was administered on indication endometrial cancer to 36 (33%) of the patients. After a median follow up of 75 months (range 61-98), five (4.6%) patients had recurrence, and three patients had died from the disease. Four of the patients who had recurrence had lymph node metastasis at diagnosis. The 5-year recurrence-free survival was 95.4% (95% CI, 91.5 - 99.3). The 5-year disease-specific survival was 97.2% (95% CI, 94.1 - 100.3). The 5-year overall survival was 92.6% (95% CI, 87.7 - 97.5). Peripheral neuropathy after chemotherapy was the most common complication (9.3%), followed by lower limb lymphedema (2%) and postoperative hernia (2%). The present study demonstrated excellent oncologic outcome and low long-term treatment complication rate in patients treated according to the SLN algorithm more than five years after diagnosis.

Association between statin use and the risk, prognosis of gynecologic cancer: A meta-analysis

Recent evidence has demonstrated that the salutary effect of statins on the prevention and prognosis of cancers, including gynecologic cancers. However, due to the heterogeneity of tumors, the results from related studies regarding the association between statin therapy and gynecologic cancers are conflicting. Thus, we conducted this meta-analysis to better understand the relationship between statins use and gynecologic cancers. We searched for articles published before July 2021 in the databases: PubMed, Web of Science, Medline, EMBASE and Google Scholar. We computed odds ratio (OR)/relative risk (RR) or hazard ratio (HR) and 95% confidence intervals (CI) regarding the association between statin use and the risk or prognosis of gynecologic cancers by using STATA 12.0 software. The present meta-analysis showed that statin use was associated with a lower risk of gynecologic cancer (OR/RR = 0.89, 95% CI 0.83 to 0.96, I Statins use was inversely associated with the risk and mortality of gynecologic cancers. Meanwhile, we need more well-designed and high-quality studies with strong evidence for definite conclusions that determine clinical practice.

Intraoperative tumor spill during minimally invasive hysterectomy for endometrial cancer: A survey study on experience and practice

Tumor spill during surgical treatment is associated with adverse oncologic outcomes in many solid tumors. However, in minimally invasive hysterectomy for endometrial cancer, intraoperative tumor spill has not been well studied. This study examined surgeon experiences and practices related to intraoperative tumor spill during minimally invasive hysterectomy for endometrial cancer. A cross-sectional survey was conducted to the Society of Gynecologic Oncology. Participants were 220 U.S. gynecologic oncologists practicing minimally invasive hysterectomy for endometrial cancer. Interventions were 20 questions regarding surgeon demographics, surgical practice patterns (fallopian tubal ablation/ligation, intra-uterine manipulator use, and colpotomy approach), and tumor spill experience (uterine perforation with intra-uterine manipulator and tumor exposure during colpotomy). Nearly half of the responding surgeons completed subspeciality training >10 years ago (50.5%), and 74.1% had annual surgical volume of >40 cases. The majority of surgeons used an intra-uterine manipulator during minimally invasive hysterectomies for endometrial cancer (90.1%), and 87.2% of the users have experienced uterine perforation with an intra-uterine manipulator. Almost all surgeons performed colpotomy laparoscopically (95.9%), and nearly 60% had experienced tumor spill while making colpotomy (59.8%). Nearly 10-15% of surgeons have changed their postoperative therapy as a result of intraoperative uterine perforation (11.8%) or tumor spill (14.5%). Surgeons infrequently ablated or ligated fallopian tubes prior to performing the hysterectomy (14.1%). Our survey study suggests that many surgeons experienced intraoperative tumor spillage during minimally invasive hysterectomy for endometrial cancer. These findings warrant further studies examining its incidence and impact on clinical outcomes.

Ovarian metastasis risk factors in endometrial carcinoma: A systematic review and meta-analysis

To investigate the incidence of ovarian metastasis in endometrial carcinoma (EC) and analyze its risk factors and provide a theoretical basis for whether retention of the ovary in patients with EC. A systematic search using synonyms of 'ovarian cancer' and 'metastasis' was conducted in PubMed, Cochrane database, Embase, Google Scholar, and WOS database. Meta-analysis was performed on 7 included studies, comprising 4281 clinical-stage I-IV EC patients. Studies were assessed using the Newcastle-Ottawa Scale (NOS) criteria. Odds risks (OR) and 95% confidence intervals (CI) were calculated using an inverse variance weighted random-effects model. The ovarian metastasis risk of EC was significantly higher for patients with myometrial invasion >1/2 (OR = 18.19, 95% CI 5.34 to 61.96 compared to myometrial invasion ≤1/2), any pelvic lymph node invasion (PLNI) (OR = 5.41, 95% CI 2.60-10.97 compared to without PLNI), G3 pathological grade (OR = 2.66, 95%CI 1.35-5.24 compared to G1-G2), non-endometrioid pathological type (OR = 6.46, 95% CI 3.25 to 12.83 compared to endometrioid), lymphatic vascular space invasion (LVSI) (OR = 6.46, 95% CI 3.25 to 12.83 compare to without LVSI), age >45 (OR = 2.01, 95% CI 0.29 to 14.11 compared to age ≤45), and cervical invasion (OR = 4.12, 95% CI 1.87 to 9.08 compared to without cervical invasion). About 4.95% of EC patients develop ovarian metastasis. Age >45, myometrial invasion >1/2, cervical invasion, PLNI, pathological type, G3 pathological grade, and LVSI were the high-risk factors for ovarian metastasis of EC. Ovarian preservation should be carefully selected for patients with EC, and preoperative and intraoperative evaluations should be entirely performed.

Importance of pre-operative ultrasound examination and pathological tumour evaluation in the management of women with endometrial cancer

Endometrial cancer (EC) is the most common gynaecological malignancy in developed countries. Early and accurate diagnostic assessment is crucial for appropriate treatment planning. Information obtained by pre-operative imaging with transvaginal ultrasound (TVUS) and histological endometrial biopsy assessment is often the cornerstone for further management planning. This study aimed to analyse the accuracy of this diagnostic approach for patient management decisions. This single-centre retrospective analysis included all patients with endometrial cancer treated between 2015 and 2019. Pre-operative TVUS staging assessment and histopathological endometrial biopsy examination were compared with the final surgical stage and histopathological diagnosis. Pre-operative and surgical pathological assessment of Type I and Type II tumours was in agreement in 95 % (174/184) and 54 % (12/22) of cases, respectively. The sensitivity and specificity of TVUS assessment of myometrial invasion were 76 % [95 % confidence interval (CI) 66.3-84.2 %] and 81.7 % [95 % CI 73.0-88.6 %], respectively. Diagnostic accuracy was higher for Type I EC (95 %) than Type II EC (54 %). Only presumed ESMO/ESGO/ESTRO risk classification (p < 0.000) and deep myometrial invasion (p < 0.000) were significant for the prediction of lymph node involvement. Pre-operative TVUS examination and pathological endometrial biopsy evaluation enable moderately accurate assessment of the risk of EC. Efforts should be aimed towards the development of novel and more reproducible methods, such as molecular tumour characterization, to improve the pre-operative assessment of risk in patients with EC.

The role of prolonged progestin treatment and factors predicting successful fertility-sparing treatment for early endometrial endometrioid adenocarcinoma

Fertility-sparing progestin therapy is highly effective in selected young women with endometrial cancer. In present study, we attempted to evaluate the role of prolonged medication and identify factors predicting successful treatment, and also assess fertility outcomes among young women with early stage endometrial endometrioid carcinoma (EC). We retrospectively reviewed clinical data from patients aged 12 months were 17.7%, 48.9%, 60.0%, 68.9% and 91.1%, respectively. Among the 41 responders, 23 attempted to conceive and nine (39.1%) achieved pregnancy with 12 live newborn infants. Eleven (27.5%) responders experienced recurrence at a median of 22 months from CR (range 3-54 months). Multivariate Cox regression analysis revealed that non-diabetes (HR: 4.59; 95% CI: 1.62-12.98) and endometrial thickness <2 cm (HR: 0.39; 95% CI: 1.41-17.67) were significantly factors associated with treatment response. We concluded that prolonged oral progestin treatment was possible with a certain proportion of responders (24.4%) being responded after one year. Diabetes controlled on metformin and endometrial thickness <2 cm could be used as surrogate markers to predict better treatment response.

Impact of restaging lymphadenectomy after sentinel node biopsy on endometrial cancer

Approximately 10 % of patients with an intra-operative diagnosis of low-risk endometrial cancer (EC) will be upstaged after a definitive histological evaluation of hysterectomy and bilateral adnexectomy samples. This study aimed to explore the results associated with the performance of pelvic and para-aortic lymphadenectomy for restaging after upstaging/upgrading these patients, and to compare those who underwent sentinel lymph node biopsy (SNB) in the first procedure with those who did not. This retrospective cohort study included 27 patients diagnosed with low-risk EC (based on the criteria of the European Society of Medical Oncology/European Society of Gynecological Oncology/European Society for Radiotherapy and Oncology), who underwent surgical laparoscopic restaging due to upstaging based on the final histological result at Hospital Universitario Donostia from April 2013 to September 2018. Surgical and oncological results were compared between patients who underwent hysterectomy and double adnexectomy without any additional procedures (SNB-; n = 17) and patients who also underwent pelvic&aortic sentinel node biopsysen (SNB+; n = 10). The main outcome evaluated in the study was intra-operative complications. Secondary outcomes were mean operative time, length of hospital stay, number of nodes obtained, progression-free survival (PFS) and overall survival (OS). The median duration of restaging surgery was 240 [interquartile range (IQR) 180-300) min in the SNB(-) group and 300 (IQR 247.5-330) min in the SNB(+) group; this difference was significant (one-sided Student's t-test, p = 0.0295). With regard to intra-operative complications, there were 17.65 % and 40 % in the SNB(-) and SNB(+) groups, respectively, all of which were vascular; this difference was not significant. There were no significant difference in the length of hospital stay, number of pelvic nodes obtained, PFS or OS between the groups. Women with EC who require lymph node restaging due to upstaging, and have previously undergone SNB, experience more surgical complications and a longer operative time. The authors advise against performing second restaging surgery in these patients.

Malignant transformation of abdominal wall endometriosis: A systematic review of the epidemiology, diagnosis, treatment, and outcomes

Malignant transformation of abdominal wall endometriosis (AWE) is rare. The clinical characteristics and treatment of malignant transformation of AWE are not well known. Therefore, in this review, we performed a thorough search for malignant transformation of AWE on MEDLINE and Web of Science from their inception to May 2021. In total, the data of 46 patients with malignant transformation of AWE were retrieved, and all the data on these patients were collected. After reviewing and analyzing the clinical parameters, we found that cesarean scar was the most common site of malignant transformation of AWE, and the most common pathological type of malignant transformation of AWE was clear cell cancer, followed by endometrioid adenocarcinoma. The main symptoms of malignant transformation of AWE included an abdominal nodule or mass, and ultrasonography was the first choice for diagnosis. The most widely accepted treatment was surgical resection of local lesions with adjunctive chemotherapy and/or radiotherapy, and the overall survival of patients with malignant transformation of AWE was poor. In conclusion, malignant transformation of AWE is rare, and the prognosis is poor. Thus, improving abdominal surgical technology and avoiding iatrogenic ectopia and implantation of the endometrium are necessary to prevent malignant transformation of AWE.

Serous endometrial intraepithelial carcinoma: A clinico-pathological study of 48 cases and its association with endometrial polyps – A tertiary care oncology centre experience

Endometrial serous carcinoma (ESC) is an aggressive neoplasm wherein the recent studies have shown that it arises from its putative precursor namely the serous endometrial intraepithelial carcinoma (SEIC). SEIC usually arises in inactive/ atrophic endometrium but surprisingly is frequently associated endometrial polyps (EPs). The aim of this study was to assess the incidence of SEIC with or without invasion, its clinical behaviour and association with endometrial polyp. After Institutional review board approval, a total of 205 samples (belonging to 120 patients); diagnosed as ESC from January 2009 to December 2015 were retrieved and reviewed for presence of in situ carcinoma and also for associated endometrial polyp. The mean age at diagnosis was 62.40 years with postmenopausal bleeding being the most common presenting symptom. The incidence of SEIC with or without invasive tumor was 40% (48/120). Of these 48 cases; 25 cases were associated with in-situ carcinoma arising in the EPs which amounted to 52% of the total cases. The overall three year survival and disease free survival in SEIC with or without invasion were 1.9% and 0.25%, indicating the aggressive nature of the disease. SEIC is a difficult histopathological diagnosis and one should carefully look for these lesion, especially in the EPs which are frequently associated with them. Extensive sampling of the EP will be helpful to pick up in-situ carcinoma arising in EP. SEIC is an aggressive disease on its own with a propensity to develop distant metastasis even in the absence of myometrial invasion and hence should be treated with optimum surgical staging and if indicated aggressive adjuvant treatment protocols.

The 10-year results after national introduction of pelvic lymph node staging in Danish intermediate-risk endometrial cancer patients not given postoperative radiotherapy

The 10-year results after national introduction of pelvic lymph node staging in Danish intermediate-risk endometrial cancer patients not given postoperative radiotherapy. Gitte Ørtoft; Claus Høgdall; Estrid S Hansen; Margit Dueholm. To prepare for the national introduction of sentinel node staging, we evaluated the consequences of the previous national decision to introduce lymph node staging in intermediate-risk endometrial cancer patients (grade 1/2 with > 50% or grade 3 with < 50% myometrial invasion) by determining the number of patients upstaged by lymphadenectomy and whether upstaging affected the survival and recurrence patterns of non-staged patients and patients with and without lymph node metastases. In a national cohort study, 2005-12, 1294 stage I-IV patients who should have been offered lymphadenectomy were progressively registered. The number of patients upstaged by lymphadenectomy, 10-year survivals were evaluated by Kaplan-Meier analysis and adjusted Cox regression. This study demonstrates that it takes time to introduce lymphadenectomy at a national level, as indicated by the increasing number of cases staged per year, from 12% in 2005 to 74% in 2012. Pelvic lymphadenectomy was performed in 43.8% (567/1294) and lymph node metastases were found in 13.6% (77/567). As 54 patients had further dissemination outside the uterine body, only 23 patients (6%) were upstaged from stage I to IIIC. Compared to lymph node-negative patients, the 77 patients with lymph node metastasis had significantly lower overall, (55% versus 68%), disease-specific (64% versus 86%), and progression-free survival (51% versus 77%), mainly due to non-local recurrences including a high number of paraaortic recurrences. In 873 final stage I intermediate-risk patients, 10-year survival and recurrence rates were not significantly lower in non-staged as compared to lymph node-negative patients (overall survival 62% versus 70%: disease-specific survival: 90% versus 90%, progression-free survival: 81% vs 83%), probably due to the low number of patients upstaged from stage I to stage IIIC. Lymph node metastases were present in 13.6% of patients with intermediate-risk who underwent pelvic lympadenectomy, and these patients had a lower 10-year survival than lymph node-negative patients. Because lymphadenectomy upstaged only 6% from stage I to stage IIIC, survival and recurrence rates were not significantly compromised in non-staged as compared to lymph node-negative intermediate-risk stage I patients. Sentinel node staging has now been implemented in Danish intermediate-risk endometrial cancer patients.

Initial experience with positron emission tomography/computed tomography in addition to computed tomography and magnetic resonance imaging in preoperative risk assessment of endometrial cancer patients

Improved preoperative evaluation of lymph node status could potentially replace lymphadenectomy in women with endometrial cancer. PET/CT was routinely implemented in the preoperative workup of endometrial cancer at St Olav's University Hospital in 2016. Experience with PET/CT is limited, and there is no consensus about the use of PET/CT in the diagnostic workup of endometrial cancer. The aim of the study was to evaluate the diagnostic accuracy of PET/CT compared to standard CT/MRI in identifying lymph node metastases in endometrial cancer with histologically confirmed lymph node metastases as the standard of reference. We especially wanted to look at PET/CT as a supplement to the sentinel lymph node algorithm in the detection of paraaortic lymph nodes. A retrospective study included all women undergoing surgery for endometrial cancer from January 2016 through July 2019 at St Olav's University Hospital. Clinical data, results of CT, MRI, and PET/CT, and histopathological results were analyzed. Among 185 patients included, 27 patients (15 %) had lymph node metastases. 17 (63 %) had pelvic lymph node metastases, one (4 %) had isolated paraaortic lymph node metastases, and 9 (33 %) had lymph node metastases in both the pelvis and the paraaortic region. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of PET/CT for the detection of lymph node metastases were 63 %, 98 %, 85 %, 94 %, and 93 %, respectively. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CT/MRI were 41 %, 98 %, 73 %, 91 %, and 90 %, respectively (p = 0.07). For the 26 pelvic lymph node metastases, PET/CT had a sensitivity of 58 %, compared to 42 % for CT/MRI (p = 0.22). PET/CT detected all 10 paraaortic lymph node metastases, for a sensitivity of 100 %, compared to 50 % for CT/MRI (p = 0.06). PET is superior to CT/MRI for detection of lymph node metastases in endometrial cancer, particularly in detecting paraaortic lymph node metastases. The ability of preoperative PET to exclude paraaortic lymph node metastases may strengthen the credibility of the sentinel lymph node algorithm.